National Maternity Service Supplement to “The Socialist Doctor,” November, 1934.
THE need for a National Maternity Service is now generally admitted, and public opinion is ripe for the launching of such a scheme, but before discussing the details of a complete service it is as well to restate the grounds for the belief that this service is necessary and would be beneficial. There has not been the reduction in mortality and morbidity in Midwifery that has been achieved in other branches of Medicine and Surgery in the last twenty or thirty years. Although this applies generally certain Maternity Services in this country, and in some foreign countries, have obtained remarkably good results over the course of years. The Maternal Mortality rate for this country for the year 1931 was 5.55 per 1,000 births. Maternal risk is the fourth highest cause of death in this country, and the third highest in America. In Denmark and Sweden the official maternal death rates for the five years 1925-29 averaged 2.74 and 3.12 respectively, compared with 4.21 for England and Wales.
Various factors influence the figures, and even in those countries wit,h a lower death rate than England and Wales there has been a slight upward movement in the last few years. In this country the Birth rate has fallen from 23.6 in 1911 to 15.8 in 1931, and this means that there are more first babies with their additional risks. While the average maternal death rate is that given above, there are some places in Great Britain where the rate is very much higher, particularly intensely industrialised areas with no co-ordinated service, such as Wlgan, Bolton, Rochdale, with rates respectively, of 10.3, 8.4, and 9.26.
These figures must be contrasted with those of certain services in the poorer parts of London. The Queen’s Institute Nurses, up to 1928, had dealt with 65,000 cases, with a death rate of 1.9 per 1,000. The East End Lying-in Hospital, from 1921 to 1928, had 17,000 cases with the amazing rate of 0.68, while, from 1910 to 1929, the Plaistow Maternity Hospital had 87,700 cases, with the low death rate of 0.77 per 1,000 births. It must be emphasised that these schemes were all dealing with people in the poorest circumstances, and most of the births took place in the patient’s homes.
A careful study of the factors behind these seemingly contradictory facts has been made by the Departmental Committee on Maternal Mortality and Morbidity, and the results are instructive. A full investigation of 5,000 deaths showed that no less than 45.9 per cent, revealed a primary avoidable factor. It is of importance to note that of these cases, 59 per cent, of those dying of Sepis and 73 per cent, of those dying of Eclampsia had a primary avoidable factor. Of the total deaths, 37.1 per cent, were from Sepsis and 11.6 per cent, from Eclampsia. There can be no question that these were wasted lives, for which our present system, or lack of system, must answer.
The Departmental Committee Report not only shows the cause of death, but it also points out (page 23) where the responsibility for that death lies. It groups the source of error into four groups and gives the relative degree of blame.
- Lack of, or Failure of, Ante-Natal Care 15.3%
- Error of Judgment 19.1%
- Lack of Facilities. 3.7 %
- Negligence on the Part of the Patient 7.7%
In seeking the ideal scheme one must aim at eliminating each of the four groups of avoidable factors detailed in the Report. The scheme must be elastic enough to be modified to meet the geographical and sociological needs of the area, economical in that every penny of public money is used to the fullest and best advantage and secure enough to attract to it workers of the highest standing. Individual schemes which at present show a low maternal death rate can be said very largely to satisfy these canons, but they operate over restricted areas in which co-operation between all concerned is easy. Our present system of private practice and private competition, to which is added a certain number of municipal and some voluntary services, is haphazard, dangerous, costly, and is a relic of the past.
Midwifery services must be organised as a complete unit, and the following is an attempt to formulate such a scheme. It must be a public service, publicly financed. It must be linked with a general improvement in the standard of living of the people, particularly in the important matters of housing and nutrition. It must be associated with careful educational propaganda, not only of the patients and their friends, but also of the medical and nursing professions.
Administration of the scheme should be in the hands of the County Council, but the detailed work of supervision of cases, and certainly the home visiting side of the work, should be delegated to the smaller sanitary authorities. The scheme should be supervised nationally by the Ministry of Health, and one must ultimately visualise a change in the organisation of the unit to that of the complete Health Unit outlined in ” A Socialised Medical Service.” There is clearly need for associating the domiciliary with the hospital services, and this is not always possible at present. It is desirable that the maternity and child welfare work should be closely associated with the general medical services, and placed under the control of the Medical Officer of Health.
THE SUPERVISING SERVICES.
The basis of the supervisory service of a national maternity scheme is tftie ante-natal clinic, and the extent to which this is used will be a measure of the success of the service as a whole. In urban areas the clinic should be in easily accessible places. Long journeys must be avoided for the sake of the mother and for the popularity of the clinic. Large clinics must not be allowed, and undue waiting must be prevented,. This can be done partly by a better system of making appointments, and by limiting the numbers seen at each session. At present with clinics of fifty to sixty patients, it-is not unusual for women to be kept waiting as long as four hours. It is rarely possible for a practitioner to see more than twenty cases in a session of two hours, and there should be a limit of eight to ten new cases in each group of twenty cases. It must be stressed that the ante-natal clinics are primarily for diagnosis and supervision. Patients requiring treatment should be referred elsewhere, and similarly the clinics should not be held at a hospital where patients with active disease congregate. When disease is diagnosed or suspected the case must be readily referable to a hospital or centre equipped for dealing with every type of disease. Treatment should be carried out by the hospital or by the home doctor. Even cases booked to have their confinements in hospital should normally attend the local supervising clinic so that they may be saved the journeying and waiting on frequent occasions. They should be seen, however, at least twice, e.g., at the twentieth and thirty-sixth -week at the hospital clinic, and at any time any abnormality develops.
It will be seen from this that in reality two types of clinic are necessary. The first is the Ante-Natal Supervisory Clinic, for new cases and all cases not requiring more than ordinary supervision. The second is the Consultative Clinic, at which cases referred from the first can be completely investigated.
It is of the utmost importance that the doctor in charge of the Supervisory Clinic should be widely experienced in obstetrics and gynaecology, and in active practice in those branches. We must condemn the common practice of local authorities appointing Assistant Medical Officers of Health to carry out .many duties of different types, and among them the important and specialised work of obstetrical diagnosis. It is probably this practice that has resulted in the disappointing achievements of the ante-natal care in some parts of the country, and must be a factor in the first group of’avoidable factors mentioned above. In Denmark, it may be noted, all practitioners must have done specialised post-graduate training before they can practice midwifery.
It is not essential, and it is indeed impracticable, that the Clinician in charge of the Supervisory Clinic should be on call for emergencies, but it is highly important that there should be close co-operation between those responsible for the confinement and the clinic. All abnormalities, as already mentioned, should at once be reported to the hospital or the home doctor booked for the confinement. The consultative clinic should be used for all abnormal cases, and for those in which a second opinion is desired.
The staffing of the clinics should be by Health Visitors holding the C.M.B., and their duties should include following up the cases to make sure that instructions are being carried out. The Health Visitors and the Midwives will be part of the same service, working under comparable conditions, and it is certain that they will therefore work in better and closer co-operation than is sometimes the case at present. The Midwives in the area should have, of course, the right to attend the clinics with cases, and should have access to all the records of their patients. These records, in addition to the usual observations on the pregnancy, should contain details of the home conditions, history of the previous pregnancies, past illness, and general health. The importance of the home conditions is discussed in the next section of this report.
In addition to a reorganisation of ante-natal clinics, it is necessary to set up Post-natal Clinics, which should, as far as possible, be, the same as, or conducted by the same clinician as the ante-natal clinic. Every mother should be encouraged, to return to the Supervisory Clinic which she attended. At the clinic she should be treated as a new case, and any abnormality arising as a result of the pregnancy should be dealt with immediately.
THE DOMICILIARY SERVICE
In quoting figures from maternity schemes already in existence, we indicated that even in districts where conditions were of the very lowest standard, the results were much above the average for the country as a whole. These results were obtained with cases having their confinements in their own homes The ideal place for a mother to bear her child is in her own home, provided that that home is in a well-built and sanitary house, suitably equipped, free from infectious disease and in touch with emergency assistance in case the unexpected happens. Such a home should provide a separate room for the mother, and the room must be well-lit well-aired, sufficiently heated, and reasonably quiet.
It will be the duty of the Health Visitors attached to the Supervisory Clinic to report on the suitability of each house, and allowance must be made for the possibility tha’t the condition of the house may be capable of adjustment. Where that is impossible, and the house cannot be considered to conform to the above criteria, the Health Visitor will report the case as one requiring to be confined in hospital.
In general normal cases should be dealt with by midwives as in the schemes alreadv quoted They should be on a full-time basis, working in a team within the area prescribed, and under the Medical Officer of Health. As a team they will have more time to give to each case and more off-duty time. Their training, conditions of service, and accommodation will require to be on a better scale than at present obtains. Salary, holidays, study, leave, pensions, housing, telephone, and transport are all urgently needing improvement and stabilisation. These conditions can only come with a unified service. Ultimately, whoever deals with the delivery of children should be a full-time officer of the State, and engaged in no other practice.
As general conditions of service will be so much improved, the salary of midwives need not be much more than the best schemes of to-day, giving some £250 non-resident, or its equivalent. Taking a unit of about 60,000 of a population each midwife will do about 120 cases per annum, and a team of approximately eight midwives with a supervisor, will be found to be a suitable unit for such a population. In close co-operation, and so far as deciding on questions of suitability’of homes and need for help in the home senior to the midwives, there will be required a team of Health Visitors, and a similar number will be needed. In this connection the question will be asked as to whether, being whole-time officers the midwives should be housed in some type of hostel, probably part ot the separate nurses’ home necessary for the maternity hospital or whether, being of senior and responsible rank, they should be allowed to live at home. It is obvious that midwives must live in close touch with the maternity centre in view of the possibility of urgent calls. It is further to be remembered that midwives suffer from great irregularity of hours, and it is suggested that they may tend to neglect their diet and general health if left to look after themselves. It is felt, therefore that the ideal would be to have all those engaged in the maternity service housed in a well-arranged hostel. Hostel life, however, does not satisfy in every respect and it must therefore be allowed that no objection could be raised to midwives living in their own homes, provided they possess adequate domestic arrangements, live within their own areas, and have suitable travel facilities and the telephone.
No Maternity service could be complete that did not adequately provide for domestic assistance in the homes of mothers at any period of the pregnancy at which it was considered desirable. This implies that each area will need a panel of Home Helps who must be carefully chosen, as there is a prejudice against “outsiders” amongst the working class. The Health Visitor will be expected to advise as to the need for help in any particular case, and at any time other than the actual puerperium. It must also be noted that home helps are needed whether the mother is delivered in hospital or at home.
Assistance is also needed in the matter of dressings and other equipment. The operating Authority, must be responsible for providing all that is necessary, including a sterilised outfit.
Apart from the sending into hospital of those cases diagnosed as abnormal bv the supervising clinic, provision must be made for abnormalities, of all degrees, arising in the course of delivery. This will necessitate the formation of a panel of medical practitioners by the Medical Officer of Health. This panel should be made up from the practitioners of the area—later, the Home Doctors of the Socialised ‘Medical Service—and should be used for minor emergencies. It should consist of those who have had post-graduate training in pbstetrics, and who are willing to serve. The doctors should be directly responsible to the M.O.H. In similar fashion a panel of anaesthetists should be made, and anaesthetics should be freely provided. There will also be required in each area obstetrical specialists, capable of handling major emergencies, at least two in the visualised area. They should be on immediate call, and should be associated with the local maternity hospital.
THE MATERNITY HOSPITAL
We have given the opinion that the idsal place for a mother to have her babies is her own home, provided that home is up to a suitable standard. There will be very many, until we have radically altered the’whole housing position, who will on this ground require hospitalisation, and there are a variety of other cases which also cannot be dealt with at home. It will, therefore, be necessary to provide enough maternity hospitals to deal with all these cases.
All cases of diagnosed abnormality and all cases of previous difficulty should be admitted to hospital so that they can be adequately dealt with. Cases suffering from concurrent disease and all who have members of. their household suffering from some grave disease should have their confinement in hospital. Provision must also be made for primigravida in particular, and all others who express a desire to enter hospital.
We have in the above paragraphs spoken of the maternity hospital as though it were a separate unit, but actually it must be a part of a general hospital, and should not be greater than fifty or sixty beds. It should be made up of small wards, six or eight beds at most for normal cases. Single-bedded observation wards will be necessary, and should be used for all cases delivered before admission, for emergency cases, for suspect, and all pre-natal cases. None of these cases should be nursed in a general surgical or gynaecological ward. The labour wards should also be single-bedded, and should be away from the lying-in wards.
When planning new maternity blocks consideration will need to be given to the housing of the nurses. While it is advantageous to have the maternity hospital a block of a general hospital, it is probably advisable to have an entirely separate home for the nursing staff away from the staff of the general hospital. In this connection our observations on the question of housing the midwives may be recalled.
It is recognised that all infected cases must be separated from the normal cases, and they should be nursed in isolation units quite apart from the general hospital and the maternity hospital. There should, therefore, be an isolation hospital which is a unit by itself, and which is used by a group of maternity hospitals.
The staffing of the maternity hospitals will, of course, require to be of the highest standing. Part of the staff will be in charge of the Consultative Clinics already described. At these will be seen all the cases booked to come into the hospital, and all cases referred to them by the Supervisory Clinic for any of the reasons detailed above. There should be provision for a full exchange of histories between the local ante-natal clinic and the hospital before delivery, from the hospital to the clinic on discharge of the patient, and from the clinic to the hospital when the post-natal visit is made.
One of the causes, if not of maternal mortality, at least of much incapacity among mothers is the lack of adequate rest during and after confinement. Fourteen days should be the absolute minimum stay in hospital after confinement, and in considering the suitability of the home for confinement there the Health Visitor must consider whether, with a home help, at least that amount of rest can be secured for the mother. For two months before and six weeks after confinement the mother cannot be considered to-be fit to carry out her normal duties, whether in her home or in industry. During this period full pay and home help, full or part-time, must be provided when necessary. In addition, convalescent homes should be available for both mothers and babies.
In conclusion, we must again refer to the absolute necessity for every mother to receive adequate ante-natal attention There does not seem to be any possible method of compulsory notification of pregnancy, but the maternity service will not be a success until every mother has made a full attendance at the ante-natal clinic. To this end there should be continuous propaganda by the local authorities.
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