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practically true of almost every other place at home or abroad. Indeed, it had now been clearly established that, aside from deaths due to injury or accident at childbirth, this large early infantile mortality was dependent upon causes which existed before birth; and it must also be recollected that as many deaths occurred before birth as in the year after birth. Of these congenital deaths some arose from difficult labour, others from prematurity (due to overwork and poor nutrition in the last months of pregnancy, too frequent child-bearing with far 100 short a period of rest after labour, the poison of syphilis, and the infants not being sufficiently developed to lead an extra-uterine life), others from malformations and from being poisoned by the toxemias of pregnancy; but I am in entire agreement with the views of Professor Whitridge Williams of the Johns Hopkins Hospital, Baltimore, that the most potent ante-natal cause of infantile death is syphilis, as we have verified at the Maternity Hospital, Belfast. There remains a large doubtful group in which we must be guided by more careful laboratory and clinical research so as to discover in time the exact cause of these infantile deaths. It is altogether a mistake to call those deaths which occur shortly after birth “birth mortality," as is done in a recent report (Special Series, No. 10) of the Mortalities of Birth, Infancy, and Childhood of the Medical Research Committee, as so many of them are due to causes acting long antecedent to birth, and in no way connected with parturition.

The Environmental Group of Causes. Unfortunately, up to the present time little progress has been made in facing the problem of the pre-natal or congenital causes of infant mortality, but the greatest results have been achieved in combating the environmental factors (bronchitis, pneumonia, diarrhea, enteritis, whooping-cough, and measles). In past years, by the adoption of measures for improved municipal and domestic sanitation, by the education of mothers in personal hygiene in regard to the feeding and proper care of their children (that is, mothercraft), and “by the elevation of the standard of conduct and moral responsibility,” great progress has been made in lowering the death-rate of children from these environmental factors.

The Solution of the Problem of Maternal and Child Welfare.

Three things must be kept in view in seeking the solution of the problem of maternal and child welfare :

First, and most pressing, the ante-natal factors must be met, and this can best be done by establishing ante-natal clinics at maternity hospitals in close touch with pathological laboratories, where—when necessary-prospective mothers can be received and treated for any condition that might (syphilis, toxæmias, contracted pelvis, &c.) interfere with their own life or with that of their unborn children, and where our exact knowledge as to the--at present--often unknown causes of congenital death or debility can be increased.

Second.-To obviate the preventable deaths and morbidity from childbirth far more maternity hospitals or homes are needed for the reception of serious cases. In connection with the splendid New Zealand scheme, not only has the Federal Government established children's hospitals and free maternity homes, but it now possesses five State maternity hospitals open for the use of the public; and since the beginning of the War it has helped the crèches previously in existence and founded new ones. While the members of the medical profession have learned by experience the great importance of looking after their obstetric patients during pregnancy, this fact has not yet been grasped by the public, and certainly not by our administrators, who, in the Insurance Act, missed the opportunity of taking a practical step in pre-natal welfare, by giving the maternity benefit only after the confinement, with the result that the Insurance Act, beyond helping in serious poverty, has done nothing, I am afraid, either to lower the maternal death-rate or to prevent or cure pre-natal disease. The public must be taught that while a large proportion of confinements are, under clean midwifery practice, attended with little risk, a complicated case of labour is always a grave surgical emergency. We must also try to raise the educational status of the midwife, and I trust the time will soon come when every midwife must have had at least a surgical nurse's training before gaining her midwifery experience.

Pre-natal care has the following advantages :-
(a) It will prepare the mother properly for her confinement.

(b) It will decide the question whether, either from disease or accident, or bcause her pelvis is deformed, the prospective mother should go into a maternity hospital to receive expert treatment.

(c) It will lessen subsequent gynæcological invalidism.

(d) It will bring about a lower mortality, and morbidity, in both mothers and infants.

(e) It will cause the birth of a larger number of healthy children.

Here is an interesting experiment demonstrating what pre-natal care will do for mother and child :--

The New York Milk Committee, by the establishment of milk stations, have accomplished such definite results that for the total deaths under one year, the rate was, in New York City, 135'8 in 1906, and 102′2 in 1911, and 937 in 1916, these figures showing a marked fall; but when the matter was carefully scrutinized it was found that the fall was during the period over one month and under one year as follows: 95'0 in 1906, 65'1 in 1911, and 568 in 1916; on the other hand, so far as the reduction of the deaths in infants under one month is concerned, there was, practically speaking, hardly any change at all, as the following statistics show: In 1906 the death-rate under one month was 408, in 1911 it was 372, and in 1916 it was 36'4. Realizing these unsatisfactory facts, the New York Milk Committee in connection with the work of their milk stations started in nine districts the experiment of carrying on pre-natal care of expectant mothers, and they also introduced the idea of pre-natal care into the health centres. "Comparing the supervised cases with the unsupervised cases in the Borough of Manhattan, we find a reduction in the number of stillbirths of 22 per cent., and a reduction in the number of deaths of infants under one month of 28 per cent. in favour of the supervised cases. Out of 3,145 women who received pre-natal care there were but five deaths, a maternal death-rate of 15, compared with the maternal death-rate of New York as a whole of 4'9." (The American Journal of Obstetrics, September, 1917, p. 508.)

Third. For the care of the mother and child, after she is safely over, and convalescent from, her confinement, what was wanted was "babies' clubs" or "schools for mothers" or "infant consultations," where the mother could take her child for advice; followed by home visiting by specially trained female visitors, who must be properly paid. The ideal home visitor was a fully qualified (three years' trained) nurse, who had also a certificate as a midwife, as well as a knowledge of the general principles of hygiene and sanitation. In the admirable “New Zealand scheme," the "Plunket" (so-called from a distinguished Irish lady, the wife of a former Governor-General, Lord Plunket, who took an intense interest in the movement) nurse is either a fully trained general hospital nurse or a registered maternity nurse, who is also specially trained in the "Karritani-Harris" Hospital (established in 1907) in Dunedin. This institution is, in some respects, the only one of its exact kind probably in the world, for in it is provided accommodation not simply for babies, but for the mothers of these infants as well, a plan which often makes all the difference between health and illness

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for both mother and child, and provides that the ideal nourishmentbreast-feeding-is secured. A nurse trained in a hospital for infants alone fails to see the proper relationship between mother and child, and is apt to think that bottle-feeding is quite equal to Nature's nourishment. This “ Karritani-Harris" Hospital is in the full sense of the term a school for mothers, and provides an object lesson for the proper training of nurses, who afterwards, throughout the New Zealand Dominion, try "sympathetically and tactfully to educate and help parents and others in a practical way in the hygiene of the home and nursery with a view to conserving the health of the whole family while directing special attention to the needs of mother and offspring. A special feature in the education of the "Plunket" nurses is that they are required to come back for a month in every two years in order to make themselves au courant with the latest and most approved methods for saving both mothers and children. Whether medical practitioners are really needed at the “ babies' clubs” or “infant consultations” is a moot question, for there is a great risk of their interfering with the interests of the general practitioner. In some of the largest of the voluntary babies' clubs in Belfast no officially paid doctor attends, the practice being that in the case of an infant or mother requiring special medical attention, the mother is directed (a card of recommendation being given her) to consult a doctor, but in case she has no special medical attendant, she is then sent either to the Belfast Maternity or to one of the Children's hospitals. By the adoption of this method no friction of any kind arises between the “ babies' clubs” and the general practitioner; indeed, it has been found that general medical practitioners constantly send patients to these clubs. This is the New Zealand plan also. Further, these clubs encourage thrift among the mothers and also diminish their running expenses by the plan that each mother pays one halfpenny every time she brings her child, and if her case is considered suitable for getting milk, she has to pay a minimum of the cost. She also pays the cost price for any article of babies' clothing, these garments being cut out and made by the voluntary lady workers of the babies' clubs.

It is a curious and most interesting circumstance that this plan of not interfering with the general practitioner is exactly on the lines of the New Zealand scheme, for one of the rules regulating the conduct of “ Plunket” nurses is as follows: The nurse must always insist on a doctor being called in for any but the simplest cases of sickness. Further, where any ailment persists in spite of her having given due

attention to the feeding and other hygienic requirements, medical aid must be sought. When advising the calling in of a doctor the nurse shall in no case give the slightest hint as to what doctor is to be consulted."

In other words, the “ Plunket” nurse is to be a nurse, domestic helper and teacher, and she is not in relationship to any special public health doctor, but rather she is required to keep in touch with all the local medical practitioners. If “maternal and child welfare” public health schemes are to succeed in Ireland they must not arouse the antagonism of the medical profession, but they must show that they are really a help and assistance to it. The multiplication of bureaucratic medical appointments is an extremely doubtful and costly experiment when it is seen that such methods are not needed in a scheme which, in New Zealand, has reduced infant mortality to its lowest limit, where the children are found to be bigger than they were before the plan was put into force, and where as a result a new. and more healthy race is arising. Dreenagh House,



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