H.—3la.

when, complications are apparent or suspected ; but even where ante-natal examination is reassuring as to the improbability of the more obvious difficulties, there are not a few cases in which quite unanticipated trouble arises. There are many details in the management of labour which can be more satisfactorily and safely dealt with in hospital where fuller and additional help is available. The Committee has given careful consideration to the above question, and in its conclusions is guided very much by the results obtained. The fact that during the decennial period 1927-36 the proportion of women confined in public or licensed private hospitals (not including one-bed maternity homes) increased from 58-69 per cent, to 81-75 per cent., and that during the same period the maternal mortality rate, excluding septic abortion, fell from 4-41 to 3-14 per 1,000 live births and the death-rate from puerperal sepsis following childbirth fell from 2-01 to 0-36 per 1,000, is a strong argument in favour of attendance in hospital (see graphs, pages 71, 72). Practically all the medical witnesses were of opinion that where confinements were conducted in hospital, with the much better facilities available there, they were enabled to deal with complications more adequately and be more certain in maintaining asepsis. A very few women stressed the desirability of the woman remaining at home for her confinement, their point of view being that the environment of the home was pleasanter and it enabled her to supervise the running of the house during the lying-in period. On the other hand, the more general opinion expressed was that a woman was better in hospital, where she could get a greater rest. Thus the different points of view were obviously influenced by the question of the ability to obtain help in the home when the wife and mother was away in hospital, a matter which has been dealt with in a separate portion of the report. In considering the pros and cons of hospitalization versus domiciliary attendance the economic factor must be given due weight, and there can be no doubt that, apart from the capital cost, if the same quality of nursing is to be given under each system the hospital is far more economical. An efficient midwife with domestic and semi-skilled nursing help can give adequate attendance to three patients at a time in a hospital, while if the woman is in her own home, and the same quality of nursing is to be given and reasonable working-hours observed by the nurses, the same two nursing attendants in addition to domestic help would be required for the one woman. It" is also easier in the case of a hospital for a nurse to carry on when t"he patients are " out in their dates " as is quite frequently the case. On the other hand, when that occurs in a domiciliary case, the nurse may have been called to another patient and is not available. Furthermore, unless she has a thoroughly competent assistant, a nurse attending a patient at home is on duty or call for the whole twenty-four hours. In a well-conducted hospital the hours on duty need not exceed more than eight to ten per and if there are more than two midwives or maternity nurses on the staff days off during the slack periods are easily arranged without sacrificing the interests of the patients in the hospital during that time. It must be understood that in England and Wales a very considerable part of the domiciliary attendance which is being recommended is carried out by district midwives who attend daily and do not live in the homes. This, of course, is a much cheaper service, but the Committee is of the opinion that it has many disadvantages and is satisfied that it is not efficient nor is it generally acceptable in New Zealand. The Committee therefore considers that the aim of the Government should be to promote the hospitalization of all maternity patients, both pakeha and Maori. The benefit to the latter was shown in the different results obtainable in Rotorua, where hospitalization has become very general as compared with other districts. At the present time New Zealand has seventy-one public maternity hospitals or maternity wards attached to public hospitals, and 191 private maternity hospitals. The small private hospital in country towns is providing a very valuable and, in the opinion of the Committee, an essential maternity service. The majority of these hospitals, of which 154 admit less than 100 cases per annum, are ordinary houses slightly altered to meet their, purpose and only equipped with the essentials to maintain asepsis and give comfort to mother and infant and moderate convenience to the nurse. Many of them are owned by elderly nurses who have always had a struggle to make ends meet, and as these nurses give up there can be no question that many of these hospitals will, cease to function unless they receive some financial assistance by way of an annual subsidy or by the subsidizing of the fees paid by those patients requiring admission, but unable to pay the full cost of hospital service. It appears to the Committee that some system of subsidy is thoroughly justified, as, if the private hospitals are given up by the licensees, the Boards will be faced with heavy capital expenditure to replace them. This under any circumstances will take place in a limited number of cases, but to replace the 154 small private hospitals at present licensed will cost not less than approximately £2,500 per hospital, making a total of £385,000.

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