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MATERNAL MORTALITY AND

MORBIDITY.

INTERIM REPORT OF DEPARTMENTAL COMMITTEE

OF THE MINISTRY OF HEALTH.1

THREE years ago Mr. Neville Chamberlain, thenMinister of Health, appointed a Departmental Com-mittee to advise upon the application to maternalmortality and morbidity of the medical and surgicalknowledge at present available, and to inquire intothe needs and direction of further research work.Sir George Newman was made chairman and Dr.Margaret Hogarth secretary, the other members beingProf. F. J. Browne, Dame Janet M. Campbell, Dr.Ethel Cassie, Dr. Leonard Colebrook, Prof. ArchibaldDonald, Dr. C. E. S. Flemming, Sir Walter Fletcher,Dr. Harold Kerr, Dr. W. H. F. Oxley, Prof. Miles H.Phillips, Dr. C. E. Tangye, and Dr. 0. L. V. S.de Wesselow. Owing to illness Dr. Margaret Hogarthwas unable to undertake the secretaryship, whichdevolved on Dr. Jane H. Turnbull. This com-

mittee has now submitted an interim report. After abrief introduction the chapters are concerned with areport of the maternal death investigation, abortionin relation to maternal mortality, puerperal sepsis,antenatal care, the use of anaesthetics and analgesicsin obstetric practice, medical education in obstetrics,a report on a national maternity service, and con-clusions and recommendations. Appendices includereports from the Royal College of Physicians, fromthe British College of Obstetricians and Gynaecolo-gists, and from a subcommittee of the British MedicalAssociation on anaesthetics in confinements ;memoranda on the sterilisation of the hands and onthe need for bacteriological services in the controlof puerperal infections, by Dr. Leonard Colebrookand Dr. F. Griffith, and a memorandum on antenatalclinics and a copy of the death inquiry form ofthe Maternal Mortality Committee.One of the most important sections of the publica-

tion is the

Report on Maternal Death Investigation.A form of inquiry was drawn up by the committee,

and the medical officer of health of the appropriatelocal authority was invited to be responsible for thecompletion of the forms. It was suggested by theMinistry that a consultant or a specially qualifiedpractitioner should be nominated to assist the medicalofficer of health in cases of unusual difficulty, and insome areas this suggestion has been adopted.The preliminary scrutiny and classification of the

forms on lines laid down by the committee wereentrusted to two medical examiners appointed by thecommittee for this purpose—Mr. G. F. Gibberd,obstetrical and gynaecological registrar, Guy’s Hos-pital, and Mr. Arnold Walker, assistant obstetricsurgeon, the City of London Maternity Hospital.The committee express appreciation of the accuracy,industry, and good judgment with which they havecarried out the onerous and difficult task of preparingthe records, of which 3079 were received betweenNovember, 1928, and April 30th, 1930. It isestimated that about two-thirds of all the maternaldeaths in England and Wales are now coming beforethe notice of the committee. In this interim reportthe first 2000 cases only are considered.

1 H.M. Stationery Office. 1930. Pp. 151. 2s.

The analysis made of these cases has been purelyclinical and administrative. They have beendivided into two classes-a first group comprisingdeaths directly due to pregnancy and childbearing(including abortion and ectopic gestation) andnumbering in all 1596, and a second group com-prising deaths due to an independent disease, con-current with pregnancy or childbirth, in which child-bearing contributed to or accelerated death or waspresent merely as an incident. In this group therewere 404.

DEATHS DIRECTLY DUE TO CHILDBEARING.

The 1596 deaths attributed directly to childbearinghave been divided into the following subclasses,which have been based on clinical rather than

pathological causes of death.

TABLE I.Per cent.

1. Sepsis ........ 616 .... 38-62. Eclampsia .... 218 13-63. Operative shock, &c..... 145 .... 9’04. Antepartum haemorrhage .. 125 .... 7-85. Postpartum haemorrhage .. 92 .... 5-76. Other toxaemias, including chorea

and mania ...... 99 .... 6-27. Embolism ........ 113 .... 7-08. Abortion ..... 168 .... 10-59. Extra-uterine gestation .... 20 .... 1-2

Total.... 1596

These figures may be studied in connexion with thefollowing table from the Registrar-General’s Returnsfor 1928, though the groups do not and cannotexactly correspond. There is sufficiently close

correspondence in the percentages to suggest that thedeaths investigated by the committee are fairlyrepresentative of the whole number occurring in

England and Wales.

TABLE II.—CAUSES OF DEATH AS RECORDED BY

REGISTRAR-GENERAL IN 1928.Per cent.

Abortion ..... 77.... 2-60* *

Ectopic (extra-uterine) gestation 86.... 2-90Other accidents of pregnancy .... 106 .... 3-60Puerperal haemorrhage .... 331 .... 11-30Other accidents of childbirth .... 331 .... 11-30Puerperal sepsis ...... 1184 .... 40-50Puerperal phlegmasia alba dolens not

returned as septic .. 31.... 1.00Puerperal embolism and sudden death 188.... 6-40Puerperal albuminuria and convulsions.. 557 .... 19-00Childbirth not assignable to other

headings ........ 21.... 0-72Puerperal diseases of the breast.... 8 .... 0-27

Total.... 2920

*Othel than those due to sepsis and excluding criminal abortion.

In some instances, in view of all the informationat its disposal, the committee has thought fit to

assign the death to some cause other than the oneentered on the death certificate.

Certain clinical points of interest have emergedfrom the reports.

Sepsis.-The 616 deaths from sepsis have been dividedinto three classes : (1) Sepsis following ordinary normallabour (294 cases); (2) sepsis following delivery by lowforceps, labour being otherwise normal (47 cases) ; and(3) sepsis following complicated labour (275 cases). Classes(2) and (3) have been differentiated because the frequencywith which delivery is effected in private practice by meansof the forceps is such that the committee considered thatit would be inaccurate to classify all such cases as com-plicated labour. In all the cases included in class (2) thereseemed to be no particular reason for the operation beyondslight delay during the second stage of labour. In themajority of the deaths which followed normal labour therewas no positive evidence of any mismanagement duringdelivery, but the records are not always explicit, and atsome stage in many of these cases there is likely to havebeen some failure to exercise due care which was ultimatelyresponsible for a fatal issue.Amongst the 616 deaths from sepsis the nature of the

antiseptic used was the subject of investigation. In 30C

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cases lysol alone was used, in 92 cases mercury preparations,and in 219 cases other antiseptics (or unstated). In fewof the reports on fatal cases of sepsis have the scheduledquestions under " disinfection " have been answered indetail. Serious lack of adequate antiseptic precautions-whether due to ineffective antiseptic solutions or to careless-ness in utilising antiseptics-is held to account for themorbidity in many of the cases. The whole question of theadequate disinfection of the hands and instruments ofthe professional attendants as well as of the surroundings andperson of the patient, is one which deserves, and indeednecessitates, far more attention than it apparently receives.

Certain other features of the deaths attributed to sepsis are of interest. For example, the day of onset of pyrexiawas recorded in 544 cases, and in 66 per cent. of these it wasobserved within the first three days ; this confirms thegeneral impression that patients who escape a rise of tempera-ture during the first three days are less likely to do badly.The duration of the illness was noted in 607 cases. It wasunder one week in 276, from one to two weeks in 182, andlonger than two weeks in 149. Here again the findingsconfirm the impressions of most doctors. Another observa-tion, however, will be a surprise to some practitioners. Theduration of labour was over 24 hours in only 97 casesout of 307 in which a note was made on the point. Itappears from these figures that prolonged labour is not initself dangerous, and that patients and their friends shouldbe educated to believe this.

Eclampsia.—Under this heading are included all cases oftoxæmia in which convulsions or fits occurred. Theynumbered 218. In 105 cases the urine was tested with somedegree of regularity. In 43 of these no albumin was found,but as the date of the last examination of urine was givenin very few cases, the conclusion that albumin was in factabsent until the onset of symptoms cannot fairly be drawn.In 62 albumin was found. Of these, very few receivedtreatment in accordance with the best modern practice andin 41 treatment was definitely deficient. In 113-i.e., overhalf the cases-the urine was either not tested at all orwas tested only occasionally. In only 23 cases is there arecord of blood pressure having been taken before theopset of fits

The committee consider that eclampsia is almost entirely apreventable disease, provided (a) that urine and bloodpressure tests are made regularly and with sufficientfrequency throughout pregnancy, and (b) that adequateand prompt treatment is carried out should an abnormalityarise. In this series 51.7 per cent. of the deaths fromeclampsia are attributed primarily to non-detection of thealbuminuria, and the committee hold that efficient ante-natal examination would probably have enabled the fatalresult to be avoided. Amongst the cases where albuminwas detected, the committee were impressed by the com-paratively frequent absence of competent treatment andparticularly by the failure to secure admission to hospital.Only in 21 out of 218 cases was the treatment really satis-factory. The futility of attempting to treat a pregnantwoman with albuminuria in her own home, where she hasher household duties always before her, is emphasised.The committee consider that the provision of more hospitalbeds for antenatal observation and treatment of suchpatients would save much morbidity and many lives everyyear. Information as to methods of treatment adopted wasnot sufficient to enable any conclusions to be drawn. Thecommittee express surprise, however, to find that accouche-ment force is still practised in the treatment of cases ofeclampsia and of antepartum haemorrhage.

Ante- and Post-partacm Hœmorrhage.—125 cases died fromantepartum and 92 from postpartum hæmorrhage.In the vast majority of cases there had been a

warning haemorrhage some days (often some weeks) beforethe fatal haemorrhage, and had this been heeded, and thepatient removed to suitable surroundings, the fatal resultmight well have been avoided in many cases. Usually thefailure to take heed lay with the patient-in a few cases thedoctor or midwife had considered the premonitory bleedingof no importance, and in some cases, although the potentialseriousness had been recognised, institutional treatmentwas not available. In cases of antepartum haemorrhagetreated in the patient’s own home, the comparative raritywith which injections of saline solution were given byintravenous or even subcutaneous methods or administeredper rectum is held to be significant. In no case of post-partum haemorrhage reviewed was a blood transfusion given,and in only a small proportion was subcutaneous, intra-venous (10 cases), or rectal (20 cases) saline used. Thus in62 cases no attempt whatever was made to replace bodyfluids except by the mouth.

Brief notes are given in respect of the deaths due toother toxaemias, embolism, abortion, extra-uterine gesta-tion. The committee consider that many of the 112 deathsfollowing Cæsarean section could have been avoided hadproper antenatal care and foresight during labour been

available, or had the operation been performed before thebirth canal had become infected.

DEATHS NOT PRIMARILY DUE TO PREGNANCY.

Out of the total of 2000 deaths, 404 were returnedas attributable to concurrent disease associated withchildbirth as follows :=

TABLE III.-INCIDENTAL DEATHS.Lung diseases (not tuberculosis) .... 153Heart disease .......... 98Chronic renal disease 40Pulmonary tuberculosis 26Cerebral hæmorrhage ........ 18Scarlet fever .......... 4Unclassified .......... 65

Total...... 404

The committee were impressed by the general lack offacilities for adequate treatment and managementduring pregnancy and labour of a woman who isseriously ill with intercurrent disease. In heartdisease, in pulmonary tuberculosis, and in chronicrenal disease there is an urgent need for accommoda-tion in institutions which would require a medicalstaff competent in obstetrics as well as generalmedicine.

The 11 primary Avoidable Factor."The committee have carefully analysed all cases of

deaths directly due to childbearing, with theexception of those due to abortion and ectopicgestation, with a view to ascertaining whether deathwas inevitable, or might have been avoided in morefortunate circumstances. In this connexion thedifficulty of correct interpretation by the committeeof the information given in the reports has had tobe faced. They have, however, felt it to be theirduty to note, in every case in which the availableinformation, after being carefully considered, appearedto warrant it, a " primary avoidable factor " in thetrain of events which led up to the fatal result.

In considering these cases the committee have nothad in mind an ideal procedure totally impracticableat the present time in domestic midwifery. Theyhave adopted for convenience a common-sense

standard which, though arbitrary, they considershould be attainable with the present personnel andunder existing general social conditions, at any ratein areas within reach of consultant and hospitalservices. It is on this agreed standard (set out inthe report) that the records have been analysed.

In summarising the conclusions with regard to theprimary avoidable factor, the committee have beenforced to use a numerical method because it seemsto be the only one that lends itself to the task, andnot because they think there is anything approachingmathematical accuracy in their conclusions. Theyare anxious to emphasise that wherever a figure isquoted in the following summary, it is meant to bea convenient index of a matter of opinion, rather thana precise observation on a mathematical certainty.The committee have made a broad general analysisof the deaths due to pregnancy or childbearingwith a view to the discovery of a " primary avoidablefactor," with the following result :-Group 1. Cases showing a primary avoidable factor.... 626

" 2. Cases in which no departure from establishedpractice having a causal relationship to thedeath has been found ........ 660

" 3. Cases not strictly relevant to this part of theinvestigation-viz., abortion and extra-uterine gestation ........ 188

" 4. Cases in which the information was insufficient 122

Total........ 1596

In other words, the committee find as a result ofnquiry into these deaths that in 39 per cent. of theotal number occurring as the direct result of child-

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birth the data obtainable indicate a primary avoidablecause. When the " irrelevant " cases and the caseswith insufficient information are excluded the net

percentage of preventable deaths is as high as 48,that is, nearly half the cases showed a primaryavoidable factor. These avoidable factors have beensubdivided under four headings : (a) omission or

inadequacy of antenatal examination, (b) error of

judgment in the management of the case, (c) lackof reasonable facilities, and (d) negligence of the

patient or her friends.OMISSION OR INADEQUACY OF ANTENATAL

EXAMINATION.

The committee have limited this group to cases

showing complete absence of proper antenatal care.In most of the instances the responsibility rested onthe patient, but it is also evident that the quality ofthe supervision given leaves a good deal to be desired.Faulty antenatal care was considered to be theprimary avoidable factor in 226 of the 626 cases in ’,this group (36 per cent.). In 157 of these cases the I

doctor or midwife responsible for the care of thepatient had failed to make any antenatal examinationat all or the patient had given them no opportunityto do so. And in 69 others antenatal examinationfailed to detect a gross abnormality which musthave been present. These cases are set out in thefollowing tables (A and B) :-

TABLE A. TABLE B. IAbsence of antenatal Failure of antenatal examiaaa I-

examination. tion to detect an abnormality.The doctor was responsible in 28 Examination by doctor 37midwife " 20 " midwife 13patient " 109 " clinic or

hospital 19

157 69

ERROR OF JUDGMENT.

Such errors of judgment as bear little or no refer-ence to the event of death have not been ascribed asa primary avoidable factor.Errors Attributed to Midwives.-The greatest number of

errors which had a direct bearing on the fatal termination- of the case were naturally attributed to doctors, as on them

rests the ultimate responsibility for all conditions showinga departure from normal. For this reason it is recognisedthat deductions based upon a comparison of mortality-rates in the practice of doctors and midwives respectively

- may be entirely misleading. Not only is the midwifeobliged in all abnormal cases to send for medical aid, but

-

she is also bound by her rules to refuse to undertake alone-

a case in which, from the history or from some other indica-tion, abnormality appears probable. Thus the midwifehas not the same opportunity of exercising an independentjudgment, and can always call for assistance when indoubt. The 57 cases where the fatal termination is con-sidered to be due primarily to error of judgment on the

_ part of the midwife were almost entirely cases of contra-vention of her rules. The small remainder were nearly allexamples of gross ignorance, and the midwife was usuallyfound to be much too old for her work.

Errors Attributed to Doctors.-These occurred chiefly indomiciliary practice, though there were a few clear instancesof mismanagement of cases admitted to hospital. In thisconnexion regard should be paid to the handicaps under

- which the general practitioner works in obstetric cases ; he- has for long acquiesced more or less unwillingly in this_ unsatisfactory position. Surprisingly good results are

often obtained in untoward circumstances, but not infre-quently the doctor attempts the impossible, and the case

- ends in a tragedy. Again, unless labour is relatively rapid,- he may find himself pressed by the patient and her relatives-

to expedite delivery, other urgent work may be awaitinghim, and there is often a strong temptation to hasten thecase, even though he may be conscious that in so doing agreater or less degree of departure from the path of soundmidwifery is entailed.

-

In nearly one-third of the cases classed as errors of- judgment on the part of the doctor, the mistake was= premature application of the forceps. In many of- these delivery was not effected, and the patient was

ultimately sent to hospital where incomplete dilata-tion of the cervix or disproportion was usually foundto be present. Other examples of common error arefailure to treat a toxaemia of pregnancy, and the neglectof early warning haemorrhage in placenta praevia.

Error of judgment on the part of the doctor ormidwife or hospital was assigned as the primaryavoidable factor leading up to the death of the patientin 224 cases (35-7 per cent. of the group of 626 cases),and these cases are analysed in the following table :-

TABLE C.

Errors of judgment. Doctor Hos- Mid- Totalpital. wife.

Treatment of severe toxaemias ofpregnancy faulty or absent .. 27 9 I 7 43

Neglect of warning hæmorrhages 17 2 I 5 24Improper use of forceps....41 4 - 45Faulty treatment of third stage oflabour . 16 2 9 27

Non-recognition of obstructedlabour ........ 8 2 10 20

Gross errors in the prevention orrecognition of sepsis.... 7 2 14 23Miscellaneous .....

[ 30 — 12 42

Total .... 146 21 57 224

LACK OF REASONABLE FACILITIES.

In this class are included cases in which the absenceof skilled assistance was the primary cause in thedeath, cases conducted in abnormal surroundings,such as delivery in a cowshed, instances of womenliving in remote and isolated situations, and one ortwo examples of extreme overcrowding. Poverty anduncleanliness, although unfortunate accessory factors,have not, so far as can be ascertained from thereports, borne any direct relation to these deaths.Lack of reasonable facilities was considered to be the

primary avoidable factor in 64 cases. Only a few of thedeaths could be attributed to difficulty in obtaining medicalassistance of some sort. In 26 cases it was thought thatthe most important factor leading to the fatal issue wasabsence of a second doctor to give an anaesthetic. In 13cases it seemed probable that if the doctor had had a trainedassistant, instead of having to rely in a difficulty upon theinadequate help of a totally incompetent relative or friend,the result would have been different. In 25 deaths it wasconsidered that the most important cause leading up tothe death lay in the bad surroundings under which thepatient was confined.Absence of hospital beds and of consultant serviceshad undoubtedly been responsible for death in manycases.

NEGLIGENCE OF THE PATIENT AND HER FRIENDS.

In 112 deaths the Committee considered that themost important cause leading up to the death wasabsence of sensible cooperation on the part of thepatient-in the majority of cases amounting todeliberate refusal to carry out advice or to take anyreasonable steps to obtain help. In addition to these,there were 109 patients who failed, presumablythrough ignorance, to submit themselves to antenatalexamination, and these have been included underthe appropriate heading.Cases where No Avoidable Cause has been

Detected.There remain 660 deaths, in some of which there

was nothing definite in the report to show that thewoman had not received attention in accord with thereasonable standard laid down, while in others thefailure to attain the standard had no apparentcausal relation to the fatal termination. It shouldbe noted that in a large number of cases failure ofthe Committee to discover an avoidable cause isprobably due to deficient information rather than tothe absence of such a cause.

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Conclusions.The committee draw certain conclusions from this

section of the report. While emphasising theextreme importance of antenatal examinations,they have found evidence of a certain amount ofinefficient work which has passed under the guiseof " antenatal care." They consider that adequateand satisfactory antenatal care requires as much

experience, as much skill and as much diligence asoperative midwifery itself, and that every effortshould be made to secure effective medical supervisionby competent medical practitioners in close touchwith actual obstetric work.Not only have the Committee found evidence of

neglect in antenatal diagnosis, but also to a greatextent in antenatal treatment. In many instancesfailure to treat a patient has largely been due to lackof facilities, and the Committee think that greatbenefit would follow an increase in the number ofbeds available for such cases in institutions. Inrelation to serious complications and accidents oflabour, the Committee have ample proof of the needfor a higher standard of knowledge and skill on thepart of the general practitioner, as well as for the

provision of consultant services and of an increasednumber of readily available hospital beds.While better facilities for blood transfusion wouldbe highly advantageous, the majority of cases of

haemorrhage and obstetric shock can be saved fromdeath by the immediate replacement of fluid by intra-venous or subcutaneous saline solution or other suit-able fluid. Saline solution per rectum may be effectivein mild cases, but the fluid is not absorbed by thebowel in cases of severe collapse. The Committee,therefore, regard the extended provision of theseservices as an essential part of any measures takenfor the improvement of midwifery work. They lookfor substantial improvement in the number of deathsfrom sepsis following abnormal labour. It seems tothem a reasonable hope that the amount of difficultmidwifery performed under unsuitable conditionswill steadily decrease, and as a result the number ofdeaths from sepsis in this group will decrease also.On the other hand, the number of deaths from

sepsis following " normal labour " demands intensive

investigation. Failure in efficient antiseptic techniqueprobably accounts for a considerable number of thesecases. (To be concluded.)

OBITUARYSIR FRANCIS CHAMPNEYS, Bt., M.D. Oxf.,

- - F.R.C.P. Lond. -

Sir Francis Champneys, the well-known obstetricphysician, died on July 30th at his residence, Little-wood, Nutley, at the age of 82.

Francis Henry Champneys was the second son ofthe Very Reverend William Champneys, Dean ofLichfield, and was educated at Winchester where hewas a scholar, at Brasenose College, Oxford, and atSt. Bartholomew’s Hospital. At Oxford he obtaineda first class in science in 1870, and two years laterhe was elected Radcliffe Travelling Fellow. Champneys

graduated inmedicine in1875, and inthe followingyear obtainedthe M.R.C.P.Lond. Whilehe held thetravellingscholarshiphe did post-graduate workin Vienna,Leipzig, and

Dresden, andin the last cityheld the postof clinicalassistant tothe RoyalSaxon Lying-in Hospital,thus commenc-ing his success-ful career as anobstetrician.On returningto London hebecame assist-ant to Dr.MatthewsDuncan, whoBartholomew’s

SIR FRANCIS CHAMPXEYS.

[Photograph by Elliott J. Fry.

was then obstetric physician at St.

Hospital, and was himself made an obstetric tutor inthe medical college, an appointment which had someinfluence on his future career. For although in 1882,the year he was elected F.R.C.P., Champneys wasmade obstetric physician at St. George’s Hospital, insuccession to that great and original teacher, RobertBarnes, he was invited to return to St. Bartholomew’sHospital on the death of Matthews Duncan, andaccepted the invitation. Meanwhile he had beenappointed assistant physician to the General Lying-inHospital, and found there material which contributedto his wide knowledge of practical obstetrics. As ateacher Champneys was fluent and informing in hislectures and clear in his practical demonstrations.While he was at St. George’s he left the operativeside of his department to some extent in the hands ofthe surgical staff, while at St. Bartholomew’s theterms of his appointment confined him to midwifery.His writings are consequently for the most partconcerned with obstetric problems, but when invitedby the Harveian Society of London to deliver theHarveian lectures in 1890 he chose for his subjectPainful Menstruation. The lectures were afterwardspublished in THE LANCET, and are noteworthy forthe lecturer’s discrimination between distress ofdifferent kinds, ranging from vague discomfort toacute localised pain. The general conclusions con-cerning dysmenorrhcea in his first lecture show abalanced outlook on the psychology of differenttypes of patient which gives a clue to his success inrelieving mental as well as physical suffering.Under the Midwifery Act of 1902 which, after

considerable opposition both within and without themedical profession, obtained a place on the Statutebook, the Central Midwives Board came into

existence, and Champneys was made its first chair-man. As is well known, the purpose of the Act wasto regulate the practice of women midwives, tostandardise the education of those who obtained aplace on the official roll of midwives, and to exercisedisciplinary powers such as would prevent the

incompetent woman, or woman who failed to observethe regulations of the Act, from maintaining theirplace on the roll. Champneys held strong viewson the importance of the duties of the Board. He