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The midwives acts and the rules of the central midwives board
P U B L I C HEA12TH.
~9'3.
SOCIETY OF MEDICAL OFFICERS H EALTH.
OF
COUNCIL MEETING. A meeting of the Council was held at the School of Art, Hull, on Tuesday, July 3tst, 1923. In the unavoidable absence of the President, Dr. Charles Porter was voted to the chair, and there were also present: Drs. Jolly, Stlrk, Joseph, Veitch Clark, Pearce, Kerr, Bertram Hill, Stocks, Cates, Barlow, Prof. H. R. Kenwood, and Lt.-Col. F. E. Fremantle, M.P. Apologies for absence were received from Dr. A. B. MeMaster, Dr. J. T; C. Nash, Dr. T. W. H. Garstang, Dr. Peyton, and Dr. YVheatley. The minutes of the last meeting, as published in " P'ublic Health " (May, 1923, p. 226) were approved and adopted. Correspondence.--(1) From the Ministry of Health acknowledging the letter from the Society dated April 23rd, 1923, in reference to public health p r o p a g a n d a (see " Public H e a l t h , " May, 1923, p. 227), and asking for detailed suggestions. Resolved that the letter be referred to a Special Committee (Dr. James Wheatley, Chairman, Dr. T. ~¥. N. Barlow, Dr. G. "~V. N. Joseph, and Dr. Veitch Clark), with a request to report at the September meeting of the Council. (2) From the Insurance Comnfittee of the County of London in reference to expenditure on health propaganda. Resolved: That this letter also be referred to Dr. \ ~ h e a t l e y ' s committee. (3) F r o m the Association of County Medical Officers of Health referring to a proposal to suspend the medical examination of school children in the intermediate age-group. It was agreed to postpone consideration of this letter until the September meeting of the Council. (4) From the County Palatine of Chester Local Medicat and Panel Committee enclosing a resolution in reference to the certification of mentally deficlent'cases. The Executive Secretary was instructed to circulate the resolution with the agenda of the September meeting of the Council. Representation of the Society.~Dr. G. A. Auden was re-elected as representative of the Society on the Council of the Central Association for Mental Welfare for the period ending June, 1924. Administration of the Midwives A c t s . ~ D r . Cates submitted the report of the Special Committee appointed to consider the working of the Midwives Acts and the Rules of the Central Midwives Boards.
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After discussion and minor amendments the report was approved and adopted. (The report will be found below.) It was Resolved: That copies of the report be forwarded to the Ministry of Health, the CenlrM Midwives Board, the College of Nursing, the Jubilee Institute of Nursing, and the M. and C.¥V. Group of the Society. On the proposal of Dr. Kerr, seconded by Dr. Pearce, a cordial vote of thanks was passed to Dr. Cates (Chairman) and the members of the special committee responsible for the report. Relation of the County M.O.H. to the District M . O . H . - - A r i s i n g out of the discussion on the above report, it was resolved: That the whole subject of the relation of the County M.O.H. t o the District M.O.H. be considered by the Society during the coming session. Disciplinary.--Several members having reported a strong feeling in the Branches in reference to a recent appointment in a metropolitan borough, where a Fellow of the Society had not been willing to co-operate with the Salaries Committee when asked to confer with them before accepting the post, it was resolved unanimously that the member in question be called upon to justify his action before the Council, in accordance with Article iI. of the Society's Articles of Association. The Council then adjourned.
S O C I E T Y OF M E D I C A L O F F I C E R S OF HEALTH. T I l E M I D W I V E S ACTS A N D T H E R U L E S OF T H E C E N T R A L M I D W I V E S BOARD. Report of the Special Committee appointed by the Council on December t5th, 1922. Reference.--" To report on the whole working of the Midwives Acts and the Rules of the Central Midwives Board." The Committee was constituted as follows : Dr. T. Eustace Hill, O.B.E., the President, Dr. T. YV. Naylor Barlow, O.B.E., Dr. Joseph Cates, Dr. J. M. Clements, Dr. R. A. Lyster; Dr. C. E. S. Flemming and Dr. J . W. Bone (nominated by the British Medical Association). The Committee elected Dr, Cates as their Chairman, mad have held five meetings. At the first it was decided to invite suggestions from Branches and Groups of the Society, from the Association of County Medical Officers of ttealth and from the British Medical Association,
344
PUBLIC
A f t e r d e t a i l e d c o n s i d e r a t i o n of t h e A c t s , t h e Committee recommend that the following amendm e n t s s h o u l d be a d v o c a t e d b y t h e S o c i e t y a n d f o r w a r d e d t o the B r i t i s h M e d i c a l A s s o c i a t i o n , the R o y a l S a n i t a r y I n s t i t u t e , and to the G o v e r n m e n t Departments concerned. M i d w i v e s Act, 1 9 0 2 . - - 1 . - - ( 1 ) It h a s been r e p r e s e n t e d to t h e C o m m i t t e e t h a t in c e r t a i n areas men without a medical qualification h a b i t u a l l y a c t as m i d w i v e s . This does not a p p e a r to h a v e b e e n c o n t e m p l a t e d by t h e A c t . S u c h p e r s o n s a r e u n d e r n o s u p e r v i s i o n o r con.trol, a n d t h e C o m m i t t e e t h e r e f o r e a d v i s e t h a t in S e c t i o n 18 a definition be a d d e d in t h e f o l l o w i n g terms :-" The word ' woman ' shall include a person of either sex who is not a legally qualified medical practitioner." 1 . - - ( 2 ) T h e r e is o v e r w h e l m i n g e v i d e n c e t h a t p r o c e e d i n g s a g a i n s t h a n @ - w o m e n a r e n o t likely to be s u c c e s s f u l until t h e r e is a m a t e r i a l a m e n d merit of this S u b - S e c t i o n of the A c t . I t is u n d e r stood that the Central Midwives Board would welcome more stringent drafting. The SubS e c t i o n at p r e s e n t r e a d s a s f o l l o w s : - " From and after the first day of April, one thousand nine hundred and ten, no woman shall habitually and for gain attend women in childbirth otherwise than under the direction of a qualified medical practitioner unless she be certified under this Act ; any woman so acting without being certified under this Act shall be liable on sununary conviction to a fine not exceeding ten pounds, provided this section shaIl not apply to legally qualified medical practitioners, or to anyone rendering assistance in a case of emergency." The Committee recommend that the SubS e c t i o n s h o u l d be a m e n d e d , t h u s : - (a) " From and after the first day of January, one thousand nine hundred and twenty-four no woman shall attend women in childbirth otherwise than under the immediate personal supervision of a qualified medical practiti'oner in attendance at the labour, unless she be certified under this Act; any woman so acting without being certified under this Act shall be liable on summary conviction to a fine not exceeding ten pounds, provided this section shall not apply to legally qualified medical practitioners, or to any one rendering assistance in a case of emergency. (b) " Any unqualified person rendering emergency assistance to a woman in childbirth, shall, as soon as she becomes aware of the emergency, immediately summon the assistance of a qualified medical practitioner or a midwife. (e) " Any woman failing to summon assistance under Sub-Section I (2) (b) shall be liable on summary conviction to a fine not exceeding five pounds." 10. ] ' h e C o m m i t t e e a r e c o n v i n c e d t h a t a m i d w i f e w h o a c t s o n l y as a m o n t h l y n u r s e , s h o u l d n o t e s c a p e s u p e r v i s i o n u n d e r t h e R u l e s of t h e C e n t r a l M i d w i v e s B o a r d , a n d s h o u l d be r e q u i r e d to n o t i f y the L o c a l S u p e r v i s i n g A u t h o r i t y of b e t
HJgALTH.
SEPT~MBE~t,
i n t e n t i o n to p r a c t i c e in t h e c a p a c i t y of a m o n t h l y nurse. M i d w i v e s A c t , 1918. 6 . - - ( 2 ) T h e C o m m i t t e e a r e satisfied t h a t m i d w i v e s , at t i m e s , suffer serious financial loss w i t h out r e d r e s s , w h e n s u s p e n d e d f r o m p r a c t i c e in o r d e r to a v o i d t h e c o n v e y a n c e of infection. It is t h e r e f o r e r e c o m m e n d e d t h a t this S u b - S e c t i o n should read :-" Wherein pursuance of any power conferred by any such rule a midwife has been suspended from practice pending the decision of her case by a court or the Board and the case is decided in her favour, or where in pursuance of the duty imposed by paragraph (3) of section eight of the principal Act a midwife has been suspended from practice in order to prevent the spread of infection, tile Central Midwives' Board or the Local Supervising Authority by whom she was suspended shall pay her such reasonable compensation for loss of practice as under the circumstances may seem just, subject to appeal by either party to the Ministry of Health." i2.--The Committee gave prolonged consideration to t h e p o s i t i o n w h i c h has a r i s e n f r o m t h e o p e r a t i o n of this S e c t i o n , w h i c h a m e n d e d S e c t i o n 9 of t h e A c t of 1902. T h e l a t t e r e n a b l e d C o u n t y C o u n c i l s to d e l e g a t e t h e i r p o w e r s a n d d u t i e s to District Councils, and representations were made to t h e C o m m i t t e e t h a t S e c t i o n 12 of t h e A c t of i918 r e p e a l i n g S e c t i o n 9 of t h e 1902 A c t o c c a s i o n e d difficulties in t h e w o r k i n g of i n f a n t w e l f a r e s c h e m e s in c e r t a i n a r e a s . After taking t h e s e c o n s i d e r a t i o n s i n t o full a c c o u n t , a n d w e i g h i n g c a r e f u l l y t h e v i e w s e x p r e s s e d in t h e t w o m e m o r a n d a on t h e s u b j e c t a t t a c h e d t o this r e p o r t , t h e C o m m i t t e e felt t h e y c o u l d n o t i g n o r e t h e e x p r e s s e d p u r p o s e of t h e A c t s , w h i c h is " to s e c u r e the b e t t e r t r a i n i n g of m i d w i v e s a n d to r e g u l a t e their p r a c t i c e . " The Committee therefore, with one d i s s e n t i e n t , . d e c i d e d t h a t n o c h a n g e s h o u l d be r e c o m r n e n d e d in t h i s S e c t i o n . 1 4 . - - ( 2 ) I n v i e w of m i s u n d e r s t a n d i n g s t h a t a r i s e in m a n y a r e a s t h r o u g h d e l a y by m e d i c a l p r a c t i t i o n e r s in r e n d e r i n g t h e i r a c c o u n t s u n d e r this St~b-Section, a n d t h e c o n s e q u e n t difficulty which the Local Supervising Authority may exp e r i e n c e in a t t e m p t i n g to r e c o v e r t h e fees, the Committee recommend that there should be a f u r t h e r c o n d i t i o n in t h i s S u b - S e c t i o n r e q u i r i n g m e d i c a l p r a c t i t i o n e r s to a p p l y f o r t h e i r f e e s w i t h i n o n e m o n t h f r o m t h e r e c e i p t of a n o t i c e from the Local Supervising Authority. RULES OF THE CENTRAL MIDWIVES BOARD. C.--The Committee considered the regulations r e l a t i n g t o t h e t r a i n i n g of p e r s o n s a d m i t t e d to examination. T h e y a r e of t h e o p i n i o n t h a t t h e t i m e is a p p r o a c h i n g w h e n t h e r e s h o u l d b e a u n i f o r m s t a n d a r d of t r a i n i n g f o r n u r s e s .
I923.
PUBLIC HEALTH.
T h e n e e d f o r m i d w i v e s is n o w n o t s u f f i c i e n t l y urgent to be an adequate excuse for the admiss i o n t o t h e e x a m i n a t i o n of w o m e n w h o h a v e undergone partial nursing training. The obligat i o n s a n d r e s p o n s i b i l i t i e s of m i d w i v e s w h o a r e t o be entrusted with the care of women before, during and after labour call for a high standard of g e n e r a l e d u c a t i o n a n d a p r o l o n g e d p e r i o d o f hospital work. Your Committee, therefore, r e c o m m e n d t h a t o n a n d a f t e r a d a t e t o b e fixed, and they suggest that 7 years from the next o c c a s i o n o n w h i c h t h e R u l e s of t h e C e n t r a l M i d wives' Board are amended would be a reasonable period, notice should be given that no woman will b e a d m i t t e d t o t h e e x a m i n a t i o n u n l e s s s h e produces I. E v i d e n c e of r e g i s t r a t i o n b y t h e G e n e r a l N u r s i n g C o u n c i l , e x c e p t in t h e c a s e o f " existing nurses," or 2. T h e c e r t i f i c a t e s i n d i c a t e d in S e c t i o n C . 2 (a), (b), (c) a n d (d). Until the suggested change comes into force t h e C o m m i t t e e r e c o m m e n d t h a t t h e p e r i o d of s i x m o n t h s m e n t i o n e d in C.1 (1) s h o u l d b e e x t e n d e d t o o n e y e a r , a n d t h e p e r i o d of f o u r m o n t h s in C. 1 (2) s h o u l d b e e x t e n d e d t o six m o n t h s . D.--The Committee reviewed the Rules of Procedure followed by the Board on the removal o f a n a m e f r o m t h e roll a n d t h e y c o n s i d e r e d t h e evidence placed before them. The Committee a r e of o p i n i o n th~/t t h e C e n t r a l M i d w i v e s ' B o a r d s h o u l d a c t in a j u d i c i a l c a p a c i t y o n l y mad n o t a s both prosecutor and judge. \aThile it is p o s s i b l e t h a t t h e R u l e s g o v e r n i n g t h e p r o c e d u r e in p e n a l c a s e s w e r e d r a f t e d o n t h e lines followed by the General Medical Council, the Committee were aware that the latter body is, i n f a c t , r e l u c t a n t i t s e l f t o p r o s e c u t e , a n d i t a p p e a r s t o t h e ~C o m m i t t e e t h a t t h e p r i n c i p l e o f a single body acting as both prosecutor and judge is r e p u g n a n t t o t h e g e n e r a l p r i n c i p l e s of t h e l a w of t h e l a n d . The Committee, therefore, recommend that the Local Supervising Authority s h o u l d a c t a s p r o s e c u t o r in p e n a l c a s e s a n d t h a t suitable arrangements should be made for holdi n g i n q u i r i e s in p e n a l c a s e s in t h e p r o v i n c e s . F r o m e v i d e n c e s u p p l i e d t o t h e C o m m i t t e e it seemed that the Central Midwives' Board was a t a d i s a d v a n t a g e in h a v i n g n o p o w e r t o s u b p o e n a witnesses or to require evidence on oath, and the Committee recommend that steps should be taken to remove this disadvantage as soon as practicable. E.--XVith regard to the Rules Regulating, S u p e r v i s i n g a n d R e s t r i c t i n g t h e P r a c t i c e of M i d -
345
wives, your Committee recommend tions and amendments following:-Section as at present drafted.
the altera-
Recommendation.
5. All instruments and other appliances nmst be disinfected, preferably by boiling, before being brought into contact with the patient's generative organs.
5. Omit the word "preferably." Add the words: " unless otherwise allowed by the Local Supervising Authority."
7. A midwife in charge of a case of labour must not leave the patient without giving an address by which she can be found without delay ; and, after the commencement of the Second Stage, she must stay with the woman until the expulsion of the platenta and membranes, and as long after as may be necessary. tn cases where a doctor has been sent for on account of the labour being abnormal or of there being threatened danger (see Rule 20), she must await his arrival and faithfully carry out his instructions, If for any reason the services of a registered medical practitioner be not available, the midwife must, if tile case be one of emergency, remain with the patient and do her best for her until the enmrgency is over. After having complied with the Rule as to the summoning of medical assistance, the midwife wilt not incur any legal liability by remaining on duty and doing her best for the patient;
7. A midwife in charge of a case of labour must not leave the patient without giving an address by which she can be found without delay; and, after the cornmencement of the Second Stage, she must stay with the woman until at least one hour after the expulsi0n of the placenta and membranes and for such further period as may be necessary. In cases where a doctor has been sent for on account of the labour being abnormal or of there being threatened danger (see Rule 20) she must await his arrival and faithfully carry out his instructions. If for any reason the setvices of a registered medical practitioner be not available, the midwife must, if the case be one of emergency, remain with the patient and do her best for her until the emergency is over. After having complied with the Rule as to the summoning of medical assistance, the midwife wilt not incur any legal liability by remaining on duty and doing her best for the patient.
8. Tile midwife must wash the patient's external parts with soap and water, and then swab them with an efficient antiseptic solution on the following occasions . . . . . (c) During the lying-in period, when wasNng is required . . . . .
8. Amend to read : " The Midwife must wash the patient's external genital parts . . . . " (c) Amend to read : " Daily during the lying-in period . . . . . ''
11. The midwife must remove soiled linen . . . . .
11. The midwife must remove all soiled l i n e n . . .
PUBLIC
346 12. The midwife shall be responsible for the cleanliness, and shall give all necessary directions for securing the comfort and proper dieting of the mother and child during tim lyingin period which shall be held, for the purpose of these regulations, and in a normal case, to mean the time occupied by the labour and a period of ten days thereafter. . . . .
12. The midwife shall be personally responsible for the dally washing of the mother and the infant, the dressing of the umbilicus and any other necessary attention, and shall give all necessary directions for securing the comfort and proper dieting of the mother and child during the lyingin period which shall be held, for the purpose of these regulations, and in a normal case, to mean the time occupied by the labour and a period of ten days thereafter . . . . Add--The midwife shall be held responsible during the wlmle of the lying-in period for all confinements which she personally conducted.
14. The midwife shall take and record the pulse and temperature of the patient at each visit, entering her records, with dates and times, in a notebook or on charts, which nmst he carefully preserved.
t,~.~Add-- The midwife shall visit her patient 1. Within 15 hours of delivery. 2. Daily during the first week after labour. If prevented from so doing she shall enter the reason in her register.
19. A midwife must note in her Register of Cases each occasion on which she is under the necessity of administering or applying in any way any drug other than a simple aperient, the name and dose of the drug and the time and cause o f its administration or application. (See Rule 24, Note.)
19. Add --- No midwife shall administer to a patient any anmsthetic or any drug other than a simple aperient, or after the completion of the third stage of labour ergot, except under the supervision or on the written authority of a qualified medical practitioner, No midwife shall use forceps.
20. In all cases of illness of the patient or child, or of any abnormality occurring during pregnancy, labour, or lying-in, a midwife, as soon as she becomes aware thereof, must call in to her assistance • . •
20 . . . . . must forthwith call in to her assistance . . . . There should be a foot note to E. 20 stating that when medical help is required the midwife shall summon the usual medical attendant of the patient unless the patient otherwise desires.
21. PREGNANCY, (2) In the case of a PREGNANT woman, when there is any abnormality or complication, such as : Deformity or stunted growth.
21. (9) Add--Persistent headache. Dimness of vision. Illness or abnormality or stillbirth in a previous pregnancy.
HEALTH.
~ EPTE M.P.,E~,
Loss of blood. Abortion or threatened abortion. ExcesMve sickness. Puffiness of hands or face. Fits or convulsions. Dangerous varicose veins. Purulent discharge. Sores of the genitals. LABOUR. O) . . . . in cases of serious rupture of the perinaeum . . . . LYING-IN. (4) . . . . Rise of temperature above 100.z~OF. with quickening of the pulse, for more than twenty-four hours. THE CHILD. (5) . . . . .
22. (b) Deaths--In aI1 cases in which the death of tile mother or of the child occurs before the attendance of a registered medical practitioner,
(Signed)
(3) Omit - Serious. ~
the
word
(4) Omit the words "with quickening of the pulse, for more than twenty-four ho~.trs. ~
(5) Add the words " premature birth endangering the child's life." 22. (b) Omit the words " before the attendance of a registered medical practitioner."
JOSEPH CATES, T . EUSTACE HILL, T. W . N . BARLOW, J. M. CLEMENTS, R. A. LYSTER, CHAS. E . S. FLEMMING, JOHN *vV. BONE.
DELEGATION OF DUTIES. MEMORANDUM BY DR. JOSEPH CATES. In practice d e l e g a t i o n has not b e e n f o u n d to be a success.
In
most
cases
councils have subse-
q u e n t l y r e v o k e d StlCh p o w e r s a s t h e y h a v e d e l e gated. In the few cases where delegated powers have not been revoked, the delegation has been f o u n d to o p e r a t e d e t r i m e n t a l l y to the p u r p o s e s of the M i d w i v e s A c t s a n d to i n t r o d u c e an e l e m e n t of c o n f u s i o n a n d u n c e r t a i n t y in t h e i r a d m i n i s t r a t i o n . The evidence given to the Midwives Act Comm i t t e e in 1909 w a s c o n c l u s i v e o n t h i s p o i n t , a n d it was then stated that delegation was an unmitig a t e d evil. T h e A c t s c a n b e a d m i n i s t e r e d in c o u n t i e s a n d county boroughs with greater
uniformity,
inde-
p e n d e n c e a n d efficiency t h a n is p o s s i b l e in t h e c a s e of s m a l l e r a r e a s . U n i f o r m i t y o f a i m a n d p r a c t i c e is u n r e a t i s a b l e u n d e r c o n d i t i o n s of e x t e n s i v e d e l e g a t i o n . In smaller a r e a s the a t t i t u d e and c o n d u c t of t h e a u t h o r i t i e s a r e m o r e likely p r e j u d i c i a l l y t o b e aff e c t e d b y local i n f l u e n c e s , j e a l o u s i e s a n d p r e j u d i c e s t h a n in c o u n t i e s .
x9=3.
PUBLIC HEALTH.
The more numerous are the authorities administering the Acts, the greater will be the resulting variety of standards of practice and methods of efficiency and the greater the amount of overlapping. The difficulties of supply distribution and training of midwives are enormously augmented by a multiplicity of authorities. The more extensive the area of administration (within reasonable limits) the wider is the experience gained by the inspector and the higher is the rate of pay she can command. The better the remuneration offered the better qualified by education, training and experience are the candidates for vacancies. An improvement in the social and educational status of the inspector may reasonably be expected to be followed by a like improvement in the general status of the midwife who comes under her influence. In counties maternity work is often done by district nurses, who are usually supervised by a superintendent of the Nursing Association ; in the event of delegations being effected over-lapping of supervision would ensue. JOSEPH CATES. DELEGATION OF DUTIES. MEMORANDUMBY DR. J. M. eLEMENTS. I have been asked to give some reasons why the Authority which administers the Maternity and Child Welfare Act in any area should be the Local Supervising Authority for Midwives in that area. In this connection it is necessary to bear in mind that the Maternity and Child Welfare Authority has statutory power to make provisions for the care of expectant mothers and infants, to organise and administer Welfare schemes which include such agencies as Infant Welfare Centres, Lyingin Homes, the provision of Home Helps, the giving of free food in necessitous eases, etc. It is their duty to see that there is an adequate supply of midwives to meet the needs of their area, and they have power to supplement this by establishing a Maternity Home, if necessary. The Authority is concerned with all influences which affect injuriously the health of mothers and children, in the case of the former more particularly during the period of pregnancy, lying-in, and lactation, and in the case of the latter from birth to age five. The r61e of the midwife is a very important one in any scheme of Maternity and Child Welfare. Her services are required at a critical time in the life of the mother and the infant, and have farreaching effects on the health of both of them.
347
If she is a good midwife and knows her work she may at times, by acting promptly, save the life of a mother or baby. O n the other hand, failure on her part to reallse the actual conditions with which she is dealing, and the need for medical assistance, or failure to take proper precautions against sepsis, may result in the loss of life or lead to impairment of the health of tile mortar or child. She is an essential and important part of any scheme for the welfare of mothers and infants. W h a t then is her proper relationship to the Authority which administers such a scheme? Should-she be subject to any supervision or control by the Authority? It has been decided by Act of Parliament that she shall be under supervision and control, and my object is to try and convince you, as nay experience has convinced me, that the proper Authority to exercise this supervision and control is the Authority which administers the Maternity and Child Welfare Act. So far as the County Boroughs are concerned, the question does not arise, as the County Borough is the Authority for both purposes. It is only in county areas which administer their own Maternity and Child Welfare Schemes that difficulty arises; here the County Council supervise and control the midwives and the Local Sanitary Authority or Authorities administer the Maternity and Child Welfare Scheme. Some of the reasons in support of my view are as follows : The Maternity and Child Welfare Authority is more intimately associated and concerned with the welfare of the mother and infant than any other. Through its officials it is brought into daily contact with the midwife and her work. By means of its maternity home, its welfare centre, and the home visiting of its health visitor, it is in a position to exercise a very close supervision and control over the midwives in its area. Compare thls with the supervision which can be given by a n Authority whose inspecting officials live 20 to 30 miles away, or even more, and who can only pay flying visits at considerable intervals for the purpose. If the same medical and nursing staff which carries out the work of the welfare centres were also responsible for supervising the midwives it would bring the latter into closer co-operation with the work of the centres and induce them to send expectant mothers to the Centre for advice. The notification of artificial feeding by the midwife to the supervising authority under Rule E. 12 A. is at present of little practical use unless the supervising authority also administers the Maternity and Child Welfare Centres.
348
PUBLIC HEALTh.
When one considers the large numbers of infant deaths that occur during the first week or ten days of life, or before the midwife ceases to attend, it emphasises the need of closer co-operation between the officials of the welfare centres and the midwives in their preventive work, both antenatal and post-natal, if the high mortality at this age is to be reduced. Such co-operation can be more easily arranged if there is only one Authority concerned. Instances have been brought to my notice of midwives who are actively hostile to the welfare centres and persuade mothers not to go there. Again, I have lmown midwives whose methods are not quite sound, some are too ready to advise the mother to give up breast-feeding if any little difficulty is experienced in the early days. Others are in the habit of giving the baby strong aperients like castor oil, with the result that the baby is brought to the Centre suffering from constipation and deranged digestion. Such irregularities as these can best be dealt with by having one and the same Authority administering the Maternity and Child Welfare A c t and Midwives Acts. Instances of other anomalies in the present arrangements can be given. Take, for example , that of a midwife who has a case of puerperal fever or gonorrheal ophthalmia in her practice. These cases have to be notified to the local Sanitary Authority, but the latter has no power to deal with the midwife if the occurrence of such is due to any default on her part. To put the matter concisely, the midwife is an essential part of any welfare scheme for expectant mothers, and if she is to be controlled or supervised by anyone then it should be by the authority which administers the scheme of which she is an integral part. J . M . eLEMENTS. REDUCTION IN INFANT MORTALITY. In order to stimulate public interest in the reduction of infant mortality the "Daily N e w s " is offering prizes to local authorities of not |ess population than 20,000. A prize of £25 is offered to the district which has secured in the year ending midsummer last the greatest reduction in the death-rate of boy babies under one year of age as compared with the previous 1~ months, and another prize of ~g25 for the lowest actual death rate among boy babies. The awards will be made upon the corrected figures furnished by the local medical officer of health, which must reach the " Daily News " office not later than October 1st, 1923.
SEPTEMBER, I923. CORRESPONDENCE.
The Editor does not accept responsibility for the opinions of correspondents. C O N T R O L OF I N F E C T I O U S D I S E A S E S .
From Dr. A. H. BURTON, M.O.H., Ilford. Dear S i r , - - I see in your August issue, page 305, that Dr. F. H. Thomson, North Eastern Hospital, M.A.B., is stated to have made the following remarks : - " It was not a problem that could very well be checked by the Medical Officer of 'Health, who as a general rule had no greater knowledge of infectious disease than the general practitioner." It would be interesting to know on what grounds Dr. Thomson makes such an ill-founded and sweeping assertion, or of whose work as Medical Officers of Health he has had experience to obtain such knowledge as to their capacity or suggested incapacity in the diagnosis of infectious disease. Surely it cannot be from the Metropolitan Medical Officers of Health, who I see have done Dr. Thomson the honour of electing him their President for the ensuing year. Has Dr. Thomson had any experience in the work of provincial Medical Officers of Health, who as a general rule have the supervision of an Isolation Hospital? As a matter of fact one of the great drawbacks which exists in Public Health work in the Metropolitan Area is the entire divorce which exists between the administration of the Isolation Hospitals by the Metropolitan Asylums Board and local health administration, as this precludes any control by the Medical Officers of Health in such matters as " return cases," the numbers of which I understand are not even now published by the M.A.B. If Dr. Thomson or any other Medical Superintendent of the Metropolitan Asylums Board could give Medical Officers of Health assurance that he could recognise without doubt a typical mild case of Scarlet Fever in its early stages, no doubt valuable assistance could be obtained, but l~ow many of these cases are placed in sidewards, even in the M.A.B. Institutions, until the Medical Superintendent sees whether or not they " peel " ? Yours faithfully, A. H. G. BURTON.
~9'3.
SOCIETY OF MEDICAL OFFICERS H EALTH.
OF
COUNCIL MEETING. A meeting of the Council was held at the School of Art, Hull, on Tuesday, July 3tst, 1923. In the unavoidable absence of the President, Dr. Charles Porter was voted to the chair, and there were also present: Drs. Jolly, Stlrk, Joseph, Veitch Clark, Pearce, Kerr, Bertram Hill, Stocks, Cates, Barlow, Prof. H. R. Kenwood, and Lt.-Col. F. E. Fremantle, M.P. Apologies for absence were received from Dr. A. B. MeMaster, Dr. J. T; C. Nash, Dr. T. W. H. Garstang, Dr. Peyton, and Dr. YVheatley. The minutes of the last meeting, as published in " P'ublic Health " (May, 1923, p. 226) were approved and adopted. Correspondence.--(1) From the Ministry of Health acknowledging the letter from the Society dated April 23rd, 1923, in reference to public health p r o p a g a n d a (see " Public H e a l t h , " May, 1923, p. 227), and asking for detailed suggestions. Resolved that the letter be referred to a Special Committee (Dr. James Wheatley, Chairman, Dr. T. ~¥. N. Barlow, Dr. G. "~V. N. Joseph, and Dr. Veitch Clark), with a request to report at the September meeting of the Council. (2) From the Insurance Comnfittee of the County of London in reference to expenditure on health propaganda. Resolved: That this letter also be referred to Dr. \ ~ h e a t l e y ' s committee. (3) F r o m the Association of County Medical Officers of Health referring to a proposal to suspend the medical examination of school children in the intermediate age-group. It was agreed to postpone consideration of this letter until the September meeting of the Council. (4) From the County Palatine of Chester Local Medicat and Panel Committee enclosing a resolution in reference to the certification of mentally deficlent'cases. The Executive Secretary was instructed to circulate the resolution with the agenda of the September meeting of the Council. Representation of the Society.~Dr. G. A. Auden was re-elected as representative of the Society on the Council of the Central Association for Mental Welfare for the period ending June, 1924. Administration of the Midwives A c t s . ~ D r . Cates submitted the report of the Special Committee appointed to consider the working of the Midwives Acts and the Rules of the Central Midwives Boards.
343
After discussion and minor amendments the report was approved and adopted. (The report will be found below.) It was Resolved: That copies of the report be forwarded to the Ministry of Health, the CenlrM Midwives Board, the College of Nursing, the Jubilee Institute of Nursing, and the M. and C.¥V. Group of the Society. On the proposal of Dr. Kerr, seconded by Dr. Pearce, a cordial vote of thanks was passed to Dr. Cates (Chairman) and the members of the special committee responsible for the report. Relation of the County M.O.H. to the District M . O . H . - - A r i s i n g out of the discussion on the above report, it was resolved: That the whole subject of the relation of the County M.O.H. t o the District M.O.H. be considered by the Society during the coming session. Disciplinary.--Several members having reported a strong feeling in the Branches in reference to a recent appointment in a metropolitan borough, where a Fellow of the Society had not been willing to co-operate with the Salaries Committee when asked to confer with them before accepting the post, it was resolved unanimously that the member in question be called upon to justify his action before the Council, in accordance with Article iI. of the Society's Articles of Association. The Council then adjourned.
S O C I E T Y OF M E D I C A L O F F I C E R S OF HEALTH. T I l E M I D W I V E S ACTS A N D T H E R U L E S OF T H E C E N T R A L M I D W I V E S BOARD. Report of the Special Committee appointed by the Council on December t5th, 1922. Reference.--" To report on the whole working of the Midwives Acts and the Rules of the Central Midwives Board." The Committee was constituted as follows : Dr. T. Eustace Hill, O.B.E., the President, Dr. T. YV. Naylor Barlow, O.B.E., Dr. Joseph Cates, Dr. J. M. Clements, Dr. R. A. Lyster; Dr. C. E. S. Flemming and Dr. J . W. Bone (nominated by the British Medical Association). The Committee elected Dr, Cates as their Chairman, mad have held five meetings. At the first it was decided to invite suggestions from Branches and Groups of the Society, from the Association of County Medical Officers of ttealth and from the British Medical Association,
344
PUBLIC
A f t e r d e t a i l e d c o n s i d e r a t i o n of t h e A c t s , t h e Committee recommend that the following amendm e n t s s h o u l d be a d v o c a t e d b y t h e S o c i e t y a n d f o r w a r d e d t o the B r i t i s h M e d i c a l A s s o c i a t i o n , the R o y a l S a n i t a r y I n s t i t u t e , and to the G o v e r n m e n t Departments concerned. M i d w i v e s Act, 1 9 0 2 . - - 1 . - - ( 1 ) It h a s been r e p r e s e n t e d to t h e C o m m i t t e e t h a t in c e r t a i n areas men without a medical qualification h a b i t u a l l y a c t as m i d w i v e s . This does not a p p e a r to h a v e b e e n c o n t e m p l a t e d by t h e A c t . S u c h p e r s o n s a r e u n d e r n o s u p e r v i s i o n o r con.trol, a n d t h e C o m m i t t e e t h e r e f o r e a d v i s e t h a t in S e c t i o n 18 a definition be a d d e d in t h e f o l l o w i n g terms :-" The word ' woman ' shall include a person of either sex who is not a legally qualified medical practitioner." 1 . - - ( 2 ) T h e r e is o v e r w h e l m i n g e v i d e n c e t h a t p r o c e e d i n g s a g a i n s t h a n @ - w o m e n a r e n o t likely to be s u c c e s s f u l until t h e r e is a m a t e r i a l a m e n d merit of this S u b - S e c t i o n of the A c t . I t is u n d e r stood that the Central Midwives Board would welcome more stringent drafting. The SubS e c t i o n at p r e s e n t r e a d s a s f o l l o w s : - " From and after the first day of April, one thousand nine hundred and ten, no woman shall habitually and for gain attend women in childbirth otherwise than under the direction of a qualified medical practitioner unless she be certified under this Act ; any woman so acting without being certified under this Act shall be liable on sununary conviction to a fine not exceeding ten pounds, provided this section shaIl not apply to legally qualified medical practitioners, or to anyone rendering assistance in a case of emergency." The Committee recommend that the SubS e c t i o n s h o u l d be a m e n d e d , t h u s : - (a) " From and after the first day of January, one thousand nine hundred and twenty-four no woman shall attend women in childbirth otherwise than under the immediate personal supervision of a qualified medical practiti'oner in attendance at the labour, unless she be certified under this Act; any woman so acting without being certified under this Act shall be liable on summary conviction to a fine not exceeding ten pounds, provided this section shall not apply to legally qualified medical practitioners, or to any one rendering assistance in a case of emergency. (b) " Any unqualified person rendering emergency assistance to a woman in childbirth, shall, as soon as she becomes aware of the emergency, immediately summon the assistance of a qualified medical practitioner or a midwife. (e) " Any woman failing to summon assistance under Sub-Section I (2) (b) shall be liable on summary conviction to a fine not exceeding five pounds." 10. ] ' h e C o m m i t t e e a r e c o n v i n c e d t h a t a m i d w i f e w h o a c t s o n l y as a m o n t h l y n u r s e , s h o u l d n o t e s c a p e s u p e r v i s i o n u n d e r t h e R u l e s of t h e C e n t r a l M i d w i v e s B o a r d , a n d s h o u l d be r e q u i r e d to n o t i f y the L o c a l S u p e r v i s i n g A u t h o r i t y of b e t
HJgALTH.
SEPT~MBE~t,
i n t e n t i o n to p r a c t i c e in t h e c a p a c i t y of a m o n t h l y nurse. M i d w i v e s A c t , 1918. 6 . - - ( 2 ) T h e C o m m i t t e e a r e satisfied t h a t m i d w i v e s , at t i m e s , suffer serious financial loss w i t h out r e d r e s s , w h e n s u s p e n d e d f r o m p r a c t i c e in o r d e r to a v o i d t h e c o n v e y a n c e of infection. It is t h e r e f o r e r e c o m m e n d e d t h a t this S u b - S e c t i o n should read :-" Wherein pursuance of any power conferred by any such rule a midwife has been suspended from practice pending the decision of her case by a court or the Board and the case is decided in her favour, or where in pursuance of the duty imposed by paragraph (3) of section eight of the principal Act a midwife has been suspended from practice in order to prevent the spread of infection, tile Central Midwives' Board or the Local Supervising Authority by whom she was suspended shall pay her such reasonable compensation for loss of practice as under the circumstances may seem just, subject to appeal by either party to the Ministry of Health." i2.--The Committee gave prolonged consideration to t h e p o s i t i o n w h i c h has a r i s e n f r o m t h e o p e r a t i o n of this S e c t i o n , w h i c h a m e n d e d S e c t i o n 9 of t h e A c t of 1902. T h e l a t t e r e n a b l e d C o u n t y C o u n c i l s to d e l e g a t e t h e i r p o w e r s a n d d u t i e s to District Councils, and representations were made to t h e C o m m i t t e e t h a t S e c t i o n 12 of t h e A c t of i918 r e p e a l i n g S e c t i o n 9 of t h e 1902 A c t o c c a s i o n e d difficulties in t h e w o r k i n g of i n f a n t w e l f a r e s c h e m e s in c e r t a i n a r e a s . After taking t h e s e c o n s i d e r a t i o n s i n t o full a c c o u n t , a n d w e i g h i n g c a r e f u l l y t h e v i e w s e x p r e s s e d in t h e t w o m e m o r a n d a on t h e s u b j e c t a t t a c h e d t o this r e p o r t , t h e C o m m i t t e e felt t h e y c o u l d n o t i g n o r e t h e e x p r e s s e d p u r p o s e of t h e A c t s , w h i c h is " to s e c u r e the b e t t e r t r a i n i n g of m i d w i v e s a n d to r e g u l a t e their p r a c t i c e . " The Committee therefore, with one d i s s e n t i e n t , . d e c i d e d t h a t n o c h a n g e s h o u l d be r e c o m r n e n d e d in t h i s S e c t i o n . 1 4 . - - ( 2 ) I n v i e w of m i s u n d e r s t a n d i n g s t h a t a r i s e in m a n y a r e a s t h r o u g h d e l a y by m e d i c a l p r a c t i t i o n e r s in r e n d e r i n g t h e i r a c c o u n t s u n d e r this St~b-Section, a n d t h e c o n s e q u e n t difficulty which the Local Supervising Authority may exp e r i e n c e in a t t e m p t i n g to r e c o v e r t h e fees, the Committee recommend that there should be a f u r t h e r c o n d i t i o n in t h i s S u b - S e c t i o n r e q u i r i n g m e d i c a l p r a c t i t i o n e r s to a p p l y f o r t h e i r f e e s w i t h i n o n e m o n t h f r o m t h e r e c e i p t of a n o t i c e from the Local Supervising Authority. RULES OF THE CENTRAL MIDWIVES BOARD. C.--The Committee considered the regulations r e l a t i n g t o t h e t r a i n i n g of p e r s o n s a d m i t t e d to examination. T h e y a r e of t h e o p i n i o n t h a t t h e t i m e is a p p r o a c h i n g w h e n t h e r e s h o u l d b e a u n i f o r m s t a n d a r d of t r a i n i n g f o r n u r s e s .
I923.
PUBLIC HEALTH.
T h e n e e d f o r m i d w i v e s is n o w n o t s u f f i c i e n t l y urgent to be an adequate excuse for the admiss i o n t o t h e e x a m i n a t i o n of w o m e n w h o h a v e undergone partial nursing training. The obligat i o n s a n d r e s p o n s i b i l i t i e s of m i d w i v e s w h o a r e t o be entrusted with the care of women before, during and after labour call for a high standard of g e n e r a l e d u c a t i o n a n d a p r o l o n g e d p e r i o d o f hospital work. Your Committee, therefore, r e c o m m e n d t h a t o n a n d a f t e r a d a t e t o b e fixed, and they suggest that 7 years from the next o c c a s i o n o n w h i c h t h e R u l e s of t h e C e n t r a l M i d wives' Board are amended would be a reasonable period, notice should be given that no woman will b e a d m i t t e d t o t h e e x a m i n a t i o n u n l e s s s h e produces I. E v i d e n c e of r e g i s t r a t i o n b y t h e G e n e r a l N u r s i n g C o u n c i l , e x c e p t in t h e c a s e o f " existing nurses," or 2. T h e c e r t i f i c a t e s i n d i c a t e d in S e c t i o n C . 2 (a), (b), (c) a n d (d). Until the suggested change comes into force t h e C o m m i t t e e r e c o m m e n d t h a t t h e p e r i o d of s i x m o n t h s m e n t i o n e d in C.1 (1) s h o u l d b e e x t e n d e d t o o n e y e a r , a n d t h e p e r i o d of f o u r m o n t h s in C. 1 (2) s h o u l d b e e x t e n d e d t o six m o n t h s . D.--The Committee reviewed the Rules of Procedure followed by the Board on the removal o f a n a m e f r o m t h e roll a n d t h e y c o n s i d e r e d t h e evidence placed before them. The Committee a r e of o p i n i o n th~/t t h e C e n t r a l M i d w i v e s ' B o a r d s h o u l d a c t in a j u d i c i a l c a p a c i t y o n l y mad n o t a s both prosecutor and judge. \aThile it is p o s s i b l e t h a t t h e R u l e s g o v e r n i n g t h e p r o c e d u r e in p e n a l c a s e s w e r e d r a f t e d o n t h e lines followed by the General Medical Council, the Committee were aware that the latter body is, i n f a c t , r e l u c t a n t i t s e l f t o p r o s e c u t e , a n d i t a p p e a r s t o t h e ~C o m m i t t e e t h a t t h e p r i n c i p l e o f a single body acting as both prosecutor and judge is r e p u g n a n t t o t h e g e n e r a l p r i n c i p l e s of t h e l a w of t h e l a n d . The Committee, therefore, recommend that the Local Supervising Authority s h o u l d a c t a s p r o s e c u t o r in p e n a l c a s e s a n d t h a t suitable arrangements should be made for holdi n g i n q u i r i e s in p e n a l c a s e s in t h e p r o v i n c e s . F r o m e v i d e n c e s u p p l i e d t o t h e C o m m i t t e e it seemed that the Central Midwives' Board was a t a d i s a d v a n t a g e in h a v i n g n o p o w e r t o s u b p o e n a witnesses or to require evidence on oath, and the Committee recommend that steps should be taken to remove this disadvantage as soon as practicable. E.--XVith regard to the Rules Regulating, S u p e r v i s i n g a n d R e s t r i c t i n g t h e P r a c t i c e of M i d -
345
wives, your Committee recommend tions and amendments following:-Section as at present drafted.
the altera-
Recommendation.
5. All instruments and other appliances nmst be disinfected, preferably by boiling, before being brought into contact with the patient's generative organs.
5. Omit the word "preferably." Add the words: " unless otherwise allowed by the Local Supervising Authority."
7. A midwife in charge of a case of labour must not leave the patient without giving an address by which she can be found without delay ; and, after the commencement of the Second Stage, she must stay with the woman until the expulsion of the platenta and membranes, and as long after as may be necessary. tn cases where a doctor has been sent for on account of the labour being abnormal or of there being threatened danger (see Rule 20), she must await his arrival and faithfully carry out his instructions, If for any reason the services of a registered medical practitioner be not available, the midwife must, if tile case be one of emergency, remain with the patient and do her best for her until the enmrgency is over. After having complied with the Rule as to the summoning of medical assistance, the midwife wilt not incur any legal liability by remaining on duty and doing her best for the patient;
7. A midwife in charge of a case of labour must not leave the patient without giving an address by which she can be found without delay; and, after the cornmencement of the Second Stage, she must stay with the woman until at least one hour after the expulsi0n of the placenta and membranes and for such further period as may be necessary. In cases where a doctor has been sent for on account of the labour being abnormal or of there being threatened danger (see Rule 20) she must await his arrival and faithfully carry out his instructions. If for any reason the setvices of a registered medical practitioner be not available, the midwife must, if the case be one of emergency, remain with the patient and do her best for her until the emergency is over. After having complied with the Rule as to the summoning of medical assistance, the midwife wilt not incur any legal liability by remaining on duty and doing her best for the patient.
8. Tile midwife must wash the patient's external parts with soap and water, and then swab them with an efficient antiseptic solution on the following occasions . . . . . (c) During the lying-in period, when wasNng is required . . . . .
8. Amend to read : " The Midwife must wash the patient's external genital parts . . . . " (c) Amend to read : " Daily during the lying-in period . . . . . ''
11. The midwife must remove soiled linen . . . . .
11. The midwife must remove all soiled l i n e n . . .
PUBLIC
346 12. The midwife shall be responsible for the cleanliness, and shall give all necessary directions for securing the comfort and proper dieting of the mother and child during tim lyingin period which shall be held, for the purpose of these regulations, and in a normal case, to mean the time occupied by the labour and a period of ten days thereafter. . . . .
12. The midwife shall be personally responsible for the dally washing of the mother and the infant, the dressing of the umbilicus and any other necessary attention, and shall give all necessary directions for securing the comfort and proper dieting of the mother and child during the lyingin period which shall be held, for the purpose of these regulations, and in a normal case, to mean the time occupied by the labour and a period of ten days thereafter . . . . Add--The midwife shall be held responsible during the wlmle of the lying-in period for all confinements which she personally conducted.
14. The midwife shall take and record the pulse and temperature of the patient at each visit, entering her records, with dates and times, in a notebook or on charts, which nmst he carefully preserved.
t,~.~Add-- The midwife shall visit her patient 1. Within 15 hours of delivery. 2. Daily during the first week after labour. If prevented from so doing she shall enter the reason in her register.
19. A midwife must note in her Register of Cases each occasion on which she is under the necessity of administering or applying in any way any drug other than a simple aperient, the name and dose of the drug and the time and cause o f its administration or application. (See Rule 24, Note.)
19. Add --- No midwife shall administer to a patient any anmsthetic or any drug other than a simple aperient, or after the completion of the third stage of labour ergot, except under the supervision or on the written authority of a qualified medical practitioner, No midwife shall use forceps.
20. In all cases of illness of the patient or child, or of any abnormality occurring during pregnancy, labour, or lying-in, a midwife, as soon as she becomes aware thereof, must call in to her assistance • . •
20 . . . . . must forthwith call in to her assistance . . . . There should be a foot note to E. 20 stating that when medical help is required the midwife shall summon the usual medical attendant of the patient unless the patient otherwise desires.
21. PREGNANCY, (2) In the case of a PREGNANT woman, when there is any abnormality or complication, such as : Deformity or stunted growth.
21. (9) Add--Persistent headache. Dimness of vision. Illness or abnormality or stillbirth in a previous pregnancy.
HEALTH.
~ EPTE M.P.,E~,
Loss of blood. Abortion or threatened abortion. ExcesMve sickness. Puffiness of hands or face. Fits or convulsions. Dangerous varicose veins. Purulent discharge. Sores of the genitals. LABOUR. O) . . . . in cases of serious rupture of the perinaeum . . . . LYING-IN. (4) . . . . Rise of temperature above 100.z~OF. with quickening of the pulse, for more than twenty-four hours. THE CHILD. (5) . . . . .
22. (b) Deaths--In aI1 cases in which the death of tile mother or of the child occurs before the attendance of a registered medical practitioner,
(Signed)
(3) Omit - Serious. ~
the
word
(4) Omit the words "with quickening of the pulse, for more than twenty-four ho~.trs. ~
(5) Add the words " premature birth endangering the child's life." 22. (b) Omit the words " before the attendance of a registered medical practitioner."
JOSEPH CATES, T . EUSTACE HILL, T. W . N . BARLOW, J. M. CLEMENTS, R. A. LYSTER, CHAS. E . S. FLEMMING, JOHN *vV. BONE.
DELEGATION OF DUTIES. MEMORANDUM BY DR. JOSEPH CATES. In practice d e l e g a t i o n has not b e e n f o u n d to be a success.
In
most
cases
councils have subse-
q u e n t l y r e v o k e d StlCh p o w e r s a s t h e y h a v e d e l e gated. In the few cases where delegated powers have not been revoked, the delegation has been f o u n d to o p e r a t e d e t r i m e n t a l l y to the p u r p o s e s of the M i d w i v e s A c t s a n d to i n t r o d u c e an e l e m e n t of c o n f u s i o n a n d u n c e r t a i n t y in t h e i r a d m i n i s t r a t i o n . The evidence given to the Midwives Act Comm i t t e e in 1909 w a s c o n c l u s i v e o n t h i s p o i n t , a n d it was then stated that delegation was an unmitig a t e d evil. T h e A c t s c a n b e a d m i n i s t e r e d in c o u n t i e s a n d county boroughs with greater
uniformity,
inde-
p e n d e n c e a n d efficiency t h a n is p o s s i b l e in t h e c a s e of s m a l l e r a r e a s . U n i f o r m i t y o f a i m a n d p r a c t i c e is u n r e a t i s a b l e u n d e r c o n d i t i o n s of e x t e n s i v e d e l e g a t i o n . In smaller a r e a s the a t t i t u d e and c o n d u c t of t h e a u t h o r i t i e s a r e m o r e likely p r e j u d i c i a l l y t o b e aff e c t e d b y local i n f l u e n c e s , j e a l o u s i e s a n d p r e j u d i c e s t h a n in c o u n t i e s .
x9=3.
PUBLIC HEALTH.
The more numerous are the authorities administering the Acts, the greater will be the resulting variety of standards of practice and methods of efficiency and the greater the amount of overlapping. The difficulties of supply distribution and training of midwives are enormously augmented by a multiplicity of authorities. The more extensive the area of administration (within reasonable limits) the wider is the experience gained by the inspector and the higher is the rate of pay she can command. The better the remuneration offered the better qualified by education, training and experience are the candidates for vacancies. An improvement in the social and educational status of the inspector may reasonably be expected to be followed by a like improvement in the general status of the midwife who comes under her influence. In counties maternity work is often done by district nurses, who are usually supervised by a superintendent of the Nursing Association ; in the event of delegations being effected over-lapping of supervision would ensue. JOSEPH CATES. DELEGATION OF DUTIES. MEMORANDUMBY DR. J. M. eLEMENTS. I have been asked to give some reasons why the Authority which administers the Maternity and Child Welfare Act in any area should be the Local Supervising Authority for Midwives in that area. In this connection it is necessary to bear in mind that the Maternity and Child Welfare Authority has statutory power to make provisions for the care of expectant mothers and infants, to organise and administer Welfare schemes which include such agencies as Infant Welfare Centres, Lyingin Homes, the provision of Home Helps, the giving of free food in necessitous eases, etc. It is their duty to see that there is an adequate supply of midwives to meet the needs of their area, and they have power to supplement this by establishing a Maternity Home, if necessary. The Authority is concerned with all influences which affect injuriously the health of mothers and children, in the case of the former more particularly during the period of pregnancy, lying-in, and lactation, and in the case of the latter from birth to age five. The r61e of the midwife is a very important one in any scheme of Maternity and Child Welfare. Her services are required at a critical time in the life of the mother and the infant, and have farreaching effects on the health of both of them.
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If she is a good midwife and knows her work she may at times, by acting promptly, save the life of a mother or baby. O n the other hand, failure on her part to reallse the actual conditions with which she is dealing, and the need for medical assistance, or failure to take proper precautions against sepsis, may result in the loss of life or lead to impairment of the health of tile mortar or child. She is an essential and important part of any scheme for the welfare of mothers and infants. W h a t then is her proper relationship to the Authority which administers such a scheme? Should-she be subject to any supervision or control by the Authority? It has been decided by Act of Parliament that she shall be under supervision and control, and my object is to try and convince you, as nay experience has convinced me, that the proper Authority to exercise this supervision and control is the Authority which administers the Maternity and Child Welfare Act. So far as the County Boroughs are concerned, the question does not arise, as the County Borough is the Authority for both purposes. It is only in county areas which administer their own Maternity and Child Welfare Schemes that difficulty arises; here the County Council supervise and control the midwives and the Local Sanitary Authority or Authorities administer the Maternity and Child Welfare Scheme. Some of the reasons in support of my view are as follows : The Maternity and Child Welfare Authority is more intimately associated and concerned with the welfare of the mother and infant than any other. Through its officials it is brought into daily contact with the midwife and her work. By means of its maternity home, its welfare centre, and the home visiting of its health visitor, it is in a position to exercise a very close supervision and control over the midwives in its area. Compare thls with the supervision which can be given by a n Authority whose inspecting officials live 20 to 30 miles away, or even more, and who can only pay flying visits at considerable intervals for the purpose. If the same medical and nursing staff which carries out the work of the welfare centres were also responsible for supervising the midwives it would bring the latter into closer co-operation with the work of the centres and induce them to send expectant mothers to the Centre for advice. The notification of artificial feeding by the midwife to the supervising authority under Rule E. 12 A. is at present of little practical use unless the supervising authority also administers the Maternity and Child Welfare Centres.
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PUBLIC HEALTh.
When one considers the large numbers of infant deaths that occur during the first week or ten days of life, or before the midwife ceases to attend, it emphasises the need of closer co-operation between the officials of the welfare centres and the midwives in their preventive work, both antenatal and post-natal, if the high mortality at this age is to be reduced. Such co-operation can be more easily arranged if there is only one Authority concerned. Instances have been brought to my notice of midwives who are actively hostile to the welfare centres and persuade mothers not to go there. Again, I have lmown midwives whose methods are not quite sound, some are too ready to advise the mother to give up breast-feeding if any little difficulty is experienced in the early days. Others are in the habit of giving the baby strong aperients like castor oil, with the result that the baby is brought to the Centre suffering from constipation and deranged digestion. Such irregularities as these can best be dealt with by having one and the same Authority administering the Maternity and Child Welfare A c t and Midwives Acts. Instances of other anomalies in the present arrangements can be given. Take, for example , that of a midwife who has a case of puerperal fever or gonorrheal ophthalmia in her practice. These cases have to be notified to the local Sanitary Authority, but the latter has no power to deal with the midwife if the occurrence of such is due to any default on her part. To put the matter concisely, the midwife is an essential part of any welfare scheme for expectant mothers, and if she is to be controlled or supervised by anyone then it should be by the authority which administers the scheme of which she is an integral part. J . M . eLEMENTS. REDUCTION IN INFANT MORTALITY. In order to stimulate public interest in the reduction of infant mortality the "Daily N e w s " is offering prizes to local authorities of not |ess population than 20,000. A prize of £25 is offered to the district which has secured in the year ending midsummer last the greatest reduction in the death-rate of boy babies under one year of age as compared with the previous 1~ months, and another prize of ~g25 for the lowest actual death rate among boy babies. The awards will be made upon the corrected figures furnished by the local medical officer of health, which must reach the " Daily News " office not later than October 1st, 1923.
SEPTEMBER, I923. CORRESPONDENCE.
The Editor does not accept responsibility for the opinions of correspondents. C O N T R O L OF I N F E C T I O U S D I S E A S E S .
From Dr. A. H. BURTON, M.O.H., Ilford. Dear S i r , - - I see in your August issue, page 305, that Dr. F. H. Thomson, North Eastern Hospital, M.A.B., is stated to have made the following remarks : - " It was not a problem that could very well be checked by the Medical Officer of 'Health, who as a general rule had no greater knowledge of infectious disease than the general practitioner." It would be interesting to know on what grounds Dr. Thomson makes such an ill-founded and sweeping assertion, or of whose work as Medical Officers of Health he has had experience to obtain such knowledge as to their capacity or suggested incapacity in the diagnosis of infectious disease. Surely it cannot be from the Metropolitan Medical Officers of Health, who I see have done Dr. Thomson the honour of electing him their President for the ensuing year. Has Dr. Thomson had any experience in the work of provincial Medical Officers of Health, who as a general rule have the supervision of an Isolation Hospital? As a matter of fact one of the great drawbacks which exists in Public Health work in the Metropolitan Area is the entire divorce which exists between the administration of the Isolation Hospitals by the Metropolitan Asylums Board and local health administration, as this precludes any control by the Medical Officers of Health in such matters as " return cases," the numbers of which I understand are not even now published by the M.A.B. If Dr. Thomson or any other Medical Superintendent of the Metropolitan Asylums Board could give Medical Officers of Health assurance that he could recognise without doubt a typical mild case of Scarlet Fever in its early stages, no doubt valuable assistance could be obtained, but l~ow many of these cases are placed in sidewards, even in the M.A.B. Institutions, until the Medical Superintendent sees whether or not they " peel " ? Yours faithfully, A. H. G. BURTON.