Questionable stats? (19th century stuff --Sorta OT)

Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

Naomi

Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

assuming those stats are correct, that's 44% got pueperal fever and of
those, 35% died, which is 15% of pregnancies resulting in a death from
puepural fever, which really cannot be right, though it could be read the
way you appear to have read it, that of the 24 out of 54 who get puerperal
fever, 19 of those 24 women die, either way, it makes no sense, if a book
(or anything for that matter) doesn't quote sources, take any results with a
large pinch of salt.

Cheers

Anne

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

Naomi

wrote:
Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

I wonder. Is it possible that they meant that
24/55 (44 percent) of pregnancies ended in puerperal
fever, and out of those with puerperal fever, 19/54
(35 percent) died. That would mean that 15 percent
of pregnancies ended in death, which is still too
high but not quite as bad.
I agree with you that the numbers sound way
too high to be accurate either way.

Best wishes,
Ericka

Well, at least I know what it is, now. At
http://www.ilt.columbia.edu/projects...ml/health.html, it
say that it's a disease that was contracted during or right after
delivery. It says the disease was(is) communicable, and that it was the
Doctors and Nurses that spread the disease. It says that simply washing
their hands cut (or would have cut) the number of cases down
drastically.

Given that the personnel wasn't entirely sanitary in those days (and I
use "entirely" as an understatement), I can now say that it doesn't
sound too unusual that 15% (if not more) died as a result of Puerpural
fever. They state that that's one of the reasons why people in Irland
wanted to leave their country so badly, leaving the potato famine
aside.

wrote:
Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

Naomi

ncrist wrote:

Given that the personnel wasn't entirely sanitary in those days (and I
use "entirely" as an understatement), I can now say that it doesn't
sound too unusual that 15% (if not more) died as a result of Puerpural
fever. They state that that's one of the reasons why people in Irland
wanted to leave their country so badly, leaving the potato famine
aside.

I don't think there's any way for that number to
be accurate. If 15 percent of pregnancies or more ended
in death (and with no birth control, most women had quite
a few pregnancies), that would be a staggering number of
women dying that just doesn't seem to be in evidence.

Best wishes,
Ericka

wrote:
Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

Naomi


When judging the validity of the statistics, you have to take into
account the nature of Puerpural Fever and where it came from, how it is
transmitted and most especially the expectations of the time.

Puerpural Fever (or Childbed Fever) was first documented in Hindu texts
sometime around 1500BC and even the Greeks knew of it, but until very
recently, most women routinely gave birth at home attended by their
closest female relatives and the 'local' midwife/wisewoman/witch and
therein lies the clue. Puerpural sepsis is caused by invasion of the
placental wound site by the streptococcus bacterium present on all of
our skins regardless of cleanliness. Further, since there were no
antibiotics to treat it, women who were naturally weakened by the
labour, were in no fit state to fight an agressive bacterium. Since
Puerpural fever was known in antiquity, we can deduce that it is not a
new phenomenon. What is new however, was the introduction of large scale
'laying in' hospitals during the late 18th and early 19th century -
proto hospitals. Although hospitals had always existed in one form or
another, all women up until that time gave birth at home in their own
environment. For the first time, women were encouraged to deliver in
specialist obstetric hospitals built and staffed for that purpose. The
primary purpose of these hospitals was to provide physicians with
training in obstetrics in general and in forceps deliveries in
particular. A procedure which is highly invasive and usually unnecessary
in the majority of cases. Essentially, doctors were learning as they
went and since almost all the patient care was taken away from the
traditional wisewomen and given to the male doctors who had generally a
cursory understanding of gynachology, this led to an increase in what we
would consider to be outrageously invasive techniques. Indeed, as late
at the 1960's in Ireland, unmarried pregnant women were being forced to
have their children under the influence of a cocktail of narcotics,
hypnotics and anesthetics just so a junior doctor could practice
episiotomies and his stitching technique!

Add to this mix the shear number of women being dealt with at any one
time and I am sure you can see the potential for disaster, especially in
a time before we understood that washing our hands could prevent these
epidemics. One of the famous names in the field was Ignaz Semmelweis in
Vienna who noted that the number of women dying of puerpural fever was
increasing and decided to investigate. In 1844, Semmelweis was appointed
assistant lecturer in the First Obstetric Division of the Vienna
Lying-In Hospital, the division in which medical students received their
training. He was appalled by the division's high mortality rate from
puerperal fever — 16% of all women giving birth in the years 1841–1843.
In contrast, in the Second Division, where midwives or midwifery
students did the deliveries, the mortality rate from the fever was much
lower, at about 2%. Semmelweis also noted that puerperal sepsis was rare
in women who gave birth before arriving at the hospital.


It wasnt until 1861 that he finally published his paper detailing his
research but still it was pooh poohed by the powerful establishment
until late in the 1880's. Ignaz deduced that when doctors in his
hospital performed autopsies in the morning and then attended labouring
women in the afternoon the incidence of puerpural fever increased.
Shockingly though, the west was way behind the times. The greek
physician Soranus noted in his writings that the incidence of fever
increased when attendants did not wash their hands between patients and
even offered general advice on hygiene to those attending pregnant women.

The first recorded epidemic of puerperal fever occurred at the Hôtel
Dieu in Paris in 1646. Subsequently, maternity hospitals all over Europe
and North America reported intermittent outbreaks, and even between
epidemics the death rate from sepsis reached one woman in four or five
of those giving birth [Loudon I. Deaths in childbed from the eighteenth
century to 1935. Med History 1986; 30: 1-41.]

Just as a general side bar note - it was standard practice well into the
20th century for a pregnant woman to organise her will before labour
commenced. One of Victoria's daughters is known to have done this in
case she died during or shortly after labour and it was noted in a
letter to her mother. I know this is true because I have a copy of the
will my Great-Grandmother wrote which specifies the reason for
completing this legal formality. She notes in her will that this is the
8th child she has carried to term and is concerned that she is 'pushing
her luck' as it were and therefore was organising her will in the event
that she died during or after the birth.

Anyway, back to the history - Semmelweis began experimenting with
various cleansing agents and, from May 1847, ordered that all doctors
and students working in the First Division wash their hands in
chlorinated lime solution before starting ward work, and later before
each vaginal examination. The results were extraordinary — the mortality
rate from puerperal fever in the division fell from 18% in May 1847 to
less than 3% in June–November of the same year [Raju TN. Ignac
Semmelweis and the etiology of fetal and neonatal sepsis. J Perinatol
1999; 19(4): 307-310.]

Paradoxically, within a few years of his death, Semmelweis' doctrine
began to be accepted by the wider medical community. In 1874, Billroth
demonstrated streptococci in pus from wound infections, and in 1879
Louis Pasteur identified the haemolytic streptococcus in the blood of a
woman with puerperal sepsis. Joseph Lister, learning of Pasteur's work
and germ theory, began to apply antiseptic principles to the practice of
surgery, with a dramatic fall in postoperative deaths from infection. As
with Semmelweis', Lister's ideas were also greeted with scepticism and
it took nearly 30 years for "Listerism" to be universally accepted by
medical practitioners.

By the end of the 19th century, the need for obstetric asepsis was well
appreciated. An authoritative text of 1905 gives detailed instructions
for the personal hygiene of physicians and nurses attending confinements
and instructions on the performance of internal examinations. The
importance of "inculcating in the student the principles of obstetrical
cleanliness, mechanical and chemical" is emphasised. The need for
meticulous antiseptic care during operative vaginal deliveries and
manipulations — more frequent then than now — is reiterated.

Australian medical practitioners were apparently quick to follow the
lead of their overseas colleagues in the application of hygienic
measures in obstetrics, and of self-regulation when puerperal fever
occurred in their practices. Most stopped attending midwifery cases for
a time after one or two deaths among their patients.

Surprisingly though, despite the new understanding of the importance of
antisepsis, puerperal sepsis still occurred frequently in developed
countries in which figures were kept. It appears the principles of
antisepsis were not universally applied.

In England and Wales, in the period 1870 to 1890, the maternal death
rate in hospital births was around 1 : 20, of which about 40% were due
to infection. In the United States, in the 1890s, 20 000 women a year
died in childbirth. In New South Wales, in 1894–1896, among confinements
of married women, both at home and in hospital, the government
statistician found a death rate of 1 : 148, and he commented on the
negligence of medical men in filling the certificates required by law.
Up to that point, causes of death had been supposedly accurately
recorded for more than 40 years, but, in fact, the puerperal nature of
fatal infections in women was frequently omitted.

Globally, the most common and most feared infecting organism at the time
was the Group A haemolytic streptococcus, whose virulence appears to
have diminished in recent years, possibly due to improved socioeconomic
conditions and the use of antibiotics. Normally found on the skin, in
the nose and throat, and in the vagina, as well as in skin lesions, the
streptococcus was introduced into the genital tract during examinations
and deliveries. Lacerations, blood loss and exhaustion from prolonged
labour increased the possibility of postpartum infection. Staphylococci,
gonococci, coliforms and other bowel flora, as well as anaerobes, were
less likely culprits, but have assumed greater importance in recent
years, as have Group B streptococci.

In conclusion therefore, I would be inclined to believe the statistics -
horrifying as they are to our modern eyes. Women did frequently die of
puerpural fever, it was very common, so common in fact that women
routinely organised their affairs before going into labour. Just
finally, in the years 1994 - 1996 there were 16 recorded deaths from
puerpural fever in the UK [Report Department of Health, 'Why women
die']. Go ask your midwife if she knows what it is and what the signs
are....I doubt she does. Arrogance breeds ignorance. Just because we
have antibiotics, doesnt mean that puerpural fever has been
irradicated...it hasnt.

Sweet dreams
Wookie

Ericka Kammerer writes:
: ncrist wrote:

: Given that the personnel wasn't entirely sanitary in those days (and I
: use "entirely" as an understatement), I can now say that it doesn't
: sound too unusual that 15% (if not more) died as a result of Puerpural
: fever. They state that that's one of the reasons why people in Irland
: wanted to leave their country so badly, leaving the potato famine
: aside.

: I don't think there's any way for that number to
: be accurate. If 15 percent of pregnancies or more ended
: in death (and with no birth control, most women had quite
: a few pregnancies), that would be a staggering number of
: women dying that just doesn't seem to be in evidence.

: Best wishes,
: Ericka

Remember that om the nineteenth century there were far fewer
hospital births than home births. I have also heard that the
neonatal death reate in hospitals at that time were orders of
magnitude higher than for homebirths, and that they did not
really come down until the germ theory, and resulting hygine
was commonly accepted by doctors. I don't find this number
staggering for, say, around 1800.

Larry

ChocolateChip_Wookie wrote:
wrote:
Cataloging a book at work today I ran across a statistic that has me
VERY puzzled. It was a book about public health history and the quote
read, "In 1857, 24 out of every 54 pregnancies in the U.S. resulted in
post-partum puerperal fever ... as a result o fpuerperal fever, 19 out
of every 54 pregnancies proved lethal to the mother. Given that most
women at that time gave birth to more than 6 children, the risk of
premature death over the course of their reproductive lives was
enormous."

The author gives no cite for this statistic ...but is he really
claiming that almost 40% of births resulted in maternal death from
puerpural fever? I can't figure out where he got the stat. Poking
around a little I couldn't find anything for that particular year, but
a few sources gave figures for the 19th-early 20th century in general
as being around 6-7% ... and that's from ALL causes, not just puerpural
fever.

Ah well ... (It does make me question much of the other data in the
book as well!)

Naomi


When judging the validity of the statistics, you have to take into
account the nature of Puerpural Fever and where it came from, how it is
transmitted and most especially the expectations of the time.



[Snip most of VERY long historical context stuff.]

have their children under the influence of a cocktail of narcotics,
In 1844, Semmelweis was appointed
assistant lecturer in the First Obstetric Division of the Vienna
Lying-In Hospital, the division in which medical students received their
training. He was appalled by the division's high mortality rate from
puerperal fever - 16% of all women giving birth in the years 1841-1843.
In contrast, in the Second Division, where midwives or midwifery
students did the deliveries, the mortality rate from the fever was much
lower, at about 2%. Semmelweis also noted that puerperal sepsis was rare
in women who gave birth before arriving at the hospital.

Right. So even in the WORST of the lying in hospitals, the rates topped
out at about 16%. (And that was an especially bad range of years for
Semmelwies's hospital. Most years the death rate in the 'medical' ward
was around 11%). And for midwife attended births (home or hospital)
most stats I've seen seem to run between 2 and 6%, presumably depending
on location and specific era. (i.e., urban women in delivering in
slums, even with a midwife, had higher rates than rural women.) And
only a tiny minority of women delivered in hospitals (or even at home
attended by doctors) during this era, so that 10-16% in lying in
hospitals-rate would only be blip on the radar.

Yet, according to this author some 35% of ALL births ended in the
mother dying from purpural fever. (Not even 35% of all women eventually
died from childbirth related causes, but about one out of every 3
births ended with the mother dying from infection.) Remember, she
claimed that 19 out of every 54 women died of purperal fever in every
delivery.) That rate would have quickly resulted in the rapid
extermination of the human race! (I'm not great at math nor am I an
epidemiologist ... but if I'm figuring correctly, if 35% of women died
after their first delivery, that left 65% of the population to have
another baby. If 35% of THOSE women died, that's another 23 deaths,
so 65-23 = we're down to 42 women. Then, if those 42 had a 35% death
rate, that's 16%, or 26 women left to have a fourth child. So only
around a quarter of all women would survive to have more than 3
children. And when you then calculate in an infant/child mortality
rate that DID approach 50% among most populations, you are well below
replacement level, since fewer than half of all women could have had
more than 2 children without dying, and only a tiny minority could have
had more than 3 or 4.

Yet that is clearly not the case. There were MANY women who gave birth
to large number of children, and MANY women who survived their
childbearing years.


The first recorded epidemic of puerperal fever occurred at the Hôtel
Dieu in Paris in 1646. Subsequently, maternity hospitals all over Europe
and North America reported intermittent outbreaks, and even between
epidemics the death rate from sepsis reached one woman in four or five
of those giving birth [Loudon I. Deaths in childbed from the eighteenth
century to 1935. Med History 1986; 30: 1-41.]

Right. In maternity hospitals. Which only accounted for a minority of
births.


Just as a general side bar note - it was standard practice well into the
20th century for a pregnant woman to organise her will before labour
commenced. One of Victoria's daughters is known to have done this in
case she died during or shortly after labour and it was noted in a
letter to her mother. I know this is true because I have a copy of the
will my Great-Grandmother wrote which specifies the reason for
completing this legal formality. She notes in her will that this is the
8th child she has carried to term and is concerned that she is 'pushing
her luck' as it were and therefore was organising her will in the event
that she died during or after the birth.

Presumably that was Princess Vicky, since none of Victoria's other
daughters had, so far as I recall, 8 children. (I think Alice had 6 or
7, Helena and Beatrice about 4, and Louise none at all.)

But that's a valid point. Victoria had 9 children herself and survived
to die of old age. Most of her 9 daughters and daughters-in-law had
numerous children, and none of THEM died in childbirth. (Though a few
had babies who died at birth or soon after.) Victoria's cousin
Charlotte (George IV's only child) did indeed die from purpural fever
-- if she hadn't Victoria probably wouldn't have been born at all! --
but I can't think of any other royal women (or mistresses) in her
generation or the previous one who did. Now yes ... these were upper
class women attended by private physicians for the most part. But
still, if the death rates were anywhere NEAR 35% we should have seen
more than one of these several dozen women succumbing.

But yes, of course childbirth was dangerous. And I'm sure many women
got their affairs in order just in case. But most women did NOT die.
Most women survived their labors and went on to have many more
children. Even the 3-5% rate that seems to be typical still adds up to
quite a few deaths when you figure that most women gave birth to 4-8
children, sometimes more. So ... again .. if we assume an average of 6
children, with about a 4% maternal mortality rate per birth that would
be about a one in four chance of dying in childbirth over a woman's
life-time, which seems fairly reasonable. (Though, of course,
first-time mothers would have been more likley to die, since many of
the causes of death were chronic things that would have killed the
mother the first time out. [i.e., prolonged, non-productive labor due
to a contracted pelvis, leading to death from either exhaustion or
infection.

There is obviously SOMETHING very wrong with the initial statistic I
quoted. It cannot possibly be right, and nothing I've ever read in any
other source even approaches her figures.

Naomi

Presumably that was Princess Vicky, since none of Victoria's other
daughters had, so far as I recall, 8 children. (I think Alice had 6 or
7, Helena and Beatrice about 4, and Louise none at all.)



Ooops, clumsy phraseology....the Great Grandmother with 8 children was
my own and no relation to Queen Victoria or her daughters. I have a copy
of my maternal ancestors will, not the will made by Victorias' daughter.
I know the will existed for Victoria's daughter but cannot recall which
one, it's one of those half remembered facts you pick up idly watching
the History Channel. I would be happy to be corrected if anyone has the
correct citation - I think it was the daughter she sent the chloroform to.

Wookie

ChocolateChip_Wookie wrote:

In conclusion therefore, I would be inclined to believe the statistics -
horrifying as they are to our modern eyes. Women did frequently die of
puerpural fever, it was very common, so common in fact that women
routinely organised their affairs before going into labour. Just
finally, in the years 1994 - 1996 there were 16 recorded deaths from
puerpural fever in the UK [Report Department of Health, 'Why women
die']. Go ask your midwife if she knows what it is and what the signs
are....I doubt she does. Arrogance breeds ignorance. Just because we
have antibiotics, doesnt mean that puerpural fever has been
irradicated...it hasnt.

A 15 or 35 percent *per pregnancy* mortality rate
(depending on how you parse things) might be an accurate
statistic for a particular hospital during an epidemic
or something, but I can't find *anything* *anywhere* that
lists even a total maternal mortality rate that high
for the mid-nineteenth century. Sweden was on the low
end with something like a rate of 5 or 6 per thousand.
The *highest* rate I can find anywhere is less than
10 percent, and that was in a particular clinic with all
the high risk practices for puerperal fever. There's
just no way that the national maternal
mortality rate due to puerperal fever could be even 15
percent/pregnancy, much less 35 percent. Reports in
the US show a much lower rate of maternal mortality.
While the trend was moving toward the hospitalization
of birth, by the mid-nineteenth century, most births
were still at home in the US, with much lower maternal
mortality rates.
If there truly were a national 15 percent
mortality rate, with an average of somewhere around
6 deliveries per woman at that time in the US, that
would mean that an average woman would have had more than a
60 percent chance of dying of childbirth at some
time in her life. That's just clearly ludicrous.
Also, why on earth would you assume that a
midwife wouldn't know the signs and symptoms of
puerperal fever? That boggles the mind.

Best wishes,
Ericka