STATISTICS RELATING TO CHILDBIRTH IN THE UNITED STATES AND IN CERTAIN FOREIGN COUNTRIES
For the last two decades civilized countries have been absorbed in the problem of preventing the enormous and needless waste of human life represented by their infant death rates. The importance of this problem has been felt more keenly in the last two years in the countries now at war; in these countries the efforts toward saving the lives of babies have redoubled since the war began. Side by side with this problem, another, which is only of late finding its true place, is that of the protection of the lives and health of mothers during their pregnancy and confinement. This is a question so closely bound up with that of the prevention of infant mortality that the two can not be separated.
It is now realized that a large proportion of the deaths of babies occur in the first days and weeks of life, and that these deaths can be prevented only through proper care of the mother before and at the birth of her baby. It is also realized that breast feeding through the greater part of the first year of the baby’s life is the chief protection from all diseases; and that mothers are much more likely to be able to nurse their babies successfully if they receive proper care before, at, and after childbirth. Moreover, in the progress of work for the prevention of infant mortality it has become ever clearer that all such work is useful only in so far as it helps the mother to care better for her baby. It must be plain, then, to what a degree the sickness or death of the mother lessens the chances of the baby for life and health.
This question has also another side. Each death at childbirth is a serious loss to the country. The women who die from this cause are lost at the time of their greatest usefulness to the State and to their families; and they give their lives in carrying out a function which must be regarded as the most important in the world.
Questions then of the most vital interest to the whole Nation are these: How are the lives of the mothers in this country and other countries being protected? To what degree are the diseases caused by pregnancy and childbirth preventable? If preventable, how far are they being prevented in this country? Has there been the same great decrease in the last few years in sickness and death from these causes as that which has marked the great campaigns against other preventable diseases such as typhoid, tuberculosis, or diphtheria? How do the conditions in the United States compare with those in other countries?
Puerperal septicemia (childbed fever).—The fact is now well known that puerperal septicemia, or childbed fever, is in reality a wound infection, similar to such an infection after an accident or an operation, and that it can be prevented by the same measures of cleanliness and asepsis which are used so universally in modern surgery to prevent infection. The proof of the nature of this disease is one of the tremendous results of the scientific discoveries which were made in the latter part of the nineteenth century.
During the early part of that century childbed fever was one of the greatest hospital scourges known. It occurred also in private practice; but in hospitals where there was great opportunity for the spreading of infection the death rate from this disease was appalling. The average death rate in hospitals in all countries was 3 to 4 per cent. of all women confined; sometimes it reached 10 to 20 per cent. and even over 50 per cent. during short periods of epidemics. In the face of this terrific mortality many obstetrical hospitals were closed. Commissions were appointed to investigate the cause of these epidemics, and medical congresses devoted sessions to the discussion of the problem. In 1843 Oliver Wendell Holmes, and in 1847 Semmelweiss, published articles stating the theory that this fever was similar to a wound infection and was due chiefly to the carrying of infectious material on the hands of attendants from one case to another.
NUMBER OF DEATHS IN THE UNITED STATES FROM CHILDBIRTH
In 1913 in the “death-registration area” of the United States 10,010 deaths were reported as due to conditions caused by pregnancy and childbirth. Of these deaths, 4,542 were reported as caused by puerperal septicemia or childbed fever.
Using the death-registration area as a basis, we are justified in estimating that in 1913 in the whole United States 15,376 deaths were due to childbirth, and 6,977 of these were due to childbed fever. As will be shown later, these figures are without doubt a gross underestimate. As it is, they are striking enough—almost 7,000 deaths in one year in this country due to childbed fever, a disease to a large degree easily preventable; and over 8,000 due to the other diseases caused by pregnancy and confinement, most of which are preventable or curable by means well known to science.
DEATH RATES IN THE UNITED STATES FROM CHILDBIRTH
The death rate from all diseases caused by pregnancy and confinement in 1913 in the registration area was 15.8 per 100,000 population (which includes all ages and both sexes). The death rate from puerperal septicemia was 7.2.
These figures, however, mean little to us unless we compare them with the death rates from other preventable diseases. In the same year and area the typhoid rate was 17.9 per 100,000 population; the rate from diphtheria and croup 18.8. The highest death rate from any one disease was that from tuberculosis, 147.6 per 100,000 population. Any such comparison with the rates from diseases to which both sexes and all ages are liable is of course very misleading; but in spite of that fact it is interesting to note that typhoid fever, the disease against which so great an amount of effort is now directed, has a rate at present but 2 per 100,000 population higher than that from the diseases caused by pregnancy and confinement.
Death rates per 100,000 women.—The death rates from childbirth are approximately doubled when worked on the basis of 100,000 women. This will be seen when Tables IV and III (p. 50) are compared. The former gives for the period 1900 to 1910, the annual death rates per 100,000 women in the group of 11 States which were in the death-registration area in 1900, the latter the death rates per 100,000 population in the same group of States for the same period. It is evident that the rates in Table IV for each year are slightly more than twice those in Table III for the same year.
Death rates per 100,000 women of childbearing age.... Again, a much higher but a more accurate death rate from these diseases is found when the basis taken is the group which alone is affected by these diseases—women of childbearing age. When the rate is based not upon 100,000 population of both sexes and all ages but upon 100,000 women 15 to 44 years of age, the rate as ordinarily given is multiplied several times.
In 1900, the only year for which the rates can be computed, the death rate in the registration area per 100,000 women 15 to 44 years of age from all diseases of pregnancy and confinement was 50.3; from puerperal infection, 21.6. The corresponding rates for the same year per 100,000 population were 13.1 and 5.6. In this year, therefore, the rates are almost quadrupled when based on that group of the population which alone can be affected by these diseases.
Moreover, the death rates as ordinarily given per 100,000 population conceal the fact that the diseases of pregnancy and childbirth are indeed among the most important causes of death of women between 15 and 44 years of age; the actual number of deaths shows this to be the case. In 1913 in the registration area these diseases caused more deaths than any other one cause of death except tuberculosis. In that year there were, among women 15 to 44 years of age, 26,265 deaths from tuberculosis; 9,876 deaths from the diseases of pregnancy and confinement; 6,386 from heart disease; 5,741 from acute nephritis and Bright’s disease; 5,065 from cancer; and 4,167 from pneumonia. Other diseases, such as typhoid, appendicitis, and the infectious diseases show far fewer deaths.
Death rates per 1,000 live births.—This rate, as will be shown repeatedly throughout the report gives a far clearer picture of the actual risk of childbirth than do any of the rates so far considered. This rate can be given only for one year, 1910, and only for the provisional birth-registration area for that year. The rate from all diseases caused by pregnancy and confinement is 6.5, from puerperal septicemia, 2.9, and from all other diseases of pregnancy and confinement, 3.6 per 1,000 live births. That is, in this area for every 154 babies born alive one mother lost her life.
COMPARISON OF THE AVERAGE DEATH RATES FROM CHILDBIRTH IN CERTAIN FOREIGN COUNTRIES AND IN THE UNITED STATES
Are the death rates from these diseases in the death-registration area of the United States higher or lower than those in other civilized countries? Have these rates in other countries been falling or rising in the last 13 years, while the rates of this country have been apparently stationary? These questions, like all those of comparative international statistics, are of immense interest, but they involve many difficulties and sources of error. They should be considered in reading the following summary.
In order to make possible a comparison of the death rates from these causes for 15 foreign countries with those for the United States, an average rate has been computed for the years 1900 to 1910 for each of the countries, using the same method as that in use in the United States. When the 16 countries studied are arranged in order, with the one having the lowest rate first, the death-registration area of the United States stands fourteenth on the list. (See Table [XII], p. [56].) Only two countries, Switzerland and Spain, have higher rates; many of the countries, however, show rates differing but little from that of the United States. Markedly low rates are those of Sweden (6), Norway (7.8), and Italy (8.9); a strikingly high rate is that of Spain (19.6).
The death rate from childbirth per 1,000 live births is not available for the death-registration area of the United States, but can be given only for the small number of States and cities included in the provisional birth-registration area and for one year, 1910. (See p. [31].) This rate, 6.5, is considerably higher than that for 1910 of any of the countries studied. When the average rates for a number of years of the 15 countries are reckoned per 1,000 live births and arranged in order, it will be seen that the same group of countries—Sweden, Italy, and Norway—shows the lowest rates. (See Table [XIII], p. [56].) Spain in this table shows the rate which is next to the highest, while Belgium now has the highest rate. For a comparative study of the rates of these countries the rates per 1,000 live births give undoubtedly the clearest picture of the actual conditions.
These rates show a wide variation. While in Sweden but one mother is lost for every 430 babies born alive, in Belgium one mother dies for every 172 babies, and in Spain one for every 175 babies born alive. The rates in Belgium and Spain are two and a half times as high as the rate in Sweden.
Far more significant than a comparison of actual death rates of various countries is a comparison of the changes which have occurred in these death rates in each country in recent years. England and Wales, Ireland, Japan, New Zealand, and Switzerland have shown a decrease in the death rate per 1,000 live births from all diseases caused by pregnancy and confinement; but, in this group, only in England and Wales and in Ireland has the death rate from puerperal septicemia decreased; in the other three countries this rate has remained practically the same, though the total rate has decreased.
In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and Sweden both the rate from childbirth and that from puerperal septicemia remained almost stationary during the periods studied.
The total rate for Scotland shows a definite increase, though the rate from puerperal septicemia has decreased. (See Table XVI, p. 66.)
Communities are still to a great extent indifferent to or ignorant of the number of lives of women lost yearly from childbirth; many communities which are proud of their low typhoid or diphtheria rates ignore their high rates from childbed fever. Communities are only beginning to realize that among their chief concerns is the protection of the babies born within their limits, and necessarily also of the mothers of those babies before and at confinement.
DEATH-REGISTRATION AREA
The statistics of causes of death are available only for a certain portion of the United States, included in the so-called “death-registration area.” Unlike other civilized countries, the United States has no uniform laws for the registration of births and deaths. Moreover, the efficiency of enforcement of existing laws varies greatly in the different States. The Bureau of the Census in 1880 therefore established a “death-registration area,” which comprises “States and cities in which the registration of deaths is returned as fairly complete (at least 90 per cent. of the total), and from which transcripts of the deaths recorded under the State laws or municipal ordinances are obtained by the Bureau of the Census.” In 1880 this area included but 17 per cent. of the total population of the United States. As States and cities have passed better laws and obtained better enforcement they have been added to the registration area; the latter has increased greatly in size, but even in 1913 included only 65.1 per cent. of the population of the United States. For the remaining 34.9 per cent. of the population of the country we have no reliable statistics. This 34.9 per cent. includes the population of the greater number of the Southern States and of many Middle Western and Western States outside of certain registration cities in these States which are included in the area. No statements can be made, therefore, of the number of deaths from any cause in the United States as a whole; only an estimate can be made on the assumption that for any cause of death the same rate prevails in the remainder of the United States as in the death-registration area.
PROVISIONAL BIRTH-REGISTRATION AREA
The registration of births is still more incomplete in this country than is the registration of deaths. For 1910 the United States Bureau of the Census established a “provisional birth-registration area,” including the New England States, Pennsylvania, Michigan, New York City and Washington, D. C.
Death rates per 1,000 births.—As shown above, the method of computation of death rates which gives the clearest picture of the hazards of childbirth is that which takes into account only the women giving birth to children in that year. This is the method in use in a large number of foreign countries. The advantages of the method are self-evident. A demonstration of the superiority of this method of computation is obtained by a study of the tables giving the death rates from these diseases for foreign countries. In certain countries, as for instance Belgium and Hungary, there has been in recent years an apparent fall in the average death rates as computed per 100,000 population, while the average rates computed per 1,000 live births have remained stationary or risen. This phenomenon is due, evidently, to a decline in the birth rate in these countries during these years, and shows how misleading the rates as given per 100,000 population undoubtedly are in countries with declining birth rates. Whether a fall in the birth rate has occurred in the United States is not known. If it has occurred in the registration area, it would mean that the slight rise in rates per 100,000 population between 1900 and 1913 means a greater rise in rates computed according to the number of births. Such an error might compensate for the opposite error due to the more complete registration of deaths from childbirth in the later years of this period.
Miscarriages are not reportable in any country, although a number of miscarriages (as the term is usually defined) probably are reported as stillbirths in certain countries. The fact that women having miscarriages are not considered in the base would lead to a somewhat higher death rate than that which would express absolutely the number of deaths per 1,000 women at risk.
COMPARISON OF THE CHANGES IN THE DEATH RATES FROM CHILDBIRTH IN CERTAIN FOREIGN COUNTRIES FOR THE YEARS 1900 TO 1913
Far more valuable than a comparison of average rates of foreign countries is a study of the rates of each country for a series of years in order to discover whether they are decreasing or increasing and to compare such changes in the various countries. While it may be dangerous on account of different countries, no such source of error is attached to the comparison of rates in the same country for a number of years. The period 1900 to 1913 (or the latest year for which figures are available) is a very short one for a study of a change in death rates. It would have been far more interesting to study the death rates for a long series of years in each country, choosing a period beginning before the introduction of methods of asepsis. But such a study for the complete list of countries considered was not thought advisable, because of the difficulties caused by variations in classification of causes of death in the earlier years.
In order to study the rates for any increase or decrease occurring during the last 13 years, the rates per 1,000 live births will be used rather than those per 100,000 population. In several countries—Belgium, Hungary, Italy, Norway, Prussia, and Spain—the rate from childbirth per 100,000 population apparently has fallen during the period, while the rate per 1,000 live births has remained almost the same, or has risen. The cause of this inconsistency is the fact that in these countries the birth rate or the proportionate number of births to the number of inhabitants has decreased.
Number of deaths of women from 15 to 44 years of age in the death-registration area from each cause and class of causes included in the abridged International List of Causes of Death (revision of 1909),[[49]] 1913.
[49]. Except No. 25, diarrhea and enteritis (under 2 years), and No. 34, senility.
(Computed from figures in Mortality Statistics, 1913, pp. 338 to 349, in which causes of death are given according to the detailed International List of Causes of Death.)
| Abridged International List No. | Cause of death. | Number of deaths. |
|---|---|---|
| 13, 14, 15 | Tuberculosis of the lungs, tuberculous meningitis, other forms of tuberculosis | 26,265 |
| 31, 32 | Puerperal septicemia (puerperal fever, peritonitis) and other puerperal accidents of pregnancy and labor | 9,876 |
| 19 | Organic diseases of the heart | 6,386 |
| 29 | Acute nephritis and Bright’s disease | 5,741 |
| 16 | Cancer and other malignant tumors | 5,065 |
| 22 | Pneumonia | 4,167 |
| 35 | Violent deaths (suicide excepted) | 3,262 |
| 1 | Typhoid fever | 2,706 |
| 30 | Noncancerous tumors and other diseases of the female genital organs | 2,669 |
| 26 | Appendicitis and typhlitis | 1,620 |
| 36 | Suicide | 1,562 |
| 23 | Other diseases of the respiratory system (tuberculosis excepted) | 1,458 |
| 18 | Cerebral hemorrhage and softening | 1,398 |
| 24 | Diseases of the stomach (cancer excepted) | 940 |
| 27 | Hernia, intestinal obstruction | 854 |
| 28 | Cirrhosis of the liver | 598 |
| 9 | Influenza | 489 |
| 17 | Simple meningitis | 484 |
| 8 | Diphtheria and croup | 330 |
| 12 | Other epidemic diseases | 312 |
| 6 | Scarlet fever | 307 |
| 5 | Measles | 304 |
| 3 | Malaria | 250 |
| 21 | Chronic bronchitis | 184 |
| 20 | Acute bronchitis | 90 |
| 33 | Congenital debility and malformations | 24 |
| 11 | Cholera nostras | 18 |
| 4 | Smallpox | 16 |
| 7 | Whooping cough | 9 |
| 2 | Typhus fever | 2 |
| 10 | Asiatic cholera | |
| 37 | Other diseases | 11,688 |
| 38 | Unknown or ill-defined diseases | 458 |
A MUNICIPAL BIRTH CONTROL CLINIC. MORRIS H. KAHN, M. D., in New York Medical Journal for April 28, 1917.
Showing that large families among the poor are the result of ignorance of methods to prevent conception among the mothers.
The following studies were undertaken with a view to determining whether there was an actual need and demand for birth control education and whether such a demand, if it existed, could be supplied with any effect by a scientifically conducted clinic in the dispensaries of the Department of Health of the City of New York; we felt that it might be of scientific and sociological interest to publish a report and an analysis of the observations made, probably the first of their kind in this country. Section 1142 of our Penal Code was ignored in conducting this birth control study.
The social and economic status of the patients was fairly uniform, about the same as that of patients attending the other dispensary institutions in this city. A tabulation of the results was made under the following headings: Name and nationality; age; number of years married; number of living children and their ages; number of deceased children; number of miscarriages or abortions; contraceptive methods known or practised. More or less complete data were secured in 464 cases.
The average number of procreative years of married life was 16.1, the age of fifty years being considered in this study as the end of the procreative period for the seventy-two women who were older than that. The average number of living children was 3.27 and of deceased children 1.2, making a total average of 4.47 children born to each family. Of the 464 women, 176, or three eighths, had had abortions or miscarriages, the total number of such interruptions of pregnancy being 324, or an average of 1.8 each for the women involved.
Of the 464 women, 192 knew of no contraceptive methods and therefore had used none. The remaining 272 women knew of one or more methods, more or less effectual, for the prevention of conception. Of the 192 women who were ignorant of the use of contraceptives, practically one half, or 104, had a history of abortions, with a total of 202 abortions, or an average of two apiece. In contrast with this, of the 272 women who knew of one or more contraceptives, only one fourth, or seventy-two, had undergone abortions, with a total of 122 abortions, or an average of only 1.6 apiece.
A further analysis of our tables shows an interesting and striking relationship between ignorance of methods for the prevention of conception and the number of children. Sixty-eight women had had three children each. Of these, twenty-six, or thirty-eight per cent., were ignorant of contraceptives. Twenty-eight women had had four children each. Of these fourteen, or fifty per cent., were ignorant of contraceptives. Fifty-five women had had five children each. Of these thirty were ignorant of contraceptives, or fifty-four per cent. Thirty-two women had had six children each. Of these twenty were ignorant of contraceptives, or sixty-two per cent. Forty women had had seven children each. Of these thirty-eight were ignorant of contraceptives, or ninety-five per cent. Twenty-one women had had eight children each. Of these twenty were ignorant of contraceptives, or ninety-five per cent. Forty-four women had had nine or more children each, and of these all were ignorant of contraceptive measures. Arranged in tabular form, these data would appear as follows:
| Number of Women | Number of Children | Number Ignorant of Contraceptives | Percentage |
|---|---|---|---|
| 68 | 3 | 26 | 38 |
| 28 | 4 | 14 | 50 |
| 55 | 5 | 30 | 54 |
| 32 | 6 | 20 | 62 |
| 40 | 7 | 38 | 95 |
| 21 | 8 | 20 | 95 |
| 44 | 9 to 17 | all | 100 |
It is sometimes stated by opponents of birth control that contraceptive methods are known by every married person and that the fault and immorality of having a large family of unprovided for dependents lies not in ignorance of contraceptives but rather in a lack of determination on the part of one or both parents to use preventive measures; in other words, that the failure to use contraceptives results from the inconvenience attending some methods and also from the influence of religious sentiment.
The above data, however, tend to show that ignorance of contraceptives not only is a great factor in the production of large families, but is also a great factor in increasing the number of abortions. From the fact that two thirds of these women knew absolutely no contraceptive method, while the methods used by many of the others were ineffectual or positively harmful, it is apparent that there is a definite opportunity for educating these women in methods of regulating conception. That there is need and demand for such education is voiced in unmistakable language by the multitude of poor who seek advice from all practising physicians.
MATERNAL MORTALITY
Prof. Theodate L. Smith, director of the Library Department, Child Study Institute, Clark University, investigated the records of the families of early graduates of Yale University (1701 to 1745) and of Harvard University (1658 to 1690); and found that of the wives of Harvard men, 37.3 per cent. died under the age of 45 years, while of the wives of Yale men, 40 per cent. died under 50 years. Prof. Smith also showed that there is a tendency for families very large in the first generation to die out in the third or fourth generation. One family of twenty children, by two wives, has living descendent by one son only, one daughter being untraceable. A family of ten brothers and sisters, only two of whom lived until 50, produced three surviving children, who in turn have produced one, and that a sickly specimen. Another family had fourteen in the first generation, eight in the second, six in the third and only two in the fourth.—Mary Alden Hopkins in Harper’s Weekly, June, 1915.