|02. Of Blind Alleys and Things that Have Worked: History's Lessons on Reducing Maternal Mortality|
Sweden is unusual in the amount of historical information available on its demography. Its General Register has systematically collected individual health data since 1749. Very much in line with the development of vital statistics and quantitative methods in the XVIIIth century (Fox 1993), the Swedish Sundhetskommissionen reported that at least 400 women out of 651 dying in childbirth could have been saved if only there had been enough midwives (Högberg et al. 1986). This de facto introduced the notion of avoidable maternal mortality. The Sundhetskommissionen had enough authority to set a policy of training midwives in such numbers as to make sure that all deliveries - home deliveries, of course, were the norm - would be attended by qualified personnel.
Training large numbers of midwives was a slow and progressive process. Results were obtained only because authorities and professionals had a common purpose in tackling the problem of maternal mortality. One century after the report, in 1861, 40% of births were attended by certified professional midwives. The figure would double over the next four decades, to 78% in 1900. In the meantime the number of home deliveries assisted by traditional birth attendants dropped from 60% in 1861 to 18% in 1900. Only a small fraction of births, between 2% and 5%, took place in hospital4.
Midwives in Sweden were allowed to use forceps and hooks for craniotomy as early as 1829. They had a great deal of autonomy - in this thinly populated rural country that was a self-evident necessity - but were supervised by the local public health doctor. The latter could be called upon in case of major complication and was held accountable for official reports. The lines of authority were strong enough to generalise the introduction of aseptic techniques as early as 1881 - only a few years after it had been introduced in hospitals. The early adoption of this original combination of professional assistance to home deliveries and use of effective techniques enabled Sweden to achieve the lowest maternal mortality ratios in Europe (228 maternal deaths per 100,000 live births) by the beginning of the XXth century.
The Swedish success was partially a result of scientific and technical advances (Högberg et al. 1986) and partially a result of social changes empowered by public authorities. It is the combination of various ingredients that made this success possible (Figure 4). The potential of this recipe was further confirmed by later adopters of the same policy5 - i.e. the Netherlands, Denmark and Norway. An active policy of training midwives, selected for their social profile and capacity to introduce modernisation as health missionaries, with a close follow-up of compliance with hygiene and technical prescriptions (Marland 1997), reduced maternal mortality ratios to below 300 per 100,000 by 1920.