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Vincent De BrouwereVincent De BrouwereVincent De Brouwere

Maternal & Reproductive Health Unit

Woman & Child Health Research Centre

Institute of Tropical Medicine, Antwerp

Why and when did maternal Why and when did maternal Why and when did maternal

mortality decline in modern mortality decline in modern mortality decline in modern

societies?societies?societies?

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

3

Childbirth before Man-Midwifery

Source: Loudon, 1997

4

Levels of maternal mortality

• Before the 18th century

– England, Somerset parishes 16th-18th: 2,440-2,940

maternal deaths/100,000 baptisms (Wilmott-Dobbie

1982)

– 1,300 on average in Europe before the mid-17th century

https://www.westsussex.gov.uk/leisure/explore_west_sussex/record_office_and_archives/family_history/parish_registers_on_microfiche.aspx

West Sussex parish

register,1561

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Levels of maternal mortality

• Variations

– Famines and chronic nutrition deficiencies

– Puerperal fever epidemics (Leipzig 1652, Germany then Paris 1664, London 1760,Dublin 1770, the rest of Europe)

– Competence of birth attendants and iatrogenesis

Consequence of rickets

Mid-17th century

1887, Britain

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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

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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)

8

A special case

In Sweden:

• Johan von Hoorne (1697)

9

Creation of Midwifery

Schools in 18th Europe

10

Field training (outside schools)

• 10,000 midwives trained by Angélique du Coudray in

France between 1760 and 1783Mme du Coudray’s teaching travel map

The ‘Mme du Coudray’s machine’

Source: Gelbart 1998

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Maternal mortality ratios in England & Wales, USA, and

Sweden

Sources:

Howard

1921;

Högberg et

al. 1986;

Högberg

and Wall

1986a;

Loudon

1992a;

WHO &

Unicef

1996

0

100

200

300

400

500

600

700

800

900

1000

1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000

Mate

rnal

death

s p

er

100,0

00 b

irth

s

England & Wales Sweden U.S.A.

Sulfonamides

Asepsis / antisepsis

1st transfusion of human blood

Blood transfusion safer

Blood bank

C-section rate rise

C-section lethality decreasedSweden

USA

E&W

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SwedenTechnical elements Political conditions

Information:Magnitude & ‘avoidability’

Awareness &

political pressure

Early reduction of maternal mortality

Number and causes of maternal deaths

1751

Health Commission:Skilled birth attendantsrequired to decrease

Maternal mortality

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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

1855

1860

1847 /

18611795

1865

14

SwedenTechnical elements Political conditions

Information:Magnitude & ‘avoidability’

Policy:Professional obstetric care

Awareness &

political pressure

Early reduction of maternal mortality

Involvement & accountability of professionals

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Sweden rural areas, 1861-95. The correlation between the % of

deliveries by trained midwives and the MMR due to maternal causes OTHER than sepsis

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SwedenTechnical elements Political conditions

Information:Magnitude & ‘avoidability’

Policy:Professional obstetric care

Strategy: Access to professional

obstetric care

Awareness &

political pressure

Early reduction of maternal mortality

Involvement & accountability of professionals

Public commitment:regulations, norms

& investment

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1800-2000: maternal mortality ratios

0

100

200

300

400

500

600

700

800

900

1000

1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000

Mate

rnal

death

s p

er

100,0

00 b

irth

s

England & Wales Sweden U.S.A.

USA

E&W

Sweden

USA

E&W

Sweden

USA

E&W

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USA

Technical elements Political conditions

Information:Magnitude & avoidability

Policy:Professional obstetric care

Strategy: Access to professional

obstetric care

Awareness &

political pressure

Stagnation

Involvement & accountability of professionals

Public commitment:regulations, norms

& investment

Late information

No pressure until 1930

Focus on gynaecologists

Abuse of technology

Focus on hospitals

Barriers to accessNo regulation

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1918-20: Maternal mortality according to policies

235

242

258

297

799

664

553

501

433

648

615

Denmark

The Netherlands

Sweden

Norway

E & W

Australia

Ireland

France

Scotland

New Zealand

US

“it was not so much the place of delivery as the type of birth attendant which was

crucial”“in Britain between 1850 and 1950 the midwife was the safer birth attendant for

normal deliveries”

Loudon, 1992

Maternal Mortality Ratio

Mainlydoctors

Mix

doctors

midwives

Mainlymidwives

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Getting all of it right

• Combined ingredients:

– Significant reduction, even without hospitalisation

– Less medicalisation in next phase

Japan, Denmark, Norway,

Sweden, The

Netherlands

• Missing ingredients

– Reduction delayed until modern hospital technologies become accessible

– More medicalisation in next phase

USA, Belgium,

Great-Britain, France, Italy

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1935-1980

Maternal mortality decline

0

100

200

300

400

500

600

700

800

900

1000

1935 1945 1955 1965 1975 1985

Sri Lanka

Costa Rica &Cuba

Japan

Ecuador

MMR

Maternal deaths/

100,000 births

Green: Europe

Purple: Asia

Blue: Latin America• Achieves stable historical lows, but only in the industrialized world

• Professional assistance becomes the norm:– purely hospital based deliveries

– mixed hospital / home

• Technology matures

• Quality of care and evidence based medicine

• Access generalized (universal coverage)

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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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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 competentmidwives with a

recognized status and local accountability

• Human resource is the key…and the biggest

challenge