¹ D Rush, ‘Nutrition and maternal mortality in the developing world’, Am. J. Clin. Nutr., 2000, 72 (suppl): 212–40s, p. 214s. During the past twenty years, attempts to reduce maternal mortality have not been overly effective. Carla AbouZahr and Tessa Wardlaw, ‘Maternal mortality at the end of a decade: signs of progress?’, Bull. World Health Organ., 2001, 79: 561–73, p. 566.

² Gijs Walraven and Andrew Weeks, ‘The role of (traditional) birth attendants with midwifery skills in the reduction of maternal mortality’, Trop. Med. Int. Health, 1999, 4: 527–9, p. 527.

³ V De Brouwere, R Tonglet, and W Van Lerberghe, ‘Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?’ Trop. Med. Int. Health, 1998, 3: 771–82.

⁴ Ibid., p. 773. What this cultural integration actually entailed is left to the readers' imagination.

⁵ For Norway see, Kristina Kjærheim, Mellom kloke koner og kvitkledde menn: jordmorvesenet på 1800-talet, Oslo, Norske Samlaget, 1987; and for Sweden, Pia Höjeberg, Jordemor: barnmorskor och barnföderskor i Sverige, Stockholm, Carlssons, 1991.

⁶ One of the most thorough investigations of the workings of the Swedish medical authorities involves an analysis of the organization of the smallpox vaccination campaign. Peter Sköld, The two faces of smallpox: a disease and its prevention in eighteenth- and nineteenth-century Sweden, Umeå, Demographic Data Base, 1996, pp. 383–99. This campaign was undoubtedly successful but it would be a mistake to view all initiatives launched by the state in such a positive light.

⁷ For a thorough discussion of midwives' responsibilities see, Christina Romlid, Makt, motstånd och förändring: Vårdens historia speglad genom det svenska barnmorskeväsendet 1663–1908, Stockholm, Forskning och Utveckling, Vårdförbundet, 1998, pp. 197–204.

⁸ Signild Vallgårda, ‘Hospitalization of deliveries: the change of place of birth in Denmark and Sweden from the late nineteenth century to 1970,’ Med. Hist., 1996, 40: 173–90, p. 177; U Högberg, S Wall and G Broström, ‘The impact of early medical technology on maternal mortality in late 19th-century Sweden’, Int. J. Gynecol. Obstet., 1986, 24: 251–61, p. 256.

⁹ Riksarkivet (hereafter RA), Sundhets Collegium, Series E5A, vol. 43, Report No. 224, ‘Årsberättelser för Sundsvalls District för År 1873’.

¹⁰ Irvine Loudon, Death in childbirth: an international study of maternal care and maternal mortality, 1800–1950, Oxford, Clarendon, 1992, pp. 542–3.

¹¹ Ulf Högberg and Stig Wall, ‘Secular trends of maternal mortality in Sweden for the years 1750–1980’, in Ulf Högberg (ed.), Maternal mortality in Sweden, Umeå University, 1985, pp. 29–34, on p. 30.

¹² Figures for nineteenth-century maternal mortality in Sweden include only deaths that are now classified as direct obstetric deaths. Ibid.

¹³ Files from the Demographic Data Base (hereafter DDB); E Wretlind, ‘Döde af barnsängsfeber och barnsbord i Sverige 1776–1900’, Jordemodern, 1904, 17: 21–7, p. 23.

¹⁴ For an excellent study of mortality in the town of Sundsvall, see Sören Edvinsson, Den osunda staden: sociala skillnader i dödlighet i 1800-talets Sundsvall, Umeå, Demographic Data Base, 1992.

¹⁵ Loudon points out that although most women die in the postnatal period, there is no uniform definition of how long this is. Loudon, op. cit., note 10 above, p. 21. See also, Y Berhane, T Andersson, S Wall, P Byass, U Högberg, ‘Aims, options and outcomes in measuring maternal mortality in developing societies,’ Acta Obstet. Gynecol. Scand., 2000, 79: 968–72, pp. 968–9.

¹⁶ These categories are summarized in T Andersson, S Bergström, and U Högberg, ‘Swedish maternal mortality in the 19th century by different definitions: previous stillbirths but not multiparity risk factor for maternal death,’ Acta Obstet. Gynecol. Scand., 2000, 79: 679–86, p. 681.

¹⁷ For example, in addition to the use of antisepsis, midwives could also have reduced the likelihood of post-partum haemorrhage by hastening the expulsion of the placenta.

¹⁸ R Schofield, ‘Did the mothers really die? Three centuries of maternal mortality in “the world we have lost”’, in L Bonfield, R M Smith, and K Wrightson (eds), The world we have gained: histories of population and social structure, Oxford, Basil Blackwell, 1986, pp. 231–60, on p. 234.

¹⁹ Andersson, Bergström, Högberg, op. cit., note 16 above, p. 681.

²⁰ Ibid. This estimate is based on studies examining maternal mortality throughout the nineteenth century. U Högberg and G Broström, ‘The demography of maternal mortality: seven Swedish parishes in the 19th century’, in Högberg (ed.), op. cit., note 11 above, pp. 37–44, p. 39.

²¹ This group included “blood flow, vomiting blood, burst vein/artery, and haemorrhage”. DDB files.

²² DDB files.

²³ Loudon identifies this problem of hidden maternal deaths and states that they could easily account for an additional 20 per cent of maternal deaths during the nineteenth century. The deliberate obscuring of maternal deaths caused by incompetence would likely have been highest after the introduction of antisepsis in the 1880s that dramatically reduced the risk to the new mother. Loudon, op. cit., note 10 above, pp. 34–7. For a discussion of the possible implications of changing cause-of-death classifications in Sweden see, Högberg and Wall, op. cit., note 11 above, pp. 29–30.

²⁴ Verbal autopsies conducted in under-developed countries of today when death appears to have been the result of childbirth have proved quite reliable. There is no reason to believe that nineteenth-century Swedish doctors or midwives would have had any more difficulty determining the cause of death using a similar strategy. Ulf Högberg, personal communication 16 Oct. 2003.

²⁵ Sam Willner, Det svaga könet? Kön och vuxendödlighet i 1800-talets Sverige, Linköping University, 1999, p. 107; T Andersson, Survival of mothers and their offspring in 19th-century Sweden and contemporary rural Ethiopia, Umeå University, 2000, pp. 22–3.

²⁶ See, for example, RA, Sundhets Collegium, Series E5A, vol. 40, annual report from Wifstavarf, 1870.

²⁷ These measures included courses in basic childcare and the treatment of childhood diseases as part of midwives’ training. Anders Brändström, “De kärlekslösa mödrarna”: spädbarnsdödligheten i Sverige under 1800-talet med särskild hänsyn till Nedertorneå, Umeå University, 1984.

²⁸ Vallgårda, op. cit., note 8 above, p. 183; Romlid, op. cit., note 7 above, pp. 291–2.

²⁹ Lennart Nordenfelt, B Ingemar, and B Lindahl, Om grunden för svensk dödsorsaksstatistik, Linköping, Department of Health and Society, University of Linköping, 1984, pp. 4–5, cited in Christina Romlid, ‘The Swedish maternal mortality rate in the nineteenth century’, unpublished paper, Uppsala University, p. 3.

³⁰ Compare Lisa Öberg, Barnmorskan och läkaren: Kompetens och konflikt i svensk förlossningsvård 1870–1920, Stockholm, Ordfronts, 1996, with Romlid, op. cit., note 7 above. Although both authors discuss the tensions that existed between doctors and midwives, it was less pronounced the farther one moved from the major cities. See also Ulf Högberg, ‘The decline in maternal mortality in Sweden: the role of community midwifery', Am. J. Public Health, 2004, 94: 1312–20.

³¹ Jean Donnison, Midwives and medical men: a history of inter-professional rivalries and women's rights, London, Heinemann Educational, 1977, pp. 113, 134.

³² Loudon, op. cit., note 10 above, p. 412.

³³ Högberg, Wall, and Broström, op. cit., note 8 above, pp. 252, 254, 258.

³⁴ Härnösand Landsarkiv (hereafter H-sand), Första Provincialläkaren i Vasternorrlands län, Series D III, ‘Barnmorskors dagböker’, “Kongl. Medicialstyrelsens cirkulär till barnmorskorna i riket, angående försigtighetsmått, som böra af dem iakttagas till förekommande utfärdadt den 13 Juni 1881.”

³⁵ Högberg, Wall, Broström, op. cit., note 8 above, p. 254. See also Loudon, op. cit., note 10 above, p. 412; and idem, ‘Maternal mortality in the past and its relevance to developing countries today’, Am. J. Clin. Nutr., 2000, 72 (suppl): 241s–6s.

³⁶ Loudon, personal e-mail communication, 1 Oct. 2003.

³⁷Bidrag till Sveriges Officiela Statistik (hereafter BiSOS) (Series K), 1870 p. 66; 1880 p. 57.

³⁸ Pia Höjeberg, Jordemor: Barnmorskor och barnaföderskor i Sverige, Stockholm, Carlssons, 1991, p. 129.

³⁹ Högberg, Wall and Broström, op. cit., note 8 above, p. 256.

⁴⁰ H-sand, Förste Provinsialläkare i Västernorrlands Län, Series D III: daybooks from midwives in Alnö, Attmar, Hässjö, Indal, Njurunda, Selånger, Skön, Sättna, Timrå and Tuna parishes. RA, Medicinal Styrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, vols 12, 16, reports from Sundvall's provincial physician for 1883 and 1885.

⁴¹ ‘Maginflammation’. Indiko database, ID No. 844002234.

⁴² H-sand, Förste Provinsialläkare i Västernorrlands Län, Series D III: 2 Skön ‘Barnmorske dagböcker’, daybook of Anna Westerlund (1 Jan. 1884–24 Nov. 1885).

⁴³ RA, Medicinalstyrelsen, Series E14A:9 (1884), ‘Instrumentförlossningar’, Report No. 424 from Anna Westerlund dated 11 May 1884, with comments from Dr Söderbaum.

⁴⁴ DDB files.

⁴⁵ There were 28 deaths between 1870–79 representing 50 per cent of the 56 deaths between 1860–90. DDB files.

⁴⁶ Figures are compiled from BiSoS (Series K), files from the DDB, and the annual reports submitted by local physicians. RA, Sundhets Collegium and Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’. Unfortunately, information contained in official statistics does not make it possible to calculate the ratio of midwives to women of childbearing age but only to all females.

⁴⁷ BiSoS, files from the DDB, and annual physicians' reports found in RA, Sundhets Collegium and Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, for the years 1860–90.

⁴⁸ In a recent study of modern Zambia, distance was found to be one of the key factors preventing women from accessing medical care. It is unlikely that long distances would not also have deterred women from seeking medical help in the Sundsvall region during the nineteenth century. F Le Bacq and A Rietsema, ‘High maternal mortality levels and additional risk from poor accessibility in two districts of Northern Province, Zambia’, Int. J. Epidemiol., 1997, 26: 357–63.

⁴⁹ Rural midwives in Sweden attended approximately thirty-seven births per year during the second half of the nineteenth century. Högberg, Wall and Broström, op. cit., note 8 above, p. 256.

⁵⁰ Thanks to Sören Edvinsson at the DDB for making this information available to me.

⁵¹ Högberg, Wall and Broström, op. cit., note 8 above, pp. 255–6.

⁵² Although parish birth records often indicate whether a midwife had attended a birth, they do not show which specific midwife was in attendance.

⁵³ RA, Sundhets Collegium, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 44, report from Sundsvall's provincial physician for 1874.

⁵⁴ The number of births attended is found in H-sand, Förste Provinsialläkarens i Västernorrlands län, Series D III:I, ‘Barnmorskors dagbocker—Tuna’. The total number of births in the parish is supplied by the ‘Birth file’ constructed by the DDB.

⁵⁵ H-sand, Förste Provinsialläkarens i Västernorrlands län, Series D III:I, ‘Barnmorskors dagbocker—Skön’. DDB files provide the total number of births in this parish.

⁵⁶ RA, Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 14, Report No. 114 from Dr Söderbaum in Sundsvall. He reported that there had been a total of 450 births in the parishes for which he was responsible.

⁵⁷ RA, Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 24, Report No. 248 from Dr Söderbaum in Sundsvall. Högberg, Wall, and Broström, op. cit., note 8 above, p. 255.

⁵⁸ H-sand, Förste Provinsialläkarens i Västernorrlands län, Series D III:I, ‘Barnmorskors dagbocker—Skön’.

⁵⁹ Walraven and Weeks, op. cit., note 2 above, p. 527.

⁶⁰ RA, Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 25, report from Sundsvall district for 1885.

⁶¹ The four doctors were J J Westerberg, W Baggstedt, O Söderbaum, and S Tornmark. Biographical information about them is garnered from the following sources: J F Sacklén, Sveriges läkarehistoria, Stockholm, n.p., 1853, p. 398; A H Wistrand, A J Bruzelius, C Edling, Sveriges läkare-historia, Stockholm, Norstedt, 1873–76; pp. 35–6, 775–6, 845; A J Bruzelius (ed.) Svensk läkare-matrikel, 3rd series, 4 vols, Stockholm, Norstedt, 1885–1901, vol. 1, pp. 36–7; vol. 2, pp. 864–5, 1604; vol. 3, pp. 1565–6.

⁶² Indiko, database, ID No. 848003084.

⁶³ Indiko database.

⁶⁴ Indiko database.

⁶⁵ Indiko database, ID No. 846002666.

⁶⁶ RA, Sundhets Collegium, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 37, annual report for 1867 from Härnösand district physician.

⁶⁷ Andersson, op. cit., note 25 above, p. 34.

⁶⁸ Romlid, op. cit., note 7 above pp. 197–204, 291; Loudon, op. cit., note 10 above, pp. 408, Högberg, op. cit., note 30 above.

⁶⁹ Sundsvall, Medelpadsarkivet, Series A1:2 Indals Kommun Kommunalstämma protokoll (12 Dec. 1880).

⁷⁰ RA, Sundhets Collegium, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 46, report from Sundsvall District 1876.

⁷¹ RA, Sundhets Collegium, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 45, report from Wifstavarf, 1875.

⁷² RA, Medicinalstyrelsen, Series E5A, ‘Årsberättelser från provinsialläkare’, vol. 4, report from Wifstavarf, 1879.

⁷³ S Edvinsson, A Brändström, J Rogers, ‘Did midwives make a difference? A study of infant mortality in nineteenth-century Sweden’. Unpublished conference paper presented at the European Association for the History of Medicine and Health Conference, Oslo, 2003.

⁷⁴ On these maps deaths that occurred within the town have been excluded.

⁷⁵ Högberg and Broström, op. cit., note 20 above, p. 41. James McCarthy and Deborah Maine, although acknowledging the relationship between socio-economic status and maternal mortality, warn against ignoring other variables that can lead to birth-related complications. J McCarthy and D Maine, ‘A framework for analyzing the determinants of maternal mortality’, Stud. Fam. Plann., 1992, 23: 23–33, pp. 28–9.

⁷⁶ We must exclude the coastal agricultural parish of Tynderö and the inland economically mixed parishes of Tuna and Attmar from consideration as there are too few deaths to make any concrete conclusions. DDB files.

⁷⁷ These conditions were particularly dangerous for children under the age of fifteen but also for adults. Edvinsson, op. cit. note 14 above, pp. 181, 188–90, 215–19.

⁷⁸ Loudon, op. cit., note 10 above, p. 541; personal e-mail communication, 1 Oct., 2003.

⁷⁹ DDB files. Andersson, Bergström and Högberg, op. cit., note 16 above, p. 684. For a discussion of these scarlet fever epidemics, see S Curtis, ‘Nutrition and patterns of scarlet fever morbidity and mortality during the epidemics of 1860–1890: the Sundsvall region’, Soc. Hist. Med., 2004, 17: 199–221.

⁸⁰ E Hertz, J Hebert, and J Landon, ‘Social and environmental factors and life expectancy, infant mortality, and maternal mortality rates: results of a cross-national comparison,’ Soc. Sci. Med., 1994, 39: 105–14, p. 110; Yemane Berhane, Women's health and reproductive outcome in rural Ethiopia, Umeå University, 2000, p. 2.

⁸¹ Andersson, Begrström, and Högberg, op. cit., note 16 above, p. 682.

⁸² Högberg and Broström, op. cit., note 20 above, p. 39.

⁸³ Jane Humphries, ‘“Bread and a pennyworth of treacle”: excess female mortality in England in the 1840s’, Cambridge J. Econ., 1991, 15: 451–73.

⁸⁴ Stephan Klasen, ‘Marriage, bargaining, and intrahousehold resource allocation: excess female mortality among adults during early German development, 1740–1860’, J. Econ. Hist., 1998, 58: 432–67, pp. 445–6, 455.

⁸⁵ For the relationship between nutrition and tuberculosis, see B-I Puranen, Tuberkulos: en sjukdoms förekomst och dess orsaker, Sverige 1750–1980, Umeå University, 1984, p. 352; P Lunn, ‘Nutrition, immunity and infection’, in R Schofield, D Reher and A Bideau (eds), The decline of mortality in Europe, Oxford and New York, Oxford University Press, 1991, pp. 131–45, on p. 137.

⁸⁶ DDB files.

⁸⁷Sundsvalls-Posten, No. 36, 27 Mar. 1880.

⁸⁸Sundsvalls-Posten, No. 126, 27 Oct. 1874.

⁸⁹Sundsvalls-Posten, No. 30, 24 Feb. 1890.

⁹⁰Sundsvalls-Posten, No. 179, 17 Nov. 1890; No. 180, 19 Nov. 1890.