Chapter V: Maternal Mortality and Diseases Affected by Pregnancy (1)

_This chapter shows that the female death-rate is much greater during the child-hearing age than at other periods and notably greater than the male death-rate at any period. The outstanding fact is that this abnormal female death-rate, between the ages of 15 and 45, must be ascribed to too frequent pregnancies and to those diseases of the lungs, heart and kidneys which are hastened by pregnancy. Ninety-five per cent. of such deaths could be averted by the dissemination of knowledge to prevent conception._

_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL BIOLOGICAL AND HYGIENIC
ASPECTS. E. HEINRICH KISCH, M.D., Professor of the German Medical
Faculty of the University of Prague, Physician to the Hospital and
Spa of Marienbad, Member of the Board of Health, etc. Translated
by M. Eden Paul, M.D. Rebman Co., New York._

It is astonishing to observe the number of full term deliveries and miscarriages that a woman will experience within a comparatively short period of time, as is seen too frequently among the laboring classes, and more especially, among the factory workers. If we assume the original mortality of childbirth to be 6 per mille, a woman who in the course of 15 years undergoes labor (at full term or prematurely) 16 times, runs a risk of death to be expressed by the ratio of 6 × 16 = 96 per mille; that is to say, on the average of 1,000 women who became pregnant as often as this, nearly one in ten will die in childbed. P. 278.

In certain serious general disorders, in diseases of the heart, or of the lungs, in pelvic deformity, and in pathological changes of the female reproductive organs, it may be right to employ means for the prevention of pregnancy—not merely sexual abstinence, but actual measures to prevent fertilization. P. 395.

Based upon the observations of Schauta and Fellner, the latter author advances the rule that in the case of a woman suffering from disease, marriage should be forbidden only when the mortality from the disease in question is not less than 10%. In this category we must include severe cases only of pulmonary tuberculosis, whilst cases of laryngeal tuberculosis will, according to this rule, be absolutely unfit for marriage. Among heart affections contra-indicating marriage, he includes mitral stenosis, other valvular affections in which there is serious disturbance of compensation, and myocarditis; he considers marriage inadmissible also in cases of chronic nephritis, and among surgical affections, in case of malignant tumor. No case in which during a previous pregnancy the patient has been affected by one of the following diseases; viz. severe chorea, mental disorders, severe epilepsy, pulmonary tuberculosis which progressed much during pregnancy, morbus cordis, with considerable disturbance of compensation, severe heart trouble due to Graves disease—in all such cases a repetition of pregnancy should be avoided. P. 261.

FOURTH ANNUAL REPORT OF THE CHIEF OF CHILDREN’S BUREAU OF THE U. S.
DEPARTMENT OF LABOR,
JUNE 30, 1916

MATERNAL MORTALITY

A study of maternal mortality, by Dr. Grace L. Meigs, head of the hygiene division of this bureau, has been undertaken as a direct corollary to the infant mortality inquiry. The sickness or death of the mother inevitably lessens the chances of the baby for life and health. A large proportion of the deaths of babies occur in the first days and weeks of life, and these early deaths can be prevented only through proper care of the mother before and at the birth of her baby.

In the introduction to the report on “Maternal mortality in connection with childbearing,” issued as a supplement to his report as medical officer of the local government board of Great Britain for 1914–15, Sir Arthur Newsholme says:

The present report is intended to draw attention to this unnecessary mortality from childbearing, to stimulate further local inquiry on the subject, and to encourage measures which will make the occurrence of illness and disability due to childbearing a much rarer event than at present.

The attainment of these ends is important as much in the interest of the child as of its mother. That the welfare of the child is wrapped up in that of the mother was fully recognized in the board’s circular letter of 31st July, 1914, and the schedule appended to that letter; and each year it is becoming more fully realized that, in order to insure healthy infancy and childhood, it is necessary that, both during pregnancy and at and after the birth of the infant, increased maternal care and guidance and medical assistance should be provided.

The Children’s Bureau studies of infant mortality in town and country reveal clearly the connection between maternal and infant welfare and make plain that infancy can not be protected without the protection of maternity.

In her report Dr. Meigs undertakes to do no more than to assemble and interpret figures already published by the United States Bureau of the Census and in the mortality reports of various foreign countries and to state accepted scientific views as to the proper care of maternity. She shows that maternal mortality, although in great measure preventable, is not decreasing in the United States. Her report reveals an unconscious public neglect due to age-long ignorance and fatalism. As soon as the public realizes the facts to which Dr. Meigs calls attention it doubtless will awake to action, and suitable provision for maternal and infant welfare will become an integral part of all plans for local protection of public health.

The report is summarized as follows:

“In 1913 in this country at least 15,000 women, it is estimated, died from conditions caused by childbirth; about 7,000 of these died from childbed fever, a disease proved to be almost entirely preventable, and the remaining 8,000 from diseases now known to be to a great extent preventable or curable. Physicians and statisticians agree that these figures are a great underestimate.

“In 1913 the death rate per 100,000 population from all conditions caused by childbirth was but little lower than that from typhoid fever; this rate would be almost quadrupled if only the group of the population which can be affected, women of childbearing age, were considered.

“In 1913 childbirth caused more deaths among women 15 to 44 years old than any disease except tuberculosis.

“The death rate due to this cause is almost twice as high in the colored as in the white population.

“Only 2 of a group of 15 important foreign countries show higher rates from this cause than the rate in the registration area of the United States. The rates of three countries, Sweden, Norway, and Italy, which are notably low, show that low rates for these conditions are attainable.

“The death rates from childbirth and from childbed fever for the registration area of this country are not falling; during the 13 years from 1900 to 1913 they have shown no demonstrable decrease. These years have been marked by a revolution in the control of certain other preventable diseases, such as typhoid, diphtheria, and tuberculosis. During that time the typhoid rate has been cut in half, the rate of tuberculosis markedly reduced, and the rate for diphtheria reduced to less than one-half. During this period the death rate from childbirth has decreased in England and Wales, Ireland, Australia, and Japan. The other foreign countries studied show stationary or slightly increasing rates. The death rate from childbed fever has decreased only in England and Wales, Ireland, and Scotland.

“These facts point to the need in this country and in foreign countries of higher standards of care for women at the time of childbirth.

“The low standards at present existing in this country result chiefly from two causes: (1) General ignorance of the dangers connected with childbirth and of the need for proper hygiene and skilled care in order to prevent them; (2) difficulty in the provision of adequate care due to special problems characteristic of this country. Such problems vary greatly in city and in country. In the country inaccessibility of any skilled care, due to pioneer conditions, is a chief factor.

“Improvement will come about only through a general realization of the necessity for better care at childbirth. If women demand better care, physicians will provide it, medical colleges will furnish better training in obstetrics, and communities will realize the vital importance of community measures to insure good care for all classes of women.”

While the figures given by Dr. Meigs are a startling indication of the great number of maternal fatalities occurring in various parts of the country, no estimates can be made of the number of mothers who survive only to suffer from a degree of preventable ill health which limits or defeats the well-being and happiness of their households.

_MATERNAL MORTALITY FROM ALL CONDITIONS CONNECTED WITH CHILD BIRTH IN
THE UNITED STATES AND CERTAIN OTHER COUNTRIES. By Grace L. Meigs,
M.D. U. S. Department of Labor, Children’s Bureau, 1917._

STATISTICS RELATING TO CHILDBIRTH IN THE UNITED STATES AND IN CERTAIN
FOREIGN COUNTRIES

For the last two decades civilized countries have been absorbed in the problem of preventing the enormous and needless waste of human life represented by their infant death rates. The importance of this problem has been felt more keenly in the last two years in the countries now at war; in these countries the efforts toward saving the lives of babies have redoubled since the war began. Side by side with this problem, another, which is only of late finding its true place, is that of the protection of the lives and health of mothers during their pregnancy and confinement. This is a question so closely bound up with that of the prevention of infant mortality that the two can not be separated.

It is now realized that a large proportion of the deaths of babies occur in the first days and weeks of life, and that these deaths can be prevented only through proper care of the mother before and at the birth of her baby. It is also realized that breast feeding through the greater part of the first year of the baby’s life is the chief protection from all diseases; and that mothers are much more likely to be able to nurse their babies successfully if they receive proper care before, at, and after childbirth. Moreover, in the progress of work for the prevention of infant mortality it has become ever clearer that all such work is useful only in so far as it helps the mother to care better for her baby. It must be plain, then, to what a degree the sickness or death of the mother lessens the chances of the baby for life and health.

This question has also another side. Each death at childbirth is a serious loss to the country. The women who die from this cause are lost at the time of their greatest usefulness to the State and to their families; and they give their lives in carrying out a function which must be regarded as the most important in the world.

Questions then of the most vital interest to the whole Nation are these: How are the lives of the mothers in this country and other countries being protected? To what degree are the diseases caused by pregnancy and childbirth preventable? If preventable, how far are they being prevented in this country? Has there been the same great decrease in the last few years in sickness and death from these causes as that which has marked the great campaigns against other preventable diseases such as typhoid, tuberculosis, or diphtheria? How do the conditions in the United States compare with those in other countries?

_Puerperal septicemia (childbed fever)._—The fact is now well known that puerperal septicemia, or childbed fever, is in reality a wound infection, similar to such an infection after an accident or an operation, and that it can be prevented by the same measures of cleanliness and asepsis which are used so universally in modern surgery to prevent infection. The proof of the nature of this disease is one of the tremendous results of the scientific discoveries which were made in the latter part of the nineteenth century.

During the early part of that century childbed fever was one of the greatest hospital scourges known. It occurred also in private practice; but in hospitals where there was great opportunity for the spreading of infection the death rate from this disease was appalling. The average death rate in hospitals in all countries was 3 to 4 per cent. of all women confined; sometimes it reached 10 to 20 per cent. and even over 50 per cent. during short periods of epidemics. In the face of this terrific mortality many obstetrical hospitals were closed. Commissions were appointed to investigate the cause of these epidemics, and medical congresses devoted sessions to the discussion of the problem. In 1843 Oliver Wendell Holmes, and in 1847 Semmelweiss, published articles stating the theory that this fever was similar to a wound infection and was due chiefly to the carrying of infectious material on the hands of attendants from one case to another.

NUMBER OF DEATHS IN THE UNITED STATES FROM CHILDBIRTH

In 1913 in the “death-registration area” of the United States 10,010 deaths were reported as due to conditions caused by pregnancy and childbirth. Of these deaths, 4,542 were reported as caused by puerperal septicemia or childbed fever.

Using the death-registration area as a basis, we are justified in estimating that in 1913 in the whole United States 15,376 deaths were due to childbirth, and 6,977 of these were due to childbed fever. As will be shown later, these figures are without doubt a gross underestimate. As it is, they are striking enough—almost 7,000 deaths in one year in this country due to childbed fever, a disease to a large degree easily preventable; and over 8,000 due to the other diseases caused by pregnancy and confinement, most of which are preventable or curable by means well known to science.

DEATH RATES IN THE UNITED STATES FROM CHILDBIRTH

The death rate from all diseases caused by pregnancy and confinement in 1913 in the registration area was 15.8 per 100,000 population (which includes all ages and both sexes). The death rate from puerperal septicemia was 7.2.

These figures, however, mean little to us unless we compare them with the death rates from other preventable diseases. In the same year and area the typhoid rate was 17.9 per 100,000 population; the rate from diphtheria and croup 18.8. The highest death rate from any one disease was that from tuberculosis, 147.6 per 100,000 population. Any such comparison with the rates from diseases to which both sexes and all ages are liable is of course very misleading; but in spite of that fact it is interesting to note that typhoid fever, the disease against which so great an amount of effort is now directed, has a rate at present but 2 per 100,000 population higher than that from the diseases caused by pregnancy and confinement.

_Death rates per 100,000 women._—The death rates from childbirth are approximately doubled when worked on the basis of 100,000 women. This will be seen when Tables IV and III (p. 50) are compared. The former gives for the period 1900 to 1910, the annual death rates per 100,000 women in the group of 11 States which were in the death-registration area in 1900, the latter the death rates per 100,000 population in the same group of States for the same period. It is evident that the rates in Table IV for each year are slightly more than twice those in Table III for the same year.

_Death rates per 100,000 women of childbearing age...._ Again, a much higher but a more accurate death rate from these diseases is found when the basis taken is the group which alone is affected by these diseases—women of childbearing age. When the rate is based not upon 100,000 population of both sexes and all ages but upon 100,000 women 15 to 44 years of age, the rate as ordinarily given is multiplied several times.

In 1900, the only year for which the rates can be computed, the death rate in the registration area per 100,000 women 15 to 44 years of age from all diseases of pregnancy and confinement was 50.3; from puerperal infection, 21.6. The corresponding rates for the same year per 100,000 population were 13.1 and 5.6. In this year, therefore, the rates are almost quadrupled when based on that group of the population which alone can be affected by these diseases.

Moreover, the death rates as ordinarily given per 100,000 population conceal the fact that the diseases of pregnancy and childbirth are indeed among the most important causes of death of women between 15 and 44 years of age; the actual number of deaths shows this to be the case. In 1913 in the registration area these diseases caused more deaths than any other one cause of death except tuberculosis. In that year there were, among women 15 to 44 years of age, 26,265 deaths from tuberculosis; 9,876 deaths from the diseases of pregnancy and confinement; 6,386 from heart disease; 5,741 from acute nephritis and Bright’s disease; 5,065 from cancer; and 4,167 from pneumonia. Other diseases, such as typhoid, appendicitis, and the infectious diseases show far fewer deaths.

_Death rates per 1,000 live births._—This rate, as will be shown repeatedly throughout the report gives a far clearer picture of the actual risk of childbirth than do any of the rates so far considered. This rate can be given only for one year, 1910, and only for the provisional birth-registration area for that year. The rate from all diseases caused by pregnancy and confinement is 6.5, from puerperal septicemia, 2.9, and from all other diseases of pregnancy and confinement, 3.6 per 1,000 live births. That is, in this area for every 154 babies born alive one mother lost her life.

COMPARISON OF THE AVERAGE DEATH RATES FROM CHILDBIRTH IN CERTAIN FOREIGN
COUNTRIES AND IN THE UNITED STATES

Are the death rates from these diseases in the death-registration area of the United States higher or lower than those in other civilized countries? Have these rates in other countries been falling or rising in the last 13 years, while the rates of this country have been apparently stationary? These questions, like all those of comparative international statistics, are of immense interest, but they involve many difficulties and sources of error. They should be considered in reading the following summary.

In order to make possible a comparison of the death rates from these causes for 15 foreign countries with those for the United States, an average rate has been computed for the years 1900 to 1910 for each of the countries, using the same method as that in use in the United States. When the 16 countries studied are arranged in order, with the one having the lowest rate first, the death-registration area of the United States stands fourteenth on the list. (See Table XII, p. 56.) Only two countries, Switzerland and Spain, have higher rates; many of the countries, however, show rates differing but little from that of the United States. Markedly low rates are those of Sweden (6), Norway (7.8), and Italy (8.9); a strikingly high rate is that of Spain (19.6).

The death rate from childbirth per 1,000 live births is not available for the death-registration area of the United States, but can be given only for the small number of States and cities included in the provisional birth-registration area and for one year, 1910. (See p. 31.) This rate, 6.5, is considerably higher than that for 1910 of any of the countries studied. When the average rates for a number of years of the 15 countries are reckoned per 1,000 live births and arranged in order, it will be seen that the same group of countries—Sweden, Italy, and Norway—shows the lowest rates. (See Table XIII, p. 56.) Spain in this table shows the rate which is next to the highest, while Belgium now has the highest rate. For a comparative study of the rates of these countries the rates per 1,000 live births give undoubtedly the clearest picture of the actual conditions.

These rates show a wide variation. While in Sweden but one mother is lost for every 430 babies born alive, in Belgium one mother dies for every 172 babies, and in Spain one for every 175 babies born alive. The rates in Belgium and Spain are two and a half times as high as the rate in Sweden.

Far more significant than a comparison of actual death rates of various countries is a comparison of the changes which have occurred in these death rates in each country in recent years. England and Wales, Ireland, Japan, New Zealand, and Switzerland have shown a decrease in the death rate per 1,000 live births from all diseases caused by pregnancy and confinement; but, in this group, only in England and Wales and in Ireland has the death rate from puerperal septicemia decreased; in the other three countries this rate has remained practically the same, though the total rate has decreased.

In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and Sweden both the rate from childbirth and that from puerperal septicemia remained almost stationary during the periods studied.

The total rate for Scotland shows a definite increase, though the rate from puerperal septicemia has decreased. (See Table XVI, p. 66.)

Communities are still to a great extent indifferent to or ignorant of the number of lives of women lost yearly from childbirth; many communities which are proud of their low typhoid or diphtheria rates ignore their high rates from childbed fever. Communities are only beginning to realize that among their chief concerns is the protection of the babies born within their limits, and necessarily also of the mothers of those babies before and at confinement.

DEATH-REGISTRATION AREA

The statistics of causes of death are available only for a certain portion of the United States, included in the so-called “death-registration area.” Unlike other civilized countries, the United States has no uniform laws for the registration of births and deaths. Moreover, the efficiency of enforcement of existing laws varies greatly in the different States. The Bureau of the Census in 1880 therefore established a “death-registration area,” which comprises “States and cities in which the registration of deaths is returned as fairly complete (at least 90 per cent. of the total), and from which transcripts of the deaths recorded under the State laws or municipal ordinances are obtained by the Bureau of the Census.” In 1880 this area included but 17 per cent. of the total population of the United States. As States and cities have passed better laws and obtained better enforcement they have been added to the registration area; the latter has increased greatly in size, but even in 1913 included only 65.1 per cent. of the population of the United States. For the remaining 34.9 per cent. of the population of the country we have no reliable statistics. This 34.9 per cent. includes the population of the greater number of the Southern States and of many Middle Western and Western States outside of certain registration cities in these States which are included in the area. No statements can be made, therefore, of the number of deaths from any cause in the United States as a whole; only an estimate can be made on the assumption that for any cause of death the same rate prevails in the remainder of the United States as in the death-registration area.

PROVISIONAL BIRTH-REGISTRATION AREA

The registration of births is still more incomplete in this country than is the registration of deaths. For 1910 the United States Bureau of the Census established a “provisional birth-registration area,” including the New England States, Pennsylvania, Michigan, New York City and Washington, D. C.

_Death rates per 1,000 births._—As shown above, the method of computation of death rates which gives the clearest picture of the hazards of childbirth is that which takes into account only the women giving birth to children in that year. This is the method in use in a large number of foreign countries. The advantages of the method are self-evident. A demonstration of the superiority of this method of computation is obtained by a study of the tables giving the death rates from these diseases for foreign countries. In certain countries, as for instance Belgium and Hungary, there has been in recent years an apparent fall in the average death rates as computed per 100,000 population, while the average rates computed per 1,000 live births have remained stationary or risen. This phenomenon is due, evidently, to a decline in the birth rate in these countries during these years, and shows how misleading the rates as given per 100,000 population undoubtedly are in countries with declining birth rates. Whether a fall in the birth rate has occurred in the United States is not known. If it has occurred in the registration area, it would mean that the slight rise in rates per 100,000 population between 1900 and 1913 means a greater rise in rates computed according to the number of births. Such an error might compensate for the opposite error due to the more complete registration of deaths from childbirth in the later years of this period.

Miscarriages are not reportable in any country, although a number of miscarriages (as the term is usually defined) probably are reported as stillbirths in certain countries. The fact that women having miscarriages are not considered in the base would lead to a somewhat higher death rate than that which would express absolutely the number of deaths per 1,000 women at risk.

COMPARISON OF THE CHANGES IN THE DEATH RATES FROM CHILDBIRTH IN CERTAIN
FOREIGN COUNTRIES FOR THE YEARS 1900 TO 1913

Far more valuable than a comparison of average rates of foreign countries is a study of the rates of each country for a series of years in order to discover whether they are decreasing or increasing and to compare such changes in the various countries. While it may be dangerous on account of different countries, no such source of error is attached to the comparison of rates in the same country for a number of years. The period 1900 to 1913 (or the latest year for which figures are available) is a very short one for a study of a change in death rates. It would have been far more interesting to study the death rates for a long series of years in each country, choosing a period beginning before the introduction of methods of asepsis. But such a study for the complete list of countries considered was not thought advisable, because of the difficulties caused by variations in classification of causes of death in the earlier years.

In order to study the rates for any increase or decrease occurring during the last 13 years, the rates per 1,000 live births will be used rather than those per 100,000 population. In several countries—Belgium, Hungary, Italy, Norway, Prussia, and Spain—the rate from childbirth per 100,000 population apparently has fallen during the period, while the rate per 1,000 live births has remained almost the same, or has risen. The cause of this inconsistency is the fact that in these countries the birth rate or the proportionate number of births to the number of inhabitants has decreased.

_Number of deaths of women from 15 to 44 years of age in the
death-registration area from each cause and class of causes
included in the abridged International List of Causes of Death
(revision of 1909),[49] 1913._

Footnote 49:

Except No. 25, diarrhea and enteritis (under 2 years), and No. 34,
senility.

(Computed from figures in Mortality Statistics, 1913, pp. 338 to 349, in which causes of death are given according to the detailed International List of Causes of Death.)

Abridged Number
International Cause of death. of
List No. deaths.

13, 14, 15 Tuberculosis of the lungs, tuberculous 26,265
meningitis, other forms of tuberculosis

Puerperal septicemia (puerperal fever,
31, 32 peritonitis) and other puerperal accidents of 9,876
pregnancy and labor

19 Organic diseases of the heart 6,386

29 Acute nephritis and Bright’s disease 5,741

16 Cancer and other malignant tumors 5,065

22 Pneumonia 4,167

35 Violent deaths (suicide excepted) 3,262

1 Typhoid fever 2,706

30 Noncancerous tumors and other diseases of the 2,669
female genital organs

26 Appendicitis and typhlitis 1,620

36 Suicide 1,562

23 Other diseases of the respiratory system 1,458
(tuberculosis excepted)

18 Cerebral hemorrhage and softening 1,398

24 Diseases of the stomach (cancer excepted) 940

27 Hernia, intestinal obstruction 854

28 Cirrhosis of the liver 598

9 Influenza 489

17 Simple meningitis 484

8 Diphtheria and croup 330

12 Other epidemic diseases 312

6 Scarlet fever 307

5 Measles 304

3 Malaria 250

21 Chronic bronchitis 184

20 Acute bronchitis 90

33 Congenital debility and malformations 24

11 Cholera nostras 18

4 Smallpox 16

7 Whooping cough 9

2 Typhus fever 2

10 Asiatic cholera

37 Other diseases 11,688

38 Unknown or ill-defined diseases 458

_A MUNICIPAL BIRTH CONTROL CLINIC. MORRIS H. KAHN, M. D., in New York
Medical Journal for April 28, 1917._

_Showing that large families among the poor are the result of ignorance of methods to prevent conception among the mothers._

The following studies were undertaken with a view to determining whether there was an actual need and demand for birth control education and whether such a demand, if it existed, could be supplied with any effect by a scientifically conducted clinic in the dispensaries of the Department of Health of the City of New York; we felt that it might be of scientific and sociological interest to publish a report and an analysis of the observations made, probably the first of their kind in this country. Section 1142 of our Penal Code was ignored in conducting this birth control study.

The social and economic status of the patients was fairly uniform, about the same as that of patients attending the other dispensary institutions in this city. A tabulation of the results was made under the following headings: Name and nationality; age; number of years married; number of living children and their ages; number of deceased children; number of miscarriages or abortions; contraceptive methods known or practised. More or less complete data were secured in 464 cases.

The average number of procreative years of married life was 16.1, the age of fifty years being considered in this study as the end of the procreative period for the seventy-two women who were older than that. The average number of living children was 3.27 and of deceased children 1.2, making a total average of 4.47 children born to each family. Of the 464 women, 176, or three eighths, had had abortions or miscarriages, the total number of such interruptions of pregnancy being 324, or an average of 1.8 each for the women involved.

Of the 464 women, 192 knew of no contraceptive methods and therefore had used none. The remaining 272 women knew of one or more methods, more or less effectual, for the prevention of conception. Of the 192 women who were ignorant of the use of contraceptives, practically one half, or 104, had a history of abortions, with a total of 202 abortions, or an average of two apiece. In contrast with this, of the 272 women who knew of one or more contraceptives, only one fourth, or seventy-two, had undergone abortions, with a total of 122 abortions, or an average of only 1.6 apiece.

A further analysis of our tables shows an interesting and striking relationship between ignorance of methods for the prevention of conception and the number of children. Sixty-eight women had had three children each. Of these, twenty-six, or thirty-eight per cent., were ignorant of contraceptives. Twenty-eight women had had four children each. Of these fourteen, or fifty per cent., were ignorant of contraceptives. Fifty-five women had had five children each. Of these thirty were ignorant of contraceptives, or fifty-four per cent. Thirty-two women had had six children each. Of these twenty were ignorant of contraceptives, or sixty-two per cent. Forty women had had seven children each. Of these thirty-eight were ignorant of contraceptives, or ninety-five per cent. Twenty-one women had had eight children each. Of these twenty were ignorant of contraceptives, or ninety-five per cent. Forty-four women had had nine or more children each, and of these all were ignorant of contraceptive measures. Arranged in tabular form, these data would appear as follows:

Number of Women Number of Number Ignorant Percentage
Children of Contraceptives
68 3 26 38
28 4 14 50
55 5 30 54
32 6 20 62
40 7 38 95
21 8 20 95
44 9 to 17 all 100

It is sometimes stated by opponents of birth control that contraceptive methods are known by every married person and that the fault and immorality of having a large family of unprovided for dependents lies not in ignorance of contraceptives but rather in a lack of determination on the part of one or both parents to use preventive measures; in other words, that the failure to use contraceptives results from the inconvenience attending some methods and also from the influence of religious sentiment.

The above data, however, tend to show that ignorance of contraceptives not only is a great factor in the production of large families, but is also a great factor in increasing the number of abortions. From the fact that two thirds of these women knew absolutely no contraceptive method, while the methods used by many of the others were ineffectual or positively harmful, it is apparent that there is a definite opportunity for educating these women in methods of regulating conception. That there is need and demand for such education is voiced in unmistakable language by the multitude of poor who seek advice from all practising physicians.

MATERNAL MORTALITY

Prof. Theodate L. Smith, director of the Library Department, Child Study Institute, Clark University, investigated the records of the families of early graduates of Yale University (1701 to 1745) and of Harvard University (1658 to 1690); and found that of the wives of Harvard men, 37.3 per cent. died under the age of 45 years, while of the wives of Yale men, 40 per cent. died under 50 years. Prof. Smith also showed that there is a tendency for families very large in the first generation to die out in the third or fourth generation. One family of twenty children, by two wives, has living descendent by one son only, one daughter being untraceable. A family of ten brothers and sisters, only two of whom lived until 50, produced three surviving children, who in turn have produced one, and that a sickly specimen. Another family had fourteen in the first generation, eight in the second, six in the third and only two in the fourth.—Mary Alden Hopkins in _Harper’s Weekly_, June, 1915.

TUBERCULOSIS, CAUSE OF THE GREATEST NUMBER OF DEATHS OF WOMEN DURING THE
CHILD-BEARING PERIOD

_OBSTETRICS. A Text Book for the Use of Students and Practitioners. J.
Whitridge Williams, Professor of Obstetrics, John Hopkins
University, Obstetrician-in-Chief to the John Hopkins Hospital,
Gynaecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co. 1912._

As a rule, all diseases which subject the organism to a considerable strain are much more serious when occurring in the pregnant woman. In general it may be said that pregnancy exerts a deleterious influence upon all chronic organic maladies, while its effect is usually less marked in acute infectious processes. The latter, however, frequently lead to premature delivery and the additional physical strain attending the latter matter render the course of the disease much less favorable. Page 489.

“Owing to the well known fact that pulmonary tuberculosis usually progresses much more rapidly after child bearing, it is advisable that tubercular women take every precaution to avoid the possibility of conception.” Page 383.

It would appear therefore that in the vast majority of cases the disease (tuberculosis) is not transmitted directly from the mother to the fetus, and that the latter is born with a tendency to tuberculosis, rather than with the disease itself. Hence it follows that the children of tubercular mothers should be brought under the best hygienic surroundings, and should not be suckled by their mothers. In view of the fact that the tubercular process usually becomes exacerbated either during pregnancy or after child birth, most authorities recommend that abortion be induced as a matter of routine in all tubercular women, and many that they be rendered sterile by artificial means. This appears to be a somewhat too extreme point of view, but I consider that abortion should be induced in the first pregnancy occurring after the onset of the disease, and whenever it makes its appearance during the early months of pregnancy. Page 494.

_THE PRACTICE OF OBSTETRICS. In original contributions by American
Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynaecology in the University of Michigan, Ann
Arbor, Mich. Obstetrician-in-Chief to the University of Michigan
Hospital. Lea Bros. & Co. Philadelphia and New York. 1907. Chapter
IX._

COMPLICATIONS ARISING FROM MATERNAL DISEASES AND ANOMALIES

Exact observations on a large number of cases have demonstrated beyond doubt that with very rare exceptions a pregnancy exerts a harmful effect upon the course of the disease (tuberculosis). Page 344.

So seriously is the tubercular process affected by a concomitant pregnancy that it seems the duty of the physician to warn every tubercular girl against marriage. Especially deleterious to the patient are pregnancies which follow each other at short intervals. In such instances the patient must be strongly advised against a new impregnation. It hardly can be denied that in some of these cases artificial sterilization may be justified. An additional argument in favor of this procedure is the comparative frequency with which, if not the infection itself, at least a marked disposition to it is transmitted to the fetus in utero. P. 344.

_A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of
Obstetrics in the University of Pennsylvania; Gynaecologist to the
Howard and Orthopaedic and the Philadelphia Hospitals, etc. W. B.
Saunders Co. 1909._

The influence of pregnancy upon tuberculosis is most unfavorable and in women predisposed to tuberculosis, gestation may be the determining factor in lighting up an attack. It is the duty of a physician to advise strongly against marriage and maternity in the case of a woman already infected, or predisposed to tuberculosis. If the patient is pregnant an induction of labor should be considered. P. 427.

_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and to
Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._

Women with tuberculosis should not marry, first, because this aggravates their own disease. Second, they may infect the husband, and third, they propagate tuberculous children. Knowing the tendency for a latent tuberculosis to break out in pregnancy, marriage is to be forbidden. If the woman marries, she should avoid conception. P. 481.

If tuberculosis of the lungs is manifested in early pregnancy, if there is fever, wasting, hemoptysis and advancing consolidation, that is, the process seems to be florid, abortion should be induced without delay. Trembley, of Saranac Lake induces abortion in the early months in all cases. Urgent symptoms of cardiac nature, persistent hemoptysis and dyspnea may require emptying of the uterus. Complicating nephritis, heart disease, and contracted pelvis, which is said to be more frequent in the tuberculous, will give early indications for interference. P. 481.

_TUBERCULOSIS. Jos. B. De Lee._

The woman should be instructed how to avoid pregnancy in the future. Something must be done until the woman is cured of her tuberculosis, so that she may safely go through a confinement, because every accoucheur recoils with horror from the task of repeatedly doing abortions on these tuberculous women. P. 482.

_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Prof. of Obstetrics
and Clinical Midwifery in the Cornell University Medical College;
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
to the Manhattan Maternity and Dispensary; Consulting Obstetrician
to the New York Maternity and Jewish Maternity Hospitals. 5th
Edition. Revised. P. Blakiston’s Co., Phil._

The subject of the relationship between tuberculosis and pregnancy has recently attained an increased degree of importance through the agitation in favor of the justification of abortion in the tuberculous pregnant woman. P. 314.

Statistics appear to show, according to Lancereaux, that a considerable number of cases of tuberculosis develop solely as a result of pregnancy. If pregnancy can thus affect health, how much more likely would it be for the disease to assert itself in a woman who is a fit subject for it, or in one who is actually consumptive. In the former class are so called candidates for tuberculosis who have a family history of the disease of much significance under these circumstances. One should strongly dissuade girls with tubercular history and antecedents from early marriage, fearing that repeated childbearing will infallibly light up the dreaded malady. What has been said of the candidate for tuberculosis applies with the same, or greater force in the case of so-called latent tuberculosis and of apparent recovery from the disease. Present sentiment is beginning to dissuade such women from marriage, not less for their own benefit than for the sake of posterity, and all organized movements which are seeking to eradicate tuberculosis from the world lay much stress on discouraging marriage in tuberculosis suspects. Until this view prevails there will necessarily be some justification for interrupting a pregnancy already under way. P. 314.

Sanatoria for consumptives do not care to admit pregnant women, and this prohibition is equivalent to ranking them as incurable. The fact that a candidate for tuberculosis runs a very great risk of becoming consumptive through childbirth is a most stubborn one, and when in addition to becoming a consumptive herself she also brings into the world an individual who is likely to become tubercular, it readily becomes apparent that the question of the propriety of therapeutic abortion is bound to become an issue in the future in the practice of obstetrics. P. 315.

EXCEPTIONAL CASES

A tubercular woman may go through gestation with no undue acceleration of her malady, only to succumb after delivery to acute general tuberculosis, or acute tubercular pneumonia. P. 315.

Tubercular pregnant women also show no little tendency to abort. P. 316.

_TUBERCULOSIS A PREVENTABLE AND CURABLE DISEASE. S. Adolphus Knopf,
M.D.; Professor of Phthisio-therapy at the New York Post-Graduate
Medical School and Hospital; Associate Director of the Clinic for
Pulmonary Disease of the Health Department; Attending Physician to
the Riverside Sanitorium for Consumptives of the City of New York,
etc. Moffat Yard & Co., 1909. New York._

We have emphasized the fact that tuberculosis is very rarely directly hereditary, but that what is often transmitted by tuberculous parents is a weakened system, or physiological poverty. Nevertheless it is evident that tuberculous individuals ought not to marry, and when tuberculosis develops in a married couple it is best that they should have no children. P. 354.

_PULMONARY TUBERCULOSIS. Its Modern Prophylaxis and the Treatment in
Special Institutions and at Home. S. Adolphus Knopf, M.D. P.
Blakiston’s Sons & Co., Phil., 1899._

If conception has taken place in a tuberculous woman institute treatment, preferably in a sanatorium near the home of the patient. But as Treaudeau says, it is essential that the treatment be continued for a long time afterwards, and I should like to add that a repetition of pregnancy must be prevented. P. 283.

_THE TUBERCULOSIS PROBLEM AND SECTION 1142 OF THE PENAL CODE OF THE
STATE OF NEW YORK. S. Adolphus Knopf, M.D. Reprinted from the New
York Medical Journal for June 12th, 1915._

There seems to be no difference of opinion in the minds of men and women who have studied rational eugenics and sociology concerning the necessity of beginning to work with the preceding generation, and of teaching parents that quality is better than quantity, and that a large number of children, underfed or of mental, moral and physical inferiority, means race suicide, while the reverse means race preservation.

I cannot defend my attitude better than by telling you the conclusions I have arrived at in my study of the tuberculosis situation in the United States. In the families of the poor where there are usually numerous children, it really matters little whether it is the father or the mother who is acutely tuberculous. Since almost invariably they live in close and congested quarters, are underfed and insufficiently clad, it is of relatively rare occurrence when most of the children do not become infected with tuberculosis. In some of our tuberculosis clinics where we insist on an examination of all the children of the tuberculous parents visiting these special dispensaries, we find as many as fifty per cent. of the children to be afflicted with tuberculosis as the result of postnatal infection. In taking the history of a patient in my private consultation work, it is my invariable custom to ask whether he comes from a large family, and if so whether he was among the first or latter born children. As a rule, especially among the poor, it proves to be one of the latter born, (the fifth, sixth, seventh, eighth, ninth, etc.) who contracts tuberculosis, and I believe this to be because when he came to the world there were already many mouths to feed and food was scant, for the father’s income rarely increases with the increase of the family; and the mother, worn out with repeated pregnancies, cannot bestow upon the latter born children the same care which was bestowed upon the first. We know tuberculosis to be a preventable and curable disease, but we also know that it is the disease of poverty, privation, malnutrition, and bad sanitation. P. 4.

I do not know the penalty to be visited upon a physician who offends the majesty of the law as set forth in section 1142 of the penal code, but I for one am willing to take the responsibility before the law and before my God for every time I have counselled, and every time I shall counsel in the future, the prevention of a tuberculous conception, with a view to preserving the life of the mother, increasing her chances of recovery, and, last, but not least, preventing the procreation of a tuberculous race. P. 5.

_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch, M.D., Professor of the German
Medical Faculty of the University of Prague; Physician to the
Hospital and Spa of Marienbad; Member of the Board of Health, etc.
Translated by M. Eden Paul, M.D. Rebman Co., New York._

As regards the marriage of any woman suffering from tuberculosis we must take into consideration a fact that medical experience has conclusively established, namely, that the processes of generation have an unfavorable influence upon pulmonary tuberculosis. P. 259.

During pregnancy tuberculosis advances with such rapid strides that pregnancy and lying-in accelerate the fatal event. In some cases of consumption it is the first pregnancy that is the most perilous, but in other cases a later pregnancy proves more perilous. P. 260.

_Dr. S. Adolphus Knopf, M.D., Professor of Medicine, Department of
Phthisio-therapy of the New York Post Graduate Medical School
and Hospital; Senior Visiting Physician to Riverside
Hospital-Sanatorium for the Consumptive Poor of the City of New
York, etc._

Reprinted from the _Women’s Medical Journal_, September, 1915.

Of the 150,000 who it is estimated die annually from tuberculosis in the United States, I venture to say 50,000 have been bread winners. Estimating the value of such a single life to the community at only about $5,000, this makes a loss of $250,000,000 each year. Another third, I venture to say, represents children at school age. They have died without having been able to give any return to their parents or to the community. Making the average duration of their young life only 7.5 years, and estimating the cost to parents and the community at only $200 per annum, the community loses another $75,000,000. The value of lives of little babes, children below and above school age, adolescents not yet bread winners, and men and women no longer able to earn their living can not be estimated in exact figures, but is reasonable to suppose the total annual financial loss from tuberculosis in the United States to be at least half a billion dollars. This does not include the expenditures for hospitals, sanatoria, clinics, dispensaries, colonies, preventoria and other agencies, devoted to the solution of the tuberculosis problem.

In the face of these figures and the suffering, misery and disappointment of parents who lose their children after having tenderly loved and cared for them for some years, I wonder if there can be any doubt in the minds of sane men that it would have been better if these children had never been born. Surely all this is race suicide instead of race preservation.

Not so very long ago I was asked by a young colleague to aid in the diagnosis of tuberculosis in a day laborer. The man earned $12 a week, was thirty-six years of age on the day the examination and diagnosis was made, had been married fourteen years, and his eleventh child had been born on his last birthday; four or five had already died, two of them of tuberculous meningitis. A glance at the rest of the family showed that nearly all of them were predisposed to tuberculosis, if not already infected, and that a few years of continued underfeeding and bad housing would finish their earthly career. With two or three children to provide for the family might have lived in relative comfort; with better food and better home environments the father might never have become tuberculous and none of the children might have contracted the disease. The commonwealth would have been the gainer by two or three mentally and physically vigorous future citizens.

Only a few days ago, while an article for the _Journal of Sociologic Medicine_ was in preparation, an Italian woman presented herself to me for examination. She gave her age as fifty-six, and had married quite young. She had borne her husband seventeen children, of which, however, only four were living. Some had died in infancy, some at school age, and some during adolescence. What useless suffering! What useless economic loss to the individual family and society at large. Upon examination, I found the woman’s mental condition even worse than her physical status. The repeated pregnancies, the frequent diseases in the family, thirteen deaths among her children, had made a mental and physical wreck of her. Yet the woman belonged to the better and well-to-do class of our population of Italian birth. What would her condition have been if she had also had to share in the struggle for the existence of the family, and had had to work in sweatshops or factories, as so many of the poor Italians have to do?

When pregnancy means danger to the life of the mother, or exacerbation of an existant mental or physical ailment, as, for example, tuberculosis, which is always aggravated by child-bearing, every conscientious physician should do his utmost to prevent childbirth in such an invalid.

Where there is tuberculosis or any other serious transmissible disease in one or both of the parents, or there is danger that it may be transmitted to the offspring, it should not only be the right but the sacred duty of the physician to prevent the conception of any physically and mentally handicapped offspring destined to become a burden to the community.

KIDNEY DISEASES

_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynecology in the University of Michigan, Ann
Arbor, Mich. Obstetrician and Gynecologist in Chief to the
University of Michigan Hospital. Lea Bros. & Co., Phil. and New
York. 1907. Chapter XIX._

Pephritis. From statistics we find that even excluding the cases of eclampsia, the maternal mortality from nephritis during pregnancy is 33%, and the fetal mortality between 50% and 60%. P. 352.

Women suffering from a chronic nephritis should be advised strongly against marriage, especially in the presence of a cardiac or pulmonary lesion. Married women should be warned against impregnation. P. 354.

Pyelitis. “On account of the increased dangers of pyelitic and especially of a pyelonephritic process during pregnancy, women suffering from these diseases should be warned against marriage. Married women should be warned against a new impregnation, on account of the marked tendency of pyelitis to recur with every pregnancy.” P. 355.

_PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician, Physician and
Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
V. Mosby Co. 1915._

Certain of the conditions enumerated form _absolute_ indications for the induction to abortion. These are nephritis, (a form of kidney disease), uncompensated valvular lesions of the heart, advanced tuberculosis, insanity, irremediable malignant tumors, hydatidiform mole, uncontrollable uterine haemorrhage, and acute hydramnios. P. 652.

_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and
Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
Co. 1913._

All forms of nephritis have a very bad influence on the pregnancy, abortion and premature labor being common. (66% Hofmeier) Seitz found that only from 20% to 30% of the children survived. One of the causes of habitual death of the fetus, abortion, and premature labor is chronic nephritis. P. 497.