H.—3la,

2. METHOD OF ATTENDANCE. The Committee found quite early in its investigation that there were two big primary considerations which would require to be discussed and decided before any general scheme for a maternity service could be outlined —■ (1) The role of the doctor, the midwife, and the maternity nurse in the proposed scheme. (2) The extent to which hospitalization or domiciliary attendance was to be recommended. The attitude of the Committee towards these two issues obviously had a very definite bearing oil its method of dealing with other questions set out in the order of reference. Already a definite tendency regarding both these points is apparent in New Zealand, but, nevertheless, since the national maternity services which are being recommended for England and for some other countries are based on an entirely different system, it was considered necessary to bring these matters fully under review. One consideration in the development of a national service is the method of attendance which is to be recommended. As regards the nursing side of the service, there are no arguments ; it is universally agreed that the lying-in patient should have the help of a fully-trained maternity nurse or midwife, either in hospital or in her home. Actually in New Zealand this practice is now almost universal ; it is illegal for an unregistered woman to attend a lying-in woman (except in emergency), and very few untrained women, registered by virtue of previous maternity experience, now remain in active employment. The role of the doctor, the midwife, and the maternity nurse in the ideal scheme of attendance at actual confinement is, however, a matter on which there is considerable difference of opinion, and in examining the development of the maternity services in the various countries of the world it will be recognized that there are, broadly, two different tendencies."" (1) The Case fob Midwife-attendance. In a number of countries the trend is tow-ax s a service in which the bulk of the normal midwifery is conducted by highly traineddmidwives. A medical practitioner of experience in obstetrics decides during the ante-natal period whether or not the patient is likely to have a normal confinement. If the examination reveals no abnormality, arrangements are made for a midwife to carry out the routine antenatal care and to attend the patient alone at the actual confinement. A doctor sees the patient on two or more occasions during the ante-natal period and is available if any unsuspected complications occur either then or during labour ; he makes a complete examination of the patient in the post-natal period, but in normal cases, he is not present at the confinement. If, on the other hand, abnormalities are evident or suspected, arrangements are made for supervision by a doctor throughout. A small proportion of women, even though normal, are attended by obstetric specialists at what must necessarily be high fees. It will be seen that in such a scheme the general practitioner is excluded from all normal midwifery practice. This system is seen at its best in Holland and the Scandinavian countries, where it has been in operation for very many years, and where the maternity services are recognized to be of a very high order. The practising midwives are very highly trained, the course for previously untrained women being three years in Holland and two years in most of the other countries. These midwives do not continue the after-confinement nursing, but are followed by maternity nurses, who have had a shorter period of training. The recommendations for a national maternity service for England and Wales put forward by the departmental Committee set up by the Ministry of HealtTi in England, by the special committee of the British Medical Association (England), and by the British College of Obstetricians and Gynaecologists, are all based on the principle of midwife attendance in normal labour ; undoubtedly they have been largely influenced by the success of the method in Holland and the Scandinavian countries. Already there are some excellent examples of this type of service both in hospitals and in district practice in Great Britain, but it is admitted that the general standard of midwife-attendance does not, as yet, compare with that of Holland. In New Zealand the midwife system is seen in operation in the St. Helens Hospitals, in many of the maternity annexes attached to public hospitals, and, to a comparatively small extent now, in the practice of district nurses. The service rendered under these circumstances has been proved to be safe and efficient. The case for the midwife system has been fully considered by Dr. H. Jellett, previously Master of the Rotunda Hospital, Dublin, and more recently Consultant Obstetrician to the Department of Health in New Zealand, in his book " Maternal Mortality" (pp. 7-28).

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