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The Decline in Maternal

Mortality in Sweden:
The Role of
Community Midwifery
The maternal mortality rate in Sweden in the early 20th century
was one third that in the United States. This rate was recognized
by American visitors as an achievement of Swedish maternity care,
in which highly competent midwives at- tend home deliveries. The
19th century decline in maternal mortality was largely caused by
improvements in obstetric care, but was also helped along by the
na- tional health strategy of giving midwives and doctors
complementary roles in ma- ternity care, as well as equal
involvement in setting public health policy.
The 20th century decline in maternal mortality, seen in all Western
countries, was made possible by the emergence of modern medicine.
However, the contribution of the mobilization of human resources
should not be underestimated, nor should
key developments in public health

| Ulf Hgberg, MD, PhD

20th-century Sweden. Source: THE DECLINE OF ciated with poverty were of rela-
Jamtli Museum, Sweden 1
MATERNAL mortality in tively minor importance. But
Western countries after the the maternal mortality pattern
1930s is believed to be before the emergence of mod-
associated mainly with the
emergence of modern obstetric
care, while it has been proposed
that public health policy, pov-
The equipment of a home- erty, and the malnutrition asso-
delivering midwife in early-

August | 2004,
1312 PublicVol 94, No.
Health Then8 and
| American Journal
Now | Peer of
Reviewed | American
Hgberg |Journal
Peer Reviewed
of Public | Health
Public Health
| August
Public Health 94,
NowNo.| 183 12
ern medical technology was not NOW
tensive collaboration between mortality of 230 per 100 1900, the United States re-
uniform in all Western coun- physicians and highly compe- 000 live births, while the ported 520 to 850 maternal
2 3
tries. In The Netherlands, Nor- tent, locally available midwives. rate for England and Wales deaths per 100 000 live births.
way, and Sweden, low maternal From 1900 through 1904, was 440 per 100 000. For This very high maternal mortal-
mortality rates were reported by Swe- den had an annual the year ity rate, especially if compared
the early 20th century and were maternal with the lower rates achieved in
believed to be a result of an ex- several less prosperous Euro-
pean countries, caused some

August | 2004,
1313 PublicVol 94, No.
Health Then8 and
| American Journal
Now | Peer of
Reviewed | American
Hgberg |Journal
Peer Reviewed
of Public | Health
Public Health
| August
Public Health 94,
NowNo.| 183 13
American obstetricians to ex- decline in maternal mortality in The profession of physician
press concern. the Western countries in the was legalized in 1663 with the
Joseph B. DeLee, commemo- 20th century. foundation of the Collegium
rated as a titan of 20th-century Medicum. In the 17th and 18th
obstetrics, studied maternity HISTORICAL centuries, many Swedish aca-
services in Europe before he es- SETTING: SWEDEN demics obtained their postdoc-
tablished the Chicago Lying-In toral training from universities in
Hospital and Dispensary in The history of maternity care Germany, France, Italy, England,
1895. His aim was to provide de- in Sweden should be interpreted and The Netherlands. By the be-
livery assistance to poor women in light of the involvement of the ginning of the 18th century, Swe-
by also offering them the option state in public health. One im- den had declined as a major
of having a safe and inexpensive portant part of the emergence of power in northern Europe. Inside
home delivery. the Swedish national state in the Sweden, the power of the
George W. Kosmak5 visited 16th century was the creation of Swedish parliament was en-
Scandinavia in 1926 and was re- the Lutheran State Church. In hanced; a so-called Time of
ported to have been very im- the 17th century, the Swedish Freedom was introduced that
pressed with the medical systems clergy created an information coincided with the Age of En-
in place there. In an address to system that included all individu- lightenment. There began an era
the American Medical Association, als in their parishes older than 6 of scientific blossoming. The two
Kosmak talked about the good re- to 7 years. By the middle of the professors of medicine at Upp-
sults obtained in a carefully super- 18th century, this registration sala University, Carl von Linn
vised system of midwife instruc- in- cluded the entire population. (17071778) and Nils Rosn
tion and practice. He stated, The information system was von Rosenstein (17061773),
based on the annual catechetical and the head of the Collegium
To begin with, the midwife in
examination of every household, Medicum, Abraham Bck
Scandinavia is not regarded as
pariah. . . . One sees, therefore, where the clergy examined (17131795), were the
in the training schools for mid- knowledge of the catechism as initiators
wives, bright, healthy looking,
well as the reading ability of all and promoters of health care and
intelligent young women of the
type from whom our best class household members. To this public health within the Commis-
of trained nurses would be re- church book, other types of sion of Health (Sundhetskommis-
cruited in this country, who are
sionen) from 1737 to 1766.
proud of being associated with

an important community work, They
and whose profession is recog- In the Netherlands, Norway, and Sweden, low
nized by medical men as an im- maternal mortality
portant factor in the art of ob-
stetrics, with which they have rates were reported by the early 20th century and

no quarrel.
were believed to be a result of an extensive
collaboration between physicians and highly
competent, locally available midwives.

He concluded, The results of

this midwife training are evi- records were linked: records of presented programs for primary
dently excellent because the mor- in- and outmigrations, births and health care and preventive mea-
tality rates of these countries are baptisms, bans and marriages, sures for communicable diseases
remarkably low and likewise, the and deaths and burials. The Of- and published pamphlets on
morbidity following childbirth. fice of the Registrar General health education, nutrition, and
What, then, was the history of (Tabellverkskommissionen), hygiene. From the start, the pub-
this system that turned out to be founded in 1749, compiled na- lic health program had an equity
a good example for the United tional statistics from the ecclesi- perspective by reaching out to
States before the emergence of astical registry. National vital sta- the poor rural population and
modern medicine in the 1930s? tistics were therefore available in making health care accessible to
The aim of this review is to de- Sweden before they were avail- them. The policy fit in with the
pict the Swedish intervention able in any other European prevailing political ideology of
against maternal mortality in the country. the time, mercantilism, which de-
18th and 19th centuries and the

(Den Swenska wl-fwade vaccinations. The midwifes for-
In 1711, the Collegium Jord- Gumman) intended for mal education was extended to 6
Medicum announced a use by both midwives and the months, and the government paid
public. allowances for 12 students each
decree of authorization for
In 1711, the Collegium Medicum year. This meant that instead of
midwives that required a 2- announced a decree of authoriza- limiting the training program to
year training period with an tion for midwives that required a the women sent by the parishes,

2-year training period with an ex- the profession was opened up to
experienced midwife, perienced midwife, followed by all interested women.
followed by an examination an examination given by the Col- The professor of obstetrics at
given by the Collegium legium Medicum. In 1715, von the time, Pehr Gustaf Ceder-
Hoorn published a textbook for schild (17821848), pushed
Medicum. midwifery training with Soranus, hard to increase the competence
the famous Roman gynecologist of midwives. By 1829, health re-
(50129 AD), as a source of in- form brought new regulations
fined the wealth of the nation by
spiration; in it, he stressed the im- authorizing midwives, after an
the number of its citizens. The portance of surveillance of the extended training period, to use
military need of the nation has delivery by internal examina- tion forceps, sharp hooks, and perfo-
also been proposed as an argu- that is, the nonintervention- ist rators, in addition to their ability
ment for investment in mothers
approach emphasizing pa- tience to perform manual removal of
and childrens health. and waiting. He also described the placenta and extraction in
The first national statistics on the mouth-to-mouth re- suscitation breech presentation. This reform
maternal mortality were pre- method for reviving was opposed by contemporary
sented in 1751, revealing a rate an apparently dead newborn. international medical societies7
of almost 900 maternal deaths Soon the need for licensed mid- but was motivated by the long
per 100 000 live births. In the wives became apparent and the tradition of community midwives
same year, the Commission of Collegium Medicum urged Swe- who assisted at home deliveries.
Health stated, Out of 651 dens parliament to push for a na- The widely scattered rural
women dying in childbirth, at tional midwifery school. How- Swedish population made it a ne-
least 400 could have been saved ever, it was not until the end of cessity for midwives to be capa-
if only there had been enough the century that such a school ble of acting in emergencies
midwives. This became the was started. when physicians could not be
starting point for the Swedish au- In 1757, the Collegium reached. Cederschild argued
thorities to campaign for im- Medicums proposal for a na- that the reform would strengthen
provements in obstetric care, tional training program for mid- the authority and acceptance of
mainly by improving training for wives covering all parishes was the midwife in the parishes.

physicians and midwives and im- finally approved. Each parish was Cederschild then wrote the
plementing a system of surveil- expected to pay for its students textbooks Manual for Midwives
lance of midwives, both at the allowance in Stockholm. The first (Handbok fr Barnmorskor) and
county and national level. What professor in obstetrics was ap- Guide to Instrumental Obstetrics
they did not know at the time pointed in 1761, and the first (Utkast till Handbok i den
was that it would take 150 years lying-in hospital, Allmnna Barn- Instru- mentala
to achieve their goal.6 brdshuset in Stockholm, was Frlossningskonsten)
founded in 1775. in support of his ambition to
LICENSED MIDWIVES The founding of Stockholms increase the competence of
Karolinska Institute in 1810 led midwives.
The professionalization of birth to a further improvement of By the government decree of
assistance in Sweden began in obstet- ric care at a national level. 1819, midwives were required
the early 18th century. Pioneer- A new government decree stated to ensure that every newborn
ing this was Johan von Hoorn in 1819 that every parish was child had his or her own bed to
(16621724), who trained in required to employ a licensed pre- vent suffocation, although
ob- stetrics at the Hotel Dieu midwife, and that the parishes little observance of this rule was
Hospital in Paris before returning were also re- sponsible for variola 9
re- ported. In the mid-19th
to Swe- den. In 1697, von Hoorn (smallpox) century,
pub- lished a textbook titled The
Well-Trained Swedish Midwife
the authorities added more regu- tion. Subsequently, the Crown tors and midwives is a recurrent
lations for midwives. It was de- withdrew the paragraph and re- theme, and Swedish historians
cided that their duties should not instated the right of district med- have reported parallels in Swe-
be limited only to childbirth, but ical officers and licensed mid- den, although more in Stock-
should also include subsequent wives to train women locally. holm than in the rural areas.

care of the infant. Consequently, The paragraph was reinstated in However, studies addressing the
education in basic neonatal care 1819 in a milder form, allowing professionalization of Swedish
at the midwifery school was im- traditional birth attendants when midwives in relation to the theo-
proved, with an emphasis on a licensed midwife could not at- ries of sociology, modernity, gen-
warmth, neonatal resuscitation tend or arrive in time. However, der, and the evolution toward
with tactile stimuli for asphyctic during the 19th century, several scientifically based obstetric care
children, daily care of the umbili- traditional birth attendants were have found few conflicts be-
cus, and early breastfeeding. prosecuted and found guilty of tween doctors and midwives.11
Many mothers fed their new- unauthorized help during child- There was a gender division in
borns cows milk, and doctors 8
birth. Not until the late 19th the professionalization process;
and midwives began informing century did professional mid- however, since doctors and mid-
young mothers and mothers-to- wifery become fully established wives were disseminators of the
be about the benefits of breast- and legitimized in the rural areas same discourse and worked to-
feeding. This strategy soon had

of Sweden.
the desired effect, and infant
Whereas during the 18th cen-
mortality was reduced by 20%.
tury midwives were recruited Community midwifery was
The antiseptic technique was from among farming families, by based on a system of close
introduced in the lying-in hospi- the 19th century the profession
tals during the late 1870s and, of midwife had become a legiti-
supervision and retraining.
by law, to midwives in rural dis- mate occupation for women from In each county, each
tricts in 1881. Also, the Cred all walks of life, and it carried as
prophylaxis to prevent neonatal
midwife was required
much weight and respect as that

blennorrhea became one of the 11
of primary school teacher. Con-
to report to the
midwifes duties. sequently, the community mid- county general
wife became a central figure and
COMPLEMENTARY practitioner.
was often the only person repre-
ROLES OF MIDWIVES senting health care at the parish
AND DOCTORS level. Over time, any technical ward the same goal, they com-
constraints were overcome and plemented rather than competed
The professionalization of there was good social representa- against each other, unlike in the
birth attendance was not a tion among midwives, thus en- US urban setting.
smooth process. Historian suring a successful implementa- These complementary roles
Christina Romlid describes the tion of obstetric services within were facilitated by the conditions
antagonism, struggles, and con- the specific cultural context of of health care in Sweden. As re-
flicts that arose between the rural Sweden. cently as the late 19th century,
medical profession and tradi- The professionalization of only 10% of the Swedish popula-
tional birth attendants until the birth assistance can be inter- tion lived in urban areas. Obste-
late 19th century. In the preted from a gender theory per- tricians were in office only in the
Swedish parliament, the peas- spective as a successive subordi- lying-in hospitals of Stockholm
antry protested against the mid- nation of women consequent to and, from 1865, also in Gothen-
wife regulation of 1777. This the appearance of male obstetri- burg and Lund. Otherwise, gen-
rule contained a quackery para- cians. Birthing is a natural event, eral practitioners in the counties
graph that banned traditional yet female traditional birth atten- and towns were the medical
birth attendants, whom the peas- dants were pushed aside with counterparts of the midwives as-
ants viewed as experienced and the medicalization of childbirth. sisting at home deliveries. In
skilled, not as dangerous and The American and British expe- practice, no system of referral
harmful as stated in the regula- rience of conflicts between doc- was available in the 19th cen-
tury. In medical emergencies, the
midwife called for the doctor, but
this rarely happened. This setting
facilitated a more noninterven- 40% to 45% of deaths among parturients were recorded to
tionist attitude, manifesting fairly married women were caused have died from puerperal sepsis
low rates of assisted delivery by complications of pregnancy in the lying-in hospitals, which
throughout Swedish history and or delivery. Among married represents 2.2% of all maternal
strengthening the midwife in her women, 1 of 14 died during deaths during the period. It was
role as the indisputable birth at- childbirth.
during the second half of the
tendant, in contrast to the more Maternal mortality declined 19th century, when the national
doctor-oriented obstetrics emerg- from 900 per 100 000 live statistics recorded puerperal sep-
ing in the United States by the births to 230 per 100 000 from sis separately, that the nation-
20th century.11 1751 to 1900. The general wide problem became obvious.
The Swedish model of mater- trend toward a decline was inter- Between 1861 and 1900, 54%
nity services was distinct even rupted during the years 1850 to of maternal deaths were caused
from the European perspective. 1880, when the recorded septic by puerperal sepsis, most of
In 1870, the ratio was 3.1 mid- maternal mortality coincided them following home deliveries.
wives for every doctor for Swe- with an increase in total mortal- This percentage was even
den, while it was 1.4 in Denmark ity due to communicable dis- higher for home deliveries be-
and Norway and 1.2 in eases. During the 19th century, fore the introduction of antisep-
France. areas of high maternal mortality
tic technique, possibly also
Community midwifery was were not restricted to the urban caused by an increased viru-
based on a system of very close environments, where there was a lence of the dominant strain of
supervision and retraining. In known high death rate due to 1
streptococcus at the time. The
each county, each midwife was 14
diagnosis of puerperal sepsis
puerperal sepsis.
required to report to the county was probably not confounded
During the 19th century, the
general practitioner. Her report by septic abortions during the
decline in maternal mortality was
had to be detailed and include 16
far greater than that in infant 19th century.
the actual record, in diary form,
mortality, or in mortality due to The adverse effects of med-
of all deliveries she had attended,
tuberculosis. The decline in ma- ical technology were predispos-
with information on the identity
ternal mortality was especially ing, positive risk factors. Before
of the parturient, complications,
pronounced between 1861 and the introduction of antiseptic
the sex of the child, birthweight,
1900, when the percent reduc- techniques, lying-in hospitals
and outcome for the mother and
tion dropped from 59% to 24%, were a positive risk factor in the
child. Also, review courses for while the female mortality reduc- transmission of puerperal sepsis.
midwives were obligatory on a 16
tion leveled out. As can be seen by extrapolating
regular basis. A standardized
In the 19th century, two from the mortality rate of puer-
protocol was necessary when
thirds of maternal deaths had di- peral sepsis between 1881 and
midwives used forceps, sharp
rect obstetrical causes, such as 1895 (after the introduction of
hooks, or perforators, giving the
difficult labor, eclampsia, hemor- antiseptic techniques), if such
reasons for the intervention and
rhage, and sepsis, while one techniques had been available
the outcome. This protocol had
third were indirect obstetric from 1776 through 1900, the
to be signed by the county physi-
deaths due to diseases such as number of puerperal deaths in
cian and was registered at the
pneumonia, tuberculosis, dysen- lying-in hospitals would have
National Health Bureau.
tery, heart disease, and malnu- been 119 instead of 1720.
trition. In the lying-in hospi- The difference, 1601 deaths,
MATERNAL MORTALITY is a measure of the potentially
tals, before antiseptic techniques
IN THE 17TH TO 19TH ad- verse effects that the lying-
became known most maternal
CENTURIES in hospitals had on the number
deaths were caused by puer-
18 of maternal deaths nationwide
In the 17th century, maternal peral sepsis. However, the epi-
from 1776 through 1900
deaths accounted for 10% of all demics of puerperal sepsis in the
lying-in hospitals did not dra- (n = 76 776). However, the pro-
female deaths between the ages tective effect of these hospitals
14 matically alter the national ma-
of 15 and 49 years. In as educational centers for mid-
ternal mortality rates. Between
women aged between 20 and wives and physicians practicing
1775 and 1900, a total of
34 years,
in rural areas has not been
considered. 90

The impact of midwife-assisted
delivery on maternal and child

outcome is of major historical in-
terest. At the beginning of the 50
19th century, almost 40% of de-
liveries were attended by a li-
censed midwife, while only a
very small fraction of women 30 Home delivery, traditional birth attendance
gave birth in a lying-in hospital. Home delivery, assisted by midwife
By the end of the 19th century, Institutional delivery
78% of parturients were at-
tended by a licensed midwife,
while only 2.8% gave birth at a
lying-in hospital (Figure 1). The
mean annual number of deliver-

ies per midwife in the rural areas 18611865 18661870 18711875 18761880 18811885 18861890 18911895
was 37 during the second half of
the 19th century. The midwives FIGURE 1Percentage of parturients in Sweden delivered by traditional
used forceps in only 1 of 133 to birth attendants, licensed midwives, and in lying-in hospitals during the
180 deliveries, with a case years 1861 through 1895.
fatal- ity rate of 27 to 39 deaths
1000 operations.16
The nonseptic maternal mor-
tality was reduced from 414
100 000 live births to 122 per
100 000 when the proportion of
deliveries assisted by midwives
in the rural areas increased from
30% to 70%. The risk of non-
septic maternal death was re-
duced fivefold, with a relative
risk of 0.2 for midwife-assisted
home deliveries. By taking the
percentage of midwife-assisted
deliveries, the prevented fraction
for nonseptic maternal deaths
associated with midwife assis-
tance can be estimated to be
46% for the years 1861
through 1900.
The antiseptic decree for mid-
wife-assisted home deliveries
was implemented in 1881, al-
though the technology was suc-
FIGURE 2Midwifer y ser vice in rural areas in Sweden and maternal mortality
cessively introduced in the lying- (septic deaths excluded)
in hospitals during the 1870s. for the years 1861 through 1894.
By defining 100% exposure of
antiseptic technique, preventive an even smaller proportion gave troduction of the antiseptic tech-
fractions can be calculated. After birth in lying-in hospitals, the in- nique, puerperal sepsis mortality
the introduction of the antiseptic troduction of the antiseptic tech- did not decline further until the
technique, the mortality rate for nique did not prevent as many introduction of antibiotics during
puerperal sepsis decreased 25- deaths in the lying-in hospitals as the 1930s.

fold in the lying-in hospitals. The it did in home deliveries. The in- With the assumption that the
potential relative risk associated troduction of the antiseptic tech- two acted independently of each
with the use of antiseptic tech- nique in home deliveries de- other, we can conclude that dur-
nique was 0.04. This was not creased the risk of death due to ing the years 1861 through
due to a reduced fatality of the puerperal sepsis 2.7-fold (relative 1900, the antiseptic technique
diagnosed cases of puerperal 18
risk = 0.37). Consequently, it is reduced mortality by puerperal
sepsis, because half of the pa- estimated that 63% of the septic sepsis by 49%, and that mid-
tients with puerperal sepsis still maternal deaths were prevented wifery reduced nonseptic mater-
died, but rather to a diminished in noninstitutional deliveries in nal mortality by 46% (Figure 3).
incidence of puerperal sepsis. Sweden between 1881 and The positive impact of this inter-
The antiseptic technique was es- 1900. This result is strengthened vention could be interpreted in
timated to have prevented by the steep decline of maternal several ways. Naturally, the mid-
96% of septic maternal deaths mortality from the 1870s and wives skill was important, but
during the years 1881 the directly inverse association they used forceps in fewer than
through between the decline in nonseptic 1% of the deliveries and per-
1900, or 65% for the years maternal deaths and the increase formed destructive operations
1861 through 1900. in deliveries assisted by midwives very seldom, so other factors
However, since only a minor- in rural areas from 1861 to must have been of importance.
ity of women at the time lived in 1894 (Figure 2).18 After the in- The contribution could also be
urban areas, and since of these interpreted in more general
terms as providing care for the
parturient and her prolonged
labor with morphine, an enema,
catheterization of the bladder,
and surveillance of the third
stage of labor.18 The importance
of supporting the parturient is
now evidence-based; continuous
support during labor from care-
givers reduces the likelihood of
operative vaginal delivery as well
as cesarean delivery and as-
phyxia of the child.
A shift in the distribution of
the parturients age, with a
smaller proportion of parturients
of advanced age, contributed to
only 2.9% of the decline in mor-
tality between 1781 and
The implementation of a
Swedish midwifery service for
home deliveries is probably one
reason why in the early 20th
century, Sweden had a lower ma-
ternal mortality rate than more
FIGURE 3Obser ved number of maternal deaths per 100 000 live births prosperous countries such as
and prevented number of maternal deaths by medical technology, midwifer Britain and the United States.
y ser vice, and antiseptic technique in Sweden during the years 1861
through 1900 (5-year mean).
The fairly centralized public wel- modern obstetrics, with its blood vitamin A supplementation in
fare system in Sweden at the transfusions, antibiotics, and safe Indonesia showing a 50% reduc-
time may have facilitated the in- operations, could be confounded
tion of puerperal fever proba-
tervention. Despite a relatively by the same factors that are now bly through better resistance
low gross domestic product, the impeding a worldwide maternal against infectionsindicate the
homogeneity of the rural areas mortality decline. A causal infer- importance of womens nutri-
and a rather smooth socioeco- ence must also take into account tional status in relation to mater-
nomic national development may the fact that socioeconomic dep- nal mortality.
also have contributed to the suc- rivation is a major factor under- A cautious interpretation of
cessful implementation of the lying maternal mortality. One the Western maternal mortality
system. Difficult social circum- oversight in the interpretation of decline should also take into ac-
stances could impede an inter- the Western maternal mortality count the concept of medical
vention, as illustrated in the decline may be that a clinical technology. These include not
Sundsvall sawmill area in Swe- perspective would underestimate only clinical and therapeutic im-
den, called Little America at a potential cohort effect of re- provements but also a mobiliza-
the time owing to its very high duced poverty and subnutrition tion of human resources with re-
immigration rate and reported on secular trends of maternal gard to clinical performance and
social turmoil; no decline in ma- mortality. Obstructed labor has community participation.
ternal mortality was recorded been one of the leading causes Maternal mortality became a
there. Even so, the preventive of maternal deaths throughout public health issue of great con-
fraction of midwifery on perina- 23
history. Evidently, the main cern in the early 20th century in
tal mortality in this area was reason for the reduced deaths both England and the United
15% between 1881 and due to obstructed labor during 3
States. The importance of the
1890, and 30% between the 1940s in Sweden was safer general understanding of the
1891 and deliveries. However, at the same road-to-death and the introduc-
1899.22 time, a decrease in the incidence tion of the concept of avoidabil-
of obstructed labor was re- ity that was presented by the
THE 20TH-CENTURY ported. This could be inter- British Health Ministry and
DECLINE IN preted as an effect of the better White House conferences during
MATERNAL nutritional status of infants born the 1920s, as well as the estab-
MORTALITY in the 1920s, who started hav- lishment of confidential en-
ing their own children during quiries and maternal mortality
A phenomenon common to the the 1940s24the era when con- committees with community in-
industrialized countries dur- ing tracted pelvis (narrow birth volvement, should not be under-
the first decades of the 20th canal due to nutritional deficien- estimated.
century was that whereas total cies) disappeared almost entirely Regarding medical technology
mortality declined, maternal from obstetric practice in West- and reproductive health, the soci-
mortality remained high or even ern society. etys and the larger populations
increased. Maternal mortality de- Vitamin A deficiency was a involvement should be considered
clined exponentially and simulta- problem still affecting Swedish as a prerequisite. Neither second-
neously in the Western countries children in the 1930s and ary nor tertiary prevention, nor
from the 1930s onward, and this 1940s, and it may have created early detection, referral, or audit
was indisputably due to modern problems for parturients as well. procedures, would have worked
obstetric care. Furthermore, Already in 1931, it was shown in the Western countries without
modern obstetrics has been pro- that vitamin A supplementation the socioeconomic progress of
posed to have been the main may reduce puerperal sepsis by public health efforts that have
contributor to the decline in mor- as much as 70%. The evi- taken place since the 1940s. In
tality, while a rise caused by pov- dence that vitamin A supplemen- this respect, the decrease in ma-
erty and associated malnutrition tation for women may have re- ternal mortality would not have
was purportedly only of minor duced maternal mortality by been as significant without the es-
importance. 40% in a Nepalese commu- tablishment of the welfare state in
However, the view that the nity, and a randomized trial of the Western countries.
steep decline in Western mater-
nal mortality rates is due only to
CONCLUSION 4. Leavitt J. Joseph B. DeLee and the the 19th century by different defini-
practice of preventive obstetrics. Am J tions: previous stillbirths but not multi-
Public Health. 1988;78:13531360. parity risk factor for maternal death.
The successful maternity care Acta Obstet Gynecol Scand. 2000;
intervention in Sweden in the 5. Kosmak G. Results of supervised
midwife practice in certain European
19th century was dependent on countries. JAMA. 1927;89:2009 18. Hgberg U, Wall S, Brostrom G.
the public health system, which 2012. The impact of early medical technology
was based in turn on equity and on maternal mortality in late 19th cen-
6. Hgberg U. Children of Poverty
tury Sweden. Int J Gynaecol Obstet.
an alliance between midwives A Public Health History of Sweden [in
Swedish]. Stockholm, Sweden: Liber;
and doctors in a system of close 1983. 19. Hgberg U. Effect of introduction
supervision and surveillance. of sulphonamides on the incidence of
7. Romlid C. Swedish midwives and
Even though the potential impor- and mortality from puerperal sepsis in a
their instruments in the eighteenth and
Swedish county hospital. Scand J Infect
tance of community midwives nineteenth centuries. In: Marland H,
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