Validation of
the Midwifery Model of Care
Statistical Comparison of Birth Attendants
(Physician and Midwife)
The problems of under-reporting of mortality by physicians.
Õ “Conclusions based on statistical studies must be accepted very charily when they deal with deaths in childbirth, for the figures are particularly liable to error. Every since such data have been collected, doctors have been prone to omit from death certificates the fact that the case was associated with pregnancy, or they have actually falsified the records to escape any stigma with might accrue to them . ...... In 1933 an error of 17.8 % was found in maternal death certificates in New York City; in 1934 an error of 21.6 % was found in Philadelphia and of 12.6 % in those of the fifteen States specially selected for study by the Department of Labor." 1937-A, p. 329-
Comparison of outcomes stats for physicians and Midwives:
Õ Dr. Ira Wile, NYC "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives. [1911-G, p.246]
Comparison of Mortality Rate in US
with that of other IndustrializedÕ Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own. Why? It cannot be because of our ignorance, for in the scientific phases of obstetrics, America is one of the world’s leaders; it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions. [1937-A]
Õ What about the conduct of labor in the two regions? Here is the major differences lie. In the first place, ... at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously.Fifty-one percent of all the maternal death in Scotland occurred in the 24 percent in which the labor was operative. Let is compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. “In Sweden the interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ..... it is under 1 percent.” [1937-A]
Õ What is responsible for this vast difference in operative rates? There are many factors: the woman of Holland and Scandinavian are by nature better equipped for spontaneous parturition. Analgesics and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn. [1937-A]
Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurse-midwifery Service, made the following statement on May 9, 1932:
“The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life.” ^137
What are the advantages of such a system? It makes it economically possible for each women to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste." [1937-A]
That the infant mortality is lower among the midwife cases and highest in the hospital is shown better by the following rates. [1917-B, Levy,MD p. 43] ^146
INFANT MORTALITY FOR INFANTS ATTENDED AT BIRTH.
By midwives . . . . . . . 70.7 per 1000 births.
By physicians . . . . . . .74.3 per 1000 births.
In hospitals . . . . . . . . 97.4 per 1000 births.
It may be argued that the effect upon the infant of good and poor obstetrics would appear principally in the deaths under one month of age and that in this group we will find the highest mortality among the births attended by midwives. Strangely enough, it appears that especially in this age group the infant mortality is lowest for infants attended by midwives and highest among those delivered by hospitals. .... hospitals delivered 20 % of the babies that died under one month of age but attended only 12 % of the births of the city.[1917-B; LevyMD; p.44]
These results will be better appreciated, perhaps, if presented somewhat differently. Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month.[1917-B; Levy, MD p. 44]
These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals. [1917-B, Levy,MD; p. 44
Table I Maternal and Infant Mortality Among Mothers Who Received Prenatal Supervision from Child Hygiene Division and Were Delivered by Midwives, Newark, N.J., 1916. [1917-B; LevyMD, p. 46]
Total Number Mothers delivered by midwives -- 586
Midwife-attended Maternal Deaths: 1 Midwives’ Rate -- 1.7 City-wide rate -- 2.2*
Deaths of babies under 1 month -- 5 Midwives’ Rate ------ 5 City-wide rate -- 8.5
Stillbirths (attended - midwives) -- 4 Midwives’ Rate --- 6.8 City-wide Rate --41.7 ** **polio epidemic summer of 1916
"...in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile."1925-A; HardinMD, p.347
"The “International Year Book of Care and Protection of Children: gives emphasis to the fact that the Untied States has still a higher rate of maternal mortality than any other of the principal countries of the world and that pregnancy causes more deaths among women ages 15-40 years of age than any other disease except tuberculosis. Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor. Three to 5% of all children die during delivery and thousands of them are crippled." 1925-A .p. 350]
While we believe our death rate to be low, both in our outdoor confinements (home-based care) and in our regular indoor applicants, it is disconcerting to find that even in these selected groups the predominating cause of death is puerperal infection. [#1] The one element of mortality in obstetrics, of which we are inclined to boast, and that we ought to have most certainly under our control, causes more than twice as many deaths as any other single complication. There were twenty-three deaths from puerperal infection among the 23,130 regular applicants confined indoor, and fifty-nine deaths puerperal infection among the 69,081 outdoor confinements; a mortality of 0.95 per thousand (Hosp) and 0.85 per thousand (home), respectively.
The babies: Hundreds of thousands of babies are permanently crippled, either mentally or physically, as the result of improper obstetrical management of their births, and in a goodly proportion the infant becomes blind as the result of carelessness. I wish, however, to emphasize this point, that the number of children becoming blind is very small to the number that are killed and injured by bad obstetrical practice. [1911-B; DeLeeMD]
Statistics (Howard) show that the stillbirth rate in the birth registration area is 60% higher than Stockholm (2.16%); rates for New York (4.38%) and Philadelphia (4.39%) are 35% higher than Birmingham, (England) (3.24%) and over 100% higher than ...Stockholm.[1922-A; ZeilgerMD, p.405]
As to maternal mortality, ...during 1913 about 16,000 women died..; in 1918, about 23,000...and with the 15% increase estimated by Bolt, the number during 1921 will exceed 26,000.Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is according to Howard “appallingly high and probably unequaled in modern times in any civilized country”.
These rates ...of 88.48 per 10,000 birth are on a par with those of Sweden 110 years ago; are 75% higher than those of England and Wales 60 years ago; are 120% higher than England and Wales in 1911-1915 and exceed the rates of England and Wales for 1918 by nearly 75% for puerperal fever and 150% for all other afflictions of the puerperal state combined. Howard shows also that New York City’s rates 46.11, which is much lower than that of any other American city, is 35% higher than that for Birmingham, England (33.49). 1922-A; ZeilgerMD
1911 - 1915 -- total number of mothers delivered by midwifery students
Deliveries by midwife students 2,731 In hospital -- 966 in home -- 1,765
Maternal Mortality Total number: 6 rate: 0.21%
Hospital 3 pneumonia, hemorrhage, ruptured uterus Home 3 ruptured uterus, puerperal sepsis, pelvis abscess
Perinatal Mortality Total -- 29 [1915-A; EdgarMD p. 99]
The conservative nature of our teaching at the Bellevue School for Midwives, is shown by the fact that in the first fours of its existence ... forceps were used only 67 time in 2,731 cases or once in each forty cases, a forceps percentage of 2.4%. [1915-A; EdgarMD p. 100]