MATERNAL MORTALITY
[To the Editor of the SPECTATOR.]
Sim—Many who praise the Interim Report issued by the Maternal Mortality Departmental Committee, appointed by Mr. Neville Chamberlain, have, unfortunately, failed to comprehend the recommendations of the Report itself. This appears to be the case of " Crusader," whose article on this question you published in your issue of September 6th. He declares, in a finale of much enthusiasm, that "at the bedside of every British mother in her creative hour should stand a woman and a man . . . , nurse and obstetrician."
I must observe in passing that we have to-day expert women obstetricians, physicians and surgeons ; and that in my view the obstetric field offers a peculiarly appropriate scope to the medical woman. Yet I am ready to absolve " Crusader " from any intention to undervalue or ignore the woman obstetrician, and to believe that his apposition of the word "man" was merely a slip of the pen.
The - main point I would make is that the outstanding feature of the Report is the effort not to summon the medical practitioner to the mother's bedside, but to banish him, or her, from the lying-in room as far as possible, relegating to the midwife all confinements, unless and until abnormality appears, the doctor merely making one or more ante-natal examinations, and one post-natal examination. This I believe to be a tragic mistake. Many childbirth emergencies arise, which ante-natal examination could by no means have foreshadowed, and with which the midwife is unable to deal. The eleventh-hour summons of a doctor, when the ease has become critical, exposes the patient to unnecessary suffering, and offers an unduly large margin of risk. I claim that even in the most normal cases, which are all painful and strenuous for the patient, both the mother and infant need the services of a fully-trained obstetrician, during the confinement and the puerperium.
Whilst I join " Crusader " in approving the Committee's recommendation that the medical student who intends to practise midwifery should be given greater experience in obstetrics, whilst training, than is the case at present, I must protest that if greater experience before graduation is to be counterbalanced by no experience of any save occasional abnormal labours when the student becomes a fully fledged practitioner, the treatment of difficult labours is likely to be even less efficient than at present. "
Crusader" declares : "We must have the National Maternity Service asked for in the present Report." I, too, most earnestly desire a National Maternity Service, but to describe the Departmental Committee's proposals as a National Maternity Service is, in my view, most grossly to misuse the term. These proposals leave virtually untouched the present Chaotic overlapping and insufficient services, which the Report itself has condemned in most drastic terms.
The inefficiency of at least a substantial proportion of the Practitioners dealing with midwifery, which the Report alleges, will not be remedied by turning over more cases to the midwife, with her brief training grafted on to an elementary school education ; or even by a longer obstetric training for medical students, necessary though this last undoubtedly is. It should be obvious, in this age of specialization, that the remedy for the present high proportion of obstetric failure is the creation of a specialist obstetric service, whose members will be fitted by constant experience and research to deal with every case which may arise. • A National Maternity Service, in my view, should be free to all mothers, as the elementary schools are free to all children, apart from any question of insurance. It should he adminis- tered by the Ministry of Health and the Local Authorities. It
should provide attendance by a fully qualified medical practi- tioner specializing in obstetrics for the ante-, intra-, and post- natal periods, as well as adequate full-time nursing, by fully trained hospital nurses, holding the C.M.B. certificate, and having great experience of midwifery, both hospital and domiciliary, who will nurse under doctors' instructions, by no means taking responsibility for the delivery. The aid of an anaesthetist should be available when desirable. The Maternity Service should insure institutional and convalescent home accommodation for all mothers needing or desiring them.
" Crusader " writes of ante-natal clinics, but Dr. S. G. Moore, the Medical Officer of Health for Huddersfield, has proved conclusively that home visitation by a qualified medical practitioner from the Health Department is infinitely more successful. The clinics attract about 5 per cent, of pregnant mothers in the localities where they are established ; 11011IC visitation, in Huddersfield, attracts 50 per cent. Home visitation is the method which every mother prefers ; it is therefore the method which should be adopted by the National Maternity Service, though the present health lectures to mothers desiring them need not be discontinued. The doctor from the Health Department who visits ante-natally should be the doctor who attends during the confinement and puer- perium. This is essential.
Here is but a brief indication of some of the measures required to reduce our present grievously high maternal mortality amt the heavy loss of infant life and mothers' travail by still-birth and neo-natal death.
More serious even than the death rate is the much greater damage rate both to mother and infant, with its far-reaching consequences, which is a substantial factor in producing a
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