Improvement in obstetric and infant care and the resultant decrease in the terrific death rates of mothers and infants are among the achievements to which modern civilization can point with greatest pride. Yet there are still far too many unnecessary deaths among both mothers and infants occurring today.
The Course of Pregnancy
Conception takes place and pregnancy begins when the male reproductive cell, called the "sperm", finds and unites with the reproductive cell of the female, called the "ovum." This union normally occurs in one of the ducts or canals, called "Fallopian tubes," which conduct the ova from the ovaries to the uterus, or womb. First there is a single new cell, then as development begins two, then four, then eight, and so on. Next, cells differentiate into different tissues and organs with growth proceeding at an intense rate.
The relative rate of growth is never again as rapid as during these early months of beginning life, yet it is not yet approximately four months after conception that it is possible to make a positive diagnosis of pregnancy by the regular examination. Two to three months earlier than this, however, an almost positive diagnosis of pregnancy can be made by means of a special hormone test; and there are the well-known suggestive signs of pregnancy such as cessation of the menses, morning sickness, breast changes, and enlargement of the abdomen. The average duration of pregnancy is 280 days-9 calendar months or 10 lunar months but there is no reliable means of estimating the exact date of the baby's arrival.
As soon as a woman suspects the possibility of pregnancy, she should consult her doctor, not only to be assured of her condition but also to provide proper care for herself and for her developing child. It is true that childbearing is a natural process, but it is one which may very quickly become seriously abnormal it is only by adequate medical care during pregnancy that the health of mother and child can be safeguarded.
Every woman should have a complete and thorough examination at the beginning of pregnancy and a subsequent examination by her physician at least once a month during the first 6 months of pregnancy, and then every 9 weeks or often until delivery. Supervision of the pregnant woman, once she has placed herself under a physician's care, naturally is his responsibility, but it is up to her to put herself under his care at the beginning of pregnancy and to cooperate by following his advice and instructions thereafter.
Every pregnant woman and her husband should inform themselves concerning the physiologic changes which occur during pregnancy, labor, and the postpartum period. They should also know the most important signs and symptoms of the possible complications of pregnancy, such as persistent headache, recurrent vomiting, dizziness, disturbances of vision, swelling of the hands, face, or ankles, severe pain in the abdomen, vaginal bleeding, acute illnesses, obstinate constipation, and marked shortness of breath, and should report the appearance of any of these promptly to their physician.
The Hazards of Pregnancy
In last decade, there were reported in the United States 4,978 deaths related to childbearing. This is a record of which we certainly can not be proud. An intensive 3-year study of the causes of maternal death in New York City concluded that 66 per cent of the women who died may have been saved if they had had proper treatment and care.
The general causes for adequate care may be grouped under three headings: poverty, ignorance, and inadequate or incompetent professional service during pregnancy and delivery. Some of the accidents and serious hemorrhages of childbirth are unavoidable, but competent professional attention will prevent most of them. Infection in connection with childbirth, called puerperal sepsis, is practically all preventable.
Oliver Wendell Holmes, physician and author, declared in a paper entitled "The Contagiousness of Puerperal Fever" that doctors, nurses, and midwives were responsible for most of the infections which occur during childbirth.
The toxemia, or poisonings, of pregnancy, which cause damage to the liver and kidneys and may result in high blood pressure, vomiting, convulsions, and death, can be recognized in their incipience and usually can be successfully combated by the program of prenatal care which has been outlined.
The Chicago Maternity Center reports a maternal mortality of less than one-fourth the rate for the country as a whole, and its clients are among Chicago's poorest mothers. In Cattaraugus County, New York, mothers receiving prenatal care have a death rate of 12 per 10,000 live births as compared to 38 for the nation as a whole.
Place of Delivery
An increasing number of mothers are going to hospitals for delivery of their babies. Obviously there are definite advantages in the better facilities of the hospital delivery room, particularly if some unforeseen abnormalities or accidents should occur. On the other hand, hospital care increases the expense and unfortunately, in many hospitals, the danger of infection during delivery is greater than in the home. Instructions in regard to proper preparation for delivery in the home may be obtained from private doctors, public health nurses, or state and local health departments.
Professional Care During Delivery
The US Children's Bureau, as a result of a study of maternal mortality in fifteen states, reported that 83 per cent of the women were attended by doctors, 11 per cent by midwives, and 4 per cent by other non medical attendants; 2 per cent had no attendant at the delivery. Without question the most competent service at a delivery can be expected from a physician ideally trained and experienced in obstetrics. Physicians in general practice are trained also to conduct normal and certain of the less seriously abnormal deliveries.
Realizing their limitations to deal with some of the rarer and more serious complications, they are quick to call for whatever consultation is in the interest of the patient. Midwives in certain foreign countries are reasonably well trained to render obstetric service in normal deliveries, but the vast majority of the midwives practicing is old, careless, and dirty and have had little or no training. Exceptions to this are the trained nurse midwives who are rendering splendid service in the mountains of Kentucky and in certain other sparsely settled regions where medical service is not available
Normal and Instrumental Delivery
The vast majority of deliveries will occur spontaneously and should be permitted to do so, because instrumental delivery increases the risk of infection, of hemorrhage, and of accidents to both mother and child. In probably not more than 5 per cent of deliveries is instrumental or operative interference really necessary.
In the New York study the death rate from instrumental and operative deliveries was five times as high as that from spontaneous delivery. In this group of operative deliveries, of course, are included the seriously abnormal cases. On the other hand, this same study reports that 77 per cent of the deaths following operative delivery were denied avoided, as compared to only 48 per cent of the deaths which followed spontaneous delivery.
Instrumental delivery is frequently a life-saving procedure for mother or child, but it is uniformly agreed by the specialists in this held that instruments are used far too often. For these doctors are themselves in part to blame, but some of the responsibility must also be laid at the door of the patients who insist upon instrumentation to shorten labor.
Cesarean section is delivery of the child through an incision in the abdominal wall and in the uterus. There are many instances in which this operation has saved the lives of both mother and child, but, like instrumentation, it is an operation attended with greatly increased risk. Many of the Cesarean operations could have been avoided by proper medical care during the prenatal period.
Anesthesia for Labor
One of the greatest blessings that science has given to mankind is that of anesthesia. Dr. Crawford Long of Atlanta, Georgia, was the first to use ether for anesthesia, but the real impetus for its use in surgery was given by Dr. WGT Morton, who demonstrated its effectiveness before a surgical clinic in the Massachusetts General Hospital. During the same year a Scottish physician, Dr. James Simpson, introduced anesthesia into the practice of obstetrics. For some time the relief of pain during childbirth was considered sacrilegious, but this opposition fell down quickly after Queen Victoria sanctioned its use on the occasion of the birth of Prince Leopold.
Today a woman has the right to expect some relief from the pain of childbirth, but no mother should demand relief at the risk of her own life or the life of the child. All substances which are used to produce anesthesia are toxic, and no single method or combination of methods is uniformly applicable. The time and degree of anesthesia must be determined by the physician and not decided on the basis of some magazine article on the subject.
Abortion means the interruption of pregnancy before the child is adequately developed to be able to live outside the mother's body. Dr. Frederick J. Taussig, who has made a greater study of abortion than anyone else, estimates that approximately 600,000 abortions occur annually in the United States, and that 8,000 to 10,000 women lose their lives from this cause every year.
Many of these deaths are reported as due to other causes and so do not show in the mortality statistics. Two-thirds of these abortions he estimates are induced and one-third is spontaneous. The death rate following abortion is three times as high and the invalid rate ten to fifteen times as high as following delivery of the child at term. The specific dangers of abortion are infection, consequential sterility, and endocrine disorders which may cause chronic invalidism.
Spontaneous abortion is a condition which needs careful medical study. Some cases are due to disease, such as Syphilis, toxemia, and diabetes; name to deficiencies in the endocrine secretions related to pregnancy; some to deficiency of vitamin E; some to weakened inherent in the germ plasm of the sperm or mount and some to physical abnormalities of the pelvic organs. Obviously, most of these are preventable.
Induced abortion carries a terrific hazard to both life and health. When the general maternal death rate declined 15 per cent, the death rate for abortions increased 25 per cent. Many of these are self-induced by methods which would make anyone who understands physiology and asepsis shudder. Others are performed as illegal operations by "doctors." Some of these abortionists are unethical physicians; others belong to some of the cults; and still others are not licensed as any type of practitioner.
The major reasons for abortions are poverty, large families and, of course, poverty is a factor here illegitimacy, marital difficulties, and selfishness. Very rarely the physician will need to perform an abortion to save the mother's life, and there are situations in which the limit of offspring is advisable. The only safe way to accomplish this, however, is not by abortion but by the practice of contraception or by sterilization.
There has long been a superstition that maternal impression or emotional distortions of the mother, such he anger, fright grief, or horror, may cause her unborn child to be marked injured, or deformed. Certain hereditary hits are transmissible from parents to offspring through the germ cells which unite to give rise to the new child; but after conception has once taken place, the mother's body purely delivers warmth and nourishment for the baby until it has developed to a point lint it is able to lead an independent existence.
The only connection between the mother and the baby is through the umbilical cord. This cord carries arteries and veins but no nerves, and even the blood of the mother does not mix with the blood of the child, the exchange of nutrients and excretory products taking place through a membrane which separates the two circulatory systems.
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