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UNITED STATES DEPARTMENT OF LABOR
FRANCES PERKINS. Secretary
L
CHILDREN’S BUREAU
>v'
G RACE ABBOTT, Chief
MATERNAL MORTALITY
IN FIFTEEN STATES
Bureau Publication No. 223
U NITED STATES
G OVERNM ENT PR IN T IN G OFFICE
WASHINGTON : 1934
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CO NTEN TS
Page
Letter of transmittal______________________________________ ____________________
S cope and method op th e s t u d y _________________________ _________________
G e n e r a l c o n sid er atio n s _________________________________ ___________________
Cause of death____________________________________________________________
Classification of deaths according to international list__________ _
Comparison of causes originally assigned and those found through
interviews_______________________ . _______ ■
______ ___________________
Changes in classification within the puerperal group_____________
Signature on death certificate and medical attention____ _________
Signature on death certificate and changes in classification of
deaths_____________________________________________________________
Autopsies___ _______________________________________________________________
Deaths excluded from study because found to be nonpuerperal______
Race and nativity__________
Deaths in urban and rural areas_________________________________________
Urban rates affected by deaths of nonresidents in hospitals_____
Accessibility and medicalattention_____________________________
Hospitalization____________________________________________________________
Interval between termination of pregnancy and death________________
Trimester of pregnancy____________________1____________________________ _
Live births and stillbirths_____________________
Parity and age____________________________________ ______ ;_________________
------ Illegitimacy_____________________ _____________________ ____________________
Comment by advisory committee__________
_________________ _____f e _________
M ate r n a l ca r e ________________________
Prenatal care__________________ . _____________ _____________________________
The group for whom report as to prenatal care was received____
Large proportion of women without prenatal care________________
Grading of the prenatal care received_____________________»________
Frequency of various elements of prenatal care____________________
Grade of prenatal care, cause of death, and period of gestation. _
Prenatal care and number of pregnancies__________________ j_______
Prenatal care in relation to live births and stillbirths____________
Prenatal care in the different States_____________________ __________
Delivery care. _ _ ________________________________________________________
Hospitalization at delivery__________________________________________
Attendant at confinement_________________ •_________________________
Technique of principal physician___________________________________
Use of pituitrin___________
Postpartum care____________________________________________________; _____
Comment by advisory committee_______________________________________
O per atio n s _____ _______________
Operations in the last trimester. _ _ ______________________________________
Operations for delivery______________________________________________
Operations other than for d e li v e r y ...._________________________
Operations in the first two trimesters_____ _____________________________
Laparotomy for ectopic gestation__________________________________
Therapeutic abortions_______________________________________________
Operations not for delivery on women who had no operation for
delivery___________________________________________________ ^_______
Onset and termination of labor in the first two trimesters_______
Incidence of operative deliveries..____________________________
Comment by advisory committee_______________
C esa r e a n sectio n ________________
Cause of death________________________________________
Indications for operation____ ____________________________ ________________
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C e sa r e a n s ectio n — C ontinued.
Parity and age_____ _______________________________________________________
Duration of labor_____________________________________
Rupture of membranes___________________________________________________
Planned and emergency operations_____ ____________________ ___________
Attem pts at other operations _”___________________________________________
Attendants preceding operator._ ________________________________________
Technique of operator_________________________ __________________________
Live births and stillbirths______________ _____________ _______________ ___
Anesthesia_______________________, ________________________________________
Cesarean section in the individual States and among urban and rural
and white and colored groups______________ ______________________ —
Comment by advisory committee_____________________________
Indications and choice of operation________________________________
Immediate cause of death_____________________ _______ _ _ _ _ ------- -A bo r tio n s ________ _____________________________ ___________________ _— ----------Definition in present study different from international l i s t .____ ____
Criminal abortion___________
Deaths following abortion and their causes--------------------------------- ---------------------Type of abortion_________________________________________ _ —
Predominance of sepsis as a cause of deaths following abortion---------Period of gestation________________________________________________________
Operations_____________
_
Indications for therapeutic abortions__________________________________
Illegitimacy_________________________ _____•.___________________ ------------- ___
Age of mother and type of abortion_____________________________________
Parity and type of abortion________________________________________
Mortality from abortion among white and colored and urban and
rural groups____________________
M ortality from abortion in thedifferent States________
—
Comment by advisory committee______________
__
P ue rperal sep tic e m ia ___________________________ 1__________________________
Deaths attributed to septicemia in the group studied______________ _
Duration of pregnancy__________________ — -------------|----------------------------117
Intrauterine manipulation___________________________________________
Operations__________________________________________________________ ?— __
First two trim esters.________ ___. ___ _______ _ _ — — - — * _______
Last trimester________________________
______
Interval between delivery and appearance of symptoms______________
Attendant at birth_________ ___________ ________ ____ ------------------- -----------Nursing care-------------------- ------------------------ --------------------------- •___.---------------Technique of principal physician------------------------------ ------------------- ----------Asepsis_____________________ ^------- ----------------------------- -------- --------------Vaginal examinations and use of rubber gloves___________________
Rectal examinations_________________________________________________
Preparation of patient_________
Hospital treatment_____ *.________________________________________;i—
Interval between delivery or abortion and death_______________________
Sepsis death rates among white and colored and urban and rural groups
in the different States_________ _ _______________________ _ _ _ _ _ — _____
Septic abortion in the different S ta te s ._________________________ _______
Comment by advisory committee___________ ____________________________
P u er per al phleg masia a l b a do len s , em bo lu s , sudden d e a t h __________
Deaths attributed to embolism_________
Deaths following abortions____________ ___ _______________ _______________
Type of delivery_________________________________
Interval between delivery or abortion and d e a t h .---------------------- ...-----Mortality rates in the States as related to other accidents of labor
and to medical c a r e ,____________________ ,______________________________
Proportion of maternal deaths and mortality rates among white and
colored and urban and rural groups___________________________________
Comment by advisory committee_______________________________________
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T o xe m ia s of p r eg n an c y --------— - - — Assignment of toxemias according to international list------------------------Puerperal albuminuria and convulsions--------- - — ------------------ - - -------Changes in assignment of deaths to albuminuria and convulsions..
Primary causes of deaths having albuminuria and convulsions as
chief contributing cause----------------------------------------------------------------Types of toxemia included------------------------------------ - - - --------------------Prenatal care received-------------------------------------------- -------------------------Cooperation of patient with physician--------- - - -----------------------------Condition of patient when first seen by physician------------------------Bed treatment and hospitalization--------------------------------------------------Onset of labor— artificial and spontaneous-------------------------- ----------Termination of labor— artificial and spontaneous-------------------- Operations for delivery--------------------- ---------- - --------------------------------Delivery before and after death, and convulsions-------------------------Live births and stillbirths-------- ----------- --------------------------- ----------------Large proportion of previous kidney disease--------- ----------------------- Parity and age--------------------------------------- .-------- •_---------- — ----------------- .
Prevalence of deaths from albuminuria and convulsions among
white and colored and among urban and rural mothers-----------Pernicious vom iting----------------------------------------------------- — -•
Comment by advisory committee------- - - - - - ------------------------------------------ P u er peral hem o r r h ag e ----- --------------------------------------------------------------------
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Puerperal hemorrhage among urban and rural and white and colored
women, by States----------------------------------------------------------------------------------Placenta previa------------ ------------- ------------- ------------------------------ ----------Other puerperal hemorrhage-------------------------- --------------------- ---------- Postpartum hemorrhage------------------------------------------ ----------------- -------Premature separation of the placenta.
---------------------------------------Comment by advisory committee--------- -------------------------------------------------O th er accidents of labo r , in clu d in g ru ptu re of the u t e r u s . — - - - - Other accidents of labor----------------------- -— ------------ --------------------- 'at
Rupture of the uterus----------------------------- --------- - - - - - - - - - - - - - - - --------Comment by advisory com m ittee------------------------------ - ------------------ - —
E ctopic g e s t a t io n . --------------------------------- - — . - — - — - - - --------r
Deaths associated with ectopic gestation m urban and rural areas
Deaths associated with ectopic gestation aniong white and colored
Medical attention and hospital care--------- -----------------------------------------Parity and age__------ *------- ------------------ — - v r - w - i T ------------------- a ~~~~
Periods in which symptoms began and m which deaths occurred----- -Operations for ectopic gestation-------------- ---------- — - — - - - - --------------Duration of symptoms before operation or before death-------------Type of operation for ectopic gestation. _ __-----------------------------------Other operations on women with ectopic gestation------ ------------- -----------Viable fetuses-------------------------------------------------Obstetric history of multigravidae---------------------- ---------------------- ---------- -Comment by advisory committee-----------------------------------------------------------R ecom m end atio ns b y ad viso r y c o m m ittee ---------------------------------------------------To the medical profession------------------------------------------- - - - ■
T o the general p u b lic ,.--------------------- -----------------.---------------Standards of American College of Surgeons for hospitals taking
obstetric patients----------------------------- ------------------------------------- --------- Appendix A .— General tables---------------- - - -------------------------------- -- — , y ~
Appendix B T h e 1929 revision of the Manual of the International List of
Causes of D eath ---------------------------------- - - — --------------------------------------- -Appendix C — Schedule used in the study------------------------------------------ (facing)
Index--------------------------------- --------------------------------------------- -------------- ---------------- -
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CONTENTS
TEXT TABLES
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1. Cause of death as given on the death certificate and as shown by inter
view, and mortality rate among women whose deaths were assigned
to puerperal causes__________________________________________
2 . Classification of cause of death as given on the death certificate and as
shown by interview among women whose deaths were assigned to
puerperal causes_________ ______________________________
Signature on the death certificate and medical attention among women
whose deaths were assigned to puerperal causes___________________
4. Classification of cause of death as certified, signature on death certifi
cate, and change in classification following interview for women
whose deaths were assigned to puerperal causes_______________ ___
5. Cause of death as shown by interview, and mortality rate among white
and colored women dying from puerperal causes__________________
6 . All live births in the State, deaths from puerperal causes, and mortality
rate among native and foreign-born white women dying from puer
peral causes in all the States included in the study and in specified
States having 2,000 or more births to foreign-born white women in
the biennium 1927-28___ *______________________________
V. Cause of death ^as shown by interview, and mortality rate among
women dying in urban and rural areas from puerperal causes______
Hospitalization and residence of women dying in hospitals among
women dying from puerperal causes in urban and rural areas of each
_
State included in the study. ________ ____ _____ ___ _______ ;-A_
9. Accessibility of physician and medical attention received by women
dying from puerperal causes______________________________________
10 . Cause of death as shown by interview and accessibility of physician
among women dying from puerperaKcauses______________ ________
11. Medical attention received by women dying from puerperal causes in
each State included in the study__________________________________
12. Hospitalization and trimester of pregnancy of white and colored women
dying from puerperal causes________________
13. Percentage of deaths from selected causes as shown by interview,
according to interval between delivery and death, among women
dying from puerperal causes______________ ______________ ________
14. Cause o f death as shown by interview, and trimester of pregnancy
among women dying from puerperal causes________________ ______
15. All live births in the State and deaths, mortality rate, and trimester of
pregnancy among white and colored women dying from puerperal
causes in all the States included in the study and in specified States
having 2,000 or more colored births annually.___________ ;_______
16. All live births in the State, and deaths, mortality rate, and trimester
of pregnancy among women dying from puerperal causes in urban
and rural areas of each State included in the study______ ____ 1____
17. Result of pregnancy of white and colored women dying from puerperal
causes____________________ ._______________________
18. Cause of death as shown by interview and result of pregnancy of
women dying from puerperal causes who had reached the last
trimester of pregnancy_______________________________ . . .
19* Number of pregnancies of white and colored women dying from puer
peral causes_________________________________________ _
_
20 . Number of deaths and mortality rate among white and colored women
dying in specified age periods from puerperal causes_______________
21. Cause of death as shown by interview, among married and unmarried
women dying from puerperal causes______________________________
22. Number of deaths of married and unmarried women dying in specified
age periods from puerperal causes________________________________
23. Prenatal care received by white and colored women dying in urban
and rural areas from puerperal causes____________________________
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24. Incidence of specified tests among white and colored women who had
received prenatal care, dying in urban and rural areas from puerperal
causes------------25. Cause of death as shown by interview,, grade of prenatal care, and
trimester of pregnancy among women dying from puerperal causes. _
26. Number of pregnancies of women for whom a report on prenatal care
was obtained and applicable among women dying from puerperal
causes___________________________
27. Prenatal care received and result of pregnancy among women dying
from puerperal causes who had reached the last trimester of preg
nancy----------- ---------------------------------------- - - - ----------■---------------------28. Prenatal care received by white and colored women for whom a report
was obtained and applicable among women dying from puerperal
causes in all the States included in the study and in specified States
having 2,000 or more colored births annually--------------------------------29. Prenatal care received by women for whom a report was obtained and
applicable among women dying from puerperal causes in urban and
rural areas of each State included in the study-----------------------------30. Relation between percentage of women receiving prenatal care and
mortality rate among women dying (a) from all puerperal causes,
(b) from all puerperal causes after they reached the last trimester
of pregnancy, and (c) from puerperal albuminuria and convulsions,
in each State included in the study----------------------------------------------31. Relation between percentage of women receiving grade I prenatal
care and mortality rate among women dying (a) from all puerperal
causes after they reached the last trimester of pregnancy and (6)
from puerperal albuminuria and convulsions, in each State included
in the study__________________________________________________ _
32. Attendant at .confinement and technique of principal physician among
women dying from puerperal causes who had reached the last tri
mester of pregnancy______________________________ _______________
33. Attendant at confinement of women who had reached the last tri
mester of pregnancy dying from puerperal causes in each State
included in the study---------------------------------------------------------- ------34. Technique of principal physician at confinement of women dying from
puerperal septicemia and from all other puerperal causes who had
reached the last trimester of pregnancy---------- -----------------------------35. Vaginal examinations and use of rubber gloves by principal physician
at confinement of women dying from puerperal causes who had
reached the last trimester of pregnancy----------------------------------------36. Vaginal and rectal examinations made by principal physician at con
finement ‘ of women dying from puerperal causes who had reached
the last trimester of pregnancy------------------------------- ,1-------------------37. Frequency of operative deliveries and other operations among white
and colored women dying from puerperal causes in urban and rural
areas______________________________ ________________ —-----------------38. Type of operation for delivery performed on women dying from puer
peral causes who had reached the last trimester of pregnancy-------39. Percent distribution of principal operations for delivery performed on
primiparae and multiparae of each age period dying from puerperal
causes who had reached the last trimester of pregnancy---------------40. Hours in labor and type of principal operation for delivery performed
on primiparae and multiparae dying from puerperal causes who
had reached the last trimester of pregnancy------- -------------------------41. Type of principal operation for delivery and technique of physician
performing final operation on women dying from puerperal causes
who had an operation for delivery in the last trimester of pregnancy .
42. Onset of labor among white and colored women dying from puerperal
causes who had reached the last trimester of pregnancy---------------43. Termination of labor among white and colored women dying from
puerperal causes who had reached the last trimester of pregnancy. _
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44. Onset and termination of labor among primiparae and multiparae
dying from puerperal causes who had reached the last trimester of
pregnancy_______________________
45. Onset and termination of labor among women dying from puerperal
causes who had not reached the last trimester of pregnancy_______
46. Onset of labor among white and colored women dying from puerperal
causes who had not reached the last trimester of pregnancy______
^ ’ Termination of labor among white and colored women dying from
puerperal causes who had not reached the last trimester of preg
^ &
nancy..._______________________ _ _____
48. Trimester of pregnancy and type of principal operation for delivery
performed on white and colored women dying from puerperal
causes in urban and rural areas________._________________ ______
49. Frequency of operation for delivery among all women who died from
puerperal causes and among those who died after reaching the last
trimester of pregnancy for whom there .was a report on operation
for delivery; each State included in the study_________ ___________
50. Principal indication for Cesarean section among white and colored
women and women in urban and rural areas who died following
L/esarean section______ - ____________ __
_
°
51. Number of pregnancies and frequency of Cesarean section among
women tor whom there was a report on operation for delivery, who
died from puerperal causes and who died after reaching the last
trimester of pregnancy_________ ____ _____ ___
52. Frequency of Cesarean section in each age period among all primiparae
a“ d nimtiparae dying from puerperal causes and among those dying
after they had reached the last trimester for whom there was a report
on operation for delivery____________________ _
__
53. Principal indication for Cesarean section and result of pregnanev
among women who died following Cesarean section _ _ _ _____ _ _ _ _ _
54. Principal indication for Cesarean section and anesthetic used for
women who died following Cesarean section_____ _________ _
55. Frequency of Cesarean section among all women who died from puer
peral causes and among those who died after reaching the last
trimester of pregnancy for whom there was a report on operation
for delivery; each State included in the study_____ _______ _
56. Cause of death as shown by interview according to the international
classification and immediate cause of death as shown by special
study of the schedules among women who died following Cesarean
section____ ________________
57. Principal indication for Cesarean section and immediate cause of
death as shown by special study of the schedules among primiparae
and multiparae who died following Cesarean section______________
58. Cause of death as shown by interview for women who died following
abortion, and trimester of pregnancy among women dying from
puerperal causes who had not reached the last trimester of preg
nancy________________________________ _
59. Cause of death as shown by interview among women who died follow
ing abortion of each specified type_________________________ _
60. Period of gestation among women who died following abortion of each
specified type________________________
of operation performed on women who died following abortion
of each specified typ e___________________
62. Relation between curettage and fever and deaths from puerperal
septicemia and from all other puerperal causes among women who
died following abortion of each specified t y p e _ l_____ ___________ _
63. Relation between curettage and fever and deaths from puerperal
septicemia and from all other puerperal causes among women having
hemorrhage and among women not having hemorrhage who died
following abortion of each specified type__________________ _____ __
64. Age at death of women who died following abortion of each specified
type among women dying from puerperal causes______________
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65. Type of abortion and mortality rate among white and colored women
and women in urban and rural areas who died following abortion. __
66. Number and percentage of women whose deaths followed abortion of
each specified type and whose deaths did not follow abortion among
women dying from puerperal causes in each State included in the
study_______________________________________________________________
67. Principal operation for delivery performed on women dying from
puerperal septicemia and on all women dying from puerperal causes
who had reached the last trimester of pregnancy________ 1__________
68. Principal operation other than for delivery performed on women dying
from puerperal septicemia and on all women dying from puerperal
causes who had reached the last trimester of pregnancy__________
69. Time between delivery and appearance of symptoms and type of
termination of labor among women dying from puerperal septicemia
who had reached the last trimester of pregnancy_____________________
70. Time between delivery and appearance of symptoms and hours in labor
among women dying from puerperal septicemia who had reached
the last trimester of pregnancy______________________________ - - - - 71. Attendant at confinement and technique of principal physician among
white and colored women dying from puerperal septicemia who had
reached the last trimester of pregnancy___________________________
72. Vaginal examinations and use of rubber gloves by principal physician
at confinement of women dying from puerperal septicemia and
from all other puerperal causes who had reached the last trimester of
pregnancy_______________________________________ — _____________
73. Place of development of sepsis and hospitalization at delivery or
abortion of women dying from, puerperal septicemia_______________
74. Number of deaths, mortality rate, and trimester of pregnancy among
white and colored women dying in urban and rural areas from
puerperal septicemia____ ___________ ________________________ . . . —
75. Number of deaths, mortality rate, and trimester of pregnancy among
women dying from puerperal septicemia in urban and rural areas
of each State included in the study________________________ ______
76. Number of deaths, mortality rate, and trimester of pregnancy among
white and colored women dying from puerperal septicemia in
specified States having 2,000 or more colored births annually----------77. Number and percentage of abortions of specified type among women
dying from puerperal septicemia in each State included in the
study________________________________________ ______ _____________
78. Mortality rate from puerperal septicemia following abortion and
not following abortion in each State included in the study______ . . .
79. Relation between mortality rates from puerperal phlegmasia alba
dolens, embolus, sudden death and (a) “ other accidents of labor” ,
and (6) percentage of women having medical care before they were
moribund among those who died from all puerperal causes in each
State included in the study_____________________ _______ __________
80. Trimester of pregnancy and grade of prenatal care received by white
and colored women dying from puerperal albuminuria and con
vulsions________________________________ s._____ ______ ___ _____ . . .
81. Time between first visit of patient to physician and death and grade of
prenatal care given to women dying from puerperal albuminuri^,
and convulsions___________________________________________________
82. Condition when first seen by physician, of white and colored women
and women dying in urban and rural areas from puerperal albumi
nuria and convulsions_____________
83. Onset of labor and trimester of pregnancy among white and colored
women and women in urban and rural areas dying from puerperal
albuminuria and convulsions______________________________________
84. Termination of labor and trimester of pregnancy among white and col
ored women and women in urban and rural areas dying from puer
peral albuminuria and convulsions________________________________
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85. Type of principal operation for delivery performed on women dying
from puerperal albuminuria and convulsions who had reached the
last trimester of pregnancy____________________________ ___________
86. Number and percentage of deaths and mortality rate among white
and colored women dying from puerperal albuminuria and convul
sions in all the States included in the study and in specified States
having 2,000 or more colored births annually_______ ___________ ___
87. Number afTd percentage of deaths and mortality rate among women
dying from puerperal albuminuria and convulsions in urban and
rural areas of each State included in the study________ ____________
88. Primary cause of death of women whose deaths were associated with
pernicious vomiting of pregnancy_____________________________
89. Period of gestation of women whose deaths were associated with per
nicious vomiting of pregnancy____________________________________
90. Number of . deaths from all puerperal causes and number and per
centage of deaths from puerperal hemorrhage in each age period
among primiparae and multiparae dying from puerperal causes____
91. Number and percentage of deaths and mortality rate among white
and colored women dying in urban and rural areas from puerperal
hemorrhage_______________________________________________________
92. Number and percentage of deaths and mortality rate among white
and colored women dying from puerperal hemorrhage in all the
States included in the study and in specified States “having 2,000
or more colored births annually___________________________________
93. Number and percentage of deaths and mortality rate among women
dying from puerperal hemorrhage in urban and rural areas of each
State included in the study_____ ____ ______________________ ______
94. Warning bleeding and treatment of placenta previa among women
whose deaths were associated with placenta previa______ _____ _
95. Type of principal operation for delivery performed on women whose
deaths were associated with placenta previa______________________
96. Type of principal operation for delivery performed on women dying
from puerperal hemorrhage exclusive of placenta previa_________ _
97. Parity and hours in labor for women who died following ruptured
uterus_______________________________:------------------------------------------98. Number and percentage of deaths and mortality rate of women whose
deaths were associated with ectopic gestation in urban and rural areas
of each State included in the study_____ ____ :_________________ ?•__ _
99. Number and percentage of deaths and mortality rate of white and
colored women whose deaths were associated with ectopic gestation
in all the States included in the study and in specified States having
2,000 or more colored births annually__________________________ L_
100. Relation between percentage of deaths associated with ectopic gesta
tion and percentage of hospitalization among women dying from
puerperal causes in each State included in the study_____________
101. Number and percentage of deaths associated with ectopic gestation
among primiparae and multiparae dying in specified age periods
from all puerperal causes________________________________________
102. Duration of symptoms before operation for women operated on
and before death for women not operated on for ectopic gestation,
afciong women whose deaths were associated with ectopic gesta
tion________________________ ,_________________________________ ___
103. Type of other operation performed for women operated on and not
operated on for ectopic gestation among women whose deaths
were associated with ectopic gestation___________ ________________
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APPENDIX TABLES
I. Cause of death as shown by interview and trimester of pregnancy
among white and colored women dying from puerperal causes in
urban and rural areas_______________________________
II. Registration by the American Medical Association, approval by
the American College of Surgeons, and bed capacity of hospitals
in which women were hospitalized at death; women dying from
puerperal causes________________________________________
III. Registration by the American Medical Association, approval by
the American College of Surgeons, and bed capacity of hospitals
in which women were hospitalized at delivery; women dying
from puerperal causes who had reached the last trimester of
pregnancy------------------------IV. Observance of minimum standards for obstetric service recom
mended by the American College of Surgeons, and deliveryroom and training-school facilities in hospitals in which women
were hospitalized at death; women dying from puerperal
causes_______________
V. Observance of minimum standards for obstetric service recom
mended by the American College of Surgeons, and deliveryroom and training-school facilities in hospitals in which women
were hospitalized at delivery; women dying from puerperal
causes who had reached the last trimester of pregnancy________
VI. Cause of death as shown by interview according to interval be
tween delivery and death, among women dying from puerperal
causes_______________
VII. Cause of death as shown by interview and number of pregnancies
among women dying from puerperal causes___________________
VIII. Cause of death as shown by interview and parity among women
dying in specified age periods from puerperal causes______192
IX . Prenatal care received by white and colored unmarried women
dying in urban and rural areas from puerperal causes_________
X . Hospitalization and trimester of pregnancy of unmarried women
dying from puerperal causes______________
X I. Type of operation for delivery in each trimester of pregnancy and
cause of death as shown by interview among women dying from
puerperal causes__________________________
X II. Type o f operation for delivery and number of pregnancies among
women dying from puerperal causes who had reached the last
trimester of pregnancy___________
X III. Onset of labor, cause of death as shown by interview, and trimester
of pregnancy among women dying from puerperal causes______
X IV . Termination of labor, cause of death as shown by interview, and
trimester of pregnancy among women dying from puerperal
causes_____________________
X V . Type of operation other than for delivery, cause of death as shown
by interview, and trimester of pregnancy among women dying
from puerperal causes_____________________________________,___
X V I. Type of operation for delivery in each trimester of pregnancy
among women dying from puerperal causes in each State in
cluded in the study____ _______ ^____________________ _______ i
X V II. Live births, and deaths and mortality rate following abortions
among white and colored women and women dying in urban and
rural areas in each State included in the study___ _____________
X V III. Number and percentage of white and colored women and women
in urban and rural areas whose deaths followed abortion of each
specified type and whose deaths did not follow abortion among
women dying from puerperal causes in each State included in
the study____________________________________________________
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XI
Page
183
186
187
188
189
190
191
195
195
196
198
199
202
204
206
208
209
XII
Chart
CONTENTS
CHARTS
Page
I. States included in maternal-mortality study_____________________
x iv
II. Maternal mortality rates, by cause______________________________
18
III. Maternal mortality rates by cause and by trimester of pregnancy_
29
IV. Type of issue among women dying from puerperal causes________
33
V. Prenatal care among women dying from puerperal causes________
41
VI. Operations for delivery in the last trimester of pregnancy among
women dying from puerperal causes____________________________
83
VII. Abortions among women dying from puerperal causes______________
106
VIII. Mortality rates for death following abortion among women dying
from puerperal causes________ ___________________________________
112
IX . Condition when first seen by physician of women who died from
puerperal albuminuria andconvulsions____________________________
144
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LETTER OF T R A N SM ITTA L
U n it e d S t a t e s D
of L ab o r ,
C h il d r e n ’s B u r e a u ,
epartm ent
Washington, September 15, 1988.
There is transmitted herewith a report on Maternal M or
tality in Fifteen States. The study was made under thé supervision
of Dr. Blanche M. Haines (the former director of the maternity and
infant-hygiene division of the Children’s Bureau) and of the Bureau’s
obstetric advisory committee (see p. 1), which also studied many of
the individual schedules and furnished the comments and recom
mendations for the report. The plan for the study was outlined by
its chairman, Dr. Robert L. DeNormandie. The material was ana
lyzed and the report was written by Dr. Frances C. Rothert, who also
coordinated the taking of schedules in the several States.
The Children’s Bureau acknowledges with appreciation the assist
ance given by the bureaus of child hygiene and of vital statistics of
the State departments of health in the States included and by the
officers of the State medical societies of those States.
Respectfully submitted.
G r a c e A b b o t t , Chief.
Hon. F r a n c e s P e r k i n s ,
Secretary of Labor.
M
adam :
X III
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C H A R T l.—S T A T E S IN C L U D E D IN M A T E f t N A L - M O R T A L l T Y S T U D Y
XIV
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MATERNAL MORTALITY IN FIFTEEN STATES1
SCOPE AND M E T H O D OF TH E STUDY
The maternal mortality rate in this country is generally recognized
as high, and it has shown comparatively slight changes over a period
of years. Moreover, information concerning the maternal deaths m
the United States has hitherto been available from two sources—
death certificates and birth certificates, which give very limited
information about all deaths in a given territorial or governmental
unit, and studies that give more complete information about
the deaths in selected groups, such as those in a hospital or those
in a physician’s practice. Information from the first source was
not sufficiently detailed and information from the second source
was not sufficiently general to give a picture of the conditions surround- ,
ing the 16,000 deaths annually assigned to causes associated with
pregnancy and childbirth. Accordingly, at a conference of the State
directors in charge of the administration of the MAternity and Infancy
Act, held at the Children’s Bureau in 1926, a plan for a study of factors
influencing the maternal death rate was presented by the chairrnan of
the obstetric advisory committee of the Children’s Bureau 2 and was
published in the proceedings of the conference.3
It was decided that a study be made only in those States which
were included in the birth-registration area and in which both the
State board of health and the State medical society made formal
request for it and assured the cooperation of the physicians of the
State. The Children’s Bureau undertook to prepare, with the assist
ance of the obstetric advisory committee, a schedule for use in all
the States studied, and to report the findings. In the preparation of
the schedule standards of prenatal care previously set up by the obstet
ric advisory committee 4 were considered, as were hospital standards
and standards of obstetric care in hospitals approved by the American
College of Surgeons.5
.
In accordance with this plan all deaths assigned to puerperal
causes in 13 States in 1927, and in these same States and two others
in 1928 were studied by the United States Children’s Bureau and its
1 An abstract of this report has been published as Maternal Deaths; a brief report of a study im de in
15 States (U.S. Children’s Bureau Publication No. 221, Washington, 1933, 60 Pp.). A brief r6sum6 was
published in the American Journal of Obstetrics and Gynecology for August 1933.
. o.
. _.
P a The members of the obstetric advisory committee are: Dr. Robert L. ^eNormandie,
obstetrics Harvard Medical School, chairman; Dr. Fred L. Adair, professor of obstetrics and gynecology,
University of Chicago; Dr. Rudolph W. Holmes, professor of obstetrics, Northwestern University Medical
School Chicago; Dr. Frank W. Lynch, professor of obstetrics and gynecology, University of California
Medical School; Dr. James R. McCord, professor of obstetrics and gynecology, Emory University School
of Medicine, Atlanta; Dr. C. Jeff Miller, professor of gynecology, Tulane University of L ou i^ n a School
of Medicine, New Orleans; Dr. Otto H. Schwarz, professor of obstetrics and gynecology, W^hington
University School of Medicine, St. Louis; Dr. Alice N. Pickett, assistant professor of obstetrics, University
by Robert L. DeN^m.endie. M .D , F w o ^ j U b .
Third Annual Conference of State Directors in Charge of the Local Administration of the ^
.5S?
Tnfancv Act of Nov 23 1921, pp. 42-52. U.S. Children s Bureau Publication No. 157. Washington, 1926.
1 < Standards of Prenatal Care; an outline for the use of physicians. U.S. Children s Bureau Publication
No. 153. Washington, 19,25.
s American College of Surgeons, Fourteenth Year Book, 1927, p. 71.
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2
MATERNAL MORTALITY IN FIFTEEN STATES
obstetric advisory committee and the State departments of health.
The States in which the study was conducted for both years are
Alabama, Kentucky, Maryland, Michigan, Minnesota, Nebraska,
New Hampshire, North Dakota, Oregon, Rhode Island, Virginia,
Washington, and Wisconsin. California and Oklahoma joined in the
study for 1928 only. In Michigan, Wisconsin, Minnesota, North
Dakota, California, and Oklahoma all or most of the schedules and
in Alabama some of them were taken by physicians on the staffs of
the State departments of health. The other schedules were taken by
physicians on the staff of the Children’s Bureau.6
The 15 States included in the study are fairly well distributed geo
graphically and are fairly typical of the sections in which they are
located. The entire western coast is included (California for only 1
year, however) and so perhaps is overrepresented, as are, probably,
the North Central agricultural States. None of the Rocky Moun
tain States is included, but conditions in eastern Washington, Oregon,
and California, are, in general, somewhat similar to those in the States
just east of them. Representation of the northeastern industrial
States and the far South is somewhat meager. (See chart I, p. X IV .)
The composition of the population for the group of 15 States
included in the study conforms very closely to that of the United
States as a whole according to the census of 1920. In the 15 States
91 percent of the population were white and 9 percent colored; in the
United States 90 percent were white and 10 percent colored.7
The distribution of the population, however, was less similar in
respect to urban and rural groups for the States of the study and the
United States as a whole. In the 15 States included in the study 36
percent of the population were in urban areas and 64 percent in rural
areas.8 In the entire United States 42 percent of the population lived
in cities of 10,000 or more and 58 percent in rural areas.
In the 15 States and during the years of the study the deaths of
7,537 women were assigned to puerperal causes by the United States
Bureau of the Census in accordance with the International List of
Causes of Death. These 7,537 deaths made up 26 percent of the
29,298 deaths from puerperal causes in the United States birthregistration area for the 2 years. In the States of the study 47 per
cent (3,546) of the maternal deaths were urban and 53 percent
(3,991) were rural; in the birth-registration area for these 2 years 54
percent of the maternal deaths were urban and 46 percent rural.
The deaths were distributed more similarly as to color. In the
States and years of the study 18 percent and in the birth-registration
area in these years 19 percent of the maternal deaths were of colored
women.
* The following persons made the interviews in the different States: Alabama—Dr. Wade H. Garner,
Dr* Charles M . Lacy, Dr. Robert A. Berry, Dr. William H. Abernathy, and Margaret Murphy, R. N .:
Kentucky—Dr. Frances C. Rothert, Dr. Frances M . Hennessy, and Dr. Janice Rafuse; Maryland—Dr.
Margaret Swigart; Michigan—Dr. Joseph H. Curhan, Dr. Dorothy L. Green, and Dr. Florence Knowlton; Minnesota—Dr. William H. Rumpf and Dr. Ruth G. Nystrom; Nebraska—Dr. Herman M . Jahr
and Dr. MaBelle True; New Hampshire and Rhode Island—Dr. Hennessy; North Dakota—Dr. Maysil
M . Williams, Dr. M . M ay Allen, and Dr. Iva Stevens Merritt; Oregon—Dr. Mildred McBride; Virginia—
Drs. Swigart, Rothert, Hennessy, and Rafuse; Washington—Dr. Harold L. Kennedy, Dr. Harvey J.
Felch, and Dr. Paul W. Spickard; Wisconsin—Dr. Charlotte J. Calvert; California—staff physicians of
the State department of health under the supervision of Dr. Ellen S. Stadtmuller and Dr. Swigart; Okla
homa—Dr. True, Dr. David M . Cowgill, Dr. Margaret Dubois, and Dr. Louise Smith King.
71n accordance with the practice of the U.S. Bureau of the Census the term “ colored” is used through
out the report to include Negro and other races such as Japanese, Chinese, and Indians. In 1930 Mexicans
(previously classified as white) were reported with “ other races” by the U.S. Bureau of the Census.
8 In the vital-statistics reports of the Bureau of the Census cities of 10,000 or more population are classified
as urban; the remainder of each State is classified as rural.
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SCOPE AND METHOD OF THE STUDY
3
As there were 1,176,603 live births 9 in the States and during the
years of the study, these 7,537 deaths gave a maternal mortality rate
of 64 per 10,000 live births; in the birth-registration area for 1927 and
1928 together the maternal mortality rate was 67. Conditions as
regards maternal mortality were evidently better in the States studied.
The four States admitted to the birth-registration area in 1928 all
had higher rates than the area as a whole for that year; if they had
been in the area in both years of the maternal-mortality study the
rate for the area for the two years would probably have been higher.
The birth-registration area in 1928 included all the continental United
States ‘with the exception of 4 States, 2 of which were admitted in
1929. It is not probable that the inclusion of these 4 States would
have lowered maternal mortality rates in 1927 and 1928.
The regions studied, then, are probably fairly representative of the
United States as a whole with some overemphasis on the Pacific Coast
and North Central States, and some underemphasis on the Rocky
Mountain regions, the far South, and the eastern industrial centers.
Conditions as regards maternal mortality were apparently better in
the regions studied— they were certainly not worse— than those
obtaining in the United States as .a whole.
Copies were made of all certificates of deaths assignable to puerperal
causes as reported to the State departments of health. Birth certifi
cates were matched to these where possible. The physicians or other
persons signing the death and birth certificates were then visited, as
well as other physicians or midwives to whom the interviewers were
referred. Except in very rare instances— usually where there was no
physician— families were not visited. Hospitals and clinics in which
the patient had received care were visited, and, with the consent of
the attending physician, the case records were studied. This consent
was practically never refused. The physicians interviewed cooper
ated most heartily, giving freely of their time and confidence and
helping in every possible way. Although comparatively few had kept
case histories, most of them had only' too vivid recollection of these
cases.
About certain cases very little information except that on the death
and birth certificates could be obtained because of the death, serious
illness, or permanent removal from the State of the attending physi
cian. These cases represented, however, only a very small percentage
of the total.
Rather more frequent were the deaths concerning which the attend
ing physician himself knew very little. Sometimes he had been called
in for the first time when the patient was dying, and it was impossible
for him to obtain an accurate history. Sometimes, as when the inter
view was delayed for some reason, he had forgotten some or all of the
details of the case. In most of these cases no laboratory work other
than urinalysis or blood-pressure examination had been done.
For cases in which there had been no attending physician it was very
difficult to obtain anything like a good medical history. The mid•Live births include all births that were so reported on the transcripts of births sent to the U.S. Bureau
of the Census. The rules of statistical practice adopted in 1908 by the section on vital statistics of the
American Public Health Association define birth as “ the instant of complete separation of the entire
body * * * of the child from the body of the mother * * *.” “ A child * * * dying a moment,
no matter how brief, after birth, was a living child * * *.” A rule adopted in 1913 states that “ no
child that shows any evidence of life after birth should be registered as a stillbirth” and that the words
“ any evidence of life shall include action of heart, breathing, movement of voluntary muscle.”
182748—34----- 2
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4
MATERNAL MORTALITY IN FIFTEEN STATES
wives attending the women in these States were practically all
untrained women. Any instruction they might have had, had been
directed almost exclusively toward cleanliness, noninterference, and
prophylaxis against ophthalmia neonatorum. Most of them, therefore,
had noticed only the very obvious symptoms. Most of the midwives
who were observing and cooperative could give fairly clear descriptions
of symptoms under careful questioning, but others were so engrossed
in their own weird ideas of pathology that they could offer almost no
information of value. If an old “ granny” was convinced that the
patient died because her “ womb had growed to her liver” , no clear
story of mere symptoms would be forthcoming. A few of the mid
wives, particularly among the southern Negroes, could not be found.
Collection of data was begun in February 1927, and most of the
schedules were completed before July 1, 1929. All schedules were
sent to the Children’s Bureau for statistical examination, and tabu
lations were made there. Close contact between the interviewers and
the Bureau was maintained in order to keep the interpretation of the
schedules uniform. To insure conformity to the census records, the
schedules were checked to the Census Bureau’s transcripts of the
death certificates as soon as they were available, which, for the 1928
deaths, was in the summer and autumn of 1929. Additional cases
found at the Bureau of the Census that had not been classified by
the States as puerperal were listed and sent to the interviewers for
study. Most of the additional interviewing and matching of sched
ules was completed by January 1930, but a few States sent in some
schedules as late as June 1930.
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GENERAL CONSIDERATIONS
CAUSE OF DEATH
C L A S S IF IC A T IO N O F D E A T H S A C C O R D IN G T O IN T E R N A T IO N A L L IS T
The International List of Causes of Death (revision of 1920)1 was
used as the chief basis for the analysis of these deaths. Deaths
classified in accordance with this list as due to the puerperal state
are those of which complications of pregnancy, delivery, or the
puerperium were the only cause or the most important cause. The
titles included are as follows:
143. Accidents of pregnancy.
а. Abortion.
This item includes miscarriage, missed abortion, premature labor, etc.
This item will be referred to throughout this report as “ abortion or
premature labor” (no. 143a). (Abortion as generally used in this
report is defined as the termination of a uterine pregnancy before the
period of viability; i.e., the first two trimesters.)
б. Ectopic gestation.
c. Others under this title.
This item includes antepartum hemorrhage, chorea of pregnancy,
pernicious vomiting of pregnancy, cornual pregnancy, hydatid mole,
pregnancy (unqualified), and others.
144. Puerperal hemorrhage.
a. Placenta previa.
b. Others under this title.
This item includes postpartum hemorrhage, accidental hemorrhage,
puerperal hemorrhage (unqualified), and so forth.
145. Other accidents of labor.
a. Cesarean section.
b. Other surgical operations and instrumental delivery.
c. Others under this title.
This item includes (1) rupture of the uterus or bladder during
parturition; (2) abnormal or difficult labor, faulty presentation,
inversion of uterus, version during labor, and so forth; ( 3) lacerations
of cervix or perineum, postpuerperal shock, labor (unqualified), and
similar terms.
146. Puerperal septicemia.
This item includes postpartum sepsis, postabortive sepsis, infected
tubal pregnancy, puerperal peritonitis or abscess, pyelitis following
childbirth, and so forth.
147. Puerperal phlegmasia alba dolens, embolus, sudden death.
148. Puerperal albuminuria and convulsions.
This item includes pyelitis or pyelonephritis of pregnancy, puerperal
eclampsia, nephritis, toxemia, tetanus, and uremia.
149. Following childbirth (not otherwise defined). •
This item includes puerperal insanity.
150. Puerperal diseases of the breast.
When more than one puerperal cause appears on a death certificate
the death is assigned to one of them in accordance with definite rules,
which are published in the Manual of Joint Causes of Death.2 For
19* Manuai of the International List of Causes of Death, 1920. U.S. Bureau of the Census. Washington,
8 Manual of Joint Causes of Death Showing Assignment to the Preferred Title of the International List
of Causes of Death When Two Causes are Simultaneously Reported. U.S. Bureau of the Census. Washlngton, 1925.
5
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6
MATERNAL MORTALITY IN FIFTEEN STATES
example: If Cesarean section and embolism appear on a death
certificate, the death is assigned to Cesarean section (no. 145a); if
Cesarean section and eclampsia appear, the death is assigned to
puerperal albuminuria and convulsions (no. 148); if Cesarean section,
eclampsia, and peritonitis appear, the death is assigned to puerperal
septicemia (no. 146).
When both puerperal and nonpuerperal causes appear on the death
certificate the rules governing classification are, in general, as follows:
1. If one of the more serious acute infectious diseases, such as
typhoid fever, smallpox, diphtheria, or if cancer or syphilis,3 or if an
external cause, such as accident or homicide (including criminal
abortion), appears on a woman’s death certificate in addition to a
puerperal cause, her death is assigned to that cause and not to the
puerperal cause. (Influenza, however, does not take precedence
over any puerperal cause except “ other accidents of pregnancy” ,
“ following childbirth (not otherwise defined)” , and “ puerperal
diseases of the breast.” )
2. Puerperal septicemia takes precedence over all puerperal or
nonpuerperal causes except the ones mentioned.
3. Tuberculosis in most forms takes precedence over all puerperal
causes except puerperal septicemia.
4. Other serious chronic diseases, such as cardiac valvular disease,
chronic nephritis, diabetes, and others, take precedence over all
puerperal causes except the most severe complications of childbirth.
5. The term “ pregnancy” appearing on a death certificate causes a
death to be classified as puerperal only when it appears alone or with
a term denoting a mild disorder, or with a cause implying a complica
tion of pregnancy.
The application of these rules to the various puerperal causes is more
fully discussed in the sections dealing with those causes.
It will be seen, therefore, that not all deaths of pregnant or par
turient women are assigned to a puerperal cause; also that a group of
causes classified under a title in the International List of Causes of
Death is not identical with the group that would be classified under
the same term if that term were used to denote a medical entity. For
instance, the title Cesarean section (no. 145a), as was noted, does not
include all deaths of women who had had Cesarean sections. The
title abortion (no. 143a) not only does not include all the deaths fol
lowing abortion, defined as the termination of a previable uterine
pregnancy, but it does include some deaths that did not follow abortion
so defined. On the whole, however, the titles describe the causes
included under them, and the system of preferences usually results in
the assignment of a death to the title denoting that condition which
was chiefly responsible.
Although the International List of Causes of Death has been used
as the chief basis for the analysis of the deaths studied, the discussion
in certain of the sections that follow will be based on the whole group
of deaths associated with certain conditions, such as abortion, ectopic
gestation, or Cesarean section, and not merely on the cases that were
assigned to those titles as the principal cause of death.
* Syphilis seldom appears on a maternal-death certificate. In the birth-registration area in 1925 (the
latest year for which the Bureau of the Census has tabulated contributory causes of death) a puerperal
cause was contributory to syphilis in only 52 cases.
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GENERAL CONSIDERATIONS
7
The revision of 1920 of the international list was followed in this
study because it was in use at the time these deaths were classified.
The list was revised by the international commission late in 1929.
The important changes are: (1) Puerperal septicemia (old no. 146) is
divided into abortion with septic conditions (no. 140), ectopic
gestation with septic conditions specified (no. 142a), and puerperal
septicemia not specified as due to abortion (old no. 145); (2) puerperal
albuminuria and convulsions (old no. 148) is divided into puerperal
albuminuria and eclampsia (no. 146) and other toxemias of pregnancy
(no. 147) (which also includes chorea and pernicious vomiting of
pregnancy from the old subtitle no. 143c); (3) old nos. 143a, 143b, and
143c are changed to nos. 141, 142b, and 143, respectively; old no. 147
becomes no. 148, and old no. 145 becomes no. 149 without change of
name or content; (4) following childbirth not otherwise defined (old
no. 149) and puerperal diseases of the breast (old no. 150) are combined
into other and unspecified conditions of the puerperal state (no. 150).
The rules for the assignment of joint causes as previously given
apply also to the 1929 list.
The new subdivisions are such that comparisons of deaths classi
fied according to the 1929 fist with those classified under the 1920 list
are possible. Comparison of the deaths in this study with deaths
classified according to the 1929 revision will be facilitated by sub
divisions similar in general to those in the 1929 list. (For a fuller
discussion of the 1929 revision of the International List of Causes of
Death see appendix B, p. 212.)
C O M P A R IS O N
OF
C A U S E S O R IG IN A L L Y A S S IG N E D
IN T E R V IE W S
AND
TH O SE FOUND
TH ROUGH
The 7,537 deaths classified by the United States Bureau of the
Census, in accordance with the international list, as due to puerperal
causes in the States and during the years of the study include not only
those originally so certified by the physician, but those added as a
result of answers to queries by the Bureau of the Census and by State
bureaus of vital statistics about certificates originally showing illdefined causes. Of this total, 7,380 were found, by means of inter
views in connection with the present study, to have been actually
puerperal in the meaning of the international classification, and 157
were found to have been nonpuerperal. Only the 7,380 puerperal
deaths were given detailed study.
There were, however, other puerperal deaths in the States of the
study during 1927 and 1928 that were not registered as puerperal
and so were not studied. The United States Bureau of the Census
and State bureaus of vital statistics make every effort, through the
querying of indefinite causes of death given on certificates for women
of child-bearing age, to have the list of maternal deaths complete.
The success of their efforts and the accuracy and completeness of the
information available as to the extent of maternal mortality in this
country depend in the last analysis on the accuracy and completeness
with which physicians and other attendants make out the death
certificates. Physicians and others occasionally told interviewers of
deaths that would have been classified as puerperal if registered and
if accurately certified; but certificates for these deaths either were
not found or were found to have been so filled out that the death was
not classified as puerperal. These deaths were not included in the
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8
MATERNAL MORTALITY IN FIFTEEN STATES
study because it would have been impracticable to discover all such
deaths and because the deaths classified as puerperal by the Bureau
of the Census had been determined upon as the basis of the investiga
tion. The experience of the interviewers makes it probable that the
number of puerperal deaths not included in the census figures exceeded
the number of nonpuerperal deaths that were included. Thus the
Census Bureau rates may be lower than the actual rates; and the rates
used in the present study are still lower, being based on the 7,380 puer
peral deaths remaining after the exclusion of 157 found on interview to
have been nonpuerperal {table 1).
Cause of death 1 as given on the death certificate and as shown by inter
view, and mortality rate among women whose deaths were assigned to puerperal
causes
T a b l e 1.—
Deaths from causes as Deaths from causes as
given on death certifi
shown by interview
cate
Cause of death 1
All causes_________________
Puerperal______________________
Rate
per
Num Percent
distri 10,000
ber
bution
live
births
1 7,537
Rate
Num Percent per
distri
10,000
ber
bution
live
births
7,537
7,537
100
64.1
7,380
100
Accidents of pregnancy_________________________
770
10
6.5
719
10
6.1
Abortion, premature labor_____ _____ -_____ _
Ectopic gestation... _______________________
Others____________________________________
S68
m
1S8
6
4
3
3.1
3.3
1.3
363
348
118
6
3
3
3.0
3.1
1.0
Puerperal hemorrhage_________ _____ _
Other accidents of labor________________________
758
812
10
11
6.4
6.9
791
652
11
9
6.7
5.5
Cesarean section. _____________ ____ ________
Other surgical operations and instrumental
delivery_________________________________
Others_____ _______ _______________
166
3
l.S
136
3
1.3
76
681
1
8
.6
19
109
407
1
6
.9
3.6
Puerperal septicemia________________________ ..
Puerperal phlegmasia alba dolens, embolus, sudden death__________________________
Puerperal albuminuria and convulsions. - - ....... .....
Following childbirth (not otherwise defined)...........
Puerperal diseases of the breast__ ____ ___________
2,827
38
24.0
2,948
40
25.1
337
2,006
24
3
4
27
(8)
(a)
2.9
17.0
.2
(3)
344
1,900
23
3
5
26.
(*)
(2)
2.9
16. L
.2
(8)
Nonpuerperal____ ______ _______________
62.7
157
1 According to the Manual of the International List of Causes of Death, 1920.
* Less than 1 percent.
* Less than one tenth per 10,000.
Deaths will be spoken of throughout the report as having been
“ assigned" or “ attributed" to the individual causes of death. The
term “ assigned" is used of the official classification by the Bureau
of the Census, as in the first 3 columns of table 1 ; the term ‘ ‘ attrib
uted" is used as referring to the classification after interview, for
purposes of this study, as in the last 3 columns of table 1.
C H A N G E S IN C L A S S IF IC A T IO N W IT H IN T H E P U E R P E R A L G R O U P
Changes in classification within the puerperal group were also made
as a result of the interviews in many of the 7,380 cases given detailed
study (table 2). For instance, 770 deaths were assigned to accidents
of pregnancy from information given on the death certificates, but
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GENERAL CONSIDERATIONS
9
32 of these were among the deaths classified after the interviews as
nonpuerperal. Of the 738 still classified as puerperal after the inter
views the assignment to accidents of pregnancy was verified in 635
cases; but it was found that the death should have been assigned to
puerperal hemorrhage in 16 cases, to other accidents of labor in 8
cases, to puerperal septicemia in 63 cases, to puerperal phlegmasia
alba dolens, embolus, sudden death in 7 cases, and to puerperal
albuminuria and convulsions in 9 cases. The interviews resulted in
the assignment of larger numbers of deaths to puerperal septicemia,
puerperal hemorrhage, and puerperal phlegmasia alba dolens, and
of smaller numbers to puerperal albuminuria and convulsions, acci
dents of pregnancy, and other accidents of labor. These changes will
be discussed in the sections dealing with the individual causes of death.
Reasons for the changes were various. Many were the results of
second thought on the part of the physician. Some of the 558 autop
sies were performed after the death certificates were signed, and a few
of the coroners signing death certificates were interested chiefly in
showing that the death was from natural causes. Clerical errors by
physicians or by those transcribing certificates for the Bureau of the
Census occasionally led to erroneous classification. Lack of knowl
edge of the International List of Causes of Death often led to the
omission of statements by physicians, which, if made, would have
caused the Bureau of the Census to classify the deaths differently.
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T
a b le
2.— Classification of cause of death 1 as given on the death certificate and as shown by interview among women whose deaths were assigned
to puerperal causes
Cause of death i as shown by interview
Cause of death 1 as given on death certificate
Total
Total
All causes.
Accidents of pregnancy______ _____________
Puerperal hemorrhage_______--------- ----------Other accidents of labor__________ _____ ____
Puerperal septicemia________ _____ ________
Puerperal phlegmasia alba dolens, embolus,
sudden death___________________________
Puerperal albuminuria and convulsions-------Following childbirth (not otherwise defined).
Puerperal diseases of the breast........................
Puerperal
Following Puerperal
phlegmasia Puerperal
Accidents Puerperal Other acci Puerperal alba dolens, albumin childbirth
(not
other diseases
of preg hemorrhage dents of
of the
uria and
septicemia embolus,
de
labor
nancy
breast
convulsions wise
sudden
fined)
death
7,537
7,380
791
652
2,948
344
770
758
812
2,827
738
756
796
2,763
635
26
25
7
16
703
41
8
63
15
54
2,7Ì7
7
26
4
337
2,006
24
3
334
1,966
24
3
2
12
28
69
286
19
22
2
According to the Manual of the International List of Causes of Death, 1920.
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4
15
5
609
2
2
1,900
4
38
22
1
1,826
23
Classified
as nonpuerperal
157
MATERNAL MORTALITY IN FIFTEEN STATES
Classified as puerperal
11
GENERAL CONSIDERATIONS
S I G N A T U R E O N D E A T H C E R T IF I C A T E A N D M E D I C A L A T T E N T I O N
Death certificates were signed in 7,046 of the 7,537 cases included
in the study by physicians other than coroners, in 362 cases by cor
oners, and in 62 cases by others (a few of these were irregular prac
titioners not listed in the medical directory, and some were parents
or husbands); 67 death certificates had no signature (table 3).
The fact that a physician signed a woman’s death certificate did
not always mean that he had attended her, nor did the fact that a
death certificate was signed by a coroner or a nonmedical person, or
was unsigned, always mean that the patient had had no medical
attention. Physicians signed the death certificates of 65 women who
had had no medical attention. Most of these were women who died
before the arrival of the physician. In a few cases a physician signed
the death certificate of a woman who had formerly been his patient,
or with whom he was acquainted, and who had had no physician in
her last illness. These women usually lived in remote places.
Of the entire group of 7,537 women who died, information as to
medical attention was obtained for 7,466. One hundred and eightyeight (3 percent) of this number had had no medical attention
and 488 (7 percent) had had no medical attention until they were
moribund.
T able 3.
Signature on the death certificate and medical attention among women
whose deaths were assigned to puerperal causes 1
Women whose deaths were assigned to puerperal
causes 1
Medical attention 2
Signature on death certificate
Total
None
Total....................... ........... _
Physician________ _____ ____
Coroner.............................
Other or none________ ____
When
Before
patient
patient
Not re
was mori was mori ported
bund
bund
7,537
188
488
6,790
71
7,046
362
129
65
47
76
428
56
4
6,513
235
42
40
24
7
1As given on the death certificates.
2 See table11 for medical attention given to the. 7,380 women whose deaths were attributed to puerperal
causes after interview.
Of 129 death certificates unsigned or signed by other persons than
physicians or coroners, 76 were for women known to have had no
medical attention. In 46 cases there was reported to have been
some medical attention, though in a few cases this consisted of treat
ment by a practitioner not listed in the American Medical Directory.
In other cases a physician had given the patient, who lived far from
town, some care, but he did not see the patient at the time of her
death nor sign the death certificate.
Most of the women whose death certificates were signed by coroners
had had some medical attention. The practice in some hospitals of
having the coroner sign the certificates of all deaths occurring soon
after admission increased the number signed by coroners. Of the
362 death certificates signed by coroners, 47 were for women who
had not had medical attention and 56 for women who had had med
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12
MATERNAL MORTALITY IN FIFTEEN STATES
ical attention only when dying. However, 235 were known to have
had some earlier medical attention. Two hundred and thirty-eight
of the 362 whose certificates were signed by coroners had had hospital
treatment, 130 of them for less than 2 days.
S IG N A T U R E
ON D E A T H
C E R T I F I C A T E A N D C H A N G E S IN C L A S S I F I C A T I O N O F D E A T H S
The changes made in the classification of deaths as a result of the
interviews are shown in table 4. The cause of death as given to the
interviewers was different from that to which the death had been
assigned on the basis of information given on the certificate in 857
(12 percent) of the 7,046 cases certified by physicians, in 59 (16
percent) of the 362 cases certified by coroners, in 15 (24 percent) of
the 62 certified by others, and in 23 (34 percent) of the 67 in which
the death certificate was unsigned. A larger proportion of changes
was made in the group of deaths certified as due to the indefinite
term “ other accidents of labor” than in those under any other title.
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T a b l e 4.
Classification of cause of death 1 as certified, signature on death certificate, and change in classification following interview for women
whose deaths were assigned to puerperal causes 2
Women whose deaths were assigned to puerperal causes *
Signature on death certificate
Physician
Coroner
Other
None
Change in classification
following interview
Change in classification
following interview
Change in classification
following interview
Change in classification
follówihg interview
Cause of death 1 as certified
Total
To other To nonpuerperal puerperal
causes
causes
None
To other To nonpuerperal puerperal
causes
causes
To other To nonpuerperal puerperal
causes
causes
None
All causes...........
7,537
6,189
707
150
303
56
3
47
13
Accidents of pregnancy.
770
552
111
31
51
10
1
2
1
S68
t64
1S8
tifi
tl9
88
68
to
S3
U
tt
tt
7
6
1
t
1
4
758
812
638
492
67
223
14
33
25
6
4
9
9
165
111
S6
1
S
1
t
76
681
6t
329
to
167
S
10
tt
S
7
1
•6
2,827
2,445
125
62
143
25
1
17
2
337
2,006
278
1,764
46
128
3
38
6
45
1
1
9
2
24
3
17
3
7
Abortion, premature labor.
Ectopic gestation...............
Others._______ __________
Puerperal hemorrhage...
Other accidents of labor.
Cesarean section....... ............................
Other surgical operations and instru
mental delivery................................
Others.....................................
Puerperal septicemia_____ _______ ______
Puerperal phlegmasia alba dolens, embo
lus, sudden death.......... ..................... .
Puerperal albuminuria and convulsions...
Following childbirth (not otherwise de
fined)........................................................
Puerperal diseases of the breast..................
s
4
2
1
1 According to the Manual of the International List of Causes of Death, 1920
8 As given on the death certificate.
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11
2
None
puerperal puerperal
causes
causes
44
21
9
2
7
t
2
2
2
20
7
1
16
1
1
19
1
4
1
1
8
2
2
GENERAL CONSIDERATIONS
None
14
MATERNAL MORTALITY IN FIFTEEN STATES
AUTOPSIES
Autopsies were known to have been performed in 571 of the 7,537
deaths certified as puerperal. They were performed in 130 (36 per
cent) of the 362 cases in which the coroner signed the death certificate,
and in 441 (6 percent) of the 7,046 cases in which a physician other
than the coroner signed the death certificate.
Thirteen of the autopsies were included in the 157 cases in which
the death was certified as puerperal but was found at the interview
with the attending physician to have been nonpuerperal. The re
maining 558 constituted only 8 percent of the 7,380 cases found on
interview to have been puerperal. As the question was not printed
on the schedule except in the copy-of the death certificate, and as the
fact that an autopsy had been performed was not always noted on
the death certificate, there may have been other autopsies concerning
which information was not obtained. However, the fact that an
autopsy had been performed is likely to have been mentioned in most
cases by the attending physician or on the hospital chart, and the
autopsy diagnosis to have been entered on the schedule by the inter
viewer. In 87 of the 129 coroners’ cases and in 383 of the 429 other
cases finally classified as puerperal in which an autopsy was performed
death had occurred in a hospital.
Of the 558 autopsies performed in cases classified as puerperal after
interview 489 were on white women and 69 on colored women. There
were only 112 autopsies on women who died in rural areas (which
includes cities of less than 10,000 inhabitants in 1920); 105 of these
112 women were white and 7 were colored. Of the 446 women dying
in urban areas on whom autopsies were performed, 384 were white
and 62 were colored.
In 99 of the 129 coroners’ autopsy cases included in the study the
death had occurred before the seventh month. In 62 of these 99 cases
there had been induced abortion other than therapeutic; in 8 there
had been spontaneous abortion; in 12 the type of abortion could not
be determined; and in 17 there had been no abortion. In 174 of the
429 autopsy cases in which the death certificates had been signed by
physicians other than coroners the death had occurred before the
seventh month. In 70 of these 174 cases there had been induced
abortion other than therapeutic; in 33 there had been spontaneous
abortion; in 12 there had been therapeutic abortion; in 9 the type of
abortion could not be determined; and in 50 there had been no abor
tion. It is probable that in a considerable number of cases, particu
larly coroners’ cases, the chief purpose of the autopsy was to discover
whether or not there had been an induced abortion.
Of the 558 deaths followed by autopsy that were included in the
7,380 deaths studied, 77 (14 percent) were caused by accidents of
pregnancy (including 29 cases (5 percent) of abortion and premature
labor, 40 cases (7 percent) of ectopic gestation, and 8 cases (1 percent)
of other accidents of pregnancy); 26 (5 percent) were caused by puer
peral hemorrhage, 48 (9 percent) by other accidents of labor, 309 (55
percent) by puerperal septicemia, 25 (4 percent) by puerperal phleg
masia alba dolens, embolus, sudden death, and 73 (13 percent) by
puerperal albuminuria and convulsions. Comparison of these figures
with those in table 1 (p. 8) shows that the proportions of deaths due
to ectopic gestation and to puerperal septicemia were larger in these
autopsy cases than in the entire group of cases studied, and the pro
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15
GENERAL CONSIDERATIONS
portions of deaths due to puerperal hemorrhage and to puerperal
albuminuria and convulsions were smaller. As puerperal septicemia
includes septic abortion, this probably means merely that autopsies
were more likely to be performed in cases in which the diagnosis was
doubtful.
DEATHS EXCLUDED FROM STUDY BECAUSE FOUND TO BE
NONPUERPERAL
Pregnancy or childbirth was a contributory factor in 89 of the 157
deaths classified by the Bureau of the Census as puerperal but found
on interview to have been due primarily to conditions which, if
certified on the death certificate, would have resulted in assignment
to nonpuerperal causes. The causes to which the 157 deaths were
attributed after interview and the presence or absence of pregnancy
as a contributory factor are shown in the following list:
Cause of death attributed after interview
Total
Women
pregnant
or
parturient
Women
not
recently
pregnant
All causes..__ ____________________________ _
157
89
68
Chronic nephritis__ ________________ ____ __________
Lobar pneumonia___________________ ___________
Tuberculosis________ ________ ____________________
_ _______________ _
Other infectious disease__
Appendicitis, hernia, intestinal obstruction ______
Chronic cardiac valvular disease _ _________ _____
Salpingitis and pelvic abscess__ __ ______________
Other diseases of the female genital organs________
Other causes__ _______________ ______________
32
18
17
7
8
12
25
18
17
5
5
13
12
21
17
19
3
7
1
21
17
7
12
Pregnancy or childbirth may have been the final factor in certain
of these deaths, particularly in those from chronic nephritis (see also "
p. 140), tuberculosis, and cardiac disease. But this was probably true
also of other deaths from these causes which had been assigned by the
Bureau of the Census to the nonpuerperal group. On the other
hand, some of the 7,380 women whose deaths were included in the
study had chronic nephritis, or chronic heart disease, or tuberculosis;
the deaths of women who had had these diseases were excluded only
when the condition had been definitely diagnosed and apparently was
in itself sufficiently serious to cause death.
Sixty-eight of the 157 nonpuerperal deaths were of women who had
had no recent pregnancy. In some cases the fact that the disorder
resulting in death may have dated originally from pregnancy or child
birth probably accounted for their inclusion in the puerperal group;
for instance, several of the deaths resulted from operations for
retroverted uterus or perineal lacerations due to childbirth many
years before. Others of these deaths were assigned to puerperal
causes through errors in transcribing certificates. A few were stated
by the physicians to have been not puerperal, but the “ not” was
omitted in copying. Some were the result of misreading nearly
illegible certificates. For instance, purpura hemorrhagica was mis-
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16
MATERNAL MORTALITY IN FIFTEEN STATES
taken for puerperal hemorrhage; the words “ psychosis” , “ cerebral” ,
and “ gonorrheal” were all mistaken for “ puerperal.” Considering
that many thousands of death certificates were involved, the wonder
is perhaps that the errors were so few.
Deaths following abortion found on interview with the physician
to have been probably criminal abortion were not excluded on that
account, although deaths certified as due to criminal abortion are not
classified as puerperal in the international list and therefore were
not included.
In accordance with the decision to exclude this group of 157 deaths
from the detailed study, the tables that follow are based on the group
of 7,380 deaths classified as puerperal after interviews with the
attending physicians.
RACE AND NATIVITY
Deaths of colored women 4 made up 18 percent of those included in
the study. The maternal mortality rate of the colored women in the
years and States of the study was nearly twice that of the white women.
Maternal mortality rates were significantly higher among colored
women for every main cause of death except puerperal phlegmasia alba
dolens, embolus, sudden death, which was about the same for both
white and colored. For others under the title accidents of pregnancy,
and for Cesarean section and other surgical operations and instrumental
delivery, the differences were insignificant. The greatest difference
was in the deaths from puerperal albuminuria and convulsions, which
caused more than twice as many deaths per 10,000 live births among
colored women as among white women (table 5 and chart II).
The reasons for these differences in the rates involve differences in
social and economic conditions as well as medical and possibly certain
purely racial factors.
In only 7 of the 15 States included in the study were there more
than 2,000 colored live births annually. The State tables based on
color are confined to these seven States: Alabama, California,
Kentucky, Maryland, Michigan, Oklahoma, and Virginia. The
maternal mortality rate was higher for colored women than for white
women in each of these States. (See table 15, p. 30.)
Of the 6,072 white women whose deaths were included in thè study,
5,109 were native born, 805 were foreign born, and the nativity of
158 was not reported. Thus 86 percent of the white women for whom
nativity was reported were native born and 14 percent were foreign
born.
In four of the States included in the study the percentage of foreignborn white women was small, and the number of live births to these
women less than 2,000. In 8 of the other 11 States the maternal
mortality rate for foreign-born white women was higher than that
for the native white women (table 6).
4 For definition of colored see Scope and Method of the Study, p. 2, footnote 7.
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17
GENERAL CONSIDERATIONS
T a b l e 5.
-Cause of death 1 as shown by interview, and mortality rate among white
and colored women dying from puerperal causes
Women dying from puerperal causes
White
Colored
Cause of death 1 as shown by interview
Total
Num
ber
Per
cent
dis
tribu
tion
Rate
per
10,000
live
births
Num
ber
Per
cent
dis
tribu
tion
All causes.«._____
7,380
6,072
100
57.5
1,308
100
Accidents of pregnancy.
719
613
10
5.8
106
8
8.8
S6S
£48
118
SOI
£10
10£
6
S
£
£.9
£.0
1.0
B£
38
16
4
S
1
4.S
S.£
l.S
791
652
670
525
11
9
6.3
5.0
121
127
9
10
10.0
10.5
Abortion, premature labor.
Ectopic gestation________
Others..................................
Puerperal hemorrhage...
Other accidents of labor.
Cesarean section_____________________ _
Other surgical operations and" instru
mental delivery______ _____________
Others..........................
Puerperal septicemia______________________
Puerperal phlegmasia alba dolens, embolus,
suddén d e a th .!....___ !_.........
Puerperal albuminuria and convulsions
Following childbirth (not otherwise defined)..
Puerperal diseases of the breast........................
Rate
per
10,000
live
births
108.5
1S6
1£S
£
l.£
IS
1
1.1
109
407
97
SOS
£
5
.9
£.9
1£
10£
1
8
1.0
8.6
2,948
2,437
40
23.1
511
39
42.4
344
1,900
23
3
314
1,493
17
3
5
25
(3)
(*)
3.0
14.1
.2
(3)
30
407
6
2
31
(s)
2.5
33.8
.5
2 Less than 1 percent.
3 Less than one tenth per 10,000.
T able 6.
All live births in the State, deaths from puerperal causes, and mortality
r<}je
naitve and foreign-born white women dying from puerperal causes in
all the States included in the study and in specified States having 2,000 or more
births to foreign-born white women in the biennium 1927-28
Total white
Native white
Deaths from
puerperal
causes
State
Live
births 1
Num Rate per
ber 1 10,000 live
births
Foreign-born white
Deaths from
puerperal
causes
Live
births 1
Num Rate per
ber 10,000 live
births
Deaths from
puerperal
causes
Live
births 1
Num Rate per
ber 10,000 live
births
A LL STATES IN CLU D ED IN THE STUDY
Total...............
1,056,063
6,072
57
931,376
5,109
55
123,864
805
65
STATES HAVING 2,000 OR M ORE BIRTHS TO FOREIGN-BORN W H ITE W OM EN IN THE
BIENNIUM 1927-28
California3....... .
Maryland_____
Michigan.......... .
Minnesota____ _
Nebraska______
New Hampshire
North Dakota...
Oregon......... ......
Rhode Island__
Washington...'..
Wisconsin..........
reported ^ ureau
78,700
51,172
191,460
99,366
55,144
17,459
29,300
28,012
26,274
44,609
114,190
Census.
459
273
1,235
481
317
109
155
175
159
291
605
58
57,069
53
46, 989
65 149,366
48
88,817
57
51,283
62
13,165
53
24,640
62
25,392
61
16,578
65
38,501
53 101,997
302
244
916
413
278
80
126
157
106
229
527
53
52
61
47
54
61
51
62
64
59
52
21,545
4,167
4l) 995
10,528 ‘
3|844
4,277
4,654
2; 598
9,680
6,083
12)043
151
22
304
60
26
23
27
13
48
47
72
70
53
72
57
68
54
58
50
50
77
60
Total live births include births to women for whom nativity was not
3 Includes deaths of women for whom nativity was not reported.
3 Figures for 1928 only.
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C H A R T I I . —M A T E R N A L M O R T A L I T Y R A T E S , B Y C A U S E
00
Total
Rural
Whit©
Colored,
L a s t t r i m estei"*
Fi p s t t w o t r i m este P s *
o
Total
5
IO
15
20
■ S lm ili
25
30
0
5
IO
15
20
25
30
35
40
45
50
55
60
65
70
75__ 60
mssmmvgasassi«»
Urban
Rural
w h ite
Colored,
Puerperal septicemia
(P uerperal albuminuria
and convulsions
P uerperal phlegmasia alba dolens,
embolus, sudden d e a th
Puerperal hemorrhage
1* A *'*il All o th e r puerperal
causes
* In the bars showing rates fo r total, urban, rural, and white, the rate fo r puerperal hemorrhage (1 tenth per 10,000 live births) is too
small to appear.
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MATERNAL MORTALITY IN FIFTEEN STATES
Urban
19
GENERAL CONSIDERATIONS
DEATHS IN URBAN AND RURAL AREAS
The maternal mortality rate was 36 percent higher in the urban
districts (75 per 10,000 live births) than in the rural districts (55 per
10,000 live births) (table 7 and chart II). Urban areas include
cities with 10,000 or more population as shown in the 1920 census.
There were more urban than rural live births in California, Maryland,
Michigan, New Hampshire, Ehode Island, and Washington; in the
other States of the study rural births predominated. The maternal
mortality rate was higher in the urban than in the rural districts in
every State included in the study except New Hampshire. (See
table 16, p. 31.)
1 as shown by interview, and mortality rate among women
dying in urban and tural areas from puerperal causes
T a b l e 7.— Cause of death
Women dying from puerperal causes
In urban areas
In rural areas
Cause of death i as shown by interview
Total
Rate
Rate
Percent per
Percent per
Number distri 10,000 Number distri 10,000
bution
live
bution
live
births
births
All causes...............1.................................
7,380
3,462
100
75.1
3,918
100
Accidents of pregnancy............... ...... ..............
719
351
10
7.6
368
9
5.1
Abortion, premature labor............ ............
Ectopic gestation......... ........... ...... .............
Others..........................................................
S5S
204
3.8
98
118
4
4
8 .2
248
149
150
52
2
1 .1
66
6
8
2
2.9
1.4
.9
Puerperal hemorrhage_____________________
Other accidents of labor____________________
791
652
331
294
10
8
7.2
6.4
460
358
12
9
6.4
5.0
Cesarean section____________ ____ ______
Other surgical operations and instrumental delivery............ ................... ..............
Others____________________ _______ ____
1S6
88
8
1.9
48
1
0.7
109
407
56
150
2
58
257
1
4
1 .2
8 .8
7
8 .6
2,948
1,543
45
33.5
1,405
36
19.6
344
1,900
23
3
157
777
7
2
5
22
(2)
(2)
3.4
16.8
.2
(3)
187
1,123
16
1
5
29
(2)
(2)
2.6
15.7
.2
(3)
Puerperal septicemia._____________________
Puerperal phlegmasia alba dolens, embolus,
sudden death_______________ ____________
Puerperal albuminuria and convulsions_____
Following childbirth (not otherwise defined)..
Puerperal diseases of the breast___________ _
54.8
.7
1According to the Manual of the International List of Causes of Death, 1920.
J Less than 1 percent.
5 Less than one tenth per 10,000.
The rates for the following groups: Accidents of pregnancy, other
accidents of labor, puerperal septicemia, and puerperal phlegmasia
alba dolens, embolus, sudden death, were significantly higher in urban
than in rural areas. There was no significant difference in the other
main groups. The greatest difference was in the rates from puerperal
septicemia. Although the rate of death from sepsis among women
who had reached the last trimester was somewhat greater in urban
than in rural areas, the difference in the total rate was largely due to
the higher rates for the first two trimesters (that is, from septic abor
tion 5) in the cities. , This will be discussed more fully in the section
on puerperal septicemia (p. 116).
•Abortion means the termination of a previable uterine pregnancy.
182748—34----- 3
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20
MATERNAL MORTALITY IN FIFTEEN STATES
URBAN RATES AFFECTED BY DEATHS OF NONRESIDENTS IN HOSPITALS
A certain number of rural women go for confinement to urban
hospitals. Some of these have normal pregnancies; others go to the
hospitals because abnormalities have been detected. Still others are
delivered at home in the rural areas and are then taken to city hospi
tals on account of complications. When these women die in the
cities their deaths are registered there. If they are delivered at home,
the births are registered in the rural areas. The deaths of nonresi
dents in hospitals, therefore, would tend to raise urban maternal
mortality rates in which residence is not taken into consideration.
Of the 3,462 maternal deaths in cities of 10,000 or more population
(urban districts) 2,804 occurred in hospitals. Of these women 1,994
were said to have been residents of the city in which death occurred,
780 were said to have been nonresidents, and the place of residence
of 30 was not reported. Therefore, of the 2,774 women dying in
hospitals for whom residence was reported 28 percent were nonresi
dents. Some of these undoubtedly came from smaller to larger
cities; but some came from rural districts, and the inclusion of these
probably contributed to the higher urban rate (table 8).
There were more deaths of nonresidents in the hospitals of the
smaller than in those of the larger cities. Of the 1,645 hospital deaths
in cities of 100,000 or more population, 1,635 were of women whose
residence was known, and of these 299 (18 percent) were nonresidents;
of the 1,159 hospital deaths in cities of 10,000 to 100,000, 1,139 were
of women whose residence was reported, and 481 (42 percent) of these
were nonresidents.
A still larger proportion of the deaths in hospitals in places of less
than 10,000 inhabitants (rural districts) were deaths of nonresidents.
Of the 1,262 deaths in hospitals in these areas 1,232 were of women
whose residence was reported, and 773 (63 percent) of these were
nonresidents. Although some of these women may have come from
urban areas, most of them came from other small cities and towns
and from the country.
To determine the effect of this factor on both urban and rural
maternal mortality rates, it would be necessary to know the number
of deaths of rural women in the urban areas and of urban women in
the rural areas; the number of births to rural women in urban areas
and the number of births to urban women in rural areas; and the
number of women who died in each area after having been delivered
in the other area. The information on births is lacking for the
present study.
The city department of health of Baltimore, however, furnished a
portion of this information for that city— the number of live births
to nonresidents in Baltimore hospitals in 1927 and 1928. Live
births to nonresidents in Baltimore that took place outside hospitals
were not given. If the live births to nonresidents in hospitals were
subtracted from the total Baltimore live births and the deaths of
nonresidents in Baltimore hospitals were subtracted from the total
number of maternal deaths in Baltimore, the maternal mortality rate
would be 59 instead of the rate of 68 obtained when residence is dis
regarded. The presence in Baltimore of these hospitalized women
from other places raised the Baltimore maternal mortality rate 9
points.
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21
GENERAL CONSIDERATIONS
T a b l e 8 . — Hospitalization
and residence of women dying in hospitals among
women dying from puerperal causes in urban and rural areas of each State in
cluded in the study
Women dying from puerperal causes
Hospital cases
Death in hospital
State and area
Total
Total.
Total
Total
Resi
dent
Nonresi
dent
Death Place
of
Resi not in death
dence
hos not re
not re pital ported
ported
Not re
Not
ported
hos whether
pital
hos
cases
pital
cases
7,380
4,213
4,066
2,453
1, 553
3,462
3,918
2,872
1,341
2,804
1,262
1,994
459
780
773
584
2,569
1,118
325
309
139
170
790
Urban.
Rural..
California..
293
825
214
205
104
109
30
96
74
77
713
401
386
246
114
Urban.
R u ral..
Kentucky..
298
195
262
139
188
58
36
56
645
205
256
130
202
99
438
115
87
77
37
401
Urban___
Rural..
Alabama.
111
Urban.
Rural..
M aryland-
153
492
382
277
Urban .
Rural..
Michigan..
257
125
223
54
1, 312
889
922
390
742
147
491
347
225
266
Urban.
Rural..
Minnesota.
Urban.
Rural..
Nebraska..
Urban.
Rural..
New Hampshire...
219
48
Urban.
Rural..
Oregon.
UrbanRural..
Rhode IslandUrban.
Rural..
Virginia.......
160
26
3,153
92
105
10
59
37
34
71
659
184
418
717
134
588
71
122
177
241
216
131
214
127
329
193
192
155
60
102
123
206
100
93
100
92
77
77
109
Urban________
Rural.... ...........
North Dakota.
Urban.
Rural..
Oklahoma.
22
170
60
62
122
144
135
135
23
112
32
30
31
128
1
63
300
164
93
207
177
71
58
143
129
42
78
57
76
53
165
117
115
157
114
3
112
8
3
276
491
UrbanRural..
Wisconsin-
183
133
617
Urban.
Rural..
316
301
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62
1
177
767
U rban..
Rural.. .
Washington.
21
50
2
42
5
164
404
224
139
219
125
141
36
256
249
154
165
91
161
118
36
43
50
18
42
233
149
218
269
130
263
88
122
189
44
52
352
60
47
171
22
MATERNAL MORTALITY IN FIFTEEN STATES
ACCESSIBILITY AND MEDICAL ATTENTION
Of the 7,311 women fo r whom a report on medical attention was
obtained, 184 (S percent) had had no medical attention from the beginning
of pregnancy till death and 488 (7 percent) had received medical attention
only when moribund {that is, when actually dying) {table 9). However,
these figures do not show the cases in which medical attendance was
delayed, perhaps by distance, until too late to be of much benefit to
the patient, even though she was not actually dying when the
physician arrived.
T a b l e 9. — Accessibility of 'physician and medical attention received by women
dying from puerperal causes
W(3men dying from puerperal causes
Medical attention
Accessibility of physician
When
patient
was
mori
bund
Total
'None
Before
patient
was
mori
bund
Not re
ported
Total....................................................................
7,380
184
488
6, 639
69
Physician in same city or town_________________ _
Physician not in same city or town or patient in open
tiuiiiiify"
Distance less than 5 miles. ......... ........... ...............
3, 956
64
309
3,667
36
704
30
71
611
3
Transportation good or fair.............................
65
639
4
16
6
65
55
556
2
Distance 5 miles, less than 10..............................-
833
34
83
713
3
Bad roads or slow transportation___________
Transportation good or "fair....... ....................
106
727
8
26
10
73
87
626
1
2
894
S3
69
793
147
747
20
13
25
44
102
690
Distance 25 miles or more.......................................
309
5
30
383
Transportation good or fair.............................
35
274
3
2
5
15
27
256
1
No report on accessibility.............................................
684
38
36
573
37
1
In the strictly rural areas distance from a physician may become an
important reason for lack of early and sufficient medical attention,
partly because of the actual distance and partly because of the charge
for country travel on a mileage basis in addition to the usual medical
fees.
The accessibility of the physician was reported on for 6,696 of the
women who died of puerperal causes in the years and States of the
study. Of these 3,956 were in the same city or town as the physician.
Of the remaining 2,740 women, 1,203 (44 percent) were 10 miles or
more from the physician, and 182 had the additional handicap of
very poor roads, practically impassable to automobiles, or slow trans
portation— sometimes horseback. A distance of 25 miles or more
separated 309 women from the physician, and in 35 of these cases
the roads were bad for at least part of this distance.
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GENERAL CONSIDERATIONS
23
Lack of medical attention was more frequent when there was no
physician living in the vicinity, but it was not always associated with
inaccessibility of a physician. Of the 3,930 women who lived in
places where a physician was near by and for whom a report as to
medical attention was obtained, 263 (7 percent) had had no care or
care only when dying.
Of the 182 women who were 10 miles or more from a physician
and were inaccessible for other reasons also, 53 (29 percent) had died
without medical attention or had had medical attention only when
actually dying.
In table 10 the 6,696 deaths concerning which there was a report
as to accessibility are divided into three groups: Cases in which the
patient and the physician were in the same vicinity, cases in which
the patient was separated from the physician not only by distance
but also by poor roads or slow transportation, and cases in which the
patient was at some distance from the physician but there was no
mention of other inaccessibility. The causes of death in these three
groups showed interesting differences, particularly in the larger pro
portion of deaths in the poor-roads group that were assigned to hem
orrhage and to the rather vague “ others” under other accidents of
labor. In the group in which the physician was in the same vicinity
there was a smaller proportion of deaths due to puerperal albuminuria
and convulsions than in either of the other groups and a larger pro
portion assigned to puerperal septicemia. This last was due in part
to the many induced abortions in the cities. '
In North Dakota, Oregon, Minnesota, Nebraska, New Hampshire,
Washington, and Wisconsin more than half the women who had not
lived in the same city or town as a physician had lived 10 or more
miles distant. But in all these States some of the women who lived
at the greater distances had received, medical attention before they
were moribund. In North Dakota 32 women who died of puerperal
causes lived 25 miles or more from a physician. All these had had
medical attention at some time before death, but 2 of them did not
receive it until they were dying. In Oregon all the 31 women who
were living 25 miles or more from a physician had had some medical
attention before death, but 4 of them had received it only when they
were dying. In Washington 3 of the 13 women who lived 25 miles
or more from a physician had had medical attention only when dying
or not at all; but 6 women living in the vicinity of physicians had had
no medical attention, and 12 had had such attention only when
dying.
Poor roads and slow transportation are greater factors in inacces
sibility than mere distance. Eight miles on horseback over a moun
tain trail may take longer to travel than 30 miles on a fair automobile
road. Apparently more patients were really inaccessible in the
Kentucky and Virginia mountains than in the western States where
distances were greater. Of the 136 women in Kentucky who had
lived 10 miles or more from a physician, 67 had had poor roads or
slow transportation as an additional handicap, and 35 of these 67
had had medical attention only when dying or not at all. Of the 158
women in Virginia who lived 10 miles or more from a physician, 41
lived on poor roads or could be reached only by slow methods of
transportation. In only 6 instances, however, was no medical
attention obtained before the patient was moribund.
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24
MATERNAL MORTALITY IN FIFTEEN STATES
1 as shown hy interview and accessibility of 'physician
among women dying from puerperal causes
T a b l e 10.— Cause of death
Women dying from puerperal causes
Physician in
same city or
town
Cause of death1as shown by interview
•Total
Physician not in same city
or town or patient in open
country
Bad roads or
slow trans
portation
Transporta
tion good or
fair
Accessibility
not reported
Per
Per
Per
Per
Num cent Num cent Num cent Num cent
ber distri ber distri ber distri ber distri
bution
bution
bution
bution
All causes................ ........... ........ 7,380
3,936
100
353
100
2,387
100
684
100
Accidents of pregnancy_____________
719
396
10
28
8
228
10
67
10
Abortion, premature labor______
Ectopic gestation______________
Others________________________
S53
U8
118
m
150
54
5
4
19
4
5
113
67
48
5
3
3
39
37
Puerperal hemorrhage............ .............
791
416
Placenta previa______________
Other_______________
347
m
187
m
Other accidents of labor_____________
652
Cesarean section______
Other surgical operations and instrumental delivery_________ _
Others______ ___ ____ __________
6
1
1
10
59
17
266
5
8
111
6
37
S3
9
351
9
41
136
95
3
109
407
73
183
3
5
Puerperal septicemia.............. _ _ ........ 2,948
Puerperal phlegmasia alba dolens,
embolus, sudden death___________
344
Puerperal albuminuria and convulsions________________ ______ _____ 1,900
Following childbirth (not otherwise
____________
defined)__________
23
Puerperal diseases of the breast...1 ..
3
1,696
43
1
4
4
11
3
11
51
7
155
6
6
33
39
3
12
192
8
68
10
3
1
36
1
13
3
4
35
1
10
36
I4 O
1
6
6
1
49
7
122
35
846
35
284
42
4
226
6
3
1
82
3
33
5
•860
22
100
28
763
32
177
26
4
1
9
3
(2)
(2)
10
(2)
1According to the Manual of the International List of Causes of Death, 1920.
* Less than 1 percent.
In Alabama 56 women died without medical attention, but there
was a report on the accessibility of only 34 of them. Thirty-one of
these lived less than 10 miles from a physician, and there was no
mention of poor roads or slow transportation. Of the 120 Alabama
women who were first seen when dying, 101 were known to have
lived less than 10 miles from a physician, and there was no further
evidence of inaccessibility (table 11).
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25
GENERAL CONSIDERATIONS
T able
11.— Medical attention received by women dying from puerperal causes in
each State included in the study
Women dying from puerperal causes
Medical attention
State
Total
Total...................... .
Alabama__________________
California..---------------------Kentucky_________________
Michigan.----------------------Minnesota________________
Nebraska_____________ ___
New Hampshire...................
North Dakota_____________
Oklahoma.... ............... ..........
Rhode Island_____________
Virginia____________ ______
Washington_______________
Wisconsin________________
7,380
1,118
493
645
382
1,312
491
329
109
159
300
177
165
767
316
617
None
Total
re
ported
7,311
1,094
484
642
382
1,297
486
328
108
158
297
177
164
764
315
615
Num
ber
Per
cent
184
56
13
37
5
7
9
4
1
3
1
4
1
28
9
6
(>)
When patient
was moribund
Before patient
was moribund
Num
ber
Num
ber
Per
cent
Per
cent
Not re
ported
3
488
7
6,639
91
69
5
3
6
1
1
2
1
1
2
120
23
55
23
62
21
15
4
17'
15
10
8
64
19
32
11
5
9
6
5
4
5
4
11
5
6
5
8
6
5
918
448
550
354
1,228
456
309
103
138
281
163
155
672
287
577
84
93
86
93
95
94
94
95
87
95
92
95
88
91
94
24
9
3
2
1
4
3
1
15
5
i
i
1
3
1
3
1
2
•Less than 1 percent.
HOSPITALIZATION
Of the 7,380 women included in the study there was a report on
hospitalization for all but 14. More than half (4,213) were hospital
ized at some time during their final illness. The deaths of 4,066
women occurred in hospitals, but the deliveries or abortions of only
2,629 occurred in hospitals. Several factors influence the number of
hospital deaths, particularly the total number of hospital deliveries,
the place of delivery of the women who die in hospitals, the prevalence
of complicated cases in hospitals, and the number of abortion cases
(table 12).
Unfortunately it was possible in only a few instances to obtain
the number of deliveries that occurred in these hospitals, or even
the number of live births occurring in hospitals and the number
occurring in homes in the States of the study. The standard birth
certificate contains an inquiry as to place of delivery, but this inquiry
is frequently not answered. The Bureau of the Census does not tabu
late live births by place of delivery, and only a few States make
such tabulations. It is, therefore, impossible to calculate death rates
for women delivered in hospitals and in homes.
Of the 4,066 women whose deaths occurred in hospitals, 2,501 had
reached the last trimester, 1,558 had not reached the last trimester,
and for 7 the period of gestation was not reported. Of the 2,501
who were known to have reached the last trimester of pregnancy,
only 1,893 were in the hospital for delivery and less than half of
these (845) were known to have planned hospitalization. Many of
the women who were delivered in hospitals had been examined vaginally, and many even had had delivery attempted, before admission.
For these reasons, even if the number of live births occurring in hos-
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26
MATERNAL MORTALITY IN FIFTEEN STATES
T a b l e 12 . — Hospitalization
and trimester of pregnancy of white and colored women
dying from puerperal causes
Women dying from puerperal causes
Hospital cases
Trimester of pregnancy and hospital
ization at delivery or abortion or at
death if not delivered
Not
hospital
cases
Died in hospital
Total
Total
Yes
Total___________ ________ _ _
No
Not re
ported
Not re
ported
whether
hospital
cases
7,380
4,213
4,066
146
1
3,153
14
4,965
2,601
2,501
99
1
2,859
5
In h o s p ita l...............................
1,971
1,971
1,893
77
1
Emergency. .........................
Planned _____________
Not reported...................
1,018
899
64
1,018
'899
54
996
845
52
22
58
2
1
Not in hospital .......... .
Not reported whether in hospital...
2,990
4
626
4
605
3
21
1
2,359
9,881
1,605
1,558
47
769
658
1,720
3
658
944
3
643
912
3
15
32
769
84
7
7
25
29
5
2
5
2
5
25
Last trimester_____________
First 2 trimesters..................
In hospital______________
Not in hospital...................
Not reported whether in hospital...
Trimester not reported...............
Not in hospital________
- Not reported whether in hospital...
W H ITE
Total.................................
Last trimester__________
In hospital..................................
Emergency..............................
Planned____________
Not reported......................
Not in hospital.........................
Not reported whether in hospital . .
First 2 trimesters...............
In hospital___________
Not in hospital.......... .
Not reported whether in hospital...
Trimester not reported...................
Not in hospital_________
Not reported whether in hospital...
6,072
3,733
3,608
124
i
2,326
13
4,027
2,280
2,195
84
i
1,743
4
1,725
1,725
1,658
66
1
848
1
827
50
827
50
829
781
48
19
45
2,298
4
551
4
534
3
17
i
1,743
2,026
1,447
1,407
40
571
590
1,432
3
590
854
3
577
827
3
13
27
571
20
6
6
12
15
5
1
5
1
5
12
848
2
COLORED
Total....................................
1,308
480
458
22
827
1
Last trimester.............................
988
821
806
15
616
1
In hospital__________________
Emergency.............................. .
Planned.............................
Not reported________________
Not in hospital.................................
First 2 trimesters.......... ....................
In hospital....... ...........................
Not in hospital................................ ..
Trimester not reported and not in hos
pital............................................
246
170
72
4
692
856
68
288
246
170
72
4
75
158
68
90
235
167
64
4
71
151
66
85
11
3
616
198
1
14
1
1
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8
4
7
2
5
198
18
GENERAL CONSIDERATIONS
27
pitals were obtained, maternal mortality rates in hospitals and out
side hospitals would not be an index of the relative safety of hospitals
and of homes as places for confinement.
Hospitalization was less frequent and more of it was of an emer
gency nature among the colored women than among the white women
who died. It was more frequent in the urban group (83 percent)
than in the rural group (34 percent). (See table 8, p. 21.) Of the
women who died in the rural areas, 69 percent of those who died in
places of 2,500 to 10,000 inhabitants and 19 percent of those who
died in places of less than 2,500 inhabitants had been hospitalized.
The percentage of hospitalization among women who died in the
different States studied ranged from 29 in Alabama to 81 in Cali
fornia and in Washington.
Size, equipment, and maintenance of hospital standards in the
hospitals in which the deliveries or deaths of women who died of puer
peral causes occurred in the States included in the study are given
in appendix tables II to V (pp. 186-189). It may be noted that 333
women died in hospitals not registered by the American Medical
Association; 174 women who died after reaching the last trimester
had been delivered in such unregistered hospitals. Refusal of regis
tration means that the American Medical Association had evidence
of such irregular or unsafe practices that these hospitals were “ deemed
unworthy of being included in any published list of reputable hos
pitals.’'
INTERVAL BETWEEN TERMINATION OF PREGNANCY AND DEATH
Some of the women included in the study died undelivered; others
lived for some time after the termination of their pregnancy (table
13). The interval between the birth, abortion, operation for ectopic
gestation, or rupture of an unoperated ectopic gestation and death
was reported in 6,303 cases. Death occurred within the first week
m 55 percent of the cases (including 31 percent in which it occurred
on the first day), in the second week in 19 percent, in the third week
m 9 percent, in the fourth week in 5 percent, and after the fourth
week in 12 percent. Death came soonest in fatal cases of hemorrhage,
ruptured uterus, and instrumental delivery and was delayed longest
in fatal sepsis. (See also appendix table VI, p. 190.)
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28
MATERNAL MORTALITY IN FIFTEEN STATES
13.— P ercen tag e o f deaths f r o m selected causes 1 as sh ow n b y in terview ,
a ccording to interval betw een d e l iv e r y 2 and death, a m o n g w o m en d y in g f r o m
p u erp era l causes
T able
Percentage of deaths according to interval between delivery 8
and death
Less than 1 week
Cause of death 1as shown by interview
Total
All causes__________ - ------ --------
Other surgical operations and instru-
Puerperal phlegmasia alba dolens, emPuerperal albuminuria and convulsions-
1week, 2 weeks, 3 weeks, 4 weeks
less or more
less
less
1 day,
Less
than 2 than 3 than 4
less
Total than 1 than 1
day
week
100
55
31
24
19
9
5
12
100
100
100
100
100
72
78
97
95
79
35
40
88
88
23
38
38
9
7
56
12
12
2
3
13
9
5
1
1
4
1
1
1
6
3
100
100
100
100
92
96
64
22
71
76
31
2
21
20
32
21
4
20
30
2
2
7
17
1
2
3
9
6
22
100
100
46
82
33
49
- 12
33
29
9
9
2
8
2
9
6
(3)
1
1
2
1
1According to the Manual of the International List of Causes of Death, 1920.
2 Also abortion, operation for ectopic gestation, or rupture of unoperated ectopic gestation.
* Less than 1 percent.
TRIMESTER OF PREGNANCY
About one third of the women included in the study had died before they
reached the last trimester of 'pregnancy. The number of deaths due to
the various causes differed considerably before and after the time of
viability of the child, as is shown in table 14. Puerperal septicemia
was the most important cause of death among women who had not
reached the last trimester and accounted for 59 percent of the deaths
in this group; but puerperal albuminuria and convulsions equaled
puerperal septicemia in importance among women who had reached
the last trimester, 31 percent of the deaths being attributed to each
of these causes (chart I I I ).
.
The distribution of these deaths by cause for urban and rural white
women and urban and rural colored women is given in appendix
table I (p. 183). Among the urban mothers, both white and colored,
puerperal septicemia caused a larger proportion of the deaths of
women who had reached the last trimester than puerperal albumi
nuria and convulsions; among the rural mothers, both white and
colored, the reverse was true.
Mortality rates by trimester of pregnancy for white and colored
women dying from puerperal causes in the States with 2,000 or more
colored live births annually and for urban and rural women dying
from puerperal causes in all the States studied are given in tables
15 and 16. The differences in the State maternal mortality rates
reflect differences between States in the proportion of maternal deaths
that occurred before the last trimester, as well as in the proportions
of urban and rural and of white and colored in the population. For
instance, in rural Alabama less than one fifth, and in urban Washing
ton about one half, of the total maternal mortality was made up of
deaths that occurred before the last trimester.
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29
GENERAL CONSIDERATIONS
1 as shown by interview, and trimester of pregnancy
among women dying from puerperal causes
T a b l e 14.— Cause of death
Women dying from puerperal causes
Trimester of pregnancy
First
trimester
Cause of death1 as shown by
interview
Before last
trimester,
not other
wise speci
fied
Second
trimester
Total
Last
trimester
Per
Per
Per
Per
Num cent
Num cent
Num cent Num cent
dis
dis
dis
dis
ber tribu ber
tribu ber tribu ber tribu
tion
tion
tion
tion
Not
re
ported
All causes_____________
7,380
1,299
100
672
100
410
100
4,965
100
34
Accidents of pregnancy______
719
363
28
140
21
72
18
142
3
2
Abortion, premature labor.
Ectopic gestation..............
Others................................
S6S
116
m
44
9
16
S
99
16
39
14
9
6
46
91
6
11
99
8
35
9
(2)
1
9
Puerperal hemorrhage_______
Other accidents of labor______
"791
652
10
1
1
1
(2)
651
13
Cesarean section_________
Other surgical operations
and instrumental delivery____________ ____
Others__________________
136
1
(s)
135
948
118
6
1
m
109
407
Puerperal septicemia________ 2,948
Puerperal phlegmasia alba
dolens, embolus, sudden
death_________________ _
344
Puerperal albuminuria and
convulsions_______ ________ 1,900
Following childbirth (not
otherwise defined)_________
23
Puerperal diseases of the
breast______________ _____ _
3
1
1 0 f)
838
65
251
77
314
37
2
407
8
1,529
31
16
31
13
18
1
27
4
8
2
291
80
6
243
36
15
4
1,549
22
(3)
2
( 2)
1 According to the Manual of the International List of Causes of Death, 1920.
2 Less than 1 percent.
C
h ar t
III.— M A T E R N A L M O R T A L I T Y R A T E S B Y C A U S E A N D B Y
TR IM E S TE R O F P R E G N A N C Y
Deaths per 10,000 live births
0 , 4
8
tg
16
20
24
ge
3g
36
40
44
48
52
56
60
Puerperal septicemia
Puerperal albuminuria
and convulsions
Puerperal hemorrhage
Accidents of pregnancyB B E
O ther accidents o f labor
Puerperal phlegmasia alba IvSH
dolens,embolu3,sudden death K S j
Following' childbirth 7
(not otherwise defined) >
First two trim esters
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L ast t r i m e s t e r ^ - '
M-
30
MATERNAL MORTALITY IN FIFTEEN STATES
T able 15.— All live births in the State and deaths, mortality rate, and trimester of
pregnancy among white and colored women dying from puerperal causes in all
the States included in the study and in specified States having 2,000 or more
colored births annually
Women dying from puerperal causes
Trimester of pregnancy
Total
Last
First two
Live
births 1
State and color
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
Not re
ported
live
births
A LL STATES IN C LU D ED IN THE STU DY
Total_____________________ 1,176,603
7,380
63
2,381
20
4,965
42
34
White— -____ _____________ ____ 1,056,063
120,540
Colored____ ____________________
6,072
1,308
57
109
2,025
356
19
30
4,027
938
38
78
20
66
17
14
STATES H AVIN G 2,000 OR M ORE COLORED BIRTH S A N N U A LLY
Kentucky_______________ _____
Virginia____________ _______ ____
130,985
83,536
121,798
64,311
197,975
42,986
114,701
1,118
493
645
382
1,312
300
767
85
59
53
59
85,010
78,700
114,077
51,172
191,460
40,457
80,833
577
459
560
273
1,235
250
426
68
45,975
4,836
7, 721
13,139
6,515
2,529
33,868
541
34
85
109
77
50
341
W H IT E
COLORED
Kentucky..................................—
Virginia________________________
* U.S. Bureau of the Census.
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66
70
67
58
49
53
65
62
53
118
70
110
83
118
198
100
242
183
210
18
22
17
127
502
107
20
127
171
172
98
472
15
108
13
200
88
115
12
38
29
30
19
92
25
25
17
22
15
19
25
22
25
25
49
22
46
75
27
859
310
428
255
809
190
566
37
35
40
41
44
49
444
288
382
175
762
160
318
52
37
33
34
40
40
39
415
90
45
60
61
72
119
73
22
46
80
47
30
248
7
1
3
1
6
6
•1
2
h
i
i
i
31
GENERAL CONSIDERATIONS
T a b le 16.— All live births in the State, and deaths, mortality rate, and trimester of
pregnancy among women dying from puerperal causes in urban and rural areas
of each State included in the study
Women dying from puerperal causes
Trimester of pregnancy
Total
State and area
Live
births 1
First two#
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
live
births
Last
Num
ber
Rate
per
10,000
Not re*
ported
live
births
Total____
1,176,603
7,380
63
2,381
20
4,965
42
34
Alabama______
California______
Kentucky_____
Maryland____...
Michigan____ _.
Minnesota i .......
Nebraska______
New Hampshire.
North D a k o ta Oklahoma_____
Oregon________
Rhode Island__
Virginia________
Washington____
Wisconsin..........
130,985
83,536
121,798
64,311
197,975
100,422
55,893
17,474
29,673
42,986
28,658
26,747
114,701
46,476
114,968
1,118
493
645
382
1,312
491
329
109
159
300
177
165
767
316
617
85
59
53
59
242
183
18
859
310
428
255
809
334
66
17
66
49
59
62
54
70
62
62
67
68
210
127
502
154
129
30
53
107
81
52
200
54
146
165
22
25
15
23
17
18
25
28
19
17
31
14
79
106
190
96
113
566
169
451
37
35
40
41
33
36
45
36
44
33
42
49
36
39
17
20
200
7
1
3
3
1
1
1
U RBAN
Total____
461,150
3,462
75
1,307
28
2,148
47
7
Alabama______
California......... .
Kentucky______
M aryland...___
M ichigan..____
Minnesota.........
Nebraska______
New Hampshire.
North Dakota__
Oklahoma___. . .
Oregon________
Rhode Islan d...
Virginia_______
Washington____
Wisconsin______
22,859
48,559
293
298
153
257
922
225
123
54
31
93
81
157
276
183
316
128
61
67
70
77
59
90
59
78
86
119
61
94
374
91
58
13
36
37
48
40
38
16
204
179
90
163
548
134
65
41
19
56
44
109
175
90
231
89
37
39
45
46
35
48
45
48
67
38
47
69
37
44
3
69
38
25
27
26
- 31
24
43
14
30
43
32
22,866
36,486
120,214
38,290
13,638
9,095
3,954
8,393
11,687
23,031
25,205
24,368
52,505
111
68
110
75
60
12
101
92
85
21
2
1
1
RURAL
Total______________ ______
715,453
3,918
55
1,074
15
2,817
39
27
Alabama_____________ ____ _ _
California_____________________
Kentucky________ __________
Maryland______________________
Michigan......................................
Minnesota_____________________
Nebraska______________________
New Hampshire.............. ...............
North Dakota__________________
Oklahoma___________________
Oregon_____________________ ___
Rhode Island................... ............
Virginia________________________
Washington____________________
Wisconsin______________________
108,126
34,977
98j 932
27,825
77i 761
62,132
42,255
8,379
25,719
34, 593
16,971
3,716
89,496
22,108
62,463
825
195
492
125
390
266
206
55
128
207
96
76
56
50
45
50
43
49
156
64
149
33
128
63
71
17
41
71
44
14
18
15
655
61
14
338
92.
261
34
5
34
32
1
3
1 U.S. Bureau of the Census.
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8
491
133
301
66
50
60
57
22
55
60
48
4
99
54
80
12
16
10
17
20 ,
16
21
26
11
11
24
13
200
135
38
87
134
45
yf1 ~
39
2
44
36
35
1
4
391
79
220
1
32
MATERNAL MORTALITY IN FIFTEEN STATES
LIVE BIRTHS AND STILLBIRTHS
The Bureau of the Census in its annual stillbirth statistics gives
the caution that the completeness of registration is not known and
that the term stillbirth is not used in the same sense in the different
States, varying between the product of 7 or more months’ uterogestation and any product of conception. In this study the term
stillbirth is used only of dead-born issue of the seventh month or later.
This should be kept in mind in comparing the material from the
present study with census material.
Only 3,091 (43 percent) of the 7,226 women dying from puerperal
causes in the years and States of the study, for whom the type of
issue was reported, gave birth to living children (table 17). In 32
of these cases the delivery was before the seventh month of gestation.
Twenty percent were delivered of stillborn children (that is, deadborn issue of the seventh month or later); 29 percent had previable
dead-born issue before the seventh month of gestation ; and 8 percent
died undelivered (chart IV).
T able
17.— Result of pregnancy of white and colored women dying from puerperal
causes
Women dying from puerperal causes
Colored
White'
Total ,
Result of pregnancy
Number
Total...... .......................... ........... —
Percent
distri
bution
Number
Percent
distri
bution
Number
1,308
6,072
7,380
Percent
distri
bution
Result of pregnancy reported------- -----------
7,226
100
5,976
100
1,250
100
Single pregnancy......................... - ........
7,054
98
6 ,8 4 6
98
1,208
97
Live birth.......................................
Stillbirth_________________ _____
Previable 2______________ _______
Undelivered..----------------------------
i 2,961
1,415
2,092
586
41
2,525
1,087
1,801
433
42
18
30
7
436
328
291
153
35
26
23
Plural pregnancy............... ............ ......
Both live births_________________
Both stillbirths_______ _____ ____
One live birth, one stillbirth-------Both previable 2________________
Both undelivered---------------- -----Not reported............ ...........-........
20
29
8
12
m
2
180
2
42
3
297
21
1
484
« 11
1
13
1
1
1
33
16
3
2
154
0
( 8)
(5)
(s)
(8)
23
10
1
1
96
(8)
(8)
(8)
(8)
(8)
» 10
7 10
6
2
i
(?)
(°)
(8)
58
-
1Includes 31 before the last trimester.
2 Born dead before the seventh month of gestation.
8 Includes 1 before the last trimester'.
. ,
„
4 Includes 1 twin pregnancy resulting in 1 live birth and 1 fetus not delivered, and 1 case of triplets, all
living.
5 Less than 1 percent.
8 Includes 1 case of triplets, all stillbirths.
7 Includes 1 case of triplets—1 live birth and 2 stillbirths.
Among these women whose deaths were studied there were 47
stillbirths to every 100 live births. In 1927 in the birth-registration
area 3.9 stillbirths were reported to every 100 live births, and in 1928,
4 stillbirths to every 100 live births.6 These rates are for all
8 Birth, Stillbirth, and Infant Mortality Statistics, 1928, p. 18. U.S. Bureau of the Census. Washington, 1930.
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33
GENERAL CONSIDERATIONS
mothers— those who lived as well as those who died. One would
expect, of course, a higher stillbirth rate in a group such as the one
studied, consisting entirely of mothers who died; even though previable fetuses are excluded from this group, the fetal mortality was
more than 10 times as high in the group in which all the mothers died
as it was in the birth-registration area.
In the present study, as in other published figures, the ratio of still
births to live births was higher among the colored women than
among the white.
The risk of maternal death appears to be much greater in plural
than in single pregnancies. In the group of women studied, all of
whom died, the percentage of plural pregnancies was almost four
times as large as it was in the 1928 birth-registration area for the
group of mothers that included both those who died and those who
I V .— T Y P E O F I S S U E A M O N G W O M E N
CAUSES
CHART
D Y IN G FR O M
PUERPERAL
Percent.
Total
white
Colored
Live births
Previa ble n
VA Stillbirths
Undelivered^"*
survived. Among the 7,226 women in the study there were 172 (2
percent) with known plural pregnancies, including four cases of trip
lets. Of the 3,091 pregnancies resulting in at least one live birth,
130 (4 percent) were plural pregnancies. In the 1928 birth-registra
tion area, 1 percent of the total pregnancies resulting in at least one
live birth were plural pregnancies.7
Table 18 shows live births and stillbirths to women dying from
specified causes after they had reached the last trimester. As would be
expected, the largest percentages of stillbirths are to those mothers who
died of accidents of pregnancy, puerperal hemorrhage, other surgical
operations and instrumental delivery, and puerperal albuminuria and
convulsions. It is not known how many of the live-born infants
died shortly after birth.
1 Ibid., p. 10.
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34
MATERNAL MORTALITY IN FIFTEEN STATES
18. Cause of death 1as shown by interview and result of pregnancy of women
dying from puerperal causes who had reached the last trimester of pregnancy
T able
Women dying from puerperal causes who had reached last trimester
Result of pregnancy
Cause of death as shown by
interview
Live birth
and
Undeliv
Total Total Live birth2 Stillbirth
stillbirth
ered
Not
(plural)
re
re
port
port
ed
ed
Num Per Num Per Num Per Num Per
ber cent3 ber cent3 ber cent 3 ber cent 3
All causes___________ ____ 4,965 4,843 3,026
62 1,436
30
42
51
62
55
329
209
40
43
33
106
80
27
20
88
85
64.
66
IM
61
SO
76
342
23
8
82
42
15
1
53
457
30
18
Accidents of pregnancy_________
Puerperal hemorrhage— _______
Other accidents of labor________
142
779
651
139
762
630
58
385
391
Cesarean section___________
Other surgical operations and
instrumental delivery.........
Others__________ ____
185
138
109
407
109
388
247
Puerperal septicemia.................... 1,529 1,488 1,128
Puerperal
phlegmasia
alba
dolens, embolus, sudden death. 291
288
236
Puerperal albuminuria and convulsions............ ....................... 1,549 1, 513
807
Following childbirth (not otherwise defined)_________________
22
21
19
Puerperal diseiases of the breast—
2
2
2
33
5
1
1
348
7
122
1
43
29
6
5
17
21
1
4
4
1
10
1
9
3
3
231
15
36
(4)
2
1
2
(<)
1
41
1
1 According to the Manual of the International List of Causes of Death, 1920.
’ Includes 1 twin pregnancy resulting in 1 live birth and 1 fetus not delivered.
3 Not shown where number is less than 50.
* Less than 1 percent.
PARITY AND AGE
Primiparae made one third, and multiparae two thirds, of the
6,854 women in the study for whom the number of pregnancies was
reported. So little was known of 526 women by the persons signing
the death certificates that it could not be determined whether they
were primiparae or multiparae. Some of these death certificates
were signed by coroners; others were those of women brought dying
into hospitals. The exact number of pregnancies of 498 of those
said to be multiparae was also unknown. Moreover, it is not likely
that the order of birth as given by the physician was in all cases exact,
as he may have been unaware of previous abortions in the patient’s
history. This statement applies with even greater force to the
entries on birth certificates, on which the Bureau of the Census must
base its data. The standard birth certificate contains inquiries
concerning the total number of children, the number of children
born alive and now living, the number born alive but now dead, and
the number of stillbirths. Some abortions are probably included in
stillbirths, but many are omitted.
For these reasons, and particularly on account of the large number
of deaths of women for whom the number of pregnancies was un
known, maternal mortality rates according to parity are not presented.
The number of pregnancies of the women whose parity was not
known probably was not similar to those of women whose parity
was known, but included a larger proportion of multiparae. In the
first place, there were many older women among those of unknown
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Federal Reserve Bank of St. Louis
35
GENERAL CONSIDERATIONS
parity. Also, the deaths of more than half the women of unknown
parity followed abortions, as compared with only one fourth of those
of known parity. As a larger proportion of the deaths of known mul
tiparae than of known primiparae followed abortions this also would
indicate that more of the women of unknown parity were multiparae.
There was a larger proportion of primiparae and of women who had
had 10 or more pregnancies among the colored women who died of
puerperal causes than among the white women (table 19).
T able 19.— Number of pregnancies of white and colored women dying from puerperal
causes
Women dying froin puerperal causes
White
Number of pregnancies
Number
Colored
Percent dis Number
tribution
Percent dis
tribution
Total................ ................... ................................
6,072
Number of pregnancies reported_____ _____________
5,688
100
1,166
100
1,895
807
684
496
359
287
219
170
110
278
383
33
14
12
9
6
5
4
3
2
5
7
439
115
93
75
67
53
48
35
32
94
115
38
10
8
6
1....... _................................................
2................y.......................
3........................... ......................
4............ .....................................
5_______________________________
6....................................................................
7........................................................
8.................................. ....................
9 ..............................................................
10 or more______ _____ _______ _ .
Multiparae, number not specified_______________
Number of pregnancies not reported_____ ____ _______
1,308
384
6
5
4
3
3
8
10
143
This study shows, as do other published figures, that the risk of
childbearing is great for mothers under 15 years of age, that the
most favorable age is from 20 to 25 years, and that from that age
onward the maternal mortality rate increases, reaching a maximum
T able 20.— Number of deaths and mortality rate among white and colored women
dying in specified age periods from puerperal causes
Women dying from puerperal causes
Total
White
Colored
Age period
Number
Total_____ _______ ______ ___ ____
Under 15 years........................... ..................
15 years, under 20__________________ ____
20 years, under 25__ ________ ___
25 years, under 30______ ________________
30 years, under 35_____ _______ _________
35 years, under 40.................................... .
40 years, under 45__________ __________
45 years and over__________ ____________
Not reported................................ ................
182748—34----- 4
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Rate per
Rate per
Rate per
10,000 Number
10,000 Number
10,000
live
live
live
births
births
births
7,380
63
6,072
57
1,308
109
25
855
1,545
1, 537
1,412
1,312
570
94
30
161
60
46
52
67
97
121
203
73
6
605
1,264
1,295
1,211
1,114
482
79
16
81
52
42
48
63
90
111
195
55
19
250
281
242
201
198
88
15
14
235
100
79
95
123
168
240
254
117
36
MATERNAL MORTALITY IN FIFTEEN STATES
in the age period 45 years and over (table 20). This is true both for
white and for colored women. The maternal mortality rates at each
age are much higher for colored than for white women. Among the
colored women the maternal mortality rate for the very young is
nearly as high as for the oldest mothers. The colored rate increases
less after 40 years than the white.
One reason for the high mortality of the youngest mothers is that
19 of the 25 girls under 15 and more than one fourth of the 855
between 15 and 20 were single. The maternal mortality among single
women was much higher than among married women. (See p. 38.)
The relationships of age and parity to the different causes of death
and to other factors in the maternal-mortality study will be discussed
in the sections on those factors. (See also appendix tables V II and
V III, pp. 191, 192.)
ILLEGITIMACY
The deaths of 509 unmarried women are included in the study.
Approximately half (51 percent) died of puerperal septicemia, as
compared with 39 percent among the married women, and of the
deaths from septicemia among the unmarried almost two thirds
(63 percent) occurred before the women had reached the last tri
mester. Puerperal albuminuria and convulsions, also, caused a larger
proportion of the deaths of unmarried than of married women
(table 21).
T able 21.
Cause o f death 1 as shown by interview, am ong m arried and unm arried
wom en dying fro m pu erperal causes
Women dying from puerperal causes
Married
Cause of death as shown by interview i
Total
All causes_______________
Accidents of pregnancy........
Puerperal hemorrhage____
Other accidents of labor.......
Puerperal septicemia____. . .
Puerperal phlegmasia alba dolens, embolus,
sudden death__________
Puerperal albuminuria and convulsions
Following childbirth (not otherwise defined)
Puerperal diseases of the breast...
Unmarried
Percent
Percent
Number distri Number distri
bution
bution
Marital
status
not re
ported
7,380
6,850
100
509
100
21
719
791
652
2,948
682
771
623
2,680
10
11
9
39
35
17
26
258
7
3
5
51
2
3
3
10
344
1,900
23
3
335
1,736
21
2
5
25
9
161
2
1
2
32
3
(s)
(J)
(»)
(2)
i According to the Manual of the International List of Causes of Death, 1920.
3 Less than 1 percent.
More than half (263) of the 509 unmarried women were colored as
compared with 18 percent colored in the entire study.
Of the women for whom parity was reported primiparae made up
.85 percent of the 474 who were unmarried and only 30 percent of
the 6,366 who were married.
The single women were a much younger group than the married
women. Fifty-two percent of the single women and only 10 percent
of the married women were under 20 years of age (table 22).
Of the 506 unmarried women for whom the period of gestation was
reported, 219 (43 percent) died before reaching the last trimester, as
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37
GENERAL CONSIDERATIONS
compared with 2,152 (32 percent) of the 6,819 married women for
whom this was reported. This larger proportion of early termina
tions of pregnancy among the unmarried women who died was con
fined, however, to the white women, among whom 60 percent of the
unmarried and 32 percent of the married died before the last trimester
of pregnancy; in the corresponding colored group the percentages
were 28 for the unmarried and 27 for the married women.
The deaths of 186 unmarried women followed abortion; 129 of them
were reported to have been induced abortions. (See p. 108.)
T able 22.— Number of deaths of married and unmarried women dying in specified
age periods from puerperal causes
Women dying from puerperal causes
Married
Unmarried
Age period
Total
Under 15 years__ ___________________
20 years, under 25______ 1____________
Percent
Percent
Number distribu- Number distribution
tion
7,380
6,850
7,350
6,826
25
855
1,545
1,537
1,412
1,312
570
94
6
609
1,393
1,475
1,388
1,298
564
93
30
24
Marital
status
not reported
509
100
(0
9
20
22
20
19
8
1
505
19
242
147
54
23
13
6
1
21
100
4
48
29
11
5
3
1
19
4
5
8
1
1
(>)
4
2
1 Less than 1 percent.
Few of the unmarried women had had any prenatal care. One
hundred and forty-four deaths, made up of those that followed induced
abortion and those that occurred after pregnancies of 2 months’ dura
tion or less, were excluded from consideration in this regard.8 Of the
324 deaths of women for whom there was a report as to prenatal
care, 238 (73 percent) had had none whatever. Only 10 (3 percent)
had had adequate or good care (grade I), 21 (6 percent) had had
indifferent care (grade II), and 54 (17 percent) had had very inade
quate cqre (grade III). There was less prenatal care among the
colored than among the white women and less among those who died
in the rural areas than among those who died in cities of 10,000 or more
population. (See appendix table IX , p. 195.)
There was practically no difference in the hospitalization of the un
married women and of the total group. (See appendix table X ,
p. 195.)
Of the 509 unmarried women 25 (5 percent) had had no medical
attention and 66 (13 percent) had had medical attention only when
they were dying; thus 18 percent of the unmarried women, as compared
with only 9 percent of the total group, had had medical attention
only when dying or not at all.
The large proportion of induced abortions, lack of prenatal care,
and lack of medical attention, as well as other factors, would tend to
* For criteria as to care and for care obtained by the entire group of women in the study see pp. 40-55.
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38
MATERNAL MORTALITY IN FIFTEEN STATES
cause a higher maternal mortality rate among unmarried than among
married women. Live births were recorded as legitimate or illegiti
mate in all the States included in the study except California. The
maternal mortality rate for unmarried mothers in all the States com
bined, exclusive of California, was 143 per 10,000 illegitimate live
births; for married mothers it was 60 per 10,000 legitimate live births.
The maternal mortality rate for white unmarried mothers was 137,
for colored 149, for urban 162, and for rural 129—all much higher
than the corresponding maternal mortality rates for the entire group
of mothers. (A number of deaths of married, widowed, or divorced
women associated with pregnancies thought to have been illegitimate
are included with those of married, rather than unmarried mothers.)
COM M EN T B Y AD VISORY CO M M ITTEE
This study apparently represents a fair sampling of paaternal
deaths throughout the registration area.
In this study the International List of Causes of Death together
with the Manual o f Joint Causes in use by the United States Bureau
o f the Census has been used as the chief basis o f classification.
While this procedure was not entirely satisfactory from a medical
point o f view, the inherent disadvantages seemed counterbalanced
by the fact that it provides a definite and understandable classifica
tion and that its use would assist the comparison o f the findings
with those of other investigators.
Certain changes in classification resulted after the interviews.
These alterations, which were made necessary by various causes,
emphasize the dependence of the official statistics on the original
death certificate and the apparent unavoidability of a small percent
age o f error. A relatively small number of cases were excluded as
nonpuerperal. These cases are easily equaled or exceeded by those
that were actually puerperal but that were classed in the vital
statistics as nonpuerperal and so were not included in the study.
Therefore, maternal mortality rates as given in this study are prob
ably low er than the actual rates.
Autopsies were held in less than 8 percent o f the cases, and many
o f the autopsies were done by coroners simply to determine the
cause of death. It is apparent that there was gross lack o f scientific
study o f the puerperal deaths included in the study.
The exceedingly high death rate among colored mothers is espe
cially challenging when considered in connection with the poor
maternal care that was received by these colored women, as will be
shown in succeeding sections.
The differences between urban and rural rates cannot be fully
explained by this study, as complete information on residence is not
available. It is apparent, however, that two o f the factors con
tributing to the higher urban rates are the larger proportion of
abortions in the urban than in the rural communities and the deaths
in urban hospitals of women who were delivered in rural areas.
The exact value of the second factor cannot be determined from this
study for reasons given in the report.
Nine percent o f the women had no medical attention whatsoever,
or else had attention only when they were actually dying. Only part
o f this was due to physical inaccessibility. Inaccessibility due to
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GENERAL CONSIDERATIONS
39
distance and bad roads, however, was a serious problem in certain
localities o f the States studied. The part played by inaccessibility in
the lack o f early, as distinguished from any, medical attention was
not measured; but the larger proportion of deaths from hemorrhage
and the toxemias in the less accessible groups is suggestive, especially
when considered in conjunction with the lack of prenatal care among
women who died in the rural areas.
It is impossible to draw conclusions as to the relative safety of
deliveries in hospitals and homes from a study o f deaths alone. Data
regarding the total number of deliveries in hospitals and homes
were lacking. Many hospital deaths followed home deliveries, and
many o f the hospital deliveries were emergency cases. However,
there were too many deaths (899) o f women who had planned hospital
deliveries in the last trimester.
The figures relative to still births and live births indicate strikingly
the appalling loss o f fetal life associated with maternal deaths; 37
percent were either undelivered or previable infants, 20 percent
were of viable age but stillborn, and only 43 percent are credited
as being live births. The number of these infants who died or were
damaged survivors was not possible to determine from this investiga
tion.
One third of all the deaths were of women who had not reached
the last trimester of pregnancy. Duration o f pregnahcy is a most
important consideration in the evaluation of any statistics on
maternal mortality.
Illegitimacy contributes to maternal mortality, as 7 percent of the
deaths in this study were o f unmarried women, and the mortality
rate is much higher for unmarried than for married mothers. There
was a larger proportion of abortions among the unmarried, and the
deaths from such preventable causes as sepsis and toxemia were
relatively more numerous among the unmarried mothers. Social
and economic factors doubtless play an important role in creating
this mortality and they should be adjusted to prevent this loss of life.
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M ATERN AL CARE
In the study of a series of maternal deaths it is obvious that the
type of care received by the women who died should have primary
attention. In its fullest sense maternal care includes many factors—
the woman’s food, her living conditions as regard housing, sanitation,
clothing, work, and exercise; whether she had been comparatively
calm and happy or had had many worries; under what conditions her
confinement took place and how she spent the lying-in period; and,
of particular importance, what type of medical and nursing care she
had. In this study attention was confined largely to the medical
aspects of maternal care.
All the cases in the present study were eventually abnormal, for
all these women died. The details of the care given them were
frequently determined by that abnormality. This was often true of
the prenatal care received by these women, but it was true of their
delivery care in more cases and of their postpartum care in still more
cases. Considerable general discussion of prenatal care is possible,
but much of the discussion of delivery care must be included in the
sections on operations and on the various causes of death; and post
partum care, because it varied greatly with the different abnormalities
that were found, will have to be discussed almost entirely in the
sections dealing with the individual causes of death.
Of the 7,380 women whose deaths were included in the study, only
933 were known to have had no complication of pregnancy before
delivery. Six hundred and sixteen of these 933 were reported to have
had no intercurrent disease, only 263 of the 616 were known to have
had normal spontaneous deliveries in the last trimester, and only 199
of the 263 were reported to have had a normal third stage of labor and
no postpartum hemorrhage. These 199 deaths were classified, accord
ing to the International List of Causes of Death, as follows: Puerperal
sepsis, 100; phlegmasia alba dolens, embolus, sudden death, 55;
other accidents of labor, 23; puerperal albuminuria and convulsions,
15; other puerperal causes, 6. It should be borne in mind in connec
tion with these figures that a large number of women who had had no
prenatal care or about whose care during pregnancy nothing was
known were for obvious reasons not included in them.
PRENATAL CARE
It is agreed that many maternal deaths may be prevented by ade
quate medical supervision during pregnancy. The records of many
clinics show that the severity of the toxemias of pregnancy has been
much reduced and that deaths from this cause are comparatively rare
among those patients who have had adequate prenatal care—par
ticularly if this is combined with adequate care at and after delivery.
Other complications accidental and incidental to pregnancy have been
prevented or have been detected early, and patients have been put in
better condition to withstand them.
40
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41
MATERNAL CARE
It is primarily in such records that evidence as to the value of
prenatal care should be sought. The case histories in this study are
all records of deaths, and so, of failures. A number of women died
in spite of excellent prenatal care; but many more women who had
inadequate care or no prenatal care at all would in all probability
have been saved by early recognition and intelligent treatment of
their symptoms. It is obvious that not only prenatal care but con
tinuous prenatal, intrapartum, and postpartum care is necessary to
prevent these deaths. The best prenatal care cannot offset faulty
technique or poor judgment at delivery.
THE
G R O U P F O R W H O M R E P O R T A S T O P R E N A T A L C A R E W A S R E C E IV E D
All pregnant women should receive prenatal care. In practice
prenatal care is seldom sought before the third month of pregnancy,
for many women are not aware of their need before that time. Also
C H A R T V .— P R E N A T A L C A R E A M O N G W O M E N
CAUSESi
D Y IN G F R O M
PUERPERAL
P e rce n t
T o ta l
U rb a n
R u ra l
white/"
C o lo r e d - '
HI None
^
1**•*•1 Ungraded
Indifferentr
Y/Á poor"*
Good
it is not sought by women who are sufficiently hostile to their preg
nancy to resort to self-induced or criminal abortions. As 1,154 of
the 7,380 women in this mortality group had pregnancies that ter
minated before the third month or were terminated intentionally,
there remained 6,226 to whom it might be expected that prenatal
care would have been given.
A report as to prenatal care could be obtained, however, concern
ing only 5,636 of the 6,226 women who might have been expected
to have such care. These 5,636 women, therefore, constituted the
group studied with reference to prenatal care.
L A R G E P R O P O R T IO N O F W O M E N W IT H O U T P R E N A T A L C A R E
Of these 5,636 women 3,025 (54 'percent) had had no prenatal ex
amination by a physician. For the most part, physicians had no
opportunity to give prenatal care to these women, for they were not
consulted. A few of the women undoubtedly had engaged a physician
for their confinement, and a few probably had seen a physician during
•Excludes women for whom pregnancy terminated before the third month and women who had
induced abortions.
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42
MATERNAL MORTALITY IN FIFTEEN STATES
their pregnancy for some intercurrent disease; but none had had any
examination or any advice from a physician regarding their pregnancy.
Prenatal care was much more frequent among the white than
among the colored women. Nearly half (48 percent) of the 4,568
whom information as to prenatal care was obtained
had had no prenatal care, as compared with about three fourths
(76 percent) of the 1,068 colored. In both groups care was much
more frequent among those dying in urban districts than in rural.
Thirty-six percent of the white women in urban districts, as compared
with 59 percent in rural districts, had had no prenatal care, and 63
percent of the colored women in urban districts had had no care, as
compared with 83 percent in rural districts (table 23 and chart V).
T able 23.
Prenatal care received by white and colored women dying in urban
and rural areas from puerperal causes
Women dying from puerperal causes
Grade of prenantai care
Total
Number
Total..................................
Report on prenatal care...........
Grade I ....... ......
Grade I I _____
Grade III______
Ungraded........................
None___________
No report on prenatal care.............
Inapplicable 1____ ____
In urban areas
Percent
distri
bution
7,380
Number
Percent
distri
bution
In rural areas
Number
3,462
5,636
100
725
499
1,337
50
3,025
13
9
24
1.
54
590
1,154
Percent
distri
bution
3,918
2,452
100
3,184
100
484
320
630
32
986
20
13
26
1
40
241
179
707
18
2,039
8
6
22
313
697
1
64
277
457
W HITE
Total........................
6,072
____
2,951
Report on prenatal care.......
4,568
100
2,061
100
2,507
Grade I .....................
Grade I I ................
Grade I I I . . . ___
Ungraded.................
None____________
694
458
1,157
45
2,214
15
10
25
1
48
463
291
540
28
739
22
14
26
1
36
231
167
617
17
1,475
No report on prenatal care____
Inapplicable1.................
458
1,046
3,121
246
644
100
9
7
25
1
59
212
402
COLORED
Total........ .....................
Report on prenatal care..............
Grade I . . . ......................
Grade II...................
Grade III..............
Ungraded_________
None______________
No report on prenatal care...........
Inapplicable1........................
1,308
511
797
1,068
100
391
100
677
100
31
41
180
5
811
3
4
17
(2)
76
21
29
90
4
247
5
7
23
1
63
10
12
90
1
564
13
132
108
67
53
t Induced abortions and cases in which pregnancy terminated before the third month.
* Less than 1 percent.
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65
55
1
2
(a)
83
MATERNAL CARE
43
G R A D IN G O F T H E P R E N A T A L C A R E R E C E IV E D
The grading of the prenatal care received by the 2,611 women who
had examinations during their pregnancy was based more on the
need for a practical way of classifying the cases than on considera
tion of what constitutes ideal care. Account was taken of the period
of pregnancy at which supervision began, of examinations that were
made, and of the regularity of - the examinations. The duration of
the care as it was affected by early terminations of pregnancy was
not considered, so that “ good” care does not always mean long care.
Neither was there an evaluation of treatment, as methods of treat
ment are not so standardized as methods of examination. The
classification “ good” prenatal care, therefore, does not necessarily
include treatment that would be accepted by a majority of obste
tricians as good.
The prenatal care given was classified as follows for statistical
purposes:
Grade la .— Only 42 (less than 1 percent) of the 5,636 women for
whom prenatal care was reported and applicable had had examina
tions as described in Standards of Prenatal Care (Children’s Bureau
Publication No. 153). This has been designated as grade la care
and is the only grade of care that can be accepted as adequate.
Care of grade la may be defined as follows: (1) A careful history, medical,
surgical, gynecological, and obstetric; (2) a complete physical examination, in
cluding the examination of heart, lungs, and abdomen; (3) pelvic measurements,
both internal and external; (4) the taking of blood for a Wassermann reaction; 2
(5) minute instructions in the hygiene of pregnancy; and (6) visits to a physician
at least once a month during the first 6 months, then oftener as indicated. (In
the cases graded as la in this study the first visit must have taken place not
later than the end of the second month.) At each of the visits the patient’s gen
eral condition was to be investigated; blood pressure, urinalysis, pulse, and tem
perature recorded; weight of the patient taken if possible; abdominal
examination made, and the height of the fundus determined.
Grade lb .— Another 683 women (12 percent) of the 5,636 for whom
prenatal care was reported and applicable had had care that may be
classified as good, although not up to the highest standards. This is
designated as grade lb care. In the tables, grades la and lb are
grouped together as grade I.
Care of grade lb consisted of at least: (1) A general physical examination, in
cluding examination of heart, lungs, and abdomen; (2) pelvic measurements,
external and internal, except in pregnancies terminating before the eighth month
and for multiparae who had had a previous normal delivery; (3) regular monthly
visits to a physician beginning with or before the fifth month, with examination
of urine and blood pressure at each visit.
Grade I I .— Four hundred and ninety-nine women (9 percent) of the
5,636 had had prenatal care that did not fulfill the requirements of
grade I but that was classed as grade II. It can only be regarded as
indifferent prenatal care.
Care of grade II consisted of at least: (1) A general physical examination, in
cluding examination of heart, lungs, and abdomen; and (2) regular monthly
visits to a physician beginning not later than the seventh month, with examina
tion of urine and blood pressure at each visit.
Grade I I I .— The largest group of those who had had any prenatal
care consisted of 1,337 women (24 percent of the 5,636 women studied
with regard to prenatal care) whose care did not even meet the re* The advisory committee has added the taking of blood counts to the Standards of Prenatal Care, but
this was not considered in this study.
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44
MATERNAL MORTALITY IN FIFTEEN STATES
quirements of grade II and had to be classified as grade III. In all
cases this care was very inadequate and must be regarded as poor.
Care classified as grade III: In some cases there was a single visit to the
physician; in some cases there were repeated visits but blood pressure was not
taken, or some other essential of a better grade of care was omitted; in other
cases the visits were irregular; and in still other cases the care was of good quality
but did not begin until the eighth or'ninth month.
The remaining 50 women had had some prenatal care, which was
not graded because information regarding it was insufficient.
To summarize: Less than one fourth of the women who could reasonably be expected to have had prenatal care had had good or even indif
ferent care. More than three fourths had had poor care or none at all.
The grading of the care, moreover, was made on the basis of examina
tions only and not of treatment.
The type of prenatal care that could be given depended on the
promptness with which the pregnant woman presented, herself to the
physician. Those patients who appeared before or during the filw
month of pregnancy were eligible, if they returned regularly, for
grade I prenatal care, and 1,478 women more than half of the 2,611
women who had some prenatal care— consulted the physician before
or during the fifth month. Of these, only 725 (49 percent) received
grade I care, 243 (16 percent) received grade II care, and 501 (34
percent) received grade III care; for 9 the grade was not reported.
Five hundred and eighty-one women first appeared during the sixth
or the seventh month, and so were eligible for grade II prenatal care;
253 (44 percent) received grade II care; and 327 (56 percent) received
grade III care; for 1 the grade was not reported. (Three women
receiving grade II care visited the physician before the seventh
month, but the exact month was not reported.)
Care of the better grades was more frequent among the white than
among the colored, 25 percent of the white women having received
care of grade I or grade II, as compared with 7 percent of the colored.
In urban districts 37 percent of the white women had had grade I
or grade II care, as compared with 16 percent in the rural districts.
Among the colored 13 percent in urban districts had had grade I
or grade II care, as compared with 3 percent in the rural.
F R E Q U E N C Y O F V A R IO U S E L E M E N T S O F P R E N A T A L C A R E
The element of prenatal care that was most frequently lacking was
the Wassermann test. Of the 2,611 women who had had some pre
natal care, 427 (16 percent) were known to have had this examination.
The 352 white women who had had Wassermann tests were only
15 percent of the 2,354 white women who had had some prenatal care.
The 75 colored women were 29 percent of the 257 colored who had
had some prenatal care. Wassermann tests had been done much
more frequently in cases of women who died in urban districts (24
percent) than in rural districts (6 percent). Twenty-two percent of
the urban white women who had care had Wassermann tests, as com
pared with 6 percent of the rural white, 47 percent of the urban
colored, and 7 percent of the rural colored. The higher frequency
of the Wassermann test among the urban colored as compared with
the urban white is probably due to the more frequent use of clinic
facilities by the colored (table 24).
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45
MATERNAL CARE
24.— Incidence of specified tests among white and colored women who had
received prenatal care dying in urban and rural areas from puerperal causes
T able
Women dying from puerperal causes who had received prenatal care
Specified tests reported
Wassermann
Color and area
Blood
pressure
Pelvic measurements
Total
External and
internal
Total
External
only
Num Per Num Per
ber
cent
ber- cent
Num Per Num Per Num Per
ber
cent
ber
cent
ber
cent
Total___1................ __
611
427
16
2,054
79
1,139
44
618
24
521
20
White...........................
2,354
Colored__________________
257
352
75
15
29
1,893
161
80
63
1,054
85
45
33
564
54
24
21
490
31
21
12
1 ,4 6 6
S57
*4
1,941
85
816
56
470
39
346
n
1,322
144
290
67
22
47
1,136
105
86
73
740
76
56
53
421
49
32
34
319
27
24
19
Rural............ ............. 1,145
70
6
813
71
393
98
148
13
175
15
62
8
6
7
757
56
73
50
314
9
30
8
143
5
14
4
171
4
17
4
Urban........_..............
White.......... .............
C olored..-....... ...............
White.................
Colored.______ _____ _____
2,
1,032
113
In connection with the study of the frequency of the Wassermann
test it must be remembered that if syphilis had been certified in
company with any puerperal cause, the death would have been classi
fied by the Bureau of the Census as nonpuerperal, in accordance with
the International List of Causes of Death.
Pelvic measurements were reported for 1,139 women; but while 618
of these were known to have had both internal and external measure
ments, only external measurements were reported for the other 521.
Pelvic measurements had been taken in the cases of 56 percent of the
urban white, 30 percent of the rural white, 53 percent of the urban
colored, and 8 percent of the rural colored who had had some prenatal
care.
Among those who had had some prenatal care the blood pressure
was usually taken. This, however, was more usual in urban districts
(85 percent) than in rural districts (71 percent). Blood pressure had
been taken at least once in 86 percent of the urban white, 73 percent
of the rural white, 73 percent of the urban colored, and 50 percept of
the rural colored cases in which there had been some prenatal care.
At least one urinalysis was included in the prenatal care of prac
tically all these women.
G R A D E O F P R E N A T A L C A R E , C A U SE O F D E A T H , A N D P E R IO D O F G E S T A T IO N
The prenatal care received by these women is best shown by giving
the grades and the causes of deaths separately for those whose preg
nancies lasted until the seventh month or later and for those who
died earlier In pregnancy (table 25).
Prenatal care of women dying before they reached the last trimester
In more than half (55 percent) of the cases of women dying before
they reached the last trimester the women died too early to have been
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T able 25.— C a u se o f death 1 as shown h y in terview , grade o f prenatal care, a nd trim ester o f p reg n a n cy a m o n g w o m en d y in g f r o m p u erp era l
^
ca uses
Women dying from puerperal causes
Trimester of pregnancy and cause of death1
as shown by interview
Total
Percent
Percent
Percent
Percent
Number distri Number distri Number distri Number distri
bution
bution
bution
bution
T o ta l............- ................... ....................Last trimester.........................................- ..........
Puerperal phlegmasia alba dolens, emPuerperal albuminuria and convulsions—
Following childbirth (not otherwise defined)----- ----------------------------------------Puerperal diseases of the breast....... ..........
First 2 trimesters..............................................
Accidents of pregnancy............ •-................
Other accidents of labor------------------------Puerperal phlegmasia alba dolens, embolus ^sudden dô&th- - - - - - - - - - - - - - - - - - —
Puerperal albuminuria and convulsions.. .
1,337
499
725
7,380
2,611
4,965
2,245
100
542
100
472
100
1,190
100
142
779
651
1,529
65
336
334
633
3
15
15
28
12
98
79
155
18
15
29
10
58
80
137
12
17
29
42
171
168
331
14
291
1,549
183
680
8
30
67
130
12
24
39
144
8
31
74
396
22
2
13
1
1
1
1
7
1
2,381
366
100
183
575
11
1
1,403
53
338
113
2
1
64
12
174
(4)
(4)
(4)
(4)
100
27
590
50
3,025
3 41
2,325
100
395
1
10
62
393
262
727
3
17
11
31
15
50
55
169
3
10
89
786
4
34
19
83
1
3
1
(4)
(4)
100
39
698
1,154
100
163
1,154
232
3
192
7
28
1
1
5
21
14
2
363
52
90
886
1
15
8
67
5.
46
4
20
116
3
17
2
31
19
17
5
17
36
20
3
88
2
48
1 According to the Manual of the International List of Causes of Death, 1920.
distri
bution
33
1
31
2Induced abortions and cases in which pregnancy terminated before the third month.
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147
Number
49
2
56
34
<*>
i
Un
graded
Inap
plica
ble s
38
2
31
1
3
48
port on
prenatal
care
Grade III
Grade II
Grade I
Total
2
32
3 Percent distribution not shown because number of women was less than 5Q.
4 Less than 1 percent.
MATERNAL MORTALITY IN FIFTEEN STATES
Who had
received no pre
natal care
Who had received prenatal care
MATERNAL CARE
47
expected to have care or they had had induced abortions or else a
report was not obtained concerning prenatal care. M ost of these
deaths were from puerperal septicemia or from ectopic gestation.
Of the 1,064 women for whom care was applicable and for whom a
report was obtained, 17 percent had received care that could be classi
fied as grade I, but the duration of this care was not necessarily long.
Three percent had had grade II care, and 14 percent had had grade III
care. For 1 percent care was reported but in insufficient detail for
grading. Sixty-six percent had received no care whatsoever.
Differences in the incidence of the various causes of death among
the women who died before reaching the last trimester and who had
had the various grades of care are not outstanding, but such differences
are striking when those who had received care are compared with
those who had received no care.
Of the deaths before the last trimester of the women who had had
prenatal care 48 percent are attributed to puerperal albuminuria and
convulsions, which includes the toxemias of pregnancy, and 14 percent
more are classified as “ others” (meaning others than abortions and
ectopic gestation, or chiefly pernicious vomiting) under the title
“ accidents of pregnancy.” Among the group having had no pre
natal care 17 percent died from albuminuria and 3 percent from
“ others” under accidents of pregnancy. That is, 62 percent of the
deaths of those who had had prenatal care and 20 percent of the
deaths of those who had had no prenatal care were due to the tox
emias. Evidently many of the women who had had prenatal care
consulted their physicians early in pregnancy because of troublesome
symptoms. Many of these women, as the discussion in the section
on the toxemias of pregnancy (p. 144) reveals, were, in fact, in very
bad condition when they first saw their physicians.
On the other hand, 17 percent of those who had had prenatal care,
as compared with 52 percent of those who had had no prenatal care,
died of puerperal septicemia. Nearly all this septicemia followed
abortions. M ost of these abortions were reported to have been
spontaneous; but some were therapeutic, and some (other than
therapeutic) were probably induced, although there was no clear
evidence of this fact. (Prenatal care was not considered in cases of
known induced abortions.)
Prenatal care of women who died after reaching the last trimester
Of the 4,570 women who died after reaching the last trimester and
for whom a report was obtained concerning prenatal care, 12 percent
had had grade I, adequate or good care (including 33 women (1
percent) with grade la, or adequate care); 10 percent had had grade
II, or indifferent care; 26 percent had had grade III, or poor care;
1 percent had had care that could not be graded on account of insuffi
cient information; and 51 percent had had no prenatal care.
In this group the differences in the incidence of the various causes
of death among women who had had some prenatal care and those
who had had none are not so marked as among those who died before
reaching the seventh month. Thirty percent of those who died after
having had some prenatal care, as compared with 34 percent of those
who had had no prenatal care, died of puerperal albuminuria and
convulsions; 28 percent of those with carte and 31 percent of those
without care died of puerperal sepsis; 15 percent of those with care
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48
MATERNAL MORTALITY IN FIFTEEN STATES
and 17 percent of those without prenatal care died of puerperal
hemorrhage; 15 percent of those with care and 11 percent of those
without care died of “ other accidents of labor” ; 8 percent of those
with care and 4 percept of those without care died of “ embolus or
sudden death” ; and 3 percent of each died of accidents of preg
nancy. These differences are small but significant, in that a larger
proportion of those who died following prenatal care died of causes
that are relatively less preventable.
Differences in the causes of death of those who had grade I prenatal
care and of those who had no prenatal care, are much more marked,
as would be expected. The differences in the proportions of the
deaths that were due to puerperal albuminuria and convulsions are
particularly significant, as are to a lesser extent the differences in the
proportions due to puerperal embolism and sudden death.
The percentage of deaths due to puerperal albuminuria and convul
sions was considerably less among those who died following good care
than among those who died following care of poorer quality or no care
whatsoever. Twenty-four percent of those who died following grade I
care, 31 percent of those who had had grade II care, 33 percent of
those who died following grade III care, and 34 percent of those who
had had no prenatal care died from this cause. Evidently, care of
grade I was the only quality that was particularly effective in pre
venting such deaths. Why grade I care did not succeed further in
preventing deaths from puerperal albuminuria and convulsions will be
discussed in the section on the toxemias (p. 139). There is a direct
relationship between the grade of prenatal care and the proportion of
deaths due to puerperal embolism and sudden death, which accounted
for 12 percent of the deaths of those who had had grade I care, 8 per
cent of those who had had grade II care, 6 percent of those who had
had grade III care, and 4 percent of those who had had no care at all.
This is not because there are more operations among those with grade I
care, for deaths from embolism following operation are usually assigned
to these operations as the cause of death. It is therefore apparent
from table 25 that among these women the better the prenatal care
the more frequently the deaths were due to the less preventable causes.
The maternal death rate evidently is less among mothers having good
prenatal care than among those having poor care or none.
PRENATAL CARE AND NUMBER OF PREGNANCIES
As the risk of childbearing is probably greater during the first preg
nancy than for the five or six subsequent ones, and as eclampsia affects
primigravidae more than multigravidae, it would seem especially essen
tial for primigravidae to have prenatal care. Of the 2,334 known primiparae whose deaths were included in the maternal-mortality study,
prenatal care was reported and applicable for 1,924. Of these, 14
percent had had grade I, adequate or good prenatal care; 14 percent
had had grade II, indifferent prenatal care; 24 percent had had grade
III, poor prenatal care; and 46 percent had had no prenatal care.
Twenty-two percent of mothers in their second pregnancy and 18 per
cent of those in their third pregnancy had had good prenatal care.
After the second pregnancy the amount of good prenatal care decreased
with the number of pregnancies. Eleven percent of the secundiparae
and 6 percent of the triparae had had indifferent prenatal care; and
27 percent of each had had poor care. Thirty-nine percent of the
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49
MATERNAL CARE
secundiparae and 48 percent of the triparae had had no prenatal care.
After the second pregnancy the percentages of those who had had no pre
natal care rose with the number of pregnancies. This trend was more
pronounced than could be accounted for by the facts that there was
a greater proportion of colored among the mothers with the larger
number of children and that the colored had less and poorer prenatal
care. Apparently more attention needs to be paid to reaching for
prenatal care these two groups of mothers, who are particularly hard
to reach— the primiparae and the mothers of many children (table 26).
26 .— N u m b e r o f 'pregnancies o f w o m en f o r w h o m a report o n prena ta l care
w as obtained and a pplica ble 1 a m o n g w o m en d y in g f r o m p u erp era l causes
T able
Women dying from puerperal causes for whom a report on prenatal care
was obtained and applicable1
Who had received prenatal care
Number of pregnancies
Total
Who had
received no
prenatal
Ungraded
care
Grade I
Grade II Grade III
Per
Total cent
Num Per Num Per Num Per Num Per Num Per
ber cent ber cent ber cent ber cent ber cent
Total__________ . . . 5,636 2,611
46
725
13
499
24
50
1_________ ____ ____ ____ _ 1,924 1,038
2 .......................................... 717
439
3___________________ ____ 602 312
4 ________ ____________
430
181
339
154
6_ ____________ _________ 276
109
7 or more________ _____
844
287
Multiparae, number not
reported____________
302
63
Not reported____________
202
28
54
61
52
42
45
39
34
274
157
109
53
41
31
43
14
22
18
12
12
11
5
274
78
39
29
15
11
41
14
11
6
7
4
4
5
470
195
162
95
94
64
200
24
27
27
22
28
23
24
20
9
2
4
4
3
3
1
1
(2)
1
1
1
(2)
886
278
290
249
185
167
Ä/57
46
39
48
58
55
61
21
14
12
5
4
2
7
5
2
2
41
16
14
8
3
2
1
1
239
174
79
86
9 1,337
1 3,025
54
1 Excludes induced abortions and cases in which pregnancy terminated before the third month,
i Less than 1 percent.
PRENATAL CARE IN RELATION TO LIVE BIRTHS AND STILLBIRTHS
In many cases the condition that caused the death of the mother
also caused the death of the child, and this distorted the proportions
of live births, stillbirths, and undelivered fetuses, Nevertheless, there
appears a relationship between the grade of prenatal care and the
percentage of live births. Among the 4,843 women who died after
reaching the last trimester and for whom there was a report on the
character of issue, 70 percent were live births for the mothers who had
had grade I care and grade II care, 63 percent for those who had had
grade III care, and 58 percent for those who had had no care (table 27).
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50
MATERNAL MORTALITY IN FIFTEEN STATES
T able 27.— P ren a ta l care received and resu lt o f p r eg n a n c y a m o n g w o m en d yin g
f r o m p u erp era l ca u ses w ho had reached the last trim ester o f p r eg n a n c y
Women dying from puerperal causes who had reached last trimester
Result of pregnancy reported
Grade of prenatal care
Live birth i
Total
Stillbirth
Total
Live birth
and still
birth
(plural)
Fetus not
delivered
Result
of
preg
nancy
not re
ported
Num Per Num Per Num Per Num Per
ber cent2 ber cent2 ber cent2 ber cent2
Total....... ........... ...... 4,965
4,843
3,026
62
1,436
30
33
542
472
Grade II______ __________
1,190
Grade III______ _____ _
41
No prenatal care_________ 2,325
395
No report on prenatal care.
542
470
1,178
41
2,280
332
379
330
740
25
1,332
220
70
70
63
141
115
350
14
719
97
26
24
30
2
1
8
32
29
22
58
66
(3)
0
1
348
7
122
1
20
24
80
2
207
15
4
5
7
2
12
9
5
45
63
1
1 Includes 1 twin pregnancy resulting in 1 live birth and 1 fetus not delivered.
2 Not shown where number of women was less than 50.
8 Less than 1 percent.
PRENATAL CARE IN THE DIFFERENT STATES
The quality and amount of prenatal care given varied greatly in the
different States included in the study. Of the women who might have
been expected to have prenatal care 71 percent in Oregon and 70 per
cent in Rhode Island had had some care, but only 22 percent in
Alabama and 30 percent in Oklahoma. The percentage of deaths
that had been preceded by grade I prenatal care ranged from 26 in
Washington to 4 in Alabama.
As fewer colored women than white had received prenatal care, the
large proportion of colored women among those who died in Alabama,
Virginia, and Maryland lowered perceptibly the percentages of those
who had received the various grades of prenatal care in these States.
The prenatal care received by the white and colored women in these
States is shown in table 28.
In every State except one more of the women who died in cities
than of those who died in the rural areas had had prenatal care
(table 29).
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51
MATERNAL CARE
T able 28.— Prenatal care received by white and colored women for whom a report
was obtained and applicable 1 among women dying from puerperal causes in all
the States included in the study and in specified States having 2,000. or more
colored births annually
Women dying from puerperal causes for whom a report on prenatal care was obtained
and applicable 1
Who had received prenatal care
State and color
Grade I
Total
Grade III
Grade II
Who had re
ceived no
prenatal
Ungraded
care
Per
Total cent
3 Num Per Num Per Num Per Num Per Num Per
ber cent 3 ber cent 3 ber cent 3 ber cent 3 ber cent 3
A LL STATES IN C LU D ED IN THE STU DY
Total.......... .
5,636 2,611
46
725
13
499
9 1,337
24
50
i 3,025
54
White____ 4,568 2,354
257
Colored__ 1,068
52
24
694
31
15
3
458
41
10 1,157
25
17
45
5
i 2,214
811
(3)
48
76
4
180
STATES H AVIN G 2,000 OR M ORE COLORED BIRTH S A N N U A LL Y
Alabama...................
935
202
22
36
4
29
3
136
15
White____ ____ _
Colored________
475
460
144
58
30
13
28
6
2
25
5
1
19
4
91
45
10
California.................
343
231
67
69
20
61
18
100
29
W hite.......... .
317
26
221
10
70
68
1
21
60
19
92
29
1
(3)
Kentucky__________
491
165
34
23
5
27
5
115
White.................
Colored________
431
60
146
19
34
32
22
1
5
22
5
102
Maryland..................
282
183
65
39
White_________
Colored...............
198
84
140
43
71
51
34
5
Michigan__________
944
561
59
195
White.................
Colored...............
885
59
532
29
60
49
188
7
Oklahoma....... .........
217
65
30
16
7
6
3
38
18
White..................
Colored—............
182
35
64
35
16
9
6
3
37
20
Virginia.....................
627
250
40
33
5
33
5
181
29
3
W h ite................
Colored...............
343
284
170
80
50
28
29
4
8
26
7
8
2
113
33
24
2
1
1
8
2
1
8
(3)
733
78
1
(?)
331
402
70
87
1
(3)
112
33
1
96
16
30
23
326
66
24
285
41
66
68
5
8
14
39
14
100
35
5
2
99
35
17
27
12
14
14
74
26
37
31
5
3
58
41
29
49
21
125
13
227
24
14
1
383
41
21
12
117
13
14
216
24
11
1
5
353
30
40
51
5
2
162
70
5
3
118
65
6
1
8
13
11
1
68
22
19
3
34
(3)
1
(3)
377
60
173
204
72
1 Excludes induced abortions and cases in which pregnancy terminated before the third month.
* Not shown where number of women was less than 50.
3 Less than 1 percent.
182748—34----- 5
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52
MATERNAL MORTALITY IN FIFTEEN STATES
T able 29.— Prenatal care received by women for whom a report was obtained and
applicable 1 among women dying from puerperal causes in urban and rural areas
of each State included in the study
Women dying from puerperal causes for whom a report on prenatal care was obtained
and applicable 1
Who had received prenatal care
State and area
Grade I
Total
Grade II
Grade III
Who had re
ceived no
prenatal
Ungraded
care
Per
Total cent
8 Num Per Num Per Num Per Num Per Num Per
ber cent 2 ber cent 2 ber cent 2 ber cent 2 ber cent 2
Total.
Urban.
Rural..
5,636 3,611
725
2,452 1,466
3,184 1,145
484
241
Alabama.
22
Urban.
Rural..
223
712
136
California.
343
231
196
147
139
92
Urban.
Rural—
1,337
320
179
Maryland.
283
M ichigan-
561
195
125
Urban.
Rural..
640
304
391
170
Minnesota.
401
204
173
228
107
97
Nebraska.
Urban.
Rural..
157
576
115
326
35
37
UrbanRural—
733
35
291
32
7
177
105
0
54
986
2,039
33
130
53
Urban.
Rural—
1
31
105
66
27
103
388
3,025
1
136
Kentucky.
Urban.
Rural..
24
630
707
51
2
237
383
138
57
149
78
249
134
81
97
24
197
0
44
233
35
33
41
49
66
131
130
42
77
156
New Hampshire.
50
48
40
85
UrbanRural..
North Dakota.
125
Urban.
Rural-
100
Oklahoma.
217
152
Urban.
Rural..
64
153
36
116
Oregon .
25
123
87
36
51
Urban.
Rural—
Rhode Island.
119
Urban.
Rural..
113
17
72
17
14
24
42
35
6
1 Excludes induced abortions and cases in which pregnancy terminated before the third month.
2 Not shown where number of women was less than 50.
8Less than 1 percent.
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29
53
MATERNAL CARE
T able 29.— Prenatal care received by women for whom a report was obtained and
applicable 1 among women dying from puerperal causes in urban and rural areas
of each State included in the study— Continued
Women dying from puerperal causes for whom a report on prenatal care was obtained,
and applicable
Who had received prenatal care
State and area
Grade I
Total
Grade II
Grade III
Who had re
ceived no
prenatal
Ungraded
care
Total cent
Num- Per- Num- Per- Num- Per- Num- Per- Num- Perher cent ber cent ber cent ber cent her cent
Virginia.....................
627
250
40
33
5
33
5
181
29
3
Urban_________
Rural__________
198
429
105
145
53
34
18
15
9
3
14
19
7
4
72
109
36
25
1
2
20 2
121
60
53
26
20
10
48
112
90
72
49
64
54
37
16
33
18
8
12
7
13
21
27
Wisconsin_________
496
266
54
83
17
65
13
101
Urban_________
Rural__________
244
252
149
117
61
46
52
31
21
12
38
27
16
49
52
Washington________
11
377
60
93
284
47
24
81
40
24
23
40
41
36
46
(8)
1
(3)
66
20
17
3
230
46
20
21
10
4
3
95
135
39
54
7
3 Less than 1 percent.
Special studies of small numbers of women indicate lower mortality
rates among women receiving prenatal care than among those not
receiving care. Material is lacking concerning care associated with
all live births in the States included in this study, and therefore it is
impossible to compare mortality rates for all mothers receiving pre
natal care and mothers not receiving it. As the percentage of mothers
who died who had received care is probably an index of the situation
in regard to care in the various States, comparisons of mortality
rates from puerperal causes and the percentage of women who died
who had received care were made.
No association was found between the mortality rate from puer
peral causes in a State and the percentage of women who died in that
State who had had some prenatal care. Perhaps this is not sur
prising in view of the fact that the mortality rate in a State is affected
by many factors other than prenatal care, such as the number o f
induced abortions. It must be remembered that women who died
following early termination of pregnancy or following induced abor
tion are excluded from the figures on which the percentages of pre
natal care are based but not from those used in computing the
maternal mortality rate (table 30).
In order to eliminate the abortion factor the maternal mortality
rate in the last trimester was compared with the percentage of women
who died after receiving prenatal care. There was apparently a
relationship between the percentage of women receiving prenatal care*
and those dying after they reached the third trimester of pregnancy»
but the relationship is more definite between the percentage of women
having grade I care and the mortality rate for women dying in this
period. Those States in which a larger proportion of the women who*
died had received grade I prenatal care had in general lower mortality
rates in the last trimester (table 31).
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MATERNAL MORTALITY IN FIFTEEN STATES
T able 30.— Relation between 'percentage of women receiving prenatal care and
mortality rate among women dying (a) from all puerperal causes, (b) from all
puerperal causes after they reached the last trimester of pregnancy, and (c) from
puerperal albuminuria and convulsions, in each State included in the study
Mortality
Mortality
Mortality
rate 1 from
rate 1 from
puerperal
rate 1 from all
puerperal
all puerperal causes, last albuminuria
causes
and convul
trimester
sions
Percent of
women
receiving
prenatal
care
State
22
Alabama. ______ _____ _______ ______________
Oklahoma__________________________________
North Dakota______ _____ _ .. . __________
Kentucky__________________________________
Virginia_________ __________________________
Nebraska____________________ ______________
Minnesota__________________________________
New Hampshire___ _ . .
......................
Wisconsin__________________________________
Michigan. _______ . . . . . . .. _____ . . . .
Washington__________ _______ _____________
Maryland__________________________________
California... ................_ . . .
Rhode Island_______________________________
Oregon_____________________________________
30
32
34
40
44
51
51
54
59
60
65
67
70
71
66
85
70
54
53
67
59
49
62
54
31
19
14
14
19
44
36
35
49
36
33
45
39
41
36
40
37
42
33
66
68
59
59
62
62
12
12
21
12
14
15
13
12
16
14
Coefficients of correlation and probable errors:
(а) Percent receiving prenatal care and mortality rate from all puerperal causes:
r= —0.3077±0.1577
( б) Percent receiving prenatal care and mortality rate from all puerperal causes, last trimester:
r——0.5000±0.1306
(c) Percent receiving prenatal care and mortality rate from puerperal albuminuria and convulsions:
r= —0.5574±0.1206
1 Deaths per 10,000 live births.
T able 31.— Relation between percentage of women receiving grade I prenatal care
and mortality rate among women dying (a) from all puerperal causes after they
reached the last trimester of pregnancy and (6) from puerperal albuminuria and
convulsions, in each State included in the study
State
New Hampshire__
Virginia._________
Oklahoma________
North Dakota____
Maryland...............
Nebraska_________
Mortality
Percent of Mortality
rate 1
rate 1
women from
from
all puerperal
receiving puerperal
albumi
grade I
prenatal causes,
nuria
last
con
care
trimester and
vulsions
4
5
5
5
7
12
14
14
66
35
45
49
44
36
40
36
State
31
14
21
19
19
14
13
12
Mortality
Percent of Mortality
rate 1
rate 1
women from
from
all puerperal
receiving puerperal
albumi
grade I
prenatal causes,
nuria,
last
care
coñ
trimester and
vülsíOns
14
17
Minnesota________
20
20
21
22
26
42
39
33
37
41
33
36
16
12
12
12
14
14
15
Coefficients of correlation and probable errors:
(а) Percent receiving grade I prenatal care and mortality rate, last trimester:
r=-0.6127±0.1088
( б) Percent receiving grade I prenatal care and mortality rate from puerperal albuminuria and con
vulsions:
r= -0.6323±0.1045
1 Deaths per 10,000 live births.
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MATERNAL CARE
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A relationship also appears between the percentage receiving pre
natal care and the mortality rate from albuminuria and convulsions
in the different States. The relationship is particularly apparent
between the percentage receiving grade I care and the rate from this
condition in the different States; the larger the percentage of women
receiving prenatal care of this grade, the lower is the mortality rate
from puerperal albuminuria and convulsions (tables 30 and 31).
DELIVERY CARE
Adequate care at the time of delivery is of paramount importance.
Such care requires the maintenance of aseptic technique, the careful
management of normal labor, and the proper handling of any abnor
malities. These in turn imply an attendant who has not only skill
but patience and good judgment. The actual evaluation of all these
factors is obviously difficult and can be made only through a careful
appraisal of each individual case with complete knowledge of the
circumstances. In this study no attempt was made to grade the
types of delivery care given, but the simplest and most objective of
the factors involved were studied separately. The place of delivery,
type of attendant at birth, technique of the physician as regards
asepsis, and the use of pituitrin will be discussed in this section.
Operations and the handling of emergencies will be taken up in other
sections.
One third of the deaths in the study occurred before the women
reached the last trimester of pregnancy. These cases are discussed
in the sections on abortion, ectopic gestation, and operations, and in
the sections dealing with the specific causes of death. This section
will deal only with those women who had reached the last trimester
of pregnancy.
H O S P IT A L IZ A T IO N A T D E L IV E R Y
Of the 4,965 women who had reached the last trimester of preg
nancy 1,971 were in hospitals for delivery or at the time of death if
they died undelivered, 2,990 were delivered, or died undelivered, out
side hospitals, and for 4 the place of delivery was not reported. The
hospitalization of 899 of the 1,971 women was planned, for 1,018 it
was emergency hospitalization; for 54 this was not reported. (See
General Considerations, table 12, p. 26.)
About half (827) of the 1,725 white women who were in hospitals
for delivery had planned hospitalization, 848 had emergency hos
pitalization, and for 50 this was not reported. The number of white
women who were delivered or who died undelivered outside hospitals
was 2,298, and the 4 women whose place of delivery was not known
were white.
Only 246 of the 938 colored women who died after reaching the
last trimester were in hospitals for delivery; 72 of these had planned
and 170 had emergency hospitalization; for 4 this was not reported.
Most of the colored women (692 of the 938) were delivered, or died
undelivered, outside hospitals.
The size and standards of the hospitals in which women whose
deaths make up this report were delivered are given in appendix tables
II to V (pp. 186-189). As the total number of deliveries occurring
in these hospitals is not known, there are no data on the mortality
rates in hospitals and outside hospitals, nor in the different types of
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56
MATERNAL MORTALITY IN FIFTEEN STATES
hospitals. Even if there were such data, the large and varying pro
portions of complicated cases among those delivered in hospitals
invalidate comparisons. Perhaps the chief value of this study as
regards hospitalization lies in its directing attention to the fact that
hospital mortality rates and mortality rates in the general population
are not comparable. (See also General Considerations, p. 25.)
A T T E N D A N T A T C O N F IN E M E N T
In all the States studied
Information on the attendant at delivery, or at death if the patient
died undelivered, was obtained for 4,903 of the 4,965 women who
died after reaching the last trimester. Of these 4,903 women, 4,065
(83 percent) were attended at confinement exclusively by physicians,
internes, or medical students (including 3,915 by physicians only, 87
by physicians preceded by internes or medical students, and 63 by
internes or medical students only). Midwives attended 550 (11 per
cent) of the 4,903 women, including 193 for whom physicians (in 2
cases internes) were called in before the delivery was completed. One
hundred and seventy-two women (4 percent) had other nonmedical
attendants, such as relatives, followed in 47 cases by physicians; and
116 women (2 percent) were said to have been unattended at the time
of delivery or at death if they died undelivered (table 32).
T able 32.— Attendant at confinement and technique of principal physician1among
women dying from puerperal causes who had reached the last trimester of preg
nancy
Women dying from puerperal causes who had reached last
trimester
Technique of principal physician 1
Attendant at confinement
Total
Aseptic
Total____ ___________________
---
Followed by physician........................
Other attendant..........................................
Followed by physician______________
Attempt Clean, not
ed aseptic sterile
Not re
ported or
no physi
cian
Dirty
4,965
1,740
510
1,099
270
1,346
4,066
1,700
492
1,012
226
635
3,915
87
63
1,566
78
56
484
5
3
1,011
1
224
630
660
S3
14
80
32
391
357
191
31
14
80
32
357
34
m
7
4
7
12
142
125
47
7
4
7
12
125
17
2
2
1
1
2
3
. 116
116
62
62
1 Includes interne or student. When there was more than one physician the one who did the actual
delivery or who was finally in charge if the woman died undelivered was called the principal physician.
Of the 3,987 white women concerning whom there was a report on
attendant, 3,536 (89 percent) had been attended by physicians, in
ternes, or students (3,431 by physicians only, 66 by physicians pre
ceded by internes or students, and 39 by internes or students only).
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MATERNAL CARE
57
Midwives attended 232 women (6 percent); in 86 of the 232 cases a
physician was called in to complete the delivery. Other persons at
tended 141 women (4 percent), followed in 41 cases by physicians;
78 (2 percent) were unattended.
-- A smaller proportion of the colored women were attended at con
finement by physicians. Information was obtained for 916 women;
529 (58 percent) were attended by physicians, internes, or students
(484 by physicians only, 24 by internes and students only, and 21 by
internes or students followed by "physicians). Midwives had at
tended 318 (35 percent), followed in 107 cases by physicians. Other
persons attended 31 (3 percent), followed in 6 cases by physicians;
38 (4 percent) were unattended.
No study of the qualifications of the individual physicians or mid
wives attending these patients was made. There were probably^ a
few foreign-trained midwives in Michigan, Minnesota, and Wis
consin and in some of the larger cities in other States; the great ma
jority, however, were “ grannies” and neighbor women who were
classified as mid wives because they made a practice of delivering
women for pay. What instruction they may have received from
official sources had been directed almost exclusively toward cleanli
ness, noninterference, prophylaxis against ophthalmia neonatorum,
and the registration of births; but many of them had had no instruc
tion whatever.
In individual States
The number of deaths of women who had been attended at confine
ment in the last trimester by physicians, midwives, and others in the
different States is given in table 33. All cases in which the patient
was delivered by a midwife and all in which a midwife was known to
have been in attendance for the purpose of delivering the patient,
even if a physician did the actual delivery, were classified as having
been attended by mid wives. If the midwife was present merely as a
nurse, the case was not assigned to midwives. (It is possible that in
some cases of women delivered by physicians previous midwife at
tendance was not known to or at least not reported by the physician.
This would be more likely to happen among the Negroes.) Many
of the women attended at confinement only by midwives or others
finally were seen by a phvsician before their death.
It will be seen from table 33 that 462 of the 550 women attended at
confinement by midwives died in Alabama, Kentucky, Maryland, and
Virginia. These 4 were the only States of the 15 included in the
study in which the number of deaths of women attended by midwives
constituted 10 percent or more of the total number of last-trimester
deaths.
In Alabama midwives had attended at confinement 24 percent of
838 women who died of puerperal causes after reaching the last tri
mester and concerning whom a report was obtained on attendant at
confinement. Physicians (including internes or students) had at
tended 72 percent. The remaining 4 percent were attended by some
nonmedical person or were unattended. During the 2 years of the
• study, according to the Bureau of Vital Statistics of the Alabama
State Board of Health, midwives reported 28 percent, physicians
reported 71 percent, and others reported less than 1 percent of the
total live births.
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MATERNAL MORTALITY IN FIFTEEN STATES
33. Attendant at confinement of women who had reached the last trimester of
pregnancy dying from puerperal causes in each State included in the study
T able
Women dying from puerperal causes who had reached last trimester
Attendant at confinement reported
Midwife
State
Physi
cian
Total
Total
Alone
©
Total
lx
©
■ fO
a
s
¡3
T o ta l..._________ 4,965 4,903 4,065
Alabama.........
.
California...................
Kentucky....................
Maryland...................
Michigan.........................
Minnesota.......... .........
Nebraska...............
New Hampshire....... .
North Dakota_______
Oklahoma_____. . .
O r e g o n .....................
Rhode Island...................
Virginia............................
Washington........... ......
Wisconsin__________
859
310
428
255
809
334
200
79
106
190
96
113
566
169
451
838
305
424
252
799
334
199
78
105
184
96
110
566
168
445
602
259
323
209
743
299
182
75
d
©
otx
©
Ph
83
72
85
76
83
93
90
91
96
88 84
166 90
88 92
101 92
362 64
157 93
411 92
Followed
by
physi
cian
a
3
fc
d
©
©
lx
©
P-i
lx
©
rO
a
3
£
d
©
©
lx
©
Ph
a
3
A
550
11
357
7
202 24
12 4
165
20
6 2
49 12
10 4
8 1
11 3
2 1
69
30
18
16
16
6
5
3
7
7
5
10
1
1
161
4
13
12
2
5
1
1
8
1
1
28
83
2
3
2
6
lx
©
Other
None
lx
©
rQ
a
3
d
©
o
©
pH
rO
a
d
fc
d
©
©
u
©*
Ph
193
4
172
4
116
2
62
37
4
10
21
1
24
13
15
3
4
4
(i)
21
4
1
1
1
1
1
6
6
20
20
10
2
5
4
8
1
1
2
32
15
6
7
4
5
4
4
3
5
4
2
2
2
1
9
7
9
4
I
15
78
14
21
4
1
1
1
At
tend
ant at
con
fine
m ent
not
re
port
ed
2
7
5
1
2
17
12
4
10
fc
1
6
22
3
2
2. n
1
©
u*
s
5
4
3
4
2
2
6
1 Less than 1 percent.
Data on attendant at confinement were obtained concerning 435 of
the 444 white women who died in Alabama after reaching the last
trimester. Of these 435 women, 89 percent had been attended by
physicians, 8 percent by midwives or by midwives followed by
physicians, 3 percent by others or by no one. During the same 2
years 92 percent of the white live births had been reported by physi
cians, 7 percent by midwives, and less than 1 percent by others.
Of the 403 colored women who died after reaching the last trimester
and concerning whom there was a report on attendant, 53 percent
had had, as far as was known, physicians only, 41 percent had been
attended by midwives, 2 percent had been attended by others, and 4
percent had had no attendant. In the same period physicians had
reported 33 percent of the colored five births, midwives 67 percent,
and others less than 1 percent.
In Kentucky physicians attended 76 percent, midwives 16 percent,
and others 4 percent of the 424 women who died after reaching the last
trimester and for whom data on attendant at confinement were ob
tained; the remaining 4 percent were unattended. During the same
2 years, according to the Bureau of Vital Statistics of the Kentucky
State Board of Health, physicians reported 84 percent and midwives
and others 16 percent of the total number of live births.
In Maryland physicians had attended 83 percent, midwives 12 per- *
cent, and others 5 percent of the 252 women who died of puerperal
causes after reaching the last trimester and concerning whom there
was a report on attendant at confinement. According to the Mary
land State Bureau of Vital Statistics, physicians reported 85 percent
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MATERNAL CARE
59
and midwives 14 percent of the total live births; less than 1 percent
were reported by other persons.
In Virginia physicians had attended 64 percent, midwives 28 per
cent, and others 4 percent of the 566 women who died after reaching
the last trimester; 4 percent had been unattended. According to the
Virginia State Bureau of Vital Statistics, physicians had reported 69
percent, midwives 30 percent, and others 1 percent of the total live
births.
Of^thn 318 white women who died after reaching the last trimester
physicians had attended at confinement 78 percent, midwives 15 per
cent, and others 3 percent; 3 percent had been unattended. Physi
cians reported 86 percent and midwives 14 percent of the total white
live births in the State.
Of the 248 colored women who died after reaching the last tri
mester, physicians had attended 46 percent, midwives 45 percent,
and others 4 percent, while 4 percent had been unattended. Physi
cians reported 31 percent and midwives 69 percent of the colored live
births during the same 2-year period.
Special conditions affecting cases attended by midwives
White women.-—The 146 white women in Kentucky, Virginia, and
Alabama who died after having been attended at their confinements
m the last trimester by midwives form a distinct group. Most of
them lived in the very rugged or mountainous portions of these
States. In general their isolation was the primary and poverty a
secondary reason for their having midwives rather than physicians.
It was usually very difl&cult for the midwife to get medical help
even if she knew that it was urgently needed. Nineteen percent of
these 146 women had had no medical attention from the beginning
of pregnancy until death, and 21 percent more had not been seen
by a physician until they were moribund.
Of the 15 Maryland white women who died after midwife attend
ance, all but 4 lived in Baltimore. The midwives there were more
closely supervised than was possible in the mountains of Kentucky,
Virginia, and Alabama.
. Colored women. The mid wives that attended the colored births
in these four States were colored “ grannies. ” They were employed
rather than physicians because their patients were not accustomed
to the services of a physician at childbirth and could not afford a
physician s care. In contrast to conditions in the corresponding
group of white women-, inaccessibility was not an important factor
m general. Of the 298 colored women who died after midwife attend
ance m these four States, concerning whom medical attention was
reported, 34 (11 percent) had had no medical attention whatever
ailnni^ ^ percent) were first seen by a physician when moribund.
Thirty percent of the deaths of colored women in these four States
who had been attended at confinement by midwives were from
puerperal albuminuria and convulsions, as compared with 45 percc^ if0? 1i his cause *n
group of colored women in the same States
who had been attended by physicians. These percentages suggest
that many of the colored patients called in a physician rather than a
midwife because of the appearance of alarming symptoms of toxemia;
and tins supposition is confirmed by the report as to the condition
when first seen, of 178 out of the 190 colored women dying from this
cause who had been attended by physicians. One hundred and six
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MATERNAL MORTALITY IN FIFTEEN STATES
(60 percent) were in coma or in convulsions when the physician first
saw them, and 44 others (25 percent) were in poor condition; only
28 (16 percent) of the 178 women were in good or fair condition.
T E C H N IQ U E O F P R IN C IP A L P H Y S IC IA N 3
The technique as to asepsis was studied only in the cases in which a
physician was in attendance for at least part of the delivery, as it
may safely be assumed that the midwives did not use sterile technique.
The technique of the principal physician at confinement was reported
in 3,619 of the 4,305 cases in which a physician attended women who
died after reaching the last trimester. (See table 32, p. 56.) In
1,740 cases (48 percent) an aseptic technique was said to have been
used. This included shaving, scrubbing, and sterile drapes, instru
ments, and rubber gloves, and adequate assistance at the delivery.4
In 510 cases (14 percent) in which the technique was graded as
“ attempted aseptic’ * a similar technique was used; but the circum
stances rendered the preservation of strict asepsis unlikely, or there
were known “ breaks” in technique. In 1,099 cases (30 percent)
the technique was “ clean but not sterile” . This meant ordinary
cleanliness and, usually, sterilization of any instruments used. In
many cases the principal physician whose technique was assigned to
one of these three classes was preceded by someone whose tech
nique was less careful. In 270 cases (7 percent) not even ordinary
cleanliness was used.
The technique as described may be somewhat better than that
which was actually used. The grading of technique was based on
the description given by the principal physician himself. When he
did not remember the exact circumstances of a case, his customary
technique, if reported, was accepted as a basis for grading.
Of the 3,089 cases of white women attended by physicians for which
the principal physician reported his technique, aseptic technique was
reported in 1,538 cases (50 percent); attempted aseptic, in 458 cases
(15 percent); clean, not sterile, in 889 cases (29 percent); and not
clean, in 204 cases (7 percent).
Of the 530 cases of colored women attended by physicians for which
the principal physician reported his technique, aseptic technique was
reported in 202 cases (38 percent); attempted aseptic, in 52 cases
(10 percent); clean, not sterile, in 210 cases (40 percent); and not
clean, in 66 cases (12 percent). The physician was preceded by a
midwife in a larger proportion of the colored cases than of the white
In addition to the cases shown in table 32 in which the principal
physician was preceded by a midwife or some other nonmedical attend
ant, there were 229 cases in which he was known to have been pre
ceded by another physician with less careful technique. In 212 of
these 229 cases the principal physician’s technique was classed as
aseptic; in 10 cases, as attempted aseptic; and in 7 cases, as clean, not
sterile
An analysis of the causes of the 4,965 last-trimester deaths shows
that the better the technique used at confinement, the smaller was the
proportion of the deaths caused by puerperal septicemia (table 34).
s When there was more than 1 physician, the one who did the actual delivery or who wag finally in
charge if the woman died undelivered was called the principal physician.
..
4 Although the use of masks in the delivery room is now considered an essential in aseptic technique it
was very uncommon at the tiine of the study, and an inquiry on this point was therefore not included in the
schedule.
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MATERNAL CARE
T a b l e 34.
T ech n iq u e o f p r in c ip a l p h y sic ia n at con fin em en t o f w o m en d y in g f r o m
p u erp era l sep ticem ia an d f r o m all other p u erp era l causes w ho had reached the last
trim ester o f p reg n a n c y
Women dying from puerperal eauses vrho had
reached last trimester
Technique of principal physician at confinement
Total
Puerperal sep
ticemia
All other causes
Number Percent1 Number Percent *
Total_________ _______ ________________ ____
Women attended by physician only *___________ ...
Aseptic technique:
Only................................................ ...............
Preceded by less careful technique of another
physician___________ ___________________
Attempted aseptic technique:
Only..................................................................
Preceded by less careful technique of another
physician______________________________
Clean, not sterile technique:
Only..................................................................
Preceded by less careful technique of another
physician.......................................................
Dirty technique...................... ............. ..................
No report on technique....... .................. __.............
4,965
1,529
31
3,436
69'
4,065
1,177
29
2,888
71
1,488
348
23
1,140
77
212
79
37
133
63
482
144
30
338
70
10
4
1,005
361
7
226
635
5
95
141
42
131
494
58
78
m
116
62
SOI
28
23
4«
*4
421
68
76
Women attended by midwife or other person *_____
No attendant................................ ....................... .........
No report on attendant_________ ____________-flSS.
6
36
644
64
9
22
88
39
1 Not shown where number of women was less than 50.
1 Includes interne or student.
* Includes midwife or other person followed by physician.
Vaginal examinations
The principal physician made vaginal examinations in 2,765 of the
3,854 cases of women dying after they reached the last trimester for
whom there was a report—-in 2,188 cases with rubber gloves, in 484
without rubber gloves, and in 93 cases in which there was no report on
rubber gloves. Further data on vaginal examinations are given in
table 35. In this table is shown the technique only of the physician
who actually delivered the patient or who was in charge if she died
undelivered. Previous vaginal examinations by other persons are
not reported. When the physician did not remember the exact
number of examinations, his customary number, if given, was used.
T a b l e 35.
V a g in a l ex a m in a tio n s a n d u se o f rubber gloves b y p r in c ip a l p h y s ic ia n
at con fin em en t o f w o m en d y in g f r o m p u erp era l causes w ho had reached the last
trim ester o f p r eg n a n c y
Women dying from puerperal causes who
had reached last trimester
Vaginal examination
Use of rubber gloves by physician
Total
Used
Total___________
No vaginal examination.................
Vaginal examination________
1 _____ ____ _
2........................ ...........
3 or more_________________
Number not reported______
No report on vaginal examination..
Inapplicable 1........ .........................
1 No physician or no report as to physician.
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4,965
1,089
2,765
871
565
771
558
45/
660
3,162
824
2,188
735
471
552
430
ISO
Not used
Not re
ported
688
455
76
93
36
189
484
100
88
201
95
15
Inappli
cable 1
669
6
18
33
286
660
62
MATERNAL MORTALITY IN FIFTEEN STATES
Rectal examinations
Rectal examinations were reported to have been made by the prin
cipal physician in 778 cases and not made in 2,845 cases; in 682 cases
there was no report. In 434 cases the physician made rectal but no
vaginal examinations; in 326 cases he made both rectal and vaginal
examinations; and in 18 cases in which he made rectal examinations
there was no report as to vaginal examinations (table 36).
T a b le 36. — V a g in a l and rectal ex a m in a tio n s m ad e b y 'principal p h y sic ia n at c o n
fin e m e n t o f w o m en d y in g f r o m p u erp era l ca u ses w ho had reached the last trim ester
o f p r eg n a n c y
Women dying from puerperal causes who
had reached last trimester
Rectal examination
Vaginal examination
Total
Yes
2,845
682
1,089
2,765
m
609
46
871
565
771
558
155
54
70
47
651
483
661
426
65
28
40
85
451
660
18
15
418
4,965
Total
No vaginal examination.
Vaginal examination___
.................*.....
.......................
1
2
3 or more....................
Number not reported.
No report on vaginal examination_________________
Inapplicable 1.................................................................
Not re
ported
No
Inappli
cable 1
................
................
................
................
660.
1 No physician or no report as to physician.
USE OF PITUITRIN
Of the 4,305 cases of women delivered in the last trimester having
as attendant a physician, an interne, or a medical student, there was
a report on the use of pituitrin in 3,718. Pituitrin was not used in
1,979 cases; in 711 cases it was used before the birth of the child, in
1,004 cases after the birth of the child only, and in 24 cases at an
unreported stage of labor. In the group in which pituitrin was not
used, 41 percent of the deaths were due to puerperal albuminuria and
convulsions, 25 percent to puerperal septicemia, 9 percent to puerperal
hemorrhage, and 24 percent to other causes. In the group in which
pituitrin had been used before the birth of the child, 21 percent of the
deaths were due to puerperal albuminuria and convulsions, 35 percent
to puerperal septicemia, 19 percent to puerperal hemorrhage, and
24 percent to other causes. This difference was probably related, in
part, to the fact that many of those with eclampsia died without
going into labor.
Sixty-one percent of the cases in which the character of issue was
reported resulted in live births in the group in which no pituitrin was
used and 59 percent in the group in which pituitrin was used before the
delivery of the child. However, in the group in which no pituitrin
was used, 29 percent resulted in stillbirths and 10 percent were
undelivered, while in the group in which pituitrin was used in the first
or second stage of labor 39 percent were stillbirths and 1 percent were
undelivered. This may be partly due to the fact that there were a
larger number of fatal eclampsia cases without delivery in the grouj)
in which pituitrin was not used.
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MATERNAL CARE
63
Pituitrin was used in 1,492 (47 percent) of the 3,161 cases of white
women attended by physicians for which there was a report on this
point, including 614 cases (19 percent of the 3,161) in which it was
used before the birth of the child (in 20 cases for induction) and 855
cases (27 percent) in which it was used only in the third stage or post
partum; in 23 cases the stage of labor at which it was used was not
stated.
Among the 557 cases of colored women delivered by physicians and
having a report with regard to pituitrin it was used in 247 cases (44
percent), including 97 cases (17 percent of the 557) before the birth
of the child (in 3 cases for induction), 149 cases (27 percent) after
delivery only, and 1 case in which the stage of labor at the time of its
use was not reported.
POSTPARTUM CARE
The postpartum care of these women depended to a great extent
on the abnormalities that were present and will, therefore, be discussed
under the various causes of death. It may be stated here that 605
women who had been delivered elsewhere died in hospitals; 534 of
these were white and 71 were colored. Most of these were hospital
ized on account of complications of the puerperium.
COM M EN T B Y AD VISO RY CO M M ITTEE
This section shows clearly what a serious situation exists in regard
to the quality of the maternal care that many women receive in this
country during their pregnancy. Although this study covered but
15 States, they represent a fair cross section of the country, and
therefore it is probably fair to assume that the findings in this sec
tion are applicable to the country as a whole.
It is discouraging to find that of the women on whom a report as
to prenatal care could be obtained and who could reasonably have
been expected to have such care, 54 percent had had no prenatal
examination by a physician. In only 1 percent was the care given
up to the standard that it is the right of every pregnant patient to
have and to demand.
For the deaths of the women who had had no prenatal examina
tion the attending physician could hardly be held responsible, for
he was not consulted until an emergency had arisen. Gross igno
rance, carelessness, and sociological and economic problems all had
a share in this responsibility. However, in those cases in which the
physician was consulted he was responsible for providing adequate
maternal care; and in many o f these cases physicians failed in their
responsibility, for half the women who did consult a physician had
poor prenatal care.
Although the question o f prenatal care was considered for only
45 percent of the women who died before they reached the last
trimester of pregnancy, 80 percent of these 1,064 women had no
care or poor care. Furthermore, many of the 20 percent who had
good or indifferent care already had troublesome symptoms before
they consulted a physician. Of those women who died after reach
ing the last trimester and for whom a report was obtained» 78 percent
had poor prenatal care or none.
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MATERNAL MORTALITY IN FIFTEEN STATES
Evidence of the value of prenatal care may be found in the fact
that smaller proportions of the women who died after- good pre
natal care than of those who died after poor prenatal care died of
puerperal albuminuria and convulsions. Further evidence may be
found in the larger proportion of live births in those cases in which
there had been good prenatal care, and in the fact that those States
with more good prenatal care, even among the women who died,
had lower death rates from albuminuria and convulsions.
Primiparse and the mothers of many children particularly need
prenatal care, but many of these women failed to receive it.
Prenatal care, such as it was, was much more frequent among the
white than among the colored women, and in both groups it was
more frequent in the urban than in the rural areas. In the rural
areas among the colored women there was practically no prenatal
care, for 83 percent had none and 13 percent had grade III, which
is poor care.
Delivery care, though as important as prenatal care, was more dif
ficult to evaluate, but certain facts were noted. For more than half
the women who died in hospitals after reaching the last trimester,
hospitalization was an emergency measure. Among the colored
women emergency hospitalization was much more frequent than
among the white women. Eighty-three percent of the women were
attended by physicians, internes, or medical students, 11 percent
by midwives, 4 percent by nonmedical attendants; 2 percent of the
women had no attendant at the delivery or at the death if the patient
died undelivered.
Figures given in the report would indicate that, though the mid
wives played a part in the mortality, they could not have been
responsible for any large proportion of the deaths because they
attended a relatively small percentage of the cases.
No study of the qualifications of the individual physicians or midwives was attempted. As it was known, however, that the majority
of the midwives were ignorant “ grannies” , it may safely be assumed
that these midwives did not use a satisfactory aseptic technique at
delivery. In 48 percent of the cases the physicians described their
technique, as they remembered it, in such a way that it was classified
as aseptic; but obviously this is not a sure way of determining how
good this technique was. The point to be noted is that the physi
cians themselves admitted it was unsatisfactory in more than 50
percent of the cases. The frequency of vaginal examinations, often
times without gloves, is clear, and the relatively small number of
rectal examinations must be noted.
Although the data on the use of pituitrin are incomplete, its use
is shown to be common and to be associated with serious accidents.
Higher percentages of maternal deaths from sepsis and from hemor
rhage occurred among those who had it than among those who did
not have it. The percentages of ruptured uterus and of stillbirths
also were higher.
The almost total lack of adequate prenatal care and the relative
infrequency of any prenatal care were outstanding. Besides permit
ting the unchecked development of unfavorable factors during preg
nancy, this situation led to delivery care that was unsatisfactory
because given without previous knowledge of the case and frequently
in circumstances that necessitated emergency hospitalization.
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OPERATIONS
More than half the women who died from puerperal causes in the
years and States of the study had had some operative procedure
before death. Of the 7,234 women concerning whom there was a
report on this point, 3,370 (47 percent) had had no operation, 2,649
(37 percent) had had an operation directed toward delivery (including
6 percent who had had both an operative delivery and at least one
other operation), and 1,131 (16 percent) had had some other operation
only. The other 84 women either had had no operative delivery with
no report as to other operation or had had some other operation
with no report as to operative delivery. By operative delivery is
meant an operation for the purpose of delivering the fetus or for the
immediate removal of the placenta. Attempts at these operations,
as well as completed operations, are included. The other operations
were secondary, usually on account of sequelae of the delivery; a
few operations for associated conditions, particularly routine appen
dectomies, are included.
There were more operations among women who died in the urban
than in the rural districts, and more operations among white than
among colored women (table 37).
OPERATIONS IN THE LAST TRIMESTER
OPERATIONS FOR DELIVERY
Of the 4,965 women who reached the last trimester of pregnancy,
2,225 were known to have had an operative delivery or an attempt
at operative delivery (table 38).
Type of operation
Cesarean section preceded the deaths of 531 women who had
reached the last trimester. For 62 of them attempts had been made
at some other method of delivery. The deaths following Cesarean
section are discussed in detail in the section on that subject. (See
p. 89.)
65
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MATERNAL MORTALITY IN FIFTEEN STATES
T able
37.— Frequency of operative deliveries and other operations among white and
colored women dying from puerperal causes in urban and rural areas
Women dying from puerperal causes
Total
In urban areas
In rural areas
Operation
Num
ber
Per
cent
distri
bution
7,380
Num
ber
Per
cent
distri
bution
3,462
Num
ber
Per
cent
distri
bution
3,918
Report on operation_________ _____ ________________
7,334
100
3,412
100
3,822
Report on operative delivery___________________
2,649
37
1,406
41
1,244
33
Operative delivery only.......... .........................
Operative delivery and other operation............
2,236
413
31
6
1,123
282
S3
8
1,113
131
29
3
No operative delivery, no report on other operation....................................................................
Other operation only___________________________
Other operation, no report on operative delivery..
No operation__________ _____________ _____ ____
61
1,131
23
3,370
1
23
642
19
1,323
19
1
38
489
4
2,047
16
0
47
146
1
39
50
100
1
13
0
54
96
•
W H ITE
6,072
2,951
3,121
leport on operation_______ _______________________
5,973
100
2,913
100
3,060
100
Report on operative delivery...................................
2,270
38
1,224
42
1,046
'34
Operative delivery only________ __________
Operative delivery and other operation............
1,899
371
32
6
968
266
S3
9
931
116
SO
No operative delivery, no report on other operatio n ........................................................................
Other operation on ly ................................................
Other operation, no report on operative delivery...
No operation______ ___ ____ ___________________
36
993
17
1
17
567
18
1,087
19
1
19
426
4
1,565
14
22
2,652
0
44
99
1
37
38
4
1
0
51
61
COLORED
511
1,308
Report on operative delivery____________________
No operative deliveiy, no report on other operaOther operation, no report on operative delivery..
100
499
100
762
379
30
181
36
198
26
337
42
27
3
166
26
31
5
182
16
24
2
25
138
2
11
1
75
15
19
63
2
8
57
236
47
482
63
1
718
47
1 Less than 1 percent.
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797
1,261
0
6
1
12
0
35
100
67
OPERATIONS
T able 38.— Type of operation for delivery performed on women dying from puerperal
causes who had reached the last trimester of pregnancy
Women dying from puer
peral causes who had
reached last trimester
Type of operation for delivery
Percent dis
tribution
Number
Total
Operation_________________. _____ ______ ____ ____________ _____ :j_______
Forceps:
Only.................... i ...........................................—........................ .........
With dilatation of cervix________________________ ____ ___________
With manual removal of placenta__________ ___ _____ ____________
With dilatation of cervix and manual removal of placenta_________
With other operation________ ____ ______ ________________________
Cesarean section:
Only....................................................... ................................... ............
Following other operation___ ___________________________ ________
Version:
Only.............................................................. ..........................................
With dilatation of cervix________________________________________
With dilatation of cervix and manual removal of placenta_________
With manual removal of placenta________ -______________________
With forceps____________ ______ ____ ____ ____________ __________
With dilatation of cervix and forceps________ ____________________
With forceps and manual removal of placenta_____________________
With dilatation of cervix, forceps, and manual removal of placenta..
With other operation..____________________ ____ ________________
Dilatation of cervix:
Only............ .................................................................
With manual removal of placenta________________
Manual removal of placenta.................... ......................
Craniotomy or embryotomy following other operation....
Breech extraction:
Only_______ ___________________________ ______ _________
With dilatation of cervix and/or manual removal of placenta.
Laparotomy for ectopic gestation.___ _______ _____ ___________
Other single operations__________ ________ ___________________
Other operation of more than one type_______________________
Type of operation not reported-............................. .........................
No operation_________
No report on operation.
4,965
225
100
518
150
24
23
7
12
1
1
1
469
62
21
218
224
48
26
64
10
10
2
1
14
21
10
3
4
3
3
1
(*)
0)
u
108
4
87
57
2
1
42
23
8
12
8
9
0)
1
(>)
(>)
2,697
133
1 Less than l percent.
Forceps, the most frequent operation, was the principal operation
for delivery in 718 cases (14 percent of all cases of women who died
after reaching the last trimester and 32 percent of operative deliveries
in this period), and in addition there were 98 cases of forceps and
version combined. (See p.68.) In 150 of the 718 cases the applica
tion of forceps followed mechanical induction of labor or artificial
dilatation of the cervix 1— manually, by bag, or by some other method;
in 24 cases the use of forceps was followed by manual removal of the
placenta; in 12 cases all three of these operations were performed;
and in 14 cases forceps were used in combination with some other
operation. Of the 162 women (including the 12 with manual removal
of the placenta also) in whose cases the use of forceps followed induc
tion of labor or artificial dilatation of the cervix, 106 were not in labor
when the dilatation of the cervix was begun; in 56 cases of women in
labor the dilatation of the cervix was done to facilitate delivery.
The 718 forceps cases include 2 in which the woman subsequently
delivered spontaneously and 13 in which she died undelivered after
unsuccessful attempts at delivery by forceps.
1 Throughout the report “ artificial dilatation of the cervix” includes mechanical induction of labor.
182748—34----- 6
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MATERNAL MORTALITY IN FIFTEEN STATES
The deaths of 253 (35 percent) of these 718 women were attributed
to puerperal albuminuria and convulsions according to the Interna
tional List of Causes of Death; 186 (26 percent), to puerperal septi
cemia; 48 (7 percent), to puerperal phlegmasia alba dolens, embolus,
sudden death; 33 (5 percent), to placenta previa; 81 (11 percent), to
other puerperal hemorrhage; 111 (15 percent), to other accidents of
labor; and 6 (approximately 1 percent), to the other puerperal causes.
Of the 162 cases in which artificial dilatation of the cervix preceded the
use of forceps, the death was attributed to puerperal albuminuria and
convulsions in 62 percent; to puerperal septicemia in 9 percent; to
phlegmasia alba dolens in 2 percent; to placenta previa in 10 percent;
to other puerperal hemorrhage in 9 percent; and to other causes in
8 percent.
In 98 cases attempts at both forceps and version operations were
made. These included: Forceps and version, 64 cases; dilatation of
the cervix, forceps, and version, 21 cases; forceps, version, and manual
removal of the placenta, 10 cases; and 3 cases in which all four opera
tions were performed. In 8 of the 24 cases with artificial dilatation
of the cervix labor had already begun spontaneously. According to
the final method of delivery these 98 cases may be classified as follows:
The delivery in 51 cases was completed by version after forceps had
failed; 25 women were delivered by version with forceps on after
coming head; there were 5 cases in which forceps had failed and the
delivery was completed by version with forceps on after-coming head;
5 women were delivered by forceps after attempts at version had
failed; there were also 5 cases in which attempts at version and forceps
delivery both failed and the women died undelivered. Seven women
who were delivered of twins each had one baby delivered by version
and one by forceps.
Of these 98 deaths 32 percent were attributed, according to the
international classification, to puerperal septicemia; 20 percent, to
puerperal albuminuria and convulsions; 12 percent, to placenta
previa; 12 percent, to other puerperal hemorrhage; 18 percent, to
other accidents of labor; 4 percent, to phlegmasia alba dolens; and
1 percent, to accidents of pregnancy.
Other attempts at forceps or version or both were made in 44 cases
of women finally delivered by Cesarean section and in 46 cases of
women finally delivered by craniotomy.
Version 2 was the principal operation for delivery in 520 cases
besides the 98 just mentioned in which forceps was used in combination
with version; or in a total of 618 cases— 12 percent of all cases of
women who died after reaching the last trimester and 28 percent of
those who had operative deliveries in this period. In 224 of the 520
cases version followed artificial dilatation of the cervix (manually, by
bag, or by some other method); in 26 cases it was followed by manual
removal of the placenta, in 48 cases it was accompanied by both these
operations, and in 4 cases it was accompanied by some other opera
tion or combination of operations. Therefore in a total of 272 cases
version was preceded by dilatation of the cervix. Eighty-four of
these were cases in which labor had begun spontaneously but the
dilatation of the cervix was assisted artificially to facilitate delivery ;
in 172 cases the dilatation was done to induce labor as well as to
2Version throughout the report refers to internal podalie version. The very small number of cephalic
versions that were done were included with other combinations. External versions were not considered
operations.
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OPERATIONS
69
facilitate delivery; in 3 cases labor had been induced medically; and
in 13 cases it was not reported whether the onset of labor was spon
taneous or artificial.
Six of the 520 women died undelivered after attempts at version
had failed. These were in addition to the five women previously
mentioned for whom attempts at version and at forceps delivery had
both failed.
.
.
Of these 520 deaths 32 percent were attributed to placenta previa
and 10 percent to other puerperal hemorrhage; 28 percent to puerperal
albuminuria and convulsions; 19 percent to puerperal septicemia,
2 percent to phlegmasia alba dolens; and 9 percent to other puerperal
causes.
In addition to the cases already mentioned, the cervix was dilated
manually, by bag, or by other artificial means in 112 cases. Eightynine women later delivered spontaneously, but 23 women died unde
livered without attempts at other operations. Four of those who
delivered spontaneously also had manual removal of the placenta.
In 29 of these 112 cases labor had already begun spontaneously, and
in 1 case labor had been induced medically, the dilatation being used
to facilitate the delivery.
Eighty-seven women, in addition to the four just mentioned, had
manual removal of the placenta after spontaneous labor and delivery.
Sixty-five women were delivered by breech extraction, alone or pre
ceded by artificial dilatation of the cervix or followed by manual
removal of the placenta. Seven of these had had labor induced
operatively and one medically; 55 had gone into labor spontaneously;
and for 2 the type of onset of labor was not reported.
Fiftv-seven women were delivered by craniotomy or embryotomy,
usually after attempts at other operations had failed; 2 of these had
had labor induced, 1 operatively and 1 medically; the onset of labor
in the other cases had been spontaneous.
Eight women with abdominal pregnancies were delivered by lapa
rotomy in the last trimester. (See Ectopic Gestation, p. 172.)
Twelve women had had some other operation and eight had had
some other combination of operations directed toward delivery; nine
women had had some operation for delivery, but its type was not
reported.
.
For 133 women no report could be obtamed as to whether or not
there had been an operative delivery. (For type of operation for
delivery by cause of death see appendix table X I, p. 196.)
Type of operative delivery and parity and age
The deaths of 57 percent of the known primiparae and 41 percent
of the known multiparae who had reached the last trimester were
preceded by operative deliveries. The relation of operations for
delivery to number of pregnancies is shown in appendix table X II
(p. 198). Cesarean sections decreased from 17 percent for primiparae,
through 12 percent for secundiparae, to 8 percent for triparae.
The percentage of deaths preceded by version and version combi
nations increased from 10 percent for women in their first pregnancy
to 16 percent for those with five pregnancies. It decreased slightly
for the sixth and seventh pregnancies and rose again to 21 percent
of those dying as a result of eight or more pregnancies. Dilatation
of the cervix preceding versions was also more common in the later
than in the earlier pregnancies.
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MATERNAL MORTALITY IN FIFTEEN STATES
The frequency of forceps operations (exclusive of forceps with
version) dropped rapidly from 24 percent for primiparae to 11 percent
for women in the second pregnancy, 9 percent for women in the third,
and 8 percent for women in the fourth pregnancy. There were some
variations in the frequency after the fourth pregnancy, but the changes
were slight and not significant.
Five percent of the women who died after seven or fewer pregnancies
were reported to have had manual removal of the placenta, either
alone or in combination with some other operation, compared with
8 percent of the women who had had eight or more pregnancies.
No significant trends were found for any of the other operations
of which there were sufficient numbers to warrant statistical
consideration.
Percent distribution of 'principal operations for delivery performed on
primiparae and multiparae of each age period dying from puerperal causes who
had reached the last trimester of pregnancy
T able 39.
Primiparae
------ Principal operation for delivery
Total
Under
20
years
20
.25
years,
under
30
years,
under
25
30
years,
under
35
35
years
and
over
Percent distribution
Total___________^________
100
100
100
100
100
100
No operation for delivery_______
Forceps (without version)______
Cesarean section_______________
V ersion......................................
Dilatation of cervix only________
Manual removal of placenta only.
Craniotomy or embryotomy........
Breech extraction_____ ____ ____
Other operations_______________
Type not reported_____________
43
24
17
50
24
13
49
31
29
18
14
31
23
32
21
10
2
2
1
1
8
2
1
1
1
1
(9
(9
22
14
8
2
2
2
1
2
2
1
1
1
0) .
0)
8
27
34
1
1
1
1
3
2
1
1
Multiparae
Principal operation for delivery
Total
Under
20
years
20
years,
under
25
25
years,
under
30
30
years,
under
35
35
years,
under
40
40
years,
under
45
45
years
and
over
Percent distribution
Total.............. 1...... .........
No operation for delivery_______
Forceps (without version)______
Cesarean section_______________
Version..................... ............... .
Dilatation of cervix only________
Manual removal of placenta only.
Craniotomy or embryotomy.___
Breech extraction_______ _______
Other operations_______ _______
Type not reported____ ____ ____
100
100
100
100
100
100
100
100
59
71
54
15
63
9
7
14
57
3
7
67
9
16
4
16
54
a
9
18
3
11
2
21
2
10
8
2
2
1
2
1
(9
8
8
1
1
6
10
2
2
1
2
2
1
2
1
1
1
(9
10
8
h
10
2
2
2
2
1
1
1
2
1
2
1
1
1
2
a
(9
1 Less than 1 percent.
The incidence of operations for delivery increased with age both
for primiparae and for multiparae (table 39). Among primiparae
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OPERATIONS
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there was a definite increase with age for Cesarean sections. Among
multiparae there was a definite increase with age for versions, forceps,
and Cesarean sections. The fact that the older multiparae had usually
had more children probably influenced the choice of operation.
Hours in labor of primiparae and multiparae
The length of time that primiparae and multiparae who had
reached the third trimester and whose deaths were preceded by tl^e
various obstetric operations had been in labor is given in table 40.
A study of this table shows that in many cases operative interfer
ence was done after very short labor. On primiparous women who
died after reaching the third trimester, 59 forceps operations were
done when labor had been established less than 6 hours, and 93 when
labor had been in progress between 6 and 12 hours. Podalic version
and extraction was done 49 times in cases of primiparae with labor of
less than 6 hours, and in 31 cases with labor of 6 to 12 hours. On
multiparous women 93 forceps operations were done when labor
had been established- less than 6 hours, and 66 when labor had lasted
between 6 and 12 hours. On multiparous women podalic version and
extraction was done 196 times where labor had not been established
for as long as 6 hours. In 137 of these 196 cases the cervix was said
to have been dilated manually or by other mechanical means. Many
of these women were in convulsions or bleeding. Operative pro
cedure aimed at delivery would seem to have been instituted prematurelv in some cases.
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T able 40.
Hours in labor and type of principal operation for delivery performed on primiparae and multiparae dying from puerperal causes
who had reached the last trimester of pregnancy
■<1
to
Women dying from puerperal causes who had reached last trimester
Hours in labor
Primiparae
Total
Less
Total None 1 than
61
T o ta l,................ ...................
4,965
1,746
Forceps (without version)............. .
With dilatation of cervix..........
Cesarean section___ ____ ________
Version...................... ........... ...........
With dilatation of cervix_____
Dilatation of cervix only__ _______
Manual removal of placenta only. .
Craniotomy or embryotomy______
Breech extraction2_______________
Other operation 3...... ........ .............
Type not reported...........................
No operation for delivery_________
No report on operation for delivery
718
408
531
618
292
164
m
m
108
87
57
65
32
9
2,607
133
204
6, less 12, less 24, less
than
12
373
133
37
26
22
15
7
67
306
27
23
5
3
9
7
2
n
747
27
than
24
than
36
36
Less
and Not re Total None 1 than
more
61
263
111
12
86
1
Multiparae
207
123
1
1
1
163
26
3,041
301
76
234
445
218
70
60
35
48
25
4
1,757
62
229
116
5
6, less 12, less 24, less
Parity
not re36
and Not re- ported
more ported
than
than
24
than
36
1,170
538
282
90
151
581
178
93
43
23
196
137
34
35
66
59
10
24
56
16
23
A
13
27
11
3
32
6
31
39
9
3
28
s
13
59
22
9
9
U
4
12
8
14
68
U
13
8
6
2
5
15
9
12
4
10
1
5
i
i
103
764
345
114
Ì7
1
7
1
1 ...........
5
9
4
1
14
1
1
2
1
3
6
2
25
389
57
103
44
2
6
1 In the column “ Less than 6:oia r e ?°“ e- <? f es irLwhi<Lh thei e was,a rapid dilatation of the cervix on a patient in whom labor had not begun. In other words the labor
__ _______
=______
|_____J
_____...v
„ equal accuracy in the .........
in some of these cases was artificial.
These
cases
might
perhaps
have ____I
been
placed
with
column “ None.” The few uuoiauuus
dilatations m
in the
None”
column werev
werp^
induce
lahor
hut labor
lahnr
H
iH
nnt eat
__.
me “ in
one column
cases in which an attempt was
was made
made to
to induce
labor' hv
by hasbag nr
o f hnmrio
bougie, but
did
not"seiTinbefore
the patient'died
2Includes 17 with dilatation of cervix.
3Includes 9 with dilatation of cervix.
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Type of principal operation for delivery
73
OPERATIONS
Live births and stillbirths in forceps -and in version cases
The numbers of live births and stillbirths were reported for 684 cases
of forceps operations alone and with dilatation of the cervix or manual
removal of the placenta or both (exclusive of versions). Of these
56 percent resulted in live births, 43 percent in stillbirths, and 1 per
cent in 1 live birth and 1 stillbirth. Of the 511 cases of versions alone
or with dilatation of the cervix or manual removal of the placenta, or
both (exclusive of versions with forceps) for which there was a report
on the result of pregnancy, 35 percent terminated in live births, 63
percent in stillbirths, and 1 percent in one of each. The proportions
of live births and stillbirths were undoubtedly very greatly influenced
by the conditions primarily responsible for the death of the mother.
Technique o f physician
The technique of the operating physician, as regards asepsis, is
shown in table 41. However, in 166 cases of women who had opera41.— Type of principal operation for delivery and technique of physician
performing final operation on women dying from puerperal causes who had an
operation for delivery in the last trimester of pregnancy
T able
Women dying from puerperal causes who had operation
for delivery in last trimester
Technique of physician reported
Aseptic
Percent 1 |
Total
Number
1 Percent 1
Number
275
13
450
21
89
4
83
43
59
97
89
40
76
27
15
14
181
52
36
27
28 . 6
200
469
62
218
18
4
7
400
108
87
57
65
61
29
19
9
393
103
67
55
61
18
230
76
18
34
30
59
74
27
62
49
64
16
21
18
5
13
9
9
19
16
15
81
17
25
9
19
3
11
16
5
5
20
12
4
2
210
9
11
12
7
. . . .
|Number
62
215
115
450
65
84
Number
518
Tech
nique
of
phy
sician
not
re
port
ed
500
196
462
62
Total_____________ ____ _______ *____ 2,225 2,142 1,328
Forceps only____________________ _______ Forceps and other operation (except version)
Cesarean section only.......... ..........................
Cesarean section following other operation..
Version only.____________ _______ _____ _
Version and other operation (including for
ceps).............................................................
Dilatation of cervix_______________ _______
Manual removal of placenta_____________ _
Craniotomy or embryotomy..........................
Breech extraction_________ ______________
Other single operations..................................
Other operations of more than 1 ty p e ..........
Type of operation not reported____ ____ _
Dirty
1 Percent 1
Total
At- / Clean,
not
tempted
sterile
aseptic
11
2
7 11
46 22
10 10
1
1
1
—
1
1
17
37
16
31
1 Percent 1
Type of principal operation for delivery
2 1
1 (2)
3
3
2
2
_
8
7
5
20
2
4
2
1
5
•Not shown where number of cases was less than 50.
8Less than 1 percent.
tive deliveries the physician was preceded by a midwife or by some
other nonmedical attendant who may have made vaginal examina
tions. In other cases he was preceded by another physician whose
technique was not so careful as his own.
The term “ aseptic” , which describes the technique of the principal
physician in 1,328 cases, is used to indicate the usual good hospital
delivery or operating-room technique, without the occurrence of
reported breaks. The wearing of masks in the delivery room 3 was
not inquired into and so is not implied in the term. The term “ at8Although the use of masks in the delivery room is now considered an essential in aseptic technique it
was very uncommon at the time of the study, and an inquiry on this point was therefore not included in the
schedule.
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74
MATERNAL MORTALITY IN FIFTEEN STATES
tempted aseptic” , which describes 275 cases, indicates the same
general technique carried out either with known breaks or under
conditions in which breaks would have been very likely; “ clean, not
sterile” , describing 450 cases, denotes ordinary cleanliness but no
claim to asepsis; and “ dirty” , describing 89 cases, indicates usually
no preparation of the patient and sometimes no preparation even of
the physician’s hands. It is very probable that there were more
breaks in aseptic technique than are shown, especially as the physi
cian’s usual custom was given in some instances in which he did not
remember his exact technique in a particular case.
Of the 1,087 operative cases in which satisfactory technique had
been used throughout the delivery, death was due to puerperal
septicemia in 218 cases (20 percent); of the 1,086 operative cases in
which an unsatisfactory technique was known to have been used at
some stage, death was due to puerperal septicemia in 337 cases
(31 percent).
Onset and termination of labor
The more important of the operations of the last trimester of preg
nancy intended to effect or to assist delivery may be grouped as
bringing about an artificial onset or an artificial termination of labor.
Cesarean section on women not in labor was arbitrarily classified as
artificial onset as well as artificial termination of labor (tables 42 and
43).
By operative onset of labor is meant operative induction; by medi
cal onset is meant induction by the use of drugs alone.
Artificial onset and artificial termination of labor were more fre-?
quent among the white than, among the colored women who died.
Not only did a larger proportion of colored women die undelivered,
but a larger proportion died before the onset of labor. Appendix
tablesX III and X IV (pp. 199,202) show the method of onset and termi
nation of labor among women dying of the various causes classified
according to the international list. These findings are discussed in
the sections on the various causes of death.
T able
42.— Onset of labor among white and colored women dying from puerperal
causes who had reached the last trimester of pregnancy
Women dying from puerperal causes who had reached last
trimester
Onset of labor
Total
White
Colored
Percent
Percent
Percent
Number distribu- Number distribu- Number distribution
tion
tion
Total....................................................
4,965
4,027
938
Onset of labor reported_____ _________ . . .
4, 766
100
3,879
100
887
100
Spontaneous..................... .....................
Artificial....... .........................................
3,815
687
80
14
3,069
618
79
16
746
69
84
Operative.._______ _____________
Medical..... ................ .....................
Method not reported......................
i 650
81
8
U
1
689
88
1
15
1
61
6
e
7
1
No onset...................................... .........
264
6
192
5
72
Onset of labor not reported______________
199
(?)
(2)
148
i Includes 250 cases of Cesarean section done on women not in labor.
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«
8
3 Less than 1 percent.
8
75
OPERATIONS
T able 43.— Termination of labor among white and colored women dying from
puerperal causes who had reached the last trimester of pregnancy
Women dying from puerperal causes who had reached last
trimester
Termination of labor
Colored
White
Total
Percent
Percent
Percent
Number distribu Number distribu Number distribubution
tion
tion
938
4.027
4.965
4.827
100
3,922
100
905
100
2,425
1,990
412
50
41
9
1,940
1,684
298
49
43
485
306
114
54
34
13
8
33
105
138
1 Includes cases in which there was no issue and in which the delivery was postmortem.
The relation of onset to termination for all the women who died
after reaching the last trimester and for primiparae and multiparae
is shown in table 44.
T able 44.— Onset and termination of labor among primiparae and multiparae
dying from puerperal causes who had reached the last trimester of pregnancy
Womei dying fro m puerper il causes w ho had
reach«ìd last trintester
Terminati Jfi of labor
Onset of labor and parity
Total
Spon
taneous
No ter
Artiflcial mination
Not re
ported
T otal______ _______________________________
4,965
2,425
1,990
412
138
Spontaneous..................................- ..............
Artificial____________________ ....................
3,815
687
2,346
72
1,345
596
115
18
9
Operative................ .............................
650
H
S
58
IS
1
573
21
2
18
1
No report on onset....... ...................... .........
264
199
7
4
45
260
19
128
Primiparae___ _______ _____________________ ______
1,746
686
■ 897
135
29
Spontaneous.......... ................................................
Artificial_______________ . . . _ ........... ...................
1,317
293
662
23
619
263
33
3
Operative__________________ _______ ______
274
16
3
18
4
1
249
12
2
6
1
6
90
90
46
1
1
6
25
Multiparae...................................................................
3,041
1,674
1,065
242
60
Spontaneous.................... ........................... ...........
2,408
389
1,619
49
707
328
77
5
372
17
40
'9
320
8
12
No report on onset------------------------ ------------ -----
150
94
6
Parity not reported.......................................... ............
178
66
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15
4
261
28
12
146
7
55
35
49
76
MATERNAL MORTALITY IN FIFTEEN STATES
Prenatal care in relation to termination of labor.—Oi the 1,990 women
who died following operative termination of labor in the last trimester
of pregnancy there was a report as to prenatal care for 1,879 (856
primiparae, 1,005 multiparae, 18 of parity not reported). Of these,
807 (326 of the primiparae, 468 of the multiparae, and 13 for whom
parity was not reported) are known to have had no prenatal care.
That is, 43 percent of the operative deliveries (38 percent of the oper
ative deliveries of primiparae and 47 percent of the operative deliveries,
of multiparae) were of women whom the physician had not seen before
labor or before the acute emergency. Of the 1,072 women who had
had some prenatal care, a report on pelvic mensuration was made m
982 cases. In 349 (36 percent) of these cases both internal and ex
ternal measurements had been taken (43 percent of the known primi
parae and 29 percent of the known multiparae); in 253 cases (26 per
cent) external measurements only had been taken (31 percent oi the
primiparae and 21 percent of the multiparae); and in 380 cases (39
percent) no measurements had been taken (27 percent of the primi
parae and 50 percent of the multiparae). There was, however, even
less prenatal care, and even less pelvic mensuration included m what
prenatal care was given, among the women who had spontaneous
terminations of pregnancy, both primiparae and multiparae.
Use of pituitrin in relation to termination of labor—The use of pituitrin was known to have preceded operative delivery in 381 cases,
about one fifth of the operative deliveries in connection with which
this information is available. Pituitrin was known to have been used
before delivery in one third of the cases of artificial termination of
labor in which a ruptured or inverted uterus was diagnosed either by
the attending physician or at operation or autopsy.
OPERATIONS OTHER THAN FOR DELIVERY
Some operation other than for the actual delivery of the fetus or
for the immediate delivery of the placenta and membranes was per
formed on 636 women who died after reaching the last trimester.
Of these women 301 had also an operative delivery. In a few in
stances the two types of operations were done at the same time, in
a few cases the “ other” operation, usually for an accidental com
plication, was done before delivery, but in most of the cases the addi
tional operations were done postpartum and were done for conditions
that were thei result of the delivery. The inference is that nearly half
these women had operations for sequelae necessitated by complica
tions arising from or in association with the operative delivery.
At least one blood transfusion was reported given to 219 women who
died after reaching the last trimester. In 62 cases this was apparently
the only operation, in 83 cases it was the only operation in addition
to the operation for delivery, in 4 cases there was no report as to
whether or not there had been an operative delivery; m the other
cases there had also been some such operation as curettage, incision
and drainage for infection, packing of the uterus, or enterostomy,
following in some cases an operative and in other cases a normal
delivery. The blood transfusion was more often done on account of
anemia resulting from hemorrhage, but in a number of cases it was
done for sepsis. Most of the deaths, however, were due to sepsis.
Packing of the uterus or the cervix was done in 138 cases, usually
of women who died of puerperal hemorrhage. In 73 cases packing
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OPERATIONS
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followed an operative delivery, and in 65 cases a normal delivery;
in 14 of the former and in 3 of the latter cases some other operation
also had been performed. This was most often a blood transfusion.
Curettage was done in 109 cases, usually of women who died from
sepsis. It followed an operative delivery in 22 cases and a normal
delivery in 82 cases; in 5 cases the type of delivery was not reported.
In 16 cases there had also been blood transfusions, and in 11 cases
(including 2 of the 16) there had been some other operation for
sequelae of the confinement in addition to the curettage. Curettage
had apparently been done after the onset of sepsis in 92 of the
100 cases of women who had curettage and who died of puerperal
septicemia.
Incision and drainage for infection was the only operation performed
on 35 women with spontaneous deliveries and the only operation
other than for delivery performed on 10 who had had operative
delivery. This operation was usually a pelvic puncture, but incisions
of abscesses are also included here. In 21 other cases this operation
was performed in addition to blood transfusion; in some of these
cases another operation also was performed. In 8 of these 21 cases
there had been an operative and in 11 a normal delivery; in 2 cases
there was no report as to the type of delivery.
Laparotomy for drainage of peritonitis was done in 32 cases.
Fifteen of these 32 had had operative deliveries, 13 had not, and for
4 the type of delivery was not reported.
Twenty-nine women had salpingectomy or salpingo-oophorectomy,
12 in addition to some other operation. Ten of the 29 (including 6
of the 12) had had operative deliveries, 16 had had normal deliveries,
and for 3 the type of delivery was not reported. Whether the sal
pingectomy would have been necessary if the woman had not been
pregnant was not usually very clear. In 3 cases the interval between
the delivery and the salpingectomy was not reported; but in all
except 5 of the remaining 26 cases the operation was performed less
than 2 months after delivery—usually about a month, or less, after
delivery.
Fourteen women had had appendectomies, 7 antepartum, 4 post
partum, 2 at Cesarean, and 1 at laparotomy for abdominal preg
nancy. Seven of these women had operative, and seven had spon
taneous deliveries. In three cases, including one of the Cesarean
cases, other operative procedures also were undertaken. In some
cases the appendectomy had apparently had little to do with the
death, in other cases it was a factor of greater importance; but in
every case the delivery had apparently had more to do with the
death than the appendectomy. In some cases the appendectomy
was routine; in some cases the appendicitis was apparently an acci
dental complication; in still other cases it was impossible to classify
the interrelationship of the factors involved.
Sixteen women (10 of whom had operative deliveries) had (subse
quent) enterostomy operations. In 5 cases there had been some
other sequelae operation also.
Hysterectomy was done in 34 cases, 16 of which were Porro Cesarean
sections and 6 were done for sepsis, 5 for ruptured uterus, 3 for
amputation of an inverted uterus, and each of the other 4 for a different
condition.
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MATERNAL MORTALITY IN FIFTEEN STATES
In 26 cases laparotomies, other than those mentioned above, were
performed. Some of these were rather extensive operations at which
several things were done; some were exploratory laparotomies at
which no pathologic condition was found.
The other operations include. 10 plastic operations on the perineum
or cervix (repairs of lacerations at delivery were not ordinarily in
cluded) and various other operations, one to three of a kind, including
tracheotomies, thoracotomies, and others.
A few of these operations other than for delivery were for acci
dental complications, but most of them were intended to alleviate
conditions arising from the delivery. Most of the deaths that were
preceded by these operations were from sepsis.
(Appendix table
X V , p. 204, gives operations other than for delivery by cause of
death.)
OPERATIONS IN THE FIRST TW O TRIMESTERS
Nearly all the operative deliveries performed on women who had
not reached the last trimester were classified either as therapeutic
abortions or as laparotomies for ectopic gestation. (See appendix
table X I, p. 196.)
Twenty-four operative deliveries before the seventh month were
not called therapeutic abortions because they were performed very
near the end of the second trimester and because most of them resulted
in live births. They included 6 Cesarean sections, 5 forceps opera
tions (3 after dilatation of the cervix), 4 versions (3 after dilatation of
the cervix), 5 dilatations of the cervix (followed in 4 cases by spon
taneous delivery, in 1 case by death without delivery), and 4 other
operations. Labor was known to have begun spontaneously for 6
of these 24 women, 2 of whom were delivered by forceps, 2 by version,
and 2 by other means.
LAPAROTOM Y FOR ECTOPIC GESTATION
Laparatomy for ectopic pregnancy (see section Ectopic Gestation,
p. 172) had been performed on 195 women who died before reaching
the third trimester. One hundred and seventy of these were done on
women who were in the first and 13 on women who were in the
second trimester; the 12 others were probably done on women who
were in the first trimester or the early part of the second. In 3 cases
abdominal pregnancies of 5 or 6 months were found.
With operation not for delivery
Sixty-five women who had laparotomies for ectopic gestation in the
first two trimesters had also had some other operation, in some cases
performed in connection with the operation for ectopic, in other cases
performed subsequently on account of sequelae of the first operation.
Six women who were operated on for ectopic gestation in the first
two trimesters had hysterectomies done as part of the operation, on
account of interstitial pregnancy, adhesions, fibroid uterus, or a
combination of these conditions. One of these women also had a
blood transfusion; another had had a diagnostic curettage.
In 13 cases the appendix was removed at the time of the operation.
It was not always made clear in the interview whether or not the
appendix was diseased, but in some cases the appendectomy appar
ently had been routine.
Fifteen women had had a curettage before the laparotomy, in some
cases for diagnosis, in other cases because of a mistaken diagnosis of
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OPERATIONS
79
incomplete abortion. Five of these women had also had blood
transfusions.
In all, only 26 of these 195 women who had had laparotomies for
ectopic gestation before the third trimester had also had blood
transfusions.
Six women had incision and drainage for infection, usually posterior
colpotomy; 10 had enterostomies, including 2 who had had appen
dectomies.
The deaths of 52 oi these 195 women were attributed to puerperal
septicemia. The deaths of the other 143 were attributed to ectopic
gestation; in other words, they died of hemorrhage and shock.
THERAPEUTIC ABORTIONS
Of the 205 therapeutic abortions, 84 were performed in the first
trimester, 117 in the second trimester; for the other 4 the trimester
was not reported. (See also Abortions, p. 107.)
Pernicious vomiting was given as the principal indication for 112
of the 205 therapeutic abortions; other toxemias, usually of a convul
sive type, for 52; hemorrhage, placenta previa, or premature separation,
for 14; dead fetus, for 12; and other causes, for 15.
According to the international classification, 94 of these 205 deaths
were attributed to puerperal albuminuria and convulsions (which
includes toxemia of pregnancy), 44 to puerperal septicemia, 32 to
abortion and premature labor, 29 to other accidents of pregnancy,
and 6 to other causes.
In 67 cases it was reported that the therapeutic abortion was done
by means of curettage. Most of the other therapeutic abortions also
were done from below. In 4 cases hysterectomy and in at least 7
cases abdominal hysterotomy was the method used.
Of the 84 cases in which therapeutic abortion in the first trimester
preceded death, the fetus was delivered by means of operation in 69
cases; it was delivered spontaneously (after an operative induction)
in 9 cases; and the patient died before the operation was completed
in 6 cases.
Of the 117 cases of therapeutic abortion in the second trimester the
fetus was delivered by means of operation in 85 cases, was delivered
spontaneously (following induction) in 23 cases, and was not actually
delivered before death in 7 cases; in 2 cases the method of the actual
delivery of the fetus was not stated. (In these last 32 cases the
induction of labor constituted the therapeutic abortion.) In the 4
cases of therapeutic abortion in which the exact period of gestation
was not known the fetus was delivered by some operative means.
With operation not for delivery
Of the 205 women who had therapeutic abortions, 38 had some other
operation as well. Nine women had a curettage subsequent to the
therapeutic abortion (for 4 of them the therapeutic abortion also was
by curettage); two women had blood transfusions in addition to the
curettage. Twelve others also had blood transfusions, two of them
with postpartum packing of the uterus. One other woman had post
partum packing of the uterus. Fourteen women had laparotomies
subsequent to the therapeutic abortion, and two women had other
operations. Most of these additional operations were for sequelae.
Sepsis caused the deaths of most of these 38 women.
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MATERNAL MORTALITY IN FIFTEEN STATES
OPERATIONS NOT FOR DELIVERY ON W OMEN WHO HAD NO OPERATION FOR
DELIVERY
At least one curettage had been done on 585 women who had had
abortions other than therapeutic, or unoperated ectopic gestation.4
(This does not include any criminal abortions that may have been
done by curettage. See Abortions, p. 103.) Of these, 361 were in the
first trimester, 112 in the second trimester, and for 112 the exact
period of gestation was not known. Fifty of these 585 women also
had blood transfusions but no other operation; 22 had laparotomy
for drainage of peritonitis, including 3 that had blood transfusions
also; 26 had some other incision and drainage for infection, usually
posterior colpotomy (one of them had blood transfusions also); 23
had packing of the uterus; 3 had both packing of the uterus and
blood transfusion; 24 had had laparotomies other than for drainage
of peritonitis, and 2 had a trachelorrhaphy in addition to the
curettage. The deaths of most of these women were due to sepsis.
Nine women who had had abortions other than therapeutic had
hysterectomies. In 2 cases evidence of preceding pregnancy was
discovered at the pathological examination of the uteri, 1 of which had
been removed for fibroids, the other for “ chronic pelvic inflammation. ” Both these women also had other operations later. Five of
the 9 hysterectomies were performed on patients who had had selfinduced abortions— 2 because the uterus had been punctured, and 3
because of sepsis. One other hysterectomy was performed for
fibroid uterus 6 days after an abortion and one for chronic atrophic
endometritis 4 % months after an abortion. This last death was
attributed to shock; the other eight women died of sepsis.
Fifty-three women who died before reaching the last trimester had
blood transfusions as their only operation. Most of these deaths
were due to sepsis.
Eighty-two who had no operation for delivery and no curettage
had laparotomies other than hysterectomy, including 34 laparotomies
for drainage of peritonitis (4 with blood transfusions also), 13 salpin
gectomies or salpingo-oophorectomies, 7 appendectomies, 8 enter
ostomies, and 20 others. Most of these operations except the appen
dectomies were for sequelae, and most of the deaths were due to sepsis.
Forty-one women had incisions and drainage for infection only and
7 had some other operation in addition; 27 had packing of the uterus
or cervix; 8 had some other operation or other combination of opera
tions; and 5 had some operation the type of which was not reported.
For operations other than for delivery, by cause of death, see
appendix table X V , p. 204.
ONSET AND TERMINATION OF LABOR IN THE FIRST TW O TRIMESTERS
The methods of onset and of termination of labor in the first two
trimesters are given in tables 45, 46, and 47. Induced abortions other
than therapeutic are included in these tables for completeness, al
though they are not considered “ operations” in this report. Women
with ectopic gestation were arbitrarily classified as having no onset
and no termination.
By operative onset of labor is meant operative induction; by medi
cal is meant induction by the use of drugs alone. For onset and
termination of labor, by cause of death, see appendix tables X III and
X IV , pp. 199, 202.
4There were also 1 premature live birth and 1 hydatidiform mole.
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OPERATIONS
T a b l e 4 5 .— O n set a n d ter m in a tio n o f labor a m on g w o m en d y in g fr o m
ca u ses w h o had n o t rea ch ed the last trim ester o f p re g n a n c y
p u erp era l
Women dying from puerperal causes who had not reached last
trimester
Termination of labor
Onset of labor
Artificial
Total
Spon
taneous
Total............ .............................
Total
Induced
abor
tion 1
Other
No ter
mina
tion 8
Not re
ported
2,381
1,005
265
56
209
560
551
598
999
521
419
34
219
8
55
34
164
35
35
326
Operative_____________ ____ ____
729
300
214
61
163
so
186
Induced abortion iT...................
Other........................................
514
215
264
36
51
163
51
163
16
14
183
2
Medical........................... .............__
SO
15
2
1
1
s
10
Induced abortion 1___________
Other..........................................
28
15
1
1
3
9
240
104
S
S
2
131
515
269
65
3
9
1
8
512
5
190
31
82
332
308
11
3
31
69
21
211
69
16
122
69
10
6
122
s
6
2
84
Spontaneous...................................... .....
Artificial______________________ _____
Method not reported 3. .............. .
No onset 8__________________...............
Onset not reported................ ................
2
1
1
3
1
FIRST TR IM E S T E R
Total_________________________
1,299
546
113
Spontaneous.......... ................................
Artificial..................... ............................
273
598
242
266
11
100
Operative__________i ................ .
426
190
97
28
Induced abortion....... ..............
Other___________ _______ ___
341
84
181
9
28
69
28
Medical (induced abortion 1) ........ .
Method not reported (induced
abortion 1) _____________ _______
19
10
1
1
I 64
66
2
2
No onset 8__________________________
Onset not reported________ __________
306
122
2
2
38
17
306
2
80
121
181
48
21
4
SECOND TR IM E STE R
T otal......... ...............................
672
310
133
Spontaneous..... .............. ............ .
Artificial_______________ ___________
244
217
212
82
21
102
11
91
13
Operative.......................„................
187
61
101
n
90
IS
12
Induced abortion 1....... ............
Other________ _____ _________
61
126
35
26
11
5
90
90
10
2
Medical............................................
6
S
1
1
2
Induced abortion 1....................
Other.........................................
4
3
1
1
]
Method not reported3......... ...........
24
18
No onset 8......... ..................... ........
Onset not reported.................................
165
46
3
7
3
6
2
16
1 Other than therapeutic.
8Includes ectopic gestation.
3 All induced abortions except 1 with spontaneous termination.
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11
8
20
1
6
1
162
2
21
82
MATERNAL MORTALITY IN FIFTEEN STATES
T able 45.— Onset and termination of labor among women dying from puerperal
causes who had not reached the last trimester of pregnancy— Continued
Women dying from puerperal causes who had not reached last
trimester
Termination of labor
Onset of labor
Artificial
Total
Spon
taneous
Total
Induced
abor
tion
Other
No ter Not re
mina
ported
tion
FIRST 2 TR IM E STE RS, NOT OTHERW ISE SPECIFIED
Total.---------------------- -------------
19
410
149
Artificial_________________ ____ _____
81
184
67
71
17
Operative..................... ...................
117
49
112
48
5
Method not reported (induced
1
5
2
62
20
44
101
1Other than therapeutic.
6
2
13
195
47
13
4
1
1
16
12
4
1
51
12
12
1
51
1
1
2
4
4
11
95
S
41
44
11
1
89
i Includes ectopic gestation.
T able 46.— Onset of labor among white and colored women dying from puerperal
causes who had not reached the last trimester of pregnancy
Women dying from puerperal causes
who had not reached last trimester
Onset of labor and trimester of pregnancy
Total
White
Colored
Total________________ —
----------------
2,381
2,025
356
First trimester... . . . . ______. ___________
1,299
1,144
155
Spontaneous_______________________
Artificial_______________________ ...
273
598
225
557
48
41
Operative____________ _________
Medical_______________________
Method not reported............... ...
425
19
154
4 O6
17
134
19
2
20
No onset » . . . .............. ...... 1.................
Onset not reported..............................
306
122
266
96
40
26
Second trimester____________ . ___ '______
672
536
136
Spontaneous........................................ .
Artificial_______________ __________
244
217
194
190
50
27
Operativi_____________________
Medical_______________________
Method not reported____ '______
187
6
24
166
5
19
21
No onset L
. ______. . . . . . ____
Onset not reported-.'.-.............4------
165
46
125
27
40
19
First 2 trimesters, not otherwise specified.
4 IO
S45
65
1Includes ectopic gestation.
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5
83
OPERATIONS
T able
47.— Termination of labor among white and colored women dying from
puerperal causes who had not reached the last trimester of pregnancy
Women dying from puerperal causes
who bad not reached last trimester
Termination of labor and trimester of pregnancy
Total
Total_________________________
First trimester............................................
White
Colored
2,381
2,025
356
i,m
um
155
Spontaneous______________________
Artificial........ ......... ............................
No termination1__________________
Termination not reported.............
Second trimester............. ............... .........
546
113
332
308
474
108
200
272
72
5
42
36
m
586
186
Spontaneous______________________
Artificial__________________________
No termination1________________ ...
Termination not reported__________
310
133
181
48
248
116
137
35
62
17
44
13
First 2 trimesters, not otherwise specified
410
845
66
1 Includes ectopic gestation.
INCIDENCE OF OPERATIVE DELIVERIES
The deaths of white women were more often preceded by operative
delivery than those of colored women, and death was more often
preceded by an operative delivery in the urban than in the rural
districts. This is shown in table 48. The differences in urban and
rural areas are chiefly in laparotonfy for ectopic gestation and Cesa
rean section, there being more in urban than in rural areas. Among
white and colored women the differences are chiefly in therapeutic
abortion, Cesarean section, and forceps operations.
C H A R T V I .— O P E R A T I O N S F O R
D E L I V E R Y IN T H E L A S T T R I M E S T E R O F
P R E G N A N C Y A M O N G W O M EN D Y IN G FR O M P U E R P E R A L C A U S E S
P ercen t
0
20
40
60
80
100
m
T o ta l
Urban
Rural
'//a &m
W h ite
C olored .
'//mm
F orceps
f>Vl V ersion
kvn
O ther o p e ra tio n s
Cesarean s e c tio n
I
I None
The proportion of the maternal deaths that were preceded by opera
tions for delivery varied in the different States. Some operation for
delivery preceded 50 percent of the maternal deaths in New Hamn182748—34----- 7
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MATERNAL MORTALITY IN FIFTEEN STATES
shire but only 27 percent of those in Oklahoma. In Nebraska 39
percent of the deaths were preceded by an operation for delivery; in
7 States there were more, and in 7 States less, than this percentage
(table 49). The percentage of operative deliveries in the last trimes
ter ranged from 34 in Alabama to 57 in California and Wisconsin. (For
incidence of specific operations among women who died in the differ
ent States see appendix table X V I, p. 206.)
Whether the incidence of the various operations among this group
of women who died was greater or less than the incidence of operations
among women who lived cannot be determined. If these figures are
to be compared with other figures on operative incidence, such as
those in hospitals or in the practice of individual physicians, for
instance, the percentages based on the women who had reached the
last trimester of pregnancy should probably be used.
T able 48.— Trimester of 'pregnancy and type of principal operation for delivery
performed on white and colored women dying from puerperal causes in urban and
rural areas
TOTAL
Women dying from puerperal causes
Trimester of pregnancy and principal operation for
delivery
Total
In urban areas
In rural areas
Percent Num Percent
Num Percent
distri Num
distri
distri
ber
ber
ber
bution
bution
bution
7,380
3,462
1,299
739
3,918
560
Report on operation for delivery________________
1,298
100
738
100
560
100
No operation................. .....................................
Operation.................................................... ........
1,044
254
80
20
576
162
78
22
468
92
84
16
Laparotomy for ectopic gestation.......... .
Therapeutic abortion..................................
170
84
13
6
120
42
16
6
50
42
9
8
No report on operation....... ........................... ..........
1
1
672
332
340
Report on operation for delivery..............................
668
100
332
100
336
100
No operation_____________________ ____ ____
Operation............................ ............. .................
614
154
77
28
252
80
76
24
262
U
78
22
Laparotomy for ectopic gestation..... ..........
Therapeutic abortion...................................
Cesarean section_____________ _____ ____
Other operation________________________
13
117
6
18
2
18
1
3
9
58
5
8
3
17
2
2
4
59
1
10
No report on operation...........................................
4
First two trimesters, not otherwise specified.................
Last trimester_________ __________________ _______ _
410
4,965
Report on operation for delivery..............................
4,832
100
2,087
100
2,745
100
No operation..................................................... .
Operation..................................... ........... ...........
2,607
2,226
64
46
936
1,162
45
55
1,672
1,078
61
89
Laparotomy for ectopic gestation...............
C esarean section..........................................
Craniotomy or em bryotom y.....................
Podalic version____ ____ _____ __________
Forceps (other than version)................. .
Other operation........................¡...................
8
531
57
618
718
293
No report on operation................. ........ ................
Trimester of pregnancy not reported............................
1Less than 1 percent.
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1
18
0
3
4
236
2,148
(0
11
1
13
15
6
3
358
31
281
332
147
174
2,817
0)
17
1
13
16
7
5
173
26
337
386
146
133
61
72
34
7
27
(0
6
1
12
14
5
85
OPERATIONS
T able 48.— Trimester of pregnancy and type of principal operation for delivery
performed on white and colored women dying from puerperal causes in urban and
rural areas— Continued
W H ITE
Women dying from puerperal causes
Trimester of pregnancy and principal operation for
delivery
Total
In urban areas
In rural areas
Percenl Num Percent
Num Percent
distri Num
distri
distri
ber
ber
ber
bution
bution
bution
Total___ ______ _____ _______ ________________
6,072
First trimester..................................... ............................
1,144
Report onJoperation for delivery________________
3,121
2,951
665
479
1,143
100
664
100
479
100
No operation_________________________ _____
Operation................. ...........................................
909
£84
80
£0
618
161
77
£8
396
88
88
17
Laparotomy for ectopic gestation________
Therapeutic abortion________ ___________
154
80
13
7
109
42
16
6
45
38
9
8
No report on operation_________________________
1
Second trimester........................ .....................................
536
Report on operation for delivery................ . ...........
535
100
271
100
264
100
No operation................................ .......................
Operation............................. ...............................
898
187
74
£6
198
78
78
£7
£00
64
76
£4
Laparotomy for ectopic gestation...............
Therapeutic abortion___________________
Cesarean section..................... ............ ........
Other operation______________ _____ ____
10
106
5
16
2
20
1
3
7
55
4
7
3
20
1
. 3
3
51
1
9
No report on operation................. ................. ........
1
First two trimesters, not otherwise specified...............
Last trimester___________________ .'________________
345
4,027
Report on operation for delivery... ......................
1
271
265
(l)
1
19
3
1
207
1,805
138
2,222
3,926
100
1,753
100
2,173
100
No operation__________ ________ ____ _____ _
Operation............................................................
£,040
B£
1,886
48
76£
991
48
67
1,£78
896
69
41
Laparotomy for ectopic gestation________
Cesarean section..........................................
Craniotomy or embryotomy_____________
Podalic version______ ______ ____________
Forceps (other than version).......................
Other operation............................................
6
456
44
514
613
253
(»)
12
1
13
16
6
2
306
23
238
292
130
0)
17
1
14
17
7
4
150
21
276
321
123
N o report on operation______________________
101
52
49
Trimester of pregnancy not reported................... .........
20
3
17
i Less than 1percent.
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0)
7
1
13
15
6
86
T
MATERNAL MORTALITY IN FIFTEEN STATES
48.— Trimester of pregnancy and type of principal operation for delivery
performed on white and colored women dying from puerperal causes m urban and
rural areas— Continued
ab le
COLORED
Women dying from puerperal causes
Trimester of pregnancy and principal operation for
delivery
In urban areas
Total
Num
ber
In rural areas
Percent Num Percent Num Percent
distri
distri
distri
ber
ber
bution
bution
bution
797
1,308
511
155
74
155
100
74
100
81
100
No operation— ......... .......................................
1S5
20
87
IS
68
11
85
15
72
9
89
11
Laparotomy for ectopic gestation------------Therapeutic abortion-----------------------------
16
4
10
3
11
15
5
4
6
5
100
61
100
72
100
q
89
11
62
10
86
14
1
8
1
11
1
1
Report on operation for delivery..............................
133
116
17
Laparotomy for ectopic gestation...............
Therapeutic abortion----------------------------Cesarean section----------------------------------Other operation............................................
75
61
136
Report on operation for delivery—------- ---------------
81
’
87
IS
2
8
3
11
1
1
2
2
7
2
3
1
1
3
5
2
2
3
3
First two trimesters, not otherwise specified--------------
Laparotomy for ectopic gestation...............
Craniotomy or embryotomy.......................
Forceps (other than version)......................
Other operation..............— — .................
Trimester of pregnancy not reported............................
i Less than 1 percent.
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36
595
29
343
65
938
906
100
334
100
572
100
667
SS9
68
87
178
161
62
48
894
178
69
81
2
75
13
104
105
40
0)
8
1
11
12
4
1
52
8
43
40
17
(»)
16
2
13
12
5
1
23
5
61
65
23
32
9
23
14
4
10
M
4
1
11
11
4
87
OPERATIONS
T able 49.— Frequency of operation for delivery among all women who died from
puerperal causes and among those who died after reaching the last trimester of
pregnancy for whom there was a report on operation for delivery; each State in
cluded in the study
Women dying from pu erperal causes for whom
there was a report on operation for delivery
All trimesters
Last trimester
State
Operation
Total
Operation
Num Percent
ber
Total
Num Percent
ber
Total................ ......................................................
7,211
2,649
37
4,832
2,225
46
Alabama............................................................................
California..........................................................................
Kentucky..........................................................................
Maryland......................... ...............................................
Michigan...........................................................................
Minnesota........................................................... .............
Nebraska..........................................................................
New Hampshire.......................... ...... ...............__...........
North Dakota..___________________________________
Oklahoma.........................................................................
Oregon...................v..........................................................
Rhode Island....................................................................
Virginia.......... ........... ................ .....................................
Washington.......................................................................
Wisconsin........................... ................................. .............
1,061
488
638
378
1,284
479
322
108
157
284
176
161
764
310
601
305
210
192
153
473
192
127
54
51
78
70
66
280
114
284
29
43
30
40
37
40
39
50
32
27
40
41
37
37
47
818
305
422
252
783
328
193
78
104
179
96
109
564
164
437
280
174
162
132
387
145
107
42
37
66
51
56
253
83
250
34
57
38
52
49
44
55
54
36
37
53
51
45
51
57
COMMENT BY ADVISORY COMMITTEE
In this series of cases all the women died (and many of the babies),
and, therefore, it is a record of failure. One cannot say that
the operative procedures followed in many cases caused the deaths,
but analysis of these procedures leads to many criticisms of the
management of these cases.
The physicians who delivered these cases cannot be blamed in all
cases for the results obtained, for in 43 percent of the operative
deliveries they had not seen the women before labor or before the
acute emergency had occurred. Under these circumstances it is a
well-recognized fact that the operation of election is not always
possible; the physician many times is forced to do something which
he appreciates may not be the best but which, at the time, seems
justifiable. This shows, from another point of view, the absolute
necessity, if maternal mortality is to be lowered, of insisting upon
continuous prenatal and adequate delivery care.
In a study of this type the physician’s ability to do well the oper
ation he has chosen can be evaluated only by the results, which
show that many of the operations either were badly chosen or were
poorly done. In nearly 40 percent of these operative deliveries it
was admitted by the physicians that their technique was at least
unsatisfactory with regard to asepsis. It is therefore not to^De
wondered at that 26 percent of the deaths following forceps deliver
ies and 19 percent of the deaths following versions were due to
sepsis. Had those women whose deaths were assigned to eclampsia
and placenta previa lived longer, many of them also would prob
ably have died of sepsis. An operative delivery is a surgical pro
cedure and should not be undertaken by physicians untrained in
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MATERNAL MORTALITY IN FIFTEEN STATES
surgical technique. It is evident that many of these physicians did
not have such training.
Many of these patients were operated upon after very little or no
labor, and this explains the frequency of artificial dilatation of the
cervix in both forceps and version deliveries. The number of cases
in which manual dilatation of the cervix, forceps or version, and
manual removal of the placenta occurred, or forceps failed and ver
sion was done, was deplorably large. From this it is evident that
accouchement forcé was resorted to many times, and accouchement
forcé is not regarded as good obstetrics today; it gives bad results
and should not be performed.
That attempts at delivery by vagina were followed by Cesarean
section in 62 cases is to be noted and condemned. (For further com
ment on the Cesarean sections done in this series see p. 98.)
That 57 women died following delivery by craniotomy or em
bryotomy shows clearly the lack of care these women had.
The frequency with which a curettage was done on women who had
developed sepsis is surprising, for such treatment has long been
condemned. Secondary operations for various conditions, usually
of a septic nature, were much too common.
Most of the operative deliveries in the first two trimesters were
classified either as therapeutic abortions or as laparotomies for ectopic
pregnancy. The main comment on the deaths occurring from these
two conditions is made in their respective sections, but a few com
ments may be made here. The removal of the appendix at the time
of operation for an ectopic gestation is not good surgery. The fact
that of the 195 women who had had a laparotomy for ectopic gesta
tion only 26 had transfusion is to be noted. It must be recognized
that preparation to transfuse is almost as essential as operation in
ectopic pregnancy. That 52 women died of sepsis shows clearly
how perfect one’s technique should be if sepsis is to be avoided.
It is to be expected that the operative incidence would be higher
in a group of fatal cases such as those included in the present study
than among women who survived. Without having all the data for
all areas studied it would be difficult to draw too many absolute
conclusions. Necessarily the more serious operations would make up
a higher percentage in a mortality study than the less dangerous
operations.
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CESAREAN SECTION
Cesarean section— that is, an abdominal operation to remove a
viable fetus through a uterine incision— preceded 537 (7 percent) of
the 7,211 deaths of women for whom information concerning opera
tion for delivery was obtained. In nearly every case the operation
performed was of the classical type. The Cesarean sections included
6 on women who had not reached the last trimester, which resulted
in live births. Abdominal hysterotomies before the time of viability
were classified as therapeutic abortions. (See p. 79.) The 531 deaths
following Cesarean section in the last trimester of pregnancy con
stituted 11 percent of the 4,832 deaths among women who had
reached this period and for whom information as to operation for
delivery was obtained, and 24 percent of the 2,216 deaths of women
who had reached this period and who had had an operation for
delivery, the type of which was reported.
CAUSE OF DEATH
For these women who died following Cesarean section the number
of deaths from each cause as given on interview by the attendant
physicians was as follows according to the international classifica
tion: Accidents of pregnancy, 3; puerperal hemorrhage, 42; other
accidents of labor, 146 (including Cesarean section, 136); puerperal
septicemia, 143; puerperal albuminuria and convulsions, 202. One
death, that of a patient who had apparently entirely recovered from
her operation before she died of embolism, was attributed to puerperal
phlegmasia alba dolens, embolus, sudden death. The 136 deaths
attributed to Cesarean section include deaths said to have been due
to shock, embolism, ileus, pneumonia, or similar complications fol
lowing Cesarean section, or to chronic cardiac or nephritic disease and
Cesarean section. (For the opinion of the consulting committee as
to the immediate causes of the deaths following Cesarean section,
see table 56 and p. 100.)
INDICATIONS FOR OPERATION
The indications given by the attending physician for Cesarean
sections are shown in the accompanying fist. Combinations of indi
cations were frequent; ip one fourth of the cases more than one
indication was given. Eclampsia, the most frequent indication, was
given alone or in combination in 165 cases. Contracted pelvis was
reported as the indication in 107 cases, in all but 28 of which it was
one of a combination. This probably does not represent the true
number of women with contracted pelvis in the group. In some of
the 61 cases in which the principal indication was given as dispro
portion or long or difficult labor the reason for the dystocia was
probably a contracted pelvis. On the other hand, not all the diag
noses of contracted pelvis were made by means of internal and
89
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MATERNAL MORTALITY IN FIFTEEN STATES
external pelvic mensuration. Preeclamptic toxemia was given as
the indication in 47 cases, uremia in 27, and placenta previa in 38.
Twenty-five of these 537 women are known to have had previous
Cesarean sections, but this was given as the sole indication in only 6
cases and as the principal indication in 17. One of the women who
had ruptured uterus as an indication and another who had ruptured
uterus discovered at operation had had previous Cesarean sections.
The principal indications for Cesarean sections among the urban
and rural and the white and colored women are shown in table 50.
Indication for operation as given by attending physician
Women who
died following
Cesarean section
Total__________________ _____ _________________________________
537
Toxic conditions_____________________________________________________
239
Eclampsia_________________________________________ :_____________165
Alone__ ______________________________________________
156
With contracted pelvis_____________________________
2
With abnormal presentation (breech)________________________ ,
1
With disproportion__________________________
2
2
With long or difficult labor__________________________________
In elderly primipara__________________________________
1
1
With lobar pneumonia________
Preeclampsia____________________________________________________
47
Alone_______________________________
With contracted pelvis______________
With abnormal presentation (breech)________________________
With disproportion (overdue)________
With long labor_____________________________________________
In elderly primipara________________________________________
Overdue____________________________________________________
With myocarditis (had previous Cesarean)---------------------------With chronic endocarditis___________________________________
With fibroids-----------------------
30
7
1
1
3
1
1
1
1
1
Uremia__________________________________
Alone (includes 1 with previous Cesarean)___________________
With contracted pelvis (had previous Cesarean)_____________
With contracted pelvis and for sterilization__________________
In elderly primipara__________________ - _____________________
27
24
1
1
1
Conditions associated with hemorrhage_______________________________
62
Placenta previa__________________________________________________
38
Alone____________________________________________________
With chronic nephritis_______________________________________
With previous Cesarean and heart lesion — -----------------------With contracted pelvis-----------------In elderly primipara_________________________________________
With lobar pneumonia__________________________________
32
1
1
2
1
1
Premature separation of placenta (includes 3 with previous
Cesarean)_____________________________________________________
Ruptured uterus (includes 1 with previous Cesarean)_____________
15
9
Previous Cesarean section____________________________________ _______
Alone____ _______________________________
With contracted pelvis___________________________________________
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11
91
CESAREAN SECTION
Indication for operation as given by attending physician
Women who
died following
Cesarean section
Absolute and relative disproportion------------- ----------------------------- ------Contracted pelvis________________________________________ ■_______
Alone_____________________________________ ________________
With abnormal presentation (1 brow, 2 breech, 2 transverse,
and 2 occipito-posterior position)------------------------- -— ------With abnormal presentation (transverse)in elderly primipara.
With long or difficult labor-------------- ------------ -— .------------- - With long or difficult labor in elderlyprimipara---------------------In elderly primipara_________________________________________
With dry labor______________________________________________
Overdue_________________________ - - ________ ■_______________
With twin pregnancy and myocarditis--------- -----------------------With previous destructive operation. _----------------------------------With previous difficult labor------------------------------------------------With fibroids______________________________
With hyperthyroidism----------------------------------------------Disproportion___________________________________________________
Alone____________________________ _______________ ^ ----- -------With long or difficult labor---------------------------------------------------Overdue----------------------------With previous operative delivery---------------------------------------Long or difficult labor_________________________________
Alone_______________________________________________________
In elderly primipara_________________________________________
144
83
28
7
1
25
1
5
1
2
1
4
6
1
1
17
11
4
1
1
44
36
8
Abnormal presentation________________________ ______________________
Alone (1 face, 1 breech, 4 transverse, 6 posterior position)---------With long or difficult labor (1 brow, 2 face, 5 breech, 7 transverse,
1 fo o t)________________________________________________________
Inf[elderly primipara (4 breech, 1 transverse)--------------------------------
33
12
16
5
Other indication___________________________________- - ________________
39
5
Scarred or rigid cervix__________________ *-------------------------- --------Hydrocephalus__________________________________________________
4
T um or.__________________________________________________________
4
Overdue_________________________________________________________
3
Bicornuate uterus______ _________________________________________
1
Tumor in elderly primipara______________________________________
1
Elderly primipara-------------- ------ --------------------!-----------------------------1
Elderly primipara and Banti’s disease-----------------------------------------1
Previous difficult labor___________________________________________
1
Sterilization__________________________ _ _ . . _-----------------------------1
Previous destructive operation and sterilization.-------------------------1
Prolapsed cord_______________________________ 1------------- ------------1
Cardiac disease__________________________________________________
6
Chorea_________________________
2
Pyelitis______________________
2
Hematuria_________________________________________________
1
Diabetes_________________________________________________________
1
Postoperative intestinal obstruction__________________________________1
Mother’s condition hopeless— “ to save child” ---------------------- i-----2
Not reported_________________________________________________________
3
A toxic condition was the principal indication for 239 (45 percent)
of all the Cesarean sections; 151 (42 percent) of those performed on
women who died in the urban areas and 88 (51 percent) of those who
died in the rural areas; in 200 (44 percent) of the white and in 39
(51 percent) of the colored cases. Conditions associated with hemor
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MATERNAL MORTALITY IN FIFTEEN^ STATES
rhage gave the indication in a larger proportion of the cases of white
than of colored women. Absolute or relative disproportion was the
indication in a larger proportion of the cases of urban than of rural
women and in a larger proportion of the cases of colored than of
white women.
T able 50.— Principal indication for Cesarean section among white and colored
women and women in urban and rural areas who died following Cesarean section
Women who died following Cesarean section
Inurban areas In rural areas
Colored
White
Total
Principal indication for Cesarean section
PerPerPerPerPerNum cent
Num cent
Num cent
Num cent
Num cent
disdisdisdisdisber tribu- ber tribu- ber tribu- ber tribu- ber tribution
tion
tion
tion
tion
174
363
76
461
Total_________________
537
Report on indication--------------
534
100
458
100
76
100
363
100
171
100
165
47
27
38
31
9
5
7
133
45
22
37
29
10
5
8
32
2
5
1
42
3
7
1
99
37
15
26
27
10
4
7
66
10
12
12
39
6
7
7
15
9
17
28
3
2
3
5
14
7
17
23
3
2
4
5
1
2
1
3
5
7
12
8
16
23
3
2
4
6
3
1
1
5
2
1
1
3
55
33
10
6
44
30
10
7
11
3
14
4
42
21
12
6
13
12
8
7
61
39
11
7
51
35
11
8
10
4
13
5
40
24
11
7
21
15
12
9
Premature separation of
Contracted ' pelvis
and
Abnormal presentation—
Disproportion and long or
3
3
3
1
Among the primiparae a toxic condition was given as the indica
tion for 52 percent of the Cesarean sections, absolute or relative dis
proportion (including long labor) for 31 percent, abnormal presen
tation for 8 percent, conditions associated with hemorrhage for 5
percent, and other indications for 5 percent. A toxic condition was
the indication for 36 percent of the operations among the multiparae,
absolute or relative disproportion for 22 percent, conditions asso
ciated with hemorrhage for 19 percent, previous Cesarean for 7 per
cent, abnormal presentation for 5 percent, other indications for 10
percent. (See table 57,, p. 102.)
PARITY AND AGE
The number and percentage of women who had had various num
bers of pregnancies and whose deaths were preceded by Cesarean
section are given in table 51. Deaths followed Cesarean section in
the cases of 13 percent of the primiparae, 8 percent of the secundiparae, 5 percent of the women who had had 3 to 5 pregnancies, and 4
percent of those who had had 6 or more pregnancies. In primiparae
the proportion of deaths that were preceded by Cesarean section rose
from 10 percent of those under 25 years of age, through 13 percent
of those from 25 to 29, to 23 percent of those from 30 to 34 and of
those 35 and over. When the percentages are based only on those
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CESAREAN SECTION
Number of pregnancies and frequency of Cesarean section among
women for whom there was a report on operation for delivery, who died from
puerperal causes and who died after reaching the last trimester of pregnancy
T a bl e 51.
Women dying from puerperal causes for whom there was a
report on operation for delivery
All trimesters
Number of pregnancies
Last trimester
Cesarean section
Total
Number
Total............................
1......................
3 to 5____________
6 or more....................
Multiparae, number not specified.
Not reported____________
Cesarean section
Total
Percent
Number
Percent
7,211
537
7
4,832
531
11
2,303
907
1,748
1,310
491
452
293
76
96
56
11
5
13
8
5
4
2
1
1,719
619
1,143
1,022
195
134
292
74
95
54
11
5
17
12
8
6
4
who died after reaching the last trimester, it is found that the deaths
of 17 percent of all primiparae and 33 percent of primiparae of 30 or
older were preceded by Cesarean section. Although the deaths of 84
of these women of 30 and over, and of 34 women of 35 and over, were
preceded by Cesarean section, in only 27 cases was elderly primiparity
given as an indication for the operation, usually with some other
indication.
T able 52.- Frequency of Cesarean section in each age period among all primiparae
and multiparae dying from puerperal causes and among those dying after they had
reached the last trimester for whom there was a report on operation for delivery
Women dying from puerperal causes for whom there was a report on
operation for delivery
All women
Age period
Primiparae
Cesarean
section
Total
Num
ber
Multiparae
Cesarean
section
Per
cent
Total
Num Per
ber cent 1
Parity
not re
ported
Cesarean
section
Total
Num
ber
Per
cent
Total_________________
7,211
537
7
2,303
293
13
4,456
239
5
452
Under 20 years______________
20 years, under 25.....................
25 years, under 30.....................
30 years, under 35........1___
35 years, under 40....................
40 years, under 45......... ...........
45 years and over__________
Not reported...................
864
1,506
1,503
1,388
1,272
558
93
27
75
106
100
108
101
45
2
9
7
7
8
8
8
2
733
787
405
217
112
32
4
13
73
82
54
50
23
10
1
10
10
13
23
21
116
618
983
1,074
1,067
2
23
44
58
76
2
4
4
6
7
15
101
115
97
93
11
1
Women dying from puerperal causes who had reached last trimester and
for whom there was a report on operation for delivery
Total........... ................... 4,832
531
u
1,719
292
Under 20 years........................
642
20 years, under 25..................... 1,009
25 years, under 30___________
940
30 years, under 35.....................
874
35 years, under 40_____ _____ _
870
40 years, under 45....... ............
413
45 years and over......................
67
Not reported.................... ......
17
74
105
98
108
100
44
2
12
10
10
12
11
11
3
566
591
299
155
77
22
2
7
72
82
54
50
23
10
1
1 Not shown where number of primiparae was less than 50.
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’
17
2,979
234
8
134
13
14
18
32
30
72
393
616
687
758
2
22
42
58
75
3
6
7
8
10
4
25
25
32
35
9
1
94
MATERNAL MORTALITY IN FIFTEEN STATES
The percentage of the deaths of multiparae in the various age
groups whose deaths were preceded by Cesarean section also increased
with age, as is shown in table 52.
DURATION OF LABOR
The duration of labor was reported for the 495 women dying after
they reached the last trimester of pregnancy whose deaths were
preceded by Cesarean section. Of these, 250 were not in labor at the
time of the operation. The cause of death for 59 percent of these
women not in labor was puerperal albuminuria and convulsions, for
12 percent puerperal hemorrhage, and for 11 percent puerperal
septicemia. Evidently most of the Cesarean sections that were done
on women not in labor were for hemorrhage or eclampsia or pre
eclampsia.
.
. ,
,
,
,,
Of the 245 women in labor at the time of the operation for whom the
number of hours was reported 38 had been in labor less than 6 hours;
35, from 6 to 12 hours; 51, from 12 to 24 hours; 32, from 24 to 36 hours;
and 89, more than 36 hours. With the duration of labor the per
centage of the deaths that were attributed to puerperal septicemia rose
rapidly from 29 percent of those in labor less than 12 hours to 51
percent for those in labor 36 hours or more. But it must be remem
bered that all these women died— and many died in shock so soon after
the operation that they did not have time to develop sepsis. This was
particularly true of those cases in which the Cesarean section was done
on account of eclampsia, placenta previa, or premature separation
of the placenta, and it was in these cases, largely, that Cesarean
sections were done early in labor or on patients not in labor.
RUPTURE OF MEMBRANES
Of the 491 cases in which there was a report on rupture of the
membranes, for women dying after Cesarean section was done in
the last trimester, the bag of waters had not ruptured^ in ^324 cases
(66 percent). The membranes had been ruptured artificially m 34
of the other 167 cases, they had ruptured spontaneously in 109 cases,
and there was no report on this point in 24 cases. Of the 324 women
with unruptured membranes, 15 percent died of puerperal septicemia;
51 percent of albuminuria and convulsions; 10 percent of hemorrhage;
and the rest of other causes. Of the 167 women with ruptured
membranes, 49 percent died of puerperal septicemia; 14 percent of
albuminuria and convulsions; 4 percent of puerperal hemorrhage,
and the rest of other causes.
PLANNED AND EMERGENCY OPERATIONS
Eighty-two of the 537 Cesarean sections were planned) and 452
were emergency operations (i.e., not previously planned); in 3 cases
there was no report on this point. All except 4 of these operations
were done in hospitals or maternity homes; for 1 there was no report
as to hospitalization.
ATTEMPTS AT OTHER OPERATIONS
Cesarean section followed attempts at some other form of operative
delivery in 62 cases. Forty-two of these women were primiparae.
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CESAREAN SECTION
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ATTENDANTS PRECEDING OPERATOR
Of the 531 women who died after Cesarean section in the last
trimester 2 had been attended by osteopaths not listed in the medical
directory, 14 by midwives, and 2 by neighbors before a physician was
— called. In 1 case the Cesarean was done by an osteopath not
listed in the medical directory. In 12 cases an interne or a medical
student was originally in charge of the case; in 1 of the 12 cases the
operation was performed by an interne. In many cases in which the
women had been attended only by physicians the operating surgeon
was a consultant. Sometimes 2 or 3 physicians—in some cases
preceded by a midwife— had been successively in charge before
the operating surgeon.
TECHNIQUE OF OPERATOR
The technique of the operating surgeon was reported as aseptic in
505 cases of women dying after they reached the last trimester; as
attempted aseptic but with known “ breaks” or under conditions that
made actual asepsis unlikely, in 18 cases; as showing no attempt at
asepsis, in 1 case of a moribund woman. In 7 cases there was no
report on the operator’s technique.
Vaginal examinations by the operating physician preceded the
Cesarean section in 254 cases, or 52 percent of the 485 women dying
after they reached the last trimester concerning whom information
was secured. Ninety-six women (20 percent) had had one vaginal
examination, 46 (9 percent) had had two vaginal examinations, 71
(15 percent) had had three or more, and for 41 (8 percent) the number
of examinations was not reported. These were in addition to any
examinations that may have been made by preceding physicians or
midwives. Of the 231 women who had had no vaginal examinations
by the operator, 20 percent died of sepsis, 43 percent of albuminuria
and convulsions, and the rest of other causes. Of the 254 women
who had had vaginal examinations by the operator, 34 percent died
of sepsis, 30 percent of albuminuria and convulsions, and the rest of
other causes.
Of the 512 women who had Cesareans and who had been attended
only by physicians (including internes and medical students) there
was a report on vaginal examinations by the operator for all but 45;
239 had one or more vaginal examinations by the operator, 228 had
none. In 225 of the 239 cases the operator used aseptic technique,
but in 83 of these 225 cases he had been preceded by another physician
with less careful technique. Of these 83 women, 43 percent died of
sepsis, 16 percent of albuminuria and convulsions, the rest of other
causes. Of the 142 cases in which aseptic technique had been used
throughout, 30 percent of the deaths were from sepsis, 37 percent
from albuminuria and convulsions, and the rest from other causes.
In the 211 cases in which there was no vaginal examination at the
time of delivery as far as was known and in which aseptic technique
was thought to have been used throughout, 19 percent of the deaths
were due to sepsis, 44 percent to albuminuria and convulsions, and
the rest to other causes. Of these 211 women 84 had had rectal
examinations (30 percent of these died of sepsis), 101 had had no
rectal examinations (11 percent died of sepsis), and for 26 there was
no report as to rectal examination.
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MATERNAL MORTALITY IN FIFTEEN STATES
LIVE BIRTHS AND STILLBIRTHS
Live-born infants resulted from 393 (74 percent) of these Cesarean
sections; in 1 of the cases there was a live birth and a stillbirth. In
three cases information as to live births or stillbirths was not obtained.
It must be remembered that these live births include all that were"
ahve at time of delivery; data on neonatal mortality were not obtained.
The principal indications for Cesarean section and live births and
stillbirths resulting are shown in table 53. The proportion of live
births to stillbirths was greater for the women who had had previous
Cesarean, contracted pelvis alone, or preeclampsia as the indication
for the operation. The proportion of stillbirths to live births was
highest for those Cesareans for which the indication was premature
separation of the placenta or ruptured uterus.
T able 53.— Principal indication for Cesarean section and result of pregnancy
among women who died following Cesarean section
Women who died following Cesarean section
Result of pregnancy
Principal indication for Cesarean section
Total
Live birth
Stillbirth
Not re
ported
Total.... .................. ..........................................- ...........
537
393
141
3
Eclampsia............................... - ................................................
165
47
27
38
15
9
17
28
55
33
61
39
3
116
» 41
21
25
1
1
16
26
46
21
48
29
2
48
6
6
13
14
8
1
2
9
12
12
10
1
Disproportion and long or difficult labor...............— ...........
1
1
1Includes a plural birth consisting of 1 live birth and 1 stillbirth.
ANESTHESIA
The anesthetic used in operations for the principal indications is
shown in table 54. Type of anesthetic was reported for 480 cases.
Ether was the most common anesthetic. It was used alone in 275
cases (57 percent) and in other cases with nitrous oxide, ethylene,
chloroform, or local anesthesia. It was used alone in 90 (60 percent)
of the 150 cases in which Cesarean sections were done on account of
eclampsia and in which a report on the anesthetic used was obtained.
Nitrous oxide oxygen anesthesia was used alone in 56 cases, with
ether in 62 cases, and in a few cases with local anesthesia. Ethylene
was used in 41 cases, in 1 of these with spinal anesthesia. Chloroform
was used in 14 cases, 7 of which were eclamptic. Local anesthesia
was used in only 19 cases, in 5 of which it was supplemented by
nitrous oxide or ether and in 1 of which it was used with sacral
anesthesia. Spinal anesthesia was used in 8 cases.
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CESAREAN SECTION
T able 54.— Principal indication for Cesarean section and anesthetic used for
women who died following Cesarean section
Women who died following Cesarean section
Report on anesthetic
4®
Principal indication for
Cesarean section
’SS
«
gja
§,§
© ’ S ’S
h3ö °
Total....................
Eclampsia______ ____ ____
Preeclampsia.......................
Uremia__________________
Placenta previa..................
Premature separation of
placenta........ ...................
Ruptured uterus.................
Previous Cesarean..............
Contracted pelvis....... ........
Contracted pelvis and other
indication______________
Abnormal presentation----Disproportion and long or
difficult labor...... .............
Other indication..................
Not reported.......................
537
165
47
27
38
480
150
43
275
57
40
56
22
37
14
8
15
23
49
29
57
33
1 Includes 3 cases in which ethylene and ether were used.
8 Includes 4 cases in which chloroform and ether were used.
* Includes 1 sacral anesthesia.
4 Includes 1 spinal anesthesia with ethylene and 1 with local.
CESAREAN SECTION IN THE INDIVIDUAL STATES AND AMONG URBAN
AND RURAL AND WHITE AND COLORED GROUPS
The percentages of the maternal deaths that were preceded by
Cesarean section in the various States of the study ranged from 1 in
North Dakota to 15 in California. For the deaths of mothers who
had reached the last trimester of pregnancy the percentages*preceded
by Cesarean section ranged from 2 in North Dakota to 24 in Cali
fornia (table 55).
T able 55.— Frequency of Cesarean section among all women who died from puerperal
causes and among those who died after reaching the last trimester of pregnancy for
whom there was a report on operation for delivery; each State included in the study
Women dying from puerperal causes for whom there was a
report on operation for delivery
Last trimester
All trimesters
State
Cesarean section
Cesarean section
Total
Total............................- ..........- .........
Alabama............................................ - ........
California-------------- --------------- ----------Kentucky............................ ..................... —
Maryland--------------- ---------------------- -----Michigan_______ _____ - --------- --------------Minnesota____ ____ - ........- ..........- .............
Nebraska..................... - ........- .....................
New Hampshire_________________ ______
North Dakota........ ..................... ...............
Oklahoma________ _______ - .............- ........
Oregon.........- --------- --------------- --------------Rhode Island............................................ .
Virginia__________ ____ -........... ................
W ashington— ....... - - ........- .........................
W isconsin___- ................ ........................
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7,211
1,061
488
638
378
1,284
479
322
108
157
284
176
161
764
310
601
Total
Number
Percent
537
56
73
26
44
97
19
31
9
2
15
11
9
51
27
67
7
5
15
4
12
8
4
10
8
1
5
6
6
7
9
11
4,832
818
305
422
252
783
328
193
78
104
179
96
109
564
164
437
Number
531
66
72
26
. 43
95
19
31
9
2
15
h
9
49
27
67
Percent
11
7
24
6
17
12
6
16
12
8
11
8
9
16
15
98
MATERNAL MORTALITY IN FIFTEEN STATES
Eleven percent in the urban and 5 percent in the rural districts
were preceded by Cesarean section. For 8 percent of the white and
6 percent of the colored women death was preceded by this operation.
The percentage of urban women whose deaths followed Cesarean
section was the same for white as for colored (11), but among the
rural women it was 5 percent for the white and 3 percent for the
colored.
For those women who died following Cesarean section in the last
trimester and for whom a report on operations was obtained, the
incidence was 17 percent among the urban white, 16 percent among
the urban colored, 7 percent among the rural white, and 4 percent
among the rural colored.
COM M EN T B Y AD VISO RY CO M M ITTEE 1
IN D IC ATIO N S A N D CHOICE OF OPERATION
The schedules for the women who died following Cesarean section
were studied with the attendant circumstances o f the cases in mind,
such as parity, duration of labor, previous attempts at operative
delivery, the condition of the patient at the time of operation, environ
ment, and accessibility o f the case. It is evident from the number o f
women who were reported to have died from sepsis and of those who
probably died from sepsis, that poor selection of cases and unwise
selection of the type o f operation were frequent, as is shown by this
case:
Primipara, aged 19, eclamptic, had been in labor 72 hours. She had probably
had vaginal examinations by midwife before admission to the hospital; the
rfiembranes had been ruptured an indefinite time. A classical Cesarean was
performed» Death resulted in 3 days from streptococcic bloodstream infection
The choice of Cesarean section in cases where the patient has lost a
great deal of blood and is in poor condition is clearly contra-indicated,
as this case shows:
A woman in her fifth pregnancy, four babies having been delivered at term
alive and with no complications. The husband came to engage a physician for
confinement and stated that at that time his wife was having “ a little” discharge
o f mucus and blood. Three days later the physician was called at 4 in the after
noon. The patient had had more than a little bleeding. A vaginal examination
showed a marginal placenta previa. At 6 o’clock that same afternoon the
patient had considerable bleeding, and she was packed by vagina and sent to the
hospital, where she arrived at 1 a.m. The pads were saturated with blood.
The packing was removed and replaced, and 12 hours later a classical Cesarean
was done under ether anesthesia. The fetus was stillborn, and the mother died
45 minutes after the operation.
A transfusion before the operation was rare; but it is easy to see by
study of the individual cases why it probably could not have been
done. But in only a few cases was preparation made to do trans
fusion if it became necessary. This obviously should be done in all
cases of placenta previa.
As would be expected, a considerable number of these operations
were done with pelvic contraction given as the indication. The
measurements often deviated but little from the normal and were
not checked by an internal pelvic examination. Practically none o f
these women had an adequate test of labor.
l The obstetric advisory committee o f the Children’s Bureau has studied and accepted the comment
of one o f its members who reviewed all the schedules on Cesarean section.
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CESAREAN SECTION
99
A primipara, aged 18, had these external measurements o f her pelvis: An
terior-posterior 19 cm, between spines 25 cm, between crests 27 cm, oblique 24
cm, between trochanters “ 52” (?). No internal examination had been made.
The patient had been in labor 2 hours when a Cesarean section was done for which
a contracted pelvis was the indication. The membranes had ruptured at the
beginning o f labor. The temperature o f the woman upon admission to the
hospital was 99; immediately following the operation it was 102. She died 6
days after the operation o f “ acute dilatation of the stomach.”
The following is a case o f an emergency Cesarean in which the
previous history of the patient had not been taken well into con
sideration and she had not been given an adequate test o f labor.
The woman was in her fourth pregnancy. Forceps had been used in 2 o f the 3
previous deliveries, and there had been one stillbirth. In this pregnancy she
was at about the eighth month when the membranes ruptured and 2 days later
a Cesarean was done. The surgeon stated that the indications for Cesarean were
obstructed labor, premature rupture o f the membranes, history o f previous
obstructed labor with delivery o f dead fetus. This patient had had only 6 hours
o f very occasional, weak pains. The external measurements were normal, and
no internal examination o f the pelvis had been made. A classical Cesarean was
done, and the patient died o f sepsis 7 days after the operation.
Difficult labor was often mentioned but was rarely discussed in
relation to the dilatation and effacement of the cervix. Probably
certain of these cases of “ contracted pelvis and difficult labor” were
actually cases of cervical dystocia, or were unrecognized occipitoposterior positions.
The indication “ to save the baby” was given several times. That a
mother with one or more small children at home should die from
Cesarean section done for eclampsia “ to save the baby” does not
seem logical. The following case is an example:
A woman in her fifth pregnancy, aged 24, had four living children. The doctor
stated that the patient was in a deep comatose state at the time o f her operation,
which was done “ to save the baby.” The mother died on the third day.
Undoubtedly this patient was in a very serious condition at the
time of operation and possibly would have died anyway, but it has
long been known that a Cesarean section done on such cases gives
bad results. In the majority of such cases the baby is in a very poor
condition, and the operation is not justifiable.
The number of cases of toxemia that were under observation for
varying lengths of time in which an emergency Cesarean was finally
done was noticeable. Early rupture o f the membranes would
probably have saved some of these lives. The following case comes
in this group:
A woman in her second pregnancy, aged 38, had had a full-term pregnancy
with a living baby. In the present pregnancy she developed a blood pressure of
160/110 in the twenty-fourth week. For this she was treated by diet and rest,
and the symptoms cleared up. In the thirty-eighth week albuminuria and high
blood pressure recurred, convulsions began, and 24 hours later a low cervical
Cesarean was done under local anesthesia.
The number of severe cases of chronic nephritis in which Cesarean
section was seemingly used as an operation of last resort was surpris
ing. Chronic nephritis in multiparous women at or about term would
probably be better treated by induction of labor. Comparatively
few o f the women upon whom the operation was done for chronic
nephritis were sterilized at the time of operation.
A woman with 11 children live-born at term, two miscarriages, no operative
deliveries. Symptoms were noted at the first examination in the twentieth
182748—34----- 8
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MATERNAL MORTALITY IN FIFTEEN STATES
week; blood pressure 265/140. She was put to bed. At the twenty-fourth week
a Cesarean section was done under local anesthetic, with resection o f tubes.
Death occurred 10| hours after the operation.
Some few of these women had been given hospital treatment for
preeclampsia. They improved and were allowed to go home, without
adequate supervision in most cases. Later they developed convul
sions, a Cesarean was done, and they died. There would seem to be
need for wider dissemination of the knowledge that severe preeclamp
sia most often calls for an early induction of labor. Observation was
made of the number of women with convulsions who were carried
rather long distances to hospitals and operated upon immediately.
It would scarcely have been believed that in a teaching hospital a
classical Cesarean for eclampsia was done, with chloroform as an
anesthetic and after an attempted accouchement forcé.
A para 2, aged 22, developed a blood pressure o f 200 about term with edema,
albuminuria, nausea, and vomiting. She had had prenatal care throughout the
pregnancy. She was under treatment at home for 1 week. She died 3 days
after a Cesarean section under ether anesthesia.
The number of classical Cesareans done for abnormal presentations
after delivery from below had been attempted was astounding. The
following is not an unusual story;
A para 2, aged 20, with a foot presentation, who had been in labor many hours
and had had frequent attempts at delivery on the outside, was carried 25 imles
to a hospital by automobile and had an immediate classical Cesarean. The
baby was still-born. The mother’s death from sepsis followed in 2 days.
Forty-five percent of all the women who had Cesareans had had
more than one pregnancy. Fifty-six women had had six or more
pregnancies. Careful study of the list of indications given for
Cesarean section (p. 90) would seem to offer evidence of the lack of
soundness of obstetric teaching. “ Contracted pelvis
difficult
labor” , “ delayed labor” seemed to have been too frequent indications
in multiparous women. The number o f multiparous women with
eclampsia upon whom a Cesarean section was done was unneces
sarily large. There seems to be need for the adoption of a uniform,
safe, and sane treatment for eclampsia, and an understanding that
Cesarean section is not such a form of treatment as a rule.
Unwise selection of anesthesia was frequent. In the cases of
Cesarean section for eclampsia ether was the most common anesthetic,
and even chloroform was occasionally used (7 cases). Ether was
also used in the presence of acute respiratory infection. Local
anesthesia was used in surprisingly few cases (19).
IM M E D IA T E CAUSE OF D E A TH
The causes of death as given by the attending physicians and
classified according to the international list are compared in table 56
with the probable immediate causes suggested by a member of the
obstetric advisory committee of the bureau after careful study of each
schedule without consideration o f the international classification.
Since puerperal sepsis takes precedence over all other puerperal
causes in the international classification, the deaths due to sepsis
would have been so classified if the fact of sepsis had been reported
either on the death certificate or at the interview. Study of the
schedules indicated that many deaths attributed by the attending
physician to “ acute dilatation of the heart” or to “ acute ileus were
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101
CESAREAN SECTION
probably due to sepsis. Also, many of the deaths that were supposed
t o be due to acute nephritis were probably due to sepsis.
'T able 56.— Cause o f death as shown by interview according to the international
classification and im m ediate cause o f death as shown by sp ecia l study o f the
schedules am ong women who died follow in g Cesarean section
Women who died following Cesarean section
'Cause of death as shown by interview
according to international classification
(1920)
Immediate cause of death
Total
All causes.........................................J
537
Accidents of pregnancy_________________
Puerperal hemorrhage__________________
Other accidents of labor..............................
3
42
146
Cesarean section..________ __________
Others under this title..........................
1S6
Puerperal septicemia..................................
Puerperal phlegmasia alba dolens, embol
us, sudden death_____ _______________
Puerperal albuminuria and convulsions...
143
10
1
202
Shock Em Car
Toxic and/or
Sep condi
PneuUn
bo diac
sis
hemor
dis- monia Other known
tions rhage lism ease
251
158
73
18
ill
H
66
139
1
*~36
"I 47"
1 Includes 5 women who died from intestinal obstruction, 1 from dilatation of stomach, 1 from chronic
hepatitis, 1 from cerebral abscess with meningitis, 1 from cerebral hemorrhage, and 2 from anesthesia (1
spinal, 1 nitrous oxide and ether).
The probable immediate causes of death are shown in table 57 by
principal indication for the Cesarean section and for primiparae and
multiparae.
According to the physicians, 27 percent of the cases were classified
as septic, but careful study of each record would seem to show that
47 percent were probably septic. This figure is conservative and is
"based upon the well-known signs and symptoms of sepsis and its
common complications. The conditions under which the operations
were done may account for this high percentage of sepsis. Eightyfive percent had not been contemplated and previously planned.
The membranes were ruptured before the operation was done in 34
percent. One or more vaginal examinations had been done upon
52 percent. Sixty-two (12 percent) had had attempted delivery from
below. The number of sections done for various types o f dystocia
after long and exhausting labors, and often after repeated attempts
■at delivery from below, shows lack of general recognition of the fact
that the mortality from Cesarean section increases with the length
o f time the woman has been in labor and with attempts at delivery
from below. In any discussion of sepsis following Cesarean it is to
be remembered that the operating surgeon often does not have “ first
«chance” with his patients. Yet this should be no reason for unwise
selection of the operation to be performed. In many o f these cases
¡a Porro or low cervical operation should have been done instead of
the classical Cesarean; in others no type of Cesarean operation should
have been done.
Many of the surgeons could appropriately analyze the selection of
their cases and study their operative technique and the surgical
technique of their institutions, for many deaths resulted from sepsis
in cases in which it apparently should not have occurred.
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MATERNAL MORTALITY IN FIFTEEN STATES
T able 57.— Principal indication for Cesarean section and immediate cause o f
death as shown by special study o f the schedules an\ong primiparae and multiparae
who died following Cesarean section
Women who died following Cesarean section
Immediate cause of death
Principal indication for operation, and
parity
Total
Shock Em Car
Toxic and/or
Sep condi
Pneu
Un
bo diac
sis
hemor
dis monia Other known
tions
rhage lism ease
Total...................................................
537
251
158
72
Eclampsia....................................
Preeclämpsia_________________
Uremia— ...................... .........
Placenta previa...........................
Premature separation of placenta....... .................................
Ruptured uterus.........................
Previous Cesarean section.........
Contracted pelvis.......................
Contracted pelvis and other indication____________________
Abnormal presentation....... ......
Disproportion and long or difflcult labor..................................
Other indication.........................
Not reported..................... .........
165
47
27
38
36
22
3
19
126
7
22
1
1
11
3
15
2
15
9
17
28
6
1
13
20
1
8
7
3
-1
1
55
33
41
23
4
5
5
2
1
61
39
3
44
22
1
8
6
4
1
2
5
34
6
5
Primiparae...................................................
Eclampsia..............................................
Preeclampsia.........................................
Uremia— .......................................... .
Placenta previa....................................
Premature separation of placenta____
Ruptured uterus................... ..............
Contracted pelvis.................................
Contracted pelvis and other indication.....................................................
Abnormal presentation........................
Disproportion and long or difficult
labor.................................i ......... .-s—
Other indication....................................
Multiparae...................................................
Eclampsia......... ..................................
Preeclämpsia.........................................
Uremia__________ _______ ____
Placenta previa............................... —
Premature separation of placenta.......
Ruptured uterus..................................
Previous Cesarean section...................
Contracted pelvis.................................
Contracted pelvis and other indication_________________________
Abnormal presentation.....................
Disproportion and long or difficult
labor............................................
Other indication.............................
Not reported...............................
Parity not reported..............................
m
1S1
1
m
122
27
3
9
4
1
22
26
15
16
1
30
22
20
17
1
39
14
28
4
m
94
4
2
3
2
18
11
x
2
12
111
2
2
1
1
1
1
1
6
1
1
2
1
1
1
6
4
2
3
1
6
3
1
1
2
2
86
18
6
118
56
9
7
3
16
4
1
13
4
32
3
20
1
25
11
21
6
3
22
24
2
16
17
1
2
3
5
e
8
5
3
9
6
4
3
1
2
2
1
1
1
1
2
7
8
1
1
1
6
2
1
3
42
20
24
29
11
6
17
6
4
6
1
4
1
1
1
1
1
1
1
2
1
x
1
1
3
3
1
1
' Includes 5 women who died from intestinal obstruction, 1 from dilatation of stomach, 1 from chronic
Hepatitis, 1 from cerebral abscess with meningitis, 1 from cerebral hemorrhage, and 2 from anesthesia (1
spinal, 1 nitrous oxide and ether).
.
In many of these cases the fundamental error was the failure of the
patient to secure adequate prenatal care and the consequent lack o f
opportunity for the physician to plan properly for the delivery.
The tremendous mortality attending Cesarean section throughout
the United States warrants a careful review o f the indications for the
choice of operation.
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ABORTIONS
DEFINITION IN PRESENT STUDY DIFFERENT FROM INTERNATIONAL
LIST
Abortion, as used in this report, may be defined as the termination
of a previable uterine pregnancy. The term includes all termina
tions of uterine pregnancies before the seventh month (except a very
few that resulted in five births), whether the termination was spon
taneous or induced.1 It includes, therefore, what is commonly known
as “ miscarriage. ”
Probably the most outstanding finding oj this study is that one fourth
of all the maternal deaths followed abortion. Almost three fourths of
the deaths following abortion were due to 'puerperal septicemia, and these
deaths from sepsis following abortion constituted nearly half of all the
deaths from puerperal septicemia, the greatest single cause of maternal
mortality.
This general term abortion is not the same as the title abortion
or premature labor (no. 143a) in the International List of Causes of
Death. This title in the international fist, as it includes premature
labor, does not necessarily denote previability. Also, many deaths
following abortion are classified under some title other than the title
abortion of the international list, as placenta previa (no. 144a), rup
tured uterus (no. 145c), puerperal septicemia (no. 146), puerperal
phlegmasia alba dolens, embolus, sudden death (no. 147), and puer
peral albuminuria and convulsions (no. 148), as well as ectopic gesta
tion (no. 143b), all take precedence over abortion (no. 143a).2
This section of the report deals with abortion as already defined,
and all deaths following abortions in the study are, therefore, included
in it. As abortion in this sense includes by definition only deaths
of women who had not reached the last trimester, the group here
discussed obviously excludes the 99 deaths of women who had reached
the last trimester that were assigned under the international classi
fication to abortion or premature labor (no. 143a).
CRIMINAL ABORTION
Deaths certified as due to criminal abortion are assigned to homi
cide in the International List of Causes of Death and therefore are
not included in “ maternal mortality.” Self-induced abortions, how
ever, are assigned to puerperal causes. The deaths certified as. due
to criminal abortion are not given separately by the Bureau of the
Census; the small number so certified is manifestly incomplete, since
undoubtedly many deaths actually due to criminal abortions are
registered as due to other causes.
t Fourteen cases of attempted abortion in which the women died without actual expulsion of the fetus
are also included.
* In the 1929 revision of the International List of Causes of Death, abortion with septic conditions (for
merly part of puerperal septicemia) is no. 140, and abortion without mention of septic conditions is no. 141.
(See appendix B, p. 212.) Except that septic abortion is no longer assigned to puerperal septicemia, the
rules of precedence given above remain essentially the same.
103
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MATERNAL MORTALITY- IN FIFTEEN STATES
As deaths following criminal abortions, if certified as such, arenot included in maternal mortality, frankness on the part of physiciansand zeal on the part of public authorities in investigating deaths
thought to have resulted from criminal abortion and in correcting the
certificates for the deaths would reduce the number of deaths assigned
to puerperal causes in a city and so in a State.
As this study is based on the group of deaths certified as due to
the puerperal causes, deaths certified as due to criminal abortion arenot included. Attending physicians said on interview that they sus
pected or were convinced of the criminal induction of certain of the
abortions that they had not certified as criminal. But it was imprac
ticable to separate such criminal abortions from self-induced abor
tions, as there were many abortions about which the physicians who
were called in at the last moment merely knew that they were arti
ficially induced. Such abortions were therefore included in the study.
Possibly some of the abortions reported by physicians as spontaneous
were actually induced. But the physicians interviewed were assured
that the information requested was for scientific purposes only, and
the impression was obtained by the interviewers that most of them
gave freely what information they had.
DEATHS FOLLOWING ABORTION AND THEIR CAUSES
Of the 2,381 deaths of women who had not reached the last tri
mester 1,825 followed abortion and 554 did not follow abortion; for 2
information on this point was not obtained. The 554 women whoso
deaths before they reached the last trimester did not follow abortion
had had ectopic pregnancies or died without termination of preg
nancy; a few (32) gave birth to living, and probably viable, children.
Of the 1,825 deaths following abortion 1,324 (73 percent) were
attributed after interview, in accordance with the international list,.
58.— Cause of death 1 as shown by interview for women who died following
abortion, and trimester of pregnancy among women dying from puerperal cause»
who had not reached the last trimester of pregnancy
T able
->«— ■
■
-
■
.........
................ .................................................................................
..
—
Women dying from puerperal causes who had not reached
last trimester
Following abortion
Cause of death1 as shown by interview
Total
All causes______ ____ _____ __________ 2,381
Total
First
trimes
ter
re
Not Not
ported
First 2 follow whether
ing
Second trimes
not abor following:
trimes ters,
abor
tion
other
ter
tion
wise
specified
1,825
991
470
364
554
Accidents of pregnancy..................................
575
290
141
100
49
285
Abortion, premature labor_____________
«54
«40
81
«50
116
88
40
40
«5
1«
S
4
«40
Ü
1,324
788
234
302
7
1
78
44
163
15
47
22
110
7
6
9
174
11
Puerperal hemorrhage (placenta previa).......
1
Other accidents of labor (Cesarean section). .
Puerperal septicemia______________ _______ 1,403
Puerperal phlegmasia alba dolens, embolus,
53
Puerperal albuminuria and convulsions____
338
4
4
1 According to the Manual of the International List of Causes of Death, 1920.
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2=
1
105
ABORTIONS
to puerperal septicemia; 290 (16 percent) to accidents of pregnancy
(250 to abortion or premature labor and 40 to others under this
title); 163 (9 percent) to puerperal albuminuria and convulsions; 44
(2 percent) to puerperal phlegmasia alba dolens, embolus, sudden
death; and 4 to puerperal hemorrhage (placenta previa) (table 58).s
Deaths due primarily to hemorrhage following abortion are assigned
to “ abortion, premature labor.”
TYPE OF ABORTION
The type of abortion was reported for 1,588 of the 1,825 cases.
Of these, 794 (50 percent) were induced abortions other than thera
peutic, 589 (37 percent) were spontaneous (that is, not brought about
by mechanical means nor by drugs), and 205 (13 percent) were thera
peutic (that is, done by any method for medical indications). Per
haps most of those of “ type not reported” (237) were actually
induced; they were almost certainly not therapeutic (table 59).
T able 59.— Cause of death 1 as shown by interview among women who died following
abortion of each specified type
Women who died following abortion of each
specified type
Cause of death i as shown by interview
Total
Sponta
neous
Thera
peutic
Induced Type not
reported
All causes............................................................
1,825
589
205
794
237
Abortion, premature labor________________ - ...........
Other accidents of pregnancy............................. .........
Puerperal hemorrhage_________ _______ ________ _ _
Puerperal septicemia_____________________________
Puerperal phlegmasia alba dolens, embolus, sudden
death............... ........................ ........ ..........................
Puerperal albuminuria and convulsions____ _____ __
250
40
4
1,324
137
11
1
354
32
29
2
44
55
26
722
1
204
44
163
25
61
4
94
13
4
2
4
1 According to the Manual of the International List of Causes of Death, 1920.
Since these were all fatal abortions, it is obvious that the propor
tions of the types found cannot be considered representative of the
proportions of types of nonfatal abortions any more than the incidence
of abortions among these maternal deaths can be assumed to be an
index of the total number of pregnancies ending in abortion. If abor
tions, or the conditions causing them, are either more or less dangerous
than term deliveries, and if induced abortions are more likely to have
fatal consequences than spontaneous abortions, the proportions of the
types of abortions among these women who died do not present a true
picture.
PREDOMINANCE OF SEPSIS AS A CAUSE OF DEATHS FOLLOWING
ABORTION
As has been noted, puerperal septicemia was attributed as the cause
of death of nearly three fourths of the 1,825 women who died following
abortion, and the 1,324 deaths from septic abortion constituted 45
percent of all the deaths from puerperal septicemia (chart V II).
* According to the 1929 revision of the International List the 1,324 deaths would be attributed to abortion
with septic conditions (no. 140), about 250 to abortion without mention of septic conditions (no. 141), and
about 200 to other toxemias of pregnancy (no. 147); the classification of the others would remain the same.
(See also appendix B, p. 212.)
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MATERNAL MORTALITY IN FIFTEEN STATES
The number and percentage of deaths from puerperal septicemia
among women who died following the different types of abortion are
shown in the following list:
Total abor
tions
Type of abortion
Septic abortion
Number
Percent
T o t a l ___________ ____ _____ _________
1, 825
1, 324
73
__
____________ _______ __
Therapeutic_________ __________ _________
I n d u c e d ._____________
_______ _________
589
205
794
237
354
44
722
204
60
S p on ta n eou s
T y p e n o t rep orted
-
_______
___
C H A R T V I I .— A B O R T I O N S A M O N G W O M E N
CAUSES
D Y IN G FR O M
21
91
86
PUERPERAL
P ercent
All causes
Septicemia
All other causes
■
induced
Spontaneous ESI Type not specified
T herapeutic
□
No abortion
Ninety-one percent of the deaths following induced abortion, 60
percent of those following spontaneous abortion, 21 percent of those
following therapeutic abortion, and 86 percent of the deaths following
abortion of unreported type were due to sepsis. Thus, though nearly
all the deaths from induced abortion were due to sepsis, deaths follow
ing therapeutic abortion were due more often to the condition that
gave the indication for the operation than to sepsis; and deaths fol
lowing' spontaneous abortion were due more often to sepsis than to
hemorrhage or to a condition that may have brought about the abor
tion. The fact that 86 percent of the deaths following abortions of
unreported type were due to sepsis suggests that most of these were
actually induced abortions. However, sepsis sometimes supervenes
in a patient weakened by another disease and the abortion resulting
from it.
PERIOD OF GESTATION
The period of gestation was reported for 1,461 of the 1,825 women
who died following abortion. In 548 cases it was less than 3 months;
in 444 cases, 3 months; in 219 cases, 4 months; and in 250 cases, 5
or 6 months. More than half the women who had induced abortions
and whose period of gestation was known had them in the first 2
months, while one fourth of the spontaneous and one eighth of the
therapeutic abortions preceding death occurred during this period
(table 60).
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ABORTIONS
T able 60.— P e r io d
o f gesta tion a m o n g w o m en w ho d ied fo llo w in g a bortion o f each
sp ecified t y p e
Women who died following abortion of each specified type
Period of gestation
Total
Spontaneous
Type
not re
Num Percent
Num Percent
Num Percent
Num Percent
distri
distri
ported
distri
distri
ber
ber
ber
ber
bution
bution
bution
bution
4 months..........................
1,461
548
443
220
119
131
364
100
38
30
15
8
9
794
205
589
1,825
Period reported......................
Induced
Therapeutic
100
25
30
20
12
13
501
127
150
100
58
66
88
201
24
60
47
28
42
4
237
610
336
185
50
25
14
184
100
12
30
23
14
21
100
55
30
8
4
2
146
61
48
23
8
9
88
OPERATIONS
A report concerning operations was obtained for 1,777 of the 1,825
women who died following abortions. Nine hundred and ninety-two
(56 percent) had had operations, including 265 (45 percent) of the 583
women who had had spontaneous abortions and 403 (52 percent)
of the 778 women who had had induced abortions. Of the 205
women who had had therapeutic abortions 38 (19 percent) had had
other operations as well (table 61).
T able 61.—
T y p e o f o p era tio n p erform ed on w o m en w ho d ied fo llo w in g a bortion o f
each sp ecified t y p e
Women who died following abortion of each specified type
Spontan
eous
Total
Therapeu
tic
Type not
reported
Induced
Type of operation
Per
Per
Per
Per
Per
cent Num cent Num cent Num cent Num cent
Num distri
distrfc ber distri ber distri ber distri
ber
ber
bu
bu
bu
bu
bu
tion
tion
tion
tton
tion
589
1,825
Report on operation_________________ 1,777
m
Operation...........................................
Curettage:
432
49
46
25
With packing of uterus and
23
5
Therapeutic abortion:
J167
^9
29
7
68
42
40
Packing of uterus and cervix
25
20
5
786
48
794
205
583
100
205
100
778
100
211
100
66
£66
46
£06
100
403
6£
119
66
24
3
3
1
159
20
17
4
27
3
3
1
213
22
23
18
27
3
3
2
60
7
6
3
28
3
3
1
1
(*>
10
2
2
11
2
(I)
9
1
2
(l)
' '4
2
2
2
13
10
11
(l)
2
2
2
1
1
(l)
11
5
1
(0
44
S18
s 167
«9
29
81
4
14
5
37
23
27
2
1
10
11
1
66
376
6
1 Less than 1 percent.
* Includes 63 cases done by means of curettage, and 4 by means of hysterectomy.
* Includes 4 cases done by means of curettage.
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237
100
16
lv
0
l
5
3
3
(i)
1
1
48
2
1
I
(0
18
9
2
9
4
1
4
4
3
9£
26
2
2
1
U
.
108
MATERNAL MORTALITY IN FIFTEEN STATES
The most frequent operation was curettage, which had been per
formed in 652 (37 percent) of the 1,777 cases. Of the women who had
had spontaneous abortions 212 (36 percent) and of those who had had
induced abortions 289 (37 percent) had been curetted.
Evidently many physicians did not consider fever a contra-indica
tion for this operation, for 1^8 (69 percent) of the 652 women who had
abortions and were curetted were reported to have had fever before the
curettage (table 62). Puerperal septicemia caused 94 percent of the
deaths of these 448 women, as compared with 50 percent of the deaths
of the women who were afebrile before the curettage and 68 percent
of the deaths of the women who had had no curettage.
The 448 cases in which fever occurred before the curettage included
234 women with induced abortions other than therapeutic; 97 per
cent of their deaths were due to sepsis. Some physicians, however,
found out only after curettage, or after the death of the patient, that
the abortion had been induced, and several stated on interview that
they would not have curetted if they had had this information earlier.
Hemorrhage was reported present for 328 of the 652 cases in which
there had been curettage, absent in 235 cases, and not reported on
for 89 cases. Of the 1,086 women who died following abortions and
who had not had curettage, 430 were reported as having had hemor
rhage, 459 as having had no hemorrhage, and there was no report
for 197. Whether or not the patient had had hemorrhage had very
little effect on the proportions dying from sepsis after curettage in
febrile cases (table 63).
The actual operations performed are discussed in the section
Operations (p. 65).
INDICATIONS FOR THERAPEUTIC ABORTIONS
Pernicious vomiting was given as the principal indication for 112
of the 205 therapeutic abortions; other toxemias, usually of a con
vulsive type, for 52; hemorrhage, placenta previa, or premature
separation, for 14; dead fetus, for 12; and other causes, for 15.
ILLEGITIMACY
Married women made up 90 percent of the women whose deaths
followed abortions; but abortion was a more frequent cause of death
among unmarried than among married mothers, as abortions preceded
the deaths of about one fifth of the married mothers in the study and
of more than one third of the 509 unmarried mothers. Live births
were reported to the Bureau of the Census as legitimate or illegitimate
in all the States of the study except California. For every 10,000
legitimate live births in the States of the study except California
there were 14 deaths of married women following abortions. For
every 10,000 illegitimate live births in these same States 50 deaths
of unmarried women following abortions were reported.
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T able
62.— Relation between curettage and fever and deaths from puerperal septicemia and from all other puerperal causes among women wh6
died following abortion of each specified type
Women who died following abortion of each specified type
Deaths from
Deaths from-
Deaths from
Deaths from
Deaths from
Type of abortion not
reported
Induced abortions
Therapeutic abortions
Spontaneous abortions
Total abortions
Curettage and fever
422
103
737
62
501
27
589
354
60
235
40
205
161
79
794
722
91
72
9
94
50
68
71
26
101
349
25
6
5C
32
29
139
73
368
9
124
34
191
5
89
47
52
15
39
177
4
11
53
48
12
3
15
12
21 ' 45
57
121
20
17 101
12
12 — r - .....
79
83
234
55
480
25
228
42
427
25
97
76
89
6
13
53
3
24
11
44
21
Percent 1
Number
Percent1
Number
Total
Percent1
Number
Percent1
Number
Total
Percent1
Number
Percent1
Number
Total
Percent1
Number
Percent1 I
Number
Total
Percent
Number
j
448
204
No fever before______________
No curettage... ...................... ............. 1,086
87
Curettage not reported------ *........ .
Percent
Number
Total
Curettage with—
73
204
86
33
14
58
60
19
15
117 . 99
41
32
97
2
4
18i
9
15
237
85
3
ABORTIONS
Total...................... ................... 1,825 1,324
Puerperal All other
septi
causes
cemia
Puerperal All other
septi
causes
cemia
Puerperal All other
septi
causes
cemia
Puerperal All other
septi
causes
cemia
Puerperal All other
septi
causes
cemia
1 Not shown where number of deaths was less than 50.
O
CO
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T able 63.— Relation between curettage and fever and deaths from puerperal septicemia and from all other puerperal causes among women
£
having hemorrhage and among women not having hemorrhage who died following abortion of each specified type
<3
Women having hemorrhage who died following abortion of each specified type
Total
Total------------------------ ------ -----------
Therapeutic abortions
Deaths from—
Deaths from—
Deaths from—
Curettage and fever
Curettage with—
Spontaneous abortions
Puer
peral
septi
cemia
All
other
causes
Total
Puer
peral
septi
cemia
AU
other
causes
Total
Puer
peral
septi
cemia
Type not reported
Induced abortions
Deaths from—
Deaths from—
All
other
causes
Total
Puer
peral
septi
cemia
All
other
causes
Total
Puer
peral
septi
cemia
All
other
causes
773
579
194
319
209
110
29
9
20
330
282
48
95
79
16
228
100
430
15
210
49
307
13
18
51
123
2
90
53
173
3
79
21
107
2
11
32
66
1
2
6
21
2
1
6
5
15
105
33
188
4
100
23
155
4
5
10
33
31
8
48
8
29
4
39
7
2
4
9
1
3
Women not having hemorrhage who died following abortion of each specified type
Total— ------------- ------------------------Curettage with—
No curettage--------- --------------- ------------- -
697
508
189
203
111
92
113
33
80
314
300
14
67
64
169
66
459
3
161
30
315
2
8
36
144
1
39
14
150
35
8
68
4
6
82
13
39
60
1
10
11
12
3
28
48
1
98
10
205
1
97
8
194
1
1
2
11
19
3
44
1
19
3
41
1
3
.
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MATERNAL MORTALITY IN FIFTEEN STATES
Total abortions
111
ABOUTIONS
AGE OF M OTHER AND TYPE OF ABORTION
The proportion of the maternal deaths that were preceded by
abortions increased with the age of the mother up to the age of 30 and
-decreased thereafter. A larger proportion of the women who died
following abortion (45 percent) than of all women dying from puerperal
causes (40 percent) were from 25 to 34 years of age (table 64).
T able
64.— Age at death of women who died following abortion of each specified
type among women dying from puerperal causes
Percent dis
tribution
Number
Percent dis
tribution
Number
Percent dis
tribution
Number
Percent dis
tribution
Type not reported
Percent dis
tribution
Not reported whether fol
lowing abortion
Women dying from puerperal causes
237
5,521
Age period reported... 7,350
100
1,810
100
585
100
204
100
792
100
235
5,502
100
32
Under 15 years___
15 years, under 20.
20 years, under 25.
25 years, under 30.
30 years, under 35.
35 years, under 40.
40 years and over..
25
855
1,545
1,537
1,412
1,312
664
(0
12
21
21
19
18
9
3
179
392
435
388
295
124
(J)
10
22
24
21
16
7
1
43
110
126
140
99
66
(»)
7
19
22
24
17
11
17
54
43
41
31
18
8
26
21
20
15
9
1
92
174
204
161
130
30
(i)
12
22
26
20
16
4
1
27
54
62
46
35
10
22
673
1,146
1,094
1,019
1,012
536
(l)
12
21
20
19
18
10
7
8
5
5
4
Age period not reported.......................
30
2
19
Total
Total__________ 7,380
1,825
9
Sponta
neous
589
4
Thera
peutic
205
1
Induced
794
2
Not
following
abortion
Number
Total
Number
Percent distribution
Number
Age period
Following abortion of each specified type
34
3
2
1 Less than 1 percent.
More than half (52 percent) of the spontaneous abortions occurred
at 30 years of age and over, as compared with 44 percent of the
therapeutic abortions and 41 percent of the induced. The age at
which the largest number of the induced abortions occurred was from
25 to 29 years (26 percent); of the therapeutic abortions, from 20 to 24
(26 percent); and of the spontaneous abortions, from 30 to 34 (24
percent). It is of interest that 12 percent of the women who had
mduced abortions were under 20 years of age, as compared with
8 percent of those who had therapeutic or spontaneous abortions.
The age distribution of women whose deaths followed abortion but
for whom the type of abortion was not reported was practically iden
tical with that of women whose abortions were reported as induced.
PARITY AND TYPE
• OF ABORTION
Abortions preceded the deaths of 18 percent of the known primi
parae and 26 percent of the known multiparae in the study. Nearly
half (49 percent) of the ^deaths of the 526 women of unknown parity
were preceded by abortions. Among the primiparae for whom type
o f abortion was reported, 31 percent of the abortions were sponta
neous, as compared with 40 percent among the multiparae. The
deaths of known primiparae were preceded in 8 percent of the cases
by induced abortions, in 5 percent by spontaneous abortions, and in 3
percent by therapeutic abortions; for 2 percent the type of abortion
was not reported. Among known multiparae death was preceded by
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112
MATERNAL MORTALITY IN FIFTEEN STATES
induced abortions in 11 percent of the cases, by spontaneous abortions
in 9 percent, and by therapeutic abortions in 3 percent; for 3 percent
the type was not reported.
MORTALITY FROM ABORTION AM ONG W HITE AND COLORED AND
URBAN AND RURAL GROUPS
The mortality rate for deaths following abortion was greater among
colored than among white women, chiefly because of the larger incidence
of deaths following spontaneous abortions among the colored (table 65).
The mortality rate for deaths following abortion was higher in the
urban districts (22 per 10,000 live births) than in the rural districts
(12), as were also the rates for deaths following each type of abortion.
C H A R T V I I I .— M O R T A L I T Y R A T E S F O R D E A T H F O L L O W I N G A B O R T I O N
A M O N G W O M EN D Y IN G FR O M P U E R P E R A L C A U SES
D e ath s p er 10,000 live b irth s
T o ta l
Urban
R u ra l
W hite.
C o lo re d .
H
1
«1
Induced.
Spontaneous
T ype not sp e cifie d -
T h e r a p e u t ic
The difference was most marked in induced abortions, for which the
mortality rate was 11 per 10,000 live births in urban districts as com
pared with 4 in rural districts (table 65). This increases the difference
between the total urban and the total rural maternal mortality rate.
T
able
65.—
T y p e o f a bortion a n d m orta lity rate a m o n g w hite a n d colored w o m en
a n d w o m en i n urban a n d rural areas who d ied fo llo w in g abortion
Women who died following abortion
Total
White
Colored
In urban areas
In rural areas
Type of abortion
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
live
births
Num
ber
Rate
per
10,000
live
births
Num
ber
......... .
1,825
15.5
1,568
14.8
257
21.3
993
21.5
832
11.6
Spontaneous............
Therapeutic.............
Induced..................
Not reported............
589
205
794
237
5.0
1.7
6.7
2.0
474
189
729
176
4.5
1.8
6.9
1.7
115
16
65
61
9.5
1.3
5.4
5.1
274
103
488
128
5.9
2.2
10.6
2.8
315
102
306
109
4.4
1.4
4.3
1.5
Total
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Rate
per
10,000
live
births
113
ABORTIONS
MORTALITY FROM ABORTION IN THE DIFFERENT STATES
The proportion of maternal deaths that followed abortion in the
various States ranged from 18 percent in Alabama and Wisconsin to
34 percent in Oregon and 37 percent in Washington. The variation
in the percentages of maternal deaths was greatest for induced abor
tions, which ranged from 3 percent of all the maternal deaths in
Alabama to 23 percent in Washington. Three percent of all the ma
ternal deaths were due to therapeutic abortion; the minimum (1 per
cent) was reported in Virginia and the maximum (7 percent), in New
Hampshire. Deaths from spontaneous abortion varied from 6 per
cent in 5 States— California, Minnesota, New Hampshire, Oregon,
and Virginia'—to 11 percent in Oklahoma (table 66).
T a b l e 6 6 . — N u m b e r a n d -percentage o f w o m en w h ose deaths fo llo w e d a bortion o f
each sp ecified t y p e and w h ose deaths d id n ot fo llo w abortion a m o n g w o m en d yin g
f r o m p u erp era l causes i n each S ta te in clu d ed i n the stu d y
Women dying from puerperal causes
Number
205
3
794
11
237
10
6
10
7
8
6
9
6
10
11
6
7
6
9
7
17
15
18
13
33
26
9
8
7
9
7
6
10
13
14
2
3
3
3
3
5
3
7
33
70
60
49
203
45
52
6
18
37
27
19
61
71
43
3
14
9
13
16
9
16
6
11
12
15
12
8
23
7
37
17
26
18
45
10
«
1
1
14
15
2
24
6
13
4
3
4
4
1
4
2
Percent
1 Percent
8
107
32
63
25
108
31
28
6
16
33
11
11
48
28
42
j
Number
589
18
27
26
27
30
23
29
19
26
31
34
23
19
37
18
No
abortion
Number
1 Percent
25
Percent
Number
Type of
abortion
not re
ported .
|Percent
194
134
167
105
389
112
97
21
42
93
60
38
143
118
112
Induced
abortion
Number
Total—........... 7,380 7,346 1,825
Alabama.................. 1,118 1,102
493
493
639
Kentucky_________ 645
382
382
Michigan_________ 1,312 1,309
488
Minnesota............... 491
329
329
109
New Hampshire___ 109
159
159
297
Oklahoma................ 300
177
177
165
165
766
V irginia................. 767
315
Washington............ 316
616
Wisconsin................ 617
Thera
peutic
abortion
Percent
Total
Total
Number
Sponta
Total
neous
abortions abortion
State
No report on abortion
Report on abortion
3 5,521
3
4
4
5
3
2
2
1
1
5
8
1
3
2
2
75'
908 82
359 73
472 74
277 73
920 70
376 77
232 71
88 81
117 74
204 69
117 66
127 77
623 81
197 63
504 82
34
16
6
3
3
__
3
1
1
1
For mortality rates following abortion in the different States see
appendix table X V II, p. 208, and for the percentages of various types
of abortion among white and colored women who died in urban and
rural areas of the different States see appendix table X V III, p. 209.
For septic abortion in the different States, see pp. 131-132.
COMMENT BY ADVISORY COMMITTEE
^
In reading the section on abortion it must be carefully kept in
mind that the definition of “ abortion” as used in this report is
different from that of the international list. In this report the term
“ abortion” is used to mean the termination of a previable uterine
pregnancy.
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114
MATERNAL MORTALITY IN FIFTEEN STATES
Undoubtedly among this number of deaths were some due to crim
inal abortions. If the abortions were known to be criminal and
death followed, the deaths were assigned by the Bureau o f the
Census, according to the International List o f Causes o f Death, as
homicides and were not included in the maternal mortality. It was
impossible, however, to separate the known self-induced abortions
from possible criminal abortions, and therefore they were included
in the figures analyzed.
That one quarter of all the maternal deaths in this study followed
some type o f abortion is probably the most outstanding finding of
the study. The further finding that three quarters of the deaths
following abortion were due to puerperal septicemia is equally sig
nificant. As 1,825 deaths followed abortion out o f the total o f 7,380
deaths in this series, abortion is evidently one o f the greatest problems
in lowering the maternal mortality o f the country.
The large proportion o f induced abortions shows a very serious
situation. Fifty percent o f abortions o f known type were induced
and 13 percent o f all the abortions were of “ type not reported” , so
that many o f these may have been induced. The seriousness o f this
situation is further shown by the fact that 73 percent o f the deaths
following abortion were due to puerperal septicemia. The high pro
portion o f deaths from sepsis (91 percent) among deaths following
induced abortion was perhaps to be expected. It is difficult to
understand, however, the number o f deaths from sepsis among those
having spontaneous and therapeutic abortions, and one cannot help
wondering if many o f the so-called spontaneous abortions were not
really induced. As was to be expected in those women who had
induced abortions, more than half were done in the first 2 months of
pregnancy. A surprising number o f therapeutic abortions were done
in the second trimester of pregnancy.
The most frequent operation in the management o f these abortions
was curettage (usually with sharp instruments, which is a procedure
definitely to be condemned). It is clear that many physicians did
not consider fever a contra-indication for curettage; yet in those cases
in which it was known that fever existed and curettage was done,
94 percent o f the deaths were due to sepsis. In marked contrast is
the fact that only 50 percent of the deaths of the women who were
afebrile at time o f operation were due to sepsis. In not a few cases
the history o f an induced abortion was not discovered until after the
patient had been curetted or even after she had died. Evidently a
careful history in many o f these cases was not obtained.
Hemorrhage was o f frequent occurrence in these abortion cases,
but the fact that the patient had had a hemorrhage had very little
effect on the proportion o f deaths from sepsis after curettage in
febrile cases.
As pernicious vomiting was the principal indication given for 112
o f the therapeutic abortions, it would seem that the physicians had
delayed in doing the abortion or had been called in consultation too
late to save the patient’s life, or else had improper technique.
Analysis o f the figures on illegitimacy brings up the whole prob
lem o f abortion in unmarried mothers, for abortions accounted for
more than one third o f the deaths of unmarried mothers in this series.
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ABORTIONS
115
This study shows very clearly the seriousness of the problem
created by the great number of abortions that are induced each year.
It also shows that the practice of curetting every patient who has an
abortion is common. Physicians must be made to appreciate the
seriousness of curetting these potentially septic cases. The manage
ment of an abortion calls for the best medical care that can be given,
and in many of the cases in this series it is obvious that such care was
not given. The abortion problem is a widespread sociological and
economic problem, which the medical profession must have help in
solving. However, the physician has one great obligation—to teach
the public the dangers entailed by abortion, whether spontaneous
or induced.
182748—34-----9
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PUERPERAL S E P T IC E M IA 1
Puerperal septicemia is the most important cause of death con
nected with pregnancy or childbirth, being responsible for 40 percent
of all the maternal deaths included in the study, for 59 percent of the
deaths of women who had not reached the last trimester, and for 31
percent of the deaths of women who had reached the last trimester.
It differs from the other chief causes of maternal death— toxemia,
hemorrhage, obstructed delivery—in that it is not in itself an abnor
mality of the ordinary process of pregnancy and labor or the puer
périum. It is, on the contrary, an invader whose entrance is facili
tated by, although not dependent upon, the lowered defenses incident
to the struggle with pathologic processes of pregnancy and labor and
the puerperium. Women who have been weakened by hemorrhage,
by eclampsia, or by the exhaustion of a long and difficult labor are
an easy prey to infection; and infection is the chief cause of death
of women for whom an operative delivery is necessary and who sur
vive the shock of the operation itself. It is also the chief cause of
death following abortion from any cause. Thus, abortions preceded
1,324 (45 percent) of the deaths due to puerperal septicemia, and
abortions reported to have been induced (other than therapeutic)
preceded 722 deaths (24 percent). Ectopic pregnancy was a factor
in 65 deaths from sepsis.2 Placenta previa was present in 53 cases
and 84 women had other puerperal hemorrhage of such severity that
it was considered the principal contributory cause of death. One
hundred and sixty-nine women who died from sepsis after delivery
were reported to have had postpartum hemorrhage as a contributing
factor. Eclampsia or severe toxemia of pregnancy was a principal
contributory cause of death in 168 cases. Operations aimed at
delivery were performed on 573 women who died of sepsis after
reaching the last trimester. Of these operations 140 (25 percent)
were Cesarean sections.
For this reason deaths from puerperal septicemia have been dis
cussed in the sections on abortions, Cesarean section, and other
operations, and will be mentioned in the sections on toxemia, hem
orrhage, and ectopic gestation.
DEATHS ATTRIBUTED TO SEPTICEMIA IN THE GROUP STUDIED
From the death certificates and subsequent queries of indefinite
certificates, 2,827 of the 7,537 deaths studied were assigned by the
Bureau of the Census to puerperal septicemia. On interview with
the attendant 110 of these were found to have been actually due
to other causes; 64 of these 110 were not strictly puerperal and were
therefore omitted from the study. (See General Considerations,
table 2, p. 10.) Some of these deaths were of women who had not
i There is no discussion of bactériologie findings as data concerning them were meager. Very few
blood cultures were made or other bactériologie studies done.
8 Abortion with septic conditions and ectopic gestation with septic conditions are separate titles m
the 1929 revision of the International List of Causes of Death. .{See appendix B, p. 212.)
116
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PUERPERAL SEPTICEMIA
117
been seen by a physician before death but were certified as due to
puerperal septicemia, or “ childbed fever” , by local registrars, coro
ners, or physicians signing the death certificate. Clerical errors in
transcribing certificates or by the physicians themselves in answering
queries led to a few mistakes in certification; and in some instances
in which an abortion was merely a terminal event in a fatal sepsis
with some other origin this fact was not made clear on the original
certificate and so the death was wrongly assigned to puerperal septi
cemia. The interviews also disclosed, however, that 231 deaths as
signed to other puerperal causes were really due to puerperal septi
cemia, and these deaths were so classified in the study. These
changes involve only the cases in which the sepsis, although not men
tioned on the death certificate, was diagnosed by the attending
physician, or in which the history of septic temperature, positive
blood culture, or autopsy findings made the change in diagnosis in
evitable. This gives a total of 2,948 deaths considered due to
puerperal sepsis.
Certain other deaths were probably due to sepsis. For instance,
in a study of the schedules of the 537 deaths following Cesarean sec
tion a member of the committee decided that the history of the cases
indicated sepsis in 251 cases, although only 143 had been attributed
to sepsis by the physicians on interview and still fewer, 113, were so
assigned according to the death certificates. (See Cesarean Section,
table 56, p. 101.) Only the 143 are included in the 2,948 attributed
to sepsis in this section.
The term puerperal septicemia, therefore, as used in this section,
means obvious and unmistakable sepsis, and the number of deaths
here attributed to the cause is the minimum.
DURATION OF PREGNANCY
Of the 2,948 women who died from puerperal septicemia 838 did
not reach the second trimester, 251 reached the second but not the
last trimester, and 314 did not reach the last trimester (whether they
reached the second was not known); 1,529 reached the last trimester;
and for 16 the trimester of pregnancy was not known. Of the 1,403
women who died from sepsis before the last trimester, 1,324 died fol
lowing abortion (the termination of a previable uterine pregnancy)
62 died following ectopic gestation, and 10 died after giving birth to
living children; in the remaining 7 cases either the women died un
delivered or the outcome was unknown.
A report as to type was obtained for 1,120 of the 1,324 abortions
preceding death from puerperal septicemia. Of these 1,120 abortions,
722 (64 percent) were induced (other than therapeutic), 354 (32 per
cent) were said to have been spontaneous, and 44 (4 percent) were
therapeutic. (See p. 131 and tables 77 and 78. Deaths following
abortion are also discussed under that heading, p. 105.)
INTRAUTERINE MANIPULATION
The first question that comes to mind in the analysis of a series of
septic deaths is whether or not there had been any intrauterine manip
ulation, such as induction of abortion, operative delivery, or curet
tage. Information on this point was obtained in 2,549 of the 2,948
cases of death from sepsis, and there had been some manipulation in
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MATERNAL MORTALITY IN FIFTEEN STATES
1,546 (61 percent) of these cases. The time of this manipulation
was reported for 1,526 of the 1,546 cases. In 748 cases (49 percent)
the manipulation had been only before the onset of sepsis; in 517
cases (34 percent), after the onset; and in 261 cases (17 percent),
both before and after.
In sepsis cases of women who had not reached the last trimester of
pregnancy the intrauterine manipulation before the onset of sepsis
was usually the induction of an abortion; after the onset of sepsis it
was usually curettage. (See p. 108.) For women who had reached
the last trimester intrauterine manipulation before the onset of sepsis
was usually an operative delivery; after the onset of sepsis it was
usually curettage, although curettage was less frequent on these
women than-on those dying from sepsis who had not reached the last
trimester.
OPERATIONS
F IR S T T W O T R IM E S T E R S
Operations for delivery
Of 1,395 women who died from sepsis before reaching the third
trimester and for whom there was a report on operation for the
delivery of the fetus, there had been a laparotomy for ectopic gesta
tion in 52 cases, a therapeutic abortion in 44 cases, and some other
operation in 6 cases. The six were not called therapeutic abortions
because they either resulted in live births or were performed at the
end of the second trimester. The remaining 1,293 women had no
operation for delivery, except that some may have had criminal abor
tions, none of which were listed as operations in this study.
Operations not for delivery
There was a report on operation other than for the delivery of the
fetus in 1,363 of the 1,403 cases of sepsis before the last trimester was
reached; 743 women had such an operation and 620 did not. The
following list shows the types of operations performed on these 743
women:
Operations other than for delivery---------------------------------------------------743
Curettage:
Only-------------------------------------- ----------------------------------------------------------- 376
45
With blood transfusions--------------------------------------------------------------------2
With blood transfusions and packing of uterus or cervix---------------------1
With blood transfusions and incision and drainage-----------------------------3
With blood transfusions and laparotomy for drainage-------------------------41
With other laparotomies-------------------------------------------------------------------With incision and drainage-for infection---------------------------------------------- 25
20
With packing of uterus or cervix--------------------------------------------------- .—
With laparotomy (appendectomy and salpingectomy) and perine
1
orrhaphy__________________________________________ _______________
1
With trachelorrhaphy and perineorrhaphy-----------------------------------------Blood transfusions (not with curettage) :
50
Only---------------------------------------- -------------------------------------------------------7
With incision and drainage for infection---------------------------------------------7
With laparotomies other than hysterectomies-------------------------------------H y sterectomies :
9
Only-------- ----------------------------------------------------------------------------------------2
With other operation---------------------------------- --------------------------------------Other laparotomies:
78
Only_________________________ _■
------- :----------------------------- r-----------------1
With incision and drainage for infection---------------------------------------------
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119
Incision and drainage for infection:
With other operation (exclusive of those with blood transfusion a lso)-Packing of uterus or cervix:
Only-------------------------------------------------------------------------------------------------With repair of lacerated uterus------------------------------------------ - - - ------------
2
„
£
Other operation-------------------------------------------------------------------------- ----------------------
.
Type not reported--------------------------------------------------------------------- — ---------
V
Many of the “ other laparotomies” were done for drainage of
peritonitis; others were salpingectomies or enterostomies. The
incisions for infection other than laparotomies were incisions of
abscesses or posterior colpotomies.
LA ST T R IM E S T E R
Operations for delivery
Of the 1,474 women who died of sepsis after reaching the last tri"
mester for whom there was a report on operation for delivery 573 (39
percent) had such an operation (table 67). The relationship of
operations aimed at delivery to the deaths from sepsis is different
from their relationship to the deaths from the other causes. In the
cases of placenta previa or eclampsia, for instance, the operation was
done on account of those conditions; but in cases of death from sepsis,
the sGpsis did not usually appear until after the^ operation the
operation being perhaps the result of placenta previa but the cause
of sepsis. For this reason the tables do not show whether operative
or nonoperative cases are more likely to result in death from sepsis
even though there were fewer operations for delivery among the women
who died from sepsis (39 percent) than among the women who died
from such other causes as puerperal hemorrhage (64 percent) and
albuminuria and convulsions (46 percent). Most of the women who
died of hemorrhage or convulsions following operative delivery had
not had time to develop sepsis.
.
,
,
Women who died of sepsis following operative deliveries developed
sepsis earlier than those who died of sepsis following spontaneous
deliveries. This is discussed more fully on page 121.
Operations not for delivery
Operations in the last trimester other than for delivery, however,
were far more numerous among women who died of sepsis than among
those who died of other causes. Although these operations were
usually performed on account of the sepsis, they may at times have
actually brought about the fatal termination of the disease. There
were, for instance, 100 women who had curettage among the 1,483
who died of sepsis after reaching the last trimester and on whom there
was a report as to type of operation other than for delivery (table 68).
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T
MATERNAL MORTALITY IN FIFTEEN STATES
67.— P r in c ip a l o p era tio n f o r d elivery p erform ed on w o m en d y in g f r o m
p u e rp e ra l sep ticem ia and o n all w o m en d y in g f r o m p u erp era l ca u ses w ho had
rea ch ed the last trim ester o f p reg n a n cy
a b le
Women who had re£iched last trimester—
Type of principal operation for delivery
Dying from all
puerperal causes
Number
Total_______________
Report on operation_________
Operation___________ ____
Cesarean section_____ _
Cesarean section following other operation . .
Forceps:
Alone___________
With dilatation of cervix_________ _
With version ..______
With manual removal of placenta:.________
With other operation______ . . .
Dilatation of cervix and version_______
Version........... ............
Dilatation of cervix___________
Manual removal of placenta__
Craniotomy or embryotomy following other
operation.... .......... ..........
Dilatation of cervix, version, and manual
removal of placenta.............
Breech extraction______
Other operation___________
.
Type not reported................
No operation.................
So report on operation_______
Dying from puerperal
septicemia
Percent
distribution
Number
Percent
distribution
1 ñ29
4,965
4,832
100
1,474
100
2 ,2 2 5
46
573
39
469
62
10
1
112
28
8
2
518
150
64
24
60
224
218
108
87
11
3
1
11
1
2
1
5
5
2
2
165
13
24
6
9
25
64
21
40
57
1
27
48
42
85
9
1
1
2
7
10
18
4
'
(0
0)
2,607
54
133
(i)
1
2
4
1
3
2
(i)
1
1
0)
901
61
55
1 Less than 1 percent.
T
68.
P r in c ip a l o p era tio n other than f o r d eliv ery p erform ed o n w o m en d y i n g
f r o m p u erp era l sep ticem ia a n d o n all w o m en d y in g f r o m p u erp era l ca u ses w ho
had reached the last trim ester o f p r eg n a n c y
a b le
Women who had reached last trimester—
Type of principal operation other than for delivery
Dying from all
puerperal causes
Number
Total____ _________ _________ ________ ________
Report on operation________________________________
Operation______________________________________
Curettage:
Alone______________ ______ _____________
With blood transfusion___________________
With incision and drainage and blood trans
fusion____ ____ ________________________
With other operation_____________________
Blood transfusion only.______________________
Blood transfusion and packing of uterus or
cervix________________ ____________________
Packing of uterus or cervix___________________
Hysterectomy only or with other operation.......
Other laparotomies______________________ . . . .
Incision and drainage for infection....____ _____
Incision and drainage for infection and other
operation__________ ______________ ____ ____
Other operation______________ _______________
Type not reported.............................. .............. ”
13
121
34
110
45
0
18
35
2
(0
No report on operation........................... ........................
126
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2
m
&
0
4,203
Less than 1 percent.
100
13
2
9
149
No operation__________________________________ _
1
Percent
distribution
4,965
4,839
636
84
14
Dying from puerperal
septicemia
Number
Percent
distribution
1,529
1,485
393
100
26
77
13
5
1
2
8
95
0
3
3
1
2
1
7
16
13
83
41
0)
1
18
18
2
87
1,092
0
44
l
6
1
1
6
3
1
1
0
74
121
PUERPERAL SEPTICEMIA
The blood transfusions which were done in these cases sometimes
were for the sepsis itself but more often were done on account of
hemorrhage. Blood transfusion was known to have been performed
on 64 women who later died of sepsis and who did not have hemor
rhage.
INTERVAL BETWEEN DELIVERY AND APPEARANCE OF SYM PTOM S
Puerperal septicemia after the last trimester of pregnancy was
reached—or roughly after delivery rather than after abortion or
ectopic gestation—caused the deaths of 1,529 women
Onset of
labor was spontaneous for most of these women— 1,386 (94 percent)
of the women for whom a report as to onset was obtained, termina
tion of labor was spontaneous in 65 percent of the cases m which
information as to termination was obtained; it was artificial in ¿4
^Sym ptom s of sepsis developed more quickly among the women
who had had operative deliveries than among those who delivered
spontaneously. More of the women with operative dehvenes showed
69.— T im e between delivery and appearance o f sym ptom s ™ dJ g P eh °f.
term ination o f labor am ong wom en dying fro m pu erperal septicem ia who had
reached the last trim ester o f pregnancy
T able
Women dying from puerperal septicemia who had reached last
trimester
.
Time between delivery and appear
ance of symptoms
'Total
......... .....................
Time reported-....................................
Before delivery..............................
Less than 2 days after delivery—
2 days, less than 1 week------------1 week or more-------------------------
Having
spontaneous
termination
Total
Having
artificial
termination
Having
no ter
mina
tion 1
Percent
Percent
Percent
Num distri Num distri Num distri
ber
ber
ber
bution
bution
bution
1,529
1,303
196
328
602
177
226
100
15
25
46
14
No.report on
termi
nation
958
507
11
53
802
wiT
«T
100
11
16
12
19
53
17
92
176
173
33
19
37
36
7
11
93
150
422
137
156
33
2
7
7
37
i Percent distribution not shown because number of women was less than 50.
svmptoms of sepsis before delivery (19 percent) than women with
spontaneous deliveries (12 percent), and nearly twice as large a pro
portion (37 percent with operative deliveries as compared with 19
percent with spontaneous) developed sepsis within the first 2 days
after delivery (table 69).
.
.
,.
,
Similarly, among the women concerning whom the time of onset
of symptoms was reported, 14 percent of the 1,206 women f° r whom
labor began spontaneously and 30 percent of the 74 women who had
operative or medical induction of labor developed sepsis before the
actual delivery. Twenty-five percent of the former and 32 percent
of the latter developed sepsis within 2 days after delivery, but this
difference is not statistically significant on account of the smallness
of the group.
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MATERNAL MORTALITY IN FIFTEEN STATES
The time between delivery and the appearance of the first symp
toms of sepsis was reported in 1,303 of the 1,529 cases of women who
died from sepsis after reaching the last trimester of pregnancy.
Symptoms of sepsis, such as fever, sometimes with chills or purulent
vaginal discharge, appeared before the actual delivery in 196 cases
(15 percent); within 2 days after delivery in 328 cases (25 percent);
between 2 days and a week after delivery in 602 cases (46 percent);
and a week or more after delivery in 177 cases (14 percent).
The 196 cases in which symptoms of sepsis appeared before the
actual delivery were studied for the presumable cause of the sepsis.
Long labor, early rupture of membranes, or attempts at delivery,
alone or in combination, were apparently responsible in 53 cases, and
one or more of these and some other factor in 7 cases. An infectious
disease (usually respiratory) at the time of labor was the probable
source of the sepsis in 38 cases. Macerated fetus was associated with
sepsis in 18 cases, pyelitis in 15, gonorrhea or pelvic inflammatory
disease in 11, and some other possible cause in 22. In 32 cases no
probable reason for the development of sepsis was given.
In general, symptoms of sepsis appeared earlier in relation to
delivery in women who had longer labors, as is shown in table 70.
T able 70.— T im e between delivery and appearance o f sym ptom s and hours in labor
am ong women dying fro m pu erperal septicem ia who had reached the last trim ester
o f pregnancy
Women dying from puerperal septicemia who had reached last trimester
Hours in labor
100
151
76
160
Not reported
68
Percent dis
tribution
100
210
Number
194
36 or
more
Percent dis
tribution
100
296
Number
275
24, less
than 36
Percent dis
tribution
100
Number
393
363
12, less
than 24
Percent dis
tribution
34
31
Number
100
6, less
than 12
Percent dis
tribution
T o ta l-...................... 1,529
Time reported.................. 1,363
o
so
fc
Number
Percent dis
tribution
Less than
6
Number
T im e between delivery
and appearance of symp
toms
Total
360
100
221
25
Before delivery______
Less than 2 days after
delivery___________
2 days, less than 1
week______________
1 week or more. _
196
15
10
59
16
26
9
21
11
15
22
40
26
328
25
11
76
21
60
22
61
31
27
40
65
43
28
602
177
46
14
8
2
168
60
46
17
149
40
54
15
87
25
45
13
21*
5
31
7
42
4
28
3
127
41
Time not reported-..........
226
3
30
21
16
8
9
139
1 Percent distribution not shown because number of women was less than 50.
ATTENDANT AT BIRTH
The questions of the attendant at birth, the technique of delivery,
and the nursing and aftercare of the patient are of particular interest
in these cases of death from sepsis.
Sepsis was the cause of a larger proportion of the deaths of women
who had been attended at delivery by midwives than of women who
had been attended by physicians. Of the 550 women who died after
reaching the last trimester who had been attended by a midwife,
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PUERPERAL SEPTICEMIA
123
or a midwife and a physician, or a midwife and an interne, 239 (43
percent) died of sepsis. Of the 4,065 women who died after being
attended at delivery by physicians, internes, or medical students
(exclusive of those attended by physicians and internes following
midwives or other attendants) 1,177 (29 percent) died of sepsis.
However, all but 24 of the women who died of sepsis after reaching
the last trimester eventually had the care of a physician before death,
no matter by whom they were delivered. Four hundred and ninety
of them received hospital care throughout their illness. Of the
women delivered outside hospitals the physician made his first
postpartum call 1 day or less after delivery in 544 cases, 2 days after
delivery in 66 cases, 3 or 4 days after delivery in 71 cases, and 5 days
or more after delivery in 121 cases. In 213 cases the time of the
physician’s first call was not reported.
NURSING CARE
Information on musing care at home was obtained in the cases
of 778 women who died from sepsis after reaching the last trimester
and who were outside hospitals at least part of the time during their
illness. Only 32 of these women had the regular care of a trained
nurse; 17 more had the care of a visiting nurse. A practical nurse did
the nursing of 82 women, and a midwife of 62 women. Members of
the family or other untrained persons nursed 402 women who died of
sepsis, and 183 women were said to have had no nursing care, although
very casual and unskilled care was probably what was meant in most
cases. Some of all these groups were later taken to hospitals.
TECHNIQUE OF PRINCIPAL PHYSICIAN
A S E P S IS
The delivery technique of the physician in charge was reported in
1,114 cases of women who died of sepsis after pregnancies lasting into
the third trimester. The technique was said to be aseptic in 445 cases
(40 percent) (usually hospital cases); attempt was made at asepsis
but under conditions making its attainment unlikely, in 158 cases
(14 percent); a technique in which there was ordinary cleanliness was
used in 405 cases (36 percent); in 106 cases (10 percent) even ordinary
cleanliness was lacking. Moreover, the physician finally in charge
was preceded in 179 cases by a midwife or by some other unskilled
attendant or by another physician with less careful technique
(table 71).
It is of some interest to compare these figures with those for women
dying of puerperal causes other than sepsis after reaching the third
trimester. Of these there was a report on technique in 2,505 cases,
with 1,295 cases (52 percent) aseptic, 352 (14 percent) attempted
aseptic, 694 (28 percent) clean but not sterile, and 164 cases (7
percent) dirty.
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MATERNAL MORTALITY IN FIFTEEN STATES
T a b l e 71.— A ttendant at confinem ent and technique o f 'principal ph ysicia n 1 am ong
'
white and colored women d yin g fr o m pu erperal septicem ia who had reached the
last trim ester o f pregnancy
TOTAL
Percent2
Number
Percent2
445
40
158
14
1,086
427 1 r
I 48
1,128
25
24
990
24
22
384
22
21
39
147
1
15
m
66
15
28
7
64
1
14
1
22
7
Followed bÿ interne or student - .
163
75
i
Other attendant................................
62
18
8
47
15
13
3
Total
Preceded by interne or student 4,_
Midwife__________________________
—
Dirty
<
ox>
Number
Number
1, lié
1,177
Total
Total________________________ 1,529
Clean,
not
sterile
a
<D
1-D
4
<
P-l
405
36
106
10
154
866
85
95
9
141
365
1
37
94
9
138
1
2
11
85
54
8
12
11
11
35
55
8
13
ii
1
8
4
8
2
3
4
3
2
No physician or attend
ant not reported
At
Aseptic tempted
aseptic
Attendant at confinement
Number
Technique of principal physician reported
1 Technique of physician
not reported
Women dying from puerperal septicemia who had reached last
trimester
261
168
163
4-7
47
28
28
28
28
W H ITE
942 381
40
145
15
335
36
81
9
135
908
873
IT
189
16
819
85
77
8
128
999
19
18
872
19
17
340
17
16
39
138
1
_
16
318
1
36
76
9
127
M idwife.............................................-
100
24
6
8
____
18
Followed by interne or student. .
71
28
i
23
1
5
1
Other attendant--............................. -
49
10
2
Followed by physician.................
37
12
10
2 —-
T o ta l-........................................ 1,218
1,036
Preceded by interne or student4-
_
1
1
____
2
141
—
6
71
71
13
2
5
—
8
2
2
3 —-
3
2
3
8
—
—-
2
87
37
18
15
18
15
1
1 Includes interne or student. When there was more than 1 physician the one who did the actual de
livery or who was finally in charge if the woman died undelivered was called the principal physician.
2 Percent not shown where number of women was less than 50.
s Includes 76 cases (59 white and 17 colored) classed as aseptic, 4 cases (all white) classed as attempted
aseptic, and 5 cases (3 white and 2 colored) classed as clean, not sterile, in which the physician had been
preceded by another physician with less careful technique.
* Includes 3 cases (1 white and 2 colored) classed as aseptic in which the physician had been preceded also
by another physician with less careful technique.
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PUERPERAL SEPTICEMIA
T a b le 71. — Attendant at confinement and technique of principal physician among
white and colored women dying from puerperal septicemia who had reached the
last trimester of pregnancy— Continued
COLORED
37
13
8
Ht
9
7
44 37
5
5
9
8
64
Number
41
25
15
19
37
18
u
IS
40
18
15
11
1
1
n
- -
6
_
6
22
—
6
—
6
70
311
172
m
m
Preceded by interne or student *-
129
6
6
118
5
5
Midwife_____ ____ ____ ____ - ..........-
139
41
9
92
47
41
9
IS
3
1
1
10
3
3
1
1
Total________________________
Physician............................................-
Only
Other attendant--...........................
10
8
4
47
No physician or attend
ant not reported
Dirty
|Percent
Clean,
not
sterile
|Percent
Number
Percent
Number
Total
Total
Percent |
At
Aseptic tempted
aseptic
Attendant at confinement
Number
Technique of principal physician reported
Technique of physician
not reported
Women dying from puerperal septicemia who had reached last
trimester
120
92
92
—
4
—
1
10
10
—
1
10
8
See footnotes 3 *, p. 124.
Of the women who were attended at delivery by physicians (in
cluding internes and medical students) and who died of sepsis, 34
percent were delivered with technique that was aseptic thrpughout
the confinement as far as is known; while of those who died of other
puerperal causes 48 percent were said to have been delivered with
completely aseptic technique. The proportion of cases in which
aseptic technique was used throughout the confinement is possibly
overestimated, as it is based on physicians’ memory of their own
procedure and on hospital records. Breaks in technique may have
occurred unnoticed ; at any rate, breaks were seldom recorded.
Unfortunately no inquiry was made as to the use of masks in the
delivery room. This was, however, probably infrequent at the time
these deaths occurred. M ost of the recent researches proving the
importance of spray-borne bacteria in the epidemiology of puerperal
sepsis have been published since this study was begun.
The frequency of aseptic technique was approximately the same at
the confinements of colored women and of white women who died of
sepsis. The technique of the principal physician at the confinement,
reported in 942 cases of white women, was described as aseptic in
381 cases (40 percent), attempted aseptic in 145 cases (15 percent),
clean but not sterile in 335 cases (36 percent), and dirty in 81 cases
(9 percent). At the confinements of 172 colored women for which the
technique was reported, it was aseptic in 64 cases (37 percent),
attempted aseptic in 13 cases (8 percent), clean but not sterile in
70 cases (41 percent), and dirty in 25 cases (15 percent).
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MATERNAL MORTALITY IN FIFTEEN STATES
VAGINAL EXAMINATIONS AND USE OF RUBBER GLOVES
Vaginal examinations and the use of rubber gloves by physicians
in charge of the confinement of these women who died of sepsis are
shown in table 72. This does not include vaginal examinations by
other physicians at these confinements, nor examinations by midwives
or nurses.
72.— Vaginal examinations and use of rubber gloves by principal physician 1
at confinement of women dying from puerperal septicemia and from all other
puerperal causes who had reached the last trimester of pregnancy
T able
Women dying from puerperal causes who had reached
last trimester
Vaginal examinations and cause of death
Use of rubber gloves by physician
Total
Used
Total............ .............................
Not used
Not
reported
Inappli
cable 2
4,965
3,162
688
455
660
Puerperal septicemia.... ........... ............
1,529
926
212
ISO
261
No vaginal examinations_________
Vaginal examinations____________
315
832
250
637
48
159
17.
36
1..................................
2 .................................
3 or more__________________
Number not reported________
238
156
262
176
211
129
167
130
19
25
84
31
8
2
11
15
No report on vaginal examinations.
Inapplicable2............................. .
121
261
39
5
77
All other puerperal causes.............. .......
8,436
2,236
476
825
No vaginal examinations_________
Vaginal examinations___, ________
774
1,933
574
1,551
141
325
59
57
1. . . « .................................. ........
2..................................
3 or more____________ _____
Number not reported________
633
409
509
382
524
342
385
300
81
63
117
64
28
4
7
18
No report on vaginal examinations.
Inapplicable2...................................
330
399
111
10
209
261
399
399
i When there was more than 1 physician the one who did the actual delivery or who was finally in charge
if the woman died undelivered was called the principal physician.
1 No physician or no report as to physician.
If the percentages are compared with those in cases of death from
other puerperal causes, they may be seen to be, in general, similar.
The chief differences are that more of the women who died of sepsis
had 3 or more vaginal examinations, and fewer of those who had 3 or
more vaginal examinations had had rubber gloves used.
Of the 656 women who died of sepsis after reaching the last trimester
and for whom information as to the number of vaginal examinations
was obtained, 262 (40 percent) had 3 or more vaginal examina
tions. Of the 1,551 women who died of other puerperal causes for
whom the number of vaginal examinations was reported, 509 (33
percent) had 3 or more vaginal examinations. Rubber gloves had
been used for 167 (67 percent) of the 251 women dying of sepsis as
compared with 385 (77 percent) of the 502 dying from other puerperal
causes who had 3 or more vaginal examinations and for whom a
report as to use of rubber gloves was obtained. The physicians
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PUERPERAL SEPTICEMIA
127
finally in charge of the delivery are known to have examined vaginally, three times or more without rubber gloves, 84 women who died
of sepsis after reaching the third trimester. This is 13 percent of the
635 women who died of sepsis for whom the number of vaginal exami
nations and the use of rubber gloves were reported. Of the 1,512
women who died of other puerperal causes and about whom these
same facts were known, 117 (8 percent) were examined three times or
more without rubber gloves by the physician in charge of the case.
RECTAL EXAMINATIONS
Rectal examinations only were made by the principal physician in
75 (13 percent) of the 569 cases of death from sepsis and in 108 (10
percent) of the 1,044 cases of death from other puerperal causes in
which information was obtained and in which there had not been an
operation for delivery-r-a difference that is not statistically significant.
PREPARATION OF PATIENT
Inquiries were made as to the preparation of the patient for opera
tion in cases of death from sepsis following therapeutic abortion or
operation for ectopic gestation as well as in delivery cases. Informa
tion was obtained as to shaving and scrubbing in 1,348 cases, includ
ing some cases of women delivered by midwives. Of these, 645 (48
percent) had been shaved and scrubbed; 263 (20 percent) were neither
shaved nor scrubbed; 428 (32 percent) had been scrubbed only; and
12 (1 percent) had been shaved only.
A report on the use of antiseptics was obtained in 1,356 cases.
Some antiseptic had been used in 1,094 (81 percent) of the cases;
none had been used in 262 (19 percent). At least 172 women who died
of sepsis had been neither scrubbed nor shaved, nor was an antiseptic
used. An antiseptic was used in the cases of 76 women, evidently with
the intention of making good the lack of other preparation.
HOSPITAL TREATMENT
Of the 2,948 women who died of puerperal septicemia, 1,950 (66
percent) had hospital treatment (table 73). Only 618 of them, how
ever, were known to have had their delivery or abortion in the hos
pital; 1,301 were known to have had their delivery or abortion out
side the hospital; 25 died undelivered; and for 6 the place of delivery
or abortion was^ not reported. The sepsis from which these women
died developed in the^ hospital in 420 of the 601 cases of women who
delivered or aborted in hospitals for whom place of development of
sepsis was reported, and in 26 cases of women who delivered or
aborted elsewhere. However, at least 69 of these 420 women had
had vaginal examinations or other vaginal manipulations which may
have been responsible for the sepsis before admission to the hospital.
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128
MATERNAL MORTALITY IN FIFTEEN STATES
T able
73.— Place of development of sepsis and hospitalization at delivery or abor
tion of women dying from puerperal septicemia
Women dying from puerperal septicemia
Place of development of sepsis
Total
Delivery
or abor
tion in
hospital
Delivery
or abor
tion not
in hospital
Place of
delivery
or abor
tion not
reported
Not de
livered
2,948
618
2,299
6
25
Hospitalized— ------ --------------------------------
1,950
618
1,301
6
25
Sepsis developed in hospital------------- -
446
420
26
Other septic cases in hospital, -----No other septic cases in hospital. —
No report on other septic cases in
hospital_______________________
51
1S9
47
134
4
5
256
239
17
Sepsis not developed in hospital--------Place of development not reported— ...
1,467
37
181
17
1,262
13
6
24
1
Total_______________ _____________
998
*
998
In the majority (256) of the 446 cases in which sepsis developed in
the hospital it was impossible to find out whether or not there had
been other septic patients in the hospital at the time. Other septic
cases had been in the hospital at the same time as 51 of these women,
but no other septic cases had been in the hospital at the same time as
the remaining 139.
.
. , ,
There were 898 hospital deaths from sepsis ol women who nad
reached the last trimester. But only 454 were delivered in the hos
pital, and 105 of the 454 were reported to have had vaginal examina
tion or attempted operative delivery before admission to the hospital.
These 105 constituted 27 percent of the 396 women delivered in the
hospital for whom a report was obtained as to manipulation.
INTERVAL BETWEEN DELIVERY OR ABORTION AND DEATH
Among the 2,948 women who died from puerperal septicemia the
interval between delivery or abortion and death was reported for
2 673 who aborted or were delivered before death. Death occurred
within the first week in 596 (22 percent) of these 2,673 cases; in the
second week in 804 cases (30 percent); in the third week in 454„cases
(17 percent); in the fourth week in 241 cases (9 percent), and later
than this, in 578 cases (22 percent).
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129
PUERPERAL SEPTICEMIA
SEPSIS DEATH RATES AM ONG W HITE AND COLORED AND URBAN
AND RURAL GROUPS IN THE DIFFERENT STATES
The mortality rates from puerperal sepsis were higher among colored
than among white women, and higher in the cities than in rural
districts. This is true of sepsis following delivery as well as of sepsis
following abortion. In tables 74, 75, and 76 the deaths from sepsis
are divided into those occurring after the beginning of the seventh
month of gestation and before that time the latter including sepsis
following abortion and ectopic gestation in the first two trimesters.
Sepsis caused the death of 1,403 women who had not reached the
last trimester of pregnancy, 1,324 of these 1,403 deaths following abor
tions. (See also Abortions, p. 105.) The differences in the mor
tality rates from sepsis in the different States are due in part to the
proportions of deaths from sepsis following abortion, and to the pro
portions of urban and rural and white and colored women in the
different States.3'
T able 74.— Number of deaths, mortality rate, and trimester of pregnancy among
white and colored women dying in urban and rural areas from puerperal septicemia
Women dying from puerperal septicemia
Trimester of pregnancy
Total
Last
First two
Color and area
Number
Rate per
Rate per
Rate per
10,000
10,000
10,000 Number
Number
live
live
live
births
births
births
Not re
ported
8,948
25.1
1,403
11.9
1,539
13.0
16
________ ___________
2,437
511
23.1
42.4
1,209
194
11.4
16.1
1,218
311
11.5
25.8
10
6
Urban__________ ________
1,643
33.5
819
17.8
719
15. 6a
5
1,316
227
31.1
59.8
721
98
17.0
25.8
592
127
14.0
33.5
3
2
1,405
19.6
584
8.3
810
11.3
11
1,121
284
17.7
34.4
488
96
7.7
11.6
626
184
9.9
22.3
7
4
White
Rural---------------------------White
____ ____________
3 See footnote 4, p. 131.
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.
130
MATERNAL MORTALITY IN FIFTEEN STATES
75. ■Number o f deaths, mortality rate, and trimester of 'pregnancy among
women dying from puerperal septicemia in urban and rural areas of each State
included in the study
T able
Women dying from puerperal septicemia
Trimester of pregnancy
Total
State
First two
Number
Total____
Alabama_______
California______
Kentucky______
Maryland...........
Michigan______
Minnesota_____
Nebraska............
New Hampshire.
North Dakota...
Oklahoma______
Oregon________
Rhode Island___
Virginia..............
Washington____
Wisconsin______
Last
Rate per
Rate per
Rate per
10,000
10,000
10,000
Number
Number
live
births
births
births
2,948
25.1
1,403
11.9
1,529
13.0
394
206
279
148
582
190
143
33
60
128
70
54
304
135
222
30.1
24.7
22.9
23.0
29.4
18.9
25.6
18.9
20.2
29.8
24.4
20.2
26.5
29.0
19.3
140
115
122
73
314
84
81
10
25
67
47
25
117
92
91
10.7
13.8
10.0
11.4
15.9
8.4
14.5
5.7
8.4
15.6
16.4
9.3
10.2
19.8
7.9
247
91
153
75
268
104
62
23
35
59
23
29
187
42
131
18.9
10.9
12.6
11.7
13.5
10.4
11.1
13.2
11.8
13.7
8.0
10.8
16.3
9.0
11.4
Not reported
16
7
4
2
2
1
URBAN
Total....... .
1.513
33.5
819
17.8
719
15.6
Alabama______
California______
Kentucky......... .
Maryland......... .
Michigan______
Minnesota_____
Nebraska.......... .
New Hampshire.
North Dakota...
Oklahoma_____
O reg o n .............
Rhode Island___
Virginia_______
Washington____
Wisconsin______
132
133
72
105
433
97
62
19
13
43
34
52
135
57.7
27.4
31.5
28.8
36.0
25.3
45.5
20.9
32.9
51.2
29.1
58
84
33
56
242
50
44
3
25.4
17.3
14.4
15.3
31.5
22.6
23
64
62
50
13.1
32.3
3.3
15.2
28.6
17.1
10.0
25.4
25.4
9.5
72
49
38
49
191
47
18
16
7
. 18
14
29
71
23
77
86
127
53.6
35.3
24.2
6
24
20
20.1
10.1
16.6
13.4
15.9
12.3
13.2
17.6
17.7
21.4
12.0
12.6
28.2
9.4
14.7
RU R A L
Total____
1,405
19.6
584
8.2
810
11.3
Alabama______
California_____
Kentucky_____
Maryland.........
Michigan______
Minnesota..........
Nebraska______
New Hampshire
North D a k o t a Oklahoma_____
Oregon...............
Rhode Island___
Virginia..............
Washington____
Wisconsin_____
262
73
207
43
149
93
81
14
47
85
36
24.2
20.9
20.9
15.5
19.2
15.0
19.2
16.7
18.3
24.6
21.2
5.4
18.9
22.2
15.2
82
31
89
17
72
34
37
7
19
43
27
2
53
30
41
7.6
8.9
9.0
6.1
9.3
5.5
8.8
8.4
7.4
12.4
15.9
5.4
5.9
13.6
6.6
175
42
115
26
77
57
44
7
28
41
9
16.2
12.0
11.6
9.3
9.9
9.2
10.4
8.4
10.9
11.9
5.3
116
19
54
13.0
8.6
8.6
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2
169
49
95
11
5
5
2
1
131
PUERPERAL SEPTICEMIA
76.— Number of deaths, mortality rate, and trimester of pregnancy among
white and colored women dying from puerperal septicemia in specified States
having 2,000 or more colored births annually
T able
Women dying from puerperal septicemia
Trimester of pregnancy
Total
State and color
First two
Number
Last
Rate per
Rate per
Rate per
10,000 Number
10,000 Number
10,000
live
live
live
births
births
births
Not re
ported
W H IT E
Alabama____________ ________
California____ _______________
Kentucky___________ ____ ___
Maryland____________________
Michigan______ ______ _______
Oklahoma___________________
Virginia_____________________
204
191
232
102
551
104
171
24.0
24.3
20.3
19.9
28.8
25.7
21.2
80
106
99
56
299
56
67
9.4
13.5
8.7
10.9
15.6
13.8
8.3
122
85
129
46
252
47
104
14.4
10.8
11.3
9.0
13.2
11.6
12.9
190
15
47
46
31
24
133
41.3
31.0
60.9
35.0
47.6
94.9
39.3
60
9
23
17
15
11
50
13.1
18.6
29.8
12.9
23.0
43.5
14.8
125
6
24
29
16
12
83
27.2
12.4
31.1
22.1
24.6
47.4
24.5
2
4
1
COLORED
Alabama_______ - ................... .
California.............. .......... .......
Kentucky____________________
M a r y la n d ..____. . . . . . . . . .
Michigan._______________ . . .
Oklahoma....................................
Virginia___________________ .
5
1
SEPTIC ABORTION IN THE DIFFERENT STATES
Deaths from sepsis following abortion make up a large proportion
of the deaths assigned to puerperal sepsis in the international classi
fication.4 In the 15 States of the study 45 percent of the sepsis deaths
followed abortion (table 77). In the individual States the propor
tion ranged from about a third in New Hampshire,- Alabama, Virginia,
and Wisconsin to nearly two thirds in Washington and Oregon. In
the 15 States one fourth of all the deaths attributed to puerperal
septicemia followed induced abortions. In the separate States the
proportion varied considerably. In Washington 48 percent of all
the puerperal-sepsis deaths on which there was a report followed
induced abortion, as compared with only 7 percent in Alabama.
This low proportion in Alabama is partly due to the large number
of colored maternal deaths in that State, as in general smaller pro
portions of maternal deaths are preceded by induced abortions among
colored women than among white women.
Mortality rates for sepsis following abortion and for sepsis not
following abortion in the various States are shown in table 78. These
are similar to the rates from sepsis in the first two and the last trimes
ter. The mortality rates from septic abortion ranged from 6 deaths
per 10,000 live births in New Hampshire to 18 in Washington. It is
of interest to note that the death rates from septic abortion were low
in New Hampshire and Rhode Island and in Wisconsin, Minnesota,
and North Dakota. They were highest in Washington, Oregon, and
Oklahoma, high in Nebraska and Michigan, and intermediate in the
Southern States.
* That is, in the 1920 revision. In the 1929 revision abortion with septic conditions (no. 140) is a separate
title. (See appendix B, p. 212.)
182748—34----- 10
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132
MATERNAL MORTALITY IN FIFTEEN STATES
T able 77.— Number and percentage of abortions of specified type among women
dying from puerperal septicemia in each State included in the study
Women dying from puerperal septicemia
Type of
Spon Thera Induced abor
No
taneous peutic
Total
tion
abor
abortion
abortion abor
abor
tion
not re
tion
tion
ported
State
Total
ta
T otal..................... .
Alabama___________ _____
Kentucky______ ____ _____
Michigan________________
Minnesota..... ...................
Oklahoma___________ ____
Oregon.................... .
......
Washington____ __________
*03
O
£
§
3
Z
2,948 2,931 1,324
394
206
279
148
582
190
143
33
60
128
70
54
304
135
222
387
206
275
148
581
188
143
33
60
126
70
54
304
134
222
135
102
118
70
296
77
80
10
25
67
45
25
109
85
80
t-4
ta
-4-3 ta
fi &© "fi' © fi© rO
©
©
o
a
S O
S~4 a
ta
3 © 3
©
© 3
P-4 Ä
Z Ph z
45 354
12
75
18
37
11
66
21
18
3
8
19
5
5
31
14
23
19
9
13
7
11
11
13
35
50
43
47
51
41
56
42
53
64
46
36
63
36
13
15
7
9
10
10
10
44
2 722
1
4
3
6
1
3
1 1
1
8
2
4
2
3
2
2
3
1
1
1
1
1 2
1 (2)
1
2
5 2
28
64
55
42
183
43
51
5
14
34
26
18
54
64
41
ta
©
Ö
rQ •fi
©
©
O
O
a
ta
©
© 3 ta
P*
z
25 204
ta
©
fi
rO
©
©
a
3
©
z - Ph
7 1,607
55
252
104
157
78
285
111
63
23
35
59
25
29
195
49
142
65
50
57
53
49
59
44
7
31
20
28
31
23
36
28
14
23
16
39
9
8
7
7
8
11
7
5
6
23
27
37
33
18
48
18
1
13
13
1
23
5
11
2
10
19
2
8
4
5
No report on abortion
Report on abortion
17
7
4
1
58
2
47
36 _____
54
64
1
37
64
1 Not shown where number of women was less than 50.
2 Less than 1 percent.
T able 78.— Mortality rate 1 from puerperal septicemia following abortion and not
following abortion in each State included in the study
Mortality rate1 from
puerperal septicemia—
State
Total_______________ ___ ____
Alabama------ ------------- --------- --------California_____________ ___________
Kentucky--------------------- ---------------Maryland_________________________
Michigan...... ...................- ..................
Minnesota________________________
Nebraska--------- ------------- --------------New Hampshire........................ ..........
North Dakota______ ______________
Oklahoma— ___________ _______ ___
Oregon________ _____ _________ ____
Rhode Island______________________
Virginia______ _____ - ............. ...........
W ashington______ _____ — ...............
Wisconsin___________ ___________—
1 Deaths per 10,000 live births.
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follow
Following Not
ing abor
abortion
tion
11.3
13.7
10.3
12.2
9.7
10.9
15.0
7.7
14.3 5.7
8.4
15.6
15.7
9.3
9.5
18.3
7.0
19.2
12.4
12.9
12.1
14.4
11.1
11.3
13.2
11.8
13.7
8.7
10.8
17.0
10.5
12.4
PUERPERAL SEPTICEMIA
133
CO M M EN T B Y AD VISO RY CO M M ITTEE
That 40 percent o f all the deaths in this study were o f women who
had such obvious and unmistakable signs o f sepsis that there could
be no question how they should be classified shows clearly the serious
condition presented by this cause o f maternal death.
The outstanding findings in regard to abortions followed by septi
cemia have already been commented on in the section on that subject.
No matter how the figures are analyzed, it is clear that the loss
o f life from sepsis is enormous. That in the last trimester o f preg
nancy 1,529 women of this series died o f sepsis, 94 percent of whom
had a spontaneous onset o f labor and 65 percent a spontaneous
termination o f labor, is nothing short o f appalling.
In this series o f deaths the midwives had a larger percentage of
deaths from sepsis than physicians. This fact, however, does not
by any means take the onus of this state of affairs from the physi
cians. Lack of adequate nursing care at home undoubtedly had
something to do with these bad results, but the ultimate responsi
bility for these deaths rests on the delivery technique o f the physi
cian. That technique was classed as aseptic in only 40 percent of
the cases in which it was reported upon, and these usually occurred
in hospitals. The frequency of vaginal examinations without gloves
is to be noted, as well as the relative infrequency of rectal examina
tions. Preparation of the patient in the majority o f the cases was
inadequate. It is not surprising to find that under these conditions
sepsis developed much earlier in operative cases than in spontaneous
deliveries. It is also to be noted that in cases of long labor signs of
sepsis appeared earlier.
The deaths of 420 women delivered in hospitals from sepsis that
developed in the hospital show clearly that the technique in the
hospitals was unsatisfactory.
In many of the septic deaths classified as abortions the physician
surely cannot be held responsible. It is admitted that many were
induced, and there is no way o f telling how many of the so-called
spontaneous abortions also were induced. Moreover, infection was
present in many of these cases when the physician was called. But
the frequency with which curettage was done on these septic cases is
not justifiable.
In the cases in the last trimester there is no such excuse for the
bad results obtained as may be offered in the abortions. Complica
tions were present in many instances in the last trimester, and
operative procedures were necessary, but these facts do not excuse
the physicians for the poor technique which they themselves
admitted.
What is the reason for the existence of this condition? It is
due to lack o f proper teaching of obstetrics in some of the medical
schools, lack o f opportunity to deliver a sufficient number of normal
cases, and almost total lack o f experience in the simplest obstetric
operating, or else it is due to the willful disregard by careless
physicians of the fundamentals o f asepsis.
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134
MATERNAL MORTALITY IN FIFTEEN STATES
'w The large number of fatal cases of puerperal infection are in
the majority o f instances due to infection that is introduced from
without. Its prevention, therefore, lies in carrying out proper
obstetric procedures, consisting chiefly of proper aseptic technique
and carrying out only definitely indicated obstetric operations. It
must be remembered, however, that there are a certain number o f
cases o f puerperal infection which are endogenous in character;
that is, they are due to organisms which the patient harbors chiefly
in her birth canal. This type of infection forms another obstetric
problem.
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PUERPERAL PH LEGM ASIA ALBA DOLENS, EM BOLUS,
SUDDEN DEATH
In the States and years of this study 337 deaths were assigned to
phlegmasia alba dolens, embolus, sudden death (number 147 of the
International list) from information given on death certificates.1 At
interview with the attending physicians 51 of these deaths were
attributed to other causes— most of them to puerperal sepsis or
puerperal hemorrhage and 3 to nonpuerperal causes. However, 58
deaths were added to the original group as a result of additional
information or of the physician’s change of opinion— 26 from the
indefinite classification “ other accidents of labor” , 19 from puerperal
albuminuria and convulsions, 7 from accidents of pregnancy, 4 from
septicemia, and 2 from puerperal hemorrhage. The group attributed
to this cause, after interview, therefore, numbered 344.
Not all deaths for which puerperal phlebitis, embolism, or sudden
death appears on the certificate are assigned to that cause in the
international classification. Ectopic gestation, puerperal hemorrhage,
Cesarean section, operative delivery, ruptured uterus, puerperal
sepsis, and puerperal albuminuria and convulsions, as well as some
nonpuerperal causes, take precedence. Deaths attributed to these
puerperal causes for which puerperal phlebitis or embolism was given
as the principal contributory cause numbered 242, for 123 of which
the primary cause was puerperal sepsis.
The heading “ phlegmasia alba dolens, embolus, sudden death” in
Itself indicates a certain amount of vagueness. Phlebitis, strictly
speaking, is a manifestation of puerperal infection, and the symptoms
of embolus are not always definite. The diagnosis was not always
clear, and in many cases the exact cause of death was unknown and
could not be demonstrated. An autopsy was reported in only 25 cases.
Some of the deaths may have been due to other causes, but the
attending physician believed the deaths due to embolism, and they
were so included.
DEATHS ATTRIBUTED TO EM BOLISM
Of the 344 deaths attributed after interview to phlegmasia alba
dolens, embolus, sudden death, 303 were attributed to embolism, in
most cases pulmonary; 10 to thrombosis, coronary, cerebral, or
mesenteric; 10 to phlegmasia alba dolens; and 21 to “ sudden death.”
The following history is typical of the deaths from embolism:
The patient had a normal delivery and a normal puerperium until the ninth
day, when on getting out of bed she was seized with a pain in her chest, became
dyspneic and cyanotic, and died immediately.
Phlebitis was diagnosed either clinically or at autopsy in 52 of the
303 cases in which death was thought due to embolism. Only those
cases were included here in which there were no other gross evidences
1 Puerperal phlegmasia alba dolens, embolus, sudden death is no. 148 in the 1929 revision of the Inter
national List of Causes of Death.
135
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136
MATERNAL MORTALITY IN FIFTEEN STATES
of puerperal infection. Even though these deaths and some others
were actually due to puerperal infection, the international classifica
tion was followed in attributing them to this group.
Of the 303 deaths attributed to embolism, 10 occurred during deliv
ery. The diagnosis may be questioned particularly in these cases.
In one case embolism was proved by autopsy. In two the histories
were particularly suggestive of ruptured uterus, though the attending
physicians favored diagnosis of embolism.
Of the 303 women whose deaths were attributed to embolism, 220
were said to have had respiratory distress, 41 were said not to have
had it, and for 42 no information was obtained on this point. Cya
nosis was reported present in 197 and not present in 53; for 53 there
was no report. Cyanosis was reported present in 183 of the 220
embolus cases with respiratory distress, and 28 of the 41 women said
to have had no respiratory distress were reported to have had no
cyanosis. In many cases there was no report oh one or on both of
these symptoms, a circumstance probably due to the suddenness of
the death. That the absence of reported cyanosis or respiratory
distress does not rule out embolism is shown in the following case:
The patient had a normal delivery, first-degree laceration. The puerperium
was normal. There was no rise in temperature after delivery or throughout the
puerperium; no pains in groins or legs. On the morning of the ninth day three
silkworm gut sutures were removed. In the afternoon when the patient was put
into a wheel chair she was seen to slip down in the chair. She was put back to
bed and died within ten minutes. Dyspnea and cyanosis were said to be absent.
The autopsy showed a large embolus in the left pulmonary artery. The site of the
primary phlebitis with thrombosis was found in the left hypogastric vein. There
were no gross evidences of pelvic infection. Microscopic sections of the uterine
wall revealed “ low-grade myometritis but no acute infection.”
DEATHS FOLLOWING ABORTION
Abortions preceded 44 of the 53 deaths of women who had not
reached the third trimester, which were attributed to puerperal phleg
masia alba dolens, embolus, sudden death. The abortion was said
to have been spontaneous in 25 cases, induced in 13 cases, therapeutic
in 4 cases, and of unknown type in 2 cases.
TYPE OF DELIVERY
The deaths of 291 women who had reached the last trimester of
pregnancy were attributed to phlegmasia alba dolens, embolus, and
sudden death. Of these women 12 died undelivered, and for 7 the
termination of labor was not reported. Of the 272 who were delivered,
delivery was spontaneous for 203 women (75 percent) and artificial
for 69 (25 percent). This is a larger proportion of spontaneous deliv
eries than was found among women whose deaths were attributed to
any of the important puerperal causes. (Deaths from embolism in
connection with Cesarean section or other operative deliveries are
ordinarily assigned to the operation as a cause of death. In 40 such
cases phlegmasia alba dolens, embolus, sudden death was given as the
principal contributory cause.) In 31 of the 69 cases of artificial ter
mination of labor, 3 or more days elapsed between the operation and
death with symptoms of embolism; but in the remaining 38 cases
death came sooner-—in 14 of them 1 hour or less after delivery—
although usually with symptoms clearly suggestive of embolism. In
6 cases, however, the history was suggestive of ruptured uterus.
(Five of these died 1 hour or less after delivery.)
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PHLEGMASIA ALBA DOLENS, EMBOLUS, SUDDEN DEATH
INTERVAL BETWEEN DELIVERY OR ABORTION AND DEATH
Death occurred within the first day after delivery in 33 percent of
the 316 cases for which the interval between delivery or abortion and
death from phlegmasia alba dolens, embolus, sudden death was
reported, and within the first week in 46 percent. Twenty-nine per
cent of the deaths took place in the second week, 9 percent in the
third week, 8 percent in the fourth week, and 9 percent in the fifth
week or later. (See appendix table VI, p. 190.)
M ORTALITY RATES IN THE STATES AS RELATED TO OTHER
ACCIDENTS OF LABOR AND TO MEDICAL CARE
The mortality rate for puerperal phlegmasia alba dolens, embolism,
sudden death, based on the deaths attributed to this cause following
interview, varied from 1.0 per 10,000 live births for Kentucky to 7.4
for New Hampshire, the rate for the group of States during the period
of the study being 2.9 per 10,000 (table 79). If the State rates for
embolism are compared with those for other accidents of labor ex
clusive of Cesarean section and operative deliveries (no. 145c), also
shown in table 79, it will be seen that in general the States with
low death rates from embolism have high death rates from “ other
accidents of labor.” States with high death rates from puerperal
phlegmasia alba dolens, embolism, sudden death are usually the States
m which more women received medical attention before they were
moribund. It is likely, then, that some of the deaths attributed to
the vague “ other accidents of labor” would have been attributed to
embolism if more information had been obtained.
79.— Relation between mortality rates from puerperal phlegmasia alba
dolens, embolus, sudden death and (a) “ other accidents of labor” , and (b) percent
age of women having medical care before they were moribund among those who died
from all puerperal causes in each State included in the study
T able
State
Kentucky................................................................
Alabama.................................. ...... ...........
Virginia_____ ______ ____ ________
Oklahoma____________ ____________ ____ _
M aryland...____ __________________
California....................................
North D akota...____ _______ _______
Minnesota.......................................
Washington____________ _____ _________
Oregon____________ _______ ____ _____
Michigan_________ ____ ___ _____
Wisconsin....... ................... .....................
Nebraska________ ______ _________
Rhode Island_________ ________________
New Hampshire__________ ________
Percent of
women having
Mortality rate1
from puerperal Mortality rate1 medical care
before they
phlegmasia al from “ other
moribund
ba dolens, em
accidents of were
among
those
bolus, sudden
labor”
who died from
death
all puerperal
causes
1.0
1.9
1.9
2.1
2.5
2.5
3.0
3.1
3.2
3.5
3.8
4.0
4.5
5.2
7.4
3.2
6.0
4.7
4.7
3.0
3.5
4.4
2.6
3.9
2.1
2.6
2.1
2.7
3.4
2.9
85.7
83.9
88.0
94.6
92.7
92.6
87.3
93.8
91.1
92.1
94.7
93.8
94.2
94.5
95.4
Coefficients of correlation and probable errors:
(а) Mortality rate from puerperal phlegmasia alba dolens, embolus, sudden death, and “ other acci
dents of labor. ”
r= - 0 . 455±0.138
(б) Mortality rate from puerperal phlegmasia alba dolens, embolus, sudden death, and percentage of
women having medical care before they were moribund among those who died from all puer
peral causes.
r= + 0 .653 ±0.100
Deaths per 10,000 live births.
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MATERNAL MORTALITY IN FIFTEEN STATES
PROPORTION OF MATERNAL DEATHS AND M ORTALITY RATES
AMONG WHITE AND COLORED AND URBAN AND RURAL GROUPS
The proportion of maternal deaths due td puerperal phlegmasia
alba dolens, embolus, sudden death was the same among the urban
as among the rural women for both white and colored 5 percent of
each among the white and 2 percent of each among the colored. There
was some difference between urban and rural, however, in the rates
per 10,000 live births. The urban white rate was 3.4 and the rural
white rate 2.7; the urban colored rate was 2.9 and the rural colored
2.3. It is likely that these differences are due largely to differences in
diagnosis.
COM M ENT B Y ADVISORY CO M M ITTEE
Little comment on this section is necessary. This number in the
international list may cover many deaths of uncertain cause. A
death certificate under this heading is oftentimes accepted without
proper understanding of the circumstances of the death.
Twenty-five percent of the women who reached the last trimester
died following operative delivery. Some had symptoms clearly sug
gestive of embolism, but in others the history obtained was o f rup
tured uterus. Many of the spontaneously delivered patients showed
the classical symptoms o f embolism with no demonstrable phlebitis.
Thrombosis and embolism are the results o f infection; and so far as
infections are preventable, thrombosis and embolism are preventable.
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T O X E M IA S OF PREGNANCY
Thirty percent (2,221) of all the deaths in the study were preceded
by some presumably toxic condition as the chief cause or the chief
contributory cause. Most of these deaths— 1,900, or 26 percent of
the total— were due to puerperal albuminuria and convulsions (no. 148
in the International List of Causes of Death), and 220 that were
attributed to other primary causes had albuminuria and convulsions
as the principal contributory cause. Sixty-one deaths were attributed
to pernicious vomiting of pregnancy, and 40 more that were attrib
uted to causes other than albuminuria and convulsions had pernicious
vomiting as the chief contributory cause.
ASSIGNMENT OF TOXEMIAS ACCORDING TO INTERNATIONAL LIST
Deaths resulting from the toxemias of pregnancy are assigned in
the 1920 revision of the international list to various numbers, most of
them, as has been noted, to no. 148, puerperal albuminuria and con
vulsions. Under this heading are included deaths that were certified
by the physician as due to toxemia of pregnancy, to pyelitis or pye
lonephritis in pregnancy, or to eclampsia, acute nephritis, nephritis
vaguely defined, or uremia associated with pregnancy or childbirth.
But death certificates on which a cause ordinarily assignable to puer
peral albuminuria and convulsions appears in company with puerperal
sepsis, puerperal hemorrhage, ectopic gestation, or ruptured uterus
are assigned to these latter causes. Death certificates of women
between the ages of 15 and 45 containing terms suggestive of albumi
nuria and convulsions but unqualified by statement of pregnancy are
queried by the State divisions of vital statistics or by the United
States Bureau of the Census. As a result of queries sent out by the
Bureau of the Census alone, the number of deaths assigned to no. 148,
puerperal albuminuria and convulsions, in the United States deathregistration area was increased 3.5 percent in 1927 and 4.1 percent
in 1928.
Deaths certified as due to pernicious vomiting of pregnancy or
hyperemesis gravidarum, if the term appears alone, are assigned to
no. 143, accidents of pregnancy. But if any other puerperal cause
also appears on the death certificate the death is assigned to the
other cause. For example, a death certified as due to toxic vomit
ing of pregnancy would be listed with puerperal albuminuria and
convulsions.1
Nephritis definitely stated to be chronic (no. 129a) takes precedence
over puerperal albuminuria and convulsions and the less definite
puerperal causes. But all puerperal causes taking precedence over
puerperal albuminuria and convulsions, and also abortion, part of
1111 tho 1929 revision of the international list the toxemias are divided into puerperal albuminuria and
eclampsia (no. 146) and other toxemias of pregnancy (no. 147), which includes pernicious vomiting. The
rmes of precedence given in the text for puerperal albuminuria and convulsions apply to both new titles.
The new no. 146 takes precedence over the new no. 147; that is, a death certified as due to toxemia of preg
nancy would be assigned to no. 147, and one certified as due to toxemia of pregnancy with convulsions
would be assigned to no. 146.
139
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MATERNAL MORTALITY IN FIFTEEN STATES
other accidents of pregnancy, Cesarean section, and puerperal embo
lism, take precedence over chronic nephritis. Included in the study
were 65 deaths with a puerperal primary cause which had chronic
nephritis as a contributory cause.
Because of the precedence of chronic nephritis over certain puer
peral causes, a number of deaths of pregnant or parturient women
from chronic nephritis are lost entirely in the puerperal group. Just
how many were so lost in the years and States of the maternalmortality study is not known. However, the tabulation of contribu
tory causes of death in relation to primary causes, made by the
United States Bureau of the Census for the registration area in the
continental United States for 1925 (the last year in which such a
tabulation was made), shows that 206 of the 93,587 deaths assigned
to chronic nephritis had a puerperal contributory cause. It is
probable that there were other deaths of pregnant or parturient women
with the puerperal contributory cause not stated, as certificates show
ing nephritis definitely stated to be chronic (no. 129a) are not queried
as to whether or not there is a puerperal contributory cause. In the
death-registration area of 1925 there were 15,315 deaths assigned to
puerperal causes, a little more than twice the number included in
this study.
Every year there are more deaths from chronic nephritis among
women of child-bearing age than among men in the same age group,
though at other ages there are more deaths from chronic nephritis
among men. Some of this excess of female deaths in the 15- to 44-year
age group is undoubtedly due to deaths in which pregnancy played
some part. In the States and during the years of the present study
the deaths of 24,306 males and 19,887 females of known ages were
assigned to chronic nephritis. Of the deaths of males, 2,282 (9 per
cent) were in the 15- to 44-year age group and 22,024 at other ages.
Of the females 2,566 (13 percent) died in the 15- to 44-year age period
and 17,321 at other ages.
Deaths from acute yellow atrophy of the liver likewise are omitted
from the puerperal group, unless puerperal sepsis also appears on the
death certificate. In 1925 the number of deaths in the death-regis
tration area assigned to acute yellow atrophy of the liver (no. 120 in
the international list) was 469. Of these deaths 64 had a puerperal
contributory cause, but this is quite possibly an understatement of
the entire number with such a cause, as a contributory cause was given
in only 223 cases. Two deaths assigned to puerperal septicemia in
1925 had acute yellow atrophy of the liver as a contributory cause.
In the States in the death-registration area2 of that year, 273 of the
deaths from acute yellow atrophy of the liver were of females and
180 of males. The excess of female deaths was practically all in the
15- to 44-year age group.
PUERPERAL ALBUMINURIA AND CONVULSIONS
As a puerperal cause of death, albuminuria and convulsions was
exceeded in importance, numerically, only by puerperal septicemia.
In the last trimester of pregnancy it was of equal importance with
puerperal septicemia— each accounting for 31 percent of the deaths
of women in this period. Among the women in rural areas, both white
» Exclusive of registration cities in nonregistration States.
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TOXEMIAS OF PREGNANCY
141
and colored, in the last trimester, it was a cause of death of numeri
cally greater importance than sepsis. (See appendix table I, p. 183.)
CHANGES IN ASSIGNMENT OF DEATHS TO ALBUMINURIA AND CONVULSIONS
Nineteen hundred deaths were attributed after interview to the
group albuminuria and convulsions. Physicians had certified 2,006
deaths as due to this cause, but the interviews showed that incomplete
or incorrect information had been given for 180, so that only 1,826
of this group were correctly certified. The additional 74 making up
the 1,900 deaths were certified as due to other puerperal causes but
were shown by interview to have been due to albuminuria and
convulsions.
Of the 180 cases originally but incorrectly certified as due to albumi
nuria and convulsions, 140 were attributed after the interviews to
other puerperal causes— 69 to septicemia, 22 to accidents of pregnancy,
19 to embolus, sudden death, and 30 to various other causes. The
remaining 40 were shown by interview to be properly attributable to
nonpuerperal causes and hence were omitted from the study. Thirtytwo of the 40 were attributed to chronic nephritis. Most of these
were cases of women whose last pregnancies had occurred several
years before their death, or who had been in sufficiently serious con
dition to warrant a physician’s care before the onset of their last
pregnancy. There were probably many more deaths due, in the final
analysis, to chronic nephritis and pregnancy, which should have been
assigned to chronic nephritis; but the evidence in these other cases
was less definite and therefore they were not excluded.
PRIM ARY CAUSES OF DEATHS HAVING ALBUMINURIA AND CONVULSIONS AS CHIEF
CONTRIBUTING CAUSE
Of the 220 deaths attributed to other primary causes that had
albuminuria and convulsions as the principal contributory cause of
death, 168 were attributed to puerperal sepsis (see Puerperal Septi
cemia, p. 116), 44 to puerperal hemorrhage, 5 to ectopic gestation, 2
to abortion, and 1 to ruptured uterus.
TYPES OF TOXEM IA INCLUDED
For some of the 1,900 deaths having puerperal albuminuria and
convulsions as the primary cause it was possible to differentiate the
types of toxemia, but for many the exact diagnosis could not be made.
Often the patient was first seen by the physician when she was in
coma or convulsions, and was delivered at once, and died, so that a
complete history was not taken and no laboratory work was done.
Even when there was earlier medical attention, laboratory work other
than urinalyses and blood-pressure examination was seldom done,
and often there was not even blood-pressure examination.
For these reasons no attempt was made at pathologic classifica
tion of these deaths, but the following considerations may give some
idea of the types of toxemias included. Convulsions were known to
have preceded the deaths of 1,305 of the 1,900 women; 521 had had
no convulsions; and in 74 cases it was not ascertained whether or not
the women had had convulsions. Seventy-eight percent of the 814
known primiparae and 66 percent of the 946 known multiparae for
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142
MATERNAL MORTALITY IN FIFTEEN STATES
whom data on this point were obtained had had convulsions. In 130
of the 1,900 cases the toxemia could have been called pernicious
vomiting of pregnancy; these will be discussed in connection with the
other deaths from pernicious vomiting. (See p . 151.) Death occurred
before the women had reached the last trimester of pregnancy in 338
cases and after they had reached the third trimester in 1,549 cases; in
13 cases the duration of pregnancy was not known. Of the deaths
early in pregnancy some were associated with pernicious vomiting;
others were probably associated with chronic nephritis.
PRENATAL CARE RECEIVED
The prenatal care received by these women is shown in table 80»
Eight hundred and fifty-four (49 percent) of the 1,756 women who
had reached their third month of pregnancy before death and for
whom there was a report as to prenatal care had had some prenatal
care. This 49 percent includes 218 women (12 percent) who had had
80.— Trimester of pregnancy and grade of prenatal care received by white
and colored women dying from puerperal albuminuria and convulsions
T able
Women dying from puerperal albu
minuria and convulsions
Trimester of pregnancy and grade of prenatal care
Colored
White
Total
1.900
1,493
407
Grade I _____
Grade I I .— . .
Grade III.......
vUngraded___
None.............
Not reported.
Inapplicable I
218
159
463
14
902
127
17
205
149
398
12
616
96
17
13
10
65
2
286
31
Last trimester............ . .
1,543
1,210
SS9>
, 130
144
396
10
786
83
124
136
344
9
532
65
6
&
52'
1
254
18.
Total.
Grade I___________
Grade II__________
Grade III_________
U ngraded..............
None_____________
Not reported...........
SS8
276
62
Grade I______________________ _____
Grade II......................- ........... - ...........
Grade III____ *..............................—
Ungraded_________________________
None_____________________________ _
Not reported................... — .............. .
Inapplicable 1_____________________
88
15
67
4
116
31
17
81
13
54
3
84
24
17
7
2
13
1
32
7
Trimester and prenatal care not reported.
IS
7
e
First two trimesters_________________ _
i Induced abortions and cases in which pregnancy terminated before the third month.
good prenatal care (grade I); 159 (9 percent) who had had indifferent
care (grade I I ) ; 463 (26 percent) who had had poor care (grade I I I ) ;
and 14 (about 1 percent) whose care could not be graded. More of
the white women than of the colored women who died had had pre
natal care. (For criteria as to grades of prenatal care see Maternal
Care, p. 40.)
Table 80 also shows the grade of care received by the women who
died, according to trimester of pregnancy. The 338 women w;ho died
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TOXEMIAS OF PREGNANCY
before reaching the last trimester included 88 who had had grade I
care and 15 who had had grade II care. (These 338 cases include 163
in which a spontaneous, therapeutic, or induced abortion preceded
death, 174 in which there had been no abortion, and 1 in which there
was no report as to the termination of the pregnancy.)
The time that elapsed between the patient’s first visit to a physi
cian for prenatal care and her death, and the grade of care received
by patients who had been under a physician’s supervision for varying
lengths of time, are shown in table 81. Only about half of the
women who had had grade I care had begun their prenatal care as
much as 5 months before death. The period of pregnancy at which
the patient first saw a physician and the period of pregnancy at which
she died both affect the time during which the physician had the
opportunity to give her prenatal care.
81.— Time between first visit of patient to physician and death and grade of
prenatal care given to women dying from puerperal albuminuria and convulsions
T able
Women dying from puerperal albuminuria and convulsions
Time between first visit to
physician and death
Grade of prenatal care
Total
I
Total............................-
II
1,900
218
81
151
150
102
84
62
97
65
30
159
902
17
1
13
31
26
34
23
39
35
15
1
III
159
463
13
41
35
14
15
24
10
7
80
125
77
41
36
24
34
19
8
19
Un
graded
None
14
Not re Inappli
ported cable 1
902
127
17
1
1
12
902
127
17
* Induced abortions and cases in which pregnancy terminated before the third month.
COOPERATION OF PATIENT W ITH PHYSICIAN
The cooperation of the patient was said to be good in a little more
than half the cases in which a report on this point was obtained.
Criteria as to “ good” and “ poor” cooperation varied so widely
among the physicians interviewed, however, that this statement is
based on data representing only the expressed opinions of the indi
vidual physicians. The inquiry referred to cooperation after the
contact between physician and patient was established; the failure of
the patient to present herself early for prenatal care was not considered
poor cooperation.
It is of interest that about one third of the women who died of albumi
nuria and convulsions could not have cooperated because they were in
convulsions or in coma when first seen by the physician— or they were not
seen before death.
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MATERNAL MORTALITY IN FIFTEEN STATES
CH ART IX .—C O N D I T I O N W H E N F I R S T S E E N B Y P H Y S I C I A N O F W O M E N
W H O DIED F R O M P U E R P E R A L A L B U M IN U R IA A N D C O N V U LS IO N S
Percent
0
100
80
20
T o tal
White
U rban
Rural
Colored
W
U rb a n
Rural
///////M
—
Fair0
W
I I I
GoocL'’
CONDITION OF PATIENT WHEN FIRST SEEN BY PHYSICIAN
The findings on this important question— What was the condition
of the patient when she was first seen by the physician?— are given in
table 82.
The condition of the patient when she was first seen by a physician
in her present pregnancy was known in 1,723 cases. Of these women,
546 (32 percent) were in coma or were having, or had had, convulsions;
508 (29 percent) were otherwise in poor condition; 313 (18 percent)
were in fair condition; only 356 (21 percent) were in good condition.
More of the women who died in rural districts (36 percent) than in the
urban districts (25 percent) and a larger proportion of the colored
women (56 percent) than of the white (25 percent) were in coma or
had had convulsions when first seen (chart IX ).
The fact that only 54 percent of the urban white, 39 percent of the
rural white, 20 percent of the urban colored, and 11 percent of the
rural colored women who died of puerperal albuminuria and convul
sions and whose condition was reported, were in good or even in fair
condition when they were first seen by a physician is of tremendous
significance, particularly in consideration of the higher mortality rates
among the colored women. (See p. 16.)
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TOXEMIAS OF PREGNANCY
T a b l e 8 2 .—
Condition when first seen by physician, of white and colored women
and women dying in urban and rural areas from puerperal albuminuria and
convulsions
Women dying from puerperal albuminuria and convulsions
Condition of woman when first seen by
physician
Total
In urban areas
In rural areas
Percent
Percent
Percent
Number distribu Number distribu Number distribu
tion
tion
tion
Total.........................
1,900
Condition reported............
1,723
100
717
100
1,006
100
356
313
508
546
21
18
29
32
191
154
193
179
27
21
27
25
165
159
315
367
16
16
31
36
Good.......................
Fair......................
Poor____ _________
In convulsions or coma—
Condition not reported____
No physician____ _________
______________________________________
777
143
34
1,123
53
7
90
27
W HITE
Total........... ..............
1,493
Condition reported............
1,371
100
593
100
778
100
333
287
402
349
24
21
29
25
179
141
152
121
30
24
26
20
154
146
250
228
20
19
32
29
Good..................... ...........
Fair.................... ..........
Poor______________ .
In convulsions or coma............
Condition not reported.............
No physician______________
638
102
20
855
40
62
15
COLORED
T o ta l..................................
Condition reported....... .........
Good..........................
Fair..................................
Poor-....... ...............
In convulsions or coma...........
Condition not reported............
No physician........................
407
139
268
352
100
124
100
228
100
23
26
106
197
7
7
30
56
12
13
41
58
10
10
33
47
11
13
65
139
5
6
41
14
13
2
61
28
12
BED TREATM ENT AND HOSPITALIZATION
Other factors than prenatal care which are necessary for the pre
vention of deaths from toxemia are the early recognition of symptoms
by the physician and prompt and judicious medical treatment. (See
p. 153.)
Whether the patient goes to bed at the first appearance of symptoms
of toxemia depends on the patient as well as on the physician. Of the
1,618 women whose deaths were attributed to puerperal albuminuria
and convulsions and about whom information on this point was ob
tained, 426 did go to bed at first symptoms, but 1,192 did not.
Of the total of 1,900 women whose deaths were attributed to albu
minuria and convulsions, 1,029 (54 percent) were hospitalized and 869
(46 percent) were not; hospitalization was not reported for 2. The
great majority (866) of the hospitalized women did not reach a hos
pital until they were in a serious condition; 138 were sent to a hos
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MATERNAL MORTALITY IN FIFTEEN STATES
pital or were already in a hospital on the first appearance of symptoms ;
for 25 the condition at the time of hospitalization was not stated.
Of the 866 women who were not hospitalized until they were in a
serious condition, only 157 were stated to have been put to bed at
home at the first appearance of symptoms.
More of the white women who died than of the colored had had
hospitalization and bed treatment. Sixty-one percent of the white
women, but only 30 percent of the colored women, were hospitalized,
and of those that were hospitalized more of the colored women (94
percent) than of the white (85 percent) were in serious condition at
the time of hospitalization. Of those for whom the question of bed
treatment was reported, 29 percent of the white and 15 percent of the
colored women were said to have been put to bed at the first appearance
of symptoms.
A number of the women who were sent to the hospital at first symp
toms improved under treatment and were allowed to go home, only
to return in convulsions.
ONSET OF LABOR—ARTIFICIAL AND SPONTANEOUS
Twenty-six percent of those who died after reaching the last
trimester of pregnancy had had artificial onset of labor. This
includes 224 women who had had labor induced mechanically, such
as by bougie, bag, or manual dilatation— in many cases accouchement
forcé; 146 who had had Cesarean section when not in labor (see also
Cesarean Section, p. 94); 10 who had had medical induction, such as
pituitrin or quinine and castor oil; and 3 for whom the exact method
was not reported. Fourteen percent died before the onset of labor.
83.— Onset of labor and trimester of pregnancy among white and colored
women and women in urban and rural areas dying from puerperal albuminuria
and convulsions
T able
Women dying from puerperal albuminuria and convulsions
Total
In urban
areas
Colored
White
Trimester of pregnancy and
onset of labor
In rural
areas
Per
Per
Per
Per
Per
Num cent Num cent Num cent Num cent Num cent
ber distri ber distri ber distri ber distri ber distri
bution
bution
bution
bution
bution
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1,900
1,493
407
777
1,549
1,210
339
607
1,123
942
1,488
100
1,167
100
321
100
583
100
905
100
902
383
203
61
26
14
687
335
145
59
29
12
215
48
58
67
15
18
296
206
81
51
35
14
606
177
122
67
20
13
61
43
18
24
37
338
276
62
169
169
334
100
274
100
60
100
167
100
167
69
107
158
21
32
47
56
97
121
20
35
44
13
10
37
22
17
62
37
53
77
22
32
46
32
54
81
4
2
2
2
2
13
7
6
1
12
100
19
32
49
147
TOXEMIAS OF PREGNANCY
Of
women who died before reaching the last trimester, 47 percent
died before the onset of labor, 21 percent had spontaneous onset,
and 32 percent had artificial onset of labor.
. A larger proportion of the white than of the colored women who
died had artificial onset of labor (table 83).
Of the 361 women who died before the onset of labor, 158 died in the
urban and 203 in the rural areas. In the last trimester larger pro
portions of the women who died in the rural than in the urban areas
had had spontaneous onset of labor or no onset, while a larger propor
tion of the women who died in the urban areas had had artificial onset
of labor (table 83).
TERMINATION OF LABOR—ARTIFICIAL AND SPONTANEOUS
Of those who reached the last trimester nearly one fifth died unde
livered; of the remainder about half were delivered spontaneously and
i?
* Of the women who died before the last trimester
half died undelivered, approximately a fourth had spontaneous termi
nation of labor, and the remainder artificial termination (table 84).
A larger proportion of the colored women than of the white died
undelivered, but there was practically no difference in the proportion
of the deaths preceded by spontaneous delivery. Proportionately
more of the women who died in the urban than in the rural areas had
Termination of ^labor and trimester of pregnancy among white and
colored women and women in urban and rural areas dying from puerperal albumi
nuria and convulsions
T a b le 84.
Women dying from puerperal albuminuria and convulsions
Total
Trimester of pregnancy and
termination of labor
White
In urban
areas
Colored
In rural
areas
Per
Per
Per
Per
Num cent Num cent Num cent Num cent Num Per
cent
ber distri ber distri ber distri ber distri ber distri
bution
bution
bution
bution
bution
Total...............................
Last trimester......................
1,900
1,493
407
777
1,549
1, 210
339
607
Report on termination___
1,513
100
1,185
Spontaneous________
Artificial_________
No termination1_____
614
630
269
41
42
18
469
524
192
No report on termination.
First 2 trimesters-...........
100
40
44 ‘
16
1,123
942
328
100
595
100
918
100
145
106
77
44
32
23
187
301
107
31
51
18
427
329
162
47
36
18
36
25
11
12
24
338
276
62
169
169
Report on termination___
334
100
273
100
61
100
167
100
167
100
Spontaneous................
Artificial......................
No termination1_____
86
80
168
26
24
50
69
74
130
25
27
48
17
6
38
28
10
62
48
35
84
29
21
50
38
45
84
23
27
50
No report on termination..
Trimester not reported___
4
3
1
2
2
13
7
6
1
12
i
1Includes cases in which there was no issue and in which delivery was postmortem.
had operative deliveries, while more of the women who died in the
rural areas were delivered spontaneously (table 84).
182748—34----- 11
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MATERNAL MORTALITY IN FIFTEEN STATES
OPERATIONS FOR DELIVERY
Operative delivery comprised part or all of the treatment of many of
the women— 46 percent of those dying from albuminuria and con
vulsions after they reached the last trimester for whom information
as to operation is available. (See also Operations, pp. 68-69.) The
actual operations performed for delivery in the last trimester are
shown in appendix table X I (p. 196), and the type of principal opera
tion for delivery is given in table 85. In this table manual removal of
placenta is disregarded, and forceps and version combinations are
included with versions. Of the 288 dilatations of the cervix, alone or
in combination with other operation, 196 were known to be manual
dilatations. In 12 cases the method of dilatation was not given.
The 80 remaining dilatations were usually by bag but occasionally
by bougie, packing of the cervix, or incision of the cervix. In the
cases in which dilatation of cervix is given as the only operation the
patient either delivered spontaneously or died undelivered.
T able 85.— Type of principal operation for delivery performed on women dying
from puerperal albuminuria and convulsions who had reached the last trimester
of pregnancy
Type of principal operation for delivery1
Women dying from
puerperal albuminu
ria and convulsions
who had reached last
trimester
Number
Total........................................................
Percent
distribu
tion
1,549
813
702
701
100
200
52
112
152
101
62
22
29
7
16
22
14
9
3
1
34
i Unsuccessful attempts at these operations were listed with the operations.
DELIVERY BEFORE AND AFTER DEATH, AND CONVULSIONS
Of the total of 1,900 women who died of albuminuria and con
vulsions, 437 (23 percent) were not delivered before death, some of
them because they were moribund when the doctor arrived. (Three
hundred and ninety-six were never delivered, and 41 had postmortem
delivery, resulting in 10 live births.3) Of the group who died un
delivered and for whom a report as to convulsions was. obtained, 69
percent had convulsions.
* The time between the death of the mother and the birth of a living baby was said to be 6 minutes, 11
minutes, and 15 minutes in 1 case each. In 4 cases the delivery was done “ immediately ; in 1 case a
few minutes” was said to intervene, and in 2 cases there was no report.
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TOXEMIAS OF PREGNANCY
149
A number of women, both among those delivered before death and
among those not delivered before death, died in their first convulsion.
Of the women who died undelivered and had convulsions more than
half (56 percent) died less than 12 hours after the first convulsion
and about two thirds (69 percent) less than 24 hours afterward. Of
the women who were delivered before death and had convulsions
about one third (31 percent) died less than 12 hours after their first
convulsion and almost half (47 percent), less than 24 hours afterward.
Of the women who were delivered before death and who died after
having convulsions, 90 percent died within the first week after de
livery (or abortion) and 56 percent within the first day.4 About 2;
percent lived 4 weeks or more.
Of the women who were delivered before death and whose deaths
were attributed to puerperal albuminuria and convulsions but who did
not have convulsions, 63 percent died within the first week after the
delivery (or abortion) and 31 percent within the first day. Fourteen
percent lived 4 weeks or more.
LIVE BIRTHS AND STILLBIRTHS
Of the women who were delivered in the last trimester 807 gave
birth to live-born and 457 to stillborn children, and 18 had 1 liveborn and 1 stillborn twin. There were 16 live births before the last
trimester. Many of the other live-born infants also were pre
mature, but no data were obtained as to the survival of these children.
LARGE PROPORTION OF PREVIOUS KIDNEY DISEASE
Past medical histories could be obtained from the attendant at
delivery or death for only 38 percent of all the women whose deaths
are included in the study and for the same proportion of the women
who died of puerperal albuminuria and convulsions. The past
medical histones that were obtained were not all complete. HoweYe^ reference was made to some kidney disease in 240 (33 percent)
of the 729 past histories obtained for women who died of puerperal
albuminuria and convulsions. In the 2,105 medical histories obtained
of women whose deaths were attributed to other causes, kidnev dis
ease was mentioned in 175 cases (8 percent).
PARITY AND AGE
Puerperal albuminuria and convulsions caused 36 percent of the
deaths oi prmuparae; between 21 and 24 percent of the deaths of
Wi° S enjm ^ s e q u e n t pregnancies, including the seventh; 18 percent
of the deaths of women m their eighth and ninth pregnancies; and
24 percent of the deaths of women in their tenth or a later pregnancv.
lh is cause accounted for 18 percent of the deaths of women of un
known parity and 9 percent of the deaths of multiparae whose exact
parity was not given.
Mortality rates (deaths per 10,000 live births) could not be calcu
lated according to parity on account of the large number of women
whose parity was unknown. However, as primiparae and the mothers
of many children have, in general, higher maternal mortality rates
th“
n whose deaths followed convulsions andwereattributed topueroeral albuminuria anH
nnaraHwf^ir
who had had an operative delivery tended to die sooner, 64 percent of those with
operative delivery dying within the first day and 93 percent dying within the first week after the rieiiwonr
However, some women with toxemia died of sepsisYr of henTorK a n d ^
gj
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150
MATERNAL MORTALITY IN FIFTEEN STATES
than the mothers of two to six or seven children, the increased risk
of death from puerperal albuminuria and convulsions among primi
parae and among the mothers of 10 or more children is even greater
than is shown by the differences in the percentages of the total deaths
that are due to this cause. Some of the multiparae had had convul
sions in previous pregnancies, but it was impossible to obtain ac
curate data on this point.
Puerperal albuminuria and convulsions caused 41 percent of the
deaths of primiparae of less than 20 years, 37 percent of the deaths of
primiparae between 20 and 25 years old, and 29 percent of the deaths
of primiparae of 25 years or older.
The proportion of the deaths of multiparae due to puerperal albu
minuria and convulsions was about the same in the different age
groups— 19 or 20 percent— except in the age group 35 to 39 years,
where it was 23 percent, and in the age group 40 to 44 years, where
it was 28 percent.
PREVALENCE OF DEATHS FROM ALBUMINURIA AND CONVULSIONS AM ONG W HITE
AND COLORED AND AM ON G URBAN AND RURAL M OTHERS
Both the percentage of the total deaths that were due to puerperal
albuminuria and convulsions and the rates per 10,000 live births
were higher among the colored than among the white mothers (table
86). This greater prevalence of deaths from puerperal albuminuria
and convulsions among the colored women influences the total mater
nal mortality rates in the States having a considerable colored popu
lation, so that comparisons between the States can best be made
with white and colored taken separately. The highest death rates
from this cause among the white women were in Alabama and New
T a b l e 8 6 . — Number
and percentage of deaths and mortality rate among white and
colored women dying from puerperal albuminuria and convulsions in all the States
included in the study and in specified States having 2,000 or more colored births
annually
Women dying from puerperal albuminuria and convulsions
Total
White
Colored
State
Percent Rate per
Percent Rate per
Percent Rate per
Num
of all
10,000 Num
of all
10,000 Num
of all
10,000
ber puerperal
live
ber puerperal
live
ber puerperal
live
deaths
births
deaths
births
deaths
births
A L L STATES IN C LU D ED IN THE STUDY
Total...........
1,900
26
16.1
1,493
25
14.1
407
31
33.8
STATES H A V IN G 2,000 OR M ORE COLORED BIRTH S A N N U A LL Y
Alabama__________
California_________
K en tu cky............
Maryland_________
Michigan_________
Oklahoma..............
Virginia...................
412
102
169
85
281
83
217
37
21
26
22
21
28
28
31.5
12.2
13.9
13.2
14.2
19.3
18.9
206
95
152
63
265
73
104
1Not shown because number of deaths was less than 50.
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36
21
27
23
21
29
24
24.2
12.1
13.3
12.3
13.8
18.0
12.9
206
7
17
22
16
10
113
38
(0
20
20
21
20
33
44.8
14.5
22.0
16.7
24.6
39.5
33.4
151
TOXEMIAS OF PREGNANCY
Hampshire; the lowest, in Wisconsin and Minnesota. Among the
colored women in those States having 2,000 or more colored births
annually, the highest rates from puerperal albuminuria were in Ala
bama and Oklahoma; the lowest,in California and Maryland. It is
rather striking that for every 10,000 live births only about one fourth
as many white women in California as colored women in Alabama
died of puerperal albuminuria and convulsions. The mortality rate
from this cause for all white women included in the study was 14 per
10,000 live births, as compared with 34 for all colored women.
The mortality rate from albuminuria and convulsions was in gen
eral higher in the urban than in the rural areas (table 87).
There was, in general, a higher rate from puerperal albuminuria
and convulsions in those States in which fewer of the mothers who
died had had good prenatal care. (See Maternal Care, p. 54.)
87.— Number and percentage of deaths and mortality rate among women
dying from puerperal albuminuria and convulsions in urban and rural areas of
each State included in the study
T able
State
In rural areas
In urban areas
Total
Percent Rate per
Percent Rate per
Percent Rate per
10,000
of all
of all
10,000 Num
Num
of all
10,000 Num
live
ber puerperal
live
ber puerperal
ber puerperal
live
births
deaths
births
deaths
deaths
births
Total............ . 1,900
26
16.1
777
22
16.8
1,123
29
15.7
412
102
169
85
281
120
68
37
41
83
41
42
217
69
133
37
21
26
22
21
24
21
34
26
28
23
25
28
22
22
31.5
12.2
13.9
13.2
14.2
11.9
12.2
21.2
13.8
19.3
14.3
15.7
18.9
14.8
11.6
90
54
36
52
181
55
25
14
11
29
18
39
■ 76
34
63
31
18
24
20
20
24
20
26
39.4
11.1
15.7
14.3
15.1
14.4
18.3
15.4
27.8
34.6
15.4
16.9
30.2
14.0
12.0
322
48
133
33
100
65
43
23
30
54
23
3
141
35
70
39
25
27
26
26
24
21
42
23
26
24
29.8
13.7
13.4
11.9
12.9
10.5
10.2
27.4
11.7
15.6
13.6
8.1
15.8
15.8
11.2
Alabama__________
California........... .
Kentucky_________
Maryland_________
Michigan_________
Minnesota..............Nebraska_________
New Hampshire___
North Dakota.........
Oklahoma________
Oregon___________
Rhode Island_____
Virginia...................
Washington_______
Wisconsin....... ........
0)
31
22
25
28
19
20
(>)
29
26
23
1 Not shown because number of deaths was less than 50.
PERNICIOUS VOMITING
Pernicious vomiting of pregnancy was the primary cause of death
given for only 61 of the 7,380 women included in the study. It was
a contributing factor, however, in 191 other cases, of which 130
having albuminuria and convulsions as the primary cause are included
in the group already discussed under that heading. The total number
of cases in which death was associated with pernicious vomiting was
thus 252. As was explained on page 139, in the assignment of joint
causes every other puerperal cause takes precedence over “ other
accidents of pregnancy” , which includes pernicious vomiting.
The primary causes of death of these 252 women are shown in
table 88.
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MATERNAL MORTALITY IN FIFTEEN STATES
T able 88 .— Primary cause of death of women whose deaths were associated with
pernicious vomiting of pregnancy
Women whose deaths were associ
ated with pernicious vomiting of
pregnancy
Primary cause of death
As a pri
mary cause
Total
All causes_____ _______ _____ _______ - _____ ______
Accidents of pregnancy_______________________________ _
Puerperal hemorrhage_______ _____ _______ _____________
Other accidents of labor______ _____ _______________ ____
Puerperal septicemia___ _____ _____________________ !-----Puerperal phlegmasia alba dolens, embolus, sudden death
Puerperal albuminuria and convulsions_________________
252
61
86
1
4
26
5
130
61
As a contributing
factor
191
.
25
1
4
26
5
130
No pathologic distinction can be made between the 130 cases
associated with pernicious vomiting that were attributed to puerperal
albuminuria and convulsions as a primary cause of death and the 61
that were attributed to pernicious vomiting as a primary cause. The
diagnosis as between these two causes of death was largely a question
of nomenclature. As either grouping seemed to accord with the
international classification, the cause as given by the attending physi
cian was followed in the tabulations.5
Nearly all the women whose deaths were associated with pernicious
vomiting died before the seventh month, and most of them died
before the fifth month (table 89).
T able 89.— Period of gestation of women whose deaths were associated with pernicious
vomiting of pregnancy
Women whose deaths were asso
ciated with pernicious vomiting
of pregnancy
Period of gestation
As a
primary
cause
Total
Total_________ _______ __________________________ _____
First two trimesters___________________________________________
Less than 3 months_______________ _________________________
As a con
tributing
factor
252
61
191
m
56
165
30
81
69
17
18
6
8
31
15
1
1
22
50
54
16
17
6
SI
5
26
The duration of the pernicious vomiting before the physician was
called was given for 164 of the 252 deaths associated with pernicious
vomiting. The vomiting was of less than 1 week’s duration in 49
cases (but 19 of these women were said to have been already in poor
condition when first seen); of 1 to 2 weeks’ duration in 24 cases, with
s According the 1929 revision 221 of these deaths—86 from accidents of pregnancy; 5 from phlegmasia
alba dolens, embolus, sudden death; and 130 from puerperal albuminuria and convulsions—would probably
be assigned to other toxemias of pregnancy (no. 147).
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TOXEMIAS OF PREGNANCY
153
13 in poor condition; of 2 to 4 weeks’ duration in 28 cases, with 13 in
poor condition; and of 4 weeks’ duration or longer in 63 cases, with
48 in poor condition when first seen.
The condition that 227 of these 252 women were in when they were
first seen by the physician was noted. Twenty-nine women were
said to have been in good condition, 62 in fair condition, and 136 in
poor condition.
Pregnancy was interrupted artificially for 121 women, or 48 per
cent of the 250 women for whom pernicious vomiting was either a
primary cause of death or a contributing factor and concerning whom
there was a report on onset of labor. Labor or abortion set in
spontaneously in 47 cases (19 percent), and 82 women (33 percent)
died without labor or abortion.
Operation was known to have been refused by 19 of the 127 women
dying without operation whose deaths were associated with pernicious
vomiting either as a primary cause or as a contributing factor. No
report as to refusal was obtained for 59. A few of these women, as
well as some who did not refuse operation, had spontaneous abortions.
There were other cases in which the patients refused interruption of
pregnancy for varying lengths of time and finally consented to opera
tions when they were in very poor condition.
Of the 112 women who had therapeutic abortions 16 died of sepsis.
In addition to the group of 252 women already discussed, there were
140 women for whom pernicious vomiting was listed as a complication
o f pregnancy but whose deaths were not actually associated with the
condition. For some of these the toxemia soon revealed itself to be
o f a convulsive type, but for many of them the condition had improved
or the vomiting had ceased before the onset of the complication that
caused death.
COMMENT BY ADVISORY COMMITTEE
The chief method of attack against the severe toxemias of preg
nancy is conceded to be their early detection and control. For this
it is necessary to have continuous intelligent medical supervision
of the prospective mother from early in pregnancy, early recogni
tion of untoward symptoms, prompt and judicious treatment of
symptoms as they appear during pregnancy as well as during and
after actual delivery of the patient, and the cooperation of the
patient. It is true that a few patients developed toxemias and died
who apparently had all these safeguards. A small number of these
seemed to be true cases of fulminating eclampsia—fatal convulsions
developing a few days after a thorough examination at which noth
ing abnormal was found. Evidently, in the present state of medical
knowledge, death from toxemia cannot be entirely prevented. But
the vast majority of toxemic deaths were of women who lacked some
or all of the safeguards mentioned.
For many of the toxic deaths studied the physician was not re
sponsible because he saw the patient for the first time when the
condition was already acute or because the patient failed to follow
his advice. Three fifths of the women were in convulsions or coma
or otherwise in poor condition when the physician saw them for
the first time. Moreover, some of the women were seen early in
pregnancy and advised concerning prenatal care—but the advice was
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MATERNAL MORTALITY IN FIFTEEN STATES
not accepted. Others were seen in the preeclamptic stage and in
duction of labor was advised—and the advice was not accepted.
Evidently there is great need for the education of patients and
families.
*
^
On the other hand, the study reveals serious conditions for which
the physicians were responsible. Even though the occurrence of
toxemia cannot be entirely prevented, many of the deaths from this
cause can and should be prevented by the early recognition of symp
toms and prompt and judicious treatment by the physician in charge.
Some of the women (12 percent) had had what could be considered
as good prenatal care, and the symptoms of approaching toxemia
were promptly recognized during the latter part of gestation, but
treatment was at fault. Induction of labor (as distinguished from
accouchement forcé) was done in surprisingly few of these cases.
Prenatal care, so far as the toxemias of pregnancy are concerned,
will not save lives unless good clinical judgment and treatment are
used.
The number of women who died during the first convulsion was
rather surprising. Probably many more women die in this way than
is realized.
Probably it is now generally conceded that radical treatment in
eclampsia is never indicated except in the best environment and with
proper anesthetic. The dire results of teaching radical treatment
for eclampsia were manifest—almost universal resort to immediate
operative interference in all kinds of cases and by all kinds of prac
titioners. Cesarean section seemed to be too often regarded as
proper treatment for eclampsia. Oftentimes the sections were done
without regard to the profound shock from which many of the
patients were suffering and without due consideration for the proper
anesthetic. Operative interference of all sorts was frequent, even in
the cases of multiparous women; a majority of the operations were
done under general anesthesia, ether being used commonly and even
chloroform occasionally. Epigastric pain, which is a prodromal
symptom of eclampsia, was occasionally observed, and was almost
always treated as acute indigestion. There were more than occa
sional instances in which rising blood pressure was noted, but its
importance evidently was not realized. In many cases treatment
other than vague advice as to diet, or the prescription of a diuretic,
was far from prompt. In other cases (202) the treatment was an
immediate accouchement forcé, which, though prompt, would be
called judicious by no leader in obstetric thought today.
Few of these women were treated along the conservative lines now
accepted—with fluids, glucose, magnesium sulphate, and morphine or
other sedative and induction of labor. There can be no question
that failure to institute prompt treatment and the injudicious treat
ment they did receive contributed to many of the deaths. It is evi
dent, therefore, that some safe, conservative treatment for eclampsia
should be agreed upon and that knowledge of it should be widely
disseminated.
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PUERPERAL H E M O R R H A G E
Puerperal hemorrhage (no. 144 in the international classification),1
which was shown by interview to be the cause of death third in im
portance in the study, accounted for 791 deaths, or 11 percent of the
total. This includes 347 deaths attributed to placenta previa
(no. 144a) and 444 deaths attributed to other puerperal hemorrhage
(no. 144b); the latter figure includes 374 deaths from postpartum
hemorrhage and 70 from premature separation of placenta, “ adherent
placenta” , and other similar causes, as well as undefined puerperal
hemorrhage. There were also 61 women with placenta previa,
38 with premature separation of the placenta, and 519 with post
partum hemorrhage (these figures include some duplications) whose
deaths were attributed primarily to other causes, such as puerperal
sepsis.
In the Manual of Joint Causes of Death placenta previa takes
precedence over all puerperal causes except ectopic gestation and
puerperal septicemia, and other puerperal hemorrhage takes prece
dence over all puerperal causes except abortion, ectopic gestation,
certain “ other” accidents of pregnancy, ruptured uterus, and puer
peral septicemia. It should be noted that deaths following abortion
with hemorrhage are classified as due to abortion rather than to post
partum hemorrhage.
Of the 758 deaths assigned to puerperal hemorrhage by the Bureau
of the Census according to information on the death certificates, 703
were so attributed in this study after interview with the attendant;
37 of the other 55 were found to be actually due to abortion or to
puerperal sepsis, 2 were nonpuerperal, and the rest were due to other
causes. However, 88 deaths not originally assigned to puerperal
hemorrhage were attributed to this cause and added to the 703 on
account of information obtained in the interview; 41 of them had
previously been assigned to “ other accidents of labor.” (See Gen
eral Considerations, table 2, p. 10.)
PARITY AND AGE
Puerperal hemorrhage was definitely related to both parity and age.
It caused 7 percent of all deaths among primiparae as compared with
18 percent among multiparae. The percentage for multiparae was
higher than the percentage for primiparae in every age group under
40. The number of primiparae 40 and over were too few for com
parison. Among both primiparae and multiparae the percentage
tended to increase with age, the figures ranging among the primiparae
from 5 percent for those under 20 years of age to 15 percent for those
from 35 to 39 and among the multiparae, from 8 percent for those
under 20 to 18 percent for those 40 and over (table 90).
1 This title was not changed in the 1929 revision of the International List of Causes of Deaths.
155
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MATERNAL MORTALITY IN FIFTEEN STATES
T able 90.— Number of deaths from all puerperal causes and number and percentage
of deaths from puerperal hemorrhage in each age period among primiparae and
multiparae dying from puerperal causes
Women dying from puerperal causes
Total
Primiparae
Parity not re
ported
Multiparae
Age period
Puerperal
hemorrhage
Total
Puerperal
hemorrhage
Total
Num Per
ber cent
Puerperal
hemorrhage
Total
Num Per
ber cent*
Puerperal
hemorrhage
Total
Num Per
ber cent
Num Per
ber cent1
Total.....................
7,380
791
11
2,334
153
7
4,520-
608
13
526
30
6
Under 20 years..............
20 years, under 25.........
25 years, under 30.........
30 years, under 35______
35 years, under 40______
40 years, under 45______
45 years and over........ .
Not reported__________
880
1,545
1, 537
1,412
1,312
570
94
30
46
120
139
178
196
93
16
3
5
8
9
13
15
16
17
741
802
409
218
114
33
4
13
35
52
32
15
17
5
6
8
7
15
118
628
995
1,084
1,092
507
85
11
10
60
101
154
173
93
15
2
8
10
10
14
16
18
18
21
115
133
110
106
30
5
6
1
8
6
9
6
7
5
8
6
1
1
‘ Not shown where number of women was less than 50.
The percentage of deaths from puerperal hemorrhage rose rapidly
from 7 for primiparae to 10 for women in their second pregnancy and
to 13 for women in their third pregnancy. It remained at 13 percent
and 14 percent for women in the fourth to sixth pregnancy, then went
to 17 percent for the seventh pregnancy, 22 percent for the eighth
pregnancy, and 24 percent for the ninth pregnancy. It caused 21
percent of the deaths of the women with 10 or more pregnancies.
Six percent of the deaths of those of unknown parity and 8 percent of
the deaths of multiparae the exact number of whose pregnancies was
unknown were due to puerperal hemorrhage. In fact, puerperal hem
orrhage was second only to puerperal sepsis as a cause of death
among women with eight or more pregnancies, as it caused 22 percent
of the deaths in this group, while puerperal sepsis caused 32 percent
and puerperal albuminuria and convulsions 21 percent.
As has been stated, maternal mortality rates by parity could not be
accurately calculated in this study because of the large number of
women concerning whom exact information on number of pregnancies
could not be obtained, and because the data on parity obtained by
interviews for this study are apparently not strictly comparable with
those given in the tables on order of birth in the census reports.
(See General Considerations, p. 34.) However, there is evidence that
the general maternal mortality rate is higher for primiparae and for
the mothers of more than 7 or 8 children.2 Therefore the mortality
rate from puerperal hemorrhage is probably not so much lower for
first than for second births as the differences in percentage might
suggest. After the seventh or eighth pregnancy, on the other hand,
the risk of death from puerperal hemorrhage is probably even greater
than the increased percentages of deaths due to this cause would
imply.
1 Woodbury, Robert Morse: Maternal Mortality, pp. 34-35. U.S. Children’s Bureau Publication N o.
158. Washington, 1926.
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157
PUERPERAL HEMORRHAGE
PUERPERAL HEMORRHAGE AM ONG URBAN AND RURAL AND WHITE
AND COLORED WOMEN, BY STATES
Puerperal hemorrhage caused a slightly larger proportion of
maternal deaths in rural areas (12 percent) than in urban areas (10
percent) (table 91). The mortality rate from puerperal hemorrhage
91.— Number and percentage of deaths and mortality rate among white and
colored women dying in urban and rural areas from puerperal hemorrhage
T able
Women dying from puerperal hemorrhage
Total
Deaths from puerperal hem
orrhage, and color
In urban areas
In rural areas
Per
Per
Per
cent
Mater
cent
Mater
Mater
cent
Num of total nal mor Num of total nal mor Num of total nal mor
ber mater tality
ber mater tality
ber mater tality
nal
nal
rate 1
rate 1
nal
rate 1
deaths
deaths
deaths
Total_________ ______
791
11
6.7
331
10
7.2
460
12
6.4
Placenta previa_____ ______
Other puerperal hemorrhage.
347
444
5
6
2.9
3.8
147
184
4
5
3.2
4.0
200
260
5
7
2.8
36
White__________ ____
670
11
6.S
290
10
6.9
380
12
6.0
Placenta previa____________
Other puerperal hemorrhage.
293
377
5
6
2.8
3.6
130
160
. 4
5
3.1
3.8
163
217
5
7
2.6
3.4
m
9
10.0
U
8
10.8
80
10
9.7
4
5
4.5
5.6
17
24
3
5
4.5
6.3
37
43
5
5
4.5
5.2
Colored_________ ____
Placenta previa.....................
Other puerperal hemorrhage.
54
67
1 Deaths per 10,000 live births.
was slightly higher in urban than in rural areas for both white and
colored women, but the differences are not sufficient to be statis
tically significant.
Puerperal hemorrhage caused a larger proportion of maternal
deaths among the white women (11 percent) than among the colored
(9 percent), but the mortality rate (deaths per 10,000 live births)
from puerperal hemorrhage was higher for the colored women than
for the white (table 92).
The mortality rate from puerperal hemorrhage ranged from 4.4 per
10.000 live births in North Dakota to 8.6 per 10,000 live births in
Rhode Island (table 93). There was more variation in the rates
among the colored women than among the white. In those States
having 2,000 or more colored births annually the rates varied from
4.0
in Oklahoma to 12.4 in California for the colored group, and from
5.1 in Kentucky to 7.1 in Alabama and 7.2 in Oklahoma for the
white group.
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MATERNAL MORTALITY IN FIFTEEN STATES
T able 92.— Number and percentage, of deaths and mortality rate among white and
colored women dying from puerperal hemorrhage in all the States included in the
study and in specified States having 2,000 or more colored births annually
Women dying from puerperal hemorrhage
Total
Colored
White
State
Num
ber
Percent Rate per
Percent Rate per
Percent Rate per
of all
of all
of all
10,000
10,000 Num puer
10,000 Num puer
puer
live
live
ber
live
ber
peral
peral
peral
births
births
births
deaths
deaths
deaths
A LL STATES IN CLU D ED IN THE STUDY
Total________________
791
11
6.7
11
670
121
6.3
9
10.0
9
10.7
12.4
5.2
10.7
7.7
4.0
9.2
STATES HAVIN G 2,000 OR M ORE COLORED BIRTHS A N N U A LLY
109
50
62
49
137
30
81
Alabama__________________
California_______ ____ _____
Kentucky____________ ____
Maryland____ _ _________
Michigan__________________
Oklahoma..............................
Virginia___________________
10
10
10
13
10
10
11
8.3
6.0
5.1
7.6
6.9
7.0
7.1
60
44
58
35
132
29
50
10
10
10
13
11
12
12
7.1
5.6
5.1
6.8
6.9
7.2
6.2
„
49
6
4
14
5
1
31
o
5
13
6
2
9
1 Not shown because number of deaths was less than 50.
T able 93.— Number and percentage of deaths and mortality rate among women
dying from puerperal hemorrhage in urban and rural areas of each State included
in the study
Women dying from puerperal hemorrhage
In urban areas
Total
In rural areas
State
Num
ber
Percent Rate per
Percent Rate per
Percent Rate per
of all
of all
of all
10,000 Num puer
10,000 Num puer
10,000
puer
ber
live
ber
live
live
peral
peral
peral
births
births
births
deaths
deaths
deaths
____
791
11
6.7
331
10
7.2
460
12
6.4
Alabama-______ ___________
California____ ____________
K en tu cky________________
Maryland_________________
Michigan_________________
Minnesota________________
Nebraska_____________ ____
New Hampshire___________
North Dakota___ __________
Oklahoma__ _____ _________
Oregon_____ ____________
Rhode Island______________
Virginia____________ ____ —
Washington_______________
W isconsin-................ ...........
109
50
62
49
137
52
35
8
13
30
24
23
81
28
90
10
10
10
13
10
11
11
7
8
10
14
14
11
9
15
8.3
6.0
5.1
7.6
6.9
5.2
6.3
4.6
4.4
7.0
8.4
8.6
7.1
6.0
7.8
24
23
7
30
96
19
14
4
1
7
8
20
17
22
39
8
8
5
12
10
8
11
7
10.5
4.7
3.1
8.2
8.0
5.0
10.3
4.4
2.5
8.3
6.8
8.7
6.7
9.0
7.4
85
27
55
19
41
33
21
4
12
23
16
3
64
6
51
10
14
11
15
11
12
10
7
9
11
17
7.9
7.7
5.6
6.8
5.3
5.3
5.0
4.8
4.7
6.6
9.4
8.1
7.2
2.7
8.2
Total_________
0
8
10
13
6
12
12
0
13
5
17
1Not shown because number of deaths was less than 50.
PLACENTA PREVIA
For 347 of the 408 women who were known to have had.placenta
previa, it was given as a primary cause of death. Fifty-three of the
408 women died from puerperal sepsis and 8 from other causes.
Some other women concerning whom little or no information could
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159
PUERPERAL HEMORRHAGE
be secured were known to have died of hemorrhage, and probably
some of them had placenta previa.
The only indication of its presence that placenta previa gives is
painless bleeding. Of these 408 women, 327 had some bleeding before
the onset of labor, 38 had no bleeding then, and for 43 there was no
information on this point. In 310 cases of bleeding before the onset
of labor for which the extent of bleeding was ascertained, it was scanty
in 44 cases, moderate in 82 cases, and profuse in 184 cases. The week
in which the bleeding began was reported for 288 of the 327 cases of
bleeding during pregnancy. It began before the thirteenth week in
7 cases; from the thirteenth to the twenty-fifth week, inclusive, in
31 cases; from the twenty-sixth to the thirty-ninth week, inclusive, in
201 cases; and in the fortieth week in 49 cases.
Of the 408 women who had placenta previa there were 107 whose
first hemorrhage— occurring in some cases before the onset of labor
and in others at the beginning of labor— was dangerously profuse,
and thus there had been apparently no warning of the existence of
placenta previa. In 286 cases, however, there had been a warning
hemorrhage earlier in pregnancy; in 65 cases there was no report on
this. The warning hemorrhage resulted in prompt treatment for the
placenta previa in 18 cases, but in 216 cases treatment was delayed;
in 2 cases in which there was warning hemorrhage there was no report
on the promptness of treatment. Of the 104 cases of hemorrhage
without warning for which the promptness of treatment was reported,
87 had prompt treatment and 14 had delayed treatment; 3 women
died at once without time for treatment. Nine of those for whom
there was no report as to warning bleeding were known, nevertheless,
to have had treatment delayed. In all, 239 women were reported to
have had delayed treatment. The delay was apparently due to the
physician in 129 cases and due to the patient, her family, or circum
stances such as inaccessibility or difficulty in reaching a physician, in
110 cases. In 61 instances there was no report as to the promptness
of treatment (table 94).
T a b l e 94.— W a r n in g bleeding and treatm ent o f 'placenta p revia a m o n g w o m en w h ose
deaths w ere associated w ith placenta previa
Women whose deaths were associated with placenta previa
Warning bleeding
Total
Treatment
Yes
Number
No
Percent
Percent
Percent
distri Number distri Number distri
bution
bution
bution
236
408
107
Not re
ported
65
Report on treatment_____ ____ ______
347
100
234
________
100
104
100
Delayed________________________
105
239
30
69
18
216
8
92
87
14
84
13
9
By physician________________
Otherwise___ ______ _________
m
110
87
88
188
98
S3
40
4
10
4
10
8
7
3
1
3
3
No report on treatment______________
61
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2
3
9
56
160
MATERNAL MORTALITY IN FIFTEEN STATES
At least 9 women with placenta previa died without medical atten
tion, and 46 were moribund when the physician arrived; in 351 cases
there was earlier medical care; in 2 cases the care was not reported.
Of the 408 women who died following placenta previa, a report con
cerning operations for delivery was obtained for all but 7. Three
hundred and twenty-five (81 percent) were known to have had some
operation aimed at delivery (table 95).
T
able
95.—
T y p e o f p rin cip a l o p era tio n f o r d elivery p erfo rm ed o n w o m en w hose
deaths w ere associated w ith placenta previa
W omen w hose deaths
were associated with
placenta previa
Type of principal operation for delivery
Number
Total _____
_________________
Report on operation____ ___________
Version____________________ _
With dilatation of cervix_________
Cesarean section___ ____ _________
Forceps (without version)......................
With dilatation of cervix_________
Dilatation of cervix only_______ ____
Other operation.. _____________
Type not reported_________________
No operation___________________
No report on operation________________
Percent dis
tribution
408
401
100
207m
41
33
18
17
24
3
76
52
■ SI
10
8
4
4
6
1
19
7
About half (207) of the women who died following placenta previa
were reported to have been delivered by some form of version, in 124
cases preceded by artificial dilatation of the cervix. This was nearly
always a version with immediate extraction. In only 2 of these 207
cases of delivery by version or version combination was there said
to have been a Braxton Hicks version without immediate extraction.
Cesarean section was the method of delivery used in the cases of 41
women (10 percent), at least 7 of whom had been packed before ad
mission to the hospital. A forceps operation alone or in combination
with some operation other than version was used in 33 cases (8 per
cent), and dilatation of the cervix— usually manual or bag dilatation—
was the only operation for delivery in 17 cases (4 percent). Only
27 of the 408 women are known to have had a blood transfusion.
The uterus was reported packed postpartum in 31 cases. This had
apparently been done as a routine procedure in only 6 cases; in the
other 25 cases the packing was done after the onset of a postpartum
hemorrhage.
Ruptured uterus was diagnosed by the attending physician after
treatment in 3 cases of death associated with placenta previa, and in
18 other cases the histories strongly suggested rupture of the uterus.
The cervix was known to have been tom in 17 cases. There were
undoubtedly more cervical tears, as inspection of the cervix was not
frequent.
There was a report on postpartum hemorrhage in the cases of 335
women whose deaths were associated with placenta previa and who
had been delivered in the third trimester. Of these women 156 had a
postpartum hemorrhage and 179 did not. Of the 347 women with
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PUERPERAL HEMORRHAGE
placenta previa as a primary cause of death, 84 had other puerperal
hemorrhage as a principal contributory cause of death.
Of the 347 women whose deaths were attributed to placenta previa
(no. 144a) 50 died undelivered, and the rest died soon after delivery.
The interval between delivery and death was reported for 290 wo
men, of whom 88 percent died less than a day after delivery and 97
percent died within the first week.
OTHER PUERPERAL HEMORRHAGE
The deaths of 444 women were attributed to puerperal hemorrhage
other than placenta previa. This title (no. 144b) includes conditions
such as postpartum hemorrhage, adherent placenta, premature separa
tion of the placenta, and bleeding during or after labor the exact cause
of which is unknown. All but 1 of these 444 deaths occurred after
the women had reached the last trimester; the period of gestation in
that 1 case was not recorded. In 215 additional cases other puerperal
hemorrhage (no. 144b) was given as the principal contributory cause
of death.
Of the 443 women whose deaths after reaching the last trimester
were attributed to other puerperal hemorrhage information as to
the termination of labor was given for all but 10. Termination was
spontaneous in 249 cases and artificial in 178 cases; the patient was
undelivered in 6 cases.
H|The principal operations for delivery that were performed on these
women are shown in table 96. Fifteen percent of all those for whom
there was a report on operation had had manual removal of the
placenta.
T a b l e 96. — T y p e o f p r in c ip a l o p era tio n f o r d eliv ery p erform ed o n w o m en d y in g
f r o m p u erp era l hem orrhage exclusive o f pla centa previa
Type of principal operation for delivery
Women dying from
puerperal hemorrhage
exclusive of placenta
previa
Number
Percent dis
tribution
444
Report on operation_____ ______ _________
Operation____________ _________ _____
Cesarean alone or following other
operation______________________
Forceps (without version)______ With manual removal of pla
centa______________________
Version_________________________
With manual removal of pla
centa_________ ___________
Manual removal of placenta (fol
lowing spontaneous delivery)____
Manual removal with operation
other than forceps or version_____
Other operation............ ....................
No operation_________ _______ _______
435
100
m
61
16
81
4
19
(9)
63
(2)
14
(14)
(3)
34
8
7
19
2
4
215
W
9
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MATERNAL MORTALITY IN FIFTEEN STATES
There was a report as to the use of pituitrin in 346 cases in which a
physician had been the attendant at confinement. In 87 cases (25
percent) no pituitrin had been used; in 22 cases (6 percent) it had been
used in the first, and in 75 cases (22 percent) in the second stage of
labor; in 162 cases (47 percent) it had been used only in the third stage
of labor or postpartum.
Of these 443 women who died after reaching the last trimester and
whose deaths were attributed to other puerperal hemorrhage, 30 were
reported to have had cervical lacerations. This is doubtless a great
understatement, for in many cases, probably the majority, there was
no inspection of the cervix for laceration.
Like the women whose cause of death was placenta previa, women
dying from other puerperal hemorrhage died soon after delivery. Of
429 women who were delivered and for whom the interval between
delivery and death was given, 88 percent died within the first day
and 95 percent died within the first week.
There was a report on medical attention for 440 of the 444 women
who died of other puerperal hemorrhage. Twenty-nine (7 percent) of
these women had had no medical attention whatever, 48 (11 percent)
had not been seen by a physician until they were dying; 363 (83 per
cent) had had some earlier medical attention.
POSTPARTUM HEM ORRHAGE
Postpartum hemorrhage was apparently the condition chiefly re
sponsible for 374 of the 444 deaths attributed to other puerperal
hemorrhage (no. 144b). In addition to the 374 deaths of which post
partum hemorrhage was the primary cause, it was present as a com
plication in the deaths of 519 other women, so that 893 women, or
21 percent of the 4,188 who died after reaching the last trimester of
pregnancy and for whom a report was made on this condition, had
postpartum hemorrhage. Of the 374 women dying of postpartum
hemorrhage, 50 had no physician at the time of delivery; in 185 cases
the physician did not leave the patient until after her death, and in
94 cases the patient’s condition was satisfactory when he left; in 28
cases she was in unsatisfactory condition; and in 17 cases a statement
as to her condition or as to attendant was not made.
The length of time the physician remained after delivery was re
ported in 104 of the 122 cases in which he left before the patient’s
death; in 20 of these cases he left before an hour had elapsed after
the delivery; in 47 cases he remained from 1 to 2 hours; in 19 cases he
remained from 2 to 3 hours; and in 18 cases he stayed 3 hours or longer.
The placenta was said to have been inspected in 259 instances of
death from postpartum hemorrhage but not inspected in 65. For 50
cases no report on inspection was obtained. The management of the
third stage was usually described as “ modified Credè” ; but as the
description given was seldom definite, tabulations on this point were
not made.
Of the 893 women who had a postpartum hemorrhage before death
(including those whose deaths were attributed to other causes) only 78
were known to have had a blood transfusion.
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163
PREM ATURE SEPARATION OF THE PLACENTA
The diagnosis of premature separation of the placenta was made by
the attending physician in 106 of the deaths. The primary cause of
death for 68 of these was other puerperal hemorrhage (no. 144b); for
12, puerperal sepsis (no. 146); and for the remainder, other causes.
There were other deaths from unexplained hemorrhage that in all
probability were caused by this condition, but information sufficient
for a positive diagnosis was not obtained.
Abdominal pain was definitely mentioned as a symptom of the
condition but 19 times in the 106 cases, was absent in 11 cases, and
was not reported upon in 76. The lack of information with regard to
pain in so many cases is probably due to the fact that the specific
question was not asked at the time of the interview.
Trauma was supposed to have been associated with the condition
in 9 cases, it was not a factor in 30, and there was no report in 67.
Toxemia was associated with the condition in 23 cases and not
associated in 39 cases; there was no report in 44.
Transfusions are known to have been given to 13 women and in
fusions to 21.
D ehvery was by manual dilatation, usually with version or forceps,
in 31 cases. In addition, there were 12 other forceps deliveries and
12 versions, and 17 Cesarean sections. In 8 cases there was some
other method of operative delivery. In 21 cases delivery was spon
taneous. In 3 cases the patient died undelivered, and in 2 cases the
exact method of delivery was not reported.
The premature separation occurred at term in 57 cases and in the
last trimester in all but 13 cases.
High fetal mortality was to be expected. Only 13 babies were born
alive.
.
The uterus was known to have been packed after delivery m only
9 cases.
The women whose deaths were associated with premature separation
of the placenta were, in general, older and had had more pregnancies
than the total group included in the study. Sixty-five percent of the
former and 46 percent of the latter were 30 years of age or older.
Eighteen percent of the women whose deaths were associated with
premature separation and 34 percent of the total group with parity
reported were primiparae. Sixty-nine percent of the women whose
deaths were associated with premature separation and for whom the
number of pregnancies was reported, compared with 49 percent of
all the women in the study with number reported, had had three or
more pregnancies.
COMMENT BY ADVISORY COMMITTEE
If the onset of hemorrhage in placenta previa were accompanied by
pain, patients would apply for treatment sooner and would not be
content with inactivity on the part of the physician. Of 234 cases in
which warning bleeding occurred, it was ignored by the patient or
by the physician in 216, and in more than half these cases it was the
physician who was responsible for the delay. Even among the 107
cases in which the first hemorrhage was profuse, and it could therefore
be said that no warning was given, there were a few cases of delayed
182748—34----- 12
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164
MATERNAL MORTALITY IN FIFTEEN STATES
treatment, for a small number of which the physician was responsible.
Placenta previa is not a condition that can safely be treated expectantly.
Here is an example:
The patient was admitted to a hospital at term after having bled off and on for
2 months without pain and having had a very profuse hemorrhage a month
before admission. She was in labor when admitted and was flowing and passing
clots. Placenta previa was diagnosed by vaginal examination. A profuse hemor
rhage occurred 9 hours after admission. Treatment: Ice cap to abdomen,
elevation of the foot o f the bed, and ergot. She was flowing freely 22 hours
after admission. The ice cap was refilled, and one-sixth o f a grain o f morphine
was given. Twenty-seven hours after admission she was still bleeding. Thirtytwo hours after admission, still bleeding and showing signs o f shock, she was
delivered by version and extraction. The child was stillborn. The mother was
then given stimulation and 1,000 cc normal saline solution, but died 5 hours
after delivery.
This case was mismanaged in several ways. Active treatment was
delayed, although the patient had been bleeding for 2 months; a
vaginal examination of a bleeding patient was made without preparing
her for delivery; expectant treatment was continued when active
treatment to control the bleeding should have been instituted; no
preparation for blood transfusion was made, although the patient had
been in the hospital for 32 hours before the delivery.
A Braxton Hicks version, which is of greatest use to control bleeding,
was rarely done, but manual dilatation of the cervix and internal
podalic version with immediate extraction were done many times,
regardless of the woman’s condition. The frequent occurrence of
rupture of the uterus, tears, hemorrhage, shock, and death immediately
after delivery illustrates the seriousness of these procedures and the
fact that they are not proper in the treatment of placenta previa.
So many of these women died immediately after delivery that rela
tively few lived long enough to die of sepsis; as it was, 53 died of sepsis.
Treatment for shock in connection with hemorrhage was rarely
mentioned in the histories as given in the schedules. Fluids of any
sort were infrequently used. That the buttocks of the child could be
used to control hemorrhage and that shock could be treated at this
time, the labor being terminated by the patient’s own efforts, was
apparently seldom thought of.
Many women with placenta previa died of hemorrhage after labor.
Only 31 of the women were packed after delivery. This would sug
gest that if proper packing were at hand it would be used more
often, and certainly blankets and sheets would not be used as emer
gency packing, with later death from sepsis.
Unfortunately rupture of the membranes was seldom done in the
appropriate cases of lateral placenta previa.
Long distances and bad roads would seem to have contributed to
some of the deaths from placenta previa.
It should be emphasized that Cesarean section is contra-indicated
in the treatment of placenta previa when the patient is suffering from
shock or hemorrhage or potential or actual sepsis. If dirty packing
had been used or if there had been previous mismanagement of any
sort, the delivery should be by vagina whenever possible. But in this
study the Cesarean sections for placenta previa were not limited to
cases in which the mother and baby were in good condition. The
operation was often done after great loss of blood and without
coincident blood transfusion, though transfusion would doubtless
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PUERPERAL HEMORRHAGE
165
have been given more frequently if equipment for blood typing and
for giving the transfusion had been at hand. The Cesarean was
sometimes performed after dirty packing had been done before the
women were admitted to the hospital. Naturally many women who
did not die at once from shock and hemorrhage died from sepsis. The
following is an extreme case:
A woman who had had eight normal deliveries, at about term, bled for 3 or 4
days and was packed several times by several physicians. A small blanket, not
sterile, was used in one instance. She was sent by ambulance 30 miles to a
hospital, where a Cesarean section was done. She died 5Vi days later from sepsis.
The treatment of placenta previa is to control bleeding and treat
shock and acute anemia; it is not to effect the immediate delivery of
the fetus except as a means to this end and only in properly selected
cases.
In the cases diagnosed as placental separation also, shock, even
when severe, did not seem to be sufficiently considered in determining
treatment. Only one fifth of the women in this group had spontaneous
deliveries. About half of the women in the group were delivered
immediately. The following histories show some of the more extreme
cases:
In a case in which the diagnosis was placental separation the cervix was dilated
manually after a short labor and a 6-month fetus was delivered with high forceps.
At a university teaching hospital a classical Cesarean was done after a 30-hour
labor for premature separation. The woman died o f sepsis.
The frequent use of pituitrin before delivery in cases of women who
later died of puerperal hemorrhage other than placenta previa is
worthy of comment.
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O TH ER ACCIDENTS OF LABOR, INCLUDING RUPTURE OF
TH E UTERUS
OTHER ACCIDENTS OF LABOR
To “ other accidents of labor” (no. 145 of the international list)
were attributed after interview 652 of the 7,380 deaths included in
the study. On the basis of information on the death certificates
812 deaths had originally been so assigned. (See table 2, General
Considerations, p. 10.) To Cesarean section (no. 145a) were attrib
uted 136 of the 652 deaths, which have been discussed under Cesarean
Section (p. 89). One hundred and nine deaths were attributed to
instrumental delivery and other operative procedures (no. 145b).
These were not deaths resulting from hemorrhage or sepsis or toxemia
but were, in general, deaths thought by the attending physician to
be due to shock, exhaustion, or embolism as a direct result of the labor
or of the operative delivery. See last two paragraphs, p. 168.
The remaining 407 deaths were attributed to “ others” under the
title “ other accidents of labor” (no. 145c). Sixty-five of these were
attributed to no. 145cl, which includes deaths due to rupture of the
uterus or bladder during delivery. The 63 that were due to ruptured
uterus are discussed on page 167. Forty-six were attributed to no.
145c2, a group including deaths said to be due to difficult or abnormal
labor, faulty presentation, inversion of the uterus (see p. 169), or
similar terms. The immediate cause of death in these cases was
usually thought to be shock or exhaustion. To others under this
subtitle (no. 145c3) were attributed 296 deaths. This group contains
those deaths about which so little was known that it was not possible
to attribute! them to a more definite cause. It includes also deaths
in which influenza, pneumonia, and certain other diseases complicated
an otherwise fairly normal childbirth.
This very miscellaneous group of cases may be listed as follows with
the international-list numbers:1
145. Other accidents of la b o r._______________________________652
a. Cesarean section_____________________________________ 136
b. Instrumental deliveries, etc___________________________ 109
c. Others___________
«»407
1. Ruptured uterus (or bladder)____________________
2. Difficult labor____________________ 1_____________
65
46
3. Others__________________________________________ 296
Of the 296 women whose deaths were attributed to no. 145c3, there
was a report on intercurrent disease during pregnancy for 203, of
whom 137 (67 percent) had had some intercurrent disease. This was
a much larger proportion than for the entire number of women studied;
» In the 1929 revision of the International List of Causes of Death other accidents of labor (no. 145) becomes
other accidents of childbirth (no. 149), consisting of Cesarean section (no. 149a), and others under this title
(no. 149b). Rupture of uterus or bladder is now no. 149bl; the conditions formerly grouped under nos.
145b, 145c2, and 145c3 are now included in no. 149b2 and 149b3.
166
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OTHER ACCIDENTS OF LABOR
167
of the 7,380 women in the study there was a report on intercurrent
disease for only 4,216, of whom 1,271 (30 percent) had had an inter
current disease. Only one other group, in fact, included a large pro
portion of women with intercurrent disease; of the 353 women whose
deaths were attributed to abortion (no. 143a) there was a report on
intercurrent disease for 232, 66 percent of whom had had such disease
during pregnancy.
Not only intercurrent disease during pregnancy but various com
plications after delivery contributed to some of these deaths. The
nonpuerperal contributory causes of death are therefore of particular
interest in these 296 cases attributed to no. 145c3. For 242 some
nonpuerperal contributory cause was given. In 65 cases influenza
(including influenzapneumonia) was given as a principal contributory
cause of death.2 Broncho-pneumonia was given as the principal con
tributory cause of death in 11 cases and pneumonia, either lobar or
unspecified, in 62 cases. Other diseases of the respiratory system
were given in five cases.
Some disease of the heart was given as the principal contributory
cause in 55 cases, but this was in some cases “ chronic myocarditis ”
the diagnosis of which had been based on evidence not at all clear.
Cerebral hemorrhage was the principal contributory cause in 12
cases, and some other disease of the nervous system or orgâns of
special sense in 4 cases. Intestinal obstruction was given in 4 cases,
some other disease of the digestive system in 10, anemia in 7, and
other diseases in 7.
RUPTURE OF THE UTERUS
In addition to the 63 deaths attributed to ruptured uterus, a sub
division of other accidents of labor (no. 145, see p. 166), 28 had a
diagnosis of ruptured uterus made by the attending physician or at
autopsy— a total of 91 out of the 7,380 deaths included in the study.
Of these 28 deaths, 17 were attributed to puerperal septicemia, 5 to
puerperal hemorrhage, and 6 to accidents of pregnancy. (Deaths
from rupture of the uterus “ during pregnancy” as distinguished from
“ at labor” are assignable to accidents of pregnancy, no. 143).
Ten of these 91 women were primiparae and 77 were multiparae; the
parity of 4 was not reported.
The number of hours that these women had been in labor is shown
in table 97. Six of them— 1 primipara and 5 multiparae— were not in
labor. In the case of the primipara the rupture was apparently
spontaneous at the site of aberrant uterine sinuses on the posterior
wall of the uterus. Of the 5 multiparae who were not in labor 2 had
had previous Cesarean sections; no adequate explanation for the
rupture was given in the other 3 cases.
Fifteen of the multiparae had been in labor less than 6 hours; 17
between 6 and 12 hours; 10 between 12 and 18 hours; 10 between 18
and 36 hours; and 10, 36 hours or more. The number of hours in
labor was not reported for 10 of the multiparae. In the cases of
eight multiparae there was evidence that the patient had been de
livered by Cesarean section in a previous pregnancy.
J Influenza was given as the principal nonpuerperal contributory cause of death in 256 of the 7,380 cases
in the study. In addition to the 65 cases mentioned above, 71 deaths with influenza as the principal non
puerperal contributory cause were attributed to abortion (no. 143a), 73 to puerperal septicemia (no. 146),
31 to puerperal albuminuria and convulsions (no. 148), and 16 to other causes.
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MATERNAL MORTALITY IN FIFTEEN STATES
T able
97.—
P a r it y a n d hours i n
labor f o r w o m en w ho d ied fo llo w in g ru p tu red
uterus
Women who died following ruptured uterus
Hours in labor
Total
Total__________________ _________________ _____
6, less than 12_____________________________ __________
36 or more______________________________ ________ ___
Not reported.......................................................................
not
Primiparae Multiparae Parity
reported
91
10
77
6
15
19
11
5
6
1
16
12
1
5
15
17
10
5
4
1
10
10
1
1
2
4
1
4
1
2
1
The type of presentation was reported in 78 of the 91 cases; it was
vertex in 59 cases, face in 6 cases, breech in 6 cases, and transverse in
7 cases.
There was a report as to the use of pituitrin in 75 cases. It was not
used in 36 cases, and was used for induction in 1 case, in the first
stage in 10 cases, in the second stage in 13 cases, in the third stage or
postpartum only in 14 cases, and at an unreported stage in 1 case.
Of the 91 women, 64 had an operation for delivery and 27 did not;
15 of these 27 died undelivered and 12 were delivered spontaneously.
As some of the operations were unsuccessful, 6 of the 64 who had opera
tions for delivery died undelivered. The operations for delivery in
cluded 11 Cesarean sections (3 of them following attempts at other
operations), 16 versions (4 of them following attempts at forceps
operations, 1 following artificial dilatation of the cervix), 19 forceps
operations in addition to the 4 followed by versions (1 following
artificial dilatation of the cervix), 5 craniotomies or embryotomies, and
13 other operations. In a few of these cases the operation was done
after rupture of the uterus had been at least tentatively diagnosed.
Very definite information as to the time of diagnosis was not often
obtained in the interview.
In addition to these 91 cases in which rupture of the uterus was
diagnosed by attending physician or at autopsy, there were many
others in which the symptoms suggested ruptured uterus, although the
attending physician had not made that diagnosis. Note was made
of such cases when the schedules were edited, and those schedules
were studied carefully by a member of the committee. His opinion
was that the history pointed clearly to ruptured uterus in 68 cases
and made such a diagnosis probable in 109 other cases. There were
other women who may have had ruptured uterus, but information
sufficient for its diagnosis was not obtained. It is probable, therefore,
that 177 women had ruptured uterus in addition to the 91 for whom
it was diagnosed by the attending physician or at autopsy.
The causes of death to which these 177 cases were attributed on
interview were: Puerperal hemorrhage, 63; other accidents of labor,
70 (including 52 attributed to instrumental delivery and operations
other than Cesarean, and 18 attributed to others under this title);
puerperal septicemia, 10; puerperal phlegmasia alba dolens, embolus,
sudden death, 8; puerperal albuminuria and convulsions, 26.
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OTHER ACCIDENTS OF LABOR
169
Seventy-three of these women were primiparae and 103 were multiparae; the parity of 1 was not reported. One hundred and sixty-two
(all but 15) had had operations for delivery—version in 72 cases
(in 25 following artificial dilatation of the cervix), forceps in 62 cases
in addition to the 20 with version (in 13 following artificial dilatation
of the cervix), and other operations in 28 cases. In 160 cases there
was a report as to the use of pituitrin; it had not been used in 40
cases, had been used in the first or the second stage of labor in 73
cases, in the third stage or postpartum only in 46 cases, and at an
unreported stage in 1 case. There had been vertex presentation in 139
cases, face in 4 cases, breech in 9 cases, transverse in 19 cases, and
vertex and transverse (twins) in 1 case; in 5 cases the type of pre
sentation was not reported.
The following are cases of death from undiagnosed but probable
rupture of the uterus:
A woman, aged 30, was in labor for the first time. She had had no prenatal
care. After 6 hours of labor described as “ difficult with no progress” , a high
forceps operation was done, which was said to have been “ rather difficult.”
The baby was born alive and weighed 10 pounds. Two hours after delivery the
patient began to bleed. She died 14 hours after delivery.
A primiparous woman, aged 24, had vertex presentation with the occ ipu
posterior. After 8 or 9 hours of first-stage labor the pains had become short and
jerky. ^ Dilatation of the cervix was not complete. Four minims of pituitrin
was given with no apparent effect. One hour later another similar dose was
given. A consultant was sent for who applied forceps. The woman had been
in labor about 12 hours, and the cervical dilatation was about four fingers.
The delivery was exceedingly difficult, both physicians pulling alternately for
35 or 40 minutes. There was complete perineal laceration and immediately after
the delivery of the baby a brief but severe hemorrhage. Although the hemor
rhage soon stopped, the patient went into shock and died shortly afterward.
She was not examined for cervical tears or uterine rupture.
INVERSION OF THE UTERUS
Twenty cases of inversion of the uterus were reported. In three
cases the condition was not discovered until necropsy was done.
These cases are probably not a true index of the frequency of the com
plication. There were many unexplainable deaths that occurred in
severe shock, some of which may have been due to inversion of the
uterus.
The causes of death were given as postpartum hemorrhage and
other hemorrhage at labor, in 13 cases; accidents of labor, in 5 cases;
puerperal septicemia, in 1 case; and embolism, in 1 case.
Six deliveries were by forceps and 1 by version, and 13 were spon
taneous.
There were 3 cases that followed manual removal of the placenta
and 5 cases in which pressure reported as moderate had been applied
to the fundus of the uterus. In 4 cases the third stage of labor was
spontaneous; in 3 cases the placenta was attached to the inverted
uterus. In 5 cases a clear history of the management of the third
stage of labor could not be obtained. In 8 cases pituitrin in small
doses had been given during the second or third stage of labor.
In only one case was traction on the cord admitted, but one of the
cases occurred in the practice of a midwife who had pulled on cords.
Only 2 of the 20 women were delivered by midwives.
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MATERNAL MORTALITY IN FIFTEEN STATES
COM M EN T B Y AD VISO RY CO M M ITTEE
A satisfactory analysis of the deaths in this miscellaneous group of
652 cases, “ other accidents o f labor” , is difficult. This is true par
ticularly o f the largest subgroup of 296 “ other” deaths, although
here the nonpuerperal contributory causes of death play an important
part.
Seemingly needless interference with labor was noticeable in these
cases, consisting of the use of pituitrin, operative procedures, or both.
Women who had had several babies without any trouble were given
pituitrin after 2, 3, 8, or 10 hours in labor, and then attempts at
forceps operations were made or versions done. The study o f this
group of deaths caused by rupture of the uterus emphasizes very
particularly the need for further education of physicians as to the
danger of pituitrin. The use o f pituitary extract during labor is
still causing deaths from rupture o f the uterus. Study o f these
records also would seem to show that there was no sound maternal
indication for many of the operative procedures that caused the death
o f mothers.
Eighth child, face presentation, woman in labor 16 to 18 hours, unsuccessful
application o f forceps, collapse, hospitalization, version, death. Ruptured
uterus was found at autopsy.
A woman was having her tenth baby; all other labors had been spontaneous
with living babies. She was in labor 6 hours with a large baby. Use o f “ low”
forceps was followed by death. Rupture o f uterus was found at autopsy.
Thirteenth delivery, all others normal, breech presentation, large baby, two
4-drop doses of pituitrin in the first stage, extraction after 5 hours’ labor, rupture
o f uterus, death.
Two previous normal labors, woman in labor 9 hours, 1 cc pituitrin, attempted
forceps, version, rupture o f the uterus (proved by autopsy), and death.
A primiparous woman had been in labor 6 hours. The record stated that
dilatation was complete. She was given one half cc o f pituitary extract.
The pains ceased and there was a little bleeding. A consultant was called who
diagnosed a ruptured uterus, which was proved at Cesarean section. It was a
shoulder presentation. The woman died soon after the operation.
It is evident that physicians often do not suspect rupture of the
uterus when there is every indication that it is present. Probably
rupture o f the uterus before or during labor kills far more women
than is generally believed, 177 probable cases having been added to
the 91 diagnosed cases after study o f the schedules.
All these 268 case records were studied by a member of the advisory
committee in the hope that they would yield some evidence as to the
preventability o f the condition. Some ruptures following Cesarean
sections were spontaneous and seemingly could not have been
avoided. Some cases o f spontaneous rupture had fibroid tumors
as a complication, and these ruptures probably could not have
been prevented. In all, 30 were apparently not preventable, and
15 were probably not preventable. It was the opinion, however,
o f the obstetrician who examined the records that in 125 cases the
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OTHER ACCIDENTS OF LABOR
171
rupture could have been prevented, in 59 cases it could probably
have been prevented, and in 39 cases it might have been prevented.
A careful study of the 20 cases of inversion of the uterus by a
member o f the committee convinced him that 2 were not preventable
and 2 were probably not preventable; on the other hand, 5 seemed
preventable and 11 probably preventable. Of the 5 cases in which
the inversion was judged preventable, 4 were thought due to improper
management o f the third stage and 1 to pituitrin.
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ECTOPIC GESTATION
Three hundred and fourteen (4 percent) of the 7,380 women whose
deaths were included in the study had ectopic gestation. Two
hundred and forty-nine of these deaths were classified, according to
the international list, under accidents of pregnancy (no. 143)— 248
under ectopic gestation (no. 143b) and 1 (a ruptured cornual preg
nancy) under “ others under this title” (no. 143c). The other 65
patients developed sepsis, and their deaths were accordingly classified
under puerperal septicemia (no. 146). This classification was made
after the attendants had been interviewed.1
T able 98.— Number and percentage of deaths and mortality rate of women whose
deaths were associated with ectopic gestation in urban and rural areas of each
State included in the study
Women whose deaths were associated with ectopic gestation
Total
In urban areas
In rural areas
State
Num
ber
Percent Rate
per
of all
puer
10,000
peral
live
deaths births
Num
ber
Percent Rate
of all
per
puer
10,000
peral
live
deaths births
Num
ber
Percent Rate
of all
per
puer
10,000
peral
live
deaths births
T ota l...........................
314
4
2.7
194
6
4.2
120
3
1.7
Alabama____ ____ _____ ___
California_________________
Kentucky_____ ____________
M aryland......... ...................
Michigan_________________
Minnesota____________ ____
Nebraska__________________
New Hampshire___________
North D a k o ta .____,_______
Oklahoma_________________
Oregon...................................
Rhode Island..... ........... ........
Virginia_____ _____________
Washington______ _________
Wisconsin_______ ____ _____
14
35
23
13
73
26
18
5
7
4
12
6
32
18
28
1
7
4
3
6
5
5
5
4
1
7
4
4
6
5
1.1
4.2
1.9
2.0
3.7
2.6
3.2
2.9
2.4
.9
4.2
2.2
2.8
3.9
2.4
4
21
12
11
59
18
4
5
1
7
8
4
6
8
3
9
1.7
4.3
5.2
3.0
4.9
4.7
2.9
5.5
10
14
11
2
14
8
14
1
7
2
2
4
3
7
.9
4.0
1.1
.7
1.8
1.3
3.3
2
7
6
13
12
20
2
9
4
5
7
6
2.4
6.0
2.6
5.2
4.9
3.8
7
2
5
5
i
5
2J7
.6
2.9
19
6
8
4
5
3
2.1
2.7
1.3
The proportion of maternal deaths that were associated with ectopic
gestation, either as a primary or as a contributory condition, varied
from 1 to 7 percent in the States of the study (table 98). The mor
tality rates ranged from 0.9 to 4.2 deaths per 10,000 live births, that
for all States combined being 2.7.
DEATHS ASSOCIATED W ITH ECTOPIC GESTATION IN URBAN AND
RURAL AREAS
Deaths reported to be associated with ectopic gestation were more
frequent in urban than in rural areas of the States. Of the 314
deaths so diagnosed, 194 occurred in the urban areas and 120 in the
1 The 314 would all be included in ectopic gestation (no. 142) of the 1929 revision, 65 in no. 142a “ with septic
conditions specified,” and 249 in no. 142b “ without mention of septic conditions.”
172
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173
ECTOPIC GESTATION
rural. In every State except Nebraska and North Dakota the
mortality rates from deaths associated with ectopic pregnancy were
higher in urban than in rural districts, the total rate for urban areas
being 4.2 per 10,000 live births, as compared with 1.7 in rural areas
(table 98). It is of importance in this connection that 83 percent of
all maternal deaths in cities of 10,000 and more were of women who
had been in hospitals, as compared with 34 percent in the rural areas.
DEATHS ASSOCIATED W ITH ECTOPIC GESTATION AM ONG WHITE
AND COLORED WOMEN
The mortality rate from deaths diagnosed as associated with ectopic
gestation for the white women (2.5 per 10,000 live births) was less
than that for the colored women (3.8) for all the States together and
also for every State having 2,000 or more colored live births annually,
with the exception of California and Oklahoma. Oklahoma had one
of the lowest rates for white women and no deaths among the colored.
In California the rate was high for both white (4.2) and colored (4.1).
The Michigan rate among the colored was, however, the highest (9.2)
(table 99).
T able 99.— Number and percentage of deaths and mortality rate of white and colored
women whose deaths were associated with ectopic gestation in all the States included
in the study and in specified States having 2,000 or more colored births annually
Women whose deaths were associated with ectopic gestation
Total
State
Num
ber
Colored
White
Percent Rate
per
of all
puer
10,000
peral
live
deaths births
Num
ber
Percent Rate
per
of all
puer
10,000
live
peral
deaths births
Num
ber
Percent Rate
per
of all
puer
10,000
peral
live
deaths births
A L L STATES IN C LU D E D IN THE STU DY
T o ta l............... ...........
314
4
2.7
268
4
2.5
46
4
3.8
1
7
5
8
1.5
4.1
7.8
3.8
9.2
5
5.0
STATES H A V IN G 2,000 OR M ORE COLORED BIRTH S A N N U A LL Y
Alabama__________________
California____ _______ _____
Kentucky_________________
Maryland_________________
Michigan____
______
Virginia......... ................ ........
14
35
23
13
73
4
32
1
7
4
3
6
1
4
1.1
4.2
1.9
2.0
3.7
.9
2.8
7
33
17
8
67
4
15
1
7
3
3
5
2
4
0.8
4.2
1.5
1.6
. 3.5
1.0
1.9
7
2
6
5
6
17
w
i Not shown because the number of deaths was less than 50.
MEDICAL ATTENTION AND HOSPITAL CARE
The diagnosis of ectopic gestation is difficult and is frequently made
only by exploratory laparotomy or at autopsy. There is often little
opportunity for clinical diagnosis. Death from ruptured ectopic
gestation often comes so soon after the appearance of symptoms that
some women fail to secure medical attention and some are not seen
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MATERNAL MORTALITY IN FIFTEEN STATES
until they are moribund. Of the 314 women whose deaths were
known to be associated with ectopic gestation, 4 2 had no medical care
by a physician and 44 were seen by a physician only when moribund;
263 patients had been under the care of the physician for a time; for 3
the medical care was not reported. Of the 314 women, 253 (81 per
cent) received care in a hospital. Hospital care was naturally more
frequent in urban than in rural areas; 173 (68 percent) of the 253
women who received hospital care died in cities of 10,000 or more.
The percentage of deaths diagnosed as associated with ectopic
gestation in the various States was closely associated with the per
centage of all women receiving hospital care. States with a smaller
percentage of deaths from ectopic gestation generally had had a
smaller proportion of all women who died cared for in hospitals, and
States with a higher percentage of deaths from this cause had had a
larger proportion of all women who died cared for in hospitals. The
differences in the mortality rates from deaths associated with ectopic
gestation in the various States are therefore associated with the
opportunity for exact diagnosis in areas having hospital facilities.
Deaths associated with ectopic gestation that occur far from hospitals
are doubtless frequently certified as due to indefinite causes, such as
sudden death or heart failure. Probably the medical evidence on the
death certificate is often insufficient even to suggest inclusion in the
puerperal group. The higher rates, therefore, are probably the more
accurate (table 100).
T able 100.— Relation between percentage of deaths associated with ectopic gestation
and percentage of hospitalization among women dying from puerperal causes in
each State included in the study
State
Percent of
Percent of
deaths asso hospitalization
among
women
ciated with
dying from
ectopic
puerperal
gestation
causes
Alabama__________
Oklahoma.___ ________
Maryland........................... ...................
Kentucky________________
Rhode Island__________________ ____
Virginia_______ _________________
North Dakota_________________ _____
Wisconsin___________________ .
New Hampshire______ _____ _________
Minnesota_____________
Nebraska______________________
Michigan.__________________________
Washington___ __________________
Oregon______________________
California..________________________
1.3
1.3
3.4
3.6
3.6
4.2
4.4
4.5
4.6
5.3
5.5
5.6
5.7
6.8
7.1
29 1
45! 0
72.5
31.8
70.9
47.3
59.1
64.7
70.6
70.7
58.7
67.8
81.0
76.3
81.3
Coefficient of correlation and probable error: r=+0.738±0.079.
PARITY AND AGE
Parity was reported for 262 of the 314 women; 93 were primigravidae and 169 multigravidae. These women constituted 4 percent of
all the primiparae and the same percentage of all the multiparae
included in the study. The 52 women whose deaths were associated
with ectopic gestation for whom parity was not reported constituted
10 percent of all the women dying from puerperal causes for whom
parity was not reported. The high incidence, in the ectopic-gesta8 The ectopic gestation was discovered at autopsy.
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175
ECTOPIC GESTATION
tion group, of women for whom parity was not reported is associated
with the fact that the condition is frequently of an emergency
character.
Among the primiparae the percentage whose deaths were associa
ted with ectopic gestation increased with age until the 35- to 39-year
age period, after which time the number of cases was insufficient to
form a reliable basis for judgment. Among the multiparae the max
imum percentage (5) was reached in the age period 30 to 34 years; the
percentage decreased in the periods 35 to 39 years and 40 to 44 years
(table 101).
Study of the age distribution of the women whose deaths were
associated with ectopic gestation as compared with all women dying
from puerperal causes, according to parity, shows that the average
T able 101.— Number and 'percentage of deaths associated with ectopic gestation
among primiparae and multiparae dying in specified age periods from all puerperal
causes
,
Women dying from puerperal causes
Age period
Whose
Whose
Whose
Whose
deaths
deaths
deaths
deaths
were asso
were asso
were asso
were asso
ciated with
ciated with
ciated with
ciated with
ectopic
ectopic
ectopic
ectopic
Total gestation
Total gestation
Total gestation
Total gestation
Total___________ .7,380
under
under
under
under
25______
30______
35...........
40______
25
855
1, 545
1,537
1,412
1,312
570
94
30
314
11
40
78
87
70
21
6
1
4
2,334
1
3
5
6
5
4
6
25
716
802
409
218
114
33
4
13
Num Per
ber cent 1
Num Per
ber cent
Num Per
ber cent 1
Num Per
ber cent 1
20 years,
25 years,
30 years,
35 years,
Of parity not
reported
Multiparae
Primiparae
Total
93
4
4,520
169
4
526
52
9
16
31
19
15
i
2
8
9
13
118
628
995
1,084
1,092
507
85
11
1
15
36
56
41
16
4
1
. 2
4
5
4
3
5
21
115
133
110
106
30
5
6
1
9
11
12
14
3
1
1
1
10
8
8
11
13
i Not shown where number of women was less than 50.
age of primiparae diagnosed as having had ectopic gestation (28.8
years) was considerably above that of all primiparae dying from
puerperal causes (23.7 years). The difference in the average age of
multiparae whose deaths were associated with ectopic gestation (33
years) and of all multiparae (32.2 years) was insufficient to be statis
tically significant. Of the 52 women (exclusive of 1 for whom age was
not reported) for whom parity was not reported and whose deaths
were associated with ectopic gestation, the average age was 31.6
years, indicating the probability that they were largely of the multi
parous group.
PERIODS IN WHICH SYM PTOM S BEGAN AND IN WHICH DEATHS
OCCURRED
The period of pregnancy at which symptoms began was reported
for 239 of the 314 cases. In all the instances in which a report was
obtained symptoms were noted by the third month. Symptoms
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176
MATERNAL MORTALITY IN FIFTEEN STATES
began before the fourth week in 30 cases, from the fourth to the sixth
week in 39 cases, from the sixth to the ninth week in 116 cases, from
the ninth to the thirteenth week in 38 cases, and at three months in
16 cases.
The estimated period of gestation was reported for 283 of the 314
women whose deaths were associated with ectopic gestation. Two
hundred and nine women (74 percent) died in the first 2 months of
pregnancy; 43 (15 percent) in the third month; 15 (5 percent) in the
fourth month; 2 (about 1 percent) each in the fifth, sixth, seventh,
and eighth months; and 8 (3 percent) in the ninth month or later.
OPERATIONS FOR ECTOPIC GESTATION
Two hundred and four of the 314 women were operated on for the
ectopic gestation; 109 3 (a surprisingly large number) died without
operation for the ectopic gestation (but 10 of them had another opera
tion other than blood transfusion), and in 1 case there was no report
on this subject. Conditions with regard to the accessibility of a phy
sician were about the same in the operated as in the nonoperated
group, about two thirds of each group being in the same vicinity as a
physician. Twenty-six of the 204 operations for ectopic gestation
were described as elective, 175 as emergency; no report was obtained
for 3.
DURATION OF S YM PTO M S BEFORE OPERATION OR BEFORE DEATH
A report concerning the duration of symptoms of ectopic gestation
before operation was obtained for 160 of the 204 women who were
operated on, and a report of duration before death for 86 of the 109
women who were not operated on, for the ectopic gestation. Among
the women who were operated on, 16 percent had had symptoms for
less than 1 day, 43 percent for less than a week, 35 percent for 1 to 3
weeks, and 23 percent for 4 weeks or more (table 102). Of the
26 women who died after elective operations, 17 were known to have
T able 102.— Duration of symptoms before operation for women operated on and
before death for women not operated on for ectopic gestation, among women whose
deaths were associated with ectopic gestation
Women whose deaths were associated with ectopic gestation
Operation for ectopic gestation
Total
Duration of symptoms
Yes
No
Percent
Number distribu
Percent
Percent
tion
Number distribu Number distribu
tion
tion
Total__________
314
204
Duration reported.......
246
160
100
Not re
ported
86
Less than 1 day___
1 day, less than 3 ..
3 days, less than 7..
1 week, less than 2.
2 weeks, less than 4
4 weeks or more___
Duration not reported..
1 The diagnosis in those cases was made by autopsy, by finding free blood by abdominal puncture either
before or after death, or from the symptoms and physical findings
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177
ECTOPIC GESTATION
had symptoms for more than a week; the duration of the symptoms of
the other 9 was not reported. Of the 86 women who died without
operation for ectopic gestation, 34 percent had had symptoms for
less than a day and 60 percent for less than a week.
TYPE OF OPERATION FOR ECTOPIC GESTATION
The operations just discussed included only those for ectopic gesta
tion; in all but one case, the removal of the fetus through a cul-de-sac
puncture for hematocele, a laparotomy was done. The usual operation
for ectopic gestation was salpingectomy. Six women had hysterec
tomy as part of the operation for ectopic gestation, on account of
interstitial pregnancy, adhesions, or fibroid uterus, or a combination
of the three. Three of the women with ectopic pregnancies last
ing into the third trimester had a dilatation of the cervix in an
attempt to bring on labor.
OTHER OPERATIONS ON W OM EN W ITH ECTOPIC GESTATION
Eighty-six of the women who died following ectopic gestation had
had operations other than for the ectopic gestation 4; 68 of the 86
also were operated on for the ectopic gestation (table 103). In
some instances the two types of operations were performed at the
same time. Thus 11 women had appendectomies at the time of the
laparotomy for ectopic. For one woman the removal of the appendix
and the discovery of an interstitial pregnancy took place at about the
second month of pregnancy. Three months later rupture occurred,
followed by laparotomy and death.
103.— Type of other operation performed for women operated on and not
operated on for ectopic gestation among women whose deaths were associated with
ectopic gestation
T able
Women whose deaths were associated
with ectopic gestation
Type of operation other than for ectopic gestation
Operation for ectopic gestation
Total
Yes
Total...........
314
109
Operation_______
18
One type only.
Blood transfusion___
Curettage__________
Appendectomy_____
Enterostomy_______
Incision and drainage.
Hysterectomy........
Other types________
Not re
ported
No
16
26
13
12
9
5
4
5
18
11
12
8
2
..........
8
1
4
1
4 __............
2
3
More than one type________________________ ____ _______
IX
9
Blood transfusion and curettage_____________________
Incision, drainage, and blood transfusion_____________
Incision, drainage, blood transfusion, and enterostomy..
Laparotomy and blood transfusion..____ ____________
Hysterectomy and blood transfusion_________________
Hysterectomy and curettage............................................
Incision, drainage, and curettage____________ ________
5
4
1
1
1
1
1
1
1
1 ................
......... .
..........
No operation.......... ......
Operation not reported.
2
1
1
227
1
4 See section Operations (p. 78) for operations in the first two trimesters.
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S
1 ...........
1 ...........
136
1
91
1
178
MATERNAL MORTALITY IN FIFTEEN STATES
Only 36 of the 314 women whose deaths were associated with ectopic
gestation had blood transfusions. Twenty-six of these also had an
operation for the ectopic gestation. Twenty of the 314 women were
curetted. In some cases this was done under the mistaken impression
that the symptoms were due to incomplete abortion. Eight of the
women who died following ectopic gestation had had attempted
induced abortions in the present pregnancy; five of them died of
sepsis.
VIABLE FETUSES
In 12 cases the period of viability of the child was reached. Diag
nosis was made either at operation or at autopsy in six cases. One
living child with no deformity was delivered: the abdominal preg
nancy was discovered, to the great astonishment of the surgeon, in
the course of an operation that was intended to be a Cesarean section
with appendectomy. “ The placenta, attached to omentum and
intestine, was separated without difficulty, and the patient did well
for 2 days, but then developed uremia followed by coma, and died.”
OBSTETRIC HISTORY OF MULTIGRAVIDAE
The past obstetric history was obtained for 140 of the 169 multigravidae; 111 were reported to have had previous pregnancies lasting
into the third trimester, and the report for 60 of these showed all
normal deliveries. Previous abortions were reported for 26 of the
140 women. Previous ectopic gestation was reported for 3 of the
women.
COMMENT BY ADVISORY COMMITTEE
Ectopic gestation is more frequently reported as a cause of death
in urban than in rural areas. But when one considers the nature
of this complication and the fact that it was given as the cause of
death for only four women who died without medical care, it is
fair to assume that, especially in the rural areas, some of the deaths
from this condition are not recognized and the cause of death is
not properly assigned. This assumption is further supported by
the fact that in those States where hospitalization was more fre
quent the diagnosis of ectopic gestation was made more frequently.
Of the 314 women whose deaths were known to be associated with
ectopic gestation, 4 had no medical care and the condition was
discovered at autopsy, and 44 were moribund when first seen.
Eighty-one percent of these cases received hospital care. It is
interesting also to note the large percentage of these cases that
occurred in multigravidae. It is likewise surprising to find that
109 of these women died without operation. As is to be expected,
a very large percentage of the others had emergency operations.
The fact that only 36 of these 314 women had blood transfusions
shows that this life-saving procedure was not available in many
of these cases, for if it had been it undoubtedly would have been
used.
That emergency operating was common and that the deaths of
65 of these patients were classified as due to puerperal septicemia
makes it very clear that the operative technique must be as perfect
as is possible if deaths from sepsis are to be avoided. ^ The removal
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ECTOPIC GESTATION
179
of the appendix in cases of ruptured ectopic is a dangerous pro
cedure and adds to the deaths from sepsis. (There were 11 such
cases.) It has long been recognized that the opening of the gut
when there is much blood in the peritoneal cavity should be
avoided.
A review of the duration of symptom» suggestive of ectopic preg
nancy before the operation was performed shows that only 16 percent
of these cases had symptoms less than a day, while 43 percent had
symptoms for a week, 35 percent had symptoms for 1 to 3 weeks,
and 23 percent had symptoms for 4 weeks or more. These figures
show clearly that in many cases the symptoms of the serious condition
o f ectopic pregnancy were ignored.
182748—34----- 13
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RECOMMENDATIONS BY ADVISORY COMMITTEE
Maternal deaths are due in large part to controllable causes. But
how is control of these causes to be established? First, the medical
profession and the public must know the facts, and then each group
should take appropriate and decisive action. Physicians have the
responsibility for leadership in both the medical and the community
program for such control. As the facts become more widely known,
others will assume this leadership if physicians do not.
Recommendations for action looking to prevention of maternal
deaths are addressed to the medical profession and to the general
public.
To the Medical Profession
A. Physicians must assume leadership in the field of maternal
care by:
1. Informing the public that the high mortality during preg
nancy, delivery, and the postpartum period is due largely to
controllable causes.
2. Recognizing that every mother must have adequate pre
natal, delivery, and postpartum care. (For definition of ade
quate see p. 43.)
3. Instructing the public as to what constitutes adequate
maternal care.
4. So organizing the available resources of their communities
that every mother can receive adequate maternal care.
5. Warning the public as to the dangers occasioned by abor
tions, spontaneous or induced.
B. In order that more accurate information may be secured relative
to cause and prevention of maternal deaths:
1. Physicians should make a greater effort to study by autopsy
and other scientific means every maternal and fetal death, for
in many cases this is the only means of ascertaining the true
cause of death.
2. Physicians are urged to exercise the greatest possible care
in making out maternal and fetal death certificates, so that vital
statistics may be more accurate and therefore more valuable.
3. Bureaus of vital statistics are urged to query maternal and
fetal death certificates recording an indefinite cause of death;
for example, “ Cesarean section” alone.
4. Medical societies and departments of health in cooperation
should investigate each maternal death within a few weeks of
the death.
180
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RECOMMENDATIONS BY ADVISORY COMMITTEE
181
C. In order that physicians in general may have a better under
standing of the fundamentals of obstetric care:
\* There should be larger and better facilities for clinical
training in obstetrics.
2. Undergraduate students should have a much wider contact
with obstetric patients.
3. The State medical societies, the medical schools, and State
departments of health should provide or arrange for postgrad
uate teaching in the various counties in order to keep the local
practitioner in touch with the best obstetric thought and practice.
D. It is recommended that all physicians practicing obstetrics give
particular consideration to:
1. The importance of good aseptic technique, including the
use of rubber gloves and masks that cover nose and mouth.
2. The danger to mothers from carriers of infection.
3. The dangers of the use of pituitrin during labor.
4. The dangers of multiple, forcible, and radical procedures in
obstetrics.
5. The proper indications and contra-indications for various
obstetric operations, especially (a) the dangers of major opera
tions in the presence of shock and hemorrhage and (b) the
dangers of Cesarean section after vaginal manipulations or long
labor.
6
6. The proper selection of anesthetics.
7. The value of blood transfusions.
8’ The dan£ers of intrauterine manipulation in cases of infected
v: abortion.
9. The importance of taking measures to protect against acute
diseases, especially infectious diseases, and of avoiding, wherever
possible, the termination of pregnancy while such disease is.
present.
10. Knowledge of the symptoms of some of the less common
but more serious complications of delivery such as rupture o f
the uterus.
E.
It is recommended that State medical societies working in coop
eration with the State departments of health consider the develop
ment of some plan by which well-trained regional obstetric consultants
may be made available.
To the General Public
There should be widespread education of the public as to the
following:
That the high maternal death rate is due largely to. con
trollable causes.
2. That it is necessary for all women to have adequate supervi
sion and medical care during pregnancy, labor, and the postpartum period, such supervision and care to begin early in pregnancy
and to be continuous through the postpartum period—
a. In order to safeguard the health of both mother and
child.
•j
order especially to control the infections), toxemias,
and hemorrhages that this study and others have shown to
be real menaces to life.
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182
MATERNAL MORTALITY IN FIFTEEN STATES
3. That there is danger of death or serious invalidism following
abortions, spontaneous or induced.
4. That the community has a definite responsibility to provide
adequate medical and nursing facilities for the care of women
during pregnancy, labor, and the postpartum period. This predi
cates the proper organization of hospitals, outpatient services,
and medical and nursing personnel and applies to both home and
hospital care. The community should know the standards for
hospitals taking obstetric cases that have been drawn up by the
American College of Surgeons. (See below.)
5. That judicious selection of the hospital to be used for ma
ternity care is of the greatest importance when hospitalization is
planned.
6. That the better education of those caring for women during
this period is essential and should have public support. This
includes adequate obstetric training for medical students, post
graduate obstetric training for physicians in practice, to keep
them abreast of modern developments, the training of nurses in
good maternity care, and the training and supervision of mid
wives in communities where midwives still practice.
7. That it is important to make careful and intelligent selection
o f the attendant for maternal care.
STAN D AR D S OF A M E R IC A N COLLEGE OF SURGEONS
FOR HOSPITALS T A K IN G OBSTETRIC P A TIE N TS
IA m e r ic a n C o lle g e o f S u r g e o n s; T w e n t ie th Y e a r B o o k .
P p . 6 8 -6 9 . C h ic a g o ]
1933
(1) Segregation o f obstetric patients from all others in the
institution.
(2) Special facilities available for immediate segregation and
isolation of all cases o f infection, temperature, or other
conditions inimical to the safety and welfare o f patients
within the department.
„
,
(3) Adequately trained personnel, the entire nursing staff to be
chosen specially for work in this department and not per
mitted to attend other cases during time on obstetric service.
( 4) Readily available, adequate laboratory and special-treatment
facilities under competent supervision.
( 5) Accurate and complete clinical records on all obstetric patients.
( 6) Frequent consultations encouraged on obstetric service, a
consultation made obligatory in all cases where major opera
tive procedures may be indicated.
(7) Thorough analysis and review of the clinical work of the
department each month by the medical staff with particular
consideration to deaths, infections, complications, or such
conditions as are not conducive to the best end results.
( 8) Adequate theoretical instruction and practical experience for
student nurses in prenatal, parturient, and postpartum care
o f the patient, as well as the care of the newborn.
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Appendix A.— GENERAL TABLES
T able
I .— Cause of death
as shown by interview and trimester of pregnancy among white and colored women dying from puerperal causes in
urban and rural areas
TO T A L
Women dying from puerperal causes
Cause of death 1as shown by interview
Not reported
Lä&t
First
two
Luol
Not reported
Total
First
two
Not reported
All causes______________________ . . . . _______
7,380
2,381
4,965
34
3,462
1,307
2,148
7
3,918
1,074
2,817
27
Accidents of pregnancy_______ _______ ____________
719
575
142
2
351
292
58
1
368
283
84
1
204
57
4
28
1
264
240
99
118
81
85
2
I 49
160
52'
107
I 46
89
42
¿4 8
66
I47
94
42
Puerperal hemorrhage_______ _______ _____________
791
11
779
1
331
4
327
460
7
452
1
Placenta previa__________ ______________ !_____
Other....... .................. a_____ ___________________
8Ç
Hi
11
I4 7
4
I 48
200
7
198
269
1
Other accidents of labor.._________________________
652
1
Cesarean section________________ ______ _______
Other surgical operations and instrumental de
livery____________________ _________________
Other_______________________________________
186
1
109
407
Abortion, premature labor____________________
Ectopic gestation_____________________________
Other.................... .................................... ..............
Puerperal septicemia_____________________ _______
Puerperal phlegmasia alba dolens, embolus, sudden
death____ _____ _____ _________________ ________ _
Puerperal albuminuria and convulsions____ _________
Following childbirth (not otherwise defined)........... .
puerperal diseases of the breast................................... .
268
2,948
1,900
23
3
8
886
44 s
184
260
651
294
294
358
1
357
185
88
88
48
1
47
109
407
56
150
56
160
53
'257
1,403
1,529
291
1,549
22
2
i According to the Marmai of the InteruatiopaPList of Causes of Death, 192Q,
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98
1
184
..
53
338
4
12
1
16
13
i
1
1,543
819
719
¿57
23
169
134
607
7
2
777
7
2
GENERAL TABLES
Total
First
two
Trimester of pregnancy
Trimester of pregnancy
Trimester of pregnancy
Total
In rural areas
In urban areas
Total
68
267
5
1,405
584
810
1
187
1,123
16
1
30
169
157
942
15
11
12
1
1
00
W
ca uses
in
184
T able I .— Causé of death as shown by interview and trimester of pregnancy among white and colored women dying from puerperal
urban and rural areas— Continued
w h it e
Women dying from puerperal causes
Total
All causes_______
Accidents of pregnancy.
Abortion, premature labor.
Ectopic gestation_________
Other_____ ____ _________
Puerperal hemorrhage.
6,07%
613
670
Other accidents of labor.
525
Puerperal septicemia_____________ _____ __________
Puerperal phlegmasia alba dolens, embolus, sudden
death------ ------------------- ------ ----------------------------Puerperal albuminuria and convulsions____________
Following childbirth (not otherwise defined)_______
Puerperal diseases of the breast................ ..................
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488
210
S77
C esarean section____________ ____________ _
Other surgical operations and instrumental de
livery....................................—------- ------------Other.............................................................: ------
2,025
SOI
Placenta previa.
Other.................
Total
Total
First
two
First
two
Not re
ported
Last
4,027
Trimester of pregnancy
Trimester of pregnancy
Trimester of pregnancy
20
2,951
125
First
two
Not re
ported
Last
1,143
1,805
3,121
259
50
304
40
Not re
ported
Last
2,222
1ÏS
79
87
5
1S6
128
28
45
165
82
57
663
290
380
375
1B9
160
160
163
217
244
244
48
48
114
287
S76
280
40
97
SOB
97
S05
m
2,437
1,209
1,218
1,316
721
314
1,493
17
3
45
276
269
1,210
146
638
6
141
16
2
2
20
49
49
191
191
1,121
126
497
6
2
168
855
11
1
25
135
143
713
10
MATERNAL MORTALITY IN FIFTEEN STATES
Cause of death as shown by interview
In rural areas
In urban areas
Total
COLORED
1,308
356
038
14
511
164
343
4
797
192
595
10
106
87
17
2
42
33
8
1
64
54
9
1
58
88
16
46
86
7
7
8
7
8
18
88
7
11
80
8
8
8
4
1
89
16
9
H
15
6
5
1
8
1
Puerperal hemorrhage________________________
121
5
116
41
2
39
80
3
77
Placenta previa................................................
Other................ ..... ......................................
64
67
6
49
67
84
17
8
84
16
87
43
8
34
13
Other accidents of labor...........................................
127
127
50
50
77
77
IS
IS
6
6
7
7
18
108
18
108
8
86
8
86
4
66
Abortion, premature labor.............. ................_
Ectopic gestation.......................... ..... ........ ....
Other.............................. ................. ............
Cesarean section_____________________ ____
Other surgical operations and instrumental de
livery..... .................................... ...............
Other____ ___ __________________________
Puerperal septicemia..................................... ......
Puerperal phlegmasia alba dolens, embolus, sudden
death.............................. ................................ .
Puerperal albuminuria and convulsions__________
Following childbirth (not otherwise defined)______
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511
194
311
30
407
8
22
62
339
6
6
6
6
227
98
127
11
3
28
8
110
1
139
1
66
2
284
96
184
4
1
19
268
5
5
34
14
229
5
GENERAL TABLES
All causes_____________________________
Accidents of pregnancy_______________________
00
Ox
T able
IL — Registration by the American Medical Association, approval by the American College of Surgeons, and bed capacity of hospitals
in which women were hospitalized at death; women dying from puerperal causes
00
05
Women dying from puerperal causes
Registration and approval of hospital, and
maintenance of standards 1
Number of beds
Total
Total
Total...........
7,380
4,066
Death in hospital.
4,066
4,066
3,726
3,726
2,338
2,338
1,388
1,388
Registered by American
Association . . . . . . . .
50,
less
than
75
75,
less
than
100
100,
less
than
125
125,
less
than
150
284
557
264
499
236
384
667
Less
than
10
10,
less
than
20
20,
less
than
35
85
245
439
439
254
513
263
489
165
35,
less
than
50
150,
less
than
175
175,
less
than
200
200,
less
than
225
225,
less
than
250
Not
250 or
re
more ported
226
139
146
157
757
336
139
146
157
767
236
226
139
146
157
757
399
217
207
129
125
126
717
90
19
19
10
21
31
40
Not re
ported
Not in whether
in
hospi
hospi
tal
tal
32
Medical
Approved by American College of
Surgeons_____________________
Not approved by American Col
lege of S u r g e o n s ....:............
5 standards i m aintained......
1 or more standards not
maintained. _____ ________
No report on standards______
164
368
4
21
228
14
164
364
233
285
95
19
S85
930
73
930
73
Not registered by American Medical
Associations________________ _____
No report on registration (name of
hospital not reported)_____________
333
333
Death not in h o s p i t a l . . - . . : . . . . . . . . . . : . : .
Not reported whether death in hospital..
,399
16
7
14
134
11
19
71
.165
6
169
31
44
7
15
1Hospital standards of the American College of Surgeons prescribe in general: (1) Organization of a staff; (2) specific qualifications for staff membership; (3) rules, regulations, and
policies governing professional work of hospital; (4) complete ease records; (5) diagnostic and therapeutic facilities. I For complété requirements seé Year Book of American College of
Surgeons, 1927, p. 51. In this study data on maintenance of standards were obtained from interviews with hospital superintendents, not by inspection of the hospital.
* Refusal of registration means that the American Medical Association had evidence of such irregular or unsafe practices that these hospitals were “ deemed unworthy of being
included in any published list of reputable hospitals. ” Journal of American Medical Association, vol. 96, no. 13, Mar. 28, 1931, p. 1022.
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MATERNAL MORTALITY IN FIFTEEN STATES
In hospital
.Wpmen dying from puerperal causes who had reached last trimester
In hospital for delivery
Registration and approval of hospital,
and maintenance of standards1
Total
Total
Hospital registered by American
Medical Association______________
1 ,9 7 1
Less
than
10
10,
less
than
20
1,971
53
134
232
132
261
126
247
124
114
1 ,971
63
134
232
132
261
126
2g
; 124
114
7
95
194
121
238
126
241
134
114
56
67
72
338
12
96
S 78
104
¡52
60 1 57
309
7
V 95 .
194 : .
109
142.
- 48,;
42
12
10
;4
4
3
■5
1
1,793
1,793
Approved by American College of
Surgeons..........................
1,079
Not approved by American Col-"
lege of Surgeons_______________
714
1,079
5 standards1maintained_____
1 or more standards not main
tained____________________
No report on standards...11111
Not registered by American Medical
Association *______ ____ ___________
No report on registration (name "of"
hospital not reported)_____________
Not in hospital for delivery____
Not reported whether in hospital' tor
delivery.....................
196
714
i
19Ç
20,
less
than
35
50,
less
than
7ff
75,
less
than
100
100,
less
than
125
125,
.less
than
150
16
22
28
46
15
16
9
81
87
SO
24
2
3
482 ,
482
6
86
1
75
6
161
se
174
174
46
39
38
4
35,
less
than
50
ii
9
11
23
3
150.
less
than
175
175,
less
than
200
200,
less
than
225
56
;
56
.
225,
less
than
250
250
Not
or
re
more ported
67
338
87
' 72 7* 338
7
15
29
12
26
1
6
Not reported
whether
in hospital for
delivery
15 2,990
4
¿5
2
1
11
4 Sl-L—
2 ,9 9 0
*
2 ,9 9 0
4 s fâ f
4
» firfdsa1 of r * f e t r ^ n m ^ ^
by
included in any published hst of reputable hospitals." Journal of American Medical ^ sociaton , v o l ! ^ n o . ^ M a r m i ^ p . 1022®hospitals were
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.
kerned unworthy of being:
GENERAL TABLES
Total................................................... 4,965
In hospital for delivery...____ _____ _____
Not
in
hospi
tal for
de
livery
ANuuiuer m oeas in nospitai
188
MATERNAL MORTALITY IN FIFTEEN STATES
IV .— Observance of minimum standards for obstetric service recommended
by the American College of Surgeons,1 and delivery-room and training-school
facilities in hospitals in which women were hospitalized at death; women dying
from puerperal causes
T able
Women dying from puerperal causes
In hospital
Hospital technique and observance
of standards for obstetric service1
Hav Not re
ing ported
Hav
Not re
as to Not in ported
neither
ing de
livery Hav Hav
whether
hos
deliv
deliv
Total
ery
ing de ing
pital in hos
ery
Total room
room room
and livery train
pital
ing
and
nor
train room school
train train
ing
ing
ing
school
school school
Total....................
7,380
4,066
2,709
786
131
407
Death in hospital______
4,066
4,066
2,709
786
131
407
On obstetric service.
8,806
1,589
463
48
SÍ5
1,661
1,313
255
72
80
46
20
7
345
126
110
96
220
104
68
40
SIS
158
Hospital observing 5 stand
a rd s..!_________________ 1,661
Hospital observing 1 or
more standards................
80
Hospital not observing all
standards but number
not reported____________
345
Hospital not observing
standards..........................
220
Not on obstetric service.
1,675
Technique up to standards
of American College of
Surgeons________ _______ 1,206
Technique below standards
of American College of
Surgeons.........................
437
32
Technique not reported.......
Not reported whether on ob
stetric service...........................
85
Death not in h ospital..................... 3,299
Not reported whether death in
hospital__________ ______ _______
15
1,676
i ,m
1,206
998
147
20
437
32
105
9
161
4
130
8
86
84
33
3,299
15
IS
19
3,299
1 Standards for obstetric service prescribe in general: (1) Segregation of obstetric patients from other
types; (2) preliminary examination for infectious or contagious diseases; (3) segregation of patients having
temperature from other obstetric patients; (4) aseptic technique; (5) incorporation of indications for
operative procedure in case record. For complete requirements on which this classification was based
see Year Book of American College of Surgeons, 1927, p. 71.
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Federal Reserve Bank of St. Louis
189
GENERAL TABLES
T a b l e V. — Observance of minimum standards for obstetric service recommended
by the American College of Surgeons,1 and delivery-room and training-school
facilities in hospitals in which women were hospitalized at delivery; women dying
from puerperal causes who had reached the last trimester of pregnancy
Women dying from puerperal causes who had reached last trimester
In hospital for delivery
Hospital having—
Hospital technique and observance
of standards for obstetric service1
Nei
Total
Deliv
ther
ery
deliv
Total room Deliv
Train ery
and
ery
ing
room
train room school nor
ing
train
school
ing
school
Notreported
as to
deliv
ery
room
and
train
ing
school
Total____________
4,965
1,971
1,304
406
48
202
11
In hospital for delivery..
1,971
1,971
1,304
406
48
202
11
On obstetric service.
1,877
1,877
i ,m
381
43
166
1
1,332
1,332
1,046
214
21
51
66
66
40
13
5
8
296
296
111
96
10
78
183
183
89
58
7
29
«7
37
11
6
«
8
11
2
2
2
Hospital observing 5 stand
ards___________________
Hospital observing 1 or
more standards_________
Hospital not observing all
standards but number not
reported........................... .
Hospital not observing
standards.........................
Not on obstetric service •_
Technique up to standards
of American College of
Surgeons..........................
Technique below standards
of American College of
Surgeons............................
17
17
10
10
Not reported whether on ob
stetric service........................
67
67
Not in hospital for delivery______ 2,990
Not reported whether in hospital for
delivery___________________ *.
4
4
7
19
Notin
hos
pital
for de
livery
2,990
Not re
ported
whether
in hos
pital? or
delivery
4
1
6
3
38
10
2,990
1
» Standards for obstetric service prescribe in general: (1) Segregation of obstetric patients from other
types; (2) preliminary examination for infectious or contagious diseases; (3) segregation of patients having
temperature from other obstetric patients; (4) aseptic technique; ( 5 ) incorporation of indications!for
operative procedure in case record. For complete requirements on which this classification was based see
Year Book of American College of Surgeons, 1927, p. 71.
2 On gynecological, surgical, or medical service.
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Federal Reserve Bank of St. Louis
190
T a b l e V I .— Cause o f death 1as shown by interview aeeording to interval between d eliv ery 5 and death, am ong w om en dying fr o m p u erp era l causes
Women dying from puerperal causes
Interval between delivery2 and death
Less than 1 week
Total
Total
Less
than
1 day
1 day,
less
than?
2 days,
less
than 3
3 days,
less
than 7
1 week,
less
than 2
2 weeks,
less
than 3
3 weeks,
less
than!
4 weeks
or more
Not re
ported
No de
livery
All causes..-_______ ________________ _______
7,380
3,455
1,923
332
240
960
1,190
591
315
752
420
657
Abortion, premature labor________________________
Ectopic gestation_______________ ____ ______ _____ _
353
248
118
347
444
136
109
407
2,948
220
160
39
280
407
106
95
241
596
105
82
21
254
379
31
73
133
43
28
22
10
8
12
8
7
29
43
20
15
3
5
2
7
6
21
51
67
41
5
13
14
60
9
58
459
37
25
3
5
12
18
4
61
804
28
11
4
2
3
6
2
22
454
2
2
1
3
2
1
1
10
241
17
6
42
38
4
7
9
1
2
18
252
7
6
67
50
6
1
4
36
23
344
1,900
•is
3
144
1.163
4
105
696
1
6
159
109
1
33
199
2
93
123
5
28
31
21
27
1
9
37
1
19
437
Other puerperal hemorrhage _____________________
Cesarean section_____________________ ___________
Other surgical operations and instrumental delivery..
Other accidents "of labor___ _________ ______________
Puerperal septicemia___________________ __________
Puerperal phlegmasia alba dolens, embolus, sudden
Puerperal albuminuria and convulsions____________
Following childbirth (not otherwise defined)_______
1According to the Manual of the International List of Causes of Death. 1920.
2 Also abortion, operation for ectopic gestation, or rupture of unoperated ectopic gestation.
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Federal Reserve Bank of St. Louis
5
3
1
19
578
27
82
12
2
1
MATERNAL MORTALITY IN FIFTEEN STATES
Cause of death 1 as shown by interview
T able
VII.
Cause of death 1 as shown by interview and number of pregnancies among women dying from puerperal causes
Women dying from puerperal causes
Number of pregnancies
Cause of death1 as shown by interview
Total
1
All causes....................................
2
7,380
2,334
Accidents of pregnancy.....................
719
176
Abortion, premature labor.........
Ectopic gestation___________
Other_____ _____ ____
858
66
77
Puerperal hemorrhage___
Other accidents of labor...... ........
791
662
203
Puerperal septicemia.......... ......
Puerperal phlegmasia alba dolens, embolus, sudden
death_________ _________
Puerperal albuminuria and convulsions..
Following childbirth (not otherwise defined)
Puerperal diseases of the breast____
2,948
109
88
46
46
55
41
6
7
8
60
867
830
8
1
254
✓ 204
3
167
4
More
than 1
ber not
specified
Not reported
267
205
142
372
498
41
23
16
12
24
79
84
6
6
10
$
8
9
9
18
8
8
8
22
1
1
40
21
18
88
42
9
59
45
45
45
34
78
40
30
S3
86
21
24
17
28
25
20
11
23
40
88
23
17
18
12
45
35
31
26
20
45
28
25
4
2
1
8
8
1
1
88
2
25
4,
20
17
10
82
4
21
1
28
165
121
94
73
44
116
238
280
• 18
104
1
20
78
13
58
3
9
36
7
25
20
88
16
96
1
7
96
3
1
6
48
10 or
more
9
340
34
-, .
H
344
1,900
23
3
64
153
114
136
75
5
6
847
444
Cesarean section.....................
Other surgical operations and instrumental delivery...........................
Other..................................
101
4
1
526
©
H
!2¡
H
W
>
F
TABLES
Placenta previa_______ _
Other__________ ____ _____
118
3
1 According to the Manual of the International List of Causes of Death, 1920.
CO
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Federal Reserve Bank of St. Louis
T able
V III.— Cause of death » as shown by interview and parity among women dying in specified age periods from puerperal causes
g
Women dying from puerperal causes
—
—
Age at death
45 years and
over
40 years,
under 45
35 years,
under 40
30 years,
under 35
25 years,
under 30
20 years,
under 25
Under 20
years
Not re
Per ported
Per
Per
1 Per
Per
Per
Per
Per
cent
Num
cent
Num
cent
Num
cent
cent Num
Num cent Num cent Num cent Num distri
distri
ber
distri
distri ber
ber
distri
ber
ber
distri
distri ber
ber
distri
ber
bution 2
bution 2
bution 2
bution 2
bution 2
bution 2
bution 2
bution 2
7,380
719
100
10
6
8
8
S6S
«48
118
Other accidents of labor-------------------------Other surgical operations and instru-
880
8
1
1
87
10
18
1,545
100
8
122
66
88
88
4
2
1
1,537
150
100
1,412
100
1,312
100
570
100
94
100
30
10
169
12
150
11
62
11
12
13
4
6
4
78
6
6
71
64
6
4
8
89
19
14
5
8
8
6
4
8
6
4
8
8
196
144
15
11
93
65
16
11
16
6
17
6
3
1
78
66
81
5
7
120
99
8
6
139
139
9
178
135
7
1
19
i
86
8
89
8
31
8
U
8
81
86
8
4
18
68
i
4
81
98
1
6
14
1
6
81
2
12
39
2
7
8
4
8
4
1
446
34
157
28
36
38
13
65
309
5
24
35
157
6
28
4
19
4
20
2
7
i
1
46
63
188
8
2,948
40
366
42
694
45
690
45
546
39
344
Puerperal albuminuria and convulsions.... 1,900
Following childbirth (not otherwise de23
fined)— ------ ------------------------------------3
Puerperal diseases of the breast......... .........
5
26
20
332
2
38
67
436
4
28
78
334
5
22
73
306
5
Puerperal phlegmasia alba dolens, embo-
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(*)
(»)
1
13
11
9
1
6
6
50
791
652
109
407
100
3
(8)
5
2
(»)
(»)
7
(8)
4
1
(8)
(8)
(8)
1
(8)
MATERNAL MORTALITY IN FIFTEEN STATES
Total
Cause of death >as shown by interview
PR IM IP A R A E
All causes..........................
100
741
Accidents of pregnancy...............................
176
8
39
Abortion, premature labor............
66
77
S3
3
3
SO
8
11
153
203
7
35
49
7
63
3
7
i
60
80
3
SI
857
37
295
106
830
5
36
14
306
Puerperal hemorrhage_________
Cesarean section______ ____ __ _
Other surgical operations and instru
mental delivery_______________
Puerperal Septicemia___________
Puerperal phlegmasia alba dolens, embo
lus, sudden death..........................
Puerperal albuminuria and convulsions___
Following childbirth (not otherwise de
fined)_______________
Puerperal diseases of the breast_____
8
1
(*)
(*)
100
802
100
409
218
100
114
100
33
4
11
29
IT
11
10
6
i
3
7
1
9
17
3
4
1
11
S7
6
8
1
S
8
S
S
S
s
52
58
6
7
32
47
.8
11
15
. 28
13
17
13
15
11
16
S
10
S
17
8
6
6
SI
6
S
3
4
3
4
3
1
4
4
5
38
143
35
66
30
29
25
10
Zu
6
29
16
63
29
6
38
5
33
3
6
44
5
1
SS
13
3
S
IS
40
307
41
44
294
(3)
37
118
(3)
(*)
1
(*)
9
13
2
S
i
1
i
8
7
7
2
3
(»)
M U LTIPA RA E
All causes____ ____ ________
4,520
100
118
100
628
100
100
1,084
100
1,092
100
507
100
85
100
11
Accidents of pregnancy_____ ____
A1»
Abortion, premature labor..... ...............
Ectopic gestation............ .................
Other_________
459
S54
1S9
7ft
10
6
S
9
8
6
60
36
IS
IS
10
6
9
6
117
60
11
6
11
6
8
53
27
10
6
IS
S
10
6
S
S
12
7
S
1
f
1
119
66
SS
21
Puerperal hemorrhage_____
Other accidents of labor______
n
ir
Other surgical operations and instrumental delivery_____________
Other.......... ........
608
424
7S
13
9
S
60
37
3
10
6
8
S
154
105
SS
14
10
S
173
124
25
16
11
S
93
55
7
18
11
1
15
6
18
7
2
1
48
1
6
74
1
7
17
82
8
8
10
38
2
7
S
4
S
6
1
469
47
429
40
364
33
134
26
33
39
2
196
20
56
219
5
20
67
253
5
23
31
141
6
28
4
16
5
19
2
3
1
1
304
Puerperal septicemia...
1,811
Puerperal phlegmasia alba dolens, embolus, sudden death...................
231
Puerperal albuminuria and convulsions___
974
Following childbirth (not otherwise defined)...........................
12
Puerperal diseases of the breast____
1
6
s
10
13
8
11
(»)
11
29
40
59
50
321
5
22
22
19
23
124
20
(3)
1According to the Manual of the International List of Causes of Death, 1920.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
44
4
IS
n
101
83
16
K
IS
(3)
(*)
63
_
«
1
2
(3)
s
«
1 Not shown where number was less than 50.
14
3
GENERAL TABLES
2,334
s
* Less than 1 percent.
CO
CO
T able
1
V III.— Cause of deaths as shown by interview and parity among women dying in specified age periods from puerperal causes— Contd.
P A R IT Y NOT R E PO R T E D
^
Women dying from puerperal causes
Tt tal
Under 20
years
Cause of death as shown by interview
20 years,
under 25
26 years,
under 30
30 years,
under 35
35 years,
under 40
40 years,
under 45
vj /
Ô
45 years and
over
Not re
Per
Per
Per
Per
PefPer
Pet:
Per ported
Num cent Num cent Num cent Num cent Num cent Num cent Num cent Num cent
ber
distri
ber
distri
ber
ber
distri
distri
distri
ber
ber
distri
ber
distri
ber
distri
bution
bution
bution
bution
bution
bution
bution
bution
All causes............. - .........................
526
100
133
100
110
100
106
30
5
6
Accidents of pregnancy________________ _
84
16
2
18
16
16
12
23
21
20
19
3
1
'1
Abortion, premature labor___________
Ectopic gestation .----------..—. . . .......
Other............. ................. .....................
S3
4*
9
6
8
5
1
1
9
7
S
8
6
S
9
6
1
7
5
1
9
It
3
8
110
3
6
13
5
5
IS
5
3
1
Puerperal hemorrhage__________ ______ _
Other accidents of labor............. ................
30
25
6
5
1
1
8
4
7
3
6
9
5
7
9
2
8
2
6
7
6
7
2
Cesarean section________ _____ ______
Other surgical operations and instru
mental delivery.................................
Other-.—- . . . _______ _____ _____ _____
1
(»)
1
1
1
S3
(>)
Puerperal septicemia.. . . . . .........................
Puerperal phlegmasia alba dolens, embo
lus, sudden death....................... ..........
Puerperal albuminuria and convulsions___
Following childbirth (not otherwise de
fined)________ _____________ __________
Puerperal diseases of the breast................. .
a Less than 1 percent.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
100
21
115
-
100
J
4
1
4
3
8
6
S
S
7
7
1
1
280
53
12
66
57
78
59
51
46
53
50
13
3
;4
7
96
1
18
1
4
16
2
20
2
15
1
24
I
22
2
18
2
17
1
10
1
1
3
1
1
2
2
(>)
18
1
1
1
MATERNAL MORTALITY IN FIFTEEN STATES
Age at death
195
GENERAL TABLES
T able
IX . — Prenatal care received by white and colored unmarried women dying i n
urban and rural areas from puerperal causes
Unmarried women dying
from puerperal causes
Grade1of prenatal care
In urban In rural
areas
ateas
Total
509
Total
253
25ft
10
21
Grade I ___
Grade II______ 1........... —
Grade III . . 4__ 1_______
Ungraded_____ - ___:_____
No prenatal! carei.__ |
_____
No report on prenatal care.
Inapplicable8.....................
54
1
238
41
144
159
14
W H ITE
T otal..___ ...___ ___
246
142
104
Grade I ___ ___ ______ ___
Grade II___;______
Grade III— .......
No prenatal care.......... ......
No report on prenatal care.
Inapplicable8______ L¡—¡...
9
13
19
78
17
110
8
11
10
29
13
71
1
2
9
49
4
39
263
uk
152
1
8
■ 35
1
160
24
34
1
7
24
1
50
14
14
COLORED
Total.!____
Grade I .___i____ .tS.i.L.L.
Grade II___:_____________
Grade III— k....... ............
Ungraded___ —
____
No prenatal care_____ . . . .
No report on prenatal care.
Inapplicable8______ _____
>1
11
110
10
20
1 For criteria as to grading see p. 43. i
8Induced abortions and cases in which pregnancy terminated before the third month.
T able
X .<—Hospitalization and trimester of pregnancy of unmarried women dying
from puerperal causes
Unmarried women dying from puerperal causes
Hospital cases
Trimester of pregnancy and hospitalization at de
livery or abortion
N ot
Total
Died in hospital
Total
Yes
hospital
caSes
No
j.— L
509
269
259
10
240
Last trim ester...!___L
jin hospital...!___L
Emergency— L
Planned, 4___ L
Not reported.L
287
1S9
70
44
25
139
189
70
44
25
135
185
69
41
25
4
|| 148
129
189
123
188
1
1
1
Total.—
Not in hospital...I
I 48
First 2 trimesters a___ L
|ln hospital__ L ...1
Not in hospital...L
219
Triinester not reported
In; hospital__ ¡----i
Not in hospital....
182748—33----- 14
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
m
90
3
t
8
4
1
3
I!
jj
1
6
6
"f
148
so
|j 90
2
8
T
able
X I .— Type of operation for delivery in each trimester of pregnancy and cause of death 1 as shown by\interview among women dying from
puerperal causes
¡iP
Women dying from puerperal causes
Cause of death i as shown by interview
Total
All deaths_________ . __________________________
7,380
Accidents
of preg
nancy
Placenta
previa
Other
puerperal
hemori
rhage
719
347
444
Puerperal
Other
phlegma Puerperal
surgical
Other
albumi
alba
Cesarean operations
Puerperal sia
accidents’
dplens, nuria and
section and instru of labor septicemia embolus,
convul
mental
sions
sudden
delivery
death
136
109
407
3,948
344
1,900
8S8
18
42
777
l
18
1
80
27
17
53
861
24
2
6
218
1
87
3
843
65
24
12
164
2
314
2
8
298
6
8
15
2
8
13
FIRST T R IM E S T E R
Total......... ........... .........................__.........................
Therapeutic abortion__________ _____ _______ _________
Laparotomy for ectopic gestation_____________ ________
No' operation...................................._.......................... ........
No réport on operation....................................... ................
i ,m
84
170
1,044
1
S6S
38
128
197
1
SECOND TR IM E S T E R
Total__________________________ _______________
Therapeutic abortion..........................................................
Laparotomy for ectopic gestation................................... __
Other operation______ ______ _____________
No operation______________ _______ ____________
No report on operation____________ ____ ____ _________
678
117
13
24
514
4
lift
23
11
4
102
10
2
1
1
6
1
1
FIRST OR SECOND T R IM E ST E R , PERIOD NOT SPECIFIED
Total______ ________________
Therapeutic abortion_____________ ____ •_
Laparotomy for ectopic gestation.................................. .
No operation........................................................
No report on operation................... ....................................
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
410
78
1
4
12
387
7
4
67
1
1
Other
causes
36
MATERNAL MORTALITY IN FIFTEEN STATES
Type of operation for delivery
LAST T R lk E S T È R
Total.............................. ................ .........
4$
14a
SS6
518
150
24
1
3
14
14
57
12
7
3
1
2
3
26
15
12
14
1
469
62
3
218
224
3
2
58
78
48
26
64
2
23
7
21
10
1
2
12
8
9
2,607
133
6
1
116
2
109
407
1,629
55
41
165
13
42
6
3
2
1
1
1
112
1
6
2
3
1
3
7
110
3
25
28
22
7
1
19
3
64
25
6
1
3
10
3
7
5
1
1
24
3
4
2
1
1
18
5
6
3
3
1
42
23
8
7
1
3
4
108
4
87
57
4
1
136
4
1
6
5
195
5
37
94
4
9
3
11
8
1
1
4
4
21
3
15
5
4
40
27
6
6
7
1
4
10
5
4
7
1
2
2
1
1
61
6
4
1
1
4
2
4
3
4
214
9
278
18
901
55
1
2
142
95
3
34
6
12
2
2
H
5
•
g
1 ,5 4 9
GENERAL TABLES
Forceps:
O nly.......... ................................................................
With dilatation of cervix.................. ............................
With manual removal of placenta.............................. .
With dilatation of cervix and manual removal of pla
centa___________________________ ______________
With other operation................. ............................ .
Cesarean section:
Only................................................................................
Following other operation............................................
Version:
Only................................... ................................ .........
With dilatation of cervix...........
With dilatation of cervix and manual removal of pla
centa............................................................................
With manual removal of placenta_________ ____ ___
With forceps........ .........................................................
With dilatation of cervix and forceps___ ___________
With forceps and manual removal of placenta..........
With dilatation of cervix, forceps, and manual re
moval of placenta.................................................. .
With other operation.............. ................................ .
Dilatation of cervix:
Only....................................... .......................................
With manual removal of placenta_________________
Manual removal of placenta____________________
Craniotomy or embryotomy following other operation...
Breech extraction:
Only......... .....................................................................
With dilatation of cervix and/or manual removal of
placenta......... ............................................................
Laparotomy for ectopic gestation........................................
Other single operations................ .....................................
Other operations of more than 1 ty p e ..________________
Type of operation not reported...........................................
No operation................. ............. .
No report on operation_____ ________________________
-------------------------------- :_________________________%
4,966
206
62
2
5
1
1
1
813
34
18
IS
2
9
1
1
T R IM E ST E R NOT R E PO RTED
Total................................................................... i . . .
34
2
1
16
No operation...................................................
No report on operation.......................... ............................
10
1
1
1
3
24
1 According to the Manual of the International List of Causes of Death, 1920.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
13
CO
T able
X I I .— Type of operation for delivery and number of pregnancies among women dying from puerperal causes who had reached the last
trimester of pregnancy
CO
00
Women dying from puerperal causes who had reached last trimester
Number of pregnancies
Type of operation for delivery
1
T o t a l - - - ^ '.i i .„ i J „ .. - J ...
......
Forceps:
O n ly ...
— . . . . . . . . . _________............ .
With dilatation of cervix___ ___________. . . . . . . . .
With manual removal of placenta_______________
With dilatation of cervix and manual removal of
placenta____________________________________
With other operation.......................................... .
Cesarean section:
Only___ ______ ____ _______ ___________________
Following other operation______________________
Version:
Only................... ......... ............................................
With dilatation of cervix_______________________
With dilatation of cervix and manual removal of
placenta____________________________________
With manual removal of placenta_______________
With forceps__________________________________
With dilatation of cervix and forceps____________
With forceps and manual removal of placenta___
With dilatation of cervix, forceps, and manual
removal of placenta......................................... .
With other operation__________ _______________
Dilatation of cervix:
Only..........................................................................
With manual removal of placenta_______________
Manual removal of placenta.............. ...........................
Craniotomy or embryotomy following other operation.
Breech extraction:
Only............. ......... .............................. ................
With dilatation of cervix and/or manual removal
of placenta___ ______________________________
Laparotomy for ectopic gestation___________________
Other single o p e ra tio n s ._________________________
Other operations of more than 1 type_______________
Type of operation not reported____ ________________
No operation_______________________________ ■
;_____
No report on operation________________ ______ ^ ___
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
2
___5...
4
a
6
-
g....
7
than 1
10 or
more
9
ber not
specified
Not reported
4,965
1,746
633
508
359
302
246
205
161
124
302
201
178
518
150
24
305
79
13
50
9
4
28
13
1
19
8
22
6
22
6
1
12
4
9
7
10
3
1
15
10
3
18
5
8
12
14
7
4
2
2
2
2
2
469
62
250
42
67
7
40
1
29
2
18
5
7
218
224
46
56
25
31
20
27
' 20
20
17
16
48
26
64
21
10
10
1
40
7
2
4
3
2
4
4
4
3
2
2
4
3
1
7
1
2
3
4
1
1
1
1
1
108
4
87
57
37
1
26
22
15
1
11
9
12
1
11
6
42
11
6
4
1
23
8
12
8
9
2,607
133
4
2
3
1
1
747
27
2
6
1
1
1
2
1
300
14
219
6
7
2
3
1
355
14
1
1
2
.
1
i
15
8
5
1
16
10
1
4
1
11
16
11
7
14
15
5
11
34
13
11
9
4
3
3
3
1
2
3
1
1
2
7
2
2
2
4
3
3
1
5
2
1
2
2
3
1
1
1
10
5
7
6
3
3
,1
6
1
1
2
5
4
2
4
1
1
5
1
8
5
2
11
4
3
2
1
4
2
3
1.
1
7
1
1
4
1
2
3
1
1
1
1
151
2
176
6
1
1
2
1
1
1
1
1
1
125
1
84
1
65
5
1
160
7
122
6
1
103
44
MATERNAL MORTALITY IN FIFTEEN STATES
Total
#
T able
X l t l .— Onset of labor, cause of death 1 as shown by interview, and trimester of pregnancy among white and colored women dying from
puerperal causes
Women dying from puerperal causes
Cause of death 1 as shown by interview
Onset of labor, and color
7,380
719
347
444
136
109
407
2,948
344
1,900
FIR ST TW O TRIM ESTERS
Total__________ _________________________
Spontaneous______ ___ _______ ________
Artificial...................................................
3,381
698~
999
575
11
1
1,403
53
338
118
8
8
1
347
761
28
69
107
1
Operative3....... ........................... ......
M edical3__________ ____ _____ ____
Method not reported.......................
729
30
240
84
10 ,
19
3
No onset....................................................
Onset not reported....................................
615
m
m i
81
S
8
White................... ...........
2,026
488
6
Spontaneous........................................................
A r tificia l....................... ....... ™.......................
478
917
ns
107
1
8
Operative 3................................. ...... ...........
M edical3........................................................
Method not reported_______________ ____
684
27
206
80
9
18
2
No onset.............................................................
Onset not reported____ _____________________
486
SO4
839
19
8
1,
* According to the Manual of the International List of Causes of Death, 1920.
3Operative induction of labor; also includes Cesarean section on women not in labor.
3 Induction of labor by use of drugs alone.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
532
18
211
69
886
’
14
6
"nagen
8
103
2
2
61
158
5
1
1,209
45
276
1
874
697
84
IS
56
6
602
16
179 ........... 7 .
...... .
61
177
3
5
Other
causes
26
GENERAL TABLES
All deaths.........................................................
Puerperal
Other surgi
Total Accidents
phlegmasia Puerperal
Other
Cesarean cal opera Other acci Puerperal alba dolens, albumi
of preg Placenta
puerperal
tions
and
dents
of
previa
septicemia embolus,
nuria and
nancy
hemorrhage section
instrumen
labor
sudden
convulsions
tal delivery
death
97
93
2
- -2
181
8
CD
CD
200
T able X I I I .—
O nset o f labor, ca u se o f death as sh ow n b y in terview , and trim ester o f p reg n a n c y a m o n g w hite a n d colored w o m en d y in g f r o m
p u erp era l ca uses — Continued
Women dying from puerperal causes
Onset of labor, and color
Puerperal
Other surgi
phlegmasia Puerperal
cal opera Other acci Puerperal alba dolens, albumi
dents of septicemia embolus
tions and
nuria and
labor
instrumen
sudden convulsions
tal delivery
death
Total Accidents
Other
Cesarean
Placenta puerperal
of preg
section
previa hemorrhage
nancy
Other
causes
FIR ST TW O T R IM E ST E R S—Continued "V
Artificial_________ - --------- ---------------------------
356
87
5
194
8
62
19.0
88
29
6
1
1
78
64
4
18
10
4
1
30
2
32
Method iiot repoi ted -- -- - - ——
—
. - -- -- -- -- -No onset________ ______ - .........................- ........
Onset not reported---------------- ----------------------
89
65
40
12
1
2
1
10
1
«
4*
8
87
LAST TR IM E STE R
Total....... ........... - -------- -----------------------------
4,965
142
336
443
135
109
407
1,529
291
1,549
24
Spontaneous...................... ...... ................
Artificial------------- -------------------- ---------
3,815
687
102
8
178
113
890
86
87
44
m
2
878
9
1,886
85
271
6
902
888
19
1
Operative2. . ------ --------------------------
650
34
8
108
5
34
2
43
1
i
1
7
73
5
1
370
10
3
1
264
199
28
19
26
2
16
4
2
28
64
4
6
8
208
61
Onset not reported---------------------------- -
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Federal Reserve Bank of St. Louis
4
4
MATERNAL MORTALITY IN FIFTEEN STATES
Cause of death as shown b y interview
White_____________
Spontaneous____ ______ .
Artificial........... .........................
Operative3________________
M edical3— .............. ..........
Method not reported_____ _
No onset____ ______ _____
Onset not reported.......... .
Colored____________
Spontaneous... . . . .
Artificial_______ . . .
Operative3________ _
M edical3................. ...........
Method not reported______
125
287
376
122
97
305
1,218
269
1,210
18
98
8
140
109
884
SO
76
48
96
8
884
8
1,096
77
851
5
687
836
15
1
589
28
1
8
104
5
29
1
42
1
1
1
7
1
67
10
4
1
326
8
1
m
148
88
3
14
84
1
11
4
1
18
8
48
6
7
145
48
8
938
17
49
67
13
12
102
311
22
339
6
746
69
10
88
4
66
6
18
1
18
89
1
890
8
80
1
815
48
4
4
5
1
1
6
8
1
68
------- -
61
6
2
78
61
6
1
1
f
11
1
18
T R IM E ST E R NOT R E PO RTED
Total................. ...........
White_________
34
2
20
14
1
16
13
2
1
10
6
7
6
2
«V
GENERAL TABLES
No onset..............
Onset not reported.............
4,027
8,069
618
f Operative induction of labor; also includes Cesarean section on woman not in labor.
" Induction of labor by use of drugs alone.
to
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
o
X IV .— Termination of labor, cause of death 1 as shown by interview, and trimester of 'pregnancy among white and colored women
dying from puerperal causes
202
T able
Women dying from puerperal causes
Total Accidents
Other
of preg Placenta
puerperal
previa
nancy
hemorrhage
All deaths. . ___ ________________ ________ __
7,380
719
347
444
Cesarean
section
136
Other surgi
cal opera
Other
tions and
accidents
instrumen of labor
tal delivery
109
Puerperal
phlegmasia Puerperal
Puerperal alba dolens, albumin
septicemia embolus,
uria and
sudden
convulsions
death
407
3,948
344
1,900
338
FIRST TW O T R IM E STE RS
Total..................................................................
3,381
575
11
1
1,403
53
Spontaneous_________ ____ ____________
Artificial__ ___ ________ ______________
No termination__________________ :___ _
Termination not reported............_...........
1,005
266
560
551
158
63
295
59
3
7
1
1
lía
79
479
g
. . . . . _____ ___ __________
2, oes
488
6
1
Artificial______________________ _________ ___
No termination.
242
465
67
255
3
1
3
White
. i . . . . . . . ___
1,209 :
_______ ‘
Spontaneous_______________________ ;________
Artificial.......................... ...................... .............
No termination______ _________ __________. . .
Termination not reported........................ ..........
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
SB6 ,
87
160
23
95
78
28
6
40
13
6 i
70
418
1
7'
6
194
na
4
il
m
276
69
1Ò2
'
Colored......................................................................
45
2 ;
130
3
Other
causes
36
MATERNAL MORTALITY IN FIFTEEN STATES
Cause of death 1as shown by interview
Termination of labor, and color
#
LAST T R IM E S T E R
T o t a l............ . .
142
336
443
2,425
1,990
412
138
89
21
30
2
38
248
43
7
249
178
6
1Ö
134
1
287
m
m
Spontaneous.................. ..........
A rtificial...___ ________ ______
No termination3____
.......
Termination not reported.......
1,940
1,684
298
105
81
18
24
2
31
218
31
209
154
C o lo r e d ......._______ ....................
988
17
Spontaneous.... . . . . . . . . . . _____
A ^ ficlàlC .-- - - - - - - - - - - - - - - - - - - No termination2_____________
Termination not reported— . . . .
485
306
114
33
t ,m
m
3
6
4?
0
7
:
w
87
7
30
12
40
24
135
121
1
IS
13
2
1
109
407
105
4
257
94
36
20
1,529
958
507
11.
55
97
S05
1 ,2 1 8
94
3
193
78
25
758
409
6
45
12
102
11
1
g
16
.. .11
Ì1
291
1,549
24
69
12
7
630
269
36
3
269
1,210
18
65
12
<5
811
, 22
200
98
5
8
17
4
1
524
192
4
3
889
6
106
77
ii
1
1
T R IM E S T E R NOT REPO RTE D
T o ta l............ .............................
White............
34
20
tf
2
1
16
13
2
1
W
6
7
2
6
GENERAL TABLES
4,965
Spontaneousì
£
Artificial.___ ___ _ Hi. . . .
No termination 2____
Termination not reported.
1 According to the Manual of the International List of Causes of Death, 1920.
2Includes Cases in which there was no issue and in which the deliver^ was postmortem.
to
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Federal Reserve Bank of St. Louis
o
00
X V .— Type of operation other than for delivery, cause of death1 as shown by interview, and trimester of pregnancy among women dying
from puerperal causes
204
T able
Women dying from puerperal causes
Cause of death 1 as shown by interview
All deaths.............................. ............ .....................................
Other
Other
puer
Cesa Other
acci
Pla
Total Abortion,
acci
prema Ectopic
rean
dents
of
centa
peral
gesta
of
ture
tion
preg previa hemor section dents
labor
labor
nancy
rhage
7,380
353
248
118
347
444
136
516
Puerperal
Puer phlegmasia Puerperal
Other
peral alba dolens,
albumi
septi
nuria and causes
embolus,
cemia
convulsions
sudden
death
2,948
344
1,900
1,403
53
338
9
6
9
2
5
FIRST TW O TR IM E STE RS
1 type only:
More than 1 type:
Curettage------- ------------------------------ ------------- ------------ --------
2,381
254
240
81
453
15
108
46
27
11
5
45
2
5
20
10
3
14
1
1
2
158
67
1
4*
12
1
£5
ss
With blood transfusion and packing of uterus or cervix-----
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
S
4
1
£
3
3
8
9
1
1
5
1,399
53
11
81
11
3
1
4
1
1
50
376
9
78
45
15
7
139
45
5
4
1
1
41
£5
£0
£
4
1
1
£
1
1
2
1
181
1
.^ v
2
2
1
1
1
2
8
9
1
1
1
166
5
• 1
73
8
2
1
4
620
40
39
1
311
4
26
MATERNAL MORTALITY IN FIFTEEN STATES
Type of operation other than for delivery
LA Ô T iT R ÎM E S T É ft
Total...............................................................
1 type only:
Blood transfusion___
Curettage............................. 1111111” ..................................
Hysterectomy____________III” ” ” ” ” **........
Other laparotomies 2_________II” ” ” ” ........
Incision and drainage for infecHonIIIIIIII” I”
Packing of uterus or cervix______________ ”
Replacement of inverted uterus..
Other operation...
More than I type:
................................. "........... .
Curettage...........................
8
1
3
1
3
35
336
443
135
516
1
13
11
4
2
8
1
1
68
5
2
2
1
u
1
_
..........
1,529
1,54»
3
1
25
25
4
5
23
_____
Blood transfusion and packing of uterus or cervix____
Hysterectomy and other operation_________ _
Other laparotomies 2and other operation___________
Incision and drainage for infection and other operation__
Packing of uterus or cervix and other operation
Other operations_____________________
Type of operation not reported..
No operation...................................... ......................... *...........
No report on operation______IIIIII........
...........
99
............... ...............
........
...............
................... : : : : : : : :
89
2
6
287
6
--------- Ö"
-IIIIII
............. - .......
34
—
4
2
2
4,203
126
—
GENERAL TABLES
With blood transfusion____________________
With laP?r°tomy other than hysterectomy_________
With incision and drainage for infection_____ _
With packing of uterus or cervix___
With laparotomy and other operation_____ 111111111"
With packing of uterus or cervix and other operation”
With incision and drainage and blood transfusion____
4,065
334
117
10
I-
467
1,480
38
T R IM E S T E R NOT R E PO RTE D
Total.................................................................
Hysterectomy and other operation........................
Type of operation not reported.
No operation.....................................IIIII I.” ..........
No report on operation__________ ” ”
34
1
........
1
4
28 ............ -*
.......
2
1
........ ........
1
1
I:::
16
- - - - - ...............
....... i"
—
1 ..................................
1
2 .....................
12
13
2
_________________
1
12 .........2
2f n T r ? w LT ivianuai oi tne international List of Causes of Death, 1920.
includes laparotomies for drainage of peritonitis, salpingectomies, appendectomies, enterostomies, etc.
205
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
X V I.— Type of operation for delivery in each trimester of pregnancy among women dying from puerperal causes in each State included
in the study
206
T able
Women dying from puerperal causes
Ala
bama
■Cali
fornia
Ken
tucky
1,118
493
645
New
Mary Michi Minne Ne Hamp North
gan
sota braska shire Dakota
land
383
1,313
491
339
109
159
Okla
Rhode
homa Oregon Island
Vir
ginia
Wash Wis
ington consin
300
177
165
767
316
617
FIRST T R IM E ST E R
Total....... ............ .............................................
m
4
Therapeutic abort ion------------------»—
Laparotomy for ectopic gestation .....-.-^ ------ ■>..... - . . 5
105
No* operation.....................—— ....................— —
4*
106
76
m
95
73
33
S3'
56
SS
S6
104
96
86
6
15
63
8
11
86
7
7
61
1
9
37
244
12
20
63
3
10
50
6
3
13
5
5
22
2
3
50
3
9
20
5
4
27
3
12
89
8
14
74
3
15
68
....................... 4 :
SECOND TR IM E ST E R
Total....................................
91
41
83
Si
117
35
39
8
14
38
SS
IS
68
H
49
Therapeutic abortion---------------Laparotomy for ectopic gestation
Other operation_______________
No operation._____________
No report on operation-------------
13
9
1
2
29
9
1
6
22
3
7
85
14
6
1
2
1
2
7
3
1
7
2
17
12
3
58
5
3
1
25
11
3
2
32
1
*4
37
3
38
16
50
23
1
1
1
24
1
3
2
26
16
29
1
3
74
1
72
1
24
1
19
1
32
5
2
10
20
1
FIRST OR SECOND T R IM E ST E R , PERIOD NOT SPECIFIED
Total...................................
Therapeutic abortion.......... .........
Laparotomy for ectopic gestation.
No operation............................
No report on operation_________
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
37
58
S3
SO
95
20
2
6
85
2
1
37
3
55
22
n
22
2
18
18
»
7
7
MATERNAL MORTALITY IN FIFTEEN STATES
Type of operation for delivery
LAST T R IM E ST E R
Total............................... . ...............................
869
S10
80
14
1
33
1
5
2
2
46
10
70
2
38
29
1
2
6
m
966
809
834
18
6
1
101
26
5
31
7
2
2
2
3
19
7
36
7
86
9
16
3
31
7
2
2
10
10
18
14
10
8
30
32
30
7
12
6
5
-T-3
1
2
4
2
2
5
3
1
7
6
9
3
11
1
2
1
1
4
1
1
40
14
4
4
2
3
11
19
4
1
79
106
190
96
118
10
8
16
2
19
2
1
16
7
18
3
12
3
10
1
8
1
12
4
4
3
3
9
11
1
8
1
I;
i
1
8
8
8
14
7
8
11
10
6
6
5
1
1
5
9
6
2
4
1
2
1
1
538
41
1
2
1
1
131
5
3
1
- 1
1
260
6
1
1
120
3
i
1
1
3
.3
1
1
1
16
4
16
2
1
6
1
6
1
1
1
396
26
169
i
i
461
1
6
1
12
1
5
9
666
1
1
. 2
1
2
12
m
GENERAL TABLES
Forceps:
Only____ _______ _________________ ________ _
With dilatation of cervix__________ . _________
With manual removal of placenta____________
With dilatation of cervix and manual removal
of placenta........... ..................... ......................
With other operation_________ _____ ...............
Cesarean section:
Only.............................................. ......................
Following other operation..................
Version:
O n ly ............ ........... ......... . . ____ ____________
With dilatation of cervix____ !___ ____________
With dilatation of cervix and manual removal
of placenta........... 1...1.L ...L .__________,___
With manual removal of placenta. ____________
With forceps__J
„
.
____ ____
With dilatation of cervix and forceps____ _____
With forceps and manual remoyal of placenta...
With dilatation of-cervix, forceps, and manual
removal of placenta...——. . 2*..., 1'.." —I ..
With other operation_______ ________________
Dilatation of cervix:
O n l y . . . . . - . . ; . . . . . . ......... ..................................
With manual removal of placenta.!____
Manual removal of placenta..— !..''---___ . . . .
Craniotomy or embryotomy following other opera
tion...............
I ___________
Breech extraction:
O n ly ...-.........................— !_____ ____
With dilatation of cervix and/or manual removal
of placenta___L............ ...... ....... L ..........
Laparotomy for ectopic gestation]____ ,_________ _
Other single o p e r a t i o n s . . ___ —
Other operations of more than 1 type___ _____
Type o f operation not rep orted .....'.___ ................
No operation___ ________________ ^ ...__ _____
NO report on operation................
1
| 1
183
6
1
2
4
2
i
1
86
7
5
1
3
36
1
67
12
1
113
11,
45
53
4
T R IM E ST E R N O T ¡REPORTED
Total................................................ .
No operation......... .................................
No report on operation____ _______ ____
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
17 -
7
1\
2
15
6
1
1
8
3
8
3
i
1
i
208
MATERNAL MORTALITY IN FIFTEEN STATES
X V II.— Live births, and deaths and mortality rate following abortions
among white and colored women and women dying in urban and rural areas in
each State included in the study
T able
Deaths following
abortion
State, area, and color
Live
births1
Rate per
Num 10,000
live
ber
births
Total............... 1,176,603
1,825
15.5
461,150
715,453
993
832
21.5
White____ 1,056,063
C olored... ' 120,540
1,568
257
14.8
21.3
Urban___
Rural____
11.6
Deaths following
abortion
State, area, and color
Live
births 1
Rate per
Num 10,000
live
ber
births
17,474
31
9,095
8,379
6
15
17.9
White
Colored..:______
17,459
15
21
12.9
North Dakota.........
New Hampshire___
Urban. ___. . .
13. a
6.6
Alabama__________
130,986
194
1 4 .8
39,673
42
14.3-
Urban_________
Rural.. ............
22,859
108,126
69
125
30.2
3,964
25,719
12
30
30 3
11 T
White.................
Colored________
85,010
45,975
107
87
12.6
29,300
373
42
14. 3.
California_________
83,636
134
16.0
43,986
93
31.8
U rb a n ......... .
Rural_________
48,559
34,977
90
44
18.5
8,393
34, 593
32
61
38 1
17 6-
White.................
Colored..............
78,700
4,836
126
8
16.0
16.5
Colored________
40,457
2,529
76
17
18 8.
67.2-
Oregon________ . . .
38,668
60
30.9•
11, 087
10, 971
25
35
Kentucky.......... .
11.6
18.9
Oklahoma_________
12.6
131,798
167
13.7
Urban_________
Rural.................
22,866
98,932
44
123
19.2
12.4
White.................
Colored..............
114,077
7,721
138
29
12.1
37.6
White
Colored________
28,012
646
59
Maryland.................
64,311
106
16.3
Rhode Island______
36,747
38
Urban_________
Rural____ _____
36,486
27,825
76
29
20.8
10.4
23,031
3 710
35
White.................
Colored________
51,172
13,139
84
21
16.4
16.0
White
Colored________
20, 274
Michigan__________
197,976
389
19.6
Virginia.-........ ........
114,701
Urban.................
Rural_________
120,214
77,761
291
98
24.2
12.6
W hite................
Colored________
191,460
6i 515
369
20
19.3
30.7
Minnesota_________
100,433
113
11.3
U rban ..............
Rural____ ____ _
38,290
62,132
66
46
17.2
7.4
White.................
Colored..............
99,366
1,056
109
3
11.0
28.4
Nebraska__________
66,893
97
17.4
Urban...... ..........
Rural_________
13,638
42,255
48
49
35. 2
11.6
White.................
Colored________
55,144
749
95
2
17.2
(2)
1
21 1
(2)
1 4 .8
(2)
143
13.5
33)868
61
18.9
46,476
118
35.4
Colored..............
l) 867
6
32.1
Wisconsin_________
114,968
113
9.7
' ’ 778
1
89 490
W h itA
Colored_______
W h itA
W h itA
Colored________
1U.S. Bureau of the Census.
2 Not shown because number of colored births was less than 1,000.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
473
1
(2)
GENERAL TABLES
209
X V II I.— Number and percentage of white and colored women and women i n
urban and rural areas whose deaths followed abortion of each specified type and
whose deaths did not follow abortion among women dying from puerperal causes
xn each State included in the study
T able
Women dying from puerperal causes
Report on abortion
1
IS
o
Eh
T otal...
___
Sponta
neous
abor
tions
Thera
peutic
abor
tions
In
duced
abor
tions
Z
0
©
©
S
-4
©
Ah
Ui
©
rû
a
9
z
©
M
a
9
S-i
rO
a
9
25
Total
abor
tions
State
'cS
o
©
rO
a
9
Ö
CD
O
U
©
Ah
Z
Ö
©
©
Ah
3
Z
Type of
abortion
not re
ported
U
©)
©
©
Ah
Z
237
a
9
a
©
©
©
Ah
©
eO
a
9
z
3
5,521
7,380
7,346
1,825
589
8
205
794
il
3,462
8,455
993
99 274
8
108
488
14
White_______ 2,951
Colored— ___
511
2,948
507
878
115
30
23
227
47
9
99
458
30
16
6
94
34
Rural.................... 8,918
8,891
882
*1
315
8
102
8
109
White............. 3,121
Colored
797
3,105
786
690
142
22
18
247
68
8
9
90
12
9
4
82
27
18
107
10
17
37
inn
908
106
116
Urban__________
Alabama____
1,118
1,102
194
Urban__________
898
291
69
White_______
Colored___ .
146
147
145
146
39
30
27
21
Rural___________
825
811
125
15
White_______
Colored____
431
394
426
385
68
57
16
15
493
493
134
27
32
6
298
298
90
SO
276 ™l27g
22 » 22
.¡¿84
6
30
20
2
California..................
Urban_________
White_______
Colored........
2
33
3
1
12
4
13
10
1
1
1
9
3
6
2
9
11
78
9
14
3
17
41
32
10
g
3
2
8
9
17
19
15
195
195
44 23
10
White
Colored..........
183
12
183
12
42
2
10
Kentucky___________
271
35
12
9
15
3
70
14
2
61
17
50
1
18
7
3
3
9
3
34
7
70
77
3
4
3,059
79
27
2,415
644
78
82
16
11
2,070
392
358
328
4
75
71
4
12
Rural___________
23
8
a
JO
u
o
rO
£0
a
o
1
O4
a
Ö
©
©
1
-4 8
o
©
PH fc
No abor
tion
82
16
76
2
73
79
1
1
85
14
84
85
5
9
359
73
208
70 —
192
16
70 —
10
6
19
10
S
161
77 —
5
9
1
5
19
10
2
141
10
77 —
3
-
60
9
26
4
472
74
6
17
11
0
8
107
71
2
14
11
—
85 69
22 —
1
1
48
9
21
4
866
76
4
36
8
13
14
7
3
332
33
77
59
4
645
639
167
26
63
10
18
158
161
44
29
16
10
7
White.
Colored_____
124
29
123
28
38
6
31
13
2
11
7
Rural___________
492
1,88
48
10
11
436
56
432
56
100 23
23 41
40
8
9
14
10
1
Maryland____ ______
382
382
105
27
25
7
13
3
49
13
18
5
277
73
Urban....... ...........
White........
Colored_____
Rural_____ _____
W hite...........
Colored_____
257
196
61
125
77
48
257
196
61
125
77
48
76 30
66 34
10 16
29 23
18 23
11 .
16
13
6
7
8
8
8
4
40
35
16
18
8
7
8
12
10
5
5
181
130
70
66 . __
-- 77 .
77 . —
Urban
White
Colored___
3
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
2
2
ñ
9
7
5 6
4 .
1 Not shown where number of women was less than 50.
-
6
4
3 4
2 .
9
6
3 .
4
3
1 —
13
6
5
4
5
2 .
96
59
37 .
—
210
MATERNAL MORTALITY IN FIFTEEN STATES
X V III.— Number and percentage of white and. colored women and women in
urban aud rural areas whose deaths followed abortion of each specified type and
whose deaths did not follow abortion among women dying from puerperal causes
in each State included in the study— Continued
T able
Women dying from puerperal causes
391
30
S3
108
79
9
3
33
3
34
Number
Number
|
8
16
45
3
920
70
3
155
17
S3
4
630
68
1
151
4
18
6
27
6
3
9
580
50
68
72 ’ ""I
Percent
203
Percent
Percent
Number
Number
L— — -------1 Percent
|
|
Percent
389
j Percent
931
m
|
1,309
Number
1,318
No abor
tion
’ Number
Urban——————
Total
Michigan-—. ————
'03
O
Type of
abortion
not re
ported
In
duced
abor
tions
Thera
peutic
abor
tions
Sponta
neous
abor
tions
Total
abor
tions
State
No report on abortion
Report on abortion
852
70
852
69
272
19
32
28
71
8
8
12
23
1
3
1
S90
S88
98
35
39
7
9
3
48
13
13
3
390
75
3
W hite............
Colored..........
383
. 7
382
6
97
1
25
29
8
9
2
48: 13
11
1
3
285
5
75
1
1
Minnesota..............—
m
Urban..................
491
488
112
23
31
6
26
5
45
9
10
2
376
77
3
m~
335
66
39
19
8
17
8
37
13 1 3
1
159
71
White— .......
Colored..........
222
3
222
3
65
1
29
19
9
17
8
27
12
2
1
1
157
2
71
m
36S
46
17
13
5
9
3
18
7:
7
3
317
83
8
White............
Colored--------
259
7
256
7
44
2
17
12
5
9
4
17
1
7
6
1
2
212
5
83
3
Nebraska...............—-
329
389
97
29
28
9
9
3
52
16
8
2
232
71
m
13S
w
39
13
10
3
3
S3
36
1
1
76
61
118
5
118
5
46
2
39
11
1
9
3
3
32
27
72
3
61
m
306
49
34
16
8
6
3
30
10 ■ 7
3
167
76
150
7
75 —
White....... —
Colored-------Rural— — — —
Rural----- —- ........
Urban— ..............
White............
Colored..........
Rural___________
White............
Colored..........
New Hampshire.......
- 1
199
7
199
7
49
25
16
8
6
3
20
10
7
4
109
109
21
19
6
6
8
7
0
6
1
1
88
11
37
4
3
7
4
1
7
3
IS
1
3
48- 89
40 78
26
16
10 - 7
4
1
Urban (white)—
Rural (white)-----
54
56
54
66
6
16
North Dakota............
159
159
42
3
14 'l l
5
3 "~3
6
11
18
11
1
4
14 "l'l
1
j«
=
81!
117
74 - -
19
98
77. —
94
4
76 -- --
Urban (white)—
Rural..................
SI
m
31
138
13
30 ~38
White— —
Colored........
124
4
124
4
30
24
14 Hr
-
2
2
14
11
Oklahoma--------------
300
297
93
31
33
11
9
3
37
12
14
5
204
69
3
10 11
9 11
1
33 11
17 10
6
3
3
3
4
60 65
52 65
8
144 70
120 71
24
1
5
4
6
4
1
9
6
3
'5
5
6
6
14 15
12 15
2
33 11
19 11
4
Urban.................
White...........
Colored........
Rural.................
White______
Colored-------
93
80
13
307
170
37
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Federal Reserve Bank of St. Louis
93
80
12
305
168
37
S3 35
28 35
4
61 SO
48 29
.
13
4
4
"l
3
2
211
GENERAL TABLES
X V III. Number and percentage of white and colored women and women in
urban and rural areas whose deaths followed abortion of each specified type and
whose deaths did not follow abortion among women dying from puerperal causes
in each State included in the study— Continued
T able
Women dying from puerperal causes
Report on abortion
Sponta
neous
abor
tions
Thera
peutic
abor
tions
In
duced
abor
tions
3
<D
O
5
-1
CD
P-f
Í4
rO
9
3
£
(Ch
D
5
h
CD
rO
34
il
Total
abor
tions
State
Type of
abortion
not re
ported
3
©
No abor
tion
5-4
o
£2
aS
35
'o3
O
fr»
Oregon______
U r b a n ...______
White_____ _
Colored................
Rural (white)
Rhode Island
5
o-4
«Q
3
s
o
Eh
s
fc
177
177
81
81
79
79
2
96
2
96
60
24
1
36
23
165
165
38
167
85
152
5
152
5
35
Rural_______________
8
W hite..
Colored____
7
White _______
Colored.................
Virginia__________
1
30
85
3
fc
6
3
©
©*
u
D
PL«
e
7
6
81
157
Urban..............
a
©
o*
u
£
2
5
i
6 6
11
7
10
23
10
8
8 ___
1
7
1
2
1
•
a
3
¡5
27
15
15
8
117
17
4
5
66
69 —
3
14
18
5
55
70
64
5
5
6
6
138
138
138
138
41
33
30
24
13
6
4
9
3
491
490
69
14
89
288
203
288
202
41
28
14
14
15
14
5
7
4
..
316
315
118
37
28
9
13
Urban_________
188
1R&
78
40
18
7
7
4 ~47~
170
13
169
13
69
3
41
12
1
.
7
4
183
183
46
121
12
121
12
43
3
617
616
816
816
313
3
313
3 .
53
801
son
59
292
9
291
9
58
White_______
Colored___ _
2 Less than 1 percent.
182748—34----- 15
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Federal Reserve Bank of St. Louis
1
—
8
10
Rural___ _____
77
.
6
2
1
2
1
61
_
24
3
623
81
1«
17
6
808
78 —
22 16
11
10
7
7
5
97
105
70 —
76 ___
6
7
i
481
86
i
1
247
174
86
86
1
1
1
(s)
10
4
71
3
3
197
63
1
8 , 110
60
1
46
27
4
2
100 59
10
1
1
6
£
84
1«
i
6
5
23
19
i
42
7
14
4
7
17
14
4
9
7
20
27
9
7
1
2
2
2
1
6
11
u
t
—
5
11
18
:
23
ñTT"
13
17
1
—
18
15
2
—
--------- -
2
6
White_______
Colored_____
117
11
7
Urban________
—
1
17
48
na
78
4
19
Wisconsin ________ ____
77
188
6
1
36
127
12
2
11 —
19
White ....................
Colored.............. .
1
i
4
87
Rural____ .
—
61
19
74
W h ite .... .
Colored_____
-------- -
h
17
143
Washington___
1
66
11
4
766
White______
Colored
1
18
876
Rural........
a
3
14
767
White..........
Colored
-4-a
4
6
7
3
(D
©
5
«-4
P-
a
3
Ue
©
P44
3
©
CD
5-4'
©
5
-4 O'
£ 55
5h
rO
©
«
m
Urban______
3
CD
O
5
-4
CD
pH
5-1
©
-O
1
1
¡
87
66
—
78
9
64
—
j
43
13
2
504
82 !
~nr
7
2
868
83
25
7
2
260
83
18
0
%
841
80
1
18
6
2
233
80
1
f
—
A P P E N D IX
B .— T H E
1929 R E V I S I O N O F
THE
IN T E R N A T IO N A L L IS T O F C A U S E S O F D E A T H
The fourth decennial revision of the International List of Causes of Death was
made by the international commission in 1929. The revised list was first used
by the United States Bureau of the Census in tabulating the deaths of 1930.
The Manual of Joint Causes of Death 2 was published in 1933.
In the 1929 revision of the international list the group Diseases of pregnancy,
childbirth, and the puerperal state” includes the titles no. 14° to no. 150. These
titles and their relation to similar titles in the 1920 list are as follows.
140. Abortion with septic conditions------
Part of former no. 146
141. Abortion without mention of septic
condition (to include hemor
rhages) .
Part of former no. 143 A c c id e n ts o f
p r eg n a n c y .
Includes all of no. 143a
A b o r tio n , part of no. 143c Others
under this title, such as a n tep a rtu m
hem orrhage, hem orrha gic m ole. _____
P u e rp er a l sep ti
___________ _
cem ia.
142. Ectopic gestation:
(a) With septic
specified.
conditions
Part of former no. 146
P u e rp er a l s ep
ticem ia .
(b) Without mention of septic
conditions.
•
Part of former no. 143 A c c id en ts o f
p reg n a n cy.
Includes all of no.
143b E c to p ic gesta tion and no. 143c
O thers und er this title, corn u a l preg
n a n c y.
143. Other accidents of pregnancy (not
to include hemorrhages).
Part of former, no. 143c
144. Puerperal hemorrhage
All of former no. 144
A c c id e n ts o f
p r eg n a n c y: Others ' u n d er this title.
Includes h yd a tid m ole, dead fe tu s
i n uterus, p r eg n a n c y [not otherwise
described], e t c . ______________
P u e rp er a l h em or
rhage.
(a) Placenta previa_______ —
All of former no. 144a
(b) Other
All of former no. 144b.
puerperal
hemor-
rhages.
P la cen ta p revia .
formerly
no. 144a, is now assigned to the
less definite no. 144b.]
[V ic io u s in sertion o f pla centa ,
145. Puerperal septicemia (not specified
as due to abortion) :
(a) Puerperal septicemia and
pyemia.
Part of former no. 146 P u erp era l s e p
ticem ia .
Includes all except parts
assigned to new no. 140 and new
no. 142.
(b) Puerperal tetanus.
Part of former no.
a lb u m in u ria
148 P u e rp er a l
con vu lsion s.
In
certified as p u erp era l
a nd
cludes only part
tetanus.
i Manual of the International List of Causes of Death, 1929. U.S. Bureau of the Census. Washington,
ington, 1933.
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Federal Reserve Bank of St. Louis
212
APPENDIX B— INTERNATIONAL LIST OP CAUSES OP DEATH
146. Puerperal albuminuria and eclampsia<
________ __ _______________
147. Other toxemias of pregnancy.
213
Part of former no. 148 Puerperal
albuminuria and convulsions. In
cludes all former no. 148 except
tetanus which is assigned to new
no. 145, and toxemia of pregnancy
and puerperal coma which are
assigned to new no. 147.
Part of former no. 143c Accidents of
pregnancy: Others under this title.
Includes chorea of pregnancy, perni
cious vomiting, etc. Part of former
no. 148 Puerperal albuminuria and
convulsions such as toxemia of
pregnancy.
148. Puerperal phlegmasia alba dolens,
embolus, sudden death (not speci
fied as septic).
All of former no. 147 Puerperal phleg
masia alba dolens, embolus, sudden
death.
149. Other accidents of childbirth_____
Former no. 145 Other accidents o f labor.
(a) Cesarean section_________
All of former no. 145a Cesarean section.
(b) Others under this title____
All of former no. 145b Other surgical
operations and instrumental delivery;
all of former no. 145c Others under
this title; part of former no. 149
Following childbirth (not otherwise
defined): result of labor without
further explanation.
(1) Rupture of the uter
us or bladder dur
ing parturitibn.
(2) Obstetric operations,
difficult labor, ab
normal presenta
tion.
(3) Lacerations of cervix
or perineum, postpuerperal shock,
labor (unqualified),
_______________
and similar terms.
150. Other and unspecified conditions of
the puerperal state.
Part of former no. 149 Following
childbirth (not otherwise defined) :
puerperium [not described], puer
peral insanity; all of former no. 150
Puerperal diseases of the breast.
The chief differences between the 1920 and 1929 revisions are as follows:
Puerperal septicemia (no. 146) of the 1920 revision is divided in the 1929
revision into Abortion with septic conditions (no. 140), Ectopic gestation with septic
c ^ r t i o ^ S(noe<145) n° ’ 142a^’ and PuerPeral septicemia (not specified as due to
2. Puerperal albuminuria and convulsions (no. 148) in the 1920 revision becomes
Puerperal albuminuria and eclampsia (no. 146) and Other toxemias of pregnancy
<no. 147). In Other toxemias of pregnancy are included chorea of preqnancv and
^title\n oU143cT*iiW^ ^rom
f ° rmer Accidents of pregnancy: Others under this
.
A?™&nts of pregnancy (no. 143) of the 1920 revision is subdivided as follows
in the 1929 revision:
. Abortion (no. 143a) becomes Abortion without mention of septic conditions (to
include hemorrhages) (no. 141).
\
Ectopic gestation (no. 143b) becomes Ectopic gestation: Without mention of
septic conditions (no. 142b).
• ^j^erSTun<^er this title (no. 143c) becomes Other accidents of pregnancy (not to
include hemorrhages) (no. 143) except that antepartum hemorrhage now goes to
no. 141, chorea and pernicious vomiting of pregnancy now go to no. 147. and
cornual pregnancy now goes to no. 142b.
rules governing the classification of joint causes of death as given on page
o apply to the 1929 as well as to the 1920 revision of the international list.
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214
MATERNAL MORTALITY IN FIFTEEN STATES
An approximate classification, according to the 1929 revision, of the 7,380
deaths included in the study is given below. The deaths were not reclassified
individually, but were shifted as accurately as possible in groups.
Per
Num cent
distri
ber
bution
1929 revision
All causes__________________
140. Abortion with septic conditions____ _________ ____
141. Abortion without mention of
septic conditions (to include
142. Ectopic gestation......... —-........
(a) With septic conditions
specified— ............ ..........
(b) Without mention of septic
conditions______________
143. Other accidents of pregnancy
(not to include hemorrhages) 144. Puerperal hemorrhage-----------(b) Other
puerperal
7,380
18
328
314
4
4
65
1
249
3
56
791
1
11
347
5
hemor-
6
444
145. Puerperal septicemia (not
specified as due to abortion). 1,559
146. Puerperal albuminuria and
1,770
eclampsia_________ _____
221
147. Other toxemias of pregnancy...
148. Puerperal phlegmasia alba
dolens, embolus, sudden
death (not specified as sep339
tic)--------------------- -------------652
149. Other accidents of childbirth...
(a) Cesarean operation-----------(b) Others under this title------150. Other and unspecified conditions of the puerperal state...
21
24
3
100
719
10
(a) Abortion ________________
(b) Ectopic gestation------ -------(c) Others under this title------144. Puerperal hemorrhage-------- —
353
248
118
791
5«
3
2'
li
(a) Placenta previa....................
(b) Other puerperal hemorrhage____________ ______
145. Other accidents of labor----------
347
5.
6>
9
—
--- :——
2
136
(a) Cesarean section—...............
(b) Other surgical operations
444
652
i
6
40*
109
livery_____ ____________
407
(c) Others under this title------146. Puerperal septicemia-------------- 2,948
147. Puerperal "phlegmasia alba
dolens, embolus, sudden
344
death_____________________
148. Puerperal albuminuria and
convulsions------------------------ 1,900
149. Following childbirth
(not
23
otherwise defined)____ _____
3
150. Puerperal diseases of the breast.
26(*)
0)
5
9
2
7
136
516
26
All causes__________________ 7,380
143. Accidents of pregnancy.............
100
1,324
Per
Num cent
ber distri
bution
1920 revision
0
1
1 Less than 1 percent.
The most important change made under the 1929 revision is the division of
P u e rp er a l sep ticem ia (former no. 146) into A b o r tio n w ith sep tic con d itio n s (new
no. 140), E c to p ic gestation with sep tic c o n d itio n s sp ecified (new no. 142a), and P u e r
pera l sep ticem ia not sp ecified as due to abortion (new no. 145).
In the present
study of the 2,948 deaths attributed after interview to P u e r p e r a l sep tic em ia
1,324 would be assigned under the 1929 revision t q A b o r tio n w ith s ep tic con d i
tion s, 65 to E c to p ic gestation w ith sep tic c o n d itio n s sp ecified , and 1,559 to P u e r p e r a l
sep ticem ia not sp ecified as d u e to a bortion, the latter including 17 deaths from
sepsis for which there was no information regarding abortion.
Examination of the death certificates of the 1,324 deaths that would havebeen assigned after interview to A b o r tio n with sep tic con d itio n s (new no. 140)
shows that the information regarding the occurrence of abortion was frequently"
missing on the original certificate as was also the presence of sepsis. A summary
of the information shown on these death certificates follows:
Number
Percent
distri
bution
T otal________ . ______ --- ----------------------------- —E v id e n c e o f se p sis on death certificate
---- ----------------
1, 324
100
1, 242
94
Evidence of abortion on death certificate--------------------, ----No evidence of abortion on death certificate----------- ----- —
977
265
----------------
82
Evidence of abortion and so assigned-------------------------------Evidence of abortion, assigned to other causes-----------------No evidence of abortion (assigned to other causes) -----------
41
29
No evidence of sepsis on death certificate
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. -----
12
74
20
6
3
2:
1.
APPENDIX B
215
Of these 1,324 deaths that would have been assigned after interview to A b o r with sep tic con d itio n s had the 1929 classification been used, only 977 (74
percent) would have been so assigned had only the death-certificate information
been available. Most of the remaining deaths (20 percent) would have been
assigned to P u e rp er a l sep ticem ia n ot sp ecified as due to a bortion . Three percent
would have been assigned to A b o r tio n w ithout m en tion o f sep tic c o n d itio n s (nol
141), and 3 percent to other puerperal causes.
J
o
in,*?lud®cL in tbe. Present study were, of course, certified in 1927
inon i
.~e l ? 20 r®vision was in use. The presence of these new titles
m. the 1929 classification will unquestionably stimulate more complete reporting
with regard to sepsis and abortion on certificates of women dying from causes
associated with pregnancy and childbirth. It will take some time, however, for
+£e in on C a l •p i'o f e s S T ? n ti? become fully accustomed to the use of these titles in
the 1929 revision. It will also require much work on the part of bureaus of vital
statistics before completeness is attained.
in the next few years changes will undoubtedly appear in the proportion of
deaths and the mortality rates from these causes, but these changes will be at
least partially attnbutable to improvement in certification. Care must be used
an their interpretation.
. J J j e fi?Hres for tbe birth registration area for 1930 and 1931, according to the
1929 revision, are given below:
ti°n
1930
Cause of death
All causes.
140. Abortion with septic conditions...............................
141. Abortion without mention of septic conditions (to include
hemorrhages)....................
142. Ectopic gestation_____________
(a) With septic conditions specified____
(b) Without mention of septic conditions!
144.
Puerperal hemorrhage.
(a) Placenta previa__ __________
(b) Other puerperal hemorrhages!
145. Puerperal septicemia (not specified as due to abortion)___
1931
Number
Percent
distri
bution
Number
14,836
100
13,964
100
1,961
13
2,049
15
671
595
5
4
653
588
5
4
103
492
1
3
109
479
1
3
169
1,523
1
10
88
1,442
1
10
546
977
4
7
475
967
3
7
Percent
distri
bution
3,321
22
3,149
23
3,303
18
22
3,137
12
22
3,589
493
24
3
3,027
529
22
4
149. Other accidents of childbirth.
702
1,767
5
12
630
1,755
5
13
(a) . Cesarean operation_
(b) Others under this title.
436
1,331
3
9
430
1,325
3
9
(a) Puerperal septicemia and pyemia
(b) Puerperal tetanus.............................
146. Puerperal albuminuria and eclampsia
147. Other toxemias of pregnancy........
...........................
148. Puerperal phlegmasia alba dolens, embolus! ’sudden death
(not specified as septic).........
150.
Other and unspecified conditions of the puerperal state__
45
(9
(9
54
(9
(9
1 Less than 1 percent.
When comparing these figures with those in the table on page 214, it must be
w ^ i T ^ ere that the oi9? ° and. 1931 fiSures are compiled from death certificates
while those on page 214 are from classifications made after interview with the
Attending physician.
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Federal Reserve Bank of St. Louis
A P P E N D IX
C — SCH EDU LE
U S E D IN
THE
STUDY
C . B . 122—Revised
U. S. DEPARTMENT OF LABOR
C H IL D R E N ’S B U R E A U
Be No.
M O T H E R (information from death certificate)
1. PLACE OF DEATH—
C o u n ty ----------------------------------------------------4______ ______
State .,____
Registered No.
Township------------------------------------------------- . ---------------------- or Village
C it y _________________________________________
No................ , .............. 4 - ........................................................... St.................. Ward
(If death occurred in a hospital or institution, give its N AM E instead of street and number)
2. FULL NAME
(a) Residence.
No. ............................... .................................. __________ S t . , ____ ___Ward.................. ............ .......... ..... ..............
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
(If nonresident give city or town and State)
days.
How long in U. SL, if of foreign birth?
PERSONAL AND STATISTICAL PARTICULARS
4. COLOR OR RACE
3. S E X
yrs.
mos.
days.
MEDICAL CERTIFICATE OF DEATH
S. SINGLE, MARRIED, WIDOWED,
OR DIVORCED (write the word)
11. DATE OF DEATH (month, day, and year)______________________ _ 19.
12.
I H E R E B Y C E R T I F Y , That I attended deceased from
Sa. If married, widowed, or divorced
W IFE of
------------------------------------------------- - 19_____ , to ____________ ____________ _ 19______
that I last saw h _____ alive o n ____________________ __________ ___ f 19______
6. DATE OF BIRTH (month, day, and year)
7. A G E
Years
and th a t death occurred, on the date stated above, a t _______________ m .
Months
If LESS than
1 d a y ,_____ hrs.
Days
T he CAUSE OF DEATH was as follows:
o r _____ m in .
8. OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work__
(d uration)----------- y r s .________ m os. . . . _____ days
(b) General nature o{ industry,
business, or establishment in
which employed (or employer)
C O N T R IB U T O R Y .............................................................................
(Secondary)
----------------------------------------- - (d uration )_______ y r s .___ ____ m os.
13. W here was disease contracted
if not at place o f d e a th ?_______________________________ __
(e) Name of employer .
9. BIRTHPLACE (city or town)
(State or country)
.days
Did an operation precede death? _____. . . . . Date of
W as there an autopsy?__________________________ _____
10. INTERVAL BETWEEN BIRTH AND MOTHER’S DEATH.
W h at test confirmed diagnosis?________________ _____
(S ign ed )----------- ---------------------------------------------------- . . . . . . . . . M . D .
, 19
14. NO BIR T H CER TIFICATE: (a) Not required,
registered
(A ddress)____________________ ______________
Reserve this space
(b) Required b ut not
International code
Date of search .
B A B Y (information from birth certificate)
15. PLACE OF BIRTH—
County---------------------------------------------------------- T---------- . . -----------
S ta te ...
Township-------------------------------------------------------------------------- ... or Village
C ity . . . . . _______________________________ _____
No................................................................................ S t . , ........ ..................... Ward
(If birth occurred in a hospital or institution, give its N A M E instead of street and number)
16.
Fun
17. S ex o f
c h i l d __________
.f child — .—
-------------- ------- -------- -
To be answered
plural births.
------------- ----------- ffiasüM Sjrrikga
20. Legiti-
21. Date
of
19. Number, in order of birth
birth-------------------------------------(Month, day, year)
22. Number of children of this mother
(Taken as of time of birth of child herein
______ certified and including this child.)
(s) Born «live and now Bring_________ ____ (b) Born afire but now dead .
(c) Stillborn
CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE*
I hereby certify that I attended the birth of this child, who w as— ..................... ............... a t __________ .~m. on the date above stated.
(Bom alive or stillborn)
* When there was no attending physician
or midwife, then the father, householder,
etc,, should make this return. A stillborn
child is one that neither breathes nor shows
FRASER
other evidence o f life after birth.
Digitized for
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182748°—33.
(Face p. 216.)
Signature.
(Physician or midwife)
23. P R E N A T A L C ARE
Month of pregnancy
Given by
26. Visits:
40.
visits:
24. Summary: Adequate, inadequate, none
j
25. Physical exam, during preg., N.
(a) Heart, N .
Normal, abnormal (spec.)
(a ) Saw patient, N.
(b) Lungs,rN .
Normal, abnormal (spec.)
(b) Urine exam., N.
(c) Measurements, N .
(c) Abdom. exam., N.
(Ext., int.) Normal, abn. (spec.)
(d) Blood pressure, N.
(d ) Wassermann, N. Neg., Pos.
28. Albuminuria, N .
27. Complications of pregnancy, None; N . R.
29. Convulsions, N.
31. Oedema, N .
Began
wk.
34. Bleeding during pregnancy. N .
35. Treatment by phys.
(b) Began
30. High blood pressure, N,
(a) (spec.)
Began
32. Prolonged headache, N.
(spec.)
33. Pernicious vomiting of pregnancy, N .
wk.
Began
wk.
(a) Began
wk.
(a) Began
wk.
(b ) Dur.
wk.
Dur.
wks.
wks.
(b) Recurred: Daily, wk., mo., irreg., N.
(c) Scanty, mod., profuse.
N.
36. Intercurrent diseases, N .
38. Attdt.: Phys., interne, student, mwf., other, none.
37. Delivery: None.
39. Technique of phys.: (a) Vaginal exam., N .
(c ) Rubber gloves, N.
(b ) Rectal exam., N.
Number
(d ) Other
40. Presentation: Normal, face, breech, transverse.
42. Labor: (a) Hrs.
(b) Type
(d) Termination: None, spon., art.
44. Tears, N.
41. Membranes: Rupt., N.
degree,
(b) How long before del.?
(c) Onset: None, spon., art. (spec.)
(See Inq. 47)
(a) Perineal, N .,
(a) Spon., art.
43. Pituitrin, N .
(b ) Cervical, N .
(a) Stage
(b) Dosage
(c) Repaired, N.
45. Third stage: Normal, abnorm. (spec.)
46. Postpartum hemorrhage, N.
Amount of blood lost
47. Operative delivery, N . (spec.)
(a) Delivery unassisted, assisted by
(b) Anesthetic (spec.) given b y attend., assistant
(c) Patient shaved, N.
(d ) Sterile goods, N.
(e) Preparation method
48. Abortion: (a) Spontaneous, self-induced,
(b) Hemor., N .
(c) Temp., N .
(d ) Curettage, N .; temp, before, N.
(e) Therapeutic abortion, Consultation, N .; Cause of
Hospital case: 50. Delivered in hospital, N.
49. Maternal history
No.
Per. gest.
Comp, o f preg.
Live or still.
Delivery
Planned, emergency.
51. Entered hosp.: Before del.; Dur. del.; After del.,
52. In hospital
days.
days.
53. (Septic case) (a) Other in hosp. at time, N.
(b) Developed in hosp., N.
54. Hospital equipment: (a) Maternity service, N.
(b ) Delivery room, N .
55. Supervision adequate, N.
(c) Training school, N.
(a) No. nurses,
56. Standing of hospital: (a) Listed A. M . A., N.
N.
(b) No. beds.
(b ) App. A. C. S.,
(c) 1, N.; 2, N.; 3, N.; 4, N.j 5. N.
Remarks
57. Hospital technique: (a) Obstet., 1, 2, 3 ,4 , 5.
58. Medical history:
(a) Heart
(b) Kidneys
(c ) Scarlet fever, N.
(d) Other
59. (a) Distance from phys. or hospital
(c)
(b ) Method of transportation
Medical attention, none, in extremis
60. Operation preceded death, N.
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(If other than shown in Inq. 47 specify)
(b ) Other .
P R IM A R Y CAUSE OF D E A T H (Check section corresponding to cause of death)
143. A C C ID E N T S O F P R E G N A N C Y
1. Abortion: (Enter details in Inq. 48)
2. Pernicious vomiting of pregnancy: (a) Duration before phys. called
(b) Condition when first seen
(c)
3. Ectopic gestation: (a) Sympt. began
Operation, N.
weeks.
Refused by patient, N.
week.
(b) Duration
(c)
Operation: Emergency, Elective (Enter details in Inq. 47)
4. Other causes under 143, remarks:
144. P U E R P E R A L H E M O R R H A G E
1. Placenta praevia
(a) Amount of blood lost
2. Postpartum hemorrhage, N .
(b) Method of delivery
(a) Delivery; Normal, operative (Enter in Inq. 47)
(b) Abnormalities (spec.)
(c) Management of third stage
(d) Left patient
hrs. after delivery,
(e) Con. satisfactory, with dropping pulse, N .
(f) Inspection of placenta at delivery, N.
3. Other causes under 144, remarks
145.
O T H E R A C C ID E N T S O F L A B O R
1. Cesarean section: (a) Indications for
(b) Elective, emergency,
(d)
(c) Vaginal exam, immediately before, N .
Patient in labor, N .
Duration, hrs.
(f) Temperature
(e) T ype of labor
(g) Rup. membranes, N .
hours
2. Instrumental delivery and other o'perative procedures (Enter details in Inq. 47)
3. Other causes under 145, remarks:
146.
1. Operative delivery (Enter in Inq. 47)
3. Care after delivery: (a) First call
4. Symptoms appeared
P U E R P E R A L SE PT IC E M IA
2. Nonoperative: (a) Shaved, N .
hrs., days after
hrs. after delivery.
(b) Scrubbed with soap and water; antiseptic (spec.)
(b) Nursing care
5. Intrauterine manipulation, N .
Before symptoms, after symptoms
6. Treatment
147.
1. Embolus:
(d)
P U E R P E R A L P H L E G M A S IA A L B A D O L E N S, E M B O LU S , S U D D E N D E A T H
(a) Phlebitis, N .
Operative delivery, N .
3. Other causes under 147, remarks
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(b) Respiratory distress, N.
(Enter in Inq. 47)
(e) Death during delivery, N .
(c) Cyanotic, N .
hrs. after
2. Autopsy, N.
148.
(See Prenatal care)
P U E R P E R A L A L B U M IN U R IA A N D C O N V U L S IO N S
(a) Medical supervision before convulsions, N.
(c) Symptoms began
(d) Cooperation by patient, good, poor
(f)
Hospital, N .
(b) Condition when first seen
before death
(e) Bed at first symptoms, N.
at first symptoms; when in serious condition
149.
C A U S E S F O L L O W IN G C H IL D B IR T H (n .o .s .)
150.
61.
Dur.
before death; Convulsions began
P U E R P E R A L D ISE A SES O F T H E B R E A S T
Contributory causes o f death (given on death cert.; not given on death cert.)
Notes:
Informant
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Agent
Date o f visit
IN D E X
Abdominal pregnancy, 69, 77, 78, 178. See also
Ectopic gestation.
Abnormal or difficult labor, classification in inter
national list, 5. See also Labor, long or diffi
cult, as indication for Cesarean section.
Abnormal presentation as indication for Cesarean
section, 90-92, 97,100,102.
Abnormal presentation, rupture of uterus, 168.
Abortion, 103-115. See also Abortion or premature
labor as cause of death.
Age of woman, 111.
Autopsy, 14,15.
Blood transfusion, 79,107.
Classification of deaths by cause, 5-10, 103-106.
See also 79, 113, 114, 116-117, 155, 212-215.
Colored and wbite women, 83-86, 112, 129, 131,
208,209-211.
. .
Comment and recommendations by advisory
committee, 38, 39,88, 113-115, 133, 180-182.
Criminal, 6, 16, 41, 103-104, 114. See also
80 and Abortion— Induced.
Curettage, 79, 80,107-110, 114, 115, 133.
Definition, 5,103, 113.
Gestation period by month, 106-107, 114.
Gestation period by trimester, 79, 81-82, 84-86,
104,114.
Hemorrhage, 79, 106, 108, 110, 114. See also
Abortion—Puerperal hemorrhage.
Hospitalization, 25, 26,127-128.
Incidence among maternal deaths, 103, 209-211.
Induced, 14, 37-38, 80, 81-82, 103-115, 116-118,
131-132, 136, 178, 209-211. See also 23, 41,
47, 143.
Operation for delivery. See Therapeutic abor
tion.
Operation other than for delivery, 79, 80,107,
108, 109, 110.
Parity, 34, 35, 111-112. See also 178.
Pernicious vomiting of pregnancy, 79, 108, 114,
153.
Placenta previa, 79, 104, 105, 108. See also
Abortion— Puerperal hemorrhage.
Puerperal albuminuria and convulsions, 103,
104,105, 143. See also 79,196-197.
Puerperal hemorrhage, 104, 105, 1£5. See also
Abortion—Hemorrhage.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 104, 105, 136. See also 103.
Puerperal septicemia, 23,47,79, 103, 104,105-106,
108, 109, 110, 114, 116, 117, 118, 129, 131-132,
133, 212-215. See also 115, 153, 178.
Rate, maternal mortality, 112, 131-132, 208.
Rural and urban areas, 23, 38, 112, 129, 208,
209-211. See also 19.
Self-induced, 41, 103-104, 114. See also
Abortion—Induced.
Abortion—Continued.
Septic. See Abortion— Puerperal septicemia.
Spontaneous, 14, 104-115, 117, 132, 136, 209-211.
See also 143, 153, 180, 182.
States, 113, 131-132, 206-207, 208,209-211. /
Therapeutic, 78, 79, 83-86, 88, 89, 105-114, 117,
118, 132, 136, 153, 196-197, 206-207, 209-211.
See also 88, 127, 143.
Unmarried and married women, 37-38, 39, 108,
114.
Abortion or premature labor as cause of death.
See also Accidents of pregnancy as cause of
death.
Accessibility of physician, 24.
Age of woman, 192-194.
Autopsy, 14.
Classification of deaths by cause, 5-10, 13, 103,
105; See also 79, 113-114, 116, 139, 141, 155,
167,212-215.
Colored and white women, 17, 183-185,
Deaths following abortion, 103, 104,105.
Definition, 5,103. See also 113.
Gestation period by trimester, 29, 183-185,
204-205.
Intercurrent disease, 166-167.
Interval between termination of pregnancy and
death, 28,190.
Operation other than for delivery, 204-205.
Parity, 191, 192-194.
Rate, maternal mortality, 8.
Rural and urban areas, 19,183-185. See also 24.
Abscess; cerebral, 101 (footnote), 102 (footnote).
Abscess, incision and drainage, 77, 79, 80, 107, 118,
119,120, 177, 204-205.
Abscess, pelvic, nonpuerperal cause of death, 15.
Accessibility of physician, 22-24.
Comment and recommendations by advisory
committee, 38, 39, 98,164.
See also 11, 25, 59, 159, 176.
Accident (not puerperal) as cause of death, 6.
Accidental hemorrhage, classification in interna
tional list, 5. See also Premature separation
of placenta.
Accidents of labor. See “ Other accidents of labor”
as cause of death.
Accidents of pregnancy as cause of death. See also
Abortion or premature labor as cause of death,
Ectopic gestation as cause of death, and “ Other
accidents of pregnancy ’ ’ as cause of death.
Abortion, deaths following, 104-105.
Accessibility of physician, 24.
Agé of woman, 192-194.
Autopsy, 14.
Cesarean section, 101.
Classification of deaths, 5-13, 135, 139-141, 167,
172. See also 103, 155, 212-215.
217
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218
INDEX
Accidents of pregnancy as cause of death—Contd.
Colored and white women, 17,183-185,199-203.
Gestation period by trimester, 29, 46, 104,
183-185.
Live births and stillbirths, 33, 34.
Operation for delivery, 68, 196-197.
Parity, 191,192-194.
Pernicious vomiting of pregnancy, 139, 152.
Prenatal care, 46-48.
Rate, maternal mortality, 8, 29.
Rural and urban areas, 19,183-185.
Unmarried and married women, 36.
Accouchement forcé, 88, 146, 154. See also Dilata
tion of cervix, artificial.
Acute infectious diseases, 6, 15, 122, 166-167, 181.
See also Hospital standards and facilities.
Acute nephritis, 101,139.
Acute yellow atrophy of liver, 140.
Adhesions, hysterectomy for, 78,177.
Age of woman, 35-36, 192-194.
Abortion, 111.
Abortion or premature labor as cause of death,
192-194.
Causes of death (table), 192-194.
Cesarean section, 70-71, 92-94. See also 90-91,
98-100.
Colored and white women, 35-36.
Ectopic gestation, 174-175.
Operation for delivery, 69-71. See also Age of
woman—Cesarean section.
Parity, 69-71, 92-94, 150, 155-156, 175, 192-194.
See also 90-91.
Puerperal albuminuria and convulsions, 150,
192-194.
Puerperal hemorrhage, 155-156,163,192-194.
Rate, maternal mortality, 35-36.
\ Unmarried and married women, 36-37.
Alabama:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 24. See also 25,^137.
Attendant at confinement, 57, 58, 59.
Cesarean section, 97, 206-207.
Colored and white women, 16, 30, 51, 131, 150151, 157, 158, 173, 208, 209-211.
Ectppic gestation, 172, 173, 174.
Gestation period by trimester, 28,30,31,130,131,
206-207.
Hospitalization, 21, 27, 174.
Live births, 30, 31, 208.
Medical attention, 24,25,137. See also 57, 58, 59.
Midwives, 57, 58, 59.
Operations, 84, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 50, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,
150-151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens. embolus,
sudden death, 137.
Puerperal septicemia, 130,131-132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 21, 24, 31, 52-53, 130,
151,158,172,208,209-211. See also 28.
See also 1-2.
Albuminuria and convulsions. See Puerperal albu
minuria and convulsions.
American College of Surgeons, 1. 182,186-189.
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American Journal of Obstetrics and Gynecology, 1
(footnote).
American Medical Association, 27, 186-187. See
also 11.
American Public Health Association, definition of
live births and stillbirths, 3.
Anemia as nonpuerperal contributory cause, 167.
See also Hemorrhage.
Anesthesia:
Cesarean section, 96-97, 99, 100, 101 (footnote),
102 (footnote).
Eclampsia, 154.
See also 181.
Antepartum hemorrhage, classification in inter
national list, 5, 212, 213.
Antiseptics, 127. See also Technique of physician
(asepsis).
Appendectomy, 77, 78-79, 80, 88, 118, 177-179,
204-205.
Appendicitis as cause of death, 15.
Asepsis. See Technique of physician (asepsis).
Attendant at confinement, 55-64. See also Delivery
care.
Cesarean section, 95,101.
Comment and. recommendations by advisory
committee, 63-64, 87-88, 133,180-182.
Puerperal septicemia, 122-128, 133. See also
60-61.
Technique, 56, 60-62, 64, 73-74, 123-127.
See also 3-4, 41-42, 98, 162, 167.
Autogenous infection. See Endogenous infection.
Autopsy, 14-15.
Comment and recommendations by advisory
committee, 38, 170, 178. 180.
Ectopic gestation, 173,178.
Inversion of uterus, 169.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 135,136. See also 14.
Rupture of uterus, 167-168. See also 170.
See also 9.
Bag. See Dilatation of cervix, artificial.
Bag of waters. See Membranes, rupture.
Baltimore, births to nonresidents in hospitals, 20.
Banti’s disease, 91.
Birth certificate, facing 216. See also 1, 3, 25, 38, 108.
Birth-registration area, 1, 2, 3, 32, 38. See also 6
(footnote).
Births. See Live births and Stillbirths.
Births, Stillbirths, and Infant Mortality Statistics,
1928 (U.S. Bureau of the Census publication),
32 (footnote).
Bladder, rupture, 5,166.
Blood count, 43 (footnote).
Blood pressure, 3, 43, 45,141,154.
Blood test. See Wassermann test.
Blood transfusion, 76, 77, 80, 181, 204-205.
Abortion, 79,107.
Cesarean section, 98, 164.
Comment and recommendations by advisory
committee, 88, 98, 164-165, 178, 181.
Ectopic gestation, 78-79, 88, 177-178.
Puerperal hemorrhage,160,162,163,164,204-205.
Puerperal septicemia, 118,120-121, 204-205.
Board of health, State. See State board or depart
ment of health.
Bougie. See Dilatation of cervix, artificial.
| Braxton Hicks version, 160,164.
INDEX
Breast. See Puerperal diseases of the breast as cause
of death.
Hreech extraction, 67, 69, 70,72, 73,120,196-197,198,
206-207.
Breech presentation, 90,91,168. See also Abnormal
presentation as indication for Cesarean
section.
^Bronchopneumonia, 167. See also Pneumonia.
'California:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
•Colored and white women, 16, 30, 51, 131, ISO151, 157, 158, 173, 208, 209-211.
Ectopic gestation, 172, 173,174.
Foreign-born and native women, 17.
■Gestation period by trimester, 30, 31, 130, 131,
206-207.
Hospitalization, 21, 27, 174.
Legitimacy not reported, 38,108.
Live births, 17, 30, 31, 208.
Medical attention, 25, 137. See also 58.
Midwives, 58.
Operations, 84, 87, 97, 206-207.
■“ Other accidents of labor” , 137.
Prenatal care, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,150151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131-132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 19, 21, 31, 52-53, 130,
151, 158, 172, 173, 208, 209-211.
See also 1-2.
Gancer, 6.
•Cardiac disease, 6, 15, 89,91, 100, 102, 167. See also
90, 101.
Case histories:
Cesarean section, 98-100.
Embolism, 135, 136.
Puerperal hemorrhage, 164, 165.
Rupture of uterus, 169-170.
Causes of death (tables) in relation to—
Abortion, 104, 105.
Accessibility of physician, 24.
Age of woman, 192-194.
Cesarean section, 101.
Colored and white women, 17, 183-185, 199-201,
202-203.
Death certificate, 8,10,13.
Gestation period by trimester, 18, 28, 29, 46,
183-185, 196-197, 199-201, 202-203, 204-205.
Interval between delivery and death, 28,190.
Live births and stillbirths, 34.
Onset of labor, 199-201.
Operation for delivery, 196-197.
Gperation other than for delivery, 204-205.
Parity, 191, 192-194.
Pernicious vomiting of pregnancy, 152.
Prenatal care, 46.
Rate, maternal mortality, 8.
Rural and urban areas, 19,183-185.
Termination of labor, 202-203.
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Causes of death (tables) in relation to—Continued.
Undelivered cases, 34.
Unmarried and married women, 36.
Census, United States Bureau of:
Classification of colored and white races, 2
(footnote).
Classification of deaths by cause, 2, 5-10,15, 38,
45, 103, 114, 116-117, 139-141, 155, 212-215. See
also 135,166,172.
Classification of live births and stillbirths, 3
(footnote), 32.
Classification of rural and urban areas, 2 (foot
note).
Information on illegitimate births, 108.
See also 4,17, 25, 30, 31, 34, 208.
Cephalic version, 68 (footnote).
Cerebral hemorrhage, 101 (footnote), 102 (footnote),
167.
Cerebral thrombosis, 135.
Certificate, birth, facing 216. See also 1, 3, 25, 38,
108.
Certificate, death, 8, 10-13, 15-16, 34, 38, 180, 214,
facing 216. See also 1-16, 100, and specific
causes of death.
Cervical Cesarean section, 101. See also 89.
Cervix:
Dilatation. See Dilatation of cervix, artificial.
Laceration, 5,160,162, 164. See also 78, 80,118,
119.
Packing, 76-77, 80, 107, 118, 119, 120, 204-205.
See also Uterus, packing.
Scarred or rigid, 91.
Trache lorrhaphy, 78, 80, 118.
Cesarean section, 89-102. See also Cesarean section
as cause of death.
Abnormal presentation, 90-92, 97, 100, 102.
Age of woman, 70-71, 92-94, See also 90-91,
98-100.
Anesthesia, 96-97, 99, 100, 101 (footnote), 102
(footnote)«
Appendectomy with, 77.
Before last trimester, 78, 89.
Cervical, 101. See also 89.
Classification of deaths by cause, 5-10, 89, 100101,197. See also 135,136,139-140,166,212-215.
Colored and white women, 83-86, 91-92, 97-98.
Comment and recommendations by advisory
committee, 88,98-102,154,164-165,170,180-181.
Contracted pelvis, 89-92, 96, 97, 98-102.
Definition, 89.
Difficult or long labor, 89-92, 96, 97, 99-102.
Eclampsia, 89-92, 94, 96, 97, 98-102, 154. See
also Cesarean section—Puerperal albuminuria
and convulsions.
Embolism, 89, 101-102, 135-136.
Emergency or planned, 94, 99, 101.
Following attempt at other operation, 68, 88,
94, 100, 101, 196-197.
Gestation period by trimester, 84-86, 97. See
also 78, 89.
Hours in labor, 72, 94.
Immediate cause of death, 89,100-102.
Incidence, 65, 67, 83, 84-86, 97.
Indications, 89-92, 94, 96, 97, 98-102.
Live births and stillbirths, 89, 96. See also 98,
,
100.
Onset and termination of labor, 74-76,199-203.
220
INDEX
Colored and white women—Continued.
■Cesarean section—Continued.
Cesarean section as cause of death, 17, 183-185,
With operation other than for delivery, 77.
199-201, 202-203.
Parity, 69-72, 92-94, 98-102, 198. See also 167.
Classification of “ colored” , 2 (footnote).
Placenta, premature separation, 90-92, 94, 96,
Comment and recommendations by advisory
97,102, 163.
committee, 38, 64.
Placenta previa, 89-92, 94, 96, 97, 98, 102, 160,
Delivery care, 55-61, 63, 64, 124-125. See also
164-165.
4,38.
Porro operation, 77,101. See also 89.
Ectopic gestation, 173.
Preeclampsia, 89-92, 94, 96, 97, 98-102,154.
Ectopic gestation as cause of death, 17, 183-185.
Puerperal albuminuria and convulsions, 89, 94,
Gestation period by trimester 18, 26, 30, 37, 8495, 99, 101, 146, 148, 154. See also Cesarean
86, 129, 131, 142, 146, 147, 183-185, 199-201,
section—Eclampsia.
202-203.
Puerperal hemorrhage, 89,94,101,161. See also
Cesarean section—Placenta previa and Pre
Hospitalization, 26-27, 55, 63, 64, 146.
Live births and stillbirths to women included in
mature separation of placenta.
Puerperal phlegmasia alba dolens, embolus,
study, 32-33.
sudden death, 89,101. See also 136.
Live births in certain States, 16, 30, 208.
Puerperal septicemia, 89, 94, 95, 98-102, 116,
Midwives, 4, 56-60, 61, 63-64, 124r-125.
117, 120, 196-197.
Onset and termination of labor, 74-75, 82-83,
Rupture of membranes, 94.
146-147, 199-203.
Rupture of uterus, 90-92, 96, 97, 102, 167-168,
Operation for delivery, 65, 66, 74, 75, 82, 83,
84-86, 199-203. See also Colored and white
170.
Rural and urban areas, 83-86, 91-92, 98.
women— Cesarean section.
States, 97, 206-207.
Operation other than for delivery, 65, 66.
Technique of operator (asepsis), 73, 95.
Parity, 35. See also 49.
Types, 77, 89, 98-101.
Pituitrin, 63.
Cesarean section as cause of death. See also “ Other
Placenta previa. See Colored and white
accidents of labor” as cause of death.
women—Puerperal hemorrhage.
Accessibility of physician, 24.
Plural pregnancy, 32, 33.
Age of woman, 192-194.
Prenatal care, 37, 41-51, 64,142,195.
Cesarean section, deaths following, 101,196-197.
Puerperal albuminuria and convulsions, 16,17,
Classification of deaths, 5-10, 13, 89. See also
18, 59-60, 140-141, 142, 144, 145, 146, 147, 150100,101, 136,139-140, 166, 212-215.
151, 183-185, 199-201, 202-203.
Colored and white women, 17, 183-185,199-201,
Puerperal hemorrhage, 17, 18, 157-158, 183-185,
202-203.
199-201, 202-203.
Gestation period by trimester, 29, 183-185,
Puerperal phlegmasia alba dolens, embolus,
196-197, 199-201, 202-203, 204-205.
sudden death, 16,17, 18,138, 183-185,199-201,
Interval between delivery and death, 28, 190.
202-203.
Live births and stillbirths, 34.
Puerperal septicemia, 17, 18, 124-125, 129-131.
Onset and termination of labor, 199-203.
183-185, 199-201, 202-203.
Operation other than for delivery, 204-205.
Rate, maternal mortality, 16-18, 28, 30, 35-36,
Parity, 191,192-194.
38,112. See also specific causes of death.
Rate, maternal mortality, 8.
Rural and urban, 28, 42, 44, 45, 64, 66, 84-86, 92,
Rural and urban areas, 19,183-185.
98, 129, 138, 140-141, 144-145, 157, 183-185,
Children’s Bureau, United States, plan for study of
209-211.
maternal mortality, 1-4. See also 43.
States, 2, 16, 28, 30, 51, 131, 150-151, 157, 158, 173,
Chloroform, 96-97,100, 154.
208, 209-211.
Chorea of pregnancy, 5, 7, 91. See also 213.
Undelivered cases, 32-34, 74-75, 199-203.
Chronic nephritis. See Nephritis.
Unmarried women, 36-38,195.
Cities. See Rural and urban areas.
Wassermann test, 44, 45.
Classification of deaths by cause, 5-10. See also
Colpotomy,’posterior, 79,80,119. See also Abscess
212-215 and specific causes of death.
incision and drainage.
Colored and white women, 2,16, 17,18, 38,183-185.
Comment and recommendations by advisory com
Abortion, deaths following, 83-86, 112, 129, 131,
mittee:
208, 209-211.
Abortion, 113-115, 180, 181, 182. See also 38-39,
Abortion or premature labor as cause of death,
88, 133.
17,183-185.
Anesthesia, 100, 154, 181. See also 98, 99, 101,
Accidents of pregnancy as cause of death, 17,
102.
183-185, 199-201, 202-203.
Autopsy, 38,180. See also 170,178.
Age of woman, 35-36.
Blood transfusion, 88,98,164-165,178,181.
Attendant at confinement, 56-60,124-125.
Cesarean section, 98-102, 181. See also 88, 154,
Autopsys, 14.
164-165,170, 180.
Causes of death (tables), 17, 183-185, 199-201,
Curettage, 88,114-115,133. See also 181.
202-203.
Death certificates, 38,180. See also 114,178.
Cesarean section, deaths following, 83-86,91-92,
Ectopic gestation, 178-179. See also 88.
97-98.
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IN D E X
Comment and recommendations by advisory com
mittee—Continued.
Examinations, rectal and vaginal, 64, 98, 101,
133, 164, 181.
General considerations (section), 38-39.
Hospitalization, 38-39, 64, 133, 182. See also
100, 164, 165, 178.
Maternal care, 63-64, 180-182. See also 38-39,
87-88, 98-102,133-134,153-154,163-165,170-171,
178-179.
Obstetric education, 87-88, 133, 181-182. See
also 100, 154, 165, 170.
Operation for delivery other than Cesarean
section, 87-88. See also 114, 133-134, 138, 154,
164-165,170,178,181.
Pituitrin, 64,165,170,171,181.
Puerperal hemorrhage, 163-165, 181. See also
39, 64, 87, 98, 101-102, 114.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 101,138.
Puerperal septicemia, 133-134. See also 39, 64,
87,88,98-102,114-115,164-165,178-179,181,182.
Recommendations by advisory committee
(section), 180-182.
Rupture of uterus, 170-171, 181. See also 64,
102,164.
Technique of physician (asepsis), 64, 87, 88,
101,114,133-134,164-165,178,181.
Toxemias of pregnancy, 153-154. See also 39,
64, 87, 99-102, 181.
Confinement, attendant at. See Attendant at con
finement.
Contagious diseases. See Infectious diseases.
Contributory causes of death, 5-10, 15,116,135-136,
139-141, 151-152, 155, 166-167, 170, 172.
Convulsions. See Eclampsia and Puerperal albu
minuria and convulsions.
Cord, prolapsed, as indication for Cesarean section,
91.
Cornual pregnancy, 5,172. See also 212-213.
Coronary thrombosis, 135.
Coroner, signature on death certificate, 9, 11-14,
34, 38,138.
Craniotomy or embryotomy, 67-69, 70, 72, 73, 84-86.
88, 120, 168, 196-197, 206-207.
Credè, modified, postpartum hemorrhage, 162.
Criminal abortion, 6, 16, 41, 103-104, 114. See also
Abortion—Induced.
Cul-de-sac puncture for hematocele, 177.
Curettage, 76-80, 204-205.
Abortion, 79-80, 107-110, 114-115, 133.
Blood transfusion, 76-79, 107, 118, 120, 204-205.
Commenit and recommendations by advisory
committee, 88,114-115, 133.
Ectopic gestation, 78-79, 177, 178, 204-205.
Febrile cases, 88,108-110,114,133.
Puerperal septicemia as cause of death, 77, 88,
108-110, 114-116, 118-120, 133, 204-205.
Cyanosis associated with embolism, 135-136.
Dead-born issue. See Stillbirths.
Dead fetus, indication for therapeutic abortion, 108.
Death before delivery, 32-34, 49-50, 67-69, 74-75, 79,
80-83, 121, 146-149, 161, 163, 199-203. See also
39.
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Death certificate, 8, 10, 13, 15-16, 34, 38,138, 180 214,
facing 216. See also 1-16, 100, and specific
causes of death.
Delivery, attendant at. See Attendant at confine
ment.
Delivery care, 40, 55-63, 64, 73-74, 87-88, 122-128,
133,162,180-182. See also 3-4, 39, 41-42, 95-98
169, Hospitalization, Medical attention, and
Operation for delivery.
Delivery and death, interval between, 27-28, 128
137, 148-149, 161, 162, 190. See also 164.
Delivery in hospital. See Hospitalization.
Delivery, operative. See Operation for delivery.
Delivery, postmortem, puerperal albuminuria and
convulsions, 148.
Department of health, State. See State board or
department of health.
Diabetes, 6,911
Difficult or long labor as indication for Cesarean
section, 89-92, 96, 97, 99-102.
Dilatation of cervix, artificial, 67, 69, 196-197.
Accouchement forcé, 88, 146, 154.
Age of woman, 70.
Comment and recommendations by advisory
committee, 88,164.
Ectopic gestation, 177.
Forceps, 67, 68, 72, 73, 78, 88, 120, 148, |6<). 163,
168, 169, 196-197,198, 206-207.
Hours in Jabor, 70, 71-72.
Parity, 69, 70, 71, 72, 198.
Puerperal albuminuria and convulsions. 148.
Puerperal hemorrhage, 160, 163.
Puerperal septicemia, 120.
States, 207.
Version, 67, 68, 69, 72, 73, 78, 88. 120, 148, 160, 163
168, 169, 196-197, 198, 206-207.
See also Cervix, packing.
Diphtheria, 6.
Disease, intercurrent, 40, 122, 166-167. See also
41-42.
Distance of patient from physician. See Access!
bility of physician.
Disproportion as indication for Cesarean section
89-92,96, 97, 102.
Drainage. See Incision and drainage for infection.
Dry labor, 91. See also Membranes, rupture.
Duration of labor. See Labor, duration.
Duration of pregnancy. See Gestation period by
month and Gestation period by trimester.
Dyspnea associated with embolism, 135-136.
Dystocia. .See Lon* or difficult labor asdndiatuion
for Cesarean section.
Eclampsia. See also Puerperal albuminuria aiid
convulsions and Toxemias of pregnancy.
Cesarean section, 89-92, 94, 96, 97. 98-102. 154.
Classification of deaths by cause, 5-10, 139.
212-215.
Comment and recommendations by advisory
committee, 87, 98-102, 153, 154.
See also 48, 87, 119.
Ectopic gestation, 172-179. See also Ectopic ges
tation as cause of death.
Age of woman, 174-175.
Appendectomy. 79. 88. 177. 178-179.
222
INDEX
Ectopic gestation—Continued.
Blood transfusion, 78-79, 88, 177-178.
Classification of deaths b y cause, 5-10, 172,
212-215. See also 103, 139, 155.
Colored and white women, 173.
Comment and recommendations by aivisory
committee, 88, 178-179.
Last trimester of pregnancy, 69, 77,176,178.
Medical attention, 13,173-174 ,178.
Operation for ectopic gestation, 67, 69, 77,78-79,
83-86, 88, 118, 173, 176-177, 178, 196-197, 198,
206-207.
Operation other than for ectopic gestation,
78-79, 88, 177-178, 204-205.
Parity, 174-175, 178.
Puerperal albuminuria and convulsions as con
tributory cause, 141, 172.
Puerperal septicemia, 88,116,117,118,172,178,179.
Rate, maternal mortality, 172-173.
Rural and urban areas, 24, 83, 172-173, 178.
States, 172-174.
Ectopic gestation as cause of death. See also
Accidents of pregnancy as cause of death.
Accessibility of physician, 24.
Age of woman, 192-194.
Classification of deaths by cause, 5-10, 13, 172.
See also 103,139, 155, 212-215.
Colored and white women, 17, 183-185.
Gestation period by trimester, 29, 183-185,
204-205.
' Interval between delivery and death, 28,190.
Operation for ectopic gestation, 196-197.
Operation other than for ectopic gestation.
204-205.
Parity, 191, 192-194.,
Rate, maternal mortality, 8.
Rural and urban areas, 19,183-185. See also 24.
Embolism, 101-102, 135-136, 166. See also Puer
peral phlegmasia alba dolens, embolus,
sudden death.
Embryotomy or craniotomy, 67-69, 70, 72, 73, 84-86,
88, 120, 168, 196-197, 198, 206-207.
Endogenous infection, 134. See also 122.
Enterostomy, 76, 77, 79, 80, 119, 177, 205 (footnote).
Ether, 96-97,101 (footnote), 102 (footnote), 154.
Ethylene, 96-97.
Examinations:
General physical, 43.
Laboratory, 3, 43-45, 116 (footnote), 141.
Rectal. See Rectal examination.
Vaginal. See Vaginal examination.
External causes of death, 6.
External version, 68 (footnote).
Extrapuerperal causes of death. See Nonpuerperal
causes of death.
Extrauterine pregnancy. See Ectopic gestation.
Failed forceps, 67, 68, 69, 88.
Faulty presentation, classification in international
list, 5, 166, 212.
Fetal mortality. See Abortion and Stillbirths.
Fetus, previable. See Viability of fetus.
Fetus, undelivered. See Undelivered cases.
Fever. See also Puerperal septicemia.
Curettage in abortion cases, 88,108,109,110.114,
133.
Segregation of patients, 182, 188 (footnote), 189
(footnote).
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Fibroid tumor:
Cesarean section, 90-91.
Hysterectomy, 78, 80,177.
Rupture of uterus, 170.
Following childbirth (not otherwise defined) as
cause of death, 5,10,13,17,19,24,29,34,36,46,
183-185,190, 191, 192-194, 213-214.
Forceps operation for delivery, 67-73.
Age of woman, 70-71.
Before last trimester, 78.
Classification of deaths by cause, 68,69, 196-197.
Colored and white women, 83-86.
Comment and recommendations by advisory
committee, 87, 88,170.
Dilatation of cervix, artificial, 67, 68, 72, 73, 78,
88, 120, 148, 160, 163, 168, 169, 196-197, 198,
206-207.
Duration of labor, 71-72.
Failed forceps, 67, 68, 69, 88.
Live births and stillbirths, 73.
Manual removal of placenta, 67, 68, 120, 161,
196-197, 198, 206-207.
Parity, 70, 71, 72,198.
Placenta previa, 68, 69,160.
Premature separation of placenta, 163.
Puerperal albuminuria and convulsions, 68, 69,
148, 196-197.
Puerperal hemorrhage, 68, 69, 160, 161, 163,
196-197.
Puerperal septicemia, 68, 69, 87,120, 196-197.
Rupture of uterus, 168.
Rural and urban areas, 83-86.
States, 206-207.
Technique of physician, 73, 87.
Version, 67, 68, 69, 73, 88, 120, 168, 169, 196-197,
198, 206-207.
Foreign-born and native women, 16-18.
Gestation, ectopic. See Ectopic gestation.
Gestation period by month:
Abortion, 106-107. See also 114.
Ectopic gestation, 176.
Pernicious vomiting of pregnancy, 152.
Gestation period by trimester:
Abortion, 79, 81-82, 84-86, 104. See also 114.
Autopsy, 14.
Causes of death, 18, 28-29, 46, 183-185, 196-197,
199-201, 202-203, 204-205.
Cesarean section, 84-86, 97. See also 78, 79.
Colored and white women, 18, 26, 30, 37, 84-86,
129,131,142,146,147,183-185,199-201, 202-203.
Hospitalization, 25-26,195.
Live births and stillbirths, 32-34.
Onset and termination of labor, 146-147,199-203.
Operation for delivery, 65-76, 78-83, 84-87, 118120, 196-197, 206-207. See also Cesarean
section.
Operation other than for delivery, 118-119,
204-205.
Prenatal care, 45-48,142.
Rate, maternal mortality, 18,29,30,31,
Rural and urban areas, 18, 28, 31,84-86,129,130,
146, 147, 183-185.
States, 28, 30-31, 54, 87, 97, 130, 131, 206-207.
Unmarried and married women, 36-37,195.
See also specific causes of death.
Gloves, rubber, for vaginal examination, 60, 61, 64,
126-127, 133, 181.
INDEX
Gonorrhea, 122.
Gravidity. See Parity.
Health, State board or department. See State
board or department of health.
Heart. See Cardiac disease.
Hematocele, cul-de-sac, puncture for, 177.
Hemorrhage. See also Hemorrhage, postpartum,
Placenta previa, and Puerperal hemorrhage
as cause of death.
Abortion, 79,106,108, 110, 114. See also 155.
Cesarean section, 90-92, 94,100,102,164-165.
Comment and recommendations by advisory
committee, 100, 102, 114, 163-164, 181.
Ectopic gestation, 79.
Puerperal septicemia, 116, 120,164-165.
Hemorrhage, cerebral, 101 (footnote), 102 (footnote),
167.
Hemorrhage, postpartum, 116, 155, 160, 162, 164.
See also “ Other puerperal hemorrhage” as
cause of death.
Hepatitis, chronic, 101,102.
Hernia, 15.
Homicide (criminal abortion), 6, 103-104,114.
Hospital standards and facilities, 1,182,186-189.
Hospitalization, 25-27, 55-56, 182, 186-189. See also
Hospital standards and facilities.
Abortion, 25, 26,127-128.
Autopsy, 14.
Cesarean section, 94, 100.
Colored and white women, 26-27, 55, 63, 64,146.
Comment and recommendations by advisory
committee, 38-39, 64,100,133,178,182.
Coroner's signing death certificate in hospital,
11-12,14.
Ectopic gestation, 173-174, 178.
Emergency or planned, 25-27, 55, 64, 94,195.
Puerperal albuminuria and convulsions, 145146.
Puerperal septicemia, 123,127-128,133.
Rural and urban areas, 20-21, 27, 38,173-174.
States, 21,174.
Unmarried women, 37,195.
See also 3.
Hours in labor. See Labor, duration.
Hydatidiform mole, 5, 80 (footnote), 212.
Hydrocephalus as indication for Cesarean section,
91.
Hyperemesis gravidarum. See Pernicious vomit
ing of pregnancy.
Hysterectomy, 77, 78, 79, 80, 107, 118, 120, 177, 204205.
Hysterotomy, 79, 89.
Ileus, acute, 89, 101 (footnote), 102 (footnote). See
also 15, 91,167, and Enterostomy.
Illegitimacy. See Unmarried women.
Inaccessibility of physician. See Accessibility of
physician.
Incision and drainage for infection, 76, 77, 79, 80,
107, 118, 119, 120,177, 204, 205.
Induced abortion. See Abortion—Induced.
Induction of labor. See Labor, mechanical induc
tion, and Labor, medical induction.
Infectious diseases, 6, 15, 122, 166-167,181. See also
Hospital standards and facilities.
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223
Influenza, 6,166,167.
Insanity, puerperal, 5, 213.
Instrumenfal delivery. See Forceps operation for
delivery and “ Other surgical operations and
instrumental delivery” as cause of death.
Intercurrent disease, 40, 122, 166-167. See also 41-42.
International Commission for the Revision of the
International List of Causes of Death, 7, 212.
International List of Causes of Death, Manual of:
1920 edition, 5-10, 38, 212-215. See also Causes
of death (tables).
1929 edition, 212-215.
See also Joint Causes of Death, Manual of, and
specific causes of death.
Internes. See Attendant at confinement.
Interstitial pregnancy. See Ectopic gestation.
Interval between delivery and appearance of symp
toms, puerperal septicemia, 119,121-122.
Interval between termination of pregnancy and
death, 27-28, 128, 137, 148-149, 161, 162, 190.
See also 164.
Intestinal obstruction, 15, 91, 167. See also 89, 101
(footnote), 102 (footnote), and Enterostomy.
Intrauterine manipulation, 117, 118, 181. See also
Operation for delivery and Operation other
than for delivery.
Inversion of uterus, 5, 76, 77, 166, 169, 171. See also
204-205.
Joint Causes of Death, Manual of:
1925 edition, 5, 38, 155.
1933 edition, Sl2.
See also International List of Causes of Death,
Manual of.
Kentucky:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 127;
Attendant at confinement, 57, 58, 59.
Cesarean section, 97, 206-207.
Colored and white women, 16, 30, 51, 131, 150,
157, 158, 173, 208, 209-211.
Ectopic gestation, 172, 173, 174.
Gestation period by trimester, 30, 31, 130, 131,
206-207.
Hospitalization,. 21,174.
Live births, 30, 31, 208.
Medical attention, 23, 25, 137. See also 57, 58,
59.
Midwives, 57, 58, 59.
Operations, 87,97, 206-207.
“ Other accidents of labor ” , 137.
Prenatal care, 51, 52-53, 64.
Puerperal albuminuria and convulsions, 54,
150,151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131-132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 21, 23, 31, 52-53,130,151,
158, 172, 208, 209-211.
See also 1-2.
Kidney disease, previous, 149. See also Nephritis.
224
INDEX
Labor, dry, 91.
Labor, duration, 71-72, 94, 122, 167, 168.
Comment and recommendations by advisory
committee, 88, 98, 133,165,170,181.
Labor, long or difficult, as indication for Cesarean
section, 89-92, 96, 97, 98-102,181.
Labor, mechanical induction, 67-69, 74-75, 80-82,
146,199, 201. See also Dilatation of cervix,
artificial.
Labor, medical induction, 69, 74-75, 80-82, 146,
199-201.
Labor, onset and termination (artificial, spontane
ous, or none), 74-75, 80-83, 199-203. See also
Operation for delivery.
Causes of death (tables), 199-203.
Colored and white women, 74-75,82-83,146-147,
199-203.
Parity, 75, 76.
Pernicious vomiting of pregnancy, 153.
Prenatal care, 76.
Puerperal albuminuria and convulsions, 146147, 199-203.
Puerperal hemorrhage, 161,199-203.
Puerperal septicemia, 121, 133, 199-203.
Trimesters, first two, 78, 79, 80-83, 146-147, 199203.
Trimester, last, 67-69, 74-75, 146-147, 199-203.
With specified operations, 67-69, 78, 79.
See also 100,154,177, and specific operations.
Labor (unqualified) as cause of death, classifica
tion in international list, 5. See also 213.
Laboratory examinations, 3, 43-45, 116 (footnote),
141,182.
Laceration of cervix or perineum, 5, 15, 78, 118, 160,
162,164. See also 80,119.
Laparotomy for drainage, 77,80, 118-119,204-205.
Laparotomy for ectopic gestation, 67, 69, 77, 78-79,
83,84-86,88,114,118, 173,176-177,178,196-197,
198, 206-207.
Laparotomy other than hysterectomy, 77-78,79,80,
107, 118, 120,177, 204-205.
Live births, definition by American Public Health
Association, 3 (footnote).
Live births in certain States, 3,16,17,19,30,31,208.
Colored and white women, 16, 30, 208.
Foreign-born women, 17.
Rural and urban areas, 19, 31, 208.
Live births to women included in study, 32-34.
See also Stillbirths.
Before last trimester, 32, 78, 89, 104, 118.
Cesarean section, 89, 96.
Classified by cause of mother’s death, 33, 34.
Colored and white women, 32-33.
Comment and recommendations by advisory
committee, 39, 64.
Ectopic gestation, 178.
Operation for delivery, 73,78, 89, 96, 118.
Pituitrin, 62.
Postmortem delivery, albuminuria and con
vulsions, 148.
Premature separation of placenta, 163. See
also 96.
Prenatal care, 49, 50, 64.
Puerperal albuminuria and convulsions, 33, 34,
148, 149. See also 96.
Puerperal septicemia, 33, 34.
Liver, acute yellow atrophy, 140.
Liver— chronic hepatitis, 101, 102.
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Lobar pneumonia, 15, 90. See also Pneumonia.
Long or difficult labor as indication for Cesarean
section, 89-92, 96, 97, 99-102.
Manipulation, intrauterine, 117-118, 181. See also
Operation for delivery and Operation other
than for delivery.
Manipulation, vaginal, 127, 128, 181.
Manual dilatation of cervix. See Dilatation of
cervix, artificial.
Manual of the International List of Causes of
Death. See International List of Causes of
Death, Manual of.
Manual of Joint Causes of Death. See Joint
Causes of Death, Manual of.
Marital status. See Unmarried women.
Maryland:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Attendant at confinement, 57, 58, 59.
Baltimore, nonresidents hospitalized, 20.
Cesarean section, 97, 206-207.
Colored and white women, 16, 30, 51, 131, 150,
151, 158, 173, 208, 209-211.
Ectopic gestation, 172,173, 174.
Foreign-born and native women, 17.
Gestation period by trimester, 30, 31, 130, 131,
206-207.
Hospitalization, 20, 21, 174.
Live births, 17,30,31, 208.
Medical attention, 25, 137. See also 57, 58, 59.
Midwives, 57, 58, 59.
Operations, 87,97,206-207.
“ Other accidents of labor” , 137.
Prenatal care, 50, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,
150-151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131-132.
Rate, maternal mortality, 30,31.
Rural and urban areas, 19, 20, 21, 31,52-53, 130,
151, 158, 172, 208.209-211.
See also 1-2.
Masks in delivery room, 60 (footnote), 73, 125, 181.
Maternal care 40-64. See also Prenatal care, Deliv*
ery care, and Postpartum care.
Maternal Deaths (United States Children’s Bureau
Publication No. 221), 1 (footnote).
Maternal Mortality (United States Children’s Bu
reau Publication No. 158), 156 (footnote).
Maternal Mortality, How to Make a Study of
(United States Children's Bureau Publica
tion No. 153), 1 (footnote).
Maternal mortality rate. See Rate, maternal
mortality.
Maternity and Infancy Act, conference of State
directors, 1.
Measurements, pelvic, 43, 45, 76, 89-90, 98-99.
Mechanical induction of labor, 67-69, 74-75, 80-82,
146, 199-201. See also Dilatation of cervix,
artificial.
Medical attention. See also Hospitalization, Pre
natal Care, and specific causes of death.
Accessibility of physician, 22-24, 38, 39, 164.
See also 11, 59, 98, 159,164, 176.
INDEX
Medical attention—Continued.
Colored and white women, 26-27, 55-61, 63, 64,
124-125,143-146. See also 4, 38.
Delivery care, 40, 55-63,64, 73-74,87-88, 122-128,
133,162, 180-182. See also 3-4, 39, 95-98.
States, 25, 137.
Technique of physician (asepsis), 56, 60-62, 64,
73-74, 87, 95,101,114,122-128,133,164-165,181.
See also 41.
Unmarried women, 37-38.
When received, 11-12,22-25,37,38-39,59-60,137,
143-145, 160, 162, 173-174, 178. See also 123,
148, 152-153.
Medical education, 87-88, 181, 182. See also 100,
133, 154, 165, 170.
Medical induction of labor, 69, 74-75, 80-82, 146,
199-201.
Medical societies, 1, 180, 181. See also American
Medical Association.
Medical students. See Attendant at confinement.
Membranes, rupture, 94, 99, 101, 122, 164. See also
91.
Meningitis with cerebral abscess, 101 (footnote).
Mensuration, pelvic, 43, 45, 76, 89-90, 98-99.
Mesenteric thrombosis, 135.
Method of study, 1-4. See also 14, facing 216.
Michigan:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Attendant at confinement, 57, 58.
Cesarean section, 97, 206-207.
Colored and white women, 16, 30, 51, 131, 150,
158, 173, 208, 209-211.
Ectopic gestation, 172,173, 174.
Foreign-born and native women, 17.
Gestation period by trimester, 30, 31, 130, *131,
206-207.
Hospitalization, 21,174.
Live births, 17, 30, 31, 208.
Medical attention, 25, 137. See also 57, 58.
Midwives, 57, 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor ” , 137,
Prenatal care, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,
150-151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131-132.
Kate, maternal mortality, 30, 31.
Rural and urban areas, 19, 21, 31,52-53,130,151,
158, 172, 208, 209-211.
See also 1-2.
M id wives, 56-61.
Comment and recommendations by advisory
committee, 64,133,182.
Puerperal septicemia, 122-127,133. See also 73,
98.
See also 3-4, 95,169.
Minnesota:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 137.
, Attendant at confinement, 57, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172,174.
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225
Minnesota—Continued.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21,174.
Live births, 17, 31, 208.
Medical attention, 23, 25,137. See also 57, 58.
Midwives, 57, 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor ” , 137.
Prenatal care, 52-53, 54.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131-132.
Rate, maternal mortality, 31.
Rural and urban areas, 21,23,31,52-53,130,151,
158, 172, 208, 209-211.
See also 1-2.
Miscarriage. See Abortion.
Missed abortion, classification in international
list, 5.
“ Modified Credè” , postpartum hemorrhage, 162.
Moribund patients. See Medical attention—When
received.
Mortality rate. See Rate, maternal mortality.
Multiparae. See Parity.
Myocarditis. See Cardiac disease.
Native and foreign-born women, 16-18.
Nebraska:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 137.
' Attendant fit-confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172, 174.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21, 174.
Live births, 17, 31, 208.
Medical attention, 23, 25,137. See also 58.
Midwives, 58.
Operations, 84, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 52-53, 54.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131-132.
Rate, maternal mortality, 31.
Rural and urban areas, 21,23,31,52-53,130,131,
151, 158, 172, 208, 209-211.
See also 1-2.
Negroes. See Colored and white women.
Nephritis:
Cesarean section, 89, 90, 99,101,139-140.
Classification of deaths by cause, 5, 6, 15, 89,
139-140,141.
Comment and recommendations by advisory
committee, 99-101.
Puerperal albuminuria and convulsions, 5,139
141,142, 149.
Women of child-bearing age, 140.
See also 149.
226
INDEX
New Hampshire:
Abortion, 113, 131, 132, 208, 209-211. See also
206-207,
Accessibility of physician, 23. See also 25, 137.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.’
Ectopic gestation, 172,174.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21,174.
Live births, 17, 31, 208.
Medical attention, 23, 25,137. See also 58.
Operations, 83-84, 87,97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 52-53, 54.
Puerperal albuminuria and convulsions, 54.
150-151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131,132.
Rate, maternal mortality, 31.
Rural and urban areas, 19, 21, 23, 31, 52-53, 130,
150-151, 158, 172, 208, 209-211.
See also 1-2.
Nitrous oxide, 96-97,101 (footnote), 102 (footnote).
Nonmedical attendants. See Attendant at con
finementNonpuerperal causes of death, 15-16, 38. See also
6-10, 45, 141, 167, 170.
Nonresidents in hospitals. See Hospitalization—
Rural and urban areas.
Normal deliveries (uncomplicated cases), 40.
North Dakota:
Abortion, 113, 131, 132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25,137.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 157, 208, 209-211.
Ectopic gestation, 172,174.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21,174.
Live births, 17, 31, 208.
Medical attention, 23, 25,137. See also 58.
Midwives, 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 52-53, 54.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131,132.
Rate, maternal mortality, 31.
Rural and urban areas, 21, 23, 31, 52-53, 130,
151, 158, 172, 208, 209-211.
See also 1-2.
Number of pregnancies. See Parity.
Nursing care, 123,133,182. See also 40.
Obstetric advisory committee, 1, 2. See also Com
ment and recommendations by advisory
committee.
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Obstetric education, 87-88, 181-182. See also 100,.
133, 154, 165, 170.
Occipito-posterior position, 91, 99.
Oklahoma:
Abortion, 113, 131, 132, 208, 209-211. See also*
206-207.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 16, 30, 51, 131, 150,.
157, 158, 173, 208, 209-211.
Ectopic gestation, 172, 173, 174.
Gestation period by trimester, 30, 31, 130, 131,.
206-207.
Hospitalization, 21, 174.
Live births, 30, 31, 208.
Medical attention, 25,137. See also 58.
Midwives, 58.
Operations, 84, 87. 97, 206-207.
“ Other accidents of labor ” , 137.
Prenatal care, 50, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,.
150,151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens, embolus,.
sudden death, 137.
Puerperal septicemia, 130,131, 132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 21, 31, 52-53, 130, 151,
158, 172, 208, 209-211.
See also 1-2.
Onset of labor. See Labor,onset and termination.
Operation for delivery, 65-88, 196-197, 198, 206-207,
See also Cesarean section and Therapeutic
abortion.
Age of woman, 69-71.
Breech extraction, 67, 69, 70, 72, 73,120, 196-197,
198, 206-207.
Causes of death (table), 196-197. See also 68-69,
199-203.
Colored and white women, 65-66, 84-86. See
also 74-75,82,83,199-203.
Comment and recommendations by advisory
committee, 87-88, 133, 138, 154, 164-165, 170,
178-179, 181.
' Craniotomy or embryotomy, 67-69,- 70, 72, 73,
84-86,88,120,168,196-197,198,206-207.
Dilatation of cervix. See Dilatation of cervix,
artificial.
Emergency ór planned, 76, 87, 178. See also
154, 164.
Forceps. See Forceps operation for delivery.
Gestation period by trimester, 65-76,78-83,84-87,
‘ 118-120, 196-197, 206-207. See also 199-203.
Hours in labor, 71-72.
Hysterotomy, 79,89.
Inversion of uterus, 169,204-205.
Laparotomy for ectopic gestation, 67, 69, 77,
78-79, 83-86, 88, 118, 176-177, 178, 196-197, 198,
206-207. See also 173.
Live births and stillbirths, 73. See also 78, 118*
Parity, 69-72,76,198. See also 154.
Placenta, manual removal, 67-70, 72, 73, 120,
161,169, 196-197, 198, 206-207. See also 65, 88Placenta, premature separation, 163,165.
Placenta previa, 160,164. See also 119.
Placenta previa as cause of death, 68,69,196-197See also 199-203.
INDEX
Operation for delivery—Continued.
Prenatal care, 76, 87.
Puerperal albuminuria and convulsions, 68, 69,
119.148.196197. See also 146-147,199-203.
Puerperal hemorrhage as cause of death, 68, 69,
119.161.163.196197. See also 199-203.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 68, 69, 196-197. See also 136,
199-203.
Puerperal septicemia, 68, 69, 74, 79, 87-88, 116,
118-120,178,196-197. See also 121,199-203.
Rupture of uterus, 168,170. See also 76.
Rural and urban areas, 65,66,83-86.
States, 83-84, 87, 206-207.
Technique of operator, 73-74,87,133,178,181.
Version. See Version, podalic operation for
delivery.
With operation other than for delivery, 66,
76-79, 88, 177, 179.
Operation other than for delivery, 65-66, 76-78, 79,
80, 204-205.
Abortion, deaths following, 79, 80, 107, 108, 109,
110.
Appendectomy, 77, 78-79,80,88,118,177,178-179,
205 (footnote).
Blood transfusion, 76-80, 107, 118, 120-121, 160,
162-165, 177-178, 181, 204-205. See also 88, 98.
Causes of death (table), 204-205.
Cervix, packing, 76-77,80,107,118,119,120, 204205. See also 160, 164-165.
Colored and white women, 65, 66.
Curettage, 76-80, 88, 107-110, 114-115, 118-120,
133, 177, 178, 204-205.
Enterostomy, 76, 77, 79, 80, 119, 177, 205 (foot
note) .
Gestation period by trimester, 76-80, 118, 119,
204-205.
Hysterectomy, 77, 78, 79, 80, 107, 118, 120, 177,
204-205.
Incision and drainage for infection, 76, 77, 79,
80, 107, 118, 119, 120, 177, 204-205.
Laparotomy for drainage, 77, 80, 118-119,
204-205.
Laparotomy other than hysterectomy, 77-78,
79, 80, 107, 118-119, 120, 177.
Packing of uterus, 76-77, 79, 80,107,118,119, 120,
160, 163, 164, 165, 204-205.
Perineorrhaphy, 15, 78, 118.
Puerperal hemorrhage, 76, 160, 204-205.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 204-205.
Puerperal septicemia, 76, 77, 78, 79, 80, 88,
108-110, 118-121, 133, 178-179, 204-205.
Rural and urban areas, 65-66.
Salpingectomy, 77, 80, 118, 119, 177, 205 (foot
note).
Trachelorrhaphy, 78, 80,118.
With operation for delivery, 65-66, 76, 77, 78,
79, 88, 177, 179.
Order of birth. See Parity.
Oregon:
Abortion, 113, 131, 132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 137.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172, 174.
182748— 34------ 16
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227
Oregon —Continued.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21,174.
Live births, 17, 31, 208.
Medical attention, 23, 25, 137. See also 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 50, 52-53, 54.
Puerperal albuminuria and convulsions, 54, 151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131, 132.
Rate, maternal mortality, 31.
Rural and urban areas, 21, 23, 31, 52-53,130,151,
158, 172, 208, 209-211.
See also 1-2.
Osteopath, 95. See also 11.
“ Other accidents of labor” as cause of death,
166-171. See also Cesarean section as cause of
death and “ Other surgical operations and
instrumental delivery” as cause of death.
Accessibility of physician, 24.
Cesarean section, deaths following, 89, 101.
Classification of deaths by cause, 5-14, 89, 135,
152, 155, 166-167, 212-215.
Colored and white women, 17, 183-185, 199-201,
202-203.
Comment and recommendations by advisory
committee, 170-171.
Gestation period by trimester, 29, 46, 183-185,
196-197, 199-201, 202-203, 204-205.
Intercurrent disease, 166-167.
Interval between delivery and death, 28, 190.
Live births and stillbirths, 34.
Onset and termination of labor, 199-203.
Operation for delivery, 196-197. See also 136,
166.
Operation other than for delivery, 204-205.
Parity, 191, 192-194.
Pernicious vomiting of pregnancy, 152.
Prenatal care, 46, 48.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 135, 136, 137,166,
Rate, maternal mortality, 8, 29, 137.
Rural and urban areas, 19,183-185. See also 24.
States, 137.
Undelivered cases, 34.
Unmarried and married women, 36.
“ Other accidents of pregnancy” as cause of death.
See also Accidents of pregnancy as cause of
death.
Abortion, deaths following, 104, 105.
Accessibility of physician, 24.
Age of woman, 192-194.
Classification of deaths by cause, 5-14, 139-140,
155. See also 212-215.
Colored and white women, 17, 183-185.
Gestation period by trimester, 29, 183-185.
Interval between termination of pregnancy and
death, 190.
Operation for delivery, 79.
Operation other than for delivery, 204-205.
Parity, 191, 192-194.
Rate, maternal mortality, 8.
Rural and urban areas, 19, 183-185.
INDEX
228
“ Other puerperal hemorrhage” as cause of death,
155,161-163. See also Puerperal hemorrhage
as cause of death,
Accessibility of physician, 24.
Cesarean section, 161,163,164-165,196-197.
Classification of deaths by cause, 5-10,155,161163, 212-215.
Colored and white women, 157,183-185,199-201,
202-203.
Gestation period by trimester, 161, 183-185,
196-197, 199-203, 204-205.
Interval between delivery and death, 28, 162,
190.
Onset and termination of labor, 161, 199-203.
Operation for delivery, 68, 69,161,196-197.
Operation other than for delivery, 204-205.
Parity, 191.
Rate, maternal mortality, 157.
Rupture of uterus, 155,168,169.
Rural and urban areas, 157,183-185.
” Other surgical operations and instrumental de_
livery” as cause of death. See also “ Other
accidents of labor ” as cause of death.
Accessibility of physician, 24.
Age of woman, 192-194.
Classification of deaths by cause, 5-10, 13, 135,
136, 166, 168, 212-215.
Colored and white women, 17, 183-185,199-201,
202-203.
Gestation period by trimester, 28, 183-185,
196-197, 199-201, 202-203, 204-205.
Interval between delivery and death, 28,190.
Live births and stillbirths, 33-34.
Onset and termination of labor, 199-203.
Operation for delivery, types, 196-197.
Operation other than for delivery, 204-205.
Parity, 191,192-194.
Rate, maternal mortality, 8, 17,19.
Rupture of uterus, 168.
Rural and urban areas, 19, 183-185.
Undelivered cases, 34.
Packing of uterus or cervix.
See Uterus, packing.
Parity, 34-36, 191, 192-194.
Abortion, 34-35,111-112, 178.
Abortion or premature labor as cause of death,
191,192-194.
Age of woman, 69-71, 92-94, 150, 155-156, 175,
192-194. See also 90-91.
Causes of death (tables), 191,192-194.
Cesarean section, 69-72, 90-94, 98-102, 198-199.
See also 154,167.
Cesarean section as cause of death, 191,192-194.
Colored and white women, 35. See also 49.
Comment and recommendations by advisory
committee, 64, 98-102, 154,178.
E c la m p s ia .
See P a r i t y — P u e r p e r a l a l b u m i
n u r ia a n d c o n v u ls io n s .
Ectopic gestation, 174-175,178.
Ectopic gestation as cause of death, 191,192-194.
Hours in labor, 71-72, 167-168.
Onset and termination of labor, 75-76.
Operation for delivery, 69-72, 76, 198-199. See
also 154 and P a r i t y — Cesarean section.
Pelvic measurements, 76.
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P a r it y — C o n t in u e d .
Placenta previa. See Parity—Puerperal hemor
rhage.
Prenatal care, 48-49, 64, 76. See also 43.
Puerperal albuminuria and convulsions, 141,
149-150, 191, 192-194. See also 48, 154, 156.
Puerperal hemorrhage, 155-156,163,191,192-194.
Puerperal phlegmasia alba dolens, embolus
sudden death, 191, 192-194.
Puerperal septicemia, 191,192-194. See also 156.
Rate, maternal mortality, 149-150,156.
Rupture of uterus, 167-169, 170.
Unmarried and married women, 36.
Pelvic abscess, nonpuerperal cause of death, 15.
Pelvic measurements, 43, 45, 76, 89-90, 98-99.
Pelvic puncture. See Incision and drainage for
infection.
Pelvis, contracted, indication for Cesarean section,
89-92, 96, 97, 98-102.
Perineorrhaphy, 15, 78,118.
Peritonitis, laparotomy for drainage, 77, 80,118-119,
204-205.
Peritonitis, puerperal, classification in international
list, 5, 6.
Pernicious vomiting of pregnancy, 151-153.
Classification, 5, 7,139, 142, 152, 212-215.
Therapeutic abortion, 79,108,114,153.
Phlebitis, 135, 136, 138.
Phlegmasia. See Puerperal phlegmasia alba
dolens, embolus, sudden death.
Physician. See IVIedical attention.
Pituitrin, 62-63, 76, 162, 168, 169.
Comment and recommendations by advisory
committee, 64,165,170-171,181.
Placenta, manual removal, 67-70, 72, 73, 120, 161,
169, 196-197, 198, 206-207. See also 65, 88.
Placenta, premature separation, 163, 165.
Cesarean section, 90-92, 94, 96, 97, 102,163.
Classification of deaths by cause,-155,161, 163.
Therapeutic abortion, 79, 108.
Placenta previa, 158-161, 163-165. See also
Placenta previa as cause of death.
Accessibility of physician, 1.59-160, 164.
Blood transfusion, 98, 160,164-165.
Cesarean section, 90-92, 94, 96-98, 102, 160,
164-165.
Classification of deaths by cause, 155, 158, 212215.
Comment and recommendations by advisory
committee, 87, 98,102,163-165.
Hemorrhage as warning of, 159, 163-164.
Operation for delivery, 79, 108, 160, 164-165.
See also 119 and Placenta previa—Cesarean
section.
Postpartum hemorrhage, 160-161,164.
Puerperal septicemia, 116, 158, 164-165. See
also 119, 155.
Therapeutic abortion, 79, 108.
Placenta previa as cause of death, 158. See also
Placenta previa and Puerperal hemorrhage as
cause of death.
Abortion, 104-105.
Accessibility of physician, 24.
Age of woman, 192-194.
Classification of deaths by cause, 5-10, 155, 158,
212-215. See also 103.
INDEX
Placenta previa as cause of death—Continued.
Colored and white women, 157,183-185,199-201,
202-203.
Gestation period by trimester, 183-185, 196-197,
199-201, 202-203, 204-205.
Interval between delivery and death, 28, 161,
190.
Onset and termination of labor, 199-203.
Operation for delivery, 68, 69, 196-197.
Operation other than for delivery, 204-205.
Parity, 191.
Rate, maternal mortality, 157.
Rural and urban areas, 157, 183-185.
Plastic operation on perineum, 15, 78,118.
Plural pregnancy, 32-34,-50.
Pneumonia, 15, 89, 90, 101, 102, 166,167.
Podalic version and extraction. See Version,
podalic, operation for delivery.
Porro Cesarean section, 77, 101. See also Cesarean
section.
Postabortive sepsis, classification in international
list, 5, 212-215.
Postmortem delivery, puerperal albuminuria and
convulsions, 148.
Postpartum care, 40, 41, 63,123,162, 180-182.
Postpartum hemorrhage, 116,155, 160, 162, 164.
Postpartum hemorrhage as cause of death, 5, 155,
161, 162, 169.
Postpartum sepsis, classification in international
list, 5.
Postpuerperal shock, classification in international
list, 5.
Precedence, rules of. See Classification of deaths
by cause.
Preeclampsia, 89-92,94,96,97, 98-102, 154. See also
Puerperal albuminuria and convulsions.
Pregnancy, abdominal, 69, 77, 78, 178. See also
Ectopic gestation.
Pregnancy, accidents of. See Accidents of preg
nancy as cause of death.
Pregnancy, care during. See Prenatal care.
Pregnancy, cornual, 5,172, 212, 213.
Pregnancy, duration. See Gestation period by
month and Gestation period by trimester.
Pregnancy, ectopic, extrauterine, or tubal. See
Ectopic gestati n.
Pregnancy, plural, 32-34, 50.
Pregnancy (unqualified) as cause of death, classi
fication in international list, 5, 6, 212.
Premature labor. See Abortion or premature labor
as cause of death.
Premature separation of placenta, 163, 165.
Cesarean section, 90-92, 94, 96, 97,102,163.
Classification of deaths by cause, 155, 161, 163.
Therapeutic abortion, 79,108.
Prenatal care, 40-55.
Abortion, 47,143. See also 41.
Blood-pressure examination, 43, 45.
Causes of death (table), 46.
Colored and white women, 37, 41-42, 44, 45, 49,
50-51, 64, 142, 195.
Comment and recommendations by advisory
committee, 38-39, 63-64, 87, 102, 153-154, ISO182.
Gestation period by trimester, 45-48,142.
Grades, 41-55, 142-143, 195.
Live births and stillbirths, 49-50, 64.
Operation for delivery, 76, 87.
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229
Prenatal care—Continued.
Parity, 48-49, 64, 76. See also 43.
Pelvic measurements, 43, 45, 76.
Puerperal albuminuria and convulsions, 46,
47-48, 54-55, 64, 142-143, 151, 153-154.
Puerperal hemorrhage, 46, 47-48. See also 39.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 46, 48.
Puerperal septicemia, 46, 47.
Rate, maternal mortality, correlation with pre
natal care, 53-55. See also 151.
Rural and urban areas, 37, 38-39, 41-45, 50, 5253, 64, 195.
Standards, 43. See also 1.
States, 51-53, 54.
Termination of labor, 76.
Unmarried women, 37-38, 195.
Wassermann test, 43, 44-45.
Presentation, abnormal, See abnormal presentation.
Presentation, breech, 90, 91, 168. See also Breech
extraction.
Previable fetus. See Viability of fetus.
Primiparae. See Parity.
Puerperal albuminuria and convulsions, 139-151.
See also Toxemias of pregnancy and Eclamp
sia.
Abortion, 103,104,105,143. See also 79,196-197.
Accessibility of physician, 23-24, 39.
Age of woman, 150, 192-194.
Autopsy, 14-15.
Cesarean section, 89, 94, 95, 99,101,146,148,154.
Chronic nephritis, 5,139, 141,142.
Classification of deaths by cause, 5-10, 13, 139141. See also 79, 89, 103-105, 135, 152, 212-215.
Colored and white women, 16, 17,18, 59-60, 140142,144-147,150-151.183-185,199-201,202-203.
Comment and recommendations by advisory
committee, 64,100,153-154.
Delivery before or after death, 147, 148,149.
Gestation period by trimester, 28-29, 142,
146-147, 183-185, 196-197, 199-205.
Hospitalization, 145-146.
Interval between delivery and death, 28, 149,
190.
Kidney disease, previous, 149.
Labor, onset and termination, 146-147, 199-203.
¡Live births and stillbirths, 33-34, 148, 149. See
also 96.
Medical attention, when received, 23, 24, 39,
141-146.
Operation for delivery, 68-69, 148, 196-197. See
also 119 and Cesarean section.
Operation other than for delivery, 204-205.
Parity, 141, 149-150, 191, 192-194. See also 48,
154, 156.
Pernicious vomiting of pregnancy, 142, 151-152.
Prenatal care, 46, 47-48, 54-55, 64,142, 143, 151,
154.
Puerperal septicemia, 28,116,119,140-141.
Rate, maternal mortality, 8,17,18,29,54-55.150,
151.
Rupture of uterus, 139, 141, 167, 168. & M
Rural and urban areas, 18,19,23-24,28,140,141,
144-147, 150-151, 183-185.
Undelivered cases, 34, 147,148-149.
Unmarried and married women, 36.
States, 54,150,151.
See also 40.
230
INDEX
Puerperal phlegmasia alba dolens, embolus, sud
Puerperal death, definition, 5.
den death—Continued.
Puerperal diseases of the breast as cause of death,
Parity, 191,192-194.
5-10, 13, 17, 19, 24, 29, 34, 36, 46, 183-185, 190,
Pernicious vomiting of pregnancy, 152.
191, 192-194, 213-214.
Prenatal care, 46, 48.
Puerperal eclampsia, classification in international
Puerperal albuminuria and convulsions, 141.
list, 5. See also Eclampsia.
Rate, maternal mortality, 8, 18, 29, 137-138.
Puerperal hemorrhage as cause of death, 155-165.
Rupture of uterus, 135, 136, 138,168.
See also Hemorrhage, Placenta previa as cause
Rural and urban areas, 18,19,138,183-185. See
of death, and “ Other puerperal hemorrhage”
also 24.
as cause of death.
States, 137.
Abortion, 104, 105, 155.
Undelivered cases, 34.
Accessibility of physician, 23-24.
Unmarried and married women, 36.
Age of woman, 155-156,163,192-194.
Puerperal septicemia, 116-134.
Cesarean section, 89, 94,101.
Abortion, 23, 47, 79, 103, 104, 105-106, 108-110,
Classification of deaths by cause, 5-10, 13, 155,
114, 116, 117, 118, 131-132, 133, 212-215. See
212-215. See also 105, 116, 139, 141, 149 (foot
also 115, 129, 153, 178.
note) .
Accessibility of physician, 23, 24.
Colored and white women, 17, 18, 157-158, 183Age of woman, 192-194.
185,199-203.
Attendant at confinement, 60-61, 122-128,
Gestation period by trimester, 18, 29, 46, 183133.
185, 196-197, 199-203.
Autopsy, 14-15.
Interval between delivery and death, 27-28,190.
Cesarean section, 94, 95, 98-102, 196-197. See
Live births and stillbirths, 33-34.
also 89, 116, 117,120.
Onset and termination of labor, 199-203.
Classification of deaths by cause, 5-10,116-117.
Operation for delivery, 68, 69,119, 196-197. See
See also 13, 103, 135, 139, 140, 141, 155, 212-216.
also Cesarean section.
Colored and white women, 17, 18, 124-125,
Operation other than for delivery, 76, 204-205.
129-131, 183-185, 199-201, 202-203.
Parity, 155-156, 163, 191, 192-194.
Comment and recommendations by advisory
Pituitrin, 62, 64.
committee, 133-134. See also 39, 64, 87, 88,
Premature separation of placenta, 163, 165.
99-102, 114-115, 164-165, 178-179.
Prenatal care, 39, 46, 48.
Curettage, 78, 88, 108-110, 114-115,118, 120, 133,
Rate, maternal mortality, 8, 156, 157-158.
204-205.
Rupture of uterus, 167,168.
Delivery care, 60-61, 62, 123-128, 133-134.
Rural and urban areas, 18, 19, 157-158, 183-185.
Ectopic gestation, 88,116, 117, 118, 172, 178, 179.
See also 23-24.
See also 129.
States, 157-158.
Gestation period by trimester, 28-29, 116, 117,
Undelivered cases, 34.
129-131, 183-185, 196-197, 199-203, 204r-205.
Unmarried and married women, 36.
Hemorrhage, 108, 110,123. See also Puerperal
Puerperal insanity, classification in international _
hemorrhage.
list, 5.
Hospitalization, 123, 127-128,133.
Puerperal peritonitis or abscess, classification in
Live births and stillbirths, 34. See also 122.
international list, 5, 6.
Midwives, 122-129, 133. See also 98.
Puerperal phlegmasia alba dolens, embolus, sudden
Nursing care, 123.
death, 135-138.
Onset and termination of labor, 121,133,199-203.
Abortion, 104, 105, 136. See also 103.
Operation for delivery, 68, 69, 74, 79, 87-88,
Accessibility of physician, 24.
116, 117, 118-120, 178, 196-197. See also Puer
Age of woman, 192-194.
peral septicemia—Onset and termination of
Autopsy, 14, 135, 136.
labor and Cesarian section.
Cesarean section, 89, 101. See also 136.
Operation other than for delivery, 76, 77, 78, 79,
Classification of deaths by cause, 5-10, 13, 135.
80, 88, 108-110, 118-121, 133, 178-179, 204-205.
See also 40, 89, 103, 139-140, 141, 152, 168, 212Parity, 191, 192-194. See also 156.
215.
Pernicious vomiting of pregnancy, 152, 153.
Colored and white women, 16-18, 138, 183-185,
Pituitrin, 62, 64.
199-201, 202-203.
Placenta previa, 116, 158, 164-165. See also
Comment and recommendations by advisory
119,155, and Puerperal septicemia—Puerperal
committee, 138.
hemorrhage.
Gestation period by trimester, 29, 46, 104, 136,
Prenatal care, 46, 47.
183-185, 196-197, 199-201, 202-203, 204-205.
Puerperal albuminuria and convulsions, 28,116,
Interval between delivery or abortion and
119, 140-141.
death, 28,137,190.
Puerperal hemorrhage, 116, 156, 158, 163, 164,
Inversion of uterus, 169.
165.
Live births and stillbirths, 34.
Rate, maternal mortality, 8, 18, 19, 29, 129, 130,
Onset and termination of labor, 199-203.
131, 132.
Operation for delivery, 68, 69,136, 196-197. See
Rupture of uterus, 167-168.
also 135, 136, 166, and Cesarean section.
Rural and urban areas, 18, 19, 28, 129-131,
Operation other than for delivery, 204-205.
183-185.
“ Other accidents of labor” as cause of death,
States, 129-132.
137. See also 166.
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INDEX
Puerperal septicemia—Continued.
Technique of physician, 60-62,74,88,95,123-127,
133-134.
Undelivered cases, 34, 121.
Unmarried and married women, 36, 39.
Vaginal examination, 95, 126-127.
Pulmonary embolism, 135-136. See also Puerperal
phlegmasia alba dolens, embolus, sudden
death.
Pyelitis or pyelonephritis, 5, 122, 139. See also 91.
Race, See Colored and white women.
Rate, maternal mortality, 3, 8.
Abortion, 112, 131-132, 208.
Abortion or premature labor as cause of death,
8, 17,19.
Age of woman, 35-36.
By cause of death, 8,17,18, 19, 29.
Cesarean section as cause of death, 8,17,19.
Colored and white women, 16-18, 30, 35-36, 38,
112, 129, 131, 138, 150, 157, 158, 173, 208. See
also 28, 38.
Comment and recommendations by advisory
committee, 38-39, 64,181.
Ectopic gestation, 172-174.
Ectopic gestation as cause of death, 8,17, 19.
Foreign-born and native womens 16-17.
Gestation period by trimester, 18, 29, 30-31,
129-131.
Medical care, when received, correlation with
maternal mortality rate, 137.
Parity, 149-150, 156.
Prenatal care, grade, correlation with maternal
mortality rate, 53-55. See also 48.
Puerperal albuminuria and convulsions, 8,
17, 18, 19, 29, 54-55, 150-151.
Puerperal hemorrhage, 8, 17, 18, 19, 29, 157-158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 8, 17, 18,19, 29, 137-138.
Puerperal septicemia, 8, 18, 19, 29, 129-132.
Rural and urban areas, 18,19,20, 31,38, 112, 129,
130, 138,151,157,158,172, 173, 208. See also 28.
States, 3, 16-17, 30, 31, 54-55, 130-131, 132, 137,
150, 157-158, 172, 173, 208. See also 28.
Unmarried and married women, 37-38, 39.
Reclassification of deaths, 5-10. See also 212-215,
and specific causes of death.
Recommendations by advisory committee. See
Comment and recommendations by advisory
committee.
Rectal examination, 62, 64, 95, 127, 133.
Repair of lacerated uterus, puerperal septicemia,
119.
Residence, 20-21. See also Rural and urban areas.
Respiratory diseases as contributory causes, 167.
Respiratory distress associated with embolus, 136.
Rhode Island:
Abortion, 113, 131, 132, 208, 209-211. See also
206-207.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172,174.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21, 174.
Live births, 17, 31, 208.
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231
Rhode Island—Continued.
Medical attention, 25,137. See also 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 50, 52-53, 54.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 157,158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131,132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 19, 21,31,52-53,130,151,
157, 158, 172, 208, 209-211.
See also 1-2.
Roads, bad. See Accessibility of physician.
Rubber gloves, use for vaginal examination, 60, 61,
64, 126-127, 133, 181.
Rupture of bladder, classification in international
list, 5,166.
Rupture of uterus. See Uterus, rupture.
Ruptured ectopic gestation. See Ectopic gestation.
Ruptured membranes, 94, 99,101, 122, 164.
Rural and urban areas, 2, 19-24, 31, 183-185.
- Abortion, 19, 23, 38, 112, 129, 208, 209-211.
Abortion or premature labor as cause of death,
19,183-185.
Accessibility of physician, 11, 22-25, 39.
Accidents of pregnancy as cause of death, 183185.
Causes of death (tables), 19, 183-185.
Cesarean section, 83-86, 91-92, 98.
Cesarean section as cause of death, 19, 183-185.
Classification of rural and urban areas, 2 (foot
note). See also 14,19.
Colored and white women, 28, 42, 44, 45, 64, 66,
84-86, 98, 129, 138, 140-141, 144, 145, 157, 183185, 209-211.
Comment and recommendations by advisory
committee, 38-39. See also 178.
Ectopic gestation, 83, 172-173, 178.
Ectopic gestation as cause of death, 19, 183-185.
See also 24.
Gestation period by trimester, 18, 28-31, 84-86,
129, 130, 146, 147, 183-185.
Hospitalization, 20, 21, 27, 38, 173, 174.
Live births in States included in study, 19, 31,
208.
Medical attention, when received, 11-12,22-25,
39, 144-145, 174. See also Rural and urban
areas— Prenatal care.
Operation for delivery, 65, 66, 83-86. See also
Cesarean section.
“ Other accidents of labor” as cause of death,
19, 183-185.
Prenatal care, 37, 38, 39, 41-45. 50, 52-53, 64,195.
Puerperal albuminuria and convulsions, 18,19,
28, 140-141, 144, 145, 146, 147, 151, 183-185.
See also 23-24.
Puerperal hemorrhage, 18, 19, 157-158, 183-185.
See also 23-24.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 18, 19, 138, 183-185. See also
23-24.
Puerperal septicemia, 18,19,28,129-131,183-185.
See also 23-24.
Rate, maternal mortality, 18, 19, 31, 112, 208.
See also 20, 38, and specific causes of death.
232
INDEX
Rural and urban areas—Continued.
States, 31, 208.
Unmarried and married women, 37, 38, 195.
Wassermann test, 44-45.
Salpingectomy, 77, 80, 118, 119, 177, 205 (footnote)
Salpingitis, 15.
Salpingo-oophorectomy, 77, 80. See also Salpin
gectomy.
Schedule used in study, 1-4, facing 216. See also 14.
Self-induced abortion, 41, 103-104, 114. See also
Abortion—Induced.
Sepsis. See Puerperal septicemia.
Shaving, scrubbing in delivery technique, 60, 127.
Shock:
Cesarean section, 89, 94, 101-102, 154, 164-165.
Comment and recommendations by advisory
committee, 101-102, 154, 164-165, 181.
Difficult labor, 166.
Eclampsia, 94,154.
Inversion of uterus, 166,169.
Operation for delivery, 79, 80, 166. See also
Shock—Cesarean section.
Operation other than for delivery, 79,80.
Placenta previa, 94,164-165.
Premature separation of placenta, 94,165.
Shock, postpuerperal, classification in international
list, 5,166.
Smallpox, 6.
Spinal anesthesia, 96-97, 101, 102.
Spontaneous abortion, See Abortion—Spontaneous,
Spontaneous delivery or termination of labor. See
Labor, onset and termination.
Standards, hospital, 27, 182, 186, 188, 189.
Standards of Prenatal Care (United States Chil
dren’s Bureau Publication No. 153), 1, 43.
State board or department of health, 1-3. See also
7, 57, 58, 139, 180, 181.
States included in study, xiv, 1-2. See also names
of States.
Sterilization of drapes and instruments. See
Technique of physician (asepsis.)
Sterilization of woman, Cesarean section, 91, 99.
Stillbirths, 3 (footnote), 32-34, 39.
Cesarean section, 96, 98, 99,100.
Classified by cause of mother’s death, 33, 34.
Colored and white women, 32-33.
Comment and recommendations by advisory
committee, 39, 64,
Definition, 3 (footnote), 32.
Operation for delivery, 73. See also Still
births—Cesarean section.
Pituitrin, 62, 64.
Prenatal care, 49, 50, 64.
Puerperal albuminuria and convulsions, 33, 34,
149. See also 96.
Puerperal hemorrhage, 33, 34, 164. See also 96.
Students, medical. See Attendant at confinement.
Sudden death. See Puerperal phlegmasia alba
dolens, embolus, sudden death.
Surgeons, American College of, 1, 182,186-189.
Syphilis, 6, 45.
Technique, hospital, 188, 189.
Technique of physician (asepsis), 56, 60-62, 73-74,
95, 122-128, 178. See also 41.
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Technique of physician—Continued.
Comment and recommendations by advisory
committee, 64, 87, 101, 114, 133, 164-165, 178,
181.
Temperature, fever. See Fever.
Temperature, taking, in prenatal care, 43.
Termination of labor. See Labor, onset and ter
mination.
Tetanus, puerperal, classification in international
list, 5, 212.
Therapeutic abortion, 78, 79, 83-86, 89, 105-114, 117,
118, 132, 136, 153, 196-197, 206-207, 209-211.
See also 88,127,143.
Thoracotomy, 78.
Thrombosis, 135, 136, 138.
Toxemias of pregnancy, 139-154. See also 5-10, 39,
40-41, 79,99,101,102,108,116,163,181, 212-215,
Eclampsia, Pernicious vomiting of preg
nancy, and Puerperal albuminuria and
convulsions.
Trachelorrhaphy, 78, 80,118.
Tracheotomy, 78.
Transfusion, See Blood transfusion.
Transportation. See Accessibility, of physician.
Trimester of pregnancy. See Gestation period by
trimester.
Triplets. See Plural pregnancy.
Tubal pregnancy. See Ectopic gestation.
Tubal pregnancy, infected, classified in inter
national list, 5.
Tuberculosis, 6,15.
Tumor. See Fibroid tumor.
Twins. See Plural pregnancy.
Typhoid fever, 6.
Uncomplicated cases, 40.
Undelivered cases, 32-34, 49-50, 62, 67-69, 74-75, 79,
80-83, 103 (footnote), 121, 146-149, 161, 163,
168, 199-203. See also 39.
United States birth-registration area, 1,2,3,6,32,38.
United States Bureau of the Census. See Census,
United States Bureau of.
United Stages Children’s Bureau, plan for study of
maternal mortality, 1-4. See also 43.
Unmarried women, 36-38, 39, 108, 114,195.
Uremia. See also Toxemias of pregnancy.
Classification in international list, 5,139.
Indication for Cesarean section, 90, 92, 96, 97,
102. See also 178.
Urinalysis, 43, 45. See also 3,141.
Uterus, bieornuate, as indication for Cesarean
section, 91.
Uterus, fibroid:
Cesarean section, 90-91.
Hysterectomy, 78, 177.
Rupture of uterus, 170.
Uterus, inversion, 5,76,77,166,169,171. See also 205.
Uterus, laceration. See Laceration of cervix or
perineum and Uterus, rupture.
Uterus, packing, 76-77, 79, 80, 107, 204-205.
Puerperal hemorrhage, 160, 163, 164, 165.
Puerperal septicemia, 118-119,120,164,165.
Uterus, punctured, hysterectomy for, 80.
Uterus, removal. See Hysterectomy.
Uterus, rupture, 167-171, 181. See also Uterus,
rupture, as cause of death.
INDEX
Uterus, rupture—Continued.
Cesarean section, indication for, 90-92, 96, 97,
102, 167-168, 170.
Cesarean section, previous, 90,167, 170.
Classification of deaths, by cause, 5, 166. See
also 103, 155.
Comment and recommendations by advisory
committee, 64, 138, 164, 170-171, 181. See
also 102.
Hysterectomy for, 77.
Operation for delivery, 76, 168.
Pituitrin, 64, 76, 168, 170.
Placenta previa, 160, 164.
Puerperal albuminuria and convulsions, 139,
141,168.
Puerperal hemorrhage, 155, 160, 164, 167, 168.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 135, 136,138, 168.
Puerperal septicemia, 167.
Undiagnosed, 168-169,170.
Uterus, rupture, as cause of death, 5, 166, 167,
212-215. See also Uterus, rupture.
Vaginal examination, 61, '62, 95, 126-128.
Comment and recommendations by advisory
committee, 64,101,133, 164,181.
See also 25, 73.
Version, Braxton Hicks, 160, 164.
Version during labor, classification in international
list, 5.
Version, podalic, operation for delivery, 67-73.
Age of woman, 69-71.
Before last trimester, 78.
Classification of deaths by cause, 68, 69, 196-197.
Colored and white worn in, 83, 84-86.
Comment and recommendations by advisory
committee, 87, 88, 164, 170.
Dilatation of cervix, artificial, 67, 68, 69, 73, 78,
88, 120, 148, 160, 163, 168, 169, 196-197, 198,
206-207.
Duration of labor, 71, 72.
Forceps, 67, 68, 69, 73, 88, 120, 168, 169, 196-197,
198, 206-207.
Live births and stillbirths, 73.
Manual removal of placenta, 67,68,161,196-197,
198, 206-207.
Parity, 69, 70, 71, 72, 198.
Placenta previa, 68, 160, 164, 196-197.
Premature separation of placenta, 163.
Puerperal albuminuria and convulsions, 68, 69,
148, 196-197.
Puerperal hemorrhage, 68, 69, 160, 161, 164,
196-197.
Puerperal septicemia, 68, 69, 87, 120, 196-197.
Rupture of uterus, 168.
Rural and urban areas, 83-86.
States, 206-207.
Technique of physician, 73, 87.
Viability of fetus, 28, 32, 39,104,178. See also Live
births and Stillbirths.
Virginia:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 137.
Attendant at confinement, 57, 58, 59.
Cesarean section, 97, 206-207.
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233
V irginia—C ontinued.
Colored and white women, 16, 30, 51, 131, 150,
158, 173, 208, 209-211.
Ectopic gestation, 172,173,174.
Gestation period by trimester, 30, 31, 130, 131,
206-207.
Hospitalization, 21, 174.
Live births, 30, 31, 208.
Medical attention, 23, 25, 137. See also 57, 58,
59.
Midwives, 57, 58, 59.
Operations, 87. 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 50, 51, 52-53, 54.
Puerperal albuminuria and convulsions, 54,
150,151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131, 132.
Rate, maternal mortality, 30, 31.
Rural and urban areas, 21, 23,31, 52-53,130,151,
158, 172, 208, 209-211.
See also 1-2.
Vital statistics. See State board or department'of
health and Census, United States Bureau of.
Vomiting. See Pernicious vomiting of pregnancy.
Washington:
Abortion, 113, 130, 132, 206-207, 208, 209-211.
Accessibility of physician, 23. See also 25, 137.
Attendant at confinement, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172, 174.
Foreign-born and native women, 17.
Gestation period by trimester, 28, 31, 130,
206-207.
Hospitalization, 21, 27, 174.
Live births, 17, 31, 208.
Medical attention, 23, 25, 137. See also 58.
Midwives, 58.
Operations, 87, 97, 206-207.
“ Other accidents of labor” , 137. .
Prenatal care, 50, 52-53, 54.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130,131,132.
Rate, maternal mortality, 31.
Rural and urban areas, 19, 21, 23, 31, 52-53, 130,
151, 158, 172, 208, 209-211. See also 28.
See also 1-2.
Wassermann test, 43, 44, 45.
White women. See Colored and white women.
Wisconsin:
Abortion, 113, 131-132, 208, 209-211. See also
206-207.
Accessibility of physician, 23. See also 25, 137.
Attendant at confinement, 57, 58.
Cesarean section, 97, 206-207.
Colored and white women, 208, 209-211.
Ectopic gestation, 172, 174.
234
INDEX
4
Wisconsin—Continued.
Foreign-born and native women, 17.
Gestation period by trimester, 31, 130, 206-207.
Hospitalization, 21, 174.
Live births, 17, 31, 208.
Medical attention, 23, 25, 137. See also 57, 58.
Midwives, 57, 58.
Operations, 84, 87, 97, 206-207.
“ Other accidents of labor” , 137.
Prenatal care, 52-53, 54.
W isconsin—C ont inued.
Puerperal albuminuria and convulsions, 54,151.
Puerperal hemorrhage, 158.
Puerperal phlegmasia alba dolens, embolus,
sudden death, 137.
Puerperal septicemia, 130, 131, 132.
Rate, maternal mortality, 31.
Rural and urban areas, 21, 23, 31, 52-53,130, 151,
158, 172, 208, 209-211.
See also 1-2*
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