THE MATERNAL MORTALITY PROBLEM ITS CAUSE AND CURE

Ladies' Mirror, Volume 3, Issue 2, 1 August 1924, Page 27

THE MATERNAL MORTALITY PROBLEM ITS CAUSE AND CURE

WITH AN INTRODUCTION BY DR. TRUBY KINQ

What is Wrong with the Truth ?

A CLEAR AND AUTHORITATIVE STATEMENT BY MISS A. PATTRICK Director of Plunket Nursing for New Zealand; Ex'Matron, Karitane Harris Hospital , Dunedin, and of the Mother craft Training Centre, London.

Concerning the request from The Ladies’ Mirror for a foreword to Miss Pattrick’s paper dealing with the Maternal Mortality question in New Zealand, I am glad to avail myself of the opportunity of saying how heartily I appreciate and endorse the whole spirit and trend of what Miss Pattrick lias to say from the point of view of her very responsible position as Director of Plunket Nursing. The whole effect of Miss Pattrick’s paper is to impress on the community the fact that to a very large extent every woman is responsible for her own health and fitness, and that she owes it as a special and sacred duty to herself and the family to spare no pains to keep herself in the best possible form and bodily fitness throughout pregnancy and nursing— only for the sake of ensuring a normal, well developed child, and for her own comfort and happiness throughout, but also as the only sure foundation of safety at her time of trial, and freedom from trouble afterwards. No one feels more strongly than Miss Pattrick the painful legacy of lifelong invalidism and ill-health which is so often the penalty of arriving at confinement in a state of muscular and general flabbiness — one serious primary handicap of childbirth applying to the majority of modern women, and the one common excuse for the use of forceps and other forms of meddlesome midwifery. Miss Pattrick ’s paper may be summed up as an earnest and convincing plea for greater uniformity in the apparently authoritative and reliable advice which is given to mothers from different sources. Over and over again, Plunket nurses have asked me what course they ought to pursue in regard to expectant mothers who are attended by doctors known to discountenance rather than to advise active exercise during pregnancy. Our nurses are taught, and mothers read in the handbooks issued by the Society and also by the Government, such passages as the following: —• “. . . . the special need of the expectant mother is plenty of open air, exVyriEN any matter whatsoever is under discussion, different viewmints affect the colour and alter the perspective of the whole subject. During the present wide publicity and discussion on the question of Maternal Mortality, this fact has been very apparent. On one side we have the mother's and expectant mothers, on another the medical and nursing professions, on a third side the interested and enlightened lay community, and lastly, the uninterested (until now) and ignorant lay community: each and all are passing opinions which vary according to their different standpoints and experiences. It naturally follows that there is much confusion of thought on the matter; but a few facts are undeniable : 1. Instead of questioning and cavilling over the actual or relative number of mothers lost unnecessarily, all sections of the community should agree to face the essential facts, and unite in order to investigate matters and determine causative

ercise and exposure to the elements, and a sufficiency of rest and sleep.” “A point proved by the observation of farm stock is the fact that there can be no good motherhood without plenty of outing and exercise during pregnancy and suckling. This applies equally to horses, cattle, sheep, etc. If the mothers lack free range and ample exercise, they and their offspring both suffer, and miscarriages and premature birth are frequent, just as as in the case of human beings. ’ ’ The value of uniform authoritative advice as to such vital essentials and the harm done by conflicting instructions • can scarcely be overstated. Miss Pattrick shows her wisdom in not touching on questions outside her immediate professional sphere, but this is not because she has any doubt as to the serious harm that is done to both mother and child by the over-use of anaesthetics and forceps. As I have only recently stated my own professional opinion emphatically on this matter and have been taxed by the Medical Association with exaggeration, I shall be glad if you will print the following extract from an exhaustive monograph by Dr. Ehrenseft on infantile birth injuries, which more than justifies my plea for mercy to the child as well as the mother; — “In considering the subject of intracranial injuries historically it seems striking that it was not the obstetrician but the neurologist who first manifested interest in the clinical aspect of the problem. . . . The last to enter the field was the obstetrician. . . . Without fear of contradiction, I make the assertion that in a large number of cases to-day definite symptoms of intracranial injuries during childbirth are overlooked. The obstetrician of to-day still fails to appreciate his responsibility in this matter. We have an utterly unjustifiable stillborn rate and infantile mortality rate within a week of birth, but the large number of survivors who are more or less gravely damaged for life involves really a much graver wrong. After detailing various grave infactorsthen co-operate wholeheartedly, and reduce risks to a minimum. 2. Co-operation and co-ordination is the keynote to remedying the present painful situation. Each and every person who obstructs reform or quibbles over minor details is guilty of something more than simply hindering progress in the right direction. There has been a good deal of loose talk as to the special responsibilities of the Royal New Zealand Society for the Health of Women and Children (Plunket Society) ‘in this matter. This organisation comprises a very large body of earnest men and women throughout the Dominion, and naturally they are intensely interested in all matters affecting the welfare of mother and child. At the same time they recognise certain limitations in the sphere of the Society’s proper activities regarding the prevention of Maternal Mortality. The Plunket Society has always recognised the supreme importance of correct

juries to the skull, brain and nervous system, etc., resulting from precipitate delivery, Dr. Ehreuseft proceeds:— 1 ‘lt will be well to remember that these represent injuries observed in obstetrical clinics where surely the majority of operations are in expert hands, and performed in general only under well-defined indications. A reduction in the number of these injuries .... can be achieved only by limitation in the number of forceps applications. ‘ ‘ Forceps must be applied only under definite indications. When the operation seems desirable in the interests of the mother the possible mutilation of the infant should be taken into account more seriously than is the prevailing custom. This applies particularly to the obvious readiness of many practitioners to apply the forceps on account of assumed exhaustion of the patient, which more critical analysis in many cases would reveal to be rather impatience of the parturient or weariness of the attendant. in the (supposed) interests of the child one must keep in mind the fact that prolonged natural compression of the head no doubt is less harmful to the infant than a difficult extraction [by artificial means understood].’ A study of recorded cases of fatal intracranial injuries (the majority are to be found in German medical literature) also reveals the frequent mention of twilight sleep. Again, this might be only the incidental results of the greater popularity of twilight sleep a decade ago among some of the German obstetricians. The fact, however, cannot be overlooked that this method ot pain relief lengthens the second stage of labour and in a large number of cases requires termination of labour by forceps. Twilight sleep may impair the life or future health of a child in that it supplies two definite factors [protraction of labour and resorting to forceps] which are commonly held responsible for intra-cranial injuries. Truby King. ante-natal advice and supervision during pregnancy, and has unceasingly stressed this important educative aspect of their work, which is of course intimately related to the question at issue. Ante-natal care is a first essential, but the successful conduct and management of labour plays a more direct part in the prevention of Maternal Mortality, and is outside the immediate functions of our Society. At this juncture I should like to stress the extreme need of consistency and cooperation on the part of all concerned in the giving of ante-natal advice. A considerable number of expectant mothers come to the Plunket Nurses at an early stage, and have been very interested and zealous about carrying out the advice given: then, when the Plunket Nurse has advised the mother to engage her Doctor and Maternity Nurse, the matter of prenatal preparation has too frequently become a debatable point. If the particular medical man or maternity nurse “does not believe in” active daily bodily

exercise (general and special) and other commonsense ante-natal measures advised by the Plunket Nurse, the expectant mother often comes back to her worried, perplexed and confusedand so sidetracking commences. In most such cases there is nothing further for the Piunket Nurse to do but to retire from the field of action, as the mother must have all necessary arrangements for her confinement in hand well ahead, and divided counsel can only hinder matters. Of course, there are many doctors who do impress on the mothers coming under their care, just as strongly as do the Plunket Nurses, the necessity of suitable daily active exercise as well as adequate daily rest for the expectant mother—and in such cases, the same advice coming from two quarters proves doubly convincing, and all goes smoothly and well. But, unfortunately, there is much division within the medical profession itself on this very important question, and the advice given by the extreme advocates of rest and relative passivity tends to nullify our best efforts to establish and maintain bodily fitness throughout pregnancy. The above is a difficulty which must be overcome, in fairness to those mothers who are anxious and willing to carry out the necessary self-preparation. When there is conflicting advice, the natural tendency of most women is to let things slide, and not to bother about attempting to establish reasonable health and fitness long as they are not seriously inconvenienced during pregnancy. This conflicting state of matters will lie remedied only when the intelligent interest and health conscience of the public is generally aroused with regard to such vital questions we cease smoothing matters over, and assuring one another that all is well in the best possible of countries, though in reality the Dominion is very far wrong in having a high maternal mortality. Instead of this easy-going attitude, let us look the facts fairly and squarely in the face, candidly admit the truth, and set to work with concerted action, through every possible channel, to put the matter right without further shilly-shallying and waste of precious time and life. Sir George Newman asks for this fact to be noted, “That no sound progress can he made in the reduction of Maternal Mortality apart from ante-natal supervision.” Dr. Janet Campbell’s recent report to the Ministry of Health, England, on Maternal Mortality, is described as not only a document of importance and interest to statisticians and those specially concerned with problems of public health, but as a moving human record on a subject which, as Dr. Campbell herself says, “bears an intimate relationship to the health and happiness of all sections of the community.” It is interesting to note that Dr. Campbell states: — “It scarcely seems necessary to enlarge upon the serious effect of a high maternal mortality rate upon the health and welfare of many hundreds of families every year. . . . Further, the fact that the mortality returns reveal only a part of the total damage and disability, and that an incalculable amount of unreported and often untreated injury and ill-health results from pregnancy and labour, has many

times been pointed out. It is this burden of avoidable suffering which we seek to relieve, scarcely less than to save lives which need not be lost.” Also, in this report, Dr. Campbell advises treating all suspicious rises of temperature or pulse for which no clear cause is shown, as probably due to infection, and acting accordingly. Further, Dr. Campbell lays great emphasis on the undesirability of resorting to forceps, either because the doctor is in a hurry, or the woman impatient, and says that a patient left to deliver herself must be reassured ■ and made to feel and know that her ease is being well managed, and that she will not be allowed to become over-fatigued, discouraged or exhausted. In relation to the question of the disabilities arising through child-birth, a matter needing recognition is the necessity for not fully resuming ordinary household duties too soon. Because a mother is “up and about” and feels well, it should not. he taken for granted that she is fit to resume her full ordinary work and responsibilities. If all concerned recognised on the one hand the necessity to safeguard the mother from attempting too much in the first few weeks, and on the other hand realised that remaining too long a passive semi-invalid may be equally harmful to mother and child, it would be better for both. The majority of people seem to think that a mother is either “perfectly well,” if she gets up and about during the second week, or that it is natural and right for her to be a helpless semi-invalid for weeks and weeks, and that she ought to be kept in bed and fed on slops accordingly. Here, again, a commonsense, happy, middle course — varying with the health, strength and recuperative power of the particular —should be aimed at; and the cooperation of all concerned mother, father, doctor, nurse, and relatives —is necessary to bring this about. OUTSTANDING FACTS 1. That poverty is not a great contributing factor in Maternal Mortality, although commonly an important factor in infant mortality. Often in districts where poverty, ignorance and superstition abound, in conjunction with a high infant mortality rate, there is a comparatively low maternal death rate. ice versa, in districts where poverty is not prevalent, and ignorance is inexcusable, there may be a low infant mortality with a relatively high maternal mortality. 2. That in those countries where the greater number of women are delivered by midwives, we have the lowest maternal mortality. This is very significant. The fact that more deaths occur amongst mothers delivered by medical men than amongst those delivered by midwives involves more complex considerations, because usually in abnormal cases the doctor is summoned to aid, and fatal consequences are more likely to occur than where the case is normal. SOME SUGGESTED REMEDIES 1. With reference to ante-natal care, I would suggest that, in the interests of all concerned, the medical and nursing professions should arrive at some degree of

uniformity as to the best and soundest fundamental principles for ante-natal guidance, and that they should then work together consistently, uniformly and harmoniously on these —the members of both professions being trusted to use their common sense and judgment in applying their knowledge to the best of their ability. 2. That the public in general be consistently enlightened and educated as to the need for, and great advantages of, ante-natal care and treatmentby constant propaganda through the medium of the Press, authoritative public lectures, classes for women and girls, and dissemination of literature of the best and most reliable kind bearing on the subject. Also, through both women's and men's organisations for social welfare taking the subject as a plank in their platform. 3. That all expectant mothers, in the true interests of themselves and their families, avail themselves more readily of the provisions made for ante-natal care and advice. We shall have to face the fact that the remedy will not lie simply in making public provision for maternity. There is much criticism and many erroneous impressions abroad regarding our State Maternity Hospitals; and this will have to be recognised as a factor to be dealt with. In these institutions everything must continue to be done to encourage a consistently sympathetic and understanding attitude towards the mothersever remembering that certain faults and invidious ideas and conceptions already exist, and that these have been sedulously fostered of late in certain quarters. It is in the best interests of mother and child that husband and wife should be warned and safeguarded against all such perversions and misconceptions. Regarding the improved education of the medical student in the principles and practice of midwifery, the average best course to pursue in the actual conduct and management of labour, the advantages of early treatment and prompt reporting of untoward symptoms, and the training and further organisation of our midwifery service— leave all such matters to be dealt with by those who are capable of speaking with authority on such special aspects of the subject. THE PLUNKET SOCIETY'S WORK 1. It is offering sound and consistent ante-natal advice, guidance and supervision to expectant mothers throughout New Zealand, and for the last ten years has done everything in its power to induce women to avail themselves of this advice and help. 2. It has made provision, through the Plunket Nurses, for ante-natal advice to be given privately, in the mother's own home; or, if preferred, the nurse will make a. special appointment for the mother to see her privately and confidentially at the Plunket Rooms or elsewhere. In most of the larger centres a special room is provided for the nurse to interview expectant mothers, but our nurses are always prepared to see pregnant women at any mutually convenient time or place—and this whether they happen to be married or single. Much has been written and said of late about publicity and discussion only

“searing” the mothers-to-be, and thus making matters worse, rather than better. Of course, there should be no wanton scaremongering; but “What is wrong with the truth?” Surely it is high time that our excessive maternal mortality should he recognised, admitted and dealt with outright, rather than that the truth should continue to be hidden from those mainly concerned, and that the mothers should be left to die needlessly, as heretofore, in a fool’s paradise. The policy of the ostrich is no use here! We may x’est assured that one beneficent result of the present discussion and publicity, followed by much earnest thought anti concerted action, will be to make maternity much safer for mother and child than ever before during our time in New Zealand. Let us all decide to play our individual parts honestly, wholeheartedly, and to the best of our abilities, and let us all pull together in the spirit of the motto of the Plunket Society:— “For the sake of Women and Children, for the advancement of the Dominion, and for the honour of the Empire.”