.—3l.

It is usually customary to pay for services rendered according to the time and skill spent on them. I doubt very much if the public recognizes that the fees paid for midwifery practice haidly compensate for the former and wholly neglect the latter. If it could recognize this fact perhaps it would be more ready to leave criticism to those who are competent to criticize, and to devote the time saved to efforts to understand and to carry out the advice it receives. Along such lines the lay press, too, can give the more useful help. Miscellaneous. I have continued the work I began in 1926 of obtaining special reports of maternal deaths and of cases of Ceesarean section, &c., which came under my notice in the monthly returns from maternity hospitals. Whenever such a course seemed of value I have written a note on the case, which the Medical Officer of Health transmits to the medical practitioner concerned. I hope that the criticisms and suggestions made in such notes may have been of some little value. I am afraid that there are some practitioners who object to my asking for the necessary information in these cases. I think such objections are unwise, for the following reason : In 1924 the National Council of Women in New Zealand asked that all maternal deaths should be the subject of a Coroner's inquiry. Further, in February of this year a very large conference of women in London passed, amongst other resolutions, the following : " That steps should be taken to obtain a medical inquiry into any maternal death during childbirth." Although it is most improbable that the suggestion of the National Council would benefit mothers, it is possible that an attempt might be made to force such a regulation on the country. If so, the fact that a medical inquiry was already being held under the directions of the Department of Health would be the surest way of checking it, especially in view of the resolution which was adopted at the London conference, and which has received the support of Sir George Newman, Chief Medical Officer, Ministry of Health, Great Britain. I have for a long time been anxious to get particulars of all maternal deaths. This, however has proved to be a very difficult matter. The number of deaths which occur in maternity hospitals is small—i.e., 0-22 per 1,000 in 1927—as the greater number of patients who are dangerously ill are transferred to other hospitals. Now, however, it has been arranged that Medical Superintendents of general hospitals shall send a report on maternity cases admitted to their wards, and this will bring information regarding deaths which otherwise would have passed unnoticed. The RegistrarGeneral has also kindly undertaken to send a quarterly list of deaths directly associated with pregnant or puerperal women. There are certain matters in the campaign to lessen maternal mortality which are still in an unsatisfactory state. Two of these I have mentioned —first, the incomplete notification and occasional unsatisfactory treatment of eclampsia, and, secondly, the insufficient education of medical students in obstetrics. A third matter is the failure to provide the means by which the general practitioner can carry out the principles of asepsis—that is to say, the failure to provide sterilized dressings which can easily be obtained by all practitioners in all cases. Thanks to the efforts of Dr. Paget, nurses in training are taught how to prepare and use these dressings. If nurses who are engaged in practice could be similarly taught it would be a great step forward. Still, even assuming this to have been done, the provision of sterilized dressings is also necessary, and until measures have been adopted to provide them at a very small cost it cannot be considered that due arrangements have been made for the practise of asepsis in midwifery. lam sure that if packets of dressings were thus available the number of medical practitioners who would not use them would be very small. Ante-natal clinics have been placed on a firm footing in the larger towns, but, so far there has been no definite effort to establish them in the smaller towns ; yet they are as necessary in one as in the other. I suggest that one way in which a start might be made in this direction is by making ante-natal work part of the curriculum for maternity nurses. The latter get ante-natal instruction at hospitals recognized for training midwives, and it is time that the maternity training-schools should also provide it, both for the good of their pupils and for the benefit of the pregnant women in their neighbourhood. Again, it is most necessary that the existing ante-natal clinics in hospitals should be widened so as to include post-natal work —i.e., the examination of the patient before she leaves the hospital. While such an examination is hardly a means of reducing maternal mortality, it is one of the most essential methods of ensuring the future health and comfort of the patient, and, in many cases, of avoiding operations which would otherwise have been necessary. It is the regular practice in some of the St. Helens Hospitals, and I think it would be a step forward if it was introduced in all maternity hospitals. The records of maternal morbidity and of puerperal pyrexia in the monthly returns furnished by maternity hospitals continue to be valueless. This fact is very disappointing in view of the efforts which the Department has made to make clear to the licensees and matrons of maternity hospitals how such records are to be kept. Moreover, Dr. Paget in the course of his inspection has done his utmost to prevent incorrect entries. In spite of all this, I find it recorded that in hospitals of between 101 and 150 beds in the Wellington District there are more cases of puerperal pyrexia than of puerperal morbidity. Every case of puerperal pyrexia is primarily a case of puerperal morbidity, and to make the former exceed the latter is akin to saying that there were forty-one cases of forceps extraction of which fifty-four were associated with perinseal laceration. I think that Nurse Inspectors ought to be able to arrange that these very simple statistics are kept correctly. Further, the statistics are, in my mind, very much too favourable. The percentage of puerperal morbidity for the whole country, as shown in the monthly returns, is less than 2 per cent., a figure which in practice I think it is very hard to reach. Further, while the percentage for hospitals with more than 150 confinements annually is 2-27, the percentage for hospitals with less than fifty confinements is only 1-63. It is very necessary that reliable statistics should be available.

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