MATERNAL MORTALITY

Pregnancy and the puerperal period—childbirth and the weeks following— presented much pain, suffering and danger to nineteenth-century Australian women. Death claimed many through eclampsia and hypertensive disorders of pregnancy, haemorrhage, embolism, complications of unsafe abortion, and that great fear of pre-antibiotic times, puerperal sepsis. In the 1890s and early 1900s, around 600 deaths a year Australia-wide were attributed to maternal causes. Quantifying the incidence of maternal mortality, however, presents problems. The nosological indexes provided neither a definition for, nor a grouping under which to count maternal deaths. Deaths resulting from complications of pregnancy and childbirth were returned under a number of causes (Table 6.3), and these were classified variously as Miasmatic diseases, Diseases of the organs of generation, Developmental diseases of adults, Septic diseases, Diseases of parturition or Puerperal conditions.

Table 6.3: Causes of maternal deaths in nineteenth-century Australian nosologies

Archer, 1853

18 Puerperal Fever 104 Childbirth, Abortion

Archer, 1863

I-1-9-Metria IV-2-2-Childbi rth

Hayter, 1886

I-6-4-Puerperal Fever VI-9-1-Abortion, Mis ca rriage VI-9-2-Puerperal Ma nia VI-9-3-Puerperal Convulsions

VI-9-4-Pla centa Praevia , Flooding VI-9-5-Phlegmasia Dolens

VI-9-6-Other Accidents of Childbi rth

Royal College of Physicians, 1896

I-5-1-Puerperal Septi caemia, Saproemia I-5-2-Puerperal Pyaemia

I-5-3-Puerperal Phlegmasia Dolens I-5-4-Puerperal Fever

II-10-1-Abortion, Mis ca rriage II-10-2-Puerperal Mania II-10-3-Puerperal Convulsions II-10-4-Pla centa Praevia , Flooding

II-10-5-Pregnancy, Childbi rth, Other Accidents

Bertillon, 1906

134 Accidents of Pregnancy 134a Illegal Opera tions 135 Puerperal Haemorrhage 136 Other Accidents of Childbi rth 137 Puerperal Septi caemia

138 Puerperal Albuminuria and Eclampsia 139 Puerperal Phlegmasia alba dolens 140 Other Puerperal Accidents, Sudden Dea th 141 Puerperal Diseases of the Breas t

Misclassification, whether unintentional or deliberate, was significant. Deaths which should have been classified as metria or as puerperal fever were often

returned as convulsions, haemorrhage, rupture of the uterus or some other cause (Jamieson, 1882b). A proportion of maternal deaths were wrongly attributed to associated symptoms or non-maternal conditions such as debility, exhaustion, peritonitis, pyaemia, septicaemia, uterus disease, cardiovascular disease, or other fevers such as typhoid (Hayter, 1889, p.143). Doctors, midwives and those managing labour were reluctant to admit that the deaths of women under their care were due to maternal causes (Jamieson, 1882b, 1887). Deaths from induced abortions were also known to be registered to other causes, such as miscarriage (Smith, 2011, pp.68–73, 190–196).

Figure 6.38: Maternal mortality ratio, by colony, 1853–1906

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 New South Wales

Deaths per 1,000 live births

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 Victoria

Deaths per 1,000 live births

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 Queensland

Deaths per 1,000 live births

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 Western Australia

Deaths per 1,000 live births

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 South Australia

Deaths per 1,000 live births

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910 Tasmania

The official statistics under-represented maternal mortality and for much of the period perhaps grossly so (Smith, 1979, p.13ff.). Kippen (2005) a number of different methods to count maternal deaths in 1880s Tasmania, finding that the Statistics of Tasmania may only have reported half of the actual number.

Nonetheless, the official statistics have here been used to calculate the maternal mortality ratio (MMR), this being the number of maternal deaths per 1,000 live births. It should also be noted that the determination of annual numbers of live births presents its own set of problems, since these were subject to under- registration, and even more so than deaths. Registering births and deaths was a legal obligation, but whereas burial could not proceed until a death had been registered, there was no equivalent sanction for birth. For whatever reason, many births were simply not registered. ‘Concealment of birth’, or misreporting of infant deaths as stillbirths by midwives and other birth attendants also occurred.

The MMR varied markedly across the colonies (Figure 6.38). It exceeded 10 deaths per 1,000 live births in Victoria in the early 1850s, in Western Australia in 1874–75 and 1884 and in Tasmania in 1875. Rates in mid-1870s Victoria remained high with Hayter’s justification being that his returns were more exact than those of other colonies (Jamieson, 1882b). Rises in 1866–67, 1874–75, 1881–82 and 1884 were concurrent with epidemics of measles and scarletina (Hayter, 1889) with one explanation linking these rises to changes in the prevalence of streptococcus in the population (Loudon, 1987).

The ‘great outbreak’ of 1874–75 occurred simultaneously in Australia, England and other countries. Farr felt that this ‘deep, dark and continuous stream of mortality’ was attributable to a want of skill on the part of midwives and physicians (Hayter, 1880, p.141). Jamieson (1882b, 1884) commented on the high prevalence of puerperal fever and other infectious diseases during these years, and proposed that puerperal fever should be closely linked if not analogous to puerperal pyaemia or septicaemia, erysipelas, pyaemia and septicaemia.

Most births occurred in the home and were attended by midwives, or increasingly by medical practitioners. Although chloroform and antisepsis were

to revolutionise obstetrics, these were confined to hospitals and had little effect on home deliveries (Woolcock et al., 1997; Loudon, 1997). Mortality was high in lying-in hospitals—charitable maternity hospitals largely utilised by the poor— although the introduction of antiseptic midwifery in 1887 led to a fall in rates at the Melbourne Lying-In Hospital (Anderson, 1888; Balls-Headley, 1888; Hayter, 1889; McCalman & Morley, 2003).

Figure 6.39: Maternal mortality ratio, Australia, 1856–1906

Unlike so many other causes of death, maternal mortality rates refused to fall in the latter decades of the nineteenth century. A number of colonies (New South Wales, Victoria, Western Australia, Tasmania) saw rises in MMR in the 1890s, although these can be partly ascribed to improvements in registration of causes of death. Coghlan (1900) believed parochially that ‘the New South Wales

0 2 4 6 8 10 12 14 1850 1860 1870 1880 1890 1900 1910

Deaths per 1,000 live births

0 5 10 15 20 25 1850 1870 1890 1910

returns since 1892 have been compiled with great care, and are perhaps nearest to the truth, while the Victorian returns are also fairly reliable’.

Deaths from maternal causes comprised around one per cent of total mortality in nineteenth-century Australia (Figure 6.39). Risks were greater for first confinements, and for unmarried women for whom many confinements took place in lying-in hospitals (Jamieson, 1884; Coghlan, 1898). Women aged in their thirties were most at risk of maternal death (Figure 6.40). In 1875–79, among women aged 35–39 years, 159 in every 100,000 died from maternal causes. By 1900–04, the rate had fallen somewhat to 111.

Figure 6.40: Age-specific maternal mortality rate, Australia, 1875–79 and 1900–04

In 1906, MMR in Australia stood at 5.80 deaths per 1,000 live births. It remained steady for the next three decades, not falling below five. This trend in maternal mortality was replicated in almost all western countries with little change in rates before the mid-1930s (Loudon, 1991).

Although a new image of responsible motherhood in Australia began to emerge around the turn of the century, fears about low levels of population growth supported efforts to increase the welfare of infants, and concern for mothers lagged (Lewis, 1980). Significant improvements were not seen before changes in maternal policies and systems of care and the advent of antibacterial sulphonamide drugs in the 1930s (De Costa, 2002; Loudon, 1992).

0 40 80 120 160 200 0 1- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- Age group (years)

1875-79 1900-04 Deaths per 100,000 females