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MIDWIFERY AS A PROFESSION FOR
A CONSIDERABLE amount of attention has been devoted lately to this subject; but it remains an awkward topic with an ugly name, and it is felt by many people that an undue amount of publicity has been awarded it. The amount of real progress has, nevertheless, been disappointingly small, and as it is a matter of vital moment to the community, it is advisable to call public attention again to a few of its most salient features.
The dangers incurred by a working woman at the birth of her children are now so generally recognised, the superiority of the results of good maternity hospitals over those in private (cottage) practice 80 marked, that it seems at first sight as though the only means of improving our statistics of maternal mortality were to provide sufficient accommodation for every woman of the working classes to be confined in an institution.
In a recent address by Miss Wilson (a member of the Central Midwives' Board), she states that the average mortality of English women, from puerperal fever, a preventible disease, is forty-seven in 10,000 or one in 213; but that in three of the best lying-in hospitals, this figure has been reduced to rather less than one in 3000. It is startling to find that only thirty-seven years ago, a diametrically opposite result was arrived at according to the best obstetricians. In 1870 we find Matthews Duncan writing ? :
If I read current literature aright, the prevalent opinion is that while medical and surgical hospitals are now on their trial, maternity hospitals are already condemned. The mortality of maternity hospitals is said to be so great that it is expedient, indeed, absolutely necessary, to close them entirely.
It is fair to add that Matthews Duncan himself disagreed with this conclusion, and occupies the remainder of his book in disproving it, but although his sympathies are warmly engaged on the side of maternity hospitals, he cannot at that time make out a better case for them than that their record of puerperal mortality is nearly the same as that outside their walls, the figures he gives being respectively one in 100 and one in 120. He admits, however, that some hospitals did show an appalling record, and cites an instance of one which, during a certain period, had lost one out of every three patients.
1. The Working of the Midwives Act.' Read to the Gloucestershire County Nursing Association.
• Mortality of Childbed and Maternity Hospitals.
We may safely draw the conclusion, from this almost forgotten page of institutional history, that there are certain dangers incurred by every woman at child-birth which are greatly increased by the propinquity of other lying-in women-or to put it more technically, that
germs which may perhaps cause only a slight rise of temperature in one maternity patient, if conveyed on the air, or by the hands, or dress of an attendant, may occasion in another a possibly fatal dose of sepsis. The conclusion will be borne out by all who have had anything to do with the internal workings of a maternity hospital. The slightest disturbance in the condition of a patient, symptoms which, in district work, would have made no demands on one's philosophy, but have been dismissed as transient and unimportant in character, become matters of the gravest import in a hospital ward. Is there any possibility of their pointing to septic disorder ? and, if so, although the original patient is hardly affected by them, may she not be dealing out disease and death to her neighbours ? Should she not instantly be isolated ? These are some of the questions which dog the footsteps and haunt the pillows of all who unwarily meddle with this most exasperating branch of the healing profession.
And then we come back to Miss Wilson's statistics. The average mortality of those three London hospitals, one in 3000. The average mortality over England and Wales, one in 213, and we feel there is something hopelessly wrong somewhere. It is almost incredible that 80 complete a reversal of the entire situation should have occurred in so short a period as thirty-seven years ; still we cannot doubt either of our authorities, and it becomes a burning question : By what means have the maternity hospitals so marvellously reduced their death rate, in spite of the heavy drawbacks under which, from the nature of things, they must always labour ? And why has their example not been followed by those not suffering from these disadvantages—i.e. those working in private practice ?
Miss Wilson says further in her address : 'The prime agent in causing the death of 4000 mothers every year is the untrained midwife, but she is the agent, not the principal
. It is we ourselves, the controllers of the government of the kingdom, who are responsible for the sins of our agent.' When we remember all that has been written and spoken, and legislated on the subject in England, during the past ten years, we are inclined to feel that this is rather hard measure ; surely we have done as much as could have been expected of us in a matter not directly concerning ourselves. But ever the thought of those 4000 unnecessary deaths of mothers of families and every
year yet another 4000-goads us onward to discover the reason why our philanthropy is so singularly inoperative.
Let us turn our attention to other countries and see what they have done in the matter.
In a paper, read before the London Obstetrical Society by Dr. Priestly, in 1884, we are told that in the far north considerable efforts were then being made and large sums of money expended to bring about better results, the alarming ones we quoted having been more or less universal between the years 1860 and 1870. In the St. Petersburg Maternity Hospital, the floors of the wards were laid in mosaic concrete, and the walls half-way up were of tiles. At the corners of the rooms were arranged taps and jets of water, so that the floor could be flooded at any time, and an antiseptic used at the same time if required. As the floors sloped towards a drain or gutter, the surface of the concrete soon dried, and was then perfectly clean. Very ordinary precautions—perhaps some of my readers are thinkinghas no one ever heard of tiled walls and concrete floors before? Yes, but thirty years ago, and in the wards of a maternity hospital ? With us there is no charity so unpopular; it is very difficult to raise funds for the ordinary upkeep of such institutions, and these funds are mostly derived from the fees of their pupils, fees so heavy that they can for the most part be afforded only by those who propose to recoup themselves in private nursing. Compare the wards of any of our maternities with those of our best equipped surgical hospitals, and the difference will be felt to be very striking. Dr. Priestly concludes his remarks on St. Petersburg with the words : 'As funds are always forthcoming for any improvements suggested,' advance is not retarded by poverty,' and he then goes on to tell his audience about the maternity hospital he had visited at Helsingfors, which was built in the form of a spacious quadrangle, the various sections being arranged on the pavilion system, and including a gynæcological department, and also a lecture theatre and a museum. The school for teaching was spacious and admirably arranged, and was used both by the twenty medical students and the forty midwife pupils, each of whom was given a course of a year's training. At Helsingfors, as at Petersburg, it was evidently recognised as a matter of such first-class importance, that expense was not spared, either in the safeguarding of patients received into the institution, or in the training of midwives to serve those at a distance. We have seen that, although such has by no means been the case in England, some of the maternity hospitals have triumphed over the innumerable obstacles in their path, and, by force of whole-hearted adherence to the antiseptic theory, have obtained magnificent results. It has been in the field of training that our economies have made themselves felt. We have much to learn on this point from all the other countries of Europe ; but of them all perhaps Holland at the present moment best deserves our consideration. The training is given to a large proportion of the students by the State, and at its completion they are bound to work wherever they may be sent, for a period of two years, at a fixed salary, provided or subsidised by the Government or community. In this way provision is made for the delivery and nursing of those women who have the misfortune to live in too sparsely populated a district to tempt any midwife working up a practice for herself, and whose case otherwise presents an insuperable problem. Other pupils pay for their own training, which is in all cases the same, with the exception of the preliminary matriculation. The first year is entirely given over to theoretical study, seven and a half hours daily, and that this is study and not play is proved by the fact that an examination bars the way to further advance.
* The funds were supplied by the Grand Duchess of Mecklenberg Strelitz.
Should the pupil fail to satisfy her teachers, she may, according to their discretion, be required either to repeat her years study, or to return home as unfitted for the work. After the passing of this first examination, the student is given a year's practical work, in attendance at the confinements, and during the subsequent convalescence of their patients, and in the nurseries which are attached to the training school. That is to say, they have really time to study and digest the innumerable deviations from the normal of even the most ordinary cases with their appropriate treatment—they have a good likelihood of meeting with abnormal cases while still under direction so that afterwards, in their own practices, they will be enabled to quickly diagnose them, and summon medical help. They will also—and one can hardly lay enough stress on this point—have time in which to become adepts in the management of younginfants, in all its different branches of clothing, digestion, and ventilation—to adjust the dietary of those who are hand-fed, not only to rule, but also to each individual little constitution to master the intricacies of bottle-cleaning of which every beginner says in turn : Well, people say they must be scalded, but they always break when I do it, I suppose these must be bad bottles.'
They will, in short, have the possibility of making themselves masters of that science, by the knowledge of which alone excessive infantile mortality can be checked, and cripples' homes rendered, to a large extent, superfluous.
This year of practical work may again, in the Dutch training schools, be prolonged into two years at the command of the teachers. The schools are supported by Government; it is not, therefore, to anyone's interest that the pupil should leave at the end of the shortest possible period in order to make room for another pupil who will pay another fee. The women whom they are going to nurse in the future need not suffer from inefficient inexperienced handling, because the hospital could not scrape together sufficient funds to nurse its own patients without constant and rapid successions of paying pupils. If we compare our own system with that of Holland, I think we shall realise why our statistics do not improve more rapidly. It is, of course, an advance on the complete lack of system which existed before the passing of the Midwives Act; but it cannot be denied that it leaves room for improvement. An English midwife must now pass the examination of the Central Midwives' Board before she is allowed to practise without a doctor. In order to pass that examination, she must have received a course of instruction extending over not less than three months, and comprising at least fifteen lectures. They must also have attended twenty cases, and nursed the same number of women during the ten days following labour; the three months' proviso does not extend here, and the twenty cases are occasionally compressed into six or eight weeks, even the 'nursing' being accomplished in an incredibly short period, owing to a somewhat liberal interpretation of the term. Some of our better maternity hospitals are trying to make a stand for four or even five months' training; but, as we have already pointed out, they are considerably handicapped by the urgent necessity of making a sufficient income from their pupils' fees to keep themselves afloat. A large number of their students, moreover, are trained nurses, who are merely learning midwifery as an extra accomplishment for private nursing, and in their case, with the prospect of always working under a doctor, a few months' work is probably sufficient. It is a very different matter with the future district midwives.
We must now turn to another difficulty. Many of the county councils are promoting the training of women to work in their own boundaries; the London County Council especially is making enlightened effort, and offers a dozen scholarships yearly for a six months' training. A certain number of free scholarships are also given by the Midwives' Institute, the Association for Promoting the Training and Supply of Midwives, and others, but we are told, in a Report published by the latter body in the Lancet for the 20th of July, that the various local associations which supply midwives to the poor out of private benevolence' are frequently only able to offer very small and inadequate salaries for the services of a district midwife. The association to whom the Report is owing has been confronted with this difficulty in a form that has occasioned much anxiety, for when it has expended its funds on the training of suitable women, it has found it no easy matter to place them. In many places the barest living is offered, with no possibility of anything being put aside for old age, or even the necessary clothing or holidays.
In short, over three thousand women are dying annually from want of good midwives, and yet the midwives now entering the field cannot find enough work to do, or to put it more truly-cannot find work which offers them an adequate livelihood. Now here is a paradox