Part 14

Without vouching for the entire accuracy of Le Fort’s data, they may still be taken generally as showing approximately the penalty which is being paid for the supposed advantages of these institutions. It is this: (see Table XV.) for every two women who would die if delivered at home, fifteen must die if delivered in lying-in hospitals. Any reasonable deduction from this death-rate for supposed inaccuracy will not materially influence the result.

TABLE XV., abstracted from TABLES III. and X., showing Comparative Mortality among Lying-in Women in Hospitals and at Home. ┌──────────────────────────────────────────┬──────────┬──────┬────────┐ │ │ │ │ │ │ │ │ │ Deaths │ │ │ │ │ per │ │ │Deliveries│Deaths│Thousand│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Total for all hospitals │ 888,312│30,394│ 34│ │Total delivered at home │ 934,781│ 4,405│ 4·7│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Excess of deaths per thousand delivered in│ │ │ │ │ hospitals │ │ │ 29·3│ └──────────────────────────────────────────┴──────────┴──────┴────────┘

The evidence is entirely in favour of home delivery, and of making better provision in future for this arrangement among the destitute poor.

CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE IMPROVED?

Must we, then, surrender the principle of lying-in institutions altogether, and limit the teaching of midwifery nurses solely to bedside cases at home, notwithstanding the well-known difficulties of teaching pupils at the beginning of their course elsewhere than in an institution? We will try to reply to this question; and, in doing so, perhaps some light may be thrown on another question, viz.: how to improve existing lying-in establishments so as to reduce the mortality in them.

Evidence sufficient has been collected to show that no one panacea will enable us either to possess a perfectly healthy building, or to improve existing hospitals.

Much has been written about the saving effect of small hospitals; but it is certain, from what has been already said, that the small-hospital idea is not sufficient of itself. It is, however, a very important idea, because all hospital problems are simplified by subdivision of the buildings. So far as we know, every one who has carefully studied the subject has given a preference to small lying-in establishments over large ones; but we should certainly be disappointed if we trusted to smallness of size alone for reducing the mortality.

The evidence further shows that in any new plan infirmary wards must be kept quite detached from lying-in wards. They should be in another part of the ground, and should be provided with their own furniture, bedding, utensils, stores, kitchen, and attendants.

The same arrangement, at least in principle, should be carried out at all existing lying-in establishments, and every case of disease should at once be removed from the lying-in wards to the infirmary, and be separately attended there.

In our proposed midwifery school the whole attendance would be supplied by midwives and pupil midwives, with a physician accoucheur, to make his visit twice a day, to be sent for in time of need, and to give instruction to the pupil midwives by lectures and otherwise; and in this way we should escape the dangers of introducing medical students.

Applying the same principle to lying-in wards to which medical students are admitted, there can be no doubt that a responsibility of the very gravest kind attaches to all teachers and managers of lying-in hospitals who do not satisfy themselves that students admitted as pupils have nothing to do, either with general hospital practice, or with anatomical schools, during the period. Midwifery instruction should be treated as a matter quite apart.

What has been already said need scarcely be repeated, about the dangers of connecting midwifery wards with general hospitals. The simple facts are sufficient to show that all midwifery wards of this class should be at once closed.

As a general result of this enquiry, applicable to all lying-in wards, the evidence shows that very much indeed of the success depends on good and intelligent administration and management.

Suppose that all these precautions could be carried out, will the cost and difficulty of giving effect to them necessarily lead to the abolition of all accommodation for midwifery cases, or for teaching midwifery?

We reply, No. The facts already adduced clearly show what may be done in this matter.

They prove, in the first place, that lying-in women should, as a rule, be delivered at home. And, as a consequence, that whatever provision may be made for cases of special destitution, or for midwifery teaching, such provision should be assimilated as far as practicable to the conditions which surround lying-in women in fairly comfortable homes.

These conditions are realised, and in some instances no doubt improved on, in the better class of workhouse lying-in wards, and of lying-in huts for soldiers’ wives.

The favourable results arrived at in many of these institutions appear to show that a little more care would lower the death-rate still further.

In every instance where it is considered necessary to organise lying-in accommodation by voluntary effort, the same principles should be kept in view.

The success which has attended Waterford Lying-in Hospital, already mentioned, shows how much may be done in rendering such accommodation a real boon to the poor.

A single hut, like the Colchester Hut, erected in a needy locality, would supply, and that safely, all the accommodation wanted. But for a training school of midwives and midwifery nurses other accommodation is required, and of a far more costly character.

It is true that any sort of building may be leased or bought and altered, or added to, and told off as a training school; but after what has been said, to take such a course would be to ensure killing a certain number of mothers for the sake of training a certain number of midwives. If we are to have a training school at all, we must, before all things, make it as safe for lying-in women to enter it as to be delivered at home; and having made up our minds what is necessary for this purpose, we must pay for it.

CHAPTER II. CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND TRAINING SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES.

To apply all this experience to the construction and organisation of a school for midwives and midwifery nurses is the next thing:—

Everybody must be born, and every woman, at least in this kingdom, is attended at the birth of her child by somebody, skilful or unskilful. Except in the case of multiple births, there are therefore as many attendances as there are births in the Returns of the Registrars-General.

This it is which makes the subject of midwifery nursing of such paramount importance.

Lying-in is an operation which occurs in England to seven women out of a hundred annually. In 1868 there were 786,858 children born alive in this country, wherefore for the midwives and midwifery nurses to be trained there will always be occupation and custom enough; whereas the occupation and custom for a surgical operator is, it is to be hoped, comparatively small, except in Franco-German wars. Even there we may trust that 7 out of 100 had not to undergo an operation. Certainly to 7 out of every 100 annually a surgical operation in England does not occur.

Between midwifery nursing and all other hospital nursing there is this distinction, viz.: the operator is herself the nurse; and the head-operator (or midwife) ought to be a woman, and is, in Paris and Vienna, and elsewhere.