H.—Bl

A similar remark applies to any effort to determine the mortality-rate associated with the various complications of labour which are recorded in the monthly reports. Morbidity-rates. —The statistics of morbidity are unnecessarily confused, a fault for which I may myself be responsible. When drawing up the form for maternity hospitals I put in a column for cases of puerperal morbidity, and another column for cases notified. It was intended that every case that fulfilled the definition of morbidity should be included in the first column, and every case in which the degree of morbidity was such as to call for notification in the second column. In this way the first column would be a record of all the morbid cases, and the second column of all notifiable cases. Unfortunately, this idea has not been parried into practice, as is shown by the fact that the numbers in the second column are sometimes greater than those in the first column, although the opposite should be the case. It is probable that some hospital matrons, when they have got a notifiable case, enter it in the corresponding column, and omit to enter it in the column of morbidity. One point, however, I think can be taken as a fact —namely, that the proportion of morbid cases and notifiable cases recorded in the fourth group of hospitals (i.e., those whose admissions are more than 150 a year) is very much higher in proportion than that in the other three groups. lam afraid this shows that in the smaller hospitals the same accuracy of record is not observed, and their own figures also tend to support this view. In my opinion, morbidity-rates of between I and 2 per cent, are too good to be actual. I think lam right in saying that a morbidity-rate of from 3 to 5 per cent, is regarded as very satisfactory in large maternity hospitals. The recording of morbid cases, and the notification of such as call for notification, is one of the important duties of matrons of nursing homes, and any confusion which is due to the present form of the monthly return should be set right. In this connection I am glad to lea-rn that the Department has adopted, or is about to adopt, the notification of puerperal pyrexia as supplementary to the notification of real or assumed cases of puerperal infection. I assume that the final diagnosis of the cause of such cases will be added to the records as soon as it is available. Mortality Statistics. —Dr. Fairbairn has published (British Medical Journal, Bth January, 1927) some very interesting statistics (vide accompanying graph), in which he compares —(a) The maternal mortality, including associated deaths for England and Wales ; (b) the similar mortality met with in the practice of the Queen Victoria Jubilee Institute midwives ; (c) the actual child-bed mortality of the East End Mothers' Lying-in Home. His figures are set out on the accompanying chart. The contrast is very remarkable and deserves close attention. The East End Home is a self-contained unit with both a district and a hospital practice. Its ordinary work is carried on by midwives, and the ante-natal supervision and the medical aid, when called for, are in the hands of a local practitioner. It neither sends elsewhere its complicated cases nor takes difficult cases from outside its own patients. It thus shows what can be done by ante-natal care, the management of normal cases by midwives, and the assistance of a thoroughly experienced practitioner in difficult cases. Its forceps rate is 2-38 per cent. Prevention of Maternal Mortality.—Some day it will come to be generally recognized that from 90 to 95 per cent, of women will conduct their labours more safely in the absence of any assistance, that for their comfort and general well-being the presence of a nurse is essential, and that in the remaining sto 10 per cent, medical assistance is imperative. The great problem that lies before us is how to recognize this 5 to 10 per cent, without in any way endangering the remaining 90 to 95 per cent. In general terms, the solution is greater ante-natal care, greater asepsis, and greater knowledge. The difficulty lies in the turning of the answer into practice. I have little doubt that throughout the world the danger of interference in midwifery practice is increasing. I have often quoted the statistics of the Rotunda Hospital in support of my views on different points, and I regret to say I can again quote it here. From 1896 to 1910 the gross mortality was 3-4 per cent. ; from 1910 to 1925 it was 6 per cent. It is probable that there were considerably more complicated and serious cases sent into the hospital in the second period than in the first, but Ido not think that this explains wholly the difference in rate. The moral is obvious. If it is essential that the great majority of midwifery cases be attended by medical practitioners, at any rate let us at least attend them in such a way as not to harm the 90 per cent, who do not need us. Ante-natal care, asepsis, and knowledge are their safeguards, and if Ido not include an absence of unnecessary interference it is because knowledge connotes it. The more we know, the more we shall avoid interference, because we shall realize its dangers and be able to provide safer substitutes. The more we know, the more patients will find themselves among the 90 per cent, or more who can conduct a physiological labour on their own account. I think that in the past year very admirable work has been done by Dr. Paget and Dr. Elaine Gurr in the promotion of asepsis and the encouragement of ante-natal care. This work must continue, but it is, in addition, necessary to make greater efforts to get the third essential which I have mentioned above —greater knowledge. Training of Nurses. —A considerable advance has taken place in the education of nurses by the institution of two classes of nurse and the extension of the period of training. There is, however, ample scope and necessity for the improvement of the actual training as opposed to the period of training. For this reason I hope that my suggestions for uniform methods of teaching and of nursing, which have been approved by the Department, will be adopted generally. There is also urgent need of refresher " courses for maternity nurses who have been for some time in practice. Training of Medical Students.—The position in regard to medical students and practitioners is still more unsatisfactory. In the last two years there has been an average of 372 cases annually available for students in the two maternity hospitals at Dunedin. Twenty conductions are usually regarded as the essential minimum for the student. Consequently this number will provide the conductions necessary for approximately seventeen students annually, without leaving any cases available for nurses. The question then arises, How is it possible for these students to get an efficient training in practical obstetrics ?

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