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SECTION 2.—REPORT OF THE INSPECTOR OF HOSPITALS, T. L. PAGET, L.R.C.P. (LOND.), M.R.C.S. (ENG.). I have the honour to submit to you my third annual report, covering the activities of the Health Department since 1924 to reduce maternal mortality. Conditions to promote Safer Maternity. —In my address at the beginning of the campaign for this purpose, and in my report to you on the question of the further help that might be given by the Health Department by organizing efforts to promote better and safer conditions for pregnant and parturient women, I classified the dangers to which they were mostly subject as follows— (1) Toxaemias of pregnancy; (2) puerperal sepsis; (3) accidents of childbirth, including haemorrhage —and stated my opinion as to the method that should be adopted to reduce these dangers to a minimum—namely, (1) the establishment of public ante-natal clinics with specially trained nurses; (2) the improvement in the training of midwives and maternity nurses in asepsis, and providing more trained maternity nurses ; and (3) an increase in the number of maternity hospitals where abnormalities discovered in the ante-natal clinics could be sent for special treatment, and an improvement in the equipment of maternity hospitals. It is now over two years since action based upon that report was commenced, and I now review the results obtained and the methods of obtaining them. Ante-natal Clinics. —As stated then, I regard ante-natal supervision as an essential basis of all efforts to improve results in the maternity work and advised the establishment of public ante-natal clinics in charge of specially trained nurses as the best method of attaining the object of reducing the number of toxaemias and eclampsias, besides being essential for the elimination of much of the danger from sepsis and accidents of pregnancy. Dr. Elaine Gurr's report for this year shows what work has been done in this direction, and the very encouraging results obtained. Briefly reviewing this, it shows that twenty clinics have been established by or with the assistance of the Department, and that during the past year 3,461 prospective mothers attended the clinics on 13,175 occasions. This shows a considerable increase of patients and visits at the clinics, which is set out in tabular form in her report. The popularity of the clinics with medical practitioners and their patients is shown by these figures, and the result of the work done is reflected in the decreased mortality and morbidity, and fully justifies our expectations. Inquiry into certain cases satisfies me that the chief factor in getting better results will be closer co-operation between medical attendants, patients, and their husbands, on the one part, with the clinic nurses and medical practitioners on the other. Inquiry into four maternal deaths occurring in women who attended the clinics established the fact that all of these would probably have been saved had that co-operation been forthcoming. Two of these cases are cases of malpresentation, which were discovered at the clinic, but owing to neglect to take full advantage of the discovery, due to want of promptness of action either on the part of the patient or doctor, much handling resulted which might have been avoided, and death from sepsis ensued. Another case was malpresentation resulting in death from shock. Neglect to take advantage of the discovery of the malpresentation at the clinic in this case must be laid at the door of the unfortunate patient, to whom, of course, it was impossible to fully warn of her prospective danger : but I have no doubt that had the husband been made fully acquainted of the danger to which his wife was exposed the delay, caused by her ignorance of the full extent of the danger, and consequent neglect to seek early help owing to nervousness, could have been avoided. The fourth case was a case of eclampsia. The pre-eclamptic signs were noted and reported to the medical attendant, but for some reason neglect to observe the warning and to take the necessary precautions eventuated, with the result that a fatality which probably could have been avoided took place. Improvement in the Training of Maternity Nurses and Midwives in the Adoption of Aseptic Methods, and the extension of Facilities for carrying out the Training of Maternity Nurses and Midwives. —The above were the methods advised to reduce puerperal sepsis, and were carried out as follows : A standard aseptic technique was adopted and circulated, to be used in the training of all maternity nurses and midwives in aseptic methods. Arrangements were made to supply, through ante-natal clinics and otherwise, reliably sterilized maternity outfits for cases attended outside hospitals ; also, an improved sterilizing equipment was required in all maternity hospitals. In order to get these results, the new Act governing the registration of midwives and maternity nurses was drawn up and passed, and the regulations under that Act brought up to date in accordance with the new methods adopted. This Act also provided for a more uniform standard of training for midwives and maternity nurses, and for control of the training schools for midwives and maternity nurses by the Registration Board. There are now thirteen training schools for midwives and nineteen training schools for maternity nurses established in the Dominion, and the standard of training has been raised and made more uniform by control by the Registration Board, and the repeated inspections of Dr. Jellett, Consulting Obstetrician to the Department, the Director, Division of Nursing, and myself. I have during the last two years inspected all these training schools, and I am pleased to be able to report that the Health Department's efforts in this direction have in the majority of cases been ably seconded by those in authority. Six hundred and fifty-two maternity nurses practising before the passing of the Act have been registered, and are controlled by the regulations, which are designed to safeguard the patients and ensure as far as possible good nursing by these registered nurses. The new Act and regulations requiring all maternity cases to be nursed by registered maternity nurses, except in exceptional circumstances, has already, in my opinion, begun to have a good effect, and as its provisions become better understood and better appreciated, I am satisfied that the medical profession will find it of use in enabling them to insist upon the same high standard of maternity nursing as they have long since demanded in medical and surgical nursing. There has been considerable difficulty in getting the necessity for strict asepsis in maternity work generally recognized, and there is still much to do before all medical practitioners and all nurses recognize that only by strict asepsis in maternity work can preventable sepsis be minimized.

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