REPORT OF CONFERENCE CONVENED BY THE HONOURABLE THE MINISTER OF HEALTH TO CONSIDER GENERAL QUESTIONS RELATING TO MATERNAL AND INFANT WELFARE

Appendix to the Journals of the House of Representatives, 1948 Session I, H-31c

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1948 NEW ZEALAND

REPORT OF CONFERENCE CONVENED BY THE HONOURABLE THE MINISTER OF HEALTH TO CONSIDER GENERAL QUESTIONS RELATING TO MATERNAL AND INFANT WELFARE

Presented to Both Houses of the General Assembly by Leave

PERSONNEL OF CONFERENCE Chairman: Hon. Miss M. B. Howard, Minister of Health. Deputy Chairman: Dr. T. F. Corkill. Members — Drs. L. C. L. Averill and T. R. Plunkett, representing New Zealand Obstetrical and Gynaecological Society. Misses L. M. Banks and D. M. Heape, representing New Zealand Registered Nurses' Association. Drs. J. Cairney, H. Selwyn Kenrick, and A. J. Mason, representing Hospital Medical Superintendents. Professor Sir J. B. Dawson, representing University of Otago. Dr. Helen Deem, representing Royal New Zealand Society for the Health of Women and Children (Plunket Society). Messrs. J. W. Dove and P. E. Stainton, representing Hospital Boards Association. Dr. D. C. Gordon, Miss M. I. Lambie, Dr. L. C. McNickle, Dr. T. R. Ritchie, Dr. H. B. Turbott, representing Department of Health. Mr. J. G. Badger, Department of Health (Secretary).

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INDEX PAGE Introduction .. .. .. .. .. .. .. 3 Section I*.. .. .. .. .. .. .. .. .. .. o To consider and recommend standards of care for mothers and infants in State and private maternity hospitals, wards, and annexes. How best to establish uniformity in maternity nurse training, pediatric care, and research. To what extent have nursing standards in obstetrical care been affected consequent upon staffing difficulties. SECTION II .. .. .. .. .. .. .. .. .. 7 To inquire into and submit suggestions relating to building programmes for maternity hospital purposes covering—(a) Centralization; (b) Decentralization; (c) Incorporation in ; or (d) Detached from existing buildings. Whether obstetrical work should bp separated from all general hospital contact, and whether maternity nurses should live in obstetrical hospitals. Section 111 .. .. .. .. .. .. .. .. 8 How to safeguard under the law maternity patients and their children from incompetence or negligence or malpractice of any doctor. SECTION IV .. .. .. .. .. .. .. .. 9 The advisability of establishing an Obstetric Council from which the Minister could obtain advice on matters affecting the maternity services of New Zealand. Section V .. .. .. .. .. .. .. .. .. .. 10 Such other matters as may arise in the course of the Conference's inquiries.

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INTRODUCTION This report presents a precis of the proceedings of a Conference convened by the Honourable the Minister of Health, Miss Mabel Howard, and held in Wellington on 29th and 30th June and Ist and 2nd July, 1948. The members of the Conference were representatives of the Registered Nurses' Association, the Hospital Boards' Association, Hospital Medical Superintendents, the Obstetrical and Gynaecological Society, the University of Otago, the Plunket Society, and the Department of Health. Dr. Doris C. Gordon, Director of Maternal Welfare, who was about to relinquish her office, had submitted to the Right Honourable the Prime Minister various proposals concerning the maternity services of the Dominion. The object of the Conference was to obtain expressions of opinion from representatives of organizations especially interested in problems of maternal and infant welfare in New Zealand. The Honourable the Minister of Health opened the proceedings, and, whenever possible, presided. In her absence the meetings were conducted under the chairmanship of Dr. T. F. Corkill. The order of reference was set out as follows : 1. To consider and recommend standards of care for mothers and infants in State and private maternity hospitals, wards, and annexes. 2. To inquire into and submit suggestions relating to building programmes for maternity hospital purposes covering (a) centralization, (b) decentralization, (c) incorporation in, or (d) detached from existing buildings. 3. Whether obstetrical work should be separated from all general hospital contact, and whether maternity nurses should live in obstetrical "hospitals. 4. How best to establish uniformity in maternity nurse training, pediatric care, and research. . 5. How to safeguard under the law maternity patients and their children from incompetence or negligence or malpractice of any doctor. 6. To what extent have nursing standards in obstetrical care been affected consequent upon staffing difficulties ? 7. The advisability of establishing an Obstetric Council from which the Minister could obtain advice on matters affecting the maternity services of New Zealand. 8. Such other matters as may arise in the course of its inquiries. The Conference found in the course of its discussions that certain of the items in the order of reference proved capable of amalgamation, while, for purposes of this report, it has further been deemed desirable to group together the remarks on those subjects which are clearly related to one another. Several important matters were added to the -agenda under the general heading set out in Item 8. In the report which follows it will be necessary to make reference from time to time to the Committee of Inquiry of 1946 or to the report of that Committee, sometimes referred to as the " 1946 report." It is desired to explain that the committee referred to is the Committee of Inquiry into Maternity Staffing which sat under the chairmanship of Dr. T. F. Corkill. The use of the terms " open " and " closed " maternity hospitals, wards, or annexes in the present report follows what has now become established practice in connection with maternity institutions, though the usage is different from that which .ajjplies in connection with general hospitals. By an " open " maternity hospital or ward is meant one in which patients are attended by their own doctors, who act in their private capacity ; by a " closed " maternity hospital or ward is meant one in which patients are attended by duly appointed members of the hospital medical staff in the course of their duties, whether such doctors are members of the full-time or of the visiting staff.

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Throughout its deliberations the Conference was impressed not only by the outstanding work of the nursing profession during the recent difficult years, but also by the great efforts of Hospital Boards in their willing endeavour to meet the unprecedented demand for hospital accommodation for maternity patients. Although many of the problems which came before this Conference had been carefully considered by the Committee of Inquiry of 1946, it was felt that during the past two years the maternity services of the Dominion had passed through a very difficult period, due to the great rise in the birth-rate and difficulties of accommodation and staffing. Many of the problems submitted to the Conference were undoubtedly the outcome of these difficulties. The Conference, which, in comparison with the 1946 Committee, had the advantage of including hospital and departmental representatives, felt that these problems warranted free discussion, but also desires at the outset to place on record its deep appreciation of the gallant efforts of both nursing and medical staffs, as well as of the co-operation of Hospital Boards. The success of these efforts is reflected in the excellent record of maternal and infant welfares ; in this connection attention is directed to the figures for the last thirteen years as presented to the Conference. and attached hereto as Addendum 1. The views of the Conference are summarized in the following resolution, which was carried unanimously : " This Conference considers that a tribute should be paid to the obstetrical section of the nursing profession for the manner in which it has stood up to great difficulties and brought us through so difficult a period of years ; and that not only the obstetric nurses, but also the institutions and the members of the medical profession responsible for the care of maternity patients, should be accorded the thanks of the Conference."

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SECTION I.—ORDER OF REFERENCE, ITEMS 1, 4, AND 6 To consider and recommend standards of care for mothers and infants in State and private maternity hospitals, ivards, and annexes. How best to establish uniformity in maternity nurse training, pediatric care, and research. To what extent have nursing standards in obstetrical care been affected consequent upon staffing difficulties ? The Conference first discussed the questions of the standards laid down for the care of mothers and infants in all maternity institutions. The Director of the Division of Nursing indicated in detail (Addendum II) the steps that had been taken to ensure a uniform high standard of teaching and practice in all such institutions. It was explained that this was largely governed by the detailed instructions laid down in the two pamphlets, H-Mt. 20, " The General Principles of Maternity Nursing, including the Management and Aseptic Techniques of Labour and the Puerperium," and H-Mt. 18, " The Technique of Isolation, Medical Asepsis and Disinfection of Maternity Hospitals." These instructions not only guided the training and examination of all pupil maternity nurses and midwives, but were also applicable to the practice of all non-training private maternity hospitals and to the open annexes of Board Hospitals. They were enforced by regular inspections. In the periodic revision of these pamphlets authoritative professional opinion was sought on all the matters involved and overseas developments were considered. The practice of private maternity hospitals was further controlled by regulations laid down in H-Mt. 33, " Regulations Governing Private Hospitals"; the same regulations apply, by decision of the -controlling authorities, in a number of open annexes of Hospital Boards. The Conference was satisfied that the requirements were sound and thorough and had in the main been successful in their purpose. It was clear that the tribute paid to the nursing staffs by the Director-General of Health was warmly endorsed. Nevertheless, it was evident, however excellent the maternity provision made by many Hospital Boards may be, that there was some ground for uneasiness and uncertainty regarding the powers of application and enforcement of standards in certain Hospital Board institutions, particularly the " closed " portions, to which it is recognized that the regulations in H-Mt. 33 in their present form cannot possibly be applied. The Director of Maternal Welfare gave some specific instances which, if proved, could not but be regarded as serious departures from the generally accepted standards and which she considered to be largely due to the fact that the same supervisory authority which was applicable to private maternity hospitals did not apply to the " closed" wards of public hospitals. The Conference was in no position to investigate the instances referred to by Dr. Gordon, and certain of them were emphatically denied by other members. It appeared to the Conference that such imperfections as had occurred had been isolated and exceptional and due to a necessity to accept admissions in the face of difficulties of accommodation and staffing ; that there was no evidence that any harm had come to any maternity patient in any of the instances referred to ; and that such imperfections were in certain cases at any rate temporary and were rectified at the first opportunity. Nevertheless, the Conference felt that steps should be taken to end any possible confusion and to correct any anomalies. The Conference, therefore, resolved—- " That every child-bearing mother and every new-born infant shall be cared for under standardized regulations no matter where they are nursed, and that to this end the existing regulations be revised." A very full discussion took place in which the importance of developing special departments for the handling of abnormal obstetric-cases in all hospitals of any size "was emphasized. These units would operate on the " closed " principle and would be

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staffed by obstetric specialists, thus utilizing to greater advantages the services of the considerable group of men who have prepared themselves for such responsibilities. This policy has been urged by the leaders in obstetrics in New Zealand for many years and was recommended and fully explained in the 1946 report. The practice is extending considerably but the Conference considered that it should be the recognized general policy. In considering the closely related matter of uniformity in nurse training, pediatric care, and research the Director of Nursing training similarly described in detail (see Addendum III) the standardized methods of instruction and the uniform practice in regard to case-histories, charts, and records. She explained the general system of inspection and the supervisory control exercised by the Nurses and Midwives Registration Board. An obstetric section of the post-graduate course was now giving advanced training to senior midwives aiming at higher-charge positions or teaching posts in obstetrical hospitals. Close co-operation was maintained with the Plunket Society's advisers in matters relating to infant-care, and in all maternity training schools one Sister at least had Plunket training to ensure uniformity in teaching regarding infant care. Touching on research, reference was made .to the combined study of new suggestions in regard to such everyday aspects of obstetric nursing as the bathing of babies and breast feeding carried out by the Nursing Education Committee of the Obstetric Branch of-the New Zealand Registered Nurses' Association. Any relevant investigations by other bodies such as the Obstetrical Research Committee of the Research Council were followed with interest. Overseas practice had also been studied by the Director of Nursing herself in visits to the training schools of Northern Europe, Great Britain, Canada, and America. Here again the Conference was satisfied with the general position, and it was obviously the general feeling that, apart from a few exceptional instances of faulty methods, a uniform and progressive practice was, indeed, followed. The Conference formally put on record—- " That this Committee approves and supports the steps already taken to obtain uniformity in nurse training outlined in the memorandum by the Director of the Division of Nursing." Considerable thought was given to the possibility of further safeguarding or improving the position. It was recognized that the extension of the "open" annexe policy, with more doctors attending some of the hospitals in which maternity nurses are trained, might lead to greater variation in practice and possibly some confusion. The nurse members of the Conference agreed that this applied more to different preferences in such matters as the use of analgesia drugs than to differences in nursing technique. The advisability of more definite charting of instructions in these, matters (a point which was later the subject of a definite resolution in relation to another question) was discussed. It was also regarded as advantageous that in all "open" units of any size one or more experienced practitioners should guide the general policy of the unit, be responsible for the teaching, and possibly organize the compilation of useful records amongst the group. Out of the discussion of this last point and as a result of a similar discussion on pediatric care, the Conference resolved—- " That this Committee emphasizes the potential value of the Obstetrical Research Committee of the Medical Research Council and advises that all obstetrical units give close co-operation by providing statistical information which may be required." One direction in which it was considered that the New Zealand service should more generally follow modern overseas practice was in the development of neo-natal units, under the care of pediatric specialists, in connection with maternity hospitals.

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While the Conference was not prepared to go the length of recommending that such pediatricians should have charge even of the normal babies in the " open " annexes, there was full agreement in advising that their services should be freely used in the supervision of all babies requiring special examination and care, whether in " closed " or "open" units. It was resolved —- " That this Committee approves in principle the appointment of pediatricians to take charge of all neo-natal units or group units of thirty or more beds, such appointees to work in close co-operation with the obstetricians concerned and also to be available for consultation in "open" wards. In smaller units the same general principle should apply." The Conference was also asked to consider whether the standards of nursing care had been adversely affected by staffing difficulties. The Director of the Division of Nursing read a report on the matter (Addendum IV) which indicated that, although staffing difficulties had thrown great strain on the nursing staffs and had led to overwork, no breakdown in essential standards had been caused. Reasonable proof of this was afforded by the records of maternal, mortality, still-births, and infant mortality (Addendum I). The report was completely endorsed by representatives speaking from their own experience in all parts of the country, and the resolution recorded in the introduction was unanimously passed. It was generally agreed that standards had been maintained in spite of great difficulties, but that this had been achieved at the expense of long hours and overwork. Satisfaction was felt that already some easing of the position was to be noted and that many of the suggestions made by the 1946 Committee in this connection had been adopted with considerable success. Figures presented by the Nursing Division of the Department of Health for the year ended 31st March, 1948, showed a total maternity nursing staff of 666 for 702 occupied beds, which gives the very satisfactory ratio of 1 to 1-05. SECTION lI.—ORDER OF REFERENCE, ITEMS 2 AND 3 To inquire into and submit suggestions relating to building programmes for maternity-hospital purposes covering (&) centralization, (b) decentralization, (c) incorporation in, or (d) detached from existing buildings. Whether obstetrical work should be separated from all general hospital contact, and whether Maternity Nurses should live in obstetrical hospitals. The discussion under this heading was opened by Dr. Gordon, who made reference to certain problems which she had encountered during her term of office as Director of Maternal Welfare. She spoke of the distances which maternity patients were in some cases required to travel to reach a maternity hospital, and of instances where in existing buildings she regarded the relationship of maternity wards to other hospital services as unsatisfactory, and where in buildings being planned there appeared to be a conflict of opinion as to whether the maternity ward should be a separate building or included with other wards in a new wing. In the discussion which followed reference was made to the recommendation of the McMillan Committee to the effect that in country districts it should be the policy to provide maternity accommodation within a short distance of the patients' own homes and their doctors. Dr. McNickle expressed the view that small units short distances apart are neither economic nor satisfactory, and adduced New Zealand instances and overseas opinion in support of his contention. It was generally agreed that in this, as in other matters, the Conference .should concern itself with principles rather than with details, and further discussion under this

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heading was largely restricted to two questions—(l) the question of centralization versus decentralization, and (2) the question of whether maternity wards or units of hospitals should be incorporated in, or be detached from, other hospital buildings. The Conference endorses the view of the 194-6 Committee on the subject of maternity hospitals in country districts. It considers that there is a definite need for the smaller maternity hospitals as well as for base maternity hospitals, and that in any area, whether city or country, the principle of a base hospital and such outlying smaller units might well apply. The question of where such outlying units should be situated must, in the opinion of the Conference, be determined by a consideration of all relevant factors, especially distribution of population and transport facilities. The base maternity hospital should be associated with the general hospital, in order that full and proper use may be made of certain facilites which the general hospital provides. The ideal arrangement is then considered to be one in which the base maternity hospital is in close juxtaposition to the general hospital but not incorporated in it. It is realized that problems of siting and of building construction may prevent the universal attainment of this ideal, and there is no intention of condemning the provision of maternity accommodation as a wing or even as one floor of a wing in a general hospital. The recommendation of the Conference is summarized in the following resolution:— " This Conference approves the principle that, wherever possible, a base maternity hospital should be a separate building in close juxtaposition to a general hospital." In connection with this discussion consideration was given, in passing, to the desirability of the provision of " flying squads " for blood-transfusion, operating from the base hospital, and serving the outlying smaller institutions. The Conference was interested in figures presented by Sir Bernard Dawson, which showed that, if available English figures are taken as a basis for calculation, the number of calls on such a flying squad for a city with the population of Dunedin might be expected to average two per year. This section of the Conference's deliberations concluded with a brief discussion on the desirability or otherwise of separate nurses' homes for the nursing staffs of those maternity hospitals which are associated with general hospitals. It was suggested by certain of the speakers that, from the point of view of fuller precautions in the avoidance of infection, the provision of a separate nurses' home might be ideal; but against this it was generally realized that, even if a separate home were provided, mingling of the two staffs would still occur during off-duty hours, while those experienced in nursing administration drew attention to the practical difficulties that arise as a result of segregation of two sections of a nursing staff. The resolution passed by the Conference reads as follows : " Under existing conditions, this Conference is of the opinion that there is no objection to maternity nurses sharing the accommodation of general nurses." SECTION lII—ORDER OF REFERENCE, ITEM 5 How to safeguard under the law maternity patients and their children from incompetence or negligence or malpractice of any doctor. . Dr. Gordon made reference to seven cases which had come under her notice, and which she considered gave evidence of incompetence or negligence on the part of registered medical practitioners. The Conference desires to make it clear that it was in no position to investigate these cases, nor was it called upon to do so, and that it therefore expresses no opinion with regard to them. Dr. Gordon's remarks did, however, promote a discussion on whether or not the existing machinery is adequate to deal with cases of the kind. It is realized that, in any case of alleged negligence, the patient or her relatives may have recourse to civil

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action against the medical practitioner if they so desire. In addition, the Medical Council of New Zealand has power, should it have reason to believe that any registered medical practitioner has been guilty of grave impropriety or infamous conduct in a professional respect, to require the practitioner to appear before the Council and to show cause why he should not be dealt with by the Council in accordance with the provisions of the Medical Practitioners Act. It is further realized that the Medical Council has from time to time investigated cases of less gravity, in which it did not see fit to impose any of the penalties provided by the law, and that it has issued warnings and advice. The Conference feels that there is need for some more clearly defined procedure for investigating and otherwise dealing with cases of less gravity than those covered by the disciplinary sections of the Medical Practitioners Act. It is pointed out, in passing, that this applies with equal force to branches of the practice of medicine other than obstetrics. The resolution passed by the Conference is as follows : " That consideration should be given either to enlarging the functions . of the Medical Council or by some other means bringing minor degrees of incompetence, &c., under investigation and control." SECTION IV—ORDER OF REFERENCE, ITEM 7 The advisability of establishing an Obstetric Council from which the Minister could obtain advice on matters affecting the maternity services of New Zealand. The discussion on the question of an advisory Council on matters affecting the maternity services was opened by the Director of Maternal Welfare, whose remarks gave the Conference the impression that she was urging the setting-up of a council representative of all the bodies interested with wide powers to deal with all policy matters connected with the service, including hospital construction, siting, and priorities. At this point the Director-General of Health made it clear that whilst the Government, through the Department of Health, welcomed expert advice, it could not possibly give to any outside body powers that seemed almost mandatory, and the Conference agreed that the discussion must centre round the advisability of an Advisory Council and the form that it should take. It was apparent that, rightly or wrongly, there was some feeling that under present conditions the considered opinions of some of the organizations vitally interested in the maternity services did not receive full weight in the final presentation of the case to the Minister. Representatives of the Obstetrical Society explained that it was felt that instances had occurred where strong representations based on the majority opinion of those actually practising obstetrics had been over-ruled. The Director-General having again assured the Conference of the Department's willingness to give full consideration to those entitled to speak on any particular aspect of the service, it was decided that in such particular and local matters consultation with the existing organizations concerned in these questions should suffice and that the combined Council suggested would be unwieldy and redundant. Discussion was then focused on an Advisory Council at a higher level, and it was agreed that there was a need for an obstetrical body corresponding to the Australasian colleges to which the Minister might refer obstetrical problems as was now done with questions relating to surgery and medicine. Professor Dawson pointed out that it was hoped that in the near future there would be in New Zealand a Regional Council of the Royal College of Obstetricians and Gynaecologists which would in effect be a sub-committee of the Council of the College in London. He felt that this Regional Council would fill the gap and act in a similar way to the Australasian Colleges of Physicians and Surgeons. Professor Dawson stressed the fact, and with this the Minister agreed, that an Advisory Council would be concerned with standards and principles, that there were advantages

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in using the Regional Council of the College of Obstetricians because it would be part of a wide inter-Empire organization recognized as the arbiter of standards for qualifications for obstetric specialists and of principles governing obstetric practice, and, further, that, if consulted upon appointments as obstetrical specialists or to hospital staffs, it would be free of any local or personal influences. He felt that the function of the Obstetrical Society would be to advise upon local problems as they might affect the welfare of general practitioners and felt sure that both organizations had their place and would work in harmony together. There was some further discussion along similar lines, and the following resolution was passed without dissent:— " It is agreed that this Conference recommends to the Minister the advisability of recognizing an Obstetric Council from which the Minister could obtain advice on matters affecting the maternity services in New Zealand." SECTION Y—ORDER OF REFERENCE, ITEM 8 Such other matters as may arise in the course of the Conference's inquiries„ 1. The Question of Early Ambulation and the Duration of the Puerperium Professor Dawson introduced several points arising out of an increase in the practice of early ambulation in the puerperium, a practice which, in itself, has much to commend it. It had been found that in some instances the period in which the patients' toilet was carried out by the nursing staff with strict precautions had been correspondingly shortened. The Obstetrical Research Committee, to whom this matter had been referred, considered this to be unsatisfactory and had made recommendations, immediately adopted by the Department, that, even when early ambulation is practised, the usual careful nursing technique should be followed in the puerperium. Early ambulation also involved the question of the duration of the puerperium. It was Professor Dawson's opinion that, while the customary fourteen days convalescent period was generally desirable, there was no reason why the period should be arbitrarily insisted on as a requirement of the regulations ; it was a matter for the decision of the practitioner concerned. With this opinion the members of the Conference were in agreement, and it appeared that in most districts this elasticity of practice was already the rule and, indeed, encouraged by the Department. It was pointed out by several members, however, that there were other considerations besides that of safety on medical grounds. Dr. Averill and Dr. Mason regarded the premature resumption of domestic burdens as undesirable for both town and country mothers. Dr. Deem's concern was lest a shorter stay in hospital would result in more mothers being insufficiently prepared for successful breast-feeding. Since 1939 a considerable increase had been noted in the percentage of babies artificially fed when leaving hospital, a fact which she attributed, in part at least, to insufficient practical instruction of the mother. Apropos this question of mothercraft instruction, it was again recommended that, wherever possible, there should be an increase in the permanent staff on the nursing side for this purpose, and the advisability of continuing the policy of utilizing Karitane Nurses, both during their later period of training and after training, was discussed. The Conference expressed its Opinion in the following resolution : " This Conference' reaffirms the desirability of an average puerperium of not less than fourteen days, but considers that the duration of the puerperium in individual cases should be the responsibility of the attending practitioner." 2. Problems of Maternity Nurse Training Dr. Plunkett brought up again the vexed question of the great wastage that occurred as the result of a very large proportion of Nurses with maternity training making no further direct contribution to the maternity service. It was pointed out that this

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question had exercised the minds of the Director of the Division of Nursing, members of the Obstetrical Society, and members of previous maternity services committees for many years, but always the final conclusion had been that these Nurses did at least help in the staffing of the maternity hospitals during their period of training and that this experience was of very great value in general nursing. It was, indeed, proposed to include maternity nursing in an extended four-year general course. It was still thought that certain conflicts between the requirements of medical students and of pupil Maternity Nurses could be satisfactorily adjusted. A very similar wastage occurred in the ranks of the general nursing service. This Conference, like its predecessors, was not in favour of any measure of compulsion, nor did it consider that a combined training in obstetrics and gynaecology would improve the service. 3. The Question of Open or Closed Maternity Hospitals (a) Several important matters relating to the general question of " open " or " closed " maternity hospitals (interpreted in the sense indicated in the introduction) were discussed. It was pointed out that the whole question had been thoroughly dealt with in the 1946 report, and it was therein recommended that accommodation provided by Hospital Boards for normal maternity patients should be open to all practitioners except in the case of obstetrical units which are used for educational purposes. Professor Dawson and other speakers stressed the necessity for some agreement between the attending practitioners and their respective Hospital Boards that would ensure, as far as possible, the maintenance of good standards of technique and methods of obstetrical practice. After some further discussion there was general agreement with the following resolution : " That it is a recommendation from this Conference that open accommodation for maternity patients provided by Hospital Boards shall be open to all practitioners provided that they have signed an agreement between themselves and the respective Boards ; such agreements shall include an undertaking to maintain the highest standards of technique and methods. It shall also be agreed that one obstetric specialist or senior practitioner shall be responsible for the teaching of the Nurses." A suggestion was made that, alternatively, a panel of practitioners should be established in all districts and that the practice of this " open " accommodation should be limited to those practitioners elected to this panel. The above resolution, however, disposed of this suggestion. (b) In connection with practice in open maternity annexes, the need for more precise charting of instructions was again raised. It was felt by many of the members of the Conference that with so many attending doctors there was the possibility of confusion for the nursing staff and some risk of mistake unless instructions were given in writing by the practitioners concerned. It was realized that the immediate charting of every detail of certain routine procedures would be impracticable, but the general opinion of the Conference was expressed as follows : "It is a recommendation of this Committee that, with the exception of recognized routine procedures, the use of which must be endorsed by the practitioner on individual charts at the first possible opportunity, all instructions for the treatment of maternity patients must be charted and signed by the medical practitioner." (c) Considerable concern was expressed by representatives of the Obstetrical Society that the policy regarding the St. Helens hospitals was apparently still undecided. As the last known declaration of the policy of the Department of Health in connection

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with, the proposed St. Helens Hospitals for Wellington and Christchurch was that the Department would conduct these hospitals on the " closed " principle, it was thought that the time had come for a definite statement as to whether this was still the intention. In the 1946 report it was recommended that, if it was insisted that the teaching of mid wives must continue under Department of Health control in " closed " St. Helens hospitals, such St. Helens hospitals should be of moderate size and that" open " maternity hospital facilities should at the same time be developed in connection with the Board Hospitals. After some discussion by members of the Conference, including the departmental officers, the following resolution was passed : " That this Conference asks the Minister of Health to declare the policy for the future development of St. Helens hospitals in New Zealand, and that the recommendation of the 1946 report be given earnest consideration." 4. The Question of Combined Units of Obstetrics and Gynaecology Sir Bernard Dawson introduced the subject by advocating the desirability of establishing in all hospitals of appropriate size, say, of two hundred or more beds, combined units of obstetrics and gynaecology controlled by unified staffs. The proposal gave rise to considerable discussion, in the course of which it was evident that the subject was one on which different views were held. Sir Bernard Dawson claimed that the divorcement of the closely allied subjects of obstetrics and gynaecology was undesirable and unnatural. He stated that, with few exceptions, combined units of obstetrics and gynaecology have existed in all the important hospitals in Great Britain and in the Dominions since the beginning of the century ; he could not understand why in New Zealand, at this much later date, opposition to the proposal still existed. He further explained that the prescriptions of the medical curricula in the calendars of all British universities referred to medicine, surgery, and obstetrics and gynaecology —i.e., to three subjects and not four—thus indicating the close and well recognized fusion of the two subjects. Dr. Cairney intimated that he could not support the proposal. He advocated the point of view that specialist departments in individual hospitals in this country should develop by a gradual process of evolution, and believed that all institutions would not necessarily follow the same lines. He stated that specialists in this field tend in many instances to become either gynaecologists or obstetricians, but not both, and saw no practical reason why, in hospital practice, the two subjects should be combined under the one specialist staff. In support of his contention that the two subjects can be separated he mentioned some Australian institutions where this practice applies. He claimed that no facts had been produced to convince him of any greater efficiency of a combined unit. Professor Dawson, in reply, suggested that there was ample proof in the fact that the majority of important hospitals had installed, and the great majority of obstetrical and gynaecological authorities had advocated combined units for the past fifty years. Dr. Averill, Dr. Kenrick, and Dr. Plunkett supported the claim for combined units, while Dr. McNickle intimated that he supported Dr. Cairney's view. The following resolution was passed as a majority decision : " This Conference recommends to the Minister of Health that the Hospital Boards of New Zealand be urged in future hospital planning and future medical appointments to give full consideration to the accepted principles of grouping obstetrical and gynaecological cases together in a combined unit with a unified staff." At the conclusion of the Conference Dr. Doris Gordon again reviewed some of the problems which she had noted in the administration of the maternity services, and expressed her satisfaction with the discussions which had taken place and her hope that they would lead to the resolution of these difficulties.

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INDEX TO ADDENDA PAGE Addendum I.—Table showing Numbers and Rates of Births, Infant Deaths, Stillbirths, and Maternal Deaths, 1935 to 1947 .. .. .. .. .. IS Addendum ll.—Miss Lambie's Report No. 1.. .. .. .. .. ..13 Addendum lll.—Miss Lambie's Report No. 4 .. .. .. .. .. 15 Addendum IV. —Miss Lambie's Report No. 6 .. .. .. .. .. .. 16

Numbers and Rates of Births, Infant Deaths, Still-births and Maternal Deaths, 1935 to 1947 (Europeans only)

No. I—TO CONSIDER AND RECOMMEND STANDARDS OF CARE FOR MOTHERS AND INFANTS IN STATE AND PRIVATE MATERNITY HOSPITALS, WARDS, AND ANNEXES 1. Since 1927 the Department of Health has published Instructions by way of Pamphlets entitled : (a) " The General Principles of Maternity Nursing, including the Management and Aseptic Techniques of Labour and the Puerperium " (H-Mt. 20). (b) " The Technique of Isolation. Medical Asepsis, and Disinfection of Maternity Hospitals " (H-Mt. 18). 2. There have been revised from time to time by an Obstetrical Nursing Committee, the last edition being published in March, 1945. A further revised edition is at present in the hands of the printer, corrected proofs having been returned to him. 3. On each occasion of the revision of these pamphlets professional advice has been sought from Dr. Corkill, Chairman of the Wellington Branch of the Obstetrical and Gynaecological Society, and by Dr. Ewart, Medical Superintendent, St. Helens Hospital, Wellington, as to obstetric nursing care ; Dr. Helen Deem, Medical Adviser to the Plunket Society, as to infant care ; and Dr. Muriel Bell, Nutritionist to the Department of Health, as to nutrition for the mother.

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Year. Live Births. Birth-rate per 1,000 of Mean Population. Infant Deaths. Infant Death-rate per 1,000 Live Births. Still-births. Still-birth Rate per 1,000 Total Births. Maternal Deaths. Maternal Death-rates per 1,000 Live Births. (a) Including Septic Abortion. (b) Excluding Septic Abortion. (a) Including Septic Abortion. 0b) Excluding Septic Abortion. 1935 23,965 16-17 773 32-26 738 29-87 101 78 4-21 3-25 ■ 1936 24,837 16-64 769 30-96 732 28-63 92 78 3-70 i 3-14 1937 26,014 17-29 812 31-21 761 28-42 94 70 3-61 2-69 1938 27,249 17-93 971 35-63 743 26-54 111 81 4-07 2-97 1939 28,833 18-73 898 31-14 900 30-27 105 85 3-64 2-95 1940 32,771 21-19 990 30-21 965 28-60 96 82 2-93 2-50 1941 35,100 22-81 1,045 29-77 971 26-92 118 94 3-36 2-68 1942 33,574 21-73 964 28-71 891 25-85 85 58 2-53 1-73 1943 30,311 19-70 951 31-37 817 26-25 67 52 2-21 1-72 1944 33,599 21-59 1,012 30-12 799 23-23 91 72 2-71 2-14 1945 37,007 23-22 1,036 27-99 865 22-84 83 72 2-24 1-94 1946 41,871 25-24 1,093 26-10 931 21-75 86 74 2-05 1-76 1947 44,816 26-42 1,122 25-04 911 19-92 48 38 1-07 0-85

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4. The standards set by the Medical Research Council of Great Britain have been used as a basis for sterilization methods. 5. The pamphlets are supplied to all midwifery and maternity training schools, and it is on the basis of these requirements that the nurses and Midwives Board examines candidates for the State Midwifery and Maternity Examinations. 6. These pamphlet instructions are supplied by the Medical Officers of Health to all maternity hospitals—State, public, and private—in their districts, and it is on this basis that all inspections of maternity hospitals are carried out. 7. It has been possible to standardize technique, on account of the fact that same is very carefully carried out in the St. Helens hospitals, wherein all future Sisters of maternity hospitals are trained as midwives. 8. It has been stated that trainees at St. Helens hospitals are not sufficiently trained in pain relief. This is not correct. These hospitals all use analgesia frequently, and obstetrical anaesthesia is carefully given. 9. I would like to quote from the annual report for the year ending 31st March, 1948, of Dr. Ewart, M.D., M.R.C.0.G., Medical Superintendent and Senior Obstetrician, St. Helens Hospital, Wellington, reading as follows : From time to time uninformed lay people have stated that patients in St. Helens receive little or no pain relief in labour. We know that this is untrue. We believe that the administration of analgesic and sedative drugs, because of the supervision and interest of Dr. Griffin, and the fall co-operation of the Matron and her nursing staff, is better carried out at St. Helens Hospital than in any other obstetric hospital in Wellington. Dr. Griffin's report is valuable not only from his findings, but also as a record which will refute allegations of the lack of pain relief. 10. Recently the Matron of one of the larger maternity training schools raised the question of what maternity nurses must be taught with regard to obstetric anaesthesia whilst awaiting the arrival of the doctor. The matter was discussed by the Nurses and Midwives Board, and a ruling was given that, until an opinion is received from the Obstetrical and Gynaecological Society of New Zealand, nurses are only to be instructed in the use of Small's ether apparatus. The Board was guided in its decision by Dr. Corkill, who is a member of the Board. 11. Due to the early ambulation policy recently adopted in several maternity annexes, the Inspecting Officers of the Nursing Division, concerned about the care being given to these patients, discussed the matter with Dr. Gordon, Director of Maternal Welfare. This was referred by Dr. Gordon to the Obstetrical Section of the Research Council. A reply was received concerning the type of perineal care which should be given to ambulant patients. This was circulated to all maternity training schools and to the Medical Officers of Health for the guidance of the Nurse Instructors. 12. Last year Dr. Deem and Miss Lusk, Nursing Adviser to the Plunket Society, were invited to a conference of Nurse Inspectors to review the care of premature babies and the encouragement of breast feeding. Certain principles were approved and subsequently circulated to all Medical Officers of Health for transmission by the Nurse Inspectors to maternity hospitals of all categories. 13. It has been found inadvisable for new-born babies whose mothers are transferred to a medical ward from an obstetric ward to be nursed in other than a new-born-infant nursery, and under the same strict conditions of isolation. 14. This standard of care has recently been under review by the Director, Division of Nursing, who visited obstetric hospitals in the United States of America and Canada last year, and by Miss J. Alley, Nurse Instructor in Obstetrics at the Post Graduate School for Nurses, Wellington, who spent the whole of last year observing obstetric nursing in Great Britain and Canada.

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No. 4—HOW BEST TO ESTABLISH UNIFORMITY IN NURSE TRAINING, PEDIATRIC CARE, AND RESEARCH 1. The question of uniformity of training has already been dealt with under para. 1 of the order of reference. 2. All maternity training schools are visited six-monthly by the District Nurse Inspectors, to check up on technique and to examine patients' charts with the object of ensuring that the methods laid down are being properly carried out. 3. In addition, all training schools are visited annually by an Inspector of the Division of Nursing to investigate nursing technique in regard to — (a) The care of the mother and baby. (b) The lectures being given. (c) The method of preparation of case-histories. (d) The method adopted in writing up charts. (e) The method in which records are kept. 4. These reports are submitted to the Nurses and Midwives Board, which holds a, minimum of five meetings per annum. The resolutions arising from the Board's deliberations are conveyed, where necessary, to the training school concerned, and .steps are taken to ensure that all " follow-up " action necessary is taken. 5. The Nursing Division of the Department of Health has co-operated with Dr. Deem, and Miss Lusk, Medical Adviser and Nursing Adviser respectively to the Plunket Society, in regard to research into breast-feeding, and in regard to any matter referred to the Division by the Obstetrical Section of the Research Council. 6. There is a standard text-book for all maternity training schools. The author is Dr. Corkill. 7. In all maternity training schools there is at least one Sister with Plunket training to ensure standard care of teaching in regard to infants. 8. The system of case nursing whereby the mother and baby are nursed as one nnit by a trainee is the practice universally advocated in New Zealand maternity training schools. 9. This year, as part of the post-graduate course, the Department has established an Obstetric Section for the training of Senior Nurses who eventually will be either in charge of an obstetrical hospital, or will be in charge of the teaching of obstetrical nursing. 10. The course in obstetrics is under the guidance of an officer of the Nursing Division, herself an experienced midwife, and who was given a year's experience abroad to enhance her fitness for this position. 11. It is hoped by this means to prepare even more adequately those whose duty it is to teach obstetrics, and generally to create a further incentive for Senior Nurses to specialize in obstetrics. 12. After visiting training schools in Northern Europe, Great Britain, Canada, and America, the nursing officers of the Division of Nursing are convinced that there is better uniformity of nursing training in New Zealand than in any other country visited, and this irrespective of the fact that this Dominion does not possess the palatial institutional buildings seen in the older countries. 13. The Nursing Education Committee of the Obstetric Branch of the New Zealand Registered Nurses' Association has from time to time carried out research into different aspects of obstetric nursing—i.e., bathing of babies, breast-feeding, &c.' —and these have been published in the New Zealand Nursing Journal.

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14. With regard to research generally, the Obstetrical and Gynaecological Society has recently completed an investigation as to the value of maternity exercises. By the courtesy of Sir Bernard Dawson, Professor of Obstetrics at the Otago University, the conclusions were submitted to the Nursing Division, and same are to be transmitted to the Medical Officers of Health for distribution by the District Nurse Inspectors to Maternity Hospitals. No. 6—TO WHAT EXTENT HAVE NURSING STANDARDS IN OBSTETRICAL CARE BEEN AFFECTED CONSEQUENT UPON STAFFING DIFFICULTIES 1. It is common knowledge that during the last two years nursing personnel of maternity hospitals have been definitely overworked. * 2. Domestic staff has been difficult to obtain. However, the Government immigration scheme has helped in some instances, and it would appear that the over-all position has become slightly easier. 3. The great difficulty has been that very few hospitals have in the past provided living-in accommodation for domestic staff, and this has been accentuated by the existing housing shortage. 4. As the consequent result of the shortage in domestic staff, nurses have had to undertake duties which normally do not fall within their sphere. 5. The position with regard to nursing personnel, however, has materially improved due to the following factors : (a) The general recruitment programme. (b) The personal appeals to, and interviews with, newly-qualified maternity nursesby the Department's Nurse Inspectors, with the object of. endeavouring to> persuade them to continue with obstetric nursing. (c) The greatly improved salary scales, which now offer a better career and which should further assist the position. As an instance of the growing popularity of obstetrical nursing, the Nursing Division recently had to approach several hospitals before being able to place eight maternity trainees upon their arrival from Britain under the immigration scheme. 6. Certain small country hospitals are still finding extreme difficulty in recruiting staff, but this is no new matter. Personnel generally are still loath to accept positions in isolated areas, particularly where but few amenities exist. 7. In spite of difficulties, the record maternal and infant death rate and still-birth rate for the Dominion this year show that the Maternity Nursing Service has coped with the position in a most satisfactory way.

Approximate Cost of Paper.—Preparation, not given; printing (963 copies), £32

By Authority: E. V. Paul, Government Printer, Wellington. —1948. Price 6d.]

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