By Nicole Baker ~
In 1935 Louis I. Dublin, Ph.D., a vice president and statistician for the Metropolitan Life Insurance Company, published “Lost Mothers,” an article in which he reported that a staggering 15,000 American women died every year during maternity. Despite improved health outcomes in other preventable and treatable conditions, at that time the United States was only bypassed by Chile in maternal death rates. Dublin further noted that the women who were dying in pregnancy and childbirth were largely the poor, who could not afford to be regularly seen by highly qualified physicians.
The Louis I. Dublin papers at the National Library of Medicine consist mainly of material relating to Dr. Dublin’s publications, such as this stirring article, and related correspondence. The role that life insurance and statistics could play in advancing social welfare and public health were the primary guiding interests in Dublin’s professional life. His publications sought to draw attention to the use of statistical data to inform how medicine and public health programs could be used to preserve, improve, and extend life expectancy.
In “Lost Mothers,” Dublin cited several organizations working on the issue of maternal mortality including the Frontier Nursing Service (FNS) of Kentucky and the Maternity Center Association (MCA) in New York City.
Mary Breckinridge founded the FNS in 1925 after learning about the high infant mortality rates in Kentucky, where a population of over 10,000 people had no doctors. In a film created by the FNS titled “The Forgotten Frontier,” we are told that in American history, we have lost more women in childbirth than men in war. The FNS provided care to those living in the rural Appalachian regions, where child hygiene, midwifery, and other medical care was otherwise not available. Breckenridge reported that from 1925 to 1931, “in the total of 1,004 women cared for during pregnancy, labor, and after delivery by the Frontier nurses, not a single one has died from causes directly attributable to childbirth.”
The MCA was founded in 1918 and had been working on this issue for nearly 20 years prior to Dublin’s article. By 1920, MCA had opened 30 birthing centers to provide maternity care, prenatal instruction, and even sewing classes in Manhattan alone. Not only was this group pioneering prenatal care, but the Board of Directors was also almost entirely female. In 1930, they launched a yearlong campaign culminating on Mother’s Day 1931 in which efforts were made to reach as wide an audience as possible with the message that the post-childbirth maternal death rate in the United States was unnecessarily high, that it could be reduced greatly by adequate and skilled obstetric care, and finally to educate the public in the essentials of such care.
That same year, the Dublin-Corbin Report was published which stated that of those patients who had been under the care of the Maternity Center Association, there was a maternal mortality rate of 2.4 patients in comparison with 6.2 patients in that same area of Bellevue-Yorkville that was not under the care of MCA. Largely these disparities were impacted by economic standing. The economic disparities encountered by impoverished pregnant women became particularly exacerbated during the Great Depression. By ensuring that even low-income women had access to regular prenatal checkups and health screening, the Maternity Center Association was able to substantially improve health outcomes and reduce risk of death to both mothers and unborn babies.
By 1945, declining maternal and infant mortality rates led the MCA to shift focus from simply surviving childbirth to making it a satisfying experience for all involved and moved towards advocating for natural childbirth. In “Ours: The Story of the Work of the Maternity Center Association for the Families of America, 1946–1951,” the MCA discusses the emotional desire from young families to move away from full anesthesia during childbirth. By attending mothers’ classes with MCA, expecting mothers could learn about what to expect during childbirth and various medical interventions that could occur.
The MCA even created a series of educational videos, including “From Generation to Generation,” about the pregnancy and birthing process to help bridge the gap in understanding what women would go through. Fathers were also increasingly brought into the hospital room to play an active supporting role in delivery, instead of remaining separate in the waiting room. Educating pregnant women on the birthing process and enabling them to play a role in developing their own hopes and expectations during and after labor led to revived interest in giving birth at home or in a home-like setting. This spurred the opening of an out-of-hospital childbearing center in New York City in 1975, which was only the second in the nation and first urban center of its kind.
Federal attempts to improve the maternal and infant mortality rates had early beginnings in the establishment of the Children’s Bureau in 1912, which completed the first study of maternal mortality in 1916. As recording systems expanded, in 1935, the National Office of Vital Statistics was mandated to promote a cooperative system of vital records and vital statistics to better state-level registration of births and deaths, and better information about causes of death. In the late 60’s, the National Center for Health Statistics prioritized automated entry, classification, and information retrieval on death certificates. To accurately track the trends in pregnancy-related mortality in the US, the Centers for Disease Control and Prevention established the Pregnancy Mortality Surveillance System (PMSS) in 1987.
“Since the (PMSS) was implemented, the number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to 17.3 deaths per 100,000 live births in 2018.”
This number has continued to rise, as the CDC reports that 754 women died of maternal causes in the US in 2019, 861 women in 2020, and all the way up to 1,205 in 2021. The leading cause of death for pregnant women in the US from 2018 to 2019 wasn’t even tied to childbirth itself; homicide accounted for 3.62 deaths per 100,000 live births, which “exceeded all the leading causes of maternal mortality, including hypertensive disorders, hemorrhage, and infection, by more than twofold.”
In 2021, the most recent year for which data are available, the US ranked the highest in pregnancy-related deaths, higher than any other high-income country, with more than 1,200 deaths from complications related to pregnancy or delivery.
“The racial and ethnic disparities in these maternal health outcomes are stark. Non-Hispanic Black people are about three times as likely as White people to die from a pregnancy-related cause, regardless of income or education level. For some causes of maternal death, these disparities are even more pronounced. Findings from an NICHD-funded study suggest that Black women are five times more likely than White women to die of postpartum cardiomyopathy (disease of the heart muscle) or the blood pressure disorders preeclampsia and eclampsia.”
—”Addressing Inequities to IMPROVE Maternal Health for All” in Musings from the Mezzanine
While we’ve come a long way since Louis I. Dublin began studying maternal mortality rates about a hundred years ago, we still have a long way to go, particularly in addressing racial and ethnic disparities. On this Mother’s Day and many before it, we are faced with the sad truth that many mothers did not survive beyond pregnancy, childbirth, or postpartum to celebrate this milestone.
“It is not sufficient for us to salve our conscience on Mother’s Day by casting a white carnation on the grave of the mother who died that her child might live; we must rather apply our knowledge and experience so that these women need not die.”
— Louis I. Dublin in “Lost Mothers”
For current information about childbirth visit MedlinePlus, an online health information resource from the National Library of Medicine.
Nicole Baker is a Reference Librarian in the History of Medicine Division at the National Library of Medicine.
Rest in peace