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The next announcement was on 10th April, as follows: "The Beneficial Adventure upon the Lives of Childbed Women, at Pratt's Coffee House, in Cateaton St., between St. Lawrence Church and the corner of Aldermanbury, this day, being the 10th April (1711), will be opened four books of ins. upon the lives of childbed women; wherein any person may become a subs. for the expense of 25. The women are to live 40 days before, and 20 days after delivery." This last feature sadly requires elucidation.

Nearly all L. ins. offices have undertaken the risk of childbirth in connexion with L. ins., charging mostly an extra prem. at least for the first child. We do not find that the Amicable made any add. charge for female lives; the Equitable, at starting, did so, but appears to have abandoned the practice. The subject will be fully considered in our art. on FEMALE LIVES; and we shall in the present art., therefore, only now speak of offices which have made a special feature of ins. against the risks of childbirth.

The Asylum L., founded 1824, made a special exception in favour of pregnant females, which we have already noted in our hist. of that co.

The British Nation, founded 1854, had a scheme of "Pregnancy or Childbirth Ins." which it presented to the world in the following elaborate phraseology:

It is also proposed by the estab. of this asso. to originate a new source of bus., by affording to females an opportunity of assu. themselves through the dangers of that crisis that nature has destined them to endure, and which creates in them so much solicitude. During that interesting epoch of female life-Pregnancy-which gives rise to so many fears and anxieties, they will be readily admitted, without medical examination, to the resources and comfort of L. assu.; and thus one cause of alarm will be assuaged by the reflection that should the mother be removed, the child or children she leaves behind will be provided for. In the event of the mother dying in childbirth, or within nine days after (or upon the 9th day), this Asso. will grant to the child, if surviving, an annu. until the age of 21, in proportion to the amount which may be assured; or according to any arrangement that may previously be entered into.

The special rates of prem. were not stated; but the advantage was extended to all ladies ins. in the office for the whole term of life without extra prem. CHILDBIRTH, RISK OF.-The question of the risk to mothers of Childbearing has, very naturally, occupied from time to time considerable attention. Some writers have been of opinion that child-bearing women are not only liable to all diseases incident to other women, and this plus the peculiar dangers of childbearing. But the majority are of opinion not simply that the pregnant state renders the constitution less susceptible of receiving or developing various diseases; but that, speaking generally, pregnancy more frequently befalls healthy than unhealthy women; and that it may therefore be regarded prima facia as a proof of health. That pregnant women appear to have the power of warding off the ravages of disease has frequently been the subject of remark in relation to Consumption; but we do not propose to follow the medical so much as the statistical aspect of the case.

Graunt remarked upon this subject in 1661, in his Obs. on the Bills of Mort.:

In regular times, when accounts were well kept, we find that not above 3 in 200 died in childbed, and that the number of abortives was about treble to that of the women dying in childbed; from whence we may probably collect that not one woman of an hundred (I may say of 200) dies in her labour; forasmuch as there be other causes of a woman's dying within the month, than the hardness of her labour. If this be true in these countries, where women hinder the facility of their childbearing by affected straitenings of their bodies; then certainly in America, where the same is not practised, nature is little more to be taxed as to women, than in brutes; among which not one in some thousands do die of their deliveries. What I have heard of the Irish women confirms me herein.

The early statistics gathered from the British Lying-in Hospital furnish the following results. Between the years 1750 and 1762 the deaths of mothers were 1 in 38; between the years 1788 and 1800, 1 in 318. These figures show a reduction of mort. in an inst. which must have commanded the best medical skill, and best nursing, of the whole period under review, of more than five-fold for children, and more that eightfold for their mothers. "In this reduction, sanitary improvements in space, ventilation, and cleanliness must have borne a very considerable part."-Dr. Guy.

Some wider obs. were taken early in the present century. Thus in the whole kingdom of Prussia, in 1817, the deaths in childbirth were I in 112. In the Dublin Hospital, in 1822, there were 12 deaths among 2675 women delivered, or I in 223. In the Edinburgh Hospital, about the same period, the deaths were found to be I in 100. At the City of Lond. Lying-in Hospital, in 1826, the deaths were I in 70; at Strasburg, about the same date, the deaths were I in 109. The deaths in childbirth shown by the Lond. bills during the 10 years 1818 to 1827 gave the proportion of deaths as I in 117-making the extra prem. for ins. about 175. p.c.

In 1829 Mr. Geo. Farren pub. Obs. on the Laws of Mort. and Disease; and therein he remarked on the comparative danger of the first and subsequent childbirths, as follows: The mort. in first labours, selected from the general mort. by childbirth, will appear to be in the proportion of 14 to 100, and there is no reason to doubt that first labour is attended with greater danger than the 2nd, 3rd, 4th, 5th, 6th among young women; but that after several labours the immediate consequences of childbirth are still more dangerous to life than the act of a first labour; and that every subsequent birth is attended with increased risk.

Where a first pregnancy takes place in the middle of life, the same consequences which frequently follow the birth of a ninth or tenth child by a young woman, may be expected at a fourth or fifth labour of a woman of more advanced age.

These remarks are intended to apply strictly to the dangers of childbirth, and its immediate con

sequences, distinguished from the state of pregnancy, with respect to which a very slight prognosis may be formed.

The following Table furnishes the statistics of childbearing in Sweden during the 5 years 1831-5:

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The figures in the 4th col. are derived by multiplying the number of childbearings in the 5 years 1831-5 (col. 3) by 100, and then dividing by 21⁄2 times the women living at the two enumerations 1830 and 1835 (col. 2).

Dr. Southwood Smith, in his famous work, The Philosophy of Health, published 1836–7, said (respecting some of the statistics already given by us):

The change that has taken place in the condition of lying-in women during the last century in all nations of Europe cannot be contemplated without astonishment. The mort. of lying-in women in France, at the Hotel Dieu of Paris in 1780, is stated to have been one in 15. In 1817 for the whole kingdom of Prussia, including all ranks, it was 1 in 112. In England in the year 1750, at the British Lying-in Hospital of Lond., it was 1 in 42; in 1780 it diminished to 1 in 60; in the years between 1789 and 1798 it further decreased to 1 in 288; in 1822, at the Lying-in Hospital in Dublin, it was no more than 1 in 223; while during the last 15 years at Lewes, a healthy provincial town, out of 2410 cases there have been only two deaths, that is, one in 1205. There is no reason to suppose that the mort. in the state of parturition is less at Lewes than in other equally healthy country town in England.

The learned writer's view in this last respect was too sanguine.

It was only when the Gen. Registration Act of 1836 had got into proper working that we began to have trustworthy national statistics on this and many other equally important subjects. In the year 1838 the deaths from childbirth in England and Wales numbered 2811; in 1839, 2915; in 1840, 2989; in 1841, 3007-being in this last year an average death of 8 mothers for every day in the year. In the 4 years the deaths were 11,722; and the mort. was I death to 171 births regis.

Dr. Farr, reviewing these statistics in an able paper in the 5th R. of Reg.-Gen., pub. 1843, admitted that they were even then "less specific than could be desired." He says:

Midwifery is as well understood in England, and the medical practice is certainly as sound, as little encumbered with obsolete prejudices, as well adapted to aid and correct the efforts of nature, as the other parts of surgery; but errors in practice are sometimes committed; and though excellent nurses -considering their education-are sometimes met with, medical precepts are too often set at naught by the nurses and old women in attendance, who have peculiar views of their own, which they lose no opportunity of announcing and carrying into effect, with the best intentions in the world, but the worst consequences. A large proportion of the 500,000 English women who lie-in every year, and have any attendance at all, are attended by midwives, who, from one cause or another, prob. delicacy of the national manners in points of this kind, receive no regular preliminary instruction in anatomy and other matters, some knowledge of which a glance at the causes of death in childbirth will show is indispensable in many emergencies. It is true that a medical man can be called in where danger is imminent; but to discover danger a knowledge of its sources is required; and those who have come in contact with midwives or "monthly nurses" are well aware that ignorance does not diminish their self-confidence.

He proceeds to note that in France the "sages-femmes" go through a regular course of instruction, theoretical and practical. Madame Boivin and others had greatly distinguished themselves there by their writings, and contributed not a little to the progress of their art. Mr. Hoffman stated that the Prussian Gov. supported, in each of the eight provinces, schools of midwifery, which in 1837 had furnished the country with 11,155 midwives, examined and passed by the Medical Boards. Among the Hebrews and the Egyptians we believe midwifery was practised by women only.

Dr. Farr proceeds:

It would be folly-with the undoubted differences in our manners and institutions-to argue that the French or Prussian systems should be introduced into this country; practically they are perhaps not more efficient than our own; but it is very well worth while, in the first place, to inquire whether our English system does not admit of essential improvements, and in the second, what steps should be taken for carrying these improvements into effect.

No one who has reflected upon the subject, and certainly no one who has a practical acquaintance with it, will contend that the ann. deaths of 3000 women in childbirth, and of 13,350 boys, and 9740 girls in the first month after delivery, or the sufferings and deformity of many who escape with life, are natural and inevitable. Admit that the lives of 1000-of 500-or of 100 of these mothers might be saved-and that many more might be rescued from injuries and pains which disable, or never leave them, and assuredly no apathy, no false sentiments of delicacy, will prevent those who have the public health at heart from giving the subject the most attentive consideration.

VOL. I.

33

He proceeds to speak of the almost national advantages which would flow from schools of trained nurses.

In a paper by Mr. Samuel Brown, contributed to the Assu. Mag. in 1853 [vol. iii. p. 17], On the Influence of the Ages of the Parents at the Time of Marriage on the Sex of Children, and on the Prolificness of Marriages, there is the following:

The average period of childbearing is not more than 30 years, and may, for the sake of limiting the term of inquiry, from the date of marriage, be taken to terminate with the age 45 on the side of the female. On the side of the male the period may extend for 20 years longer, which accounts for the fact of there being more second marriages of males than of females. It is a wise provision of nature that in countries where the period of female prolificness commences at an earlier age, it terminates much earlier in proportion, or the constitution of the mother might be exhausted, and the children of later life be born only to die of debility and disease.

In the 13th Report of Reg.-Gen., pub. 1854, Dr. Farr returns to the subject, "The great loss of women in the prime of life is the result of negligence and ignorance in many cases, and would be diminished by the education of the nurses and midwives who attend the poor."

From the Swedish returns (1776-1855), it appears that 100 childbearings produced 101 62 children, viz. 282 stillborn, 98 80 quickborn; consequently 100 quickborn children imply 101 21 childbearings. In the year 1852 in England 624,012 children were born alive by 617,902 mothers; of whom 6036 bore twins, 37 bore triplets. So 99 mothers bore 100 live children; or 100 live children implied 99 childbearings. To these should be added the childbearings yielding still-births unregistered.-Dr. Farr.

Dr. Farr said in the 17th Report of Reg.-Gen., pub. 1856, It may be probably assumed that the child-bearing women of a pop. are, in the language of ins. offices, "select lives," -at least, select in a certain sense; but it can only be determined by further researches whether they are less or more liable than other women to be attacked or to die by the diseases not incident to childbirth. It is only well known that when they are attacked by zymotic diseases, such as cholera and smallpox, they succumb in unusually high proportions. In the 20th Report, pub. 1859, the learned Doctor says, "The happy decrease of the danger of childbearing continues; 42 mothers died to every 10,000 children born alive in 1857; in 1847 the proportion was 60; in 1848 it was 61; and since that date the mort. has regularly declined year by year, leaving the average loss in the ten years, 51 mothers to every 10,000 children born alive."

In the Medico-Chirurgical Trans., 1864, Dr. Brodie, of Queen Charlotte's Hospital, Lond., gave some valuable statistics regarding deaths from childbirth in various Lond. institutions. He found that in Queen Charlotte's Hospital, while the deaths of married women were only 18 p. 1000, the deaths of single women were 35 p. 1000-or nearly double. He says, "A great mort. among unmarried women on their passage through the puerperal stage has always existed." He considers the depressing circumstances necessarily incident to their unfortunate condition furnishes a solution. Speaking of the outpatients of St. George's Hospital, he says, "Women delivered at their own habitations, as I know by experience, are often living in the greatest filth and poverty, with only one room to accommodate the wants of a whole family; and yet, as will be seen, those patients do infinitely better than those who are removed to a spacious, well-ventilated building, with every comfort and attention that can be desired." This is certainly a very startling statement, and it was at one time believed that the only solution of it was that the worst cases went to the Hospitals. That theory has since been dispelled.

Thirty Workhouses...

Soon after his accession to office (1866), Mr. Gathorne Hardy, as President of the Poor Law Board, moved for a return of the number and mort. of child-bearing women in the metropolitan workhouses. It appeared there were 39 workhouses in the metropolis, that during the year 1865 the number of cases of childbirth was 2728, and that the deaths from that cause amounted to 16 in the same year. These deaths occurred in nine workhouses only. The facts may be summarily expressed by naming only those places which experienced any mort.

Thus :

...

St. Martin-in-the-Fields...
St. Marylebone
Hampstead
St. Pancras
Islington ...
East London
West London
Whitechapel

St. George's, Southwark...

No. of Cases No. of Deaths of Childbirth. therefrom.

1754

Nil.

27

I

306

2

5

I

249

91

41

I

52

I

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354

Taking the aggregate number of both series, we find that the death-rate in childbirth for all the metropolitan workhouses was 6 p. 1000 cases. Is this a small or a large ratio? To discover the means of a very exact comparison-so exact that all the conditions of the problem shall be rigidly alike-is difficult, and in Lond. perhaps impossible. Some test, however, is supplied by the experience of one or two of the larger lying-in hospitals. Dr. Brodie, in the work already mentioned, gave the mortuary statistics of Queen

Charlotte's Hospital, and of several kindred establishments. From it the following figures are drawn:

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Of the four in-door establishments named, the London workhouses exhibit the lower death-rate. It is only when we reach the out-door cases of St. George's Hospital that we discover a death-rate yet lower. The heavy mort. of Queen Charlotte's Hospital Dr. Brodie assigns to very special causes. Foremost is the great number of single women received there, the mort. of the unmarried being far beyond that of the married women in childbirth, as already stated. At the Rotundo Hospital, where the death-rate is fully four times that of the Lond. workhouses, the authorities "profess only to admit married women. "The British Hospital approximates closely to the Lond. workhouses by its low death-rate. This institution restricts its benefits to married women, and to "these in not larger numbers than about 120 annually." The eight years' practice of the out-door midwifery department of St. George's reveals a death-rate exactly one-half that assigned to the British Hospital, and rather more than half that which occurred in the workhouses. The death-rate in Queen Charlotte's Hospital was more than sixfold that deduced from the workhouse data of 1865. The subject clearly requires further investigation.

Statistics collected for the French Government, and pub. by Dr. Le Fort, of Paris, in 1867, give the following results. Among 888,312 women confined in the principal lying-in hospitals of Europe, including those of Gt. Brit. and Ireland, France, Denmark, Russia, etc., and 934,781 cases, collected from the same cities and medical schools, of poor women confined in their homes as out and dispensary patients, the proportions of deaths were as follows: Of the 888,312 hospital patients, 30,394 died; while out of the 934,781 external or home patients, 4405 died. The result is most startling. For out of all the women delivered in hospitals, I in 29 died; whilst of all those delivered at their own impoverished and often wretched homes, only 1 in 212 died. This is not to be accounted for by the worst cases only going to the hospitals. It is believed to be the result of the crowding and sympathetic and contagious influences. See Sir James Simpson's Address on Public Health, Social Science Congress, 1867.

In the 30th R. of Reg.-Gen., pub. 1869, Dr. Farr returns to the subject, having before him statistics much more complete than any previously available. Hence we learn that in England the mort. by childbirth to every 10,000 women living, in the four decenniads of age from 15 to 55, was 3'96, 8·96, 8·66, and 0.65 in the period from 1855-67; in the preceding period it was higher at all ages. The excess in the middle age 25-35 is due to the great proportion of married child-bearing women at that age, and to the number of pregnancies then occurring. The excess of violent deaths among males of 15 and under 35 does not raise the mort. from all causes to the same pitch as the mort. of females. the age 25-35 the deaths to 10,000 living men are 95'5, while the mort. of women at the corresponding age is 987; the excess is 32, with which the mort. by childbearing, 8.96, may be compared.

At

The mort. by childbirth is much less under the age of 35 in the healthy districts than it is in Lond. and the large towns; but after 35 the women in the country die by childbearing in larger numbers than the women in the towns. In towns they are more exposed to puerperal fever; in the country many, probably, perish for want of skilful help. During the ten years 1851-60, to 10,000 births in the Eastern Division (Essex, Suffolk, Norfolk), 41 mothers died in childbirth; in Lond. 49; in Lancashire and Cheshire 54; in Wales and Monmouthshire 61. In the healthy districts the mort. in childbearing was 43, in the large towns 49. Nothing in England approaches the fatality to mothers in Wales, where they must be greatly mismanaged.

In the English and Welsh healthy districts the mort. at the ages 15-45 of women is higher than the mort. of men from all causes: thus, of 1000 living at the age 25-35, the men die at the rate of 8.18, the women at the rate of 8'94; the excess on women is 0.76; and the excess is nearly the same through the whole of the procreant part of life. The humane Doctor, impressed by these facts, asks:

How can the dangers of childbearing, which have been traced to various causes, be alleviated? This question was asked many years ago, and was answered by the establishment of lying-in hospitals. Many of the mothers are poor married women; and some of them unmarried, abandoned, inexperienced, repudiated by society, incur double dangers. What seemed more likely to save these women in travail from peril than the maternity? Unfortunately, experience has proved that the assemblage of child-bearing women under one roof gives rise to fatal epidemics of childbirth fever; and the mortality is almost invariably in excess of the mortality in detached dwellings. No help is to be expected from maternities. There is hope, however, to see the mortality sensibly reduced by the progress of midwifery.

He adds:

The utmost care on the part of medical men who practise as accoucheurs is indispensable. That puerperal fever has been transmitted from patient to patient is deplorably true. No precautions can be too great. Then the contagion of scarlatina evidently in some cases lights up a puerperal disease, which has not yet been distinguished from puerperal fever. So does erysipelas, and so do perhaps other diseases. The dangers of a general hospital to puerperal women have been revealed by recent experience. Students cannot study in the dissecting room and at the same time practise midwifery without risk. Nurses are often mediums of disease.

Dr. Farr supplies (inter alia) the following Tables. The first shows the mort. among the women of England of the child-bearing age; the next that of mothers in childbearing. Mortality of Women by Childbearing at different Ages in England, in the 7 Years 1848-54, and in the 13 Years 1855–67 :—

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Mortality of Mothers by Childbearing at different Ages in England, in the 7 Years 1848-54, and in the 13 Years 1855-67.

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In 1870 Dr. J. Matthews Duncan, M.D., pub. a work on the Mort. of Childbed and Maternity Hospitals. One of the objects of the work was to refute the statement made by the French writer Le Fort, already quoted in this art., as to the proportions of childbed women dying in hospitals as against those dying at their own homes. Dr. Duncan pronounces this to be "a terribly erroneous statement." Dr. Farr [33rd R. of Reg.-Gen. P. 407] inclines to support Le Fort. Even Dr. Duncan goes so far as to say, "I dare say an hospital could be so constructed and managed as to kill all the inmates.' He argues, however, that exceptional cases should be set aside, and that only well-conditioned maternities should be selected for argument. But he frankly adds, "It is well known that the best maternities are susceptible of vast improvements." Dr. Duncan draws a proper distinction between deaths in childbirth and deaths of childbirth. "Deaths in childbirth," he says, "are all deaths, from whatever cause, occurring within the four childbed weeks, including the period of labour.' Dr. Farr admits the necessity of this distinction, and says it is adopted in the Regis. abstracts.

Dr. Duncan had a careful search made in the Scotch regis. of deaths in Edin. and Glasgow, and found that 153 mothers died out of 16,393, within six weeks after delivery; or I in 107. He also deduced from certain returns of private practice a rate of mort. among mothers not very different from this. From all his inquiries he draws the inference that "no fewer than 1 in every 120 women delivered at or near the full time die within the four weeks of childbed." Dr. Farr considers that estimate too unfavourable. He analyses the data upon which it is founded, and adheres to the national returns, as shown in the reports of the Reg.-Gen. (See 1872.)

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