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Eclampsia is the occurrence of one or more convulsion in association with the syndrome of pre eclampsia. It is relatively uncommon in developed countries where it complicates about one in every 200 deliveries. Eclampsia can be 20 times more common in developing countries and it probably accounts for more than 50,000 maternal deaths worldwide each year. Which anticonvulsant for women with eclampsia Evidence from the collaborative Eclampsia Trial lancet 1995, 345, 1445-63. The main objective of this study was to observe the clinical profile of antepartum eclampsia cases. The study was carried out with 100 cases that were selected randomly during year 2004. 58% of the patients were primigravida; among them 25% patients were in age group 15-14 years. About 95% patients were illiterate, low socio economic group, and in 53% patients' convulsion occurred in 32-37 weeks of pregnancy.Among 100 patients, 71 patients had normal vaginal delivery and 25% patients needed Caesarean section. Maternal mortality rate was 2%, perinatal mortality was 38%. Perinatal mortality was higher in vaginal group (12%) than LSCS group (7%). doi: 10.3329/taj.v17i2.3450 TAJ 2004; 17(2): 80-83

The tables and discussions have been given with an idea of showing the number, incidence, method, and results of 1,322 cesarean sections done in a large clinic during the past ten years. Two five-year periods of work have been compared with the idea of seeing what changes occurred. 1. 1. The report has demonstrated that the private service has increased during the second five-year period, and that the incidence of cesarean section has dropped on the private service. 2. 2. The chief indications for cesarean sections have remained about the same. 3. 3. The types of cesarean section have varied considerably but the tendency is toward the classical operation. There seems to have been no maternal mortality or morbidity which could be directly ascribed to the type of operation performed. 4. 4. The maternal mortality rate was low for the 1,322 cases, an incidence of 1.96 per cent. During the second period of this report, it was 1.37 per cent for both private and ward services and during the second period of this report it was 0.65 per cent for 460 private patients. 5. 5. The infant mortality rate was high during the first period of this report and showed considerable droup in the second period. 6. 6. Finally, this report shows that the attitude toward cesarean section has changed some during two five-year periods, and that the results from the work have improved but still leaves something to attain.

1. Ninety-seven maternal deaths occurring on an all-charity obstetrical service at Grady Memorial Hospital in the course of 80,403 live births between Jan. 1, 1949, and Dec. 31, 1961, have been reviewed and analyzed. 2. The maternal mortality rate was 12.1 per 10,000 live births, a gratifying reduction since a previous report. 3. Deaths from direct obstetrical causes accounted for 68 per cent (infection, 23.7 per cent; hemorrhage, 16.5 per cent; and toxemia, 16.5 per cent). 4. Indirect obstetrical causes of death accounted for 17.5 per cent, and nonrelated causes accounted for 12.4 per cent. 5. There were 20 deaths caused by septic abortion, the most frequent obstetrical condition causing death. 6. Some of the findings of this study are discussed and the need to improve maternity services for the indigent obstetrical patient in the urban communities of the South is stressed.

I MPROVED care and management of the parturient have resulted in a gratifying reduction in the maternal mortality rate. This has been accomplished primarily by a marked decrease in deaths due to purely obstetrical causes, but those due to nonobstetrical factors have not demonstrated a similar improvement. This emphasizes the necessity of directing attention to the latter group. With increased knowledge and awareness, the obstetrician in cooperation with the internist has been able to decrease the maternal mortality due to cardiac disease, diabetes, and other complications responsive to modern therapeutic regimes. However, there are other nonobstetrical abnormalities which are almost’invariably fatal. This may be attributed largely to an almost universal ladk of suspicion of their presence in conjunction with pregnancy so that the true diagnosis is made too frequently at postmortem examination. Furthermore, there is little clinical consciousness of these entities in pregnancy since scant attention is given to them in obst,etrical teachingl-” and literature. This is unfortunate, since some of these are amenable to correction either before or during pregnancy. Greater awareness will lead to their earlier diagnosis and treatment with resultant improvement in maternal salvage. Aneurysms constitute one of these nonobstetrical abnormalities which have not received adequate attention despite the fact that rupture during pregnancy is associated with a maternal mortality varying from 40 to 100 per cent. Although rupture of an aneurysm most commonly occurs after the age of 40, it may happen during the childbearing period and complicate pregnancy. Furthermore, the various clinical pictures produced by ruptured aneurysms simulate more obvious obstetrical complications. As a result, the treatment instituted is generally not directed toward the actual defect. The purpose of this paper is to stimulate an awareness and develop a clinical consciousness of the coexistence of aneurysms of the arterial system and pregnancy, so that early and adequate therapy may be instituted. Hence, this publication will consider aneurysms of the aorta and its abdominal branches, and a companion paper will discuss cerebral aneurysms. This report is based upon 75 cases of aneurysm of the aorta and 50 cases of aneurysm involving the major branches of the abdominal aorta culled from the literature (Tables I to IV). Two additional cases of saccular aneurysm

Although the infant mortality rate in Iwate Prefecture was annualy reported to be the highest in the country in the period of ten years from 1955 to 1964, the perinatal mortality rate in the Prefecture was on a little lower level than the rate in all the country. From this fact, it is surmised that the factors influencing upon the perinatal mortality rate are somewhat different from the factors influencing upon the infant mortality. In order to elucidate the meaning of the perinatal mortality rate as a maternal and child health indicator, the author has performed statistical investigation. Perinatal mortality rate in each city, town, or village in Iwate Prefecture was calculated using the vital statistics of the Prefecture in 1955 and 1960, and the association between the perinatal mortality rate in 1955 and the rate in 1960, as well as the association between perinatal mortality rate or other maternal and child health indicator were studied. Perinatal mortality rate was also observed to be not always low in the areas where the health level was evaluated to be high by life expectancy or other indicator. Using the vital statistics of Japan in 1960, correlation coefficients between two of seven indicators, that is, late fetal mortality rate of 29 weeks or more, early neonatal mortality rate under one week, perinatal mortality rate, infant mortality rate, maternal mortality rate, Uematsu's Indicator (normal deviation of mortality) for female and the Indicator for male, were studied. And then, factor analysis was performed with the obtained correlation matrix. According to the result of factor analysis, seven indicators studied could he classified into next three groups; 1. Late fetal mortality rate of 29 weeks or more. 2. Perinatal mortality rate and maternal mortality rate. 3. Early neonatal mortality rate under one week, infant mortality rate, Uematsu's Indicator for female and Uematsu's Indicator for male. Taking these facts into consideration, it has been deducted, according to the author's opinion, that perinatal mortality rate is a useful indicator for evaluating maternal and child health level of the communities.

Background information: Since the early 1990s, emergency obstetric care (EmOC) in Bangladesh has played important role to reduce the maternal mortality rate. Along with other indicators of improved maternal care, there is a trend of rising caesarean section rates over the last decade affecting the economy of the country. According to demographic and Health Surveys conducted between 1993 and 2004, rate of caesarean section has risen from 2% to 6% which is more pronounced in urban area. Objective: To assess the indications and the trends of caesarean sections done over a 10-year period from 1995- 2004. Study Design: A retrospective observational study of the cases of caesarean sections over a decade. Study setting: Holy Family Red Crescent Medical College Hospital. Results: 23748 women were admitted in department of Obstetrics and Gynacology. Total deliveries were 21149(89.05% of total admission). The caesarean birth rate increased from 45.85% to 70.55%. The indications varied a little in cases of malpresentation and eclampsia. APH and IUGR has risen a little (from 2.56 to 2.6 to 1.83 to 2.34%) respectively. But proportion of repeat caesarean section and that of presumed foetal distress (or less foetal movement) increased (from 25.99 to 31.45% and from 8 to 15%), recently the indication, as maternal choice is also coming up (from .43 to .8%). The proportion has fallen in prolonged labour for cervical dystocia (from 17 to 2.6%) and obstructed labour (from 4.6% to .36%). The data were compared and analyzed by Z Test and corresponding P value was calculated which was not significant. Conclusion: Though caesarean section is a very safe intervention in obstetrics at present, crucial evaluation of the indications is advocated to reduce the rates of caesarean secion. Keywords: Caesarean section rates; Indications DOI: http://dx.doi.org/10.3329/jbcps.v29i3.9432 JBCPS 2011; 29(3): 126-132

1. 1. An analysis of 1,231 consecutive cesarean sections performed at Milwaukee Hospital from 1933 through 1947 has been presented. 2. 2. The cases were divided into three five-year periods, showing the trends in present-day cesarean sections. 3. 3. The total incidence of cesarean section was 6 per cent, with a maternal mortality rate of 0.81 per cent, neonatal death rate of 3.6 per cent, and stillbirth rate of 1.95 per cent. 4. 4. No maternal deaths occurred during the last five-year period when approximately one-half (560) of the operations were performed.

1. 1. A survey of 852 cesarean sections performed during the 9 year period from Jan. 1, 1943, through Dec. 31, 1951, is presented. 2. 2. An increase in incidence from 2.5 per cent to 5.1 per cent during the time surveyed is noted, with an average incidence of 3.5 per cent. 3. 3. The most frequently noted indications were previous cesarean section, cephalopelvic disproportion, and hemorrhage. There has been a liberalization of indications for fetal causes, for elderly primigravidas, and for bad obstetrical history. 4. 4. There has been a steady, marked increase in the low cervical two-flap cesarean section with a constant decrease in the classical type. 5. 5. There has been a steady rise in the use of regional rather than inhalation anesthesia, from 42.7 per cent of cases during the first 3 years of the survey, to 76.2 per cent of the cases during the last 3 years. 6. 6. The morbidity rate was 49.2 per cent. The use of antibiotics as a prophylactic measure in all cesarean sections has lowered the rate constantly. It is believed that penicillin should be given prophylactically to all patients in labor or with ruptured membranes for 12 hours. A plea is entered to change the obstetrical standard for the determination of morbidity following cesarean sections. 7. 7. The chief postoperative complications encountered were ileus, wound infection, and thrombophlebitis. 8. 8. The corrected maternal mortality rate was 0.47 per cent. One death was due to anesthesia, 1 death was due to postoperative pneumonia, 1 death was due to hemorrhage, and 1 death was due to paralytic ileus. 9. 9. A gross fetal mortality rate of 6.92 per cent is reported. The corrected fetal mortality rate, eliminating those cases in which the fetal heartbeat was nor heard prior to surgery and cases of fetal abnormalities not compatible with life, was 3.05 per cent.

1. 1. The purposes and methodology of the Hartford Community Obstetrical Study are presented and discussed. 2. 2. The maternal mortality rate was 2.5 per 10,000 live births, 1.5 per 10,000 for the white patients and 15.4 per 10,000 for the nonwhite. Four postmortem cesarean sections were performed and 4 living children were obtained. 3. 3. Cesarean section was performed at a frequency of 8.2 per cent which varied in the individual institutions from 1.9 per cent to 9.4 per cent. About one half, 50.5 per cent, were primary sections. The indications for primary sections are discussed. 4. 4. The perinatal mortality experience was found to be favorable. This was considered to be related to the low incidence of premature births. 5. 5. Congenital malformations were presented as “incompatible, consequential, or inconsequential.” The total frequencies were similar for the races, but quite different as far as the breakdowns were concerned. The nonwhite had fewer “consequential” malformations. 6. 6. The results of a superficial analysis of stimulation of labor with oxytocin suggest a possible adverse effect upon the infants. A more definitive analysis in this area has been recommended. 7. 7. Elective induction of labor has been subjected to a special statistical analysis and some results were presented. This special analysis indicated no undue risk to mothers and/or infants.

This study is a preliminary endeavor to ascertain data pertaining to maternal and fetal morbidity and mortality through routine and special methods for the examination of the placenta and umbilical cord; also by clinical controls to further accurate estimation of the significance in the histopathologic changes obtaining beyond the normal for a matured decidual organ. Statistical estimates have assigned for United States a maternal mortality rate second highest of a large number of countries. Students of public welfare point to the fact that there has not been any noticeable decrease in this mortality for twenty-five years. In many cities, according to Levy, the percentages vary from 5.6 to 11.9 per 1000 births (1 in 178 to 1 in 84). The neonatal mortality has ranged from 23 per 1000 (1 in 43) to 49 per 1000 (1 in 20). The combined loss for mother and child in the first month reaches the appalling figure of 61 per thousand (1 in 17). It would seem urgent that all possible means from clinical and laboratory sources should be utilized and combined to further economy here in human lives.

1. 1. A brief history of the handling of cesarean section cases in Houston, Texas, is given with an analysis of twenty-two years' experience. 2. 2. The incidence of cesarean section in private practice limited to obstetrics was found to be 6 per cent. Reasons for this relatively high rate are given. 3. 3. Morbidity and mortality figures obtained by obstetricians are compared with those obtained by well-recognized general surgeons and by general practitioners. 4. 4. Nitrous oxide-ether anesthesia was the anesthetic of choice, but maternal and fetal mortality rates for all types of anesthetics used are given. 5. 5. The low cervical type outnumbered all other varities performed in this series by 2.5 to 1. 6. 6. Pelvic dystocia was the primary indication for cesarean section in the great majority of the 362 operations. Maternal and fetal mortality rates associated with each indication are tabulated. 7. 7. Survival rates are tabulated against birth weights of the infants in the toxemia group, and it is concluded that one is hardly justified in performing cesarean section in the interest of the child if it weighs less than 3 pounds but that there is a definite place for cesarean section in salvaging children from mothers with toxemia if the fetus weighs from 3 to 4 pounds or more. 8. 8. Fetal mortality is also tabulated against the primary indication for cesarean section and important conclusions are drawn from these. 9. 9. The gross fetal mortality for the current series was found to be 4.4 per cent and the corrected rate, 1.4 per cent. 10. 10. Brief summaries of maternal deaths are recorded. 11. 11. The gross maternal mortality rate in this series is 2.2 per cent, while the corrected rate is 0.83 per cent.

The treatment of abruptio placentae offers a ripe field for improvement in its maternal mortality rate. The possible relationship between late gestational toxemia and abruptio placentae is discussed. The pathology of abruptio placentae and the changes in the physiologic functions of the uterus in this condition, are considered. A plea is made for earlier resort to cesarean section in cases of abruptio placentae.

1. 1. A survey is made of 1,710 cesarean sections occurring in 39,156 public and private ward deliveries in the Toronto General Hospital. 2. 2. Public and private incidence and mortality are compared. 3. 3. A more detailed survey is made of 544 sections in 21,151 deliveries in the public ward service over a twenty-five year period as to changing trends in indications, and the type of operation employed. 4. 4. Maternal mortality rate shows marked reduction. 5. 5. The still birth and neonatal mortality during this twenty-five year period is noted and that of the last fifteen-year period compared with that of the first ten-year period. 6. 6. From the almost routine use of the low segment operation without mortality to the exclusion of the classical section, one might infer that with proper conduct of test labors it should not be necessary to employ the extraperitoneal type of operation except in those cases where supervision of labor has been grossly inefficient.

The gravity of the complication of rupture of the uterus to the mother and the consequences to the fetus still provides an important subject for discussion in the world literature. Although the incidence varies between countries and centers, a study of statistics presents facts and insight into the problem and hammers the ways and means to reduce the gravity. The present study includes 104 patients with uterine rupture admitted, studied, and treated in the Maternity Hospital, Amman. A maternal mortality rate of 36.5 per cent and fetal loss of 80.7 per cent is explained according to the causes of uterine rupture.

One hundred and eighty-three maternal deaths occurring in the University College Hospital, Ibadan, over a 10 year period are reviewed. The hospital maternal mortality rate was 8.2/1,000. Severe anemia in pregnancy was responsible for 18.6 per cent of all maternal deaths during the period under review. Acute hepatic failure was responsible for 15.3 per cent of maternal deaths. It is suggested that improvement in public health and maternity services along with transport and communication facilities will greatly reduce the very high maternal mortality rate in Nigeria.

The cesarean section rate at this hospital from 1948 to 1952 was 2.3 per cent. This is identical with the cesarean section rate from 1932 to 1937. There have been marked changes in indications for cesarean section. Medical indications, postmaturity, and toxemia of pregnancy have occurred less frequently as indications and cephalopelvic disproportion, previous cesarean section, premature separation of the placenta, and placenta previa have increased in frequency. Comparison of currently accepted indications for cesarean section at this hospital with indications prevalent in other hospitals with cesarean section rates of 6 to 10 per cent reveals that the latter institutions have a greatly increased incidence of previous cesarean section and elderly nullipara as reasons for cesarean section. Cephalopelvic disproportion as a primary indication for cesarean section occurs more frequently in the current St. Louis Maternity Hospital statistics than in statistics reported in the previously mentioned papers. Despite the relatively low cesarean section rate at this hospital, the maternal mortality rate was 2.4 per 10,000 vaginal deliveries and none in the cesarean section deliveries. The maternal mortality in the 1932–1937 series at this hospital was 30 deaths per 10,000 vaginal deliveries. The cesarean section maternal mortality was 57 deaths per 10,000 cesarean sections. The perinatal fetal mortality has decreased from 4.6 per cent in the 1932–1937 series to 3.6 per cent in the current series. The perinatal mortality following cesarean section in the 1948–1952 series was 9.6 per cent as compared to the 5.8 per cent reported in the 1932–1937 series. This is the result of the change in indications for cesarean section in the current series, with many infants dead or compromised prior to the cesarean section. Despite the use of various operative techniques and prophylactic antibiotics the maternal morbidity in cesarean section patients is about five times that in deliveries of all types. There was no demonstrable decrease in maternal morbidity when the low transverse cervical cesarean section was used as compared to the morbidity following the use of the classical cesarean section. Maternal morbidity in cesarean sections preceded by labor was about twice that of cesarean sections not preceded by labor. The neonatal fetal mortality in elective cesarean section because of previous cesarean section was 2.9 per cent as compared to the neonatal mortality in deliveries of all types of 1.5 per cent. Analysis of the fetal deaths that occurred in all types of deliveries indicates that cesarean section was indicated but not done in 2 per cent of the cases of fetal death. If cesarean section had been accomplished in these instances the cesarean section rate would have been increased from 2.3 to 2.4 per cent.

1. In 22 years, 1,154 cesarean sections have been performed at Charlotte Memorial Hospital, the rate being 4 per cent. 2. In the past 10 years: (a) A significant decrease in the rate of cesarean section has occurred. Factors responsible include the use of intravenous oxytocin, less pre-eclampsia, and a somewhat more conservative attitude on the part of the attending staff. (b) The maternal mortality rate was 0.3 per cent. (c) The section fetal mortality rate was 3.8 per cent (uncorrected); term 2.2 per cent (uncorrected); and 1.3 per cent (corrected). 3. Questionnaire replies from 40 per cent of the membership of the South Atlantic Association showed the predominant cesarean section rate to be virtually unchanged for the past 20 years, remaining a conservative 2 to 3 per cent.

The lowest maternal mortality rate ever recorded in the United States, 43.5 per 10,000 live births, has been reported by the United States Bureau of the Census for the year 1938. For the first time on record less than 10,000 (9,953) deaths were assigned to puerperal causes. The number of live births registered in 1938 was 2,286,962, a birth rate of 17.6 per thousand of population. This was a slight increase over 1937. The maternal death rate for all causes decreased 11 per cent during the year 1938 (from 49 per 10,000 in 1937 to 43.5 per 10,000 in 1938). The combined rate for abortion and ectopic pregnancy decreased 16 per cent; the rate for puerperal sepsis, including phlegmasiaalba dolens, and so on, decreased 12 per cent; the rate for all toxemias decreased 11 per cent, and the combined rate for puerperal hemorrhage and other accidents of childbirth decreased

Foi analisado o coeficiente de mortalidade materna no município de Osasco e observado que o mesmo ainda é alto comparado ao de S. Paulo (Capital) e ao de cidades localizadas em países mais desenvolvidos. Porém, o comportamento deste coeficiente, nos diversos anos, mostra efetiva melhora nos serviços de saúde materna, através da redução de 28,99% no período de 1967/1970. Observou-se que, ao ser analisado o coeficiente de mortalidade materna deve ser levado em consideração não só a sua magnitude, como também o seu comportamento nos diferentes anos. Além disso, deve-se considerar a proporção que apresenta em relação às demais causas de óbitos no grupo fértil feminino e o relacionamento entre si das causas obstétricas. Foi salientada a correspondência existente entre causas obstétricas de óbito e serviços de saúde materna. The maternal mortality rate in the county of Osasco (S. Paulo State, Brazil) was analysed and it was observed that this rate is still high comparing with the city of S. Paulo (S. Paulo State, Brazil), as well as with towns of more developed countries. Even so, one can notice that this rate shows a real improvement in the maternal health service with a reduction of the rate of 28,99% during the 1967-1970 period. The necessity that the maternal mortality rate be analized in respect to not only its magnitude but also as to its conduct during the different years, was showed. It is important to compare the obstetrical causes of death with others in the feminine fertile group and the relationship between the different obstetrical causes. The importance between these and the maternal health services, was showed.

1. 1. A total of 783 pregnancies of 500 consecutive multigravidas, gravida vi and over, are analyzed. 2. 2. One-fourth of these are private patients. 3. 3. Maternal morbidity is increased, necessitating an average increased hospitalization of 2.4 days per patient. 4. 4. The maternal mortality rate is seven times that of the average mortality rate. 5. 5. Fetal mortality is high in the multigravida, and the morbidity cannot be estimated. 6. 6. Toxemias in the grandipara are increased over the average expectancy. 7. 7. The frequency of placenta previa and premature separation is greater in the multigravida. 8. 8. Malpresentations increase maternal and fetal mortality. 9. 9. False labors are common in the multigravida. 10. 10. Infections are prominent as causes of morbidity in the multigravida in pregnancy, labor, and the puerperium. 11. 11. Medical complications other than those summarized above, which require treatment, are found frequently.

The downward trend of maternal mortality in the United States continued through 1949, according to data collected from the state health departments. Provisional reports received in correspondence with the states furnished information on the numbers of live births and maternal deaths for 47 states and the District of Columbia. With the 1948 data for the nonreporting state, Rhode Island, an estimated maternal mortality rate of slightly less than one maternal death per 1,000 live births was obtained for the United States in 1949. The maternal mortality problem in the United States is no longer a serious national problem but is, rather, one for local action in those areas in which maternal mortality rates are still relatively high. The rate for the United States has been declining rather steadily since 1933, the first year in which all the states were in the birth and death registration areas. The rate for 1933

T HE toxemias of pregnancy are still one of the three majo causes of maternal death, just as they have been throughout history. While maternal mortality statistics reflect the improvements brought about in the control and treatment of obstetric infection and hemorrhage, there has been no proportionate improvement in regard to pregnancy toxemias. Even though the over-all maternal mortality rate has decreased during the last ten years, the toxemias of late pregnancy still kill the same percentage of mothers dying from all obstetric causes as it did ten years ago. The over-all decrease in maternal mortality has perhaps initiated a false sense of security, and this may well have been a factor in considering toxemia of pregnancy as not too important. While the toxemias of pregnancy themselves may not be the immediate cause of death, they may have been the originating factor that has contributed to deaths ascribed to causes other than toxemia. Such conditions are abruptio placentae, some intrapartum or postpartum hemorrhage, cerebral hemorrhage, pulmonary edema, and thrombophlebitis, as well as some deaths from anesthesia where the wrong anesthetic agent was chosen or perhaps the wrong method of delivery was used for a severely toxic patient.

The maternal mortality rate has decreased but little during the last twenty years. This is in spite of important advances in other branches of medicine, including medical research and public health education. It is the general opinion that the time allotted to the teaching of obstetrics is too limited. Rowland 1 has shown that 50 per cent of the general practitioner's time is devoted to medicine, from 25 to 35 per cent to obstetrics and the remainder to minor surgery, gynecology and a few special cases. In all the published curriculums, obstetrics, which occupies at least 30 per cent of the general practitioner's time, is allowed only 4 per cent of the total time provided for a medical course, while surgery, which occupies less than 10 per cent of the practitioner's time, is given from 15 to 18 per cent of the hours allotted to the medical course. Questionnaires were

During recent years certain accepted principles for the care of the maternity patient and her infant have been challenged. Ideas have been expressed questioning the reality of labor pain or the need for analgesic and anesthetic drugs during labor. It has been claimed that labor pain is psychologically necessary for the mother. Furthermore, certain psychologic dangers to the newborn child have been suggested as arising from routine hospital nursery care and infant feeding. These claims challenge principles and procedures that have been taught as sound modern obstetrics. 1 During the past two decades, with these principles in use, the maternal mortality rate in this country has become one fifth of that observed at the beginning of this period. 2 This gratifying reduction in the national maternal mortality rate reflects a general reduction in the three major causes of maternal deaths, puerperal septicemia, toxemia and hemorrhage. 3 The recently advocated methods

The United States holds at present an unenviable position with regard to its maternal mortality rate. According to the latest available statistics, this country ranks nineteenth among the twenty nations of the world which can offer data on this subject. The only civilized country that shows a higher death rate among women from accidents and diseases incident to childbirth is Chile. Moreover, the maternal mortality rate in the United States is one-third higher than that of England and Wales and more than twice as high as that of Denmark, Italy, Japan, Netherlands, New Zealand and Sweden. Even allowing for possible doubt as to the entire accuracy of the statistics from the countries studied, and taking into consideration the varying methods used in computing these rates, it is evident that the present obstetric practice does not assure to the women of this country the safety which they have the right to

Our explanation of the latitudinal and altitudinal variation in litter sizes of small mammals invokes the effect of length of season and parental mortality related to reproduction. It may be assumed that a portion of the maternal mortality rate varies directly as the size of litter produced. Short seasons limit the maximum number of times a female can reproduce in her lifetime and give an advantage to phenotypes producing large litters. Long seasons favor producers of small litters. The contribution to the total rate of increase of the litters produced in the additional time afforded by long seasons is greater for producers of small litters because a larger proportion of parents of small litters survive to produce throughout the periods. The increment provided is sufficient to overcome the initial advantage of parents producing large numbers of young in their first litters.

If statistical studies throw any light on maternal mortality, it is certain that: Six or seven women out of every thousand confined die from causes directly or indirectly related to pregnancy, labor and the puerperium. There has been no improvement in maternal mortality records in the United States during the past ten years. In 1915 the maternal mortality rate in the registration area was 6.1, in 1920, 8, and in 1927, 6.7 per thousand births. Such statistics in the face of the advances made in prenatal study and supervision suggest that women are not receiving clean or scientific intrapartal care and that something is wrong with the teaching and training given to the undergraduate. More than 40 per cent, or two fifths, of all maternal deaths are due to infection, supposedly a preventable cause, while 27 per cent are chargeable to the toxemias and eclampsia, also preventable conditions. Of the

Has there been an actual reduction in the maternal mortality rate in Cleveland or only a fictitious one? The answer requires a critical analysis of all the factors involved: socio-economic conditions, completeness of vital statistics, changes in classification, medical and nursing technics and adequacy of hospital facilities. Changes in the birth rate and movements of population also enter into the problem. Prior to 1931 Cleveland, in company with other cities of comparable size, exhibited considerable variation from year to year in official maternal mortality rates (table 1). The rate varied irregularly from 4.3 to 7.2 deaths per thousand registered live births. Careful analysis of the vital statistics for the period from 1910 to 1930 indicates, as the main factors which account forthis irregularity, (1) incompleteness and irregularity in the reporting of births and the misinterpretation of stillbirths, (2) a declining birth rate due to later marriages, contraception and induction

Editorial comment1on United States infant and maternal mortality rates inThe Journalopened with this significant statement: "Maternal mortality rates of the United States have been reported and discussed for several years apparently to conjure conclusions designed to throw discredit on the medical profession." I agree with the Editor that such conclusions have been drawn. I submit the record made by North Dakota physicians to prove, for my state at least, that they are fallacious. North Dakota held the enviable position of having the lowest maternal mortality rate in the United States for 1938, 2.4 per thousand live births. The provisional rate for 1939 is 2.3. In a report2to the North Dakota State Medical Association I stated: "The problem of maintaining this low rate or even of lowering it still further is our problem as private practitioners. I believe that the private physician in North Dakota

A review of the 746 cesarean sections performed at the University of California Hospital from 1907 through 1948 shows an overall cesarean section incidence of 3.91 per cent. The maternal mortality rate associated with these cesarean sections has been 1.61 per cent. There has been a steady decline in mortality over the 40-year period and there have been no deaths from cesarean section in the last ten years. The over-all incidence of morbidity associated with cesarean section has been 40.5 per cent and again there has been a significant improvement in recent years. The fetal mortality associated with cesarean section has been 6.1 per cent. In view of recent experience, standards based on figures collected 20 years ago are no longer tenable.

To the Editor: —The editorial "Saver of Mothers" (The Journal, March 12, p. 891) is splendid. Years ago a statement was made, and it has been repeated thousands of times, that the maternal mortality rate of the United States is higher than that of any other civilized country—seventeen civilized countries are mentioned. This seems so impossible and preposterous that it should be questioned. The first premise to investigate is: Are the statistics of different countries absolutely comparable?There is ground for a difference of opinion concerning the need for isolation of obstetric from other patients.If there is a really higher maternal mortality rate in the United States, it is up to the obstetricians to look into the cause.If one obstetrician or one hospital has a higher maternal mortality rate than another, the causes should be studied by their peers, that is, by competent obstetricians assisted by a statistician.