Chapter XV.
MATERNAL AND NEONATAL MORTALITY.
1. Birth Statistics of New Haven. For purposes o comparison with current mortality rates we have in other chapters used the statistics of fifty years and twenty years ago. Similar data for birth rates and general death rates in New Oaven are presented below.
BIRTH RATES AND DEATH RATES IN NEW HAVEN.
(PER 1000 POPULATION).
| Years | 1876-8 | 1906-8 | 1924-6 |
| Birth Rate | 33.9 | 27.5 | 21.5 |
| Death Rate | 19.4 | 17.9 | 12.2 |
| Difference | 14.5 | 9.6 | 9.3 |
It is evident that during the period from 1877 to 1926 the birth rate of New Haven fell even faster than its death rate, so that the net increase in population (due to excess of births over deaths) is now only two-thirds of what it was half a century ago.
This is of course a world-wide and universal problem and one which may be regarded with equanimity except in such nations as still yearn for "cannon-fodder" in the interest of aggressive nationalism. Furthermore, during the past twenty years the decline in the death rate has practically caught up with that of the birth rate.
If we proceed to our analysis of certain specific factors in the death rate which are closely associated with the problem of child birth we find again some cause for satisfaction, combined with evidence that still greater gains in the prevention of preventable disease may be anticipated.
Childbirth should be a normal process, not a disease, and the fact that it is still so often fatal is one of the outstanding reproaches to our civilization. New Haven has, however, made substantial progress in dealing with this problem as indicated in the table below.
DEATH RATE FROM PUERPERAL CAUSES.
(DEATHS PER 1000 BIRTHS).
|
Puerperal Septicemia |
New Haven |
U.S. Birth Reg. Area |
Denmark | ||
| 1876-8 | 1906-8 | 1924-6 | 1926 | 1926 | |
| 4.3 | 2.5 | 1.9 | 2.4 | 1.1 | |
|
Other puerperal causes |
3.6 | 4.0 | 2.8 | 4.1 | 1.5 |
| Total | 7.9 | 6.5 | 4.7 | 6.5 | 2.6 |
The puerperal death rate in the United States as a whole is seen to be abominably high, as indicated by the 1926 figures for the Registration Area which are the same as the rate for New Haven twenty years ago. Our local rate has now been reduced to 60 per cent of what it was half a century ago but is still nearly twice as high as the rate for Denmark, the country which has the best record in the world in this respect.
Closely allied to the maternal mortality rate and essentially due to the same factors, is the health rate of infants during the first month of life from the group of so-called congenital causes. The classification of causes of death fifty years ago was too inaccurate to make comparisons in this respect possible; but twenty years ago the mortality from these diseases of early infancy was 48 per 1000 births (average of 1906-8) while in 1924-6 it fell to 30 as against a rate of 34 for the Registration Area. For the years 1918-21, 35 infants out of every 1000 born died within the first month of life while for the year 1927 (a preliminary analysis for which has just been completed) the rate rose to 39. In Amsterdam the mortality rate for the first month of life has been reduced to 13.
New Haven, as in other respects, has made substantial progress in the reduction of maternal mortality and mortality of infants during the first month of life, - progress distinctly better than that which has been made in the United States as a whole. Much, however, still remains to be done.
2. The Program for Reducing Maternal Mortality. The mortality of mothers in childbirth and the mortality of infants from the so-called congenital causes, during the first month of life, are due to two sets of factors, - operating respectively before and at the time of birth. They are due either to the impaired physical conditions of the mother during the period of pregnancy or to poor obstetrical care. Our program of control must therefore concern itself with prenatal service and good obstetrics; and it is along these two lines that our program in Armerica has been deficient in the past and it is here that we must progress in the future if we are to control maternal and neonatal mortality.
3. Prenatal Conference Service. The first essential in a program of maternity hygiene is to provide effective machinery for the supervision of the health of the expectant mother. This demands that she should be brought, as early as possible in the period of pregnancy, in contact with a physician who will make, - and will repeat at frequent intervals up to the time of delivery, - physical examinations to detect abnormalities which require attention and who will give the necessary hygienic advice as to the rules of personal hygiene (adequate diet, avoidance of overstrain, etc.) necessary to keep the mother in the best of physical condition.
In order to attain this end, there are at present four prenatal conferences operated in New Haven, one by the New Haven Dispensary (under Dr. A. E. Morse), one at Grace Hospital (under Dr. E. B. Perrins) and two by the Visiting Nurse Association (under Dr. Margaret Tyler) One of the latter is held at Christ Church Parish House, 94 Broadway, the other, - generously supported by the Junior League and known as the Junior League Clinic, - at 519 Ferry St.
The character of these conferences is entirely admirable but there seems to us a certain technical objection to the plan under which medical service for such conferences is provided by the Visiting Nurse Association. It is very common for nursing organizations to provide medical service for such conferences and in the present instance Dr. Tyler is probably the one person best suited for the task; but in theory it seems sounder that medical appointments should be made by an official medical institution rather than by a board primarily interested in nursing. It would seem proper to ask the Board of Health to assume responsibility for the medical appointments in question, with the counsel of an advisory group of obstetricians.
The volume of prenatal conference service rendered in New Haven is also admirable as compared with generally accepted standards. In the year 1926 the Junior League clinic had not been opened. During that year 865 visits were paid to the New Haven Dispensary Conference, 671 to the Visiting Nurse Association conference and 236 to the Grace Hospital conference or 1772 in all. The Appraisal Form standard calls for 250 visits per 1000 births which would correspond to but 925 visits so that New Haven has a figure nearly double the quota. This quota, however, is altogether too low in comparison with the real needs of the case. Actually 217 prenatal patients attended the Visiting Nurse Association conferences and 301 the Dispensary conferences or 518 in all, - only one-seventh of the pregnant women in New Haven. We believe that one of the most important problems of the future is the considerable expansion of this service.
4. Pre-Natal Nursing. In the field of prenatal nursing the Visiting Nurse Association is again doing a remarkably extensive work. During the year 1926 the nurses of the Association made 4299 prenatal visits to 391 patients, and nurses attached to the Dispensary obstetrical service made 1131 visits to 301 patients, - in all 5430 visits to 692 patients. The Welfare Nurses of the Health Department also do some prenatal visiting. Even the figure for the V. N. A. Service by itself is well in excess of the standard of one visit per birth (3698) set by the Appraisal Form.
It seems on the whole undesirable to interfere with the general program of generalized home nursing service by sending nurses from the Dispensary staff into the homes. It would, we believe, be productive of economy and effieiency, if all follow-up of the New Haven Dispensary Conference were placed in the hands of the Visiting Nurse Association to conduct as they conduct the follow-up for the other two clinics. It would be necessary if this were done, however, - and it seems in any case essential for the best prenatal nursing service, - that the Visiting Nurse Association nurses (whenever physicians in charge do not object) should make blood pressure observations and urine tests on all prenatal cases visited. A special course of instruction should of course first be provided to perfect them in their technique.
5. Obstetrical Service. The second important element in the control of maternal mortality is good obstetrical care, which means intelligent cooperation with, - not radical interference with, - the process of delivery. It is a fact worthy of note that the countries, like Denmark and Holland, where maternal mortality is lowest are the countries where the midwife is most extensively used and most carefully trained and supervised; but it is our belief in America that even better results will ultimately be secured by really expert medical obstetrical care assisted by the graduate nurse. We are inclined therefore to measure the success of our program by the degree to which midwife practice is eliminated and the degree to which hospital deliveries are increased.
New Haven has for years enjoyed a high quality of obstetrical service and as a result considerable progress has been made along this line. In the year 1926 the attendance at delivery was as follows:
|
Type of Attendance at Delivery. |
Per cent of Births. |
| Midwives | 14 |
| Physicians in Homes | 40 |
| Physicians in Hospitals | 45 |
At Grace Hospital there were 653 births, at New Haven Hospital, 477, at St. Raphael's Hospital 452 and at various small hospitals and nursing homes, 148.
Midwives are registered by the State Department of Health and supervised and instructed by the city Department as well. There were 26 of them licensed to practice in New Haven in 1926 but only half of these are in active practice.
The proportion of all the births in the city occurring in the three general hospitals has risen steadily from 21 per cent in 1917 to 41 per cent in 1926, an excellent record. It is just over the quota of 40 per cent called for by the Appraisal Form. It would be highly desirable, however, to increase this figure still further. Many western cities reach a figure of 75 per cent of all births occurring in hospitals, and Hartford has a ratio of 70 per cent, a highly desirable situation, since it is only in a well-equipped hospital that ideal delivery service can be provided.
A particularly admirable factor in the local situation is the home obstetrical service provided free or at cost of transportation by the staff of the Department of Obstetrics of the New Haven Hospital, which makes it possible for the mother who cannot for any reason go to the hospital to obtain the best of expert care.
6. Obstetrical Nursing. One real lack in the New Haven machinery for maternity care has been the absence of obstetrical nursing service in the home, except that provided by the New Haven Hospital for the home delivery service just described. Whatever we may think of the desirability of more general hospitalization of obstetrical cases, a considerable proportion of such cases will always be cared for in the home. Indeed no great addition to the 1600 obstetrical cases now hospitalized each year is possible without expansion of existing hospital facilities for this class of cases. With over 1500 cases a year delivered by private physicians in the homes there is a natural and proper demand for visiting nurse service, - in this as in other conditions requiring nursing care.
In the years 1920-23, the Visiting Nurse Association did operate a delivery service which was later adandoned on account of lack of funds. The Community Chest has recently agreed to provide an appropriation for the resumption of this work but has wisely provided that nursing service for obstetrical cases shall be free only when medical service for such cases is also free. There is danger that a delivery service operated without adequate safeguards may actually do harm by encouraging poor obstetrics and the restriction imposed by the Chest cannot work any hardship since free home medical service from the staff of the hospital is always available. With this provision the resumption of delivery service by the Visiting Nurse Association should form a most valuable element in the community health program; and the service thus provided might naturally and properly cover the home obstetrical service now provided by the Yale School of Nursing.
7. Post-Natal Care. As a final step, the Visiting Nurse Association continues its supervision of the maternity case on into the post-natal period; and in 1926, 913 cases of this type were discharged, with an average of 11 visits per discharged case.
8. Summary and Recommendations. lt is evident that the New Haven program for the control of maternal and neonatal mortality is already far above the average. On the Appraisal Form standards it obtains a perfect score of 75 points (30 for ratio of prenatal nursing visits to homes, 25 for ratio of visits to prenatal conferences, 8 for supervision of midwives and 12 for hospitalization). The results obtained are equally notable, since both maternal mortality rates and mortality rates from diseases of early infancy are now substantially lower than those for the registration area as a whole.
Nevertheless there is still more to be accomplished if New Haven is to approach the results attained in such foreign cities as Copenhagen and Amsterdam. The following readjustments and expansions, none of them involving additional expenditure except in so far as an increase in the staff of the Visiting Nurse Association may be ultimately involved, would we believe assist materially in attaining such an end.
Recommendation 48. That the responsibility for the appointment of medical staff for the prenatal conferences of the Visiting Nurse Association should be transferred to the Department of Health, to be exercised with the aid of an advisory group of obstetricians.
Recommendation 49. That the home nursing service in connection with the obstetrical service of the New Haven Dispensary be carried by the Visiting Nurse Association, if a mutually satisfactory agreement between the two organizations can be reached.
Recommendation 50. That the staff nurses of the Visiting Nurse Association be trained in the technique of blood-pressure readings and urine tests and make such tests and readings on all prenatal cases unless the physician in charge prefers this should not be done.
Recommendation 51. That special efforts be made to increase the volume of prenatal conference work and to promote a further increase in the number of deliveries which take place in hospitals and under the care of expert obstetricians.
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