|02. Of Blind Alleys and Things that Have Worked: History's Lessons on Reducing Maternal Mortality|
Although the historical evidence is patchy, we do know that in countries like England maternal mortality levels were halved - compared to natural maternal mortality - towards the beginning of the XIXth century. Progress was in fact much more impressive for maternal than for overall mortality. Loudon explains this largely in terms of factors specific to childbirth rather than in terms of factors likely to have impinged on mortality of all causes: the decline in maternal mortality [between 1750 and 1850] was related both to an increasing proportion of midwife deliveries and to a higher standard of midwifery (Loudon 1992a). By 1850 maternal mortality was at a level of around 800/100,000 or even lower: levels not unlike the median poor country today.
Between the mid-XIXth century and the late 1930s, the patterns of reduction diverge markedly (Figure 3). On the one hand there are Northern European countries - Sweden is the prototype, but Denmark, Norway or the Netherlands follow roughly the same pattern: a clear downward trend from as early as 1870, stabilising at 250-300 per 100,000 between 1900 and 1940. At the other extreme, maternal mortality ratios in the United States remained in a 600-800 bracket up to the mid-1930s. In-between the Swedish success story and the American failure one finds south-west Europe.
The North European success story is all the more impressive since it was achieved before modern hospital technology, transfusions, caesarean sections, or antibiotics became available, and, in the case of Sweden, in a poor rural country with a dispersed population. The circumstances and strategies that made this possible and conversely, that caused the USA to lag behind, may help to understand why many poor countries have failed to reduce maternal mortality at a time when the technology to avoid maternal deaths is well known.
Figure 3. Maternal mortality from 1870 to 1993 in Sweden, the USA and England & Wales