Community-based prevention of perinatal deaths: lessons from nineteenth-century Sweden

T Andersson1,2, U Högberg1,2 and S Bergström3

a Department of Public Health and Clinical Medicine, Epidemiology, Umeå University, Umeå, Sweden.
b Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
c Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.

Reprint requests to: Tobias Andersson, Department of Public Health and Clinical Medicine, Epidemiology, Umeå University, 901 85 Umeå, Sweden. E-mail: tobias.andersson{at}epiph.umu.se


    Abstract
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Background Perinatal deaths have been more difficult to prevent than infant deaths in low- income countries due to its close relation to poor maternal outcome. The aim of the study was to perform a comprehensive population-based analysis of perinatal mortality in a high mortality setting and to determine the impact of midwifery-assisted home deliveries.

Method The study design was a community-based cohort study. In all, 4876 perinatal deaths were recorded among 116 211 newborns in the districts of Sundsvall and Skellefteå in northern Sweden during the years 1831–1899. Relative risks, 95% CI, population attributable proportions and prevented fractions were calculated.

Results The overall perinatal mortality rate was 42.0 per 1000 births. A previous stillbirth represented one of the most important risk factors (RR = 3.25, 95% CI : 2.97–3.56), with a population attributable proportion of 7%. Two or more previous stillbirths gave an RR of 8.50 (95% CI : 7.58–9.53) and a population attributable proportion of 4%. There was an increased risk of perinatal mortality for mothers over 35 years old, the primiparous and the unmarried, while grandparous women had a higher perinatal mortality that was accounted for completely by a poor history of previous stillbirths and infant deaths among these women. The children of crofters, farmers and workers had higher perinatal mortality, but area had no significant impact. During the years 1881–1890 and 1891–1899, the prevented fractions of midwifery were 15% and 32%, respectively.

Conclusion Poor reproductive history, particularly previously high perinatal mortality, is associated with high perinatal mortality. Midwifery-assisted at home deliveries successfully reduced perinatal mortality.

Keywords Nineteenth century, developing countries, epidemiology, history of medicine, perinatal mortality, preventive health services, reproductive medicine

Accepted 8 November 1999


    Introduction
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Each year, about eight million perinatal deaths occur, 98% of them in developing countries.1 Perinatal mortality has been more difficult to prevent than infant mortality and has only recently received global attention. Because it is closely linked to maternal outcomes, perinatal mortality can be used as a proxy indicator of maternal mortality and maternal health care status. There are an estimated ten perinatal deaths for each maternal death.2 At least three-quarters of the perinatal deaths that occur in developing countries are caused by problems that also kill women: obstructed labour, eclampsia, sepsis, and the woman's nutritional and infection status.3 The majority of perinatal deaths are thus preventable.4

Data regarding perinatal mortality in developing countries derive mainly from hospital-based studies. This fact hampers an assessment of the causes of poor child outcomes because the vast majority of births in rural areas in low-income countries occur at home, attended by relatives or traditional birth attendants.5,6 However, the information on perinatal mortality coming from today's impoverished countries can be supplemented by examining historical cohorts from periods of high mortality in currently affluent countries. Sweden is one of the few countries offering reliable historical vital statistics for population studies.

In developing countries, it may be difficult to refer ‘at risk’ neonates to hospital, and birthing women may have to resort to domiciliary care, intervention through primary health care and female community health workers.7 The community-based study in Matlab, Bangladesh, showed a perinatal mortality of 75 per 1000. A controlled study found that family planning and maternal health service programmes significantly reduced perinatal mortality, offering support for the inclusion of a strong maternity care component in primary health care strategies.8 In Sweden, in the nineteenth century, the authorities also campaigned for obstetric competence among primary health care doctors and for the assistance of licensed midwives at home deliveries. The competence of the midwives was improved in 1829 when they were licensed to use forceps, sharp hooks and perforators, and in 1881, when by law (The Antiseptic Decree), antiseptic techniques were instituted at midwifery-assisted home deliveries, thus preventing septic as well as non-septic maternal deaths in rural areas.9

The aim of this study was to analyse perinatal outcomes in nineteenth-century Sweden and to evaluate the impact of a community-based intervention.


    Subjects and Methods
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
In the seventeenth century, the Swedish clergy created an information system that covered all individuals in their parishes above the age of 6 or 7 years. By the middle of the eighteenth century this registration system covered the entire population. The information system was based upon the catechetical examination registers and was revised annually. Other types of records were also linked to these parish records: in and out migrations, births, baptisms, banns, marriages, deaths, and burials. The Tabellverket (Office of the Registrar General) was founded in 1749 and compiled national statistics. In 1858, the Tabellverket became the Central Bureau of Statistics. Demographic and social data from a large number of parishes in Sweden have been computerized and are available for research at the Demographic Data Base of Umeå University. These statistics have been judged to be reliable.10 During a fire in Sundsvall town in 1888 a number of church books were lost and because of this the reporting of births and deaths in this part of the study area is missing up to 1860.

This database was used to examine all live births and stillbirths from 18 parishes in northern Sweden in the years 1831–1899. Altogether, 116 211 births of 32 184 parturients were recorded during the period. The following data were obtained for this study: the mother's date of birth and marital status, the birth order of the child, each child's date of birth, previous reproductive outcome (such as previous stillbirths), previous infant deaths (0–11 months), the occupation of the father (foundry proprietor, academic, military, employee, civil servant, farmer, worker, crofter, etc.) domicile, and presence of midwife at birth. Information on midwife's assistance was not available for all parishes until the second half of the century.

Stillbirths were registered in the database. Perinatal mortality was defined as the total number of stillbirths and deaths within 7 days of birth per 1000 live and stillbirths. Infant mortality was defined as all deaths within the first year of life per 1000 live births. Perinatal and infant deaths were calculated using the data of birth and date of death registrations in the database.

The determinants for risk factor analysis were categorized as follows: maternal age (<35/>34); parity (I,II–IV/V+); previous stillbirth or not; previous infant death or not; married or unmarried; father's profession as white-collar worker, farmer, craftsmen, crofter and worker; domicile (the town of Sundsvall, the agricultural parish of Skellefteå, the agricultural parishes of the Sundsvall region [Ljustorp, Hässjö, Tynderö, Sättra, Indal, Tuna, Attmar and Selånger], the old iron foundry communities [Galström, Lögdö, Lagfors], and the new booming industrial sawmill communities [Alnö, Skön, Timrå, Svartvik, Njurunda]). Information on parental education was not considered valid for analysis.11

For the risk factor assessment, surviving children with exposure to risk were compared with the number of surviving children within the group at least risk by relative risks (RR) with 95% CI (Epi-Info 6.04B, 1997) Population attributable proportion (= p(RR – 1)/[1 + p(RR – 1)], where p = the proportion exposed in the population) was calculated when appropriate. Interactions between age, parity and previous reproductive history (stillbirths and/or infant deaths) were analysed by stratification and logistic regression.

The impact of intervention was analysed by stratifying background factors for midwifery-assisted home deliveries and other deliveries. The final model for analysis was stratified by time period and the impact of midwifery was adjusted for marital status, reproductive history, age, parity and area. Adjusted rates in the final model were calculated by multiple logistic regression (SPSS for Windows 7.0, 1997). The prevented fraction is defined as the quotient of prevented cases (cases that would have occurred in the absence of exposure minus the cases that did occur) and the cases that did occur.


    Results
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
During the years 1831–1899, there were 116 211 newborns in the area of Skellefteå and Sundsvall. Of these, 2662 were stillbirths and 2214 children died within the first 7 days. The perinatal mortality rate (PMR) was 42.0 per 1000 births. Mortality rates were relatively stable during the period 1830–1850. They increased during the 1860s and 1870s, and then decreased again (Figure 1Go). Due to underreporting and the church books lost in the 1888 fire in Sundsvall town, the PMR varied slightly (Figure 1Go).



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Figure 1 Stillbirth rate and perinatal mortality rate per 1000 births, 1831–1899, in Sundsvall and Skellefteå and in the total study area except Sundsvall town

 
As shown in Table 1Go, advanced maternal age, primiparity and grandmultiparity represented a moderate risk increase. Triplets (RR = 10.55, 95% CI : 7.59–14.66), twins (RR = 3.74, 95% CI : 3.41–4.09), one previous stillbirth (RR = 3.25, 95% CI : 2.97–3.56) and two previous stillbirths (RR = 8.50, 95% CI : 7.58–9.53) had the highest RR. Previous stillbirths, previous infant death and twin births had population attributable proportions between 4% and 11%. Birth out of wedlock represented a certain increase in risk (RR = 1.29, 95% CI : 1.20–1.43), but had a very small population attributable proportion, 3%. Crofters and workers had a moderate but significant risk increase, with a population attributable proportion of 12%. The new sawmill area and the urban and farming areas tended to have an increased risk of perinatal death compared to the old iron-industrial community, although the difference was not significant.


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Table 1 Perinatal death by age, parity, reproductive history, multiple birth, domicile, profession and marital status in Sundsvall and Skellefteå, Sweden, 1831–1899, perinatal mortality, relative risks (95% CI) and population attributable proportion
 
Combining age and parity strengthened the risk pattern for primiparity and grandmultiparity, especially in combination with advanced age. Combining previous stillbirth and infant death revealed that the main group at risk were those with two or more previous stillbirths, and that the risk was further strengthened if there had also been a previous infant death. Age, parity and reproductive history interacted. Once reproductive history was taken into account, grandmultiparity lost its relationship to perinatal death, age <35 and parity V+ (RR = 0.98, 95% CI : 0.87–1.10), age >35 and parity V+ (RR = 1.21, 95% CI : 1.11–1.32), while advanced age was enhanced as a risk factor. Further, the importance of bad reproductive history was enhanced when combined with age and parity (Table 2Go).


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Table 2 Perinatal deaths stratified by age and parity, and previous stillbirth and infant death in Sundsvall and Skellefteå, Sweden, 1831–1899. Univariate and multivariate relative risk (95% CI) in a logistic regression model
 
The midwifery system was successively implemented during the period studied, with 43.7% of home deliveries being midwife assisted in 1871–1880, increasing to 73.4% during the last decade of the century. Mothers in the town and new sawmill area evidently had better access to midwives than mothers in the farming parishes, 73.6% and 50.8%, respectively, giving a significant decrease in risk of perinatal death in the town and sawmill area (RR = 0.75, 95% CI : 0.66–0.84) and in the farming areas (RR = 0.79, 95% CI : 0.72–0.87). White-collar workers summoned the midwife most frequently, to 77.0% of deliveries, while farmers only summoned her for 60.4% of deliveries. The unmarried had less access and least benefit, (RR = 0.99, 95% CI : 0.82–1.21). In conjunction with the antiseptic decree that was implemented in 1881, midwifery-assisted home delivery had a progressively protective affect on the risk of perinatal death during the last two decades of the study (Table 3Go). This tendency was enhanced when the model was adjusted for marital status, age and parity, reproductive history, area and father's occupation for the period 1881–1890 (RR = 0.86, 95% CI : 0.75–0.98) and the period 1881–1899 (RR = 0.71, 95% CI : 0.62–0.82), respectively. Midwifery-assisted home deliveries represented an increased risk for perinatal death during the years 1871–1880, although the adjusted RR increase was not significant (RR = 1.07, 95% CI : 0.90–1.27) (Table 4Go). The preventive fractions of the intervention for the decades 1881–1890 and 1891–1899 were 15% and 32%, respectively, among those exposed to risk, and 6% and 21%, respectively, among the population (Table 5Go).


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Table 3 The effect on perinatal mortality of midwife assistance by marital status, maternal age, parity, reproductive history, profession and domicile in Sundsvall and Skellefteå, during the years 1871–1899, relative risk (95% CI)
 

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Table 4 The impact of midwifery-assisted home delivery in Sundsvall and Skellefteå, during the years 1871–1899, relative risk adjusted for marital status, reproductive history, age, parity and domicile (95% CI)
 

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Table 5 Prevented fraction of midwifery-assisted home deliveries among exposed and in the population, Sundsvall and Skellefteå, 1881–1899, perinatal death per 1000 births
 

    Discussion
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
The most important conclusion from this study is that intervention through midwifery-assisted home deliveries, in combination with antiseptic techniques, were effective in preventing perinatal deaths, with a preventive fraction of 32% during the last decade of the century. The other important finding is that poor obstetric history, particularly at least two previous stillbirths, is directly associated with future poor reproductive outcome. This further underlines the close relationship of perinatal death and poor maternal outcome, supporting perinatal mortality as a proxy indicator of maternal mortality. Class (father's occupation) and births out of wedlock seem to have been the strongest socioeconomic risk factors for death, while domicile (farming, booming sawmill and urban area) had a non-significant risk increase.

Underreporting of vital statistics, stillbirths, and early neonatal deaths is common in low-income countries because of home deliveries and early discharge from puerperal care. The results of this study could contribute to gaining a comparable perspective as well as to identifying perinatal risks in high mortality societies. The perinatal mortality of 42.0 in the current study was in the same range as that found in the Matlab survey.12 In the latter study, previous stillbirths represented the most important risk factor for perinatal mortality. Even in high-income countries, obstetric history is of importance in perinatal death.13

The Matlab study found no increase in perinatal death with high parity when age was taken into account.12 Our study showed a risk increase for multiparity, even when stratified by age, while a gradient by increasing age was evident. However, the important finding of our study in this respect was that multiparity as a risk factor was confounded by bad reproductive history. Previous stillbirths were associated with the highest risk for subsequent perinatal death. This finding is consistent with recent findings from Malawi, where previous fetal or neonatal deaths had a population attributable risk of 14%.14 The conclusion should therefore be that multiparity per se is not a risk factor for perinatal death.

The causes of death were not available for the study. However, from 1870 to 1875, 46 of 213 infant deaths in Linköping were due to causes closely related to birth, such as prematurity, convulsions, congenital syphilis, weakness, malformations and apoplectic stroke, whereas 136 deaths were caused by infection.15

The chances of perinatal survival improve with socioeconomic status, as measured by such indicators as parental education and parental occupation.16–18 A relatively low-risk gradient by parental socioeconomic level was observed. This corresponds to the study in rural Bangladesh, where no measures of socioeconomic status could be related to perinatal mortality.12 In our study perinatal mortality was not analysed in relation to parental education. However, reading ability and comprehension have been included in the basic parish education in Sweden since the seventeenth century and marriage was not allowed without an approved certificate of reading ability and preparation for confirmation.

The rise in the perinatal mortality rates during the 1860s reflects an increase in general mortality, especially infections, during these decades, which was partly due to food shortages. Both perinatal mortality and maternal mortality increased in parallel with the general mortality. Epidemics of infectious diseases such as scarlatina and diphtheria were on the increase and contributed to the infant and under 5 mortality in Sundsvall during the 1860s and 1870s.19 The last peak of smallpox epidemics also occurred during this period.20

This study shows that, after 1881, a developed midwifery organization, with licensed midwives assisting at home deliveries, proved to be a successful intervention with a considerable preventive fraction of 15–32% among those exposed to risk. The increased risk before 1881 should be interpreted in the light of the dangers of intervention without knowledge of asepsis. Success was the product of a two-century effort towards improved perinatal care. Johan von Hoorn, the founder of the first midwifery school in Sweden, had stated in 1711 that ‘Of 100 stillbirths, 80 could have been prevented if a competent midwife had been with them. My heart sheds tears of blood every time these innocent souls are lost in death.’ From this point on, the objective was to have home deliveries assisted by a licensed midwife. In the middle of the nineteenth century, the authorities added additional regulations for midwives. It was decided that their duties should not be limited only to childbirth, but should also comprise subsequent care of the infant. Further, the education in basic neonatal care at the midwifery school was improved with an emphasis on warmth, neonatal resuscitation with tactile stimulus for asphyctic children, daily care of the umbilicus, and early breastfeeding.21 Doctors and midwives in nineteenth-century Sweden campaigned for breastfeeding in areas where cows' milk feeding was common, and succeeded in reducing infant mortality by 20%.22 Swedish midwifery was firmly established in the rural areas, since midwives were explicitly recruited from the families of farmers. Thus, this intervention overcame technical constraints and demonstrated good social representation, enabling a successful implementation of obstetric techniques within the specific cultural context.23 By the turn of the nineteenth century, two out of every three deliveries was attended by a licensed midwife (Table 3Go).

Perinatal mortality can be seen as a proxy for maternal health. Effective antenatal health care not only reduces maternal morbidity and mortality, but also saves children at birth. Up to now, community-based data on interventions have not been available, but hospital-based intervention has been successful in reducing perinatal mortality. For example, a Zimbabwean (30.6 per 1000) programme for reducing perinatal mortality included: (1) an educational programme to convince all pregnant women to attend antenatal care at least once, (2) closer monitoring of fetal conditions during labour, and (3) skilful management of dystocia.24 Abnormal presentations, which comprised 4.5% of deliveries in a teaching hospital in Nigeria, has a perinatal mortality of 16–18%. Close and thorough supervision of the patients during the antenatal period and labour to detect abnormal presentations could reduce perinatal mortality.24 A medical audit of perinatal deaths could be successful in improving clinical judgements in maternity care and in the utilization of hospital services, thus reducing perinatal mortality, especially intrapartum fetal mortality.24 Reduced access to obstetric care, however, increases perinatal mortality.24 One way to overcome the logistics of providing this could be maternity waiting shelters, which might improve perinatal outcomes.24

The success of the Swedish intervention should be viewed in the perspective of a well-organized health care system, from national level to parish level. The intervention cannot be transferred directly to developing countries that lack health care resources or in which the majority of the births are attended by traditional, rather than trained, birth attendants. Nevertheless, we believe that the Swedish experience is of interest, especially in terms of what could be achieved by community-based midwifery services.

The critical points are: (1) the quality of care at home deliveries, (2) recognition of the need for referral, (3) access to transport, and (4) the quality of care in rural hospitals. Traditional birth attendants can recognize birth asphyxia, and with suitable training they should be able to deal with it.24 The Swedish experience from the late nineteenth century testifies to the importance of the quality of care at the primary level and community-based intervention in successfully reducing perinatal mortality. In this sense, perinatal survival is a suitable index of health.24 Early neonatal mortality is still unacceptably high in developing countries, and it is estimated that the majority of neonatal deaths could be avoided by intervention.

To conclude, this study indicates that high perinatal mortality in nineteenth-century Sweden was associated with advanced maternal age, single marital status and low social class. However, the strongest risk factor for perinatal death was previous stillbirths. Multiparity was not a risk factor. In home deliveries, intervention by midwives to prevent perinatal deaths was a successful approach.


    Acknowledgments
 
This research was supported by grants from the Swedish Council for Social Science Research, the National Institute of Public Health, and the Medical Faculty, Umeå University, Sweden.


    References
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
1 World Health Organization. Perinatal Mortality: A Listing of Available Information. Geneva: World Health Organization, 1996.

2 Campbell O, Koblinsky M, Taylor P. Off to a rapid start: appraising maternal mortality and services. Int J Gynaecol Obstet 1995;48:S33–52.[ISI][Medline]

3 Commentary: Is perinatal mortality a useful indicator of maternal mortality? MotherCare Matters. Arlington: MotherCare/Johns Snow 1991;2:p.9.

4 Bai NS, Mathews E, Nair PM, Sabarinathan K, Harikumar C. Perinatal mortality rate in a south Indian population. J Indian Med Assoc 1991; 89:97–98.[Medline]

5 Espeut D, Koblinsky M. Methodological issues in perinatal mortality research. MotherCare Matters 1997;6:pp.1–18.

6 Fikree FF, Gary RH. Demographic survey of the level and determinants of perinatal mortality in Karachi, Pakistan. Paediatr Perinat Epidemiol 1996;10:86–96.[ISI][Medline]

7 Shah U, Pratinidhi AK, Bhatlawande PV. Perinatal mortality in rural India: intervention through primary health care. II Neonatal mortality. J Epidemiol Community Health 1984;38:138–42.[Abstract]

8 Fauveau V, Wojtyniak B, Mostafa G, Sarder AM, Chakraborty J. Perinatal mortality in Matlab, Bangladesh: a community-based study. Int J Epidemiol 1990;19:606–12.[Abstract]

9 Högberg U, Wall S, Brostrom G. The impact of early medical technology on maternal mortality in late 19th century Sweden. Int J Gynaecol Obstet 1986;24:251–61.[ISI][Medline]

10 Högberg U. Maternal mortality in Sweden. Umeå University Medical Dissertation. New Series 156. 1985 (ISSN 0346;

11 Brändström A. "The loveless mothers": infant mortality in Sweden during the nineteenth century with special attention to the Parish of Nedertorneå (In Swedish with a summary in English). Umeå Studies in the Humanities Umeå 1984;62.

12 Mostafa G, Foster A, Fauveau V. The influence of socio-biological factors on perinatal mortality in a rural area of Bangladesh. Asia-Pacific Population Journal 1995;10:63–72.

13 Oyen N, Skjaerven R, Irgens LM. Population-based recurrence risk of sudden infant death syndrome compared with other infant and fetal deaths. Am J Epidemiol 1996;144:300–05.[Abstract]

14 McDermott J, Steketee R, Wirima J. Perinatal mortality in rural Malawi. Bull World Health Organ 1996;74:165–71.[ISI][Medline]

15 Bengtsson M. The child at risk. Linköping's study in Arts and Science (Diss). Linköping 1996.

16 UNICEF. The state of the world's children, 1995. Oxford: Oxford University Press, 1995.

17 Forbes JF, Pickering RM. Influence of maternal age, parity and social class on perinatal mortality in Scotland: 1960–82. J Biosoc Sci 1985;17:339–49.[ISI][Medline]

18 Bergström S, Höjer B, Liljestrand J, Tunell R. Perinatal health care with limited resources. London: Macmillan, 1994.

19 Edvinsson S. Urban Health and Social Class. In Health and Social Change. Disease, health and public care in the Sundsvall district 1750–1950. Brändström A, TLG. Umeå: Report no 9, Demographic Database, Umeå University 1993.

20 Sköld P. The two faces of small pox: a disease and its prevention in eighteenth- and nineteenth-century Sweden. University of Umeå: Report from the Demographic Database, 1996;12.

21 Cederschiöld FA. Lärobok för barnmorskor. Stockholm 1873.

22 Brändström A. "The loveless mothers"—infant mortality in Sweden during the 19th century with special attention to the parish of Nedertorneå. Umeå: Umeå Studies in the Humanities 62;1984.

23 Jaffre Y, Prual A. Midwives in Niger: an uncomfortable position between social behaviours and health care constraints. Soc Sci Med 1994;38:1069–73.[ISI][Medline]

24 De Muylder X. Perinatal mortality audit in a Zimbabwean district. Paediatr Perinat Epidemiol 1989;3:284–93.[Medline]





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