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U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAU JU L IA C. LA TH R O P. Chief MATERNAL MORTALITY FROM ALL CONDITIONS CONNECTED WITH CHILDBIRTH https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN THE UNITED STATES AND C ER TA IN O T H ER C O U N TR IES GRACE L. MEIGS, M. D. MISCELLANEOUS SERIES No. 6 Bureau Publication No. 19 WASHINGTON GOVERNMENT PRINTING OFFICE 1917 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A D D I T I O N A L C O P IE S OF THIS PUBLICATION M A T BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE ■WASHINGTON, D. C. AT 10 C E N T S P E R C O P Y A 1 v CONTENTS. Page. Letter of transmittal............................................ .............................................. .................. .... Summary..........................................................................v .......................................................... Part I . General discussion........................................................................ Statistics relating to childbirth in the U nited States and in certain foreign countries...................................... Introduction................................................... . . .......................................... .............. Are the diseases caused b y pregnancy and confinement preventable diseases?................................................................ R eliability of data.................................... Number of deaths in the United States from childbirth........................ Death rates in the United States from childbirth............1........................... Is the death rate from childbirth falling?................................... ................. Diagram 1. Death rates per 100,000 population from typhoid, diph 5 7 9-27 9-27 9 10 IS 14 14 16 theria and croup, and diseases caused b y pregnancy and confinement in the death-registration area of the United States, 1900 to 1913........... 18 Diagram 2. Death rates per 100,000 population from tuberculosis and pneumonia in the death-registration area of the United States, 1900 to 1913............................................ .......... ' . . ........................................ .. 19 Death rates from childbirth in urban and rural districts............................ 20 Death rates from childbirth in different States.............................................. 21 Death rates from childbirth of white and colored population.................. 22 Comparison of the average death rates from childbirth in certain foreign countries and in the United States.......................... ....................... 22 Conclusions.................................................................................. v ............................. 23 Part I I . Detailed analysis of methods and statistical d a ta ............................ 29-47 Discussion of certain terms and methods used in this report.................... 29-34 International Classification of Causes of D e a th ............ ............................... 29 Death-registration area............................................................................................ 31 Provisional birth-registration area..................................... 1.............................. 31 Methods of computing the death rates from all causes connected with pregnancy and confinement.......................................................................... .... 31 Sources of error in the study of death rates from childbirth.................................34-43 Inaccuracy of returns........................................................................................... s 35 Lim ited area and short period of tim e represented b y figures............... 36 Methods of computation.................................... ................................. .............. ... 37 Sources of error in comparisons of death rates of different years............. 37 Sources of error in a study of foreign statistics............ .................................... 41 Foreign .statistics................................... ........................................ . .................................. 43-47 Comparison of the average death rates from childbirth in certain foreign countries and in the United States................. ................................ 43 Comparison of the changes in the death rates from childbirth in certain foreign countries for the years 1900 to 1913.................................................. 44 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 3 ■ 4 CONTENTS. Page. Part I I I . General tables...................................................................................... ...................49-66 Table I . Population, deaths, and death rates per 100,000 population in the death-registration area from diseases caused b y pregnancy and confine m ent, 1890 and 1900 to 1913........................................................ ............ ................. 49 Table I I . Deaths and death rates per 100,000 population in the 8 States within the death-registration area in 1890 from diseases caused by pregnancy and confinement, 1890 and 1900 to 1913......................................... 49 Table I I I . Deaths and death rates per 100,000 population in the 11 States within the death-registration area in 1900 from diseases caused by pregnancy and confinement, 1900 to 1913.............................. ............................. 50 Table IV . Death rates per 100,000 female population in the 11 States within the death-registration area in 1900 from diseases caused b y pregnancy and confinement, 1900 to 1910........................................................................... .. 50 Table V . Number of deaths of women from 15 to 44 years of age in the death-registration area from each cause and class of causes included in the abridged International List of Causes of Death (revision of 1909), 1913................................................... . ............................................ .................................. 51 Table V I. Population, live births, deaths, and death rates per 100,000 pop ulation and per 1,000 live births from diseases caused b y pregnancy and confinement, by States and principal cities in the provisional birthregistration area, 1910........................ ............................... .......................................... 52 Table V II . Death rates per 100,000 population in the death-registration area from certain important causes of death, 1890 and 1900 to 1913......... .. 53 Table V II I. Deaths and death rates per 100,000 population in cities of at least 8,000 population and in smaller cities and rural districts in the death-registration States from diseases caused b y pregnancy and confine m ent, 1900 to 1913......................................................................................................... 53 Table I X . Death rates per 100,000 population in cities that had at least 200,000 population in 1900, and were within the death-registration States of 1900, from diseases caused by pregnancy and confinement, 1900 to 1913. 54 Table X . Death rates per 100,000 population in the 11 States within the death-registration area in 1900 from diseases caused b y pregnancy and confinement, 1900 to 1913.................................................................................... .. 54 Table X I . Deaths and death rates per 100,000 population in the deathregistration area from diseases caused, b y pregnancy and confinement, b y color of decedent, 1910 to 1913.................................................................. .. 56 Table X I I . Average death rates per 100,000 population in certain countries from diseases caused b y pregnancy and confinement, 1900 to 1910......... 56 Table X I I I . Average death rates per 1,000 liv e births in certain foreign countries from diseases caused b y pregnancy and confinement, 1900 to 1 9 1 0 ...................... 56 Table X I V . Deaths in certain countries from diseases caused b y preg nancy and confinement and number and per cent of such deaths from puerperal septicemia, 1900 to 1910.......................................................................... 57 Comment on sources of statistics for foreign countries........................ ................. 57 Table X V . Population, births, deaths, and death rates per 100,000 popula tion, per 1,000 births, and per 1,000 live births from diseases caused b y pregnancy and confinement in certain foreign countries for specified years...................................................................... 60 Table X V I . Average death rates per 100,000 population and per 1,000 liv e births from diseases caused by pregnancy and confinement in certain foreign countries for specified periods of years........................ ......................... 66 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis LETTER OF TRANSMITTAL. U. S. D epartm ent of L abor, Ch il d r e n ’ s B u r e a u , Washington, September 25,1916. I transmit herewith a report entitled 11Maternal Mortality from all Conditions Connected with Childbirth in the United States and Certain Other Countries,” b y Dr. Grace L. Meigs, in charge of the hygiene division of this bureau. This report has been prepared because the bureau’s studies of infant mortality in towns and rural districts reveal a connection between maternal and infant welfare so close that it becomes plain that infancy can not be protected without the protection of maternity. In this study Dr. Meigs undertakes to do no more than to assemble and interpret figures already published by the United States Bureau of the Census and by the statistical authorities of various foreign countries, and to state accepted scientific views as to the proper care of maternity. She points out clearly that maternal mortality is in great measure preventable, that no available figures show a decrease in the United States in recent years, and that certain other countries now exhibit more favorable rates. This report reveals an unconscious neglect due to age-long ignorance and fatalism. It is earnestly be lieved that whenever the public realizes the facts it will awake to action and that adequate provision for maternal and infant welfare will become an integral part of all plans for public health protection. The generous assistance of the United States Bureau of the Census in the preparation of this report is gratefully acknowledged. Dr. Meigs desires that special mention be made of the assistance of Miss Emma Duke, head of the statistical division of the Chil dren’s Bureau, and of Miss Viola Paradise, research assistant in the division of hygiene. Respectfully submitted. J u l i a C. L a t h r o p , Chief o f Bureau. Hon. W i l l i a m B. W i l s o n , Secretary o f Labor. S ir : https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ■ ■ -RÌSISI MATERNAL MORTALITY FROM ALL CONDITIONS CONNECTED WITH CHILDBIRTH. SUM M ARY. In 1913 in this country at least 15,000 Women, it is estimated, died from conditions caused b y childbirth; about 7,000 of these died from childbed fever, a disease proved to be almost entirely preventable, and the remaining 8,000 from diseases now known to be to a great extent preventable or curable. Physicians and statisticians agree that these figures are a great underestimate. In 1913 the death rate per 100,000 population from all conditions caused b y childbirth was little lower than that from typhoid fever; this rate would be almost quadrupled if only the group of the population which can be affected, women of childbearing age, were considered. In 1913 childbirth caused more deaths among women 15 to 44 years old than any disease except tuberculosis. The death rate due to this cause is almost twice as high in the col ored as in the white population. Only 2 of a group o f 15 important foreign countries show higher rates from this cause than the rate in the registration area of the United States. The rates of 3 countries, Sweden, Norway, and Italy, which are notably low, show that low rates for these diseases are attainable. The death rates from childbirth and from childbed fever for the registration area of this country apparently are not falling to any great extent; during the 13 years from 1900 to 1913 they have shown no demonstrable decrease. These years have been marked by a revolution in the control of certain other preventable diseases, such as typhoid, diphtheria, and tuberculosis. During that time the typhoid rate has been cut in half, the rate from tuberculosis markedly reduced, and the rate from diphtheria reduced to less than one-half. During this period there has been a decrease in the death rate from childbirth per 1,000 live births in England and Wales, Ireland, Japan, New Zealand, and Switzerland. These facts point to the need in this country and in foreign countries of higher standards of care for women at the time of childbirth. The low standards at present existing in this country result chiefly from two causes: (1) General ignorance of the dangers connected https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 7 8 M A T E R N A L M O R T A L IT Y . with childbirth and of the need for proper hygiene and skilled care in order to prevent them; (2) difficulty in the provision of adequate care due to special problems characteristic of this country. Such prob lems vary greatly in the city and in the rural districts. In the country inaccessibility of any skilled care is a chief factor. Improvement will come about only through a general realization of the necessity for better care at childbirth. If women demand better care, physicians will provide it, medical colleges will furnish better training in obstetrics, and communities will realize the vital importance of community measures to insure good care for all classes of women. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PA R T I. G E N E R A L D ISC U SSIO N . STATISTICS RELATING TO CHILDBIRTH IN THE UNITED STATES AND IN CERTAIN FOREIGN COUNTRIES. Introduction. For the last two decades civilized countries have been absorbed in the problem of preventing the enormous and needless waste of human life represented by their infant death rates. The importance of this problem has been felt mojre keenly in the last two years in the coun tries now at war; in these countries the efforts toward saving the lives of babies have redoubled since the war began. Side by side with this problem, another, which is only of late finding its true place, is that of the protection o f the fives and health o f mothers dur ing their pregnancy and confinement. This is a question so closely bound up with that of the prevention of infant mortality that the two can not be separated. It is now realized that a large proportion of the deaths of babies occur in the first days and weeks of fife, and that these deaths can be prevented only through proper care of the mother before and at the birth of her baby. It is also realized that breast feeding through the greater part of the first year of the baby’s fife is the chief pro tection from all diseases; and that mothers are much more likely to be able to nurse their babies successfully if they receive proper care before, at, and after childbirth. Moreover, in the progress of work for the prevention of infant mortality it has become ever-dearer that all such work is useful only in so far as it helps the mother to care better for her baby. It must be plain, then, to what a degree the sickness or death of the mother lessens the chances of the baby for fife and health. This question has also another side. Each death at childbirth is a serious loss to the country. The women who die from this cause are lost at the time of their greatest usefulness to the State and to their families; and they give their fives in carrying out a function which must be regarded as the most important in the world. Questions then of the most vital interest to the whole Nation are these: How are the fives of the mothers in this country and other countries being protected ? To what degree are the diseases caused by pregnancy and childbirth preventable ? If preventable, how far are they being prevented in this country? Has there been the same great decrease in the last few years in sickness and death from these causes as that which has marked the great campaigns against 64614°— 17----- 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 9 10 M A T E R N A L M O R T A L IT Y . other preventable diseases such as typhoid, tuberculosis, or diph theria? How do the conditions in the United States compare with those in other countries ? In the following report the attempt has been made to derive answers to these questions from the official records of this country and of foreign countries. Are the diseases caused by pregnancy and confinement preventable diseases? These diseases 1 fall naturally into two groups, which differ con siderably as to the degree to which they are preventable: 1. Childbed fever, or puerperal septicemia (an infection arising in connection with miscarriage or confinement), which is to a great degree a preventable disease. 2. All other diseases and complications caused by pregnancy and confinement, including conditions varying very much in the degree to which they can be prevented or cured. Puerperal septicemia (childbed fever) .— The fact is now well known that puerperal septicemia, or childbed fever, is in reality a wound infection, similar to such an infection after an accident or an opera tion, and that it can be prevented by the same measures of cleanliness and asepsis which are used so universally in modern surgery to prevent infection. The proof of the nature of this disease is one of the tre mendous results of the scientific discoveries which were made in the latter part of the nineteenth century. During the early part of that century childbed fever was one of the greatest hospital scourges known. It occurred also in private prac tice; but in hospitals where there was great opportunity for the spreading of infection the death rate from this disease was appalling. The average death rate in hospitals in all countries was 3 to 4 per cent of all women confined; sometimes it reached 10 to 20 per cent and even over 50 per cent during short periods of epidemics.2 In the face of this terrific mortality many obstetrical hospitals were closed. Com missions were appointed to investigate the cause of these epidemics, and medical congresses devoted sessions to the discussion of the problem. In 1843 Oliver Wendell Holmes, and in 1847 Semmelweiss, published articles stating the theory that this fever was similar to a wound infection and was due chiefly to the carrying of infectious material on the hands of attendants from one case to another. The i Throughout this report when reference is made to causes of death the term “ childbirth” will he used as synonymous w ith “ all diseases caused b y pregnancy and confinement” ; and each of these terms will be used as being the sum of the tw o groups, “ puerperal septicemia” and “ all other diseases caused b y preg nancy and confinement.” It will be noted that diseases of the breast during lactation are included in the latter group. For a fuller discussion of these causes of death, and the titles of the International List of Causes of D eath to which they correspond, see p . 29. * W illiam s, J. W . “ Obstetrics and animal experimentation.” Defense of Research Pamphlet X V I I I , Am er. M ed. A ssn., Chicago, 1911, pp. 6-19. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 11 same ideas had been published much earlier but had not received attention. At the time of the publications of Holmes and Semmelweiss it was not known that the infection of wounds is caused by the action of bacteria or germs. This discovery followed the pioneer discovery of living bacteria causing fermentation, made by Pasteur about 1863, which has revolutionized all surgery and preventive medicine. In 1867 Lister began to apply to surgery the work of Pasteur; he taught that wound infection at operation could be prevented by the destruction of bacteria through disinfection or antisepsis. Though these methods have been supplemented in later years by the better methods of absolute surgical cleanliness or asepsis, they represented at that time a great advance. About 1875 Lister’s methods began to be generally accepted and applied in hospitals to the prevention of infection at childbirth. This movement gained great support in 1879 when Pasteur proved definitely that childbed fever is caused b y bacteria. Gradually the methods of antisepsis or disinfection and later the better methods of asepsis were accepted in obstetrical hospitals; and at the same time the mortality, once so high, dropped enormously. At present the death rate from puerperal septicemia among cases delivered in hospitals is extremely low. Williams says: “ A t the present time it is safe to say that in well-regulated hospitals the mor tality from puerperal infection is less than 0.25 per cent. This is in great contrast with the average mortality of 3 to 4 per cent observed [in hospitals] throughout the world prior to the introduction of anti septic methods, and means that only 1 woman now dies as compared with 15 or 20 formerly.” 1 This experience in hospitals has proved definitely that puerperal septicemia is to a very large degree preventable. One fact, however, complicates the whole question and makes it impossible to say that the disease is in all cases absolutely preventable, namely, that a very small number of cases develops even under conditions of the best hospital or private care, when every method for avoiding infection has been used. This fact has led to much controversy. In general obstetricians of the greatest experience believe that a small number of cases of infection after childbirth may develop from bacteria which were already in the body of the patient before confinement; but that in the main such cases are of mild severity and that only a few fatal cases are due to this cause. Another point which must be borne in mind is that, in a certain number of cases, women may infect themselves through improper hygiene during pregnancy or just before or at confinement. Therefore the teaching of proper hygiene is an essential part of the work for the prevention of infection. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis i W illiam s. J. W . Supra cit., p. 19. 12 M A T E R N A L M O R T A L IT Y . To sum up, experience has shown that b y far the major part of all serious cases of infection at childbirth may be prevented by the application of such principles of hygiene and of strict surgical cleanli ness as are now established beyond question. A ll other diseases caused by 'pregnancy and confinement.— The dis eases and complications included under this heading are those given on page 30 as being included under “ Other puerperal acci dents of pregnancy and labor.” A definite statement such as that made above regarding the preventability of puerperal septicemia can not be made about this second group of diseases, which includes many different conditions. How ever, it is a fact well proved in practice that a large number of these complications can be prevented through proper hygiene and super vision during pregnancy and through skilled care at labor. Certain other complications which can not be prevented can be detected before serious harm is done, and treatment can be given which will save the mother’s fife. We can see this more clearly if we consider as examples two of the most important complications. Puerperal albuminuria and convulsions, called also eclampsia, or toxemia of pregnancy, is a disease which occurs most frequently during pregnancy but 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 symp toms are slight, puffiness of the face, hands, and feet; headache; albumen in the urine; and usually a rise in blood pressure. Very often proper treatment and diet at the beginning of such early symptoms may prevent the development of the disease; but in many cases where the disease is well established before the physician is consulted, the woman and baby can not be saved b y 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 she should know the meaning of these early symp toms if they arise, so that she may seek at once the advice of her doctor; and that she should have regular supervision during preg nancy, with examination of the urine at intervals. Some obstruction to labor in the small size or abnormal shape of the pelvic canal causes many deaths of mothers included in the class “ other accidents of labor” and also many stillbirths. If such diffi culty 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 preg- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 13 nancy— an examination in which measurements are made to enable the physician to judge whether or not there will be any obstruc tion to labor. A case in which a complication of this -kind is found requires the greatest skill and experience in treatment,1 but with such treatment the life and health of the mother are almost always safe. These two examples will suffice. In the same way it could be shown, with regard to all the other complications of pregnancy and labor, that those which can not be prevented can be treated success fully in most cases if detected in time. • It can be regarded, then, as a generally accepted fact that all illness and death connected with childbearing is, to a certain and large degree, preventable, through the application of the scientific knowledge which is now well established. The next questions are, How far are these diseases being prevented in the United States ? How many deaths do they cause each year ? What are thé death rates from these causes, and are they decreasing or in creasing? The statistics gathered by the United States Bureau of the Census have been studied for answers to these questions. There are other equally important questions to which these figures will not give answers. In addition to the number of deaths and death rates, it is important to know how much illness is caused by the diseases of pregnancy and confinement. How many women do they disable for months or years ? Undoubtedly the health of these mothers affects enormously the welfare of their children. Unfortu nately such questions can not be answered; puerperal septicemia is not a reportable disease in this country as it is in many others. We can only remember that for each woman who died there are surely many who were ill for days, weeks, or months, but who finally, recovered. The following pages give a brief summary of the data, published b y the United States Bureau of the Census, dealing with deaths from childbirth. These are discussed in further detail in other sections of the report. Reliability of data. The statement is frequently made that all statistics on this subject are incomplete. This is undoubtedly true with regard to the figures available in each country. A detailed discussion of the many sources of error in the statistics of the United States and of foreign countries on this subject will be found in another section, beginning on page 34. 1 The public m ust be taught that the conduct o f labor complicated b y a moderate degree of pelvic con traction is quite as serious as a case of appendicitis, and that its proper management requires the highest degree of judgm ent and skill, while eclàmpsia or placenta prævia are even more serious.— W illiam s, J. W . “ The midwife problem and medical education in the United States.” Trans. Am er. Assn, for Stü dy and Prevention of Infant Mortality, 1911, p . 189. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 MATERNAL M O R T A L IT Y . From that discussion several conclusions may be drawn: 1. Though the figures of the number of deaths from puerperal septicemia and from all other diseases connected with childbirth are certainly incomplete, yet they are reliable as far as they go; they may be accepted as a statement of the minimum number of deaths which have actually occurred as a result of these diseases. 2. All conclusions as to comparative death rates in various years and in various countries can be made only with caution and by bearing in mind the many statistical pitfalls connected with such comparisons. With a full understanding of the limitations of the figures avail able, it has seemed worth while to publish the following figures of the deaths in the United States due to childbirth. Number of deaths in the United States from childbirth. In 1913 in the “ death-registration area” 1 of the United States 10,010 deaths were reported as due to conditions caused b y preg nancy and childbirth. Of these deaths, 4,542 were reported as caused by puerperal septicemia or childbed fever. Using the death-registration area as a basis, we are justified in estimating that in 1913 in the whole United States 15,376 deaths were due to childbirth, and 6,977 of these were due to childbed fever. As will be shown later, these figures are without doubt a gross under estimate. As it is, they are striking enough— almost 7,000 deaths in one year in this country due to childbed fever, a disease to a large degree easily preventable; and over 8,000 due to the other diseases caused by pregnancy and confinement, most of which are preventable or curable by means well known to science. Death rates in the United States from childbirth. The death rate from all diseases caused by pregnancy and con finement in 1913 in the registration area was 15.8 per 100,000 popu lation (which includes all ages and both sexes). The death rate from puerperal septicemia was 7.2. These figures, however, mean little to us unless we compare them with the death rates from other preventable diseases. In the same year and area the typhoid rate was 17.9 per 100,000 population; the rate from diphtheria and croup 18.8. The highest death rate from any one disease was that from tuberculosis, 147.6 per 100,000 population. Any such comparison with the rates from diseases to which both sexes and all ages are liable is of course very misleading; but in spite of that fact it is interesting to piote that typhoid fever, the disease 1 The death-registration area comprises the States and cities in which the registration of deaths is returned as fairly complete.— U . S. Census. M ortality Statistics, 1911, p . 9. I t is estimated that in 1913 the death-registration area included 65.1 per cent of the population of the U nited States. (See Table I, p. 49.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 15 against which so great an amount of effort is now directed, has a rate at present bnt 2 per 100,000 population higher than that from the diseases caused b y pregnancy and confinement. Death rates per 100,000 women.— The death rates from childbirth are approximately doubled when worked on the basis of 100,000 women. This will be seen when Tables IV and II I (p. 50) are com pared. The former gives for the period 1900 to 1910, the annual death rates per 100,000 women in the group of 11 States which were in the death-registration area in 1900, the latter the death rates per* 100,000 population in the same group of States for the same period. It is evident that the rates in Table IV for each year are slightly more than twice those in Table II I for the same year. Death rates per 100,000 women o f childbearing age.— Again, a much higher but a more accurate death rate from these diseases is found when the basis taken is the group which alone is affected by these diseases— women of childbearing age. When the rate is based not upon 100,000 population of both sexes and all ages but upon 100,000 women 15 to 44 years of age, the rate as ordinarily given is multi plied several times. In 1900,1 the only year for which the rates can be computed, the death rate in the registration area per 100,000 women 15 to 44 years of age from all diseases of pregnancy and confinement was 50.3; from puerperal infection, 21.6. (See p. 32.) The corresponding rates for the same year per 100,000 population were 13.1 and 5.6. In this year, therefore, the rates are almost quadrupled when based on that group of the population which alone can be affected b y these diseases. Moreover, the death rates as ordinarily given per 100,000 popula tion conceal the fact that the diseases of pregnancy and childbirth are indeed among the most important causes of death of women between 15 and 44 years of age; the actual number of deaths shows this to be the case. In 1913 in the registration area these diseases caused more deaths than any other one cause o f death except tuber culosis. In that year there were, among women 15 to 44 years of age, 26,265 deaths from tuberculosis; 9,876 deaths from the diseases of pregnancy and confinement; 6,386 from heart disease; 5,741 from acute nephritis and Bright’s disease; 5,065 from cancer; and 4,167 from pneumonia. Other diseases, such as typhoid, appendicitis, and the infectious diseases show far fewer deaths. (See Table V, p. 51.) Death rates per 1,000 live births.— This rate, as will be shown repeat edly throughout the report (see p. 32), gives a far clearer picture of the actual risk of childbirth than do any of the rates so far con sidered. This rate can be given only for one year, 1910, and only for the provisional birth-registration area for that year. The rate from all diseases caused by pregnancy and confinement is 6.5, from puer- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1 Census year ending May 31. 16 M A T E R N A L M O R T A L IT Y . peral septicemia, 2.9, and from all other diseases of pregnancy and confinement, 3.6 per 1,000 live births. That is, in this area for every 154 babies bora alive one mother lost her life. (See Table VI, p. 52.) Is the death rate from childbirth falling? Has there been in the last few years any decrease in the death rates from puerperal septicemia and from other diseases caused by preg nancy and confinement? The general opinion o f the medical pro fession and of the laity is that these death rates, and especially the rate from puerperal septicemia, are fast decreasing. The fact that hospital epidemics of puerperal septicemia are now things of the past is thought to be evidence that deaths from this disease are now rare. On the other hand, many obstetricians of wide experience believe that outside of hospitals there has been no great decrease in the death rate from puerperal septicemia. Dr. Williams,1professor of obstetrics, Johns Hopkins University, be lieves that there has been no great improvement in this country; Dr. Webster,2professor of obstetrics, Rush Medical College, University of Chicago, and Dr. Powell3hold the same opinion; Dr. De Lee,4professor 1 In private practice it is doubtful whether the results are materially better to-day than they were before the introduction of antiseptic methods, for the reason that the doctrines of asepsis have not yet permeated the rank and file of medical men, m uch less of midwives, to whose care is committed a very large propor tion o f obstetrical cases. Though, at the same tim e, it m ust be admitted that we rarely hear of outbreaks of puerperal infection such as are mentioned in the historical work of Hirsch, w ho gives the particulars of 216 epidemics occurring between the years 1652 and 1862. Boehr stated in 1875 that 363,324 wom en had died from puerperal infection in Prussia during the preced ing 60 years, and calculated that every thirtieth married wom an eventually perished from it; while Ehlers contended that outside of the well-regulated hospitals the results were equally bad in 1900. Furthermore, Fromme stated, in 1910, that at least 5,000 wom en succumb each year in Prussia to this preventable malady. Bacon, in an article based upon the records of the health department of Chicago, showed that for the 40 years prior to 1896 puerperal infection w as assigned as the cause of death in 12.75 per cent of the women dying between the ages of 20 and 50 years, varying between 20 per cent in 1873 and 7.3 per cent in 1895. Similar results were reported b y Ingerslev, w ho stated that, even at the present tim e in Denmark, with the single exception of tuberculosis, puerperal infection is the most frequent cause of death in women during the childbearing period. - The investigations of Boxall, Byers, and Lea show a similar condition in England, where it m ay be said that outside of the lying-in hospitals this preventable scourge claims as m any and perhaps more vic tim s than it did 20 or even 40 years ago. Moreover, in trying to determine the frequency of puerperal infection, one can not be guided altogether b y the m ortality statistics, inasmuch as the largest proportion of these cases do not end fatally. O n the other hand, anyone w ho deals m uch w ith gynecological patients can not fail to be impressed w ith the very large proportion whose troubles have originated from febrile affections during the puerperium, which in m any instances were clearly due to the neglect of aseptic precautions on the part of the obstetrician or midwife.— W illiam s, J. W . Obstetrics, 1913, pp . 900,901. 2 I t is the general impression that there has been a marked diminution in the mortality of puerperal sepsis since the introduction of antiseptics. This is probably true only as regards hospital prac tice. * * * A s regards private practice, it is doubtful if there has been much diminution in mortality, either in Europe or America.— Webster, J. C. A Text-book of Obstetrics, 1903, p . 640, 3 1 am quite sure it is the belief of all w ho have given attention to this subject, that the mortality from puerperal infection has been diminished little i f any in private practice.— Powell, H. H . “ Mortality from puerperal infection.” Surgery, Gynecology and Obstetrics, 1906, V o l. I l l , p. 11. < I do not fear to hazard the statement that 8,000 wom en die annually in the U nited States from child bed infections. W h en one considers that the m ajority of cases of puerperal infection get well, the con clusion is inevitable that the disease is still— in these modern aseptic and antiseptic times— very preva lent.— D e Lee, J. B . Principles and Practice of Obstetrics, 1913, p . 870. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 17 of obstetrics, Northwestern University, comments on the great preva lence of puerperal septicemia in spite of onr present knowledge of asep sis. Dr. Moran1 points ont the lack of decrease in the figures as given in the census reports, as does also Dr. Davis2 in a recent volume. Dr. Edgar,3 professor of obstetrics and clinical midwifery, Cornell Univer sity Medical College, on the other hand, believes that there has been a decrease. W e need a definite answer to this question, based on a study of unassailable statistics. Unfortunately the available figures on this subject for this country and foreign countries have many possibilities of error, as will be shown in a later section (see p. 34). The errors have been avoided as far as possible; those which can not be avoided must be considered in reading the following summary. Especially to be remembered is the fact that in recent years great improvement has been made in the registration of deaths from childbirth and childbed fever. According to the evidence available, these death rates are appar ently not decreasing. During the 23 years ending in 1913 in this coun try no definite decrease in the death rate from the diseases caused by pregnancy and confinement can be demonstrated; nor can any decrease in the death rate from puerperal septicemia be shown. In the registration area as a whole the death rates have shown no decline in the years between 1890 and 1913. The death rate from all diseases caused by pregnancy and confinement, which was 15.3 in 1890, fell to 13 in 1902, and then with annual fluctuations rose to 16 in 1911; in 1913 the rate was 15.8. The annual average for the period 1901 to 1905 was 14.2; for the period 1906 to 1910, 15.5. (See Table I, p. 49.) The death rate from all diseases caused b y pregnancy and con finement for the group of eight States which have been included in the death-registration area from 1890 to 1913 4 also has shown no decrease during the course of these 23 years. There was a slight fall in the rate for the year 1900 as compared with that for the year 1890, followed b y a slight rise. (See Table II, p. 49.) In 1890 the rate was 14.1 per 100,000 population; in 1900, 12.6; in 1913 it was 14.3-, The death rates for a second group of States 4 (those included in the death-registration area since 1900) show between 1900 and 1913 a 1 jjoran, J. E . “ The endowment of motherhood,” Jour. Am er. M ed. A ssn., 1915, V o l. L X I V , p. 122. 2 probable that very few physicians realize that w ith the great progress of preventive medicine and aseptic surgery that there has not been a similar increase in the safety of maternity.— Davis, C. H. Pain less Childbirth, Eutoeia, and Nitrous O xid-O xygen Analgesia, 1916, p . 62. s I t isw ery difficult to estimate the frequency of puerperal infection outside of hospitals * * * but it is undoubtedly much less than it used to be.— Edgar, J. C. The Practice of Obstetrics, 1903, p . 752. 4 Selectee for study because good methods of death registration m ay be assumed to have become estab lished, andalso because comparisons of the rates of such a group of States are not open to the error due to the changing'pharacter of the registration area. 64614°— 17------ 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 M A T E R N A L M O R T A L IT Y . slight increase, from 12.9 to 14.9, with the high point 15.5 in 1911. (See Table III, p. 50). These rates are more fully discussed on page 38. The death rates from puerperal septicemia or childbed fever during these years in each group of States have run parallel with those from the whole group of diseases connected with childbirth; they, too, have shown practically no change in 13 years. It is probable that the improvement in reporting deaths from child birth may account for the apparent rise in the rates since 1900; it may also perhaps conceal a slight improvement in actual conditions since that time; but it is safe to say that any marked decrease in the actual death rate from childbirth during the last 13 years could not have been masked b y this error. In these years what has been the change in the death rates from other preventable diseases? These death rates tell a very different story from that of the rates from childbirth. They give a bare out line of the remarkable achievements of modern medicine in the prevention of certain diseases. DIAGRAM I.— DEATH RATES PER 100,000 POPULATION FROM TYPHOID, DIPHTHERIA AND CROUP, AND DISEASES CAUSED BY PREGNANCY AND CONFINEMENT IN THE DEATHREGISTRATION AREA OF THE UNITED STATES, 1900 TO 1913. RATE. YEAR. TYPHOID. DIPHTHERIA AND CROUP. DISEASES OF PREGNANCY AND CONFINEMENT. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 19 DIAGRAM 2.— DEATH RATES PER 100,000 POPULATION FROM TUBERCULOSIS AND PNEU MONIA IN THE DEATH-REGISTRATION AREA OF THE UNITED STATES, 1900 TO 1913. TUBERCULOSIS. PNEUMONIA. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 M A T E R N A L M O R T A L IT Y . Between 1890 and 1913 the death rate from typhoid fever in the death-registration area fell from 46.3 to 17.9; that from diphtheria and cronp from 97.8 to 18.8; from tuberculosis from 252 to 147.6; from pneumonia from 186.9 to 132.4; from diarrhea and enteritis under 2 years from 139.1 to 75.2. (See Table T i l , p. 53.) If we consider only the 13 years since 1900, for which we have annual reports, the changes are just as startling. In that time the death rate from typhoid fever has been cut in half; that from diph theria and croup has dropped to less than half; those from tubercu losis and pneumonia have both shown a marked fall. These changes, together with the lack of change in the death rates from the diseases caused by pregnancy and childbirth, are shown graphically in diagrams 1 and 2. , Death rates from childbirth in urban and rural districts. Besides the questions applying to the death rates of the country as a whole, there are further questions which it would be interesting to answer from the data given b y official figures. Is the rate higher in the cities than in rural districts ? Does a comparison of the rates of different sections o f the country reveal any significant facts ? Is there any difference in rate among different groups of the population ? No figures,1 unfortunately, are available for the death rates from these diseases in what is generally understood as the rural portion of this country; that is, among the population scattered in districts outside of even the smallest towns and cities. In view of the fact that standards of obstetrical and prenatal care differ so widely in these rural districts from those in large cities a comparison of the rates would have been extremely significant. The death rates for the group of cities of 8,000 2 or more inhabitants in the registration States3 have been studied, as contrasted with the death rates of the smaller cities, towns, and rural districts classed together. The rates in each year are higher for the larger cities of the registration States than for the smaller cities and rural districts. (See Table V III, p. 53.) Part of this difference may'be due to greater incompleteness of the returns from the second group. Further than this, many factors may be involved in "the higher rate in the larger 1 In the publications of the Bureau of the Census on Mortality Statistics figures are given for the popula tion classified into urban and rural or of cities and rural districts. For the years 1900 to 1909 urban is defined as including the population of all cities of 8,000 or more inhabitants at the census of 1900; rural as including that of all cities and towns of less than 8,000 inhabitants, as well as of the districts outside of any cities, towns, or villages. For the years 1910 to 1913 the division is made between cities having a population of 10,000 or more in 1910 and those cities having less than 10,000 inhabitants, together with rural districts. 2 Ten thousand inhabitants, 1910 to 1913. s It has been thought better to compare the urban and rural rates in the group of registration States in each year rather than to compare these rates for the whole registration area as constituted in each year. A s the registration area includes cities in several States of which the smaller towns and rural districts are not included, the latter comparison would seem to be scarcely fair. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E B N A L M O B T A L IT Y . 21 cities. While some of the larger cities afford better provision for obstetrical and prenatal care than do the smaller cities and rural districts, this is not true of all; moreover, the larger cities probably show a much higher rate among the less favored than among the more favored groups of their inhabitants. Overcrowding, over work, low incomes, ignorance of the need for good obstetrical care and how it can be obtained may all play their part in producing this high rate in the larger cities. The figures do not show a decrease in the death rates from child birth in the larger cities in recent years. The death rates of the whole group of cities of 8,000 1 or more inhabitants in the registration States for the years 1900 to 1913 (see Table V III, p. 53) show no decline. The rate in 1900 was 14.9; in 1913, 17.2. The rates from childbirth for the same period in a group of 7 large cities have been studied. (See Table IX , p. 54.) The rates for New York City alone show a definite and steady decline; in 1905 the rate per 100,000 inhabitants was 20.3; in 1913, 14.1. The rates of Boston, Buffalo, Detroit, Jersey City, and Washington show wide annual fluctuations, but no general tendency to increase or decrease. The rate of Newark, on the other hand, shows an increase. Death rates from childbirth in different States. The death rates of only 11 States (including the District of Colum bia) can be studied through a period of time (1900 to 1913) long enough to justify any conclusions. These States, unfortunately, do not represent any widely different sections of the country, as they include only the New England States, two Middle Atlantic States (New York and New Jersey), the District of Columbia, and two North Central States (Indiana and Michigan) . The western and southern sections of the country are unrepresented. Though the rates for each State vary considerably from year to year, it will, be noted that certain States show high average rates; among these are the District of Columbia, Michigan, and Rhode Island, whose rates are 17.6, 17.1, and 16.8, respectively. (See Table X , p. 54.) Other States show comparatively low average rates; for example, New Hampshire (11.2) and Maine (11.8). It seems premature at this time to draw any conclusions as to the cause of these differences in rates in different States. When the rates are available for all sections of the country, a comparison of rates for different large sections presenting similar problems will be very useful. \ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis i Ten thousand inhabitants. 1910 to 1913. 22 M A T E R N A L M O R T A L IT Y . Death rates from childbirth of white and colored population. No facts brought out in this study are as striking as the difference1 in rates from childbirth of the white and colored population of the death-registration area. In some cases the rates for the colored popu lation are almost double those for the white. Table X I, page 56, which gives the rates so divided, demonstrates this difference. In 1913 the death rate from all diseases caused by pregnancy and confinement was 15.2 per 100,000 white population and 26.1 per 100,000 colored. In the same year the rate from puerperal septicemia was 6.9 for the white population and 11.5 for the colored. A similar relation is shown b y the rates for each year from 1910 to 1913. Although the rates can be given only for four years, and are based on small figures, yet they show differences so marked that they picture without doubt a very great difference in standards of care at childbirth in these two groups. When all the Southern States are included in the deathregistration area the magnitude of this problem undoubtedly will be shown b y the death rates from childbirth in these States. A t pres ent but a small percentage of the colored population of the United States is represented b y the figures available. Comparison of the average death rates from childbirth in certain foreign countries and in the United States. Are the death rates from these diseases in the death-registration area of the United States higher or lower than those in other civilized countries ? Have these rates in other countries been falling or rising in the last 13 years, while the rates of this country have been apparently stationary? These questions, like all those of comparative interna tional statistics, are of immense interest, but they involve many diffi culties and sources of error. These are discussed on page 41. They should be considered in reading the following summary. In order to make possible a comparison of the death rates from these causes for 15 foreign countries with those for the United States, an average rate has been computed for the years 1900 to 1910 1 for each of the countries, using the same method as that in use in the United States. When the 16 countries studied are arranged in order, with the one having the lowest rate first, the death-registration area of the United States stands fourteenth on the list. (See Table X II, p. 56.) Only two countries, Switzerland and Spain, have higher rates; many of the countries, however, show rates differing but little from that o f the United States. Markedly low rates are those of Sweden (6), Norway (7.8), and Italy (8.9); a strikingly high rate is that of Spain (19.6). , The death rate from childbirth per 1,000 live births is not available for the death-registration area of the United States, but can be given 1 Or for that portion of this period for which figures are available. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 23 only for the small number of States and cities included in the pro visional birth-registration area and for one year, 1910. (See p. 31.) This rate, 6.5, is considerably higher than that for 1910 of any of the countries studied. When the average rates for a number of years of the 15 countries are reckoned per 1,000 live births and arranged in order, it will be seen that the same group of countries— Sweden, Italy, and Norway— shows the lowest rates. (See Table X III, p. 56.) Spain in this table shows the rate which is next to the highest, while Belgium now has the highest rate. For a comparative study of the rates of these countries the rates per 1,000 live births give undoubtedly the clearest picture of the actual conditions. These rates show a wide variation. While in Sweden hut one mother is lost for every 430 babies bom alive, in Belgium one mother dies for every 172 babies, and in Spain one for every 175 babies horn alive. The rates in Belgium and Spain are two and a hah times as high as the rate in Sweden. Far more significant than a comparison of actual death rates of various countries is a comparison of the changes which have occurred in these death rates in each country in recent years. England and Wales, Ireland, Japan, New Zealand, and Switzerland have shown a'decrease in the death rate per 1,000 live births from all diseases caused b y pregnancy and confinement; but, in this group, only in England and Wales and in Ireland has the death rate from puerperal septicemia decreased; in the other three countries this rate has remained practically the same, though the total rate has decreased. In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and Sweden both the rate from childbirth and that from puerperal septicemia remained almost stationary during the periods studied. The total rate for Scotland shows a definite increase, though the rate from puerperal septicemia has decreased. (See T ableX V I, p. 66.) Conclusions. In the foregoing pages the attempt has been made to draw, from available statistics, answers to certain important and urgent ques tions relating to the hazards of childbirth in this country and in other countries. It has been shown that a large number of women die year after year in this country from childbed fever, a disease proved over 40 years ago to be almost entirely preventable; and that a still larger number die from other conditions connected with childbirth which are known to be to a large degree preventable or curable. The proportionately small number of women lost from these causes in certain foreign countries demonstrates the needless ness of the greater part of our losses. There is no evidence, moreover, of any great advance made during the last 13 years in this country in the prevention of disease and death due to childbirth, though the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 M A T E R N A L M O R T A L IT Y . same period lias been marked by a notable decrease in the death rates of certain other diseases which have been proved preventable. What is the cause of these conditions in this country? At the root of the matter, apparently, lie two chief causes: First, general ignorance of the dangers connected with childbirth and the need of skilled care and proper hygiene in order to prevent them; second, such difficulties related to the provision of proper obstetrical care as are characteristic of conditions in this country. A general realization of certain of the fundamental facts related to the bearing of children has only begun; this function has always been looked upon with a mixture of ignorance and fatalism. The hazards to health and life connected with childbirth have been either ignored or accepted as unavoidable accidents. B y most people childbirth is regarded as an entirely normal process, and, happily, in the great majority of cases this is true. But, the figures given in this report show that it is not true of all. Each year there is a vast number of normal deliveries, and among them the relatively small but absolutely very large number of complicated cases is lost sight of. On the other hand, most people regard such illness and deaths as do occur as unpreventable. Only very gradually and incompletely are women beginning to realize the simple facts that certain accidents and complications occur in a definite percentage of cases of childbirth, but that almost always these may be avoided or cured if women exercise the proper hygiene during pregnancy, secure proper supervision during that time, and have skilled attend ance at labor. Like other essentials of hygiene and preventive medicine these principles are at last becoming public property in stead of being the exclusive possession of physicians. But in this case progress has been very slow. Knowledge of the need for good care at childbirth is essential; the lack of such knowledge and of a demand for this care has been, probably, the chief factor in producing the present indifference to this phase of preventive medicine. The husbands of women bearing children do not realize that money paid for skilled service at childbirth is one of the most neces sary family expenditures; hence, obstetrics has become one of the worst paid though one of the most taxing branches of medicine. Dr. Williams 1 speaks of the small fees usually paid for maternity care and says that ‘ ‘ doctors who are obliged to live from their prac tice can not reasonably be expected to give much better service than they are paid for.” Naturally enough, the lack of interest of physicians in obstetrics is partly due to this fact. No doubt another reason why many able physicians dislike this branch of practice is the fact that they feel strongly the responsibility assumed in the care of » W illiam s, J. W . “ The midwife problem and medical education in the United States.” Assn, for Study and Prevention of Infant Mortality, 1911, p. 190. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Trans. Am er. M ATERNAL M O R T A L IT Y . 25 women at childbirth; yet they are frequently called upon to take this responsibility in the face of conditions which they can not control and which threaten the safety of their patients. A conscientious physician does not willingly undertake the conduct of a difficult case of labor outside a hospital and without skilled assistance; but fre quently he must do so, either because there is no hospital or trained nurse available, or because the patient and her family are unable or unwilling to pay for the needed help. The physician either must give up the case to an attendant who is less skillful and careful than himself or must take the risk that puerperal septicemia or some other complication may occur. If either' follows he has the blame. Alto gether a physician has little incentive to specialize and acquire great skill in this branch. Necessarily the same apparent indifference to the importance of obstetrics is reflected in the courses of many medical colleges. Dr. W illiams1 pointed out in 1911 that in the majority of medical col leges in the United States instruction in this subject was grossly neglected; that graduates from these colleges beginning their prac tice were totally unprepared to manage any but absolutely normal cases of confinement, and that they were untrained in the practice of the principles of asepsis as applied to this branch. Other papers and discussions in the Transactions of the American Association for Study and Prevention of Infant Mortality have emphasized the same facts. In the five years since the article of Williams was written some improvement in these conditions has undoubtedly taken place, as would be expected in connection with the present remarkable tendency toward the raising of standards of medical education in the United States. However, there is no question that further im provement is greatly needed. Communities are still to a great extent indifferent to or ignorant of the number of lives of women lost yearly from childbirth; many communities which are proud of their low typhoid or diphtheria rates ignore their high rates from childbed fever. Communities are only beginning to realize that among their chief concerns is the protection of the babies bom within their limits, and necessarily also of the mothers of those babies before and at confinement. The second fundamental cause of the high death rates from child birth in this country previously spoken of— that is, the difficulty of obtaining adequate care— is seen to depend to a large extent on the first, the general ignorance of need for good care. As women, their husbands, physicians, and communities realize the absolute need of skilled care for the prevention of needless deaths from childbirth, methods for providing such care will be developed. In this develop ment special problems will have to be solved in each type of commui 64614°— 17----- 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis W illiam s, J. W . Supra cit., p . 182. 26 M A T E R N A L M O R T A L IT Y . nity, and in each section of the country— North, South, East, and West. These problems are different from those of foreign countries. While the methods being employed in such countries for reducing the maternal death rate may be suggestive, special methods adapted to the conditions in this country will probably have to be worked out. Of the greatest value, however, as examples, are pieces of work such as that now being carried on in England and other European countries for maternal and infant welfare, that of the New Zealand Society for the Health of Women and Children, the work of the Victorian Order of Nurses of Canada, and of the mayor of the little French town of Villiers-le-duc.1 Certain typical problems, characteristic of especial types of com munities in this country, may be outlined briefly. In many of the larger cities excellent prenatal and obstetrical care can be obtained b y those who can pay considerable sums for it and who realize its importance sufficiently to be willing to do so. In many cities, also, much progress has been made in the provision, through obstetrical clinics and hospitals, of good prenatal and obstetrical care, free or at Ipw cost, for those who otherwise could not afford it. Y et even in a city well supplied with such clinics the number of women reached is relatively small in comparison with the total number of women who bear their children without adequate care during pregnancy and labor. In many large cities, especially those with a large percentage of for eign or of colored population, the untrained midwife is a muchdiscussed problem. It is well known, moreover, that women of moderate means, who represent a very large proportion of women bearing children, have, in most modern cities, received least benefit from improvements in standards o f prenatal and obstetrical care. In working out plans for decreasing the death rate from childbirth in large cities the interests of this group can not be ignored. The problem must be considered as one which must be solved for all classes in a community; it must be realized that it is a problem of the greatest importance to the community as a whole. A very hopeful tendency is the one shown already in some cities, to look upon such service not as a charity but as a concern of the municipality as truly as the protection of its homes from fire and burglary or its milk and water supply from contamination. In rural districts the problems are essentially different. In many such districts, especially in the North and West, where -pioneer con ditions still prevail, the question is not one of good or bad obstetrical care but of the inaccessibility of any care at all at this time. Many women bear their children with no attendant other than the hus1 Rapport sur un Arreté Municipal pris par M . Morel de Villiers. Bulletin de l’ Académie de Médecine. 1904. 3« série, V o l. L I , p . 222. Moore, S. G . “ The Milroy lectures on infantile mortality and the rela tive practical value of measures-directed to its prevention.” Lecture I I I , Lancet, 1916. V o l. C X C , p . 943. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 27 band, a relative, or a neighbor. The nearest physician may be many miles away, the nearest hospital much farther. The expense of calling a physician must necessarily be great, and usually is, not considered justifiable. These women have of course no care during pregnancy; if complications develop they are unforeseen, and help is not available. As help in household tasks is usually unprocurable, many women must take up their work much sooner than they should. It may be urged that in practice it would be quite impossible for women living under rural conditions to be provided with such skilled supervision during pregnancy and such care at and after confinement as are now considered ideal. It certainly is not true, however, that a feasible community plan could not be worked out, if the interest of the community demanded it. Such a plan would necessarily recog nize two main problems: (1) The best practical care of normal cases and (2) the detection of abnormal cases and their care. A unit plan for a rural county would perhaps include: 1. A rural nursing service, centering at the county seat, with nurses especially equipped to discern the danger signs of pregnancy. The establishment of such a service would undoubtedly be the most economical'first step in creating the network of agencies which will assure proper care for both norm al. and abnormal cases. In the rural counties in the United States which already have established nurses, the growth of this work will be watched with the greatest interest. 2. An accessible county center for maternal and infant welfare at which mothers may obtain simple information as to the proper care of themselves during pregnancy as well as of their babies. 3. A county maternity hospital, or beds in a general hospital, for the proper care of abnormal cases and for the care of normal cases when it is convenient for the women to leave their homes for confine ment. Such a hospital necessarily would be accessible to all parts of the county. 4. Skilled attendance at confinement obtainable b y each woman in the county. As examples have been chosen the special problems in large cities and in pioneer rural districts. Other types of communities in this country present some of the same problems or others just as urgent. In each community, large or small, the essential problem is the same— how to bring about a general realization of the need for adequate care for each woman at childbirth, and how to secure such care. This report attempts to open for lay discussion and medical study the subject of the preventable loss of life caused by childbirth in this country. Greater interest in the subject surely will lead to the development of new and successful methods for the prevention of these needless deaths. * . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis P AR T II. D ETAILED A N A L Y S IS O F M E T H O D S AN D S T A T IS T IC A L D A T A .1 DISCUSSION OF CERTAIN TERM S AND METHODS USED IN TH IS REPORT. International Classification of Causes of Death. Official mortality statistics are derived from the returns of the causes of the deaths which occur annually. Such a return is made on the death certificate by the attending physician or by some person assumed to be familiar with the facts as regards the cause of death. Before the establishment in 1900 of the International Classification of Diseases and Causes of Death many different methods were used in different countries for the classification of these causes as returned on the certificates. The resultant confusion made difficult or impos sible the comparison of the mortality statistics of various countries and led to the proposal of this uniform method of classification, called the “ International Classification.” Various countries have adopted this system of classification at various times; the United States Bureau of the Census adopted it for use in the calendar year 1900; Great Britain for use in 1911. It is planned to keep this clas sification up to date through revisions at 10-year intervals. The second revision was made in 1909, and a considerable number of changes were made. Differences in classification between the Inter national List of Causes of Death and the lists in use in countries where the International has not been adopted and between the dif ferent revisions of the International List are extremely important, as will be shown, in any comparison of the death rates of various countries and of the same country for a series of years.2 In the detailed International List of Causes of Death, second de cennial revision, Paris, 1909, the heading “ V II— 1The Puerperal State” includes: (134) Accidents of pregnancy; (135) Puerperal haemorrhage; (136) Other accidents of labor; (137) Puerperal septichaemia; (138) Puerperal albuminuria and convulsions; (139) Phleg masia alba -dolens, embolus, sudden death; (140) Following child birth (not otherwise defined); (141) Puerperal diseases of the breast. The abridged International List of Causes of Death (same revir sion) makes but two divisions of all the causes of death included in the detailed list under The Puerperal State. These divisions are: (31) Puerperal septichsemia (puerperal fever, peritonitis), corre sponding to number (137) of the detailed list. 1 Part I I will be of interest chiefly to students of statistics. 2 For a discussion of this subject see Bureau de la statistique générale de la France: Statistique Inter nationale du Mouvement de la Population, 1913, p. 155*. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 29 30 M A T E R N A L M O R T A L IT Y . (32) Other puerperal accidents of pregnancy and labor, corre sponding to Nos. (134), (135), (136), (138), (139), (140), and (141) in the detailed list. In this report in the discussion of the Census figures and the tables, the classification of deaths according to the International List of Causes of Death, second revision, is used. The names for the differ ent groups have been slightly changed, as it was felt that the names used in the International List give a misleading or obscure impression to those unfamiliar with this list. In giving deaths and death rates the following terms and classi fication are used: (a) Childbirth, or all diseases caused by 'pregnancy and confine ment, which is the sum of (b) and (c) and corresponds to V II— The Puerperal State of the detailed International List and to the sum of (31) and (32) of the abridged International List. (b) Puerperal septicemia, or childbed fever, which corresponds to (31) Puerperal septichsemia of the abridged International List, and to (137) Puerperal septichsemia of the detailed International List. (c) A ll other diseases caused by pregnancy and confinement, which corresponds to (32) Other puerperal accidents of pregnancy and labor of the abridged International List, (134) to (136), and (138) to (141) of the detailed International List. A few words of explanation may be useful with regard to these diseases and complications. In the term “ accidents of pregnancy” the word “ accident” is not used in its ordinary sense but in the sense of complications due to the pregnant condition. It includes miscarriage, severe hemorrhage during pregnancy, uncontrollable vomiting, and other complications. “ Puerperal haemorrhage” includes severe hemorrhage at or follow-, rug labor. It includes placenta praevia. 11Other accidents of labor” includes cases of difficult labor, opera tive delivery, rupture of the womb, and other complications, except hemorrhage, occurring at the time of labor. “ Puerperal septichaemia” (childbed or milk fever) is an infection coming on after labor or miscarriage. “ Puerperal albuminuria or convulsions,” or “ eclampsia,” is an acute toxemia occurring during pregnancy, or during or after confine ment, characterized, in its severest form, b y convulsions. “ Phlegmasia alba dolens,” often known as “ milk leg,” is a disease characterized by the swelling of a leg after confinement or miscarriage. The cause is the stoppage of a large vein of the thigh b y a blood clot. “ Embolus” means blood clot. Sudden death may result from the carrying of such a blood clot to the heart or lungs. “ Following childbirth” (not otherwise defined) includes among other conditions insanity occurring after pregnancy or labor. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 31 “ Puerperal diseases of the breast” include inflammation or in fection of the breast during lactation. Death-registration area. The statistics of causes of death are available only for a certain portion of the United States, included in the so-called “ deathregistration area.” Unlike other civilized countries, the United States has no uniform laws for the registration of births and deaths. Moreover, the efficiency of enforcement of existing laws varies greatly in the different States. The Bureau of the Census in 1880 therefore established a “ death-registration area,” which comprises “ States and cities in which the registration of deaths is returned as fairly complete (at least 90 per cent of the total), and from which trans scripts of the deaths recorded under the State laws or municipal ordinances are obtained b y the Bureau of the Census.” 1 In 1880 this area included but 17 per cent of the total population of the United States. As States and cities have passed better laws and obtained better enforcement they have been added to the registra tion area; the latter has increased greatly in size, but even in 1913 included only 65.1 per cent of the population of the United States. For the remaining 34.9 per cent of the population of the country we have no reliable statistics. This 34.9 per cent includes the popula tion of the greater number of the Southern States and of many Middle Western and Western States outside of certain registration cities in these States which are included in the area. No statements can be made, therefore, of the number of deaths from any cause in the United States as a whole; only an estimate can be made on the assumption that for any cause of death the same rate prevails in the remainder of the United States as in the death-registration area. Provisional birth-registration area. The registration of births is still more incomplete in this country than is the registration of deaths. For 1910 the United States Bu reau of the Census established a “ provisional birth-registration area,” including the New England States, Pennsylvania, Michigan, New York City, and Washington, D. C.2 Methods of computing the death rates from all causes connected with pregnancy and confinement. (1) Death rates per 100,000 inhabitants.— T rask3 gives the defini tion, “ Death rates may be expressed as the ratio of the total number of deaths, taken as a Unit, to the population. For example: 1 in 60. The usual method, however, is to express these rates in terms of the 1 U . S. Census. Mortality Statistics, 1911, p. 9. 2 U . S. Census. Mortality Statistics, 1911, p. 25. 3 Trask, J. W . “ V ital statistics.” U . S. Public Health Service, Supp. to the Public Health Reports, N o. 12, p . 59. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 M A T E R N A L M O R T A L IT Y . number of deaths per 1,000 population, or in some instances per 10.000 or even 100,000, or 1,000,000.” In the publications of the United States Bureau of the Census the death rates of all diseases, including those of the diseases connected with childbirth, are usually expressed in terms of the number of deaths per 100,000 total popula tion. But a death rate computed in this way obviously gives a very misleading impression with regard to a disease to which only one group of the population is liable. In computing the death rate from the diseases connected with childbirth, only women of childbearing age should be considered, or, still better, only women actually bear ing children in a given year. All individuals of all ages and both sexes may be exposed each year to a risk of typhoid fever, pneumonia, or tuberculosis; but during the year only the women pregnant or bearing children are exposed to the risk of death from the diseases connected with these functions. (2) Death rates 'per 100,000 women— This method of computing rates is somewhat superior to that of computing the deaths per 100.000 total inhabitants. It is used to some extent in foreign reports. These rates have been computed from estimates of female population furnished by the United States Bureau of the Census for the years 1900 to 1910 for the group of 11 States within the deathregistration area in 1900. These are given in Table IV, on page 50. (3) Death rates per 100,000 women o f childbearing age} — Such a rate, which is a much more accurate one than either of those men tioned above, can be computed for the registration area for only one year, the census year 1900. For that year only has the age and sex distribution of the registration area been published. The number of women 15 to 44 years of age in the registration area in that year was 7,383,154.2 The number of deaths from childbirth among women 15 to 44 years was 3,712; of these 1,594 were from puerperal septicemia and 2,118 from all 'other diseases of pregnancy and confinement.3 The death rates were, therefore, from childbirth or all diseases caused by pregnancy and confinement, 50.3; from puerperal septicemia, 21.6; and from all other diseases of pregnancy and confinement, 28.7. (4) Death rates per 1,000 births.— As shown above, the method of computation of death rates which gives the clearest picture of the hazards of childbirth is that which takes into account only the women giving birth to children in that year. This is the method in use in a large number of foreign countries. The advantages of thé method are self-evident.4 A demonstration of the superiority of 1 The female population between the ages of 15 and 45 years as determined b y census enumeration or b y estimation for intercensal and postcensal years.— Trask, J. W . Supra cit., p. 23. 2 U . S. Twelfth Census, 1900. V ital Statistics, Part I , p . X L I I . a U . S. Twelfth Census, 1900. V ital Statistics, Part I I , p . 242. « Each death rate is in terms of registered, i. e ., living, births. This is a more accurate measure than a statement per 1,000 of total population or per 1,000 total or married women at childbearing ages.__Newsholme, A . Maternal Mortality in Connection w ith Childbearing. Grt. Brit. Local Govt. B d Sudd to Report of Medical Officer for 1914-15, p. 24. • https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 33 this method of computation is obtained by a study of the tables giv ing the death rates from these diseases for foreign countries. In cer tain countries, as for instance Belgium and Hungary, there has been in recent years an apparent fall in the average death rates as com puted per 100,000 population, while the average rates computed per 1.000 live births have remained stationary or risen. This phenom enon is due, evidently, to a decline in the birth rate in these countries during these years, and shows how misleading the-rates as given per 100.000 population undoubtedly are in countries with declining birth rates. Whether a fall in the birth rate has occurred in the United States is not known. If it has occurred in the registration area, it would mean that the slight rise in rates per 100,000 population between 1900 and 1913 means a greater rise in rates computed accord ing to the number of births. Such an error might compensate for the opposite error due to the more complete registration of deaths from childbirth in the later years of this period. In computing the rates per 1,000 births two methods are in use: The computation of the number of deaths per 1,000 total births and that per 1,000 live births. Both methods depend upon an accu rate registration of births; the first method is used in those foreign countries in which all births including stillbirths are required to be reported; the second, in those countries where only live births are reported. The first is probably tlie better method, because b y it the whole number of women bearing children in a certain year is considered. But even this rate is not absolutely accurate. While the number of deaths includes those from diseases connected with miscarriage, the whole number of women having miscarriages is not used as a base, but only the number of those bearing stillborn and five children. Miscarriages a re . not reportable in any country, although a number of miscarriages (as the term is usually defined) probably are reported as stillbirths in certain countries. The fact that women having miscarriages are not considered in the base would lead to a somewhat higher death rate than that which would express absolutely the number of deaths per 1,000 women at risk. On the other hand, in the computation of this rate the fact is not taken into consideration that a certain number of births are multiple; that is, the number of births is larger than the number of women bearing children. Still another objection to the use of this rate, especially in the comparison of the rates of different countries, is the fact that the definition of stillbirth varies greatly according to the laws of different countries;1 that is, in one country many cases may be reported as stillbirths which in another country, having a different 1 Royal Statistical Society. “ Report of special committee on infantile mortality.” Royal Statistical Society, 1913, Vol. L X X V I , p . 27. 6 4 6 1 4 ° — 17------ 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Journal of the 34 M A T E R N A L M O R T A L IT Y . interpretation of this term, might not be reported at all, as they would be classed as miscarriages. The second method, in which the number of deaths per 1,000 live births is considered, is that used by foreign countries in which the registration of stillbirths is not required. England and Wales, Ireland, Scotland, and New Zealand are among this number. The variation in different countries with regard to the definition of stillbirth causes a difficulty in the use of this method. In three of the countries studied— France, Belgium, and Spain— the term stillbirth includes infants alive at birth but dying before the regis tration of birth, i. e., within one to three days of birth. Because of these various difficulties, death rates for the foreign countries have been, wherever possible, computed by both methods. On account of the lack of accurate birth registration neither method has been used in computing rates for the United States. Only for States and cities in the provisional birth-registration area, and for one year, 1910, can the death rates per 1,000 live births be given. These are shown in Table VI* page 52. SOURCES OF ERROR IN THE STUDY OF DEATH RATES FROM CHILDBIRTH. In all mortality statistics, and especially in those with which we are especially concerned in this bulletin, there are two general sources of inaccuracy in the figures: First, the figures for each year may be inaccurate, or may give an incomplete picture of actual conditions because of many different factors, such as incompleteness or inac curacy of the figures, inappropriate methods of classification or computation, etc. Second, the figures for different years may not be comparable simply because of the great improvements that are made each year in methods of registration, computation, and classifica tion. With the object in view of giving each year as accurate and clear a picture of the actual conditions as possible, tremendous advance in methods has been made yearly in this country and in other countries. This very advance, however, brings with it many difficulties in comparing the figures for the years before such improvements were instituted with those of the years after that time. Each year the figures give us more accurate information of the actual number of deaths and of the death rates; yet each year the comparison of the figures for that year with those in the past is fraught with more danger of error. In general, therefore, the study of the actual number of deaths and the death rates -for the last years for which figures are obtainable is more valuable than any comparison of rates for different years. All these sources of errorwill now be discussed in detail. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A TERN A L M O R T A L IT Y . 35 Ináccuracy of returns. As all mortality statistics depend upon the returns of the cause of death as given by the physician or other person on the death certifi cates, their value depends on the degree of accuracy of diagnosis shown by these returns. As Hoffman1 has pointed out, the returns for countries in which a medical certificate of the cause of death is not required must he of very small value. He states, however, that “ For most of the civilized countries this requirement is met to a reasonably satisfactory degree.” The objection has frequently been raised, however, that there is a large percentage of error even in the returns made b y physicians due to mistakes in diagnosis, such errors being more numerous in the case of certain diseases than of others. This matter has been considered by the United States Bureau of the Census.2 Hoffman3 defends the general validity of the death returns. He admits that there is serious risk of error in the “ Careless or superficial use of the data of mortality statistics, irrespective of the diseases dealt with; for, as pointed out by Longstaff, * * * ‘ there are numerous fallacies to which the classification of deaths according to their alleged causes is liable/ and he enumerates particularly * * * the more or less varying, pro portions of indefinite causes, the deliberate falsification of returns for personal or family reasons, and the effect of the progress o f medical science, improved diagnosis, etc.” Hoffman, however, concludes: “ All of these reasons notwithstanding, the conclusion appears to be incon trovertible that on the whole the present system of death registration is entitled to confidence and the results approximately represent the true state of the nation’s health.” With regard to the diseases in question, however, inaccuracy of the returns undoubtedly constitutes a special source of error in the figures for all countries. The statistics of deaths due to puerperal septicemia (childbed fever or infection at the time of miscarriage or childbirth) are without question very incomplete. Many deaths due to this disease are reported, for obvious reasons, as due to some other condition or to some general condition, such as septicemia, pyemia, and the like. This fault in all statistics on the subject has been commented on very frequently both in this country and in foreign countries.4 1 Hoffman, F . L . The Mortality from Cancer Throughout the W orld, 1915, p. 2. 2 TJ. S. Census. Mortality Statistics, 1912, p. 24. * Hoffman, F . L . Supra cit., p. 3. 4 (a) It is very difficult to make accurate statements as to the frequency of puerperal infection, especially when it occurs outside of hospital practice. Concerning this condition the vital statistics of the health officers of the various American cities are. of no value, inasmuch as the vast majority of deaths from this disease are returned as being due to malaria, typhoid fever, pneumonia, or other causes.— William s, J. W . Obstetrics, 1913, p. 900. (6) It is very difficult to estimate the frequency of puerperal infection outside of hospitals, since m any deaths are reported as due to typhoid, malaria, pneumonia, etc.— Edgar, J. C. The Practice of Obstetrics, 1903, p. 752. (c) It is not unlikely, furthermore, that in a considerable number of deaths due to childbearing the fact that they are associated w ith childbearing escapes certification. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 M A T E R N A L M O R T A L IT Y . It follows, however, that almost never is a case reported as due to infection at confinement when it is really due to some other cause; in other words, the figures though undoubtedly incomplete are reliable as far as they go;, they are a statement of the minimum number of cases which have occurred. As Newsholme remarks,1 many cases of puerperal septicemia probably are reported as due to other conditions associated with childbirth; so that the total figures for all diseases associated with this condition should always be noted, although it may be the figures for puerperal septicemia in which our immediate interest lies. Many deaths due to other complications of pregnancy and con finement are also undoubtedly reported under other headings. This is especially true of cases of puerperal albuminuria and con vulsions, which are reported as due to acute nephritis or simply to convulsions; and of hemorrhage or phlebitis following miscarriage or labor, reported without reference to their connection with child birth. Limited area and short period of time represented by figures. In, the United States the limited area of the country (the deathregistration area) for which any figures are available is an element of weakness in the statistics. Though this area and its population are absolutely very large, they can not be considered as representa tive of the entire country. Any estimate based on the figures for the registration area is open to criticism on account of differences in age and sex distribution in different parts of the country. In the United States the short period for which any figures are available lessens greatly the value of a study such as this. In foreign countries comparisons of the death rates for a long series of years may be made, even though errors due to lack of comparability of the figures may occur. In this country information is available Deaths from puerperal fever are likely also to be understated; and the desirability is confirmed of basing inferences as to excessive mortality from childbearing on all the conditions concerned in this mortality, and not merely on the death returns for puerperal fever.— Newsholme, A . Supra cit., pp. 26, 30. (d) It m ay be objected that owing to faulty registration and deficient death certification the returns are not reliable. T h at this objection m ay have some weight in estimating the amount of mortality, especially as regards puerperal fever (in which for obvious reasons the death returns are avowedly defective), I fully admit; bu t, as this communication seeks to compare the mortality of one year with that of another and of one part of the kingdom w ith that of another, and as the sources of error apply to each, the result can not be materially affected. In estimating the true amount of mortality, however, a mental correction should certainly be made for this obvious source of error.— Boxall, R . “ The mortality of childbirth,” Lancet, 1893, V o l. I I , p . 10. (e) Warren, S. P. “ The prevalence of puerperal septicemia in private practice at the present time, contrasted with that of a generation ago.” Am er. Jour, of Obstetrics, 1905, V o l. L I , p. 301. 1 B u t the above extreme local variations in the proportion between deaths from puerperal fever and from other dangers of childbearing suggest that in death certification there m ay be local variations in the extent to which deaths from puerperal fever are returned under the heading of other conditions associated with childbearing. * * * O n the whole, it is likely that in comparing counties and county boroughs with each other, the safest plan is to utilize only the death rates from the two sets of conditions taken together.— Newsholme, A . Supra c it., p . 26. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 37 only for the census years 1880, 1890, and 1900 and for the calendar years from 1900 to 1913, inclusive. Moreover, the area covered by the reports previous to 1890 was so small that any comparison between years prior to 1890 and years subsequent to that date has seemed unwise. Methods of computation. In the United States the computation of the death rates from the diseases in question by a method (computation per 100,000 total popu lation) giving but an inaccurate picture of the facts is necessarily a source of error in the study. This method also makes difficult a com parison of the death rates with those of foreign countries. Sources of error in comparisons of death rates of different years. There are many special sources of error involved in the comparison of death rates of the registration area of the United States from these causes in different years. First. Differences in the constitution of the death-registration area cause one of the most important difficulties in comparison. As before stated, the death-registration area is not an unchanging entity, but has been added to almost yearly as registration has improved in various States and cities. This constant increase con stitutes a serious source of error in comparing the death rates for this area for different years. Within the course of the years studied, States or cities having a particularly high or low rate from the disease in question may have been added to the registration area.1 This difficulty is so serious that in making comparisons of the death rates in the registration area of the United States from a certain disease through a series of years the publications of the United States Bureau of the Census always point out the influence which the inclusion of a certain State may have had upon the rate of the disease in question for the registration area. The same method may be applied, for example, to a comparison of the death rates from childbirth in the registration area for the years 1909 and 1910. In 1909 the rate for the registration area was 15.3; in 1910, 15.7. In 1910, however, four States—Minnesota, Montana, Utah, and North Carolina2— were added to the registration area and one State— South Dakota— was dropped. In that year the death rate from childbirth in Minnesota was 11.9 per 100,000 inhabitants, in Montana 16.4, in Utah 18.4, and in the municipalities of North Carolina 30.7. That in South Dakota in 1909 was 21.7 for the urban and 12.9 for the rural portions of the State. Evidently the exact determination of the effect which the inclusion or exclusion of any one of these States exerted upon the death rate of the regis tration area is a complicated matter. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1 U . S. Census. Mortality Statistics, 1909, p . 9. 2 Municipalities of 1,000 or more inhabitants in 1900. 38 M A TERN A L M O R T A L IT Y . It was thought wise, therefore, in this study to make, in addition, to a comparison of the death rates from childbirth in the registration area for 1890 and from 1900 to 1913, a comparison of the death rates shown (1) for the same series of years by the group of States which have been registration States since 1890, and (2) for the years 1900 to 1913 by the group of States which have been registration States since 1900. Obviously these two comparisons contain no error due to changes in the groups of States compared from year to year. The group of eight States which have been registration States since 1890 includes all the New England States except Maine, also New York, New Jersey, and the District of Columbia. (See Table II, p. 49.) For this group of States no permanent decrease has occurred in the death rate from childbirth per 100,000 population in the 23 years studied. There was a decrease in the rate between 1890 and 1900, followed by a rise, and then by slightly fluctuating rates. The rates for 18901 and 1913, however, are almost identical— 14.1 and 14.3 per 100,000 inhabitants. The rates for the second group of 11 States show no decline but rather an increase in the 13 years from 1900 to 1913. These States have been registration States since 1900 and include, besides the 8 above mentioned, Maine, Michigan, and Indiana. The death rate from childbirth in 19002 was 13.4; in 1913, 14.9; with fluctuations between 12.7 and 15.5. The fact that the death rates from childbirth show no decrease in the registration area from 1890 to 1913 (see Table I, p. 49) is there fore corroborated b y the two comparisons just made. The rates for this area also show fluctuations from year to year, but are nearly identical for 1890 and 1913, i. e., 15.3 and 15.8. This possible source of error in the comparison of the rates in the registration area for different years, therefore, is shown to be of practical unimportance. A comparison of the three Tables I, II, and III brings out several interesting facts. Tables I and II both show a decline in the rates between 1890 and 1900; this fall is followed b y a corresponding rise and fluctuating rates. The rates for the group of 8 States shown in Table II are almost uniformly slightly lower for each year than are those of the death-registration area shown in Table I. Second. The most important source of error in the comparisons of the death rates of various years is due to the improvements which have been made yearly in the accuracy of the returns of the cause of death. In each State, newly admitted to the registration area, improvements are made continually in the completeness and accuracy of the death returns. In addition one special improvement has been made in the returns in the registration area. 1 Census year ending M ay 31. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 Calendar year M A TERN A L M O R T A L IT Y . 39 It has already been pointed out with regard to the diseases under consideration that deaths due to puerperal septicemia and to other complications of pregnancy and confinement are frequently reported, as due to such indefinite causes as septicemia, pyemia, hemorrhage, phlebitis, convulsions, etc. In several foreign countries the attempt has been made for some years to render the records more complete by making inquiries*as to cases of death of women of childbearing age where the cause of death is an indefinite one of this character. To each physician making such a report for a woman of childbearing age a confidential inquiry is sent, asking whether or not the cause of death had any relation to childbirth or miscarriage. Boxall1states that this has been done in England since 1881 and has resulted in an increase of about 12 per cent in the number of cases reported as due to puerperal septicemia. In this country since about 19062 the State registrars of vital statistics have cooperated with the United States Bureau of the Census in making their reports more complete through this practice. For several years2 the Census Bureau has made an inquiry in many cases where the cause of death of a woman of childbearing age has been returned to it as septicemia, pyemia, or peritonitis, and additional cases of puerperal septicemia have been added in this way. That bureau is unable, however, to estimate the percentage of cases which have thus been added. In a test3 in which a number of letters of inquiry were sent to physicians returning deaths as due to meningitis, paralysis, convulsions, pneumonia, and peritonitis, 102 cases returned as peritonitis were thus investigated. Eight cases were changed to puerperal septicemia following the answer to these inquiries. The following statement is made: “ I f the percentages of change result ing from this investigation, which, though limited, may prove to be fairly representative, be applied to the numbers of deaths compiled from the various causes for the registration area for 1911, * * * some of the definite causes would be increased as follows: * * * Puerperal septicemia from 4,376 to 4,560, or 4.2 per cent.” 3 Without doubt, therefore, the records in this country since 1906, and especially since 1912, are more complete than those for previous years.4 ‘ Obviously greater accuracy of the returns leads to an apparent rise in rate, even when the true death rate is stationary or declining slightly. It is impossible to estimate how great has been the influence 1 Boxall, R . “ Mortality in childbed, both in hospital and in general practice,” Jour, of Obstetrics and Gynaecology of the'British Empire, 1905, Vol. V I I , p. 322; Newsholme, A . Supra cit., p. 25. 2 Statement b y Chief Statistician for Vital Statistics, U . S. Bureau of the Census. 3 U . S. Census. Mortality Statistics, 1911, pp. 37,38. * Similar improvements in the records for other causes of death have been made in recent years through the method of making similar inquiries w ith regard to deaths reported as due to such indefinite causes as simple meningitis, paralysis without specified cause, etc. See U . S. Census. Mortality Statistics, 1912, pp. 23, 24, and D ublin, L . I .,a n d K opf, E . W . “ A n experiment in the compilation of mortality sta* tistics,” Quart. Public, of the Amer. Stat. Assn., 1913, Vol. X I I I , p. 639. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 M A T E E N A L M O E T A L IT Y . of this factor upon the death rates of childbirth and of puerperal septicemia since 1900. As an index the changes in the death rates •for the death-registration area from the indefinite causes, “ purulent infection and septicemia,” “ simple peritonitis,” “ convulsions/’ and “ hemorrhage, other diseases of the circulatory system,” between 1900 and 1913 should be studied. It is significant that the average death rate from purulent infec tion and septicemia, which in 1901-1905 was 6.1 per 100,000 popu lation, fell in 1906-1910 to 3.8 and then decreased steadily, being 2.8 in 1913.1 In the same way the death rate from simple peritonitis, which was 10.8 in 1901-1905, fell to 6.1 in 1906-1910 and 2.7 in 1913.1 The other causes mentioned have shown a decline which is much less marked. As these death rates represent those of the entire population, not those of women of childbearing age, their decline can be ascribed only in part to the fact that a number of cases formerly returned as due to these causes are now ascribed to puerperal septicemia and other diseases caused by pregnancy and confinement. It is plain, however, that this factor has been a very important one in deter mining their decrease. In general, then, it may be stated that recent improvements in death certification must be borne in mind in making comparisons of the death rates from childbirth since 1900; that these improvements probably account for the apparent rise in the death rate between 1900 and 1913, and may, indeed, conceal a slight actual decrease in the rates during those years. It is not, however, probable that any substantial decrease in rate has been concealed in this way. The comparisons made in Tables II and III of rates for the group of 8 States which have been in the registration area since 1890 and for that of 11 States which have been in this area since 1900 are probably less subject to this source of error than is a comparison of rates for the registration area. In the States in which registration has been good for a number of years improvements made in the returns for the more recent years will not be so marked a factor. Third. A third source of error in the comparison of death rates for various years in this country results from the changes in classi fication of causes of death which have been made. In the United States the International List of Causes of Death was adopted for use in the calendar year 1900. A different classification was in use be fore that time. The group of diseases included in the' older classi fication under “ Affections connected with pregnancy” are included under the title “ The puerperal state,” Division Y II of the detailed International List (see p. 29), corresponding to the terms “ Child- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis i U . S. Census. Mortality Statistics, 1913, pp. 53,54. M ATERN A L M O R T A L IT Y . 41 birth” or “ All diseases caused by pregnancy and confinement” as used in this bulletin. Therefore these large groups can be compared for the census years 1890 and 1900 and the calendar years 1900 to 1913. The title puerperal septicemia of the older classification does not correspond, however, to that of “ puerperal septichsemia ” of the International Classification. Nevertheless, it has been thought best to print the figures for puerperal septicemia for the census years 1890 and 1900 with the warning that these figures are not exactly comparable with the figures for this disease for the calendar years 1900 to 1913. At the second revision of the International Classi fication, in force for the registration area January 1, 1910, several changes were made in the classification of the group of diseases with which we are concerned, i. e., “ The puerperal state.” These changes do not affect the whole group, but only the subgroups, especially No. 137, “ Puerperal septichsemia.” Three causes of deaths included under this heading under the first revision were removed and in cluded under other headings; these are: Puerperal toxemia, in cluded now under 138; puerperal phlebitis, changed to a separate heading, 139; and retention of the placenta, now included under 135. No other groups previously not included were added to “ Puerperal septichsemia” in that year. These changes would naturally cause a decrease in the number of deaths ascribed to puerperal septicemia and a corresponding decrease in the death rate for this disease, with an-increase in the rate of those included under “ Other diseases caused by pregnancy and confinement.” This must be remembered in comparing the rates for years succeeding 1910 with those preceding it, both in the United States and in all other countries studied. How far this change in the death rate for puerperal septicemia com pensates in the United States for the opposite error due to the more complete returns for this disease brought about by the inquiries sent by the Bureau of the Census it would be impossible to say. Sources of error in a study of foreign statistics. It may be claimed that a comparison of the vital statistics of various foreign countries involves a certain risk of error due to differences in the methods of registration employed in the various countries and in the degrees of accuracy of the returns. For instance, the compara tively low death rate of a certain country may be explained as being due to the incompleteness of the returns in that country. Beyond this source of error, which can not be avoided, two other especial sources appear to exist in the comparison of the death rates from the diseases caused by childbirth. The first one is that already treated at some length, i. e., the development of errors due to the different methods used by different countries in computing the rates. This source of error has been avoided by reckoning the rates uniformly for https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 42 M A T E R N A L M O R T A L IT Y . each country in the group considered according to two different methods, i. e., per 100,000 total population and per 1,000 live births. While neither method of computation is an ideal one, it has been neces sary to use them as they alone, give a basis of comparison of the rates of all the countries considered. A second source of error has also been alluded to ; it is the lack of uniformity in methods of classification of the causes of death. Many of the countries under consideration have not used the Inter national Classification at all, or only for a portion of the period stud ied. As the best means available for avoiding this difficulty, the figures for each country have been used as published in the Statistique Internationale du Mouvement de la Population d’ après les Registres d’Etat Civil, prepared by the Ministère du Travail, Bureau de la Statistique Générale of France. In this publication figures for coun tries not using the International Classification have been rearranged to conform as nearly as possible to the divisions of the International List. Figures, however, are available from this source only up to the year 1910; for the years following, figures have been obtainéd from the latest available original reports of each country. For those coun tries not using the International Classification the figures have been rearranged in the, same way to conform to it as nearly as possible.1 Slight differences in methods of classification will probably not affect the death rates to any great extent, nor will they often affect the number of deaths, and consequently the death rates, of the whole group of diseases— “ The puerperal state,” or “ All diseases caused by pregnancy and confinement.” Only the proportion of deaths to be ascribed to either of the two subgroups “ puerperal septicemia ” and “ other diseases caused b y pregnancy and confinement,” will be affected. A rearrangement of the deaths within the group, ascribing a larger number of deaths to puerperal septicemia will bring, of course, a decrease in those reported as due to “ other diseases caused b y pregnancy.and confinement.” For this reason, therefore, the total number of deaths for the large group and the death rate for this group are more important than those of the subgroups. (See p. 36.) An exception to the statement in regard to the differences in method of classification must be made for the figures of England and Wales. Previous to 1911, the year in which the International Classification was adopted, a certain group of deaths almost universally included under the large group “ The puerperal state” or “ All diseases caused by pregnancy and confinement” was not included in the English and Welsh figures, i. e., deaths due to puerperal nephritis and albu minuria. Consequently in these earlier years the reports of deaths i On pages 57 to 59 will be found especial notes as to difficulties encountered in the reclassification of the figures of various countries. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 43 ascribed to childbirth or all diseases caused by pregnancy and confinement are incomplete and the death rates from this group of causes are lower than would have been the case had the International Classification been used. This fact must be remembered in making comparisons between England and Wales and other countries. The amount of the error, which is not a very large one, can be estimated by noting the number of deaths annually reported from this cause for the years 1911 to 1914. (See p. 58; also Table X V , p. 60.) Whether or not there is the same incompleteness in the figures of other coun tries could not be learned from the reports. In general, foreign statistics have been used in this report as giving a rough estimate of actual conditions. Unfortunately more exact information is not in existence. It has not been considered wise, in view of the possibilities of error in the material, to use any method of analysis which assumes a higher degree of accuracy than can be attributed to all the existing figures. FOREIGN STATISTICS. Comparison of the average death rates from childbirth in certain foreign countries and in the United States. 1. Average death rates per 100,000 population.— In order to obtain a basis for comparison with the rates for the death-registration area of the United States jyhe average rates for 15 foreign countries have been reckoned according to the number of deaths per 100,000 population. These rates are given in Table X II, on page 56, in which the countries are arranged in order, the one having the lowest rate being first. Many of the countries show rates differing but very little from that of the United States. The rates for 9 of the 16 countries vary between 12.4 and 15.2, while that of the registration area is 14.9. Other facts brought out by this table are mentioned bn page 22. 2. Average death rates per 1,000 live births.:—It has been realized that the average death rate from these diseases as above computed gives a very misleading idea of the actual death rate on the basis of the number of women bearing children. Differences in the age and sex composition of the population of the countries studied, and, above all, differences in the birth rate, obviously lead to great error. Un fortunately the rate per 1,000 births can not be given for the deathregistration area of the United States, though it can be given for one year (1910) for the provisional birth-registration area. This rate is 6.5 per 1,000 five births. The comparison of such a rate, for a limited area of a country reckoned only for one year, with average rates of other countries reckoned for a series of years, is of course unfair. Still it is a noteworthy fact that the rate for this small area of the United States is considerably higher than that for any country in the group considered. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 44 M A T E R N A L M O R T A L IT Y . Table X II I, page 56, gives the average death rates reckoned per 1,000 live births for the 15 foreign countries already studied arranged in order, the one having the lowest rate being first. The order here shows a considerable variation from that in the previous table. How ever, the same group of countries shows the lowest rates computed according to either method of computation; these are Sweden, Italy, and Norway. Similarly, the highest rates in both tables are shown b y a second group of countries— Belgium, Spain, Switzerland, Aus tralia, and Scotland. The rates for Ireland form an exception. The rate for that country, reckoned per 100,000 inhabitants, is only moderately high; reckoned per 1,000 live births, however, it is one of the higher rates. 3. Percentage o f deaths caused by puerperal septicemia.— Another interesting feature of the foreign figures is the great variation shown among the different countries in the percentage of the total deaths from childbirth which are ascribed to puerperal septicemia. Table X IV gives these figures for each country for as large a part of the period 1900 to 1910 as figures are available. As pointed out fre quently throughout this report, on account of the inaccurate returns from puerperal septicemia the total rate from childbirth is a more reliable one than is the rate from puerperal septicemia; therefore, sweeping conclusions can not be based on these comparisons. Other wise these figures would be extremely significant, as the deaths from puerperal septicemia are the most easily preventable of all the deaths from childbirth. In the larger number (11) of the 15 foreign countries studied the deaths from puerperal septicemia constitute from 30 to 50 per cent of the total number of deaths from childbirth. In the registration area of the United States they represent 44 per cent. Norway, 51.2 per cent, and Spain, 62.8 per cent, show the only two percentages higher than 50; New Zealand, 25.2 per cent, and Hun gary, 26.7 per cent, show markedly low percentages. Comparison of the changes in the death rates from childbirth in certain foreign countries for the years 1900 to 1913. Far more valuable than a comparison of average, rates of foreign countries is a study of the rates of each country for a series of years in order to discover whether they are decreasing or increasing and to com pare such changes in the various countries. While it may be dangerous on account of different methods of registration and classification to compare the rates of different countries, no such source of error is attached to the comparison of rates in the same country for a num ber of years. The period 1900 to 1913 (or the latest year for which figures are available) is a very short one for a study of a change in death rates. It would have been far more interesting to study the death rates for a long series of years in each country, choosing a https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 45 period beginning before tbe introduction of methods of asepsis. But such a study for the complete list of countries considered was not thought advisable, because of the difficulties caused b y variations in classification of causes of death in the earlier years. In order to study the rates for any increase or decrease occurring during the last 13 years, the rates per 1,000 1 live births will be used rather than those per 100,000 population. In several countries— Belgium, Hungary, Italy, Norway, Prussia, and Spain— the rate from childbirth per 100,000 population apparently has fallen during the period, while the rate per 1,000 live births has remained almost the same, or has risen. The cause of this inconsistency, as ex plained on page 33, is the fact that in these countries the birth rate or the proportionate number of births to the number of inhab itants has decreased. Average death rates for the foreign countries studied are given for periods of from 3 to 5 years in Table X V I. Differences in averages from period to period are more significant than differences in rates from year to year, and they indicate more accurately and readily whether death rates in a given country are increasing or decreasing. In preparing Table X Y I it would have been more satisfactory to base averages on identical five-year periods for all countries, but since the periods for which the information was available varied so widely in different countries, this procedure was impracticable, and the com plete periods were divided into as nearly uniform subperiods as possible. The countries will be considered in different groups. Countries showing a decrease in the death rates from all diseases caused by 'pregnancy and confinement.— England and Wales show a fall in the total death rate from these diseases and also a fall in the death rate from puerperal septicemia in the years between 1900 and 1914.2 The total death rate per 1,000 live births fell from 4.4 in 1900-1904 to 3.7 in 1910-1914. The death rate from puerperal septicemia per 1,000 live births was 1.9 in 1900-1904, and 1.4 in 1910-1914. The still greater apparent drop in the rates per 100,000 inhabitants will be noted. This decrease in the rates from these diseases in England and Wales since 1900 is especially important because the lack of decrease for a long period of time before 1900 has been the subject of considerable discussion. B oxa ll3 in 1893 and 1905 published two reports which aroused medical interest. Based on studies of the figures published by the 1 The rate per 1,000 live births w ill be found in column 8 of Table X V , p. 60. 2 In studying the figures after 1910, only the figures given as 1911 (a) and 1912 (a), etc., m ust be compared w ith the figures of years before 1910, for the reasons explained on p . 58. . 3 Boxall, R . “ The mortality of childbirth,” Lancet, 1893, V o l. II, p . 9; “ Mortality in childbed, both in hospital and in general practice.” Jour, of Obstetrics and Gynaecology of the British Empire, 1905, V o l. V I I , p . 315. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 46 M A T E R N A L M O R T A L IT Y . registrar general, these reports comment on. the lack of decrease in the total mortality from childbirth and from puerperal septicemia in the period since the introduction of methods of antisepsis. Sir Arthur Newsholme, medical officer of the Local Government Board of England, published last year a most interesting report on maternal mortality in connection with childbearing in England and Wales.1 The report in question will no doubt be the inspiration of studies of this subject in many countries, just as it has been of the present report on conditions in the United States. He finds that from 1874 to 1893 there was no decline in the rates from puerperal septicemia, or from other conditions associated with childbirth, but that since 1895 there has been a marked decline in the rate from puerperal septicemia and a decline in the total rate from childbirth. There has been, however, little change in the death rate from condi tions other than puerperal septicemia caused b y childbirth. He writes: “ Even so far as puerperal fever is concerned, notwithstand ing the improvement already secured, it must be regarded as highly unsatisfactory that in 1914 for every 644 infants bom 1 mother lost her life from puerperal infection, either present before the birth of the infant, or more often acquired during or soon after its birth. A large portion of this mortality, with its still greater amount of asso ciated sickness, could at once be prevented were adequate antenatal care and skilled attendance under satisfactory conditions at and after birth made available.” 1 The interest in this subject in England is reflected in several acts which have been passed in recent years with the object of securing better antenatal and confinement care for all women at childbirth. These are the midwives act, 1902; the notification of births act, 1907; the notification of births (extension) act, 1915, the maternity benefits under the national insurance act, and the voting of grants b y Parliament in aid of work done b y local authorities and voluntary agencies to promote maternal and child welfare work. The rates for Ireland show a decrease in the death rate from child birth. In 1902 to 1906 the rate was 5.8; in 1911 to 1914 it was 5.2. There was also a slight decrease in the rate from puerperal septicemia. Japan shows also a fall in the rate from childbirth from 4.2 in 19011904 to 3.6 in 1909-1912. The death rate from puerperal septice mia, however, has increased slightly. The rates for New Zealand and Switzerland have also shown a decline in the periods studied. Countries showing „almost stationary rates from the diseases caused by pregnancy and confinement.— This group includes all the remaining countries considered except Scotland. In several of these countries i Newsholme, A . Maternal Mortality in Connection w ith Childbearing. B d ., Supp. to Report of Medical Officer for 1914-15, pp. 22, 23. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Grt. B rit. Local Govfc. M A T E R N A L M O R T A L IT Y . 47 there has been a slight fall or rise in the rates between the first and last period, amounting in each case to less than 0.5 of 1 per 1,000 live births. In Prussia no demonstrable fall has occurred in the rate per 1,000 live births from all diseases caused b y pregnancy and confinement, nor in that from puerperal septicemia. The total rate in 1903 to 1906 was 3.2; in 1907 to 1910 it was 3.1. The almost stationary rates for Australia, Belgium, Hungary, Italy, Norway, Spain, and Sweden will also be noted in the tables. In all of these countries numerous physicians have called attention to the stationary or rising death rates from childbirth and from childbed fever. A large medical literature has grown up on this subject. Yon H erff1 comments on the figures published b y Krohme, showing for Prussia an increasing death rate from puerperal septi cemia in the years 1901 to 1904. He attributes it to the laxity of physicians in carrying out antiseptic methods and to the unneces sarily frequent use of forceps and to other obstetrical operations. Buess 2 and W in ter3 are among those who have written more recently on the question of these death rates in Switzerland, East Prussia, and other European countries. Countries showing a rise in rates.—-The total mortality rate from diseases of childbirth for Scotland has shown a definite increase from 5.1 per 1,000 live births in 1901-1905 to 5.8 in 1911-1914. This in crease, however, has not been due apparently to an increase in the rate from puerperal septicemia; in fact, this rate has shown a fall. 1 V on Herff, O . “ W ie ist der zunehmenden Kindbettfiebersterblichkeit zu steuern ? Minderung der Operationen. Besserung der Desinfektion in der Hauspraxis.” Münchener Medizinische Wochenschrift, 1907, V o l .L I V ,p . 1017. 2 Buess. Zeitschrift für Geburtshülfe und Gynäkologie, 1915, V o l. L X X V T I , p . 735. 3 W inter. “ D ie Bekämpfung des Kindbettfiebers in Ostpreussen.” Deutsche Medizinische W ochen schrift, 1908, V o l. X X X I V , p . 2244. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PART III. GENERAL TABLES T a b l e ] . — P o p u la tio n , deaths, and death rates per 1 0 0 ,0 0 0 p o p u la tio n in the deathregistration area fr o m diseases caused by pregnancy and con fin em en t, 1 8 9 0 and 1900 to 1 9 1 3 . • Deaths from diseases caused b y pregnancy and confinement. Population of deathregistration area. Rate per 100,000 population. Number. Year.1 Total. 1890 3..................................... 1900 3. .. ................................ 1900....................................... 1901....................................... 1902....................................... 1903....................................... 1904....................................... 1905....................................... 1906....................................... 1907....................................... 1908....................................... 1909....................................... 1910....................................... 1911....................................... 1912....................................... 1913....................................... Annual average: 1901 to 1905........ 1906 to 1910................ 19,659,440 28,807,269 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 53,843,896 59,275,977 60,427,247 63,298,718 Per cent of popu lation of United States. Total. 31.4 37.9 40.5 40.3 40.4 40.4 40.4 40.4 48.9 ... 49.2 52.5 56.1 58.3 63.1 • 63.2 65.1 Puer peral septi cemia. A ll other. Total. Puer peral septi cemia. All other. 3,011 3,772 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 »1,383 3 1,619 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 1,628 2,153 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 15.3 13.1 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 3 7.0 3 5 .6 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 8.3 7.5 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 8.6 4,643 7,330 2,057 3,224 2,586 4,106 14.2 15.5 6.3 6 .8 7.9 8.7 32,699,843 47,300,947 1 Calendar year, unless otherwise specified. 3 Census year ending M ay 31. 3 Figures for puerperal septicemia for the census years 1890 and 1900 not comparable w ith those for later years. See p. 4i. T a b l e I I .— D eaths and death rates p er 1 0 0 ,0 0 0 p o p u la tio n in the 8 S ta tes w ith in the death-registration area in 1 8 9 0 1 fr o m diseases caused b y preg n a n cy and con fin em en t, 1 8 9 0 and 1 9 0 0 to 1 9 1 3 . Deaths from diseases caused b y pregnancy and confinement. Number. Year.3 Total. 1890».............................................................................. 1900 ». . ............................................................... 1900 ........................................................................... 1901............................................................................... 1902............................................................................... 1903............................................................................... 1904 ............................................................................. 1905................................................. ............................. 1906...... ......................................................................... 1907............................................................................... 1908 .............................................................................. 1909............................................................................... 1910........................................... .................................... 1911................................................... ............................ 1912..................................................................... .. 1913............................................................................... 1,655 1,806 1,905 i;903 1,842 1,998 2,305 2,434 2,434 2,595 2,450 2,537 2,608 2,722 2,574 2,707 Puer peral septi cemia. <698 <791 798 747 762 801 996 1,033 989 1,086 1,050 1,034 1,145 1,179 1,049 1,140 Rate per 100,000 population. A ll other. 957 1,015 1,107 1,156 1,080 1,197 1,309 1,401 1,445 1,509 1,400 1,503 1,463 1,543 1,525 1,567 Total. 14.1 12.6 13.3 13.0 12.4 13.1 14.9 15.4 15.0 15.6 14.4 1415 14.6 14.9 13.9 14.3 Puer peral septi cemia. A ll other.' < 6.0 < 5.5 5.6 5.1 5.1 5.3 6.4 6.5 6.1 6.5 6.2 5.9 6.4 6.4 5.6 6.0 8.2 7.1 7.7 7.9 7.2 7.9 8.4 8.9 8.9 9.1 8.2 8.6 8.2 8.4 8.2 8.3 t Excluding Delaware. 3 Calendar year, unless otherwise specified. 3 Census year ending M ay 31. ., .... , , . 1 Figures for puerperal septicemia for the census years 1890 and 1900 not comparable w ith those for later years. See p . 41. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 49 50 M A T E R N A L M O R T A L IT Y . I I I .— D eaths and death rates p er 1 0 0 ,0 0 0 p o p u la tio n in the 11 S ta tes w ith in the death-registration area in 1900 fr o m diseases caused by pregnancy and con fin em en t, 1 90 0 to 1 9 1 8 . T able Deaths from diseases caused b y pregnancy and confinement. Number. Rate per 100,000 population. Y ear.1 Total. 1900 2............................................................................. 19ÓÓ........................................................... .................. 1901 ............................................... ........................ 1902 ...............................................1.................. 1903 ........................................... - ......................- ____ 1904............................................................................. -. 1905 .............................................................................. ................................................................. 1906 Í907 .............................................................................. 1908 ..................................................................... 1909 ........................................................................... 1910 ......................................................................... 1911................................................................................ 1912___ ; ....................................................................... 1913................................................................................ 2,568 2,682 2,704 2,626 2,778 3,216 3,219 3,229 3,448 3,343 3,422 3,641 3,806 3.527 3,789 Puer peral septi cemia. '* 1 ,1 5 0 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 All other. 1,418 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 Total. 12.9 13.4 13.3 12.7 13.2 15.1 14.8 14.5 15.2 14.4 14.5 15.1 15.5 14.1 14.9 Puer peral septi cemia. 8 5 .8 5 .8 5.5 5.3 5.5 6.6 6.4 5.9 6.5 6.2 6.1 6.7 7.1 6.0 6.5 A ll other. 7.1 7.6 7.8 7.4 7.7 8.5 8.4 8.7 8.7 8.2 8.3 8.4 8.4 8.2 8.4 1 Calendar year, unless otherwise specified. * Census year ending M ay 31. 8 Figures for puerperal septicemia for the census year 1900 not comparable with those for later years. See p . 41. I V .— D eath rates p er 1 0 0 ,0 0 0 fem a le p o p u la tio n in the 11 S ta tes w ith in the death-registration area m 1 90 0 fr o m diseases caused b y p regn an cy and con fin em en t, 1 90 0 to 1 9 1 0 . T able D eath rate per 100,000 female population from diseases caused b y pregnancy and confinement. Death rate per 100,000 female population from diseases caused b y pregnancy and confinement. Year. Year. Total. 1900............................... 1901 ............................. 1902 ........................... 1903............................... 1904............................... 1905............................... https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26.9 26.7 25.5 26.6 30.3 29.8 Puerperal A ll other. septi cemia. 11.6 11.1 10.6 11.0 13.2 13.0 15.3 15.6 14.9 15.5 17.1 16.8 Total. 1906............................... 1907............................... 1908............................... 1909............................... 1910............................... 29.2 30.6 29.1 29.2 30.4 Puerperal septi A ll other. cemia. 11.8 13.1 12.4 12.4 13.6 17.5 17.5 16.6 16.8 16.9 M A T E R N A L M O R T A L IT Y . 51 T a b l e Y . — N u m ber o f deaths o f w om en fr o m 1 5 to 4 4 years o f age in the death-registration area fr o m each cause and class o f causes in clu d ed in the abridged In tern a tion a l L is t o f Causes o f D eath (revision o f 1 9 0 9 ),1 1 9 1 3 . [Computed from figures in M ortality Statistics, 1913, pp. 338 to 349, in which causes of death are given ac. cording to the detailed International List of Causes of Death.] Abridged Inter national List N o. 13,14,15 31,32 19 29 16 22 35 1 30 26 36 23 18 24 27 28 9 17 8 12 6 5 3 21 20 33 11 4 7 2 10 37 38 Cause of death. Tuberculosis of the lungs, tuberculous meningitis, other forms of tuberculosis........ Puerperal septicemia (puerperal fever, peritonitis) and other puerperal accidents of pregnancy and labor................................................................................. . . . . ......................... Organic diseases of the heart................................................... '. ..........».......................................... A cute nephritis and Bright’s disease................................................... ' . .................................... Cancer and other malignant tum ors............................................................................................. Pneumonia......................... ........................................................................................................ . ......... Violent deaths (suicide excepted)................................................................................................ Typhoid fever......................................................................................................................................... Noncancerous tumors and other diseases of the female genital organs........................... Appendicitis and typh litis..................................... ........................................................................ Suicide.......................................................................................................................................w......... . Other diseases of the respiratory; system (tuberculosis excepted):.................................. Cerebral hemorrhage and softening............................................................................. ................ Diseases of the stomach (cancer excepted)............................................................................... . Hernia, intestinal obstruction........................................................................................................ Cirrhosis of the liver.............................................. ............................................................................. Influenza................................................................................................................................................. . Simple meningitis........................................................................................................................... . Diphtheria and croup........................................................... ......................, . ................................ : Other epidemic diseases................................................................................... ’............................... . Scarlet fever....................................................................................................................... *.................. Measles...................................................................................................................................... . ............ Malaria................. ............................................................ ......................................................... Chronic bronchitis.................................................................................................................. - .......... Acute bronchitis................................. ................................................................................................ Congenital debility and malformations............. ^ ................................................... Cholera nostras..................................................................................................................................... Sm allpox................................................................................................................................................. W hooping cough.................................................................................................................................. . Typhus fever............................................................................................................................. Asiatic cholera ............................................................................................................... r . . . . “..... Other diseases.................. .................................................................................. .................................. Unknow n or ill-defined diseases................................................................................................... * Except N o. 25, diarrhea and enteritis (under 2 years), and N o. 34, senility. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Num ber of deaths. 26,265 9,876 6,386 5,741 5,065 4,167 3,262 2,706 2,669 1,620 1,562 1,458 1,398 940 854 598 489 484 330 312 307 304 250 184 90 24 18 16 9 2 11,688 458 T a b l e Y I . — P o p u la tio n , live births, deaths, and death rates p er 1 0 0 ,0 0 0 p o p u la tio n and p er 1 ,0 0 0 live births fr o m diseases caused by pregnancy and con finem ent, by S tates and p rin cip a l cities in the p rov isio n a l birth-registration area,1 1 9 1 0 . ' Deaths from diseases caused b y pregnancy and confinement. Puerperal septicemia. Total. Staté and'city. Population July 1,1910 (estimated). Live births, 1910. Rate. Rate. Number. ' Per 100,000 popular tion. A ll other. Per 1,000 live births. Number. Per 100,000 popular tion. Rate. P qt 1,000 live births. Number. Per 100,000 popula tion. Per 1,000 live births. 22,222,404 562,390 3,652 16.4 ' 6.5 1,612 7.3 2.9 2,040 9.2 3.6 1,119,109 743,382 3,381,657 2 , 820,108 430,972 7,693,866 545,282 356', 216 4.799,639 332,173 27,291 15,578 86,766 63,566 9,385 202 ; 643 13,439 7,351 129,355 7,016 148 110 412 474 52 1,441 82 61 802 70 13.2 14.8 12.2 16.8 12.1 18.7 15.0 17.1 16.7 21.1 5.4 7.1 4.7 7.5 7.1 6.1 8.3 6.2 10.0 65 46 166 196 18 656 27 22 376 40 5 .8 6 .2 4.9 7.0 4.2 8.5 5 .0 6.2 7.8 12.0 2.4 3.0 1.9 3.1 1.9 3.2 2.0 3.0 2.9 5.7 83 64 246 278 34 785 55 39 426 30 • 7.4 8.6 7.3 9.9 7.9 10.2 10.1 10.9 8.9 9.0 3.0 4.1 2.8 4.4 3.6 3.9 4.1 5.3 3.3 4.3 4,182,448 109,755 744 17.8 . 6.8 357 8.5 3.3 387 9.3 3.5 102,709 134,145 673i 744 119; 864 106,761 146,736 470,118 113; 168 1,554,395 535,384 225,424 2,976 3,772 17,758 4,591 2,631 3,921 11,960 2,693 38,667 15,059 5,727 15 19 94 15 8 , 20 97 20 290 120 46 14.6 14.2 14.0 12.5 7.5 13.6 20.6 17.7 18.7 22.4 20.4 5.0 5s0 5;3 3.3 3.0 5.1 8.1 7.4 7.5 8.0 8.0 6 5.8 7.5 5.6 5.0 .9 8.2 10.2 4.4 9.1 13.3 8 .0 2.0 2.7 2.1 1.3 .4 3.1 4.0 1.9 .3.7 4.7 3.1 9 9 56 9 7 8 49 15 148 49 28 8.8 6.7 8.3 7.5 6.6 5.5 10.4 13.3 9 .5 9.2 12.4 3 .0 2.4 3.2 2.0 2.7 2.0 4.1 5.6 3 .8 3.3 4.9 * A s established-by United States Bureau of the Census. 10 38 6 1 12 48 5 142 71 18 See Mortality Statistics, 1911. M A T E R N A L M O R T A L IT Y . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis j-g 53 M A T E R N A L M O R T A L IT Y . T able V I I . — D eath rates per 1 0 0 ,0 0 0 p o p u la tio n in the death-registration area fr o m certain im p orta n t causes o f death, 1 89 0 and 1 90 0 to 1 9 1 3 . Death rate per 100,000 population from— Year.1 Diph theria and croup. Ty phoid lever. Meas les. 97.8 45.2 43.3 34.0 30.8 31.7 28.3 23.6 25.7 23.6 21.5 20.4 21.4 18.9 18.2 18.8 46.3 18902............... 33.8 1900 2___ : . . . 35.9 1900................. 32.3 1901................. 34.3 1902................. 34.1 1903................. 1904................. 31.7 • 27.8 1905................. 31.3 1906................. 29.5 1907................. 24.3 1908................. 21.1 1909................. 23.5 1910................. 21.0 1911................. 1912................. 16.5. 17.9 1913................. W hoop ing cough. 13.5 13.2 12.5 7.3 9.5 9.8 11.0 7.5 12.1 10.0 9.9 9.6 12.3 10.0 7.0 12.8 Scar let fever. 15.8 12.7 12.1 9.7 12.0 15.8 6.5 : 10.6 15.1 11.3 10.6 9.6 11.4 11.3 9.3 10.0 Diar rhea Tuber Pneu and culosis monia enter (all (all itis forms). forms). (under 2 yrs.). 13.6 11.6 10.2 13.1 12.6 12.2 10.8 6.7 7.7 10.0 11.9 11.4 11.6 8.8 6.7 8.7 252.0 190.9 201.9 196.9 184.5 188.5 200.7 192.3 180.2 178.5 167.6 160.8 160.3 158.9 149.5 147.6 186.9 192.0 180.5 161.4 155.7 155.1 171.4 148.8 145.5 156.5 130.9 137.6 147.7 133.7 132.3 132.4 139.1 97.5 108.8 90.9 84.0 81.6 90.9 97.0 101.4 96.6 95.2 87.8 100.8 77.4 70.3 75.2 Diseases caused b y pregnancy and confinement. Total. Puer peral septi cemia. 15.3 13.1 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 3 7.0 3 5.6 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 A ll other. 8.3 7.5 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 8.6 1 Calendar year, unless otherwise specified. 2 Census year ending May 31. 3 Figures for puerperal septicemia for the census years 1890 and 1900 not comparable w ith those for later years. S e e p . 41. T a b l e Y I 1 1 .— D eaths and death rates p er 1 0 0 ,0 0 0 p o p u la tio n in cities o f at least 8 ,0 0 0 1 p o p u la tio n and in sm aller cities and ru ral districts in the death-registration ¡States fr o m diseases caused b y pregnancy and con fin em en t, 1 90 0 to 1 9 1 3 . Deaths from diseases caused b y pregnancy and confinement. Num ber. Cities of at least 8,000 population. Cities of less than 8,000 population and rural districts. Cities of at least 8,000 population. Cities of less than 8,000 population and rural districts. 442 463 382 438 511 464 761 821 1,085 1,212 1,305 1,678 1,417 1,717 A ll other. Cities of less than 8,000 .population and rural districts. 713 661 710 715 892 937 1,308 1,427 1,532 1,678 2,029 2,202 1,997 2,353 Puerperal septicemia. Cities of at least 8,000 population. 1,087 1,097 1,051 1,119 1,248 1,150 2,063 2,145 •2,654 2,936 3,123 3,926 3,551 4,013 Total. Cities of less than 8,000 population and rural districts. 1,595 L607 1,575 1, 659 1,968 2,069 3; 060 3,245 3,384 3,734 4,271 4,543 4,463 5,031 A ll other. Cities of at least 8,000 population. Cities of at least 8,000 population. 1900....................... 1901...... ................ 1902....................... 1903....................... 1904...................... 1905....................... 1906...................... 1907...................... 1908....................... 1909....................... 1910....................... 191 i ....................... 1912....................... 1913....................... Cities of less than 8,000 population and rural districts. Year. Cities of less than 8,000 population and rural districts. Puerperal septicemia. .Cities of at least 8,000 population. Total. Rate per 100,000 population. 882 946 865 944 1,076 1,132 1,752 1,818 1,852 2,056 2,242 2,341 2,466 2,678 645 634 669 681 737 686 1,302 1,324 1,569 1,724 1,818 2,248 2,134 2,296 14.9 14.4 13.7 14.1 16.4 16.8 16.8 17.3 16.6 16.2 17.0 16.5 15.9 17.2 11.7 12.0 11.5 12.1 13.4 12.3 13.2 13.5 14.5 13.8 13.8 14.6 13.1 13.8 6 .7 5 .9 6.2 6.1 7.4 7,6 7.2 7.6 7.5 7.3 8.1 8 .0 7.1 8.0 4.8 5.1 4 .2 4.7 5.5 5 .0 4.9 5 .2 5 .9 5 .7 5 .8 6 .2 5 .2 5.9 8.3 8.5 7.5 8 .0 8.9 9.1 9 .6 9 .7 9.1 8.9 8 .9 8.5 8.8 9 .2 6.9 7.0 7.3 7.4 7.9 7.3 8 .3 8.3 8 .6 8.1 8 .0 8.4 7.9 7.9 i For the years 1900 to 1909, inclusive, basis of division was 8,000 according to the census of 1900; for the years 1910 to 1913, inclusive, basis of division was 10,000 according to the census of 1910. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 54 M A T E R N A L M O R T A L IT Y . T a b l e I X .— D eath rates p er 1 0 0 ,0 0 0 p o p u la tio n in cities that had at least 2 0 0 ,0 0 0 p o p u lation in 1 9 0 0 , and w ere w ith in the death-registration S ta tes o f 1 9 0 0 , fr o m diseases caused by pregnancy and con fin em en t, 1 90 0 to 1 9 1 3 . Year. Boston. Buffalo. 18.5 13.4 14.7 17.4 15.8 14.1 15.0 15.9 12.1 20.7 14.0 19.4 17.9 20.6 1900....... ...................... 1901............................. 1902........... .................. 1903............................. 1904............................. 1905............................. 1906............................. 1907............................. 1908............................. 1909............................. 1910............................. 1911..................... ....... 1912............................. 1913............................. 9.1 15.3 12.5 18.1 16.0 12.9 20.4 19.8 16.1 13.4 12.5 10.2 13.0 13.9 Jersey City. Detroit. 24.7 19.5 15.7 15.0 16.3 16.7 15.7 17.1 18.5 14.6 20.6 21.6 17.7 26.5 N ew York. 15.9 16.0 16.4 12.0 17.3 17.6 18.4 11.6 24.2 15.6 17.1 21.8 18.1 18.1 19.3 17.7 16.4 15.7 19.0 20.3 18.3 18.9 17.1 16.3 16.7 15.8 14.8 14.1 Newark. Washing ton. 12.6 14.8 16.8 9.7 14.6 16.3 18.1 16.9 20.0 19.7 18.0 19.8 20.6 23.2 15.4 23.6 15.2 18.0 17.6 17.7 17.0 16.8 17.7 17.1 21.1 16.9 14.0 18.1 X .— D eath rates p er 1 0 0 ,0 0 0 p o p u la tio n in the 11 S ta tes w ith in the death-regis tration area in 1 9 0 0 fr o m diseases caused by pregnancy and con fin em en t, 1 9 0 0 to 1 9 1 3 . Table Death rate per 100,000 population from diseases caused b y pregnancy and confinement. Connecticut. District of Columbia. Indiana. Maine. Year. Total. Puer PuerPuer Puer peral A ll ' peral A ll A ll peral A ll Total. Total. Total. peral septi other. septi other. septi other. septi other. cemia. cemia. cemia. cemia. 1900....................... 1901....................... 1902....................... 1903....................... 1904....................... 1905....................... 1906....................... 1907....................... 1908....................... 1909....................... 1910....................... 1911....................... 1912....................... 1913....................... 13.0 11.9 13.4 13.2 13.2 15.0 13.6 13.4 11.7 13.1 13.2 11.3 15.2 12.1 5 .7 4.4 5 .0 4.4 4 .8 5 .7 5.4 6.4 4.3 4.1 5 .8 5 .0 5 .3 4 .7 7.3 7.5 £4 8.7 8.4 9 .3 8.2 7.0 7.4 9 .0 7.4 6 .3 9 .9 7.4 15.4 23.6 15.2 18.0 17.6 17.7 17.0 16.8 17.7 17.1 21.1 16.9 14.0 18.1 5.4 10.5 5 .9 9.2 8 .0 6 .2 7.7 7.3 4.7 7.6 12.0 7.4 4.4 6 .9 10.0 13.0 9 .3 8.8 9 .7 11.5 9.3 9.5 13.1 9.5 9.0 9.5 9.6 11.2 10.4 10.2 9 .0 10.5 12.3 12.3 11.2 13.3 13.2 14.5 16.6 17.7 16.5 15.1 4.8 5 .0 3 .8 5.4 5 .8 6.5 4 .8 7.1 6.1 7.2 8.8 10.9 8.7 8.0 5 .6 5 .2 5 .2 5.1 6.4 5 .7 6 .3 6 .3 7.0 7.3 * 7 .8 6 .8 7.8 7.2 9.4 11.0 15.2 13.1 12.7 11.7 10.1 10.8 11.2 10.6 14.8 13.4 10.1 11.3 3 .0 4.1 6.1 3 .9 5 .3 5.1 2 .3 4.3 4.1 4.6 6 .2 3 .9 2 .8 3 .7 fi. a 6.9 9.1 9 .2 7.4 6.5 7.7 6.6 7.1 6 .0 8.6 9.5 7.3 7.7 Annual average, 1900 to 1913............... 13.1 5.1 8.0 17.6 7.4 10.2 13.1 6.7 6.4 11.8 4.2 7.6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 55 M A T E R N A L M O R T A L IT Y . X .— D eath rates p er 1 0 0 ,0 0 0 p o p u la tio n in the 11 S ta tes w ith in the death-regis tration area in 1 900 fr o m diseases caused by pregnancy and con fin em en t, 190 0 to 1913 — Continued. Table , Death, rate per 100,000 population from diseases caused b y pregnancy and C onfinem entContinued. Massachusetts. New Hampshire. Michigan. New Jersey. Year. Total. Puer peral A ll septi other. cemia. Total. Puer A ll peral septi other. cemia. Total. Puer Puer A ll peral peral A ll Total. septi other. septi other. cemia. cemia. 1900....................... 1901....................... 1902....................... 1903....................... 1904....................... 1905....................... 1906....................... 1907....................... 1908....................... 1909....................... 1910....................... 1911....................... 1912....................... 1913....................... 11.1 9.4 9.5 11.7 13.3 11.9 12.5 12.8 11.0 14.6 12.2 14.8 13.1 14.4 3 .7 3.2 3.1 4.0 4.5 4.0 3 .9 4.3 4.0 5.1 4.9 6.1 5.3 5.3 7.4 6 .2 6.4 7.7 8.8 7.9 8.5 8.4 6.9 9.4 7.3 8.7 7.8 9.1 18.5 19.0 18.1 16.7 19.8 14.8 16.3 15.7 16.9 15.0 16.8 17.5 1 4 .7 19.7 8.8 9.1 7.7 7.4 8.6 6 .2 6.4 6.4 6.9 6 .9 7.0 8.5 6 .2 9.3 9.7 9.9 10.4 9.3 11.2 8.6 9.9 9.3 10.0 8.2 9.9 9.0 8.5 10.4 8.0 7.0 6 .7 10.5 9.1 12.6 14.9 10.6 10.1 13.1 12.1 13.6 15.2 13.5 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 5.6 3.9 4.1 6 .7 5 .7 9.3 9.9 7.5 7.7 8.6 7.9 9.5 10.1 9.4 Annual aver age, 1900 to 1913............... 12.4 4.4 7.9 17.1 7.5 9.6 11.2 3 .7 7.6 New York. Year. Total. Puer peral septi cemia. Total. 1900................. .. 1901....................... 1902....................... 1903....................... 1904....................... 1905....................... 1906....................... 1907....................... 1908....................... 1909....................... 1910....................... 1911....................... 1912....................... 1913....................... 14.1 15.1 13.7 14.0 16.0 16.9 15.9 17.1 15.7 14.9 15.1 15.0 13.5 14.0 6.5 6.2 6.0 6 .0 7.3 7.8 7.0 7.7 7.2 6.3 6 .7 6.6 6 .0 6 .2 7.6 8 .9 7.7 8 .0 8 .7 9.1 9 .0 9.4 8.5 8 .7 8.4 8.4 7.6 7.8 20.8 18.9 15.8 13.5 20.6 20.8 17.8 19.5 16.7 15.4 15.0 15.9 14.1 12.6 Annual aver age, 1900 to 1913............... 15.1 6.7 8.4 16 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis .a Puer peral septi cemia. 4.9 3 .8 4.8 4.6 6 .3 6 .2 6 .2 5 .2 7.1 5 .7 7.5 7.7 6.1 7.8 7.9 6.1 6 .2 6 .9 6.4 7.0 8.3 7.8 7.5 7.0 8.1 8.4 9.2 8.4 13.7 6.1 7.6 Vermont. Rhode Island. A ll other. 12.8 9.9 11.0 11.5 12.7 13.3 14.6 13.1 14.5 12.7 15.5 16.1 15.2 ' 16.2 A ll other. Total. Puer peral septi cemia. A ll other. 8.4 6 .8 7.1 5.9 10.6 8.9 6.9 8.1 6.0 7.3 5.0 5 .2 5.1 4.0 12.4 12.1 8.7 7.6 10.0 11.8 10.9 11.4 10.8 8.1 10.1 10.8 9.0 8.6 13.4 9.6 11.3 14.7 16.9 18.9 15.9 27.0 18.9 18.9 17.1 13.7 13.7 15.3 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 .2 4.7 8.4 6 .7 7.5 11.2 11.5 14.6 12.0 19.9 12.7 9.9 10.9 9.2 11.4 10.6 6.7 10.1 16.1 4.9 11.2 56 M A T E R N A L M O R T A L IT Y . X I .— D eaths and death rates per 1 0 0 ,0 0 0 p o p u la tio n in the death-registration area fr o m diseases caused by pregn an cy and con fin em en t, b y color o f decedent, 1 91 0 to 1 9 1 3 . T able Deaths from diseases caused b y pregnancy and confinement. Number. Year. Total. 1910........... 1911........... 1912........... 1913........... T able Rate per 100,000 population. Puerperal septicemia. A ll other. Total. Puerperal septicemia. A ll other. W h te . Col ored. W hite. Col ored. W hite. Col ored. W hite. Col ored. W hite. Col ored. W hite. 7,902 8,783 8,365 9,167 553 673 670 843 3,609 ■4,038 3,580 4,170 283 338 325 372 4,293 4,745 4,785 4,997 270 335 345 471 15.3 15.5 14.5 15.2 25.6 26.8 26.0 26.1 7 .0 7.1 6 .2 6.9 13.1 13.5 12.6 11.5 8.3 8.4 8.3 8.3 Col ored. 12.5 13.3 13.4 14.6 X I I .— A verage death rates per 1 0 0 ,0 0 0 p o p u la tio n in certain cou n tries fr o m diseases caused by pregn an cy and con fin em en t, 1 90 0 to 1 9 1 0 . Country. Sw eden1.............................. I t a ly ..".................................... France2.................................. England and W a le s ........... N ew Zealand........................ Ireland4................................. H ungary................................. Death rate per 100,000 population from dis eases caused b y preg nancy and confine ment. Total. Puer peral septi cemia. 6 .0 8.1 8.9 10.3 10.4 11.1 12.4 12.9 13.3 2.4 4.1 3.3 4 .8 4.7 4.7 3.1 4.5 3 .6 Country. A ll other. 3.5 3.9 5 .7 5.5 5 .8 6.5 9.3 8.4 9.8 Death rate per 100,000 population from dis eases caused by preg nancy and confine ment. Total. Puer peral septi cemia. 13.3 14.1 14.8 14.8 14.9 15.2 19.6 (7) 4.5 4.7 5 .8 5.5 6.5 6.4 12.3 6 .6 A ll other. 8.8 9.4 9.0 9.4 8.3 8.8 7.3 (0 1 Rates based on figures for 1901 to 1910. 2 Rates based on figures for 1906 to 1910. 3 Rates based on figures for 1903 to 1910. 4 Rates based on figures for .1902 to 1910. 6 Rates based on figures for 1907 to 1910. 6 Rates based on figures for death-registration area which increased from year to year; in 1900 it comprised 40.5 per cent of the total population of the United States and in 1910, 58.3 per cent. 1 Figures not available. T able " K i l l — A verage death rates p er 1 ,0 0 0 live births in certain fo r eig n cou ntries fro m diseases caused b y pregn an cy and con fin em en t, 1900 to 1 9 1 0 . Death rate per 1,000 live births from diseases eaused b y pregnancy and confinement. Death rate per 1,000 live births from diseases caused by pregnancy and confinement. Country. Country: Total. Puer peral septi cemia. 2.3 2.7 2 .9 3.2 3 .6 4.1 4.1 4.6 0.9 1.0 1.5 1.4 1.0 1.7 1.4 1.2 .A ll other. 1 Rates based on figures for 1901 to 1910. 2 Rates based on figures for 1903 to 1910. 3 Rates based pn figures for 1906 to 1910. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1.4 1.7 1.4 1.8 2 .6 2.4 2 .7 3.5 Total. Puer peral septi cemia. 5.2 5.2 5.3 5.5 5 .6 5.7 5 .8 (6) 2.4 1.9 1.8 1.9 2.4 3 .6 2.3 1.9 1 Rates based on figures for 1907 to 1910. 5 Rates based on figures for 1902 to 1910. 6 Figures not available. A ll other. 2.8 3.3 3.5 3 .6 3.3 2.1 3.5 (6) 57 M A T E R N A L M O R T A L IT Y . T a b l e X I V . — D eaths in certain cou ntries fr o m diseases caused b y pregnancy and con fine m e n t and num ber and p er cent o f such deaths fr o m pu erperal septicem ia, 1 90 0 to 1 9 1 0 . D e a t h s fr o m d is e a s e s cau sed b y p re g n a n cy and confinement. Country. Puerperal septi cemia. D e a t h s fr o m d is e a s e s cau sed b y pregnan cy and confinement. Total. Total. N um ber. Sweden i ............................. N orw ay............................... Ita ly ..................................... France2.............................. Prussia3............................. England and W a le s ___ N ew Zealand.................... Ireland4............................. 3,179 2,032 32,651 20,217 31,680 41,691 1,190 5,109 Puerperal septi* cemia. Country. 1,294 1,041 11,901 9,424 14,151 17,433 300 1,792 Per Cent. 40.7 51.2 36.4 46.6 44.7 41.8 25.2 35.1 N um ber. ' H ungary............................. Japan1................................ Au stralia9......................... B elgiu m 3........................... Scotland1........................... U nited States6........ .. Switzerland....................... Sp ain1........ ........................ 29,273 63,908 2,388 8,588 6,839 63,969 5,897 37,504 7,824 21,494 800 3,392 2,522 28,176 2,485 23,557 Per cent. 26.7 33.6 33.5 39.5 36.9 44.0 42.1 62.8 1 Figures for 1901 to 1910. 2 Figures for 1906 to 1910. 3 Figures for 1903 to 1910. 4 Figures for 1902 to 1910. 6 Figures for 1907 to 1910. 6 Figures for death-registration area which increased from year to year; in 1900 it comprised 40.5 per cent of the total population of the United States and in 1910, 58.3 per cent. COMMENT ON SOURCES OF STATISTICS FOR FOREIGN COUNTRIES. The following paragraphs present, by countries, the sources of the figures subsequent to 1910 in Table X V for foreign countries and also notes on certain of these figures which call for comment or explanation. Unless otherwise specified the figures for all countries for the years 1900 to 1910, inclusive., are taken from the Statistique Internationale du Mouvement de la Population d’après les Registres de Y Etat G vil, of the Bureau de la statistique générale de la France. The figures for 1900 come from the volume published in 1907; those for 1901 to 1910 from that published in 1913. These foreign sources were used only for the figures in columns 1, 3, 4, 9, and 13, from which the figures in columns 2, 5, 6, 7, 8, 10, 11, 12, 14, 15, and 16 were computed. Blank spaces indicate that statis tics were not available. Similarly, where a table begins with data for a year subsequent to 1900, it indicates that the figures for the earlier years were not available, unless otherwise noted. A u stra lia (p. 60).— Bureau of census and statistics. Population and vital statistics. B ulletins 29 and 30. 1911-1912. A u stria (p. 60).— Statistisches Centralcomm ission. Österreichisches statistisches Handbuch für die im Reichsrathe vertretenen Königreiche und Länder. Nebst einem Anhänge für die gemeinsamen Angelegenheiten der österreichischungarischen Monarchie. Hrsg, von der statistischen Centralcommission. X X X I Jahrgang. 1911. The statistics for Austria give the deaths from puerperal septicemia only. The figures for deaths from other diseases of pregnancy and confinement were not available. The population for 1911 could not be secured from official publications, and was there fore estimated. In making this estim ate, one-tenth of the increase from 1900 to 1910 was added to the figure for 1910. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 58 M A T E R N A L M O R T A L IT Y . B elg iu m .(p . 60).— Ministère de l ’intérieur et de l ’instruction publique. Annuaire statistique de la Belgique. 1912-13. \ The population is that estimated as of December 31 of each year. Belgium classifies stillbirths as “ mort-nés et autres enfants présentés sans vie. \ E n g la n d and W ales (p. 61).— 74th-77th annual reports of the registrar general of births, \ . deaths, and marriages in England and W ales, 1911 to 1914. Several points should be noted in the figures for England and Wales. I. The registrar general’s reports, prior to 1911, grouped deaths from diseases of preg nancy and confinement into the two large groups “ puerperal septic diseases” and “ diseases of pregnancy and childbirth (not septic),” and included phlegmasia alba dolens in puerperal septic diseases. F or the years 1900 to 1910 the figures used are those given b y the Statistique Internationale. The deaths from phlegmasia alba dolens have apparently been subtracted from puerperal septic diseases and have been added to the other group, thus making the classification conform more nearly to the inter national nomenclature. Therefore, while the figures for “ deaths from all diseases caused b y pregnancy and confinement” w ill agree with the official English figures, those for the two other groups, prior to 1911, w ill not. I I . A s the registrar general’s report for 1914 gives a table of deaths for the years 1900 to 1914 according to the detailed list of causes of death in use prior to 1911, this table has been used as the source for the figures for England and W ales after 1910, so that the statistics after 1910 can be compared with those of earlier years. The number of deaths from puerperal septicemia for the years after 1910 is slightly lower when the deaths are classified according to the International Classification than when they are classified according to the older method, as given in table for England and W ales. The deaths from other diseases of pregnancy and confinement are, of course, correspondingly higher. This difference can be seen from the following: N u m ber o f deaths fr o m pu erperal sep ticem ia . Year. 1911.......................................................................................................... 1912.......................................................................................................... 1913.......................................................................................................... 1914.......................................................................................................... According to the Inter national Classification. According to the classi fication in use prior to 1911. 1,262 1,216 1,108 1,365 1,267 1,223 1,119 1,372 III. The International Classification was not used in England until 1911, and deaths from puerperal nephritis and albuminuria were not distinguished as puerperal until after 1910. For England and W ales, therefore, the figures are presented for 1911 to 1914, inclusive, in two ways: (a) According to use in England prior to 1911, exclud ing deaths from puerperal nephritis and albuminuria; and (&) including deaths from puerperal nephritis and albuminuria. The number of these deaths was as follows: D eaths fr o m pu erpera l n ep h ritis an d albu m in u ria . Year: 1911 1912 1913 1914 H u n g a ry (p . 61).— Statisztikai hivatal. 177 174 221 198 Magyar statisztikai evkonyv. 1911. The figures given for Hungary include those for Fium e and Croatia-Slavonia. Irela n d (p . 62).— 51st detailed annual report of the registrar general of marriages, births, and deaths in Ireland in 1914. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N A L M O R T A L IT Y . 59 I. /The registrar general’s reports for Ireland, up through. 1914, classify deaths from diafeases of pregnancy and confinement into two large groups— puerperal septic dis eases and diseases of pregnancy and childbirth (not septic), and include phlegmasia /a l b a dolens in puerperal septic diseases. This was the method used in England and Wales prior to 1911. See note on England and W ales. In the figures for Ireland, given by the Statistique Internationale, apparently no correction has been made as in the case of England and W ales, but in the table here given the figures have been corrected to make them comparable with those for Eng land and W ales and for other countries. To make this correction the deaths from phlegmasia alba dolens were subtracted from deaths from puerperal septic diseases and added to the other group. Thus while the figures for “ deaths from all diseases of pregnancy and confinement ” w ill agree with the official Irish figures and with those given in the Statistique Internationale, those for the other two .groups w ill not. I I . The figures for 1900 and for 1901 are not given because in those years the regis trar general’s reports did not include under puerperal septic diseases either pyemia or septicem ia. Ita ly (p. 62).— Direzione generale della statistica. Statistica delle cause di morte. 1911-1913. Movimento de la popolazione. 1913. * O nly columns 1, 3, and 4 for 1900 to 1910 were taken from the Statistique Interna tionale. The above original Italian sources were used, as in the Statistique Interna tionale the deaths from “ other diseases of pregnancy and confinement ” and the deaths from “ noncancerous tumors and other diseases of the female genital organs” were added together, for several years. (The figures here given were probably notavailable when the Statistique Internationale was published.) Japan (p. 63).— Bureau de la statistique générale. Mouvement dfe la population de l ’empire du Japón for 1911 and 1912. • The population is that estimated as of December 31 of each year. N ew Z ea la n d (p. 63).— Registrar general’s office. Statistics of the Dominion of New Zealand. 1911-1914. N orw a y (p . 63).— Statistiske centralbureau. Statistisk aarbok for kongeriget norge. 1914. The population for 1911 and 1912 is that estimated as of December 31. S cotla n d (p . 64).— 57th-60th annual reports of the registrar general for Scotland. 1911-1914. The registrar general’s reports for Scotland prior to 1911, like those of England and W ales and Ireland, included phlegmasia alba dolens under puerperal septic diseases. As in the case of Ireland, the figures given b y the Statistique Internationale have apparently not been corrected. However, in the table here given the figures have been corrected by the method described above in the comment on the statistics for Ireland. Sw eden (p . 65).— Statistiska centralbyrán. Statistisk ársbok for Sverige. 1915. The population is that estimated as of December 31 of each year. S w itzerla n d (p. 65).— Statistisches Bureau. Statistisches Jahrbuch der Schweiz. 1914. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T a b l e X V . — P o p u la tio n , births, deaths, and death rates per 1 0 0 ,0 0 0 p o p u la tio n , p er 1 ,0 0 0 births, and per 1 ,0 0 0 live births fr o m diseases m u sed by pregnancy and con fin em en t in certain fo r eig n cou ntries f o r specified, years. Deaths from diseases caused b y pregnancy and confinement. Births. Country and year. Live births. Still births. Number. 6 7 Per 1,000 live births. Number. 8 9 tPer Per 100,000 1,000 popula births. tion. 10 11 Per 1,000 live births. 12 Number. 13 Per Per 100,000 1,000 popula births. tion. 14 15 Australia: 1 9 0 7 .. 1 9 0 8 .. 1 9 0 9 .. 1 9 1 0 .. 1 911 .. 1 9 1 2 .. 614 ' 606 577 591 615 644 110,347 111.545 114,071 116,801 122,193 133,088 14.9 14.4 13.5 13.5 13.7 13.9 5.6 5.4 5.1 5.1 5.0 4.8 179 202 201 218 209 231 1.6 1.8 1.8 1.9 1.7 1.7 4.3 4.8 4.7 5.0 4.7 5.0 . . . . . 4.124.000 4.194.000 4.275.000 4.370.000 4.490.000 4.645.000 1 9 0 0 .. 1 9 0 1 .. 1 9 0 2 .. 1 9 0 3 .. . . . . 25.976.000 26.279.000 26.535.000 26.780.000 995,537 988,985 1,010,843 969,960 967,939 961,501 984,240 943,953 27,598 27,484 26,603 26,007 1,952 lj944 l'92 2 1^ 780 7.5 7.4 7.2 6.6 2.0 2.0 1.9 1.8 2.0 2.0 2.0 1.9 1 9 0 4 .. 1 9 0 5 .. 1906.. . . 1 907 .. . . 27.021.000 27.229.000 27.448.000 27.706.000 987,425 945,978 987,166 966,911 961,430 921,764 961,258 942,169 25,995 24,214 25,908 24,742 1,911 l'6 2 2 l '¿ 9 2 l'60 9 7.1 6.0 6.2 5.8 1.9 1.7 1.7 1.7 2 .0 • 1.8 1.8 1.7 1 9 0 8 .. 1 9 0 9 .. 1 910 .. 1 911 .. . . . 27.950.000 28.186.000 28.427.000 28.672.000 965,593 965,096 946,820 920,945 941,375 941,239 923.545 898,702 24,218 23,857 23,275 22,243 1,822 1,734 1,770 1,712 6.5 6.2 6.2 6.0 1.9 1.8 1.9 1.9 1.9 1.8 1.9 1.9 . . . . . 6.694.000 6.800.000 6.896.000 6.985.000 7.075.000 202,790 209,340 204,846 200,870 200,333 193,789 200,077. 195,871 192,301 191,721 9,001 9,263 8,975 8,569 8,612 432 445 6.2 6.3 2.2 2.2 2.2 2.3 . Austria: . . « 435 404 376 373 406 413 10.5 9.6 8 .8 8.5 9.0 8.9 773 734 11.1 10.4 Per 1,000 live births. 16 3.9 3.6 3.3 3.2 3.3 3.1 Belgium: 1 9 0 0 .. 1 9 0 1 .. 1 9 0 2 .. 1 9 0 3 .. 1 9 0 4 .. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1,046 1,055 1,080 1,205 1,179 15.6 15.5 15.7 17.3 16.7 5.2 5 .0 5.3 6.0 5.9 5.4 5.3 5.5 6.3 6.1 3.8 3.7 4; 0 M A T E R N A L M O R T A L IT Y . 5 Per Per 100,000 1,000 popular births. tion. Rate. Rate. Rate. Total. A ll other. Puerperal septicemia. Total. Population July 1 each, year (estimated). 1905............................. 1906............................. 1907............................. 1908............................. 7,161,000 7,239,000 .7,318,000 7,386,000 196,029 194,775 193,449 192,397 . 187,437 186,271 185,138 183,834 8,592 8,504 8,311 8,563 995 1,029 1,053 1-, 121 13.9 14.2 14.4 15.2 5.1 5.3 5.4 5.8 5.3 5.5 5.7 6.1 389 403 407 466 5.4 5.6 5.6 6.3 2.0 2.1 2.1 2.4 2.1 2.2 2.2 2.5 606 626 646 655 8.5 8.6 8.8 8.9 3.1 3.2 3.3 3.4 3 .2 3.4 3.5 3.6 1909............................ 1910............................. 1911............................. 1912............................. England and W ales: 1900............................ 1901............................ 1902............................. 1903............................ 1904............................. 7,452,000 7,424,000 7,490,000 7,571,000 184,700 184,421 179,359 178,976 176,431 176,413 171,802 171,187 8,269 8,008 7,557 7,789 1,039 967 1,024 1,122 13.9 13.0 13.7 14.8 5.6 5.2 5.7 6.3 5.9 5.5 6.0 6.6 439 411 398 476 5.9 5.5 5.3 6.3 2.4 2.2 2.2 2.7 2.5 2.3 2.3 2.8 600 556 626 646 8.1 7.5 8.4 8.5 3.2 3 .0 3.5 3.6 3.4 3.2 3 .6 3 .8 32,249,000 32,612,000 32)951)000 33,'2931000 331639'000 927,062 929' 807 940 509 948,271 945,389 4,455 4,394 4,205 3)857 3)667 13.8 13.5 12.8 11.6 10.9 4.8 4.7 4.5 4.1 3,9 1,941 2,005 1)908 1,581 1)560 6.0 6.1 5.8 4.7 4.6 2.1 2.2 2.0 1.7 1.7 2,514 2)389 2)297 2)276 2) 107 7.8 7.3 7.0 6.8 1905............................. 1906............................ 1907............................. 1908............................. 1909............................. 33,989,000 34l342)000 34l6991000 35l0591000 35,424,000 929,293 935 081 918,042 940,383 914,472 3,905 3,757 3,520 3)361 3, -379 11.5 10.9 10.1 9.6 9.5 4.2 4.0 3.8 3.6 3.7 1,631 1)538 1,381 1,312 1,357 4-8 4.5 4.0 3.7 3.8 1.8 1.6 1.5 1.4 1.5 2,274 2)219 2) 139 2) 049 2)022 1910............................. 1911ai........................ 1911b.......................... 1912a.......................... 1912b.......................... 35,792,000 36,190,000 896,962 88l)l?8 3,191 3)236 3.413 3)299 3,473 8.9 8.9 9.4 9.1 9.5 3.6 3; 7 3.9 3.8 4.0 1,219 1)267 3.4 3.5 1.4 1.4 1,972 l)969 2) 146 2,076 2,250 3,271 3,492 3,469 3,667 8.9 9.5 9.4 9.9 France: 1 9 0 6 ........................ 1907............................. 1908............................ 1909............................ 1910............................ H ungary: 1900............................ 1901............................ 1902............................ 1903............................ 1904............................ 1905.......... ................. 1906............................ 1907............................ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 872,737 36,606,000 881,890 36,961,000 879,096 1,223 3.4 1.4 3.7 4.0 3.9 4.2 1,119 3.1 1.3 1,372 3.7 1.6 2.4 2 .4 6 .3 2.2 6 .7 6 .5 6 .2 5 .8 5 .7 2.4 2.4 2.3 2.2 2.2 2.2 2.2 5 .5 5 .4 2.4 2.4 5.9 5 .7 6.2 2.6 5 .9 2.4 2.7 2.4 2,152 2)373 2)097 2) 285 5 .7 6 .2 6.5 2.6 39,282,000 39,279,000 39,368,000 39,421,000 39,528,000 844,173 809,446 829, 714 805,641 810,399 806,847 772,681 792,178 769,565 774,390 37,326 36,765 37,536 36,076 36,009 4,067 4,499 3,982 4,097 3,572 10.4 11.5 10.1 10.4 9.0 4.8 5.6 4.8 5.1 4.4 5.0 5 .8 5.0 5.3 4.6 1,873 2,117 1,855 1,900 1,679 4.8 5.4 4.7 4.8 4.2 2.2 2.6 2.2 2.4 2.1 2.3 2.7 2.3 2.5 2 .2 2,194 2,382 2,127 2,197 1,893 5 .6 6 .1 5 .4 5 .6 4 .8 2.6 2.9 2.6 2 .7 2.3 2.7 3.1 2 .7 2.9 2.4 19,144,000 19,342,000 19,513,000 19,669,000 768,673 747,224 775,641 740,405 752,718 731,721 759,739 725,239 15,955 15,503 15,902 15,166 2,606 2,789 2,665 2,562 13.6 14.4 13.7 13.0 3.4 3.7 3.4 3.5 3.5 3.8 3.5 3.5 636 687 622 571 3.3 3.6 3.2 2.9 .8 .9 .8 | .8 .8 .9 .8 .8 1,970 2,102 2,043 1,991 10.3 10.9 10.5 10.1 2.6 2.8 2.6 2 .7 2.6 19,832,000 19,969,000 20,099,000 20,260,000 755,526 734,335 748,060 755,653 740,799 720,532 733,953. 740,867 14,727 13,803 14,107 14,786 2,678 2,694 2,490 2,552 13.5 13.5 12.4 12.6 3.5 3.7 3.3 3.4 3.6 3 .7 3.4 3.4 654 689 602 720 3.3 3.5 3.0 3.6 .9 .9 .8 1.0 .9 1.0 .8 1.0 2,024 2,005 1,888 1,832 10.2 10.0 9.4 9.0 2.7 2.7 2.5 2.4 i See explanatory note on p . 58. . 2 .9 2 .7 2.7 2.7 2.8 2.6 2.5 m M O R T A L IT Y . 1913a.............. ............ 1913b.......................... 1914a.......................... 1914b........................ . 36,382,000 • 2.7 2.6 Table X V . — P o p u la tio n , births, deaths, and death rates per 1 0 0 ,0 0 0 p o p u la tio n , p er 1 ,0 0 0 births, and per 1 ,0 0 0 live births fr o m diseases caused b y g pregnancy and con finem ent in certain fo reig n countries fo r specified years— Continued. Deaths from diseases caused b y pregnancy and confinement. Births. Country and year. Hungary— Continued. 1908............................ 1909............................ 1910............................ 1911............................ Ireland: 1002 1002 20.426.000 20.606.000 20.793.000 20.958.000 2 771,126 792; 354 758,566 747,916 • Live births. 3 755,888 776,395 742,899 732,767 Still births. Number. 4 5 15,238 15,959 15,667. 1 5 ;149 Per Per 100,000 1,000 popula births. tion. 6 2,892 2,839 2,506 ■2,443 14.2 13.8 12.1 11.7 ' 7 3.8 3.6 3.3 3.3 Number. Per 1,000 live births. 8 9 Per Per 100,000 1,000 popula births. tion. 10 3.8 3 .7 3.4 3.3 889 961 793 869 ' 4.4 4.7 3.8 4.1 11 1.2 1.2 1.0 1.2 Rate. » Number. Per Per Per 100,000 1,000 1,000 popula births. live tion. births. 12 13 14 1.2 1.2 1.1 1.2 2,003 1,878 1,713 1,574 9.8 9.1 8.2 7.5 15 2.6 2.4 2.3 2.1 Per 1,000 live births. 16 2.6 2.4 2.3 2.1 1000 4.434.000 4.416.000 4.405.000 4.396.000 4.393.000 101,863 101.831 103,811 102.832 103,536 635 573 583 573 607 14.3 13.0 13.2 13.0 13.8 6 .2 5.6 5.6 5.6 5 .9 214 222 206 217 218 4.8 5 .0 4.7 4.9 5 .0 2.1 2.2 2.0 2.1 2.1 421 351 377 356 389 9.5 7.9 8.6 8.1 8.9 4.1 3.4 3.6 3.5 3.8 1007 1008 1000 1010 4.383.000 4.379.000 4.380.000 4.378.000 101,742 102,039 102,759 101,963 505 530 561 542 11.5 12.1 12.8 12.4 5 .0 5 .2 5.5 5.3 152 *178 207 178 3.5 4.1 4.7 4.1 1.5 1.7 2.0 1.7 353 352 354 364 8.1 8.0 8.1 8.3 3.5 3.4 3.4 3.6 4.384.000 4.385.000 4.379.000 4.381.000 101,758 101,035 100,094 98,806 514 549 527 497 11.7 12.5 12.0 11.3 5.1 5.4 5.3 5.0 165 187 163 182 3.8 4.3 3 .7 4 .2 1.6 1.9 1.6 1.8 349 362 364 315 8.0 8.3 8.3 7.2 3.4 3.6 3.6 3 .2 3,034 2,767 2,807 2,771 2,981 9.4 8.5 8.6 8.4 9.0 2.8 2.6 2.6 2.7 2.7 1,033 994 1,037 1,112 1,082 3.2 3.1 3.2 3.4 3.3 .9 .9 .9 1.0 1.0 .9 .9 1.1 1.0 1.0 2,001 1,773 1,770 1,659 1,899 6.2 5.4 5.4 5.1 5.8 1904 1005 1011 1012 1012 10*14 Italy: 1900............................ 1901............................. 1902............................ 1903............................ 1904............................ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32.346.000 32.533.000 32.700.000 32.840.000 33.016.000 1,113,055 1,104,017 1,141,749 1,088,797 1,134,552 1,067,376 1,057,763 1,093,074 1,042,090 1,085,431 45,679 46,254 48,675 46,707 49,121 2.7 2.5 2.5 2.5 2.6 1.8 1.6 1.6 1.5 1.7 1.9 1.7 1.6 1.6 1.7 M ATERN A L 1 Rate. Rate. Total. A ll other. Puerperal septicemia. Total. Population July 1 each year (estimated). g $ 33,193,000 33,325,000 33,515,000 33,827,000 34,077,000 1,133,979 1,119,131 1,110,356 1,190,278 1,166,121 1,084,518 1,070,978 1,062,333 1,138,813 1,115,831 49,461 48,153 48,023 51,465 50,290 3,198 2,791 3,074 3,315 3,127 9.6 8.4 9.2 9.8 9.2 2.8 2.5 2.8 2 .8 2.7 2.9 2 .6 2.9 2.9 2.8 1,147 1,245 1,242 2.9 3.1 3.4 3.7 3.6 1910............................ 1911............................ 1 912 .......................... 1913............................. Japan: 1901............................ 1902............................ 1903............................. 1904............................ 34,377,000 34,689,000 35,026,000 35,418,000 1,194,747 1,141,036 1,181,553 1,169,353 1,144,410 1,093,545 1,133,985 1,122,482 50,337 47,491 47,568 46,871 2,786 2,612 2,743 2,811 8.1 7.5 7.8 7.9 2.3 2.3 2.3 2.4 2.4 2.4 2 .4 2 .5 1,011 929 899 1,037 2.9 2.7 2.6 2.9 45,437,000 46,022,000 46,733,000 47,220,000 1,657,080 1,668,543 1,643,736 1,587,429 1,501,591 1,510,835 1,489,816 1,440,371 155,489 157,708 153,920 147,058 6,671 6,556 6,071 5,742 14.7 14.2 13.0 12.2 4 .0 3.9 3.7 3.6 4 .4 4 .3 4.1 4 .0 1,885 1,983 2,028 1,810 1905............................ 1906............................ 1907............................ 1908............................ 47,678,000 48,165,000 48,820,000 49,589,000 1,594,862 1,544,026 1,773,286 1,825,491 1,452,770 1,394,295 1,614,472 1,662,815 142,092 149,731 158,814 162,676 6,185 6,237 6,728 7,091 13.0 12.9 13.8 14.3 3.9 4 .0 3.8 3.9 4.3 4.5 4.2 4.3 1909............................ 1910............................ 19111.......................... 19121.......................... New Zealand: 1900............................ 1901............................ 1902............................ 1903............................ 1904............................ 50,254,000 50,903,000 51,435,000 52,167,000 1,855,426 1,870,249 1,903,122 1,885,219 1,693,850 1,712,857 1,747,803 1,737,674 161,576 157,392 155,319 147,545 6,399 6,228 6,192 5,770 12.7 12.2 12.0 11.1 3.4 3.3 3.3 3.1 764,000 778,000 798,000 820,000 845,000 19,546 20)491 20,655 2l)829 22,' 766 75 90 110 128 106 9.8 11.6 13.8 15.6 12.5 1905.......................... . 1906............................ 1907.................... .. 1908............ ................ 1909............................ 870,000 896,000 919,000 945'000 972'000 23,682 24'252 25'094 25'940 26' 524 100 94 116 119 135 11.5 10.5 12.6 12.6 13.9 1910............................ 1911.............. .............. 1912............................. 1913............................. 1914............................. Norway: 1900............................ 1901............................ 1902».......................... 1903..................... 1904............................. 993,000 1,015,000 1,039,000 1,069,000 1,090,000 25,984 26,354 27)508 27)935 28,338 117 114 100 100 118 11.8 11.2 9.6 9.4 10.8 184 219 207 205 199 8.4 9 .8 9.2 9.1 8.8 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2,200,000 2,235,000 2,255,000 2,265,000 2,274,000 67,765 67,935 66,854 66,797 65,533 66,149 66,207 65,262 65,155 63,955 1,616 1,728 1,592 1,642 1,578 977 1 ,0 2 1 2 ,2 2 1 1:1 1,770 1,927 2,070 1,885 6.7 5.3 5.7 6.1 5.5 2 .0 1.6 1.7 1.7 1.6 .8 .8 .8 .9 .9 .8 .8 .9 1,775 1,683 1,844 1,774 5.2 4.9 5.3 5.0 1.5 1.5 1.6 1.5 4.1 4.3 4.3 3.8 1.1 1.2 1.2 1.1 1.3 1.3 1.4 1.3 4,786 4,573 4)043 3,932 10.5 9.9 8.7 8.3 2.9 2.7 2.5 2.5 3.2 3.0 2.7 2.7 1,878 1,915 2,294 2,570 3.9 4.0 4.7 5.2 1.2 1.2 1.3 1.4 1.3 1.4 1.4 1 5 4,307 4,322 4,434 4,521 9.0 9.0 9.1 9.1 2.7 2.8 2.5 2.5 3.0 3.1 2.7 2.7 3.8 3.6 3.5 3.3 2,575 2,556 2,512 2,357 5.1 5.0 4.9 4.5 1.4 1.4 1.3 1.3 1.5 1.5 1.4 1.4 3,824 3,672 3,680 3,413 7.6 7.2 7.2. 6.5 2.1 2.0 1.9 1.8 2.3 3.8 ¿4 4 .7 24 20 25 28 21 ij 1 2. fi 3.1 3 4 ¿_5 4 .2 3 .9 4 .6 4 .6 5 .1 21 18 29 46 33 2.4 2.0 3. 2 4. Q 2 4 4 .5 4 .3 3 .6 3 .6 4 .2 35 27 19 29 35 2. fi 2.7 1.8 2.7 3 .2 2 .8 3 .3 3 .2 3 .1 3 .1 111 101 109 113 106 5 .0 4 .5 4 .8 5 .0 4 .7 5 .3 5.9 2.7 3.2 3.1 3.1 3.0 2.0 .9 1.0 1.1 1.1 1.1 » .9 .9 1 .0 1 .0 1.7 1.8 1.8 1.7 1.6 1.6 1.5 1.6 2.1 2.1 2.0 1 2 1 0 2.6 7 3.3 3.1 3.4 4.1 4.6 3.7 M A T E R N A L M O R T A L IT Y . 1905............................ 1906............................ 1907............................ 1908............................ 1909............................ 3.8 1.6 1.5 1.6 1.7 1.6 1 .2 83 7.6 1 .7 1 .5 1 .7 1 .7 1 .7 • 73 118 98 92 93 3.3 5.3 4.3 4.1 4.1 3.2 3.3 2.9 2 .5 2.9 1.1 1.7 1.5 1.4 1.4 1.1 1.8 1.5 1.4 1.5 1 Figures for Dec. 31. 05 CO T a b l e X V .— P o p u la tio n , births, deaths, and death rates per 1 0 0 ,0 0 0 p o p u la tio n , per 1 ,0 0 0 births, and per 1 ,0 0 0 live births fr o m diseases caused by pregnancy and con finem ent in certain fo reig n countries f o r specified years— Continued. 05 Deaths from diseases caused by pregnancy and confinement. Births. Total. Country and year. Population July 1 each year (estimated). Live births. Still births. Number. 2 3 4 5 2,284,000 2,294,000 2,303,000 2,318,000 64,158 62,743 62,151 62,286 62,698 61,316 60,722 60,866 1,460 1,427 1,429 1,420 163 152 168 183 1909......................... 1910.......................... 1911.......................... 1912.......................... Prussia: 1900.......................... 1901.......................... 1902.......................... 1903.......................... 1904......................... 2,338,000 2,353,000 2,415,000 , 439; 000 62,846 62,890 62,867 62j581 61,407 61,461 61,468 6 i;151 1,439 1,429 1,399 L430 34,254,000 34; 802,000 35,366,000 35,930,000 36,494,000 1,275,712 1,301,092 1,295,914 1,274,666 1,304,697 1,235,719 1,260,379 1,255,686 , 235; 213 1,264,534 39,993 40,713 40,228 39| 453 40,163 1905.................. 1906.......................... 1907.......................... 1908.......................... 1909.......................... 1910.......................... Scotland: 1901.......................... 1902.......................... 1903.......................... 1904.......................... 1905.......................... 1906.......................... 1907.......................... 37,058,000 37,628,000 38,203,000 38,777,000 39,352,000 39,926,000 1,279,992 1,308,912 1,298,291 1,308,283 1,287,030 1,256,613 1,241,620 1,269,611 1,259,636 1,269,399 1,249,040 1,219,447 38,372 39,301 38,655 38,884 37,990 37,166 4,479,000 4,507,000 4^535; 000 4'564^ 000 .................... , 592; 000 4,621,000 4,650,000 132,192 132Ì267 133,525 132', 603 13i;410 132; 005 128,840 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 4 ............. 1 All other. Rate. Rate. Per Per Number. Per Per Number. Per Per Per Per Per 100,000 1,000 100,000 1,000 100,000 1,000 1,000 1,000 popular 1,000 live popula popula live live tion. births. births. tion. births. births. tion. births. births. 6 12 7 8 7.1 6.6 7.3 7.9 2.5 2.4 2.7 2.9 2.6 2.5 2.8 3.0 75 78 92 98 3.3 3.4 4.0 4.2 1.2 1.2 1.5 1.6 1.2 1.3 1.5 1.6 88 74 76 85 3.9 3.2 3.3 3.7 1.4 1.2 1.2 1.4 1.4 1.2 1.3 1.4 187 165 8.0 7.0 3.0 2.6 3.0 2.7 81 77 87 90 3.5 3.3 3.6 3.7 1.3 1.2 1.4 1.4 1.3 1.3 1.4 1.5 106 88 4.5 3.7 1.7 1.4 1.7 1.4 4,074 3,992 4,080 ,120 4,395 11.9 11.5 11.5 11.5 12.0 3.2 3.1 3.1 3.2 3.4 3.3 3.2 3.2 3.3 3.5 1,986 2,103 5.5 5.8 1.6 1.6 1.6 1.7 2,134 2,292 5.9 6.3 1.7 1.8 1.7 1.8 3,963 3,722 3,771 3,899 3,913 3,897 10.7 9.9 9.9 10.1 9.9 9.8 3.1 2.8 2.9 3.0 3.0 3.1 3.2 2.9 3.0 3.1 3.1 3.2 1,789 1,456 1,529 1,744 1,772 1,772 4.8 3.9 4.0 4.5 4.5 4.4 1.4 1.1 1.2 1.3 1.4 1.4 1.4 1.1 1.2 1.4 1.4 1.5 2,174 2,266 2,242 2,155 2,141 2,125 5.9 6.0 5.9 5.6 5.4 5.3 1.7 1.7 1.7 1.6 1.7 1.7 1.8 1.8 1.8 1.7 1.7 1.7 627 682 709 615 718 717 686 14.0 15.1 15.6 13.5 15.6 15.5 14.8 4.7 5.2 5.3 4.6 5.5 5.4 5.3 280 307 291 241 248 263 228 6.3 6.8 6.4 5.3 5.4 5.7 4.9 4 9 10 11 2.1 2.3 2.2 1.8 1.9 2.0 1.8 14 13 347 375 418 374 470 454 W 458 7.7 8.3 9.2 8.2 10.2 9.8 9.8 15 16 2.6 2.8 3.1 2.8 3.6 3.4 3.6 M A T E R N A L M O R T A L IT Y . N orway—Continued. 1905.......................... 1906.......................... 1907.......................... 1908.......................... Rate. Total. 1 Puerperal septicemia. 1908............................. 1909............................. 4,679,000 4 , 708' 000 131,362 128' 669 676 699 14.4 14.8 1910............................. 1911............................. 1912............................. 1913............................ 1914............................. Spain: 1901............................. 1902............................. 1903........................ / . 1904............................ 1905............................ 4,737,000 4', 75l) 000 4 , 74l' ÓÓÓ 4' 728' 000 4,747,000 124,059 12l' 850 122', 79Ó 12Ó)5Í6 123,934 710 699 675 708 746 15.0 14.7 14.2 15.0 15.7 666,252 683,153 703,568 667,125 688,058 650,649 666,687 685,265 649,878 670,651 15,603 16,466 18,303 17,247 17,407 3,674 3,494 3,771 3,885 4,115 19.7 18.6 20.0 20.5 21.6 1906............................ 1907............................ 1908............................ 1909............................ 1910............................ Sweden: 1900............................ 1901............................ 1902............................ 1903............................. 19,147,000 19,245,000 19,343,000 19,442,000 19,540,000 666,874 661,981 674,125 666,551 662,934 650,385 646,374 657,701 650,415 646,787 16,489 15,607 16,424 16,136 16,147 3,860 3,930 3,725 3,643 3,407 20.2 20.4 19.3 18.7 17.4 > 5,117,000 5,156,000 5,187,000 5,210,000 141,717 142,998 140,879 137,334 138,139 139,370 137,364 133,896 3,578 3)628 3,515 3,438 315 306 305 1904.................. 1905...................... .. 1906............................ 1907............................ 5,241,000 5,278,000 5,316,000 5,357,000 138,484 138,827 140,069 140,330 134,952 135,409 136,620 136,793 3,532 3,418 3,449 3,537 288 333 325 318 1908............................ 1909............................ 1910............................ 1911............................ Switzerland: 1900............................ 1901............................. 1902............................ 1903............................. 1904............................ 5,404,000 5,453,000 5,499,000 5,562,000 142,309 142,987 138,976 136,335 138,874 139,505 135,625 132,977 3,435 3,482 3,351 3,358 295 349 345 354 5.5 6.4 6.3 6.4 3,302,000 3,341,000 3,385,000 3,429,000 3,472,000 97,695 100,635 99,993 97,119 98,300 94,316 97,028 96,481 93,824 94,867 3,379 3,607 3,512 3,295 3,433 523 586 500 554 590 15.8 17.5 14.8 16.2 17.0 1905.................. : . . . . 1906............................ 1907............................ 1908.......... i ............... 3,516,000 3,560,000 3,604,000 3,647,000 98,057 98,971 97,696 99,468 94,653 95,595 94,508 96,245 3,404 3,376 3,188 3,223 551 495 553 554 15.7 13.9 15.3 15.2 1909............................ 1910............................ 1911............................ 1912............................ 3,691,000 3,735,000 3,781,000 3,831,000 97,296 96,669 94,185 95,171 94,112 93,514 91,320 1 92,196 3,184 3,155 2,865 2,975 544 447 501 484 14.7 12.0 13.3 12.6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6.1 5.9 5.9 . 5.5 6.3 6.1 5.9 M A T E R N A L M O R T A L IT Y . 18,657,000 18,755,000 18,853,000 18,951,000 19,049,000 66 M A T E R N A L M O R T A L IT Y . X V I .— A v era g e death rates p er 1 0 0 ,0 0 0 p o p u la tio n an d p er 1 ,0 0 0 live births fr o m diseases caused b y preg n a n cy and con fin em en t in certain fo r eig n cou n tries f o r specified p eriod s o f yea rs. T a b ie Death rate from diseases caused b y pregnancy and confinement. Country and specified period of years. Puerperal septicemia. Total. A ll other. Per 100,000 Per 1,000 Per 100,000 Per 1,000 Per 100,000 Per 1,000 population. live births. population. live births. population. live births. Australia: W hole period.......................... 1907-1909................................... 1910-1912................................... Austria: 1900-19(53................................... 1904-1907................................... 1908-1911................................... Belgium : W hole period.......................... 1903-1907................................... 1908-1912................................. England and W ales: W hole period.......................... 1900-1904................................... 1905-1909................................... 1910-1914a1.............................. France: W hole period.......................... 1906-1910................................... H ungary: W hole period......................... 1900-1903................................... 1904-1907................................... 1908-1911................................... Ireland: W hole p e rio d ........................ 1902-1906................................... 1907-1910................................... 1911-1914................................... Italy: W h o le period.......................... 1900-1904................................... 1905-1909................................... 1910-1913................................... Japan: W hole period.......................... 1901-1904................................... 1905-1908................................... 1909-1912................................... N ew Zealand: W hole period.......................... 1900-1904................................... 1905-1909................................... 1910-1914................................... Norw ay: W hole period.......................... 1900-1903................................... 1904-1907................................... 1908-1910................................... Prussia: W hole period.......................... 1903-1906................................... 1907-1910................................... Scotland: W hole period.......................... 1901-1905................................... 1906-1910................................... 1911-1914................................. Spain: W hole period.......................... 1901-1905................................... 1906-1910................................... Sweden: W hole period.......................... 1901-1904................................... 1905-1908................................... 1909-1911................................... Switzerland: W hole period.......................... 1900-1904................................... 1905-1908................................... 1909-1912................................... https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14.0 14.3 13.7 5.2 5.3 5.0 4 .8 4 .6 4 .9 1.8 1.7 1.8 6 .5 7 .2 6 .2 6 .2 1.9 2 .0 1.8 1.9 9.2 9.6 8.8 3.4 3 .6 3 .2 14.7 15.3 14.1 5.9 5.8 6.0 5.8 5.8 5.9 2 .3 2 .2 2 .5 8.8 9 .5 8 .3 3.5 3.6 3.5 10.6 12.5 10.3 9.1 4.0 4.4 3.9 3.7 4.3 5 .5 4.2 3.4 1.6 1.9 1.6 1.4 6 .3 7 .0 6 .2 5.6 2 .4 2 .5 2 .3 2 .3 10.3 10.3 5.2 5.2 4.8 4.8 2 .4 2 .4 5 .5 5 .5 2 .8 2 .8 13.2 13.7 13.0 12.9 3.6 3.6 3.5 3.6 3 .6 3.2 3 .3 4.2 1.0 .8 .9 1.2 9 .6 10.4 9 .7 8.7 2.6 2 .7 2 .6 2.4 12.6 13.5 12.2 11.9 5.4 5.8 5.2 5.2 4.4 4.9 4.1 4.0 1.9 2.1 1.8 1.7 8 :2 8 .6 8 .1 7.9 3.6 3.7 3 .5 3 .5 8.7 8.8 9 .2 7 .9 2.7 2 .7 2.8 2 .4 3.1 3.2 3 .4 2.8 1.0 1.0 1.0 .9 5 .5 5.6 5.9 5.1 1.7 1.7 1.8 1.6 13.0 13.5 13.5 12.0 4.0 4.2 4.3 3.6 4.5 4.2 4 .5 4.9 1.4 1.3 1.4 1.5 8 .5 9 .3 9 .1 7.1 2.6 2 .9 2 .9 2.1 11.7 12.7 12.3 10.5 4.4 4.8 4.5 4.0 3.0 2.9 3.2 2.8 1.1 1.1 1.2 1.1 8 .8 9 .8 9.1 7 .8 3.3 3.7 3 .3 3 .0 8.1 9.1 7.4 7.6 2 .9 3.1 2.7 2 .9 4.1 4.8 3.8 3.7 1.5 1.7 1.4 «* 1.4 3 .9 4.3 3 .6 4 .0 1.4 1.4 1.3 1.5 10.4 11.0 9.9 3.2 3.2 3.1 4.7 5.0 4.4 1.4 1.5 1.4 5 .8 6.0 5 .5 1.8 1.8 1.7 14.9 14.8 14.9 14.9 5.4 5.1 5.4 5.8 5.0 6.0 4.9 4.0 1.8 2.1 1.8 1.5 9 .8 8 .7 10.0 10.9 3.6 3 .0 3.6 4.2 19.6 20.1 19.2 5.7 5.7 5.7 12.3 12.6 12.1 3.6 3 .6 3 .6 7.3 7.5 7.1 2.1 2.1 2.1 6.0 5.8 6.0 6.3 2.4 2 .2 2 .3 2.6 2 .4 2 .7 2 .4 2 .2 1.0 1.0 .9 .9 3 .6 3.2 3 .6 4.1 1.4 1.2 1.4 1.7 14.9 16.3 15.0 13.1 5.6 5.8 5.7 5.3 6.4 6 .7 6 .5 5.9 2.4 2 .4 2 .4 2 .4 8 .5 9 .6 8 .5 7.3 3 .2 3 .4 3 .2 2.9 1 See explanatory note on p . 58. o
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