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Vincent De Brouwere: New Approaches to Maternal Mortality In Africa

CRASSH, University of Cambridge
CRASSH, University of Cambridge

Vincent De Brouwere (Professor of Public Health at the Institute of Tropical Medicine, Antwerp, Belgium): Why and when did maternal mortality decline in modern societies?

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Why and when did maternal mortality decline in modern societies? Vincent De Brouwere Vincent De Brouwere Maternal & Reproductive Health Unit Woman & Child Health Research Centre 1 Institute of Tropical Medicine, Antwerp
Decline of maternal mortality in Western modern societies Midwifery development: 17th century Textbooks of obstetrics and illustrated manuals (initiated by French men-midwives) Midwifery schools: 18th century in Europe Professionalization of childbirth: 19th century Success however depended on social integration of techniques and political willingness to scale-up the professionalisation of childbirth 2
Childbirth before Man-Midwifery Source: Loudon, 1997 3
Levels of maternal mortality Before the 18th century England, Somerset parishes 16th-18th: 2,440-2,940 West Sussex parish maternal deaths/100,000 register,1561 baptisms (Wilmott-Dobbie 1982) 1,300 on average in Europe before the mid-17th century 4 https://www.westsussex.gov.uk/leisure/explore_west_sussex/record_office_and_archives/family_history/parish_registers_on_microfiche.aspx
Levels of maternal mortality 1887, Britain Variations Famines and chronic nutrition deficiencies Puerperal fever epidemics (Leipzig 1652, Germany then Paris 1664, London 1760, Dublin 1770, the rest of Europe) Mid-17th century Competence of birth attendants and iatrogenesis Consequence of rickets 5
Guilds and regulations Internal regulations through the guilds (professional oath) External regulations from City Council Paris: 1560 The Netherlands (early 17th century): town midwives Germany, England & Wales (18th century) Countryside: no real regulation but religion and social pressure 6
Training midwives: the 17th French school Textbooks first Louise Bourgeois (1609) Fran巽ois Mauriceau (1668) Cosme Viardel (1671) Jane Sharpe (Britain) (1671) Paul Portal (1685) Hendrik van Deventer, Holland (1685) Philippe Peu (1694) 7
A special case In Sweden: Johan von Hoorne (1697) 8
Creation of Midwifery Schools in 18th Europe 9
Field training (outside schools) 10,000 midwives trained by Ang辿lique du Coudray in France between 1760 and 1783 Mme du Coudrays teaching travel map The Mme du Coudrays machine Source: Gelbart 1998 10
Maternal mortality ratios in England & Wales, USA, and Sweden Sulfonamides 1st transfusion of human blood 1000 Blood bank Blood transfusion Maternal deaths per 100,000 births 900 safer Asepsis / antisepsis 800 USA 700 C-section rate E&W rise Sources: 600 Howard C-section lethality 1921; 500 Sweden decreased H旦gberg et al. 1986; 400 H旦gberg 300 and Wall 1986a; 200 Loudon 1992a; 100 WHO & 0 Unicef 1996 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 11
Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Number and causes Health Commission: of maternal deaths Skilled birth attendants 1751 required to decrease Maternal mortality Early reduction of maternal mortality 12
Professionalization of midwifery in Sweden 1708: midwifery school 1723: J. von Hoorn 1st paid state employed teacher of midwifery 1751: decision to increase the number of midwives 1829: training in the use of forceps and sharp instruments 1881: asepsis and antisepsis 1847 / 1795 1861 1855 1860 1865 13
Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Policy: Involvement & accountability Professional obstetric care of professionals Early reduction of maternal mortality 14
Sweden rural areas, 1861-95. The correlation between the % of deliveries by trained midwives and the MMR due to maternal causes OTHER than sepsis 15
Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Policy: Involvement & accountability Professional obstetric care of professionals Strategy: Public commitment: Access to professional regulations, norms obstetric care & investment Early reduction of maternal mortality 16
1800-2000: maternal mortality ratios 1000 Maternal deaths per 100,000 births 900 USA 800 700 E&W 600 500 Sweden 400 300 200 100 0 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 17
USA Technical elements Political conditions Information: Late information Awareness & Magnitude & avoidability No pressure political pressure until 1930 Policy: Involvement & accountability Focus on gynaecologists Professional obstetric care of professionals Abuse of technology Strategy: Public commitment: Focus on hospitals Access to professional regulations, norms obstetric care Barriers to access & investment No regulation Stagnation 18
1918-20: Maternal mortality according to policies Maternal Mortality Ratio Mainly 799 US doctors 648 New Zealand 615 Scotland it was not so much the place of delivery France 664 as the type of birth attendant which was Ireland 553 Mix doctors crucial 501 Australia midwives in Britain between 1850 and 1950 the 433 E&W midwife was the safer birth attendant for 297 Norway normal deliveries Sweden 258 Mainly midwives 242 Loudon,Netherlands The 1992 235 Denmark 19
Getting all of it right Combined ingredients: Missing ingredients Significant reduction, even Reduction delayed until modern without hospitalisation hospital technologies become Less medicalisation in next accessible phase More medicalisation in next phase Japan, Denmark, Norway, USA, Belgium, Sweden, The Great-Britain, France, Italy Netherlands 20
Maternal deaths/ 1935-1980 MMR 100,000 births 1000 Maternal mortality decline Green: Europe 900 Purple: Asia Achieves stable historical 800 Blue: Latin America lows, but only in the 700 industrialized world Professional assistance 600 becomes the norm: Sri Lanka 500 purely hospital based deliveries mixed hospital / home 400 Technology matures 300 Quality of care and evidence Ecuador based medicine 200 Japan Costa Rica & Cuba Access generalized (universal 100 coverage) 0 1935 1945 1955 1965 1975 1985 21
Lessons from European history Knowledge of maternal mortality levels and concept of avoidable death Professionalisation of childbirth Education leading to competence Non interventionism and patience Recognized status by the government Accountability Scaling up of skilled attendance at delivery Midwives in numbers Financial barrier removed Backup from hospitals 22
Messages from historical Europe to Africa The key to reduction of MM is professionalisation of obstetric care backed-up by a network of accessible hospitals (C-EmOC) The key to successful professionalisation is the production of adequate numbers of competent midwives with a recognized status and local accountability Human resource is the key and the biggest challenge 23

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Vincent De Brouwere: New Approaches to Maternal Mortality In Africa

  • 1. Why and when did maternal mortality decline in modern societies? Vincent De Brouwere Vincent De Brouwere Maternal & Reproductive Health Unit Woman & Child Health Research Centre 1 Institute of Tropical Medicine, Antwerp
  • 2. Decline of maternal mortality in Western modern societies Midwifery development: 17th century Textbooks of obstetrics and illustrated manuals (initiated by French men-midwives) Midwifery schools: 18th century in Europe Professionalization of childbirth: 19th century Success however depended on social integration of techniques and political willingness to scale-up the professionalisation of childbirth 2
  • 3. Childbirth before Man-Midwifery Source: Loudon, 1997 3
  • 4. Levels of maternal mortality Before the 18th century England, Somerset parishes 16th-18th: 2,440-2,940 West Sussex parish maternal deaths/100,000 register,1561 baptisms (Wilmott-Dobbie 1982) 1,300 on average in Europe before the mid-17th century 4 https://www.westsussex.gov.uk/leisure/explore_west_sussex/record_office_and_archives/family_history/parish_registers_on_microfiche.aspx
  • 5. Levels of maternal mortality 1887, Britain Variations Famines and chronic nutrition deficiencies Puerperal fever epidemics (Leipzig 1652, Germany then Paris 1664, London 1760, Dublin 1770, the rest of Europe) Mid-17th century Competence of birth attendants and iatrogenesis Consequence of rickets 5
  • 6. Guilds and regulations Internal regulations through the guilds (professional oath) External regulations from City Council Paris: 1560 The Netherlands (early 17th century): town midwives Germany, England & Wales (18th century) Countryside: no real regulation but religion and social pressure 6
  • 7. Training midwives: the 17th French school Textbooks first Louise Bourgeois (1609) Fran巽ois Mauriceau (1668) Cosme Viardel (1671) Jane Sharpe (Britain) (1671) Paul Portal (1685) Hendrik van Deventer, Holland (1685) Philippe Peu (1694) 7
  • 8. A special case In Sweden: Johan von Hoorne (1697) 8
  • 9. Creation of Midwifery Schools in 18th Europe 9
  • 10. Field training (outside schools) 10,000 midwives trained by Ang辿lique du Coudray in France between 1760 and 1783 Mme du Coudrays teaching travel map The Mme du Coudrays machine Source: Gelbart 1998 10
  • 11. Maternal mortality ratios in England & Wales, USA, and Sweden Sulfonamides 1st transfusion of human blood 1000 Blood bank Blood transfusion Maternal deaths per 100,000 births 900 safer Asepsis / antisepsis 800 USA 700 C-section rate E&W rise Sources: 600 Howard C-section lethality 1921; 500 Sweden decreased H旦gberg et al. 1986; 400 H旦gberg 300 and Wall 1986a; 200 Loudon 1992a; 100 WHO & 0 Unicef 1996 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 11
  • 12. Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Number and causes Health Commission: of maternal deaths Skilled birth attendants 1751 required to decrease Maternal mortality Early reduction of maternal mortality 12
  • 13. Professionalization of midwifery in Sweden 1708: midwifery school 1723: J. von Hoorn 1st paid state employed teacher of midwifery 1751: decision to increase the number of midwives 1829: training in the use of forceps and sharp instruments 1881: asepsis and antisepsis 1847 / 1795 1861 1855 1860 1865 13
  • 14. Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Policy: Involvement & accountability Professional obstetric care of professionals Early reduction of maternal mortality 14
  • 15. Sweden rural areas, 1861-95. The correlation between the % of deliveries by trained midwives and the MMR due to maternal causes OTHER than sepsis 15
  • 16. Sweden Technical elements Political conditions Information: Awareness & Magnitude & avoidability political pressure Policy: Involvement & accountability Professional obstetric care of professionals Strategy: Public commitment: Access to professional regulations, norms obstetric care & investment Early reduction of maternal mortality 16
  • 17. 1800-2000: maternal mortality ratios 1000 Maternal deaths per 100,000 births 900 USA 800 700 E&W 600 500 Sweden 400 300 200 100 0 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 17
  • 18. USA Technical elements Political conditions Information: Late information Awareness & Magnitude & avoidability No pressure political pressure until 1930 Policy: Involvement & accountability Focus on gynaecologists Professional obstetric care of professionals Abuse of technology Strategy: Public commitment: Focus on hospitals Access to professional regulations, norms obstetric care Barriers to access & investment No regulation Stagnation 18
  • 19. 1918-20: Maternal mortality according to policies Maternal Mortality Ratio Mainly 799 US doctors 648 New Zealand 615 Scotland it was not so much the place of delivery France 664 as the type of birth attendant which was Ireland 553 Mix doctors crucial 501 Australia midwives in Britain between 1850 and 1950 the 433 E&W midwife was the safer birth attendant for 297 Norway normal deliveries Sweden 258 Mainly midwives 242 Loudon,Netherlands The 1992 235 Denmark 19
  • 20. Getting all of it right Combined ingredients: Missing ingredients Significant reduction, even Reduction delayed until modern without hospitalisation hospital technologies become Less medicalisation in next accessible phase More medicalisation in next phase Japan, Denmark, Norway, USA, Belgium, Sweden, The Great-Britain, France, Italy Netherlands 20
  • 21. Maternal deaths/ 1935-1980 MMR 100,000 births 1000 Maternal mortality decline Green: Europe 900 Purple: Asia Achieves stable historical 800 Blue: Latin America lows, but only in the 700 industrialized world Professional assistance 600 becomes the norm: Sri Lanka 500 purely hospital based deliveries mixed hospital / home 400 Technology matures 300 Quality of care and evidence Ecuador based medicine 200 Japan Costa Rica & Cuba Access generalized (universal 100 coverage) 0 1935 1945 1955 1965 1975 1985 21
  • 22. Lessons from European history Knowledge of maternal mortality levels and concept of avoidable death Professionalisation of childbirth Education leading to competence Non interventionism and patience Recognized status by the government Accountability Scaling up of skilled attendance at delivery Midwives in numbers Financial barrier removed Backup from hospitals 22
  • 23. Messages from historical Europe to Africa The key to reduction of MM is professionalisation of obstetric care backed-up by a network of accessible hospitals (C-EmOC) The key to successful professionalisation is the production of adequate numbers of competent midwives with a recognized status and local accountability Human resource is the key and the biggest challenge 23