puerperal pyrexia, 122 Local Authorities have now made arrangements for institutional treatment, 132 for the services of specialists for consultation, and 68 for skilled nursing assistance. There are, however, still certain areas in which much remains to be done. and the latest statistics show that in 1926 and 1927 the maternal mortality rate in England and Wales was practically the same as it was 20 years ago. The publication during the year of a report by Dame Jane Campbell, D.B.E., M.D., M.S., Senior Medical Officer of the Ministry for Maternity and Child Welfare, on "The Protection of Motherhood," has once more focussed public attention on the question of maternal mortality, and the following steps have been taken in the Department to give effect to recommendations contained in the report. (1) A further circular has been issued to Local Authorities stressing the need for a complete maternity service in every area, and the importance of investigating all maternal deaths and all cases of puerperal fever. The British Medical Association have expressed general approval of the objects of these investigations, the results of which are intended to be used exclusively for scientific and public health purposes, and have communicated with their local Divisions urging them to give all the assistance they can towards making the observations as accurate and complete as possible. It is important also that Local Authorities should provide expert advice or assistance, institutional or otherwise, so far as available, for general practitioners in dealing with these cases. (2) A Departmental Committee has been appointed to enquire into the training of midwives and the conditions under which they are practising. (3) A representative Maternal Mortality Committee is being set up at the Ministry with a view to co-ordinating and stimulating research into questions relating to the prevention of maternal mortality. It will be one of the duities of this Committee to assist in securing that local investigations into maternal deaths and cases of puerperal fever are conducted on uniform lines, and to collate and classify the information obtained as the result of these investigations. MIDWIFERY. Of the 641,926 births registered in England in 1926, 383,401, or 60 per cent were notified by midwives. 16,436 midwives gave notice of their intention to practise as such in England and Wales in 1926, but the number actually practising is less than this, as a considerable number of midwives practise in more than one area and are consequently obliged to notify more than one Local Supervising Authority. 89.4 per cent. of the total number of women on the Midwives Roll (63,478) are now certificated. The recent increase in the length of training from four to six months in the case of trained nurses, and from six to twelve months for other candidates, resulted in a considerable diminution in the number of women who entered for the examination of the Central Midwives Board in 1927, and only 2,046 obtained the certificate of the Board during the year, as compared with 3,008 in the previous year. There is, however, evidence to show that this falling off was only temporary, and that in future a sufficient number of candidates may be expected to offer themselves for this important work. The grant from this Department in aid of the training of those candidates who intend to practise midwifery should make it possible for some women to undergo the lengthened period of training who could not otherwise afford to do so. There are 74 training institutions recognized by the Department for the purposes of this grant at the present time, and grant has been paid during the year in respect of the training of 555 pupilmidwives, of whom 392 have already begun to practise in England and Wales. Ten whole-time post-certificate courses at recognized institutions, for the further instruction of midwives already in practice, were approved during the year. Section 2 (1) of the Midwives and Maternity Homes Act, 1926, provides that where a midwife has been suspended from practice in order to prevent the spread of infection, she shall, if she was not herself in default, be entitled to recover from the Local Supervising Authority such amount by way of compensation as is reasonable in the circumstances of the case. It has been decided that the expenditure of Local Supervising Authorities for this purpose will be eligible for grant under the Maternity and Child Welfare Regulations, if the Minister is satisfied in each case that the compensation paid is reasonable. A circular (Circular 857) was issued to the local Supervising Authorities on the 31st January, 1928, announcing this decision, and stating that the prior consent of the Minister should be obtained to the amount of compensation proposed to be paid, if the period of suspension exceeds seven days. It was pointed out that it is important that the suspension of a midwife should be for a period sufficiently long to ensure that there is no risk of the spread of infection, but that in the large majority of cases all that is necessary is to suspend the midwife until she has been efficiently disinfected. It was also suggested that normally compensation should be assessed by reference to the loss of income actually sustained by the midwife. The midwifery service in rural areas is carried out mainly by the district nurse-midwives who are employed by District Nursing Associations, most of which are affiliated to the appropriate County Nursing Association. In sparsely populated areas it is necessary to combine the duties of district nurse and midwife, and in some districts the Nursing Associations also undertake health visiting. school nursing and other health services by arrangement with the County Councils. Eighty-three new Nursing Associations were started in England during 1927, while sixteen of the existing Associations ceased work. Eighteen District Nursing Associations, which had hitherto worked independently, became affiliated to the appropriate County Nursing Association. Eighty per cent. of the rural population of England are now provided with the per services of trained midwives. With a view to increasing the supply of trained midwives, 37 County Councils have, with the approval of the Minister, agreed to make contributions to the County Nursing Associations in respect of the provision of trained midwives for service in the respective counties. These contributions are of value in assisting the County Nursing Associations to secure and train a sufficient number of suitable women for the work of nurse-midwife. REGISTRATION OF STILL-BIRTHS. Under the Births and Deaths Registration Act, 1926, which came into force on the 1st July, 1927, the registration of stillbirths by the Registrars of Births and Deaths is required. The Act provides that, when a still-birth is registered, the relatives or other persons giving information must, if possible, deliver to the Registrar a written certificate that the child was not born alive, signed by a registered medical practitioner or certified midwife, who was in attendance at the birth or who had examined the body of the child. A circular (Circular 802) was issued to Local Supervising Authorities in June, 1927, requesting them to draw the attention of midwives practising in their area to the importance of giving to the relatives the prescribed certificate in every case in which they attend the still-birth, if no such certificate is being given by a registered medical practitioner. A further circular was issued to Maternity and Child Welfare Authorities drawing attention to the requirement in the Births and Deaths Registration Act, 1926, that where neither a registered medical practitioner nor a certified midwife has been in attendance or present at a still-birth, or where his or her certificate cannot be obtained, the relatives or other persons giving information must make a declaration to this effect and that the child was not born alive. It was suggested that, if any such cases are brought to the notice of the Local Authority by the Registrar. it would be desirable that the Medical Officer of Health should arrange for inquiries to be made, for example, by a Health Visitor, in order that he may be in a position to inform the Registrar whether he is satisfied that the child was really still-born, or whether there are any suspicious circumstances attaching to the case. FEES OF DOCTORS CALLED IN BY MIDWIVES. Section 14 of the Midwives Act, 1918, provides that in the case of any emergency, as defined in the rules of the Central Midwives Board, a midwife shall call in to her assistance a registered medical practitioner, and the Local Supervising Authority are required to pay to the practitioner a sufficient fee according to a scale fixed by the Minister. The Local Supervising Authority have power to recover the fee from the patient or her husband or other person liable to maintain the patient, unless it be shown to their satisfaction that the patient or her husband or such other person is unable by reason of poverty to pay the fee. Section 2 (3) of the Midwives and Maternity Homes Act, 1926, empowers a Local Supervising Authority, with the sanction of the Minister, to make arrangements whereby an expectant mother can, by the prior payment of such sum as may be agreed, insure against the liability for the payment of a doctor's fee under the provisions above referred to. Arrangements of this kind are now in operation in the Counties of Somerset and Southampton, and in the County Boroughs of Birmingham, Portsmouth, Southampton, West Hartlepool and Worcester. HOME NURSING. or Grant is payable in respect of arrangements made by Local Authorities, with the approval of the Department, for the home nursing of children under five years of age who are suffering from measles, whooping cough, gastro-enteritis, poliomyelitis ophthalmia neonatorum, and for maternity nursing and the nursing of cases of puerperal fever and puerperal pyrexia. 252 Local Authorities have now made such arrangements, 169 having con. tracted with District Nursing Associations for this service, while others employ their Health Visitors, and in a few large districts special nurses are provided. CENTRES. There were 2,431 Maternity and Child Welfare Centres known to the Department on the 31st March, 1928, an increase of 107 during the year. Of these 1,561 were conducted by Local Authorities and 870 by voluntary agencies. These Centres all receive grants from the Department either directly, or, in the case of some Centres carried on by voluntary agencies, indirectly through the Local Authority of the area served by the Centre. Arrangements for dental treatment at, or in connexion with, the Centres are now in operation in about 890 cases, and for ante-natal consultation in about 784 cases, in addition to 63 special Centres for ante-natal work only. The latter include an experimental antenatal clinic which has been organised by the Middlesex County 'Council at the Guildhall, Westminster. Monthly sessions are held at this clinic, to which difficult cases may be referred for specialist advice from any part of the county. Maternity and Child Welfare Centres are now general throughout the country in practically all considerable centres of popula tion. In some sparsely populated districts where it is impracticable to provide a Centre, arrangements have been made for the transport of mothers and children to and from a Centre established in an adjoining district. Experiments have been started in connexion with some Centres with the special object of advising the mothers in regard to the feeding of their babies, and in a few cases Observation Nurseries have been established for this purpose. ARTIFICIAL LIGHT TREATMENT. Reports have been received from the various institutions at which the installation of artificial light treatment has been approved, and useful data have been supplied with regard to the value of this form of treatment for various conditions in young children. The Minister is advised that this form of treatment must still be regarded as in the experimental stage, and that it is best provided at, or in connexion with, the light department of a hospital. In all cases in which approval has been given, the Department have first been satisfied that a medical officer with special experience of this form of treatment would be responsible, and that he would be assisted by a nurse who has received suitable training for the work. The number of artificial light installations in connexion with Maternity and Child Welfare approved up to the 31st March, 1928, was 101, of which 33 are provided at Maternity and Child Welfare Centres carried on by Local Authorities, 17 at Centres organised by voluntary agencies, and 51 at hospitals and other institutions. DAY NURSERIES. Day Nurseries make provision for the care and supervision of young children of mothers who are obliged to go out to daily work, and who are unable to make other suitable arrangements for the care of their children. Only children under five years of age are admitted to these Nurseries, and in most of the large Nurseries kindergarten teachers are employed. These institutions meet a definite need in some districts, and during the past few years several Nurseries have moved into better and more commodious premises, owing to an increasing demand for the facilities offered. In a few cases specially designed premises have been erected. The number of Day Nurseries is now 98, of which 79 are maintained by voluntary associations. One Day Nursery has been closed during the past year, and another has been converted into a Residential Nursery. |