Public health and insurance: American addresses

by Sir Arthur Newsholme

It will be noted that although there has been a marked decline of deaths from puerperal sepsis, the death-rate from other complications of childbearing has not declined. The decline in puerperal sepsis is general throughout the country, and evidences the greater care in midwifery both on the part of doctors and of midwives. The administration of the Midwives Act, 1902, has doubtless done much to secure this. The death-rate from conditions other than puerperal fever continues to differ greatly throughout the country. It is highest in Welsh counties, Westmoreland, Lancashire and Cheshire coming next in order of unfavourable portion; in many industrial, including textile, towns it is also excessive. The general conclusion reached by the writer in an elaborate official report on the subject is that “the quality and availability of skilled assistance before, during, and after childbirth are probably the most important factors in determining the remarkable and serious differences in respect of mortality from childbearing shown in the report.”—“The differences are caused in the main by differences in availability of skilled assistance when needed in pregnancy, and at and after childbirth.”

The Midwives Act, 1902

This Act forbade any woman after April 1, 1906, who was not certified under the Act, from using the title of midwife or any similar description of herself. It forbade after April 1, 1910, any such woman from “habitually and for gain attending women in childbirth, except under the direction of a qualified medical practitioner”; and it forbade any certified midwife to use an uncertified person as her substitute. The Act defined the limits of function of the midwife by stating that the Act did not confer upon her any title to give certificates of death or of still-birth, or to take charge of any abnormality or disease in connection with parturition.

The Act set up the Central Midwives Board, giving it special disciplinary powers over midwives. It also imposed on county councils and the councils of county boroughs the duty of supervising the work of midwives. For further details the Act itself and the Rules of the Central Midwives Board made under the Act should be consulted.

The Midwives Act, 1918, gave further powers to the Central Midwives Board and to local supervising authorities, and made it the duty of the latter to pay the fee of a doctor called in by a midwife in any of the emergencies for which Rules are made by the Central Midwives Board, the fee paid to be in accordance with a scale prescribed by the Ministry of Health.

As at least three-fourths of the total births in England and Wales are attended by midwives with or without the assistance of doctors, their work has great importance in relation to the reduction of maternal disablement and mortality and to the prevention of early infant mortality, and it is of happy augury that they are being enlisted more and more in official work for safeguarding the health of the mother and her unborn or recently delivered infant. An important recent addition has been made to the rules of the Central Midwives Board, which makes it obligatory on the midwife to notify to the medical officer of health any instance, while the patient is under her charge, in which for any reason breast-feeding has been discontinued.

Administrative Work.—Largely through the machinery provided by the Midwives Act and the Notification of Births Act a system of supervision of maternity and child welfare has been organized in every county and county borough, and this has been responsible for a large share of the improvement experienced in recent years. The character and extent of development of the work varies greatly in different centres; and as a rule the work is more fully developed in county boroughs than in counties. In county districts it has sometimes been found necessary to unite the offices of assistant inspector of midwives, infant visitor and tuberculosis visitor in one adequately trained health visitor, thus saving time in travelling by enabling the visitor to have a smaller district allotted to her than if she undertook only one branch of work. In some counties the school nurse’s work is also undertaken by the health visitor. In some country areas arrangements have been made for infant visiting to be carried out by district nurses who are also midwives.

Voluntary Workers.—Much of the success so far achieved in improving the health conditions of infancy and childhood has been secured by coöperation between voluntary and official health visitors. Excellent work has been done by local and other societies, particularly during the last ten years, in educating public opinion and in direct assistance to mothers and their infants. It is essential that such voluntary work should have a nucleus of highly trained and well-paid workers; but given this condition, a large amount of good work can be accomplished by voluntary aid.

The main work has been that of the health visitor. The details of this work, the conditions of qualification of workers, the number of visits which it is desirable to make, the character of the advice intended to be given at these visits are set out in an official memorandum of the Medical Officer of the Local Government Board and it is unnecessary to repeat this information in these pages.

A similar remark applies to the next most important development of work, the institution of Maternity and Child Welfare Centres. The conditions of work of these institutions are set out in the same document.