H.—3l

42

length of illness was 11-1 days. In the 104 cases that recovered inquiry was made into the number of days of illness. The result was as follows : In the ninety-nine cases in which the inquiry extended to the twenty-eighth day of the illness only fifty-four cases had recovered by that time, and forty-five were still persisting. In five cases the investigation was extended beyond the twenty-eighth day, and the average period of illness in those cases was forty-eight days. The average for the 104 cases was 19-9 days. Taking the total of 184 cases of puerperal sepsis following labour which were notified during 1928, and deducting the forty-three fatal cases due to the same condition, it leaves 141 cases which recovered, and which it may be presumed had the same average period of illness as the 104 cases of recovery which were investigated —viz., 19-9 days. According to these figures, the economic loss in 1928 from this disease was therefore forty-three fatal cases, and a minimum of 2,806 days of illness, not allowing for the period over twenty-eight days in forty-five cases, or the period of convalescence and a further economic loss in those cases in which health has been permanently damaged, or in which further medical or surgical treatment is or was required. I advance these figures as the first result of an investigation into these cases which it is hoped will be extended and improved upon from year to year. So far, though imperfect and incomplete, they give food for serious thought, but are not to be regarded as forming the basis of any definite conclusions. I wish to point out that this is not a problem special to New Zealand. There is no reason to suppose that similar investigations elsewhere would reveal a material difference in the average economic loss incurred by each case of puerperal sepsis. The economic loss is a very serious matter, and that a great deal of it is preventable is shown by the results quoted in Dr. Jellett's report. From the purely economic point of view the question arises as to what expenditure of money in preventative measures is justifiable to save this substantial economic loss every year due to the largely preventable illness of so many wives and mothers. I further quote here the information given me by the Medical Superintendent of one of our St. Helens Hospitals, who says : " Under conditions of systematic and skilled ante-natal care, complete sterilization of dressings, and sound aseptic technique the last thirteen thousand consecutive deliveries in this St. Helens Hospital resulted in only one maternal death, which was due to embolism, and occurred after the patient had returned home against the advice of the medical officer. One other death which occurred in this hospital during this period was a case of eclampsia which was brought in after delivery elsewhere, and was then in a comatose condition." The first case rejected the advice of the Medical Officer ; the second case had no systematic ante-natal care. The same authority also states that the still-birth rate and the deaths of infants in the first fortnight of life have been reduced under these conditions to thirty-eight per 1,000 births, as compared with New Zealand rate of fifty-two per 1,000. Referring to the same subject, the Government Statistician says: "It is gratifying to note that a definite improvement has been recorded in the last few years in which ante-natal clinics have been established and other steps taken to ensure healthy children being born." The more my experience of investigation into the conditions influencing maternal mortality extends, the more I am convinced that the problem of reducing maternal mortality can be solved best by three principal methods : Firstly, by the universal acceptance by women of the necessity for skilled and systematic ante-natal care during pregnancy, which can best be brought about in New Zealand, firstly, by lectures to women's societies emphasizing this important fact, and, secondly,, by the institution of public ante-natal clinics conducted by nurses trained for this work and co-operating in every way with the medical attendant of each expectant mother who attends ; secondly, by the general application of the principles of aseptic surgery in the practice of obstetrics both in and out of hospitals, which can be greatly helped by the provision of sterilized outfits through the ante-natal clinics ; thirdly, by the provision of small well-equipped maternity hospitals so located that they are available within reasonable distance to all women where the conditions of their home make it impossible to give reasonable attention therein, and particularly to all those cases in which ante-natal investigation leads one to anticipate some serious departure from normal during labour. Of these the most important are the first two, and the number and quality of the maternity hospitals being on the whole satisfactory ; and as the provision of more public maternity hospitals must be a gradual process depending largely on financial conditions, I propose to give as much attention as possible to sound propaganda work in a further and extended effort to increase the quantity and quality of public ante-natal clinics and the universal provision of means of maintaining asepsis throughout labour and the puerperium. Success will depend largely on the hearty and friendly co-operation of all forces concerned, which, judging by the past year's work, I anticipate will continue to increase as the importance and nature of the subject becomes better understood. I therefore invite the continued help of all those societies that have so far co-operated with us in this work. In conclusion, I wish to express my thanks for and appreciation of the help extended to me by the many members of the medical and nursing profession, and by the societies mentioned in the body of this report; also to my fellow-officers of the Health Department for their co-operation and advice on many points, particularly to the Medical Officers of Health and their Nurse Inspectors, with whom my work is most closely associated, and on whom the main burden of inspecting the private hospitals conducting inquiries has fallen.