|02. Of Blind Alleys and Things that Have Worked: History's Lessons on Reducing Maternal Mortality|
In the period before hospitals could intervene effectively and safely, the relative successes and failures appear to have depended less on the development of science and technology than on a combination of information, policy and strategy.
The first element was information. Countries with an early reduction in maternal mortality were also the ones where information on the extent of the problem had been around for a long time, and where public authorities reacted on this information. In countries where such information was more recent maternal mortality was not on the agenda, and the development of a control policy was delayed.
But the information was not enough. The nature of public administration, its commitment to public health and its capacity and willingness to react on information about avoidable deaths was just as important. What is sometimes less appreciated is that in the first half of the XXth century the debate on maternal mortality was not a matter for doctors and administrators alone. In various European countries, from the early XXth century to the late 1930s, committees concerned to improve maternal mortality were formed and associations with the same object, sometimes medical and sometimes lay, were founded. In the UK, for example, this eventually led to the 1938 Conference, attended by women from over 60 local associations, which gave rise to a comprehensive Mothers Charter (Oakley 1984). In Sweden the concern of the medical establishment with the levels of maternal mortality was sufficient to obtain a public commitment. In many other countries legislation was only introduced and funds made available after pressure mounted from the civil society.
If information and public concern were elements that determined success or failure, another was the choice of policy. With hindsight we can say that before the technological hospital delivery of the second half of the XXth century came of age, the safer and more effective policy was to provide professional midwifery assistance at delivery, supervised, controlled, chosen on basis of a social profile that would promote modernisation (Marland 1997). Where this was the backbone of maternal health policies, mortality ratios dropped. Where it was not, they stagnated (Figure 5).
There is a whole body of evidence, and not only from north-west Europe, that shows that professional midwifery as such makes a difference, even in the absence of modern hospital technology. In the first half of the XXth century delivery was safer with a professional midwife than with a doctor. For example, Mary Beckenridges Frontier Nursing Service in the USA brought maternal mortality down to 66 in 1935-37 among the population it served, whereas in the same years hospital physicians in Lexington, Kentucky remained with a mortality of 800-900 among their white clientele.
Those countries that managed to get doctors to co-operate with a midwifery-based policy fared relatively well. Where doctors won the battle for professional dominance - and for their share of the market - women died. It may be an extraordinary conclusion, but it is likely that [in the 1920s] at least 200,000 lives might have been saved by a maternity system based on trained midwives in the very country [the USA] in which the midwife was branded as a relic of the barbaric past (Loudon 1997).
Figure 5. Maternal mortality in 1919-20 in countries with deliveries predominantly assisted by midwives (bottom), by both midwives and doctors (mid) and predominantly by doctors (top)
No country in the Western world has escaped the midwife-doctor debate, from the violent denunciations of the midwife in the United States, through the struggles for midwife registration in Britain, to the more measured but none the less significant discussions on the place of Dutch midwives in providing obstetric care (Marland & Rafferty 1997). But the potential of midwives has been realised only where they were well trained, supervised, regulated, and held accountable for results. The relatively poor performance of doctors and hospitals - and their contribution to mortality through iatrogenesis - in the same period can best be explained by the greater difficulty in making them adhere to scientific standards and in holding them accountable for results.
It was not, however, merely a question of public authorities making the right policy choice; it was also a matter of being able to implement such a policy with enough authority to make professional delivery care accessible. North-west Europe adopted different versions of Swedens strategy of putting a midwife in every parish: a strategy based on proximity, geographical, but also cultural and financial, based on a long term effort in financing and training as well as regulating midwifery. When hospital- and obstetrician-based delivery care came of age in the second half of the XXth century, proximity and access also became the determining factors, as in many developing countries today.
This combination of the technical and political factors (Figure 4) resulted in a significant reduction of the maternal mortality in Sweden, Japan, Denmark, Norway and The Netherlands, even without hospital technology. In countries like the USA, Belgium, Great-Britain, France or Italy ingredients were missing and mortality remained higher until modern hospital technologies became accessible; in those countries medicalisation of delivery would eventually be more pronounced. The commitment and sense of responsibility of health professionals and the State, clearer understanding of the causes of mortality - associated with the advent of effective technologies: caesarean section, antibiotics, blood transfusion - and extension of coverage to the population as a whole enabled the industrialised countries to attain extremely low maternal mortality ratios in some twenty years (between 1937 and 1960). By that time it did not make a difference whether the policy was to promote confinement in hospital (as in the United States) or at home (as in the Netherlands): that became a question of culture and efficiency, not of effectiveness in reducing mortality.