Full text of Maternal Mortality : The Risk of Death in Childbirth and From All Diseases Caused by Pregnancy and Confinement, Bureau Publication No. 158

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U. S. DEPARTMENT OF LABOR
J A M E S J. D A V I S , Secretary

CHILDREN'S BUREAU
GRACE ABBOTT, Chief

MATERNAL MORTALITY
THE RISK OF DEATH IN CHILDBIRTH AND FROM
A LL DISEASES CAUSED BY PREGNANCY
AND CONFINEMENT
^

By

ROBERT MORSE WOODBURY, Ph. D.

Bureau Publication N o. 158

WASHINGTON
GOVERNMENT PRINTING OFFICE

1926


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SINGLE. COPIES OF THIS PUBLICATION MAY BE
OBTAINED FREE UPON APPLICATION TO THE
CHILDREN’ S BUREAU.

ADDITIONAL COPIES MAY

BE PROCURED FROM THE SUPERINTENDENT OF
DOCUMENTS, GOVERNMENT

PRINTING

WASHINGTON, D. C.
AT

25 CENTS PER COPY


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OFFICE

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$ I5 ^

CONTENTS

Letter of transmittal_______________________ __________
Introduction_______ _________________ _______ ¡j
Definition and measurement of puerperal mortality
Definition_______________________ __-.___i. -_!'.______ _ j~ _ _ I: I j JI Measurement___<____________ ____ ;_n ____ j d l i auibul
~s~Deaths from puerperal causes in the' United -StatesTIZIZI_uZuZZ_Z_IZZZI
Estimated maternal mortality r a te ____^ ._iii_;_^__l'i_i^.:jj.
Margin of error______________ _ _ _ !:___ ___________ \
i Z I=__ ~
Pathological causes of puerperal mortality_________ _u i:a i i
Primary causes__________1 _._________ ______._L&JLi
Contributory causes_______________________ t ~«»h '
Factors in puerperal mortality____ _______ d.'iutc
.>a K T ,t 7r l.i
Q
Stage of pregnancy or period of gestation. _ _ l ___
Stillbirths________;_ _ ________ _____Jt____ ^
Complications of pregnancy or confinement.
^
i___ L
Obstetrical operations______ ______ _
1
Time from childbirth to death of mo t h e r _ _ _ _ I _ _ I I I _ _ I I I ‘__I " II ~
Single or plural birth________________ _ ____________ ___;___ _ _ _ ! '
Age of m other__________ _._______________________
Order of birth_______ _______ _______________________
Earnings of father____________________________________
Color and nationality of mother____________________________'_I
Urban and rural districts_____________ ____________ _____
Trend of puerperal mortality in the United States, I I I _ _ I I I _ _ _ I I I _
” I
Comparison of maternal mortality in the United States and in certain
foreign countries______ ______ ___________________ ____
Comparative maternal mortality rates__________________________ _ __
Significance of differences in rates_____________ ______________I]
Trend of maternal mortality rates in certain foreign countries. _ _ ____
Preventability of puerperal mortality________________________________
Puerperal septicemia______________________________________
Other puerperal causes ________________________________________
Prevention of maternal mortality___________ ,____ I _ ______ I _ _ _ _ I I _ I I _ _
Protective legislation________ _________________ I _
_ _ 11 _ I _ I _ _I
Provisions for maternity care____________ ______________________
Governmental responsibility_____ __________________________ I - I I I I I I I T
Need for information________ ;___________ ___

Page

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A P P E N D IX E S

Appendix A.— Rules for the classification of puerperal causes of death
>
in use by the Bureau of the Census___________________
B. — Completeness of birth registration___________________ _
C. — Registration and definitions of stillbirths_______________
D. — Statistical comparability of maternal mortality rates in the
United States and certain foreign. countries_________ _
E. Summary of laws and regulations governing midwives in the
United States__ _____ ____ ___________________________ .
F. Summary of laws and regulations governing midwives in
certain foreign countries__________ ________________ ___
G.— General tables___________________ ____
Index________________________________________________________
~ ~~
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103
H2
114
118
132
136
140
157

CONTENTS

IV

G ENERAL TABLES

Table
Table
Table
Table
Table
Table

Table
Table
Table

Page

1.

— Maternal mortality rates, by cause of death; United States ex­
140
panding death-registration area, 1900-1921------------------2. — Maternal mortality rates, by cause of death; death-registration
140
States as of 1900, 190()-1921--------3. — Maternal mortality rates, by cause of death; District of y o lumbia and each. State included in the death-registration
141
area of 1900, 1900-1921------------------------------------------------ - 4. — Proportion of deaths from ill-defined and unknown causes, by
145
States, 1921----------------------------------~ 7— - - - - - - - - h r — r~
5. — Estimated additions to puerperal deaths m original death-regis­
tration States of 1900 from ill-defined and unknown causes
146
and from five poorly defined causes, 1900-1920---------------6 — Maternal mortality rates per 1,000 live births for urban and
rural areas; United States birth-registration area as of 1915
(excluding Rhode Island) and United States expanding birth147
registration area, 1915—1921------------ ------------------------------7. — Proportion of physicians to population in certain countries. _ 148
8. — Proportion of births attended by physicians and midwives m
148
certain countries----------------------- -----------Hr---------------- . '¿ “ j
9.

Table 10.
Table 11.

— Scope and effect of system of querying unsatisfactorily certified

149
causes of death in England and Wales, 1911-1921------- —
— Live births, deaths, and death rates per 1,000 live births from
diseases caused by pregnancy and confinement in certain
149
foreign countries for specified years------------------------ - - - - - ____Registered and estimated births and reported and adjusted
155
puerperal deaths; United States birth-registration area, 1919-


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LETTER OF TRANSMITTAL

U n it e d S t a t e s D e p a r t m e n t o f L a b o r ,
Ch i l d r e n ’ s B u r e a u ,

Washington, August 4, 1925.
S i r : There is transmitted herewith a report on Maternal Mortality

by Robert Morse Woodbury, Ph. D., formerly director of statistical
research in the Children’s Bureau. Miss Rena Rosenberg assisted
Doctor Woodbury in the preparation of statistical material, and Miss
Anna Kalet assisted in assembling information from foreign sources.
Eight years ago the bureau published a bulletin on maternal
mortality because investigation showed the direct relation between
maternal and infant mortality and between conditions which lead to
the death of mothers in childbirth and the high death rate of infants
during the first month of life.
If the statistics of maternal mortality are accepted at their face
value the mortality from puerperal septicemia increased from 1900
to about 1911, since which time it has shown a slight decrease, while
the mortality from other causes showed a steady increase from 1900
to 1921, with the result that the mortality from all puerperal causes
has been gradually rising in the United States. In comparison with
other foreign countries which have good mortality statistics the
United States ranks with those having highest rates; and in many
European countries the maternal mortality rate, in particular the
mortality from puerperal septicemia, has shown a marked decrease
during the last 20 or 30 years. In order to test whether these con­
clusions are correct or whether they should be modified it is necessary
to study in detail the sources of error in the statistics.
The assistance of the United States Bureau of the Census was
most helpful in assembling the material for the study, and the sug­
gestions and criticisms made by Dr. William H. Davis, chief statisti­
cian for vital statistics of the bureau, were of particular importance.
The registry offices in Maryland, Massachusetts, North Carolina, and
Wisconsin, and the offices of the commissioner of health in Baltimore,
Md., and of the city registrar in Boston, Mass., were very helpful
also in connection with special studies made in these cities and States.
Dr. Grace Meigs Crowder, who wrote the previous bulletin on
Maternal Mortality for the Children’s Bureau, went over this manu­
script with great care and made many valuable suggestions and
criticisms. The Children’s Bureau is also indebted to Dr. J. Whitridge Williams, Dr. William Travis Howard, Jr., Prof. Walter F.
Willcox, and Dr. F. L. Adair for helpful suggestions.
Respectfully submitted.
G r a c e A b b o t t , Chief.
Hon. J a m e s J. D a v i s ,
Secretary o f Labor.
▼

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MATERNAL MORTALITY
INTRODUCTION

The growth of interest in the subject of the protection of the HVes
and health of mothers is due not only to a realization that a large
proportion of the mortality and sickness caused by pregnancy and
confinement is preventable hut also to an appreciation of the farreachmg influence over infant mortality that is exerted by the health
and condition of the mother. With reference to the proventabili ty
of mortality from puerperal causes, the knowledge that ptierperal
septicemia, the chief cause of this mortality, is largely preventable
has been known to the medical profession since the discoveries of the
transmissible nature of this disease by Oliver Wendell Holmes,
Semmelweiss, Pasteur, and others. Deaths from other puerperal
causes are also preventable to a very considerable degree, as: careful
studies of such causes and the results of the application of appro­
priate preventive measures show. If, then, mortality from puerperal
pauses is preventable, it is important to know the precautions and
measures by which it can be prevented, whether thesje means arc in
use in this country, and whether preventable ddAths and'illiiesses
from these causes are actually occurring.
Interest in maternal mortality has been especially stimulated in
recent years by the progress of the movement for reduction of infant
mortality. A very considerable proportion of all deaths of infants
under 1 year of age occur during the first month of life from causes
which have their origin in the care and condition of mothers during
pregnancy and confinement. For example, in 1921 in the United
States birth-registration area 44.5 per cent of all deaths of infants
under 1 year of age occurred during the first two weeks of life, and 8
per cent more occurred during the rest of the first month. Therefore,
since nearly all the deaths in the first month are due to causes that
have their origin in natal and prenatal conditions, approximately^
half the total number of deaths during the first year were due to such
causes. In the United States as a whole it may be estimated that
about 100,000 deaths of infants under 1 month of age occur every
year.1 Reduction in the mortality from these causes depends upon
improvement and extension of facilities for prenatal, confinement,
and postnatal care.
The causes of stillbirth, like those of deaths in early infancy, are
natal and prenatal in origin, and prevention of these depends likewise
upon better prenatal and natal care. In the United States little
information is available regarding the number of stillbirths. Figures
for the States in the birth-registration area in 1918 2 based on still­
births registered as births showed that for every 1,000 live births on
1 The deaths of infants under 1 month in the birth-registration area in 1921 numbered 68,021; in the United
States as a whole it may be estimated that there were at least 100,000 such deaths. Birth Statistics, 1921.
pp. 7 and 238. U. S. Bureau of the Census, Washington, 1923.
2Exclusive of Massachusetts, Rhode Island, Washington, and the city of Baltimore, Md.

1


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2

M A T E R N A I. M O R T A L IT Y

an average 40 stillbirths occurred. In the United States as a whole
it may be estimated that at least 100,000 stillbirths occur each year.3
The same measures which will safeguard the lives and health of the
mothers during pregnancy and labor and which will prevent to a
large extent the unnecessary mortality of mothers will also tend to
reduce the stillbirth and neonatal mortality rates.
Ill health or death of the mother exerts a powerful adverse in­
fluence upon the chances of life of her child. In studies made by
the Children’s Bureau in eight cities the mortality from all causes
among infants of mothers who died either immediately following
childbirth or within one year was found to be between four and five
times, and that from causes peculiar to early infancy was over seven
times, the corresponding rates among other babies.4
The prevention of the mortality and morbidity of maternity is
therefore of far-reaching interest and importance. The first step is
to secure accurate and complete statistical information regarding
the nature and extent of the problem. The present bulletin aims
to bring together such statistical evidence with especial reference
to conditions in this country. Though much progress has been made
in recent years in the accumulation of statistics relating to maternal
mortality, the absence of comprehensive and satisfactory data on
many questions is still noteworthy. Though many questions,
therefore, must remain unanswered for lack of the necessary data,
the evidence that is available is sufficient for sound conclusions of
great practical importance.
5In the birth-registration area in 1921, at this rate of 40 stillbirths to every 1,000 live births, there were
approximately 68,000 stillbirths; since the area contained 65.3 per cent of the total population it may be
estimated t L t in the United States as a whole about 100,000 stillbirths occurred. Compiled from Birth
Statistics 1918 p 30. and Ibid., 1921, p. 7 (U. S. Bureau of the Census).
’E y.;.
, ~
St<a|ee Causal’ Factors in Infant Mortality, by Robert M . Woodbury, p. 34 (U. S. Childrens Bureau
Publication No. 142. Washington, 1925).


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DEFINITION AND MEASUREMENT OF PUERPERAL MORTALITY
D EFIN ITIO N

Deaths from puerperal causes include all those of which pregnancy
and confinement are the only, or the decisive, cause. For example,
they include deaths from hemorrhage and from other “ accidents”
of pregnancy; deaths from difficult labor (dystocia); deaths ‘from
puerperal convulsions, or toxemias of pregnancy, and from puerperal
infection. On the other hand, they do not include deaths resulting
from accidents sustained by pregnant women if the accidents them­
selves were sufficient to cause death, nor do they include deaths
resulting from criminal abortion.
In practice, for inclusion in the statistics puerperal deaths must
be registered and must be certified by the physician in attendance
or by some other person as due to or complicated by some cause con­
nected with pregnancy or confinement and must be classified by the
agency in charge of the compilation of statistics as due primarily
to a puerperal cause. The procedure of registration and the accuracy
of certification, so far as they affect the completeness of the record,
are discussed elsewhere; they do not affect the definition. But some
consideration of the rules for the classification of puerperal causes—
especially for the decision, in cases in which two or more causes of
death are reported, as to whether the puerperal or the other cause
should be regarded as the principal one— is necessary to an under­
standing of the term “ puerperal deaths.”
According to the International List of Causes of Death in use by
the United States Bureau of the Census eight groups of causes are
classified as puerperal.
The titles included within each group are given in full in Appendix
A, page 103, and need not be considered in this connection. When
one o f these causes appears in conjunction with some nonpuerperal
cause on a death certificate, the death is classified according to
definite rules irrespective of the order in which the causes are stated,
or of the apparent assignment as primary or contributory which the
physician m attendance may have indicated. Definite rules were
found to be necessary in order to secure a uniform treatment of each
combination of causes; for, though in theory the assignment of the
preferred cause should be made b y the physician in charge of the
case, who is in the best position to know the relative importance of
the several causes, in practice it was found that these decisions varied
not only because of differences in judgment on the part of the phy­
sicians but also because o f differences in interpretation of principal
and primary causes. In order to secure uniformity in classifica­
tion of identical combinations of joint causes in statistics for all parts
of the country, all cases of joint causes are classified in accordance
with definite rules, which are published in the Manual of Joint Causes
of Death.
3


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4

M ATERNAL

M O R T A L IT Y

The principal rules relating to the preference of puerperal over
other causes and of other over puerperal causes are as follows:
1. Most acute infectious diseases (e. g., diphtheria, smallpox) and
external causes, including criminal abortion, are preferred to any
puerperal cause.
2. Puerperal septicemia is generally preferred to any other cause
excepting some acute infectious diseases, cancer, syphilis, or external
causes.
3. A serious disease (e. g., pulmonary tuberculosis) is preferred to
any puerperal cause except puerperal septicemia.
Details of the application of the rules relating to other combina­
tions of causes are summarized in Appendix A, page 109.
The deaths classified as puerperal, then, include only those which
are regarded as caused primarily by pregnancy and childbirth.
Deaths to which puerperal conditions are contributory but not
decisive causes are not included in puerperal mortality.
M EASUREM ENT

The mortality rate from puerperal causes is best expressed in theory
by comparing the number of deaths from such causes with the num­
ber of cases exposed to risk. This number of cases exposed to risk is
equal, except for cases of pregnancy terminated in the early months,
to the number of confinements.
Since in most countries, including the United States/ statistics of
confinements are not available the nearest approximation to them.1is
the total number of births, including live births, stillbirths, and mis­
carriages. This number, if all births are registered, is greater than
the number of confinements by the difference between the number
of twins, triplets, quadruplets, etc., and the number of confinements
during which they were born. The number of extra twins and trip­
lets, however, is relatively small (the number equals only about 1
per cent of the total number of births) and is more than offset by
incompleteness of registration, especially of miscarriages.
A difficulty in the use of rates of maternal mortality based upon
live births and stillbirths (including miscarriages) lies in the varia­
tions in definition of stillbirth in different countries and States.
The official definitions for purposes of registration differ principally
in the minimum period of gestation. Some definitions require all
stillbirths of more than four months’ gestation to be registered;
others require registration only of those of seven or more months’
gestation; others have intermediate periods; and still others have
alternative definitions in terms of length or weight of the fetus.
The definitions in use in the several States and in certain foreign
countries are given in Appendix C, page 114. A further difficulty lies
in the fact that in certain countries, notably England and Wales,
Scotland, Ireland, and certain States of Australia, the law does not
require the registration of stillbirths.1
In the United States figures for stillbirths for certain areas were
published by the Bureau of the Census for 1^18.2 Statistics of still­
births are available only for certain States and cities.
1Annuaire International de Statistique, Renseignements sur l’organisation actuelle de l’état civil dans
divers pays, p. 6- La Haye, 1921.
a The annual publication of statistics of stillbirths by the Bureau of the Census was commenced in 1922.


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D E F IN IT IO N A N D M E A S U R E M E N T OF P U E R P E R A L M O R T A L I T Y

5

The number of live births gives a fairly close approximation to
the number of confinements. Since the number of stillbirths is
equal to about 4 per cent of the number of live births and since the
number of confinements is .about 1 per cent less than the number of
births, the number of live births, provided birth registration is
complete, falls short of the number of confinements by about 3 per
Cent.3
The use of live births as a basis for calculating the maternal mor­
tality rate yields, therefore, approximately the same result as would
be secured by using the number of confinements. Since the number
of confinements is about 3 per cent larger than the number of live
births, the quotient obtained by using the live births only is about
1.03 times that obtained by using the number of confinements and
thus very slightly overstates the true risk of dying in childbirth.
On the other hand, when live births only are used, comparisons
between States and countries are not subject to errors arising from
differences in definition of stillbirth. (See p. 131.)
Because of the incomplete material relating to stillbirths in the
United States, in the present bulletin rates of maternal mortality are
calculated for the most part as deaths from puerperal causes per 1,000
live births. This rate gives the “ cost” in mothers’ lives of bringing
into the world 1,000 live-born babies.4
. 8 But in comparing maternal mortality in a group, such as the negro, having an exceptionally high still­
birth rate, with that in a group having an average rate, the use of the number of live births as an approxi­
mate equivalent of the number of confinements in the two groups results in a slight overstatement of the
maternal mortality rate of the former as compared with that of the latter.
4 Other methods of measuring maternal mortality—for example, deaths from puerperal causes per 100,000
population, deaths from puerperal causes per 100,000 female population, and deaths from puerperal causes
p.er 100,000 female population of child-bearing ages—are less valuable than rates based upon births, because
they are much less closely related to the risk of death from childbirth. In the present study such rates
are used only when the more accurate measures fcan not be applied, and in such cases the error involved
by the usé of the less satisfactory rates is discussed.


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DEATHS FROM PUERPERAL CAUSES IN THE UNITED STATES
E S T IM A T E D M A T E R N A L M O R T A L IT Y RATE

In 1921 the United States death-registration area included 82.2
per cent of the total population. The number of deaths in this area
classified as due to puerperal causes was 15,027.
Not all the States in the death-registration area have a sufficiently
complete birth registration for admission to the registration area for
births. In order to compare the deaths from puerperal causes with
births, therefore, the figures must be limited to the area in which
birth registration has been accepted by the Bureau of the Census as
at least 90 per cent complete. In 1921 this area included 65.3 per
cent of the total population; 11,688 puerperal deaths occurred, or
6.8 to every 1,000 live births.
•
From the figures of deaths in the death-registration area an esti­
mate may be made of the total number of deaths from puerperal
causes in the United States. Assuming that 15,027 is 82.2 per cent
of the total number of puerperal deaths, the total number is esti­
mated at 18,281. This procedure assumes that the death rate per
100.000 population outside the death-registration area is identical
with that within it, an assumption that is probably not exactly
correct. But since the error in this assumption affects only about
17.8 per cent of the total population, it can not affect materially the
figure for the total number of puerperal deaths. The States outside
the death-registration area of 1921 included a much larger proportion
of colored and a much smaller proportion of urban population than
those within it. As will be shown ldter, the maternal mortality rate
was higher for the colored than for the white population; therefore,
the assumption made for purposes of estimate tends to understate
the true death rate in those States not included in the area for which
death statistics are published. On the other hand, since the maternal
mortality rate was higher for urban than for rural districts, the
assumption that the death rate was the same outside as within the
area tends to overstate the true death rate for these States so far as
the fact that the excluded States had a smaller proportion of urban
population is concerned. These two tendencies thus partly offset
each other with the result that so far as they are concerned the esti­
mate may be regarded as fairly satisfactory.
An estimate of the rate of maternal mortality for the United States
as a whole may be made from the figure for the birth-registration
area. If it could be assumed that the birth rate outside the area
was equal to that within it and that the maternal mortality rate per
1.000 births outside was equal to that within the area, the average
rate for the United States would be identical (6.8 to every 1,000 five
births) with that found for the birth-registration area. But the
States outside the area included a much larger proportion of popula­
tion living in the Southern States where the birth rate is higher than
in the Northern States, and a much larger proportion of negro popula­
tion, for which the maternal mortality rate is high; the assumption
stated above is, therefore, not correct and tends to understate the
true rate. If it is assumed, however, that the birth rates and the
maternal mortality rates for white and colored separately are the
6

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DEATHS

PROM PU E RPE R A L CAUSES IN

U N IT E D

STATES

-

7

same outside as within the area, the average rate of maternal mor­
tality for the whole United States would be 7 to every 1,000 live
births.
M A R G IN OF ERROR

The errors in the assumptions upon which are based estimates of
the total number of puerperal deaths and of the maternal mortality
rate m the entire country are of secondary importance, though they
serve to call attention to the differences between the maternal
mortality rates for colored and for white and between those for
urban and for rural populations. Of more importance is the fact
that any such assumptions tend to exaggerate the errors in the basic
figures from which the estimates are made. For if the basic figures
are too high or too low any estimates made from them will be subject
to the same proportionate error. To arrive at any conclusion,
. therefore, as to the true number of puerperal deaths, the errors in the
basic figures must be considered.
Errórs hi maternal mortality rates may be due either to errors
with regard to the number of deaths from puerperal causes, or to
errors with regard to the number of confinements (births).
Registration and certification of deaths.

The number of deaths from puerperal causes as reported in the
death-registration area is subject to errors arising from three sources*
(1) Incomplete registration of deaths; (2) faulty certification of
causes of death; and (3) statistical errors. These sources of error
a£e bv no means of equal importance. Their importance varies in
the different States with the character of the registration law and its
enforcement; with the average training and ability of physicians; and
with the extent to which causes of death are certified by physicians
and the conscientiousness with which they make their certifications!
These sources of error tend to become less and less important as thè
machinery of death registration improves and as standards of medical
education are raised. As the returns become more nearly complete
and accurate, the classification becomes less and less subject to error.
Incomplete registration o f deaths.— The completeness of death
registration depends upon the character of the death registration law
its enforcement, the number and location of registration offices, the
proportion of the population living in cities, the familiarity of the
population with the requirements of the law, and the strength or
weakness of motives for evasion.
In view of the fact that the data are limited to the death-registration
area of the United States, in which the death registration laws and
their enforcement have passed the tests required for admission of
a State to the area,1 the number of deaths from puerperal causes
omitted through failure to register may be considered relatively
negligible. Death registration is comparatively easy to enforce
through the legal requirement that no body may be buried or removed
without a burial or removal permit, which may not be issued by the
local registrar until after a death certificate is on file. In cities and
well-populated areas, where burial in cemeteries is the rule, evasion
of the Taw is difficult. On the other hand, in sparsely settled rural
1 CeLtS ? ti pes ofllaws are not approved by the Bureau of the Census (for example, that providing but
one registrar for each county); for admission to the area death registration must be accepted by the Bureau
of the Census ¡«bein g at least 90 per cent complete on the basis of tests which are made when the State


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8

M ATERNAL

M O R T A L IT Y

areas where private burial is common, evasion of the law is easy.
In such areas, however, the only motive for failure to register is
unwillingness to take tlie trouble,2 and this motive is onset by feai4
of the penalties of the law. Where a population is familiar with the
requirements of the law and where registry offices are comparatively
easy of access this motive can play but a small part' In States, with
good registration laws and with populations familiar thropgh tjiG
experience of years with their requirements, especially in States with
a large proportion of the population living in places where the custom
of burial in cemeteries is observed and with registry offices convenient
of access to all, registration of deaths may be considered practically
complete. In this connection Table 1 shows for the several States
the date of first enactment of a compulsory registration law, the
proportion of population living in cities of over 10,000 populations
the number of registry offices, and the average area and the average
population served:
T able

State

California---------------Colorado___________
Connecticut..______
Delaware..................
District of Columbia.
Florida.— —— —
G eorg ia ................ .
Idaho______ :----------Illinois-------------------Indiana____________
Iow;a_____________
Kansas____________
Kentucky--------------Louisiana..----------L-.
Maine_____________
Maryland-------------Massachusetts--------Michigan..... .............
Minnesota_________
Mississippi................
M issouri..................
Montana...................
Nebraska--------------New Hampshire.......
New Jersey...............
New York.................
North Carolina------Ohio________ . . . . . . .
Oregon......................
Pennsylvania........ .
Rhode Island---- ----South Carolina.........
Tennessee--------U tah..'........ ............
Vermont---------------Virginia-----j----------Washington----------Wisconsin-...............
W yom ing................

1.— Death registration in the registration States
Year in Year in
Local registrars
which
first
State
com­
ad­
Average Average
pulsory was
area to
death tomitted
popula­
death- Number® each
regis­
tion to
regis­
(square
tration
each *
tration
miles)*
law was
area
passed®

1899
1903
1907
1877
- 1881
1881
1885
1851
1855
1875
1880
1842
1867
1872

1906
1906
1890
1890
1880
1919
1922
1922
1918
1900
1923
1914
1911
1918
1900
1906
1880
1900
1910

1891
1895
1905
1849
1848
1847
1879
1867
1903

1911
1910
1920
1890
1880
1890
1916
1909
1918

1850-2
1856
1881

1890
1916
1917
1910
1890
1913
1908
1908
1922

1877
1876
1848
1881

1856
1852
1889
1852
1907

IQOfi

350
152
197
30

444.7
682.0
24.5
65.5

9,791
6,182
7,008
7,433

565
1,092
101
1,417
541
812
1,027
1,286
685
522
431
355
1,722
2,664
1ST R
1,033
152
512
235
536
1,325
1,460
1,088
213
N. R.
39
450
974
N .R .
249
1,208
355
1,723
48

97.1
53.8
825.3
39.6
66.6
68.5
79.6
31.2
66.3
57.3
23.1
22.6
33.4
30.4

1,714
2,6524,276
4,577.
5,417
2.961
1,723
' 1,879
2,626
1,471
3,363
10,852
2,130
896

66.5
961.4
150.0
38.4
14.0
36.0
33.4
37.4
448.9

3,295
3,611
2,532
1,885
5,888
7,838
1,753
5,294
3,678

27.4
67.8
42.8

15,497
3.742
2,400

36.6
33.3
188.3
32:1
2,032.3

1,415
1,912
3,821
1,528
4,050

Urban
popula­
tion;
cities of
10,000
and
over,
per cent
of total:
1920d
57.1
38.6
: 74.9
49.4
100. 0
24.4
18.0
8.4
58.7
40.0
25.1
•23.6
; 17.9
27.6
28.0
56.2
81.6
. . 51. 6
34.6
> 7.6
39.8
•' -21.4
21.8
43.7
65.6
78.0
12.1
54.9
38.4
50.8
83.0
10.3
19.2
35.9
13.5
23-8
47:3
36.6
13.0

Urban '
popola- j
Won,
cities of
2,500
and
over,.
per cent
of total:
1920«

.

68.0
48.2
67.8
54.2
100.0
¡36.7
25; 1
27.6
67.9
60.6
36.4
' ' 34.9
26.2
34.9
i >39.0
60.0
94.8
61.1
44.1
13.4
46.6
31.3
31.3
63.1
‘ 78.4
82 7
19.2
S 63:8
49.9
64.3
97,5.
' 17.5
26.1
48,0
31.2
29.2
' * 55.2
47.3
29.5

« Data furnished by courtesy of vital-statistics division, U. S. Bureau of the^ Censps.
k Fourteenth Census of the United States, 1920, Vol. I, Population, Table 14, p. 26.
d M1
ortaUty>1Statistics,‘ l920, Table 1A, p. 74. U. S. Bureau of the Census.
2 Desire to avoid the consequences of criminal acts, as in criminal
failure to register such deaths, would affect deaths from violence, with which such deaths are classified, and
not deaths from puerperal causes.


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DEATHS

FROM

PUERPERAL

CAU SES IN

U N IT E D

STATES

9

Tf ^ U °i e i n iideath .r^ istration result in too favorable rates
If, then the death rate is so low that it is improbable it suggests
that death registration is imperfect. A study of the death ratfs in
the different cities and rural parts of counties in the death-registration
was less than 5, m 2 counties m Colorado with a largely Mexican
population and in 1 county in Utah not a single death was registered
n s
and11» rural parts of counties the rite was between® and 7 :
s
“l
'l1,1' t27 rUra! Parts of countles the rate was between 7 and
between1'«
and 9.
r S
& ,“ ?42
T f Poff 4?
counties
tbe * *nf tho
Detween 8 and
Without
a study
theofage
composition
TinPaJhid0n aiJd wi^ n taki^ af count of the size of the community
(m addition to which there is the danger of errors in estimates of
population) it is difficult to say that a low rate in a particular com­
munity indicates deficient registration, yet it should L remembered
that a crude death rate of 8 per 1,000 in an average ^ n u l a W
indicates roughly an average life span of about 65 years and that
1
f i e de ^ateJ meaiJ correspondingly longer expectation of life.3
No figure for the total number of omissions in the death-registran area is given because it is impossible to estimate it without
th a fd ^
di atu Fat •• In any Case the in clu sion can be draJ
imti Tdeatj \ reg f tratlon Is not complete but that a considerable
number of deaths are omitted.
^
,

a r f tLseeo r d ^ lt b /c /P0Se the
-hat have to be considered
X se
FvLni i l , 5
ym ° f cipidbeanng age due to a particular
cause. Jixcept m areas where no deaths are registered deaths from
t h o T irom
f r e mother
T w “ causes,
6 Pr0baK
Wy m° re
Ukdy
he negistoed
than fretnose
because
cases
of t0
childbirth
are more
Ph^sicians than cases of ordinary sickness.
Faulty certification o f causes.— Errors in the numbers of puerperal
deaths may be due to faulty certification of causes. Most laws require
f lw E ^ T 01*111 m attendance on the deceased to certify to the cause of
death. In case no physician was in attendance the cause is either
or stated PY a coroner or examiner, who is usually, if not
n a,ll cases, a physician, or by some other person. Obviously the
value of the certification depends upon the person making it- that is
whether he is qualified and in a position to know the facts and
whether he reports them faithfully
’ and
Statistics showing the proportions of puerperal deaths in 1920 that
g tatesCf tliied hy Physicians are given in Table 2 for eight selected
In these States the proportions were found to vary from 100 per
pflM v n ^ ebraSka t0 8 3 Cent for South M e lin a . Unfortu­
nately no figures are available'to show the proportion of deaths of

ages- that are certiied
to'arouse or strengthen the behe? thaïn otaf/the deaths a^ rem frw f t
W be S0 low as of itself
13 probably, and below 12 certainly, shifts the burden nf nrmf0^
^Py opmion a death rate below
doubting the accuracy of su chà rate, S s theoffiebd
th.at 1
i that one is justified in
it by showing that the age and sex composition nf the
-f°r 14 reblits the Presumption against
rate or. that all possible sources of e r r o f h a Æ ^
18 unusually favorable-to a low death
which are sparsely settled the lowest death rate
Tbu* ln tbe registration States
(counties) where the obstacles to c o m p l é t e r a i s ^
sparsely settted countries
o f vital Statistics in the United States1” m is-ie
mo%t s,enous-. Wiiicox, Walter F.: “ Progress
Institute, Belgium, 1924.
,
’ PP' 5
Paper read a* meeting of the International Statistical
. .‘ .Based upon a study of the transcripts of death certificates made for th<i Bureau of the Census


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M ATERNAL

10

M O R T A L IT Y

T able 2.— Proportion of deaths from puerperal causes certified by physicians in

certain States, in cities of 10,000 population and over and m rural areas, 1MU
Deaths from puerperal causes

Certified by physi­
cians

State and area
Total

Certified by other
persons or not
certified

Number Per cent Number Per cent

Pennsylvania 3.:_______ _______ _____ 1------------------

Rural areas------------------ ---------------------------------

T> ^ 1
South Carolina-.......... - ------ ------------------------------- Cities

California 10-------------------------------------------------- -

147

145

98.6

2

1.4

52
95

52
93

100.0
97.9

*2

2.1

1,615

1,491

92.3

124

7.7

944
671

837
654

88.7
97.5

< 107
17

11.3
2.5

844

823

97.5

21

2.5

486
358

466
357

95.9
99.7

<20
1

4.1
•3

220

220

100.0

69
6151

69
151

100.0
100.0

274

261

95.3

13

4.7

160
114

147
114

91.9
100.0

713

8.1

579

482

83.2

97

16.8

80
499

79
403

98.8
80.8

1
896

1.2
19.2

478

446

93.3

32

6.7

72
406

72
374

100.0
92.1

»32

7.9

514

480

93.4

34

6.6

' 333
181

307
173

92.2
95.6

<26
>18

7.8
4.4

i it should be remembered that the evidence is based not upon the death certificates t upon t
from them made for and filed with the Bureau of the Census. The instructions for copying the records
call for the name of the physician who signed the death certificate,
aIncludes 1 signed by a registered nurse and 1 unsigned.
3 Certificates for certain cities in Pennsylvania not available.
4 Signed, by coroner (not stated whether a physician).
s Mortality °Stat1stics?l920,agives 152 deaths from puerperal causes in Nebraska. (One certificate not
located.)
7 Includes 11 signed by coroners and 2 unsigned.
, . . .,
* Includes 1 signed by coroner, 1 unsigned, and 94 with the entry no physician. (
9Includes 1 signed by registrar, 2 unknown, and 29 with the entry no physician.
i° Exclusive of Riverside City.
ii Includes 7 signed by coroner and 1 unsigned.

Three types of faulty certification- affect the statistics of causes of
death published by the United States Bureau of the Census. In
some cases no cause is given, or the cause is stated in such vague
terms that it is meaningless and no additional information can be
obtained, and the deaths are classified as from “ ill-defined or un­
known” causes. In other cases the causes are certified m terms
which are not sufficiently full to insure their correct classification.
For example, a final symptom is certified instead of the true cause of
death, as when “ convulsions” is stated instead of puerperal albu­
minuria,” or an essential qualifying term is omitted as when the entry

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DEATHS

FROM

PUERPERAL

CAUSES IN

U N IT E D

STATES

U

is “ septicemia ” instead of “ puerperal septicemia.” A third group
that in practice is difficult to distinguish from the second comprises
cases where the certification is erroneous either through failure or
inability on the part of the attendant to diagnose correctly or through
unwillingness to certify to the true cause. So far as failure to diag­
nose correctly is concerned, however, if the fact of pregnancy or
childbirth as a complication in connection with the death is stated, the
application of the rules of statistical preference will usually secure a
correct5 result, and the medical attendant can hardly fail to be
aware of the puerperal condition in those cases in which it is a com­
plicating factor in the death. Unwillingness to state the true cause
may be due to a knowledge that the certificates become part of a
public record and may be evidence, therefore, for possible criticism
in cases of deaths from puerperal septicemia, which are frequently,
though not invariably, due to carelessness on the part of the medical
attendant. In such cases, however, if the death is registered as due
to a noninfectious instead of an infectious puerperal cause, the
erroneous return will not affect the total of deaths from puerperal
causes.
Estimates o f omissions due to faulty certification.— One method of
estimating the number of omissions is from the evidence furnished
in the statistics themselves. This evidence concerns the deaths from
ill-defined or unknown causes, the statistics of the system of querying
unsatisfactory returns, and the possible extent of transfers from puer­
peral to other important causes of death.
A small number of deaths of women of the childbearing ages are
classified as from ill-defined or unknown causes; these, if full infor­
mation were available, would be assigned to definite causes, and the
puerperal group would receive its share. In 1920 in the United States
death-registration States, deaths of women between 15 and 45 years
of age from ill-defined or unknown causes numbered 987. Unfortu­
nately, no specific evidence is available to indicate what proportion
of these were puerperal; on the conservative assumption that the
proportion was equal to the percentage that the known puerperal
formed of the total deaths from known causes, 120 would have been
added to the puerperal deaths in the registration States, an increase
equal to seven-tenths of 1 per cent of the puerperal deaths.
Special efforts are made by the Census Bureau to reduce to a
minimum the number*of faultily certified causes. These efforts
include the distribution of pamphlets to physicians explaining the
purposes of certification and giving cautions against the use of vague
and unsatisfactory terms;6 the education of local registrars to call
for more satisfactory and complete records;7 and the sending to the
physicians of letters of inquiry regarding the unsatisfactorily certified
causes of specific deaths.8 The effectiveness of these measures is
8Correct from the point of view of the statistical office.
* Mortality Statistics, 1912, p. 23. U. S. Bureau of the Census.
7Ibid., 1907, p. 80; ibid., 1914, p. 34.
‘ The report on Mortality Statistics for 1907 mentions (p. 76) that lists of cases of deaths from violence
were sent to State and city registrars with the request that additional information be secured if possible.
The report for 1911 gives (p. 37) the results of sending circular letters asking for more information in regard
to deaths certified as from meningitis, paralysis, convulsions, pneumonia, and peritonitis. Since 1914
this procedure has been made routine, and the list of causes queried has been extended from time to time.
In the report for 1917 mention is made of the fact that letters of inquiry were sent out from certain of the
State offices (1914, p. 35; 1917, p. 65), a practice, however, which many State offices ¿ready followed as a
matter of routine. See also Maternal Mortality from All Conditions Connected with Childbirth in the
United States and Certain Other Countries, by Grace L. Meigs, M . D , p. 39 (U. S. Children’s Bureau
Publication No. 19, Washington, 1917).

60564°—26----- 2

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12

M ATERNAL

M O R T A L IT Y

evidenced by a decrease in the proportion'of deaths in the registration
States from ill-defined and unknown causes from 3.8 per cent in
1900 to 0.2 per cent in the same States in 1920.9
The scope of the system of querying unsatisfactory causes of death
is indicated by the fact that 50,000 letters were sent out directly by
the Bureau of the Census to physicians in 1916, 43,876 in 1917, 42,549
in 1920, and 35,145 in 1921, concerning 5, 4.1, 3.7, and 3.4 per cent
of the deaths in those years, respectively.10 These figures do not
include the many letters sent out by special agents of the bureau
beginning in 1917, nor do they include the letters sent by State
registrars. The proportion of replies received in answer to the letters
sent by the Census Bureau and the changes resulting are shown in
Table 3. The list of causes queried, so far as those terms are con­
cerned under which deaths from puerperal causes might be returned,
include septicemia, convulsions, hemorrhage, peritonitis, Bright’s,
disease, nephritis, uremia, salpingitis, and related terms.
Table 4 shows the results of these letters of inquiry. In 1921 the
net additions to deaths from puerperal septicemia numbered 148 (2.4
per cent of the total), and the net additions to deaths from puerperal
albuminuria and convulsions numbered 160 (4 per cent). To the
extent to which these inquiries are successful in eliciting correct state­
ments of cause the. published figures of deaths from puerperal causes
are corrected by the additional information secured.
A considerable proportion of the letters are never answered. In
192Pno replies were received to 37.9 per cent of the inquiries. On the
assumption that if these had been answered they would have resulted
in the same proportion of additions to deaths from puerperal causes as
did result from those to which replies were received, 187 more would
have been added to the deaths from puerperal causes, representing
an increase of 1.2 per cent. This figure may be regarded as a mini­
mum number of additions, since even in cases in which replies were
received they may have failed to give the full information necessary
for correct classification.
T able 3.— Scope and effect of system of querying deaths certified in vague and

unsatisfactory terms; United States death-registration area, 1914 to 1921 °
Replies received
Year

1 92 1 .-..................................................

Total
deaths

898,059
909,155
1,001,921
1, 066,711
1,445,158
1,096,436
1,142,558
1,032,009

Number

Per cent
of total
deaths

7,527
19,092
37,802
b 32,702
16,393
«23,287
* 23,925
« 21,816

0.8
2.1
3.8
3.1
1.1
2.1
2.1
2.1

Changes made
Per cent Per cent
Number of replies of total
reoeived deaths
3,461
7,484
19,267
17,171
8,183
11,248
11,501
9,047

46.0
39.2.
51.0
52.5
. 49.9
48.3
48.1
41.5

0.4
.8
1.9
1. 6.
.6
1.0
1. 0
.9

• Mortality Statistics, 1914-1921. U. S. Bureau of the Census.
74.5 per cent of total queries.
«57.3 per cent of total queries.
d56.2 per cent of total queries.
•62.1 per cent of total queries.
•Compiled from Mortality Statistics, 1900, PP- 40-41, and ib id .,1920, pp. 308-478 The variations in
the proportion of deaths from ill-defined and unknown causes in the different States in 1921 is given in
General Table 4, p. 145.
w Mortality Statistics, 1917, p. ;65 ibid., 1921, p. 98.


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DEATHS

FROM

PUERPERAL

CAUSES IN

U N IT E D

STATES

13

T able 4.— Total deaths from puerperal causes and number and percentage added as

result of investigation; United States death-registration area, 1911—1921

Number Number
Total
puerperal of causes of replies
deaths
queried received

Year

Changes in classiflcation
Number

1911
1914.
1915
1916.
1917.
1918.
1919.
1920.
1921.

9,456
10,518
10,237
11,642
12,528
18,177
14,488
16,776
15,027

Puerperal septicemia
Year

4,376
4,664
4,214
4,786
5,211
5,250
4,950
5,800
6,057

‘8
464
484
66
182

m

126
133
148

0.2
1.4
2.0
1.4
3.5

0

2.6
2.3
2.4

0)
46.0
39.2
51.0
52.5
49.9
48.3
48.1
41.5

Cases added
Total

Number Per cent
2,094
2,617"
2,673
3,087
3,409
3,651
3,592
4,246
4,032

0)
3,461
7,484
19,267
17,171
8,183
11,248
11,501
9,047

All other

Cases added
Total

Number Per cent
1911...............................
1914________________
1915_____ _______
1916 ..................
1917..................
1918 _________ _____
1919________i ____
1920......... .........
1921................... .........

(»>
7,527
19,092
37,802
32,702
16,393
23,287
23,925
21,816

Puerperal albuminuria
and convulsions

Cases added
Total

0)
(‘)
W
p
43,876
0)
40,608
42,549
35,145

Percent

>12
424
<48
106
168

0)

133
146
160

0.6
.9
1.8
3.4
4.9

(')

3.7
3.4
4.0

Number Per cent
2,986
3,237
3,350
3,769
3,908
9,276
5,946
6,730
4,938

0)
(*)
ft
ft)
m
g
m
<»)

(0

(i)
m
g
28

(i)
(i)
(i)
P

0.7

! Figures not reported. For 1916 the number of causes queried was approximately 50,000.
‘ Out of 102 cases of "peritonitis” investigated.
* Out of 268 cases of convulsions investigated.
4 Number estimated.

The third source of evidence regarding possible omission of puer­
peral deaths is in the sex distribution of deaths from those causes to
which transfers might have been made. For example, if any con­
siderable number of deaths from puerperal causes were classified as.
due to nephritis, peritonitis, or Bright’s disease because they were
either incompletely or erroneously certified, their transfer would
result in an unusual preponderance of female deaths at the child­
bearing ages. By comparing, therefore, the death rates, or more
simply the number of deaths from these diseases of males and females
at. different ages it could easily be ascertained whether any consider­
able number of transfers could have occurred.11
In Table 5 the relative numbers of deaths of males and females
under 15, from 15 to 49, and 50 and over are compared for peritonitis,
acute nephritis, and Bright’s disease in the registration States in
1920. In each case a marked excess is found of female deaths dur­
ing the childbearing ages. At ages 15 to 49 the number of deaths from
peritonitis among females was over twice that among males, under 15 the
numbers were practically equal, and over 50 the male deaths were
in the majority. From nephritis the ratio of female to male deaths
at ages under 15 was 80, at ages 15 to 49 it was 106, and at ages 50
ii Supplement to the Seventy-Fifth Annual Report of the Registrar-General of England and Wales
Part UI, by T H. ° . Stevenson, p. im. Cd. 8002. Ehlers, Philipp: Die Sterblichkeit “ im Kindbett”
in Berlin und Preussen, 1877-1896, pp. 55-84. Stuttgart, 1900.


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14

M ATERNAL

M O R T A L IT Y

and over it was 80 to every 100 deaths of males in the corresponding
age groups. From Bright’s disease the ratio of female to male
deaths shifted from practical equality under 15 (99 female to 100
male) to a marked excess for females at ages 15 to 49 (113 female to
100 male) and back to a marked excess for males at ages 50 and
over (83 female to 100 male).
5 — Relative mortality of males and females from peritonitis, acute nephritis,
and Bright’s disease, by age groups; United States death-registration States,
1920 1

T able

Deaths from—
Bright’s disease

Acute nephritis

Peritonitis

Age

Males Females R atio2 Males Females Ratio2 Males Females R atio2
Total_____________

668

886

133

2,878

2,572

89

37,845

33,115

88

Under 15------------,---------$
15-49-.-.............................
50 and over..___________
Unknown................. ........

217
230
219
2

218
482
186

100
210
85

706
999
1,166
7

563
1,063
938
8.

80
106
80

513
5,730
31, 542
60

507
6,494
26,071
43

99
113
83

i Mortality Statistics, 1920, pp. 278-279. U. S. Bureau of the Census.
cluded in the registration States.)
* Females to 100 males. Not shown for unknown ages.

(The District of Columbia is in­

No such marked changes in the ratios of male to female deaths are
found, however, for appendicitis or typhoid fever, which are some­
times mentioned as terms under which puerperal septicemia is
concealed. The changes in the ratios of male and female deaths at
different ages from peritonitis, nephritis, and Bright’s disease suggest
that transfers are made from puerperal to other causes and that, as
a result, the recorded mortality from puerperal causes falls con­
siderably short of the true mortality.
.
:
Assuming that these changes in the relative ratios of male to fe­
male deaths at the childbearing ages are due to transfers of deaths
from other causes, the number of such transfers may be estimated
as follows: If the deaths from peritonitis of females between 15 and
50 years of age had actually been no more numerous than those of
males, 252 deaths attributed to that cause must have been due to
something else, many of them probably to puerperal causes. If the
ratio of 80 female to 100 male deaths from nephritis that prevailed
at ages over 50 and at ages under 15 is assumed to express the true
ratio for ages 15 to 49, the number of transfers, doubtless mainly of
puerperal Heaths, to this cause is found to have been 264, and if the
true ratio of female to male deaths from Bright’s disease at ages 15
to 49 is assumed to be 91 to. 100 (an average between the ratio of 99
to 100 at ages under 15 and that of 83 to 100 at ages over 50), the
excess of female deaths from this cause is estimated at 1,280. . From
all these estimates it appears that a total of 1,796 represents, on the
assumption stated, the deaths transferred to these three causes.
This figure is equal to 11 per cent of the deaths from puerperal
causes.
Though this method of approach suggests that transfers from
puerperal to other diseases may be frequent, the difficulty of proving

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DEATHS

FROM

PUERPERAL

C A U S E S IN

UNITED STATES

15

the validity of the assumption precludes an accurate estimate of
the understatement of puerperal deaths due to such transfers. On
the one hand, in the material relating to the three diseases already
discussed no distinction can be made between transfer of deaths
because of incorrect or faulty certification and an actual change in
the ratio of male and female deaths for the ages under consideration
as compared with other ages. Such an increase in the number of
female as compared with male deaths from peritonitis, for example,
might be due to or result from gynecological operations, and in the
case of nephritis or Bright’s disease might be due to a real change
in the incidence of mortality by sex; such changes are doubtless
connected directly or indirectly with sex differences if not specifi­
cally with the childbearing function. On the other hand, the cal­
culation leaves out of account those causes peculiar to the female
sex to which transfers from puerperal causes might have been made
but to which this method of estimate is inapplicable. For example,
deaths from puerperal causes may be incorrectly reported and
classified as due to “ salpingitis.” 12
Another method of testing the number of omissions of deaths
from puerperal causes is to check the deaths of women of the child­
bearing ages with birth certificates in order to discover not only
whether childbirth was a complication in the death but especially
whether in any considerable proportion of cases failure to mention
childbirth as a complication resulted in erroneous classification.
Such a check is of course dependent upon complete registration and
is inapplicable, furthermore, in those cases where death occurs during
pregnancy and without a miscarriage, a stillbirth, or a birth having
occurred. Such' a test was carried out in four States. All the
death certificates for women between 15 and 50 years of age 13 were
compared with the birth certificates; and if a birth had occurred to
the deceased within two months before her death that fact was noted
on the death certificate. All the cases in which this check resulted
in additional information, either by adding the fact of childbirth
as a complication in the death or by adding new evidence that
might affect the decision as to whether childbirth or another cause
should have been preferred, were submitted to the Bureau of the
Census for its rulings.14
In addition to this check by matching the death with birth cer­
tificates a second check was made in three States by matching State
death certificates with the Census Bureau transcripts and by veri­
fying, in doubtful cases, the classification of causes made for purposes
of tabulation with a second classification of the same causes or
combinations of causes.
The net result of these checks was to indicate that the number of
deaths classified as due to puerperal causes fell short of the true
number by about 12 per cent in Maryland and Wisconsin, 13 per
cent in Massachusetts, and 30 per cent in North Carolina.
" The total number of deaths in 1920 in the death-registration States from causes classified under the
rubric “ salpingitis and other diseases of the female genital organs” was 1,569.
n In North Carolina between 13 and 50 years of age.
14These rulings are necessarily based upon the information available; if additional data had been on
hand the final classification might have been different. Furthermore, if the physician in attendance
reports the death of a woman during pregnancy or shortly after childbirth and states explicitly that the
pregnancy or childbirth was not a cause of her death, his statement in most cases would be accepted. The
results of these tests, therefore, may slightly overstate the true number of puerperal deaths.


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16

M ATERNAL

M O R T A L IT Y

Reference should be made to the study of the accuracy of reporting
maternal deaths in Wisconsin in 1915 by Dr. Dorothy Reed Men­
denhall.15 Letters were sent to physicians reporting deaths m
which puerperal conditions were suspected to have been a factor,
and the health officers in the 20 largest cities in the State were
requested to check names of women between 15 and 50 years of age
who died in 1915 with certificates of births in 1915 to see if any of
these women had borne a child during the month before her death.
As a result of these means “ 38 cases of deaths among women in 1915.
accompanying the puerperal state, not appearing clearly as such on
the death certificate, ” were found. This figure is 11.9 per cent oi
the 318 deaths originally classified as from puerperal causes.
Statistical errors.—Under statistical errors may be included errors
of classification, transcribing, tabulation, and printing. Uniformity
of classification in accordance with the International List of Causes
of Death is secured by having all causes classified in a single office
(the U. S. Bureau of the Census) and by means of definite printed
rules.16 The correctness of-the final classification depends not only
upon the certification of cause in full and correct terms, a point
which has already been discussed, but also upon the accuracy of the
work of .classification in the statistical office. So far as the second
point is concerned it may be noted that the work is performed by
clerks who have had special training in classification of cause of
death, and the entire work of tabulation is conducted by an office
in which every effort is made to reduce statistical errors to a mini­
mum.
<
Registration of births.

- .

-

......

Since the calculation of puerperal mortality rates in terms of live
births is limited to the United States birth-registration area, in
which the registration of births must have been sufficiently complete
(90 per cent) to pass the tests of the Bureau of the Census for admis­
sion to the area, the error due to the omissions of births is presumably
less than 10 per cent.
i . .
The maternal mortality rate is overstated m the same degree that
the registered births fall short of the true numbers. To throw light
upon the completeness of birth registration, the laws in force in the
different States, the methods of enforcement, the familiarity of the
population with the law, and the motives for evasion must be briefly
considered. The duty of registration in most laws is placed, first,
upon the attendant at the birth, and, secondarily, if no attendant
was present, upon the father and mother of the child. Since there
is no easy method of control over birth registration as there is over
death registration, the completeness with which births are recorded
depends directly upon the cooperation of physicians and midwives
with the registrars and upon popular support of the law. Prosecu­
tion of physicians and other attendants who fail to register births is
an effective method of enforcement, especially if the cases are given
wide publicity. The issue of special certificates to parents showing
that the birth of their child has been registered is another method
that has been growing in favor in recent, years, since if the parents
• is Mendenhall, Dorothy Reed, M . D.: Prenatal and Natal Conditions in Wisconsin. Reprint from
Wisconsin Medical Journal, Vol. X V , No. 10 (March, 1917), PP-9-10.
t .
. , , .
i®Published in the Manual of the International List of Causes of Death and in the Manual of Joint
Causes of Death. See pp. 3,103-111.


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DEATHS

EROM

PUERPERAL

CAU SES IN

U N IT E D

STATES

17

are educated to demand these certificates, they quickly bring to the
attention of the registrars any cases of failure to register on the
Par^ oi i e attefidant. Practically the only motives for. evasion
ot the law requiring registration of birth are desire to shield the
mother of an illegitimate infant and unwillingness to take the trouble
to register. A device frequently used to lessen the unwillingness to
take the trouble is the payment of a small fee for the registration
v ^ ^ dence available to indicate the proportion of unregistered
births is rather incomplete. Tests of birth registration in 1916 were
made by the Bureau of the Census in the six New England States,
lu e preliminary results indicated that registration was less than 90
per cent complete in two of these States.17
These tests consisted of a comparison of deaths in 1916 of infants
under 1 year of age who had been born in the State during the same
year with the list of registered births, the percentage of cases for
which no birth certificate was found being used to indicate the pro­
portion of unregistered births. This percentage would probably
tend to overstate this proportion, since cases in which a death could
not be identified with a registered birth for any reason (such as
variations in spelling of the names, insufficient identification in the
birth certificate, removal from place to place in the State) would all
be counted as if the birth had not been registered. The Census
Bureau did not consider these tests final, but in the two States
having percentages of less than 90 other tests were made to deter­
mine whether or not the State should be dropped from the birthregistration area.
C0TF se of studies of infant mortality in selected cities the
Bnildren s Bureau tested the completeness of birth registration at
tbe time these studies were made. In Waterbury, Conn, for the
period June 1 , 1913, to M ay 31, 1914, the results of a house-to-house
canvass showed that at least 12.8 per cent of the live births had not
been registered.18 The greatest number of omissions were found
among certain foreign-born nationalities. In interpreting these
results for a single city it must be remembered, of course, that
they may not be typical of the State. Though official figures for
the birth-registration area were not regularly published until 1915
nevertheless Connecticut was included among the States in thé
provisional birth-registration area in 1910 19 and was one in which
a compulsory birth registration law had been in force for manv
years.
J
. ^ n°ther means of checking the completeness of birth registration
is by comparison with the census enumeration of the infant population. For example, the births registered in 1919 less the deaths
before December 31 of infants born m that year should equal, leaving
migration out of account, the infant population under 1 year of age
on January 1, 1920, the date to which the census referred. Such a
comparison encounters special difficulties not only in calculating
errors of omission and overstatements of age in the census returns but
certifl^te^^re^fonniflri^thp' J?r « ¿E l w Bureafu ° f the Census)
n *HnrcSr

a


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Percentages of births for which no birth

study in Waterbury, Conn., based on births in one year, by Estelle

M ATERNAL

18

M O R T A L IT Y

S ^ m e a n T o f Stimating the proportion of unregistered births in
% h ? r i u l t °onf comparing the numbers of
during 1919 with the estimated number of births is presented

S ft» * & £ * * !"
«

_

“^

«

'

3 ‘B = r -",S i “

g ; > = j : = sar

“

under

r a w 's s ia
w

m

s

i

” T h e^th n ate for the underenumeration of the ncgm mfant populati°o population under ^ S l 2 S « l p o p u l a t i o n
K f a r y f a n d (of the States having considerable negro P?P“ lat‘° “

s s i s a

“ ■ssESSsSiii"V4*

whSe infants ft seems probable that this figure
mAnt rather than an overstatement, from the fact that the cnecK oi

S Jiia
as that of the whites, though home out by the study of the birth
' . Basal upon *

»

■Rnrftan of ttlfi C6BSUS.


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for 0 « n M y cited to United S .a .« M e T .b l.s , 1890,1*1,1910, 19 0H M , P- 3*0

DEATHS

FROM

PUERPERAL CAUSES IN

U N IT E D

STATES

19

records in the District, is probably too favorable to the status of the
birth registration among the negroes in Maryland, judging from the
evidence for other States of the birth-registration area.
The estimate for omissions of “ other colored” is based upoij the
following considerations: The “ other colored” are principally
Japanese in California, Washington, and Oregon, and principally
Indian in other States. In California, upon the assumption that the
registration of “ other colored” is subject to the same error as that
estimated to characterize registration of white births, the estimated
infant population is calculated from this corrected figure for births
and the figure for deaths among the infants born prior to the date of
the census^ the comparison of the estimated with the enumerated
population indicates that the omissions equaled 39.8 per cent of the
enumerated population. Even if birth registration of the “ other
colored ” had been assumed perfect the omissions would have equaled
24.7 per cent; therefore, as a conservative compromise between these
two values, 30 per cent is assumed as the proportion of unregistered
births 24 for “ other colored.”
T

able

6 . — Estimated

deficiency in birth registration, by States; United States birthregistration area, 19191

State

Estimated Registered
births, 1919 births, 1919

Deficiency of regis­
tered births
Number Per cent

Birth-registration area___________
California______________________
C onnecticut.....___________
Indiana_____________________
Kansas______ ____________
Kentucky________________
Maine______________________
Maryland...................................
Massachusetts_____________ __
Michigan______________ _
Minnesota_______________
New Hampshire__________ ____ _
New York_______________ _
North Carolina_____________
Ohio_______________. . . .
Oregon............................................
Pennsylvania________ _________
South Carolina_____________ __
Utah.........................................
Vermont________________ _
Virginia_______________________
Washington_______________ _
Wisconsin..............................................
District of Colum bia.._______ ________

1,491,199

1,373,438

4 119,078

62,687
34,984
63,900
41,547
67,292
17,058
35,710
87.338
89,845
56,135
9,237
225,469
85,310
129,660
15,518
228,988
55,306
13,864
7,604
66,356
28.338
61,180
7,873

56,528
33,912
59,286

6,159

8.7

Esti­
mated
per cent
of births
omitted*
Oku

-

¿174
15*496
87,709
83,910
51,942
8,778
226,108
73,854
207,685

*371
6.6
459
* 639

21,303

10.3

*307

*3.8

7,032
60,785
25,112
8’ 180

9.3

11.4

1 For method of computation see pp. 18-19.
* Calculated by dividing deficiency by the registered births.
* Calculated by dividing deficiency by the estimated births.
* Excludes States showing an excess of registered births.
1 Excess of registered births.

The result of this calculation gives 8.7 per cent as the proportion
that the omitted births bore to the registered births in 1919. This
proportion, on the assumptions stated in describing the method of
estimate, varied from zero for Massachusetts, New York, and the
District of Columbia to 23.9 per cent for South Carolina.
N ° esthete of the omissions from the census enumeration of “ other colored” was made for the United
States Abridged Life Tables,


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20

M ATERNAL

M O R T A L IT Y

As to whether this estimate gives too favorable of-' too unfavorable
a picture of birth registration the following points may he noted,: In
New York evidence from State tests indicates that births are more
completely registered in cities than in rural districts.' It seems prob­
able, therefore, that the number of registered births in New York
State falls somewhat short of the true number of births and that the
factor lor correction of the enumerated infant population calculated
on the assumption that birth registration was complete is too small
rather than too large. The test made in the District pf 'Columpia
showed that 4.5 per cent of the births were actually unregistered,
although in the estimate registration in the District was considered
complete. Furthermore, the assumption that registration of negro
births in Maryland was 95 per cent complete (that is, equal to tho
percentage calculated for white births) is probably too favorable.
There is no reason to suppose that census enumeration in New
York and Massachusetts, Maryland and California was worse than
average or tliat the selection of these States as a basis for catcnl^tiiig
a “ factor of correction w ou ld have tended to inflate the estimate
of unregistered births. It seems probable, therefore, ^hat the esti­
mate tends to err, if it errs at all, on the side of being too favorable
to birth registration. Nevertheless, it should be borne in mind that
these figures are merely estimates and subject to a very consider­
able margin of error.25
Net error of the maternal mortality rate.

The survey of the omissions from the deaths from puerperal
causes has led to the conclusion that probably the deaths fell, short
of the true number by as much as 12 per cent; a survey of the amissions from th.6 registered live hirths n&s led to the conclusion thut
these births fell short of the true number by 8.7 per cent, and there­
fore fell short of the number of confinements by about 12 per cent.
(See p. 5.) Because of the omission of not far from equal propor­
tions from both numerator and denominator of the fraction which
gives the maternal mortality rate, the conclusion is perhaps justified
that the maternal mortality rate for the birth-registration area as u
whole as calculated by dividing the number of registered deaths
classified as puerperal by the registered live births is probably not
far from correct.
m
;v
. .
„ '.
Since in the different States the proportion of omissions of births
probably varies much more than does the proportion of omissions of
puerperal deaths, the rates calculated upon registered births do not
give exactly comparable figures of maternal mortality. Table 7,
which is based upon the assumptions that in each State, the propor­
tion of puerperal deaths omitted is 12 per ce n t25 and that the pro­
portion of live births omitted is correctly given by the percentages
in Table 6, shows mortality rates in the several States after correc­
tion for variations in accuracy of the basic data.
2» Additional evidence was obtained by correspondence with the State ¿registrars
statistics, extracts from which are given in Appendix B. The estimates of completeness of registration m^de hy the
State registrars, which were based in part upon tests such as that of checking infant deaths with births,
were somewhat higher than the percentages given in the table, but most of
subseauent to 1919; in one or two cases practically perfect registration was claimed. Nevertheless, m spite
of the divergences from estimates made by the State officials, the method described in the text has been
presented, sfnee it affords a method of estimate upon a uniform basis applicable to all the States m the.ai ea.
m For exceptions see General Table 11, footnote 2, p. 155.


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DEATHS

FROM

PUERPERAL

CAUSES IN

U N IT E D

STATES

21

T a b l e ? 7 .^Maternal mortality rates adjusted for estimated omissions of births and

puer-peral deaths compared with unadjusted figures; United States birth-registration
States, 1919 1
Maternal
mortality rates
State 1

Maternal
mortality rates
State

Un­
adjusted

Ad­
justed

Birth-régistratioñ area..

1 7.4

7.7

California....... ........ ll________
C o n n ë C t ie u t ÍÍ1í i.LL ___. . .
Indiana______ _____ ...____
K ansas.L-----.-L'.LL-'---'..L.
Kentucky..............................
Maine______________ ______
Maryland................ ................
Massachusetts................... ......
Michigan...................... .........
Minnesota....______fn tri/t 1
New Hampshire.__ ________ _

8.0
6.2
8.4
8.2
6.3
8.6
8.4
7.1
7.7
6.7
8.0

8.1
6.7
8.7
8.1
6.1
8.7
8.9
8.0
8.1
7.0
8.4

Un­
adjusted
New Y o rk .......... ..........

1 For estimated births and estimated puerperal deaths, see General Table 11, p. 155.


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6.2

Ad­
justed
7.0

74
10 1
112
84
80
¿_2
8. fi
4. 8
8.5

9.5

PATHOLOGICAL CAUSES OF PUERPERAL MORTALITY

The pathological causes of puerperal deaths are classified in the
International List of Causes of Death under eight groups. These
are: (1) Accidents of pregnancy, a group which includes, for example,
abortion (if not criminal) or miscarriage, tubal or ectopic pregnancy,
and persistent vomiting of pregnancy; (2) puerperal hemorrhage,
including placenta praevia and premature separation of placenta,
(3) other accidents of labor, including, for example, difficult labor,
faulty presentation, Cesarean section; ( 4 ) puerperal septicemia;
(5) puerperal phlegmasia alba dolens, embolus, sudden death, (6)
puerperal albuminuria and convulsions; (7) deaths following child­
birth not otherwise defined, including those from puerperal insanity;
and (8) puerperal diseases of the breast.1
P R IM A R Y CAUSES

Puerperal septicemia was the most important single cause, and
contributed two-fifths of the total deaths Tor causes connected with
pregnancy or childbirth, according to the figures for the death-regis­
tration area in 1921. (Table 8.) In interpreting this proportion
the difficulty of obtaining a full statement of the deaths from puer­
peral septicemia must be borne in mind; on the other hand, special
efforts are made in querying unsatisfactory statements of causes to
obtain the true numbers. If two or more puerperal causes are
stated on the death certificate, puerperal septicemia is preferred to
any other. Among other causes “ puerperal albuminuria and con­
vulsions” was most important, contributing over one-fourth of
these deaths. “ Accidents of pregnancy,” “ puerperal hemorrhage,
and “ other accidents of labor,” each contributed not far from onetenth of the total “ maternal deaths.”
T a b l e 8 .— Causes

of puerperal deaths; Vnited States death-registration area, 1921 a
Deaths from puer­
peral causes
Cause of death

Other ^ccidoiits of labor
Other surgical operations and instrumental delivery--------------------------------------Others under this t it le - - - - - - - - - - - - » - - - - - - - - - - - ““““
Puerperal albuminuria and convulsions------................................................................
Following childbirth (not otheiwise defined) - - - - - - - - - - - - - - - - - - - Puerperal diseases of the breast----------------— ------------------------ • Mortality Statistics, 1921, p. 5. U. S. Bureau of the Census.
* Less than one-tenth of 1 per cent.
i. p 0r details of the titles-induded in each group see Appendix A, p. 103.

22

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Per cent
Number distribu­
tion
15,027

100.0

1,258

8.4

505
465
288

3.4
3.1
1.9

1,533
1,507

10.2
10.0

247
170
1,090

1.6
1.1
7.3

6,057
4,032
550
85

40.3
26.8
3.7

5

«

.6

P A T H O L O G IC A L C A U S E S

OF P U E R P E R A L

23

M O R T A L IT Y

In general the classification into “ puerperal septicemia” and
“ other puerperal causes” permits ready discussion of two broad
groups and will be followed throughout the report, especially in
those sections where comparisons are made between the rates in
different countries.
C O N TR IB U TO R Y CAUSES

Statistics showing the contributory causes of puerperal deaths in
the death-registration area are available only for 1917. In Table 9
figures are given showing the deaths classified as due to causes con­
nected with childbirth in which some other cause was also a contribut­
ing factor. These deaths constituted nearly one-fifth (18.7 per cent)
of all those grouped as puerperal. Pneumonia and heart affections
were complications in nearly one-fourth of all cases reported with
contributory causes. Table 9 shows also that besides these nonpuerperal complications, other puerperal causes than those to which
the deaths were attributed were contributory to the deaths in an
even larger proportion of cases (20.8 per cent). Of these causes
“ accidents of pregnancy” were most important, contributing to
one-seventh of all puerperal deaths. Puerperal septicemia was not
classified as a contributory cause in a single case, a result due, of
course, to the fact that it was given preference whenever it appeared
in combination simply with another puerperal cause.
T able 9.— Contributory causes of puerperal deaths; United States death-registration

,

area, 1917 1

Deaths from
puerperal
causes, 1917

Deaths from
puerperal
causes, 1917

Contributory cause of death

Total puerperal deaths.

Num­
ber

Per
cent
distri­
bution

12,528

100.0

With contributory causes, ex­
clusive of contributory puer­
peral causes__________________
Influenza__________________
Anemia, chlorosis__________
Cerebral hemorrhage____ ___
Acute endocarditis.................
Organic diseases, heart______
Broncho pneumonia________
Pneumonia (total)__________
Lobar pneumonia.______
Pneumonia (undefined)..
Pulmonary congestion............
Appendicitis...........................
Intestinal obstruction_______
Bright’s disease.1____ ______
Salpingitis and other diseases
of the female genital organs.
All other___________________

Contributory caùse of death
Num­
ber

With contributory puerperal
causes..______ ______________

18.7
44
98
57
149
362
83
509
320
189

.4
.8
.5

1.2

2.9
.7
4.1

2.6

47
65
44

1.5
.9
.4
.5
.4

122
651

5.2

112

L0

i Compiled from Mortality Statistics, 1918, pp. 50-91.
* Less than one-tenth of 1 per cent.


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Accidents of pregnancy_____
Puerperal hemorrhage....... .
Other accidents of labor____
Puerperal septicemia..............
Puerperal albuminuria and
convulsions___ __________
Puerperal phlegmasia alba
dolens, embolus, sudden
death.............. ...... ..............
Following childbirth (not
otherwise defined)_______ _
Puerperal diseases of the
breast___________________

Per
cent
distri­
bution

2,600

20.8

1,796
253

14.3

2.0
1.6

171
167

1.3
.1

«

FACTORS IN PUERPERAL MORTALITY

The risk of death from the spécifio cause's discussed in the pre­
ceding section may vary, of course, with other circumstances, such
as the state of pregnancy, whether it resulted in a premature or still
birth or in a live birth at term, whether the pregnancy and delivery
were normal or attended with complications, whether any opera­
tion was performed in connection with delivery, the time that has
elapsed since the birth, whether a single infant or twins or triplets
were born, the age of the mother, the order of birth, and other fadiors.’
The evidence as to the influence of these factors over puerperal
mortality is considered in this section.
In addition to the variations in mortality. due to différences in:
risk here discussed, other variations are due undoubtedly to differ­
ences in the amount and quality of medical and nursing services
availed of by the mother.1 That these differences exist,is easy to
prove, though to bring statistical evidence of their exact influence
over puerperal mortality or morbidity is rendered difficult by the
tendency of mothers who experience ill health during pregnancy or
who know they are threatened with complications to sèCure the best
services available. In case of complications expert medical assist­
ance is obviously the only means, of lessening the risk of death. For
example, the discovery that aseptic metnbds are necessary to pre­
vent puerperal septicemia makes it clear that only the practice of
asepsis by the medical attendant or by the midwife will greatly
reduce the mortality rate from this disease. Striking evidence of the
effect of increases in medical skill and knowledge of how best to
meet various pathological conditions is given later in the report
(see pp. 64-73) in considering evidence for the preventability of ma­
ternal mortality.
Though certain groups, such as the various nationality and race
groups, differ in their rates of puerperal mortality, the evidence is
not sufficient to prove whether these variations are due to differ­
ences in risk or to differences in medical and nursing services. Such
variations may be influenced or caused by differences in the mothers’
ages or in the order of birth or in the prevalence of conditions favor­
able or unfavorable to a low puerperal mortality. Differences
between urban and rural rates in particular are doubtless to be
explained in large part in terms of other factors than differences in
the true risk of mortality of the rural and urban populations. These
questions will be discussed in more detail in the sections dealing
with these factors.
STA G E OF P R E G N A N C Y OR P E R IO D OF G E STA TIO N

Only meager data are available to show changes in the risk of
death as pregnancy advances, but some light can be thrown upon
this question by a study of the several causes of death.
1 See discussion by Dr. William Travis Howard, jr., “ The real risk—rate of deaths to mothers from
causes connected with childbirth,” in American Journal of Hygiene, vol. 1, pp. 217-220 (March, 1921).

24


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FACTORS IN

25

P U E R P E R A L M O R T A L IT Y

To the early months of pregnancy must be assigned deaths result­
ing from tubal pregnancy or ectopic gestation, those due to uncon­
trollable vomiting, and those due to the consequences of abortions
and miscarriages. In the statistics these causes are not so classified
that they can lie added. For example, deaths resulting from puer­
peral septicemia following abortion are classified as due to septicemia;
deaths following self-induced abortions, the increased mortality
attending which should not be considered part of the “ risk of death^
to which expectant mothers are exposed, are included with those
following abortions due to natural causes.2 Deaths from puerperal
albuminuria and convulsions and from certain other causes occur
in the great majority of cases during the later months of pregnancv
before confinement.
J
Deaths resulting from difficulty of labor due to contracted pelvis
or following Cesarean section occur only when pregnancy has ad­
vanced to or nearly to full term. Deaths from puerperal septicemia
from puerperal hemorrhage, from puerperal phlegmasia alba dolens’
or embolus, from puerperal mania, and from puerperal diseases of
the breast, all follow the termination of pregnancy, but the statistics
do not indicate whether they resulted from abortion or miscarriage
premature birth, or birth at term, and, therefore, do not show at
what stage of pregnancy they occurred. If data were, available an
analysis could be made to show whether the risk of death from puer­
peral sepsis, for example, varies with the period at which the preg­
nancy is terminated.3
^ &
. Data relating to deaths of mothers within three months after
child birth obtained in connection with a study of infant mortality
m Baltimore permit a classification showing the variation in the risk
of death m three periods of pregnancy. According to Table 10, the
mortality rate of mothers in cases of confinements which resulted in
miscarriages before the end of the seventh month was 26.8 per 1 000
as compared with 23.5 in cases of confinements which resulted in
premature stillbirths of at least seven months’ gestation or in pre11m‘i l l l «•T®
and with 3.9 in cases of confinements at term.
In interpreting these figures it should be mentioned that since the
basis oi the study in Baltimore was births, deaths of mothers in the
early months of pregnancy and in cases in which no births were
registered were probably omitted; on the other hand, it is probable
that many other pregnancies which terminated in these early months
were omitted.
'
*he ¡ W # St^tes certification of causes of death is not, in the opinion of the C e n s u s
t0 °ompile separately deaths from puerperal septicemia

distth^^hed°fr^eJis^of|death fro^M se^es^ame^b^regnScy^woSd^^necessary^^be^W e to
a ^ e ^ o v ^ e ^ V(SiwSel^ to meM^e^l^rSk^^Ieath1iifchUdhirth0astlu^^efined^ ^ 8^08 *

rtc


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l

n0t«

26

M ATERNAL

M O R T A L IT Y

T able 10. -Rates of maternal mortality, by result of confinement and term; Balti­

more births in 1915

Deaths of mothers
within 3 months
after confinement
Result of confinement, and term

1

Confinements

Rate per
Number 1,000 con­
finements

410
722

11
17

26.8
23.6

160
562

4
13

25.0

10,331

40

3.0

228
10,103

14
26

61.4
2.6

----------

i Dead births of less than 7 months' gestation.

STILLBIRTH S

In connection with the risk associated with premature births as
compared with that associated with full-term births, the differences
in risk associated with whether the infant was born alive or dead
should be considered. Table 10 gives also the rates of maternal
deaths in Baltimore for live births and stillbirths. In confinements
which resulted in premature stillbirths the death rate o f mothers was
25 as compared with a rate of 23.1 in confinements which resulted
in premature births of living infants. But m confinements which
resulted in stillbirths at term the death rate of mothers was 61.4,
as compared with only 2.6 in those which resulted m births at term
of living infants. In interpreting these results it should be remem­
bered that the same condition might have been responsible both for
the death of the mother and for the premature birth or stillbirth.
The confinements which resulted in stillbirths at term probably
include many in which some obstruction to labor, such as contracted
pelvis, necessitated operative interference, a group of ca se in which
the risk both to the infant and to the mother is relatively high.
C O M P LIC A T IO N S OF PR E G N AN C Y OR C O N F IN E M E N T

The frequency with which certain conditions that may gravely
affect the chances of life of the mother are found to occur is of great
importance in a consideration of the factors affecting maternal mortalitv- In this section the available statistical data with regard to
the frequency of occurrence of four of the most important of these
conditions— contracted pelvis, abnormal presentation, placenta
praevia, and eclampsia—will be considered.4
Contracted pelvis.

.

.

. .

.

Contracted pelvis, the most frequent cause of which is rickets m
infancy but which may be due to other bone diseases, developmental
causes, or certain other causes (including perhaps heredity), is a
complication of pregnancy that requires skilled obstetrical service if
the pest possible results are to be obtained. Depending on the
4 For other aspects of the subject and for a discussion of other
the reader is referred to medical treatises on obstetrics and to special articles and reports.


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discuss®d hera

F A C T O R S IN ' P U E R P E R A L

M O R T A L IT Y

27

te * contraction different procedures are recommended: in all
cases,therefore, it is essential that the presence, and if present the
degree of contraction be determined by careful pelvic measurements
m lX “adopted.
“ ***
5 » best Sethod
m The proportion of confinements found by different series of measura4
a f^ r
Taried from about
measurementsni i R 7 ? 1
Wdll?.ms gives figures based upon
measurements of 3,837 consecutive patients who were delivered in
the lying-,n department of Johns Hopkins Hospital, which show thit
8.5 per cent of the white and 32.6 per cent of the n^gro patients had
contracted pelves.* He also cites the statistics of Flint, who in 1897
observed 8.46 per cent of contracted pelves in 1 0 233 patient!
delivered by the Society of the New York Lying-in Hospital ; Accord
mg to Doctor Williams, statistics for Germanf based upon data from
™ r!en \ t o T ie
#8*8?
pePr centi to 24^
from 3 8 t o ^ n a ®
‘ y f e i m. Austria the available figures vary
to 10'-4 pwr cent’ indicating a rather lesser frequency than
n Germany; m France "th e yeafly reports from Pinard’s eliSc
indicate a frequency of about 5 per cent, while Budin and Tarniei
giye an incidence of 8 and 16 per cent, respectively” ’
p
of S S S r l fre9™“ cy »{ contracted pelvis depends hpon the frequency
of occurrence of its causes, variations in the prevalence of these causey
especially rickets, may result in differences m the prevalence of pefvft
contraction as a complication of pregnancy.
^
Abnormal presentations.

eoTU^ml1 Presentations ar6 found to occur in between 3 and 4 per
cent and transverse presentations in slightly less than 1 per c e r / o l
all cases that come to or nearly to full term. FiguresPfor j i n s
n
Hospital based upon 7,500 cases show 94.6 per cent of cases
f normal or vertex presentation, compared with 0 .3 per cent of face
3.9 per cent of breeA, and 0.96 per Cent of transversPe preTentation?«
Placenta praevia.

U
fePioj7 motner
S X ? r ^and
d ah
h n T is
diti0ni,V
? icl; graVely
aiieots the chances
of
ue
child,
a relatively
rare complicationit omira
l Cmit4o f8everthi o n n T * 68 ?f
to inly about
eveiw fn n n T 7 1>9°0 eases in private practice and in about 4 out of
every 1,000 cases in hospital practice.9 It is verv rarelv found in W
Qf lts occurrence increases with the number
or previous oirtbs
In cases of placenta praevia abnormal presen t«
tarns are ^ u su a lly frequent, X c c o r d h /t o sta tist^ d f s f f c a s S
given by Midler, 9 per cent were breech and 24 per cent transverse

aj

•dopted throughout the world."

gsn

Williams, J. Whitrldge,

largertioporHons w e ^ o b ta ln S fto U -p e r ^ n tr flth e ^ w fite ^ d ^ ^ ™ ,* 0
contraction involving the inlet and in « § percent of
7 Ibid., p. mvolving the outletwaa
8Ibid., p. 225.
8Ibid., p. 884.
0bw Placenta Praevta-”

60564°— 26—

3


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« i s 1??
"funnel” telvis,
V.™0*** pelvic
deliveries.

^

Chrobak's Berichte aus der 2ten geb.;gyn. Klinik

M ATERNAL

28

M O R T A L IT Y

presentations, as compared with 4 per cent and 1 per cent respectively
for normal cases.11
Eclampsia.

,

Eclampsia, according to Dr. Whitridge Williams, occurs about
twice in every 1,000 labors. In hospital practice it appears about 0
times in every 1,000 cases, its greater relative frequency being due to
the tendency of patients who have had one attack of convulsions to
seek hospital care.12 It is relatively much more frequent among
primiparae than among multiparae, and in cases of twms or triplets
than in cases of single birth.
OBSTETRICAL O PER AT IO N S

In a small proportion of cases operative interference is necessary
to save the lives of mother and child, and in other cases operative
interference greatly improves the chances of life and health. I he op­
erative procedures most frequently resorted to are instrumental
delivery version, and extraction; of the operations proper, Cesarean
section is the most frequent. Operations or operative procedures are
resorted to most often on account of obstruction to labor due to dis­
proportion between size of head of the infant and birth canal,, to
malformation of mother or child, or to tumor; malposition of the
infant and placenta praevia are also important causes of operative
interference with normal labor.
Frequency.

.

,

".

,

, *. •

*

Statistics showing the frequency of the most important obstetrical
operations and operative procedures are not available for the United
States; in some instances figures have been compiled for certain
hospitals or have been gathered in special studies in particular areas.
The frequency with which Cesarean section is performed in Massachu­
setts is indicated by figures for the year 1922, which show that 1,161
Cesarean sections were performed for 90,904 births (including still­
births) or 13 to every 1,000.13 In 100 cases which terminated
fatally’ the primary indications upon which this operation was per­
formed were in 37 per cent of the cases obstruction due to malforma­
tion of mother or child, to disproportion between size of head and
birth canal, or to tumor; in 25 per cent of the fatal cases the operation
was resorted to because of toxemia.14
.
.
Figures showing the frequency of all kinds of obstetrical operations
performed by physicians in Norway in 1917-18 are given in Table 11.
Such operations were performed in 4 per cent of all deliveries; in­
strumental delivery was by far the most frequent, being performed in
three-fourths of the cases. Besides these operations performed by
physicians a considerable number— 1,764, equal to 1.4 per cent ol
all confinements— were reported by midwives.15
n Williams, J. Whitridge: Obstetrics, p. 887.
U This figuremay be too low since “ replies were not received from a few of the ^nailer hospitals and it is
probable that the total number of Cesarean sections
Angelina W
*
statistical study of 100 Cesarean sections.” The Commonhealth [Boston], vol. 10 (1923), p. ill.
n The soon» does not indicate the number of operations in the cases reported by midwives, if any, other
rhaninsfmmentaldelivOTy! version, extraction, and afterbirth operations;, it does not indicate whether
these operations were performed by the midwife in attendance or by a physician who was
R
B
S
S
f i
The numbers of extraction and “ afterbirth’ ’ operations reported by .midwives exceed the numbers reported as Performed by physicians S u ^ h e t s t d s ta n d e n ^ M ^ in ^ o r holdene, 1917 and 1918, Norges Offisielle Statistikk VII. 3, p. 57*-60*, VU. 58, pp. ¿7 -4U . njisiiama,
1921 and 1922.


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F A C T O R S -IN P U E R P E R A L M O R T A L I T Y

T a b l e 11.

29

Frequency of obstetrical operations performed by physicians: Norway,
1917-181
y,
Obstetrical operations

Num­
ber

Per
cent
distri­
bution

. Per
1,000
con­
fine­
ments 1

T o ta l..____ _____

3 5,234

100.0

40.45

Instrumental delivery...
Version______ _________
E x traction..;.._______
Induced premature deliv
ery.......... ................ .

4,044
454
245

77.3
8. 7
4.7

31.26
3.51
1.89.

68

1.3

.53

Kind of operation

Obstetrical operations
Kind of operation
Num­
ber

Per
cent
distri­
bution

20
44
15
39
304

0.4
.8
.3
.7
5.8

Cesarean section_______
Craniotomy__________
Embryotomy..................
Induced abortion.. .
Afterbirth operation4___

Per
1,000
con­
fine­
ments'
0
.34
. 12
30
2.35

V I L ^ ^ M ^ a M ^ f L ^ S ^ p 8^ 1*1611 og' MedisinaliorhoIdene- 1917 and 1918, Norges Offisielle Statistikk
fProportiod based on 129,369 confinements in 1917-18.
* Total includes 1 case of pubiotoiny.
4Efterbyrds operation.

j TheJ TeW}ency of obstetrical operations and operative procedures
depends primarily, of course, upon the prevalence of the specific
conditions which call for operative interference and would be expected
ho change with any change in the prevalence of these conditions.
This frequency depends also upon changes in the judgment of physi­
cians and obstetricians as to whether an operation is advisable. With
the advance of obstetrical knowledge on the one hand and with the
decreased risk which operative interference now involves as compared
with that prevailing a few decades ago (see Table 49, p. 72) on the
other, the frequency with which operations are performed has prob­
ably increased. Figures for Norway for the period from 1900 to
1917, which are given in Table 12, show a marked increase in the
frequency of operations performed by physicians. In spite of the
increase in frequency of operative interference in Germany, according
to Doctor Weinberg, the mortality following operations has decreased;
in other words, the decrease in case mortality has more than offset
the increase in the proportion of operations.16
T a b l e 12.- -Frequency of obstetrical operations performed by physicians: Norway

1900-1917 «

■

Confinements—
Year
Total

1900.......................
1901......................
1902________
1903....... ..............
1904....................
1905._________
1906.......................
1907.......................
1908.......................

67,070
66,994
65,974
65,917
64,671
63,277
61,877
61,270
61,454

Confinements—

Requiring oper­
ative interference

Year
Total

Number

Per 1,000

1,724
1,825
2,156
1,790
1,990
2,049
2,015
2,105
2,467

25.7
27.2
32.7
27.2
30.8
32.4
32.6
34.4
40.1

Requiring oper­
ative interference
Number Per 1,000.

1909
1910
1911
1912.
1913
1914
1915
1916.
1917.

61,962
62,050
61,989
60,249
61,485
62,423
59,268
66,458
65,182

2,497
2,372
2,414
2,746
2,855
2,899
2,764
2,601
2,602

40.3
38.2
38.9
45.6
46.4
46.4
46.6
39.1
39.9

° Compiled from Sundhetstilstanden og Medisinalforholdene, 1900-1917; Norges Offisielle Statistikk.
i# Weinberg, W .: “ Kindbettfieber imd Kindbettsterblichkeit.” Handwörterbuch der Sozialen Hygiene
(A. Grotjahn and J. Kaup), p. 589.. Leipzig, 1912.
^


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30

M ATERNAL

M O R T A L IT Y

Kecently there has been a marked reaction, at least in this country,
against the tendency to resort to the use of instruments in normal cases
merely to hasten delivery, since experience has shown that any
operative interference is likely to increase the risk to both mother
and child. Perhaps the decrease in the frequency of operations n
1916 and 1917 in Norway was due to a similar reaction against un­
necessary operative interference.
Case mortality.

_

Comprehensive statistics showing the case mortality following the'
various obstetrical operations are difficult to obtain. Estimates
based upon cases reported in medical literature are frequently quoted;
they give undoubtedly a somewhat favorable picture, since, on the
one hand, such results are usually presented by specialists who have
a high degree of training and experience and, on the other, cases with
favorable outcome are perhaps more likely to be deemed worthy of
notice in the medical journals than cases with unfavorable outcome.
Case-mortality figures based upon continuous series of unselected
cases are not subject to such criticisms, though even such figures are
likely to he from the practice of specialists in the types of obstetrical
operations upon which they report. Statistics are available for hut'
few entire States or countries.
, •
.
"
The mortality in cases of Cesarean sections performed m Massa­
chusetts during 1922 was 88 per l,000.n Of the 100 deaths in
such cases that formed the subject of a special study 30 per cent were
caused by septicemia.1819
\ . %
The mortality following or attending upon cases of obstetrical
operations performed bv physicians in Norway is shown in Table 13
for the period 1910-1918. The death rate in cases m which oper­
ative interference of any kind was resorted to was 12.9 as compared
with an average mortality from puerperal causes of only 2.9 per 1,000
live births during this period. The mortality following instrumental
delivery was low compared with that following other operative
procedures.
...
,
. ,
'-1
-d j
The case mortality following obstetrical operations m Baden
during the period 1900-1909 and in Bavaria during the period
1901-1906 is shown in Table 14.
1? Hamblen, Angelina D., “ A statistical study of 100 Cesarean sections. ”

The Commonhealth [Boston],

V0118 I b i d e m l i in Massachusetts in 1921, according to the report of the committee of the Massachusetts
Medical 'Society on maternal and infant welfare, “ one-sixth of all puerperal deaths were associated with
C^arean section,°onedialf of which were due to sepsis. ” Report of committee, Appendix 3 to. Proceedings
of the Council of the Massachusetts Medical Society, Feh. 7,1923. Boston Medical and Surgical Journal,
s e^fmated^hat toe mortality from Cesarean section if the operation is performed before labor has
begun is about one-half of 1 per cent, if performed after labor has begun is 5 per cent, and if performed after
labor has lasted for a considerable time rises as high as 10 per cent.

V0» I U


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FACTORS IN

T a b l e 13.

P U E R P E R A L M O R T A L IT Y

31

Mortality of mothers following obstetrical operations performed by
physicians; Norway, 1910-1918 1

Operation

Total___________
Instrumental delivery...
Version.. . . .
. . . . . ___
Extraction. . . . . . .......... .
Induced premature deliv­
ery..___ i . . . _________

Deaths of
Con­
mothers
fine­
ments
with
out­
come Num­
Per
re­
ber
1,000
ported*
23,729

305

12.9

18,265
1,923
1,128

122
86
11

6.7
44.7
9.8

285

10

35.1

Operation

Deaths of
mothers

Confinements
with

come Numreber
ported *
Cesarean section__
Craniotomv
Embryotomy___
Induced abortion
Afterbirth operation..
Other operations 3__

110
317
60
145
1,485
11

21
24
9
2
19
1

Per
1,000

190.9
75.7
150.0
13.8
iâ.8
«
;

^
ug ivieuismanornoiaene, jyoo-1918, Norges Omsielle Statistiklr.
In cases m which different operations were performed upon each twin, or two or more triplets the con*
finement is classified according to the operation performed upon the last twin or triplet
P
, rupiotonjy 3, laparotomy 2, supra-vaginal amputation 3, accouchement forcé 3
*Not shown because base is less than 50.

T a b l e 14.

Case mortality following specified operations in Baden, 1900-1909
and in Bavaria, 1901-1906 1
Deaths per 1,000
cases

- Operation

. Baden

Bavaria

Deaths per 1,000
cases
Operation

1900-1909 1901-1906
Placenta praevia.^:..
Instrumental d e liv e ry .....
Vëfsion..____
Extraction....___
Cràniotòmy.. . . .

{

85 j
6
20
4 }
58

147
13
21
72 ‘

Baden

Bavaria

1900-1909 1901-1906
Induced premature birth; ___
Cesarean section
Premature separation of pla­
centa___________

20.
200‘

18
177

13

34

(A*.l^rotjalin’and'J'' K a u p ) f p ^ ^ Kindbettsterblichkeit.” Handwörterbuch, der Sozialen Hygiene

T IM E F R O M C H ILD B IR TH T O D E A T H OF M O T H E R

Z No comprehensive data are available for the United States, show­
ing-the .-distribution of maternal deaths following childbirth according
to the time interval between the birth and the mother’s death. Such
figures for Saxony in 1901-1904 are shown in Table 15. Over onefourth of the deaths occurred during the first day and approximately
one-half ^within ^the first week. In case of deaths from puerperal
septicemia the interval was slightly longer than in case of deaths
from other consequences of childbirth; frq>m puerperal septicemia
over one-third occurred after the end of the second week, and from
other consequences of childbirth, three-fourths occuried within one
week after confinement.


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32

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T a b l e 15.— Time interval from childbirth to death of mothers who died front causes

connected with childbirth; Saxony, 1901—1904 1
Deaths from puerperal causes

Time from childbirth to death of mother

Total

Deaths
from nonpuerperal
causes
Other which
oc­
conse­
cur fol­
Puerperal quences
fever * of child­ lowing
confine­
birth
ment

Per cent distribution
1.8
27.5
33.6
14.0
8.1
1.5
2.8
2.5
8.1

27.2
50.6
21.8
8.8
5.5
2.5
1.8
1.5
7.4

9.5
33.9
. 20.6
13.3
13.0
9.3
5.7
.4
3.6

54.4
75.8
9.4
3.3
2.7
1.4
.6
.1
6.7

i Weinberg, W.: “ Kindbettfieber and Kindbettsterblichkeit.” Handwörterbuch der Sozialen Hygiene,
(A. Grbtjahn and J. Kaup), p. 585.
, „
\ ' „ , ....
j For puerperal fever, the sum of the percentages exclusive of the first line “ first day (which is included
in the term “ first week” ) does not equal 100 per cent. Presumably the figures 27.5 for “ first week”
should read 29.3. The error appears in the source quoted. •

SIN G LE OR PLURAL BIR TH

With reference to the maternal mortality rate in cases of plural
and single births data are available for Norway which suggest that
the mortality is higher in case of plural than in case of single births.
According to figures given in Table 16, operative interference was
nearly twice as frequent in plural as in single births, and according
to Table 17 the mortality following obstetrical operations in cases of
plural births was over twice as high as that in cases of single births.
T a b l e 16 — Frequency of obstetrical operations performed by physicians in single

and plural births; Norway, 1910-1917 1
Confinements, 1910-1917—
With recourse tò op­
erative interference

Single or plural birth
Total

Number Per 1,000
499,104

21,264

492,102
7,002

20,687
a577

!

42.6
42.0
82.4

1 Compiled from Sundhetstilstanden og Medisinalforholdene, 1910-4917, Norges Offisielle Statistikk, and.
from Norges Statistisk Arbok.
•' . ,
’
.
.
. .. , ’ . "
1 Confinements with recourse to operative interference in case of either 1 twin or triplet or botn twins,
2 triplets, or all 3 triplets.


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T a b l e 17 .— Case mortality following obstetrical operations performed by physicians;

Norway, 1900-1917 1
Opera­ Deaths of mothers
tions with
outcome
reported Number Per 1,000

Single or plural birth

Total....................... ...... __ _
S ingle________
Plural______________
Twin births............ ........
Operation for both twins. . .......
Operation for one only .
Triplet births_________

41,742

691

16.6

40,581
1,161

651
40

16.0
34.5

1,141
649
492
20

39
26
13
1

34.2
40.1
26.4
(*)

l Compiled from Sundhetstilstanden og Medisinalforholdene, 1900-1917, Norges Offisielle Statistikk
1Not shown because base is less than 50.

A G E OF M O T H E R

Figures showing the correlation between the mother’s age and the
maternal mortality rate are available for the United States birthregistration area and are shown in Table 18 for the year 1921. The
mortality was lowest for the age group 20 to 24 and highest for the
group under 15 years. For the oldest mothers— those 45 years of age
and over— the rate was practically as high as for those under 15 years.
This characteristic variation of maternal mortality with age is quite
similar to the variations with age of mother of infant mortality from
all causes and from causes peculiar to early infancy.20 With regard to
both puerperal and infant mortality the most favorable age period
was found between 20 and 30 years. This variation undoubtedly
reflects the mother’s condition of health; the high mortality in the
earliest age period is due perhaps to the physical immaturity of the
mother, and the increasing mortality in the later periods is doubtless
to be ascribed to the same lessening physical vitality which appears
in the general tendency for morbidity and mortality rates to increase
with age.
T a b l e 18.— Maternal mortality rates, by age of mother; United States birth-

registration area, 1921 °
Deaths per 1,000 live births
from—
Age of mother
All pu­
erperal
causes

Puerper­ All other
al septi­ puerperal
cemia
causes

Deaths per 1,000 live births
from—
Age of mother

•
Total_______

6.8

2.7

4.1

Under 15..........
15-19........................
20-24.......................

20.0
6.8
5.0

5.4
2.7
2.2

14.6
4.0
2.8

25-29.....................
30-34............. ......
3 5 -3 9 ..................
40-44................
45 and over_____

All pu­
erperal
causes
5.6
7.4
10.3'
13.1
19.2

Puerper­ All other
al septi­ puerperal
cemia
causes
2.4
2.9
3.6
4.3
6.5

3.2
4.5
6.7
8.8
12.8

• Mortality Statistics, 1921, p. 80.
catio^N o1142Ct°rS iQ InfaDt Mortality’ by Robert M . Woodbury, p. 40.


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34

M ATERNAL

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The variation in the mortality from puerperal septicemia follows
the same general trend as that from all causes but is slightly less
marked. With regard to this cause particularly the question might
be raised whether the variation is due in part to differences in the
average quality of care received by the youngest or the oldest moth­
ers, as both groups had a somewhat larger proportion of foreignborn and colored mothers than the intermediate groups. On the
other hand, this variation may be due in large part to differences in
case mortality. Unfortunately no statistics are available to shpw
variations in case mortality by age of mother.
The mortality from puerperal causes other than septicemia was
highest for the youngest mothers— those under 15 years of age. This
is due in part to the fact that a large proportion of these mothers are
primiparae, among whom, as will be, shown in the next section, the
mortality is especially high, and in part to the greater frequency of
complications in confinement of mothers under 15 years of age.
The high mortality from the causes other than septicemia among
mothers over 40 years of age is due likewise in large part to the greater
frequency of complications.,
; .U
. „.,
; i^
iftavdiun
To throw light upon the influence that the disproportionate number
of primiparae among the younger mothers has upon their mortality
rate, figures are shown in Table 19 based upon births in New South
Wales during the period 1893-1898. Although the average mortality
rate for mothers between 15 and 20 years of age was 1.6 times that
for mothers between 20 and 25, when the rates for these groups are
compared first for primiparae and then for multiparae it appears that
the mortality in the age group 15 to 19 was only 1.2 times and 1.1
times, respectively, that in the age group 20 to 24. In other words
a considerable part but not all of the greater mortality found for the
youngest mothers finds its explanation in the disproportionate num­
ber of primiparae. Except for the age group 15 to 19 the Mortality
rate increased markedly with the age of the mother among both the
primiparae and the multiparae.
T able

19.— Maternal mortality rates, by age of mother and order of birth? New
South Wales, 1893-1898 1
Deaths from puerperal causes
per 1,000 live births

Deaths from puerperal causes
per 1,000 live births
Age of mother

Age of mother
Total

30-34...................

' 7.74
4.79
5.29
7.41

Multi­
parae

Primi­
parae
8.19
7.09
9.31
15.2?

3.34
3.04
4.41
6.80

Total

35-39..— — ______
40-44...........•-...........
45 and over ......... .

8.99
11.56
12.54

Primi­
parae
13.02
20.41

Multi;
parae
8.85
11.40
12.66

1 Compiled from Childbirth in New South Wales; a study in statistics, by T. A. Coghlan, pp. 48-50,,53
(Sydney, 1900).

ORDER OF BIRTH

Data showing the relative maternal mortality rates by order of
birth are available for Baltimore, where infant mortality was-studied
by the Children’s Bureau. Though these figures, as has been sug­
gested, probably do not include all cases of deaths of mothers during
the early months of pregnancy for which no births were recorded
and though they do include all deaths whether from puerperal or from

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other causes if they occurred within three months after confinement,
yet they doubtless indicate the trend of the rates by order of birth.
According to Table 20 the mortality was found to be higher for
first births than for second, third, or fourth births; for third births it
was lowest of all, and it gradually increased from the third until it
reached a maximum with orders “ eighth and later.” This trend of
maternal mortality, like that shown in considering the age of the
mother, is similar to that of infant mortality.
T a b l e 20. — Maternal mortality rates, by order of birth; Baltimore, 1915
Deaths of mothers
within three months
after confinement
. Order of birth

Confinements

Deaths of mothers
within three months
after confinement
Confinements

Order of birth
Number

Per 1,000
confine­
ments

Number

Total.............

11,463

62

5.4

Third____________

First
Second ..... .............

8,050
2,532

19
11

6.2
4.3

Fifth to seventh__
Eighth and later...

1,580
1,197
2,002
1,102

3
15
9

Per 1,000
confine­
ments
1.9
4.2
7.5
8.2

The most comprehensive study of the influence of order of birth
upon thé maternal mortality rate is that made by T. A. Coghlan of
data for New South Wales.21 He shows that for married mothers
the “ risk attending the first birth is greater than at any subsequent
one up to but not including the ninth.” The smallest risk was found
in the second confinement, though that in the third was not much
greater. After the third confinement the risk increased rapidly.23
The rates of mortality are shown in Table 21.
T a b l e 21. — Maternal mortality rates, by order of birth; births to married women,

New South Wales, 1893-1898 °
Maternal mortality
rate
Order of birth

First....;..!________
Second, j . itSy____—
Third.___ ................ .
F o u r t h ....'......!...
F ifth .....
....... i
Sixth______ ___ ___
Seventh.. . . . . . . . . . .
Eighth-,— _______
N in th ..!.__ . . . . . . . .
Tenth.___________ _
Eleventh.......... .
Twelfth!. J.L'.U.__ _
Thirteenth;-. . _____
Fourteenth and over

Births

Deaths
in child;
birth

41,385
34,089
29,334
24,675
20,621
16,788
13,479
10,328
7,510
5,213
3,420
1,983
1,071
1,039

365
150
150
130
136
104
99:
90
79
47
31
. 28
15
'8

Actual
experi­ Adjusted
figures
ence
.i 4*:

’

8.82
8.80
4.40
4.70
: 5.11
5.09
5.27
5:54
6.60
6.10
6.19
6.82
7.34
7.54
8.71
8.72
10.52
9.92
9.02
. 10.40
9.06
11.0Ô
14.12
12.46
14.01
. 14.50
7.70 f « ;

“ Coghlan, T. A.: Childbirth in New South Waies,pp. 47-48, 65. The original probabilities are multiplied by 1,000 for this presentation. Total number of qases, 21Q.935 births and 1,432 deaths of mothers.
1 Figures not computed in original, since they are based upon relatively feW cases. n Coghlan, T. A.: Childbirth in New South Wales; a study in statistics.
u Ibid., p. 48.


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Sydney, 1900.

36

M ATERNAL

M O R T A L IT Y

EARNINGS OF FATHER

* The figures in Tablé 22 show for three broad groups classified by
father’s earnings the maternal death rates in seven cities in which
special studies of infant mortality were made by the Children’s
Bureau. These figures suggest that the rate varies inversely with
the amount of father’s earnings; it was only 3.3 (per 1,000 confine­
ments) in families in which the fathers earned $850 or over, compared
with 5.3 in families in which the fathers earned less than $850.
This relationship is doubtless to be explained by differences in the
quality of care available to the mothers m the various income groups.
An analysis of the amount and type of prenatal and confinement
care available to mothers in Baltimore showed clearly that the lowincome classes were materially handicapped in the matter of medical
prenatal care, nursing services, duration of hospital care after con­
finement, and in other ways,23 though because of the free clinic ser­
vice that is unusually plentiful in that .city they were not so much
handicapped as would otherwise have been the case.
T able 22 .— Death rates of mothers dying within three months after confinement, by
earnings of father; confinements in seven cities 1

Earnings of father

Deaths of mothers
w ith in th re e
months after con­
Confine­
finement.
ments
Number Per 1,000
'22,435
.14,810
7,233.
392

4.9

lit
78
24
9

5.3
3.3
0)

1In which infant-mortality studies were made by the Children’ s Bureau,
aNot shown or not reported because not significant.
color

An d n a t i o n a l i t y o f m o t h e r

Color and race.

The death rate from all puerperal causes is higher for the negro
than for the white race. In the birth-registration area in 1921 the
maternal mortality rate per 1,000 live births was 67 per cent greater
for the colored than for the white mothers. A relatively greater
mortality among the colored was found both in the cities and in the
rural districts; but since a larger proportion of the colored than of
the white lived in rural areas, in which the average rate of mortality
was lower than in the cities, the mortality among the colored appears
even greater relatively to that among the white when the urban and
rural districts are considered separately. In the cities the- colored
rate (13.1) was 77 per cent greater than the white (7.4); and m the
rural districts the colored rate (9.7) was 80 per cent greater than the
white (5.4).
The analysis by cause of death in Table 23 shows that the rates
for thè colored were higher not only from puerperal septicemia but
33 See Infant Mortality: Results of a field study in Baltimore, M d., based on births in one year, Appendix
V I (U. S. Children’s Bureau Publication No. 119, Washington, 1923).


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M O R T A L IT Y

also from the group of all other puerperal causes. The excess
mortality from puerperal septicemia among the colored was most
marked in the cities, where the rate was three-fourths higher than
that for the white (5.7 as compared with 3.2); in the rural areas
the rate for the colored was one-half higher than that for the white’
(3.1 as compared with 2). In both urban and rural districts the
mortality from “ other puerperal” causes among the colored was
approximately one and four-fifths times that prevailing among the
white.
T a b l e 23.— Maternal mortality rates, by cause of death and by color, in urban and

rural districts; United States birth-registration area, 19211
Deaths from puerperal causes
per 1,000 live births
Urban or rural districts, and color
All
causes

White....................... ........................ ...... ........................
Urban.......... ......................... ............................ ................
Rural...................................... __....... ......................
Colored________________ _____ ___________ ____ ________ _______ _
Urban............... . ......... ......... ..................__________________ _
Rural................. ........... ........................... ..........................

.

Puerperal
septicemia

Other
puerperal
causes

6.44

2.59

3.85

7.40
5.42

3.16
1.99

4.25
3.43

10.77

3.89

6.88

13.10
9.74

5.66
3.11

7.44
6.63

1 Compiled from Mortality Statistics, 1921, pp. 312-317, and Birth Statistics, 1921, p. 43 (U. S. Bureau
of the Census).

The rates for white and colored are shown separately in Table 24
for each State in the birth-registration area in which at least two
in every hundred of the population were colored. In all but two
States, California and Washington, the rate for the colored was
higher than that for the white; in these two States the colored were
largely Japanese. It is noteworthy that the excess mortality among
negroes appeared both in States with large proportions and in those
with small proportions of negroes in the population. From puerperal
septicemia the rate for colored in many of the Northern and Western
States was even higher in relation to that for whites than in the
Southern States. Thus, in New Jersey the colored rate from puer­
peral septicemia was over three times and in New York nearly three
times the white rate.
The high mortality among negro mothers was found in spite of
an unusually favorable age composition. In 1921, of the negro
births, 72 per cent, compared with only 64.2 per cent of the white
births, were to mothers between 15 and 30 years of age, the age
groups for which the maternal mortality rate was below average.24
24 Compiled from Birth Statistics, 1921, p. 179. Percentages based upon cases for which age of mother
was reported.


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24.— Mortality rates from puerperal septicemia and from all puerperal
causes, by color, in States in the birth-registration, area with at least 2 per cent
of the population colored, 1921 1

T able

State

Death rates per
1,000 live births—
all puerperal causes

White
7.1
6.1
9.9
6.6
6.4
5.7
6.0
7.1
5.6
6.1
6.1
7.1
6.7
7.8
5.7
7.9

Colored
4.5
7.7
10.8
15.9
7.6
14.8
9.6
12.0
12.5
13.9
10.2
11.6
9.8
11.8
9.9
5.6

Death rates per
1,000 live births—
puerperal septi­
cemia
White
3.1
2.9
3.1
■3.3
2.8
2.6
2.0
2.2
2.2
2.4
1.4
3.3
2.9
1.7
1.8
3.6

Colored
2.0
3.1
3.8
6.5
4.7
7.0
3.7
4.0
7.0
6.8
3.0
5.4
4.0
3.4
3.5
3.1

1 Compiled from Mortality Statistics, 1921, pp. 312-341

An important cause of the heavier puerperal mortality among the
colored25 is probably the poorer medical and midwifery service which
they receive. Their excessive death rate from puerperal septicemia
was undoubtedly due to poor quality of confinement care, and a con­
siderable part of their high mortality from other diseases connected
with pregnancy and confinement was probably due to lack of skilled
attention during pregnancy as well as at confinement. Among the
conditions which cause high mortality among the colored from “ other
puerperal” causes must be mentioned the relative prevalence of
venereal disease, as indicated, for example, by studies made by Dr.
Whitridge Williams.26 Conclusive evidence is not available as to
whether the negro race is less resistant than the white to puerperal
septicemia or more Subject to “ contracted pelvis” (see p. 27) or diffi­
cult labor— causes which are likely to lead to increased puerperal
mortality.27
Nationality.

Marked differences were found in the maternal mortality rates
for the several nationality groups within the birth-registration area.
Table 25 shows that in 1921 the mortality was slightly lower among
foreign-born white mothers than among native white mothers. Among
' the nationalities included in the foreign-born white group it was
lowest (5) for mothers born in Russia, who were doubtless largely of
Russian-Jewish nationality, and next to lowest (5.1) for mothers
born in Italy. At the other extreme were the rates for mothers born
» Variation in the completeness of birth registration among white and colored groups may account for a
small part of the difference in the rates; thé colored rate is probably overstated relatively to the white
because of less complete registration of births. See Birth Statistics, 1921, pp. 11-13.
'
» Williams, J. Whitridge: “ The limitations and possibilities of prenatal care.” Transactions of Fifth
Annual Meeting of the American Association for Study and Prevention of Infant Mortality, Boston,
Mass., No. 12-14,1914, pp. 32-48. Baltimore, 1915.
.
» “ Evidence for Baltimore indicates that contracted pelvis (following rickets in infancy) is much more
common among negroes than among whites. Evidence indicates that in the cities rickets is especially
common among negroes, and among negroes in the country districts rickets is infrequent. It is difficult,
therefore, to draw any conclusion as to whether throughout the United States contracted pelvis is more or
is less prevalent among the negroes than among the whites.” Williams, J. Whitridge: Obstetrics, p. 769.


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in Ireland (9.1), Great Britain (8.1), Canada (7.9), Hungary (7.4),
and Germany (7. t ) . The racial stocks represented in the nationalities
of the foreign-born groups for which the rate was highest are those
which principally compose the native white population; it is note­
worthy, however, that the puerperal death rate for the native white
population was considerably below the rates for any of these foreignborn groups. The mortality in the .Scandinavian group was prac­
tically the same as that in the native white population. Mothers
born in Austria and Poland had rates considerably below that for
the native white population, though not quite so favorable as those
for mothers born in either Italy or Russia.
Similar variations were found in the mortality rates from puerperal
septicemia and from “ other puerperal causes.” The lowest rates
from puerperal septicemia were those for mothers born in, Italy,
Russia, and the Scandinavian countries; the highest, for mothers
born in Hungary, Great Britain, Ireland, and Germany. The lowest
rates from “ other puerperal causes” were found for mothers born in
Poland, Russia, Italy, and Austria; the highest, for mothers born in
Ireland, Canada, Great Britain, and the Scandinavian countries.
T able 25.— Maternal mortality rates, by cause of death and nationality of mother;

United States birth-registration area, 1921 1
Deaths from puerperal causes
per 1,000 live births
Country of birth, and race
AH puer­
peral
causes

Puer­
peral
septi­
cemia

Other
puer­
peral
causes

Birth-registration area___________

6.8

2.7

4.1

White_______________________ ____ ___

6.4

2.6

3.8

United States.....................................
Foreign............... J.............................
Austria 2_________________ . . . . .
Hungary_____________ ______ _
Canada_______ _______ ________
Denmark, Norway, and Sweden.
England, Scotland, and Wales..
Ire la n d .....__________________
Germany 3________ *___________
Italy. ________________________
Poland (n. o. s.)_______________
Russia4______________________
Other..._______________________

6.6
6.0
5.9
7.4
7.9
6.4
8.1
9.1
7.1
5.1
5.7
5.0
5.6

2.6
2.5
2.7
3.8
2.7
2.3
3.5
3.3
2.9
2.0
2.7
2.0
2.7

3.9
3.5
3.3
3.6
5.2
* 4. 2
4.6
5.8
4.2
3.1
3.0
3.0
2.9

10.8

3.9

6.9

Colored_____ _______________ _______ _

1 Mortality Statistics, 1921, pp. 80-81. All these rates are subject to a slight error, as a small number of
deaths for which country of birth and births for which country of birth of mother were not reported could
not be classified according to country of birth.
2Includes Austrian Poland.
3Includes German Poland.
4Includes Russian Poland.

Différences in death certification and in registration of births, in
prenatal and confinement care, and in health conditions or physical
vigor peculiar to the nationality may be considered as causes of these
variations.
Since the maternal mortality rate is higher for births to older than
for those to younger mothere, except for the relatively small group
under 15 years of age, variations in the average age of mothers in the

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nationality groups would alone cause differences in the rates for these
nationalities. When the varying ages of the mothers are taken into
account, as in Table 26, the mortality among foreign-born mothers
appears relatively more favorable than that among native white
mothers. The mortality among mothers born in Great Britain
and Canada was found to be only slightly above, that among
mothers born in Hungary identical with, and that among mothers
born in Germany slightly lower than, that among mothers bom in the
United States. Furthermore, the allQwance for differences in age of
mother tends to make the rates for mothers bom in Italy, Russia,
Poland, and the Scandinavian countries even more favorable,, as
compared with that for native white mothers, than appeared from the
crude figures.28
26.— Maternal mortality rates, by country of birth and race, adjusted to
eliminate influence of differences in age composition; United States birth-regis­
tration area, 1921 1 -

T able

Deaths from puerperal causes
pèr 1,000 live births
Country of birth, and race

England, Scotland, and Wales-------------------------------------------------

All puer­
peral
causes

Puer­
peral
septi­
cemia

Other
puer­
peral
causes

6.8

2.7

4.1

6.4

2.6

3.8

6.7
5.5
5.4
6.7
7.5
5.6
6.9
8.8
5.7
4.7
5.1
4.8
5.4

2.6
2.4
2.5
3.4
2.8
.2.1
3.2
3.5
2.3
1.9
2.4
2.0
2.6

4.0
3.1
2.8
3.3
4.8
3.5
3.7
5.3
3.5
2.8
,2.7
2.8
2.8

10.8

3.9

6.9

; i,Mortality Statistics, 1921, pp. 80-81.
* Includes Austrian Poland.
* Includes German Poland.
* Includes Russian Poland.

Little evidence is available regarding the extent of prenatal care
or the quality of confinement care received by mothers of the various
nationality groups.29
;
Iri a study of prenatal care in the city of Baltimore m 1915 it
was found that the mothers of the Jewish race had consulted a physi28 Mortality Statistics, 1921, pp. 80-81.
^
,
.
, v,
29 No separate discussion is given of attendant at birth as a. factor m maternal mortality for the reason
that statistical comparisons of rates among births attended by physicians compared with those among
births attended by midwives are complicated by (1) a selection of risks fav ia b le to the
favorable to the physician; (2) difficulties in assignment of cases attended by both physicians and midwives; and (3) the influence of nationality customs and preferences upon the choice of
factors are impossible to separate satisfactorily in existing statistical material, and witoout their seps^at on
no final conclusion can be drawn from the statistics rnone regarding the relative m ort^ ty m the tw
groups. For an interesting study of this problem see ‘ MAtamd .mortality m tte ffist month (rf Mfe m
relation to attendant at birth,” by Julius Levy, M. D., in American Journal of Public Health, Vol. X III
(February, 1923), pp. 88-95. See also “ The relation of the midwife tp obstetric mortality, vuth especial
reference to New Jersey,” by M . Pierce Rucker, M . D., in American Journal of Public Health. Vol.
XIII^ (October, 1923), pp. 816-821, and Doctor Levy’s discussion, pp. 821-822.


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FACTORS IN

PUERPERAL

41

M O R T A L IT Y

cian at least once during pregnancy in nearly as large a proportion
of cases as those of the native white or of colored groups. Very
few Polish mothers, on the other hand, saw a physician during
pregnancy. The extent of prenatal care is shown in Table 27.
These figures may depend to a considerable extent upon the special
facilities for prenatal care given by the clinics of Baltimore and there­
fore may not be typical of other cities.
T able 27.-—Extent of prenatal care among mothers, by source of care and by color

and nationality of mother; Baltimore, 1915
Per cent having prenatal care—
Per cent
having
Total
Color and nationality of mother
pre­
mothers1 no
natal
care

T otal..... .............. .

.

Native white_______
Jewish....... ..............
Polish_________
Italian___________________
Other foreign-born w h it e .......
Colored_________ ____

Per
cent
From
not
re­
private
The
Other
physi­ ported
three clinics
cian only
clinics8

From clinic phjrsician 2
Total
Total

11,463

47.5

52.4

12.6

7.8

4.8

39.8

0.1

7,117
996
646
435
780
1,489

41.5
46.5
86.1
77.9
63.1
42.8

58.3
53.4
13.9
22.1
36.5
57.0

5.6
31.7
8.2
8.5
8.8
38.1

3.8
22.6
57
fi 4
6.4
18.9

1.8
9.1

52.8
21.7

.i
.1

2.4
19.2

27.7
18.9

.4
.2

1Includes only married mothers to whom children were bom in 1915.
2 With or without care from other physician.
* Johns Hopkins, Babies’ Milk Fund Association, and Mothers’ Relief Society.

So far as confinement care is concerned, the evidence available is
limited to kind of attendant at birth and to whether the birth
occurred in a hospital. Such information is available for births in
Newark, N. J., in 1921, and for births during the period from 1911 to
1915 in eight cities in which studies of infant mortality were made by
the Children’s Bureau. Tables 28 and 29 summarize this material.
The figures show that Italian mothers, especially, prefer the midwife
to the physician and that English and Irish mothers are attended
by physicians in an even larger proportion of cases than are native
white mothers. Though these figures throw some light upon the
preference of certain nationalities with regard to confinement care,
without evidence relating to the quality of such care they are in­
sufficient for definite conclusions.
T able 28.— Attendant at birth, by nationality of mother, Newark, N. J., 1921 1

Nativity of mother
Total..................................
N ative2_____ i___________
C olored........................
Foreign born:
Italian____ _________
Russian____ ______ _____
Austrian!...... .....................
German..............................
English___ ______ _________________
Irish___________ _____
Other______________________

Per cent
distribu­
tion

Per cent of births attended by—
Total

Physician Hospital Midwife

100.0

100

30.1

51.5
0

100
100

37.3
37.0

20.9
7.1
4,8
1.3
1.0
2.2
10.9

100
100
100
100
100
100
100

39.3
25.2
35.9

Ao. «
M l

Al. o

51.9
20.5

« Levy, Julius, M . D.: “ Maternal mortality m the first month of life in relation to attendant at birth.’
American Journal of Public Health, Vol. X III (February, 1923), p. 88.
2Includes colored.
8 Equals 5.4 per cent of total and 10 per cent of native.


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42

M ATERNAL

T able

M O R T A L IT Y

29.— Attendant at birth, by color and nationality of mother; births in eight
cities
Births attended by—

Color and nationality of mother

Total
births

Physician

Midwife

Other or none
j Not
reported

Num­
ber

Per
cent

Num­
ber

Per
cent

Num­
ber

Per
cent

22,281

16,200

72.7

5,780

25.9

293

1.3

8

White.......................................................... 20,704

15,058

72.7

5,351

25.8

287

1.4

8
2
6

Total.............................................. -

Native...................... ...........................
Foreign born______________________

li,664
9,040

9,534 81.7
5*58* 6L1

2,082
3,269

17.8
36.2

46
241

.4
2.7

Italian...................... ...................

1,407
1,257
l|ll9
'750
1,202
687
2,615
3

601 42.7
892 71.0
1,103 98.6
'414 55.2
464 38.6
212 30.9
1,836 70.2
2

760
363
12
326
728
389
691

54.3
28.9
1.1
43.5
60.6
56.6
26.4

4»
2
4
10
7
85
86
1

3.3
.2
.4
1.3
.6
12.4
3.3

1,577

1,142

429

27.2

6

.4

Polish............................................
Portuguese............................. ......
Other....... ................ ...............—

72.4

____
3
1
2

Though differences may exist in the qualifications of the physicians
who attend at deaths of mothers of different nationalities, or in the
manner or the faithfulness with which they certify to the cause of
death, no specific evidence on these points is available. It is doubtful
whether the differences in the rates can be due to variations in methods
of certification, since all are subject to the same system of checking
up of unsatisfactory returns of cause of death. So far as birth regis­
tration is concerned it is probably better among the native white
than among the foreign-bom population and better among the
(English-speaking than among the non-English-speaking foreign-born
groups. But as the maternal mortality rates for the former groups
are high better birth registration would tend to increase the differ­
ences in favor of the non-English-speaking foreign-born nationalities.
With reference to the influence or even the existence of racial fac­
tors apart from those which may influence the quality and types of
prenatal and confinement care no clear evidence is available. It is
perhaps suggestive that in maternal mortality rates the relative rank
of the various countries is similar to that of the corresponding nation­
ality groups among the foreign-bom mothers in this country. For
example, the puerperal death rate in Italy is one of the lowest, and
the rates in England and Wales, Scotland, Ireland, New Zealand, and
Australia are relatively high. (See p. 57.) Though the rates in these
country-of-birth groups in the United States are all considerably
above those in the corresponding foreign countries, the relative rank
may perhaps indicate the presence of racial factors; on the other hand
it may indicate merely tne influence of some custom or preference
that is associated with the race or nationality group.
URBAN AND RURAL DISTRICTS

The maternal mortality rate in 1921 for cities in the birth-registra­
tion area, according to Table 30, was considerably higher than that
for rural districts (7.7 as compared with 5.9). From puerperal

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FACTORS IN

PUERPERAL

43

M O R T A L IT Y

septicemia the rate for the cities (3.3) was
times that for the rural
districts (2.1). From other puerperal causes the urban rate was only
very slightly higher than the rural (4.4 as compared with 3.8)
In
each of. the years 1915 to 1920, according to Table 31, the maternal
mortality rates in urban and rural districts had the same relative
positions as m 1921.
T able

30.^-Maternal mortality rates, by size of city; United States birth-registration
area, 1921 .
Deaths from puerperal causes
per 1,000 live births
Cities and rural districts1
All puerr Puerper­ All other
peral
al septi­ puerper­
Causes
cemia
al causes

Rural districts. . . . . .

5.9
7.7
8.3
8.1
7.9
7.5

Cities

10.000- 25,000.....
25.000- 50,000..
50.000100,000....
_ ,,, 100,000 and over.

c o u n t?? toCl“ de W - th° Se ° f 10 000 popu?ation and over: the ^

2.1
3.3
3.4
3.6
3.3
3.2

3.8
4.4
4.9
4,5
4.7
4.2

districts include the remainder of the

T ab^ .f1- Maternal mortality rates in urban and rural districts; United States
birth-registration area as of 1916 (exclusive of Rhode Island), 1915-1921 1
Deaths from puerperal causes per 1,000 live births

Year

All puerperal
causes

Cities *
1915
•1916,

6.39
6.48
6.53
9.06
7.26 r it
J ,7.95
,7.18

1917!
1918
1919.
1920.
1921.
2

Rural
districts
5.55
5.78
5.81
8.58
6.06
7.00
5.36

Puerperal sep­
ticemia
Cities a

Rural
districts

2.68
2.88
2.83
2.52
2.64
2.81
2.98

1.96
1.97
. 2.18
lyse
1.77
2.10
1.99

Other puerperal
causes

Cities *

3.72
3.60
3.69
6.54
4.62

5.14

4.21

Rural
districts
3,59
3.82
3.63
6,66

4.29
4.91
3.37

«4%“ “ lawsucs, 1915-1921, and Mortality Statistics, 1915-1921.
n cities are counted only those which at the date of the preceding census had at least 10,000 population.

Ond possible"source of error in comparing death rates from puerperal causes, other than septicemia, in urban and rural districts lies in
the tendency of mothers in rural areas to seek the better hospital
facilities ot the cities, especially when complications are expected.
Confinements of nonresident mothers in urban areas probably in­
clude therefore, a disproportionate number of difficult cases, in which
tne risk oi death is considerably higher than normal. For example in
Baltimore m 1921, deaths of nonresidents from puerperal causes
formed 11 per cent of the total of such deaths, whereas in 1915 during
the course of an intensive study of infant mortality in that city it
was found that only 2.8 per cent of the legitimate births occurred to
60504°—26----- 4


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44

M A T E R N A L , M O R T A L IT Y

nonresident mothers.30 In Milwaukee in 1921 the deaths of ^onresidents from puerperal causes formed at least 11.1 per cent ot tne
total of such deaths, and in the same year 5.6 per cent of the births
occurred to nonresident mothers.31 The rates, therefore, calculated
per 1,000 births, are biased in favor of the rural districts because ot
this transfer of cases involving a high degree of risk-32
If allowance were made for the transfer of difficult cases to city
hospitals the mortality rates from puerperal causes other than septi­
cemia might be found to be higher for rural than for urban areas.
This conclusion is further strengthened by consideration of the prob­
ability that the deaths are more correctly certified m the cities than
in the rural districts.
,
,.
On the other hand, the mortality rates from puerperal septicemia
(per 1 000 births or per 100,000 population) are for the most part
characteristic of the locality.33 For puerperal septicemia is due to
an infection which is contracted usually at the place of confinement
and is chargeable in most cases, though not in all, to the physicians
or other persons in attendance. Consequently, most of the deaths
from puerperal septicemia among nonresident as well as among resi­
dent mothers are properly chargeable to the locality where the con­
finement occurred, in the mortality from this disease the rural
areas appear to have a decidedly better record than do the urban;
but this apparently more favorable record may be in part merely a
reflection o f less accurate reporting in the rural areas. .
The classification of cities into groups according to size brings out
the interesting fact that the highest mortality from puerperal septi­
cemia was found not in the largest centers but in the group of cities
which had populations of 25,000 to 50,000. The rate increased from
2.1 in the rural areas to 3.4 in the cities of 10,000 to 25,000, and to a
maximum of 3.6 in the cities of 25,000 to 50,000. In the cities of
50,000 to 100,000 population the rate was 3.3, and in the group of
cities of 100,000 population or over it was 3.2. Except for the rural
areas the largest cities had the lowest rate. (See Table 30.)
From “ other puerperal causes” the lowest rate (3.8) was also for
the rural districts, followed by the rate of 4.2 for the largest cities;
the highest rate (4.9) was for the places of 10,000 to 25,000 popula­
tion. The low relative mortality in the rural districts may be due
in part to a transfer of the complicated cases to the city hospitals
and in part to a poorer certification of causes of death. The low rela­
tive mortality in the largest cities suggests that the superior hospital
facilities and medical attendance at childbirth and during pregnancy,
which are usually available in such cities, are important factors m
reducing the mortality rates.
w Mortality Statistics, 1921, p. 84; Infant Mortality; results of a field study in Baltimore, Md., p. 20.
w The deaths from puerperal causes in Milwaukee in 1921 numbered 81, a figure which was reduced by
the net excess of deaths in Milwaukee of nonresidents over deaths elsewhere of residents of Milwaukee to
72 Mortality Statistics, 1921, p. 84. Information as to the percentage of births to nonresidents and tran­
sients was furnished by courtesy of Dr. I. F. Thompson, Deputy Health Commissioner, Milwaukee, Wis.
si Rates per 100,000 population are, of course, subject to an even greater error; m this case to obtain rates
valid for comparative purposes all the deaths of nonresidents should he allocated to the' P^ce <rf residence.
33 But there is no doubt that the risk of infection is greatly increased m complicated cases reqnin nS
tive interference over that in cases of normal delivery.1 Some infected cases also may be transferred from
rural districts *o city hospitals.


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TREND OF PUERPERAL M ORTALITY IN THE UNITED STATES 1

Figures showing over a 22-year period changes in the rate of. mor­
tality from all puerperal causes per 100,000 population in thè expand­
ing death-registration area are given in Table 32. If these figures
are accepted at their face value the rate increased from 13.3 in 1900
to 16.9 m 1921. From puerperal septicemia it increased from 5.7 in
1900 to a maximum of 7.4 in 1911, from which point it decreased to
6.8 in 1921. From other puerperal causes it increased from 7.6 in
1900 to 10.1 in 1921. In this comparison rates expressed in terms
of population are used since satisfactory birth statistics are not avail­
able throughout the period for the whole of this area. Since the
birth rate is falling, a constant puerperal mortality measured in terms
of births would show a slight decrease if measured in terms of popu­
lation; and hence these rates expressed in terms of pppulation under­
state the increase in the risk rates from puerperal mortality during
this period. Because of this fact the slight apparent decline in puer­
peral septicemia since 1911 which is indicated by the figures can hot
be accepted as conclusive evidence of the real trend of mortality
until the influence of the decrease in birth rate has been eliminated.
(See p. 51.)
T able 32.— Trend of mortality rates from puerperal causes; expanding death-

registration area, 1900-1921
Deaths from puerperal causes,
per 100,000 population
Year
Total

1900............... __
1901______.
1902........................
1903............... ........
1904................
1905........................
1906___________
1907..................
1908................ ........
1909................
1910....... ................

13.3
13.7
13.0
14.0
15.3
14.9
15.1
15.6
15.7
15.3
15.7

Puer­
peral
septi­
cemia
5.7
6.0
5.7
6.1
6.9
6.8
6.2
6.8
7.0
6.7
7.2

Deaths from puerperal causés,
per 100,000 population

Other
puerperal
causes

7.6
7.7
7.3
7.9
8.5
8.1
8.9
8.9
8.7
8.6
8.5

Total

1911.
1912.
1913.
1914.
1915.
1916.
1917.
1918.
1919.
1920.
1921.

16.0
15.0
15.8
16.0
15.3
16.3
16.7
22.3
17.0
19.2
16.9

Puer­
peral
septi­
cemia
7.4
6.5
7.2
7.1
6.3
6.7
6.9
6.5
5.8
6.6
« 1

Other
puerperal
causes

8.6
8.5
8.7
8.9
9.0
9.6
9.8
15.9
11.2
12.5
10.1

With the possible exception of mortality from puerperal septicemia
the figures in Table 32 indicate a marked increase in maternal death
rates during the 22-year period covered. In order to determine
whether this increase indicated by the statistics is due to an increase
in the mortality from puerperal causes or is simply the result of
changes in the area to which the statistics relate, of improvements in
certification of causes of death, or of the method of calculating the
‘ A summary of this section was published in the American Journal of Public Health for September,
1924 (Vol. X IV , pp. 738-743).

45


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46

M ATERNAL

M O R T A L IT Y

rate, a detailed examination of the influence of these statistical factors
must be made. Three factors should be considered. (1) The expan
sion of the area; (2) the decrease in the birth rate; and (3) improve­
ments in certification of causes of death.
i ±
With regard to the first factor,, since these figures relate to the
expanding death-registration area, the first questions which must be
answered^ are, How much, if any., of the apparent increase is due
merely to the addition to this area of States with higher puerperal
mortality rates than those in the original area, and how much is due
to an increase in mortality .rates m the; original or m
In 1900 the death-registration area included 40.5 per cent ol the pop
lation of the United States; in 1920 it included more than twice as
laree a proportion (82.2 per cent). The mortality rates m the original
registration States (including the District of
registration cities in nonregistration States) and in States added
S g h a c h year are shown in Table 33:, The result of additions pf
new States to the area was to increase slightly the mortality rates
from all puerperal causes in 1906, 1911, 1913, 1916, 1917,
19 ,
and to decrease them slightly in 1908, 1909, 1910,
1920, relatively to what they would have been if no additions had
beTSieiniluencc of changes in territory may be eliminated in cither of
two ways. The simpler method is to study the trend of mortality m
the original registration States of 1900. In this area the rate fro
W
m
rose from 13.4 in 1900 to 15.1 «
»
W
I
septicemia it rose from 5.8 in 1900 to a maximum of 7.1 m 1911^and
fell to 6.1 in 1921. From all other puerperal causes, how ever.it
showed a continuous increase, from 7.6 in 19(KI to 11.5 m 1920, with
a decrease to 9 in 1921. These increases m each case are slightly less
{.pfl/n the increases shown in the expanding area.


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T able

Maternal mortality rates in the original death-registration area and in each addition to the area• 1900-1921
DEATH RATES PER 100,000 POPULATION

Area
1900 1901

1902 1903

1904 1905 |1906 1907 1908 1909 1910 1911

1912 1913 1914 1915 1916

J

1917 1918 1919 1920 1921

ALL PUERPERAL CAUSES
Death-registration States (includes
District of Columbia)___________ 13.4
States in area in 1900 L-—T~,___I___ 13.4
States added in 1906 exclusive of
South Dakota3.......
South Dakota.........
States added in 1908 (Washington,
Wisconsin)..... .......
State added in 1909 (Ohio)
States added in 1910 (Minnesota.
Montana, U tah )......
States added in 1911 (Kentucky,
Missouri).............
State added in 1913 (Virginia).
State added in 1914 (Kansas)
States added in 1916 (North Carolina.
South Carolina)_____
State added in 1917 (Tennessee)
States added in 1918 (Illinois, Louisiana, Oregon)____
Florida, Mississippi).. .

State added in 1920 (Nebraska)__

13.2
13.2

12.6
12.6

13.1
13.1

14.9
14.9

14.6
14.6

15.0
14.4

15.5
15.1

15.5
14.3

15.0
14.4
18 3 -

15.4
15.1
(4)

........

.. .

—

........

—
—

........

14.1

—

-r----

—
—

—
—

15.5
15.5

14.4 15.5
14.1 14.9

15.4
15.4

14.8
14.8

16.0
14.8

16.5 22.1
15. 5 20.5

16.8
15.3

19.0 16.7
17. 5 Ï5.1

.«

15.2
(4)

16.0
(4)

15.6
(4)

16.2
(4)

18. 0 24.6
(4)
(4)

16.1
(4)

18.5
(4)

13. 5 13.3 15.8
15.2 15. 7 21.5

12.1
14.6

16. 0 14.0
16.9 15.8

15. 0 16.3

17.9

19.2

12. 5 12.0 12.6
XÔ. 2 14. 7 14.4 13.6 15.4 13.3
_
TO O
1J.
6
15.1
15. 3 14.1 14.5
—
—

17.3 16.0
------— ----- —

—

—

-------

16.9
(4)

*------ —

16. 9 15.8 14.3
19.0 22. 5 21.4
—
12. 3 13.1

14.8
21.0
16.9

—
—

—
26.9
¿MS--- ____ ____

—

—
—
------

22.6

M— —

15.1

16.0 19.8 15.2 15.2 15.7
22.1 29. 7 ■21. 9 24.5 20.9
16.8 25.4 17.0 18.8 15.0
26.0
18.2

33.3
21.0

28.0
21.2

20. 2 17.1
—

16. 6
(4)

32.7 26.5
20.4 1$.9
18.9

16.1

..J__ 23.3 25.8 24.7
— --......... 17.0 16.2

1Indudes District of Columbia; excludes registration cities in nonregistration States
S S S S F
New York, Bb.de b t a d . VermoM, M in e , M iohig«,, M l.n o .
4 Dropped from area.

TREND OF PUERPERAL MORTALITY IN THE UNITED STATES

;

33.

47


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T able 3 3 .-M o im .a i mortality rates in the original death-registration area and in eaeh addition to the area, 1 9 0 0 -i m

Continued

£

DEATH RATES PER 100,000 POPULATION
Area

|
1900 1901

1912 1913 1914 1915 1 1916 1917
1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 ,
T

1918 I 1919 j 1920 1921

PUERPERAL SEPTICEMIA

Death-registration States (includes
District of Columbia)-----------------

6.3
6.3

States added in 1906 exclusive of
States added in 1908 (Washington,
Wisconsin)........ l....... .................. - --- --State added in 1909 (Ohio).......... ......
States added in 1910 (Minnesota,

--- ---

6.5
6.4

6.7
6.1

6.5
6.1

7.0
6.7

7.1
7-1

6.2
6.0

7.0
6.6

6.8
6.5

6.1
5.9

6.5
6.1

6.8
6.4

6.3
5.6

5.7
5.2

6.5
6.1

6.7
6.1

6.7
4.1

6.6
3.4

8.3
4. 9

7.4
4.6

7.6
(4)

6.9
V/

6.5

7.6
wS

7.2
(4)

6.5
(4)

6.8
(4)

6.7
(4) '

7.0
(4)

5.8
«

6. 5
«

7.0
(4)

5.8

5.3
7.3

6.0
8.0

6.0
7.5

4.1
6.8

6.0
7.0

5.0
7.9

5.3
5. 7

5.6
7.3

5.3

5.1
7.1

3.9
5.7

4.6
7.3

5.8
7.4

___

6.0

7.3

5.4

6.0

6.0

5.2

5.8

7.3

6.2

5. 5

6.8

6,7

6.7
7.6
8.1

7.9
8.5
7.5

7.2
7.2
9.6

6.6
5.5
6.5

7.2
6.4
7.7

7; 8
6.9
6.7

7. 2
—

6.9
7.5

7.4
6.7

6.7
8.2

71
7.6

6.9
8.3

5.6

6.1

6.7

6.8

6.3

8.4
5.8

8.1
6.6

11.1
10.1

12.4
11.5

10.0
9.0

10.4 12.1
(4)
(*)
10.7 8.2 11.4
14.4 8. 9 9.6

(4)
8.2
8.4

-----------

—

—

6.1
5.8

—

States added in 1911 (Kentucky, Mis­
.......
........
souri).— ...................................... - ........ — — - -- — — .......
State added in 1913 (Virginia)............
—
—
—
____
State added in 1914 (Kansas).............
States added in 1916 (North Carolina,
,
—
—
—
South Carolina).............................. ____ —
—
State added in 1917 (Tennessee)---- — —
States added in 1918 (Illinois, Louisiana, Oregon)..... .............................
States added in 1919 (Delaware,

........ — —

8.1

7.5

__
___

8.7
6.7

8.2
8.3
4.3

6.8
7.3
5.3

—
_____ —
____ ____ —

____ ____ ........ ........ .........
.........

........
1

1

ALL OTH1ER PUI;rper>L CAUSF.9
Death-registration States (includes
District of Columbia)............. — --

7.6
7.6

7.7
7.7

7.4
7.4

7.7
7.7

8.4
8.4

8.2
8.2

States "added in 1906 exclusive of
States added in 1908 (Washington,
—
—
Wisconsin)..........- .......................... —
State added in 1909 (Ohio)------------- ....... ......... ......... .......


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"--- %
.........

9.0
8.6

9.0 1 8.8
8.6 8.2

8.5
8.3

8.4
8.4

8.4
8.4

8.3
8.2

8.5
8.4

8.6
8.8

8.8
8.8

9.5
8.7

9.7
9.1

15.8
14.9

9.7
9.7

9.8 1 10.0
9.2 7.6

10.0

9.5
(4)

8.8

8.7

9.3

8.9

9.2
(4)

9.4
(4)

9.2
(<)

17.6
(4)

7.3
7.6

7.9
7.9

8.0
8.0

J 9.0

7.5
6.8

7.3
7.2

7.7
7.2

7.9
7.5

6.5
6.6

(4 )

7.0
7.5

MATERNAL MORTALITY

5.4 6.5
5.4 . 6.5

5.2
5.2

5.5
5.5

5.8
5.8

States added in 1910 (Minnesota,

Montana, U t a h ) .....________ . . . . .

States added in 1911 (Kentucky,
Missouri)............................................

South Carolina)..___ ________ ____

State added in 1917 (Tennessee)____
States added in 1918 (Illinois, Louisi­
ana, O regon)....._____
States added in 1919 (Delaware, Flor­
ida, Mississippi)___
State added in 1920 (Nebraska)"” ” !!

7.8

8.3

9.3

8.1

9.2

9.1

9.1

16.5

12.3

12.4

8.4

8.6

8.1

7.6
14.2

7.5
14.0
7.8

8.1
13.5
8.8

8.0
13.6
9.3

12.6
22.5
15.8

8.6 8.0
16.3 161

10.5

11.1

7.9
14.0
8.3

19.8

19.1
10.7

25.9
14.3

21.3

110

25.6
12.8

19.6
11.6

10.9

12.2

9.3

17.1

17.4

16.6
9.6

12.3

8.0

*C a S n t t S o S d o ; M ^ r y l a S p e ^ s y W a n ^ 13’ Connecticut' New Hampshire, New York, Rhode Island, Vermont, Maine, Michigan, Indiana.
4Dropped from area.

14.5

11.1

TREND OF PUERPERAL MORTALITY IN THE UNITED STATES

State added in 1913 (Virginia)..1 .1..
State added in 1914 (Kansas) . .
States added in 1916 (North Carolina,

7.3

49


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MATERHAL m o r t a l i t y

50

This method does not take into account, however, changes in rates
in the States which were added to the original registration area. In
most of the added States, but not in all, the rate from all puerperal
causes in 1921 was higher than in the year of admission.
A second method, taking into account changes m mortality rates
within the added as well as within the original territory and giving
to each change its due weight in the calculation, is as follows: _ Ihe
percentage of change in rate from each year to the next m the terri­
tory common to both years is first ascertained. The initial rate>m
1900 is multiplied by the percentage of change from 1900 to 1901
in the territory common to both years; the result is then multiplied
by the percentage of change from 1901 to 1902 in the territory-com­
mon to these years; and similarly each successive result is multiplied
by the corresponding percentage of change. The final result is a
series of adjusted figures which measure the change m maternal
mortality in the expanding area after the influence of differences m
initial rates in the added States is eliminated. The series of figures
so constructed is compared in Table 34 with the rates m the expand­
ing area and with those in the original registration States. A com­
parison of these three groups of figures shows that eliminating me
influence of the expansion of the area gives a trend not far different
from the trend of the rates from puerperal causes in the original
registration States.
T

a b le

3 4 — Trend of maternal mortality rates; United States death-registralion
area, 1900-1921
Maternal mortal­
ity rates per
100,000 popula­
tion
Year

190019011902.
1903.
1904.
1905.
1906.
1907.
1908.
1909.
1910.
1911.
1912.
1913.
1914.
1915.
1916.
1917.
1918.
1919.
1920.
1921.

,
’

Expand­
ing
deathregistra­
tion area1

13.4
13.2
12.6

13.1
14.9
14.6
15.0
15.5
15.5
15.0
15.4
15.5
14.4
15.5
15.4
14.8
16.0
16.5
22.1

16.8
■19.0
16.7

Ratio to 1900
rate3

Original Expand­ Original
deathdeathing
registra­
deathregistra­
tion
registra­
tion
States* tion area States

13:4
13.
12.6

13.1
14.9
14.6
14.4
•15.1
14.3

14.4
15.1
15.5
14.1
14:9
15Í4
14.t8
14.-8
15.
20.5
15.3

17:5
15.1

Index
number
of rates
in ex­
panding
area

100.0

1Ò0.0

100.0

110.8

110.8

110.8

98.8
-2
94.0
97.5

108.8
111.9
115.4
115.9
112.2

114.5
115.8
107:7
115.3
115.2
110.5
119.6
-123.0
-5
165.0
125.5
141.5
124.5

98.8
94.0
97.5

108.8
107.1
112.3
106.9
107.6
112.5
115. 6
105.4
111.5
114.5

98.8
94.0
97,5

108.8
106.9
110.4
111.5
108.6
111.8
111.6

103.8
110.2

110.6

110.0
nao

106r2
: 109.9

112.6

-152.7
114.5
129.8
113.8

■115: 2
153.1
113.8
.130.8

112.6

> I n c f u d e s 6t h
e
E n g f a n ^ S tatel* New York, New Jersey, District of-Columbia,:;Indiaha, and
Michigan.
>The 1900 rates equal 100.


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TREND OF PUERPERAL MORTALITY IN THE UNITED STATES

51

The decrease in the birth rate is a second factor which must-be
considered before definite conclusions can be drawn; since the birth
rate decreased during the years from 1900 to 1920, the maternal
mortality rate, when expressed in terms of deaths per 1,000 births,
would show a greater increase than when expressed in terms of deaths
per 100,000 population. To estimate the influence of the fall in the
birth rate upon the apparent changes in rates of puerperal mortality,
it is necessary first to ascertain the amount of this fall; with this in­
formation its influence upon the puerperal mortality rate as stated in
terms of population can easily be calculated.2
The chief difficulty in making a correction for the fall in birth rates
is to ascertain the rates themselves. The registration of births in
many of the States composing the death-registration area of 1900 is
mcomplete, and statistics based upon registered births during the
period from 1900 to 1920 are subject, therefore, to errors of varying
size due to omissions. Perhaps the most satisfactory method is to
estimate the average number of births for the five years preceding
each census date, 1900, 1910, and 1920, from the enumerated popu­
lations under 5 years of age and the statistics of deaths of children
under 5.3 This method gives estimated birth rates for the original
^ ^ r e g is t r a t io n States of 25.6 in 1900, 24 in 1910, and 23.2 in 1920*
the birth rate, therefore, appears to have decreased 9.4 per cent
during these years. Assuming that these estimates give a fairly
accurate picture of the fluctuations in the actual birth rates during
~*1S
T a^ e 35 indicates the trend, after allowance is made for
the tailing birth rate, of maternal mortality in the original deathregistration States from all puerperal causes, from puerperal septi­
cemia, and from other puerperal causes.
As would be expected, the result of this correction is to make still
larger the apparent increase in mortality from puerperal causes,
in e rapid tall shown in the crude death rates from 1900 to 1902
appears to be caused in large part by the markedly lower birth rates
m the years 1901 and 1902 as compared with that in 1900, which was
unusually high The decrease in mortality from puerperal septicemia
irom 1911 to 1921, which m the crude figures appeared to be 14.8
per cent, was reduced, after allowance was made for the falling birth
rate, to 11.9 per cent. The conclusion is justified, therefore, that
2If B, and Bs are birth rates in different years, and

m

w

m

w


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a

m

(i. e., the proportion that the second birth

w

m

m

m

MATERNAL. MORTALITY

52

though, since 1911 at least, the mortality from puerperal septicemia
in the original death-registration States has actually decreased, the
trend of the rates from $ other puerperal causes” appears even more
definitely upward than would be inferred from the crude figures.
T able

35.— Trend in maternal mortality rates after allowance is made for falling
birth rate; V mted States death-registration States of 1900, 1900-1921
Trend in death rates 1

Year

Trend
in birth:
rates1

All puerperal
causes
Crude
figures

190019011902.
1903.
1904f 1905.
1906.
1007:
19081909.
19101911.
1912.
1913.
1914.
1915.
1916.
19171918.
1919.
1920.
192Í.

100.0

96.5
96.1
97.4
95.8
. 93. 6
95. 8;
: 97. 0
97.4
'92.6
93.8
94.3
93.4
92.4
93.8
92.8
92. 3.95.0 :
94.0
86.5
90.5
91.2

Adjusted Crude >Adjusted
ior falling
'or falling figures
birth rate
oirth rate

100.0
100.0
102.4
98.8
97.9
94.0
100.2
97. 5
115.6
110.8
116. 2
, 108.8 ■
111.8
’ - 107.1
115. 8:
112. 3
109.7
106.9
116.2
•107.6
, 120.0
112.5
122.6
115. 6
112.9
105.4
120. 6
111.5
114. 5 » 122.0
118. 5.
. 110.0
119.2
’ 110.0
121.2
115.2
153.1
113.8
130. 8
112. 6

Puerperal septi­
cemia j

162.8
131.6
144.4
123.4

100.0
95.3
91.8
94.0
112. 2
109.9
100. 3
111.6
106. 3
100.1
116.5
123.3
103.3
113.5
113.3
102.4
105.6

110. 4
97.2
89.7
104.7
105.1

100.0
98.8
94. 5
96.5
117.1
117.4
104.7
119.6
109.1
114.6
124.3
130.8
110.6
122.8,
120. 8
110.3

114.4
116.2
103.3
103.7
115.7115.2

Other puerperal
causes
Crude
figures
100.0
101.4
96.5
100.2
109. 6
107.9
112.3
112.8
107.4
1Ó8.7
109.5
109.8
107. 1
109.9
115. 3
. 115-7
113. 3
118. 9
195.4
132.1
150.5
118.3

Adjusted
’or falling
birth rate
100.0
105.0
100.4
102.9
114.5
115.3
117.1
116. 3
110.2
117.4
116. 7
116.4
.114.6
119.0
122.9
124.7
122. 8

125.1
207.8
152. 7
166.2
129.6

i The 1900 rates equal 100.

The improvement in the certification of causes of death during the
period from 1900 to 1920 is the third factor which must be taken into
account in determining whether the mortality from puerperal causes
iis actually increasing. The results of the campaign for securing more
accurate reporting of causes of death and of the ‘querying of unsatis­
factory causes reported have been to make the statistics for the later
years more nearly correct than those for the earlier years of the period.
So far as mortality from puerperal septicemia is concerned, the
first inquiries related to deaths in 1911, and in that year the death
rate from puerperal septicemia reached its maximum. Since in the
changes made as a result of the inquiries the cases added to puerperal
septicemia have always exceeded the cases subtracted from it, the
decrease in the rate since that year points to an improvement in
mortality from this cause. The real improvement is greater than
appears on the face of the figures because it is in part masked by the
continual betterment of certification resulting from extension of the
system of querying unsatisfactory certifications of cause.
The influence of the improvement in accuracy of certification, so
far as the net additions made to puerperal deaths as a direct result of
letters of inquiry to physicians are concerned, may be eliminated by
subtracting the additions. The number of cases added is given in
Mortality Statistics for the entire death-registration area for each

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TREND OE PUERPERAL MORTALITY IN THE UNITED STATES

53

year since 1911, with the exception of 1912, 1913, and 1918. Table
36 shows the trend in the rates of puerperal mortality corrected to
eliminate all cases added as a direct result of letters of inquiry. : As
would be expected, the index numbers for the later years are slightly
reduced by this procedure.
This method of correction, however, obviously can not eliminate
additions resulting indirectly from the system of letters of inquiry'
because of the fact that physicians who have received such letters
are likely to be more careful afterwards in reporting causes of death.
T a b l e 36.— Trend in maternal mortality rates after the elimination of additions

resulting directly from letters of inquiry; original death-registration States, 1900—
1921 1
Trend in maternal death rate3
All puerperal causes
Year

Puerperal septi­
cemia

Other puerperal
causes

Adjusted
Adjusted
Adjusted
for falling
Cor­
for falling
forfaiting
Cor­
Cor­
birth
rected 4
birth
birth
rected 4
rected 4
rate3
rate3
rate3
1900_____
1911.
1912......... .
1913______ ! ___________ ______
1914_________ ______
1915____ : ...............
1916____ . . . . . ______ _
1917.;........ . . . .
1918_________________ _
1919._____________ ...
1920._____ ______
1921............ ................ . _

100.0
122.6
112.9
120.6
122. 0
118.5
119.2
121.2
162.8
131. 6
144.4
123.4

100.0
122.4
112.9
120.6
121.0
117. 0
117.4
117.6
(*)
129.2
141.9
120.9

100.0
130.8
110.6
122.8
120.8
110.3
114.4
116.2
103.3
103.7
115.7
115.2

100.0
130.5
110.6
122.8
119.1
108.1
112.8
112.1
(5)
101.1
113.0
112.4

100.0
116.4
114.6
119.0
122.9
124.7
122.8
125.1
207.8
152.7
166.2
129.6

100. 0:
116:2'
114.6.'
119 . o:
122.4
-123.7
121.0
121.7
({) :
150'..6
16410
127,13:

1For basic figures upon which factors, for correction are based, see p. 13. Figures for 1901 to 1910 are
omitted, since no additions were made and no statistics of such additions were published.
1 Rate in 1900eauals 100.
3From Table 35.
4The corrected figures are found by multiplying the adjusted figures by a.factor of correction found by
dividing the deaths originally certified as puerperal (in the entire death-registration area) by the total of
deaths finally so classified.
4Figures for additions in 1918 not available.

The influence of the increasing accuracy in certification which is
reflected in a decrease in thé proportion of deaths classified as due to
ill-defined and unknown causes may be estiitiated and eliminated,: so
far as transfers from these indefinite to puerpéral causes are concerned.
In 1900 the proportion of deaths from ill-defined and unknown causes
in the death-registration States was 3.8 per cent, and in 1920 in the
same area it was only 0.2 per cent. In 1921 only 942 deaths in this
area were classified as due to ill-defined and unknown causes, as
compared with 13,199 that would have been so classed if the propor­
tion that prevailed in 1900 had prevailed also in 1921/ In 1900, of
the deaths from these indefinite causes 2.8 pet cent were of women
between the ages of 10 and 50 years. Assuming that an equal pro­
portion of these deaths were connected with pregnancy of childbirth
the puerperal deaths formed of the total deaths between these
ages from known causes (11.7 per cent) , then it may be estimated, that
0.33 per cent of the total deaths from ill-defined causes were maternal.
On this assumption the number probably added to puerperal deaths

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Federal Reserve Bank of St. Louis

54

MATERNAL MORTALITY

by transfer from ill-defined causes bas been estimated. The trend
in the rates after eliminating these estimated additions, as well as
the additions resulting directly from letters of inquiry, is shown m
Table 37. As would be expected, this correction still further reduces,
though but slightly, the index numbers of rates in the later as com­
pared with the earlier years of the period.
,
/ >
T

37.— Trend in maternal mortality rates after the elimination of additions
resulting directly from letters of inquiry and estimated additions transferred from
ill-defined and unknown causes', United States death-registration States as of
1900, 1900-1920

a b l e

Trend in maternal mortality rate 1
All puerperal
causes

190019011902.
1903.
1904.
1905.
1906.
1907.
1908.
1909.
19101911.
1912.
191».

1914.
1915.
1916.
1917.
1918.
1919.
1920

Puerperal septice­
mia

Other puerperal
causes

Crude1

Cor->
rected 3

Crude 8

Cor­
rected 3

Crude2

100.0
102.4
97.9
100.2
115.6
116.2
111.8
115.8
109.7
116.2
120.0
122.4
112.9
120.6
121.0
V 117.0
117.4
117.6
(‘ )
129.2
141.9

100.0
102.1
97.6
99.7
115.0
115.6
111.1
115.0
1Ò8.9
115.3
118.9
121.1
111.5
119.3
119.7
. 115.7
116.0
116.3
(4)
127.9
140.6

100.0
98.8
94.5
96.5
117.1
117.4
104.7
119.6
109.1
114.6
124.3
130.5
110.6
122.8
119.1
108.1
112.8
112.1
(«)
101.1
113.0

100.0
98.6
94.2
96.0
116.4
116.7
104.0
118.6
108.2
113.6
123.2
129.1
109.2
121.3
117.8
106.7
111.4
110.1
(*)
98.9
111.6

100.0
105.0
100.4
102.9
114.5
115.3
117.1
116.3
110.2
117.4
116.7
116.2
114.6
119.0
122.4
123.7
121.0
121.7
(‘)
150.6
164.0

Cor­
rected 3
100.0
104.7
100.1
102.5
113.9
114.7
116.5
115.5
109.5
116.5
115.7
115.0
113.4
117.7
121.2
122.5
119.7
120.5
(4)
149.4
162.7

>^ e fig d t e 'fo r 81900 to 1910 are the adjusted figures of Table 35, p. 52; from 1911 to 1920 the corrected
fl^The6L S ? t Ced6figur“ ' are found by multiplying the “ crude figure” in columns 1,3, and 5 by a factor of
correction for estimated transfers from ill-defined and unknown causes as explained m the text, p. 53,
4 Figures for additions in 1918 not available.

Neither of the preceding methods, however, takes account of
improvements due to, the campaign for better certification of causes
of death, so far as they have reduced the mortality ascribed both to
such poorly defined terms as septicemia and convulsions and to
terminal conditions such as. peritonitis and nephritis, the true or
underlying cause of which may b e. puerperal. An estimate of the
effect of such improvements in certification can be made on the
following assumptions: hirst, that the excess in the actual number
of female deaths in the age group 15 to 49 over the number expected
if the ratio of female to male deaths at these ages were the same as
the average ratio of female to male deaths under 15 and over 50
years of age, represents transfers from causes of death peculiar to
women; and second, that 80 per cent of these were transfers from
puerperal causes/. On the basis of these assumptions the total
«.Of all deaths from 10 to 49 years of age from causes peculiar to women 77.5 per cent were puerperal In
1900 and 80.1 per cent hi 1920; ¡80 per cent is.taken as a rough approximation to apaverage percentage.


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TREND OE PUERPERAL MORTALITY IN THE UNITED STATES

55

number of maternal deaths including those ascribed to poorly defined
terms and terminal conditions in each year from 1900 to 1920 has
been calculated; and Table 38 gives the rates based upon a comparison
of these deaths with the estimated births to indicate the trend in
maternal mortality after allowance is made for improvements in
certification in these cases.
T a b l e 38. — Estimated trend in maternal mortality rates after allowance is made

for improvement in certification of causes of death; United States death-reqistration
States of 1900, 1900-19201
Estimated death rates per 1,000 live births
Year

All puerperal
causes

Puerperal sep­ Other puerperal
ticemia
causes

Rate Trend * Rate
1900-......................

8.5

1902................
1903-.................... .......
1904........................
1905___________
1906_____ ___________
1907.............................
1908_____________
1909......................
1910___________
1911______ _____
1912_________
1913—............. ..............
1914______________
1915_____
1916........ ............
1917—.............
1918—........... —...........
1919_______________
1920............................

7.4
7.0
7.9

8.0

.

8.0
7.1
7.2
6.7
7.0
6.9
7.0
6.5

6.8

7.1
6.9
6.7

6.6

9.3
7.5
7.8

100.0
94.3
86.8

82.1
92.6
94.2
83.5
85.0
79.2
82.6
81.0
82.5
76.6
80.0
83.2
81.2.
78.8
78.3
109.2

88.2
91.8

4.3
3.7
3.6
3.3
3.9
3.8
3.2
3.3
3.0
2.9
3.1
3.2
2.7
2.9
2.9

2.6
2.7
2.8

2.5
2.4
2.7

Trend»

Rate

Trend1

100.0
86.8

4.2
4.3
3.8
3.6
4.0
4.2
3.9
3.9
3.7
4.1
3.8
3.8
3.8
3.9
4.2
4.3
4.0
3.9

100.0

83.2
78.2
91.0

88.1

73.8
77.8
71.1
69.0
72.8
75.4
63.0
67.6

68.0

60.9
63.0
64.8
58.2
57.4
64.0

6.8

5.0
5.1

101.9
90.4

86.1

94.2
100.5
93.2
92.3
87.4
96.4
89.4
89.6
90.3
92.4
98.5

101.8

94.8
91.9
160.8
119.5

120.0

1 Formetlmd of calculation, see p. 54. The allowance made is for estimated additions to puerperal deaths
from ill-defined and unknown causes and from peritonitis, septicemia, convulsions (unqualified), acute
nephritis, and Bright’s disease.
s The 1900 rates equal 100.

The trend in the maternal mortality rates after allowance has been
made for transfers from these five poorly defined terms and terminal
conditions is strikingly different from that shown in preceding tables.
From all causes the trend appears to have been very slightly down­
wards, the highest rate, with the exception of that for 1918 when
influenza was a factor, being for 1900. The trend of mortality
from puerperal septicemia, however, appears to have been sharply
downward throughout the period, the figures indicating a decrease
of 36 per cent during these years. From other puerperal causes
the rates appear to have been fairly uniform except in 1918, 1919, and
1920, when they were abnormally high.
The validity of these conclusions rests obviously upon the validity
of the method of estimate of the number of puerperal deaths roughly
classified in past years as due to poorly defined and terminal, rather
than causal conditions. In support of the method it should be
mentioned that marked decreases in mortality from “ septicemia, ”
“ peritonitis,” and “ convulsions (unqualified)” have occurred during
the 20-year period, and that, in part at least, deaths from these
causes have been transferred to puerperal septicemia /and other


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56

MATERNAL MORTALITY

puerperal causes. Furthermore, sòme such improvement would be
expected in view of thè experience of other countries, and especially
in view of the marked improvement in standards of medical education
and medicaLlicensure in this country.
.
_
'
r
The figures, therefore, raise a strong presumption that the mortality
from puerperal septicemia actually decreased throughout the, period
from 1900 to 1920, while that from other puerperal causes remained
approximately the same.


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COMPARISON OF MATERNAL M ORTALITY IN THE UNITED
STATES AND IN CERTAIN FOREIGN COUNTRIES
C O M P A R A T IV E M A T E R N A L M O R T A L IT Y RATE S

Comparative maternal mortality rates per 1,000 live births in
1920 are shown in Table 39 for countries for which statistics are
available. Though the comparability of the figures must be studied
before any final conclusion can be drawn it is evident on the face
of the figures that the United States ranked among the countries
with the highest rates, such as New Zealand and Chile. The mor­
tality in England and Wales, Ireland, and Germany occupied an
intermediate position, and that in the Netherlands, Norway, Sweden,
and Denmark was low.. The relative positions of the rates;for the
different countries have not changed materially from year to vear.
(See Table 42.)
T a b l e 3 9 .— Maternal mortality rates in certain countries, 1920 1
Deaths from puerperal causes
per 1,000 live births, 1920
Country

Country

Fuer-,
Other
All
causes peral sep­ puerperal
ticemia
causes.
Australia_______ . . . . . 5.01
Belgium________ _
6. 09
Chile A . . . ..............
7.48
Denmark__ _______
2.35
England and Wales:.
4.33
F inland....________
3.60
France (1915)___ .
6.64
Germany (1919)____
5.15
Ireland.__________
5.53
Italy...........................
3.67
Japan___ ______ ____
3.53

Deaths from puerperal causes
per 1,000 live birtbs,1920
PuerOther
AH
causes peral sep- puerperal
) ticemia
causes

. : ,1.83
3.17
2.62
3.47
2. 09
5.39
1.34
1.01
1.81
2.52
.0
■■ 0)
3.30
3.34
2.86
2.29
1.66
. 3.87
L 41
2.26
1.33
2.20

The Netherlands....^
New Z e a la n d .........
Norway (1918).uj.i_.

.2.42
6.48
2.97
Spain..____ _____
5.01
Sweden (1918)....I ..1 • 2.58
Scotland_____
6.15
Switzerland.!_______
0
Union of South Africa
4.10
United S ta tes....___ . 7. .99
Uruguay!.:....I;....
3.38

;
.

0.84
1.58
2.24
4.24
.82
iti 2.15
3.10
. 1.91
1.26 •J* i;3 ?
1..77
. 4. 38
2.89
0
1.93 :
2.16
2.67
5.32
2.06
1.32

1
1Compiled from official statistical publications of the several countries Figures for 1920 unless otherwise indicated.
1 2 According to figures given in Appendix D, p. 120, the proportion of deaths in Chile which are certified
by physicians is unusually small; in this respect the figures for Chile are not comparable with those for the
other countries. Nevertheless, the unusually high mortality from all puerperal causes for Chile indicated
by these figures may easily be understated; the division of the mortality between puerperal septicemia
and other puerperal causes is probably not significant. Séé in this connection discussion in Appendix D of
the sources of error in the statistics.
.
* Not available in source.

The mortality from puerperal septicemia in the United States was
somewhat more favorable, as compared with that in other countries.
In 1920 the rate for this country was lower than the rates for
Switzerland, Spain, Germany (1919), or France (1915), and nearly
equal to that for Belgium. On the other handy it was over three
times the rates in Norway and the Netherlands; ever twice the rates
in Sweden and Japan; and almost twice the rate in Denmark;
The mortality from other puerperal causes in the United States
was equaled only by that in Chile, although New Zealand and Scot­
land had rates not far behind. On the other hand', the rates from
these other causes for the Netherlands, Sweden, and Denmark, to
mention only a few countries, were relatively very low.
57


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MATERNAL MORTALITY

58

SIG N IFIC AN C E OF D IFFER E N C ES IN RATES
Comparability of the statistics.

A full discussion of the comparability of statistics in the United
States and foreign countries is given in Appendix D ; the principal
conclusions Of this discussion, however, may be summarized here.
So far as the definitions of “ puerperal causes” as a group are con­
cerned, the various countries either use the International List of
Causes of Death in which the puerperal causes are defined in equivalént terms in the several languages, or they have lists of their own,
in which, though puerperal septicemia and other consequences of
pregnancy and childbirth usually are given separately, the two
groups appear to be together equivalent to the puerperal causes of the
International List.1 So far as the classification of joint causes is
concerned the countries using the International List (except England
and Wales) follow presumptively the rules laid down by the Inter­
national Commission (see p. 122); and the rules followed in other
countries, for example, those in Germany quoted in Appendix D
(see p. 123), may be considered roughly comparable in their results.
A detailed study of the results of applying the United States instead
of the English rules to the deaths in England and Wales in 1920
indicates that the rate in England and Wales would have been
increased b y about 15 per cent if the United States rules had been
applied. “ (See p. 130.)
Equally important is the question of the accuracy of the reports
of causes of death. In the preceding discussion of the accuracy of
the rate in the United States the most significant test was the study
of the relative incidence of male and female deaths from the poorly
defined terms septicemia and convulsions, and from the terminal
conditions, peritonitis, and acute and chronic nephritis. Table 40
presents the results of a similar test of the statistics of the countries
for which maternal mortality rates are shown. The percentage which
the estimated excess of female deaths from these five causes formed
of the deaths classified as puerperal was higher than in the United
States in only two European countries, Norway and Holland; it is
significant, however, that in these two countries the puerperal mor­
tality rates were extremely low and that the estimated transfers
were largely from septicemia and peritonitis. Nevertheless, even
after allowing for an increase in mortality from puerperal septicemia
in these two countries of 25, or even 50, per cent, their rates were
still less than half that in the United States.2 In general, this test
does not reveal such inaccuracies in the present certification of causes
in those foreign countries as were found in the United States, for
example, in 1900. Therefore in spite of some differences in the
significance of the statistics of these countries the conclusion seems
justified that the high rates in the United States both from puerperal
septicemia and from other puerperal causes indicate conditions which
are less favorable to safe maternity than those which are found in
other countries.
, :T
i, For countries using the International List see p. 118.
.
nhvqi„-ans
* In-Norway the further correction needs to be made that only causes of deaths certmed by physicians
are included in,thB tables showing causes of death. In 1917, of the deaths
cent were certified by physicians. (See p. 66.) In 1918, of 188 puerperal deaths, 1 5 5 siehe Statiscertified by physicians. See Sundbetstilstandea og Medismalforholdene, 1918, Norges Ofnsiehe btatis

tikis, p. 21*.


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COMPARISON IN UNITED STATES AND FOREIGN COUNTRIES

in oT ta in tu n tr?es

59

omissionf f r° m Puerperal deaths on account of inaccurate
’ Ventomtis, acute or chronic nephritis, and convulsions

Estimated excess of actual over expected i female deaths from—
Country

Puer­
peral
deaths

All five causes
Num­
ber

England and Wales (1922)....
Norway (1918)______ _______
Scotland (1922)__^___ _
Ireland (1920)............ .........
The Netherlands (1921)
chile (1921) . .........
Uruguay (1921)......................
Japan (1921)____...........
Australia (1 9 2 2 )......___
New Zealand (1918)_____
United States death-registra­
tion area (1920)...................

2,971
188
759
550
443
1,170
129
7,181
621
134
16,776

Per
cent

75
2.5
53 28.2
51
6.7
15 2.7
100 22.6
34
2.9
46 35.7
4,290 59.7
23
3.7
13 9.7
1,899

11.3

Septi­
cemia

Perito­
nitis

Acute
nephri­
tis

8
15

67
15
23
11
3
2
14
557

23
5
56

4
41

18
231
23

3
2,126

72

269

Chronic
nephri­
tis

Con­
vul­
sions

23
32
11
1,376
9

4
263

1,295

1 Expected at average ratio of female to male deaths under 15 and over 50 years of age.

Differences in prevalence of important causal factors.

Among the conditions which might explain such differences in the
maternal mortality rates should be considered: (1) Variations in the
ages of mothers at the time of childbirth; (2) possible racial differ­
ences, as m susceptibility or resistance to infection or prevalence of
contracted pelvis due to rickets in infancy; and (3) differences in the
quality of care received.
Agre of mother. In the United States the lowest mortality was
found among mothers between 20 and 25 years of age, and the mor­
tality among mothers between 15 and 30 was below the average for
all ages. (See p. 33). If an unusually large proportion of the mothers
m JNorway or Italy, for example, were of these ages for which the
maternal mortality rates appear to be low, their low average rates
might be accounted for in part by this unusually favorable age
composition.
The percentages of births to mothers between 15 and 30 years of
age, the ages for which the maternal mortality rates are less than
average, are shown in Table 41 for the countries for which such
figures are available. The figures indicate that the United States
had a larger proportion of births to mothers of the ages when mor­
tality is lowest than had any of the other countries for which figures
could be obtained.3 In other words, the high mortality in this coun­
try is found in spite of the unusually favorable ages of the mothers.
l o make the comparison more concrete, if the mothers of infants
born m the United States in 1920 had had the same age distribution
as, for example, those of infants born in Norway in 1916 the maternal
mortality rate in this country, at the same rates as actually pre­
vailed at each age, would have averaged 8.9 instead of 8. To make
a fair comparison of maternal mortality in the United States with
that in Norway, therefore, the United States rate should be raised
about one-ninth to allow for the unusually favorable ages of the
mothers in this country.
*The figure for France is almost as favorable as that for the United States.

60564°— 26------ 5


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60

MATERNAL MORTALITY

T a b l e 41. — Percentage of births to mothers between 15 and SO years of age in certain

countries
Live births—
To mothers between
15 and 30 years of age

Country and year
Total

Number

Australia (1922) 1-------------------------------------Austria (1913) 2~ -------------------------------------Denmark (1915)4......................... ...................
France (1913) s----------- ------------ - - - - - ----------New Zealand (1920) 6----------------- -------------Norway (1916) i----------------------- ------ ------ ~
Sweden (1917) 8------- --------------------------- ---United States birth-registration area (1921) ».

136,056
886,788
70,841
780,818
29,921
61,108
121,791
1,714,261

77,239
8462, 599
839,174
482,099
15,797
28,734
861,540
1,078,274

Per cent

I

56.8
52.2
55.3
61.7
52.8
47.0
50.5
62.9

i Summary of Australian Population and Vital Statistics 1922 and Previous Years, p. 94. Australian
64,141.
8 Includes births to mothers under 30.
4 Aegteskaber Fodte og Dode i Aarene 1911-15, p. 61.
, ,
™
t Includes both live births and stillbirths. Statistique du mouvement de la population, 1911 13, pp.
126” 127
« Statistics of the Dominion of New Zealand for the year 1920, Vol. I, pp. 36-39.
7 Folkemengdens bevegelse 1916. Norges Offisielle Statistikk, Series VI, No. 163, pp. 20-21.
» B h th ^ ta ttstic si^ l^ .1! ^ ’. PThe percentage based upon the births of known ages is 64.9.

Racial factors.— No conclusive evidence is available as to whether
racial differences in maternal mortality actually exist, but the
possibility of their existence may be conceded. The differences in
the prevalence of contracted pelvis (see p. 26) might be true racial
differences, although more probably they are the consequences ot
racial customs which influence the prevalence of rickets m infancy.
Statistics already presented indicate that in Germany, for example,
the percentage of mothers who have contracted pelvis is not far
different from that of white mothers in this country. However,
the statistics for both countries are limited to a few cities and to
clinic or hospital patients, and the figures, therefore, may not be
significant of the true relative prevalence of this condition. Neverthe­
less so far as the evidence goes it tends to indicate that the low
European mortality is not obtained because of any less prevalence of
contracted pelvis. No figures are available which could establish
the existence of marked differences in case mortality from puerperal
septicemia in the principal European nationalities; not only do some
cases escape being reported, but the definitions vary as to what cases
are to be reported, and it is also probable that the methods of treat­
ment followed vary. So far as other specific factors m puerperal
mortality are concerned little or no evidence is available. Even if
the existence of racial differences could be proved, before they could
be relied upon to account for differences in maternal mortality rates
some evidence should be available to indicate that they are such as
would tend to explain the actual differences found m the rates.
If they tended in a contrary direction they would merely mask
differences due to other causes.
.™
,
Though the possible influence of racial differences upon maternal
mortality rates in the several countries is a question upon which it
is difficult to throw light certain comparisons can be made which


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COMPARISON IN UNITED STATES AND FOREIGN COUNTRIES

61

eliminate the effect of such influence upon comparisons of rates in
the United States with those of foreign countries. For example, the
rates for mothers of each nationality group in the United States can
be compared with those for the mothers of the same nationality in the
country of origin. (Seep. 42.) Furthermore, comparisons between
the rates for certain States, such as Minnesota, in which a large
proportion of the population is of Scandinavian stock, and the rates
for Norway or Sweden may be made without having to consider the
possible influence of racial factors; and comparisons may be made
between the maternal mortality rate for the white population of the
United States and the rates for England and Wales, Australia, or
New Zealand, without consideration of racial factors since the same
racial stocks predominate in these populations. All such comparisons
tend to indicate higher mortality in the United States than in the other
countries with similar racial stocks.
Differences in maternity care.— Differences not due to differences in
the statistical methods followed in the several countries nor to
differences in such factors as age of mother, or race, are to be ex­
plained in terms of differences in maternity care. But it is difficult
to bring adequate or satisfactory positive evidence in regard to
differences in the kind or quality of maternity care. Light on the
subject might be thrown by studies of the relative qualifications of
physicians and midwives,4 of the regulations to which the midwives
are subject in the several countries, and of the arrangements for
prenatal consultations and for .confinement care. A thorough
study of these points would be necessary to form sound conclusions,
and an inquiry of this kind would fall outside the scope of the present
bulletin. Such a study would undoubtedly be especially valuable,
not so much for the light it would throw upon the question of the
relative quality of maternity care in the several countries, as for
the suggestions it would give with regard to the best experience of
other countries in dealing effectively with maternal mortality and
morbidity.
TREND

OF M A T E R N A L

M O R T A L IT Y RATES IN
CO UN TRIES

CERTAIN

FO R E IG N

The trend of maternal mortality rates during the period from 1900
to 1922 in each of the countries for which figures for 1920 have
already been presented is shown in Table 42. Conclusions drawn
from these figures are, of course, subject to qualification wherever
improvement in certification or changes in methods affect the com­
parability of the data; correction for such improvements or changes
would doubtless tend to increase the apparent fall in mortality, or,
if the apparent movement of the rates is upward, to lessen the up­
ward movement or to convert it into a downward trend. Such
corrections for most of these countries, if made in the way described
in a preceding section (see pp. 45-56) would probably not produce so
< With regard to qualifications of medical practitioners see Laws (abstract) and Board Rulings Regulating
the Practice of Medicine in the United States and Elsewhere (34th Edition, revised to Jan. 1,1924, American
Medical Association, Chicago, 1924). With regard to the licensing and regulation of midwives the principal
points of the laws and regulations of certain European countries are summarized in Appendix P; the laws
and regulations of the different States in this country are treated briefly on page 76 and given in chart
form in Appendix E, page 132). Figures showing the proportion of births attended by physicians and by
midwives in certain countries, which ar,e presented in General Table 8, page 148, should be interpreted in
the light of these minimum qualifications for the practice of obstetrics.


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62

MATERNAL MORTALITY

marked a change in the trend as was found when the correction was
made for the United States.
In England and Wales, Finland, Ireland, Japan, Spain, and
Switzerland the trend of puerperal mortality during these years
appears to have been downward. On the other hand, increases due
to improved certification of deaths or to an increased mortality
from puerperal causes appear in the rates for Germany, Hungary,
Scotland, and Sweden. In Germany and one or two other countries
the higher rate for the quinquennium 1915 to 1919 as compared
with those for earlier years may have been due to war conditions.
In view of the probable increasing accuracy in certification of
causes of death these decreases in the rates in certain countries
indicate that in these countries the advance in medical knowledge
•and the development of public-health control are lessening maternal
mortality.


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T a b l e 42.— Maternal mortality rates for certain countries, by cause of death; 1900-1922 1

Country

All puerperal causes

Puerperal septicemia

Other puerperal causes

1900-1904 1905-1909 1910-1914 1915-1919 1920-1922 1900-1904 1905-1909 1910-1914 1915-1919 1920-1922 1900-1904 1905-1909 1910-1914 1915-1919l1920-1922

4.

2.

4.
2.
4.
3.
4.
5.
«2.
5.
2.

4.1
75.3
3.3
3.9
3.1
3.6
5.4

2.8

4.2
2.4
4.5

2.8

5.4
5.9
2.4
5.7
2.3

6.8

5.3
2.5
5.2
2.4

4.9

4.7

4.1

53. 9
4.0
63. 6

7.6
3.8

3.8

'6.6

4.6
104. 5
4.6
‘ 4.0
5.1

13 2. 8

3.5

2.8
5.4
3.0

6.2
5.4
»2.8
«5.5
2.7
7.3

1.7

7.8

«5.2
"<~5.~6
3.5
2.4
5.6
6.4

>5.0
4 3.3
7.1

91.6
1.6
» 1.6
.9
» 2 .1
1.0
1.3
1.1
1.6
2.0
3.3
•1.0
2.4
1.1

83.
2.
» 1.

1.1
1.7

«1.
1.
331.
1.
1.
1.
1.
1.
3.
331.
2.
1.
2.

1.6

1.1
1.2
1.6
3.3

1.0

2.3
1.4

2.

1.6
2.2

3.8

11.6

2.3

1.5

! 2. 6

81.8

«3.1
~4~2.~2
" ï.'à
.8

2.2
» 1.8
2.7
323.7
1.7
3.0
1.8

1.9

■3.7

1.9
‘ 3.1

2.8
2.3
‘ 1.2
3.4
1.3

«2.9
42.0
2.6

3.2
6.1
2.3

1.4

72.8
1.8
2.4
1.7
2.6
3.5
1.8
2.7
1.7
3.3
1.4
3.5
2.1
1.5
3.2
.9

71906-1909.
«1915.
•1901-1904.
301915-1916.
33 1903-1904.
32 1902-1904.
» 1915-1918.

2.5
1.8
2.2
1.8
2.2
3.5
1.6

2.0
1.6

3.0
1.7
4.2
2.0
1.5
2.9
1.0

3.3
5.8
2.4
2.7

«3.3
2.2
382.6
2. 1

>2.7
3.4

331.8
2.2
1.8

3.6
1.9
4.6
2.1
33 1.4
«3.2
1.1
4.7

3.2
5.6
42.3
2.5

«2.1
”43.4
2.2
1.7
3.7

4.4

41.9
41.3
4.5

63


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1.8
1.4
1.4

C O U N T R IE S

41920-1921.
«1911-1914.
*1920.

1.6

2.4
1.6
1.5

.8

1 Compiled from official sources and from Annuaire International de
Statistique. Where figures are not filled in, they a n not available
1List of causes of death in use prior to 1911.
3International list adopted in 1911.

1.7
1.4
1.4
«1.4

S T A T E S A N D F O R E IG N

«3.
3.
3.
3.
125.

4.9
7.6
3.7
•4.0
3.9
4.9
3.5
3.7
3.4
3.3
5.2
2.4
3.5
2.3
4.0
2.9

U N IT E D

Australia...
Chile____ ____ ■
England and Wales 2___
England and Wales 2___
F inland..—............ _
France________ Sj______
■Germany._____ _______
Bavaria_______;•___
Prussia____ it______ _
Hungary____ __________
Ireland_______________ .
Italy.-------------------- -----Japan____________ ___*__
Netherlands__________ .
New Zealand_________ _
Norway_______________
Scotland____ - _____ ___
Spain.
Sweden___
Switzerland.
Uruguay____ ____
|........... ____j
United States birth-registration area.

C O M P A R IS O N I N

Deaths from puerperal causes per 1,000 live births

PREVENT ABILITY OF PUERPERAL MORTALITY

Since puerperal mortality is due to a variety of causes and pre­
disposing conditions preventive measures must be directed toward
removing these causes or altering or modifying the conditions, and the
preventability of puerperal mortality is measured by the degree to
which such measures can be successfully applied. The pathological
causes fall into two main divisions: Puerperal septicemia, the pre­
vention of which depends upon the rigorous observance of surgical
cleanliness or asepsis, and “ other puerperal causes,” the prevention
of which depends largely upon competent medical supervision and
assistance during pregnancy and at confinement.
From the point of view of public-health work the problem of
preventability requires not only such general control over medical
licensure and the licensing of midwives as to insure that medical
practitioners and midwives are adequately trained, but also that
facilities shall be available to provide for every mother the skilled
medical attention and care which she requires.
Finally, it is important that the mother should be educated to
demand competent medical supervision during pregnancy and that she
should realize the importance of early consultation with .her physician
if the presence of certain complications is to be discovered and proper
steps taken to minimize the dangers from them. In this connection
it may be pointed out that the risk of death in cases of so-called
“ self-induced”, abortions is very high because of the liability to
septic infection. Deaths from these abortions, in contrast to those
following “ criminal” abortions, are included in puerperal deaths.
PUERPERAL SEPTICEMIA

Almost all the mortality from puerperal septicemia is preventable.
Puerperal septicemia is infectious in origin, and its prevention
depends upon the rigorous observance of asepsis.
The success of aseptic procedures is shown by the experience of
well-conducted hospitals in which the mortality has been reduced to a
minimum. Thus, in Australia, the Sydney Women’s Hospital in
1904 reported 10 years’ work with nearly 4,000 cases, and not one
death from puerperal sepsis. At the Rotunda Hospital in Dublin,
2,0,60 women were confined in 1907-8; only 3 died from puerperal
sepsis, and in each of these cases the infection occurred outside the
hospital. At the York-Road Lying-in Hospital, Lambeth, during
16 years, 8,373 deliveries took place, and not a single death due to
infection occurred within the hospital. Prof. O. von Herff in 1907
reported that at his own hospital in Basle, among 6,000 cases con­
fined during the preceding 14 years, not a single woman died of
puerperal fever contracted in the hospital, and only 0.8 per 1,000 of
the total 6,000 cases died of puerperal fever contracted previous to
admission to the hospital.1
i Maternal Mortality in Childbirth, p. 3. Committee Concerning Causes of Death and Invalidity in
the Commonwealth. Australian Department of Trade and Customs, Melbourne, 1917.

64

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PREVENTABILITY OF PUERPERAL MORTALITY

65

Similar results are to be found in American hospital experience.
For example, in the hospital and out-patient services of the Chicago
Lying-m Hospital, among 11,605 confinements during 1919 to 1923,
inclusive, only 5 deaths from puerperal sepsis occurred, and in all
but 1 of these 5 cases the delivery took place outside the hospital.2
At the Swedish Hospital in Minneapolis, among 1,512 cases of preg­
nancy admitted from November, 1921, to April, 1923, no deaths from
puerperal infection occurred.3
In. regard to the prevention of puerperal septicemia the Australian
committee appointed to study the causes of death and invalidity in
the Comnionwealth states: “ Puerperal septicemia is probably the
greatest reproach which any civilized nation can by its own negligence
offer to itself. It can be prevented by a degree of care which is not
excessive or meticulous, requiring only ordinary intelligence and
some careful training.” 4
If the prevention of puerperal septicemia in a given case is a
matter of attention to rigorous surgical cleanliness (asepsis), its
prevention in an entire country, so far as normal confinements are
concerned, is primarily a matter of insuring that the requisite pro­
cedure not only is familiar to but is practiced by all the persons
who are authorized to attend confinements. For this purpose effec­
tive supervision by a public-health agency over hospitals, over the
training and admittance to practice of physicians, and over mid­
wives and nurses is necessary. Among public-health measures for
the control of puerperal septicemia the requirement that it shall be
reported like other infectious diseases is of great importance, since if
public-health authorities are promptly notified of the occurrence of
each case they are in a better position to take necessary precautions
and effective steps to prevent the spread of infection.
The preceding statement applies, of course, only to ordinary con­
finements. In some cases infection occurs before the physician is
called or before the patient is received in the hospital. In rare
instances, furthermore, even with the most rigorous asepsis on the
part of the physician, auto-infection may take place.
With regard to infections following self-induced abortions, preven­
tion is a social rather than a medical problem, since probably in
most such cases infection occurs before a physician is called.5 Un­
fortunately, very little evidence is available to indicate the propor­
tion of cases of infection which follow self-induced abortion.6 Never­
theless, except for the rare cases of auto-infection, the conclusion is
justified that nearly all the deaths from puerperal septicemia are
preventable, since deaths from self-induced abortions are obviously
2Information furnished by the Chicago Lying-in Hospital.
U M .p ., and C. O. Mai;and, M. D.: “ Results gained in maternity cases in which antenatal
+£reo 38 been given, ^ p. 19. Paper read before section on obstetrics, gynecology, and abdominal surgery at
the Seventy-fourth Annual Session of the American Medical Association, San Francisco, June 1923 (Re­
printed from Journal of the American Medical Association, Sept. 22,1923, Vol 81 nn 992-998 )
4Maternal Mortality in Childbirth, p. 9.
,
5“ During my 20 years of active hospital work, having had an unusual opportunity to observe a large
number of cases, I never saw a case develop sepsis in whom an abortion had been performed Now all
patients upon wlmm an abortion is performed in a reputable hospital usually have a definite medical
indication for the interruption of pregnancy. It is always a constitutional condition of either an organic
or a metabolic nature. The resistance in such cases is very much diminished and the women are therefore
TTTife Prpne
infection; still they pass through the ordeal well and but seldom develop complications
Why then, do patients upon whom abortions are performed outside of hospitals develop so many com­
plications?
Rongy, A. J.: ‘ A review of the maternal mortality associated with pregnancy and labor
in the Bronx during the past 10 years,” Medical Record, vol. 99 (Apr. 23, 1921), pp. 691, 696.
®fn two years in Bronx County of 309 deaths from puerperal sepsis 140 were postabortal. Ibid., p. 693.
Of 751 cases in Berlin from 1910 to 1912, 506 (67.4 per cent) followed abortions. Statistigches Jahrbuch
der Stadt Berlin, 32 year (1908-1911), p. 143,
'
'


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66

MATERNAL MORTALITY

unnecessary, and those from septicemia following other confinements
can be prevented in almost all cases by the observance of asepsis by
the attendants at birth.
The experience of certain countries which have trustworthy sta­
tistics covering a considerable period of years shows that puerperal
septicemia can be effectively controlled on a large scale. The figures
for Norway are particularly impressive. In Norway this disease
was early made reportable, and statistics not only of deaths from,
but also of cases of, puerperal septicemia are available for a period
beginning as early as 1859. The figures for the years from 1876 to
1918, presented in Table 43, show a striking reduction of four-fifths
in the case rate and of nearly three-fourths in the death rate during
this period.
T able

43.— Decrease in 'prevalence of and mortality from puerperal septicemia;
Norway, 1876-1918 1

Year

Cases of Deaths
puer­
from
peral
Septice­ puerperal
septice­
mia, noti­ mia per
fied per
1,000
1,000
births2
births2

1876. _____________________
1877. _____________________
1878. _____________________
1879..................................... .
1880- _____________________
1881 _____________________
1882......................... ..........
1883 ______________________
1884___________________
1885- _____________________
1886______________ _________
1887_____________________
1888______________________
1889_______________________
1890_________________
1891 - _____________________
1892 __________ __________
1893-__________________
1894 __________ ______
1895 _____________________
1896______________________
1 8 9 7 --................................... .

12.60
10.50
8.65
9.32
8.42
8.27
7.11
8.36
7.91
8.10
7.83
9.30
8.14
9.17
8.03
7.20
7.35
6.82
7.01
6.08
5. 84
• 5.78

3.15
2. 76
2.13
2. 50
2.02
2.09
1.37
2.11
2.25
2.41
2.15
2.66
2.39
2.86
2.48
2.00
2.21
2.39
2.12
1.45
1.90
1.77

Year

1898____________ ______
1899 ______________________
1900_____________________
1901_____________
1902- ________ _____
1903- __________ __________
1904 ___________________
1905____ _______
1906 ....... .......
1907 ............ . —I________
1908--....................................
1909. ..............
1910- ____ ____ ____________
1911. ___ ___________
1912- ____ ______
1913- ............... ........... - _____
1914_ __________ ___________
1915
_______ ^______
1916- _____________
1917- _____________________
1918- ______________________

Cases of Deaths
puer­
from
peral
septice­ puerperal
septice­
mia noti­ mia per
fied per
1,000
1,000
births2 births2
5.39
5.29
5.22
4.24
4.98
4.43
5.23
4.05
4; 33
4.29
4.33
4.03
4.25
5. 04
4.67
3. 70
3.79
3. 85
3.33
3.:78
2.38

1.56
1.88
1.63
1.48
1.61
1. 70
1.63
1.18
1.24
1.48
1. 57
1. 26
1.23
1.39
1.42
.95
1.12
.92
.98
1.25
.80

1Statistisk Arbok for Kongeriket Norge, 1880-1922. Births taken from yearbook for 1900, p. 8, and
1922, p. 26.
2Includes stillbirths.

The decrease indicated by these figures, furthermore, is consider­
ably understated owing to the increasing completeness of the sta­
tistics of cause of death during the period covered. In Norway,
only those deaths the causes of which are stated definitely by phy­
sicians are included in the cause-of-death . tables; in other words,
deaths not certified at all or ,those which, though certified by phy­
sicians, are reported as due to “ unknown” causes are omitted from
tables dealing with the causes of mortality. But the proportion of
all deaths certified by physicians increased from 44.5 per cent in
1876 to 88.9 per cent in 1917.7 Of the deaths of women of child­
bearing ages (15 to 50) the proportion certified by physicians was
slightly greater than of all deaths so certified (in 1917, 93.7 per cent
7C. no. 4, Beretning om Sundhedstilstanden og Medisinalforholdene i Norge i 1876, p. iv, 1917, p. 33*.


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PREVENTABILITY OF PUERPERAL MORTALITY

67

as compared with 88.9 per cent), but the increase in the proportion
certified was about as great for deaths of women of childbearing
ages as for all deaths— namely, from 59.2 per cent in 1876 to 93 7
per cent in 1917.8
The mortality from puerperal septicemia in England and Wales
shows a marked reduction during the 30 years from 1891 to 1920
(Table 44). The rate fell from 2.60 for the period 1891-1895 to
only 1.59 for the period 1916-1920, reaching its lowest points (1.34
aftd 1.35) in 1913 and 1918, respectively.9 In commenting upon
this decrease Sir Arthur Newsholme calls attention to the enact­
ment in 1902 of the midwives act which was applicable to Eng­
land and Wales, and shows that during the period immediately
following, the rate fell much more rapidly in these two countries
than m either Scotland or Ireland (Table 45).10
T able 44.

Decrease in mortality from puerperal sepsis; England and Wales
1891-1920 1
’
Deaths
from
puerperal
sepsis
per 1,000
births

Period

1891-1895__________ k
1896-1900_________
1901-1905_________

2.60
2.12
1.95

Period

Deaths
from
puerperal
sepsis
per 1,000
births

1906-1910
1911-1915
1916-1920

1.56
1.59

-v¿»“ y.
mo xvcgiowai-ueuenu ior j^ngiana ana wales (1920). d. lxxxvi Tho
classification of causes was that m use before 1911.
v
w v i. m e

T able 45.— Death rates from puerperal fever per 1,000 births; United Kingdom

1881-19141
Wales,
England including
Scotland
Mon­
mouth

Period

1881-1890_________
1891-1900_________
1901-1902 9...............
1903-1910__________
1911-1914___________

’

Ireland

2.56

2.83

......................
____

M °rtf lity in Connection with Childbearing and Its Relation to Infant Mortality. Suni0^®. Forty-fourth Annual Report of the Local Government Board, 1914-15. p. 40.
**
The statistics for the two years 1901-02 are given separately from the rest of the period 1901-1910 The
ma<miklves ^ct, .w,^s Passed July 31, 1902. Its terms applied only to England and Wales
a These statistics are for the years 1911-1913 *

Figures given m Table 46 show a decrease in the mortalitv '
puerperal septicemia in the Netherlands from a rate of 1.3?
births in 1876-1880 to 0.68 in 1921.
1876 p. liv-lv, and 1917, p. 106M07*; and Statistisk Arbo> ‘
and 1920, p. 19.
9 Based upon classification in use before 1911. Eiehtv-third
for England and Wales (1920), p. lxxxvi.
10 Maternal Mortality in Connection with Child9'plement to the Forty-fourth Annual Report of V
London. (Reprinted in part in Monthly ^
vol. 4, pp. 75-84.)


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68

MATERNAL MORTALITY
T able 46.— Decrease in puerperal mortality; the Netherlands, 1876-19211
Deaths from puerperal
causes per 1,000 births
Period
Total

1876-1886
1881 1§85
1886-18901891 1895
1896 1900
1901—1905
1906-1910
1911 1915
1916-1920

L . *________________ _________ ______ _______
______ _______ Í ___ ................ ................ ................ .................. ........... ..................................... ...................
‘ . _ _______ /fiL ____ ______ ____ ______ ______ ______
___ ________ __________ ______ - ___________
__1______ ___ - ____ i t i _____ ____ _
___ - __________ ________________________ _______
1
h i ______________Í1Ü______ ____ _______ _____
> __ ______ 'É._________ _____ _______ ____________

4.08
4.08
3.59
3.02
2.50
2.39
2.39
2.24
2.69
2.28

Puerperal All other
septi­ puerperal
causes
cemia
1.33
1.20.
1.18 :
1.10
.69
.72
.71
. 66
.94
.68

. 2.75
2.88
• 2.41
1.92
1.81
1.67
. 1.68
1.58
1.75
1.60
.

1Statistiek van de sterfte naar den Leeftijd en de oorzaken van den Dood over het jaar, 1921, Statistiek
van Nederland No. 362, p. x*xvii. ’s=Gravenhage, 1922.

The figures in Table 47 are of special interest as a demonstration
of what can be done in a large city in this country. The figures show a
marked decrease in the mortality from puerperal septicemia in New
York City from 1900 to 1921; the rate decreased from 4.1 per 1,000
births in 1900 to a minimum of 2 in 1918, after which it increased
slightly to 2.5 in 1921.
T able 47.— Decrease in the maternal mortality rates; New York City, 1900-1921
Deaths caused by pregnancy and confinement

Year

Live
births1

Puerperal septi­
cemia

All puerperal
causes

Other puerperal
causes

Rate per
Rate per
Rate per
Number 1,000 live Number 1,000 live Number 1,000 live
births
births
births
1900190119021903.
1904..
1905.
19061907-,
19081909.
191019111912.
1913.
1914-,
1915.
191619171918.
1919.
1920.
1921.

,

1915.
1916.
1917.
1918.
1919.
1920.
1921.

81,721
80, 735
85,644
94,755
99,555
103,881
111, 772
120,720
126,862
122,975
129,080
134, 544
135,655
135,134
140, 647
141,256
137,664
141,564
138,046
130,377
132,856
134,241

666
636
611
603
759
837
779
832
772
759
802
r 779
748
733
771.
779
728
715
1,011
750
864
. ; 832

8.1
7.9
7.1
6.4
7.6
8.1
7.0
6.9
6.1
6.2
6.2
5.8
5.5
5.4
5.5
5.5
5.3
5.1
7.3
5.8
6.5
6.2

2 140,177
2 137,923
2141, 234
2 137, 649
2 130,308
2 132,823
2 134,058

779
i 728
715
1,011
750
864
832

5.6
5.3
5.1
7. 3
5.8
6.5
6.2

2 Annual Report, Department of Health, city of New York.
* Birth Statistics, 1915-1921, U. S. Bureau of the Census.


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.

333
292
317
293
385
435
386
413
364
336
376
375
350
338
375
362
314
297
272
281
306
332

4.1
3.6
3.7
3.1
3.9
4.2
3.5
3.4
2.9
2.7
2.9
2.8
2.6
2.5
2.7
2.6
2.3
2.1
2.0
2.2
2.3
2.5

333
344
294
310
374
402
393
419
408
423
426
404
398
395
396
417
414
418
739
469
558
500

4.1
4.3
3.4
3.3
3.8
3.9
3.5
3.5
3.2
3.4
3.3
3.0
2.9
2.9
2.8
3.0
3.0
3.0
5.4
3.6
4.2
3.7

362
314
297
272
281
306
332

2.6
2.3
2.1
2.0
2.2
2.3
2.5

417
414
■ 418
739
469
558
500

3.0
3.0
3.0
5.4
3.6
4.2
3.7

PREVENTABILITY OP PUERPERAL MORTALITY

69

The evidence presented indicates that great progress has been made
in certain localities in the control of mortality from puerperal sep­
ticemia. If statistics were available for the United States from a
period before the nature of the disease and the methods of asepsis were
known the present rate doubtless would show a great reduction in
comparison with such figures. But the present mortality rates for
European countries are much below those for the United States. If
the statistics are comparable they suggest, therefore, either that meas­
ures for control in these foreign countries are more effective or that
the conditions under which they operate are more favorable than in
the United States. A careful study ,of the best methods in use in
this country and elsewhere, of public control over hospitals and over
the licensing and practice of physicians and midwives (such as, for
example, the compulsory reporting of cases of puerperal septicemia)
doubtless would reveal ways in which these methods could be
improved.
OTHER PUERPERAL CAUSES

Puerperal causes other than septicemia fall into seven main groups:
(1) Accidents of pregnancy; (2) puerperal hemorrhage; (3) other
accidents of labor; (4) puerperal albuminuria and convulsions;
(5) following childbirth (not otherwise defined); (6) puerperal phleg­
masia alba dolens, embolus, sudden death; and (7) puerperal diseases
of the breast.
The first four groups comprise the great majority (in 1921, 92.9
per cent) of all deaths from puerperal causes exclusive of septicemia.
The fifth group includes deaths reported as “ following childbirth”
and those from puerperal mania. The sixth, “ Puerperal phlegmasia
alba dolens, embolus, sudden death,” contributes a comparatively
small number of deaths. Very few deaths are assigned to the seventh
group.
Under the term “ accidents of pregnancy” are included three
causeé of death: Ectopic or extra-uterine gestation, abortion or mis­
carriage, and “ other accidents of pregnancy.” The first condition
is relatively infrequent but requires operative interference and is,
therefore, coupled with some extra risk, though with early diagnosis
and in skilled nands the case mortality is not nigh.
Deaths following abortions or miscarriages include those in which
the abortion was caused by diseased or abnormal conditions and also
those in which it was self-induced, provided in both cases that no
infection was reported. An important cause of abortion is syphilis
in the mother; most miscarriages due to this cause, however, can be
prevented by treatment commenced early in pregnancy. Many
miscarriages due to other causes also may be prevented by appro­
priate treatment.11 Except where accompanied by infection or
hemorrhage, however, abortion or miscarriage is not coupled with á
high risk of death for the mother.12
Deaths from self-induced abortions in which no infection has
occurred, or if it has occurred has not been reported, like those which
because of infection are classified under puerperal septicemia, are, of
11
Adair, Fred L., M . D., and C. O. Maland, M . D.: “ Results gained in maternity cases in which an­
tenatal care has been given,” pp. 19-21.
18 Ibid., pp. 9-10. “ Aside from the effect on the maternal impulse, the Woman suffers no ill effects from
the abortion except such as result from certain complications such as hemorrhage or infection.’’


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70

MATERNAL MORTALITY

course, preventable, but prevention is a social rather than a medical
problem. Little or no information is available as to the total number
of such abortions, the proportion that result in death, or the pro­
portion of the total number of deaths from puerperal causes that
follow self-induced abortion.13
Among 266 puerperal deaths in Maryland in 1921, based upon a
study of death certificates, 13 (4.9 per cent) were due to admittedly
self-induced abortion, and 7 of these deaths were classified, as due to
puerperal septicemia. In Wisconsin in the same year; among the
378. puerperal deaths 14 (3.7 per cent) were cases oi admittedly selfinduced abortion; 6 of these were classified as due to puerperal
septicemia.14
The second cause of deaths from “ other puerperal causes” —
puerperal hemorrhage following labor— according to the report of
the Australian Committee is “ under hospital conditions no more
than a more or less serious incident which in almost all cases can with
care be brought under control. The death rate from this condition
is a measure of the ignorance of those attending on the patient of
the proper measures to be immediately resorted to, and often the
degree of ignorance is so complete that the necessity for summon­
ing medical assistance is not realized until it is too late.” 15
Among the causes included under “ other accidents of labor” are
obstructions due, for example, to the small size or abnormal shape of
the pelvic canal. Doctor Meigs states in the Children’s Bureau
bulletin to which reference has already been made that if this condi­
tion is discovered before labor—
proper treatment will in almost all cases insure the life of mother and child:
if it is not discovered until labor has begun, or perhaps until it has continued for
many hours, the danger to both is greatly increased. Every woman, therefore
should have during pregnancy— and above all during her first pregnancy— an
examination in which measurements are made to enable the physician to judge
whether or not there will be any obstruction to labor. A case in which a com­
plication of this kind is found requires the greatest skill and experience in treat­
ment,16 but with such treatment the life and health of the mother are almost
always safe.
Puerperal albuminuria and convulsions, called also eclampsia or toxemia of
pregnancy, is a disease which occurs most frequently during pregnancy but which
may occur at or following confinement. It is a relatively frequent complication
among women bearing their first children. When fully established its chief
symptoms are convulsions and unconsciousness. In the early stages of the
disease the symptoms are slight puffiness of the face, hands, and feet; headache;
albumen in the urinej and usually a rise in blood pressure. Very often proper
treatment and diet at the beginning of the early symptoms may prevent the
development of the disease; but in many cases where the disease is well estab­
lished before the physician is consulted, the woman and baby can not be saved
by any treatment. In the prevention of deaths from this cause it is essential
therefore, that each woman, especially each woman bearing her first child should’
know what she can do, by proper hygiene and diet, to prevent the disease; that
13 Figures for the Minneapolis, General Hospital in 1922 showed 210 abortions or threatened abortions
during a period m which 1,069 births occurred in the hospital, a rate of 1 in every 6; of these abortions 54
(over one-fourth) were admittedly induced. One maternal death occurred in th s group ofpaUents
ir e h J if e n g i v ^ n ,” 3 r ^ - 2 1
’ M - D " “ Eesultsgainedinmatemity easesin whichfntenatai
Ehlers gives figures for Berlin in 1895—96 indicating that a large percentage (34 3 Der cent) of the

i “«“*s K S , S . “ 8' ™ ‘PP: D1'

,P!“ “ »*•»"

16 Maternal Mortality in Childbirth, p. 9. .
f
!*. 2 3 ? .Public must be taught that the conduct of labor complicated by a moderate degree of pelvic
S
S
S
S
as.% cas®of appendicitis and that its proper management requires the highest
degree of judgment and skill, while eclampsia or placenta prsevia are even more serious.” Williams, J. W.:
tirm1
a
n
£ medical education in the United States.” Transactions of American Associa­
tion for Study and Prevention of Infant Mortality, 1911, p. 189.


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LÈEVÉNTa BÎLÎTY OP PUERPERAL MORTALITY

71

she should know the meaning of these early symptoms if they arise so that shf>
m ay seek at once the advice of her doctor; and that she
vision during pregnancy, with examination of the urine at intervals.1?S
P

In a study of the results gained by antenatal care in 2,000 mater­
nity cases Doctor Adair and Doctor Maland state: “ We-feel justi­
fied m concluding that maternal, but not fetal, deaths* from toxemia
may be practically eliminated by adequate antenatal supervision and
intervention at the proper time.” 18
The report of the committee appointed to study causes of death
and invalidity m the Commonwealth of Australia sums up the situa­
tion as follows:
The principal causes of death are five in number— 1. Accidents of pregnancy
Puerperal hemorrhage; 3. Other accidents of labor; 4. Puerperal septicemia5. Puerperal albuminuria and convulsions. The results obtained in hosoitals or
where skilled attention is available, show that these last four causes of death can
be almost entirely eliminated. Such a result can be achieved, but it will be
m Î S S ï ï S 7 m pr? P° rtT
Î ° the extent to which skilled assistance, properly
after l| b o ?^ pr° perly Controlled’ 18 available to all mothers before, during; and

2.

From official statistical sources, however, little evidence is avail­
able as to a decrease in puerperal mortality from other causes than
septicemia, in many countries whatever tendency toward decrease
m the rate there may be is so slight as to be offset by the tendency
toward better certification of causes. Table 48 shows that in Eng­
land and Wales there occurred a decrease in the mortality from these
causes from 2.89 for thé period 1891-1895 to 2.18 for 1906-1910 fol­
lowed by a slight increase to 2.29 for 1916-1920.
/
T a b l e 48.

Decrease in mortality from puerperal causes (except sepsis) • Enaland
and Wales, 1891-1920 1

Period

1891-1895__________
1896-1900_____....
1901-1905___________

Deaths
from
puerperal
causes
(except
sepsis)'
per 1,000
births
2.89
2.57
2.32

Deaths
from
puerperal
causes
(except
sepsis)
per.1,000
births

Period

1906-1910___
1911-1915............
1916-1920____

clasSflcation of c£5es was tnat in usebe&r'e W n. en6ra^

‘

——
_____

2.18
2.31
2.29

England and Wales (1920), p. Ixxxvi. The

Figures given in Table 49 showing the decrease in the mortality
following obstetrical operations in Bavaria and Baden are of interest
m this connection, for although much of the decrease in mortality
is undoubtedly due to the application of aseptic methods and to a
decrease m the incidence o f puerperal septicemia, yet operation is
usually resorted to m those cases in which the risk of death from other
pil$rMral causes is high. Consequently, a decrease in the mortality
attending operative procedures would be likely to mean a reduction
m the mortality from these causes. ^
Fore^n C o u l i t i S f i y l i 0!™ AU Conditions Connected with Childbirth in the United States and Certain
S a f e ’ hafbeen g ^ e ? ” p U 6Q' ° ' Maland’ M ' D " “ Results gained in maternity cases in which ante19 Maternal Mortality in Childbirth, p. 10.


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T able 49.— Decrease in case mortality following specified operations in Baden

from 1870-1879 to 1900-1909, and in Bavaria from 1888-1890 to 1901-1906
Deaths per 100 cases
Operation

Bavaria

Baden

1870-1879 1900-1909 1883-1890 1901-1906
Placenta prsevia----------1..............
Instrumental delivery--------------- Version-.— - ------------------ --------Extraction......................................
Craniotomy---------------■-------------Induced premature birth----------Cesarean section----------------------Premature separation of placenta.

24.8
3.2
7.3
6.5
23.9,
10.0
100.0
6.6

8.5
.6
2.0 j
.4
5.8
2.0
20.0
1.3

22.4
2.9
5.6
18.3
5.8
84.2
4.8

14.7
1.3
2.1
7.2
1.8
17.7
3.4

i Weinberg, W.: “ Kindbettfieber und Kindbettsterblichkeit, ” p. 589.

The preventability of mortality from puerperal causes other than
septicemia is shown in striking fashion, though on a relatively small
scale in the results obtained by intensive prenatal work among small
groups of mothers. In New York City, in a study of 8,743 mothers
who received prenatal nursing care through the Maternity _Center
Association o f New York City working in cooperation with the
Henry Street Settlement, it was found that “ the intensive care
given to mothers during the period of pregnancy, and especially
the emphasis on controlling the albuminurias of pregnancy, brought
immediate results. The mortality from eclampsia was so reduced
to about one-third of the proportion that usually occurs in the
general population from this cause. There were only three maternal
deaths definitely ascribed to eclampsia when nine were expected.
It is significant also that 95 per cent of the cases which showed albu­
minuria during pregnancy resulted in full-term d elivery. A proportion
of only 5 per cent prematurity is a good result for this type of case,
coupled with the reduced maternal mortality from toxemia. 20
The maternal mortality rate from all puerperal causes except sep­
ticemia in the group of mothers who received prenatal care was only
2.06 per 1,000 births as compared with a rate of 2.84 in Manhattan
Borough as a whole.21
.
.
Information on the results of prenatal nursing in the reduction
of maternal mortality may be obtained also from the report of the
Committee on Nursing Education.22 In Boston the Instructive Dis­
trict Nursing Association reported that “ the prenatal nursing ot the
Instructive Nurse Association reduced, tlie m&tern&l de&th. ra/te for
the year 1920 from 7 in every 1,000 births to 2 in every 1,000 births.’ 23
The Metropolitan Life Insurance Co. “ reports that during the period
zo Dublin, Louis I.: “ The mortality of early infaney.II Transactions of the Thirteenth Annual Meeting
of the American Child Hygiene Association, Albany, 1923, p. 89-90. See also PP W1 192•
„„ (<I
21 Report of the Work of the Maternity Center Association, April, 1918, to Dec. 31,1921, p. 33.
In
passing it may be noted that the stillbirth rate was reduced to one-half and the neonatal mortality rate to
threedourths of the rate of the city.” Dublin, L 1.: “ The mortality of. early infancy. ’ Transactions
of the Thirteenth Annual Meeting of the American Child H y p p e Association, pp. W-91. _,
22 Nursing and Nursing Education in thp United States; report of the Committee for the Study of Nursing
^^Instructive District Nursing Association; a review by Mary Beard, p. 14. Boston, 1921. “ LwentYeight thousand and thirty-one visits were paid during the year to 4,353 expectant mothers. _Tw^ty-sa
ner cent of this work was carried on for patients of the Boston Lying-In Hospital in cooperation with the
Harvard Medical School, 3 per cent for the Jewish Women’s Maternity Service Association m cooperation
with Tufts Medical School, and the remaining 71 per cent of the service for about 600 private physicians.


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fr o m 1911 to 1919, a m o n g w o m e n b e tw e e n th e a ges o f 29 a n d 34,
w h o m th e n u rsin g se rv ic e [fo r its p o lic y h o ld e r s] e sp e c ia lly se r v e d in
m a t e r n i t y c are, th e m o r t a li t y r a t e w a s re d u c e d 20.5 p e r c e n t, w h ile
N am on g w o m e n o f th e se a ges m th e p o p u la t io n as a w h o le , th e r e d u c ­
tio n o f th e s a m e p e rio d W as 3.8 p e r c e n t .” 24
34 Frankel, Lee K . : “ A decreasing mortality rate.”


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The Public Health Nurse, February, 1921, p. 73.

PREVENTION OF MATERNAL MORTALITY

Authorities are agreed that in order to secure the best results in
preventing both the mortality and the morbidity associated with
pregnancy and childbirth skilled care must be made available to
every mother not only during the period of confinement but also
during pregnancy and during the postnatal period immediately
following confinement. Furthermore, if such a program is to be
effectively realized the mothers themselves must be educated to
demand such skilled attendance. Only by competent care and super­
vision during pregnancy can the condition of the mother be ascer­
tained, the presence of impediments to normal labor be discovered,
the onset of dangerous symptoms be recognized, and the appropriate
preventive measures be adopted. During confinement the presence
of a skilled practitioner with proper qualifications is essential, and
if any untoward symptoms develop, medical assistance, if not at
hand, must he promptly secured. Supervision during the postnatal
period is also necessary to guard against the development of late
complications and to insure that the mother is given the best chance
for full recovery.
Thus the problem of preventing deaths from puerperal causes
resolves itself into a problem of insuring that every mother shall
receive skilled assistance. In practice its solution requires not only
regulation of the training and qualifications for admission to practice
of physicians, midwives, and nurses, supervision over public and
rivate hospitals in which confinement cases are received, and publicealth control over puerperal septicemia, but also the education
of mothers to demand the proper kind, quality, and amount of skilled
attendance.
In this section are presented: (1) A brief statement of those public
health laws which establish safeguards for the protection of maternity
(laws prescribing minimum qualifications for the practice of obstetrics
or midwifery, laws providing for the licensing and inspection of
maternity and other hospitals, and laws and regulations for the
control of venereal diseases and puerperal septicemia); (2) a sum­
mary statement of the available resources in the United States in
personnel and facilities for maternity care, and evidence of the extent
to which mothers in this country actually receive adequate prenatal,
confinement, and postnatal care from the use of present resources;
and (3) consideration of governmental responsibility, as indicated
by measures which have been adopted in this country and elsewhere,
for the extension of facilities to improve the quality of care and for
the education o f mothers to the need for care.

E

P R O T E C T IV E L E G IS L A T IO N

Four aspects of public-health protection which have to do most
directly with the protection of motherhood are considered here
briefly: (1) Regulation of obstetrical practice; (2) licensing and
inspection of public and private hospitals and maternity hospitals;
74


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PREVENTION OF MATERNAL MORTALITY

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(3) social-hygiene legislation and the control of venereal diseases;
and (4) reportability of puerperal septicemia. On account of the
limitations of the present bulletin these topics can be dealt with only
^summarily, but references are given to sources from which details
can be obtained.
Regulation of the practice of obstetrics.

The regulation of the practice of obstetrics both by physicians
and by midwives takes the form of requiring a license to practice, of
establishing minimum requirements for obtaining such a license, and
of defining and prescribing penalties for malpractice.
Licensing o f physicians.— The licensing of physicians is regulated
by State laws, which vary in scope, in standards for licensing, and in
methods of administration. Nevertheless, all States require by law
the licensing and registration of physicians; all laws provide for a
board or boards of medical examiners charged with the duty of exam­
ining applicants for licenses; and all laws provide both for revocation
of licenses upon conviction for specified offenses and for penalties for
practicing without a license. The diversity in the State requirements
is summed up in the words of Dr. N. P. Colwell:
At the present times, instead of one law and one board in each State to enforce
its provisions [of the medical practice act] there are,' in the 48 States, 96 separate
and independent boards, some States having as many as five or six different
boards, created by as many independent practice acts outlining as many differing
standards of educational qualifications.1

Important points covered by the laws or in some States by the
regulations of the boards are: Educational requirements preliminary
to the medical course, medical education, examination for license,
and reciprocity between States.
With regard tq educational requirements preliminary to the
medical course a great many States (38 in 1924) require the com­
pletion of at least two years of collegiate work; a few States (3 in
1924) require-the completion of but one year of collegiate work;
and a few (5 in 1924) require simply graduation from a standard
four-year high-school course. Two States and the District of
Columbia had in 1924 no requirement as to preliminary education.2
Most States admit to examination for a license to practice medicine
only graduates from a' “ reputable medical college” or from a college
approved by the board of medical examiners. In approving medical
colleges many States accept the ratings of the Council on Medical
Education and Hospitals of the American Medical Association;
some States admit graduates only of “ Class A ” medical colleges,
and others admit graduates of both “ Class A ” and “ Class B ”
colleges. One State (Massachusetts) and the District of Columbia
in 1924 admitted to examination graduates of any “ legally chartered”
medical college.3
All States require that applicants for licenses to practice medicine
pass a written examination. This examination may be waived,
1 Colwell, N. P., M . D.: Medical Education, 1920-1922, pp. 14-15. U. S. Bureau of Education Bulletin,
1923, No. 18.
’ Laws (abstract) and Board Rulings Regulating the Practice of Medicine in the United States and
Elsewhere (revised to Jan. 1,1924), pp. 234-235. American Medical Association, Chicago, 1924.
, Ibid., extract opposite p. 320. For summaries of the Medical Practice Acts, see pp. 13-164: definitions
of
B ’ .?nd °> medical colleges, pp. 214-223; ratings of the medical colleges of the United States,
pp. 223-228, and summaries of State laws with respect to examinations, reciprocity, etc., pp. 234-245,

60564°—26-

-6


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MATERNAL MORTALITY

76

however, in the majority of States (in all except 4 in 1924) in ac­
cordance with “ reciprocity arrangements” by which under certain
conditions a physician within a State who has been licensed in another
State may be granted a license to practice without examination.
The conditions upon which such licenses by reciprocity are granted,
the number of States the licenses of which are recognized, and the
strictness with which these arrangements are enforced vary from
State to State. In some cases the State board may grant licenses
upon the basis of licenses granted in other States without “ reciprocal
Licensing and regulation o f midwives.—In the United States the
licensing of midwives, as in the case of the licensing of physicians,
is a matter for the individual States to regulate, j A wide variety
of laws is found, the principal points of which are given in Appendix
E (p. 132). In general, legislation regarding the midwife, except m
a few States, is in an extremely backward condition. In some States
this results from the fact that there are relatively few midwives; m
other States it is due in part to the association of the problem with
the growth in number of the foreign-born population groups m which
the midwife is preferred by custom to the physician, and in part to
the reluctance on the part of the medical profession and the health
authorities to recognize the lowering of the standards that the in­
creased employment of midwives seems to imply; and in still other
States, which have a considerable proportion of colored population,
the condition is associated with special difficulty in providing ade­
quate trained personnel.
- i l i
In one State (Massachusetts) midwives are not recognized by law,
though special investigations have shown that many of them were
practicing.5 In the majority of States (37 in 1924) a midwife is
required to register, usually with the local health officer, but in only
a few States (18 in 1924) is a license a prerequisite to such registra­
tion. In thè States in which midwives must be licensed the license
is issued only after examination;6 but in few such States (10 in 1924)
are there any educational qualifications, and these qualifications
vary from State to State. Because of the fact that there are few
satisfactory schools of midwifery in this country,7 relatively few
midwives have adequate educational training. Among those that
serve foreign-born groups, however, many have had training in good
foreign schools of midwifery. Midwives in the Southern States,
especially the negroes, are for the most part untrained.
Appendix E gives also the principal regulations in effect governing
the practice of midwives. In general, these regulations prescribe
that the midwife shall restrict her practice to normal cases and to
normal procedures; she is prohibited from performing operations
and from using instruments or drugs, and in all abnormal cases she
is required to call in a physician.
t For details of these reciprocal arrangements see Laws (abstract) and Board Rulings, pp. 236-237. See
also discussion by N. P. Colwell, M. D.: “ Legislation regulating the practice of medicine, preliminary and
medical education, ” in The Monthly Bulletin of Medical Education, p. 10. (Reprinted from the Monthly
Bulletin of the Federation of State Medical Boards, September, 1915, pp. 129-136.)
taÌl U ì
** «Huntington, J. L., M . D.: “ Midwives in Massachusetts.” Boston Medicai and Surgical Journal,
V

xTO^^latema1andPRhodeLÌ and ; Minnesota accepts a diploma from a school of midwifery in lieu of

an7 AnTnauby addressed by the U. S. Children’s Bureau in 1921 to the directors of child-hygiene divisions
in the several States elicited information regarding the existence of only two such schools.


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Licensing and inspecting of hospitals.8

Kegulation of public and private hospitals and maternity hospitals
in the United States includes legal provisions governing the estab­
lishment of such institutions and requiring that they be licensed and
subject to inspection.
Public hospitals may be Federal, State, or local in character; in
most States a local government body must obtain specific authority
from the legislature to establish a hospital, but in some States general
legislation requires counties or cities of a certain size to maintain
hospitals. In 1925 in 39 States municipalities had specific authority
to establish hospitals, although in some of these States such authority
is subject to certain restrictions and limitations.9
Private hospitals may be operated either for profit or for charitable
purposes, and may be either incorporated or unincorporated institu­
tions. Some States require all such hospitals to be licensed ; in some
States the power to require licensing is delegated to municipalities;
in others the law contains no provisions on this subject.10
The licensing of maternity hospitals is a comparatively recent de­
velopment. In 1925 in- 29 States licenses were required for such hos­
pitals. With the power of licensing is usually associated the power
of inspecting, and the power to revoke the license for cause.11.
Social-hygiene legislation.

Since venereal diseases are serious complications in pregnancy and
confinement, legislation for the control of these diseases is of great
importance in public-health protection of maternity. Such legisla­
tion takes two forms.12 In the first place, a number of States have
enacted laws, which are for the most part of recent origin, requiring
a certificate of physical fitness or of freedom from venereal disease
as a prerequisite for obtaining a marriage license. Such laws have
been enacted (1925) in eight States,13but are not always well enforced.
In the second place, practically all the States have made venereal
diseases reportable by physicians with certain safeguards, such as
secret returns on reports by number instead of by name. This is
secured as a rule by regulations promulgated by the State board of
health, but in some States special laws have been enacted to deal
with this public-health problem.
Except for the laws of two States all this legislation was enacted
during or following the Great War, and to a large extent as a result
of the stimulation to State activity given by the Federal grants under
the provisions of the Chamberlain-Kahn Act of 1918. The annual
reports of the United States Public Health Service from 1918 to 1923
contain a full description of the campaign undertaken to combat
venereal disease.
In order to obtain the grants from the Federal funds, according to
the regulations adopted by the Interdepartmental Social Hygiene
Board, a State must satisfy, the following conditions: Either by law
8The information upon which this section is based is contained in an article entitled “ Legislation affect­
ing hospitals, by Dorothy Ketcham, in the Modern Hospital Year Book (5th Edition), pp. 25-44 (Chicago
1925).
'
9Ibid., pp. 31-32.
»»Ibid., pp. 32-37.
11 Ibid,, p. 37.
k See Social Hygiene Legislative Manual, 1921, published by the American Social Hygiene Association,
New York; also Digests of Social Hygiene Laws of all States in the United States in 1922, New York
13Alabama, Louisiana, Minnesota, North Carolina, North Dakota,- Oregon, Wisconsin, and Wyoming
See alsoi ‘ The ^eugenic’ marriage laws of Wisconsin, Michigan, and Illinois,” by Bernard C. Robert
in Social Hygiene, Vol. VI, No. 2 (April, 1920), pp. 227-254.


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MATERNAL, MORTALITY

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or by regulations having the force of law it must provide that venereal
disease be reportable to local health authorities, and there must b
penalties for physicians and others in case of failure to report; cases
of diseases must be investigated to discover the source of infection;
the spread of venereal disease must be declared unlawful; there must
be provision for the control of infected persons who will not cooperate
in preventing the spread of infection; the travel of infected persons
must be restricted, and patients must be given pamphlets of in­
structions.
At the close of the fiscal year 1919, the first- year in which the
Chamberlain-Kahn Act operated, 46 States had qualified to obtain
the Federal grant of money, and hence had laws or regulations that
satisfied these minimum requirements; by 1922 all the States had
qualified for their quotas of the Federal appropriation, but the Dis­
trict of Columbia had not.14
Reportability of puerperal septicemia.15

For the prevention of puerperal septicemia the importance of mak­
ing it a reportable disease is clear, since the health authorities are able
to enforce necessary precautions only if they have prompt information
that cases have occurred. In the United States m 1923 the laws or
regulations of 16 States included puerperal septicemia among reportable diseases (Table 50). But in only one of the States within the
death-registration area (Mississippi) did the number of cases reported
to the State health officer exceed the number of deaths.16
T able 50.— States in which puerperal septicemia is a reportable disease and the

year in which it was made reportable 1

State

„ ;

,

Year
when
made
reportable

State

Year
when
made
reportable

1916
(2)
1916
(3)
1917
1911
1919
1914

Oklahoma.__________ _______ _________
Oregon__________ __________ _________
Pennsylvania-------------- --------- -----------South Dakota---------- -------------------------Vermont______________________ ____
Washington___________________ ______
Wyoming____________________ _______

(3)
1920
1918
1906
1912
1908
1921
(3)

1 Compiled from replies to questionnaires relative to reportability of puerperal septicemia sent by the
Children’s Bureau in 1923 to State boards of health.
1 Before 1918.
3Year not stated.

Personnel.

PR O V ISIO N S FO R M A T E R N IT Y CARE
«

The number of physicians legally qualified to practice in the
United States in 1925 was 147,010,17 or 13 per 10,000 population.
In Table 51 are given the number and proportion to population of
legally qualified physicians in each of the States. In view, however,
ü Annual Reports of the Surgeon General of the U. S. Public Health Service, fo: the fiscal years 1918,
1919, 1920, 1921, 1922, 1923.
. , ,
£
,
c.
u The information upon which this section is based Was obtained by correspondence mom the State
boards of health. Returns were not received from Georgia, North Carolina, and South Carolina.
« Returns for Mississippi in 1920 gave 736 cases and 165 deaths. For Nevada, outside the death-regis­
tration area, returns for 1912 gave 15 cases and 6 deaths. In a number of States, however, no figures as to
the number of casei reported were obtained.
,
.
ü American Medical Directory, 1925, p. 8. American Medical Association, Chicago.


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& * & « & » differences in the requirements set up by different Sfirf«»

Z n t caseT Bu^nn l l
“ ° f th??\Phy«icians who take confine* cases. tiut no figures are available on these points.20
T able 51.

-Proportion of physicians to population, hy States, 1925
Physicians (1925)

State

Per 10,000
Number1 ^timated
popula­
tion

United States.
Alabama___
Arizona____
-Arkansas__
California__
Colorado___
Connecticut.
Delaware.
District of Columbia.
I
Florida..............
....... **81<f
Georgia........ . . . "
Idaho................
Illinois_____
Indiana........*’ II
Iowa...... .......... .................
Kansas.____l~l
.......
Kentucky____
Louisiana__ 1___
Maine________
M aryland..!
Massachusetts..
Michigan_______
Minnesota______
Mississippi______1
"
Missouri___

111

147, 010
2,284
378
2,212
8,363
1, 837
1,884
i sfq
1,452
3,122
416
10, 743
4,251
3, 378
2,364
3,041
1,901
1,037
2,313
6,187
4,837
2,823
1, 702 j
5,806

13.0

Physicians (1955)
State

Montana______
Nebraska______
Nevada_____ HI
New Hampshire.
New Jersey_____
New Mexico____
New York_____
North Carolina
North Dakota..
Ohio________ _
Oklahoma______
Oregon________ 1]
Pennsylvania___
Rhode Island
South Carolina
South Dakota___
Tennessee_______
Texas...............
Utah___________"
Vermont____ 1111
Virginia..____ V
Washington____ 1
West Virginia____
Wisconsin_______
Wyoming______

Pet 10,000
estimated
popula­
tion
525
1,869
129
601

3,567
365
17, 671
2,281
485
8,113
2,524
1,176
11,140
771
1,317
604
3,128
6,063
505
537
2,534
1,781
1,753
2,826
255

l3.g

16.7
13.4

10.2

American Medical Directory, 1925, 9th Edition, p.8. American Medical Association,

physicians per 10,000
T k l twice ,as high
-,ese % ures indicate

as that in more sparsely settled areas (9 7)
that the cities are better n rovfi£T ^ /fL
the rural ^ ' t r i c f e ; i f w F r e ' * 2 * 9 than are
of obstetrical specialists tfi^Y
m
showing the distribution
cities, especkUyP t h r C e 7 ^ undoub<*dly show that the
toasted with the smaller cities and'the m rIlH igI? ” l faTOred “ con-


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MATERNAL MORTALITY

T able 52 .— Proportion of physicians to population for urban and rural areas, 1920 1

Population

Number
of cities

Bolow 5,000..... ........................

Per cent Number
popula­ of physi­
cians 2
tion

Ratio of Physi­ Percent­
physi­ cians per age all
10,000
cians to
physi­
popula­ popula­
cians
tion
tion 3
726

13.8

100

105,710,620

100.0

145,608

1,467

49,710,650

47.0

91, 565

12
21
111
602
721

16,369,301
6, 353, 529
9,972, 243
12,017, 783
4,997, 794

15.5
6.0
9.4
11.4
4.7

30,932
12,862
17,254
21,204
9,313

529
494
578
566
537

18.9
20.2
17.3
17.6
18.6

21
9
12
15
6

55,999,970

53.0

54,043

1,036

9.7

37

United States..^_______

500,000 and above_______
200,000 to 500,000________
50,000 to 200,000_________
10,000 to 50,000__________
5,000 to 10,000...................

Total
popula­
tion

18.4

1 Compiled from Medical Education, 1920-1922, by N. P. Colwell, p. 12 (U. S. Bureau of Education,
Bulletin, 1923, No. 18) and Fourteenth Census of the United States, 1920, Vol. I, Population, Tables 31
and 38, pp. 50, 58 (U. S. Bureau of the Census).
2 From the American Medical Directory for 1921.
8The number of physicians is compared with the population on Jan. 1,1920, as enumerated by the census.

The number of nurses in the United States in 1920, according to
the census, was about 300,000, including both male and female.
Approximately half of these (149,128) were reported as trained and
registered nurses, of whom perhaps 11,000 were engaged in publichealth nursing, about the same number in hospitals and other insti­
tutions, and the rest (over 120,000) in private duty. In addition to
the trained and registered nurses there were 151,996 attendants, prac­
tical nurses, and others below the grade of registered nurse, and 54,953
student nurses in hospitals. In 1920, therefore, it was estimated that
there was one registered nurse to every 700 persons, and one nurse
(trained or untrained) to every 294 persons in the United States.21
As in the case of physicians these figures represent, of course, the total
nursing personnel available for all purposes and not nurses engaged
in obstetrical work.22
The number of midwives engaged in practice in the several States
in 1923, compiled from the scanty evidence available, is shown in
Table 53. In the United States as a whole, according to figures fur­
nished the Children’s Bureau by State boards of health or State
bureaus of child hygiene, at least 26,633 midwives in 31 States were
registered or licensed to practice. But even in States which require
a license or registration or both, in addition to authorized midwives,
a larger or smaller number were reported as practicing without the
required license. In nine States, which did not require licenses or
registration, estimates were furnished by the State health officials of
the number engaged in practice. For a few States no estimates could
be furnished, and the numbers in the table are merely those given in
the census of occupations; these figures are undoubtedly a minimum*
for in practically every State the number of midwives reported as
authorized to practice by State health officials exceeded the number
enumerated by the census.23 As already noted (see p. 76) except in the
21 Nursing and Nursing Education in the United States; report of the Committee for Study of Nursing
Education, p. 171. New York, 1923.
. „,
„
. ,, TT
.
22 For a discussion of nursing education see Nursmg and Nursing Education m the United states, also
Statistics of Nurse Training Schools, 1919-20. U. S. Bureau of Education Bulletin, No. 51, 1921.
23 The total number of midwives enumerated in the census of 1920 for the entire United States was 4,773.
Fourteenth Census of the United States, Vol. IV, Population, p. 43.


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PREVENTION OE MATERNAL MORTALITY

81

States which exercise strict supervision probably comparatively few
of these midwives were adequately trained.24
T able 53.— Midwives authorized to practice and percentage of births attended by

midwives, by States, 1928 1
Midwives
State

T ota l.....___
Alabama....... ..........
Arizona____ ______
Arkansas......... .......
California___ _____
Colorado____
Connecticut_______
Delaware_____ ____
District of Columbia.
Florida_________
Georgia................... .
Idaho____________
Illinois................. .
Indiana.................
Iowa__ ___________
Kansas_______ ____
Kentucky................
Louisiana. ..........
Maine.....................
Maryland_________
Massachusetts_____
Michigan____ _____
Minnesota___ _____
Mississippi________
Missouri__________
Montana____ _____
Nebraska.................
Nevada.__________
New Hampshire____
New Jersey.............. ;
New Mexico_______
New York...____ ...
North Carolina........
North Dakota........
Ohio__________ ___
Oklahoma_____ ___
Oregon.......... ...........
Pennsylvania______
Rhode Island______
South Carolina___...
South Dakota______
Tennessee..;_______
Texas.:___________
U t a h ...............:.
Vermont._________
Virginia........... ........
Washington________
West Virginia...___
Wisconsin_________
Wyoming__________

Percent­
Author­
Others
age of
ized to estimated
births
practice
attended
26,633
1,862
45
3181
104
15
123
200
33
(2)
1,800
100
1,115
4 254
40
(2)
2,500
230
(«)
339
(5)
0
118
3,218
8 803
334
(«)
(2)
7
415
(*)
1,976
2,500
(2)
(2)
None.
16
0
47
996
(6)
815
(8)
(2)
h
6,036
50
(0)
361
(2)

18,045
(2)
(2)
(2)
(2)

i

25
(2)
(2)
(2)
2,000
(2)
(2)
(2)
(2)
. (2)
*8
(2)
1,808
65
346
7 117
1,162
48
991
(2)
(2) j
20
(2)
None.
262
85
(2)
4,000
42
8152
816
(2)
1,500
(2)
3,715
133
1,000
300
350
81
(2)
(2)
8 19
(2)
(2)

(2)
32
12
17
8
(2)
16
16
4
38
(2)
(2)
(2)
5
0.1
(2)
18
47
(2)
22
(2)
7
(2)
48
' (2)
3
2, (2)
. (2)
27
(2)
» 11
35
(2)
(2)
(2)
(2)
(2)
(2)
(2)
3
12
(2)
(2)
(2)
35
4
(2)
10
(2)

1Except where otherwise noted, data were obtained by correspondence with State boards of health or
bureaus of child hygiene. The totals give the sum of the figures so far as information is available.
2Not available.
3Figures for six counties only.
4Number licensed since 1897."
5Fourteenth Census of the United States, Vol. IV, Population, Table 15.
6State does not license nor register midwives.
7In a surveyed district only.
8Number registered since 1887.
9 Percentage based on figures for_New York State exclusive of New York City.
24
A study of 115 midwives in Minnesota who were interviewed by representatives of the State division
of child hygiene showed only 3 in grade A (“ women who were * * * alert and intelligent, who gave
evidence of understanding the proper technique of a normal delivery, the recognition of obstetrical compli­
cations, and particularly an understanding of their limitations * * * a high degree of neatness, cleanli­
ness and orderliness” ) and only 5 in grade B (those who failed in one or two respects from qualifying or
belonging to grade A). Boynton, Ruth E., M . D.: “ The midwife survey in Minnesota.” Child Health
Magazine, Vol. V (Apr. 5,1924), p. 164. For a discussion of the whole subject see Anna E. Rude, M. D.,
“ The midwife problem in the United States,” Paper read before the section on Obstetrics, Gynecology,
and Abdominal Surgery at the 75th Annual Session of the American Medical Association, San Fran­
cisco, June, 1923.


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82

MATERNAL MORTALITY

Facilities.

Information is not available for the whole United States on the
number of agencies giving prenatal care. An inquiry made by the
Children’s Bureau in 1920 showed that there were at least 558
agencies which gave prenatal care to mothers either exclusively or
in connection with other health activities) and which served States,
counties, or urban areas of 10,000 or more inhabitants.25 This
figure is an understatement of the total number of such agencies,
since the inquiry was limited to cities of at least 10,000 population
and since even in these cities agencies may have been omitted because
of inadvertent omissions from the list of those to which questionnaires
were sent, failure to reply to the questionnaire, or for other reasons.
The number of public and private hospitals in the United States
in 1924, according to the Modern Hospital Year Book, was 6,762,
including 180 exclusively maternity hospitals.28 Unfortunately, no
comprehensive statistics are available to show the number of beds
available for confinement care in these institutions.27
Information as to the number of maternity homes in which ex­
pectant mothers are cared for both before and after childbirth as
well as during confinement, as distinguished from maternity hospitals
in which women are received for confinement only, is available
for only a comparatively few States. In Minnesota 11 and in Penn­
sylvania 24 maternity homes were found and visited in the course
of a survey made by the Children’s Bureau in 1923.28
Inadequacy of care received.

To serve as a rough basis for judging the types and amount of
skilled care and supervision now j actually received by mothers in
the United States, the minimum standards for public protection of
the health of mothers adopted by the Washington and regional con­
ferences on child welfare in 1919 29 are given below:
1.
Maternity or prenatal centers, sufficient to provide for all cases not receiving
prenatal supervision from private physicians. The work of such a center should
include:
(а) Complete physical examination by physician as early in pregnancy as
possible, including pelvic measurements, examination of heart, lungs, abdomen,
and urine, and the taking of blood pressure; internal examination before seventh
month in primipara; examination of urine every four weeks during early months,
at least every two weeks after sixth month, and more frequently if indicated;
Wassermann test whenever possible, especially when indicated by symptoms.
(б) Instruction in hygiene of maternity and supervision throughout pregnancy,
through at least monthly visits to a maternity center until end of sixth month,
and every two weeks thereafter. Literature to be given mother to acquaint her
with the principles of infant hygiene.
(c)
Employment of sufficient number of public-health nurses to do home
visiting and to give instructions to expectant mothers in hygiene of pregnancy
and early infancy; to make visits and to care for patient in puerperium; and to
see that every infant is referred to a children’s health center.
88 Compiled from list given on pp. 321-340, Directory of Local Child-Health Agencies in the United States
(U. S. Children’s Bureau Publication No. 108, Washington, 1922).
28 The Modem Hospital Year Book (Fifth edition), p. 16. Chicago, 1925. Of the 6,762 hospitals, l,604 were
public and 5,158 were private; 4,725 were general hospitals and of these the majority were doubtless open
to maternity cases.
27 Figures from 2,645 hospitals which admitted maternity cases in 1920 (including 97 exclusively maternity
hospitals) showed at least 27,405 beds available for maternity cases. See Anna E. Rude, M. D.: “ The
Sheppard-Towner Act in relation to public health,” p. 11 (Paper read before the section on preventive
and industrial medicine and public health at the Seventy-third Annual Session of the American Medical
Association, St. Louis, May, 1922).
28 See A Study of Maternity Homes in Minnesota and Pennsylvania (U. S. Children’s Bureau Publica­
tion; in press).
29 Minimum Standards for Child Welfare, Adopted by the Washington and Regional Conferences en
Child Welfare, pp. 7-8. U. S. Children’s Bureau Publication No. 62. Washington, 1920.


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PREVENTION OP MATERNAL MORTALITY

83

a t S d a n ” flOTtoefho*pita“ e by a physioian or a W f i ? » « n e d and qualified
i j e r i o d f o i K p S e l r e ! h° me

*he tlme ° f C' ,nfl,,ement a,ld during the lying-in

°th6r VMtS dUring 8e0°nd Week
,Ai , least.tenr days’ rest in bed after a normal delivery, with sufficient
househoid service for four to six weeks to allow mother to recuperate.
patient™
10n by physlcian six weeks after delivery before discharging
Where these centers have not yet been established, or where their immediate
em fm prSn 11n 1S 11,mPractlc.abJlei fs many as possible of these provisions here
- d e r the direction
duringpTegiaTcy. ** dental CliniCS and venereal clinics for needed treatment
3.
Maternity hospitals, or maternity wards in general hospitals, sufficient to
provide care m all complicated cases and for all women wishing hospital careh o^e o ? t J ’a h o^ eital°bStetrlCal ?*** t0 be provided in eveiT necessitous case at
licensed ancf eupejv^sed6 reqUlred by

*° 8b° W adequftte trftinil*

“ d

b*

nursin^pexioi mCOme *° allow the mother to remain in the home through the
in fan f mortality 'ftn^their' solution.88 ‘ ° Pr° blem8 presented ^

maternal and

Prenatal care.— Evidenee relating to the amount or quality of
prenatal care afforded mothers in the United States is relatively
meager. _In special studies made by the Children's Bureau such
evidence has been obtained for a few cities and rural districts, which
in the absence of comprehensive statistics may serve as an indication
ot the prevalence of prenatal care in typical communities.
in Baltimore, Md., a city which has an excellent medical school and
hospital and well-developed clinics but in which a comparatively small
proportion of the births occur in hospitals (see p. 86), a study was
made of the prenatal care received by all mothers of legitimate
infants born m 1915.30 Among mothers who had had some prenatal
care were included all who either had had a urinalysis or had made
one or more visits to a physician during pregnancy. A visit merely
to engage the services of a physician without medical consultation
was not considered a visit for this tabulation.
Nearly half the mothers studied (47.5 per cent) had had no medical
prenatal care of any kind. On the other hand over half (52.5 per
cent) had received medicai care— 12.6 per cent froih physicians
attached to the clinics and 39.8 per cent from private physicians.
.v .? proportion of mothers in the different nationality groups
who had received prenatal care varied from 13.9 per cent of the
o ish and 22.1 per cent of the Italian, to 53.4 per cent of the Jewish,
57 per cent of the colored, and 58.3 per cent of the native white.
Ut the mothers whose husbands earned from $550 to $649, only
b0'V pei T ni M reT v®d Prenatal care, whereas of those whose
husbands had died or had earned nothing during the year following
the birth of the baby, 57.3 per cent had received such care. But
m the group whose husbands earned $2,850 and over the proportion
receiving prenatal care was 89.2 per cent. These variations were
idently influenced m part by prejudice against receiving such care,
Rochester, A p p e S x v l! p'g


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StUdy “ Baltimore’ M <b based on births in one year, by Anna

M A T E R N A L M O R T A L IT Y

84

as in case of the low proportions of Polish and Italian mothers,
in part by provisions for free care by clinics and by proximity to
them, as in case of the comparatively high proportion of colored
mothers, and in part by the funds available to pay for medical preThe care received was classified roughly into three grades, desig­
nated by the letters A, B, and C. In grade C were placed all cases
in which the mother either had had one urinalysis or had made one
or more visits to a physician during pregnancy but in which the care
could ,not qualify as either grade A or grade B
To qualify m
grade B the care received by the mother must have satisfied all
four of the following requirements: (1) Some supervision by a
physician; (2) at least one urinalysis; (3) at least an abdominal
examination; (4) pelvic measurements if a pnmipara. To qualilv
in grade A, the care must have fulfilled the following additional
requirements: Monthly visits to clinic from the fifthl to the ninth
month, or under supervision of private physician from the filth to the
ninth month, and monthly urinalysis during the same period.
Of the entire group of married mothers, only 5.1 per cent had pre­
natal care which could be classified as of grade A ; 17.1 per cent had
grade B care; 25.6 per cent had grade C care; and 4.5 per cent had
care the grade of which could not be definitely determined. For 48
per cent of the mothers who had received prenatal care this care did
not begin until after the fifth month and consequently could not
satisfy the requirements for grade A. More than one-fourth ol the
mothers who were classified as having had prenatal care saw a physi­
cian only once during pregnancy. Only 31.4 per cent had had as
many as five consultations.
, ¿'.V
,
,■
* x?Qu;
The following is quoted from the publication based on the Balti­
more study:
Several points may be mentioned in connection with these results. In the first
place the requirements even for grade A are low and may by no means be co sidered ideaL The fact that so small a proportion of mothers received care of
grade A with its low standard is therefore all the more significant. In the second
rhapp though the care given by the three clinics was based upon their records,
the private physicians was based upon the
mothers’ statements. The results are, therefore
^
thp mothers’ memories may have been at fault or that the motners may
have u n d S to S l the object or scope of the examination made by the Physicians
On the other hand, the agents were given careful instructions m regard to the
questions t o b e a s k k and in every case the answers were so classifysd as tc>over
state rather than to understate the extent of care actually received. In the third
nlfce ft should be emphasized that the results of this study can not be interpreted
ss fn anv wav a criUcism of the physicians or the clinics, since the small proporff o i of cases^eceiving the best grade of care is largely determined by the fact
that the mothers did not present themselves for treatment early en0^ h mb^ te
nrpgnancies or did not continue visits with sufficient regularity, b or a better
showing the fuller cooperation of the mothers is required, and this can be secured
o n l^ S p r t h l M P o H S of early care is generally recognized and appreciated.^

In Gary, Ind., a city with relatively undeveloped clinical facilities,
a similar study was made relating to prenatal care received by
mothers of infants born in 1916. The result of the study showed
that 70.2 per cent of the mothers had not received any medical pre
natal care. Only 2.4 per cent had received care of grade A, 3.9 per
» Ibid., pp. 208-209.


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PREVENTION OP MATERNAL MORTALITY

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cent had received care of grade B, and 23.1 per cent had received
care of grade C.32
Studies made in rural districts have shown on the whole even
smaller proportions of mothers who had received prenatal care. In
one rural district in northern,Wisconsin, in only one-eighth of the
recorded pregnancies during the period covered by the survey did
the mother have any medical prenatal care, and in only one-fifth of
the cases in which a physician attended the birth did he give any
prenatal supervision. In a rural district in the southern part of the
same State, however, the proportion receiving supervision was much
larger; of the mothers attended at confinement by physicians, nearly
two-fifths (38 per cent) had received supervision during pregnancy.
In a rural county in Kansas one-third of the mothers of infants born
in a two-year period had received some prenatal care from physicians;
but less than 1 per cent had care that could have been considered as
of grade A. In a homesteading county in Montana, on the other
hand, a proportion of less than 1 in 4 of all the mothers visited had
consulted a physician during pregnancy, and in no case was the care
received such as to satisfy the requirements for grade A. In com­
munities studied in the Southern States the situation with regard to
prenatal supervision was found to be very similar to that found in
the rural districts of the Northern and Western States. In a rural
county in North Carolina only 21 of 79 white mothers, or less than
one-third, saw a physician during pregnancy, and only 12 had urin­
alysis. Of the 86 negro mothers, 2 saw a physician before confine­
ment, and 1 reported urinalysis. In all, therefore, only 21.8 per
cent of the cases had any prenatal care. None of these mothers
could be regarded as having had care of grade A. In another county
in a mountainous district of North Carolina only 5 per cent of the
mothers visited had any medical prenatal care, and again in no
casre could the care received be classified as of grade A. In selected
rural areas of Mississippi only about 16 per cent and in a mountain
county in Georgia only 14 per cent of the mothers had received any
medical prenatal care.33
The surveys referred to, made by agents of the Children’s Bureau,
relate to a period from four to eight years ago, and the relatively small
proportions of mothers shown by them who had received prenatal
care have probably been increased since that time as a result in part
at least of the campaigns of popular education on this subject (see
pp. 95-97) and of the establishment and development of prenatal
clinics. The development of prenatal care and nursing services to
mothers by some of the larger life-insurance companies has been
another important factor in securing better care of mothers during
pregnancy.34 The establishment of prenatal clinics in many cities,
usually in connection with but in some cases entirely separate from
the infant-welfare centers, has made available to many mothers skilled
care and advice. But even yet, in spite of these encouraging
32 Infant Mortality; results of a field study in Gary, Ind., based on births in one year, by Elizabeth
llughes, p. 28-29. U. S. Children’s Bureau Publication No. 112. Washington, 1922,
33 Maternity and Infant Care in Two Rural Counties in Wisconsin, by Florence Sherbon, M . D., and
Elizabeth Moore, pp. 37-38, 64; Maternity and Infant Care in a Rural County in Kansas, by Elizabeth
Moore, p, 28; Maternity Care and the Welfare of Young Children in a Homesteading County in Montana,
by Viola I. Paradise, p. 37; Rural Children in Selected Counties of North Carolina, by Frances Sage Brad­
ley, M . D., and Margaretta A. Williamson, p. 30; Maternity and Child Care in Selected Rural Areas of
Mississippi, by Helen M. Dart, p. 24; Maternity and Infant Care in a Mountain County in Georgia, by
Glenn Steele, p. 11. U. S. Children’s Bureau Publications Nos. 26, 33, 34, 46, 88, and 120.
34See Nursing and Nursing Education in the United States, p. 49.


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MATERIAL MORTALITY

86

developments, probably but a small proportion of mothers receivé
anything like adequate care during the prenatal period.35
Confinement and 'postnatal care— With regard to confinement car
evidence is available, though only for certain areas, on two points—the
proportion of births that occurred in hospitals and the proportion of
births that were attended by physicians.
The proportion of births m hospitals in 1921 in cities from which
the Children’s Bureau was able to secure information on this point is
shown in Table 54. The figures varied from 85 per cent in San
Francisco and 62.1 per cent in Minneapolis to 18.7 per cent in Balti­
more (in 1920) and 9.2 per cent in New Bedford.
The proportion of hospital confinements is much larger in cities
than in rural districts. The better hospital facilities not only would
attract mothers living in the cities but would induce many mothers
living in neighboring districts to come to the city hospitals for con­
finement. The effect of such a tendency for mothers from the
country and from small towns to seek the special facilities of the cities
would be to increase the number of births in the city hospitals and
thus to increase the proportion of hospital births in cities. The
contrast between the proportions of hospital births in city and coun­
try districts can be shown in figures for Maryland; of the births in
Baltimore, 18.7 per cent occurred in hospitals, as compared with
only 2.6 per cent of the births in Maryland outside Baltimore.
T able

City

San Francisco, Calif-Minneapolis, M inn,,,
:St. Paul, M inn........ ¡Spokane, Wash---- —
Hartford, Conn—
¡District of Columbia,
¡Springfield, Mass----Syracuse, N. Y --------Albany, N. Y ----------Oakland, Calif--------Duluth, M inn,______
Cincinnati,. Ohio------Salt Lake City, Utah.
Cambridge, Mass----Columbus, Ohio------Philadelphia, Pa-----Bridgeport, C o n n ,--,
Newark, N. J , - .........

54.— Proportion of births in hospitals in certain cities 1

Year

1921
1921
1921
1921
1921
1921
1921
1921
1921
1921
1921
May, 1922
1921
1921
May, 1922
1921
1921
1921

Per cent
of births
in hos­
pitals
85.0
62.1
60.4
60,0
53.0
52.9
50.1
48.3
47.3
45.8
38.7
36.7
36.7
36.3
33.6
31.2
30.9
30.6

City

Yonkers, N. Y _ I .......
Pittsburgh, Pa______
Cleveland, Ohio------Grand Rapids, MiehBuflalo, N. Y -_ _ ,—
Wilmington, D e l,-,,Scranton, Pa_______
Indianapolis, Ind____
Toledo, Ohio_______
Trenton, N. J---------New Orleans, La____
Baltimore, M d _____
Louisville, K y....... .
Akron, O h io........... .
Lowell, M a ss..,,----Fall River, Mass____
Milwaukee, Wis— ,
New Bedford, Mass,.

Year

1921
1921
1921
1921
1921
1921
1921
1921
1921
1921
21922
1920
1921
1921
1921
1921
1921
1921

Per cent
of births
in hos­
pitals
30.4
27.4
26.7
26.2
26.1
24.7
24.0
22.1

21.9
20.1

19.0
18.7
18.1
18.0
17.7
16.1
9.8
9.2

i Based upon reports of State or city bureaus of vital statistics,
s First six months.

Though the best type of care can be obtained in well-regulate
hospitals, confinement in a hospital does not necessarily insure sue
care. Information concerning the proportion of births in hospital
care,
25 in a study of the health work in 1920 in the 83 largest cities of the United States prenatal clinics were
found in 68 cities, and in 5 of the 15 which apparently had no such clinics visiting nurses provided care and
advice to expectant mothers. “ Of 35 cities giving definite figures, 6 report that less than one mother pe100 infants born (including stillbirths) attended a prenatal clinic during year; 17 cities report from 1 1
mothers in attendance; 9 from 5 to 10; and 3 over 10 (Indianapolis 11.9, Cleveland 12.2, and Boston 20.Zf,
Infant Hygiene, Report of the Committee on Municipal Health Department Practice of the American
Public Health Association in cooperation with the United States Public Health Service, by Ira V . Hiscoek,
pp. 115-116. Public Health Service Bulletin No. 136. Washington, 1923.


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PREVENTION OF MATERNAL MORTALITY

87

therefore, without further evidence as to the management and the
routine precautions taken in these hospitals, can not be considered
ijmpletel3rsatisfactory evidence as to the quality of confinement care,
buch evidence, unfortunately, is not available.
On the other hand, in certain respects hospital care is distinctly
superior to that received by many mothers who are confined at home.
Hospital care implies that the mother receives medical attention
that she has the services of a nurse and whatever additional attend­
ance is required, and that, in case her condition requires it, she can
be operated upon with a minimum of risk. Furthermore, while in a,
hospital a mother has complete rest from housework and from otheremployment.
For a few cities evidence is available which shows that the propor­
tion ot births m hospitals is increasing. For example, in Milwaukee
Minneapolis, and St. Paul, the proportion of hospital births, (see
I able 65) increased rapidly during the last decade. Unfortunatelv
comprehensive statistics on this question are not available.
T able

55.

Increase^ in proportion of deliveries in hospitals; Minneapolis and St.
faut, Minn., and Milwaukee, Wis., 1918—1922 1
Births (including stillbirths)
Minneapolis

St. Paul

Milwaukee

Year
In hospitals
Total
Numher
1913.
1914.
1915.
1916.
1917.
1918.
1919.
1920.
1921.
1922.

7,407
8,220
8,842
9,163
8, 986
9,028
8,457
9,200
9,436
9,543

1, 514
2,084
2,629
3,307
3,717
4,442
4, 365
5,535
5,859
6,175

Per
cent
21
26
30
37
41
49
52
60
62
65

In hospitals
Total
Num­
ber
4,964
5,162
5,469
5,461
5,352
5,351
5,013
5,355
5,812
5,907

Per
cent

1,280
1.506
1,768
2,068
2,219
2,164
2,618
2,989
3.506
3,846

, care h S ^ e n giT C n ^ byyredL . ^ da ir^ M T X , am^cl^O f M*aland, % % %
courtesy'of Docto? Thompson) Deputy C o ^ b S r ^ ‘lSait&

In hospitals
Total
Num­
ber
11,270
11,929
11,278
11,369
11,555
11, 697
10,844
11,219
11,179
10,563

Per
cent

568
707
819
987
1,320

1,666

1,778
2,407
2,493
2,709

iT fg fr e T ^ V lf ^
Iep° rt furnished by

The proportions of births attended by physicians and midwives
are shown in Table 56 for the States, and in 'Table 57 for the cities
ot over 100,000 population from which the Children’s Bureau re­
ceived information on this point. The proportions attended by physiciahs were highest in those States and cities where the proportions
ot foreign born and of colored were low. Births to native white
mothers were practically all attended by physicians where they were
available. Among the foreign born and the colored, however (espeCially the latter), midwives frequently attended births (see p. 76).
n the Southern States a considerable proportion even of the births
\native white mothers were attended by midwives.


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MATERNAL MORTALITY

T able

56.— Proportion of births attended by physicians, midwives, and others1
Per cent of registered sirths
attended by—
State

In birth-registration area:
C onnecticut---- ------------ ------------New York State (exclusive of New York City).
New Jersey__________________ _____ ___ _____
Indiana____ - ---------------------------------------------Wisconsin____________ |------------------------ - - - r
Nebraska------- ----- ---------------------------- - - - - Maryland--------------------------------------------------White______________ ______________
Colored_________ ____ ----------- ------ -------District of C olum bia.-.................. ..............
Virginia..----------------- - ,-----------------------------North Carolina.------- ------ ----------------- ---------White---- --------- -------------------------- --------Colored............. - --------- ---------------- ------ -Kentucky______________________
Montana2-------------------------------- — ------------Washington_______________________________ White______________________ ____ ______
Japanese-------- -------------------------------------Indian------- -----------------------------------------Other colored______________ i— - - - .........
Outside birth-registration area:
Florida 3--------------------------------- --------- --------Tennessee-----;--------------------------------Alabama— ---------------------------------- 1--------- -Arkansas.................. .............- - - ...... .......... ......
Louisiana (exclusive of New Orleans)------------White------------Colored................ ......... ................... - .........

Year
Physieians

Midwives
and
others

84.1

15.9

1920
1921
1921
1921
1921
1921

95.3
87.4
97.0
77.4
81.8
58.5
95.6
64.6
fi4 9
82 2
26.5
82
93.5
95.0
98.6
26.3
56.5
85.1

4.7
12.6
3.0
22.6
18.2
41.5
4.4
35.4
35.1
17. 8
73.5
18
6.5
5.0
1.4
73.7
43.5
14.9

1921
1921
1915
1921
1920
1920
1920

58.8
87.7
59.1
81.7
50.7
71.2
17.8

41.2
12.3
40.9
18.3
49.3
28.8
82.2

1918
1921
1921
1919
1921
1920
1920
1920
1921
1921
1921

|
Midwives

16.1
15.1
26.7
4.4
9.7
2.1
22.2
17.9
40.8
4.4
33.3

0.8
.3
3.0
.9
.4
.3
.7
2.0

3.4
3.9
.8
66.0
9.5
10.3

3.1
1.2
.6
7.7
34.0
4. 6

38.4
12.0
32.3
16.6

2.8
.3
8.6
1.7
I .........
1 ■

1Statistics furnished by State boards of health. When leaders are inserted no information was received.
2Admitted to birth-registration area in 1922.
s Admitted to birth-registration area in 1924.
T able

57.— Percentage of births attended by physicians and midwives in cities of
100,000 population and over; United States birth-registration area1
Per cent of births attended
by—
City

Year
Physi­
cians

Jclotij Vluj ; XN.•« --

88.0
1922
74.0
1920
1922 S 66.7
78.1
1922
97.7
1922
66.6
1922
1922 About 80
1922
77.9
98.6
1922
97.3
1922
79.2
1918
96.1
1922
87.8
1922
99.8
1922
1921
0
97.6
1922
81.0
1920

Mid­
wives

12.0
25.9
33.0
21.7
2.2
33.0
(2)
22.0
1.4
2.7
17.9
3.8
11.9
.1
38.0
2.3
17.7

Others,
no at­
tendant,
or not
reported

0.1
.3
.3
.1
.4
m

(2)

.1
2.9
.2
.3
.1
.2
1. 3

i Figures furnished by the city registrars of vital statistics through correspondence. In a few cases
printed reports were available. Cities of over 100,000 population in the birth-registration area for which
figures were not obtained, are omitted from tbe list*
3 Information not available.


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Percentage of births attended by 'physicians and midwives in cities of
100,000 population and over; United States birth-registration area— Contd.

T a b l e 5 7 .—

\

Per cent of births attended
by—
Year
Physi­
cians

Minneapolis, M inn..
New Bedford, Mass..
New York City.'____
Newark, N. J_______
Oakland, Calif______
Paterson, N. J___ . . .
Philadelphia, Pa____
Pittsburgh, Pa_____
Providence, R. I .......
Reading, Pa________
Richmond, Va______
St. Paul, M inn_____
Salt Lake City, Utah
San Francisco, Calif..
Spokane, Wash_____
Syracuse, N. Y . . . . . .
Toledo, O h io.-i.____
Trenton, N. J .. .. . . . .
Washington, D. C . . .
Wilmington, Del___
Yonkers, N. Y ______

1921
1919
1921
1921
1922
1921
1922
1922
1922
1922
1922
1921
1922
1922
1922
1922
1919
1921
1921
1922
1922

91.8
0)
74.4
(2)
87.3
(2)
87.6
70.7
80.5
94.5
81.6
83.8
97.0
85. 0
96.1
92.7
82.9
(s)
95.6
69.0
76.9

Mid­
wives

8.0
38.3
25.6
38.0
11. 1
27.0
12. 3
29.3
19.0
5.1
18.4
16.0
2.8
13.0
2.3
7.1
16.3
29.0
4.4
22.9
22.6

Others,
no at­
tendant,
or not
reported
0.2
(2)
(2)
(2)

1.6
.1
.5
.4
.2
.2
2.0
1.6
.2
.8

(2)
8.1
.5

2Information not available.

Attendance by a physician does not necessarily insure the best
care, nor does attendance by a midwife necessarily mean the poorest
care; much depends upon the qualifications and training of the par­
ticular physician or midwife. Attention has already been called
(see p. 75) to the fact that all States have minimum requirements
for the admission of physicians to the practice of medicine, though
in certain States the standards are low; but many States have no
requirements for admission of midwives to practice, or if they have
such standards do not enforce them, and one State (Massachusetts)
does not even recognize the existence of midwives. Midwives who
have been trained in recognized training schools either in this country
or abroad are in an entirely different class from those who, often
without even a common-school education, and with no special training
in their profession, are sometimes found in attendance upon negro
mothers in the Southern States. Nevertheless, even the midwife
with the best of training is not qualified to take charge of compli­
cated cases, and in such cases she should call in a physician.
Figures are available for certain areas which tend to show a de-,
crease in the proportion of births attended by midwives. For ex­
ample, in Minneapolis, St. Paul, and Milwaukee, one consequence of
the increase in the proportion of births in hospitals, all of which are
attended by physicians, is a decrease in the proportion of home con­
finements attended by midwives., Table 58 shows the proportion of
births attended by midwives in Wisconsin. These figures, which
are available for a series of years, show a decrease from 13 per cent
of births so attended in 1915 to 6 per cent in 1922. In view of the
great variety of conditions in different parts of the country, however,
no generalizations can safely be drawn from statistics relating to
two States only.

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T able 58.— Decrease in 'percentage of births attended by midwives; Minneapolis

and St. Paul, Minn., Milwaukee, Wis., and the State of Wisconsin, 1913-1922
Per cent of births attended by midwives

Per cent of births attended by midwives
Year

1913........
1914____
1915........
1916........
1917____

Year
Minne­ St. Paul1 Milwau­
apolis 1
kee2
23

20
19
17
15

23
26
25
24

22

32
32
28
26
25

Wiscon­
sin 3
m
«

13

12
12

1918____
1919____
1920____
1921........
1922____

Minne­ St. Paul1 Milwau­ Wiscon­
sin 3
apolis 1
kee2

12
11
9
8
7

19

21

19
16
. 13

22
21
17
15
13

'

11
10
8
7

6

1 Compiled from “ Results gained in maternity eases in which antenatal care has been given,” by Fred L,
Adair, M . D ., and Ç. O. Maland, M . D., p. 11.
2 Child Welfare Statistics, Milwaukee, Wis., p. 14.
! Compiled from annual reports of vital statistics.
4 Figures not available.

Details in regard to the following aspects of the confinement and
postnatal care received by mothers are available for two cities: The
number of visits from physicians or midwives following delivery, the
final examination before discharge, the type and duration of nursing
care, the number of days spent in bed or in hospital following delivery,
etc. The statistics relate to married mothers of children born in
Baltimore in 1915 and in Gary, Ind., in 1916.
With regard to visits by the attendant during the. confinement
period “ the usual arrangement reported in Baltimore, both in cases
attended by physicians and in those attended by midwives, was a
daily visit through the fourth day and at least one visit thereafter.
Seven-eighths of the physicians’ cases for which the visits were
reported, and practically all the midwives’ cases, fell into this group.” 38
The postnatal care received from physicians and midwives by the
mothers in Gary, Ind., was classified into grades on the basis of the
number and time of visits; To qualify in Grade A, daily visits through
the fifth day, a visit on the seventh or eighth day, and another visit
on the tenth or eleventh day were l-equired ; 30_>per cent of the cases
attended by physiciaiis at delivery, as compared with 26 per cent of
those attended by midwives, were classified as having had Grade A
postnatal care. Ôn the other hand, in Grade D, including cases in
which only one visit besides the visit at delivery was made, were
classified 6 per cent of the cases attended by physicians, but only 0.3
per cent of the midwives’ cases. Furthermore, when cases which
had at least daily visits through the fourth day (Grades A and B)
are considered, 97 per cent of the cases attended by midwives satisfied
these requirements, as compared with only 64 per cent of those
attended by physicians. When both a physician and a midwife
attended the case the care received was relatively poor, perhaps
because neither attendant felt full responsibility.37
A final examination of a maternity patient six weeks after delivery
was included in the minimum standards for the protection of the
health of mothers which were adopted by the Washington and
regional conferences on child-welfare standards.38 In the study of.
49Infant Mortality; results of a field study in Baltimore, Md., p. 213. For detailed tables see ibid.,
p. 214.
37Infant Mortality; results of a field studyin Gary, Ind., p. 36.
« Minimum Standards for Child Welfare Adopted by the Washington and Regional Conferences on
Child Welfare, p. 7.

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PREVENTION OP MATERNAL MORTALITY

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infant mortality in Gary, special attention was paid to the question
whether the mother h&d had an examination from four to six weeks
after delivery before her case was discharged by the physician or
other attendant at birth. Of the Gary mothers studied in 1916,
only 8.6 per cent reported any final examination; of the patients
attended by a physician only, or by both a physician and a midwife,
11.7 per cent were given a final examination by the physician, in fourfifths of the cases four weeks or more after delivery.39 Of the moth­
ers attended by midwives only 6.9 per cent were given a final exami­
nation, and in view of the midwives’ limited training these examina­
tions were probably not so thorough as those given by the average
physician.
&
Nursing service, at home unless hospital care is given, at the time
of confinement and during the lying-in period is included in the
minimum standards to which reference has already been made. In
the city of Baltimore in 1915, over one-fourth of all mothers were
found to have had no nursing c-are; the proportion reporting nursing
care, among whom were considered those confined in hospitals and
those who had trained nurses, midwives, or practical nurses in attend­
ance, was highest among the Polish mothers and lowest among the
Italian mothers. In both these groups comparatively few mothers
received any nursing care except that given by midwives (82 per
cent of the Polish mothers were attended by midwives, who were con­
sidered as having given nursing care). The Jewish group had the
largest proportion of mothers delivered in hospitals and the largest
proportion attended by trained nurses at home. The proportion of
mothers who had nursing care was found to have been highest in the
group of families in which the fathers earned $2,850 and over, and
lowest in the group in which the fathers earned less than $450. The
duration of nursing care in Baltimore was found to have been rela­
tively longer for the native white mothers than for foreign-born white
or for colored mothers. Of the native white mothers, 31.5 per cent as
compared with 16.1 per cent of the foreign-born white mothers and
with only 12.4 per cent of the colored mothers, had nursing care which
lasted two weeks or more.40
Figures for Gary, Ind., show a much larger proportion (39.6 per
cent) of cases in which the mothers received nursing care during at
least the two weeks following confinement. A correlation is indicated
between the duration of nursing care and the amount of father’s earnibgs, since the proportion of cases in which such care was received for
at least two weeks was nearly twice as high in families in which the
father earned $1,850 or over as in families in which the father earned
less than $1,050.
In the minimum standards for the protection of the health of
mothers, at least 10 days rest in bed after a normal delivery was
specified as one requirement. In Baltimore in 1915 nearly one-third
of the mothers reported they had stayed in bed less than 10 days (3.4
per cent reported less than 4 days). As would be expected, the
Er<?Pfrtl011 °* khese cases was highest in families in which the fathers
u- K annual earnings; 43.5 per cent-of the mothers in families in
which the father earned less than $450 stayed in bed less than 10 days,
‘‘ Infant Mortality; results of a field study in Gary, Ind., p. 36.
4 Infant Mortality; results of a field study in Baltimore, M d., pp. 215, 216.

60564°— 26------7


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MATERNAL MORTALITY

as compared with only 11 per cent in families in which the father
earned $1,450 or oyer. Of the different nationality groups, the pro­
portion of Polish and Italian mothers who stayed in bed less than 10 i
days after delivery was unusually high (74.7 per cent and 73.7 per
cent, respectively). This proportion was lowest for the native white
mothers and next lowest for the Jewish mothers (22.4 per cent and
25 per cent, respectively). In Gary, 54 per cent of the mothers
remained in bed less than 10 days after delivery, a much larger pro­
portion than in Baltimore. In the Gary study, as well as in that
in Baltimore, a direct relationship was traceable between the time
the mother spent in bed following confinement and the amount of
the father’s earnings.
. .
This survey of the confinement and postnatal care received by
mothers, fragmentary though the information is, indicates clearly
that in the cities studied a comparatively small proportion of moth­
ers received adequate care. If these conditions are at all typical, as
they probably are, a vast amount of work remains to be done if all
mothers are to receive the minimum protection which the conferences
of experts on this subject considered essential.
G O V E R N M E N T A L R ESPO N SIB ILITY

Governmental responsibility for the adequate protection of mater­
nity is evidenced not only by protective legislation, which has already
been discussed, but also by various types oi measures for the provision
of additional resources for such protection and for the better utiliza­
tion of the resources available. Such measures take in general three
forms: (1) Provision of more adequate resources for maternity care,
such as better facilities for training personnel, and more adequate
clinics, hospitals, and maternity homes; (2) subsidies in aid oi State
or local activities by Federal or State governments; and (3) educa­
tional work directed toward informing mothers of the need tor ade­
quate maternity care.41
Provision of resources for maternity care.

Governmental provision of resources for maternity care includes
the maintenance and extension of educational facilities for physicians,
nurses and midwives, and the maintenance of hospitals, maternity
homes’ clinics, and other centers for prenatal and confinement care.
Such provision may be made either by a local, State, or central gov­
ernment, or by a local government subsidized by a State or central
^ So far as the provision for educational facilities is concerned, many
countries maintain out of public funds medical colleges for the train­
ing of physicians and schools for the training of midwives and nurses.
« Tn Australia for example, one aim, though not the principal one, sought in maternity-allowance legislation w^tlfereducWon™ f maternal mortality.
and invalidity in the Commonwealth in its report in 1917 on Maternal Mortality
general conclusion that the grant of maternity allowances is a very expensive method of attaimng this
end The conclusion of the committee in its report was as follows:
, , . stained from
“ Speaking generally, your committee is of the opinion that much greater benefit could
^
the large sum of money spent annually than is being obtained
to fheignofance
wastage of life and damage to health now oceumng m connection with
twn dfr ections^m The
nf tho mnther and lack of skilled care, such improvement should be sought in two directions. (,i; aub
nrovfsiSr of every facilityfor pregnant^^omen to obtain skilled advice before the confinement occurs;
(2) the provision of trained attention by a properly qualified ^ d w o p e r iy w p irm ^ ^ id w ife or nm^e
during the lying-in period.” (Report on Maternal Mortality m Childbirth, p. 18. Ciramttee concern ng
causes of death and invalidity in the Commonwealth. Australian Department of Trade and Customs
119171.)


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PREVENTION OE MATERNAL MORTALITY

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In the United States medical schools are maintained in connection
with many State universities and training schools for nurses in connec­
tion with many municipal hospitals.42
Provision of facilities for maternity care includes not only the estab­
lishment and maintenance of prenatal and maternity centers, clinics,
hospitals, and maternity homes, but also the maintenance of medical
and midwifery services tor communities in which otherwise such serv­
ices could not be obtained. Direct partial or complete support of
practicing midwives in certain districts is given, for example, in
England, where mid wives are sometimes employed or their salaries
guaranteed by local authorities in order that their services may be
provided for areas in which they could not otherwise secure a living . 43
'Establishment and maintenance of hospitals has been generally
recognized as a proper function of local government bodies. Many
cities and counties m the United States maintain general hospitals,
and some provide also special maternity hospitals. In general, every
patient who is able to do so is expected to pay for the care received.
The portion of the cost of maintenance of these hospitals which the
cities contribute varies, therefore, from place to place and from time
to time according to the policy of the institutions relative to taking
nonpaying cases.
Maternity centers at which mothers may receive medical advice
and prenatal care during pregnancy are not infrequently maintained
ky governmental agencies; for example, by local government boards
in England, where they are subsidized by the central government
through the health department.44 In New Zealand the Royal Society
for the Health of Women and Children, which maintains infantwelfare centers in many cities and which gives prenatal advice to
many expectant mothers through its specially trained “ Plunket”
nurses, receives a substantial subsidy from the central government.45
In a few cities of the United States prenatal consultations are
available to mothers at inf ant-welfare centers maintained by the
municipalities.46 According to the Report of the Committee on
Municipal Health Department Practice, which summarized the
results of a survey of the 83 largest cities in the United States, in 24
cities prenatal clinics were maintained in 1920 by the health depart­
ments, and in 12- other cities by combined municipal and private
support.
Governmental subsidies.

Systems of subsidies by central governments, designed to promote.
and aid work for the protection of maternity by local governments
are worthy of special consideration.
Perhaps the most extensive system of grants in aid of local activities
is that in effect in England and Wales, the scope of which is de­
scribed in the reports of the Ministry of Health and examples of
which have already been cited. The grants for the fiscal year 1922-23
amounted to $3,821,195.27 (£785,204), of which over three-fourths
42 See Nursing and Nursing Education in the United States, p. 190 ff.
43 Fourth Annual Report of the Ministry of Health [Great Britain], 1922-23, p. 15 Cmd 1944
“ Infant-Welfare Work in Europe, by Nettie P. McGill, pp. 20-31. U. S. Children’s Bureau ‘ Publicajon No. 76. Washington, 1921. See also Fourth Annual Report of the Ministry of Health [Great Britain],
1922 23, pp. 11-16.
43 Infant Mortality and Preventive Work in New Zealand, by Robert M . Woodbury p 48 U S
Children’s Bureau Publication No. 105. Washington, 1922.
'
‘ '
4‘ Infant Hygiene, Report of the Committee on Municipal Health Department Practice, by I V
Hiscock, pp. 114-115. Public Health Service Bulletin No. 136.


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MATERNAL MORTALITY

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was paid to local government authorities and the rest to voluntary
societies. In Table 59 are given the detailed objects of this expendi­
ture in 1921-22. A considerable portion, though not all, was devoted .
to work for the protection of maternity. The department subsidizes
expenditures for purposes specified in the regulations by a sum equal
to 50 per cent of the approved net expenditure.
T able

5 9 .—

Net expenditures of local authorities for purposes subsidized by the
central government; England, 1921—1922
fOne pound equals $4.8665]

Purpose

Amount of net expen­
ditures
£1,380,312 I $6,717, 288.35

Medical officers of health and assistant medical officers for mater-

103,524
420,399
51,805
28, 596
16,248
147,510
44,977
5,644
280,946
7,041
67,176

503,799.65
2,045, 871.73
252,109.03.
139,162. 43
79,070. 89
717,857. 42
218, 880.57
1,004, 669.46
27,466. 53
1,367,223.71
' 34,265.03
326,912.00

Per cent
distribu­
tion
100.0
7.5
30.5
3.8
1.2
15.0
20.4
.5

'Fourth Annual Report of the Ministry of Health [Great Biitain], 1922-23, pp. 12 13. London, 1923.

A brief statement of the scope of the work in England may_be of
interest The number of local authorities which administer schemes
of maternity and child welfare is 436, including the 49 county councils,
the 78 county borough councils, the 28 metropolitan borough councils,
and 281 councils of noncounty boroughs and urban and rural dis­
tricts. Among them these councils cover the whole of England. Tor
the supervision of this work 196 assistant medical officers of health
have been appointed. On March 31, 1923, health 'Visitors numbered
3 508 of whom 893 were employed wholly in promoting maternity
and child welfare and 1,124 combined these duties with other publichealth activities of a similar character. The work included pro­
vision of an adequate service of qualified midwives m every district
which in many cases required the employment of a midwife out of
•public funds, the giving of a subsidy, or the guaranteeing of the
midwife’s salary. The maintenance of maternity and infant-welfare
centers was a very important branch of health work, each health
visitor’s district was served, whenever practicable, by such a center.
The number of these centers in England alone at the close of the
fiscal year 1923 was 1,950. Maternity beds in hospitals and in homes
subsidized by the department numbered 1,879 in 128 such hospitals
and homes. In addition, homes for mothers and babies numbered
100 and contained beds for 1,334 mothers and 1,288 babies. Other
work included maintenance of children’s hospitals and homes for
convalescents, provision of milk at less than the cost price to expect­
ant and nursing mothers and to young children, and inspection of
foster homes for children.47
Fourth Annual Report of the Ministry of Health [Great Britain], 1922-23, pp. 11 1?.


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In the United States the Federal Government grants funds to
States which accept the provisions of the Sheppard-Towner Act 48
for the promotion of the welfare and hygiene of maternity and infancy.
vThe total appropriation for carrying out the provisions of this act
during the first full year of its operation was $1,240,000, of which each
State accepting the act received (1) $5,000 outright, (2) $5,000 more
if it appropriated an equal amount, and (3) its share of the remaining
fund of $710,000 which is apportioned to the States on the basis of
population, if matched by State appropriations.49 The conditions
for grants have been accepted by the State legislatures of 43 States.50
Under the act each State is allowed to develop its own plans for the
expenditure of the funds allotted to it. The plans are subject to the
approval of a board consisting of the Chief o f the Children’s Bureau,
the Surgeon General of the Public Health Service, and the Commis­
sioner of Education; if these plans are in conformity with the pro­
visions of the act and are reasonably appropriate and adequate to
carry out its purposes the board must approve them. The law pro­
vides that no part of the Federal funds may be used for the purchase,
rental, or maintenance of any building or equipment, nor may either
Federal funds or State moneys appropriated to match the Federal
allotment be used for the pajunent of maternity allowances. The
act is, therefore, clearly directed toward educational measures,
especially toward stimulating the appropriate State agencies to under­
take educational work.
Educational work.

The importance of educational measures directed toward informing
the public in general and mothers in particular of the need for ade­
quate medical supervision during pregnancy and nursing and medical
care during confinement is indicated by the figures given in the pre­
ceding section (see pp. 83-92) showing the large proportion of mothers
who do not now receive adequate supervision and care—in many
cases, probably, because they do not appreciate the need for it.
Only by the education of the public will it be possible to awaken the
demand for and call forth resources in trained personnel and facilities
sufficient to give adequate protection to every mother during preg­
nancy and confinement.
To a large degree all the activities of State and local public and
private health agencies are educational. The giving of prenatal care
by child-welfare centers and by visiting nurses lias an important edu­
cational aspect. In the annual report of the administration of the
Sheppard-Towner Act for 192451 it is stated that “ children’s health
centers or health conferences and prenatal or maternity centers or
conferences are everywhere recognized as the best teaching agencies.”
In most of the States consequently efforts are being directed toward
•
November 23> !921; for text of act see U. S. Children’s Bureau Publication No. 95 (WashiDgton, 1922).
v
!! The balance of $50,000 was allowed the U. S. Children’s Bureau for expenses of administration.
80During the first three months after the passage of the act 12 States accepted through legislative enact­
ment, and 30 through the approval of the governor pending the meeting of the legislatures. For a full
discussion of the work undertaken under the Sheppard-Towner Act see the reports on The Promotion of the
Welfare and Hygiene of Maternity and Infancy (U. S. Children’s Bureau Publications Nos. 137 and 146,
Washington, 1924 and 1925). See also Federal Aid for the Protection of Maternity and Infancy, by Grace
Abbott (revised reprint from the American Journal of Public Health, September, 1922): and The SheppardTowner Act in Relation to Public Health, by Anna E. Rude, M. D. (paper read before the section on
preventive and industrial medicine and public health at the Seventy-Third Annual Session of the Ameri­
can Medical Association, St. Louis, May, 1922).
81 The Promotion of the Welfare and Hygiene of Maternity and Infancy, p. 4. U. S. Children’s Bureau
Publication No. 146. Washington, 1925.


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MATERIAL MORTALITY

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state-wide establishment of permanent locally supported children’s
health centers and prenatal centers accessible to all the population in
need of such assistance and instruction. A “ center” is to be in te r-/
preted as an established time and place at which a physician and nurse
are present for the examination of children ana the instruction of
mothers on the essentials in the feeding and care of babies and
children of preschool age. The usefulness of such a health center is
usually demonstrated by single health conferences held by county
“ health units” consisting of at least a physician and nurse, often a
dentist also and still other assistants. Frequently, not only the per­
sonnel of the county health unit but its whole equipment is itinerant,
as indicated by such popular terms as “ healthmobile,” “ health
caravan,” “ traveling dental ambulance,” “ health movie truck,” etc.
Auxiliary to conferences and the activities in centers are the scarcely
less important “ home visits” by which the public-health nurse
follows up the work previously done, emphasizing and explaining
facts made known in the examinations, giving further instruction
and demonstrations of the kind of care needed in individual cases,
and advice on methods of accomplishing the indicated corrections.
Instruction on prenatal care in many States is given in connection
with child-health conferences and centers, yet there were 6,088 pre­
natal conferences, reported by workers under the Sheppard-Towner
Act, with an attendance of 38,662 women.52 The importance of pre­
natal care is not appreciated by a very large part of the public, and
in many parts of the United States women do not have medical
supervision during pregnancy nor medical care during confinement
and the lying-in period. However, the technique and unit costs of
the prenatal conference, already learned for urban districts, are
being worked out for rural districts through State activities, and the
necessary modifications are being noted.
The Fourth Annual Report of the Ministry of Health of Great
Britain thus calls attention to the educational value oi such health
centers for mothers and infants; “ It can not be emphasized too
strongly that the main object of the center is preventive and educa­
tional and that its primary aim should therefore be to provide advice
and teaching for the mothers together with supervision of the healthy
infant, rather than treatment for the sick.” 53
Another method o f . disseminating information consists of the
distribution of pamphlets and leaflets of instruction. This .has been
one of the activities of the Children’s Bureau since its establishment
in 1912. Especial mention may be made of one of its first bulletins,
a popular pamphlet on prenatal care.54 This bulletin sets forth the
need for prenatal care and gives in clear language the simple hygienic
principles which every expectant mother should know and follow.
Especial emphasis is placed upon the necessity for early consultation
with a doctor. During the years from 1915 to 1925 over a million
and a half copies of this pamphlet— averaging 140,000 annually—
were distributed throughout the country. Another bulletin which
should be mentioned in this connection is a study of maternal mor­
tality,55which calls attention to the unusually high maternal mortality
5* Ibid., p. 9.
a Fourth Annual Report of the Ministry of Health [Great Britain], 1922-23, p. 15.
m Prenatal Care, by Mrs. Max West. U. S. Children’s Bureau Publication No. 4. Washington, 1915.
“ Maternal Mortality, by Grace Meigs, M. D. U. S. Children’s Bureau Publication No. 19 Washing-


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rate in the United States and furnishes a statistical measure of the
need for the movement to protect maternity.
Bulletins on prenatal care nave been issued by some State bureaus, 56
’ and distributed by them in addition to, or in connection with, their
wide distribution of copies of publications of the Federal Children’s
Bureau. Many local health departments also provide mothers with
pamphlets on prenatal as well as infant care. 57
In many States correspondence courses for mothers are conducted.
These vary from regular instruction for a registry of mothers to the
mere monthly distribution of a series of prenatal letters to mothers
who request them, or whose names are furnished to the State bureau
by physicians or nurses.
Lectures, some of which are illustrated by model equipment, by
slides, or by motion pictures, have formed a satisfactory method of
instruction; special films dealing with prenatal, infant, and child care
have been prepared and their showing has met with appreciation and
interest. Articles on infant and child care have been accepted and
published by local and county papers and by magazines of both
technical and popular character; and the radio talks on prenatal,
infant, and child care already reported in some States are an indica­
tion of the coming use of a new medium for disseminating instruction
on maternal and infant care.
m Bureaus or divisions of child hygiene or child welfare are functioning in all the States, nearly all of
them now cooperating with the Federal Children’s Bureau under the Sheppard-Towner Act Most of
these bureaus were established during the period from 1915 to 1922, largely as a result of the “'children’s
year campaign for the better protection of the health of children. Before 1918 there were child-hvgiene
^visions in 7 States. Such divisions were established in 4 States in 1918, in 17 in 1919, in 7 in 1920, in 3 in
i9zii &nci m o m ivZZ.
87 In this connection the example of New Zealand may be cited: In that country for years registrars
have provided each mother on the registration of birth of her first child with a copy of a special pamnhlet
entitled “ The Expectant Mother and Baby’s First Month,” which contains simple rules for the health
of mothers. Recently the registrars have been instructed to give a copy to each man who applies for a
marriage license, and the Health Department has undertaken the task of sending copies to everv married
woman under 35 years qf age in New Zealand. Annual Report of the Royal New Zealand Society for the
Health of Women and Children, pp. 4-5. Dunedin, 1922.


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NEED FOR INFORMATION

At many points in the preceding discussion the inadequacy of the
information at hand has been evident. Statistics of puerperal mor­
tality are not available for the whole country, but only for the deathregistration area, and even for this area they are subject to'qualifica­
tions and interpretation. Practically no evidence is available with
regard to so important a group as deaths following self-induced abor­
tion, though without information on this point it is impossible to
determine how much of the mortality could be prevented by rigorous
asepsis in obstetrical work and how much must be controlled by
other types of measures. Information is also lacking as to the.
number of obstetrical operations, the indications upon which they are
performed, and the mortality following each type of operation, as
well as complete information concerning the prevalence of the various
kinds of complications. Only when such data are available will it be
possible to judge accurately the nature of the problems of puerperal
mortality and morbidity and the best methods for reducing them to
a minimum.
,
Not only is information unavailable regarding many important
details connected with puerperal mortality, but data on the publichealth aspects of the problem are likewise in large part lacking. Data,
for example, concerning the proportion of births which are attended
by physicians, midwives, and other persons are far from comprehen­
sive. Many States are ignorant of the number, as well as the qualifi­
cations, of midwives practicing in their territory. The proportion ol
births in hospitals is available for relatively few areas. Furthermore,
data on the quality of care received by mothers are extremely limited.
On all these and other points relating to childbirth information is
needed, not only to aid in a thorough understanding of the problems
to be dealt with, but also to suggest fruitful methods of approach, and
to aid in guiding the adoption of control measures.
......
On the other hand, the value of the statistics^ already available is
not always fully appreciated, nor are these statistics always used in
the most effective ways to aid in establishing control over puerperal
mortality and morbidity. The methods by which, vital statistics can
be utilized in preventive work may be considered here briefly.
From the vital statistics of a community the health administration
can secure prompt information as to the causes from which the death
rate is excessively or unusually high and in the light of this knowledge
can take necessary steps to prevent or reduce this excessive mortality.
This requires, of course, an accurate measure of the death rate, to
furnish which in the case of puerperal mortality the complete record­
ing of both births and deaths is required.
The use by the health department of records of cases, or n a i l
cases are not reportable, of deaths from puerperal septicemia offers
manifest possibilities. The occurrence of this disease in the practice
of physicians or midwives gives an immediate clue to where effective
control work can be applied. An example of such control may be
9$

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99

•found in the Prussian regulations governing the practice of midwives
which prescribe that a midwife who has had a case of septicemia must
the W a ldw S PfflCedu5e °f disinfection and may be forbidden by
' he local health officer to practice her profession until after the
W
° n of a sÎated period. 1 Another example of the effective use
of such reports is found m the practice of the New Zealand health
department of investigating promptly each case of puerperal septi­
cemia that occurs m a private hospital, a procedure which is followed
necessary, by the temporary closing of the hospital or by the
the llCenSe
° perate- With alert public-health admin­
istration the occurrence of a series of cases of puerperal septicemia in
nated™CtlCe ° f & SmglG physician or midwife should be entirely elimiAnother effective method of utilizing vital statistics to aid in the
prevention of maternal mortality is that used for a time by one of the
State health departments in the United States of sending to the
physician m attendance m case of each death from puerperal causes a
S
Z
? ^
ed t o ^ g
on the one hand a complete state“ tîief ntW f i h » TS comPllcatmg the pregnancy or confinement, and
on the other the possibilities of reducing such mortality by more
adequate hospital care, by earlier consultation with a physician or
by changes m methods of treatment.
P y
’
H andw & terbuch^^So^âle^^y^en^^ol1" lUm r !^ nG rotjato^n^plSf','D:>^ T ^ Wei^b?rg. P- 588, in

(Reprint from the American Journal of Obstetrics and O y n e ® ^ I S f ^ S " < ^ f g g f ^ p ^ g


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'S

APPENDIX A.— RULES FOR THE CLASSIFICATION OF PUER­
PERAL CAUSES OF DEATH IN USE BY THE BUREAU OF
THE CENSUS 1
PAR T I.— P R IM A R Y CAUSES
The following list contains the details of the titles included under the eight
groups of pathological causes of puerperal deaths in the International List of
Causes of Death in use by the Bureau of the Census: (1 ) Accidents of pregnancy:
(2) puerperal hemorrhage; (3) other accidents of labor; (4) puerperal septicemia;
(5) puerperal phlegmasia alba dolens, embolus, sudden death; (6) puerperal
albuminuria and convulsions; (7) following childbirth, not otherwise defined;
and (8) puerperal diseases of the breast.
1.— 143 (134) ACCIDENTS OP PREGNANCY >

(a) Abortion.

Abortion.
Accidental abortion.
Immature birth.
Immaturity.
Induced abortion.
Induced premature labor.
Miscarriage.
Missed abortion.
Premature birth.
delivery.
(b) Ectopic gestation.

Abdominal pregnancy.
Ablation of pregnant tube.
Ectopic gestation.
pregnancy.
Extrauterine gestation.
pregnancy.
Interstitial pregnancy.
Rupture of sac (ectopic gestation).
. (tubal pregnancy).
Tubal abortion,
gestation,
pregnancy.
(c) Others under this title.

CD
Accidental hemorrhage of preg­
nancy.
Antepartum hemorrhage.
Carneous mole connected with
pregnancy.
Chorea gravidarum.
of pregnancy.
Cornual pregnancy.
Dead fetus in uterus.
Evacuation of uterus.
Hemorrhage of pregnancy.
Hemorrhagic mole.

(c) Others under this title.— Con.
Hydatid mole.

Hydatidiform mole.
Missed labor.
Molar pregnancy.
Mole (pregnancy).

Retention of dead ovum.
Vesicular mole.
( 2)

Accident of pregnancy.
Cyesis.
Displacement of pregnant uterus.
Dropsy of amnion.
Emesis gravidarum.
Gestation..

Hydramnios (mother).
Hydrops amnii.
Hydrorrhea gravidarum.
in pregnancy.
Hyperemesis gravidarum.
of pregnancy.
Hysteralgia of pregnant uterus.
Menstruation during pregnancy.
Multiple pregnancy.
Neuralgia of pregnant uterus.
Pernicious vomiting (female, 15 y44y).

Persistent vomiting (pregnancy).
Pregnancy.
in abnormally formed
uterus.
Prolapse of pregnant uterus.
Puerperal vomiting.
Retroversion of pregnant uterus.
Spurious labor pains.
Uncontrollable vomiting (female,
15y-44y) of pregnancy.
Vomiting of pregnancy.

i From hlanual of the International List of Causes of Death, Based on the Third Revision by the Inter­
nationa Commission, Paris, October 11 to 15, 1920, pp. 116-120 (the numbers of the third revision are giver
foilowed by the numbers of- thesecond revision in parenthesis); and from Manual of Joint Causes ol
Death. Second Edition, pp. 51, 52. (U. S. Bureau of the Census, Washington, 1924 and 1925 )
Does not include puerperal septicemia during pregnancy, 146 (137); nephritis of pregnancy, 148 (138)
In the second revision no subgroups were shown. In the third revision the following titles were included
m accidents of pregnancy which were not included in the second revision: Chorea gravidarum chorea
of pregnancy (transferred from “ puerperal albuminuria and convulsions” ), Hydatid mole, hydatidiform
mole (transferred from “ cancer and other malignant tumors of the female genital organs” ), and dead fetus
in uterus.

103

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2 .— 1 4 4 (1 3 5 ) P U E R P E R A L H E M O R R H A G E

Accidental hemorrhage of parturition.
puerperium.
Adherent placenta.
Apoplexy of placenta.
Detachment of placenta.
Hemorrhage after labor.
during parturition,
from detachment of pla­
centa.
uterus after parturi­
tion.
during
par­
turition.
puerperium.

Malposition of placenta.
Placenta praevia.
Postpartum hemorrhage.
Puerperal hemorrhage.
metrorrhagia,
uterine hemorrhage.
Retained membrane.
placenta,
secundines.
Retention of placenta.
Separation of placenta.
Vicious insertion of placenta.

3 .— 1 45 (1 3 6 ) O T H E R A C C I D E N T S O F L A B O R *

(a) Cesarean section.

Cesarean section.
Porro’s operation.
(b) Other surgical operations and in­
strumental delivery.

Application of forceps.
Cephalotomy.
Cephalotripsy.
Craniotomy.
Embryotomy.
Forceps operation.
Hebotomy.
Instrumental delivery.
Laparoely trotomy.
Obstetric operation.
Symphysiotomy.
(c) Others under this title.

( 1)

Diruptio uteri.
Laceration of peritoneum (partu­
rition) .
u rin ary b la d d e r
(parturition).
Metrorrhexis.
Puerperal apoplexy.
metrorrhexis,
perforation of uterus.
Rupture of bladder (parturition).
uterus (parturition).
( 2)

Abnormal labor.
parturition.
Accident of labor.
Atony of uterus during parturition.
Breech presentation.
Deformed pelvis (female, 15y44y).
Delayed delivery.
Difficult labor.
Dystocia.
Faulty presentation.
Foot presentation.

(cj Others under this title.— Con.

Forced delivery.
Inertia of uterus.
Injury in delivery.
Inversion of uterus during parturi­
tion.
Malpresentation.
Multiple birth.
parturition.
Postpartum curettement.
Prolonged labor.
Protracted labor.
Retarded labor.
Transverse presentation.
Version (during labor).
(3)
Accouchement.
Childbed.
Childbirth.
Confinement.
Consequence of labor.
Disease of placenta.
Fistula from parturition.
Hematoma of vulva (puerperium).
Labor (unqualified).
Laceration of cervix.
pelvic floor,
perineum.
(parturi­
tion) .
uterus (parturition),
vagina (parturition).
vulva (parturition).
Overdistention of utérus.
Parturition.
Perineorrhaphy.
Postpuerperal shock.
Puerperal hematoma of vulva.
Result of labor.
Rupture of perineum (parturition).
vagina (parturition),
vulva (parturetion).
Shock of birth.
Subinvolution of uterus.

s In the second revision no subgroups were shown. In the third revision the following titles were added:
“ Laceration of pelvic floor,” “ obstetric operation, ‘ overdistention of uterus.”


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APPENDIXES

105

4 .— 1 4 6 (1 3 7 ) P U E R P E R A L S E T T I C E M I A 4

Childbed fever.
Decidual endometritis.
\Infected tubal pregnancy
Metritis of pregnancy.
Milk fever (female).

Postabortive sepsis.
Postpartum pyemia.

. sepsis,
septicemia.
Puerperal5 abscess.
abscess of broad ligament.
cellulitis.
endometritis.
erysipelas.
fever.
infection.
inflammation of uterus.
lymphangitis.
metritis.
metroperitonitis,
metrosalpingitis.
parauterine abscess,
pelvic cellulitis,
pelvic peritonitis.
5 .— 1 4 7 (1 3 9 ) P U E R P E R A L P H L E G M A S I A A

Milk-leg (female).
Puerperal embolism.
embolism of lung,
phlebitis.
phlegmasia alba dolens,
pulmonary embolism,
sudden death,
syncope,
thrombosis.
Sudden death after delivery.
from cardiac e m b o li s m

after

delivery,
thrombosis

after

delivery,
cerebral hem or­
rhage after de­
livery.
embolism after de­
livery.

Puerperal5 pelviperitonitis,
perimetritis,
peri metrosalpingitis,
peritoneal infection,
peritonitis,
periuterine cellulitis,
phlegmon of broad liga­
ment.
purulent endometritis.
pyemia.
pyohemia.
pyrexia.
salpingitis.
sapremia.
sepsis.
septic endometritis,
fever,
infection,
intoxication,
metritis,
peritonitis,
septicemia,
suppurative metritis.
Septicemia following abortion.6
ÌA D O L E N S , E M B O L U S , S U D D E N D E A T H 7

Sudden death from entrance of air into
vein after deliv­
ery.
n e r v o u s exhaus­
tion after deliv­
ery.
pulmonary e m b o l­
ism after deliv­
ery.
pulmonary throm­
bosis after deliv' ery.
shock after deliv­
ery.
thrombosis
after
delivery,
in puerperium.
Venous thrombosis consequent on par­
turition.
White-leg (female, 1 5 y -44 y ).

♦Does not include: Septicemia (unqualified) except in connection with childbirth, 41 (20); puerperal
scarlatina, 8 (7).
8 Any of the conditions following are compiled as puerperal when returned in connection with abortion,
miscarriage, childbirth, labor, etc., even if not definitely so stated.
8 Added on the third revision.
7Does not include: Phlegmasia alba dolens (nonpuerperal), 92 (82). A frequent complication is gangrene
in the second revision “ embolism” was stated as a frequent complication.


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MATERNAL MORTALITY

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6 .— 1 4 8 (1 3 8 ) P U E R P E R A L A L B U M I N U R I A A N D C O N V U L S I O N S *

Albuminuria of pregnancy.
Eclampsia gravidarum,
of labor.
pregnancy.
Nephritis of pregnancy.
Postpartum eclampsia.
Postpuerperal nephritis.
Puerperal albuminuria,
anuria.
Bright’s disease,
coma.
convulsions,
cramps,
dropsy,
eclampsia,
nephritis.
7 .— 1 4 9

Puerperal spasms.
tetanus,
toxemia,
uremia,
uremic coma.
convulsions.
delirium.
dementia.
eclampsia.
intoxication.
poisoning.
Pyelitis of pregnancy.
Pyelonephritis of pregnancy.
Toxemia of pregnancy.
Uremia of pregnancy.

(1 4 0 ) F O L L O W IN G C H IL D B IR T H

Following childbirth.
Puerperal accident.
displacement of uterus.
insanity.
mania.

(N O T O T H E R W I S E

D E F IN E D )9

Puerperal melancholia,
state.
Puerperium.
Result of labor (without further ex­
planation) .

8 .— 1 5 0 ( 1 4 1 ) P U E R P E R A L D I S E A S E S O F T H E B R E A S T >«

Abscess of the breast following par­
turition.
Fissure of nipple, puerperium.
Fistula of breast (puerperal or un­
qualified) .
Galactocele.
Galactorrhea.
Mammary fistula.
Puerperal abscess of breast.
mammary gland,
diffuse mastitis.

Puerperal disease of breast.
fissure of nipple,
fistula of breast.
mammary gland,
galactophoritis.
inflammation of areola.
breast.
mammary abscess.
mammitis.
mastitis.

Note.— The purpose of the foregoing group of titles 143 150 (134 141) is to
include all deaths of women due more or less directly to childbearing. Ihe
terms are to be understood in all cases to apply to the death of the mother
(certain terms which may also designate the death of the child may be found in
the index in use by the Bureau of the Census). The word "puerperal is used
in the broadest sense to include all affections dependent upon pregnancy, par­
turition, and also diseases of the breast during lactation. It is to be understood
as a qualification of every term included in this group and is so expressed m the
index for many terms that might or might not be puerperal.
The fact that childbirth occurred within a month previous to death should
always be stated even though it may not have been a cause of death. It is pre­
ferable to show the direct connection, when it exists, as by writing puerperal
septicemia,” "peritonitis following labor,” etc., although the separately stated
ioint causes "childbirth” and "septicemia,” or "parturition’ and peritonitis
would lead, by interpretation, to the same statistical assignment. Whenever a
woman of childbearing age (approximately 15 to 44 years), especially if married,
is reported to have died from any of the following causes which might have been
puerperal, the local registrar should endeavor to obtain a definite statement from
the reporting physician:
s Does not include: Puerperal scarlatina, 8 (7). In the second revision “ chorea of pregnancy ” was in­
cluded in this group. In the third revision the titles “ pyelitis of pregnancy” and pyelonephritis ol preg­
nancy” were added, and chorea of pregnancy transferred to No. 143c.
•Does not include: Nonpuerperal sudden death, 204 (188); puerperal scarlatina, 8 (7).
i®In the third revision the title ‘ 'inflammation of areola” was added.


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APPENDIXES
Abscess of the breast.
Albuminuria.
Cellulitis.
Coma.
Convulsions.
Eclampsia.
Embolism.
Gastritis.

14w i

107

Hemorrhage (uterine
unqualified).
Lymphangitis.
Metritis.
Metroperitonitis.
Metrorrhagia.
Nephritis.11
Pelviperitonitis.
Peritonitis.11

Phlebitis.
Phlegmasia alba dolens.
Pyemia.
Septicemia.
Sudden death.
Tetanus.
Thrombosis.
Uremia.11

c H1^CiU^ l V nder Üties 128 019), 133 (124), 138 (128), 140 (130),

L
d 142 0 3 3 > are understood to be nonpuerperal (or unqualified).
imDoîtfn?phnf n°rffimî+lled+ T 6’ m+fact, due to puerperal conditions; hence the
importance of a definite statement in all cases concerning which there can be a
/ i f W ° rti0- of ^he “ u n q u alified^h oiild diminish with
offices
P
t
° f physic,ans and more effective administration of registration
m

P A R T I I .— J O I N T C A U S E S

than one cause of death is stated on the death certificate, the proS tk )rnfli°T?fiTed byKthe
«J the Census is to assign each cause to its Interwît w î i
i
*
and t ^ n t? determine the preferred cause in accordance
with the rules for the classification of such cases. The only combination of
causes with which this report is concerned is that of a puerperal with a nonfhe7rP?umber.rfnllFOr referH
encf the International List of Causes of Death with
their numbers follows, and also each puerpéral cause with the nonpuerperal
i ? dtedWb v 7 a7 eTnPtr
î
t(? - I -W:hen th®y appear together on a death certificate
by i international List number. In case of combination with other
S?3 ?rrpdper7 qcauses §?• “ u.mbers H whicfl aTe not given, the puerperal cause is
preierred.
(borne subdivisions used m combinations are not shown.)
IN T E R N A T IO N A L L IS T O F C A U S E S O F D E A T H

1. Typhoid and paratyphoid fever.
2 . Typhus fever.
3. Relapsing fever (spirillum obermeieri).
4- Malta fever.
5. Malaria.
6 . Smallpox.
7. Measles.
8. Scarlet fever.
9. Whooping cough.
10 - Diphtheria.
1 1 . Influenza.
1 2 . Miliary fever.
13. Mumps.
14. Asiatic cholera.
15. Gholera nostras.
16. Dysentery.
17. Plague.
18. Yellow fever.
19. Spirochetal hemorrhagic jaundice.
20 . Leprosy.
2 1 . Erysipelas.
2 2 . Acute anterior poliomyelitis.
23. Lethargic encephalitis.
24. Meningococcus meningitis.
25. Other epidemic and endemic dis­
eases.
26. Glanders. .
27. Anthrax.
28. Rabies.
29. Tetanus.
30. Mycoses.
31. Tuberculosis of the respiratory
system.
11

Added in third revision.

60564°—26-----8


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W IT H N U M B E R S

32. Tuberculosis of the meninges and
central nervous system.
33. Tuberculosis of the intestines and
peritoneum.
34. Tuberculosis of the vertebral col­
umn.
35. Tuberculosis of the joints.
36. Tuberculosis of other organs.
37. Disseminated tuberculosis.
38. Syphilis.
39. Soft chancre.
40. Gonococcus infection.
41. Purulent infection, septicemia.
42. Other infectious diseases.
43. Cancer and other malignant tumors
of the buccal cavity.
44. Cancer and other malignant tumors
of the stomach, liver.
45. Cancer and other malignant tumors
of the peritoneum, intestines,
rectum.
46. Cancer and other malignant tumors
of the female genital organs.
47. Cancer and other malignant tumors
of the breast.
48. Cancer and other malignant tumors
of the skirt.
49. Cancer and other malignant tumors
of other or unspecified organs.
50. Benign tumors and tumors not
returned as malignant (tumors
of the female genital organs
excepted).
51. Acute rheumatic fever.

108

MATERNAL MORTALITY

rheumatism,
osteoar- 103. Congestion and hemorrhagic in­
52. Chronic
farct of the lung.
thritis, gout.
104. Gangrene of the lung.
Scurvy.
53.
105. Asthma.
54. Pellagra.
106. Pulmonary emphysema.
55. Beriberi.
107. Other diseases of the respiratory
56. Rickets.
system (tuberculosis excepted).
57. Diabetes mellitus.
108. Diseases of the mouth and annexa.
58. Anemia, chlorosis.
109. Diseases of the pharynx and ton­
59. Diseases of the pituitary gland,
sils (including adenoid vegeta­
60. Diseases of the thyroid gland,
tions) .
61. Diseases of the parathyroid glands, 110. Diseases
of the esophagus.
62. Diseases of the thymus gland,
111.
Ulcer
of the stomach and duode­
63. Diseases of the adrenals (Addison’s
num.
disease).
112. Other diseases of the stomach
64. Diseases of the spleen.
(cancer excepted).
65. Leukemia and Hodgkin’s disease.
113. Diarrhea and enteritis (under 2
66. Alcoholism (acute or chronic).
years of age).
67. Chronic poisoning by mineral sub114. Diarrhea and enteritis (2 years
stances.
.
and over).
68. Chronic poisoning by organic sub115. Ancylostomiasis.
stances.
116. Diseases due to other intestinal
69. Other general diseases.
parasites.
70. Encephalitis.
117. Appendicitis and typhlitis.
71. Meningitis.
72. Tabes dorsalis (locomotor ataxia). 118. Hernia, intestinal obstruction.
119. Other diseases of the intestines.
73. Other diseases of the spinal cord.
120. Acute yellow atrophy of the liver.
74. Cerebral hemorrhage, apoplexy.
121. Hydatid tumor of the liver.
75. Paralysis without specified cause.
122. Cirrhosis of the liver.
76. General paralysis of the insane.
123. Biliary calculi.
77. Other forms of mental alienation.
124. Other diseases of the liver.
78. Epilepsy.
79. Convulsions (nonpuerperal; 5 years 125. Diseases of the pancreas.
126. Peritonitis without specified cause.
and over).
80. Infantile convulsions (under 5 127. Other diseases of the digestive
system (cancer and tuberculo­
years of age).
sis excepted).
81. Chorea.
128. Acut# nephritis (including un­
82. Neuralgia and neuritis.
specified under 10 years of age).
83. Softening of the brain.
84. Other diseases of the nervous sys­ 129. Chronic nephritis (including un­
specified 10 years and over).
tem.
130. Chyluria.
85. Diseases of the eye and annexa.
86. Diseases of the ear and of the mas­ 131. Other diseases of the kidneys and
annexa.
toid process.
132. Calculi of the urinary passages.
87. Pericarditis.
88. Endocarditis
and
myocarditis 133. Diseases of the bladder.
134. Diseases of the urethra, urinary
(acute).
abscess, etc.
89. Angina pectoris.
135. Diseases of the prostate.
90. Other diseases of the heart.
136. Nonvenereal diseases of the male
91. Diseases of the arteries.
genital organs.
92. Embolism and thrombosis (not
137. Cysts and other benign tumors of
cerebral).
the ovary.
93. Diseases of the veins (varices,
138. Salpingitis and pelvic abscess (fe­
hemorrhoids, phlebitis, etc.).
male) .
94. Diseases of the lymphatic system
139. Benign tumors of the uterus.
(lymphangitis, etc.).
95. Hemorrhage
without
specified 140. Nonpuerperal uterine hemorrhage.
141. Other diseases of the female geni­
cause.
tal organs.
96. Other diseases of the circulatory
142. Nonpuerperal diseases of the
system.
breast (cancer excepted).
97. Diseases of the nasal fossae and
143. Accidents of pregnancy.
their annexa.
144. Puerperal hemorrhage.
98. Diseases of the larynx.
145. Other accidents of labor.
99. Bronchitis.
146. Puerperal septicemia.
100. Broncho-pneumonia.
147. Puerperal phlegmasia alba dolens,
101. Pneumonia.
embolus, sudden death.
102. Pleurisy.


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APPENDIXES
148. Puerperal albuminuria and con­
vulsions.
149. Following childbirth (not other­
wise defined).
'1 5 0 . Puerperal diseases of the breast.
151. Gangrene.
152. Furuncle.
153. Acute abscess.
154. Other diseases of the skin and annexa.
155. Diseases of the bones (tuberculo­
sis excepted).
156. Diseases of the joints (tuberculo­
sis and rheumatism excepted).
157. Amputations.
158. Other diseases of the organs of
locomotion.
159. Congenital malformations (still­
births not included).
160. Congenital debility, icterus, and
sclerema.
161. Premature birth; injury at birth.
162. Other diseases peculiar to early
infancy.
163. Lack of care.
164. Senility.
165. Suicide by solid or liquid poisons
(corrosive substances excepted).
166. Suicide by corrosive substances.
167. Suicide by poisonous gas.
168. Suicide by hanging or strangula­
tion.
169. Suicide by drowning.
170. Suicide by firearms.
171. Suicide by cutting or piercing in­
struments.
172. Suicide by jumping from high
places.
173. Suicide by crushing.
174. Other suicides.
175. Poisoning by food.
176. Poisoning by venomous animals.
177. Other acute accidental poisonings
(gas excepted).

109

178. Conflagration.
47 9 . Accidental burns (conflagration
excepted).
180. Accidental mechanical- suffoca­
tion.
181. Accidental absorption of irrespira­
ble, irritating, or poisonous gas.
182. Accidental drowning.
183. Accidental traumatism by fire­
arms (wounds of war excepted).
184. Accidental traumatism by cutting
or piercing instruments.
185. Accidental traumatism by fall.
186. Accidental traumatism in mines
and quarries.
187. Accidental traumatism by ma­
chines.
188. Accidental traumatism by other
crushing (vehicles, railways,
landslides, etc.).
189. Injuries by animals (not poison­
ing).
190. Wounds of war.
191. Execution of civilians by belliger­
ent armies.
192. Starvation (deprivation of food or
water).
193. Excessive cold.
194. Excessive heat.
195. Lightning.
196. Other accidental electric shocks.
197. Homicide by firearms.
198. Homicide by cutting or piercing
instruments.
199. Homicide by other means.
200. Infanticide (murder of infants less
than 1 year of age).
2 0 1. Fracture (cause not specified).
202. Other external violence.
203. Violent deaths of unknown causa­
tion.
204. Sudden death.
205. Cause of death not specified or
ill-defined.

P R E F E R E N C E O F N O N P U E R P E R A L C A U S E S W H E N R E T U R N E D IN
. ,
P U E R PE R A L CAU SES

143 (a). Abortion.

C O M B IN A T IO N

W IT H
W 11H

^ The following nonpuerperal causes are preferred.— 1 to 6 inc.. 8 to 10 ino 14
! 6 b , 17,18, 20, 21 a, 22 to 24 inc., 25cl, 26 to 28 inc., 29 1S, 30a, 31 to 35 inc ’ 36a
and b, 36c 1, 36d and e, 37, 38, 40 “ 43 to 49 inc., 54, 55, 57, 59, 60b 1, 63 65 ’67a
J7bl» J8a, 72,73 76 84a, 90a, 91a, 91cl, 92 « , l l l a l , l l l b l , 112a, 116al, 116cl|
202&’2038a1, 118b’ 120,
122a> 122bl> 165 to 191 inc., 193 to 199 inc., 201a|
143 (b). Ectopic gestation.

The following nonpuerperal causes are preferred.— 1, 2, 6. 8. 10 14 17 IS 20
? L 12’ 2a t0 £ 4 i T 25^
6-to 28 inc-’ 29 13’ 30a- 31 to 35 inc., 36a m d b / m i ,
??«
3 7 ,3 8 ,4 3 40 49 m e, 54 55, 63, 65, 72, 76, l l l a l , l l l b l , 112a, 116al
H 6cl, 120, 121, 165 to 191 me., 193 to 199 inc., 201a, 202, 203.
12 Assign to 146 unless erysipelas is known to have preceded delivery
13 Assign to 148.
MGonococcic peritonitis and gonococcic salpingitis assign to 146,
15Assign to 147.


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no

MATERNAL MORTALITY

143 (c l). Other accidents of pregnancy.

The followinq nonpuerperal causes are preferred.— I to 6 inc., 8 to 10 inc., 14, 16b,
17, 18, 20, 21 12 22 to 24 inc., 25cl, 26 to 28 inc., 29 13, 30a, 31 to 35 m e., 36a and b,
36c 1, 36d and e, 37, 38, 40a 14, 40b, 43 to 49 inc., 54, 55, 57 % ^ b l ^ 6 3 , _ 6 5 ^ j | ^ ,
67 b l, 68a, 72, 73, 76, 84a, 90a, 91a, 91cl, 92 » , l l l a l , l l l b l , 112a, 116al, 116cl,
117a, 118al, 118b, 120, 121, 122a, 122b l, 165 to 191 inc., 193 to 199 inc., 201a,
202, 203.
143 (c2). Other accidents of pregnancy.

The followinq nonpuerperal causes are preferred.— 1 to 28 inc., 29J3, 30 to 38
inc., 40, 41 i«, 42a, 43 to 52 inc., 54, 55, 57, 58b l, 59 to 68 inc., 69a, 70 to 73 me ,
74al, 74b, 75, 76, 77 " , 78, 83, 84, 86, 87, 88a
88b 89, 90a a n d b 91, 9 2 » , 9 3 »
94 97al, 97b, 98a, 99 to 102 inc., 104 to 106 me., 107a and b, 107cl, 108, 109b,
110 111 112a, 114a, 116al, i l 6c l, 117, 118, 119a and b, 1 1 9 c », 120 to 123 me
124a, b, and c % 2 5 , 129a, 130, 131a2«, 132, 134, 137, .139, 151a, 151b " , 152, 153a 22,
153b » , 154a, 155, 156a, 165 to 191 inc., 193 to 199 me., 201a, 202, 203.
144. Puerperal hemorrhage.

The following nonpuerperal causes are preferred. 1, 2, 6 , 8, 10, 14, 17, 18, 20,
21 12 22, 24, 25cl, 26 to 28 inc., 30a, 31 to 35 inc., 36a and b, 36cl, 36d and e, 37,
38, 43 to 49 inc., 54, 55, 60b l, 63, 65, 72, 76, 91a, 91cl, l l l a l , l l l b l , 112a, 116al,
116cl, 120, 121, 165 to 191 inc., 193 to 199 inc., 201a, 202, 203.
145 (a). Cesarean section.

The following nonpuerperal causes are preferred.— I, 2, 6, 8, 10, 14, 17, 18, 20,
2 1 12 22 to 24 inc., 25cl, 26 to 28 inc., 29 1S, 30a, 31 to 35 inc., 36a and b, 36cl, 36d
a n d e, 37, 38, 43 to 49 inc., 54, 55, 60 b l, 63, 65, 72, 76, 91a, 91cl, l l l a l , l l l b l ,
112a, 116al, 116cl, 120, 121, 165 to 191 inc., 193 to 199 me., 201a, 202, 203.
145(b). Other surgical operations and instrumental delivery.

The following nonpuerperal causes are preferred.— 1, 2, 6 , 8, 10, 14, 17, 18, 20,
2 1 12 22 to 24 inc., 25cl, 26 to 28 inc., 29 » , 30a, 31 to 35 inc., 36a and b, 36cl, 36d
and e, 37, 38, 43 to 49 inc., 54, 55, 60 b l, 63, 65, 67a, 67b l, 68a, 72, 76, 91a, 91cl,
l l l a l , l l l b l , 112a, 116al, 116cl, 120, 121, 129a, 165 to 191 inc., 193 to 199 me.,
2 0 1a, 202, 203.
145 (c l). Other accidents of labor.

The following nonpuerperal causes are preferred.— 1, 2, 6, 8, 10, 14, 17, 18, 20,
2 1 12 22 24, 25 cl, 26 to 28 inc., 29 » , 30a, 31 to 35 inc., 37a, 38, 43 to 49 me., 54,
55, 72, 76, l l l a l , l l l b l , 112a, 116al, 116cl, 120, 121, 165 to 191 inc., 193 to 199
inc., 201a, 202, 203.
145 (c2). Other accidents of labor.

.

The following nonpuerperal causes are preferred.— 1, 2, 6 , 8, 10, 14, 17, 18, 20,
2 1 12 22 to 24 inc., 25 c l, 26 to 28 inc., 29 13, 30a, 31 to 35 inc., 36a and b, 36 cl,
36d and e, 37, 38, 43 to 49 inc., 54, 55, 6 0 b l, 63, 65, 67a, 6 7 b l, 68a, 72, 76, 91a,
9 1 c l, l l l a l , l l l b l , 112a, 116al, 116cl, 120, 121, 129a, 165 to 191 me., 193 to
199 inc., 201a, 202, 203.
.
__________
12Assign to 146 unless erysipelas is known to have preceded delivery. '
12Assign to 148.
.
11 Gonococcic peritonitis and gonococcic salpingitis assign to 146.
15 ASsign to 147.
is Assign to 146 unless the septic condition is known to have been independent of the puerperal condition,
u Pregnancy with dementia assign to 149.
is 9 ^ n y e m ic phlebitis, pyophlebitis, septic phlebitis, septic thrombo phlebitis, suppurative phlebitis,
with titles 143a to 150, assign to 146. All other terms under this title with 143a, 143cl, 143c2,145c3,149, and
150, assign to 147.
*
.. .
19 In combination with certain forms of abscess assign to 146.
20 Assign to 148 unless kidney complication is known to have preceded pregnancy.
21 151b in combination with certain gangrenous infections assign to 146.
« 153a in combination with abscess of iliac region or retroperitoneal abscess assign to 146.


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APPENDIXES

111

145 (c3). Other accidents of labor.
The follow in g n onpu erperal causes are preferred.— 1 to 10 inc . 12 to 14 i n c
16b, 17 to 20 inc 21L» 22 to 28 inc., 29 » 30a, 31 to 35 4 . , 36a and b, 3 6 c i!
x j o d >,ond
38’ 42a’ 43 to 49 m c-> 54> 55> 57’ 59, 60b 1, 63, 65, 67a, 67 b í, 68a
72 73a, 76, 84a, 90a, 91a, 91 cl, 92 1S, 110a, l l l a l , l l l b l , 112a, 116al 116cl
n 7 a 118al n 8b l 120, 121, 122a, 122bl, 129a, 130, 165 to 191 inc., 193 to 199
lnc.j zy ia , z u z f ^Uo.
146. Puerperal septicemia.
The follow in g nonpuerperal causes are preferred. — 1, 2, 6. 8 10 14 17 18 20
43 to 49 inc., 72, 76, 116al, i l V ’l M t o 191
193 to 199 me,, 201a, 202, 203.
147. Puerperal phlegmasia alba dolens, embolus, sudden death.
The follow in g nonpuerperal causes are preferred. — 1, 2, 6. 8 10 14 17 18 20
S h ’ 2 h t0 l i in,S " 2 * ? - t i ° 28 inc-’ 28 “ ■ 30a' 31
36a and b 36??;
36d and e, 37, 38, 43 to 49 me., 54, 55, 60 b l, 63, 65, 72, 76, 91a, 91cl l l l a l
l l l b l , 112a, 116al, 116cl, 120, 121, 165 to 191 inc., 193 to 199 inc., 201a, 202, 203.’
148. Puerperal albuminuria and convulsions.
The follow in g nonpuerperal causes are preferred.— 1 , 2 , 6 , 8. 10 14 17 18 20
2 1 ,2’ 2 q7ÍOo8 4 ,on i ’ 26% 26c\° 28 inc., 30a, 31 to 35 inc., 36a and b, 3 6 c l,3 6 d
e,^ h 38> 43 to 49 m c-> 54 > 55, 60 b l, 63, 65, 72, 76, 91a, 91cl, l l l a l , l l l b l
112a, H 6a l, 116cl, 120, 121, 129a, 165 to 191 inc., 193 to 199 inc., 201a, 202, 203!
149. Following childbirth (not otherwise defined).
oí Tn eo o ll? WinS ™on p^ rRer®l causes are p referred — l , 2, 5 to 14 inc., 16 to 20 inc.,
V ? * » mc‘’r ? 9 ctr’
ton 35 m c-» 36a and b > 3 6c l, 36d and e, 37, 38,
QO«’ q? toa í V noo
^
S9, eob1, 63y 65, 67a, 67 b l, 68a, 72, 73a, 76, 84a,
90a,
94®i> 92 • > 11 l a l , l l l b l , 112a, 116al, 116cl, 117a, 118al, 118bl 120
121, 122a, 122bl, 129a, 130, 165 to 191 inc., 193 to 199 inc., 201a, 202, 203.
150. Puerperal diseases of the breast. .
J ? ll. owinR n °npuerperal causes are preferred.— 1 to 14 inc., 16 to 20 inc
22 +° In •
ln° ’’ In . y P f c 3 ! to 35 inc,> 36a and b, 36 cl, 36d and e, 37, 38, 42a!
43 towf,9 1SC’’ 50a’ 51, 54> 66) 57, 58a, 58b l, 59, 60a, 60b l, 63 to 65 inc 67 68

S h i 7 ?nb7 h72i i7h
J to 1
,■ ! & ,7Bi 7«<,83- 84a and b - 8« b- 87> «>. 90a b , and i? 9?!
92 ’ 10Jty .„A 112a’ 1 1 0 a l, H 6c l, 117, 118, 119a, 120, 121, 122a, 122bl 125

Í 9 ^ nf 201a 202?220334b1’ ^

1§

^

155a’ 165 t0 191 ^

Assign to 146 unless erysipelas is known to have preceded delivery.
13Assign to 148.
J
15Assign to 147.
151b in combination with certain gangrenous infections assign to 146.
23Assign to 146 which takes preference.


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193

APPENDIX B.— COMPLETENESS OF BIRTH REGISTRATION
Information supplied by State registrars of vital statistics on the subject of
the completeness of birth registration is summarized for States m the birth-registration area in 1919 as follows. In many States effective and ingenious methods
of checking birth registration are in use which the following brief quotations do
not adequately describe:
Connecticut— “ We estimate the proportion of births registered to be
about 95 per cent plus. * * * I am of the opinion that birth registra­
tion has been improved in the last few years, due largely to the fact that
we send each mother a complimentary birth certificate.”
,
District of Columbia.— “ Between 95 and 96 per cent of the births m
1919 registered.**
Indiana.— Test made by the United States Census Bureau in 1922;
“ about 92 per cent” of the births are registered.
.
,
Kansas.— “ No check of birth registration in Kansas in last few years.
I estimate * * * very near 99 per cent at the present time. I am
sure there has been an improvement in the last few years.”
>
Kentucky.— “ We are receiving in this department between 90 and 95
per cent of all births occurring in the State. * * * A check of still­
births and infant death certificates against birth certificates is made at
stated times— usually once or twice a year.”
„
Maine.— “ Between 98 and 99 per cent of all births registered.
Maryland.— Test made by the Bureau of the Census by checking infart
deaths against birth certificates in 1917 indicated registration 94 per cent
complete. “ Since then we have conducted no test to ascertain the com­
pleteness of birth registration. I am satisfied that it is better now than
it was in 1917.”
.
,
Massachusetts.— “ In the majority of cities and towns a canvass is made
in January each year, and from results of this canvass it would ^appear
that less than one-half of 1 per cent of the births are unrecorded.”
Michigan.— Official check made by Bureau of the Census in 1921.
Unofficially informed that it showed about 94 per cent complete.
Minnesota.— A test made by the Bureau of the Census in 1921 showed
94.5 per cent of the births registered. 'Now “ at least 96 per cent (and
probably more) of our births are registered.”
.
New Hampshire.— il Whenever & death, record of an infant under 1 year
of age is reported, we always check up with the births and almost always
find the birth record. * * * We now believe that less than 1 per
cent are not reported.”
.
New York (exclusive of New York City).— Test made m January, 1928,
by checking deaths of infants under 1 year against birth certificates
indicated 97.4 per cent registered. “ Birth registration to-day is nearly
perfect; possibly the only unrecorded births are those occurring in isolated
districts and in foreign families where no attendant was present. * * *
The birth rate in 1919 was at least 95 per cent perfect and in all probability
was higher.”
,
. . ..
,
New York City.— “ We can safely say that our present registration of
births is well over 99 per cent of total number born.”
North Carolina.— “ We have never tested our birth registration for the
year 1919. We have always felt that we were getting nearly all births
reported.”
. . . .
. ori
Ohio.— Test made by Bureau of the Census of birth registration m 29
counties of Ohio in October and November, 1923, indicated birth regis­
tration 92.1 per cent complete.
Oregon.— A test made in 1919 indicated birth registration about 93 per
cent complete.
Rhode Island.— “ Estimating the proportion of births now registered in
this State, it would be safe to say that only a very small proportion are
among the unregistered. I feel sure that this work has improved wonder­
fully since the middle of 1921.”

112


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APPENDIXES

113

South Carolina. A test in 1919 made by the United States Census
Bureau indicated registration over 90 per cent complete. Test for 1923
showed only about 82 per cent. “ For the year 1924, owing to extra
effort on the part of this office, we are approximately 1,500 births ahead
of last year for the first four months.”
Utah.— No test made for 1919. The test made by the United States
Bureau of the Census in June, 1924, “ found approximately 97 per cent
registration. In my opinion this is not far from correct.”
Vermontr- N o test made for 1919. “ I feel that our birth registration is
well over 90 per cent; in fact, I should put it at 95 or better ”
•
made
the United States Bureau of the Census
“ ,191J indicated over 92 per cent of registration.” “ We are getting
at least 95 per cent, possibly more.” '
6
Washington.— “ About 96 per cent complete.”
WisMnsin.— Test of birth registration in January and February, 1923
made by checking deaths of infants under 1 year of age against the birth
certificates showed 93 per cent registered.


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APPENDIX C — REGISTRATION AND DEFINITION OF STILL­
BIRTHS
PART I.— UNITED STATES
In order to obtain the most accurate measure of maternal mortality the deaths
shiSlS be compared with the number of confinements £
'
<? ^ ¿ n still births less the extra twins and triplets; it is important, therefore, to con
Sder ttT s S S e o t of the registration of stillbirths. But if accurate maternal
mortality rates are to be based upon the number of confinements, not oniy must
the stillbirths as well as the live births be
states but they must be uniformly defined. In the United States mere is
neither a uniform requirement for registering stillbirths, nor is there a umfor
^R^aui^ement of registration.— In 37 States the law requires stillbirths to be
registered both as births and as deaths. Eight otherf Stat
of stillbirths as births and deaths under regulations of the State board of health
or of public welfare. This double requirement provides for securing the infor­
mation called for on the death certificate, including cause, :if known, ;as well as
the details called for on the birth certificate. Since in most States death certifi
cateslto stillbirths must be attested by a physician or, in case no.Physician .
was in attendance, must be certified by a coroner or other ° ® “ r
law before a burial permit can be obtained, the double requirement of registra
tton of stillbirths as births and as deaths tends to insure more complete
registration-s ^
Jergeyj and the District of Columbia stillbirths must be
registered as’ such upon a special form provided for the purpose. Connecticut
^^^om phd^tatm lation^^T tillbirths is possible only by m atchm ^the birth
and death certificates for the same stillbirths, for only m th s W j v ÿ l all the
data be made available. In practice, the registration of ptillbirths as deaths
is usually slightly better than the registration of stillbirths as births. In a few
cases a stillbirth may be registered as a birth but not as a deatn.
_.
D e n s o n — 'The so-called “ model law ” for the registration of births and
deaths reads in part as follows: “ A stillborn child
nnH Also as a death. * * * Provided, that a certificate of birtfi ana a cer
tificate of death shall not be required for a child that has not advanced to the
fifth month of uterogestation.”
,
. ,
„„ hirt.hs
In 16 States the law providing for the registrarion «of
and deaths defines stillbirths as suggested m the model law. In 6 States tùe
same period of uterogestation for stillbirths is adopted by regulation of State
boards of health or of public welfare, and in 1 State instructions issued by the
State registrar require to be reported stillbirths that have advanced to the
fifth month. In other States various periods of uterogestation have been
adonted as a requirement for reporting births either by law or regulation,
,
in some instances, as a matter of practice. The method of reportmg these
births and the period of uterogestation are shown m the accompanying chart.
lo o t, «tat lois spc 329 amended by Public Acts of 1919, ch. 56, requires the registration of the birth
of Æ
S
’ TheîComec“
Depyartment of Health states, “ There is ^ h m ^ h ^ s o e v e m n tte
statutes relating to the registration of stillbirths. However, this department has for some time distributed
blanks for the registration of stillbirths.”

114


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APPENDIXES

115

Summary of regulations regarding the registration and definition of stillbirths in the
United States in force December, 1924

State

Period of uterogestation—

Reported Reported
as
births
still­
and
births
deaths

Defined by
regulation

Defined by law

Defined by instructions
to physicians or other­
wise

Alabama............ Yes____
month.

Arizona.............. Yes____ L ..........
Arkansas_______ Yes i___ 1_____ ___

Advanced to fifth
month.

California______ Yes____ I_________
month.

Colorado........... . Yes____ 1_______

Custom by common con­
sent to report after
sixth month.

Connecticut2___
|
Delaware______ Yes____
District of CoY e s..^ .. Passed fifth month
lumbia.
Florida________ Yes____
month.
Georgia________ Yes____
____do
...
,
Idaho_________ Y es..._J__
Illinois_______
Indiana______

Yes____

Iowa________

Yes____

Kansas..........

Yes 1___

Kentucky___

Yes____

Louisiana__

Y e s .....

Maine________

Yes____

■-

Yes____ Advanced to fifth
month.
and over.
month.

■

Passed the twentyeighth week.
Pretty generally under­
stood that births occur­
ring after 4Yt months
are to be reported.
month.

Maryland........... Y e s .....

•
Massachusetts . Yes____
Michigan
Yes 1___
Minnesota..
Yes___ _
Mississippi...

Yes i.

Missouri..

Yes____

Montana..

Yes____

Nebraska.......

Yes____

Nevada..........

Yes.......

New Hampshire
New Jersey...

Yes....... i

Practice to report as still­
birth from 3 months.

(’)

Five months and over,
by order of State com­
missioner of health.
Any product of human
gestation which can be
recognized as such
which after birth * * *
does not breathe.

Over 6 months___

month.

■

Advanced to fifth
month.

Passed
fourth
month or six­
teenth week.

In addition to filing of
stillbirths, all abor­
tions shall likewise be
filed
regardless
of
period of uterine gesta­
tion.

month.

7
!
1

No provision by State
board of health “ but
is generally understood
to have passed the
period of quickening.”

|

Yes_________________

!

:i

After fifth month (in­
structions to physi­
cians) .

1Regulation State board of health
2 See note 1, p. 114.
3 The State department of public health states, “ The word (stillborn) is nowhere in our laws defined or
explained. Moreover, we have found that even individual hospitals have established their own standard
as have several of the boards of health of the larger cities. The standard we have set for our own use is
that a stillbirth is the birth of the fetus of 6 months’ development or over.


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216

MATERNAL. MORTALITY

Summary of regulations regarding the registration and definition of stillbirths in the
United States in force December, 1924:— Continued
Period of uterogestation—
State

Reported Reported
as
as
births
still­
and
births
deaths

Defined by law

North Carolina..
North Dakota...

V

PR

Advanced to fifth
month.

Advanced to fifth
month.
....... d o____ ______

Passed fourth month
(rule of State depart­
ment of health).

Pennsylvania___
After sixth month.
Advanced to fifth
month.
____do___________

Rhode Island___ YfiS
South Carolina.. Yas i
South Dakota. . .

Yes____

Advanced to fifth
month.
After 7 months___

6 months and over.
Advanced to fifth month
(instruction of State
registrar).

Y p.s

Yes
West Virginia__ Yes

Yes 1

Defined by instructions
to physicians or other­
wise

Advanced to fifth
month.

Y es4
Yes 5___

Defined by
regulation

Beyond seventh
month.
Advanced to fifth
month or to
total length of
10 inches.

.
After fifth month (in­
structions to physi­
cians and others).
Advanced to fifth
month.

i Regulation State board of health.
Ì T C s t a t ^ w S S i o n l r o f h e a l t h may furnish a combined certificate of birth and death and require
it to be used instead of separate certificates.

The rules of statistical practice regarding stillbirths adopted by the American
Public Health Association include the following definitions:

"R u le No. 17.— For registration purposes, stillbirths should include all children
born who do not live any time whatever, no matter how brief, after birth.
"R u le No. 18.— Birth (completion of birth) is the instant complete separation
of the entire body (not body in the restricted sense of trunk, but th,e entire
organism, including head, trunk, and limbs) of the child from the body of the
mother. The umbilical cord need not be cut or the placenta detached m order
to constitute complete birth for registration purposes. A child dead or dying a
moment before the instant of birth is a stillbirth, and one dying a moment no
matter how brief, after birth, was a living child, and should not be registered as
a "R u le No. 19.— No child that shows any evidence of life after birth should be
registered as a stillbirth.
,,
, , . ., ^ •
"R u le No. 20.— Stillbirths should not be included in tables of births or in
tables of deaths. They should be given in separate tables of stillbirths.
"R u le No. 21.— It is not desirable that midwives be allowed to sign certificates
of stillbirths.” 2
2
Rules of Statistical Practice, adopted by the American Public Health Association, section on Vital
Statistics, at the annual meeting, Winnepeg, Manitoba, August 25-28, lauo.


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a p p e n d ix e s

117

PART II.— FO R E IG N CO UN TRIES

Summary of regulations regarding the registration and definition of stillbirths
■
certain foreign countries 1
Country

Australia..
Belgium..
Chile..
Denmark___
England and Wales..
Finland__
France__
Germany..
Hungary___
Ireland..
Italy___
Japan..
1 he Netherlands.
New Zealand
Norway..
Spain___
Sweden___
Scotland...
Switzerland
Uruguay...

Regis­ | Regis­
Regis­
tered as
tration tered as
births
births
compul­
and
or
sory 2
deaths
deaths

In sepa­
rate
register

No. 3...
Yes 4___

Subsequent to sixth month of preg­
nancy.
Over 6 months.

Yes____
As birth...

No
Y e s...

XT

Y e s ...
Yes
Y es1“ .
Y e s...
No

After 6 months.
If sex can be determined.

As death..

Y e s ...
Yes___
N o ....

After 7 months’ gestation.
As birth...
After 4 months.
I

As b irth ..

N o .... 1
Yes 12-_. Ÿes___

At least 28 weeks.

As birth.
1
As death;.!

After 6 months.

1 Sources:

London, 1912

Period of uterogestation

‘

“

'' .

~— ~ ------ ;—

' f ana deaths Wlth reference to infantile mortality, pp. 10, 12, 36 47

o £ “ S , : N o 'f i S ”

TL' « ’ ™

a <M^OV*Iiiie n t o l a Poblacion, Chile, 1904, P. X L

S“ “ cs’

« * « » » » Health O r » * » « « .

»»■

the general law refating1t o ^
births’ such l a w s ^ ^ ^ h 617
£x^e? tions' required under
they require the registration of all births or the l K ^
. h
bee? drafted in general terms (i. e„
living child, as in England) It is n o S r t h t
™ ? J V? Ty ei?lld- and not merely the birth of every
the present, enacted any definition of stillbirth nrffi rhJfthf Ca? be “ eertamed no legislature has, up to

bo.™ child is deemed to have been born alive and to h a v e re d
tion,

i.

C h ild r e n

’

purposes of registration a still-

b0m dead: (2) Children born alive but dying before registra-

and is*in practice C t t o v f f g ^ S S S & i f f i i g S » compulsory
matter what the duration of gestation mav S
ni
.the wor d 1S. counted as a live birth, no
signs of life during or after the t o v e n t S ? h w i S ’KS every f<?tus « » ? “ # into the world without 4ny
“ DI n Q r lflfp )qbefT h thetWenty'nintb week is reckonedef sn|nLabort1onnted “ & stUlbirth- An embfyo
birth o lfn y
notM ctlon of birth, act the

»'era awaaT^-S?SSKa£?‘5^a» a s r

born if after complete birth it “ has not hronthprif>r
adopted in that country and

prescribes that an infant is to be regarded as stilltbis,is tbe defiifition generally

enter ihecM eCM<death)

I—

S s?r°a K ^ ^ ^
appear in the registers as stillborn )
child1born
counted
as “ live birth.”

*■ *>

°r reglstratlon a certain number of children bom alive

th is
°ther’ born
^
A
registration ofbT
of birth
is, at law, stillborn but for statistical
purposes
is

Children born „ „ t o * , nd
birth (for which three days are allowed) Since 1917 sno^iai
^ut dym£ before registration of
»live but dying before registration.
'
917 special tabulations have been made of those born
10 White births only.

wSSsftS?“ l

i

separatSffromth^motoer t o M d


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f

e
b S S ^ S .“ 8 ^

cb(ildr / r Iude those born
Any ^

d ^ bi" b bas * * * * * after

APPENDIX d :— s t a t i s t i c a l c o m p a r a b i l i t y o f m a t e r n a l
MORTALITY RATES IN THE UNITED STATES AND CERTAIN
FOREIGN COUNTRIES
In attempting to compare maternal mortality rates for different countries it is
necessary to consider whether and to what degree the figures are statistically
comparable. Exact statistical comparability would be secured,
rate were accurate and if the causes or the groups of causes had the same or
equivalent definitions. Following the lines of the discussion for the United
States, the points to be considered are: (1) Uniformity^.or
tions ¿f puerperal causes with respect to accuracy of rates; (2) completeness oí
death registration; (3) accuracy of certification; (4) rules for classification o
causes. ofgdeath; and (5) completeness of birth registration. Each of these points
will be discussed briefly.
UNIFORMITY OF DEFINITIONS OF PUERPERAL CAUSES
The *1puerperal causes ” as a group and also the subgroups of “ puerperal
septicemia” and of “ all other puerperal causes,” may be considered comparable
as to definition.1 Many of the countries for which statistics are presented use the
International List of Causes of Death in which each rubric is defined m corre­
sponding terms in the different languages. Certain of the countries which use
this list and the years when its use was adopted— that is, the first year for which
causes of death were classified according to the list— are: ^he United States
(1900),2 England and Wales (1911),3 Scotland (1911)* Ireland (1911),® Austra­
lia (1907)/ France (1901),5 The Netherlands (1901),8 New Zealand (1908),
Spain (1900),8 Uruguay (1901),8 and Chile (1903).9 In other countries other
lists of causes are in use; in each of these lists though puerperal septicemia and
“ other puerperal causes” are shown separately, when taken together t y
correspond to the group “ all puerperal causes of the International List.
COMPLETENESS OF DEATH REGISTRATION
Death registration is réquired by law in each of these countries, and in most of
them, if not in all, the method of enforcement is similar to that m use m the
United States, namely, the requirement that a death certificate be filed as a pre­
requisite to obtaining a burial permit.10 In most of these
of deaths has been in force for a much longer period,11 ;a ndUg} udensity of P ^ ula’
tion, or the proportion living in cities, is higher than m the United States, it would
be expected, therefore, that death registration would be relatively more complete
than in the United States.12
i Annuaire International de Statistique: Europe, Mouvement de la population, pp. 168-179; Amerique,
^^^ortSSy^tldisüc^lQOO-ÍMui P.3X. °'Special Reports, U. S Bureau of the Census
3 Annuaire International de Statistique: Europe, Mouvement de la population, p. 174.
4 Official Year Book of the Commonwealth of Australia, No. 12, 1919, p. lav.
« S t S i q u e Santoire de la France, 1909, Vol. 24, p. 143. Published by Direction de 1’Assistance et de
YStatetique Internationale du Mouvement de la Population, 1901-1910, p. 146. Published by Direction
du Travail, Paris.
i The N ew Zealand Official Year-Book, 1919, p. 166.
PnWiched hv Direction
i Statistique Internationale du Mouvement du la Population, 1907, pp. 577-598. Published by Direction
dl» Oficina’ Central de Estadística, Población calculada de la República de Chile en 1910 i Resena del
Movimiento de Población del mismo año, p. 50. Santiago de Chile, 1912.
_
, af-u,
.i Qnf,ietv
io See on this point Infantile Mortality. Report of the special committee of the Royal Statistical Society,
" fc Ibidfpp. 20-25.

Compare accompanying list giving dates from which annual statistics.of births and

d hTbidr,e ppa26-33t replies from the different countries (1912) to the question “ Do many births or deaths
escape registration? ”

118

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a p p e n d ix e s

119

Dates from which annual statistics of births and deaths are available in certain
countries
Eu rope:

Alsace Lorraine
_________ 1841
A u s tr ia ___
1819 (N ov. 1 )
Baden __ __
Bavaria,
1825-26 (Oct. 1 )
Belgium _
_________ 1830
Bulgaria _
Denmark _
. _______1801
England and Wales _________ 1838
Finland _ _
_________ 1751
France___
German Em pire.
_________ 1841
Greece___ __ _
. _ _ ____ 1864
Hamburg
_________ 1849
Hesse___ __
_________ 1841
H ungary. _
_________ 1876
Ireland. _ _
_________ 1864
Italy _ _ _ _
The Netherlands
_ ____ 1839
N orw ay. _ __ .
________ 1801
Portugal _
------------ 1886
Prussia, _____
_______
1816
Rumania _
________ 1859
Russia (Europe) __
________ 1867

E u r o p e — Continued.
Saxony------------------------------------ 1827
1851
Scotland____________________
Serbia-----------------------ZIZ 1862
Spain-------------:---------------- £■_*_ 1858
Sweden_____ , _ _ „_•_ ____ ___
1749
Switzerland____ _______________ 1870
Wurttemburg___ _
1841
A u s t r a l a s ia :
- - - - - - - - New South Wales___ _________ i860
New Zealand______ - 1861
Queensland__________________
i860
1861
South A u stralia-_ __________
Tasmania_______________L j -Jm 1861
Victoria_______ _______________ 1854
Western Australia______
1861
A s ia :
Japan------ig72
C e n t r a l a n d S o u th A m e r i c a :
1899
Argentina-----------------------Chile___---------_ _ _ _ _ _ _ ----------- 1880
Mexico_____________________
1895
Uruguay------------------------ E l l 1878

ACCURACY OF CERTIFICATION OF CAUSE OF DEATH
Upon the question of comparative accuracy of certification of the cause of
death it is relatively difficult to adduce satisfactory evidence. Nevertheless
light can be thrown upon this subject by a consideration of the proportion of
deaths certified by physicians, the proportion of deaths certified as due to illdefined or unknown causes, the means by which the accuracy of certification is
checked, and the evidence of possible transfers of puerperal to nonpuerperal
causes. Indirect evidence is also furnished by the proportion of physicians to
population and their average qualifications. (See pp. 79-80, 148.)
The first question do be examined is what proportion o f’ deaths are certified
by physicians. Evidence on this point is presented in the following table for
the countries and the latest years for which the data could be obtained: 13
13 See P-10 for results of a special study of death certificates in selected States in the United States.


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MATERNAL MORTALITY

120

Proportion of deaths certified by physicians in certain foreign countries
Per cent
of deaths
with phy­
sician’s
statement
of cause

Year

Country

Australia......... ...........
Austria (new boundaries) —
C hile..______- ........... — ~
England and Wales.............
Germany:
Baden________ _______
Bavaria......... ...............
Hesse.------- ---------------Saxony----------- -------W urttemberg ......... —■

1921
1920
1921
1920'

89.4
97.6
25.0
92.1

1892-1901
1901-1902
' 1898
1906
1899-1900

70.3
64.8
87.0

Ä

Ä

8 56.7
» 77.8
299.4
» 96. 5

n 88.9
1298. 9
« 65.6
« 97.9

62.8

or hv medical examiner.

A «»ano Estedistlco

Ä

1913
1920
1916
1921
1917
1921
1916
1920

H u ngary............
Ireland....... .........
Italy----------------The Netherlands .
Norway............ .
Scotland-----------Sweden-------------Switzerland-------

66.0

tralia, No. 15, PP- 125-126P'>3c L Ä d S

Year

Country

Per cent
of deaths
with phy­
sician’s
statement
of cause

Ä

Ä" Ä n c e r t i M

From Statistisches Jahrbuch fur

by
. ' Eighty-third Annual B.port of

«»«>. Printing. F.: Handbuch d „
^ ^ S ^ l S ^ ^ t ^ o Ä ^ Ä Ä o .r .- b y W

c»” »m

Jahrbuch, Neue Folge, X X I, 1913, pp. 47-49.

iÄ

iiÄ

S

Ä

i b

, 1S

were certified. Ibid., P J> -^ *TL i attpnrlnnce

S

s g

S

S

a l t i F w

S

ir°mD™“ is<i‘“ s“ “ ,sd“

Annual Report of the Registrar-General for
; ,“Ä
y ? a » oi aga, inclusiv., 90.8 per cent

Deaths from violence and suicide are included with those

Ä

Ä

.c i .V i l l c o n .

t

de aterfte „aa, de. Eeei.iid en de Oortahen

Ä

'S Ä ? Ä Ä

ä
s Ä

r - ' ?—
S

i

F Ä M 9 1 2 , pp.

13, 27.

France Prussia and New Zealand also provide spaces on the j^ iv id u a l death
f cia£ ?. * i ? v t o T h e cause of^eath, it is probable that a very large proportion
0 7 d ea lL are » ?ert?fied. In Prassii p W tf«U »»ig attendance may be required
which t i e cause of death wan certified
b y ^ p h y a ld ^ ^ ^ b ^ ^ ^^glj^^l^Q ^^h ^prop ortion ^f^w h ic’h'the^cau^iof

1.7 P j
cent for women from 20 to 29, 1.2 per cent for women from 30 to 39, and 1.9 per
cent for women from 40 to 49 years of age.1

Prinzing, F.: Handbuch der Medizinischen Statistik, p. 320.


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APPENDIXES

121

Fiirthcrmöre, although a distinction between several puerperal causes would
t X f Z Z f y drawn only by a properly qualified physician who had been 7n at­
tendance, m case of a death connected with childbirth a statement of the cause
by a medmal examiner who had not been in attendance, or even by a layman
d °ubtless result m the great majority of cases in a correc/assignment
to the group of puerperal causes. In most cases the fact of childbirth would be
quite as well known to the members of the family as to the physicians ^ n a tfactd wo°uidabe lfk ?lv 'T n h occurr®d at the time of, or soon after, childbirth that

t

a

Ä

8

Ä

ev“

y a layman as a factor in’ “ not the

nn7+i^CC!,nfd/ riiuri(ln ° f
accuracy of certification might be found in the pro­
portion of deaths from ill-defined or unknown causes. But unfortunatelyP no
comparison can be made of the proportions of cases assigned to these causes
because of the great divergence between the various countries in the practice
.deaths- In Switzerland, for example, all causes whielTare not
certified by physicians are classed as ill-defined or unknown.19 In the classificaln E? gland and Wales up to 1911 ah deaths certified as due to old age
or semhty were included with those from unknown causes; 20 deaths the causes of
which were certified in accordance with inquest findings by nonmedicalCoroners
Fn s h o r e s a r e the86
P ^ ic ia n s , according to the causes assigned,
in short, such are the variations in practice in the different countries that no
%S t0 the COI?P arative value of the certification of causes

°f th6 proportion of « “”» f w * «
thirA cr^®r^on of the value of the certification of cause is found in the nro-

the Uniter^Sti+e/T? 1106 thef n i 61" ° f uvnsatisfactory reports. The practice of
ne United States Bureau of the Census, beginning in 1911, of sending l e t t e r s nf
inquiry to physicians in regard to the true causes of all deaths rep orted ^ unsatisterms has already been discussed (pp. 11-12). In England
General ta 1 8 a f Ä f
Z T 7^
Causes’ c° m« d
by the R e Ä ?
j
.
n
’ ba,s resulted m the addition of considerable numbers of deaths
due to puerperai causes. (See Gen. Table 9, p. 149.) According to PrinzSg a like
method has been used in Prussia since 1901.22 A different procedure and one cnlonlated to secure even better results is followed in Switzerland. In that country the
physician in attendance, in addition to filling in the certificate of cause for the local
registrar, sends directly to the central statistical office a secretStatement o fth e
true cause; this latter report is used only for statistical
S e n d e d °? n ?8 9 3 to a8h l S CltieS
m ° re ¿ han 10>°0° inhabitants and was
t f t h e entSe countrv S c™
unes with more than 5,000 population and in 1901
cities 2*
OUntry'
The same system has been adopted in certain German

a fpurtli criterion of the accuracy of certification may be sought in the
e v ^ r e l A t o g t o p o s s 1^ transfers of deaths from puerperal to other causes 1»
The results of a test showing the number of puerperal deaths in comnarison wffh
the estimated excess of female over male deaths from peritonitis acute nenhritis
septicemia and convulsions (unqualified), and Bright’s disease for countries
for which the detailed statistics necessary for the computation were available
have been presented and discussed earlier in the report. (See pp. 58-59).
addition to transfers of puerperal deaths to these particular causes transfers
may have been made to others, such as salpingitis, to which this method of
estimate is inapplicable. Furthermore, in certaiA c o u n trie s-fo r ^ S a m p le
Chile and Hungary— in which a large proportion of the deaths are certifiedby
to puerperaincSses8I S ^¿r r a n t ^ e r e ^ ^ d ^ ^ p h y s i c ^ 1 ^h^deathTcertmed h 16

assigned

from U i i B a r i ' i i S J a £ f e , , S K
20
Handbuch der Medizinischen Statistik, p. 326.
21 SupD^lemen?to the^iftv^fifth0^ ^ 6 ßfgjstrar-Qeneraltor England and Wales, 1920, p. xciv

S
7

(LoVon’

f, Prmzmg F : Handbuch der Medizinischen Statistik, p. 321.
lo t t e n f e h 322 (Berlm>smce 1904); Kisskalt- Karl: Einführung in die Medizinalstatistik, p. 41 (Char” Such evidence has been presented for the United States, pp. 13- 14.


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122

MATEEN AL MORTALITY

nonmedical persons, the causes of puerperal deaths may frequently have been
reported in popular or in indefinite terms which might be classified in other
groups than those that have been discussed. If so, in order to obtain an estimate
of all the transfers from puerperal to other causes, the comparison of actual with
expected female deaths would have to be applied to all the causes to which such
transfers may have been made. On the other hand, if in those cases in which
childbirth is a cause of death the layman simply states “ childbirth” they may
be correctly classified as puerperal, though not properly allocated to the particular
puerperal-disease group to which they belong. _The fact that in Chile the
mortality from puerperal causes is exceptionally high suggests that many deaths
returned by laymen are allocated to the puerperal group.20
Special investigations into the mortality from puerperal causes are few in number,
and though they furnish perhaps the best type of evidence, they usually relate to
small areas and are not up to date. Perhaps the best of these special investiga­
tions is that by Doctor Ehlers into the mortality from puerperal causes in Berlin
during two years, 1895-96. By correspondence with physicians, study of
hospital records, and personal investigation he discovered many puerperal deaths
which had been returned as nonpuerperal. The net result of the investigation
was to add 68.7 per cent to the total puerperal deaths (26.8 per cent to the deaths
from puerperal septicemia) in that city in 1895-96.27
_
Since that date the system of a confidential return of cause of death (which is
sent directly by the physician to the statistical office) has been introduced in
Berlin. The statistical office in that city has adopted also the routine sending
of letters of inquiry to the physician in cases of doubtful diagnoses. In 1910, for
example, of the 250 cases of deaths from puerperal septicemia, 48 had been added
as a result of the information secured by these letters of inquiry.28
RULES FOR CLASSIFICATION OF JOINT CAUSES OF DEATH
When two or more conditions are assigned as primary or contributory, causes
of death it is customary to select one for purposes of tabulation. In practice,
the exact comparability of statistics relating to deaths from puerperal causes
depends not only upon the diseases which are included together in the group but
also upon the rules governing decisions as to whether a puerperal or a non­
puerperal cause shall be selected as the principal one for purposes of statistical
analysis.
C O U N T R IE S U S IN G IN T E R N A T IO N A L L IS T O F C A U S E S W I T H O U T M O D I F I C A T I O N

So far as the countries which use the International List of Causes of Death are
concerned, the classification of deaths which are assigned to two or more causes is
made in accordance with general rules adopted by the International Commission.29
These rules are given in the French edition of 1903 as follows:
“ (1) If one of the two diseases is an immediate and frequent complication of
the other, the death should be classified under the head of the primary disease.
“ (2) If the preceding rule is not applicable, the following should be used: If
one of the diseases is surely fa ta l20 and the other is of less gravity, the former
should be selected as the cause of death. Example, ‘Pulmonary tuberculosis
and puerperal septicemia, classify as tuberculosis.’
“ (3) If neither of the above rules is applicable, then the following: If one of
the diseases is epidemic and the other is not, choose the epidemic disease.
“ (4) If none of the three preceding rules is applicable, the following may be
used: If one of the diseases is much more frequently fatal than the other, then it
should be selected as the cause of death.
“ (5) If none of the four preceding rules applies, then the following: If one of
the diseases is of rapid development and the other is of slow development, the
disease of rapid development should be taken.
“ (6) If none of the above five rules applies, then the diagnosis should be
selected that best characterizes the case.
MIn Chile in 1921 of the deaths from puerperal septicemia only 30.2 per cent, and of deaths from “ other
accidents of childbirth ” 89.8 per cent were reported by laymen. Compiled from Anuario Estadístico de la
República de Chile, Vol. I, Demografía, Año 1921, p. 68.
2? Ehlers, Philipp, M. D.: Die Sterblichkeit “ im Kindbett ” in Berlin und in Preussen, 1877-1896, p. 30.
Stuttgart, 1900.
5
.
28Statistisches Jahrbuch der Stadt Berlin, 32d Jahrgang, enthaltend die Statistik der Jahre 1908 bis
1911, sowie Teile von 1912, p. 143*. Prof. Dr. H. Silbergleit, Berlin, 1913.
22 For rules in use in England and Wales see pp. 126-129; United States see pp. 107-111.
80Apart from all treatment. This provision is necessary to assure stability in the application of the rules.
Otherwise a therapeutic discovery, for example that of the antidiphtheritic serum, would modify the tables
and injure the comparability of the statistics.


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APPENDIXES

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“ Precise diagnoses should be given the preference over vague and indeterminate
terms such as ‘ hemorrhage/ ‘ encephalitis/ etc. Arbitrary decisions should be
avoided as much as possible by the use of the preceding rules. None of them
. 18 absolute but all are subject to exceptions, which may vary according to local
usages.31 In practice the first rule, which is the most logical of all, is the one Sf
most frequent application. The others have been formulated only to prepare
for all cases and to treat them with system and uniformity.” 32
1 1
The decisions of the United States Bureau of the Census for carrying these
rules into effect m particular cases are published, as already stated, in the Man­
ual of Joint Causes of Death. (See pp. 107-111).
GERM ANY

The rules for allocating joint causes adopted in Germanv, one of the countries
which uses a special list of causes, are as follows:
' wP 16 death is’ as a ™le, to be assigned to that number which represents the
probable primary cause (Grundleiden). Only when the primary cause is not a
real disease may it be disregarded.
“ o' w -iu ^wo. ^dependent diseases, the more severe should be chosen,
be ch osen ” ^ mfectlous disease and a noninfectious disease, the* former should
to bt* preferred diSeaSGS

reported with chronic diseases, the acute diseases are

“ 5. If two infectious diseases are reported as causes of death, then smallpox
scarlet fever, measles, typhus fever, diphtheria and croup, whooping cough'
croupous pneumonia, influenza, typhoid fever, paratyphoid fever, Weil’s disease’
relapsing fever, cerebrospinal fever, erysipelas, tetanus, septicemia, puerperal
fever, plague, Asiatic cholera, dysentery, anthrax, glanders, rabies, and trichiniasis should have the preference over tuberculosis, malaria, or a venereal disease
o. causes of death from violence are usually preferred.
7. Such returns as heart weakness (‘ heart failure’), cardiac paralysis of
the lungs, pulmonary edema, coma, and the like, should be disregarded if other
causes are named.
•
&
“ 8. With tuberculosis of several organs, including that of lungs, tuberculosis
of the lungs should be selected.” 33
SW EDEN

The rules used in Sweden for certifying and for classifying of joint causes of
death are contained m a circular of the medical administration dated October 9
k 7-1’
S 7 es tiie classification of causes of death together with an alpha«o
The PnnciPal points in these instructions are as follows:
3. The new nomenclature shall be used beginning with the year 1911. and in
aPPlymg it the following rules shall be observed:
“ (a) The nomenclature of causes of death (appendix 1) is principally designed
tor service to physicians and persons who have to tabulate the statistics and register
the certificates of death, while for the terms to be used as causes of death, physi­
cians who have to fill out death certificates are referred to the alphabetical list
(appendix 2) and to the notes and remarks which apply no less to the nomen­
clature than to the list.
,
As principal cause of death is to be given the disease which, so far as can
be determined, was the major disease. A complicating disease is to be desig­
nated as a contributory cause of death.
“ N o t e 1 . — Death from pneumonia complicating a case of typhoid fever
whooping cough, measles, influenza, etc., should accordingly be returned as
typhoid fever, etc., with pneumonia as a contributory cause of death, even if at
the end the last-mentioned disease was the outstanding one. A death from
Purulent peritonitis’ following appendicitis or puerperal fever should be returned
a s appendicitis or puerperal fever with peritonitis as a contributory cause, etc.
impropriety of certain expressions should be noted particularly. For example, if a physician
y ?r0m-° neghrit/ s’ V s alm-ost certain
he intended to i n S e typhdd fever
S
f ?
1«
and not a patient with Bright’s disease attacked with typhoid fever. When
^ l 8/ 38! orf m ^ iy rare or absent undergoes a large extension (e. g., cholera, yellow fever, etc.) the total
naryrules°Uld b6 noted wltllout anY exception whatever. For such cases it is necessary to waive all ordiw^he International List of Causes of Death based on the Second Decennial Revision by the
International Commission, Pans, July 1 to 3, 1909, pp 17.18
*
MIbid., pp. 18-19.

60564°—26----- 9


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“ N ote 2.— If the deceased was suffering from two different independent dis­
eases the one which can be considered to have caused the death should be
designated as the principal cause. If one is an acute infectious disease it should
be preferred as a rule as the principal cause. Accordingly, if, for example, an
insane person dies of typhoid fever, the latter as a rule should be given as the
principal cause.
,. „
.
,
. ,,
c
“ (c) Phvsicians who fill out death certificates need note only the name or
the principal and of the contributory cause of death; the list number is to be
entered by the person who enters the death upon the register. In case there is
any reason for concealment as in case of syphilis, suicide, etc., the principal
cause of death may be entered by the person who fills out the death certificates
by writing the list number of the disease in the nomenclature, as 33, 44, 99, etc.;
in such a case if there is a contributory cause present it may be written out in
full.” 34
An article by Gustav Hultquist, who assisted in deciding the various questions
which arose in determining causes of death in the compilation of Swedish sta­
tistics for 1911, throws further light upon these rules and upon the procedure of
the statistical office in classifying causes of death in Sweden.
“ The instruptions which the circular in question gives are few. However,
certain conclusions can be reached as to what should be given in a death certificate
as the principal cause of death, and in general how the certificate should be
prepared. The most important of these instructions and conclusions are as
follows:
. . .
.
. ,,
, ,
“ 1 Only one principal cause of death is to be given, and the accepted nomen­
clature is to be followed as closely as possible. Contributory causes of death
should be given as
fully as the
attending physician deems suitable.
*

*

*

*

*

*

*

“ 3. With malformations and diseases of the newborn ‘diseases which occur in
the first week of life ’ should be preferred.
“ 4. If pulmonary tuberculosis is given along with some other form ol tuber­
culosis on the death certificate, the case is classified as pulmonary tuberculosis
even if the latter is not given as the principal cause of death. If tuberculosis is
found as the contributory cause in connection with some disease other than
tuberculosis— for example, with diabetes— the death is classified as caused by the
“ 5. An accidental death due to an epileptic attack is classified as epilepsy.
“ 6. If suicide is committed by a person suffering from mental disease (as
previously diagnosed), the cause of death is classified as mental disease.
“ 7. Terms designated * in the alphabetical list may be given as principal
causes of death only in case a fundamental disease can not be ascertained.
“ Upon looking over the terms designated *, which number 130, one finds m
general that it is a question of (1) symptoms, anatomical changes, and insuf­
ficiently defined diseases, such as cardiac asthma, convulsions, hematuria,
hemiplegia, icterus, pulmonary edema, spasm of the glottis, degeneration of the
heart, hydronephrosis, anemia, tumor, etc., or (2) diseases which usually com­
plicate some other disease the designation of which in the alphabetical list is not
preceded by *; as, for example, cholecystitis, mastoiditis, ostitis, peritonitis,
thrombophlebitis. The great majority of diseases preceded by * belong to the
latter group. In the filling out of a death certificate one can go back from the
so-called medical causes of death through a whole list of terms .designated *;
for example, purulent meningitis*, cerebral abscess*, mastoiditis*, otitis media .
All these are marked with an *, and therefore one should follow the causal con­
nections until one comes to the fundamental disease which does not have an *;
for example, scarlet fever. If otitis is a complication following trauma, it belongs
under violent death. It is only when a fundamental disease can not be de­
termined that a term designated with * may be used.
A i . ,,
“ 8. In case of the terms designated by ** it should if possible be stated whether
death occurred as a result of accident or through murder or suicide In a case
of accident it should be stated whether the accident occurred during intoxication
or as a result of an epileptic attack and in case of suicide whether the person was
suffering from mental disease. In deaths due to accident, suicide,^ or murder
the death certificate should contain, in addition to the above, specifications in
accordance with Items X V III, 98-100 in the nomenclature. In case of crush­
ing” accidents or fractures it should be stated whether the injury was due to
railway accident or explosion, etc., and in case of poisoning the kind of poison.
MKunel. Medicinalstyrelsens cirkular till samtliga lakare i riket angaende uppgifter om dodsorsaker;
utfardadt i Stockholm den 9 Oktober 1911. Bihang till Svensk Forfattnings-Samling, I\o. 58, pp. 1 2.


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APPENDIXES

125

,
5 ^be P^a®e affected is a significant part of the cause and the localization
Hpa+h 0t ai >pear from the name of the disease in the alphabetical list of causes of
death, such as in case of abscess, carcinoma, fracture, hernia, etc., the localization
° f th® disease should be given in the death certificate.
, , 1"; All congenital malformations, with the exception of those given in the
alphabetical list, should be designated ‘ Monstrum,’ the physician who fills out
the n «riL C,i i + Cate ^ ^ r e s p o n s ib le for stating in parenthesis, so far as possible
the particular type of malformation which is present.
P
*
„
comparing the alphabetical list for guidance in filling out death
S
Hnd- ^ e cl.assific+at.10n for use in tabulation of the data one can get some
priLipafcauses8
of death“
CaUSGgiven
S- sh°uld
receive
preference
the
principal
causes of
death. I he 450 causes
m the
alphabetical
listashnvp
S
a^ f > gGf- m
Previously m e n tio n e d % la s s ifica tio n in p S in ^ deflate
groups infectious diseases, chronic diseases, new growths, and accidental

ccuiai;ory,
r s ^ 8lrespiratory,
p t a t o v aetcer
r M
ari;anf
p by lhe
° r*an
etc. In
each
of ? these
groups
are listed seoaratelv tho
T w f 1 S °+
f ,greatest lmP°rt, and the remainder are grouped under other diseases
TnuS
group mental diseases dementia paralytica is shown separately
other psychoses are grouped under other mental diseases. Sim ilarl/
m the group of skin diseases pemphigus appears separately, and in the grono
chronic poisoning chronic alcoholism appears separately. On the other Shand
S f i l S i la^ e" numbt rs of the causes of death listed under infectious diseases
and violent death are shown separately in the statistical report. Of the diseases
oifJ,hl rf-SPT^Hry Zr-gt nt f are tabulated separately, whereas 24 diseases ?n the
Hi?i1«a Aetlfa+hllSt WH h belong to thls group are grouped together under other
aro + K
resPlrat°ry organs. Among the diseases of the digestive organs 8
digestWeatrea(i t eParately and 34 ar® grouped together under othef diseases of the
*
*
*
*
*
*
*
i “ A. eomparison between the Swedish and the German instructions shows that
w r +in+SWedeii the Physuuan makes decisions, but in Germany the matter is
left to those who compile the statistics. If the patient has suffered from two
major diseases, the physician m Sweden decides which of the diseases contributed
most to the patient s death. It does not always follow that the disease which is
considered in general the most serious is the one which contributed S o s t to the
death. In Germany in such a case the most serious of the diseases mpnfirmcri
considered the principal cause of death. F u r t h i / S S “ SruhHhnri
show quite specifically which diseases take precedence over othere Violent
causes of death usually take precedence over all others; acute S e a se s take

mfectious over

*

*

*

*

w

*

%

« ¡S r s a ft

*

*

‘ The rule amongst us [in Sweden] that the physician himself shall decidp thp
predominating cause of the patient’s death is preferable because the decision is
S
nT de fr?“
pomt ?.f Vlew of the medical expert. I can not go into more
detail concerning the question as to what should be given as the principal caSse
of death in cases of so-called competition in causes of death. If the physician
experiences any difficulty n reaching a decision as to the principM cause of
death, he can in general follow the German instructions concerning precedence
for certain diseases, instructions which on the whole agree with the S t of
view which m my judgment is the basis of the alphabetical list and Smse of
death nomenclature mentioned in this article. In the meantime the
ino^nf^+hp P°r!+lt ° f
4
tb<? Pbysician should interpret correctly the mean­
ing of the not very fortunate phrase ‘ principal cause of death’ and should not
answer the question by what might be called the medical cause of death for
example, a patient naturally does not die of appendicitis but of peritonitisS
fni lS 1S’
i OUJ i e’ ^be caiise ° f death, and as another patient can not have
erushed finger without septicemia, the latter must be given as the
fhp «1o^ifi^Gath' ®V;cb ai\ interpretation shows complete misunderstanding of
fne sigmfica.nce of the stetistics of cause of death.
8
Causal connections should not be considered beyond certain limits.- In case
of an intoxicated person, who because of intoxication falls in the sea and drowns
JrA°T™ ng and no,t rCute alc°holic poisoning should be given as the cause of death!
+
own part, I must say that I believe the decisions go too far which specify
that an accidental death as a result of an epileptic attack should be given as
epilePsy, and suicide by an insane person should be ascribed to insanity. Two
subsections of the accident and suicide groups are lost through these decisions

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MATERNAL MORTALITY

126

groups which to social hygiene would be very interesting.35 Statistics should be
so compiled that they serve practical purposes, but in case of the rules just men­
tioned little note seems to have been taken of this principle.
*

*

*

*

*

*

*

“ In a considerable portion of the primary returns which have been sent to the
central statistical bureau, as was previously mentioned, the instructions of the
health administration were not followed. Often several diseases were given as
causes of death without special information as to which was the principal cause ;
for example, ‘ ambulant erysipelas and pulmonary tuberculosis and cancer uteri
et vesicae,’ ‘ organic heart disease and chronic endocarditis and chronic nephritis
and diabetes mellitus,’ ‘ fetid bronchitis and pulmonary abscess and hernia crural,
incarcer and psychoses and dermoid cysts of the sacral region. ^ In many cases
of this type it has been difficult and often impossible to determine the principal
cause. In other cases thé combination of diseases and other circumstances give
a clue; for example, ‘paralysis cordis and cholelithiasis;’ |acute pneumonia and
appendicitis.’ When these cases occurred in a hospital it is clear that the latter
disease was followed by another disease after the operation. Many physicians
stationed in hospitals have plainly followed the pathological anatoniical diagnosis of. the autopsy, and many of the previously mentioned designations in death
certificates have arisen in this way. Another type of designation has been septi­
cemia post hysterectomy,’ and in this case it is not possible to tell what was the
principal cause of death. In some cases physicians have given designations which
do not appear in the alphabetical list; as, for example, ‘ alimentary intoxication,
and ‘ pedatrophia,’ which diseases I changed to acute and chronic gastroenteritis,
respectively. In a number of cases the cause of death given by the pastor was
allowed to remain as the physician evidently could not give any other; for
example, stroke, teething fever, sudden chill, chest disease, mother passion,
rheumatic fever, nervous prostration, stomach trouble. Not infrequently such
causes are approved by the physician; indeed in some cases they are even filled
in by physicians. Many such cases (for example, the term sudden chill )
had to be placed in the group ‘ no cause given;’ some cases could be placed under
‘ other diseases’ of certain groups; for example, ‘ nervous prostration under
‘ other diseases of the nervous system.’ In certain cases the age of the deceased
gave a hint for the decision as to where the case should be classified.
‘ ‘ It has been impossible for me to overlook the fact that many inconsistencies
arise from the rules for deciding what disease shall be considered the principal
cause of death where many diseases are given or where causes shall be classified
which are not given in the alphabetical list. In the beginning of tne work too
much emphasis was placed on the rule, which appears both in the bwedish^and
in the German instructions, that the fundamental or major disease should be
considered the principal cause of death. I made a diagnosis, so to speak, from
the death certificate, naturally with careful attention to giving preference of
those diseases which should under the rules have precedence over others. But m
the meantime I discovered by degrees that cases with several diseases and symp­
toms stated fall usually into one of two groups. In one group the diseases were
given without any definite order, and in the other it was apparently, meant that
the first-given disease was the major one and that the following were contnbutory diseases. Because of the introduction of this last-named point of view a
a great many inconsistencies have no doubt arisen. When the diseases given
were of nearly equal importance, such as measles and whooping cough, bron­
chitis, and acute gastroenteritis, the disease first given was throughout taken as
the principal cause of death.” 37
ENGLAND

AND

W ALES

The rules used in England and Wales are as follows:
“ 1. In cases where the effect of any two rules appears to be at variance, the
first stated is to be followed, unless the second refers explicitly to an exception
to be made in the application of the first.
“ 2. In cases of the separate statement as joint causes of death of two diseases
the names of which are components of a single compound pathological term the
MIn the final preparation of the figures relating to cause of death at the central statistical bureau the
instruction that suicide during insanity should be classified as insanity was not followed, bucfi cases are
entered under suicide, but they are differentiated. Certain physicians, however, very carefully folioweu
the instructions that these cases should be entered under insanity as the principal cause of death but aid
not give suicide as a contributory cause. In such cases the correction could not be made in the final figures.
s« In Sweden clergymen serve as registrars of births, deaths, and marriages.
> *'
,
37 Hultquist, Gustaf: “ Nàgra anmarkningar till vàr nya dofisorsaksstatistik.
Allmanna bvensKa
LSkartidningen, 11th year, No. 51, Dec. 18,1914, p. 1179.


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APPENDIXES

127

death is generally to be classed as indicated in the manual for the compound
term, e. g., gastritis, enteritis, treat as gastroenteritis. (This does not apply to
bronchitis, pneumonia.)
“ 3. The general order of preference is as follows:
a. V iolence (N os. 155-186).
b. G e n er al diseases (N os. 1-59).
c. L ocal d is e a s e s (N os. 6 0 -1 4 9 ).
d. I ll - defined causes of d eath (N os. 187-189).
(For Nos. 150-154, see rule 8.)
VIOLENCE
“ 4. Where any forms of violence and disease are jointly stated as causes of
death, the violence is to be preferred except in the following instances:
(а) Deaths from any definite disease stated to have been accelerated by
accident are to be classed to the disease.
(б) Deaths during or resultant from operation or the administration of an
anesthetic are to be classed to the disease or injury for which the
operation was performed.
(c) Deaths from pneumonia or other lung diseases consequent upon
accidental immersion are to be classed to the disease.
(d) Deaths from injuries received during an epileptic or apoplectic fit are
to be classed to epilepsy or apoplexy as the case may be.
(e) Deaths from tetanus, erysipelas, pyemia, septicemia, blood-poisoning,
etc., following accident are to be classed to the disease if the injury
was slight, such as 'scratch’ or ,‘ abrasion,’ but if the injury was
apparently severe enough to kill by itself (e. g., by vehicle, machin­
ery, etc.), the death is to be classed to violence.
(f) Deaths from cancer and accident in conjunction are to be classed to
cancer.
GENERAL DISEASES
“ 5. Any general disease, except—
(а) Membranous laryngitis (9B) and croup (9C), which for this purpose
are regarded as local diseases, and—
(б) Undefined anemia and chlorosis (in 54), other tumors (46), and
chronic rheumatism (48A), which for this purpose rank below all
except the ill-defined causes of death,
is to be preferred to any local disease except aneurism (81 A), strangulated hernia
and acute ‘intestinal obstruction (in 109), and puerperal fever, phlebitis, and
diseases of the breast (137, 139A, and 141), which for this purpose are included
with the general diseases in Group I below.
“ 6. The general diseases are divided into four groups in order of their im­
portance for the purpose of selection. Any disease in Group I is to be selected in
preference to any other not in Group 1; any in Group II is to be preferred to any
other not in Groups I and II, and so on. If two or more of the diseases in any
group are stated together the disease of longest duration or that first mentioned
in the certificate, should as a rule be chosen. (See rule 10.)
G roup I

5.
12.
21.
22.
23.
24.
39-45.
57-59.
81.
In 109.
137.
139A.

Smallpox.
Asiatic cholera.
Glanders.
Anthrax (splenic fever).
Rabies.
Tetanus.
Cancer (all forms).
Chronic lead and other chronic
poisonings.
Aneurism.
Strangulated hernia and acute
intestinal obstruction.
Puerperal fever.
Puerperal phlegmasia alba dolens and phlebitis.


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141. Puerperal diseases of the
breast, and other epidemic
diseases of exceptional in­
terest such as Mediterranean
fev6r (3B), plague (15),
yellow fever (16), leprosy
(17), beri-beri (27), etc.
G roup II

1.
2.
3A.
4.
6.
7.
8.
9A.
14.

Enteric fever.
Typhus.
Relapsing fever.
Malaria.
Measles.
Scarlet fever.
Whooping cough.
Diphtheria.
Dysentery.

128

MATERNAL MORTALITY
G r o u p II I

10.
25.
2 8 -3 5 .
3 7 -3 8 .
47.
52.

19B.
19C.
20(A . B .).
36.
48B.
48C .
49.
50.
51.
53.

Influenza.
Mycoses.
Tuberculosis (all form s).88
Venereal diseases.
Rheumatic fever.
Addison’s disease.
G r o u p IV

18. Erysipelas.
19A. Mumps.

*

German measles.
Varicella.
Pyemia and septicemia.89
Rickets, softening of bones.
Osteoarthritis.
Gout.
Scurvy.
Diabetes.
Exophthalmic goitre.
Leucocythemia, Lymphadenoma.
In 54. Pernicious anemia.
55. Other general diseases.

/ “ 7. If one of the diseases mentioned is an immediate and frequent complica­
tion of another the primary disease should be preferred to its complication.
" 8 . The conditions comprised under headings 150-154 are to be dealt with as
follows, notwithstanding anything to the contrary implied in any preceding rule.
(a) Congenital defects (150), premature birth (151 A ), icterus neonatorum
(151C ), and sclerema and edema neonatorum (151D )— under 3
months these conditions are to be preferred to any disease except
syphilis and the diseases in Groups I and II. Over 3 months any
definite disease not presumably the consequence of a congenital
defect is to be preferred to these conditions. Premature birth (151 A)
is to be preferred to congenital defects (150) and other diseases
peculiar to early infancy (152) when occurring together on the same
certificate.
(b) Other diseases peculiar to early infancy (152) are to receive the same
preference as congenital defects under 3 months of age.
(c) Atrophy, debility, and marasmus of infants (151B ), want of breast
milk (151E), and senile decay (154B) are to be treated as ill-defined
causes of death.
(d) Lack of care (153) is to be treated for this purpose as a form of vio­
lence.
(e) Senile dementia (154A) is to be treated in the same manner as other
forms of insanity. (See rule 9.)
L O C A L D IS E A S E S
“ 9. The following are to be selected in preference to any other local diseases
appearing in the same certificate, except aneurism (81 A ), strangulated hernia,
and acute intestinal obstruction (in 109), and puerperal fever, phlebitis, and
diseases of the breast (137, 139A, and 141):
C olum n A

C olu m n B

61 A . Cerebrospinal fever.
61B. Posterior basal meningitis.
78B. Infective endocarditis.
92A . Lobar pneumonia.
104 and 105A. Infective enteritis.
106, 107, 112, 121, and other headings
according to part affected. Parasitic
diseases (except thrush).
108. Appendicitis.
143. Carbuncle, boil.
144A. Phlegmon.

62. Locomotor ataxia.
63. Other diseases of spinal cord.
67. General paralysis of insane.
68. Other forms of mental alienation.
69. Epilepsy.
74A. Idiocy, imbecility.
74C. Cerebral tumor.
154A. Senile dementia.

“ A disease in column A is to be preferred to any disease in column B when
occurring upon the same certificate. (See also rules 6 and 10.)
“ 10. Where two or more local diseases, neither of which is included in the pre­
ceding list, are certified together, that of longest duration should be preferred;
if duration is not recorded, any disease of a chronic nature should be preferred
38 Deaths from tubercle of two or more organs should he assigned to No. 28 or No. 29 if the lungs are
involved; otherwise to 35. (See notes to Nos. 28 and 35, pp. 5 and 8).
. 39 Pyemia and septicemia are subject to rule 7, but in cases where the application of this rule causes a local
disease to be preferred to either of them, the local disease acquires Group IV precedence.


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A P P E N D IX E S

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to a disease not so characterized; if neither disease can be assumed to be chronic,
the first mentioned on a medical certificate should be selected. Exceptions to
this rule are as follows:
(а) Any definite disease of the heart (7 7 -8 0 and 85A) or kidney (119-122)
is to be preferred to any disease of the respiratory system (86—98).
(б) Congestion of any organ, convulsions (70 and 71), hemorrhage (85C),
laryngismus stridulus (87A ), thrush (99B), and dyspepsia (in 103B
and 104 and 105E) rank below all except the ill-defined causes of
• death. Alcoholism, however stated, takes the same rank, in view
of the treatment of organic disease attributed to it.
(See pp. xi
and xiv.)
v
(c) Arterial sclerosis (8IB ), heart diseases (7 7-80 and 85A ), cirrhosis of
the liver (113), and Bright’s disease,(120 A) are to be preferred to
. apoplexy (64A ), cerebral hemorrhage (6 4E ), hemiplegia (66A ), and
cerebral embolism and thrombosis (82A ), which, on the other hand,
are to be preferred to bronchitis (89 and 90 B ).
(d) Cirrhosis of the liver with neuritis is to be taken as alcoholic cirrhosis
of liver (113B).
(e) In the case of deaths occurring in lunatic asylums, nervous diseases
other than those mentioned under (6) and (c) are to be preferred to
other local diseases, except those receiving special preference under
rules 6 and 9.
r
“ N o t e .— The foregoing rules have been framed primarily
one from two jointly stated causes of death. Where three
jointly stated it may occasionally be found that the effect
conflicting. In these cases, which are infrequent, the coder
own judgment for guidance as to the rule to be followed.” 40

for the selection of
or more causes are
of different rules is
must rely upon his

PR O PO R TIO N OF CASES REPO RTIN G JOIN T CAUSES

The rules for classifying joint causes are, of course, applicable only to those
deaths for which two or more causes are stated. The importance of these
rules depends, therefore, upon the proportion of cases thus reported. In practice,
furthermore, since one cause is commonly stated as primary or most important,
the additional information as to the existence of a secondary cause is essential
only in those cases in which the so-called secondary cause is, according to the
rules, the preferred or true one. Hence the rules are of practical importance
only in “ correcting,” as to order of importance, the entries made by the phy­
sicians. In other words, the rules insure the same classification of similar cases
in which the physicians have differed in deciding which of two causes— both of
which are stated on the death certificate— was primary.41
Evidence in regard to the proportion of cases in which secondary causes are
given is meager. In the United States in 1917 the proportion of all deaths for
which secondary causes were stated was 34.9 per cent.42 Of the puerperal
deaths, 39.5 per cent were reported as due to two or more causes. Since many
of the secondary causes, however, were also puerperal, a better indication of the
possible influence of changes in preference is given by the proportion of puerperal
deaths that were complicated by nonpuerperal conditions. Of these deaths a
much smaller proportion, only 18.7 per cent, were reported as complicated by
nonpuerperal causes.43 On the other hand, puerperal causes were contributory
to deaths classified as due to nonpuerperal causes in cases equal to 10 per cent
of the maternal deaths.
APPLICATION OF R U L E » FO R CLASSIFYING JOIN T CAUSES

Specific detailed evidence as to the actual practice of different countries in
applying the rules of the International Commission for classifying deaths from
joint causes is available for only two countries, the United States and England
40Manual of the International List of Causes of Death as Adapted for Use in England and Wales, based
on the second Decennial Revision by the International Commission, Paris, 1909, pp> xxxii-xxxvi.
London, 1912.
« The death certificates used in many countries (for example, in the United States, England and Wales,
Scotland, Ireland, Switzerland, parts of Australia, and New Zealand) provide spaces both for primary
and for secondary causes. The bulletin of the International Statistical Institute already referred to gives
also as providing spaces for secondary causes, Prussia, Wurttemburg, France, Hungary, Italy, and Japan.
42 Compiled from Mortality Statistics, 1918, p. 50 II. The unit is the International List number; thus,
pneumonia complicated with bronchitis, and puerperal albuminuria complicated with “ accidents of preg­
nancy,” are considered as joint causes, but not two causes which, if given separately, would each be assigned
to the same International List number, that is, are the same “ cause.”
43Ibid., pp. 50-91.


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m a t e r n a l m o r t a l it y

130

and Wales; the former publishes its rules for classifying joint causes, and the
latter publishes details of the contributory causes of deaths classified as puerperal
and of the cases in which puerperal conditions were contributory.
The chief difference in practice is in the allocation of deaths from influenza
complicated by a puerperal cause. In the United States and in Scotland (until
1921)44 such deaths have been classified as puerperal, and in England and Wales,
and probably in most other countries, they have been classified as due to influenza.
In 1918 and”to a less extent in 1919 these deaths from influenza complicated by a
puerperal condition caused a marked rise in the rate of maternal mortality in
the United States and in Scotland; but in other countries no such rise was noted,
and in some a slight decrease appeared.
If the rules for classifying these deaths in use in the United States had been
applied in England and Wales, then of the 4,144 deaths in 1920 attributed to
puerperal causes, 5 45 would have been assigned to other causes; on the other
hand, 158 deaths from influenza, as well as 32 46 assigned to other causes, would
have been added to the puerperal figures. In addition to these, 34 47 other
deaths would probably have been classified as puerperal. And with regard to a
large group of 601 deaths from various diseases the classification according to
the United States rules would have depended upon whether the case was asso­
ciated with pregnancy or with childbirth; if with the former they would have
been classified as in the English statistics, but if with the latter they would have
been transferred to puerperal causes.48
The source does not show whether the 601 deaths from various causes were
associated with childbirth or with pregnancy; assuming, however, that the same
proportion of deaths from each of these causes was associated with childbirth as
was so associated among deaths returned from the same cause in connection
with either pregnancy or childbirth in the United States registration area in
1917,49 then roughly 85.2 per cent, or 512 of these deaths, would have been
associated with childbirth and would have been classed as puerperal according
to the United States rules. If, then, the United States rules for classification
had been used, the rate in England and Wales in 1920 would have been raised
from 4.33 to 4.97, an increase of 14.8 per cent.50
C O M P LE T E N E SS OF R E G IST R A T IO N OF B IR TH S
Much greater emphasis has been placed upon birth registration in European
countries than in the United States. In Europe birth certificates are frequently
used for identification purposes and may be called for on many occasions. Thus,
in the enforcement of the law providing for compulsory vaccination reliance is
placed in part upon the recorded births; and the compulsory school attendance
and military service laws require the evidence of age which the birth certificates
furnish. These uses to which birth certificates are put have resulted in making
the general population thoroughly familiar with the requirement of registration.
44 In Scotland in 1920 only 21 deaths from this combination of causes were reported—2.5 per cent of the
total puerperal deaths. The exclusion of these deaths would have reduced the rate from 6.15 to 6. Com­
piled from Sixty-seventh Annual Report of the Registrar-General for Scotland, 1921, p. xxxviii. In 1921
the rule in Scotland was changed so that such deaths might be classified as due to influenza. In the
United States in 1917 only 44 deaths from this combination of causes were reported—0.4 per cent of the
total puerperal deaths. Information on this point for other years is not available.
48 2 from bronchitis complicated with pregnancy and 3 from pyelitis complicated with pregnancy.
48 Includes pyemia, septicemia, 1; chorea, 7; cerebral embolism and thrombosis, 1; phlebitis, 1; varix, 3;
diarrhea and enteritis, 17;- and peritonitis, 2.
47 Includes pregnancy or childbearing associated with “ anemia,” 29, and with “ infective endocar­
ditis,” 5. According to the United States rules, if associated with childbirth, all these would have been
classified as puerperal; if associated with pregnancy, those complicated with anemia would have been
classified as puerperal if the anemia were unqualified or if qualified as cerebral or pernicious, but not if
qualified as splenic; those complicated with endocarditis would have been classified as puerperal provided
the endocarditis was qualified as malignant, septic, or ulcerative, but not if gonorrheal, rheumatic, acute,
chronic, or unqualified.
48 The principal causes “ returned as associated with but not classed to pregnancy and childbearing”
were influenza (158), epilepsy (7), acute endocarditis (12), fatty degeneration of heart (15), other organic
diseases of heart (73), bronchitis (27), broncho-pneumonia (30), lobar pneumonia (97), pneumonia (63),
pleurisy (5), asthma (13), tonsilitis (5), appendicitis (14), intestinal obstruction (20), acute yellow atrophy
of liver (13), uterine tumors (17), ovarian cyst (7), all others (25).
48 Compiled from Mortality Statistics, 1918, pp. 50-91. U. S. Bureau of the Census.
50 In securing this figure 97 deaths which could not be classified according to the United States printed
rules, either because the specific combination of causes is not there given or because the specific cause is
not stated in the English tabulation, were distributed between puerperal and nonpuerperal causes in the
same proportion, in case of death from each cause, as the deaths jointly from that and a puerperal cause
were distributed between puerperal and nonpuerperal causes in the United States birth-registration area
in 1917. (Details of joint causes are given in Mortality Statistics, 1918, pp. 50-91.)


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131

A P P E N D IX E S

In European countries, therefore, birth as well as death registration may be
regarded as practically complete.51
In passing it is of interest to note that Doctor Farr estimated that in England
and Wales even during the period of voluntary registration from 1837 to 1876
birth registration was 95 per cent complete. Under the compulsory law Sir
Arthur Newsholme regards registration as practically perfect.52
Furthermore, for New Zealand a comparison of birth records with the results
of the 1916 census led to the conclusion that “ probably unregistered births do not
exceed 100 annually.”
Since the average number of births is in the neighbor­
hood of 25,000, the proportion of unregistered births on this basis would be less
than one-half of 1 per cent.53
Another point which must be considered in comparing rates is that in three
countries (France, Belgium, and the Netherlands) the registered “ live births”
include only the infants who survive at the time of registration, which must take
place within three days after the birth. In Belgium and since 1917 in the Neth­
erlands special analyses of the group “ infants born dead or dead at the time of
registration” show the number of those who were born alive but who died before
registration. In 1920, for example, in the Netherlands, these deaths before
registration of infants who were born alive but who were omitted from the statis­
tics of “ live births” (levend aangegevenen) equaled 1.1 per cent of the total
number of live births.54 Since an understatement of 1.1 per cent in^the number
of live births means an overstatement of the same percentage in th e maternal
mortality rate, the necessity for a correction of the rates for France, Belgium, and
the Netherlands must be borne in mind, especially when comparisons are made
with rates in other countries.
All the countries using the International List, except England and Wales, Scot­
land, Ireland, and parts of Australia, require that stillbirths be registered.55 In
New Zealand they have been required to be registered only since 1913.56 Tne
definitions of stillbirths in use in the several countries are given in Appendix C,
page 117.
81 For replies from European countries (1912) to the question,” Do many births or deaths escape regis­
tration?” see Infantile Mortality, Report of the Special Committee * * * of the Royal Statistical
Society, pp. 26-35 (London, 1912).
** Newsholme, Sir Arthur: The Elements of Vital Statistics in Their Bearing on Social and Public Health
Problems, p. 71. London, 1923.
MReport on the Results of a Census of the Population of the Dominion of New Zealand, taken for the
night of October 15,1916, p. 13. Wellington, 1920.
MCompiled from Statistiek van de Sterfte naar den Leeftijd en de Oorzaken van den Dood over het
jaar 1920, Bijdragen tot de Statistiek van Nederland, No. 329, p. xl, and Statistiek van den loop der
bevolking in Nederland over 1920, Bijdragen tot de Statistiek van Nederland, No. 328, p. xi.
55 Annuaire Internationale de Statistique; Renseignements sur l’ organisation actuelle des statistiques
de l’état civil dans divers pays. Annexe aux Tomes I-V (Partie Démographie), p. 6-7. La Haye, 1921.
MNew Zealand, Statutes, 1912, No. 18, sec. 4.
’

J


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APPENDIX E.— SUMMARY OF LAWS AND REGULATIONS GOVERNING MIDWIVES IN THE UNITED STATES
IN FORCE DECEMBER, 1924
Laws and regulations govern­
ing practice

Educational or other require­ Registration
ments

A L A B A M A ___
[Laws of 1919.]

No; by •county
board.

ARIZON A....................
[Rev. Stat. 1913 and
State Board of
Health rules.]

Permit only.

Knowledge of midwifery; Local.
freedom from communi­
cable disease; moral char­
acter.
Indorsement of physician of ___ do— '___ Shall not give drugs, give in­
jection into birth canal, nor
district.
make internal examinations;
shall secure physician for
abnormal cases.
___do.
Four years’ high school;
specified professional train­
ing and examination.

COLORADO................
[Medical Practice Act
1917.]

.do.

Examination in such subjects as board deems neces­
sary.

C O N N E C TIC U T.......
[Gen. Stat. 1893 and
Laws of 1923.]

.do.

Graduation from school of
midwifery; certificate of
character and examination,

D E L A W A R E ____ ___
[Rev. Code 1915.]
DISTR IC T OF CO­ Board of Medical
Supervisors.
LUMBIA.
[Regulations Board of
Medical Supervi­
sors.]


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Graduated nurse or regu­
larly engaged as obstetric
nurse for not less than 2
years; actual attendance
upon not less than 5 cases
of confinement under care
of physicians; good moral
character..

Penalties for violation Report Report ophthalmia and
of requirements of births
use prophylactic
practice
Y e s ... Yes.1

Permit valid so long
as law and rules
obeyed.

Y es...

Report and advise use
of prophylactic.

Y es-

Do.

Shall not give drugs, use in­ Revocation of license; Y e s ... Report; use of prophy­
lactic optional.1
$100-$600 or 60-180
struments, make internal
days, or both.
examination, nor give injec­
tion into birth, canal; shall
attend normal cases only;
must have specified equip­
ment.
Shall
not give drugs or anes­ Revocation of license; Y es.. Yes.
____do-------$50-$300 or 10-30
thetics, use instruments, nor
days, or both.
practice medicine in any
other form.
Do.1
State and Shall not prescribe or use Not more than $100 Y e s..
for each violation of
drugs, use instruments, per­
local; an­
any provision.
form version, remove adher­
nual.
ent placenta, attend eases of
other than normal labor or
cases of labor until the
seventh month of uterogestation shall have passed.
Do.1
Y es..
Local .
___ do.

M O R T A L IT Y

ARKANSAS.................
[State
Board
of
Health rules 1913.]
C A LIFO R N IA............ Yes.
[Medical Practice Act
1917.]

to

M ATERNAL

Examined and li­
censed by State

State and source

CO

F LO R ID A___

[Laws of 1915,

GEORGIA

[Code 1914.]

I D A H O ..._____

[Laws of 1911.]
ILLIN O IS............
[Medical Practice Act

1923.]

IN D IA N A ......................
[Medical Practice Act"

.do.

IO W A .....................

.do.

1897.]

[Laws of 1897.]

High school, 1 year; comple­
tion of 6 months’ course in
college of midwifery and
graduation therefrom.
High school, 4 years or
equivalent; diploma from
obstetric school, and ex­
amination.

Shall not treat beyond the
scope of license.
.do.

K A N SA S........ „ .....

[Gen. Stat. 1915.]
K E N T U C K Y ............

L O U ISIAN A.

Yes.

[Act of 1918.]

M A IN E ..................
[Rev. Stat. 1916.]

Such examination as re­
quired by State board of
medical examiners.

Report only;1 may ad­
vise or use with con­
sent of parent.

From $25 to $200 or
revocation oflieense.

Y e s.. . Report and use in sus­
pected cases.

.do.

Y e s ... Yes.

.do.

Y e s ... Report and use with
limitations.1
Y e s ... Yes.1

Local, an- Shall not give drugs, use innual.
| struments, give injection in­
to birth canal, make internal
examination, nor attend ab­
normal cases; shall observe
other specified sanitary rules
Local.

Permit valid so long
as law and rules
obeyed.

Y e s...

Y es..

M A R Y L A N D ..

-do.

Certificate of moral char­
acter and of qualification
for licensure and examina­
tion by 2 physicians.

Local.

Diploma from school of
midwifery or examination.

N o.

M ISSISSIPPI.............. Permit given by
fS ta te B o a r d of
county health
Health rules 1912.]
officer.

Attendance at class instruc­
tion, investigation as to
character, cleanliness, eta

Local.

MISSOURI............
[Rev. Stat. 1909.]

Examination in obstetrics... -------do_____

[Laws of 1924.]

Shall not give drugs, use in­
struments, make internal
examinations, nor attend ab­
normal cases.

M IC H IG A N ..............

[Laws of 1915.]

M IN N E SO T A ..............

Yes.

[General Stat. 1913.]'

Yes.

Not less than $5 nor
more than $100; re­
vocation of license
for second offense,
and for procuring
an abortion or in­
ducing premature
labor.

Y es-

Yes..

1Gratuitous distribution of a prophylactic is made by the State health authorities.

Revocation of license.. Y es..
Shall not give drugs, use in­
struments, give injection
into birth canal, nor attend
abnormal cases; must have
specified equipment.
Shall engage in no other
branch of medical practice.

From $5 to $100 or 60
days, or both.

Y es-

From $10 to $50 or 10
days to 2 months,
or both.

Y e s ...

Do.«
Report; use prophylac­
tic unless parents ob­
ject.
Yes.1

A P P E N D IX E S

Permit only, given Attendance at annual course
by county health
of instruction; under­
officer.
standing of essentials of
hygiene; freedom from
communicable disease.

[State
Board
of
Health Rules 1915.]

Revocation of license;
not over $100 or 6
months or both.

Do.
Report and use pro­
phylactic unless pa­
rents object.*
Yes.1

Do.

CO

CO


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State and source

Examined and li­ Educational or other require­ Registration
ments
censed by State

Report; use of prophy­
lactic optional.1
Yes.

Examine and li­
cense annually.

NORTH CAROLIN A. Permit only.
[Stat. 1919.]

Common school or equiva­ ___ do_____
lent; certificate or diploma
from school of midwifery
or maternity hospital hav­
ing 1,800 hours’ instruc­
tion within a period of not
less than 9 months, and
examination.
Attendance at series of 10 ....... do____
classes of instruction, sign­
ing of midwife’s pledge,
■and freedom from com­
municable disease.
Ability to read and write
(waived for foreigners);
either diploma from school
of midwifery or other sat­
isfactory evidence.
Must not be addicted to
drugs or habitual drunk­
enness.

Shall not give drugs nor use
instruments; local health
boards must have physician
or nurse visit all cases at­
tended by midwives.
Shall not give drugs; shall
secure physician in all ab­
normal cases of mother or
infant.

Shall not give drugs, give in­
jection into birth canal, use
instruments, nor make in­
ternal examination; shall
call physician in all abnor­
mal cases, and have speci­
fied equipment.
____ do--------- Shall not give drugs, use in­
struments, remove adherent
placenta, perform version,
nor treatfdisease; shallattend
normal cases only.
Disinfection of hands of prac­
titioners required.

Do.»

$200 or 100 days if fine
not paid; revocation
of license.

Y e s ... Report;» use of pro­
phylactic optional.

Certificate may be an­
nulled.

Y es... Yes.

License revoked.

Y es..

Do.

From $5-to $10.

Y e s ...

Do.»

Report; use prophy­
lactic in suspected
cases.
Yes.

NORTH D A K O T A ...
[Laws of 1907.]
OHIO............................. Yes.
[Medical Practice Act
1910.]
O K L A H O M A -[Laws of 1917.]
O R E G O N .!....
[Laws of 1915.]


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High school or equivalent, ___ do_____
diploma from school of
midwifery or license of
foreign country, and exam­
ination.

Shall not perform version,
treat breech or face presenta­
tion, or other abnormal con­
ditions, nor use instruments.

Refusal, suspension,
or revocation of li­
cense for unprofes­
sional conduct.
Y es...

Do.»

Y es...

Do.

M A T E R N A L . M O R T A L IT Y

Yes.

N EW M E X IC O ....... . Permit and physi­
cal examination
[State 'Board Public
annually.Welfare rules 1921.]

N EW Y O R K ..........
[Gen. Laws 1922.] *

Penalties for violation Report Report ophthalmia and
of requirements of births
use prophylactic
practice

Local.

M O N TA N A .................
[Rev. Code 1921.]
N E B R ASK A ............ ..
[Act of 1919.]
N E V A D A ....................
[Rev. Laws 1912.]
NEW HAM PSHIRE.
[S ta te B o a r d o f
Health rules 1916.]
N EW JERSEY..........
[Laws of 1910 and
1923.]

Laws and regulations govern­
ing practice

Continued

134

A p p e n d ix E .— Sum m ary o f laws and regulations governing midwives in the U nited States in fo rce Decem ber, 1924

P E N N S Y L V A N IA .... Yes.
[Laws of 1913 and
D e p a r tm e n t o f
Health rules.]

Graduation from approved ___ do_____
school of midwifery; or
other satisfactory evi\ dence, and examination
in English language only.

RHODE IS L A N D .... Licensed only.
[Laws of 1918.]
SOUTH CAROLIN A. Permit only.
[S t a t e B o a r d o f
Health rules 1920.]

Completion of course of 10
lessons given by State
board of health; signing of
midwife pledge.

W ASH INGTON.
[Acts of 1917.]

W EST V I R G IN IA ...
[Code of 1913.]
WISCONSIN______
[Stat. 1919.]

Yes.

Local.

Yes.

Local.

Shall use prophylac­
tic.1
Report; advise use of
prophylactic.1
Yes.1

Local.

Common-school education,
diploma from school of
midwifery, application in­
dorsed by physician, and
examination.

.d o__

Shall not give drugs, give in­ Revocation of permit..
jection into birth canal
(except when ordered by
doctor); make internal exam­
ination, nor attend abnormal
cases; shall obey other sani­
tary rules.
Shall not prescribe medicine Revocation of license; Y e s ...
$80-$200 or 10 days
or drugs; shall call physician
to 6 months, or both.
in abnormal cases; shall re­
port puerperal contagion or
infectious disease to health
officer.

Do.

Local..
Diploma from college of ....... do.
midwifery, evidence of
good moral and profes­
sional character, and ex­
amination.

Shall not administer drugs,
use instruments or any arti­
ficial means, remove adher­
ent placenta, nor undertake
any other form of medical
practice.

W YO M IN G ......... .
[Comp. Stat. 1910.]
1 Gratuitous distribution of a prophylactic is made by the State health authorities.


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Do.1

Revocation of license;
$25-$100 or not over
6 months, or both.

Y e s ...

Do.»

1New York City and Rochester have special laws.

A P P E N D IX E S

SOUTH D A K O T A ...
[Laws of 1913.]
TENNESSEE.............
[Act of 1913.]
T E X A S .........................
[Laws of 1911.]
U TA H ...........................
[Laws of 1917.]
V E R M O N T .................
[Gen. Laws of 1917.]
V IR G IN IA .................. Permit only.
[Laws of 1918; State
Board of Health
rules.]

Local.

Do.
Shall not prescribe drugs nor From $10 to $50 or 10 Y e s ...
to 50 days, or both;
perform operations other
license may be re­
than tying cord; shall notify
voked or suspended.
inspector of all abnormal
cases, also of delayed labor;
other sanitary requirements.
Do.1
State board of health makes Not over $100 or 6 Y e s ...
months or both; li­
rules and regulations.
cense may be re­
voked.
Shall not give drugs, give in­ Permit may be re­ Y e s ... Report; use of prophy­
lactic advised.
voked.
jection into birth canal, nor
make internal examinations;
shall secure physician for
abnormal cases and obey
rules of personal hygiene.
Report only.1

APPENDIX F.— SUM M ARY OF LAWS AND REGULATIONS GOVERNING MIDWIVES IN CERTAIN FOREIGN
COUNTRIES

Country and date of
enactment

Examination andlicense

A U S T R IA ................... Diploma issued by
[Ministerial d e c r e e
school of midwifery.
of Sept. 10, 1897,
amended by decree
of April 17, 1924.]


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Diploma of midwifery
given upon passage
of examination.

Registration

Laws and regulations
governing practice

Penalties for violation
of requirements of
practice

Diploma issued to person Local (administrative Regulated by decree which No information.
prescribes details of pro­
authorities).
who has finished pre­
fessional conduct, enum­
scribed course of 10
erates articles in outfit,
months, is considered
and describes operations
qualified for the occu­
midwife is not allowed
pation of midwifery, and
to perform.
passes both preliminary
and final examination.
Completion of course
prerequisite to applica­
tion for license.
Only the following ad­ Local (medical com­ Prescribe in detail conduct Fines or suspension
from practice for a
while on case; enum­
mission of Province).
mitted to examination:
period up to 1 year.
erate circumstances in
(1) Graduates of schools
which midwife must
of midwifery with 2-year
send for physician and
course given by doctors
require her to report
of medicine. To each
immediately each case
school must be attached
of puerperal fever and
maternity clinic with at
death of mother and
.least 50 confinements per
child during or as result
year for each 10 pupils.
of labor; forbid use of
(2) Recipients of State
instruments for acceler­
nurse’s diploma, who
ating d e l i v e r y and
have had 1 year of in­
enumerate other things
struction at school of
she is not allowed to do.
midwifery.

Remarks

Supervised by •local
public-health officer.

Must report imme­
diately to chairman
of provincial medical
com m ission every
case of puerperal
fever in her practice.
If 2 or more cases of
puerperal fever take
place in succession
in a midwife’s prac­
tice, chairman of
commission may sus­
pend her from prac­
tice for 2 weeks. If
parturient woman or
the child dies during
or as result of de­
livery and if midwife
was not assisted by
physician she must
report fact within
24 hours to chairman
of commission.

MATERNAL MORTALITY

BELGIUM.................. .
[Royal decree of Sept.
6.1924.]

Educational or other
requirements

£
O)

D E N M A R K .................
[Laws of Nov. 30,
1714, and 1810 and
s e v e r a l later de­
crees.]

Licenses issued by
special examining
commission.

1 year in school of mid­
wifery prerequisite to
application for license.
(Apparently only one
school of midwifery and
that belongs to the
State.)

ENGLAND A N D
WALES.
[Mid wives act of 1902,
amended in 1918.]

Central M idw ives’
Board conducts ex­
aminations and is­
sues certificates.

Course of 6 months for
untrained women and
4 months (or in some
cases three months) for
certain trained nurses.
med­
2 years’ course at medical school,
school, preparatory
preparatory
ical
school
school of
of medicine
medicine and
and
pharmacy, or maternity
hospital.

Before beginning prac­ By order of Nov. 25,1896,
tice must report to
required to report each
district health of­
case of puerperal fever,
ficer. (This seems
pemphigus, ophthalmo­
to be equivalent to
blennorrhea neonatorum
registration.)
to district physician.

Chief health officer of
Province may sus­
pend midwife from
practice for a certain
period; for serious
offenses fines are
prescribed, diploma
may be withdrawn,
or salary or pension
reduced.

If puerperal fever ap­
pears i n , midwife’s
p ra ctice, p u blib health officer may1
suspend her from
practicing for not
more than 4 weeks.


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APPENDIXES

F R A N C E ...................... Diploma issued by
Local . (Prefect’s of- Prohibits use of instru­ Fines or imprisonment[Law of Nov. 30,1892.]
school where course
flee or civil court of
ments; requires mid­
is taken and examidistrict.)
wife to call physician or
nation passed, in­
public-health officer in
struction given at
Case of difficult labor and
medical schools of
to report all epidemic
universities, which
cases; forbids prescrib­
are all State in­
ing medicines.
stitutions. Also at
schools of midwifery
at municipal or pri­
vate maternity hos­
pitals.
■.
.
<
V
G E R M AN Y
Legislation on the practice of midwifery differs in every German State. National legislation refers only to penalties for women practicing without a license
j'o rePOrt births. Men may practice midwifery without a license, but in such cases they may not call themselves “ Geburtsheltitle can be used only by men who had the proper training; a fine is prescribed for violation of this law. In 1917 the Federal Government
and^axo^^offiy tove
thegmcommendaüra^ery
recommended enactment of corresponding laws by the States. So far (end of 1924) Prussia
B A V A RIA ......... ......... Schools of midwifery. 4 months in Government Local (present diploma Rules contained in in­
Prescribed by instruc­ Supervised by district
[Royal decree June 4,
In most cases State
school of midwifery.
to local police au­
structions issued June
tions issued June 9,
public-health phy­
1899.]
institutions; some
thorities and report
9,1899, prescribe in great
1899.
sician and district
belong to local gov­
personally to dis­
detail conduct on nor­
police
authorities.
ernment.
trict public-health
mal and abnormal cases;
Former watches pro­
physician.)
method of dealing with
fessional work, ob­
puerperal fever and other
serves condition of
infectious cases. By
instruments, visits
ministerial order of Apr.
at house, and gives
5, 1909, midwife must
“ repetition tests” at
call physician in abnor­
intervals.
mal
cases.
PRUSSIA..................... License by local health 18 months in school of Local (permission to Enumerate duties of mid­
Fines or withdrawal Supervised by local
[Law of July 20, 1922.1
officer. Diploma is­
midwifery prerequisite
settle and practice
wife and regulate con­
of permission to
public-health officer.
sued by president of
to application for li­
in given locality
duct; require her to take
practice.
province to Whom
cense. Mostschoolsare
must be obtained
repetition test before
chairman of examin­
State institutions. Pri­
from local health of­
local health officer every
ing board forwards
vate institutions must
ficer).
2 years and postgrad­
examination papers.
be approved by minister
uate course every 5 years
J
of welfare.
unless over 55 years old.

A p p e n d ix

F.— Summary of laws and regulations governing midwives in certain foreign countries— Continued

CO

00
Examination and license

Educational or other
requirements

SAXON Y.......................
[Royal decree of April
2, 1818, amended in
1924 to conform to
standards
recom­
mended by Federal
G ov ern m en t in
1917.]

Diploma and license
issued by publichealth authorities
after examination.

1 year in school of mid­
wifery a prerequisite to
application for license.

Local (must be ap­
pointed by lo c a l
authorities as “ dis­
t r i c t m id w ife .”
This seems to take
place of registra­
tion) .

H U N G A R Y ...
[Law of 1876.]

License issued by per­
son in charge of
municipal pUblichealth work (chief
health officer), aLer
examination.

5 months’ course in a
school of midwifery pre­
requisite to application
for license in case of
every woman living
within 75 kilometers of a
university or school of
midwifery; if living at
a longer distance may be
given a diploma by the
health physician* of the
Province.
2 years in school of mid­
wifery. A p p a r e n t ly
all these schools are
State in s t it u t io n s —
either schools of obstet­
rics in cities where there
are m edico-surgical
schools or higher obstet­
rical gynecological in­
stitutions. Course may
also be taken at Some
other schools belonging
to State universities.

No information.

IT A L Y ........................... University of district
[Law on public health,
where course is
Dec. 22, 1888.]
taken.


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Registration

Local (registe- diplo­
ma at office of com­
mune).

Laws and regulations
governing practice

Laws and regulations pre­
scribe in detail rules of
midwife’s conduct while
on case and also outside
her work; specify instru­
ments and other articles
she must have in her
possession; enumerate
conditions under which
she must send for a
physician.
Regulated by ministerial
order of Oct. 3, 1902,
which forbids midwife
to perform certain kinds
of work outside her pro­
fession and enumerates
circumstances in which
she must call physician.

Fines, arrests, or sus­
pension of practice
are penalties pro­
vided.

Supervised by local
public-health physi­
cian.

No information.

Supervised by. chief
health officer of mu­
nicipality, who veri­
fies a n d registers
midwife’s diploma.
Municipalities
are
divided into districts,
healtn officers of
which also exercise
supervision.

Various penalties.

Supervision consists in
registering diploma
within 1 month of set­
tling in given locali­
ty; reporting each
case to local authori­
ties. If puerperal in­
fection d e v e lo p s ,
midwife must report
case to the local
health, officer.
In
case of puerperal infection midwife must
not approach anoth­
er without permis­
sion from health offi­
cer; she may also be
ordered by mayor to
abstain from prac­
tice 5 days or longer.

Regulated by royal decrees
of Feb. 23, 1890, and
May 28,1914, forbidding
use of surgical instru­
ments or performance of
certain e n u m e r a te d
manipulations.

Remarks

MATERNAL MORTALITY

Country and date of
enactment

Penalties for violation
of requirements of
practice

THE N E T H E R ­
LANDS.
[Royal decree of Feb.
12, 1870.]

60564

Diploma issued, after
examination, by ex­
amining commission
appointed by royal
order.

§ SPAIN ......... ............... . Licensed by medical
|
[General regulations
faculties of State
on public health,
universities.
E xJan. 12, 1904.]
amined by board of
university.

Diploma
required,
issued by school and
countersigned by
public-health au­
thorities.

Local (chief publichealth inspector).

2-year course at medical Local (local publicschool of a State univer­
health authorities).
sity (“ official studies”
or “ unofficial studies.” )
(General regulations on
public instruction define
unofficial students as
those studying outside
ot State establishments
but passing examinations
at State institutions.)
Course lasts 1 year for Local (with medical
midwives of first class
“ foremen” ).
and 9 months for those of
second class. In case of
former, additional 3
months are spent in in­
struction in use of
forceps and performance
of certain operations.

Midwife to take normal
cases only. In all other
cases must call qualified
physician, or in his
absence, another mid­
wife. If operation can
not be delayed she may
perform one but with­
out use of obstetrical in­
struments.
Midwife permitted to care
for normal cases only; in
case of abnormality or
accident she must ask
for a physician.

Midwife may operate only
in emergency and then
must have one or more
witnesses; never allow­
ed to refuse case.

Fines and imprison­
ment.

Penalties provided in
sec. 67 of general reg­
ulations on public
health.

Fines.

Apparently no regular
supervision o v e r
midwives,
except
that they are com­
pelled by law to
furnish to the State
supervisors of public
health all the in­
formation requested
; by them.
Supervised by the local
public-health officer.

Supervised by publlohealth authorities of
district.

APPENDIXES

SW EDEN .....................
[Regulations on mid­
wifery of Nov. 21,
1010.]

2-year course in State
school of midwifery.

CO

CO

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Federal Reserve Bank of St. Louis

V

APPENDIX G.— GENERAL TABLES
G e n er al T able 1.— Maternal mortality rates, by cause of death; United States

expanding death-registration area, 1900-1921
Deaths from puerperal causes

Number

Rate per 100,000
population

Puer­
All
Total peral sep­ other
ticemia

Puer­
All
Total peral sep­ other
ticemia

Estimated
population,
July 1

Year

1900........................................................
1901-......................................................
1902
...................... ..........................
1903 ......................... — - .....................
1904................... ....................................
1905..................................................... 1906............................. ........................ 1907 ____________________________1908- ________ _______________ ____
1909- ................................... ................
1910 ......... ............................................
1911-...........- .............- ..................... 1912.................................... - , ................
1913 - ................................ ...................
1914 ___ ______ ______ ____________
1915 ........................................... ..........
1916-.........- ..........................................
1917____ ________________ ______ ___
1918 ........... ................ ........................ 1919.-....................................................
1920............................. ...... ...................
1921......................................................

30,765,618
31,370,952
32,029,815
32,701,083
33,345,163
34,052,201
41,983,419
43,016,990
46,789,913
50,870,518
53,831,742
59,183,071
60,359,974
63,200,625
65,813,315
67,095,681
71,349,162
74,984,498
81,333,675
85,166,043
87,486,713
88,667,602

1,769
1,882
1,813
1,992
2,291
2,309
2,622
2,«08
3,271
3,427
3,892
4,376
3,905
4,542
4,664
4,214
4,786
5,211
5,250
4,950
5,800
6,057

4,106
4,294
4,164
4,569
5,109
5,077
6,341
6,719
7,344
7,791
8,455
.9,456
9,035
10,010
10,518
10,237
11,642
12,528
18,177
14,488
16,776
15,027

2,337
2,412
2,351
2,577
2,818
2,768
3,719
3,811
4,073
4,364
4,563
5,080
5,130
5,468
5,854
6,023
6,856
7,317
12,927
9,538
10,976
8,970

13.3
13.7
13.0
14.0
15.3
14.9
15.1
15.6
15.7
15.3
15.7
16.0
15.0
15.8
16.0
15.3
16.3
16.7
22.3
17.0
19.2
16.9

5.7
6.0
5.7
6.1
6.9
6.8
6.2
6.8
7.0
6.7
7.2
7.4
6.5
7.2
7.1
6.3
6.7
6.9
6.5
5.8
6.6
6.8

7.6
7.7
7.3
7.9
8.5
8.1
8.9
8.9
8.7
8.6
8.5
8.6
8.5
8.7
8.9
9.0
9.6
9.8
15.9
11.2
12.5
10.1

G e n e r a l T a b l e 2.— Maternal mortality rates, by cause of death; death-registration

States 1 as of 1900, 1900-1921
Deaths from puerperal causes

Year

Estimated
population,
July 1

Regis­
tered
live
births

Esti­
mated
live
births*
Total

1900___
1901___
1902— ¿
1903— .
1904—
1905___
1906___
1907___
1908___
1909___
1910—
1911___
1912___
1913—
1914___
1915___
1916___
1917—
1918—
1919—
1920___
1921.__

19,995,213
20,408,869
20,822,526
21,236,179
21,649,836
22,063,490
22,477,147
22,890,804
23,304,457
23, 718,114
24,129,977
24,535,075
24,940,176
25,345,275
25,750,376
26,155,475
26,560,573
26,965,674
27,370,773
27,775,874
28,180,9J3
28,586,073

399,764
396,265
409,088
426,736
438,976
450,302
484,804
510,855
537,452
530,193
554,373
571,466
586,656
597,389
623,427
633,859
644,613
663,798
662,907
616,083
653,714
668,226

512,416
504,531
512,691
529,940
531,550
529,288
551,960
568,876
581,983
562,732
579,863
593,103
597,041
600,071
619,258
622,266
628,141
656,628
659,397
615,864
653,842
668,404

2,682
2,704
2,626
2,778
3,216
3,219
3,229
3,448
3,343
3,422
3t641
3,806
3,527
3,789
3,954
3,859
3,919
4,167
5,621
4,241
4,943
4,317

i Includes District of Columbia.

140


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Rate per 100,000
population

Number

Puer­
peral
septi­
cemia
1,155
1,124
1,092
1,153
1,403
1,401
1,302
1,476.
1,431
1,453
1,624
1,748
1,488
1,661
1,686
1,547
1,620
1,719
1,536
1,439
1,705
1,735

Rate per 1,000 es­
timated live births

Puer­
All
peral
other Total septi­
cemia

Puer­
All
peral
other Total septi­
cemia

1,527
1,580
1,534
1,625
1,813
1,818
1,927
1,972
1,912
1,969
2,017
2,058
2,039
2,128
2,268
2,312
2,299
2,448
4,085
2,802’
3,238
2,582

7.6
7.7
7.4
7.7
8.4
8.2
8.6
8.6
8.2
8.3
8.4
8.4
8.2
8.4
8.8
8.8
8.7
9.1
14.9
10.1
11.5
9.0

13.4
13.2
12.6
13.1
14.9
14.6
14.4
15.1
14.3
14.4
15.1
15.5
14.1
15.0
15.4
14.8
14.8
15.5
20.5
15.3
17.5
15.1

5.8
5.5
5.2
5.4
6.5
6.4
5.8
6.4
6.1
6.1
6.7
7.1
6.0
6.6
6.5
5.9
6.1
6.4
5.6
5.2
6.1
6 .1

5.2
5.4
5.1
5.2
6.1
6.1
5.9
6.1
5.7
6.1
6.3
6.4
5.9
6.3
6.4
6.2
6.2
6.3
8.5
6.9
7.6
6.5

* For method of estimate see pp. 51-52.

2.3
2.2
2.1
2.2
2.6
2.6
2.'4
2.6
2.5
2.6
2.8
2.9
2.5
2.8
2.7
2.5
2.6
2.6
2.3
2.3
2.6
2.6

All
other

3.0
3.1
3.0
3.1
3.4
3.4
3.5
3.5
3.3
3.5
3.5
3.5
3.4
3.5
3.7
3.7
3.7
3.7
6.2
4.5
5.0
3.9

appendixes


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142

MATERNAL MORTALITY

G en er al T able 3.— Maternal mortality rates, by cause of death; District o f

Columbia and each State included in the death-registration area of 1900, 19001921— Continued
Deaths from puerperal causes

State and year

Esti­
mated
population,
July 1

Indiana—Con.
1918______ 2.894,930
1919______ 2,918,570
1920_______ 2,942,210
1921______ 2,965,851
Maine:
694,870
1900............
699,722
1901............
704,574
1902...........
709,425
1903______
714, 277
1904___ i.__
719,128
1905_______
723,980
1906...........
728,832
1907______
733,683
1908______
738, 535
1909______
742,922
1910......... .
745,563
1911............
748,205
1912-.........
750,846
1913............
1914-.........
753,487
1915............
756,128
758,769
1916— .......
761,410
1917-.........
764,051
1918............
1919-......... • 766,693
769,334
1920-.........
771,976
1921______
Massachusetts:
1900______ 2,810,081
1901-....... . 2,866,898
1902....... — 2,923,716
1903-....... . 2,980,534
1904______ 3,037,351
1905______ 3,094,169
1906______ 3,150,986
1907______ 3,207,804
1908........... 3,264,622
1909.......... . 3,321,439
1910-....... . 3, 376, 844
1911-......... 3,426,897
1912— ....... 3,476,952
1913______ 3,527,007
1914............ 3,577,060
1915............ 3,627,114
1916........... 3, 677,168
1917-........... 3', 727', 221
1918-.......... 3,777,275
1919--......... 3,827,329
1920.-......... 3,877,382
1921............ 3,927,436
Michigan:
1900........... 2,424,266
1901
2,463,678
1902........... 2,503,090
1903-.......... 2,542,501
1904
2,581,913
1905--........ 2,621,324
1906-.......... 2, 660,736
1967
2, 700,148
1908........... 2,739,559
1909-— — 2,778,971
1910
2,828,590
1911-......... 2,916,992
1919 .
3,005,394
3,093,797
1913
1914........... 3,182,199
1915.......... 3,270,601
1916........... J 3,359,003


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Federal Reserve Bank of St. Louis

Regis­
tered
Esti­
live
mated
births
live
from births
State
reports

Rate per 100,000
population

Number

Rate per 1,000 live
births

Puer­
Puer­
Puer­
peral AU
peral AU
peral AU
Total septi­
other Total septi­ other Total septi­ other
cemia
cemia
cemia

401
286
307
236

23.1
17.1
19. 3
15.8

9.3
7.3
8.8
7.8

13.9
9.8
10.4
8.0

10.2
8.3
8.7
6.8

4.1
3.6
4.0
3.4

6.1
4.8
4.7
3.4

65
77
107
93
91
84
73
79
82
78
110
100
76
86
87
110
125
112
144
133
147
131

44
21
29
48
43
64
28
65
38
53
47
37
17
56
31
48
30
52
44
34
64
46
29
71
21 . 55
28
58
29
58
34
76
94
31
82
30
21
123
30
103
27
120
34
97

9.4
11.0
15.2
13.1
12.7
11.7
10.1
10.8
11.2
10.6
14.8
13.4
10.2
11.5
11.5
14.5
16.5
14.7
18.8
17.3
19.1
17.0

6.3
3.0
6.9
4.1
9.1
6.1
9.2
3.9
7.4
5.3
6.5
5.1
2.3 : 7.7
4.3
6.6
7.1
4.1
6.0
4.6
6.2
8.6
9.5
3.9
7.4
2.8
7.7
3.7
7.7
3.8
4.5 10.1
4.1 12.4
3.9 10.8
2.7 16.1
3.9 13.4
3.5 15.6
4.4 12.6

4.1
5.1
6.8
5.9
5.8
5.2
4.4
4.8
4.9
4.7
6.7
6.1
4.5
5.2
5.2
6.4
7.6
6.6
8.5
8.6
8.5
7.4

1.3
1.9
2.7
1.8
2.4
2.3
1.0
1.9
1.8.
2.0
2.8
1.8
1.3
1.7
1.7
2.0
1.9
1.8
1.2
1.9
1.6
1.9

2.8
3.2
4.1
4.1
3.4
2.9
3.4
2.9
3.1
2.6
3.9
4.3
3.3
3.5
3.5
4.4
5.7
4.8
7.3
6.6
6.9
5.5

75,197
74,806
75,241
77,501
78,492
77,113
80,929
85,123
86,911
84,039
86,539
88,327
89,882
91,644
93,399
93,155
93,487
95,731
95, 607
87,827
91,859
92,245

312
267
274
341
394
359
385
404
355
482
412
510
456
510
571
533
559
622
882
619
684
601

105
92
89
116
133
120
122
137
131
170
166
210
184
187
193
155
228
261
204
180
219
200

207
175
185
225
261
239
263
267
224
312
246
300
272
323
378
378
331
361
678
439
465
401

11.1
9.3
9.4
11.4
13.0
11.6
12.2
12.6
10.9
14.5
12.2
14.9
13.1
14.5
16.0
14.7
15.2
16.7
23.4
16.2
17.6
15.3

3.7
3.2
3.0
3.9
4.4
3.9
3.9
‘ 4.3
4.0
5.1
4.9
6.1
5.3
5.3
5.4
4.3
. 6.2
7.0
5.4
4.7
5.6
5.1

4.1
7.4
3.6
6.1
6.3
3.6
4.4
7.5
5.0
8.6
4.7
7.7
4.8
8.3
4.7
8.3
4.1
6.9
9.4
5.7
4.8
7.3
5.8
8.8
5.1
7.8
9.2
5.6
6.1
10.6
10.4
5.7
6.0
9.0
9.7
6.5
9.2
17.9
7.0
11.5
12.0
7.4
10.2 , 6.5

1.4
1.2
1.2
1.5
1.7
1.6
1.5
1.6
1.5
2.0
1.9
2.4
2.0
2.0
2.1
1.7
2.4
2.7
2.1
2.0
2.4
2.2

2.8
2.3
2.5
2.9
3.3
3.1
3.2
3.1
2.6
3.7
2.8
3.4
3.0
3.6
4.0
4.1
3.5
3,8
7.1
5.0
5.1
4.3

61,249
60,793
63,471
64', 152
62,475
59,933
70,750
68,047
72,186
71,986
73,224
74,586
77,727
80,123
81,876
84,674
89,462 1

449
465
447
417
502
381
428
421
460
417
474
503
425
578
528
538
592

214
222
»0
184
218
160
169
172
187
191
196
244
179
273
227
204
269

235
243
257
233
284
221
259
249
273
226
278
259
246
305
301
334
323

18.5
18.9
17.9
16.4
19.4
14.5
16.1
15.6
16.8
15.0
16.8
17.2
14.1
18.7
16.6
16.4
17.6

8.8
9.0
7.6
7.2
8.4
6.1
6.4
6.4
6.8
6.9
6.9
8.4
6.0
8.8
7.1
6.2
8.0

64,313
59,273
64,809
68,247

65,684
59,828
65,454
68,899

669
499
567
468

14,905
14,021
14,508
14,453
14, 673
15,294
15, 878
15,914
16,173
16,041
15,798
15, 635
15,869
15, 719
15,980
16,671
16,033
16,651
16,798
15,496
17,328
17,712

15,965
15,161
15, 663
15,849
15,690
16,267
16, 619
16,532
16,719
16,664
16,437
16,424
16, 717
16,413
16,660
17, 318
16,456
17,091
16,896
15,496
17,328
17,712

73,386
71,976
72,219
73, 584
75,014
75,022
80, 237
85,001
86,911
84,039
86,539
88,327
89,882
91,644
93,399
93,155
93,487
95,731
95,607
87| 827
91,859
92,245
42,580
42,115
44,380
44,842
45,880
45,773
57.099
57,518
63,114
62,677
64,109
65,756
69,537
73,058
76,761
81.100
87,062

268
213
260
232

9.7
9.9
10.3
9.2
11.0
8.4
9.7
9.2
10.0
8.1
9.8
8.9
8.2
9.9
9.5
10.2
9.6

7.3
7.6
7.0
6.5
8.0
6.4
6.0
6.2
6.4
5.8
6.5
6.7
5.5
7.2
6.4
6.4
6.6

3.8
3. 5
4.0
3.7
3.0 t 4.0
3.6
2.9
4.5
3.5
3.7
: 2.7
2.4
3.7
3.7
2.5
3.8
2.6
2.7
3.1
3.8
. 2.7
3.3
3.5
3.2
2.3
3.4
3.8
2.8
3.7
2.4 ! 3.9
3.0
3.6

APPENDIXES

143

G e n e k a i , T able 3.— Maternal mortality rates, by cause of death; District of

Columbia ana each state included in the death-registration area of 1900 1900—
1921— Continued
’
Deaths from puerperal causes

State and year

Esti' mated
popula­
tion.
July 1

Regis­
tered
Esti­
live
births mated
live
from
State births
reports

Tota

Michigan—Con
1917....... .
3,447,405 89,419 92,829
662
1918______ 3,535,808 91, 261 95,005
782
1919______ 3,624,211 84,062 88, 215
648
1920______ 3,712,613 92,245 99,864
864
1921........ . 3,801,016 96,322 106,806
660
N ew H am p shire:
1900...........
411, 748 8,425
9,294
33
1901...........
413,671
8,164
9,058
29
1902______
415, 593
8,249
9,155
28
1903...........
417, 515 8,318
9,204
44
1904
419,438
8,364
9,080
38
1905______
421,360
8,782
9,399
53
423,283
1906............
9,234
9,733
63
1907
425, 205 9,083
9,503
45
1908______
427,127
9,270
9,576
43
1909...........
429,050
8,913
9,259
56
1910
430,841
9,386
9,748 r 52
1911
432,129
8,993
9,356
59
1912
433,417
9,133
9,382
66
1913
434,706
9,236
9,378
59
1914............
435,995
9,531
9, 543
69
1915_______
437,284 10,003 10,003
61
1916..........
438, 573
9,665
9, 665
70
1917............
439,861
9,564
9,564
67
1918.......
441,150
9,635
9,635
75
1919___ ___
442,439
8,852
8,852
70
1920............
443,728
9,974
9,974
71
1921............
445,016 10,125 10,125
63
New Jersey:
1900_____
1,889,184 32,270 51,395
241
1901___
1,955,361 34,812 55,062
192
1902___
2,021, 539 35,116 53,887
219
1903.......... 2,087,717 37,242 56, 254
235
1904.......... 2,153,894 38,751 57,625
265
1905 ______ 2,220,072 39, 689 57,715
285
1906____
2, 286,249 42,677 60, 645
325
1907______ 2,352,427 44,651 62,464
302
1908______ 2,418,605 47, 405 63,672
348
1909.......... 2,484, 782 47,508 61,177
313
1910........... 2, 550,445 53,942 66,838
397
1911...
2, 614,177 58,133 69,897
424
1912............ 2, 677,909 60,073 69,281
409
1913
2,741,642 61,432 69,445
446
1914______ 2,805,374 65,403 72, 682 416
1915____
2,869,106 66,476 72, 092 419
1916_______ 2,932,838 70,211 74> 831 •414
1917.......... 2,996,569 75,309 80,632
433
1918______ 3,060,301 74,549 79,305
575
1919
3,124,034 70,935 80,999
426
1920
3,187,767 76,431 82,728
512
1921............ 3,251,499 78,172 84,497
458
New York:
1900
7,284,461 143,156 99,102 1,023
1901........... 7,471,269 140,539 93,209 , 121
1902
7,658,077 L46,740 97,377 ,039
1903 _
7,844,884 58,343 98,329 ,084
1904______ 8,031,692 65,014 10,258 ,268
1905______ 8,218,499 72,259 10, 794 ,365
1906............ 8,405,307 83,012 216,722 ,323
1907............ 8,592,115 96,020 226,888 : ,455
1908............ 8,778,922 03,159 227,230 : ,367
1909............ 8,965,730 02,656 219,579 : ,337
1910.______ 9,140,901 213,235 225,867 ! ,386
1911__ ____ 9,271,883 221,678 231,677 : ,405
1912.
1 9,402,864 227,120 231,593 : ,290
1913_______1 9,533,845 228,713 229,054 ],358
1914............ 1 9,664,826 240,038 240,038 1,442


https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis

Rate per 100,000
population

Number

Rate per 1,000 live
births

Puer­
Puer­
peral All
peral All
septi­ other Tota septi­ other Tota
cemia
cemia

Puer­
peral All
septi­ other
cemia

291
236
248
314
295

371
546
400
550
365

19.2
22.1
17.9
23.3
17.4

8.4
6.7
6.8
8.5
7.8

10.8
15.4
11.0
14.8
9.6

71
82
73
87
6.2

10
13
11
16
14
14
21
13
10
19
18
18
22
18
24
19
21
20
16
17
13
17

23
16
17
28
24
39
42
32
33
37
34
41
44
41
45
42
49
47
59
53
58
46

8.0
7.0
6.7
10.5
9.1
12.6
14.9
10.6
10.1
13.1
12.1
13.7
15.2
13.6
15.8
13.9
16.0
15.2
17.0
15.8
16.0
14.2

2.4
3.1
2.6
3.8
3.3
3.3
5.0
3.1
2.3
4.4
4.2
4.2
5.1
4.1
5. 5
4.3
4.8
4.5
3.6
3.8
2.9
3.8

5.6
3.9
4.1
6. 7
5. 7
9.3
9.9
7.5
7. 7
8. 6
7.9
9. 5
10.2
9.4
10.3
9. 6
11. 2
10. 7
13.4
12.0
13.1
1Ò.3

3. fi
32
3 1
48
42

11

fi. fi
47
4 fi
fi fì
fi 3
fi 3
70
fi 3
72
fi 1
72
70
78
79
7 1
6.2

2, 2
14
i n

93
74
95
94
131
134
139
121
169
141
191
202
163
215
183
181
185
167
169
138
193
190

148
118
124
141
134
151
186
181
179
172
206
222
246
231
233
238
229
266
406
288
319
268

12.8
9.8
10.8
11.3
12.3
12.8
14.2
12.8
14.4
12. 6
15. 6
16.2
15.3
16.3
14.8
14.6
14.1
14.4
18.8
13.6
16.1
14.1

470
457
457
466
577
630
579
658
626
563
616
622
567
600
656

553 14.0
6:5
664 15.0
6.1
582 13.6
6. 0
618 13.8
5.9
691 15.8
7.2
735 16.6
7.7
744 15.7
6. 9
797 16.9
7.7
741 15.6
7.1
774 14.9
6.3
770 15.2
6.7
783 15.2
6.7
723 13.7
6.0
758 14.2
6.3
786 I 14.9 • 6.8

4. 9 7. 8
3.8
6. 0
4.7
6.1
4. 5 6.8
6.1
6. 2
6.0
6.8
6.1
8.1
5.1
7. 7
7.0
7.4
5.7
6. 9
7.5
8.1
7; 7 8. 5
6.1
9.2
7.8
8.4
6.5
8.3
6. 3 8.3
6.3
7.8
5.' 6 8. 9
5.5 13.3
4.4
9. 2
6.1 10. 0
5.8
8.2
7. 6
8.9
7. 6
7.9
8. 6
8.9
8.9
9.3
8.4
8. 6
8.4
8.4
7.7
8. 0
8.1

fi fi

47
3 fi
4 1
42
4 fi
49
fi 4
48
fi 1
fi 9

3 i

2.8

3.4

18
19
23
19
19
17
19
1.7

45

18
13
18
17
23
23
27
23

fi 9
fi 4
fi 7
fi’ 8
fi fi
fi 4
73

24
3 1

2 1

5.4

2.2

2' fi "

3.2

fi 1
fi 8
fi 3

fi fi

fi 0
fi fi
fi 1
fi 4
6.0
fi. 1
fi. 1
fi. 1
5. 6
5.9
6.0

3n
29
28
2 fi
2. 7
2 7"£?
24
2 fi it
2.7

.3 \
3.3

MATERNAL. MORTALITY

144

3 . — Maternal mortality rates, by cause of death; District of
Columbia and each State included in the death-registration area of 1900, 19001921— Continued

G eneral T able

Deaths from puerperal causes

State and year

Esti­
mated
popula­
tion,
July 1

N ew Y ork —
Continued.
1915............ 9, 795,808
1916........... 9,926,790
1917............ 10,057,772
1918............ 10,188,754
1919.......... 10,319,736
1920______ 10,450,718
1921........... 10,581,700
Rhode Island:
1900_______
429,519
441,068
1901______
1902...........
452,618
1903............
464,168
1904______
475,718
1905...........
487,268
1906______
498,818
1907............
510, 368
1908...........
521,918
1909...........
533,468
1910............
543,936
1911_______
550,300
1912............
556,664
1913_______
563,028
1914...........
569,392
1915............
575,756
19 l£...........
582,120
1917............
588,485
1918...........
594,850
1919............
601,215
1920-.........
607,580
1921............
613,944
Vermont:
343,745
1900...........
1901— .......
344,992
1902............
346,239
1903...........
347,485
1904............
348, 732
1905-.........
349,979
1906............
351,226
1907............
352,473
1908............
353, 719
1909............
354,966
1910-.........
355,880
1911............
355,517
1912............
355,154
1913...........
354,791
1914...........
354,428
1915............
354,065
1916............
353,702
1917— __
353,338
1918............
352,974
1919............
352, 610
1920............ * 352,428
1921............ * 352,428

Regis­
tered
Esti­
live
births mated
from births
State
reports

Number

Rate per 1,000 live
births

Puer­
Puer­
Puer­
peral All Total peral All
peral All
Total septi­
other
septi­ other Total septi­ other
cemia
cemia
cemia

242,950
240,817
246,453
242,704
226,269
235,243
239,875

242,950
240,817
246,453
242,704
226,269
235,243
239,875

1,418
1,310
1,413
1,931
1,412
1,616
1,504

11,084
11,292
11,227
11, 781
12,076
12,305
12, 677
13,188
13, 279
12,870
13,354
13,503
13,594
13,905
14,484
13,987
14,622
15,248
15,547
14,360
15,197
14, 499

11,516
11, 709
11, 602
12,163
12,425
12,503
12,828
13,441
13,462
13,008
13,552
13,782
13,731
14,080
14,614
13,987
14, 622
15,248
15,547
14, 360
15,197
14,499

89
83
71
62
97
100
88
99
87
82
82
89
80
73
80
92
85
97
152
97
120
103

7,047
6,973
7,239
7,182
7,366
7,378
7,520
7,550
7,694
7,587
7,356
7,263
7,547
7,477
7,512
7,875
7,805
7,574
7,564
7,091
7,500
7,977

7,465
7,416
7,706
7,607
7,717
7,699
7,773
7,793
7,932
7,849
7,593
7,537
7,841
7,643
7,560
7,905
7,806
7,640
7,698
7,170
7,577
8,100

46
33
39
51
59
66
56
95
67
67
61
49
49
65
71
48
61
48
60
56
52
58

1Population Jan. 1, 1920; no estimate made.


https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis

Rate per 100,000
population

628 790
526
784
568 845
499 1,432
483 929
530 1,086
596 908

14.5
13.2
14.0
19.0
13.7
15.5
14.2

6.4
5.3
5.6
4.9
•4.7
5.1
5.6

8.1
7.9
8.4
14.1
9.0
10.4
8.6

5.8
5.4
5.7
8.0
6.2
6.9
6.3

2.6
2.2
2.3
2.1
2.1
2.3
2.5

3.3
3.3
3.4
5.9
4.1
4.6
3.8

53 20.7
36
53 18.8
30
32
39 15.7
27
35 13.4
47 20.4
50
43
57 20.5
34
54 17.6
41
58 19.4
31 > 56 16.7
39
43 15.4
27
55 15.1
29
60 16.2
29
51 14.4
23
50 13.0
22
58 14.1
26
66 16.0
64 14.6
21
36
61 16.5
119 25.6
33
29
68 16.1
34
86 19.8
57 16.8
46

8.4
6.8
7.1
5.8
10.5
8.8
6.8
8.0
5.9
7.3
5.0
5.3
5.2
4.1
3.9
4.5
3.6
6.1
5.5
4.8
5.6
7.5

12.3
12.0
8.6
7.5
9.9
11.7
10.8
11.4
10.7
8.1
10.1
10.9
9.2
8.9
10.2
11.5
11.0
10.4
20.0
11.3
14.2
9.3

7.7
7.1
6.1
5.1
7.8
8.0
6.9
7.4
6.5
6.3
6.1
6.5
5.8
5.2
6.5
6.6
5.8
6.4
9.8
6.8
7.9
7.1

3.1
2.6
2.8
2.2
4.0
3.4
2.7
3.1
2.3
3.0
2.0
2.1
2.1
1.6
1.5
1.9
1.4
2.4
2.1
2.0
2.2
3.2

4.6
4.5
3.4
2.9
3.8
4.6
4.2
4.3
4.2
3.3
4.1
4.4
3.7
3.6
4.0
4.7
4.4
4.0
7.7
4.7
5.7
3.9

13.4
9.6
11.3
14.7
16.9
18.9
15.9
27.0
18.9
18.9
17.1
13.8
13.8
15.5
20.0
13.6
17.2
13.6
17.0
15.9
14.8
16.5

4.9
2.9
3.8
3.5
5.4
4.3
4.0
7.1
6.2
9.0
6.2
4.5
2.3
4.8
6.8
3.4
1.4
4.2
2.8
3.4
4.0
5.7

8.4
6.7
7.5
11.2
11.5
14.6
12.0
19.9
12.7
9.9
11.0
9.3
11.5
10.7
13.3
10.2
15.8
9.3
14.2
12.5
10.8
10.8

6.2
4.4
5.1
6.7
7.6
8.6
7.2
12.2
8.4
8.5
8.0
6.5
6.2
7.2
9.4
$.1
7.8
6.3
7.8
7.8
6.9
7.2

2.3
1.3
1.7
1.6
2.5
1.9
1.8
3.2
2.8
4.1
2.9
2.1
1.0
2.2
3.2
1.5
.6
2.0
1.3
1.7
1.8
2.5

3.9
3.1
3.4
5.1
5.2
6.6
5.4
9.0
5.7
4.5
5.1
4.4
5.2
5.0
6.2
4.6
7.2
4.3
6.5
6.1
5.0
4.7

17
29
23
10
13
26
12
39
19
40
15
51
14
42
25
70
22
45
32
35
22
39
16
33
8
41
17
38
24 • 47
12
36
5
56
15
33
10
50
44
12
14
38
20
38

APPENDIXES
G e n e r a l T a b l e 4 . — Proportion

State

United States deathregistration area_____
California__________________
Colorado_________ ________
Connecticut.................. ...........
Delaware__ ___ ........... ...... . . .
District of Columbia________
Florida................................
Illinois____________
Indiana________ ______ ___
Kansas________ _______
Kentucky________ __________
Louisiana..............................
M aine.......................
Maryland________________
M assachusetts _____________
Michigan___________________
Minnesota_________________
Mississippi. . . . ...........

1Mortality Statistics, 1921, pp. 93-94.


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of deaths from ill-defined and unknown causes, bv
States, 1921 1

Death
Per cent rate per
of deaths 100,000
due to
popula­
unknown tion from
or illunknown
defined
or illdiseases
defined
diseases

1.4
.1
.2
.3
.4
.1
5.3
.2
.2
1.2
1.9
3.0
i.2
.9
.3
.6
.7
10.5

145

16.0
1.8
2. 6
3.2
5.7
1.4
62.7
2.2
1.9
12.1
19.5
33.6
17.1
11.6
4.2
7.1
6.3
117.3

State

Missouri....... ...................... .
Montana___

U. S. Bureau of the Census.

Per cent
of deaths
due to .
unknown
or illdefined
diseases

1.2
17

Death
rate per
100,000
popula­
tion from
unknown
or ill- H
defined
diseases
12 fi

4.3

G e n e r a l T able 5 - -Estimated additions to puerperal deaths in original death-registration States of 1900 from ill-defined and unknown causes

and from five poorly defined causes,1 1900—1920

05

D eaths from puerperal causes
A 11 other puerperal causes

Puerperal septicemia

Year

1900.
1901.
1902.
1903.
1904.
1905.
1906.
1907.
1908.
1909.
1910.
1911.
1912.
1913.
1914.
1915.
1916.
1917.
1918.
1919.
1920.

Esti­
mated
Actual transfers
deaths
classed
in death- to septi­
registra­
cemia
tion area and peri­ Number
tonitis

1,769
1,882
1,813
1,992
2,291
2,309
2,622
2,908
3,271
3,427
3,892
4,376
3,905
4,542
4,664
4,214
4,786
5,211
5, 250
4,950
5,800

C

D

1,549
1,220
1,183
1,041
1,058
949
860
795
746
466
410
399
302
186
302
188
202
289
350
234
273

3,318
3.102
2,996
3,033
3,349
3,258
3,482
3,703
4,017
3,893
4,302
4,775
4,207
4,728
4,966
4; 402
4,988
5,500
5,600
5,184
6,073

E
1.88
1.65
1. 65
1.52
L 46
1.41
1.33
1.27
1.23
L 14
1.11
1.09
1.08
1.04
1.06
1.04
1.04
1.06
1.07
1.05
1.05

F
1,155
1,124
1,092
1,153
1,403
1,401
1,302
1, 476
1,431
1,453
1,624
1,748
1,488
1,661
1,686
1,547
1,620
1,719
1,536
1,439
1,705

2,166
1,853
1,805
1,756
2,051
1,977
1, 729
1,880
1,757
1,651
1,795
1,907
1,603
1,729
1,795
1,616
1,688
1, 814
1,638
1,507
1,785

Esti­
Esti­
mated
mated
Actual
transfers total in
classed
original indeaths
deathto illdeathdefined registra­ registra­
tion
area
and un­
tion
known
States 4
causes3
I

H
22
17
16
14
14
13
11
10
9
7
7
2
2
2
2
2
2
2
1
1
1

2,188
1,870
1,821
1,770
2,065
1,990
1,740
1,890
1,766
1,658
1,802
1,909
1,605
1,731
1,797
1,618
1,690
1,816
1,639
1,508
1,786

J

Esti­
Actual
Estimated deaths
Esti­
mated
deaths
mated
deaths
from all from all
transfers
other
classed
other
puerperal puerperal
to con­
causes in causes in
vulsions,
Ratio
to
original original
acute
actual
deathnephritis, Number
deaths registra­ deathand
registra­
tion
Bright’s
tion
States
disease
States 5
O
N
M
L
K

2,337
2,412
2,351
2,577
2; 818
2,768
3,719
3,811
4,073
< 364
<563
5,080
5,130
5,468
5,854
6,023
6,856
7', 317
12,927
9,538
10', 976

942
878
626
455
447
630
447
454
482
696
372
455
593
542
792
941
636
298
1,227
1,030
246

3,279
3,290
2,977
3,032
3,265
3,398
4,166
4,265
4,555
5,060
4,935
5,535
5,723
6,010
6,646
6,964
7,492
7,615
14,154
10, 568
11,222

1.40
1.36
1.27
1.18
1.16
1.23
1.12
1.12
1.12
1.16
1.08
1.09
1.12
1.10
1.14
1.16
1.09
1.04
1.09
1.11
1.02

1,527
1,580
1.534
1,625
1,813
1,818
1,927
1,972
1,912
1,969
2,017
2,058
2,039
2,128
2,268
2,312
2,299
2,448
4,085
2,802
3,238

2,143
2,155
1,942
1,912
2,101
2,232
2,159
2,207
2,138
2,283
2,181
2,242
2,275
2,339
2,575
2,673
2,512
2,548
4,473
3,105
3,311

Esti­
Esti­
mated
mated
transfers total
in
classed
original
to illdeathdefined registra­
and un­
tion
known
States
causes3
R

P
21
17
15
14
13
14
14
11
10
9
8
3
3
2
2
2
2
2
4
2
2

2,164
2,172
1,957
1,926
2,114
2,246
2,173
2,218
2,148
2,292
2,189
2,245
2,278
2,341
2,577
2,675
2,514
2.550
4,477
3,107
3,313

i (1) Septicemia, (2) peritonitis, (3) convulsions, (4) acute nephritis, and (5) Bright’s disease
^irYr»in<sivft nf transfers to ill-defined and unknown causes. Column F multiplied by ratio m column
.
,
. ' » The estimated transfers* fromnpdefined and unknown causes calculated as described on p. 53 were distributed between puerperal septicemia and other puerperal causes in the
proportion that these formed of the total puerperal deaths.
4 Exdusiv?o?transfers to ill-defined and unknown causes.


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Column N multiplied by ratio in column M.

MATERNAL

Actual
deaths
from
puerperal
septi­
cemia in
Ratio to original
actual
deathdeaths registra­
tion
States

Estimated deaths

Esti­
mated
deaths
from
puerperal
septi­
cemia in
original
deathregistra­
tion
States 2
G

G e n e r a l T a b l e 6 . — Maternal

mortality rates per 1,000 live births for urban and rural areas; United States birth-registration arèa as of
1915 (excluding Rhode Island) and United States expanding birth-registration area, 1915-1921 1
Deaths from puerperal causes
Registered live
births

Total

Puerperal septicemia

All other puerperal causes

Year and area
Number

Rate per 1,000
live births

Number

Cities

Rural

470,089
479,628.
496,138
493,949
463,595
503,524
509,349

292,310
291,090
290, 752
290,048
267,157
270,124
284,880

3,005
3,108
3,238
4,477
3,365
4,002
3,658

1,622
1,683
1,689
2,490
1,620
1,891
1,527

6.39
6.48
6.53
9.06
7.26
7.95
7.18

5.55
5.78
5.81
8. 58
6.06
7.00
5.36

1,258
1,381
1,405
1,246
1,223
1,416
1,516

572
572
633
557
474
566
568

2.68
2.88
2.83
2.52
2.64
2.81
2.98

1.96
1.97
2.18
1.92
1. 77
2.10
1.99

1,747
1,727
1,833
3,231
2,142
2,586
2,142

1,050
hill
1,056
1,933
1,146
1,325
959

3.72.
3.60
3.69
6.54
4.62
5.14
4.21

3.59
3.82
3.63
6.66
4.29
4.91
3.37

481,496
507,736
682,158
686,561
677,503
763,209
852,519

294,808
311,247
671, 634
677,088
695,935
745,665
861,742

3,088
3,306
4,773
6,589
5,336
6,534
6,571

1,631
1,785
4,185
5,907
4,791
5,524
5,117

6.41
6.51
7.00
9.60
7.88
8.56
7.71

5.53
5.73
6.23
8.72
6.88
7.41
5.94

1,283
1,461
2,136
1,993
1,986
2,408
2,805

573
605
1,544
1,480
1,380
1,628
1,834

2.66
2.88
3.13
2.90
2.93
3.16
3.29

1.94
1.94
2.30
2.19
1.98
2.18
2.13

1,805
1,845
2,637
4,596
3,350
4,126
3,766

1,058
1,180
2,641
4,427
3,411
3,896
3,283

3.75
3.63
3.87
6.69
4.94
5.41
4.42

3.59
3.79
3.93
6.54
4.90
5.22
3.81

Cities

Rural

Cities

Rural

Cities

Rural

> Compiled from Birth Statistics, 1915 to 1921, and Mortality Statistics, 1915 to 1921 (U. S. Bureau of the Census).


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Rate per 1,000
live birtns

Number

Cities

Rural

Cities

Rural

Cities

Rural

APPENDIXES

United States birth-registration.
area as of 1915 (excluding
Rhode Island):
1915................. „.....................
1916.......................................
1917........................................
1918........................................
1919.......................................
1920........................................
1921_________ ________
United States expanding birthregistration area:
1915........................................
1916........................................
1917........................................
1918................... ..............
1919........................................
1920....... .................................
1921____________

Rate per 1,000
live births

MATERNAL MORTALITY

148

G e n e r a l T able 7.— Proportion of physicians to population in certain countries

Year

Country

Italy »..........................................

Ratio of
physi­
cians to
popula­
tion (per
10,000)
8.77
4.68
5.78
3.08
6.34
5.91
5.73
5.06
14.96
6.91

1911
1913
1912
1907 .
1922
1923
1911
1911
1923
1911

Country

Year

New Zealand70_______________

1921
1918
1911
1900
1921
1917
1921
1908
1923

Scotland73________ ____ ______
Spain73______________________
Sweden77................................
The Netherlands 78___________
Uruguay77_____ _____________
United States78______________

Ratio o r
physi­
cians to
popula­
tion (per
10,000)
8.79
5.02
6.78
18.18
2.79
6.83
8.02
4.01
13.19

i Official Year Book 1901-1918, p. 102, from the number of physicians as reported in the census of 1911;
731 classed as “ irregular” have been deducted.
* Aerztliches Jahrbuch für Oesterreich, quoted in Wiener Klinische Wochenschrift, 1914, p. 30.
8Annuaire Statistique, 1913, p. 258.
* Census of 1907, pp. 1,262 and 1,300.
I Statistisk Ârbok for Danmark, 1922, pp. 1, 25.
II Medical Register for 1923, p. lxxxvi.
7 Resultats Statistiques du Recensement Général de la Population, 1911, Vol. I, Pt. 3, p. 63. Annuaire
Statistique, 1912, p. 3.
8 Reichsmedizinal Kalendar für Deutschland auf das Jahr 1912, Teil II, p. 754.
8 Census of 1911, Part VIII.
10 New Zealand Official Yearbook, 1923, pp. 51,151.
11 Sundhetstilstanden og Medisinalforholdene, 1918, p. 8.*
11 Census of 1911; 3,228 physicians, surgeons, and registered practitioners; population, 4,760,904.
13 Census of 1900, Vol. 4, p. 215, Vol. 1, p. 331: 33,883 in the “ medical professions” (a term which is not
defined). Of this number 1,586 were women.
m Statistisk Irsbok, 1923, p. 57. (Population 1920, 5,847,037. Ibid., 1921, p. 3.)
78 Statistisches Jahrbuch, 1920, p. 322. (Population 1920, 3,880,320. Ibid., p. 43.)
18Jaarcijfers voor het Koninkrijk der Nederlanden, Rijk in Europa, 1921, p. 37. ’s-Gravenhage, 1923.
17 Census of 1908, pp. VII, X X X V I.
78American Medical Directory for 1923, p. 8. Population estimated from censuses of 1910 and 1920.
G e n e r a l T a b l e 8 . — Proportion

of births attended by physicians and midwives in
certain countries
Per cent of births ttended
by—

Country

Year
Physi­
cian

1922
1921
1911-13
1918
1922-23
‘ 1921
1916

76.0
22.3

38.5

Midwife

24.0
53.6
66.6
85.0
37.0
84.3
58.9

Attend­
ant not
Other or reported
no at­
tendant

11.0

2.7

1 Compiled from Maternity Allowances, 1922 (Department of the Treasury, Commonwealth of Aus­
tralia).
'
3 Fourth Annual Report of the Ministry of Health (Great Britain), 1922-1923, p. 14; Cmd. 1944. Of
782,266 registered births in England, 419,655 were notified by midwives.
3 Statistique du Mouvement de la Population, Années 1911, 1912, et 1913, pp. 140, 143. Paris, 1917.
The percentages based upon cases with attendant reported were 74.9 per cent attended by physicians
and 25.1 per cent attended by midwives.
i
,
* Sundhetstilstanden og Medisinalforholdene, Norges Offisielle Statistikk, 1918, pp. 21,* 36.* Of 64,187
confinements in 1918, 54,670 were attended by midwives.
8 Report of the Central Midwives’ Board for Scotland for the Year Ended Mar. 31, 1923, as abstracted
in Nursing Notes and Midwives’ Chronicles, December, 1923.
.
8 Compiled from Allmân halso-och sjukvârd, àr 1921, av Kungl. Medicinalstyrelsen, p. 22 (Sveriges
Officiella Statistik, Stockholm, 1923).
.
' U
^
7 Statistiek van den loop der bevolking in Nederland over het jaar 1916, p. 62-63. Bijdragen tot de
Statistiek van Nederland. No. 248.


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APPENDIXES

149

Scope and effect of system of querying unsatisfactorily certi­
fied causes of death in England and Wales, 1911-1921 1

G en er al T able 9.

Queries sent
Year

Total
deaths
Number

1911................
1913______ _____
1915_______

1919__ _____

527,810
486, 939
504,975
516,742
562,253
508,217
498,922
611,861
504,203
466,130
438,629

12,563
9,912
8,552
7,808
6,869
6,255
6,046
6,114
5,980
6,402
6,222

Replies received

Per cent
of total’ Number
deaths

2.4
2.0
1.7
1.5
1.2
1.2
1.2
1.0
1.2
1.4
1.4

10,718
8,305
7,575
6,594
5,951
5,451
5,350
5,384
5,320
5,452
5,399

Deaths
trans­
Replies ferred
to
amplify­
puerperal
ing-pre­
Per cent vious in-, septi­
of total
cemia as
queries formation result of
inquiry1
85.3
83.8
88.6
84.5
86.6
87.1
88.5
88.1
89.0
85.2
86.8

8,196
6,064
5,495
5,028
4,917
4,602
4, 686
4,763
4,538
4,668
4,743

60
40
29
29
28
29
25
23
29
16

and°WalPiIed fr° m annual reports of the Registrar-General of Births, Deaths, and Marriages in England
s Includes only transfers from “ pyemia, septicemia, etc.,” and 1peri t oni t i snot stated whether any
transfers were made from other causes to puerperal septicemia. '

G e n e r a l T able 10.— Live births, deaths, and death rates per 1,000 live births

from diseases caused by pregnancy and confinement in certain foreign countries
for specified years
Deaths from diseases caused by pregnancy and confinement

Country and year

Number

Live births
Total

Australia:
1905--................................
1906- ................................
1907 ................................
1908 ...................
1909- ................................
1910- ...........................
1911-.............................
1912--......................... „
1913-.............................
1914 _______________
1915______________
1916 ........................
1917..........................
1918..........................
1919 ______________
1920-........................
1921______________
1922- ___________
Belgium:
1900-...................... .
1901......................
1902--......................
1903--............ ........
1904 .....................
1905____________
1906 __________
1907____________
1908.....................
1909 - ...........................
1910____________
1911__________ ___ ___
1912_________________
1913............ ..................
1919_________________
1920 .............................
1921....................................


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104,941
107,890
110,347
111, 545
114,071
116,801
122,193
133,088
135,714
137,983
134,871
131,426
129,965
125,739
122,290
136, 406
136,198
137,496
193, 789
200,077
195,871
192, 301
191,721
187,437
186, 271
185,138
183,834
176,431
176,413
171,802
171,187
171,099
123, 314
163, 738
163, 333

616
626
614
606
577
591
615
644
663
634
576
693'
732
592
570
683
643
621
1,046
1,055
1,080
i;205
1,179
995
1,029
1,053
1,121
1,039
967
1,024
1,122
950
894
997
941

Rate per 1,000 live births

Puérpera
septice­ All other
mia

205
168
179
202
201
218
209
231
235
215
182
282
250
183
166
250
208
196

411
458
435
404
376
373
406
413
428
419
394
411
482
409
404
433
435
425

Total

5.9
5.8
5.6
5.4
5.1
5.1
5.0
4.8
4.9
4.6
4.3
5.3
5.6
4.7
4.7
5.0
4.7
4.5

Puérpera
septice­ All other
mia

3^9
42
39
3 fi
33
32

2.0
1.6
1.6
1.8
1.8
1.9
1.7
1.7
1.7
•1.6
1.3
2.1
1.9
1.5
1.4
1.8
1.5
1.4

3 1
3l2
30
2 C)
31
37
33
33
32
32
3.1

2. 2
2. 3
2.1
2. 2
2. 2
2.5
25
2.3
2.3
2.8
2.3
3.3
2.6
24

40
33
3. 2
3. 4
3. 5
3.6
3.4
3.2
3.6
3.8
3.3
3.9
3.5
3.3

A4
432
445
389
403
407
466
439
411
398
476
389
409
429
395

773
734
606
626
646
655
600
556
626
646
561
485
568
546

6.3
6.1
5.3
5.5
5.7
6.1
5.9
5.5
6.0
6.6
5.6
7.2
6.1
5.8

MATERNAL. MORTALITY

150

G e n er al T able 10.— Live births,* deaths, and death rates per 1,000 live births

from diseases caused by pregnancy and confinement in certain foreign countries
for specified years— Continued
Deaths from diseases caused by pregnancy and confinement
Rate per 1,000 live births

Number
Country and year

Live births
Total

Chile:
1910
_____________
1911
__ ___________
1912 ...................... ...........
1913 ____ ____ _________
1914
_______________
1915__...........A.................
1916
_______________
1917
1918
.............................
1919
............... .............
1920
_______________
1921
...........................
1922. ...................... i ........
1920
____ _ _ _ _______
1921 __________________
England and Wales:1
1900 _
____ __________
1901
1902
...........- ................ 1903
........................... 1904
______________
1905
______________
1906
. _______________
1907
_________
1908
_______________
1909
________ ____
1910
............... ..............
191ia _’ _______________
1912a ................................
1913a ..........................—
1914a __ ................... .
1915a .................................
1916a ......... .....................
1917a __.............................
1918a__ - ..........................
1919a
___________ ____
1920a __________________
1921a .............................
1911b
____________
1912b ....... ....................
1913b
_______________
1914b ....... ...... ..............
1915b
....... L................
1916b —■.........................
i917b ________________
1918b
....... ...................
1919b _________- ____ —
1920b
!•____ __________
1921b ..............................
1922b ___________ _____
Finland:

Puerperal
septice­ All other
mia

130,052
133,468
135, 373
140,525
136,550
136,597
144,193
149,161
145,871
144,980
146,725
147,795
147, 205

1,131
973
965
1,053
987
907
1,051
1,081
1,197
1,270
1,098
1,170
1,177

233
174
185
192
183
185
234
307
291
305
307
354
320

78,230
78,808

184
161

105
105

4,455
4,394
4,205
3,857
3,667
3,905
3,757
3,520
3,361
3,379
3,191
3,236
3,299
3,271
3,469
3,210
3,038
2,446
2,353
2,852
3,942
3, 145
3,413
3,473
3,492
3,667
3,408
3,239
2,598
2,509
3,028
4,144
3,322
2,971

1,941
2,005
1,908
1, 581
1,560
1,631
1,538
1, 381
1, 312
1,357
1, 219
1,267
1, 223
1,119
1,372
1, 217
1,089
888
854
1,167
1, 740
1,240
1,262
1, 216
1,108
1, 365
1,201
1,083
873
845
1,157
1,736
1,171
1,079

927,062
929,807
940, 509
948, 271
945, 389
929, 293
935,081
918,042
940, 383
914,472
896,962
881,138
872,737
881,890
879,096
814, 614
785,520
668, 346
662,661
692, 438
957,782
848,814
881,138
872,737
881,890 •
879,096
814,614
785,520
668,346
662,661
692,438
957, 782
848,814
780,124

.

Total

Puerperal
septice­ All other
mia

898
799
780
861
804
722
817
774
906
965
791
816
857

8.7
7.3
7.1
7.5
7.2
6.6
7.3
7.2
8.2
8.8
7.5
7.9
8.0

1.8
1.3
1.4
1.4
1.3
1.4
1.6
2.1
2.0
2.1
2.1
2.4
2.2

6.9
6.0
5.8
6.1
5.9
5.3
5.7
5.2
6.2
6.7
5.4
5. 5
5.8

79
56

2.4
2.0

1.3
Ì.3

1.0
0.7

48
47
45
41
3.9
4.2
4.0
3.8
3.6
3.7
3.6
3.7
3.8
3.7
3.9
3.9
3.9
3.7
3.6
4.1
4.1
3.7
3.9
4.0
4.0
42
A 42
4.1
3.9
3.8
4.4
43
3.9
3.8

2.1
2.2
2.0
1.7
1.7
1.8
1.6
1.5
1.4
1.5
1.4
1.4
1.4
1.3
1.6
1.5
1.4
1.3
1.3
1.7
1.8
1. 5
1.4
¡H 4
1.3
1. 6
1.5
1.4
1.3
1.3
1.7
1,8
l: 4
1.4

2,514
2,389
2,297
2,276
2,107
2,274
2,219
2,139
2,049
2,022
1,972
1,969
2,076
2,152
2,097
1,993
1,949
1,558
1,499
1,685
2,202
1,905
2,151
2,257
2,384
2,302
2,207
2,156
1,725
1,664
1,871
2,414
2,151
1,892

2.7
2.6
2.4
2.4
2.2
2.4
2.4
2.3
2.2
2.2
2.2
2. 2
2.4
2.4
2.4
2.4
2.5
2.3
2.3
2. 4
2.3
2.2
2.4
2.6
. 2.7
2.6
2.7
2.7
2.6
2.5
2.7
2.5
2. 5
2. 4

4.9
427
86,339
4.6
407
88,637
4.8
421
87,082
1QH9--------------------------4.2
1QAQ---------------85,120
45
408
IQfU ---------------90,253
4.3
374
ion*----------------------------87 841
4.0
368
91,401
1QOA ------------------------4.0
370
92 457
1907-----------------------------3.9
359
92 146
4.2
395
95 005
3.7
346
92,984
4.3
388
91, 238
3.7
342
92, 275
3.9
343
87,250
4.1
1914
............................................................
3.4
284 —- .......
83,306
1915 ................................ ,|
• i From 1911 through 1922: a—according to classification of cause of death used in England and Wales
prior to 1911; b—according to international classification of cause of death.
ioc? ------------------------------


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Federal Reserve Bank of St. Louis

APPENDIXES

151

G e n e r a l T able 10.— Live births, deaths, and death rates per 1,000 live births

from, diseases caused by pregnancy and confinement in certain foreign countries
for specified years— Continued
Deaths from diseases caused by pregnancy and confinement

Country and year

Number

Live births
Total

Finland—Continued.
1916 ___________ : .........
1917- _________
1918- ________ _________
1919 _____________
1920 .............................
France:
1906--............
1907-.........................
1908___________
1909. ______
1910_________
1911 _________
1912............... ...
1913 ..... ........
1914__________________
1915 ...............................
Germany:
1901. ...................
1902______
1903_______________
1904______________
1905 ................. ........
1906..-........................
1907 ......... ................
1908 ____________
1909 ____ _______
1910. __________________
1911................
1912............
1913.................... ........
| 1914___ t..................
i
1915 ......................
1916. ......................
1917 ...................
1918______
1919- _____ ________
Hungary:
1900- _____________
1901. ___________ _
1902............... —
1903 ........................
1904______________
1905-...____ ____ _______
1906- ....... .............. — .
1907 ................................
1908...... ................... .........
1909____________ _______
1910.
____________
1911______________
1912-.............................
1913-..................................
1914 .................................
1915 ...................... ......
Ireland:
1902................................
1903- ................. ...............
1904 .................................
1905 ..................................
1906--._________________
1907...... ...... ......................
1908 ........................ ..........
1909....................................
1910____________________
1911 .................................
1912.................................
1913...................................
1914...................................
1915...................................
1916 .................................
1917...................................|


https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis

Rate per 1,000 live births

Puerpera
sc ptiee- All other
mia

Total

Puerpera
septice­ All other
mia

79,653
81,046
79,494
63,896
84, 714

290
307
352
256
305

806,847
772; 681
792,178
769, 565
774, 390
742,435
750,379
746, 014
594,222
387,806

4,067
4,499
3,982
4,097
3,572
3,513
3, 756
3,428
3,410
2,575

1,873
2,117
1,855
1,900
1, 679
1,727
1,850
1,648
1, 624
1,278

2,194
2,382
2,127
2,197
1,893
1,786
1,906
1,780
1,786
1,297

5.0
5.8
5.0
5.3
4.6
4.7
5.0
4.6
5.7
6.6

2.3
2.7
2.3
2.5
2.2
2.3
2.5
2.2
2.7
3.3

2.7
3.1
2.7
2.9
2.4
2.4
2. 5
2.4
3.0
3.3

2,032, 313
2, 024, 735
1,983,078
2, 025,847
1,987,153 •
2,022,477
1,999,933
2, 015,052
1,978, 278
1,924, 778
1,870, 729
1,869,636
1,838, 748
1,818, 596
1, 382,546
1,008, 033
912,109
926,813
1,260, 500

6,668
6,663
6,843
7,152
6,802
6,316
6,326
6,576
6,595
6,243
6,584
6,510
6,314
6,537
5,493
4,504
4, 139
4,570
6,485

3,011
3,005
3, 294
3', 454
3,081
2,587
2,675
2,987
3,041
2,879
3,219
3,072
2,981
3,054
2,687
2, 277
2,091
2,454
3,603

3,657
3,658
3,549
3,698
3,721
3,729
3,651
3,589
3,554
3,364
3, 365
3,438
3, 333
3,483
2,806
2,227
2,048
2,116
2,882

3.3
3.3
3.5
3.5
3.4
3.1
3.2
3.3
3.3
3.2
3.5
3.5
3.4
3.6
4.0
4.5
4.5
4.9
5.1

1.5
1.7
1.7
1.6
1.3
1.3
1.5
1.5
1.5
1.7
1.6
1.6
1.7
1.9
2.3
2.3
2.6
2.9

1.8
1.8
1.8
1.8
1.9
1.8
1.8
1.8
1.8
1.7
1.8
1.8
1.8
1.9
2.0
2.2
2.2
2.3
2. 3

752, 718
731, 721
759, 739
725,239
740, 799
720, 532
733,953
740,867
755,888
776,395
742,899
732, 767
765,891
735,626
746,911
512,261

2,606
2,789
2, 665
• 2,562
2,678
2,694
2,490
2, 552
2,892
2,839
2,506
2,443
2,529
2,365
2,470
2,048

636
687
622
571
654
689
602
720
889
961
793
869
902
744
764
648

1,970
2,102
2,043
1,991
2,024
2,005
1,888
1,832
2,003
1,878
1, 713
1, 574
1,627
1,621
1,706
1,400

3.5
3.8
3.5
3.5
3.6
3.7
3.4
3.4
3.8
3.7
3.4
3.3
3.3
3.2
3.3
4.0

.8
.9
.8
.8
.9
1.0
.8
1.0
1.2
1.2
1.1
1.2
1.2
1.0
1.0
1.3

2.6
2.9
2. 7
2.7
2.7
2.8
2.6
2. 5
2.6
2.4
2.3
2.1
2.1
2.2
2.3
2.7

101,863
101,831
103, 811
102,832
103,536
101, 742
102,039
102, 759
101,963
101, 758
101,035
100,094
98,806
95,583
91,437
86,370

635
573
583
573
607
505
530
561
542
514
549
527
497
515
504
426

214
222
206
217
218
152
178
207
178
165
187
163
182
172
170
130

421
351
377
356
389
353
352
354
364
349
362
364
315
343
334
296

6.2
5.6
5.6
•5.6
5.9
5.0
5.2
5.5
5.3
5.1
5.4
5.3
5.0
5.4
5.5
4.9

3.6
3. 8
4.4
4. 0
3.6

2.1 ■
2.2
2.0
2.1
2.1
1.5
1.7
2.0
1.7
1.6
1.9
1.6
1.8
1.8
1.9
1.5

:

4.1
3.4
3.6
3.5
3.8
3.5
3.4
3.4
3.6
3.4
3.6
3.6
3.2
3.6
3.7
3.4

MATERNAL. MORTALITY

152

10.— Live births, deaths, and death rates per 1,000 live births
from diseases caused by pregnancy and confinement in certain foreign countries
for specified years— Continued

G eneral T able

Deaths from diseases caused by pregnancy and confinement

Country and year

Live births
Total

Ireland—Continued.
1918_____________ ______
1919, .................................
1920___________ ____ _
1921 ._............................
Italy:
1900____________________
1901_______________ ____
1902 __________________
1903___________ _______ _
1904 ___________________
1905_ __________________
1906- ____ _____________
1907- __________________
1908- __________________
1909--._________________
1910-,__________________
1911 _________________
1912.,................................
1913....................................
1914...................................
1915-................................
1916- __________________
1917____________________
1918___ _______ _________
Japan:
1900-______ ______ ______
1901____________________
1902 ___________ ____
1903-_____ ______ _____
1904-,............... - .............
1905- ................................
1906- .......... ....................
1907 ___________________
1908___________ ________
1909________________ _
1910- .......... ...............
1911 ______ ____________
1912..................................
1913. ................................
1914. ...............................
1915 ............ .............. .
1916 _________ _______ _
1917__ ____ ______ ______
1918___ ___________ ____
1919...... ...........................
1920. ........................... .
1921. _________________
1922. .......... ............... .
The Netherlands:
1900- ............ ...................
1901- ................................
1902 ...................... .........
1903 ............... ...... .........
1904 ............ ...................
1905. ............ ................. .
1906 .................... ..........
1907...................................
1908-....................... ' ___
1909 ...............................
1910......... .................... .
1911____________________
1912...................................
1913 ......................... ......
1914.......................... .
1915...................................
1916...................................
1917
..............................
1918....................... ...........
1919...................................
1920....................................


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Federal Reserve Bank of St. Louis

Number

Rate per 1,000 live births

Puerperal
septice­ All other
mia

Total

Puerperal
septice­ All other
mia

87,304
89,325
99,536
90,720

419
418
550
508

139
135
225
187

280
283
325
321

4.8
4.7
5.5
5.6

1.6
1.5
2.3
2.1

3.2
3.2
3.3
3.5

1,067,376
1,057,763
1,093,074
1,042,090
1,085,431
1,084,518
1,070,978
1,062,333
1,138,813
1,115,831
1,144,410
1,093,545
1,133,985
1,122,482
1,114,091
1,109,183
881,626
691,207
634, 389

3,034
2,767
2,807
2,771
2,981
3,198
2,791
3,074
3,315
3,127
2,786
2,612
2,743
2,811
2,696
2,477
2,351
2,041
2,330

1,033
994
1,037
1,112
1,082
977
1,021
1,147
1, 245
1,242
1, Oil
929
. 899
1,037
1,036
877
841
779
897

2,001
1,773
* 1,770
1,659
1,899
2, 221
1,770
1,927
2,070
1,885
1,775
1,683
1,844
1,774
1,660
1,600
1, 510
1, 262
1,433

2.8
2.6
2.6
2.7
2.7
2.9
2.6
2.9
2.9
2.8
2.4
2.4
2.4
2.5
2.4
2.2
2.7
3.0
3.7

1.0
.9
.9
1.1
1.0
.9
1.0
1.1
1.1
1.1
.9
.8
.8
.9
0.9
0.8
1.0
1.1
1.4

1.9
1.7
1.6
1.6
1.7
2.0
1.7
1.8
1.8
1.7
1.6
1.5
1.6
1.6
1.5
1.4
1.7
1.8
2.3

1,420,534
1,501, 591
1, 510,835
1,489,816
1, 440,371
1, 452, 770
1,394,295
1, 614,472
1, 662,815
1,693,850
1,712,857
1, 747,803
1,737, 674
1,757,441
1,808,402
1,799,326
1,804,822
1,812,413
1,791,992
1, 778, 685
2,025,564
1,990,876
1,969,314

6,200
6,671
6,556
6,071
5,742
6,185
6,237
6,728
7,091
6,399
6,228
6,192
5,770
5,900
6,418
6,452
6,337
6,368
6,812
5,910
7,158
7,181
6,565

1,679
1,885
1,983
2,028
1,810
1,878
1,915
2,294
2,570
2,575
2,556
2,512
2,357
2,425
2,762
2,657
2,468
2,503
2,558
2,148
* 2, 698
2,667
2,280

4,521
4,786
4,573
4,043
3,932
<307
4,322
4,434
4,521
3,824
3,672
3, 680
3,413
3,475
3,656
3,795
3,869
3,865
4,254
3,762
4,460
4,514
4,285

4.4
4.4
4.3
4.1
4.0
4.3
4.5
4.2
4.3
3.8
3.6
3.5
3.3
3.4
3.5
3.6
3.5
3.5
3.8
3.3
3.5
3.6
3.3

1.2
1.3
1.3
1.4
1.3
1.3
1.4
1.4
1.5
1.5
1.5
1.4
1.4
1.4
1.5
1.5
1.4
1.4
1.4
1.2
1.3
1.3
1.2

3.2
3.2
3.T)
2.7
2.7
3.0
3.1
2.7
2.7
2.3
2.1
2.1
2.0
2.0
2.0
2.1
2.1
2.1
2.4
2.1
2.2
2.3
2.2

144
140
131
120
121
119
138
129
122
111
113
129
111
103
104
132
164
137
169
202
162

314
280
276
313
299
295
290
274
308
265
306
269
295
261
271
291
280
301
329
349
305

2.8
2.5
2.4
2.5
2.4
2.4
2.5
2.3
2.5
2.2
2.5
2.4
2.4
2.1
2.1
2.5
2.6
2.5
3.0
3.4
2.4

.9
.8
.8
.7
.7
.7
.8
.8
.7
.7
.7
.8
.7
.6
.6
.8
1.0
.8
1.0
1.2
.8

1.9
1.7
1.6
1.8
1.7
1. /
1.7
1.6
1.8
1.6
1.8
1.6
1.7
1.5
1.5
1.7
1.6
1.7
2.0
2.1
1.6

162,611
168,380
168, 728
170,108
171,495
170,767
170,952
171, 506
171,861
• 170,766
168,894
166,527
170,269
173, 541
176,831
167,423
172, 572
173,112
167, 636
164,447
192,987

458
420
407
433
420
414
428
403
430
376
419
398
406
364
375
423
444
438
498
551
467 \

APPENDIXES

153

G e n er al T able 10.—-Live births, deaths, and death rates per 1,000 live births

from diseases caused by pregnancy and confinement in certain foreign countries
for specified years— Continued
Deaths from diseases caused by pregnancy and confinement

Country and year

Number

Live births
Total

The Netherlands—Contd.
1921................
1922.................
New Zealand:
1900....................
1901 ...........
1902.............
1903. ............ .
1904..........
1905.............
1906..............
1907..........
1908_______
1909..........
1910............
1911........
1912............
1913..........
1914..........
1915..........
1916 .......
1917...........
1918..........
1919. . . .
1920 ........
1921_____
1922 ___
Norway:
1900.............
1901............
1902..........
1903.............
1904.............
1905.............
1906.............
1907............
1908............
1909............
1910..........
1911.........
1912..........
1913..........
1914...,.......
1915...C ...
1916............
1917..........
1918..........
1919— .......
Scotland:
1900.............
1901...........
1902...............
1903...............
1904...............
1905___ ____
1906...............
1907............
1908______
1909____ _____
1910.................
1911...............
1912...............
1913.................
1914..................
1915:............
1916..................
. 1917.................
1918...............
1919.................
1920...............
1921...............
1922.....................


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Federal Reserve Bank of St. Louis

189, 546
181,886

443
454

19,546
20,491
20,655
21,829
22,766
23,682
24,252
25,094
25,940
26,524
25,984
26,354
27.508
27,935
28,338
27,850
28.509
28,239
25,860
24,483
29,921
28,567
29,006

75
90
110
128
106
100
94
116
119
135
117
11'4
100
100
118
131
167
169
134
124
194
145

66,229
66,719
65,916
64,901
63,586
62,057
61,553
60,769
61.151
62,579
61,147
61.151
61,937
61,665
62,223
58,540
61,108
63,915
63,326
59,013
131,401
132,192
132, 267
133,525
132,603
131,410
132,005
128,840
131,362
128,669
121,850
122,790
120,516
123,934
114,181
109,942
97,441
98,554
106,268
136,546
123,201
115,085

Rate per 1,000 live births

Puerpera 1
septice­ All othei
mia

132
132

91
là
29

29

Oja
111
109
106

90
60

o2

280

248
231
212

229
221

150
242
250

Total

Puerpera
septice­ All other
mia

322

2.3
2.5

0.7
.7

1.6
1.8

51
70
85
100
85
79
76
87
73
102
82
87
81
71
83
109
107
110
86
72
127
97
97

3.8
4.4
5.3
5.9
4.7
4.2
3.9
4.6
4. 6
5.1
4.5
4.3
3.6
3.6
4.2
4. 7
6.9
6.0
5. 2
6.1
6. 5
5.1
5.1

1.2
1.0
1.2
1.3
.9
.9
.7
1.2
1.8
1.2
1.3
1.0
.7
1.0
1.2
.8
2.1
2.1
1.9
2.1
2.2
1.7
1.8

2.6
3.4
4.1
4.6
3.7
3.3
3.1
3.5
2.8
3.8
3.2
3.3
2.9
2.5
2.9
3.9
3.8
3.9
3.3
2.9
4.2
3.4
3.3

73
118
98
92
93
74
76
85
106
88
102
95
99
135
103
110
107
136
126

2.8
3.3
3.1
3.2
3.1
2.6
2.5
2.8
3.0
3.0
2.7
3.1
3.0
2.6
3.3
2.7
2.8
3.0
3.0
3.5

1.7
1.5
1.7
1.7
1.7
1.2
1.3
1.5
1.6
1.3
1.3
1.4
1.5
1.0
1.1
.9
1.0
1.3
.8
1.3

1.1
1.8
1.5
1.4
1.5
1.4
1.2
1.3
1.4
1.7
1.4
1.7
1.5
1.6
2.2
1.8
1.8
1.7
2.1
2.1

342
347
375
418
374
470
454
458
445
487
489
526
482
548
517
477
441
409
575
511
598
536
531

4.3
4.7
5.2
5.3
4. 6
5.5
6.4
5. 3
5.1
5.4
5.7
5.7
5. 5
6.9
6.0
6.1
5.7
5.9
7.0
6.2
6.2
6.4
6.6

-

1.7
2.1
2.3
2.2
1.8
1.9
2.0
1.8
1.8
1.6
1.8
1.4
1.6
1.3
1.8
1.9
1.7
1.7
1.1
1.4
1.8
2.0
2.0 1

2.6
2.6
2.8
3.1
2.8
3.6
- 3.4
3.6
3.4
3.8
3.9
4.3
3.9
4.5
4.2
4.2
4.0
4.2
5.8
4.8
4.4
4.4
4.6

MATERNAL MORTALITY

154

G ener al T able 10.— Live births, deaths, and death rates per 1,000 live births

from diseases caused by pregnancy and confinement in certain foreign countries
for specified years-—Continued
Deaths from diseases caused by pregnancy and confinement

Country and year

Number

Rate per 1,000 live births

I ’uerperal
septice­ All other
mia

Total

Live births
Total

Spain:
1,811
3,557
627,848
1900
- - ............ - ...........
2,178
3,674
650,649
......... .............1901
2,116
3,494
666,687
1902
....... ..............■—
2,362
3,771
685,265
1903 ....... .......................
2,465
3,885
649,878
1004
............ ..........
2,715
4,115
670,651
1905
........................
2,469
3,860
650,385
IQOfi
2,549
3,930
646,374
1907
................. ............
2,316
3,725
657,701
1908
..............................
2,280
3,643
650,415
1909
.................... .
2,107
3,407
646,975
1910
____ ____ ___
2,024
3,294
628,443
1911
_____ _______
2,135
3,392
637,860
1912
____________
2,027
3,244
617,850
1913
..............................
1,953
3,211
608,207
1914
..............................
1,953
3,255
631,462
1915
....... ..................
1,825
3,085
599,011
1910
1,884
3,055
602,139
1917
................. .
2,535
3,896
612,637
1918
1,917
3,085
585,352
1919
.............................1,931
3,120
622,468
1920
...........- ____ _____
2,073
3,290
649,171
1921
.........................
Sweden:
152
315
139,370
1901
....................
146
306
137,364
1902
. ..........................
128
305
133,896
......................... .
1903
126
288
134,952
1904
..............................
169
333
135,409
1905
.............................
124
325
136,620
1906
____________
110
318
136,793
1907
...........- ..................
107
295
138,874
1908
___________ _____
' 113
349
139,505
_________ - ...........
1909
119
345
135,625
1910
.................... .........
136
354
132,977
1911 ....... .........................
125
309
132,868
1912 .................................
135
296
130,200
1913 ................................
141
337
129,458
................. .........
1914
153
357
122,997
1915...................................
148
324
121,679
1916 ............................. .
136
297
120,855
1917 ................................
149
304
117,955
1918
..... ..................
Switzerland:
193
523
94,316
1900
____ _________
250
586
97,028
1901 ...............................
196
500
96,481
1902 ...............................
237
554
93,824
1903
. ................. ......
257
590
94,867
1904
................. ..........
253
551
94,653
1905
_______________
191
495
95,595
1906 ..............................
261
553
94,508
1907
......... .......... ........
227
554
96,245
1908 ................—...........
238
544
94,112
1909
_______________
182
447
93,514
1910
...........................
245
501
91,320
1911 ...............................
218
484
92,196
1912 ...............................
197
440
89,757
1913
.... ......... ..........
188
467
87,330
1914 ..............................
174
412
75,545
1915
.....- ..............
179
73,660
1916
.....................
204
72,065
1917.................................
209
1918
---------------- 196
72,125
1919
................................................................................
235
81,19C
1920
____ _______
Union of South Africa:
85
189
42,014
1912 ...............................
87
190
42,138
1913 ...............................
80
169
40,886
1914 ...............................
63
161
40,471
1915
_ : ......................
61
144
41,196
1916..................................
67
177
40, 722
1917
______________
74
172
41,582
1918
...........................
61
154
39,72<
1919..................................


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1,746
1,496
1,378
1,409
1,420
1,400
1,391
1,381
1,409
1,363
1,300
1,270
1,257
1,217
1,258
1,302
1,260
1,171
1,361
1,168
■1,189
1,217

’uerperal
septice­ All other
mia

5.7
5.6
5.2
5.5
6.0
6.1
5.9
6.1
5.7
6. 6
6.3
5. 2
6.3
5. 3
5.3
5. 2
6.2
5.1
6.4
5.3
5.0
5.1

2.9
3.3
3.2
3.4
3.8
4.0
3.8
3.9
3.5
3.5
3.3
3.2
3.3
3.3
3.2
3.1
3.0
3.1
4.1
3.3
3.1
3.2

2.8
2.3
2.1
2.1
2.2
2.1
2.1
2.1
2.1
2.1
2.0
2.0
2.0
2.0
2.1
2.1
2.1
1.9
2.2
2.0
1.9
1.9

163
160
177
162
164
201
208
188
236
226
218
184
161
196
204
176
161
155

2.3
2.2
2.3
2.1
2. 5
2.4
2.3
2.1
2. 5
2.5
2.7
2.3
2. 3
2.6
2.9
2. 7
2. 6
2. 6

1.1
1. 1
1.0
.9
1. 2
.9
.8
.8
.8
.9
1.0
.9
1.0
1.1
1.2
1.2
1.1
1.3

1.2
1.2
1.3
1.2
1.2
1.5
1.5
1.4
1.7
1.7
1.6
1.4
1.2
1.5
1.7
1.4
1.3
1.3

330
336
304
317
333
298
304
292
327
306
265
256
266
243
279
238

5.5
6.0
5.2
5.9
6.2
6.8
5. 2
5.9
5.8
5.8
4.8
5. 6
5. 2
4.9
5.3
5.5

2.0
2.6
2.0
2.5
2.7
2.7
2.0
2.8
2.4
2.5
1.9
2.7
2.4
2.2
2.2
2.3
2.4
2.8
2.9
2.7
2.9

3.5
3.5
3.2
3.4
3.5
3.1
3.2
3.1
3.4
3.3
2.8
2.8
2.9
2.7
3.2
3.2

104
103
89
98
83
110
98
103

4.5
4. 6
4.1
4.0
3.5
4.3
4.1
3.9

2.0
2.1
2.0
1.6
1.5
1.6
1.8
1.3

2.5
2.2

2.6

APPENDIXES

155

G en er al T able 10.— Live births, deaths, and death rates per 1,000 live births

from diseases caused by pregnancy and confinement in certain foreign countries
for specified years— Continued
Deaths from diseases caused by pregnancy and confinement

Country and year

Number

Live births
Total

Union of South Africa—Con.
1920................
1921________
Uruguay:
1900................
1901__ _______
1902................
1903_______ _
1904................
1905_________
1906.... ...........
1907..................
1908_______
1909.........
1910........... .
1911_________
1912._________
1913_________
1914......................
1915________
1916_________
1917..............
1918_______ _
1919_________
1920................
1921__ . _____

Rate per 1,000 live births

Puerperal
septice­ All other
mia

Total

Puerpera
septice­ All other
mia

43,445
43,302

178
178

84
69

94
109

4.1
4.1

1.9
1.6

%2
2.5

30,589
31,703
31,526
32,600
26,984
33,709
32,578
33,657
35, 520
35,663
35,927
37,530
39,171
40,315
38,571
38,046
36,983
36,752
38,914
39,307
39,335
39,611

62
71
77
86
65
75
71
86
72
83
95
69
104
90
98
85
106
116
116
91
133
129

30
28
35
39
37
48
40
56
51
45
58
41
57
55
54
49
69
60
69
59
81
76

32
43
42
47
28
27
31
30
21
38
37
28
47
35
44
36
37
56
47
32
52
53

2.0
2.2
2.4
2.6
2.4
2.2
2.2
2.6
2.0
2.3
2.6
1.8
2.7
2.2
2.5
2.2
2.9
3.2
3.0
2.3
3.4
3.3

1.0
.9
1.1
1.2
1.4
1.4
1. 2
1.7
1.4
1.3
1. 6
1.1
1.5
1.4
1.4
1.3
1.9
1.6
1.8
1.5
2.1
1.9

1*0
14
1.3
T 4
1. Q
.8
1.0
.9
1.1
1.0
7
L-2
.9
1.1
.9
1O
1.5
1.2
.8
1.3
1.3

G e n er al T able 11.— Registered, and estimated births and reported and adjusted

puerperal deaths; United States birth-registration area, 1919
Births

Puerperal deaths

Registered Estimated

Registered Adjusted *

States

Birth-registration area.
California_________
Connecticut..............
District of ColumbiaIndiana___________
Kansas_______ _____
Kentucky_________
Maine____________
Maryland_________
Massachusetts. . . ___
Michigan__________
Minnesota_________
New Hampshire....... .
New York.................
North Carolina_____
Ohio____ _________
Oregon............. ..........
Pennsylvania_______
South Carolina______
Utah______________
Vermont___________
Virginia.................. .
Washington________
Wisconsin........ ..........

1,373,438

1,491,199

10,127

11,559

56,528
33,912
8,180
59,286
36,373
57,737
15,496
33,972
87, 709
83,910
51,942
8,778
226,108
73,854
113,054
13,540
207,685
44,624
13,040
7,032
60,785
25,112
54,781

62,687
34,984
7,873
63,900
41,547
67,292
17,058
35, 710
87.338
89,845
56,135
9,237
225,469
85,310
129,660
•15,518
228,988
55,306
13,864
7,604
66,356
28.338
61,180

451

505
236
78
559
336
409
149
318
699
726
392
78
1,581
889
934
153
1,586
647

211

70
499
300
365
133
284
619
648
350
70
1,412
684
834
137
1,416
498
109
56
502
216
263

122

63
562
242
295

1For method used in estimating births see pp. 18-19.
„
a<?ded f° r each State except Massachusetts where 13 per cent was added, and North Carolina
and South Carolina where 30 per cent was added in each State.

60564°— 26-

-11


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IN D E X
Abnormal presentation, 2i.

Abortion:
Classification—
In use by Census Bureau, 69,103.
When returned as joint cause of death, 109.
Criminal, exclusion from puerperal causes of
death, 3, 8 (footnote 2), 64.
Deaths following (exclusive of criminal abortion), 22, 25, 64, 69-70, 98, 103, 109.
Self-induced—
Classification, when followed by puerperal
septicemia, 25, 64.
Classification, when no infection is re­
ported, 69.

Deaths following, inadequate statistics,

70, 98.
Syphilis as cause, 69.
See also Accidents of pregnancy.

Accidents of labor (abnormal labor, operations,
etc.):
Classification—
In use by Census Bureau, 104.
When returned as joint cause of death, 110-

Deaths^from^ (U. S. death-registration area,
Preventability, 70.
See also Obstetrical operations; Pathological
causes, primary.
Accidents of pregnancy:
Classification—
In use by Census Bureau, 69,103.
When returned as joint cause of death, 110.
Deaths from, 22.
Preventability, 69.
See also Pathological causes, primary, accidents
of pregnancy.
Accidents and external causes, classification:
England, 127.
International List, 109-111.
Adair, Fred L., M. D.:
Preventability of puerperal mortality, 69 (foot­
note 11), 71.
Age of mother, maternal mortality ratesNew South Wales (1893-1898), 34.
U. S. birth-registration area (1921), 33.
United States and certain foreign countries—
. significance of differences, 59.
Albuminuria, puerperal. See Puerperal albumi­

nuria.
Anemia, chlorosis, deaths from:

U. S. death-registration area (1917), 23.
See also Pathological causes, contributory (non-

puerperal).
Appendicitis:
Deaths from—
Erroneous certification and method of
correcting, 14.
_ V'
death-registration area (1917), 23.
See also Pathological causes, contributory (nonAsepsis:

puerperal).

Puerperal^septicemia prevention, 24, 64, 65, 66,
See also Puerperal septicemia.
Attendant at birth:
Aseptic requirements of, as preventive of puer­
peral septicemia, 24, 65, 66, 98-99.
B y color and nationality of mother, 40, 41, 87 91
Births in certain States, 88.
’
Births in eight cities (1911-1915), 41, 42.
Births in Newark, N. J. (1921), 41
B y country, 148.
By populationForeign countries, 148.
United States, 79,148.

Attendant at birth—Continued.

. By States, 87, 88.
Statistics, inadequacy, 98.
Australian Committee on maternal mortality, 64.
65,70,71.
*

Birth registration:
Colored groups, 18-19. 20.

Completeness—

B y countries, 130-131.
B y States, 19, 112-113.
•n. „u .- ,s - birth-registration area, 16-20.
Definition “ registered live births” in certain
foreign countries, 131.
Enforcement* 16.
Importance, 130.
Laws, 17, 130-131.
Omissions^und methods of correcting, 16-20,

Puerperal mortality rates in relation to, 16.
Responsibility, with whom placed, 16
Urban and rural districts, 20.
Birth-registration area, United States:
Puerperal deaths occurring in (1921), 6.
Puerpera1mortality rates limited to, 6, 16.
Stillbirths (1918 and 1921), 1-2, 2 (footnote 3).
See also Stillbirths.
Breast, puerperal diseases. See Puerperal diseases
of the breast.
Bright’s disease (chronic nephritis):
Deaths from—

'

Corrections for erroneous certification—
Foreign countries, 59.
U. S. death-registration area (1920).
13, 14, 15, 58.
’
U. S. death-registration area (1917), 23.
See also Pathological causes, contributory (non-

puerperal).

Bronchopneumonia, 23.
See also Pathological causes, contributory (ncn-

puerperal).

Causes of death. See Nonpuerperal causes; Pathological causes; Puerperal causes.
Centers, child-health:
Definition, 96.

Educational value, 95.
Governmental provision for, 92, 93.
Standard adopted by Washington and regional
conferences on child welfare (1919), 82, 83.
Cerebral hemorrhage, deaths from (U. S. deathregistration area, 1917), 23.
See also Pathological causes, contributory (non­

puerperal).
Certification of causes of death:

Accuracy—
Foreign countries, 58-59, 62, 119-122.
Bearing upon accuracy of number of
puerperal deaths, 58, 59,62.

Methods used in correcting unsatisfac­
tory returns, 121-122.

United States, 11-16.
Bearing upon accuracy of number of
puerperal deaths, 9, 10, 13, 45, 52, 55,
58.
Method used by Census Bureau in correcting unsatisfactory returns, 11-16,
Proportion of deaths certified by physicians—
Foreign countries, 58 (footnote 2), 120
States (U. S.), selected, 9-10.

Requirement that physicians certify, 9, 120.
Cesarean section:

Classification—
In use by Census Bureau, 104.
When returned as joint cause of death, 110-

157


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158

INDEX

Death registration area, U. S.:
Cesarean section—Continued.
Dates of admission of States, 8.
Frequency, 28, 29.
____
Deaths due to nonpuerperal contributory
Maternal mortality, 22, 25, 28, 30, 31, 72.
causes (1917), 23.
/ '¿ j.
See also Obstetrical operations.
See also Pathological causes, contributory ,
Chlorosis anemia. See Anemia, chlorosis.
(nonpuerperal).
.
Classification of causes of death:
Deaths due to puerperal causes (1921), 6, 22.
Joint causes, rules for classification, 3-4, oo,
Decrease in puerperal mortality. See Trend, puer­
107-111, 122-130.
peral mortality.
Non puerperal causes—
Definitions:
..... ,
Preference over puerperal causes wnen
All other puerperal causes, comparability in
joint causes are returned, 4, 109-111.
United
States
and
certain
foreign
coun­
See also Pathological causes, contributory
tries, 58,118.
(non puerperal).
Center, child-health, 96.
Puerperal causes—
,
Nonpuerperal causes, in the United states, a.
Preference over nonpuerperal causes wnen
Puerperal causes—
,
.
joint causes are returned, 4.
Comparability in United. States and certain
Rules in use by Census Bureau, 3, 69,103foreign countries, 3, 58,118.
111.
In United States, 3,106 (Note).
Clinics:
.
. . ,
„„
Puerperal septicemia, comparability m United
Governmental provision for, 92, 93.
States and certain foreign countries, 58,
Prenatal care, 41, 83-86.
118.
l t .
Coghlan, T. A.:
. __V *
,
Registered live births (in certain foreign coun
Childbirth in New South Wales, 34,35.
tries). 131.
.
Stillbirth (in United States and foreign coun­
Colored race:
Maternal mortality—
tries). 4,114-117.
■
Dentistry, clinics for treatment during pregnancy,
Cause of death—
In certain States, 37, 38.
96.
In urban and rural areas, 36-37.
Minimum standards adopted by Washington
and regional conferences on child welfare
Midwifery in relation to, 38
Prevalence of certain causes, 27, 36, 37,
(1919), 83.
Difficult labor. See Labor, difficult.
.
.
38.
Diseases of the breast, puerperal. See Puerperal
Rates, 6, 37, 38.
Midwifery, prevalence, 76, 87, 88.
diseases of the breast.
Prenatal care, extent (Balt., 1915), 41, 83.
Dystocia. See Labor, difficult.
Registration of births, 18-19, 20.
Earnings of father:
Complications of pregnancy or confinement:
Confinement care, extent, 36, 91.
Abnormal presentation, 27.
Maternal mortality, 36.
Contracted pelvis, 26-27, 38, 59.
Postnatal care, duration, 91-92.
Eclampsia, 28, 72.
Prenatal care, extent, 36, 83.
Placenta praevia, 27-28.
Eclampsia:
Other. 26 (footnote 4).
Frequency, 28, 70.
Confinement care, 86-92.
Prevention, 72.
.
,
By attendant at birth, 86-91.
See also Puerperal albuminuria and convul­
and nationality and color, 40, 41,87,91.
sions.
Biuhs in certain States, 87, 88.
Ectopic or extra-uterine gestation.
Biiths in eight cities (1911-1915), 41,42.
Classification, 22, 25, 69.
. , ..
Births in Newark, N. J. (1921), 41.
When returned as jomt cause of death, 109.
By earnings of father (Balt., 1915), 36, 91.
See also Accidents of pregnancy.
Differences in United States and foreign coun­
Education:
tries, and their significance, 61.
Mothers—
.» .
,
Duration of care, 90-91.
Importance of competent medical supervi­
Facilities, 82.
sion during pregnancy, 64,76-71,74,92,95,
Infant mortality as influenced by, 1.
In maternal and infant hygiene, 70-71, 82.
Maternal mortality as influenced by, 1, 44, 6495, 96, 97.
65, 70.
Public, 70 (footnote 16), 83, 95-97.
Stillbirths in relation to, 1.
. ,
Ehlers, Philipp, M. D.: Study of errors in certifica­
Visits, number received from physicians or
tion of puerperal deaths in Prussia and
midwives, 90.
„
A
„ .
Berlin, 13 (footnote 11), 122.
See also Maternity care; Prenatal care; Post­
Embolus:
natal care.
,
Classification—
Confinements, as base for measuring puerperal
In use by Census Bureau, 105.
mortality, 4-5, 20.
When returned as jomt cause of death, ill.
Contracted pelvis, prevalence, 26-27, 38, 59.
Death from, 69.
.
See also Pathological causes, primary, puerperal
Contributory causes of puerperal mortality. See
phlegmasia, etc.,
under Pathological causes.
Endocarditis (acute), 23.
.. .
,
Control of maternal mortality. See Preventability;
See also Pathological causes, contributory (non­
i , evention.
puerperal).
Convulsions:
. .
.
Errors in maternal mortality rates:
Erroneous certification and method of correct­
C&US6S 20«
ing,. 10, 58.
Faulty certification of causes of death, 7,
Puerperal—
9-16.
Classification in use by Census Bureau, 106.
Incomplete registration of deaths, 7-9, 118Mortality from, 3, 69.,
119
Tiend in United States, 55.
Statistical errors, 7,16.
See also Pathological causes, primary.
Methods of Census Bureau in correcting, 11-21.
Craniotomy:
=
•
Examinations:
••
• .
..
Maternal mortality, 31, 72.
Midwives, requirement for license to practice,
See also Obstetrical operations.
76.
.
x.
L
Criminal abortion, exclusion from puerperal causes
Mothers (physical examination)—
of death, 3, 8 (footnote 2), 64.
During pregnancy, 70, 82, 84.
Crowder, Mrs. Grace Meigs, V, 11 (footnote 8), 70.
Following childbirth, 83, 90-91.
See also Prenatal care; Postnatal care.
Death rate. See Mortality, puerperal (rates).
Physicians, requirement for license to practice,
Death registration:
75-76.
,
v,
Completeness—
External causes and accidents, classification:
Foieign countries, 118.
England,
127.
United States, 6, 7,118.
International List, 109-111.
Laws, date of enactment, by State, 8.


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INDEX
Extraction:
Frequency, 28, 29.
Maternal mortality, 31, 72.
See also Obstetrical operations,
y Extra-uterine gestation. See Ectopic or extrauterine gestation.
Foreign born:
Birth registration, 17.
Midwifery, prevalence, 41, 87, 91.
Mortality, 38-40.
Foster homes, inspection, governmental provision
for (England), 94.
Full-term births (live and still):
Bisk as compared with premature births
(Baltimore, 1915), 25-26.
Governmental responsibility for adequate protec­
tion of maternity, 92-97.
Educational work, 95-97.
Facilities, 92-93.
Subsidies, 93-95.
Health units, county, health conferences held by, 96.
See also Centers, child-health: Clinics.
“ Healthmobile,” 96.
Heart affections (organic):
Deaths from, in U. S. death-registration area
(1917), 23.
See also Pathological causes, contributory
(nonpuerperal).
Hemorrhage:
Cerebral, deaths from (U. S. death-registration
area, 1917), 23.
See also Pathological causes, contributory
(nonpuerperal).
Puerperal. See Puerperal hemorrhage.
Hospital care:
Factor in reducing mortality rates, 44, 64-65,87.
Urban and rural areas, 44, 86.
Hospitals:
Births—
Number in certain cities (1913-1922), 86, 87.
Statistics, inadequacy of, 98.
Governmental provision for, 92, 93, 94.
Licensing, 74, 77
M aternityGovernmental provision for, 93, 94.
Legislation re regulation, 77.
Number in United States, in 1924, 82.
Standards adopted concerning, 83.
Number in United States in 1924, 82.
Number of births in certain cities (1913-1922),
86, 87.
Standards adopted concerning, 83.
Supervision over—
Factor in preventing puerperal mortality,
74.
Factor in preventing puerperal septicemia,
65, 69.
Legislation, 74, 77.
Income and puerperal mortality. See Earnings of
father.
Infection following childbirth. See Puerperal
septicemia.
Influenza:
Death from—
Classification in United States and foreign
oountries, 130.
U. S. death-registration area (1917), 23.
See also Pathological causes, contributory
(nonpuerperal).
Insanity, puerperal. See Puerperal insanity.
Inspection, hospitals, 74, 77.
Instruction. See Education.
Instrumental delivery:
Classification in use by Census Bureau, 104
Frequency, 28, 29.
Maternal mortality, 22, 30, 31, 72.
See also Obstetrical operations.
Interdepartmental Social Hygiene Board, regula­
tions adopted by, 77-78.
International List of Causes of Death:
Classification of puerperal causes, 22, 103-107.
Joint causes of death (list including puerperal
and nonpuerperal causes with numbers
for use in classifying joint causes, 107-111.
Rules for classifying, 3-4, 58, 107, 122-130
Countries using, 118,122-129.


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159

Interval from childbirth to death of mothers who
died from causes connected with child­
birth (Saxony, 1901-1904), 31-32.
Intestinal obstruction, deaths from (U. S. deathregistration area, 1917), 23.
See also Pathological causes, contributory
(nonpuerperal).
Joint causes of death:
International list (puerperal and nonpuerperal
list for use in classifying joint clauses),
107-111.
Classification rules, 3-4, 58, 107, 122-130.
See also International List of Causes of Death.
Labor, difficult:
Death from, classification, 3.
See also Accidents of labor.
Laws and regulations:
Births, registration, 17,130-131.
Deaths, registration, 7-8.
Hospitals—
Licensing and inspecting, 74, 77.
Maternity, regulation, 74, 77.
Midwives, licensing and regulation—
Foreign countries, 69, 98-99, 136-139.
United States, 69, 76, 80, 132-135.
Physicians—
Certification requirement, 9,120,121.
Licensing, 69, 75-76, 78-79.
Puerperal septicemia, reportability, 75, 78.
Social hygiene, 75, 77-78.
Stillbirths, registration and definition—
Foreign countries, 4, 117,131.
United States, 4,114-116.
Letters to physicians to correct causes of death:
England and Wales, 121.
Germany (Berlin), 122.
United States, 11-12,121.
Licensing See Hospitals; Midwives; Physicians.
Maland, C. O., M. D.:
Preventability of puerperal mortality, 69 (foot­
note 11), 71.
Mania, puerperal. See Puerperal insanity.
Maternal mortality. See Mortality, puerperal.
Maternity care:
Confinement, 1, 36, 40, 41, 42, 44, 64-65. 70
86-92.
’
'
Differences in United States and foreign coun­
tries, and their significance, 61.
Duration, 90-91.
Postnatal care, 1, 74, 82, 83, 90-92.
Prenatal care, 1, 36, 40-41, 44, 61, 70-71, 72-73.
82, 83-86, 92, 95, 96.
Provisions, 78-92.
Facilities, 82.
Inadequacy, 82-92.
Confinement and postnatal care, 86-92.
Prenatal care, 83-86.
Personnel, 78-81.
Standards adopted by Washington and re­
gional conferences on child welfare (1919).
82-83.
See also Prenatal care; Confinement care;
Postnatal care.
Maternity homes:
Governmental provision for, 92, 94.
Number giving prenatal, confinement, and
postnatal care, 82.
Maternity hospitals. See Hospitals, mater­
nity.
Meigs, Grace L., M. D, See Crowder, Mrs.
Grace Meigs.
Mendenhall, Dorothy Reed, M. D.:
Accuracy of reporting of puerperal deaths in
Wisconsin, 16.
Mid wives:
Births (proportion) attended—
Foreign countries, 148.
United States, 81, 87-90, 98.
Examination requirement, 76.
Governmental provision for education, 92.
Laws and regulations—
Foreign countries, 69, 98-99,136-139.
England and Wales, 67.
Prussia, 98-99.
United States, 69, 76, 80,132-135.
Licensing and regulation—
Foreign countries, 69, 98-99,136-139.
United States, 69, 76, 80, 132-135.

160

IN D E X

Midwives—Continued.
■■
;
Number engaged in practice, by States (1923;,
80-81, 98.
Prevalence—
Colored group, 76, 87, 88.
Italian group, 41, 42, 91.
Polish group, 42, 91.
Puerperal mortality in relation to—
Colored group, 38.
England and Wales, 67.
Inadequate data in United States, 40 (foot­
note 29).
Standards concerning, 83, 89.
Supervision—
,
Factor in preventing puerperal mortality,
Factor in preventing puerperal septicemia,
Visits to mothers, number during confinement
period, 90.
Milk, reduced price for mothers and infants, provi­
sion for (England), 94.
Miscarriage:
Classification, 69.
Maternal mortality, 25.
See also Accidents of pregnancy.
Morbidity, puerperal, 1-2.
Puerperal septicemia, 66, 78.
See also Complications of pregnancy or confine­
ment; Obstetrical operations.
Mortality, infant:
.
Maternal morbidity as affecting, 1, 2,33.
Maternal mortality as affecting, 1, 2.
Mortality, nonpuerperal:
Classification preference of nonpuerperal causes
when returned jointly with puerperal
causes, 4,109-111.
See also Pathological causes, contributory (non­
puerperal).
Mortality, puerperal:
Causes, puerperal—
Other than puerperal septicemia—
By age of mother, 33,34.
By color and nationality, 36-40.
By urban and rural area, 37, 43, 44. '■
Comparison between rates in United
States and foreign countries, 57-63,
118-131.
T. j
Definition—comparability m Umted
States and foreign countries, 58, 118.
Prevenfability, 69-78.
Trend—
j „„
Foreign countnes, 63,71, 72.
United States, 45-56, 71-73.
Puerperal septicemia. See Puerperal septi­
cemia.
_
,
See also Pathological causes; Puerperal
causes of death.
Certification of causes—
Accuracy—
Foreign countries, 58-59, 62, 119-122.
United States, 9,10,11-16,52,55,58,121.
Proportion of deaths ' certified by physi­
cians—
Foreign countries, 58, (footnote 2), 120.
States (U. S.), selected, 9-10.
Requirement of physician or other attend­
ant, 9, 120.
Comparability of statistics in United States
and certain foreign countries, 58-59, US131.
Definition, 3, 58, 106 (Note), 118.
Factors, 24-44.
Age of mother, 33-34, 59.
Complications of pregnancy or confine­
ment, 26-28.
See also Abnormal presentation; Con­
tracted pelvis; Eclampsia; Placenta
praevia.
Earnings of father, 36.
See also Earnings of father.
Maternity care, 1, 36, 40 (footnote 29), 61,64.
See also Maternity care.
Midwifery, 38, 40 (footnote 29), 67.
See also Midwives.
Nationality and color of mother, 36-42, 6061„ ,
See also Nationality and color.


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Mortality, puerperal—Continued.
Factors—Continued.
Obstetrical operations, 28-31.
See also Obstetrical operations.
Order of birth, 34-35.
See also Order of birth.
Interval from childbirth to death of mother,
31-32.
Single or plural birth, 32-33.
Stage of pregnancy or period of gestation,
24-26.
Stillbirths, 26.
See also Stillbirths.
Urban and rural districts, 42-44.
See also Urban and rural areas.
Inadequacy of statistics, 98.
Infant mortality as affected by, 1, 2.
Preventability, 1, 24, 64-73, 98.
Prevention, 1, 2, 24, 74-97.
Comparability in United States and certain
foreign countries, 58-59,118-131.
Comparison in United States and certain
foreign countries, 57-63.
Rates (certain foreign countries.)
B y order of birth (New South Wales, 18931898), 35.
Trend, 61-63, 66-69.
Certification accuracy as affecting, 58,
59, 61-62.
Rates (U. S.).
By color and nationality, 6, 37, 38,
B y earnings of father, within three months
after mother’s confinement, 36.
By order of birth (Balt., 1915), 34—35.
Error, margin of, 7-21.
Certification of causes of death, 7,9-16.
Registration of deaths, 7-9,118-119.
Statistical errors, 7,16.
Method of calculation, 5, 20.
Trend, 45-56, 68.
Certification accuracy as affecting, 9,
10, 13, 45, 52, 55, 58.
Urban and rural areas, 6, 9, 24, 42-44.
, Colored race, 36-37.
Rates (U. S. and certain foreign countries),
57-63.
Comparability of statistics, 58-59,118-131.
Differences in prevalence of causal factors,
59- 61.
Age of mother, 59-60.
Maternity care, 61.
Racial factors, 60-61.
Multiparae:
Placenta praevia, frequency, 27.
See also Order of birth.
Murder and other external causes, classification:
England, 127.
International List, 109-111.
Nationality and color:
Attendant at birth, 40, 41, 87, 91.
Births in certain States, 88.
Births in eight cities (1911-1915), 41, 42
Births in Newark, N. I. (1921), 41.
Birth registration, 17,18-19, 20.
Maternal mortality—
By cause of death, 36-40.
Racial factors, significance of, differences in
United States and foreign countries,
60- 61.
Rates (U. S.), 6-7, 36-40.
Postnatal care, duration, 91, 92.
Prenatal care, extent (Balt., 1915), 40-41, 83-84.
Negroes. See Colored race.
Nephritis, deaths from:
Erroneous certification and method of correct­
ing, 13,14, 15, 58-59.
See also Bright’s disease.
Nonpuerperal causes of death. See Mortality, non­
puerperal.
Nonresident mothers:
Births to, corrections for measuring puerperal
mortality, 43-44.
Deaths of, corrections for measuring puerperal
mortality, 43-44.

161

IN D E X
Nurses:
Governmental provision for education, 92.
“ Home visits” by public-health nurse, 82, 95.
Number of and proportion to population, 80.
Supervision of—
Factor in preventing puerperal mortality,
*> -v
74.
Factor in preventing puerperal septicemia,
65.
Obstetrical operations (principal ones discussed):
Cesarean section, 22, 28, 30, 31, 72, 104, 110.
Craniotomy, 31, 72.
Extraction, 28, 29, 31, 72.
Frequency, 28-30, 32, 98.
Instrumental delivery, 22, 28, 30, 31, 72, 104.
Mortality, 30-31, 71-72, 98.
Single or plural births, relative risk to mother,
32-33.
Surgical operations, 22, 28, 30, 31, 72,104. '
Version, 28, 29, 31, 72.
Obstetrics, regulation of practice, 74, 75-76.
Licensing of physicians, 69, 75-76, 78-79.
Licensing and regulation of midwives, 69, 76,
80, 98-99, 132-139.
Operations, obstetrical. See Obstetrical opera­
tions.
Order of birth:
Maternal mortality rates by, 34-35.
Placenta praevia frequency by, 27.
See also Primiparae; Multiparae.
Organic diseases of the heart:
Deaths from, in U. S. death-registration area
(1917), 23.
See also Pathological causes, contributory
(nonpuerperal).
Pathological causes of puerperal mortality:
Classification in use by Census Bureau, 3, 69,
103-111.
Contributory (nonpuerperal)—
Anemia, chlorosis, 23.
Appendicitis, 14, 23.
Bright’s disease (chronic nephritis), 13, 14,
15, 23.
Cerebral hemorrhage, 23.
Endocarditis (acute), 23.
Influenza, 23,130.
Intestinal obstruction, 23.
Pneumonia, 23.
Pulmonary congestion, 23.
Salpingitis and other diseases of female
genital organs, 15, 23.
Contributory (puerperal).
Same as primary causes listed below.
Primary—
Accidents of labor—
Cesarean section, 22, 25, 28, 29, 30, 31,
72, 104, 110.
Other surgical operations and instru­
mental delivery, 22, 28, 30, 31, 72, 104,
110.
Others under this title, 3, 22, 69, 71, 7071, 104, 110-111.
Accidents of pregnancy, 3,22,23,69,103,110
Abortion (excluding criminal), 22, 25,
64, 69-70, 98, 103, 109.
Ectopic gestation, 22, 25, 69, 109.
Others under this title, 22, 69,110.
Following childbirth (not otherwise de­
fined), 22, 69.
Puerperal albuminuria and convulsions, 3,
10, 22, 55, 58, 59, 69, 71, 72, 106, 111.
Puerperal diseases of the breast, 69,106, 111.
Puerperal hemorrhage, 3, 22, 69, 70, 71, 104,
110.

Puerperal phlegmasia alba dolens, embolus,
sudden death, 69, 105, 111.
Puerperal septicemia, 1, 3, 10-16, 24, 25,
36-40, 42-44, 45-62, 64-70, 71, 74, 75, 78, 9899, 103, 105, 111, 118.122.
See also Puerperal causes of death.
Peritonitis, mortality:
Erroneous certification made and method of
correcting, 13, 14, 15, 58, 59.
Trend in United States (1900-1920), 55.
Phlegmasia alba dolens, puerperal. See Puerperal
phlegmasia alba dolens.


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Physicians:
Births, proportion attended, 86, 87, 88-89, 98,
148.
Certification of cause of death—
Proportion of deaths certified by physi­
cian—
Foreign countries, 58 (footnote 2), 120.
States (U. S3 selected, 9-10.
Requirement of certification, 9,120.
Examination requirement, 75-76.
Governmental provision for education, 92.
Licensing requirement, 69, 75-76, 79.
Proportion to population—
Foreign countries, 148.
United States, 78-80.
Supervision over—
Factor in preventing puerperal mortality,
74.
Factor in preventing puerperal septicemia,
65, 69.
Legislation relative to, 9, 69, 75-76, 78-79,

,

120 121

.

Visits, number during confinement, 90.
Minimum standards adopted by Washing­
ton and regional conferences on child
welfare (1919) 83.
Placenta praevia:
Frequency, by order of birth, 27.
Operative interference, 27, 28.
Mortality from, 72.
Plural births:
Eclampsia, frequency, 28.
Mortality, 33.
Obstetrical operations, frequency, 32.
Pneumonia, 23.
Postnatal care, 90-92.
Duration—
B y earnings of father, 91-92.
B y nationality and color of mother, 91, 92.
Facilities, 82.
Importance in prevention of mortality and
morbidity, 1, 74.
Physical examinations, 83, 90-91.
Postnatal care:
Rest period, 83, 91-92.
Standard adopted by Washington and regional
conferences on child welfare (1919), 83.
Visits, number received from physicians or
midwives, 90.
See also Maternity care; Prenatal care; Confine­
ment care.
Premature births (live and still):
Induced, maternal mortality following, 72.
Risk as compared with full-term births, 12.
Premature separation of placenta:
Maternal mortality from, 72.
See also Obstetrical operations.
Prenatal care, 83-86.
Extent—
By color and nationality, 40-41, 83-84.
By earnings of father, 36, 83.
By grade of care, 84-85.
Differences in U. S. and foreign countries
and their significance, 61.
Infant mortality as influenced by, 1.
Maternal mortality as influenced by,
1, 44, 64, 72-73.
Facilities, 82.
Instruction—
Mothers, 64, 70-71, 74, 82, 92, 95, 96.
Public as to importance of prenatal care, 70
(footnote 16), 83, 95.
Physical examinations, 71, 82, 83-86.
Prenatal conferences giving instruction in, 95.
Stillbirths in relation to, 1.
See also Maternity care; Confinement care;
Postnatal care.
Prenatal conferences:
Costs, by unit, in urban and rural areas, 96.
Number and attendance, 96.
Prenatal letters to mothers, State distribution, 97.
Preventability of puerperal mortality, 1,24,64-73..
Puerperal septicemia, 1, 24, 64-69, 98-99.
Other puerperal causes, 69-73.
Prevention of maternal mortality, 1, 2, 24, 74-97.
Governmental responsibility, 92-97.
Protective legislation, 74-78.
See also Laws and regulations.
Provisions for maternity care; 78-92. '
Puerperal septicemia, 74, 75, 78, 98-99.
Vital statistics, methods of utilization, 98,99.

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IN D E X

Primiparae:
Eclampsia, frequency, 28, 70.
Physical examination, 82.
See also Order of birth.
Puerperal albuminuria and convulsions:
Classification—
In use b y Census Bureau, 106.
When returned as joint cause of death, 111.
Death from, 22, 69.
Preventability, 70-71, 72.
See also Convulsions; Pathological causes,
primary.
Puerperal causes of death:
Certification, 3,9-16,45, 52, 55,58-59,62,119-122
Classification—
Preference over nonpBerperal causes when
joint causes are returned, 4.
Rules in use by Census Bureau, 3, 69,103111.
Definition—
Comparability in United States and certain
foreign countries, 3, 58,118.
In United States, 3,106 (Note).
Omissions of deaths from, and Census Bureau’s
method of rectifying, 7-21.
Other than puerperal septicemia.
Definition comparability in United States
and foreign countries, 58, 118.
Mortality. See under Mortality, puerperal.
Puerperal septicemia. See Puerperal septicemia.
See also Pathological causes of puerperal mor­
tality.
Puerperal diseases of the breast:
Classification—
In use by Census Bureau, 106.
When returned as joint cause of death, 111.
Death from, 69.
See also Pathological causes, primary.
Puerperal hemorrhage:
Classification—
In use by Census Bureau, 104.
When returned as joint cause of death, 110.
Death from, 3, 22, 69, 71.
Preventability, 70.
See also Pathological causes, primary.
Puerperal insanity, 22, 25, 69,106.
Puerperal morbidity. See Morbidity, puerperal.
Puerperal phlegmasia alba dolens, embolus, sudden
death:
Classification—
In use by Census Bureau, 105.
When returned as joint cause of death, 111.
Death from, 69.
See also Pathological causes.
Puerperal mortality. See Mortality, puerperal.
Puerperal septicemia:
Certification omissions—
Foreign countries, 58, 59.
United States, 10-16.
Classification—
In use by Census Bureau, 105.
When returned as joint cause of death, 111.
Definition—
Comparability in United States and foreign
countries, 58,118In United States, 3,103.
Mortality rates—
By age, 33-34.
By color and nationality, 36-40.
By urban and rural areas, 37, 42-44.
Comparison between United States and
foreign countries, 57-60.
Trend—
Foreign countries (1900-1922), 63.
United States (1900-1921), 45-56.
Prevalence, 22.
Preventability, 1, 24, 64-69, 98-99.
Prevention, 74, 75, 78, 98-99.
Public-health control, 65, 69, 74, 75, 78, 99.
Reporting requirement aid to prevention, 65,
69, 78.
Resulting from self-induced abortion, classifi­
cation, 25, 64, 69-70.
See also Pathological causes, primary.
Pulmonary congestion, 23.
See also Pathological causes, contributory (nonpuerperal).
Questionnaire sent to physicians as aid in preven­
tion of maternal mortality, 99.


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Racial factors. See Nationality and color.
Registration:
Births—
Colored race, 18-19, 20.
Completeness of registration—
By countries, 130-131.
By States, 112-113.
.v.
By urban and rural areas, 20.
Definition “ registered live births” in cer­
tain foreign countries, 131.
Enforcement, 16-17.
Importance of registration, 130.
Laws, 17,130-131.
Omissions and methods of correcting, 16-20.
Puerperal mortality rates in relation to, 16
Responsibility, with whom placed, 16.
Urban and rural areas, 20.
Deaths, 7-9.
Completeness of registration—
Foreign countries, 118,119.
United States, 6, 7-9,118.
Laws by State and date of enactment, 7-8.
Stillbirths—
Foreign countries, 4,117,131.
United States, 1-2, 4,114-116.
Registration areas, U. S.:
Birth—
Puerperal deaths occurring in (1921), 6.
Puerperal mortality rates limited to, 6,16.
Stillbirths (1918 and 1921), 1-2,2 (footnote 3).
See also Stillbirths.
Death—
Dates of admission by States, 8.
Deaths due to nonpuerperal contributory
causes (1917), 23.
See also Pathological causes, contribu­
tory (nonpuerperal).
Deaths due to puerperal causes (1921), 6,22.
Regulations. See Laws and regulations.
Reportability of puerperal septicemia, 65, 69, 78.
Rickets, relation to contracted pelvis, 26, 27,59.
Rural and urban areas:
Birth registration, 20.
Maternal mortality, 6, 9, 42-44.
By cause of death, 37,42-44.
Colored race, 36,37.
Maternity care—
Hospital care, 44, 86.
Physicians in attendance, 79-80.
Prenatal conference, cost, 96.
Salpingitis and other diseases of the female genital
organs, 15, 23.
See also Pathological causes, contributory (non­
puerperal)
Septicemia:
Erroneous certification and method of correct­
ing, 12, 58.
Puerperal. See Puerperal septicemia.
Sheppard-Towner Act (an act providing for the pro­
motion of the welfare and hygiene of
maternity and infancy), 95.
Single or plural births, 32-33.
Maternal mortality rates following obstetrical
operations, 33.
See also Plural births.
Social-hygiene legislation, 77-78.
Standards for public protection of the health of
mothers adopted by the Washington and
regional conferences on child welfare
(1919), 82-83.
Statistics, comparability in United States and
foreign countries, 58-59, 118-131.
Stillbirths:
Definition and registration (United States and
foreign countries), 1-2, 4,114-117,131. _
Exclusion of, in calculating maternal mortality,
4-5.
Mortality resulting from (Baltimore, 1915), 26.
Number in birth-registration area 1918 and 1921,
1- 2.

Prenatal care in relation to, 1.
Registration and definition (United States and
foreign countries), 1-2, 4,114-117,131.
See also Registration, births, deaths.
Subsidies, governmental. See Governmental re­
sponsibility for adequate protection of
maternity.

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IN D E X
Sudden death:
Classification—
In use by Census Bureau, 105.
When returned as joint cause of death, 111.
Deaths from, 69.
, See also Pathological causes,
uicide and other external causes, classification:
England, 127.
International List, 109-111.
Surgical operations, 22, 28, 30, 31, 72.
Classification in use by Census Bureau, 104,110.
See also Obstetrical operations.
Syphilis:
Classification when joint cause, 4.
Relation to abortion, 69.
See also Venereal diseases.

See Plural births.

Venereal diseases:
Legislation for control, 75, 77-78.
Prevalence in negro group as influencing
maternal mortality in that group, 38.
Version:
Frequency, 28, 29.
Maternal mortality, 31, 72.
Violence, death from, classification:
England, 127.
International List, 109-111.
Visits, home, by physician, nurse, or midwife, 90,
95, 96.
Standards adopted by Washington and re­
gional conferences on child welfare (1919),
82, 83.
Vomiting (uncontrollable):
Classification, 22.
Factor in maternal mortality, 25.
See also Accidents of pregnancy.

Toxemia of pregnancy:
Preventability, 70, 72.
Prevention, 72.
See also Puerperal alb uminuria and convulsions.
Trend:
Puerperal mortality—
Foreign countries (1900-1922), 61-63.
Netherlands (1876-1921), 67-68.
United States (death-registration area, 19001921), 45-56.
New York City (1900-1921), 68.
Puerperal septicemia—
Foreign countries (1900-1922), 63.
England and Wales (1881-1914; 18911920), 67.
Netherlands (1876-1921), 67-68.
Norway (1876-1918), 66.
United States (death-registration area, 19001921),45, 46, 48, 51-52, 53, 54, 55, 56.
New York City (1900-1921), 68.
Tubal pregnancy. See Ectopic or extra-uterine
gestation.

Wassermann test, 82.
Williams, J. Whitridge, M. D.:
Frequency of complications of pregnancy and
confinement, 27-28.

o


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Twins.

United States registration areas. See Registration
areas, U. S.
Urban and rural areas:
Birth registration, 20.
Maternal mortality, 6, 9, 42-44.
By cause of death, 37, 42-44.
Colored race, 36, 37.
Maternity care—
Hospital care, 44, 86.
Physicians in attendance, 79-80.
Prenatal, conference, cost, 96
Urinalysis, 71, 82, 84.
See also Examinations, mothers.


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