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© 2004 American Public Health Association PUBLIC HEALTH THEN AND NOW
The author is with Obstetrics & Gynecology, Department of Clinical Science, and Epidemiology, Department of Public Health and Clinical Medicine, University of Umeå, Umeå, Sweden.
Correspondence: Requests for reprints should be sent to Ulf Högberg, MD, PhD, Obstetrics & Gynecology, Department of Clinical Science, University of Umeå, S-901 87 Umeå, Sweden (e-mail: ulf.hogberg@obgyn.umu.se).
http://ajph.aphapublications.org/cgi/content/full/94/8/1312#BDY
Abstract:
The maternal mortality rate in Sweden in the early 20th centurywas one third that in the United States. This rate was recognizedby American visitors as an achievement of Swedish maternitycare, in which highly competent midwives attend home deliveries.The 19th century decline in maternal mortality was largely causedby improvements in obstetric care, but was also helped alongby the national health strategy of giving midwives and doctorscomplementary roles in maternity care, as well as equal involvementin setting public health policy.
THE DECLINE OF MATERNAL mortality in Western countries afterthe 1930s is believed to be associated mainly with the emergenceof modern obstetric care, while it has been proposed that publichealth policy, poverty, and the malnutrition associated withpoverty were of relatively minor importance.1 But the maternalmortality pattern before the emergence of modern medical technologywas not uniform in all Western countries. In The Netherlands,Norway, and Sweden, low maternal mortality rates were reportedby the early 20th century and were believed to be a result ofan extensive collaboration between physicians and highly competent,locally available midwives.2 From 1900 through 1904, Swedenhad an annual maternal mortality of 230 per 100 000 live births,while the rate for England and Wales was 440 per 100 000. Forthe year 1900, the United States reported 520 to 850 maternaldeaths per 100 000 live births.3 This very high maternal mortalityrate, especially if compared with the lower rates achieved inseveral less prosperous European countries, caused some Americanobstetricians to express concern.
The 20th century decline in maternal mortality, seen in allWestern countries, was made possible by the emergence of modernmedicine. However, the contribution of the mobilization of humanresources should not be underestimated, nor should key developmentsin public health policy.
Joseph B. DeLee, commemorated as a titan of 20th-centuryobstetrics, studied maternity services in Europe before he establishedthe Chicago Lying-In Hospital and Dispensary in 1895. His aimwas to provide delivery assistance to poor women by also offeringthem the option of having a safe and inexpensive home delivery.4
George W. Kosmak5 visited Scandinavia in 1926 and was reportedto have been very impressed with the medical systems in placethere. In an address to the American Medical Association, Kosmaktalked about the good results obtained in a carefully supervisedsystem of midwife instruction and practice. He stated:
To begin with, the midwife in Scandinavia is not regarded aspariah. . . . One sees, therefore, in the training schools formidwives, bright, healthy looking, intelligent young women ofthe type from whom our best class of trained nurses would berecruited in this country, who are proud of being associatedwith an important community work, and whose profession is recognizedby medical men as an important factor in the art of obstetrics,with which they have no quarrel.
He concluded, “The results of this midwife training are evidentlyexcellent because the mortality rates of these countries areremarkably low and likewise, the morbidity following childbirth.”5
What, then, was the history of this system that turned out tobe a good example for the United States before the emergenceof modern medicine in the 1930s? The aim of this review is todepict the Swedish intervention against maternal mortality inthe 18th and 19th centuries and the decline in maternal mortalityin the Western countries in the 20th century.
Historical Setting: Sweden
The history of maternity care in Sweden should be interpretedin light of the involvement of the state in public health. Oneimportant part of the emergence of the Swedish national statein the 16th century was the creation of the Lutheran State Church.In the 17th century, the Swedish clergy created an informationsystem that included all individuals in their parishes olderthan 6 to 7 years. By the middle of the 18th century, this registrationincluded the entire population. The information system was basedon the annual catechetical examination of every household, wherethe clergy examined knowledge of the catechism as well as thereading ability of all household members. To this “church book,”other types of records were linked: records of in- and outmigrations,births and baptisms, bans and marriages, and deaths and burials.The Office of the Registrar General (Tabellverkskommissionen),founded in 1749, compiled national statistics from the ecclesiasticalregistry. National vital statistics were therefore availablein Sweden before they were available in any other European country.
The profession of physician was legalized in 1663 with the foundationof the Collegium Medicum. In the 17th and 18th centuries, manySwedish academics obtained their postdoctoral training fromuniversities in Germany, France, Italy, England, and The Netherlands.By the beginning of the 18th century, Sweden had declined asa major power in northern Europe. Inside Sweden, the power ofthe Swedish parliament was enhanced; a so-called “Time of Freedom”was introduced that coincided with the Age of Enlightenment.There began an era of scientific blossoming. The two professorsof medicine at Uppsala University, Carl von Linné (1707–1778)and Nils Rosén von Rosenstein (1706–1773), andthe head of the Collegium Medicum, Abraham Bäck (1713–1795),were the initiators and promoters of health care and publichealth within the Commission of Health (Sundhetskommissionen)from 1737 to 1766. They presented programs for primary healthcare and preventive measures for communicable diseases and publishedpamphlets on health education, nutrition, and hygiene. Fromthe start, the public health program had an equity perspectiveby reaching out to the poor rural population and making healthcare accessible to them. The policy fit in with the prevailingpolitical ideology of the time, mercantilism, which definedthe wealth of the nation by the number of its citizens.6 Themilitary need of the nation has also been proposed as an argumentfor investment in mothers’ and children’s health.7
The first national statistics on maternal mortality were presentedin 1751, revealing a rate of almost 900 maternal deaths per100 000 live births. In the same year, the Commission of Healthstated, “Out of 651 women dying in childbirth, at least 400could have been saved if only there had been enough midwives.”This became the starting point for the Swedish authorities tocampaign for improvements in obstetric care, mainly by improvingtraining for physicians and midwives and implementing a systemof surveillance of midwives, both at the county and nationallevel. What they did not know at the time was that it wouldtake 150 years to achieve their goal.6
LICENSED MIDWIVES
The professionalization of birth assistance in Sweden beganin the early 18th century. Pioneering this was Johan von Hoorn(1662–1724), who trained in obstetrics at the Hotel DieuHospital in Paris before returning to Sweden. In 1697, von Hoornpublished a textbook titled The Well-Trained Swedish Midwife(Den Swenska wäl-öfwade JordGumman) intended for useby both midwives and the public. In 1711, the Collegium Medicumannounced a decree of authorization for midwives that requireda 2-year training period with an experienced midwife, followedby an examination given by the Collegium Medicum. In 1715, vonHoorn published a textbook for midwifery training with Soranus,the famous Roman gynecologist (50–129 AD), as a sourceof inspiration; in it, he stressed the importance of surveillanceof the delivery by internal examination—that is, the noninterventionistapproach emphasizing patience and waiting. He also describedthe mouth-to-mouth resuscitation method for reviving an apparentlydead newborn. Soon the need for licensed midwives became apparentand the Collegium Medicum urged Sweden’s parliament topush for a national midwifery school. However, it was not untilthe end of the century that such a school was started.
In 1757, the Collegium Medicum’s proposal for a nationaltraining program for midwives covering all parishes was finallyapproved. Each parish was expected to pay for its students’allowance in Stockholm. The first professor in obstetrics wasappointed in 1761, and the first lying-in hospital, AllmännaBarnbördshuset in Stockholm, was founded in 1775.
The founding of Stockholm’s Karolinska Institute in 1810led to a further improvement of obstetric care at a nationallevel. A new government decree stated in 1819 that every parishwas required to employ a licensed midwife, and that the parisheswere also responsible for variola (smallpox) vaccinations. Themidwife’s formal education was extended to 6 months, andthe government paid allowances for 12 students each year. Thismeant that instead of limiting the training program to the womensent by the parishes, the profession was opened up to all interestedwomen.
The professor of obstetrics at the time, Pehr Gustaf Cederschiöld(1782–1848), pushed hard to increase the competence ofmidwives. By 1829, health reform brought new regulations authorizingmidwives, after an extended training period, to use forceps,sharp hooks, and perforators, in addition to their ability toperform manual removal of the placenta and extraction in breechpresentation. This reform was opposed by contemporary internationalmedical societies7 but was motivated by the long tradition ofcommunity midwives who assisted at home deliveries. The widelyscattered rural Swedish population made it a necessity for midwivesto be capable of acting in emergencies when physicians couldnot be reached. Cederschiöld argued that the reform wouldstrengthen the authority and acceptance of the midwife in theparishes.8 Cederschiöld then wrote the textbooks Manualfor Midwives (Handbok för Barnmorskor) and Guide to InstrumentalObstetrics (Utkast till Handbok i den Instrumentala Förlossningskonsten)in support of his ambition to increase the competence of midwives.
By the government decree of 1819, midwives were required toensure that every newborn child had his or her own bed to preventsuffocation, although little observance of this rule was reported.9In the mid-19th century, the authorities added more regulationsfor midwives. It was decided that their duties should not belimited only to childbirth, but should also include subsequentcare of the infant. Consequently, education in basic neonatalcare at the midwifery school was improved, with an emphasison warmth, neonatal resuscitation with tactile stimuli for asphycticchildren, daily care of the umbilicus, and early breastfeeding.Many mothers fed their newborns cows’ milk, and doctorsand midwives began informing young mothers and mothers-to-beabout the benefits of breastfeeding. This strategy soon hadthe desired effect, and infant mortality was reduced by 20%.10
The antiseptic technique was introduced in the lying-in hospitalsduring the late 1870s and, by law, to midwives in rural districtsin 1881. Also, the Credé prophylaxis to prevent neonatalblennorrhea became one of the midwife’s duties.
COMPLEMENTARY ROLES OF MIDWIVES AND DOCTORS
The professionalization of birth attendance was not a smoothprocess. Historian Christina Romlid describes the antagonism,struggles, and conflicts that arose between the medical professionand traditional birth attendants until the late 19th century.8In the Swedish parliament, the peasantry protested against themidwife regulation of 1777. This rule contained a “quackeryparagraph” that banned traditional birth attendants, whom thepeasants viewed as experienced and skilled, not as dangerousand harmful as stated in the regulation. Subsequently, the Crownwithdrew the paragraph and reinstated the right of districtmedical officers and licensed midwives to train women locally.The paragraph was reinstated in 1819 in a milder form, allowingtraditional birth attendants when a licensed midwife could notattend or arrive in time. However, during the 19th century,several traditional birth attendants were prosecuted and foundguilty of unauthorized help during childbirth.8 Not until thelate 19th century did professional midwifery become fully establishedand legitimized in the rural areas of Sweden.
Whereas during the 18th century midwives were recruited fromamong farming families, by the 19th century the profession ofmidwife had become a legitimate occupation for women from allwalks of life, and it carried as much weight and respect asthat of primary school teacher.11 Consequently, the communitymidwife became a central figure and was often the only personrepresenting health care at the parish level. Over time, anytechnical constraints were overcome and there was good socialrepresentation among midwives, thus ensuring a successful implementationof obstetric services within the specific cultural context ofrural Sweden.
The professionalization of birth assistance can be interpretedfrom a gender theory perspective as a successive subordinationof women consequent to the appearance of male obstetricians.Birthing is a natural event, yet female traditional birth attendantswere pushed aside with the medicalization of childbirth. TheAmerican and British experience of conflicts between doctorsand midwives is a recurrent theme, and Swedish historians havereported parallels in Sweden, although more in Stockholm thanin the rural areas.8,12 However, studies addressing the professionalizationof Swedish midwives in relation to the theories of sociology,modernity, gender, and the evolution toward scientifically basedobstetric care have found few conflicts between doctors andmidwives.11 There was a gender division in the professionalizationprocess; however, since doctors and midwives were disseminatorsof the same discourse and worked toward the same goal, theycomplemented rather than competed against each other, unlikein the US urban setting.11
These complementary roles were facilitated by the conditionsof health care in Sweden. As recently as the late 19th century,only 10% of the Swedish population lived in urban areas. Obstetricianswere in office only in the lying-in hospitals of Stockholm and,from 1865, also in Gothenburg and Lund. Otherwise, general practitionersin the counties and towns were the medical counterparts of themidwives assisting at home deliveries. In practice, no systemof referral was available in the 19th century. In medical emergencies,the midwife called for the doctor, but this rarely happened.This setting facilitated a more noninterventionist attitude,manifesting fairly low rates of assisted delivery throughoutSwedish history and strengthening the midwife in her role asthe indisputable birth attendant, in contrast to the more doctor-orientedobstetrics emerging in the United States by the 20th century.11
The Swedish model of maternity services was distinct even fromthe European perspective. In 1870, the ratio was 3.1 midwivesfor every doctor for Sweden, while it was 1.4 in Denmark andNorway7 and 1.2 in France.13
Community midwifery was based on a system of very close supervisionand retraining. In each county, each midwife was required toreport to the county general practitioner. Her report had tobe detailed and include the actual record, in diary form, ofall deliveries she had attended, with information on the identityof the parturient, complications, the sex of the child, birthweight,and outcome for the mother and child. Also, review courses formidwives were obligatory on a regular basis. A standardizedprotocol was necessary when midwives used forceps, sharp hooks,or perforators, giving the reasons for the intervention andthe outcome. This protocol had to be signed by the county physicianand was registered at the National Health Bureau.
MATERNAL MORTALITY IN THE 17TH TO 19TH CENTURIES
In the 17th century, maternal deaths accounted for 10% of allfemale deaths between the ages of 15 and 49 years.14 In womenaged between 20 and 34 years, 40% to 45% of deaths among marriedwomen were caused by complications of pregnancy or delivery.Among married women, 1 of 14 died during childbirth.15
Maternal mortality declined from 900 per 100 000 live birthsto 230 per 100 000 from 1751 to 1900. The general trend towarda decline was interrupted during the years 1850 to 1880, whenthe recorded septic maternal mortality coincided with an increasein total mortality due to communicable diseases. During the19th century, areas of high maternal mortality were not restrictedto the urban environments, where there was a known high deathrate due to puerperal sepsis.14
During the 19th century, the decline in maternal mortality wasfar greater than that in infant mortality, or in mortality dueto tuberculosis. The decline in maternal mortality was especiallypronounced between 1861 and 1900, when the percent reductiondropped from 59% to 24%, while the female mortality reductionleveled out.16
In the 19th century, two thirds of maternal deaths had directobstetrical causes, such as difficult labor, eclampsia, hemorrhage,and sepsis, while one third were indirect obstetric deaths dueto diseases such as pneumonia, tuberculosis, dysentery, heartdisease, and malnutrition.15,17 In the lying-in hospitals, beforeantiseptic techniques became known most maternal deaths werecaused by puerperal sepsis.18 However, the epidemics of puerperalsepsis in the lying-in hospitals did not dramatically alterthe national maternal mortality rates. Between 1775 and 1900,a total of 1720 parturients were recorded to have died frompuerperal sepsis in the lying-in hospitals, which represents2.2% of all maternal deaths during the period. It was duringthe second half of the 19th century, when the national statisticsrecorded puerperal sepsis separately, that the nationwide problembecame obvious. Between 1861 and 1900, 54% of maternal deathswere caused by puerperal sepsis, most of them following homedeliveries. This percentage was even higher for home deliveriesbefore the introduction of antiseptic technique,18 possiblyalso caused by an increased virulence of the dominant strainof streptococcus at the time.1 The diagnosis of puerperal sepsiswas probably not confounded by septic abortions during the 19thcentury.16
The adverse effects of medical technology were predisposing,positive risk factors. Before the introduction of antiseptictechniques, lying-in hospitals were a positive risk factor inthe transmission of puerperal sepsis. As can be seen by extrapolatingfrom the mortality rate of puerperal sepsis between 1881 and1895 (after the introduction of antiseptic techniques), if suchtechniques had been available from 1776 through 1900, the numberof puerperal deaths in lying-in hospitals would have been 119instead of 1720. The difference, 1601 deaths, is a measure ofthe potentially adverse effects that the lying-in hospitalshad on the number of maternal deaths nationwide from 1776 through1900 (n = 76,776).
However, the protective effect of these hospitalsas educational centers for midwives and physicians practicingin rural areas has not been considered.16
IMPACT OF INTERVENTION — for those interested in reading the remainder of this excellent article and its citation are available @ the URL provided below:
http://ajph.aphapublications.org/cgi/content/full/94/8/1312#BDY
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