Vincent De Brouwere (Professor of Public Health at the Institute of Tropical Medicine, Antwerp, Belgium): Why and when did maternal mortality decline in modern societies?

1. Why and when did maternal
mortality decline in modern
societies?
Vincent De Brouwere
Vincent De Brouwere
Maternal & Reproductive Health Unit
Woman & Child Health Research Centre
1
Institute of Tropical Medicine, Antwerp

2. Decline of maternal mortality in Western
modern societies
• Midwifery development: 17th century
– Textbooks of obstetrics and illustrated manuals (initiated
by French men-midwives)
• Midwifery schools: 18th century in Europe
• Professionalization of childbirth: 19th century
Success however depended on
social integration of techniques and
political willingness to scale-up the
professionalisation of childbirth
2

3. Childbirth before Man-Midwifery
Source: Loudon, 1997
3

4. Levels of maternal mortality
• Before the 18th century
– England, Somerset parishes
16th-18th: 2,440-2,940
West Sussex parish maternal deaths/100,000
register,1561 baptisms (Wilmott-Dobbie
1982)
– 1,300 on average in Europe
before the mid-17th century
4
https://www.westsussex.gov.uk/leisure/explore_west_sussex/record_office_and_archives/family_history/parish_registers_on_microfiche.aspx

5. Levels of maternal mortality
1887, Britain
• Variations
– Famines and chronic nutrition deficiencies
– Puerperal fever epidemics (Leipzig 1652,
Germany then Paris 1664, London 1760,
Dublin 1770, the rest of Europe)
Mid-17th century – Competence of birth attendants and iatrogenesis
Consequence of rickets
5

6. Guilds and regulations
• Internal regulations through the guilds (professional
oath)
• External regulations from City Council
– Paris: 1560
– The Netherlands (early 17th century): town midwives
– Germany, England & Wales (18th century)
• Countryside: no real regulation but religion and
social pressure
6

7. Training midwives: the 17th French school
Textbooks first
Louise Bourgeois (1609)
François Mauriceau (1668)
Cosme Viardel (1671)
Jane Sharpe (Britain)
(1671)
Paul Portal (1685)
Hendrik van Deventer,
Holland (1685)
Philippe Peu (1694)
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8. A special case
In Sweden:
• Johan von Hoorne (1697)
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9. Creation of Midwifery
Schools in 18th Europe
9

10. Field training (outside schools)
• 10,000 midwives trained by Angélique du Coudray in
France between 1760 and 1783
Mme du Coudray’s teaching travel map
The ‘Mme du Coudray’s machine’
Source: Gelbart 1998 10

11. Maternal mortality ratios in England & Wales, USA, and
Sweden Sulfonamides
1st transfusion
of human blood
1000 Blood
bank Blood transfusion
Maternal deaths per 100,000 births
900 safer
Asepsis /
antisepsis
800 USA
700 C-section rate
E&W rise
Sources: 600
Howard
C-section lethality
1921; 500 Sweden decreased
Högberg et
al. 1986; 400
Högberg 300
and Wall
1986a; 200
Loudon
1992a; 100
WHO & 0
Unicef
1996
1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000
England & Wales Sweden U.S.A. 11

12. Sweden
Technical elements Political conditions
Information: Awareness &
Magnitude & ‘avoidability’ political pressure
Number and causes Health Commission:
of maternal deaths Skilled birth attendants
1751 required to decrease
Maternal mortality
Early reduction of
maternal mortality
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13. Professionalization of midwifery in
Sweden
1708: midwifery school
1723: J. von Hoorn 1st paid state employed teacher of midwifery
1751: decision to increase the number of midwives
1829: training in the use of forceps and sharp instruments
1881: asepsis and antisepsis
1847 /
1795 1861
1855
1860 1865
13

14. Sweden
Technical elements Political conditions
Information: Awareness &
Magnitude & ‘avoidability’ political pressure
Policy: Involvement & accountability
Professional obstetric care of professionals
Early reduction of
maternal mortality
14

15. Sweden rural areas, 1861-95. The correlation between the % of
deliveries by trained midwives and the MMR due to maternal
causes OTHER than sepsis
15

16. Sweden
Technical elements Political conditions
Information: Awareness &
Magnitude & ‘avoidability’ political pressure
Policy: Involvement & accountability
Professional obstetric care of professionals
Strategy: Public commitment:
Access to professional regulations, norms
obstetric care & investment
Early reduction of
maternal mortality
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17. 1800-2000: maternal mortality ratios
1000
Maternal deaths per 100,000 births
900
USA
800
700
E&W
600
500
Sweden
400
300
200
100
0
1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000
England & Wales Sweden U.S.A.
17

18. USA
Technical elements Political conditions
Information: Late information Awareness &
Magnitude & avoidability No pressure political pressure
until 1930
Policy: Involvement & accountability
Focus on gynaecologists
Professional obstetric care of professionals
Abuse of technology
Strategy: Public commitment:
Focus on hospitals
Access to professional regulations, norms
obstetric care Barriers to access & investment
No regulation
Stagnation
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19. 1918-20: Maternal mortality according to policies
Maternal
Mortality Ratio
Mainly 799 US
doctors
648 New Zealand
615 Scotland
“it was not so much the place of delivery
France 664
as the type of birth attendant which was
Ireland
553
Mix
doctors
crucial” 501 Australia
midwives “in Britain between 1850 and 1950 the
433 E&W
midwife was the safer birth attendant for
297 Norway
normal deliveries” Sweden
258
Mainly
midwives 242 Loudon,Netherlands
The 1992
235 Denmark
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20. Getting all of it right
• Combined ingredients: • Missing ingredients
– Significant reduction, even – Reduction delayed until modern
without hospitalisation hospital technologies become
– Less medicalisation in next accessible
phase – More medicalisation in next
phase
Japan, Denmark, Norway, USA, Belgium,
Sweden, The Great-Britain, France, Italy
Netherlands
20

21. Maternal deaths/
1935-1980 MMR
100,000 births
1000
Maternal mortality decline
Green: Europe
900
Purple: Asia
• Achieves stable historical 800
Blue: Latin America
lows, but only in the 700
industrialized world
• Professional assistance 600
becomes the norm: Sri Lanka
500
– purely hospital based deliveries
– mixed hospital / home 400
• Technology matures
300
• Quality of care and evidence Ecuador
based medicine 200
Japan
Costa Rica &
Cuba
• Access generalized (universal
100
coverage)
0
1935 1945 1955 1965 1975 1985
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22. Lessons from European history
• Knowledge of maternal mortality levels and concept
of avoidable death
• Professionalisation of childbirth
– Education leading to competence
– Non interventionism and patience
– Recognized status by the government
– Accountability
• Scaling up of skilled attendance at delivery
– Midwives in numbers
– Financial barrier removed
– Backup from hospitals
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23. Messages from historical Europe to Africa
• The key to reduction of MM is professionalisation of obstetric
care backed-up by a network of accessible hospitals (C-EmOC)
• The key to successful
professionalisation is the
production of adequate
numbers of competent
midwives with a
recognized status and
local accountability
• Human resource is the key…
and the biggest
challenge
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