H.—3l.

The improved training of maternity nurses and midwives is slowly working an improvement on the conditions governing asepsis ; but there is still a great deal to be done in this direction, particularly in private practice. One must recognize the magnitude of the task of teaching the principles and practice of asepsis to all nurses ngaged in maternity practice, especially as the original training of most of these nurses did not include the teaching of asepsis. A useful lesson can be learnt by considering what had to be done some forty years ago when the practice of asepsis was first introduced into surgery. Within my own knowledge, which goes back over forty years, the general adoption of asepsis in surgery, and the perfecting of it to its present degree, took at least fifteen years ; and the teaching of the. nurses, who had not been originally trained in asepsis was at first carried out by the surgeons in actual practice, beginning with those surgeons whose enthusiasm and convictions of its benefits finally caused it to be generally adopted. To any one with a knowledge of the subject it must be obvious that it is quite impossible to withdraw hundreds of maternity nurses and.midwives every year from practice and give them a refresher course in asepsis. The cost would be enormous and the consequent dislocation of the nursing service disastrous. The obvious conclusion is that the training of maternity nurses in asepsis can only be accomplished in a reasonable time, when every medical practitioner feels it his duty to his patient and to himself to see that the practice of asepsis in maternity work is carried out completely and that the principles of surgical asepsis are efficiently applied to obstetrics. As long as the practitioner is forced or is content to accept nurses untrained in asepsis and not to practise asepsis himself, so long will his work be incomplete and unsatisfactory, and not in the best interests of the patient. Unfortunately, the ignorance of the patient and her nurse as to what is required of them often forces the medical attendant to accept conditions which he disapproves. It is of the utmost importance that the expectant mother should be well instructed as to what tier duties to herself and to her medical attendant are in order that full precautions against sepsis may be made. If sepsis is to be practically excluded, the patient herself must be made to recognize the importance of asepsis, and to take her medical man's advice upon the selection of a trained maternity nurse who understands asepsis and to provide a sterilized maternity outfit for the benefit and use of her attendants. That at present she does not recognize this necessity is shown by the returns of the ante-natal clinics. Out of 3,919 new cases attending the clinics, only 515 of these patients availed themselves of the opportunity of providing themselves with these necessary outfits. Allowing that the ordinary proportion of these cases were attended in private hospitals which provide sterilized outfits, approximately 1,900 outfits should have been provided. It cannot be said that there is any economic difficulty in providing these outfits. As has been pointed out before, practically the whole of the outfit, if made of new material, is convertible at the end of the lying-in period into babies' napkins, the cost of the material being approximately £1 ss. If, however, it is made of old sheeting the cost to the woman is the value of the old sheets, plus approximately 2s. 6d. for cotton-wool and tow and 2s. 6d. for sterilizing. Full details with regard to these outfits have been embodied in the new edition of " Suggestions to Expectant Mothers," and model outfits have been distributed to all training-schools, Nurse Inspectors, and those clinics which have applied for them, and I hope by this means to bring home to those interested the necessity of providing this safeguard against infection. It is interesting to note that during last year the provision of maternity outfits through the ante-natal clinics, which was initiated in New Zealand some years ago, was strongly advocated by Professor Beckwith Whitehouse, Royal Society of Medicine, as an important means of preventing puerperal sepsis, and that he considered the ante-natal clinic was the best means of distributing these outfits. He also states that "an experimental clinic with a team headed by a sister who really knew her job " (the italics are mine) had been started in connection with a maternity hospital at Birmingham, and that in the first thousand cases the morbidity rate was only 2 per cent., and only one woman in one thousand died, and that she had not had full ante-natal supervision. It is, however, obvious that there is little difference of opinion as to what should be done, and the difficulty of getting it done is found to exist in most countries. In my opinion, the key to the solution of the problem of promoting maternal welfare is cooperation between the expectant mother and her husband, a well-trained ante-natal clinic nurse, an alert and efficiently trained medical attendant, and well-trained maternity nurse or midwife, and the Hospital Board's services, which latter can provide maternity hospitals for those cases requiring hospital attendance and services for sterilizing outfits for all patients. Of these the most important factor is a medical attendant determined in ensuring aseptic conditions. The most useful work that the Health Department can do is in organizing these forces so that they work harmoniously together to promote maternal welfare. Having satisfied myself that a reasonable standard of efficiency exists in the majority of the hospitals under my inspection, I intend to devote more time to organizing-work to promote the desirable co-operation indicated above. In conclusion, I wish to express my thanks for and appreciation of the help cordially extended to me by many members of the medical and nursing profession, and, like Oliver Twist, to ask for more, particularly from the Obstetrical Society and the Plunket Society ; also to yourself and my fellow officers of the Health Department, particularly to Dr. Jellett, Consulting Obstetrician, for his invaluable advice on many points, and to the Medical Officers of Health and their Nurse Inspector, with whom my work is most closely associated and to whom, any credit for the result achieved in bringing to a fairly satisfactory uniform standard the 387 private maternity hospitals in New Zealand is mainly due.

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