Excerpts from Charter 4, "Safer Childbirth", p. 329
written for the lay public by Alan Frank Guttmacher, MD
Associate in Obstetrics, John Hopkins University, 1937
Original Founder of the Guttmacher Institute, NYC

Conclusion based on statistical studies must be accepted very charily when they deal with deaths in childbirth, for the figures are particularly liable to error. Every since such data have been collected, doctors have been prone to omit from death certificates the fact that the case was associated with pregnancy, or they have actually falsified the records to escape any stigma with might accrue to them . ...... Because of the labor and expense involved, bureaux of vital statistics have ordinarily accepted the death certificates of pregnant and puerperal (intra and postpartal) without checking their accuracy. However, such a check has been made in a few special investigations. In 1933 an error of 17.8 percent was found in maternal death certificates in New York City; in 1934 an error of 21.6 percent was found in Philadelphia and of 12.6 percent in those of the fifteen States specially selected for study by the Department of Labor.

Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own. Why? It cannot be because of our ignorance, for in the scientific phases of obstetrics America is one of the world’s leaders; it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions.

What about the conduct of labor in the two regions? Here is the major differences lie. In the first place, as I have shown in a previous chapter, at lest 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. The Scottish Report states (Scotland has a higher maternal mortality than our own) "In as high a proportion as 24 percent of all birth recorded during the six months’ intensive survey delivery was not spontaneous." Fifty-one percent of all the maternal death in Scotland occurred in the 24 percent in which the labor was operative. Let is compare the operative rates of these relatively dangerous countries with those of the countries which are safer. "In Sweden the interference rate if 3.2 percent, in Denmark it is 4.5, while in Holland ..... it is under 1 percent."

What is responsible for this vast difference in operative rates? There are many factors the woman of Holland and Scandinavian are by nature better equipped for spontaneous parturition; analgesics and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural functions which rarely requires artificial aid from steel or brawn.

We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. .... The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery.

In their first report they stated that they have delivered over 1000 women with only two deaths -- one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses, made the following statement on May 9, 1932

" The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life."

What are the advantages of such a system? It makes it economically possible for each women to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste. In 1927, 2875 midwives delivered 78,647 Swedish women, an average of 27 to 28 cases per year for each. ..... Midwives can be better coordinated, better disciplined, and better supervised by governmental agencies. Such a system does not obviate the necessity for expertly trained obstetrician. They also must deliver the abnormal and complicated cases. What it does is to displace the general practitioner, who is scarcely trained at all in obstetrics, by an expertly trained women."