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Introductory notes on lying-in institutions

Chapter 9: OBJECTIONS TO THE DATA.
By Florence Nightingale
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Health & Medicine

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The author analyzes maternal mortality in maternity hospitals and wards, compiling statistics on deaths from puerperal fever, peritonitis, pyæmia, haemorrhage, and other causes. Comparisons are drawn between hospital, workhouse, and home birth death-rates to estimate a baseline risk and to highlight higher institutional mortality in some settings. She investigates institutional contributors to infection such as crowding, poor ventilation, mixed wards, and attendants serving diverse classes of patients, and recounts a midwifery ward outbreak that led to closure. Practical proposals are advanced for building arrangements, infection control, and the organized training of midwives and midwifery nurses to reduce maternal deaths.

OBJECTIONS TO THE DATA.

The value of the Registrar-General’s results, and of those given by Le Fort, has been called in question by Dr. Duncan in his work already cited, partly on the authority of certain results of home practice, quoted from Dr. M’Clintock, who has collected the statistics of 16,774 deliveries exclusively from home practice. There were among these 45 deaths from accidents of labour, 52 deaths from puerperal diseases, and 34 deaths from non-puerperal diseases; giving a total mortality of 131, or nearly 8 per 1,000. On considering these figures, the first impression they convey is not that either the Registrar-General or Le Fort is wrong. But it is a very painful impression of another kind altogether. One feels disposed to ask whether it can be true that, in the hands of educated accoucheurs, the inevitable fate of women undergoing, not a diseased, but an entirely natural condition, at home, is that one out of every 128 must die? If the facts are correct, then one cannot help feeling that they present a very strong prima facie case for enquiry, with the view of devising a remedy for such a state of things. It must be seen, however, that these statistics of home practice are as open to the charge of want of accuracy as those of the Registrar-General or Le Fort. The question can only be settled by enquiry, and by more carefully kept statistics of midwifery practice; but in the meantime here are a few facts, kindly placed at my disposal by Mr. Rigden, of Canterbury, which are by no means so hopeless as those given by Dr. Duncan.

‘An analysis of 4,132 consecutive cases in midwifery occurring in private practice during a period of 30 years, particularly in reference to mortality. Eight mothers died: three from convulsions and coma; 4 from puerperal fever; and one from heart disease, about an hour after a comparatively easy labour.’

The report states 8, but after it was supplied another death took place, the day after delivery, making 9 in all. The cause of death is not given.

Mr. Rigden explains that these figures relate only to the first fortnight after delivery; but he states that if any other deaths had taken place within the month, he must have heard of them.

Assuming the Deliveries at 4,133 and the Deaths at 9, Mr. Rigden’s facts show a total mortality of 2·17 per 1,000, of which less than 1 per 1,000 was due to puerperal fever.