Death before Birth: Fetal Health and Mortality in Historical Perspective (review)

The sad neglect of fetal death in historical studies is attributable to both a paucity of data and definitional difficulties: Stillbirths were not registered in England and Wales until 1927 and in Scotland until 1939, and even today, countries and cultures are not wholly homogenous in their definitions of live birth, stillbirth, and miscarriage. This problem was far larger in the past. Some places treated all infant deaths before baptism as stillbirths, and others probably inflated the number of live births through emergency baptism. As a result, they evince wide differences in the calculation of fetal losses, live births (therefore fertility), and early neonatal mortality (therefore life expectancy) that complicate new research into comparative levels and trends. Health and survival are affected by a spectrum of influences that change gradually over the life course. Fetal health is located at one extreme of this range, where maternal health and conditions in the womb are of particular importance. Birth represents an added risk, rendering the study of influences on fetal health particularly interesting. The issues surrounding fetal mortality in the past have never been adequately addressed until now.

Drawing on a wide range of sources—national-level statistics, surveys, hospital records, and physicians’ case notes—Woods addresses these matters in detail (although inevitably the period from conception to viability is speculative). The early chapters of the book thoroughly cover the exigencies of definition and measurement, highlighting the problems that different registration practices cause for comparisons between one time and/or place and another. Woods explores levels and trends for a wide variety of places, primarily in Europe where data are more available, though he also makes interesting observations about Japan and more recently developing countries. His comparisons inform new estimates of levels and trends in stillbirth and fetal death for Britain before World War II. Contrary to previous assumptions of a much higher stillbirth rate, which declined between the seventeenth and nineteenth centuries, he suggests the stillbirth rate remained between forty and sixty per thousand births from 1600 to 1930, showing a gentle decline after 1650 and a precipitous one after 1930.

Subsequent chapters examine possible influences on fetal death, including midwifery and obstetric practice, and different approaches to the measurement and classification of fetal death, as practiced by influential midwives and medical personnel. The final chapter discusses the role of induced abortion and the modern-day paradox of high levels of induced abortion and unprecedented concern for the fetus as a patient.

Woods claims that his approach is neither interdisciplinary nor multidisciplinary but “antidisciplinary”; he claims not to “offer a history in the normal sense” but to reveal “how and why change occurred in the long term[,] . . . prepared to use whatever is available and relevant to reach that goal” (9). Rather than eschewing disciplines, however, he mixes and matches, demonstrating in true interdisciplinary fashion how a collaboration of methods is necessary to an understanding of this topic.

In this regard, the penultimate chapter is the most interesting and controversial section of the book, using different approaches (particularly medical history and demography) to answer the question of why fetal health improved between 1650 and 1930.Woods argues that progress in midwifery could have played only a small role in reducing intrapartum fetal death prior to the 1930s. He maintains that mothers’ freedom from infections during pregnancy rather than better nutrition, as suggested by Wrigley, was the key influence on long-term changes in fetal health.¹ Though the evidence is more suggestive than conclusive, the combination of arguments from multiple disciplines is elegant and persuasive: Contemporary observations show that smallpox during pregnancy increases the risk of fetal loss; smallpox and fetal mortality followed similar trends in their decline over time; and hypothetical models under various demographic conditions indicate that declines in smallpox could well have produced declines in fetal mortality.

Woods’ study does for fetal mortality what Irvine Loudon’s Death in Childbirth (New York, 1992) did for maternal...