H.—31

87

The question to be answered is, Why has it ceased to be effective ? I am unable to give any positive answer, but from the reports by the Nurse Inspectors under the Medical Officers of Health and from my own observations the only changes in the technique of which T am aware have occurred during the years when the deaths increased were the use of masks which before 193o were used in very few instances, and the substitution of an antiseptic ten times the cost per unit of lotion for the one previously used. Since the economic factor has always to be taken into consideration it probably accounts for the frequent use of this expensive antiseptic in the ineffective strength of 1 drachm to 1 pint instead of its proper strength of 3 drachms to 1 pint. In thfi proper strength it is effective, but costs ten times as much per unit as the one most generally used in the past.

What effect the increased use of masks has had it is difficult to say. _ I am, however, of the opinion that few midwives or maternity nurses have acquired a technique of using these effectively, and there is undoubtedly greater risk if bacteria intercepted by the masks are transferred to the hands than if no masks were used. In short, if the technique is so elaborated as to make it inapplicable by the person of average intelligence and training it is liable to become a danger. Every effort has been made, and will continue to be made, to correct the faults mentioned above. The matter, however, is a difficult one, as it means correcting the practice of many hundreds ol nurses. Medical practitioners can do much to help. During the past year 145 cases of sepsis were notified, of which 136 were the subject of inquiry by questionnaires. Of these, 114 cases occurred in Europeans and 22 in Maoris. I regret to say that the routine inquiries by questionnaire and occasionally by personal interview revealed very little of value. The returns show that only in the cases of 6 Europeans was faulty technique regarded as giving rise to the infection. In the cases of the Maoris, 15 out of the 22 were nursed under conditions in which asepsis was impossible to maintain. The inquiry again reveals the fact that the most outstanding cause of sepsis is manual removal of the placenta. This method of delivery occurred in 22 out of the 136 investigated cases, a rate of 16-18 per cent., as against 0-52 per cent, in the 24,086 confinements reported in Table I. Four of the 22 patients died. PART lI.—MAORI MATERNAL MORTALITY. The following table gives the Maori maternal-mortality rate and the numbers and rates under the different headings for the last nine years on the same lines as those for the Europeans.

Maori Maternal Mortality. Table VIII.—Showing the Maori Mortality by Causes for the Nine Years 1930-38.

The total rate, 5-14, remains approximately the same as those for the five years 1934 to 1938, a substantial drop having occurred in 1934. No deaths from septic abortion among Maoris were reported during 1938. It is impossible to expect any material lowering of the maternal-mortality rate among the Maoris as long as they follow the obsolete methods of delivery dictated and sanctified by old customs and followed by the uninstructed members of the hapu who act as midwives and whose knowledge of the causes and methods of dealing with complications is on a par with the ignorant European midwives of a hundred or more years ago. If we are right in considering the ordinary European house as lacking the facilities necessary to safeguard women in childbirth except in absolutely normal oases, how much more so does this apply to the Maori whare with its earthen floor, no bedstead, no bed linen, and the most meagre facilities for washing. If it is correct to attribute the reduction in European maternal mortality over the last twelve years to the attendance of the majority of the cases in hospital where skilled nursing and a doctor are available for the slightest abnormality, it is logical to conclude that the same improvement may be effected among the Maoris if the same conditions are applied to them.

1930. 1931. 1932. 1933. 1934. 1935. 1936. 1937. 1938. Cause of Death. No. Rate. No. Hate. No. Bate. No. Rate. No. Rate. No. Rate. No. Rate. No. Rate. No. Rate. Puerperal sepsis following 5 2-35 5 2-16 5 1-82 7 2-37 3 1-01 7 2-15 6 1-65 4 1 01 6 1-62 Acddents'of labour (hsemorr- 12 5-65 9 3-89 14 5-10 14 4-75 8 2-68 10 3-07 12 3-31 13 3-27 10 2-70 hage, thrombosis, phlegmasia, embolism, and following childbirth not otherwise defined) _ l 2 0-54 Toxaemia, albuminaria, and 1 0-36 1 0-34 .. 1 0 30 .. Accidents'of pregnancy .. 3 1-41 2 0-87 1 0-36 .. 4 1-34 3 0-92 .. 5 1-26 2 0-54 Total, maternal causes (ex-~20" 9-42 16 6-92 21 7-65 22 7-46 15 5-03 21 0-46 18 4-96 23 5-79 20 5-41 eluding septic abortion) . Septic abortion .. V, \~. 3 0-76 .. ..