Early
1900s
Domiciliary
(Outdoor) Services
Hospital-affiliated, MD-provider, Home-based Birth
"The hospital is to care for all who, for one reason or another, cannot secure proper attention at home and the dispensary for those are delivered at home. In the majority of them, her presence in the home is necessary to order and discipline. Then too, the cost of caring for patients in hospital is much greater than in their own homes." [1912-B, p.231] ^64
"The Boston Lying-In Hospital Out-patient department (domiciliary service) cared for 2,007 cases with no deaths, the dangerous cases being sent to the hospital, where all recovered. The extra expense to the Hospital ... was less than 83 cents per patients, while at the same time these patients subscribed voluntarily an average of $1.28 each. thus the hospital received a balance of $807 over their actual cost." [1911-D, p 216] ^52
Question #12: “Do you maintain an outdoor (domiciliary) service?”
“The following answers were received:
5, none;
6, small without data;
16, with less than 250 (home) deliveries;
6, between 250 and 500 (home) deliveries;
5 between 500 and 1,000 (home) deliveries and
5 with 1,000 or more (home) deliveries per year.”
[32 hospitals with a combined estimate of 12,000 to 20,000 home births annually] ^53
“At first glance these figures appear much more satisfactory than those for lying-in hospitals, as they show that ten of the schools have a fair material. In order to be efficient for teaching, an out-patient service must be held in rigid discipline, be organized as an integral part of the regular obstetrical service, and conducted through the lying-in hospital. Moreover, the students should be accompanied by an assistant to demonstrate the care as well as by a trained nurse to prepare the patient properly.[i.e. public shaving].. Under such conditions, out patient material may be utilized for teaching purposes almost as satisfactorily as ward patients.” 1911-B; WilliamsMD p. 172 ^54
"It is in the outdoor (domiciliary) service especially that we are able to appreciate the approach to the irreducible minimum {of mortality} to be obtained in private practice and where the figures are not distorted by the inclusion of the emergency failure of others." [1917-A; HarrarMD] ^55
"From the organization of the service of the Lying-In Hospital in 1890 until July, 1917, the institution has cared for, in the wards and in the homes of the patients, 115,439 women. Of these 7,213 were gynecological ward cases and women late in the puerperium; 37,483 were parturient and recent admissions to the wards, and 70,743 were labors conducted in the tenements." [1917-A; HarrarMD] ^56
"Of the 70,743 confinement cases on the outdoor service, 1662 were abortions, leaving 69,081 confinements in the outdoor service at or near term. In all 101,197 actual confinements at or near term have been conducted by the hospital, and it is with the mortalities in these that we are especially interested." [1917-A; HarrarMD] ^57
"For purposes of study it is necessary to divide the mortalities in to groups. In the outdoor service, in 69,081 actual confinements, 218 women died. Of these 218, 137 died in their homes, and 81 after transfer into the wards of the Lying-In or other hospitals, so that 218 is the full maternal mortality in the tenement service to date. This represents one death in every 317 women confined, or 0.31 per cent mortality. In the last eight years, the maternal mortality of the outdoor tenement service had fallen from one death in every 312 confinements to one death in every 326 confinements."[1917-A; HarrarMD] ^45
"On the indoor service, of 23,130 regular applicants confined, 109 died. This is one death in every 212 women confined, or 0.47 percent. One important reason for the somewhat higher mortality among the indoor regular applicants over the outdoor is the much greater proportion of primiparae on the indoor service. In the tenement service twenty out of every 100 labors are primiparae, while on the indoor service forty-eight out of every 100 are primiparae." [1917-A; HarrarMD] ^46