HC Deb 25 March 1935 vol 299 cc1595-699

Order for Second Beading read.

Motion made, and Question proposed, "That the Bill be now read a Second time."

3.25 p.m.

Mr. RHYS DAVIES

I am sure that I am voicing the feeling of Members in all parties when I say that we very much regret the absence of the Minister of Health and especially the reasons for his absence. It falls to me to call the attention of the House to two or three very human problems. They may not appear very important to some hon. Gentlemen, but the questions I am about to raise affect intimately the domestic lives of several millions of our people. I want to devote my attention, first, to infant mortality. It is not necessary to say more than a few words on this interesting subject, because, in spite of the industrial depression, there has been a steady decline in the infant mortality rate during the last decade or so. I am one of those who measure civilisation not only by the number of churches or the number of schools that a country possesses, but largely by the care bestowed by a nation upon its little children. From that angle, I am proud of these statistics. It is a remarkable achievement that we have been able to reduce the infant mortality rate by one-half from 1905 to 1934. The number of children who died before they reached the age of 12 months was 128 for 1,000 births in 1905. Last year it was only 64.

There are many things to account for that decrease, but some of us are not very happy when we take into account the various mortality rates throughout the country. It is possible for the rate to be down as low as 30 per 1,000 in Bournemouth, Hastings, St. Leonards, Cheltenham, Bath, Blackpool, St. Anns-on-Sea and other districts where the well-to-do and comfortably-off people reside, but in the distressed areas it may soar as high as 80 and 90 or even 100. Am I right in assuming that whereas the infant mortality rate is declining in general, it is possible that in Durham, in parts of Lan- cashire, in Cumberland and in South Wales the rate is going up? We shall not be satisfied to see the general rate declining if there is a steady decline in well-to-do districts and a proportionate increase in the depressed areas. There is very little else to say on this problem of infant mortality, except to ask once again whether we can have the detailed figures from the depressed areas.

I come now to a much bigger question. While we can compliment ourselves on the results attained in connection with infant mortality, the problem of maternal mortality remains a very disturbing one. The country does not regard this as a party question; indeed, I have found people of all parties interested in it, and I wish that on this issue, above all, I might be allowed to say that there is a new phase of the problem before us to-day. A very representative committee was appointed some time ago. I would not like to say that it was done at the instigation of the Government, but there were important people, supporters of the Government, on that committee, and I was a member of the committee too. It was called the Joint Council on Midwifery. It came to a unanimous conclusion, and it put forward one of the most remarkable suggestions for reform that we have had for some time past. The report has been sent to the Ministry of Health, and before I conclude I shall wish to ask what is the attitude of the Ministry towards the recommendations it contains. It is worth while giving the figures to Parliament, which is the best sounding board, I suppose, in the whole of Europe, and I hope the information will percolate into the minds of all who have the welfare of mothers at heart. The figures are rather familiar to those keenly interested in this problem, but their significance has not yet impressed itself upon the minds of the people most concerned.

In 1923 the maternal mortality rate in this country was 3.82 per 1,000 live births, and in 1933 it was 4.51, an increase of 18.46 per cent. in 10 years. It is an amazing state of affairs that whereas the infant mortality rate is declining steadily year by year, just as almost every other rate in the vital statistics of the nation is showing improvement, this particular death rate, in my view the most important of all, is increasing. Con- sequently, I make no apology for calling attention to these figures, and I will therefore pursue them a little further. I have already given the figures of the ordinary maternal mortality. The total maternal mortality figures, including deaths from associated causes, are even more menacing still. They were 4.83 in 1923 and 5.94 in 1933, or a rise of 22 per cent.; and the stillbirth rate rose from 38 per 1,000 in 1927 to 41 in 1933. It is, therefore, very pertinent to ask: What are the Government doing about this very important problem? I would like to know whether the municipalities have had their attention called to the report to which I have referred, and, if so, what they intend to do. I shall have a word to say on that subject later. The report to which I am referring is as stated the report of the Joint Council on Midwifery, which was issued about a fortnight ago. I refer to it as one of the most remarkable reports issued, because one of its recommendations provides, in my view, the only immediate way out of this terrible problem.

I do not intend to dwell to-day on the cause of maternal mortality. There is a difference of opinion regarding it. Some will argue that mothers die because they are under-nourished and others will argue—and there is probably some point in this argument—that the maternal mortality rates are not fair because the number of children per mother is declining annually and, consequently, the comparisons are not based on the same foundations. That, of course, is a matter very largely for statistical calculation, and I mention it because I want to show that there are differing reasons as to why the maternal mortality rate is so high.

The report comes down at once to what is regarded as the main reason for this terrible rate of maternal mortality. There are 52,872 midwives on the roll in this country, but only about 15,000 of them are in serious practice. The council found that there are some women over 80 years of age practising as mid-wives, and as a member of that council I agree that until we improve the training and the competency of the midwives of this country there is very little hope for any decline in the maternal mortality rate.

In coming to the remedy which is suggested I hope no Member of any party will be frightened at the suggestion made. Some time ago I was astonished to learn that there is legislation already on the Statute Book to permit every local authority to employ midwives direct and pay them a salary. I have heard since that only one or two local authorities have ever taken advantage of that legislation, one of them, I understand, being the city of Bradford. The proposal now made, among others, is that there shall be established in this country a municipal and salaried midwifery service; that the municipalities shall no longer shield behind the word "may" for not doing anything, but that the Government shall undertake the responsibility of compelling every local authority by law to establish such a service. The main reason for that recommendation is simple. Midwives are very badly paid, indeed, some of them are not paid at all, and consequently the efficiency of midwives declines because the job is not attractive enough. It is amazing that we should so neglect what is probably the biggest task in the whole life of any nation. I press the Ministry to do something in this connection.

It is argued that we ought to provide more maternity hospital accommodation, but let it be remembered that the problem as yet is, in the main, a domiciliary one, and that 60 per cent. of the confinements in the country are attended by mid-wives. I repeat that the one issue that arises to-day is the attitude of the Government towards this very important recommendation. It is an astonishing thing that a family will spend £50 on a funeral and 50s. on a confinement. I have seen that happen. We pay ample tribute to the dead in this country and very little to the source of life. May I now be allowed to say just a word about nursing in general? It is a subject in which the Minister will be interested. I am not happy about the figures which have been supplied to me. I am speaking now of district nurses attending sick people, apart from nurses in institutions and apart altogether from midwives. This is the state of affairs: the population per district nurse in the home counties is 2,800; in the Rhondda Valley, on the other hand, there are only three district nurses for a population of 140,000. Those were the figures 12 months ago. They show that where nursing is most required nurses are most scarce. I hope that the Ministry will pay a little more attention to questions of nursing in general.

Having dealt with the smaller issues, I come to what we on this side of the House regard as one of the biggest points of all. I have had the honour of dealing at this Box more than once with the administration of national health insurance, but I do not remember that the voices of insured persons have been so persistent and plaintive as they have become during the last 12 months. Before I speak of that section of the insured population who are in distress and whose future is very dark, I would like to say a word or two in general about the administration of the biggest piece of social insurance, not only in this country but in the whole world. There is nothing like it anywhere. There are 17,000,000 lives affected by this scheme, and 7,500 approved societies are in existence. There are thousands of officers and clerks administering this colossal business. The assets of the approved societies to-day amount to about £130,000,000. The scheme is still actuarially sound and, in the main, properly administered. Some of us who are interested in this matter are not, however, quite happy as to its future. When the second valuation of the approved societies took place, there was a surplus of £25,000,000. When the third valuation came along, the surplus had dwindled to one-half of that figure, £12,500,000. The next, the fourth, valuation is now being taken. Perhaps the Minister will give us some indication of what we may expect as a consequence of the present valuation.

Let us remember that 6,250,000 persons had their additional benefits reduced consequent upon the third valuation and that 4,500,000 insured persons were, at the same time, deprived of all additional benefits. I ought to tell the House how the Ministry, by administrative action in the main, have achieved the result of keeping the scheme on a sound financial and actuarial basis, in spite of the industrial depression. First of all, the period of redemption of reserve values was extended and during the last few years the Ministry have done the most remarkable thing. Societies used to pay for their property, new offices, furniture, inkwells, and so on, out of revenue. There must be some very clever gentlemen behind the scenes at the Ministry. In order to swell the assets of the societies for the purposes of the present valuation, they determined to bring into the assets the buildings, the furniture, the inkwells, the steel pens and the like, in order apparently to give the Government the credit of the financial stability of the societies. I would tell the Parliamentary Secretary that we are not quite willing that this should be done. If a society is compelled to sell its property later, it cannot get as much for it then as the sum that has been brought into assets for the purposes of the current valuation.

Before I come to the most important point of all which I desire to raise on the administration of societies, I would like to draw the Parliamentary Secretary's attention to a very simple matter. Hon. Members who are interested in these affairs will know that societies employ sick visitors to see that nobody malingers. On the whole, malingering, I am happy to say, has never affected the societies to a considerable extent, but we are experiencing now a new feature in connection with sick visitation. I understand that some approved societies employ sick visitors and actually farm them out to other approved societies. Some of us do not like that system, and the Ministry ought not to let it continue. Approved societies should look after their own business and maintain their own sick visitation.

Let me now turn to the real issue which I want to raise with the Minister this afternoon. There are at least 110,000 unemployed persons who were connected with the approved societies in this country, and who have already been cleared off the books because they have been unemployed for a long period. This has been a very sore point, especially in the distressed areas. I was in a village in Cumberland yesterday, where I was told that practically every male person in the village, which is not a big one, has already been cleared off the panel doctors' list. It is grossly unfair that men should be wiped off the books in that way simply because they have been unemployed. The Government did a dirty trick on those people. Let me be quite frank about it. I am amazed when I look at the speeches of the present Minister of Health when he introduced the Act of 1932. There never was a bigger piece of camouflage oratory in this Parliament than what was said by the Government of the day about the people of whom I am talking this afternoon. They have fallen out of benefit of the approved societies because they have been unemployed and because no contributions have been paid in respect of them. The Ministry—I will pay them this tribute—have been a little ashamed of themselves, and have tried by devious means to get the societies to retain these people in benefit. But, of course, some societies have no money with which to do that. My own society is paying the whole of the arrears of its unemployed members; but my own society, naturally, is in a fairly good position, and is well managed. In the case of some approved societies, however, no matter how well they are managed, unemployment among their members is such that they could never find the money to pay these arrears. Some societies are in a position to pay every benefit that the Act allows, but the number of societies that can do nothing but pay the minimum statutory benefit is growing as the years go by, and these 110,000 people are losing all their benefits—they are losing sickness, disablement and maternity benefit, optical, dental and convalescent home benefit; and, what is still more important, they are losing their medical benefit as well.

I speak with some reserve here, because of the technicalities of the law, which, however, I have read very carefully, but, unless I am mistaken, these 110,000 people will in due course lose their contributory pensions as well. I think they are safeguarded to the end of 1935, and the hon. Gentleman will probably suggest that we should, therefore, wait until the Actuary's report is received. But I want hon. Members to understand the difference between the Actuary's report on contributory pensions and the reports of the societies on valuation. Let me make it clear that the Actuary's report on the contributory pensions scheme has nothing at all to do with the loss of benefit by these 110,000 people under the National Health Insurance scheme. They are two problems apart, and the Actuary's report, when it is issued, will have nothing to do with the National Health Insurance benefits of the 110,000 people to whom I have referred. The Ministry have been so ashamed of what they have done that they have suggested to the approved societies two or three ways out of the difficulty. One was to postpone the payment of arrears, and allow the arrears to be paid in instalments. That is a new feature. Of course those societies which, having a surplus on valuation, can afford it, can pay up the whole of the arrears of these unemployed persons if they choose to do so, but under the Act of 1932 the fact that the arrears have been paid does not extend their insurance; it simply retains them in membership for the period for which the arrears are paid. Some of us who have been concerned with this matter for many years have been a little disgusted at the operation of the 1932 amending scheme. We on this side of the House are very much disturbed at the implications of the whole thing.

I have tried to get at the figures to show how heavy a burden is placed upon the poorest among us. It is very remarkable that the poor suffer because they are poor; they seem to be made poorer deliberately by this 1932 enactment. I do not say it was designed to do that, but that is the fact. I have the figures from the Insurance Committees showing the numbers of people who have gone out of Health Insurance already. Let us remember that not only have these 110,000 already gone out, but others are going out daily, and the number now must be very many more than 110,000. The figures show how unfair the position is. The number of exits from the panel doctors' lists, that is to say, including unemployed persons, was only 6 in Bournemouth at the end of last year, 66 in Blackpool, 27 in Bath, 4 in Hastings, 10 in Southend-on-Sea, 31 in Southport, and 37 in Worcester. But look at the figures on the other side. There were 460 in Barrow-in-Furness, 700 in Birkenhead, 3,700 in Blackburn, 1,200 in Burnley, 1,700 in Gateshead, 2,000 in Leeds, 2,000 in Middlesbrough, 3,400 in Newcastle-on-Tyne, 500 in Oldham, and 5,800 in Sheffield; while in the county of Durham, outside the boroughs, there were 1,500, in Lancashire 9,300, and in the West Riding of Yorkshire 3,300. I will now ask the House to listen to the figures for some other well-to-do districts. There were only 3 in the whole of Cambridgeshire, 17 in Dorsetshire, 76 in Surrey, 423 in Middlesex, and only 2,000 in the whole of London. I have said more than once, and I am coming to believe it more and more, that it is rather a pity that the centre of government in this country continues to be in London; it ought to be shifted on occasion to these depressed areas, so that Ministers and their staffs could see what is happening. London is not England; London is not a picture of what is happening in this country. We are very much disturbed, therefore, at what is happening in this connection.

Let me put the ease a little more strongly still. The Ministry said in 1932 that there would be 80,000 of these persons; that was the calculation when the Bill came before Parliament. There are 110,000 now. I have tried to find out how many there are in the county of Lancashire alone. I am informed that there are 30,000 in the county of Lancashire alone, and 36,000 in Scotland. I have not seen the figures for Glamorgan, Monmouthshire or Durham, but I am sure they are very bad there. Consequently, it comes to this, that the very benefits which are essential to these people in adversity are taken away from them just at a time when they are most required, and we shall not be satisfied until something is done to relieve the position.

I return to what I said about the Minister's 1932 speech. As I said at the beginning of my remarks, we all regret the right hon. Gentleman's absence, and especially the reason for it. He said, when he was introducing the Bill: I take powers, if there is any improvement in the unemployment position, to give more generous treatment by an excusal of more than one-half of the arrears due to unemployment."—[OFFICIAI REPORT, 11th May, 1932; col. 1935, Vol. 265.] When you analyse a statement like that, you ask yourself what is meant by an improvement of the unemployment position. According to this Government, it is always improving, whatever the figures are, and, if that be true, something ought to be done at once in accordance with that promise. The right hon. Gentleman said in the course of the same speech that he was taking power to put things back in a better state than that in which they were before, if and when the general finance of the scheme enabled him to do so. I think that the time has arrived when the Ministry ought to be able to tell us whether some of these promises are going to be implemented. What has made some of us more sore than anything about that speech is that, although the Minister said that the Bill was designed to save these 80,000, it is because of the provisions of the Bill that the 80,000 have gone out, and I repeat that we are not satisfied that the promises made in that speech are being implemented.

My final word is this. Knowing the plight of this army of unemployed persons, presumably everyone of them now on the means test, they are nevertheless given facilities to become voluntary contributors in order that they may continue in insurance, and the voluntary contribution rate is 1s. 6d. a week. Really, is it not a mockery? 1s. 6d. a week amounts to £3 18s. a year. There are people getting £500 a year who would jib at paying a sum like that for any kind of insurance. In many cases these unemployed people have not got the money. They were kept in insurance by prolonging their conection with a society for years on end, until the present Government came into power and turned them out. Then the Government blamed the Consultative Council, saying that this was what the Consultative Council agreed to. I have been a member of that council, and I see an hon. Member on my left who has also been a member. I will tell the House what the Ministry do with the Consultative Council. They apparently tell them, "These are the figures. There are two or three alternatives—which will you have?" And the council, of course, have to accept one of the alternatives they suggest. They accept, but in any case, the Ministry need not adopt the suggestions of the Consultative Council unless those suggestions are in the interests of the Ministry. Let me say, therefore, that we shall continue to press the Ministry to do something for these 110,000 people, because not only have they gone out—and there are more to follow—but, unless I am mistaken, no proposal of the actuary dealing with contributory pensions at 65 years of age will avail them very much if they have lost their connection with approved societies. We therefore appeal to the Minister to restore their rights, and rescue the 110,000 and their families as soon as possible from their hapless position.

4.3 p.m.

Mrs. TATE

I do not wish to follow all that the hon. Member for Westhoughton (Mr. Rhys Davies) has just said, but I would like to touch, for a few moments, on a subject which he said should be outside the range of political parties, and that is the subject of maternal mortality. With all due deference to the hon. Member for Westhoughton, he touched on the subject, I thought, with very great brevity. He said that the reasons which could be given for these terrible figures of maternal mortality might be disputed. He also said that one of the reasons that some people might give was that of malnutrition. I think that none of the figures which have been issued in any report affords any justification for such a conclusion. Maternal mortality, as the hon. Member said, most certainly should be kept out of party politics, and it certainly is a question which deserves the most serious consideration of the Ministry of Health. I think that some of the conclusions which have been drawn up in the report do not go far enough. The hon. Member referred to the very large number of women who have become certified midwives. Of that very large number, we know that there remain a very small number who actually practise midwifery. That has one very serious effect. It means that there is an enormous wastage of material. There are not nowadays the number of births that there were in former years, and if all these women are going to learn the science of midwifery, they use up valuable material and then if they do not practise—both the material and their knowledge is wasted, which will be a very serious thing for the country.

If our midwifery service is to be perfected we must limit training to those who intend practising. I am not condemning midwives. They do magnificent work under extraordinarily difficult and very ill-paid conditions. It is not their fault that the midwifery service is not as practical as it ought to be. At present, if a woman wishes to take up midwifery, she has to spend 12 months in a general hospital if she has had no previous knowledge of nursing, and six months if she has had a previous knowledge of nursing. There is not one of us, I believe, who would allow our child to be nursed in measles or some trifling disease by a woman who has not had a full three years' nurse's training. Yet you hand over the care of a woman and her child at a very dangerous time to someone who has had, perhaps, 12 months' training all told. We all know that these women who go into hospital for midwifery training are very often found to be rather a nuisance to other nurses. Who would say that they get a full 12 months' training in midwifery? We all know that it is not the case. Part of the time is occupied in taking temperatures, making beds and dusting wards, and is not devoted to the actual study of midwifery. A great part of the fault lies with those who have to appoint nurses to certain jobs, and who will not give those jobs to anyone unless they take the diploma of the Central Midwives Board. Nurses have to take that diploma in order to get appointments, though they will never as long as they live practise midwifery. That is one of the things which ought to be stopped at once. No woman should be given midwifery training unless it is more or less reasonably certain that she intends becoming a practising midwife.

Therefore, I say that a midwifery training in no case should be under three years all told. That would entirely prevent the general nurse, who thinks that in order to get a job she can take up her Central Midwives Board diploma and get it in six months, and that it does not much matter. Then I would also say that it is not enough to deal with the subject of midwives. Let us bring the criticism to where it is really needed, and that is the question of the doctors. I maintain that at present in this country the training of doctors where midwifery is concerned is grossly insufficient. An hon. Member laughs. I do not think it is a subject for merriment when women are dying by thousands in childbirth.

Mr. ALBERY

The hon. Lady is entirely mistaken. No one was laughing.

Mrs. TATE

I apologise. It is certainly not a subject for laughter. It is not only a case of mothers who die, but hundreds of thousands of women after childbirth never know good health again. It should be the concern of this House. The fact is that a great many doctors have very insufficient training in this re- spect. The report on maternal mortality showed that instead of the 20 cases—and in all conscience, 20 is little enough—that a student was required to study before supervising the bringing of babies into the world, in a great many cases only as many as 2.8 cases had been the actual number which students had studied. The whole question of medical knowledge of midwifery should be specialised. The ordinary medical practitioner, with all that he has to do to-day, has not the time to take on the very arduous, laborious and lengthy process of looking after a mother while she is having her child. Therefore, I think there should be specialists who should be specially trained in that work. We very often hear in this House of the very high standards of the Northern countries, particularly Holland, and very often we are told that it is because so much more milk is drunk there that maternal mortality is lower. I do not believe that it is entirely a case of milk. In Holland they have, perhaps, the most perfect midwifery schools in the whole world. The midwifery training lasts for three years, and is of an extraordinarily high standard. I believe it is because of that high standard of training, and not because of the mere drinking of milk, that the maternal mortality figures are more satisfactory in those countries.

I have proved, I think, that the mere recommendations of the committee are not enough, because in the constituency I represent in the borough of Willesden, we have perhaps one of the best and most complete services for mothers in any part of the country, and we certainly have one of the best medical officers of health. Yet our figures of maternal mortality in Willesden are 5.2 per thousand. We have medical examinations for mothers at the health centres; we have obstetric surgeons ready for consultations; we give extra milk; there is a certified midwife who may attend a patient; and we give the mother help and ante-natal care and after-care treatment. Yet we have these awful figures. Therefore, I say it must be in the training and knowledge of the doctors and midwives, and we shall not get a better training for midwives unless the profession is made a little more lucrative, and a little more worth while than it is at present. In very many parts of the country, as the hon. Member for Westhoughton is fully aware, a woman is expected to be not only the local midwife but also one of the health visitors and one of the district nurses. The two positions are very often combined. All this combined work is more than any should be expected to do for the remuneration these women receive. We have got to have fewer midwives, better trained and far better paid. I agree that very often midwives do rather better than doctors, but you cannot do without both trained doctors and trained midwives, and how are you going to do it? I think that every medical school in the district in which they serve outside should send out a doctor and a midwife who have been trained together. There is plenty of work for the two to do, and it is the only way in which you can divide up the available material. I hope that the Parliamentary Secretary when he replies will tell us whether there is any hope of really preventing these women who take up midwifery training without intending to practice.

With regard to the figures which the hon. Member gave as to malnutrition, he knows these reports so well that he cannot have failed to notice on page 66 of the report on the state of public health that where the Ministry sent out questionnaires with regard to cases of death in maternity, and had some 2,000 replies, in 12 cases only were home conditions said to have contributed in some measure to death, and in 17 cases to malnutrition. I would like, however, to draw attention to the fact that in 406 cases there had been insufficient ante-natal care, and in 456 cases there had not been sufficient care at the time of the actual birth. Those are very serious figures. I believe, too, that we have far too large a number of schools giving training to midwives. In the year 1931 there were no fewer than 67 centres in this country at which mid-wives could be trained, and the number has now increased, and I do not think that that makes for the very efficient training of the midwife. We want to have a very high standard of training for these women, and we are all agreed that as far as possible it should be standardised. You will not get very much standardisation of training, and you will not get the same esprit de corps if you have such large numbers of train- ing centres. Have, by all means, a large number of maternity wards if you want them, but do not allow them all to be training schools for midwives. The number of training schools should be very small and very efficient, and I hope that when the Minister replies he will deal with these points.

4.16 p.m.

Mr. JANNER

I rise to speak on the same problem which was dealt with in the first part of the speech of the hon. Member for Westhoughton (Mr. R. Davies) and in the speech of the hon. Member for West Willesden (Mrs. Tate). The question which is being raised in this Debate is one which is of extreme importance to the welfare of the community, and any time taken in considering these problems will be very well spent indeed. The facts which have been elicited by the inquiries which have taken place are grave and demand immediate attention. The 15th Annual Report of the Ministry of Health, 1933–34, states, under the heading of "Maternal Mortality," that the rate of maternal mortality per 1,000 live and still births during the year 1933, according to the provisional figures issued by the Registrar-General, was 4.32, comprising a rate of 1.75 of deaths from puerperal sepsis, and 2.57 from deaths from other causes. This compares with a total rate of 4.04 in 1932 and 3.94 in 1931, on the basis that was then being considered.

The rate of infant mortality in England and Wales, that is, the number of deaths of infants under one year of age per 1,000 births, was 64 in 1933, as compared with 65 in 1928, 74 in 1929, 60 in 1930, 66 in 1931 and 64.6 in 1932. I understand that for the present period the rate may be even higher. If they remain at the same serious rate of deaths per 1,000 births we cannot leave the matter at that stage because there is the additional question of maternal morbidity to consider, which, in my view, is perhaps more grave than the plain question of the deaths which take place at the time when the mother is delivering the child. This is where I differ to a certain extent from the conclusion at which the hon. Lady has arrived on the question of malnutrition. I shall try to show that there are authorities who have given very definite statements as to the detrimental results which accrue to mothers not only at the time of the delivery of the child, but also at a later stage. Very marked effects are left upon the mothers of the country due to the bad conditions under which they live, and to a considerable extent to the malnutrition which is taking place owing to the shortage of food, which, unfortunately, too often prevails in their midst.

I have collected some figures on this matter, because I feel that the House ought to know how serious the problem really is. Professor Blair Bell estimates that 5,000 women die each year in this country as a result of the illnesses which follow confinement, of the after-effects of delivery, and of the operations which are necessary to repair damage. In all, the number of deaths are well over 7,000 per year, and it will be interesting for the House to reflect that this is very much in excess of the toll of the roads, concerning which there has been so much anxiety for a long time and about which the House has debated and legislated for such a considerable period, and rightly so. We have to face this fact and to deal with it.

There is a further important matter. We are told on good authority that 60,000, that is about 10 per cent. of all mothers bearing children, are damaged to a greater or less degree each year. That this is not an inevitable state of affairs is perfectly obvious because statistics which have been obtained from various maternity centres show at least that the position can be partly dealt with if properly handled. For example, at Plaistow Maternal Hospital, which has dealt with 90,000 cases in 20 years, the rate of maternal mortality has been 1.4 per 1,000. The Queen's Institute of District Nurses shows an average of 1.9 per 1,000 in respect of 600,000 cases. The General Lying-in Hospital has dealt with 10,000 cases in four years with a death-rate of .5 per 1,000, and I am pleased to point out that the Jewish Maternity Hospital, in my constituency, last year had only one death in 800 cases, and that that death was due to heart trouble from which the patient suffered long before the confinement.

These results were undoubtedly obtained by the splendid team work on the part of doctors, nurses and all en- gaged at or attached to the institutions to which I have referred. In some countries, such as Holland, Denmark, and Norway, the ratio of maternal mortality are three per thousand, and it is obvious that there must be a method of dealing with the position. If that method is being adopted by some other countries and by some of our own institutions and by ancilliary bodies working round such institutions in this country with this effect it must when used result in a better opportunity of life and health for those who become mothers elsewhere. I have endeavoured to trace from the various reports which have come before the country from time to time the salient points and the opinion of expert people who are dealing with this problem day by day. The Departmental Committee on Maternal Mortality and Morbidity in their final report, state: We are confirmed in the opinion expressed in our interim report that at least half the deaths"— It is a very important statement— which have come under review could have been prevented had due forethought been exercised by the expectant mother and her attendant, a reasonable degree of skill been brought to bear upon the management of the case, and adequate facilities for treatment been provided and utilised. The Maternal Mortality Committee too have produced some very pertinent figures. They investigated how far the local authorities are using their powers, and I am going to ask my hon. Friend the Parliamentary Secretary to see what he can do with regard to these figures. They have made an investigation as to how far the local authorities are using their powers under the Maternity and Child Welfare Act, 1918, and have divided their inquiry into three categories; county councils, county boroughs and metropolitan borough councils. I will quote some of the results which they have arrived at, and ask the House whether something cannot be done in order to improve the conditions which have been found to exist by the Maternal Mortality Committee. In their report on the county councils they say that there are 62 administrative counties in England and Wales, and of these they have analysed 61 reports for the year 1932. This is the last statement they have issued, and it will suffice for the present, because I do not think that there has been a very material step forward since then. They say that as far as they can gather from the reports of the medical officers of health of the county councils, the position with regard to the powers of a local authority under the Maternity and Child Welfare Act. 1918, is as follows: (1) The appointment of health visitors whose duties include attendance at an ante-natal and post-natal centre and the visiting of expectant mothers. All the councils have health visitors, but not all the councils have ante-natal centres, and it is difficult to see in many counties what, if any, arrangements have been made for post-natal examination. They report on The establishment of ante-natal clinics for expectant mothers, and of post-natal clinics which mothers can attend immediately after confinement. In 40 counties it is stated that antenatal clinics have been established. (3) Assistance to midwives. (a) Provision of sterilised maternity outfits free or at cost price. They say that this very valuable provision is carried out by 16 county councils. (b) A subsidy to enable a midwife to practise in a district which would otherwise not support her. This is extremely important and was not referred to by the hon. Member, but it must be appreciated by anyone who has any knowledge at all of rural districts. It is essential that there should be a subsidy in respect of midwives so that there may be a proper and adequate supply of the best type of attendant instead of the handy woman so often employed in places where we have not the maternity centres for dealing with cases. This power is used by 19 councils. (c) The appointment, where necessary, of municipal midwives. This power is used by two. (d) The payment of part fees to a midwife when the patient cannot afford the full fee. This power is stated to be used by only six. (e) 'Refresher' courses for practising midwives. This is available in order to enable mid-wives to keep up with modern knowledge and ideas in obstetrical maternity and this power was used by 14 county councils. (4) Maternity homes or beds in a maternity hospital for: (a) complicated cases. It appears that 46 counties provided beds for these. (b) patients whose whole circumstances are unsuitable for a confinement at home. Only 37 provided for these. (c) Anti-natal observation. They say that provision for this was made in 26 counties. (d) The treatment of puerperal sepsis. Thirty-eight counties reported that beds were available for this purpose. And so the report goes on through the list of possible duties and concludes by saying that about 29 county councils are aiding the maternal service of the district by putting into force half or more of the services they have power to provide. With regard to county boroughs, there were 85 county boroughs and the committee analysed 84 reports for the year 1932. Roughly speaking, about 44 county boroughs are aiding the maternity services of their districts by putting into force one-half or more than one-half of the services which they have power to provide. As regards the 29 Metropolitan Borough Councils, the committee received reports from 28 and their conclusion was that, roughly speaking, about 22 Metropolitan Boroughs are aiding the maternity services of the districts by putting into force one-half or more than one-half of the services that they have power to provide. As a result of this activity on the part of the Metropolitan Boroughs there is a smaller death rate prevailing in London than has been found in the country as a whole. The rates of maternal mortality in the County of London were 3.8 as compared with 3.94 for the whole country in 1931. In 1932, the figures were 2.89 as compared with 2.04 for the whole country, and in 1933 the figure was 3.55 compared with 4.32.

It is true that the Ministry has from time to time issued instructions to the local authorities asking them to do more than they are doing in the direction of providing the facilities to which I have referred. I would ask the Parliamentary Secretary to do more than that. I would ask him to insist as far as possible that the local authorities shall see to it at once that they take advantage of the opportunities offered to them and that they should not neglect the very important duties which they owe to those people who are placed in their charge. I would also ask whether it has occurred to him that, in order to obtain the assistance of the mothers themselves in this matter, it would be wise to impress upon the authorities the desirability of providing educational facilities for teaching this important subject, not only for those who have left the schools and the clubs but also for those who are still in school or members of clubs and are between the ages of 13 and 16; an age when they can retain a considerable amount more of what is being taught them than they do in later years.

If proper instructors were provided I believe that young girls between the ages of 13 and 16—those who have attended such classes in the schools or who have later done so, in the girls clubs—could realise the importance of this subject and not be frightened at what might be the result of child bearing. If they are not properly instructed it may very well be that there will be more abortions or attempts at abortion than occur already, and heaven knows there are all too many. They must be taught in such a way that they will have an opportunity of realising and appreciating the difficulties that may occur and of dealing with them as and when they arise. That is not only my opinion. It is the opinion of imminent medical men. The hon. Lady opposite has referred to the excellence of the medical officer in her own district, I feel the same about the medical officer of health for Stepney, who has done remarkably good work. Stepney with all its tremendous disadvantages, with its overcrowding and all the economic trouble that the people have to contend with, has had provided for it by public and voluntary effort as satisfactory a system in relation to maternity matters as prevails in some of the best centres. The Medical Officer of Health for Stepney, Dr. Fergusson, feels that the question of maternal mortality ought to be tackled by the proper education of those who are to become the mothers of the future who should also be trained in the care of infants so that the infant mortality rates not only in the first year of their lives but also in later years may be drastically reduced.

I agree that the system of providing midwives who are expert in the work is one that should be striven for by everyone concerned with this important problem. The handy woman is regarded by all who have considered the subject as being of very little use, for the purpose of avoiding the difficulties that exist. Complaint in that respect has been made by medical men and one cannot blame them. It is absurd that a person will go to a specialist for trouble in the ear, the nose or the throat, or for some trifling complaint, and yet when a question of life and death is at issue not only for the mother but for the child umbrage is taken at the suggestion that there should be specialists in that particular kind of work. The medical profession ought to welcome, as many of them do welcome with open arms the suggestion that there should be a body of medical men who do definitely specialise on this subject: general practitioners if you like with a specialised knowledge in this direction and a liking for the work should deal with such cases.

I propose to deal with the question of malnutrition which I consider to be most vital. The hon. Member for West Willesden said, and I think quite rightly, that a number of people believe that malnutrition does not directly affect the position. I do not agree with them. Let me quote the opinions of authorities on this matter. I will read a few words from the report of Dr. Redwood, medical officer of the Rhymney Urban District. He said: Compared with normal times, in my opinion there is a considerable amount of under-nourishment in mothers, more than in infants, due to unemployment, working short time, shortage of money in the home due to illness, delay in payment of compensation after injury, etc. The Medical Officer of Health for Smethwick says: I attribute a considerable proportion of these deaths to poor nutrition on the part of the mother. It is probable that when economic circumstances are at their worst the mother denies herself the necessities of life to improve the lot of her husband or children, and when in addition to her ordinary life she is bearing another child, her misguided unselfishness is having deleterious effects on two valuable lives. The result is that she is weakened, is less able to resist the strain of childbirth, is more susceptible to puerperal infection, and runs a great risk at her confinement. The uninsured worker, that is, the wife of the uninsured man, the wife of hawkers, small tradesmen and people of this description cannot claim the maternity benefit and is frequently unable to obtain the nourishment that is necessary. Moreover, those who have fallen outside benefit are unable to get maternity benefit. Since the last Insurance Act women are receiving a smaller amount of allowance in case of illness and disablement. These circumstances create a position which must have a very serious effect upon the health and life of those who come within the purview of the matters to which I have referred. I hope the Minister will take this question into consideration and that he will realise the serious position that exists, owing to the inadequate amount that is given to unemployed persons: inadequate, because the British Medical Association states that under the conditions that prevail to-day the amount that is allowed by the Unemployment Assistance Board or the public assistance committees is not sufficient to keep the body and soul of a family together properly. The woman takes the main brunt of this shortage and in consequence of that, in my view and in the view of many thousands of others, the mother suffers heavily at a time when she is giving birth to a child, or within a short period after the birth of the child. Indeed, she very frequently suffers for the whole of her life in consequence of the circumstances to which I have referred, namely, the inability to obtain the bare necessities of life, particularly when she is passing through this very trying period.

I hope that we shall hear from the Parliamentary Secretary that steps are to be taken and taken quickly to deal with these problems not only through the Ministry directly but through the local authorities who should be guided by the Ministry. I hope that steps will be taken to extend the period of ante-natal attention and the period of post-natal attention and that instead of there being 14 days or so of attention one way or the other, there shall be a more extended period of two or three months ante-natal treatment and two or three months postnatal treatment. The results of such treatment would redound to the credit of the Ministry and ultimately to the benefit of the community as a whole. I am afraid that I have kept the Committee for a considerable time but I feel that this matter must be dealt with exhaustively, and now that we are discussing this and cognate subjects I hope the Minister will take all the steps he can to relieve the anxiety of the people of this country on this very grave and important problem.

4.43 p.m.

Mr. J. P. L. THOMAS

I had hoped for more co-operation than criticism in this Debate and except for the second half of the speech of the hon. Member for Westhoughton (Mr. Rhys Davies) we have achieved that. The cause of national health ought to be far above party warfare or party bickering. Every party ought to welcome whole-heartedly any additions, whatever may be the Government of the day, towards making the nation more health-minded and towards arousing the whole public conscience on this great issue. I do not think that the cause of health is helped by refusing to recognise plain facts or by withholding from the present Minister of Health or the Parliamentary Secretary due praise for the benefits to national health which will undoubtedly come from their housing and slum clearance schemes and their Bill for dealing with overcrowding. I was glad that the hon. Member for Whitechapel (Mr. Janner) praised them for the work which they have already done. I also do not think that the cause of maternal mortality, which is a problem about which many of us feel very deeply, is helped in any way by being dragged, as it was not long ago, through the mire of party by-elections. I think the hon. Member for Westhoughton set an example to the less responsible Members of the Labour party in the country and I hope that the deplorable manoeuvre to which I have referred will cease, because I do not think that it reflects any credit upon the Labour party as a whole; in fact, it can only lower their party in the judgment and in the eyes of the country.

On the question of maternal mortality I had a talk during the week-end with two doctors, one of whom has been in practice for many years and one who is just beginning his work as a medical practitioner and they both agree on many points. Both agreed that the great tragedy of maternal mortality is that medical research, which has gone on under successive governments, has failed so far to get down to the real root of the cause of the evil or to find the secret of a successful cure. They are still working hard, and I am sure that the House is united in hoping that their efforts may be successful. I would like to urge the Minister of Health to spare neither encouragement nor finance in backing up this work undertaken by the Medical Council. It was said in a remarkable speech at the Iron and Steel Association dinner last week that "economy in research is false economy." If that can be said about iron and steel, then surely where human lives are at stake economy in research is something bordering on culpable negligence. I know that the economies made in 1931 did not apply to maternity and medical research, and that the grants were continued to maternity services and maternity research, and I feel it is the wish of the House that it should be the same in the years to come.

The hon. Member for Whitechapel mentioned under-nourishment as a cause of maternal mortality. I do not think it is a true picture of the whole position to maintain that under-nourishment is the main cause. The doctors to whom I was talking agreed that the maternal mortality rate is sometimes higher in the well-to-do areas than it is in the depressed areas. But I admit that undernourishment in some cases is the cause, and I welcome the decision of the Milk Marketing Board, which is preparing to study the possibility of extending their scheme for milk at a reduced price in schools, to other sections of the community. I hope the Minister of Health will urge the claims of mothers attending ante-natal clinics during pregnancy, of mothers while they are nursing their children, and if possible of the children themselves throughout their ante-school years. I know that there are difficulties of administration, but I do not think they are insurmountable, especially as we look forward in the coming year to having a large surplus of milk supplies in this country.

Reference has already been made to the good work which ante-natal clinics are doing. I agree they are doing admirable work, but I feel that there is still need for further co-operation between doctors and nurses attending ante-natal clinics and the actual doctor or midwife who is going to be present at the delivery of the child. In the country areas women come in from the more isolated and distant villages on market days, go to the ante-natal clinic and get valuable advice from the doctors and nurses there. Then they go home, and when the actual moment of confinement comes, perhaps there is no maternity home to which to go, or perhaps the difficulties of transport to one are great—and the husband immediately turns to the local village doctor, who comes along without having any previous knowledge of the case. I hope the Minister will appreciate the importance of this and that he will arrange that the ante-natal clinics shall get in touch with the doctor or midwife who is likely to be present at the confinement and see that they are supplied with a full account of the antenatal work and the ante-natal record of the particular case. They should be in full possession of all the facts.

I was particularly interested that both the old doctor of many years' experience and the young doctor agreed on the subject of the Midwives Act, 1902. They said that it was a great blessing and that admirable work was being done by midwives, who are now better trained and possess their certificates. I agree with the hon. Member for Westhoughton that a rise in salary would do untold good in this particular profession. But the Midwives Act, 1902, according to these doctors, has had an unforeseen result. The result is that midwives have taken over a large portion of the obstetrical work of this country. The local practitioner of to-day probably takes about 10 years to collect the experience of confinement cases which his predecessor of 30 years ago obtained in one year. He frequently is not called in to-day unless the case is difficult and abnormal, and when he comes in he has to face the case without the accumulated knowledge of continual practice. I hope the Minister will impress on the Medical Council that this change of practice makes it all the more necessary that the training of medical students at hospitals in confinement cases should be intensified. I should also like the Minister to press on the Medical Council that intensive training should be given in the actual administration of anaesthetics at confinements. One of the greatest blessings of this age is this use of anaesthetics, and those who are tirelessly working to bring anaesthetics within the range of the poorest woman want to feel certain that when these anaesthetics are administered, they are administered by well-trained and the safest possible hands. I hope the House will give united support to the Minister and those voluntary organisations who are doing wonderful work to help to wipe out this bad blot of the maternal mortality figures on the otherwise remarkable record of the nation's health.

I hope that I shall be in order in referring to another subject. We come to a far happier chapter when we look at the health of the child at school. Year after year it becomes more satisfactory, and we can take comfort and not a little pride in it. I wish we could feel the same comfort and pride when we look at the position of these same children in the immediate years after they have left school. After all this care in the schools they are let down badly and suddenly at the most important time of their adolescence, and when they are having their first taste of industrial life. For that reason I welcome the suggestion that has been made for an extension of health insurance in order to bridge the gap from the school-leaving age to the time in which they go into insurance at the present time, in the same way as has been done in unemployment insurance. But apart from that, what are the main wants of young boys and girls leaving school? They love their games; they want their outdoor sports. In fact, they want their open spaces. Green belts round the towns are admirable, but green belts inside the towns would be better still. I have read the report of the National Playing Fields Association, and in spite of its excellent work I find that in, the Metropolitan area, and in other large towns, there is still a 50 per cent. shortage of open spaces, while only 25 per cent. of the actual needs for playing fields themselves have been realised.

I know that the need of the towns is infinitely greater, but I want hon. Members to realise that we in the country villages have our difficulties too. In the past, these country villages have relied on the generosity of the local squires not only to give them their playing fields, but for the necessary finance which has usually accompanied the loan of the fields. With the breaking up of big estates it is no longer possible to get these fields loaned as they have been in the past, and the position of the village club is beginning to become precarious. I should like to ask the Parliamentary Secretary for an assurance that any plans put before the Ministry under the Town and Country Planning Act shall contain, as far as possible, and especially in the undeveloped and semi-developed areas, adequate spaces for playing fields. Such an assurance would go a long way to ease the mind of the House on this vital question. I have heard the allegation made that since 1931 the Ministry of Health has refused, on grounds of economy, to sanction many loans to local authorities for playing fields. I should like to know whether that allegation is true, and if so when the ban if likely to be lifted? The question of playing fields, however, only concerns the outdoor lives of these young boys and girls. There is still the indoor life, the long winter evenings, when the need for indoor recreation has to be met. I think that the House was genuinely alarmed at the high percentage of rejections, owing to physical unfitness, in the recruiting figures which were published a few weeks ago. I suppose that the average age of a recruit is between 18 and 20, and this surely proves that a marked deterioration is going on during the immediate post-school years. I think it could be corrected if public gymnasiums were provided in all our towns, in the same way as public libraries are provided. They would supply the indoor needs of recreation, especially during the winter months.

We are living in changing times. The hours of labour are likely to grow less and less, and the hours of leisure and time for physical recreation are likely in the future to become correspondingly greater. Over 50 years ago George Eliot wrote. Important as it is to organise the industry of the world, it is of greater importance still to organise the leisure of the world. How much more true those words are today than they were 50 years ago, and how important it is that this leisure should be used to better the health of the in- dividual and of the nation as a whole. I believe there is a genuine desire among the youth of this country to-day for physical fitness, and if the Ministry can add to its great record by satisfying this desire, it will have the backing of all parties in the House and of the country as a whole.

4.58 p.m.

Mr. GEORGE GRIFFITHS

I am sorry that the Minister of Health is not present, but I understand that it is due to health reasons. I wanted to put one or two pertinent points to him, but I have no doubt that the Parliamentary Secretary will be able to give me a reply almost as well as the Minister himself. During the discussion my mind has gone back to a conference held at the Friends' Meeting House in Euston Road, called by the National Women's Association. After the annual report on public health by Sir George Newman had been published some alarm was felt at the figures relating to maternal mortality. As I have been sitting here I have looked at the empty benches of the House and felt that I should have liked to have brought that conference to the public gallery for them to have seen the great interest taken in this question by the House of Commons. If we had been discussing pepper, shellac or tin, the House would have been full, but as we are discussing a question which affects the motherhood of this country, and is, I think, the most important question of the day, we are discussing it in practically an empty House. The figures show that there were 613,972 births in 1932 and the maternal deaths totalled 3,300, of which Sir George Newman said in his annual report that at least 50 per cent. would have been saved if proper attention had been given. The return shows that in 1933 the births were 580,413 and the total maternal deaths 3,444, a decrease of births of 33,559, but an increase of maternal deaths of 144; or a total percentage of maternal deaths in 1932 of 5.37 and a total percentage in 1933 of 5.94. The Minister of Health, when speaking on 3rd July last year, made this statement: We have an object; it is to reduce the rate of maternal mortality. We will try these methods of achieving that object. If they do not succeed, we must proceed to others. I do not think it is possible to state the policy more clearly than in these words. These are, in my belief, the right methods to adopt—the improvement of existing services all over the country to the greatest possible extent in order to deal with the matter. If they fail, undoubtedly we shall have to take more urgent and strenuous measures; but I do not think they will fail."—[OFFICIAI. REPORT, 3rd July, 1934; col. 1879, Vol. 291.] That is what the Minister said 12 months ago. I want to say, frankly, that if these figures state anything at all, then the measures that the Ministry have taken up to the present time have failed. I want to ask the Parliamentary Secretary what they intend to do in the near future with the figures that are in front of them—births 33,000 fewer and maternal deaths 144 more. I would like the Ministry to take to heart that the mothers of this country are perturbed about this business. We talk about the fatalities of mining. The fatalities in child-birth, the most precious occupation in the world, are the most dangerous and the most severe.

I am sorry that the hon. Member for Willesden (Mrs. Tate) has gone out, because I wanted to cross swords with her over this malnutrition business. I am satisfied that over and above the figures there is a tremendous amount of malnutrition which causes maternal deaths. Sir George Newman himself, leaving out the cold figures, makes a statement on pages 260 and 261 of his report: A second factor in the poor results obtained in midwifery may be the result of the nutrition of the mother during pregnancy, and particularly her diet. A well-known medical authority who has been exceptionally successful in ante-natal preparation for child-birth has laid down for his midwifery cases three very simple rules as to dietary—(1) eat light meals. The majority of my people have got to eat light meals, because they cannot get anything else. (2) Eat little or no meat. They carry that out almost 100 per cent., because they cannot get hold of it. (3) Eat plenty of fruit and uncooked food. Sir George goes on further, and this is very interesting: After all sound nutrition in a pregnant mother is obviously the only way of sustaining her own health and strength and that of her forthcoming child. She should become accustomed to a diet which includes ample milk, two pints a day, cheese, butter, eggs, fish, liver, fruit and fresh vegetables, which will supply her body with the essential elements, salts and vitamins, without over-burdening the organs of excretion. Instruction in dietary, as well as personal hygiene, should be given at every antenatal centre, but at present it is largely neglected. Sir George Newman makes the statement that they should have two pints of milk-that is 7d.—eggs, fresh fruit, fish and liver. We agree with every word that he tells us, but I want to ask across this table: "Where is the money coming from?" That is the point. There are 750,000 men at the present time on transitional payment, and some of these men, according to statements that have been made, have been out of work two, four, six, and some of them eight years.

I should like to quote some other figures. They are percentages of maternal deaths. Out of 36 authorities with very high figures, there are only two authorities belonging to the south of England. All the others are north of the Trent or in South Wales. There are 36 authorities with percentages of maternal death-rates which are higher than the average for the country, and 34 out of the 36 are situated in the northern or north-Midland areas or in South Wales, which points definitely to this fact: In the industrial centres that have been smitten with depression, underwork and unemployment are the places where the highest maternal mortalities are, showing that the mothers in the long run have not had sufficient to eat against the time when they have to fight the greatest fight of their lives. In a great percentage of the cases of maternal deaths the cause is malnutrition. In hundreds of mining districts to-day, when a mother knows that she is going to have a new life coming into the home, instead of that being a joyful time it is the reverse. I saw this morning, when I picked up my paper, that a certain earl's wife had given birth to a son. They had had four daughters and yesterday morning the bells were rung because of the birth of a son. The bells do not ring in the majority of the miners' homes to-day, where there are two or three children in the house, when another comes along. Generally speaking, they almost feel like drawing the blinds, because they know there is not the food to feed the additional mouth. When a young mother in the mining districts knows that she is going to have another baby, the mothers that live in the same street, instead of congratulating her, are usually sorry for her. I am giving you bald facts. I am not giving it in the language of Oxford or Cambridge. I am putting it in everyday language.

I see in the Estimates that the Ministry have decided that they must wipe out this high percentage of maternal mortality, and the way they are going to do it is given on page 23: Grants for the training of midwives in 1935, £24,000. The grants for the training of midwives in 1934 were £26,500, so that they are cutting off £2,500. The hon. Member for West Willesden stated that we wanted a higher degree of training. I do not think we are going to get that by paying less money for it. A most interesting thing happened this year. A young monkey was born at the Zoo. As soon as they knew the mother was going to have a young monkey, there were two attendants on her every moment, watching every movement, and when the young one landed they had two special attendants on the mother. The monkey was born about six weeks ago, and they have had two special attendants on the mother monkey and on the young one. I know my friends smile, but the mothers of the country are not smiling. They are watching. They say if the country can be so excited and if the Zoo management can look after a monkey that is going to have a young one, it is time the country looked after the mothers who are going to bring new lives into the country.

Mr. GLOSSOP

May I ask the hon. Gentleman whether he thinks it is not a little unfair to make a comparison between the mothers of this country and monkeys? He suggested that this monkey got special treatment. Does he not realise that the monkey was in entirely strange and unnatural surroundings?

Mr. GRIFFITHS

Yes, that is true. I was only drawing the analogy. I hope it has gone home. I did not think that anyone in the House was going to take the side of a monkey against a baby. I would like to say a few words about the 110,000 who have lost maternal and medical benefits. In my own district, in the Hemsworth division, in one little village we have 110 men who have lost all these benefits. I know we cannot touch the pension benefit, because there is a report coming on that. I only want to touch the fringe of this question, because I desire to touch on a vital point affecting a smaller number. In a small village 110 have been out of work for more than two years and nine months. They have lost these benefits. I had a letter the other day from the secretary of a medical association stating that when they were employed at the pit they paid 5d. a week for the family doctor, who did all the doctoring in the house. In addition the family doctor got their panel tickets. I believe that the panel fee for the doctor is 8s. 6d. per annum. In round figures that is 2d. per week. The family doctor stated to these men immediately he lost the 8s. 6d., "I am now going to charge you 9d. per week." That was said to men who have been out of work not less than 33 months. The doctor is going to charge them 9d. per week when they have practically nothing with which to pay him. I ask the Parliamentary Secretary to give serious consideration to the position of the 110,000 people who are now out of the three benefits. Unless something turns up by December, 1935, they will also forgo any pension benefits. Inside the industrial areas this is a very important matter.

I put a question about diabetics to the Parliamentary Secretary to-day at Question Time, and the answer that he gave me was in effect, "We do not know." There are in this country to-day 200,000 suffering from diabetes, or one in every 250. I am told that in America one in every 100 suffers from diabetes. A saying there is, that when shares go down diabetes goes up. There are 110,000 who lose their medical, maternity and money benefit. There are in this country at least 470 men suffering from diabetes who were receiving insulin treatment free before they ran out of medical benefit. To-day they cannot receive that insulin treatment free. I know that the Parliamentary Secretary will tell me that they can get it from the public assistance committee. But let us see whether they can. If these persons were eligible for medical benefit, irrespective of what was the income going into their homes, they would receive medical benefit and free insulin but now, if they are put on transitional benefit or public assistance on the unemployment assistance scales, and there is any income going into their homes they cannot receive treatment from the public assistance committees because they are not entitled to draw anything from a public assistance committee, and not being entitled to draw anything they cannot get the special medical benefit as far as insulin is concerned. To-day insulin costs 1s. 5d. a bottle.

Mr. T. SMITH

Only to-day I have been informed by the unemployment assistance board in my area that where there is a case of diabetes in a family and insulin is needed, it is possible to get that insulin from the public assistance authority.

Mr. GRIFFITHS

Let us get the matter clear. Suppose that I myself am unemployed and that I have gone out of medical benefit, and there is an income coming into my home which cuts me out of unemployment benefit, I cannot get the insulin from the public assistance committee. The income prevents me going to the public assistance committee. But suppose that my wife and not myself had diabetes. She would be able to get the insulin. I am speaking, however, about the 470 men on an average who have run out of medical benefit entirely. What will insulin cost these people? Mark you, they are on the unemployment assistance board scales and not on unemployment benefit. While a man is employed he can draw medical benefit from the State, but if he is out of work and is drawing unemployment assistance board payments, he has 24s. for himself and his wife, 4s. for the first child, and so on.

Allen and Hanbury insulin is 1s. 10d. a bottle, or 1s. 5d. if bought wholesale. But how many unemployed are able to buy 24 bottles at a time? If a man gets one bottle he has to pay 1s. 10d. I know that Boots, the cash chemists, have put 100 unit bottles on the market at 1s. Let us take the price as 1s. The majority of these 470 people must have four bottles a week. That means 400 units. Four bottles will cost 4s. Iodine will cost them 6d. a week, methylated spirit 2d., needles 3d. per week, and wadding another 3d. It means that the diabetic patient when he has medical benefit cut off must find 5s. 2d. a week out of his unemployment assistance if he is to live. To the diabetic insulin means life and joy and happiness, and no insulin means slow death. I appeal to the Parliamentary Secretary. I ask him somehow or other to see that these men are considered, so that they can look to him and be able to say that he prolonged their life and brought joy and happiness into it to the end of their days.

5.22 p.m.

Lieut.-Colonel Sir ARNOLD WILSON

I suppose that no more important subject than maternal mortality could have been raised by the hon. Member for Westhoughton (Mr. R. Davies), but scarcely any more difficult to discuss with advantage in this House. I notice with great regret but with less surprise that none of the hon. Members who are learned in medicine are in the House—none except the hon. Member for Denbigh (Dr. Morris Jones), to whom I apologise. The difficulty of training mid-wives has been emphasised, but to-day only 3½ per cent. are untrained.

The hon. lady the Member for West Willesden (Mrs. Tate) thought that there were too many institutions for training, and said that there were 68. There are, in fact, no fewer than 186 institutions in this country engaged in training mid-wives. That is far too many; if the midwifery service is to improve the number must be reduced. But the question goes far deeper than that. The obstetric service provided by doctors in this country is now recognised by the medical profession itself to be inadequate, and it cannot be dealt with merely by improving the training of doctors. The material is too small and too widely scattered. The problem is one of hospital management and administration, and must be dealt with as a whole. It has been suggested that we should increase the number of lying-in institutions, but the latest report on the state of the public health by Sir George Newman shows that opinion on that subject is by no means unanimous, owing to the danger of infection. It was suggested, I think, by the hon. Member for West Willesden that we should have fewer midwives, so that they might have a full day's work. That brings its own peril, for, as the current report of Sir George Newman emphasises, the danger of carrying infection from one patient to another is very great, and the success of the woman who seldom practises is to some extent due to the fact that she is less liable to carry infection from one patient to another.

The hon. Member for Stepney (Mr. Janner) made great play with suggestions. Even the most carefully prepared official statistics are of limited value when we are dealing with this subject. There are many factors not susceptible of statistical analysis. Compare Bath, a favoured place, with a maternal mortality of 5.19 and a birth rate of 10.9, with the maternal mortality of Liverpool, which is 3.41, and of Bootle, which is 4.05. These two latter are poor districts, well below the average for England and Wales. Blackburn, which is not well off now, has a maternal mortality of 2.60. These low figures are associated with a high birth-rate—19.7 and 21.4 for Liverpool and Bootle, respectively. These figures are clearly inconsistent with the view that maternal mortality is related to the social position of women; the well-to-do seem in practice more liable to a high maternal mortality rate than the less well-to-do. The reasons are obscure, and cannot be dealt with here.

In the area of Guy's Hospital, I am informed, the maternal mortality rate is barely one per 1,000, and the figures quoted for the Queen's Institute of District Nursing 1.46, shows that the poorer classes, for whom the hospitals and the district nurses oater, are getting a thoroughly good and adequate obstetric service. The Ministry of Health should now tackle this problem not simply as one of obstetrics and maternal or infant mortality, but as one side of a much larger question, the question of hospital administration as a whole. Should we not attempt to reorganise all the backward hospitals of the country and get them to specialise more than they do now? The dangers of infection in a maternal ward which is not detached from a hospital are very well known to all doctors.

To digress for a moment from the question of maternal mortality, the difficulty of getting fractures adequately dealt with in the existing hospitals has been the subject of a very grave and weighty report in which eminent surgeons show that in orthopaedic hospitals the results are something like 30 times as good as the results in hospitals where there is no specialisation. There is one factor which is probably at the bottom of the increase in maternal mortality which has taken place during the last three or four years. It is a matter of which it is exceedingly difficult for any Member of Parliament to speak, because it rouses the greatest prejudice in the minds of those who have not given it the fullest consideration. Sir George Newman, in his latest Report on the State of the Public Health, writes on page 69: Consideration of the number of deaths of women due to and following on abortion furnishes evidence of the important part this condition pays in influencing the maternal mortality rate … On page 68 the report states: It has been estimated that about one in seven pregnancies terminate in abortion. The figure on which this estimate is based cannot be assumed to furnish, a true index of its frequency throughout this country. Its frequency is, probably, much greater. The report continues: It is argued that the termination of cases of pregnancy under 12 weeks' duration under surgical conditions in recognised hospitals represents an advance in maternal care. The mortality under these conditions is reported as notably low. That is, says Sir George Newman, the view of an increasing number of experts and social workers. It is impossible to deny that the lower middle and working classes are unable to obtain expert medical assistance to terminate pregnancies in the first weeks, with the result that they suffer if not death very often permanent disability and illness from unskilled hands. Maternal invalidity is of even greater importance than maternal mortality. There are scores of thousands of women as the hon. Member for Westhoughton (Mr. R. Davies) has said who are permanently disabled not from accidents after the birth but from abortions, involuntary or deliberate, under unhealthy and undesirable conditions. I am not advocating the adoption of the methods indicated by Sir George Newman as being likely greatly to diminish maternal mortality, but it is the fact that puerperal sepsis, consequent upon unskilled abortion is probably the main cause of the increase in maternal mortality during the past few years. However little we may like to do so, it is time that we recognised and took stock of that fact.

I have one other observation to make on a matter which indirectly deals with maternal mortality and morbidity, namely, the lack of adequate attention, under the existing national health insurance scheme to oral hygiene and dentistry. One of the first essentials in the care of women before and after childbirth should be attention to the condition of their teeth, which have been damaged by lack of calcium. That is frequently a cause of poisoning and of the inability of women to nurse their own children. Less than one-third of all the women under the national health insurance scheme are at present entitled to dental treatment under that scheme. About 9,000,000 men and 2,000,000 women out of 12,000,000 insured men and 6,000,000 insured women get dental benefit. Even those do not get more than half the cost of the dental treatment; the remainder get just nothing. The middle class and the well-to-do in this country spend at least three times as much on their dentists as upon their doctors, and consequently maintain their health and their ability to work. As the national health insurance scheme now works, we spend little if anything at all more on dentists than on drugs.

With such experience as I have gained as chairman of the executive committee of the largest single dental charity in this country, the Ivory Cross, I submit that no form of expenditure would be better justified by immediate results than an increase in the dental benefit services, and some system whereby those services would become universal. It is scarcely to be tolerated that the question of whether a man or a woman is or is not to get even 50 per cent. of the cost of dental treatment should depend upon the chance of the financial status of the particular society which that person has happened to join at the beginning of his or her working career—and notoriously young entrants have for practical purposes no choice in the selection of a society. There is a sorry tale of avoidable misery and suffering running right through this country which can be traced, as every one knows who has had experience of medicine, to bad teeth. It is the largest single cause of rejection of recruits by the Army to-day.

In the report on the health of the Army for 1933, the statement is made that there has been no improvement during the past 10 years in the oral hygiene of those applying for admission to the Army and that the school dental service has not had the effects which it ought to have had for all gains being lost between the ages of 14 and 18. Failing a continuous dental service covering the ages from 14 to 18, we may find that all the money that we are spending on providing dental treatment between the ages of 6 and 14 is wasted on account of the teeth troubles which supervene in later years. At present dental benefit is not a statutory but merely an additional benefit. There will be, I believe, next year an actuarial ascertainment of the National Health Insurance Funds. I hope when that is concluded, the Government of the day will seriously consider whether it should not, at a single stroke, take the next great step towards national health by placing dentistry and medicine upon an equal footing and not making dentistry merely an additional or supplementary benefit as it is at present.

5.40 p.m.

Mr. T. SMITH

The hon. Member for Hereford (Mr. J. P. L. Thomas) commenced his speech by saying that he was disappointed with the criticism offered to the House by the hon. Member for Westhoughton (Mr. Rhys Davies), and went on to say that he expected the fullest co-operation among all parties on matters connected with infantile and maternal mortality. If he looks up the record of the Labour party upon those subjects he will find that in season and out of season we have sought to secure remedial action in connection with both. If he has any knowledge of local government he must know that the Labour groups on various councils have been foremost in their agitation to get something done with regard to infantile and maternal mortality, and he may take it for granted that we are prepared to support any party at any time, in any measure which will make for a reduction of mortality from these causes. With regard to maternal mortality, I want to put one specific question to the Parliamentary Secretary. I notice that while Sir George Newman's excellent report states that the average figure of maternal mortality is 4.32, he mentions a number of authorities whose figures are higher than the average, and on page 263 he says: Is it asking too much of the authorities responsible for the health governance of these 36 sanitary districts, to call for a report on this continually high death rate among mothers if they have not already done so? I wish to ask the Parliamentary Secretary whether the Ministry takes care to get into communication with these authorities and whether there is the necessary co-operation between the Ministry and these particular sanitary districts, in order to deal with what is, after all, to be regarded as an abnormal state of things. Perhaps the hon. Gentleman will answer that question when he is winding up the debate? Whatever may be said about those two important subjects, there is another matter upon which the hon. Member for Hereford and the Government need not look for co-operation from this side and that is the 1932 National Health Insurance Act which is, I say without fear of contradiction, the meanest little Act that has been passed since this Government was returned. It was passed six months after this Government returned here, flushed with victory. The Minister of Health in introducing it said that the task was not only disagreeable to the House but disagreeable to himself, but he added that the stern financial necessities of the approved societies demanded it. He went on to point out that roughly 80,000 people would be thrown out of insurance and would lose among other things their right to contributory pensions at the age of 65, while, when they died, their widows and children would also lose pension rights.

The hon. Member for Westhoughton is to be congratulated on having raised this matter and, whether the Parliamentary Secretary knows it or not, I want the House to know what is taking place in industrial districts. A few weeks ago the Minister of Labour and the House admitted that a mistake has been made concerning the regulations in connection with the Unemployment Assistance Board and the Minister was frank enough to withdraw the regulations and introduce a stand-still order. It was shown that certain things had taken place in regard to those regulations and the same things are taking place in isolated districts, as regards the effect of this Act of 1932. For the first time since the introduction of National Health Insurance in 1912 the cash benefits of 5,500,000 people have been reduced by this Act—despite the fact that we were told by the Ministry that at a certain period the approved societies had great accumulations of money. In addition, this Act terminated the prolongation of insurance as far as the unemployed were concerned—a most unnecessary and mean thing to do. It laid down that instead of the unemployed man having a frank for each week out of work he should get a frank for each two weeks out of work and at the end of the year the unemployed man was presented with an arrears card for 24 weeks at 9d. a week or 18s. After all, 18s. is not much to a man who has some money, but 18s. is a lot to those who are out of work, and have been out of work for a long period. I met many people in my constituency who were at their wits' end to know where the 18s. was coming from. While it is true that the Minister made it easier for them to find the 18s. by arranging an instalment plan, that amount of money had to be found.

There are some hon. Members who, while not being very well acquainted with national health insurance, seem to be of the opinion that so long as these arrears are paid by the unemployed, they are kept in insurance. That is not the case. It means that even when the arrears are paid these men more or less automatically go out of insurance when they have been out of work on an average more than 2¾ years. We are told by the Minister that the alternative is to become a voluntary contributor. It is easy to find 1s. 6d. a week if you have it, but it is very difficult to expect a man who is out of work, who is drawing 24s. a week for himself and wife, with an assumed rent of 7s. 6d., leaving 16s. 6d. with which to keep the two of them for a week, to reduce that amount by 1s. 6d. in order to become a voluntary contributor. I think there is a case here for reconsideration by the Government. I believe the figures are nearer 130,000 than 110,000 The effect of the Act is to throw a bigger burden on the local authorities. If a man cannot get his panel doctor, he has to get the parish doctor. If a man is not in benefit, he has to go for public assistance. If a man is thrown out of pension rights and he dies, his widow becomes a permanent Poor Law case. There is plenty of room, therefore, for reconsideration.

The PARLIAMENTARY SECRETARY to the MINISTRY of HEALTH (Mr. Shakespeare)

No widow among those 110,000 persons loses pension rights.

Mr. SMITH

No. If I did not know the Parliamentary Secretary well enough, I might think he was trying to lead me up the garden. It is true that under the 1932 Act if a man falls out of work at about 58½ years of age and he has had 10 years in national health insurance, he is safeguarded for pension rights, but surely the hon. Gentleman knows that not all these people who are going out of insurance are turned 58½ years of age. If the Parliamentary Secretary does not appreciate it, I will illustrate what is taking place. There are scores of men in industrial districts who are being thrown out of work at 50 years of age, who have been out of work three or four years, and who, by the very nature of the industrial circumstances of the district, have very little hope of ever getting back into insurable occupation. Surely the Parliamentary Secretary is not trying to tell this House that when such a man has been out of work continuously for more than three years, his wife, if he dies, can legally expect a widow's pension. If so, I will send him a few letters with regard to cases that have been turned down. Many of these people who have been thrown out of work at 50, particularly in the mining industry, are men who have drawn very little out of national health insurance and who, during the best years of their life, were working. I am a case in point. I was insured under national health insurance, and I am pleased to say that I never drew any benefit. I always had good health, which I appreciated very much. I always understood that the benefit of insurance and of pooling contributions was that those who were less fortunate should be helped in time of need. These men of middle life, who have spent the whole of their working life in insurable occupation and have paid continuously from 1912, are going to be faced with this, that if they cannot get back into insurable occupation, they lose all pension rights, and if they die, there is no pension for their widows. I certainly think there is a good case for a reconsideration of the position. What was done by the Act saved the approved societies about £1,000,000 a year, but the House must not forget that only six years previous to the passing of that Act the Government relieved itself of £2,750,000 per annum by lessening the grants to the approved societies.

There are one or two other matters that ought to be said with regard to national health insurance. My hon. Friend the Member for Westhoughton is in a favoured position. As he said, his approved society is well managed, bas a surplus, is able to give additional benefits of all kinds and to pay the arrears of unemployed people, and so on. That is the position generally of the majority of the approved societies, but it is rather a matter of luck that they are in this fortunate position. They have been fortunate enough to have what are known as good lives as members. But what is the position in other approved societies, where in some cases they have not a surplus, but a deficit, where there are no additional benefits, and where members have been denied proper dental treatment? I think there ought to be a complete overhauling. If you call it national health insurance, there ought to be a pooling of additional benefits, so that those people who are unfortunate enough to work in an industry in which there is a lot of sickness shall be able to get the same additional benefits as those who are in more fortunate employment. I hope the Parliamentary Secretary will not disappoint us when he comes to reply, and I hope he will be more than sympathetic. We have had sympathy by the bucketful. I remember that the Parliamentary Secretary, in answering a question, said he believed the limit of generosity had been reached, but I would suggest to him that that is not the kind of reply to give in this House on these industrial matters. At a time when £1,000,000 per annum will put these unemployed back into insurance, when the State is ladling out millions to certain industries by way of subsidies, when we are having extraordinary expenditure in other directions, I think we are justified in asking for a reconsideration of this matter, and I hope the Government will not disappoint us.

5.53 p.m.

Countess of IVEAGH

I am very glad that so much attention should have, been given to-day to the question of maternal mortality, although it is in the presence of a diminished attendance of Members. This question is giving increasingly great concern to the country, in view of the admitted failure to cope with it adequately. It is rather a humiliating admission of failure, when we think that whereas our health services and our medical science have so greatly improved as to diminish the general death-rate and to raise the general expectancy of life very highly in the last decade, on this question of maternity, which is not a disease at all, but a process of nature, so far from there being any diminution of mortality, the number of deaths is not even stationary but is rising, so that in spite of 10 years' widespread efforts, we have had a rise in the rate of mortality during that period of from 3.82 to 4.51. All this, in spite of the fact that the social services connected with maternal welfare have greatly increased during that time and that local authorities have been given additional powers, which many of them are exercising, although I think it is not an exaggeration to say that none of them is perhaps exercising all its powers as adequately as it should, and some are certainly not doing what they could. Nevertheless, a great deal is being done, and yet we get this most unsatisfactory result.

Inquiries have been made into the cause of this state of things. I am not going to traverse again ground that has been covered by other hon. Members, many of whom have mentioned the Departmental Committee, which collected a large amount of most valuable information, the most valuable part of which was the fact that 50 per cent. of maternal deaths were from preventable causes. The rise during the last few years is chiefly due to puerperal sepsis rather than other causes, so that while I do not fall foul of hon. Members opposite on the point and agree that malnutrition may be a cause, it is obvious that it is not the only cause. We have had statistics given showing that women who are nursed under good conditions and have facilities at their command nevertheless suffer from a high maternal death-rate. Therefore, we have to look further for the cause, and undoubtedly the answer is that the causes are many. Such information as we have gathered already is admittedly not enough.

There is the question of medical training both for doctors and for midwives. I agree with my hon. Friend the Member for West Willesden (Mrs. Tate) that there must be, when one examines exactly what the training is for doctor, general practitioner, and midwife, something lacking, and it would be interesting if the Parliamentary Secretary could give us any information as to whether there is a prospect of a greater increase in the training given to doctors and midwives and post-graduate training in obstetrics. In that connection I would like to emphasise, though it has been mentioned before, the difficulty which arises in consequence of the diminishing birth-rate, owing to the fact that there is a smaller number of confinements available upon which students may get their practice before qualification. A great number of those cases are absorbed by women who proceed to get their certificate, but afterwards never practice.

Admittedly, that is not all that lacks, and I would like to ask the Parliamentary Secretary whether it would be possible to make compulsory the confidential notification to the medical officer of health of maternal deaths which occur in his area. This is done in some areas, and it was successfully carried out for the information of the Departmental Committee, providing a great deal of valuable information which could not have been obtained in any other way. There need be no breach of confidence arising out of these investigations if they were made in all areas. If a confidential return were made to medical officers of health immediately after a death occurred, there would then be a full, up-to-date record, and the Ministry would be able to make further inquiries and by this means get more accurate data as to the cause of death, and then it would be easy to see where the local facilities were lacking. The facilities offered by local authorities are admittedly very patchy.

The other question that I would like to ask the Parliamentary Secretary is whether it would not be possible, in view of the fact that more information and data are wanted before we can be sure of what is still needed, to provide what might be necessary, if necessary out of public funds, for experimental work in selected areas, preferably among those towns where the death-rate is high and tending to rise rather than to go down? If there could be a few small model maternity services in suitable areas, where the local authorities and the medical men and midwives were all co-operating in a drive to make them a success, perhaps we should learn what more is really lacking. Something of the kind has been done in Rochdale with some substantial results. If it were possible for the Ministry to assist in bringing that about, I am convinced that they would be able to see what could be done and has been done with satisfactory results to bring down the number of maternal deaths; and there would be such a drive of public opinion as would ensure that that example was copied everywhere, and this stigma removed from the country.

6.1 p.m.

Mr. BATEY

The hon. Member for Westhoughton (Mr. Rhys Davies) described these questions as human problems, and no hon. Member will disagree with him. I will leave the question of maternal mortality to those who are qualified to deal with it, for I want to ask the House to come back to the effects of the National Health Insurance Act, 1932, on the unemployed. This question closely touches some of us who come from the depressed areas, for most of those who suffer under the 1932 Act live in those areas. The Civil Lord of the Admiralty in the report which he made upon the North-East Coast area, which is principally the county of Durham, said there were over 63,000 persons who had been idle for more than two years; over 40,000 for more than three years; over 18,000 for more than four years; and over 9,000 for more than five years. He also said that there were 52,000 married men over 35 years of age unemployed. These are the people who are suffering under the 1932 Act. I want to ask the House to consider whether the time has not come when the Government should do with this question what they did with the unemployment regulations and create a standstill order, and, admitting they had made a mistake, go back to the normal position.

The 1932 Act was passed in an atmosphere of economy. Had there not been the economy mania at that moment, I do not think the House would have agreed to pass the Act. All that it saved the Treasury was something like £128,000 a year. If that be the whole cost, the Ministry ought really to consider whether they cannot now afford to have a standstill order in regard to this Act, and to revert to the former condition. When we had the Budget last year and the House considered that we did not need any longer to practise economy because conditions were altogether different from those of 1931 and 1932, it was said that those who had the first claim on the recovery were the unemployed. The Government claimed credit for giving them something in order to put them into the position in which they were prior to the Economy Act. I submit that the time has now come when the Ministry and the Treasury ought to put this class of the unemployed back to their former position.

Not only do the unemployed who have been out of work for a few years lose their medical and maternity benefit under this Act, but, at the end of this year, they will lose their pension rights. The losing of medical benefit is bad enough, but for a man to lose his pension rights when he reaches 65 years of age is more than a human problem—it is a human tragedy. It seems that the Government want to punish men for prolonged unemployment, and as if they want to make it a crime. A man who but for this Act would have been able to claim his pension at 65 years of age has now to wait until he is 70, and his wife, too, will have to wait until she is 70. That means that an immense fine is being put on a man for being unemployed. He and his wife, by losing their pensions for five years, will be fined no less than £260 because of unemployment. That is not worthy of the Government, and they ought to face this question. If they left their supporters to vote as they pleased, there is not one who comes from a depressed area who would not vote for something being done. I have seen in the newspapers that some of the supporters of the Government who come from depressed areas have been urging the Government to remedy this state of affairs. The Parliamentary Secretary, in answer to a question recently, asked the House to wait until there is some report. On 1st May last year he stated, in reply to a question: This matter was fully debated during the passage of the National Health Insurance Act, 1932, and again in November last, and nothing has since transpired to call for the re-opening of the question."—[OFFICIAL REPORT, 1st May, 1934; col. 155, Vol. 289.] I would like to ask the Parliamentary Secretary whether that is where he still stands? Does it mean anything when he tells the House, as he told the House recently, that we should wait until there is some special report, and that after the report was received the Ministry might consider the matter? Do the Government still consider that nothing has transpired to call for a re-opening of the question? I submit that a good deal has transpired, and that we are justified in pressing the Ministry of Health to take steps in order to put these unemployed men in the position to be able to claim medical and maternity benefit, and in such a position at the end of this year that they will not lose their pension rights. Not only does such a man lose his pension rights, but if he dies his widow loses her right to a widow's pension.

Mr. SHAKESPEARE

Not one of the 110,000 men about whom we are talking loses pension rights, and if any of them die their widows get pensions.

Mr. BATEY

Let us be clear about that, because I have a different opinion. My view is that after the end of this year a man loses his pension rights, and, it he dies 12 months hence, his widow will not have a widow's pension.

Mr. SHAKESPEARE indicated assent.

Mr. BATEY

I notice that the Parliamentary Secretary agrees with me. The loss of pension rights is a real tragedy for these unemployed men and their widows. That is mean conduct on the part of the Government, and the Ministry ought to get in touch with the Treasury in order to see that something is done to remedy this state of affairs before the end of this year.

I want to turn to the report issued by the Ministry of Health showing the number of persons in receipt of Poor Law relief in England and Wales in the quarter ending December, 1934. That is the last report to be issued. This is a barometer of the poverty of the country and shows a very sad state of affairs. On page 3 the report says that the total number of men, women and children in receipt of Poor Law relief in England and Wales on the last Saturday in December, 1934, was 1,432,582. Then the report says: Throughout the quarter there was a continuous increase in the number of persons in receipt of Poor Law relief. That is a most disquieting condition of things, because the House has been told again and again that employment is getting better. Yet here is the last statement issued by the Ministry of Health showing that Poor Law relief is growing. The figures at the end of December, 1934, when compared with those for the end of September, 1934, show an increase of 133,349, or 10.3 per cent. That is an alarming increase. I was amused to see that the Prime Minister, when speaking in his division last February, dealing with the unemployment figures and making great capital of the reduction in unemployment, was asked by somebody in the audience, "What about the Poor Law figures?", but he skilfully brushed the question aside, and did not answer. The figures show that they have grown in an alarming way. Let us see where the increase has taken place. In page 3 of this statement it says: The totals given above include large numbers returned as persons who would ordinarily be employed. Nearly all the relief given to these persons is given to them while resident in their homes. The average number of persons returned as ordinarily engaged in some regular occupation who were in receipt of Poor Law relief in December, 1934, while resident in their own homes, including wives and dependent children, was 630,741, an increase of 104,296 as compared with the corresponding number in September, 1934. Of the total increase of 133,000 no fewer than 104,000 were people ordinarily engaged in some occupation but unemployed. Next I want to read a paragraph just above that, because it seems to give a reason for this state of affairs. It is clear from information available that the increase in certain areas is due to the practice in these areas of making small allowances during the winter months in large numbers of cases to people in receipt of unemployment benefit or transitional payment. The effect of these allowances is reflected in the figures for the week ending 10th December, 1934, and later weeks. Those figures ought to teach us two lessons. Seeing that so many of those receiving Poor Law relief were unemployed and it may be receiving unemployment benefit or transitional payments we want to know what their position is to-day. We understood that when the Unemployment Assistance Board started its operations in January it would be illegal to give any further Poor Law relief. Seeing that we have got the standstill order, can the Poor Law authorities to-day supplement the allowance which is given in the form of transitional payment? If they cannot, God help the people who are receiving transitional payments. I find that in our area they are refusing benefits in spite of the standstill arrangements. I have particulars of a case in which a man, his wife and four children have been awarded 25s. a week. Nobody can live on that sum and pay the rent, and that family will be bound to apply for Poor Law relief.

Mr. MARTIN

Have they no other income?

Mr. BATEY

No other income. Seeing that the regulations have laid down that there is to be a standstill, there ought to be a standstill in regard to the prohibition on granting Poor Law relief. There ought to be some arrangement somehow by which those who come under transitional payment and do not get sufficient to live upon can still go to the Poor Law to get the allowance supplemented. This seems to be all the more necessary in view of what was said on the 19th February by the chief official under the Unemployment Assistance Board in the county of Durham: In some hundreds of cases these persons had their cuts restored last week, although strictly they were not entitled to have them restored. That was when the standstill order came into force. That was a most extraordinary statement.

Mr. BUCHANAN

Who said that?

Mr. BATEY

A Mr. Pearce. He is the district officer.

Mr. KIRKWOOD

Is he a "Chinee," or what is he?

Mr. BATEY

He made that statement on the 19th February. We shall come to that statement when we have a debate on unemployment. It is the Poor Law aspect of the matter with which I am dealing to-day. In the same statement he went on to say: They will not, of course, remain indefinitely on their restored rates. They will get precisely what the P.A.C. would have allowed or what the Regulations allow, whichever is the higher figure, but either of these figures may be less than the amount to which they were restored last week. He is carrying out that policy in the county of Durham, and we are having cuts made in benefits at the present time. I am anxious that these people should not be allowed to starve. If they are not to get sufficient from the Unemployment Assistance Board to enable them to live they ought to have the right to go to the Poor Law. The Ministry of Health and the Government ought to say where they stand on all these questions affecting the unemployed. They ought to recognise that the unemployed are human beings, and have a right to live, and they should not seek to push them right down into the gutter of poverty but deal with them in a more humane manner. I remember when I was a boy that my father had a saying which I then found it difficult to understand. It was a line from Bobbie Burns: Man's inhumanity to man Makes countless thousands mourn. I can understand the meaning of that now, and the Government ought seriously to consider whether the time has not come when we should deal altogether differently with the unemployed: treat them as if they were human beings, scrap the Act of 1932, give the unemployed medical benefit, the maternity benefit, and pension rights, and also give them the right, where they have not been properly treated to apply to the Poor Law authorities. The local authorities would be the best able to deal with them, because they know them. These Poor Law figures show that poverty in this country is increasing, and therefore it is the duty of the Government to meet the situation and see that the people have some chance to obtain work rather than having to depend upon the Poor Law.

6.25 p.m.

Mr. CLEMENT DAVIES

I desire to direct the attention of the Parliamentary Secretary to another matter of serious concern, especially to those who live in Wales, and that is the figures of mortality due to tuberculosis. In Wales we have had a very bad record in regard to this particular disease for many years, but about 1910, thanks to the activity of my predecessor in the representation of Montgomeryshire, now Lord Davies of Llandinam, and largely owing to his generosity, there was established a King Edward VII Memorial Fund which undoubtedly has done a great deal to stamp out this dire disease from Wales. Nevertheless, according to the latest figures which I have been able to obtain, those for the year 1933, the first seven places—the worst places—among the administrative counties of England and Wales are still occupied by seven Welsh counties, and out of the first 18 places 12 are occupied by Welsh counties. That is extraordinary when one considers that they are agricultural counties, and that the worst of them are not the industrial counties.

The first place is occupied by Carnarvonshire, the second by Pembrokeshire, the third by Anglesey, the fourth by Merionethshire, the fifth by Glamorganshire—which is the first of the industrial counties—the sixth by Cardiganshire and the seventh by Radnorshire. Carmarthenshire is tenth, Monmouthshire thirteenth, Denbighshire fifteenth, Breconshire sixteenth, Montgomeryshire eighteenth, and Flintshire forty-eighth. There may be several reasons for this state of affairs, but we in our ignorance do not know it. It may be due to bad housing, it may be due to malnutrition—undoubtedly there is bad feeding in some of our agricultural districts and undoubtedly the housing conditions are bad—it may be said that heredity has something to do with it, and it may be that all three are contributing causes. I should like to ask the Parliamentary Secretary to cause an inquiry to be made, so that we may have the causes ascertained, and then do our best to remove them. I understand that the last occasion on which a commission inquired into this question was as long ago as 1909. In the 26 years which have elapsed science has made tremendous progress, and the knowledge of doctors and other scientific men is now infinitely better. If the Parliamentary Secretary will consider this matter to see whether it is not possible to have a fresh inquiry I am sure it will be a great satisfaction to many of us.

6.29 p.m.

Miss RATHBONE

I wish to bring the discussion back to the subject of maternal mortality. We have had several speeches on that subject from people who seem to be very well informed and as I do not want to indulge in repetition which would merely waste the time of the House I will say nothing on that question except that I think several speakers tended to discount too much the possible effects of malnutrition. I do not think anyone who has studied this difficult and intricate question and who realises how much a number of causes apparently act and interact would maintain that malnutrition is the only, or even probably the main, cause of maternal mortality, but several speakers to-night have tended to imply that it has nothing to do with it, and I would suggest that the evidence on the subject really does not bear out that contention. One speaker has already quoted a passage from Sir George Newman's report which shows that although that, it tends on the whole to give as optimistic a picture as it possibly can in relation to malnutrition, the report gives malnutrition of the mother during pregnancy as one of the factors in the poor results.

I want to draw the attention of those who take that view to the inquiry recently carried out by Professor Mellanby and described in his book on "Malnutrition and Disease." He records the result of an investigation into the condition of 550 women attending ante-natal clinics in Sheffield. He says—I will not read the details—that an experiment was tried of feeding one half of these on a preparation rich in particular vitamins considered necessary for the nutrition of pregnant women, and the other half received no such supplementary food. He says: The morbidity rate … was 1.1 per cent. in the vitamin group and 4.7 per cent. in the control group, a difference of 3.6 per cent. At one hospital where over 400 of the cases were delivered the morbidity rate in the treated group was 1.0 per cent. as compared with 5.8 per cent. in the untreated group. That is a rather remarkable comparison, and several medical officers of health who have contributed to Sir George Newman's own report noted the same con- nection of malnutrition of pregnant women and morbidity. Another body of experts says: The condition now is tragic in its futility. One sees all round, people with deformed bones"— and they go on to give a list of diseases, mainly among pregnant women. Forty-five per cent. of pregnant women attending London ante-natal clinics suffer from marked anaemia and much general ill health probably has the same basis… Malnutrition shows plainest in pregnant women, owing to the much larger demands made upon their system at that time. In view of those facts, no one can say that that is a factor that ought to be ignored. It is a pity that that impression has been sought to be given.

I particularly rose to say something on the question of married working women apart from maternal mortality. I feel that the whole question of the health condition of married working women receives too little attention. Too little is known about it, and far too little is done. Just because married working women—except those who are insured in their own respect—do not come under unemployment or national health insurance. There is no thermometer for testing their health conditions comparable to that which exists in the ease of insured people. Except in the one respect of maternity benefit, they do not benefit from health insurance, and therefore we have no statistics regarding married working women, except the statistics relating to birth and death, and unless some special inquiry is conducted by the Ministry of Health. Some years ago I employed a statistical expert to rout out for me everything she could find bearing on the health of married working women, other than insured working women. The information amounted to very little because the evidence simply does not exist.

Few people who are closely acquainted with the facts and who are in touch with married working women will doubt that there is great cause for uneasiness as to their physical condition and also as to the effect of that condition upon the health of future generations. A good deal of their ill-health arises in connection with unemployment, though by no means all of it. I noticed last year that the Minister admitted the importance of that factor, when he said in a speech: When you are looking for a place in the family where malnutrition will show itself, and where the bad effects of unemployment and depression will show themselves, look at the mother, look at the woman. It is impossible, and beyond the power of any man to prevent a mother from depriving herself for the sake of her children."—[OFFICIAL, REPORT, 7th July, 1933; col. 657, Vol. 280.] In Sir George Newman's report, although there has been what appears as a too careful selection of the reports of medical officers of health from the localities, there is quite a number of reports which bear striking testimony to the unsatisfactory condition of the health of the women. To take only a single example: One, Dr. Keith, medical officer of health for Dept-ford, speaks of the loss of vitality with mental depression, apathy, anaemia, decay of the teeth … unhealthy appearance … poorness of blood, etc. Another doctor speaks of an investigation made in Aberdeen into the condition of 1,000 unemployed families. The investigation showed that 50 per cent. of the mothers of the families suffered from anaemia largely due to malnutrition. We ought to bear that kind of evidence in mind when we consider the very optimistic reports that have been put about as to the effect of unemployment upon the health of the children.

I think Sir George Newman's report is too selective in the sense of selecting only the local reports that give a favourable view. If anyone wants to see a summary of a large amount of evidence of an unsatisfactory character, I commend them to the two memoranda issued by the Children's Minima Committee who have, in order to counterbalance what was considered the too excessive optimism of the Ministry's report, collected evidence of the contrary kind. Where the evidence, taken all together, is satisfactory, it is very important to remember how much of it is due to the fact that where the children's health is being properly maintained it is being maintained at the expense of the mothers. It is the natural thing, where the mother is the administrator of the family income and wants to make the income go as far as possible, that, if somebody has to go short, she goes short herself as any normal unselfish, person would do in her place.

It is not only with regard to the wives of the unemployed that there is considerable ground for anxiety. The Unemployment Assistance Board have excused themselves, and the Minister has excused them, for the inadequacy of their relief scales, on the ground that otherwise relief might exceed wages. That condition will exist so long as wages make no definite provision for child dependants, whereas systems of relief do make such provision. There is always the difficulty of getting the wage system and the relief system to fit together without incurring the danger that relief will exceed wages.

The alarming thing, to my mind, about the whole position is that the eugenic results are attracting so little attention. The mothers are taking the remedy into their own hands and are simply abstaining from having children. We have a steadily decreasing birth-rate, almost the lowest birth-rate of any country in the civilised world. I forget whether one of the Scandinavian countries has a lower birth-rate than we have, but, anyhow, we have a lower birth-rate than even France. Many of the countries which are exciting the greatest alarm in Europe today are faced with the same phenomenon of a falling birth-rate, but they are taking strong steps to counteract it by giving every kind of encouragement to the propagation of children. I often think that the day will come when the people of this country will wake up to the gravity of that side of the question, and will ask themselves whether a country with Imperial responsibilities such as ours can afford to look on and do nothing about the steady shrinkage of the white populations compared with the yellow, the brown and the black. It is impossible to discuss any of the really fundamental remedies for this great difficulty without dealing with questions which require legislative action, which it would be out of order in the course of this Debate to do more than allude to. The only really satisfactory remedy would probably be a system of family allowances such as has been adopted in several Continental countries.

Another remedy which I wish the Ministry of Health would take into consideration is the possibility of extending health insurance in two respects: to give dependent allowances to the wives and children of men when the men are sick, and to give medical benefit to the wives and the children when they themselves are sick. An alternative way would be to have some form of State medical service. These are the only really satisfactory remedies which would ensure that the wives and the children get the same amount of medical attention and assistance during the time of sickness as at present the insured population are getting. We hear so much in this House and elsewhere of the grievances of the insured part of the population that the grievances of the uninsured part tend to be very much overlooked. I often wonder that they bear it as patiently as they do.

Even without legislation there are certain steps which the Ministry might be taking. I would like to ask the Parliamentary Secretary what is being done about gynaecological clinics for women. I think it was in 1929 that this subject first found a place in the report of the chief medical officer of health, when there was a recommendation that gynaecological clinics should be set up so that women should be able to get medical advice, not only with regard to questions of pregnancy. At present there are antenatal clinics for a woman to go to when she is in a pregnant condition, although they are by no means as universal as they should be, but there are many other gynaecological conditions which require treatment which is not at present supplied. The Minister or his medical officer feel that themselves, because, in report after report, we see allusions to the necessity of it. I hope that the Parliamentary Secretary will be good enough to tell us how far those recommendations which appear year after year are being taken up by the local authorities, and how many gynaecological clinics do in fact exist.

The other direction in which the Ministry ought to be taking active steps is in regard to the provision of milk for mothers and children. There, again, we know that the local authorities have certain limited powers, and that a certain amount of milk is supplied in connection with child welfare centres. But there is practically no provision for the nursing mother or for children under five.

We all know that the interesting experiment which is being tried by cooperation between the Milk Marketing Board, the Ministry of Agriculture and the Board of Education in connection with the supply of cheapened milk to school children is a very great success, and we should like to see it expanded so far as the school children are concerned; but the Ministry of Health ought also to bear its part by making similar provision for the nursing mother and for children under five, whose need is so obvious that it is unnecessary to enlarge upon it. Sir George Newman has pointed out again and again the importance of the supply of milk for the nursing mother and the pregnant mother, and we all know how necessary it is for the young child.

The supply of milk for nursing mothers and children under five could be arranged for in a variety of ways. For instance, the schools or child welfare centres could be used, and, where these do not exist, the milk could be distributed through the dairies. There is no form of social service that would bring a richer return than one which would secure a greater supply of cheap or free milk for mothers and children. In all these respects, there is a real danger that the employed person, because he is insured and, generally speaking, organised in trade unions, will get all the attention, while that most patient class—I often think they are far too patient—the nursing mothers, who are producing the citizens of the future and on whose health in the long run the health of the whole community depends, are in danger of being neglected. I hope the Ministry of Health will give attention to their needs in some of the respects I have mentioned.

6.47 p.m.

Dr. O'DONOVAN

I think that the medical profession of England will to-morrow read our proceedings with both refreshment and encouragement; that a debate should be given to one aspect of their heavy responsibilities without scolding and with much appreciation of their work is to be noted gratefully. One of the most interesting monuments in Westminster Abbey is that put up to the Chamberlen family by public subscription—a family which for three generations had in its possession the secret of obstetrical forceps for the ease of difficult labour—an invention of the greatest human value. The people of this country were so grateful to the Chamberlen family for revealing to the obstetric profession that secret, under the three Peters control till 1683, that they erected in Westminster Abbey, in the Gospel aisle, a most magnificent marble monument with a handsomely grateful Latin inscription showing the public interest that has been taken in the past, and will be taken, I am sure, in the future, in the welfare of parturient women.

In handling this matter in public discussion we must have a certain care in the use of words, and even as politicians we are obliged to talk with a certain bedside manner. For a Noble Lady and for politicians in this House to talk about admissions of failures in the care of parturient women may have ill effects which they may have hardly considered when they gave voice to such sentiments. What has been said in this House about the public health is repeated in the public Press, and is read by many young pregnant women whose nervous tone has not always the stability of the toughened men and women politicians who sit on these benches, and there is no question that, if there be too much and too morbid discussion in public assemblies with regard to the inescapable risks of pregnancy, there will grow up a widespread anti-conception practice such as was never dreamed of when Ignaz Phillip Semelweiss discovered the cause and prevention of contagious puerperal sepsis about 1850. It is simple to say, that a cause having been discovered, a remedy can be applied, but if through the growth of a public fear of pregnancy practices become widespread which our mothers and grandmothers never dreamed of, doctors are presented with an entirely new social problem, and the historic discovery of the microbic cause of fatal puerperal disease is a very small contribution to the now changing problem of morbidity.

Since I was a student I have read many reports about the morbidity of pregnant women, and it is sometimes a source of astonishment to me that practitioners have stood up so manfully to their work. After having been shrewishly scolded and condemned as being untrained and incompetent, they have stuck night and day to their obligation of assisting women in the most difficult period of their lives. To-day I have noticed with pleasure a welcome change exhibited in the tone of the discussion. The doctors are no longer particeps criminis; they are no longer at the whipping post; they are looked upon, as far as I can judge by the course of this Debate, as an ever-welcome and inescapable aid to the burden and solution of this problem. It is strange, however, that so many lay interveners have said that our knowledge is incomplete, that we need more research, and yet that our doctors need more training; but, if they are to be trained more and more in incomplete and untrustworthy facts and opinions, the results cannot be anything but unsatisfactory, and it is to that point that I should like to address myself. I should not like the House to finish this Debate with the impression that our students are untrained, and that new knowledge is not pursued with the utmost vigour.

I remember that when I was a student I delivered 37 women in one fortnight in their own homes, largely teaching myself anxiously by the aid of a little red handbook, and with the assistance, at my first two cases, of a young newly qualified doctor. That condition no longer obtains. Students taking up their midwifery course are trained under the most expert staffs that the teaching hospital can put at their disposal. They are taught the delivery of women first in the lying-in wards of the hospital, before they go to what is called "the district" to learn the delivery of women in their own homes, and it is worth while remembering that this is not a narrow, isolated part of medical training. The whole field of a student's training is brought to the study of obstetrics. What he learns of pathology, of bacteriology, of physiology, what he learns of the diseases of the heart, the lungs and other parts of the body—all that knowledge is brought into the field of obstetrics when a student embarks on that special study, and I would suggest a line of advance that is more hopeful and encouraging to my profession, namely, that an effort should be made to avoid a mere narrow and concentrated study of obstetric problems, and to heighten and extend medical training in all its branches, so that students who become doctors and take up obstetric work shall have a deepened intellectual training and a wider professional training, and shall not be encouraged to become those narrow specialists about whom the jibe is properly directed that they know more and more about less and less.

One must note that in the advance of obstetrics the advance of medicine and surgery has played its part. I have seen the rise of bacteriological specialists, and they have freely directed their knowledge and research to obstetrics. I have seen tremendous improvements during two decades in the study of anaesthetics, and again those improvements have been brought to the assistance of the parturient woman. I have seen, too, great improvements in our nursing standards, which also have been brought to the assistance of the woman in labour; while even administration itself has been pressed into service in the care of pregnant womanhood. The responsibility in the end is not the responsibility of Whitehall officials or of Government chiefs. To throw that responsibility upon the Cabinet or upon Whitehall is not throwing it upon the proper shoulders; it is inescapably the responsibility of the medical profession, and I think the House will be interested to know in what way we try to discharge that responsibility—not alone the responsibility of day-to-day work, but the responsibility of keeping knowledge fresh and up to date and at the disposal of every medical practitioner.

First of all, I would remind the House that the present Government and the London County Council have given generous assistance to the establishment of the post-graduate school of medical studies at Hammersmith, and if there is any demand for gynaecological clinics, it is to be hoped that the Government will hold its hand and let us first produce competent gynaecologists before we scatter gynaecological clinics all over the country. New buildings, devoted nurses, and equipment do not make competent doctors, and, unless we have first-class gynaecologists to start with, gynaecological clinics will be little more than disinfected first-aid stations. It is competent men with trained first-class brains that are wanted, not clinics, for that word can cover a multitude of in-competencies.

The College of Obstetricians has received a charter since the War in order that those who teach this special subject may be able to meet and discuss such problems and give diplomas of special competency to those who will be assisting in the future to man the establishment of gynaecological clinics. At the Royal Society of Medicine all the teachers of and specialists in obstetrics meet regularly, and such knowledge and experience as they have acquired are interchanged with the utmost freedom. There is no monopoly of obstetric knowledge in London; it is distributed from there to teaching centres throughout the Empire, and is reciprocally received. Then again the British Medical Association—a great association of ordinary general practitioners—holds annual meetings at which it invites the leading authorities and those who have done notable research in the last few years to address the whole profession on the results of their work; and, not content with that, it has a system by which it sends specialists in this work, as judges on circuit are sent, up and down the country to lecture at professional meetings, small and large, so that what advance is made in the teaching centres is rapidly brought into the homes of the general practitioners and into the bedrooms of their patients. One must confess that our work is hampered by the ever-changing social aspect of married life, which has become different from what Nature intended, and if there are practices, unnatural or criminal, which are not willingly disclosed to the practitioner, no amount of notification of puerperal morbidity will assist in finding the cause of the trouble. A review of our social life is needed, and a frank recognition of the way in which the married people live. Then we shall see whether or not the problem is entirely medical, or whether it is also a problem of quack abortionists and of lay interference with natural processes of conception.

Lastly, I would like the House to remember that this problem is not only an English problem. Doctors throughout the world are concerned with it, and it is discussed at International Congresses in professional papers in all languages. We attend these International Congresses and we read the papers presented there, many of them in languages which we can translate, and others which are prepared in abstract form for us in our special journals. The whole medical profession is concentrating upon these problems in both their medical and social aspects, and even the eugenic aspect, to which reference, very properly, has just been made, has not been neglected in the councils of the profession, I would like the House to feel assured that, as far as men can do it, my profession are applying their minds and hearts and souls constantly and watchfully to the care of these our women folk, and we may feel sure on our part, I think, that should we ask as a profession for administrative help, this would not be the House nor this the Government that would refuse it.

7.0 p.m.

Mr. R. T. EVANS

The whole problem of mortality and morbidity, and the problem of malnutrition, and all the sociological aspects of the matter, have been treated very exhaustively and authoritatively, and I rise to make only two points. The first is to offer support to my hon. and learned Friend the Member for Montgomeryshire (Mr. C. Davies) in calling the attention of the Parliamentary Secretary to the persistence of an evil reputation in the Welsh counties in the matter of tuberculosis. I doubt whether any nation has spent so much time and organised its abilities as thoroughly as Wales as done—thanks to the initiative of Lord Davies of Llandinam. Despite these efforts, despite the outpouring of wealth, the researches of an expert staff, and the provision of clinics and sanatoria, this evil reputation still dogs us. The appeal which my hon. Friend has made is one that I would like to press upon the Ministry—that a situation has now arisen where something ought to be done to collect and collate this amazing mass of evidence which has been accumulated as the result of many years of experimentation. There must be some aspects of this trouble other than medical. There is the question of rural housing, the question of feeding in the rural areas, and a hundred and one sociological elements which must me taken into account. This is not purely a medical question; it has a much more comprehensive connotation. I feel that the House will support the appeal made by my friend that the Ministry should now take the matter in hand. It cannot be said that our people are ignorant. They have had lessons in the schools, there has been Press propaganda, special lecturers have been engaged and yet this state of affairs persists. An inquiry, I think, is needed, and I want to support very strongly the appeal which my hon. Friend has made.

The other point that I want to make is that this afternoon, with one exception, all who have discussed maternal and infantile mortality have addressed themselves to conditions in the industrial areas. I represent an agricultural constituency, and I feel that however badly served the industrial areas are, the rural communities are in a much worse plight. Inevitably that is so. There are populations thinly scattered over a wide area with homes four or five miles away from a telephone and a greater distance than that away from a doctor. The houses often are utterly unfit for children to be born in. Doctors in my constituency have told me of appalling conditions under which they work and perform operations. Despite all this, although women sometimes have to go through agonising experiences which often mean the ruin of their health because a doctor is not available in time, and because of inadequate midwifery services, yet in an area like that one finds over a period of years carnivals and similar functions being organised to provide funds for the provision of a maternity wing to our county hospital. This is a problem which has poignancy, intimacy, and a vital bearing on the future of the race; and it is not the kind of problem which ought to be treated in a haphazard fashion.

I feel that if State help and State initiative are needed in any connection, surely they are needed in connection with the bringing of the next generation into the world. We want to make that appeal. I know there are provisions whereby county and other local authorities can exercise powers under the Maternity and Child Welfare Act, 1918, but it is a fact that in many cases to-day, owing to financial stringency, reductions are being made in such expenditure. I know of one county in Wales which has withdrawn its grant of £350 to its nursing association. The county of Monmouthshire—and I have no doubt that other hon. Members can quote many similar cases—has reduced by several thousands of pounds the amount of money allocated to the pro- vision of milk, cod-liver oil and so forth, to necessitous mothers and children. It seems to me that at a time like this we ought, above all else, to safeguard these services. It may be that financial stringency demands the curtailment of expenditure here and there, and perhaps it can be done for a short period of time without permanent injury. But I suggest that these services should be the very last on which economy ought to be exercised.

I want to make an appeal to the Ministry that they shall survey the position in the rural areas. I assure the Parliamentary Secretary that the conditions there are thoroughly bad. I see that there is sitting on the Front Bench at this moment a Member who does really know the conditions in some of the Welsh counties and I think he would assure the House that I am right in saying that conditions in the rural areas are appalling. If it is possible to do anything by making grants, facilitating loans to enable the provision of maternity wings to county hospitals, or in providing any other services in those areas, now is the time to do it, when there is widespread poverty and mental depression arising from the hopelessness of the people's outlook on the future. This is the time, above all others, when we should not stint the provision of these services.

7.8 p.m.

Captain ELLISTON

In the few minutes for which I shall ask the indulgence of the House I propose to limit myself to the subject of maternal mortality, which, I think, is one of the most urgent matters engaging the attention of the Ministry of Health. There seems to be a tendency, even in this House, to fasten on some particular cause for the incidence of maternal mortality and morbidity. We heard that in the ease of the hon. Member for Westhoughton (Mr. Rhys Davies), who thought that inadequate midwifery and the means test explained everything. We heard the hon. Member for the English Universities (Miss Rathbone) just now say, with strict reservations, that she thought nutrition probably might be a tremendous factor in this problem of mortality. Then we heard my hon. Friend the Member for Mile End (Dr. O'Donovan) tell us very kindly and nicely that this was a medical question, and that all the rest of us might stand aside and leave it to them. Nobody could accuse me of a lack of sympathy for the medical profession, in which I was born and bred; but I am going to say in a very modest way, as one engaged in public health administration, that this subject is not definitely and simply a medical question. I think that a problem which for years past has baffled the Ministry of Health, the local authorities and the medical profession does demand very general discussion in this House.

It is only fair, I think, to consider in some detail what has been done or attempted in connection with these problems by the Ministry of Health, by local authorities, and by the medical profession. As far back as December, 1930, the Ministry of Health issued to local authorities what was, in effect, a plan of campaign for dealing with maternal mortality and morbidity. That was the famous Memorandum 156 on Maternity and Child Welfare, which indicated to local authorities measures that might be considered desirable. Last year, in October, the Ministry followed that up with circular 1433 in which they reviewed the position as it was at that time and as it had resulted from the circular of 1930. The Ministry of Health were able to show in this last circular that in the three years which had intervened between the first and the second circular the ante-natal centres provided by local authorities had increased from 1,048 to 1,340. During the same period the number of expectant and nursing mothers who had sought the assistance of these clinics provided by local authorities had increased from 27.8 per cent. to 42.2 per cent. More than that, the circular showed that local authorities had provided something like 7,250 beds for maternity cases

In view of these figures it is no good anybody suggesting to this House that local authorities have been wholly negligent of their responsibilities. Nevertheless, we have to admit here—and it is a very serious thing—that they have achieved no appreciable effect on the rate of maternal mortality. That this single problem has defied them is the more mortifying when you think of the spectacular achievements of the public health service in almost every other branch of preventive medicine. It is no good mask- ing the fact and saying this is purely a technical question. Let us be bold and admit that we have failed, and are failing. That is why, I think, the House has been asked this afternoon to give this matter considered discussion. In Circular 1433 the Ministry of Health tried to assist local authorities to remove this stigma on our health services, and asked them again to develop more fully the services suggested in the memorandum of 1930. They also urged local authorities to assist nursing and expectant mothers to secure supplies of milk. That has been mentioned by one or two speakers in the debate, and I hope it will interest the Parliamentary Secretary sufficiently for him to mention it in his reply to-night. It may be that he does not know that there is a certain movement on foot to persuade the Milk Marketing Board to develop a scheme in the interest of nursing mothers on the lines of the scheme now so successfully working for school children.

The Ministry must find, I think, a feeling among experienced public health administrators that if such a scheme could be devised to procure supplies of milk for nursing mothers, so as to ensure that the mother really got milk, and that she got safe milk, then it would be a very great step forward as regards the health of the nursing mother. The Ministry's circular also advised local authorities to develop more maternity wards in the hospitals and institutions taken over under the Local Government Act, 1929, rather than to persist in keeping small maternity homes as separate units. Local authorities in all parts of the country are further advised to develop and foster maternal services in those great institutions which they now control, and for which they are securing the support and influence of the leading medical men in the various local government areas all over the country. In that direction the Minister of Health may find some very effective means of increasing the efficiency of the maternal services generally throughout the United Kingdom. But the outstanding and really the most important feature in Circular 1433 is the request of the Minister for a report from the medical officer of health on what has been done by local authorities to meet the recommendations in the Final Report of the Departmental Committee on Maternal Mortality which was published in 1932. That report asks for several things. First of all, it wants to know what the local authority is doing for the improvement of ante-natal services. The circular which I quoted just now said that less than 50 per cent. of the expectant mothers in this country attend clinics.

Dr. O'DONOVAN

Does my hon. and gallant Friend imply that over 50 per cent. are not seeking advice from any competent, established general practitioners in the district?

Captain ELLISTON

Certainly not. I am sure, for instance, that my hon. Friend's patients would go to him with perfect confidence, and that numbers of the population do have the assistance of their family doctors, but there still must be a large number of people who are failing to avail themselves of the expert advice placed at their disposal by local authorities. That is a most deplorable thing in view of the mortality statistics before us, and it points once again to the need which I have already expressed in this House for the better education of the people in health matters. When you instruct the parents of the importance and, in spite of what some doctors say, the dangers of childbirth, because the mortality in childbirth is a greater risk than that of the dangerous occupation of coalmining—when you make the people realise those dangers, they will not fail to avail themselves of services provided for them by the local authority.

The next point in the report on which the medical officer of health was requested to inform the Minister is as to what measures have been taken to secure trained midwives for all confinements, even when a doctor is engaged. It has been said this afternoon, and many times in recent months, that midwifery is an underpaid and arduous profession. It is never self-supporting, I suppose, in a working class area, and the Minister might well press local authorities to subsidise midwives for necessitous women, because where the midwife cannot be paid you have the dangerous handy woman, who, many of us believe, is responsible for many of the accidents connected with childbirth. The trained midwife is essential whether a doctor is in attendance or not, and many people think that the employment of a midwife should be compulsory, even when a doctor is in attendance, to secure the necessary skilled nursing for a maternity case. The Maternal Mortality Committee also ask for more beds in those transferred hospitals and institutions to which I have referred, and for more consultants for the domiciliary assistance of doctors in attendance upon difficult cases. I think that we can all realise, whether we have any professional training or not, the need of such expert consultant assistance for a practitioner who is faced with some emergency in connection with childbirth. We hope that the medical officer of health, in responding to this invitation of the Minister, will be frank, and not ready with excuses and explanations. In my belief the justification for the medical officers of this country is to be found to-day in the library of the Ministry of Health. Any of us who have made an effort to read some of the reports of these medical officers will have seen nearly all those recommendations that I have mentioned again and again in the reports of the maternity services of public health authorities.

Even without this new inquiry, I think the Minister could satisfy himself that, if there has been any lack of enterprise in applying the necessary measures to deal with maternal mortality, it has not been on the part of the medical officers. I am rather wondering, especially since the last speaker referred to conditions in Wales as a, result of the reduction of the grant, whether it can be that the maternity services are deficient in some areas because of the security of the block grant and freedom from the supervision which was formerly applied by the Minister of Health wherever public money was spent. One knows of the difficulties of local authorities to-day, hut the block grant made adequate provision for the continuation of these services in connection with maternal mortality and morbidity, and when one hears it stated that such economies have been effected anywhere, one asks whether the conditions of the block grant are being honestly observed.

Notwithstanding all these steps by the Ministry, the real and greatest need was indicated by the Chancellor of the Ex- chequer in his address to the National Conference on Maternity and Child Welfare at Birmingham last autumn. After deploring the persistence of the high rate of maternal mortality, he said that, in spite of the efforts of the Ministry and local authorities, the remedy would be found only by persistent research and investigation. It is true that the Ministry have done much for research, and the Secretary of State for Scotland told us in this House only the other day that over 42,000 cases bearing on maternal mortality and morbidity are being investigated at the present moment by the Scientific Advisory Committee of the Scottish Board of Health. We know that similar inquiry has been made in England and Wales, but I should have liked to have asked the Parliamentary Secretary if he were here just now, whether the whole field of necessary research has been planned and covered by the Ministry of Health? Dame Janet Campbell, who did such magnificent pioneer work for the Ministry in connection with maternal and child welfare, indicated the lines of necessary investigation last year in a speech which she made at Bristol. I deal with these points because we have been told to-day by speakers that one would do this, and that another would do that.

Here you have one of the greatest experts on the subject saying that it is not one matter we want to investigate, but many matters. She starts off with the causes and control of puerperal sepsis in the home and in the hospital. That, of course, is a commonplace, and is already practically being done. Next she would inquire—and this will please the hon. Lady the Member for the English Universities (Miss Rathbone)—into the nutrition during pregnancy, including the effects of vitamins, drugs and foods. That is a big subject for research. The next is the alleged increase of abortion and its immediate and remote results. I have met people, especially in the North of England, who believe that the practice of abortion is one of the greatest causes of maternal mortality to-day. I believe that more than a year ago the British Medical Association brought this matter to the notice of the Ministry of Health, and I should like to hear from the Parliamentary Secretary to-night whether the matter has been pursued further. Again, we must inquire into the growing vogue of birth control, and its possible consequences. Who knows what effects may result from the growing use of contraceptives in this country? There you have a quite possible cause of maternal mortality, or one, at any rate, which calls for investigation. Then you come to the overstrain and fatigue of mothers resulting from unemployment. There, surely, is a matter calling for immediate investigation which has been referred to by several speakers this afternoon.

Finally, I am going to add one research on my own suggestion, and that is that I should like the Minister to conduct an inquiry as to the safety of milk as food for mothers and children. I mention this because the Ministry last October appealed to local authorities to provide more milk for mothers and children, and we have also had recently letters in the "Times" and appeals in this House for the setting up of a Royal Commission to inquire into the whole subject of the purity of milk supplies. I think that in justice to my hon. and gallant Friend the Member for Hitchin (Sir A. Wilson), who is so constantly telling us that we are unduly nervous on the subject of milk, and who has appealed for an inquiry, we should let him have his inquiry. Nothing, I am sure, would be welcomed more by those who know something about the dangers of milk offered to the public to-day. We suffer in this House from the presence of hon. Members who run magnificent model dairy farms which are an example to the whole of Europe, and who speak as if all the rest of the milk comes from similar establishments. The medical officers of health and the Ministry of Health know perfectly well that the milk supplied to the people to-day is often deserving of suspicion and often a real danger. I think that if we have established nothing more this afternoon, for the time being, we have to admit that we are baffled by the causes of maternal mortality and morbidity, and it is up to us to give the Ministry of Health all the support they may require from this House in order to encourage them to go ahead with all the necessary investigation and research. Without such investigation we are not likely to be able to remove the reproach which at present is the only really bad feature in our English public health service, and which spoils our world position in respect of other branches of preventive medicine. Nothing is to be gained by extenuating the position. Let us admit that it exists and do everything possible to support the Minister of Health in the measures which he may consider necessary in order to safeguard the lives of mothers in this country.

7.31 p.m.

Mr. BUCHANAN

I do not intend to follow hon. Members into all the arguments about the maternal death-rate in this country, other than to say that I agree with the last speaker that wonderful progress has been made in almost every branch of medical science. Medical men are often subjected to a good deal of unfair criticism rather than due credit being given to them in respect of their research work. They have undoubtedly done good research work, but the problem of maternal mortality seems to have baffled them so far. Poverty does play some part in connection with the problem, but I do not think that it accounts for whole of the problem, or anything like it, because the figures show that in some cases the poorest districts have not the highest mortality but rather the richer districts.

I should like to deal more particularly with health insurance administration, the question of pensions, the provision of doctors and maternity benefit. The Government passed the National Health Insurance Act which was responsible for the abolition of what was known as the prolongation period. The question of health insurance in relation to the unemployed has been such that each Government at the end of the particular term that they were in office passed an Act continuing health insurance benefits, with certain restrictions, to those who were in health insurance but had suffered long periods of unemployment. That was the position until the present Government introduced a Bill which abolished prolongation and substituted the Act which now governs the position. I have always thought that the Parliamentary Secretary's statement was an unfair piece of debating. He used an argument something on these lines: that the Government were granting a year's extra respite. That was true if one took that statement baldly and one assumed that prolongation was not to be continued. But over a period of years prolongation had taken place, and it was assumed that it would continue. However, the Government undertook to deal with the position of what might be described as long-term unemployment.

Briefly, this is the effect of the Measure: That those who for the purposes of the Act had, roughly speaking, been about two and a-half years unemployed lost their maternity benefit. If the wife of such an unemployed man gave birth to a child no maternity benefit was to be received. The same man receives no medical benefit in case of sickness and he has lost his right to have a doctor. In addition, unless we pass an Act at the end of this year, that class of person will lose the right, if they are under 60 years of age, to receive an old age pension, unless they can become voluntary contributors, which is practically an impossibility for the great mass of the unemployed. In the event of the death of such an unemployed man, the widow loses the right to a widow's pension, or, if there are children and no widow, the children lose the right to orphans' pensions. I think it will not be denied that that is an accurate description of the present condition. Those people have lost all those rights.

I am not going into the unemployment question now, but when we dealt with the question there was great indignation about the cuts on the unemployed. The cuts on the unemployed were vicious, cruel and inhuman, but the attack on the sick has been far more inhuman. I regret that the Minister of Labour is not present, but I am glad that the Under-Secretary of State for Scotland is here, because he knows the position in regard to Scotland. Take the position in regard to maternity. Hitherto this has been the position, that those who were unemployed became for the purposes of maternity benefit chargeable to the Poor Law, but only if the Poor Law agreed to make the necessary grant. A new position has now arisen. A person drawing transitional benefit is not eligible to be subsidised from the Poor Law. It may be true to argue that such a thing as a woman giving birth to a child is a medical need, but that has not been done by the Poor Law authorities. So far there is no authority to guide the Poor Law authorities on the subject.

Those responsible for transitional payment have in many cases, as they have in Glasgow, made the amount up to £2, 30s. or 35s., but in other cases those responsible for transitional payments have said: "This is a medical need, and we cannot deal with it." When the poor people have gone to the Poor Law they have been told: "We are not allowed to help." I know of one case in Glasgow where a poor man went to the Poor Law authorities and then to the Ministry of Labour. The Poor Law people said: "We have no power to give you a penny." The Ministry of Labour said: "We have no power to give you anything; this is a medical issue." For weeks the poor man went from one department to another, and he was met by legal difficulties. When a man's wife is going to have a child legal difficulties ought not to matter, especially when the people are living under shocking conditions. The result of the position that I have stated is that the man is faced with a great difficulty at a most critical period. In cases of sickness, instead of reducing benefit we ought to increase it. If a man knows when he is ill that actual poverty is not just at his door, he will get better more quickly than if he knows that poverty is attacking him. The same may be said about a woman at childbirth.

Whatever we may say about the failure of the medical profession and whatever we may say about vital statistics between one town and another, at least we ought to free the woman at childbirth from anxiety. We ought to let her know that she will get the maternity benefit. I am not arguing the ethics of the position, but I say that, whoever is to blame, everybody ought to be agreed that the unborn child should not suffer. People argue about the rights and the wrongs of birth control, but I think that all are agreed that once the possibilities of a child being born are there we ought to give that child every reasonable chance of life. Why should we punish the wife and child to be of the unemployed man. I would ask hon. Members to think of the brutal theory of the Ministry of Health and of the Scottish Office, for it is brutal—the Greenock figures are the worst for Scotland—which says to the child a day old: "You did not choose your father, but you happen to have one who has been out of work for three years, and because of that you will not get the £2 maternity benefit; but, if your father had happened to be out of work only six months, you would get the maternity benefit." That is an indefensible thing to say. There should be no punishment of the child that happens to be born although its father is unemployed.

I said that I would not enter into the question for or against birth control. But I am not going to have birth control forced on the poor because they are poor. If the country goes in for birth-control it must not be with the idea of selecting the poor for it. At the moment some poor law authorities in Scotland refuse an able-bodied unemployed man increased payments on the birth to a child. That has been the case in Glasgow. If a man has been a long time out of work and his wife gives birth to a child she gets no extra allowance. It seems to be considered as a crime for a man who has been out of work to have a child. You have no right to punish a man because his wife happens to have a child during a period of long unemployment. You have no right to say to a man who has been out of work for years that he must not have children. You have no right to say to the unemployed that they ought not to add to their family, that they must not be human and have the ordinary relationships of married life. You have no right to say that they should cease to have ordinary marital relationships.

The answer we have had about the old age pensions which expire at the end of this year has been most evasive. It amounts to this, that until the balance sheet has been made of the income and expenditure in connection with health insurance we cannot say what is to be done about the old age pensions which expire at the end of this year. The assumption is that if the valuation is not good these people will not get their pensions. That is a terrible thing, I was almost saying a hellish thing. It is a proposal which language can hardly describe. It means that unless the balance sheet shows a profit and a handsome profit they are to get no pensions. Surely we are not going to allow such a thing to happen. When the Act was passed we thought that everybody who was in insurance at 60 years of age could not be put out of his pension afterwards. But that is not what has been happen- ing, and men who were 58½ years old at the date of their last stamp and who have been idle for some years are to be affected. The only thing which saves the Government from having to face the same indignation as they did in the case of the unemployed is that these numbers are smaller and that those involved are the old, the sick and infirm, who cannot enter into the whirlwind of active politics like younger men who are unemployed. The Parliamentary Secretary, whatever he does, ought to say that whether the balance sheet is good or bad the Government will see that provision is made for these people as a matter of duty on the part of the State.

There is one other matter to which I want to call attention. Under the Health Insurance Acts there was a provision which threw the responsibility on to the approved societies to say whether a man should be kept in the society or not. It was a provision like that of not genuinely seeking work, and people out of work could be put out of an approved society on the ground that they had ceased to be persons normally within insurable employment. The Government in a recent Act abolished the not-genuinely-seeking-work provision and the not-normally in an insurable occupation provision. There is no test now, and I trust that as we have abolished these things in unemployment insurance that the provision which gives approved societies this power should also go, and provided that a man has his card franked and returned he should not be subject to this provision on the part of approved societies.

I hope that the Government will reopen the decision on the question of free doctors and allow the unemployed the right of free medical treatment. The unemployed feel that they have missed the right of access to a doctor on equal terms with their employed colleagues. You have given the Poor Law authorities the right to provide a doctor but it is not giving the unemployed the same right of access to a doctor. I hope that the Parliamentary Secretary will not say that these things are governed by the balance-sheet mind. There may be a great need for providing good houses, but what is the use of giving them good houses unless you allow them to live in decency. It is a mockery if you take away their pensions, their maternity benefit and the right to medical treatment. What is the use of providing houses unless you are also prepared to allow these other things. I trust that the Parliamentary Secretary in his reply will bring a little brightness into the lives of a section of the community which I think are the most shockingly treated of all—the poorest classes in this country.

7.58 p.m.

Mr. EDWARD WILLIAMS

I have listened to the whole of the Debate, and I am delighted to find the interest taken in the subject by hon. Members. We have had some of the finest speeches I have heard for a long time, and it is regrettable that there has been such a sparse attendance. I trust that the Department will take due notice of the enormous interest taken in the death-rate of mothers and children in this country. Regardless of the figures in the report as to the percentage rates of mortality in what may be described as depressed areas, or industrial areas, as compared with areas which are better situated, I believe that the primary cause of the death rate of mothers in this country is poverty. That term covers unemployment, low wages, and the low incomes received by the black-coated professions; all those things which cause such enormous worry to the mother in the pre-natal period and obviously cause lack of nourishment, or a lack of the proper food required by a mother, in order to go through that perilous period of her life. It is in regard to that that I want to make one or two suggestions to the Parliamentary Secretary.

There has been some conflict, arising out of the Local Government Act, 1929, between local authorities and the health department. For instance, in the County of Glamorgan a large number of infirmaries, which formerly were under the jurisdiction of the Poor Law, were taken over by the county council on the creation of the public assistance committee. A large number of infirmaries and institutions automatically came under the county council. If the county council could have been certain that they would not have lost any grant due to them under the Poor Law they might have transferred some of these institutions from the Poor Law administration to the health administration. In doing so, they would have lost grants that are due to them under the Poor Law. If that matter were straightened out, I think that much might be done. It might be possible, for instance, for certain institutions that now come under the jurisdiction of the Poor Law to be transferred to the health department, and, if the whole thing were properly co-ordinated in that way, it might be possible for a number of such institutions to be used specifically either for maternity purposes or for the aged in the county, instead of being left, as they are left, in this rather peculiar state, to the chance of administration, to find what is best to do for an institution or part of an institution. I suggest to the Parliamentary Secretary that his department might inquire into what seems to me to be a paradoxical position. It is a paradox, and I am sure that when it is properly analysed it will be found that what I am stating applies to Glamorgan applies in precisely the same manner to every other county authority throughout the length and breadth of Britain.

In poverty I include bad housing, because if people have an adequate income they will not live in rotten dwellings. It is because people are poor that they live in slums and rotten houses. It is all due to a shortage of income, and that is what I mean when I generalise and say "poverty." If there are well-to-do mothers who die in childbirth in nursing and maternity homes, that is a matter that might be inquired into also by the Parliamentary Secretary and his chief. Up to the moment these maternity homes are not properly registered, and I think it is a standing disgrace that there are maternity homes in this country to which quite well-to-do people may go and in which the child may be nursed and the mother cared for by people who are not properly trained. Anybody in this country may set up a home. I am not casting a reflection on the medical profession, but some are partial to this maternity home and some to that maternity home until one is inclined to believe that there may be some small portion of vested interest attached to the medical profession. All these maternity homes ought to be properly registered, and they ought to come under an inspectorate. We are paying much too high a price for this slipshod way of treating the maternity problem of this country. Frankly, if there is a high percentage of mortality in well-to-do towns like Bath, the Minister and his Department may find that it is attributable to the fact that, although many well-to-do mothers can afford to go to these homes, the homes are not properly fitted for the task, the mothers do not receive proper care, the homes are not registered, and because of that people may do precisely what they like, and mothers and children may be sacrificed as a result.

I press the Parliamentary Secretary to look into the paradoxical situation which I have put to him, which has become evident since the 1929 Act abolished the Board of Guardians, and under which certain grants under the Poor Law may be lost if institutions are transferred to hospital or to maternity purposes, and also to see whether the time has not arrived when all maternity homes in this country should be properly registered.

8.7 p.m.

Mr. LYONS

I am sure that the hon. Gentleman who has just sat down will forgive me if I do not follow him on the many points which he has raised, but I would like to offer my endorsement of his suggestion for the registration of all maternity homes in this country, because I believe that in a subject so vital as this no step should be left untraced which might lead to the safety of women in childbirth and the proper supervision of the conditions under which they live at the time. I rise to ask the Parliamentary Secretary if he will give the House a little enlightenment as to the steps which have been taken by his Department on the report of the Departmental Committee which was set up in 1928 by the right hon. Gentleman who is now the Chancellor of the Exchequer and which made its final report sometime during 1932.

If I read the summary aright, the recommendations mainly were these: That there should be provided in every case the services of a qualified midwife or maternity nurse; that there should be provided a doctor to carry out all antenatal and post-natal examination in every case, and to attend all pregnancy and labours; that there should be provided a consultant whenever it was so desired by the doctor in attendance during pregnancy, labour, and the puerpereum; the provision of hospital beds for such cases as needed institutional care; and the provision of all ancillary services, such as transport, sterilised equipment, and laboratory facilities for each and every woman who desired them or were advised to have them, irrespective of the standing of the patient. There was an important recommendation that such facilities could not prove effective unless they were both used sand co-related. The committee stated that it was convinced that many cases can in fact be prevented. That was a very serious thing to say. It came from a very authoritative body of persons, who had gone into this matter with great care and with great experience behind them.

I should like to know what steps have been taken by the Ministry to deal with these important recommendations. This is a very serious topic, one which goes right into the heart of the country, one about which no examination and help should be spared. Whatever the reasons may be for this high maternal mortality, we do want in dealing with it to mobilise every kind of aid, medicine, surgery, scientific invention and advice, that can help the women of this country. The problem is not confined to this country. I notice in the "Times" of 6th September last year it is reported that in an address to a women's meeting in South Australia Mr. Lyons, the Commonwealth Prime Minister, said that the Federal Government were providing financial assistance for research and other means to lessen the abnormally high maternal mortality in Australia. I see that the annual report of the Chief Medical Officer of Health in New York for 1933 shows that there was a much higher death-rate than was at first calculated.

I hope that the Minister will see that to every woman there is given every possible chance that may help her health and circumstances while in this position, because the country cannot afford to have a high rate of mortality that can be kept down.

I do not want to make any capital out of the reasons that may exist for the figures, or to try to suppress any steps that can be or may be taken for the alleviation of poverty and distress. No doubt these circumstances play a part in this matter. I think the figures for individual townships are extraordinary. I see in the return for last year that the maternal deaths per 1,000 births in the Isle of Wight are very much higher than in the City of Durham. Whereas the figure for Gateshead is said to be 2.55 per 1,000 births, the figure at Bournemouth is said to be 6.03, and Bournemouth is far away from any question of trade depression, bad dwellings and bad air. In Merthyr Tydvil, which we look on, I regret to say with truth, as the very centre of depression, the figure was 3.62, whereas at Hastings it was 6.74, and Hastings is situated on the sunny Sussex coast. Lincoln had the remarkable figure of 14.59, while at Tynemouth the figure was 5.13.

I mention these figures, not because one is pleased that there should be a high figure at Bournemouth and a low figure at Tynemouth—I want to see a low figure all over the country—I mention them to show that you cannot airily dismiss this topic by saying that the figures are high because of depressed areas or the means test. The figures show that for some reason Bournemouth has a very much higher maternal death-rate than Gateshead. We should not in our desire we have to raise the conditions of living and the lot of the people who live under bad conditions in depressed areas get a false perspective; we should not cast this matter aside by saying that it is due to the means test or to bad living. The figures show nothing of the kind. All these unfortunate circumstances have to be taken into account; they have to be ended, and a better standard of life brought by every means practicable. But there is something more than that when these figures are carefully considered town by town. I hope that my hon. Friend when he replies can give the House some information as to why these figures in the districts which I have quoted are so high. Each one of us in our respective ways would gladly make any contribution he could to this important subject. We realise how fundamental it is. I hope that no time will be lost in bringing to the aid of women in this condition every kind of assistance that is available.

It is only right that I should say that as recently as last October or November the Minister issued a very strong circular to local authorities requesting them to make further efforts to reduce this death rate. In that circular it was pointed out that the number of antenatal clinics had increased considerably since 1930, that the proportion of expectant mothers who avail themselves of the ante-natal services had increased by a very large number, and that the increase of maternity beds was a very satisfactory feature. There must be many areas where the local authorities are not co-operating with the Minister in this way. I should be glad if the Parliamentary Secretary would indicate what steps the Minister is taking to see that every local authority is brought into line, that the most intense efforts are made by each local authority to use the facilities now existing and, what is equally important, to bring to the notice of the Minister omissions which ought to be, and I am sure this House would like to see, remedied at the earliest moment.

8.17 p.m.

Mr. KIRKWOOD

I did not clearly follow the hon. and learned Member for East Leicester (Mr. Lyons) in the list that he quoted, when he said that the rate of maternal mortality in Gateshead was not as high as the rate at Bournemouth. I am not going to challenge that statement. It has been thrown across the Floor of the House several times that the death rate in child-birth in this country is as bad amongst the well-to-do as amongst the poor. I am not going to challenge that statement. But as far as tuberculosis cases are concerned I have here one or two figures which show that the tuberculosis death rate, particularly amongst children in the first year, is frightfully high, that it is 300 per cent. higher in the poor districts of Glasgow than in the well-to-do districts.

Dr. A. S. MacGregor, the Medical Officer of Health for Glasgow, states that the incidence of tuberculosis and the death rate from the same disease are twice and four times as great respectively in small dwellings compared with the more commodious residences. He makes the same comment regarding infantile mortality. The death rate amongst infants, in the overcrowded tenement areas, is 131 per thousand in Calton; 125 in the Exchange Ward, 119 in Anderston; but in Langside 46. The last-named is the district which the Secretary of State for Scotland represents. The death rate there is only 46 as against 131 in Calton. Take city for city in Scotland. The comparative figures are these: Glasgow, 96 deaths per 1,000 births; Dundee, 98; Aberdeen 79; London 60; Manchester 75; Birmingham 66. Glasgow, the medical officer states, has 50 per cent. of its houses restricted to one apartment or two apartments, while in Birmingham over 60 per cent. of the houses contain five or more apartments.

The reason why I have raised that matter is this: The average individual would think, because of that terrible death rate, that English mothers are better mothers than Scottish mothers. That is not the case. The reason is that the housing conditions in Scotland are a disgrace to Christianity. When any trouble ensues, any kind of fever, the Scottish mother loses her child; it is taken from her and removed to a hospital. The reason for that is that the whole family in many instances lives in one room, where all the functions of life have to be performed, and where the whole family sleeps. Whenever any infectious trouble breaks out the child is taken from its parents and taken away, whereas under the English housing conditions it is possible to separate the sick child from the rest of the family by putting it in another room.

I am raising the matter because the Parliamentary Secretary to the Ministry of Health was with the Chancellor of the Exchequer last Thursday when we from the distressed areas appealed to the Chancellor to deal a little more kindly with us. In great industrial centres such as Glasgow and Liverpool we are right up against it. The Parliamentary Secretary heard us state the case on behalf of those areas. What we are up against is just poverty. It is all a question of poverty. The hon. and learned Member for East Leicester made an eloquent appeal for proper attention to the mothers of our race. Think of it. Here we are in 1935 appealing to the Government, this all-powerful Government, which has such a majority that it can do anything, and even their own supporters are appealing to the Government on behalf of the mothers of our race. The extraordinary statement has been made that, despite all our progress in science and in other respects during the last 30 years, we have made no advance whatever in saving the mothers of our race. To-day we are told that child-bearing is the most dangerous occupation in Britain and this Government has not done much to ease that situation. I leave it at that. I want to make an appeal to the Parliamentary Secretary who is, I understand, to reply on behalf of the Government. On 12th March I put this question to the Minister of Health: whether he is aware of the large numbers of members of approved societies who are now out of health insurance owing to prolonged unemployment, and so must apply to the Poor Law medical officers instead of the panel doctors; what is being done to prevent these medical officers being unable, through overwork, to deal efficiently with their large numbers of new patients; and whether he will take steps forthwith to enable all such persons to regain medical benefit with the panel doctors? I wish the House to pay particular attention to the terms of that question. It relates to people whose only crime is that they have been subject to prolonged unemployment, a matter over which they have absolutely no control. This Government cannot find employment for them. Yet because they have suffered from prolonged unemployment they are compelled to apply to the Poor Law medical officer for medical attention instead of to the panel doctor. This is the reply given to me by the Parliamentary Secretary and it will be observed that at the outset of it admits the fact set out in my question: A number of persons have ceased to be entitled to benefits under the scheme of national health insurance by reason of prolonged unemployment and a proportion of these are having recourse to the public assistance authorities when in need of medical attendance. As regards the second part of the question, it is for the public assistance authority to see that their medical service is adequate for the needs of the area, and my right hon. Friend has every reason to believe that the authorities generally are alive to their responsibilities. As regards the last part, my right hon. Friend has already stated that the whole position will be considered in the light of the first report of the Government Actuary on the financial operation of the Contributory Pensions Acts."—[OFFICIAL REPORT, 12th March, 1935; col. 200, Vol. 299.] I wish the House could realise the tragedy which is wrapped up in that question and answer. Here you have as decent a body of men as ever drew the breath of life who are unemployed through no fault of their own. Neither this Government nor any of the Governments which have preceded it has been able to find work for them. Every means of solving the problem has been tried except the method which we have proposed time and time again, namely, Socialism. The present Prime Minister when he was at the head of the Labour Government appointed the present Dominions Secretary to act as Minister of Employment but that office was abolished because the present Dominions Secretary could not handle the business. He said himself in this House that as soon as he put 1,000 men into work it would appear that 2,000 other men went out of work. The result was that the Government did away with that new office. Then the Prime Minister set up a committee with the "high falutin'" designation of an Economic Committee and made Lord Weir chairman of it. That committee was supposed to find work. It was going to change the situation but it has done nothing of the kind. Unemployment has continued, and neither the Government nor the employers of labour can find employment for these millions.

Our plea has always been that in such circumstances we have no right to treat the unemployed as if they were an army of criminals. They are entitled to be treated with justice and respect. It is not treating them with respect to cut them off from the services of the panel doctor simply because they have been subject to long periods of unemployment. Some of them are men who never dreamt that they would ever require to go to the Poor Law—decent hard-working men who have rendered yeoman service to the country, both industrially and on the field of battle. Now they are being reduced to the lowest stratum. I remember a time when one of my race would have considered it a disgrace to take anything from the Poor Law. I cannot say that now because conditions have reduced every section of the working class down to the lowest level. I have seen men refuse to go even to the employment exchange because they considered it a disgrace to do so but now they have been brought down to such a state that they are glad to go to the employment exchange. Even worse they have been brought to a stage at which they are glad to go to the public assistance committee.

Now we are bringing them down one stage further. Now when they fall ill they have to go to the Poor Law doctor and the Poor Law doctor is already overwhelmed with work. The local authorities have not the wherewithal to engage a sufficient number of Poor Law doctors. That is why we went before the Chancellor of the Exchequer last week and made an appeal to him on behalf of the local authorities—and I understand that representatives of the local authorities are coming again from Scotland. I am told that the West of Scotland is going to refuse the offer which has been made and that the Chancellor of the Exchequer is going to get the chance of his life to go there and operate this Measure for himself—and if he does we shall see what kind of job he will make of it. I am referring to Glasgow and I am glad to see that the Secretary of State for Scotland is here though I am not complaining about his absence up to this.

The hon. Gentleman the Parliamentary Secretary replied that his right hon. Friend had already stated that the whole position would be considered in the light of the first report of the Government actuary on the financial operation of the Contributory Pensions Act. That means, if it means anything, that there is going to be legislation, but this cannot wait on legislation. This is something that is going on now, and you are breaking the hearts of hundreds of men who are just as independent as we are and who have every right to be independent. They have never committed any wrong. It is not a crime to be unemployed. They are victims, and I appeal again to the Government to consider those appeals that have come from every quarter of the House to-day. We are not simply airing our own individual cases. We are here today expressing the point of view of men and women who have sent us here to do it. They are dumb, they have no means of expressing their point of view, but we are here to do it, and I am satisfied that if we were able to get the Government to understand, to see it as we see it, to feel it as those individuals feel it, we should get some concession from the Government to-night. It is no use telling me it requires legislation and that we require to economise. If anything went wrong with the arrangements of the Foreign Secretary and the Lord Privy Seal, and war was declared this week, do you think there would be a shortage of cash or of anything else? There would be no shortage. We should meet every requirement. Millions would be spent like water. We are here to-night asking for a few hundred thousand pounds to save life, not to destroy life. That is our appeal to the Government, and we press the Government whether they, in their day and generation, are going to put into operation the power they have to relieve suffering humanity.

8.39 p.m.

Mr. JOHN

We have had a very interesting debate, and there is no need for the party to which I belong to apologise for introducing these very important questions that appertain to the health of the people of this country. We have had a very interesting discussion on the question of maternal mortality. In fact, the main discussion has been concentrated around that very important problem. I hope the effects of the discussion will be seen in the activities of the Ministry of Health in the very near future. I shall confine myself mainly to the second question, and that is the question of the administration of the National Health Insurance and Contributory Pensions Act. The experience of the past two years has been such that it is essential to direct the attention of the Ministry of Health, and even to call the attention of the whole country, to the sorry plight of a large number of persons who are adversely affected by the change made in the amending Act of 1932. Those changes adversely affect a very large number of people, and I think we are entitled to know what the Ministry intends to do in order to retain these people who have gone out of insurance, so far as cash and medical benefits are concerned, in full insurance rights.

When the Minister introduced that Bill, on the Second Reading, he was very much concerned about retaining the rights of insurance for these people, and be said that we ought to give the unemployed an opportunity of being retained in insurance pending a betterment of the national situation. At that time the Minister was in a very optimistic mood. They had just come back as a National Government with a very large majority and were full of enthusiasm with regard to the prospects of the future. There was to be a better- ment in the conditions of the country. They thought the National Government would mean a kind of Open Sesame to the trade of the world, but to-day that optimism does not exist. There is a spirit of pessimism even in the National Government. [HON. MEMBERS: "No!"] I will try to ascertain whether or not that is so by their policy. There is no optimism in the National Government as far as the depressed areas are concerned, and, after all, the people who are adversely affected by the changes in this particular Act are living in the depressed areas.

If they were optimistic with regard to the depressed areas, why did they send commissioners there, why did we pass the Special Areas (Development and Improvement) Act? We passed it because, in accordance with the report of the commissioners, it was understood even by the National Government that there was a large number of people in those areas who would not again be absorbed into industry. Even the report of the investigator in South Wales stated that even if they got back to the days of 1921, there would still be 40,000 in that area who would not be absorbed. As a result of the failure of absorption of these 40,000 into industry, the Government passed the Special Areas Act and sent a roving commissioner with £2,000,000 in his pocket to ascertain whether it was possible to assist those people. Therefore, hon. Members opposite who say that the Government is optimistic forget that the policy of their own Government has arisen out of a spirit of pessimism so far as the distressed areas are concerned.

Mr. HANNON

Surely the hon. Member would not contend that because the Government have taken every reasonable measure within their power in the last two or three years to examine the possibilities and to make provision for them, that is pessimism?

Mr. JOHN

What the Government have done is to send a commissioner to be a salvage officer to try to repair the ruins in the depressed areas. Everybody admits that it is not possible to introduce new industries into those areas and for a large number of the people to be absorbed into industry. Having regard to the failure to absorb a large number of the unemployed who are affected by the changes made in the Act of 1932, we are entitled to ask the Parliamentary Secretary what steps the Government intend to take to put their policy into effect, in view of the fact that the Minister of Health said, on the Second Reading of the Act, that it was the intention of the Government to retain the rights of insurance for these people. The rights of insurance were anticipated on the ground that there would be an improvement in trade in the depressed areas. In the absence of that improvement it naturally follows that there is a responsibility on the Government to see that these people are retained in insurance. I am afraid, in view of the interjections that were made just now, that there is a danger of this problem being overlooked because of the improvement in trade.

It has been contended that there are about 750,000 more people in employment now than there were two years ago, but the improvement in trade shown by that figure does not affect the problem of the unemployed who are affected by the changes of the 1932 Act. Therefore, to minimise this problem on the ground that there has been an increase of employment will serve no value. Under the present administration there is no possible chance of those people who are suffering the consequences of this Act again being employed. The policy of the Government recognises that. The export trade of the mining industry is being stabilised through international agreements. The rationalisation of industry, the introduction of machinery into the mining industry and economising in human labour in the distressed areas mean that there is no possible chance of these people being absorbed into industry. What is to become of them? Is there no other ideal for them than to-spend the rest of their lives entirely dependent on public assistance? They have lost their rights of insurance, there is no sickness, maternity or medical benefit for them, and nothing is left for them but to be dependent upon public assistance. What an ideal of the National Government for thousands of people who are unemployed. This problem is growing in seriousness. When the Act of 1932 was introduced, the Minister of Health said that by the end of 1932, 80,000 people would be affected. Before the Bill was made an Act of Parliament the Minister said that in accordance with the calcu- lations there would be an addition of 10,000 a year between 1933 and 1935 Later, however, on the 17th April, 1934, the Minister, in reply to a question, said: The returns which have now been received from approved societies that the number of members who after a period of prolonged unemployment were continued in insurance during 1933 by virtue of Section 1 (5) of the National Health and Contributory Pensions Act, 1932, but ceased to be entitled to medical benefit on the 31st December (though continuing to be insured for pension purposes) is approximately 125,000. This number will, however, be substantially reduced by reinstatements to medical benefit … at the rate of several hundreds a week."—[OFFICIAL REPORT, 17th April, 1934; col. 899, Vol. 288.] The number affected is largely in excess of the Government's figure, because, taking into consideration the figure of the Minister of Health of 80,000, and adding the other 10,000 which was expected to be the number for 1933, it should have been 90,000. The calculation is out therefore by 35,000. And that notwithstanding the improvement in trade, the betterment of the general situation of the country and the fact that there are 750,000 more in employment. Notwithstanding also the fact that, as the Minister said, in reply to a question on the 22nd March, 1934, an indication of improvement in the general trade of the country was to be seen in the number of insurance stamps that were sold from time to time, and that the number of stamps sold showed that there was an increase in employment of 13,000,000 weeks in the last 10 months of 1933 as compared with a corresponding period in 1932. Notwithstanding that there was this increase in employment, the figures of the Ministry were out by over 35,000. By the 25th February, 1935, these figures had increased to 170,000. If the figure was 80,000 when the Bill was being discussed with an additional 10,000 for every year up to 1935, the total would now be 100,000, but it is actually 170,000.

The Parliamentary Secretary, when he gave that figure of 170,000, added, probably as an afterthought or ironically, that it would be possible for a large number of those people to become entitled to insurance benefits as voluntary contributors. That shows very clearly a lack of co-ordination between the Departments of the Government. At that time the Ministry of Labour had issued their regulations, which were reducing very materially the allowances that were to be paid to the unemployed; and then the Ministry of Health step in and say, "It is all right, you can become insured as voluntary contributors." At the moment when the Ministry of Labour were undermining the physical condition of the unemployed, the Ministry of Labour come along and say, probably on the basis of "the doctor's mandate," "We will repair your health again on condition that you pay us eighteen pence a week." How can the hon. Gentleman expect the unemployed to pay 1s. 6d. a week? I will challenge anybody in the House to rise and say that he could expect the unemployed, out of the allowances they receive, to pay eighteen pence a week in order to get back into insurance. It is impossible. It cannot be done.

Mr. HANNON

But is that not a very unfair argument? The hon. Member knows that the actual amount at the disposal of the Unemployment Assistance Board is millions more, in the aggregate, than the sum that was available before.

Mr. JOHN

The figures of the Ministry of Labour were as fallacious as those of the Ministry of Health. The Minister of Labour admitted that they were over 5,000,000 out, just as the figure of 80,000 which the Ministry of Health gave in 1932 has become 170,000. The problem has increased beyond the anticipations of the Ministry of Health. If the Act of 1932 was passed, I will not say on false information, but on wrong information given by the actuaries, why should not the Ministry of Health follow the example of the Ministry of Labour? It was admitted by the Ministry of Labour that the figures given to them were wrong, and that their regulations had been based upon a wrong calculation, and they introduced the standstill arrangement. Why should not the Ministry of Health say, "This Act of Parliament was based on wrong information, the calculations were not correct, and we will introduce a standstill arrangement and reinstate all these persons into insurance, in order that we may have time to reconsider the situation in the light of better and more accurate information." The hon. Member for Gorbals (Mr. Buchanan) and others have referred to the sorry plight of these people. They have lost their sickness benefit, and that at a time when they most require it.

It is all very well for the Minister to say that it is possible for medical schemes to be arranged between the public assistance committees and the medical men in the areas where those committees operate. Such schemes are costly; they cast a burden on the depressed areas, where the poor rate is already high. Merthyr, for example, has a poor rate of 15s. 7d. in the pound, and yet the Ministry of Health would say, "Now, all you people who are unfortunate enough to be unemployed and have lost your rights to sickness benefit, there is no alternative for you but to go on public assistance," and at the same time turn to the public assistance committee and say, "Although your poor rate is 15s. 7d. in the pound, you have no alternative but to take over the additional burden of these people who have lost their rights to insurance benefit." That means transferring a national obligation to an already overburdened area. Take the case of the Rhondda district. In a small society composed of miners, with a membership of 6,500, close on 900 have already lost all their rights to medical benefit, sickness benefit and maternity benefit. By the end of this year 1,200 will have lost their rights to all those benefits, and will have lost their title to pension as well, unless something is done.

In the county of Glamorgan alone 33,000 persons have lost their right to sickness and medical benefits, that is, 40 per cent. of the figure of 80,000 which was mentioned at the commencement of the operation of the Act. The figures for Monmouthshire approximate to those of Glamorganshire. How is the public assistance committee of Glamorgan county going to deal with this additional 33,000 people and their families—a very large number of them have families? In case of sickness every one of them will have to apply to a relieving officer in order to get medical attention. Is the number of doctors engaged by the public assistance committee of Glamorganshire sufficient to deal with the requirements of that 33,000? It is impossible. One cannot expect the medical profession in those depressed areas to carry on in that way. No profession has sacrificed more for the unemployed in the depressed areas than the medical profession. Doctors have been giving their services freely, frankly and without any payment at all, and it is too much to expect them to provide for the medical needs of 33,000 people when that ought to be an obligation on the Government.

We have been speaking of maternal mortality. A large proportion of the 33,000 have lost their maternity benefit. A great deal has been said about there being a large number of contributory factors to account for the increase in maternal mortality, but maternal mortality is not entirely due to science not having understood all the changes in social diseases. Poverty is a strong and a grave contributory factor in maternal mortality. These persons have been unemployed for a long period. At the end of 2¾ years they lose their right to sickness, medical and maternity benefits. It is not only a question of poverty but of the effect of the economic conditions of the home on the mind of the mother. There is an anguished mind. If anybody in the home sacrifices it is the mother. We cannot prevent the mother sacrificing for her children or depriving herself of a good many of the necessities of life in order to provide for her offspring, but we can prevent the necessity for her doing that. We can create conditions making it unnecessary for the mother to deprive herself of the necessities of life in order to provide for her children. One of the ways in which that can be done is to restore the insurance rights of the husband to sickness, medical and maternity benefit.

The argument is that that would cost too much. It was costing the approved societies £1,000,000 a year. When the scheme was originally introduced, it was a tripartite scheme among employers, workers and the State, and contributions were based upon a long sight view. When the approved soceities were in a flourishing condition and there was a large surplus, the right hon. Gentleman the Member for Epping (Mr. Churchill), when Chancellor of the Exchequer, saw in those large surpluses of the approved societies a nice little nest-egg, which he took by reducing the grant of the Government by £2,750,000 per annum. The finances have therefore to some extent been impoverished since 1926. There was no question of contractual obligations or of the Government having fixed the grant in relation to the contributions of the workers and the employers when the scheme was originally introduced. If there was any measure of justification for the Government reducing the grant by £2,750,000 when the approved societies were a financial success, there is equal justification now that the approved societies are in low water, for expecting that the Government will pay at least £1,000,000 per annum back to them. That would be 50 per cent. less than the Government took away. If the Government gave the £2,750,000, to which the fund is entitled, there would be no difficulty at all, and no need, as the hon. Member for Westhoughton (Mr. Rhys Davies) mentioned in his opening speech, for the surplus to be reduced from £25,000,000 to £12,500,000. The Government are under an obligation to increase the grant to the figure at which it stood prior to 1926. I do not accept the figure of 170,000. In fact, a number of large approved societies put the figure as nearly 300,000.

Mr. BUCHANAN

It is 170,000 in Scotland.

Mr. JOHN

At the end of this year, not only will those people lose their sickness, maternity and benefit rights, but they will lose what the Minister said was their most valuable and precious possession, their right to pension. I ask what the Government intend to do about that? Are the Government going to do something to ease the minds of those people so that at the end of the year they will not lose their right to pension? It is all very well to say that the Government have improved the position by reducing the age from 60 to 58¼. The Minister said that they had done that because they realised that the man at 60 years of age could not get any employment. If that was true when it was said, it is more true now. What about men who are now 60 years of age? Have they any better chance of employment? Competition for employment is becoming keener, and the mechanisation of industry makes it far more difficult for a man of 60 years of age to be employed. Rationalisation of in- dustry and of markets, and the general tendencies of industry make it more difficult for him to get employment than it was even two or three years ago. Is there to be no other life for people of 58, or even of 50 years of age than to be entirely dependent upon public assistance? That is what it means.

Some of these people have paid for 20 years into the fund. Even insurance companies offer a free policy to people who have paid for a certain number of years. Because of circumstances over which they have no control, industry tells these people at the end of 20 years that they are not wanted. The unemployment insurance scheme tells them, "Not wanted"; the health insurance scheme says, "Not wanted." They are forced to go to the only other place, not because they are wanted there, but because there is no other place for them to go in order to eke out their miserable existence. I ask the Parliamentary Secretary whether he can give us the precise number of those who have lost their rights to medical, sickness and maternity benefits and whether it is the intention of the Government to do something to restore to those people the benefit rights which they have lost. Is it the intention of the Government not only to restore those rights to benefit but to introduce something to provide means whereby all those people will not be disentitled to their pensions at the end of December this year?

9.15 p.m.

Mr. SHAKESPEARE

We have had a very interesting Debate, with a wealth of contributions from Members who not only take a personal interest in the questions which have been discussed but who, from their long experience, have a real contribution to make. The discussion has ranged round two main problems, and it is with those problems that I am primarily concerned; but perhaps the House will allow me to answer some of the specific questions which have been put to me on a number of other matters. Some questions have been put to me which I cannot answer on the spur of the moment, as they will require a little investigation, but, if there are any questions that I do not answer, I will write to the Members who have put them.

Two Members for Welsh constituencies—my hon. and learned Friend the Mem- ber for Montgomeryshire (Mr. C. Davies) and my hon. Friend the Member for Carmarthen (Mr. R. T. Evans)—asked whether it was not time that an inquiry should be made into the cause of the high incidence of tuberculosis in Wales. It is true that the figures in Wales are higher than those in England, but over the last decade there has been a noticeable fall. The death rate per 1,000,000 of population has come down from 1,171 in 1924 to 986 in 1933, and in the last three years the average death rate has been below the figure of 1 per 1,000. My hon. Friends will remember that there have been two special inquiries into the incidence of tuberculosis, initiated by the Welsh Board of Health and the Welsh National Memorial Association. We shall certainly suggest to the Welsh Board of Health that they should see whether advantage might be taken of any further information in their possession.

My hon. Friend the Member for Hereford (Mr. J. P. L. Thomas) asked what was the attitude of the Ministry of Health towards the provision of playing fields in town planning schemes. I can certainly give him an assurance that it is a matter to which we attach the greatest importance. There is no foundation for any rumour that we have put a ban on the provision of playing fields by local authorities. We consider applications for loans on their merits, and do our best to encourage them. The hon. Member for Ogmore (Mr. E. Williams) discussed with considerable knowledge the very useful public health work carried on by the hospitals transferred from boards of guardians to local authorities, and he asked whether the block grant would be affected by this. He will remember, however, that the contribution to local authorities is now made in the form of one block grant, and no block grant is involved in this question. With regard to the question of registration of nursing homes which the hon. Member also raised, I understand that the registration now takes place under the local authority. The hon. Member for Dumbarton Burghs (Mr. Kirkwood) raised the question of tuberculosis in Glasgow. I have not the figures with me; in fact, this matter is not within my province; but I accept the hon. Member's figures as correct prima facie, because in my experience nothing is more noticeable than the high prevalence of tuberculosis in slum areas. That is one of the vilest of evils, and, until we have eradicated the slum, we cannot eradicate tuberculosis. For that reason we all welcome the slum crusade as a real health contribution of the widest scope, if for no other reason.

I come now to the two major points of the debate, which were dealt with, if he will allow me to say so, with such knowledge and in such a reasonable manner by the hon. Member for Westhoughton (Mr. Rhys Davies), who has had a lifelong experience of these problems, not only in theory but in practice. The first is that of maternal mortality, that vital and very mysterious question. It is not a political question, and I am very glad that so many hon. Members, even on the other side of the House, have protested against this scientific question being dragged into politics. No good can come from treating a problem which baffles the medical profession as though one party were interested in its solution and the other were not. No one can listen to debates in this House without realising the intense feeling that, whatever effort may be necessary to solve this problem, that effort should be made; and, if we knew of a definite remedy for this intractable problem, no consideration of cost would weigh for one moment with any government, and least of all with this government. It has, however, been pointed out already that, although the expenditure on public health services has returned good results in almost every field, yet for some reason or other the percentage of maternal deaths remains about the same as it was in pre-War days. My own view is that, if we had not taken the very wide measures which all governments have taken, that percentage would be very much higher, and I think that everyone who has studied the subject will agree that that is so. The matter is one that needs constant care and supervision.

Let me give the House the exact figures. In 1914, the total number of births was 879,000, and the maternal mortality figure was 3,667. That is a rate of 4.51 per 1,000 births. In 1933, the total number of births was 580,000—a considerable fall; and there is also a fall in the total number of deaths to 2,618, the rate again being 4.51 per 1,000 births, or exactly the same as in 1914. The House will notice, of course, that the total number of mothers who died in childbirth decreased during that period from 3,667 to 2,618, so from that point of view it looks as though the efforts which have been made have shown tangible results; but the position must be judged in relation to the steep fall in the birth-rate. It may be said that the fact that out of 580,000 births only 2,618 mothers died gives cause for congratulation, but the poignancy of these figures is the fact that half of them are preventable; that is, something like 1,300 mothers die a year who should be kept alive. For one reason or another, whether it be the fault of the medical service or the ante-natal service, or our lack of knowledge, these mothers who should be kept alive, die. Death in childbirth is one of the bitterest blows in the sufferings of every day life, but the bitterness is accentuated and heightened when the husband feels that that loss would have been prevented if our knowledge were improved.

Several Members asked what steps the Government have taken to deal with this problem. We are trying a general attack over the whole country. In October we issued our circular asking all the maternity and child welfare authorities to survey urgently their services. So far the result has been satisfactory. Of the 421 authorities, 155 have replied that they are taking steps to improve or to extend their services; 174 have reported that they do not propose improvements, but in only 23 of these cases are the services regarded as not reasonably complete; 84 promised attention. I need hardly say that we are in touch with every authority which admits that improvement is necessary, either by correspondence, by interviews with the department, or by inspectors on the spot. This general attack over the whole ground of maternity and child welfare service will be carried on week by week throughout this year. Something more than that is necessary. In that circular we directed a special attack on the black areas, where the figures show that for some reason or other there is an abnormally high maternal mortality rate. It is clear that if we can find out the reasons in these areas and take effective steps to remedy them, the percentage will appreciably fall. The House will find the black areas in the report of the Chief Medical Officer of Health on page 262. These areas consist of 14 counties and 22 county boroughs.

We have asked the Medical Officers of Health to make an urgent report to us covering these points—what improvement of the ante-natal service is necessary; the measures taken in the district for the provision of a midwifery service for all confinements and the provision of adequate beds for complicated cases in hospitals; the steps taken for the isolation of cases of puerperal sepsis, and arrangement for consultant services in difficult cases. When we receive these reports we shall have the advantage of the services of an eminent obstetrician, not of the Ministry of Health. We send down to each of these areas two inspectors from the Ministry of Health, one a medical officer with an administrative knowledge of this question, and the other a lady doctor with a long experience of the maternity side. These two, together with the medical officer on the spot, go into the report and find out where are the weak places in the provision of these services. We have already dealt in this way with Blackpool, Wigan, Plymouth and Wakefield, and we always have a check borough so that we can make comparisons. Visits are in progress in the following county boroughs: Preston, Barnsley and Dewsbury. As regards South Wales, where the black spots are in two counties, special inquiries are being made in Carmarthenshire and Denbighshire, and an inquiry into Monmouthshire is now in progress.

I hope the House will agree that it is along the line of these special urgent local inquiries, in consultation with our experts and medical officers on the spot, and with outside advice, that we hope to find in these areas the causes of the high mortality rates and, once we find them, to take urgent steps, in conjunction with the local authority, to see that they are put right. Towards the end of the year we hope to consolidate all these reports and to issue a report which I am sure will be awaited with great interest by all Members who follow these things closely. My Noble Friend the Member for South-end-on-Sea (Countess of Iveagh) and the hon. Member for Westhoughton asked me what is our attitude on the report of the Joint Council of Midwives. That is a most valuable document. I believe the hon. Gentleman himself was on the Council, but the mere composition of that committee means that any Government must of necessity give it the most careful consideration. As soon as we received it we got in touch with the representative associations of local authorities, the County Councils Association and the Association of Municipal Corporations and the London County Council, and asked them to furnish their views. Meanwhile, in the Department we are giving it our special study. More than that the House will not expect me to say, except that everyone agrees that if we are to get the right person into the midwifery service we must do something to raise the dignity and the status of that great profession, and see that there is an adequate salary attaching to this most noble of all work.

My Noble Friend raised another very interesting question as to the training not only of students but of midwives. The training of medical students has been considered by the General Medical Council and that recently the curriculum has been strengthened to see that there is a more extensive course of training and examination given to the students in the question of midwifery. I understand that the Central Council of Midwives are considering the same thing and I expect that shortly an agreement will be reached by which the course of training of mid-wives will be extended and improved. The hon. Member for Leicester East (Mr. Lyons) and the hon. Member for Hems-worth (Mr. G. Griffiths) raised the question of the relation of malnutrition to maternal mortality. Common sense would dictate that if a woman is ill-nourished, she is less able to bear the shock of childbirth than the woman who is well nourished. That is the common sense point of view, but the medical evidence that we have, strangely enough and somewhat mysteriously, does not support the common sense point of view. Indeed, the most expert survey undertaken by the departmental committee in 1932, which examined in great detail a large number of cases, came to the conclusion that at least half the cases of maternal mortality occurred where there was no poverty at all.

That, really, is one of things that baffles all investigation and makes it quite impossible to deal with this as a matter of poverty. Moreover, the geographical nature of the incidence of mortality confirms the same point of view. If you compare the rate of maternal mortality in Durham, with its well known distress, and the maternal mortality in Middlesex, where comparatively there is no distress, strangely enough the rate is the same, which again bears out the point of view put by the hon. and learned Member for East Leicester that poverty has nothing whatever to do with it. The hon. Member for Hereford raised the all important question of the provision of milk for pregnant mothers, and we called attention to that matter in our circular and impressed upon local authorities the extreme importance of seeing that supplies of pure milk are available where necessary.

Mr. E. WILLIAMS

Can the hon. Gentleman say whether the maternal services in Middlesex are comparable with those in Durham, whether there is any neglect to apply public services in those areas where there is a high mortality rate, and whether there are other significant factors, such as maternity homes not properly registered and persons not properly trained, whereas in a depressed area you may have all these things properly attended to?

Mr. SHAKESPEARE

That might well be so, but I do not think that it is so in this case. I do not think that anyone would suggest that the services in Middlesex are inadequate, but it bears out the argument I made before.

Mr. G. GRIFFITHS

Middlesex is not in the black list?

Mr. SHAKESPEARE

No, Middlesex is not in that list. In my belief the solution of this problem does not only lie along the lines of the special attack which we are making, for it will not yield to any one specific remedy, but it will yield in the course of time to a number of co-ordinated factors. The hon. Member for Whitechapel (Mr. Janner) spoke about team work and gave examples whereby, owing to complete team work between doctors and nurses, and with the co-operation of patients themselves, which is so vital in the way of antenatal services, remarkably low figures had been achieved. There is abundant evidence that a figure of just over one per thousand can be reached, and we shall not cease in our labours until the highest figures decrease, and compare favourably with the low figures which obtain in those areas where there is first-class supervision.

Mr. KIRKWOOD

On the question of malnutrition and child-birth, the hon. Member has made out a case that the death rate is just as high among the well-to-do folk as it is among the poor. Will he turn this point over in his mind? Is it not simply a question of common sense that poverty has to do with it, and that it is impossible to expect that an undernourished woman can bring forth a child as well as the woman that is nourished? That would be all right if they were of the same class. All that to which I have listened here to-day goes to prove what I have always held, that the working class are hardier than the pampered class. It is because they are pampered that their death rate is up, and the very opposite holds good with the working class. The death rate of the poor goes up because they do not get sufficient nourishment.

Mr. SHAKESPEARE

That may be, but the fact remains that the rate is terribly high in areas where there is no poverty and areas where there is great poverty. The hon. Gentleman the Member for Westhoughton asked me a specific question about the infant mortality rate, and here I think we can all point with pride to the considerable achievement in the realm of saving the lives of the children in the last 20 or 30 years. It is apparent, considering the infant mortality in, say, the 10 years before our present King came to the throne, and taking into consideration the provisions for the saving of life since, that to-day something like 30,000 children are alive who would have died in the decade from 1901 to 1910. That is good progress and gives us cause for congratulation and pride in the efficiency of our infantile services. I was asked whether the improvement was widespread, or whether the records in the distressed areas were indifferent. The answer is no—the improvement is just as remarkable in the distressed areas. I have here the record of seven county boroughs and seven town councils that were mentioned in the Schedule to the recent Act dealing with depressed areas, and examining the record of infant mortality in the last decade from 1924 to 1933, I find that in five of the seven county boroughs the figure in 1933 is substantially lower than it was in 1924. In one it is the same, and in the other it is slightly higher. In six of the seven counties, the figure is lower at the end of the decade than it was at the beginning, and in one it is slightly higher. That shows that the general improvement in figures has been maintained in these special areas. The hon. Gentleman mentioned the rate of 64 in 1933, but the rate for 1934 is still more remarkable, namely, 59, which is the lowest in the history of this country.

I now come on to the question of health insurance. The hon. Member for Westhoughton asked me what would be the result of the fourth valuation. He knows as well as I do that it is too early to say. The report has been made only as regards societies with an aggregate membership of about 3,250,000. That is about one-fifth of the whole. Their financial position I think we may say is rather better than one could have anticipated in 1931 or 1930. I would rather not guess what the result of the full valuation will be.

I come to a point that was raised by many hon. Members, a point on which every one feels very strongly, and that is, what happens to those who have fallen out of insurance and whose pension rights are safeguarded until the end of this year? A number of figures were given by two hon. Members opposite showing the exits from insurance. One realises that those figures covered also the cases of people who have left insurance not on account of unemployment. Therefore, those exit figures are not accurate figures of those who have fallen out of insurance on account of unemployment. One hon. Member mentioned the figure of 110,000 and one mentioned the figure of 107,000. I will accept either of those figures for the purpose of argument. The principle is the same whether the figure is 107,000 or 110,000. But let me make it perfectly clear that the pension rights of not one of those persons has been jeopardised. If any one of those persons died the widow is secure.

Mr. G. GRIFFITHS

Will they be secure after the 1st January next?

Mr. BUCHANAN

The Parliamentary Secretary must remember that the insurance societies have always had a power equivalent to the not-genuinely- seeking-work principle, and they have had the power to pass them out.

Mr. SHAKESPEARE

I was dealing with the point of the effect of the Act of 1932. My hon. Friends know that those with less than four years' insurance have always, if they suddenly became unemployed, lost their pension rights. Therefore, the position was not altered by the Act of 1932. We simply dealt with a solid body of people, then supposed to be 80,000, which has grown to whatever figure one accepts. All those have been kept in insurance and will be kept in insurance until the end of 1935. The vital question is the deprivation of their pension rights. It is the pension side of the whole benefit system that is so much appreciated. The Government have given very careful consideration to this question. It will be remembered that when the Act of 1932 was passing it was stated that the position of these persons would be reviewed when the report of the Government actuary had been received. I understand that that report will be presented very shortly, but the Government have already decided that steps must be taken to modify the hardships that will be involved if those persons are deprived of their pension rights. The Government have decided that the existing arrangements must be modified, and legislation will be introduced as soon as we have had time to consider the actuary's report. The scope of the legislation must depend on the report of the Government actuary, and when we get that we shall consider the whole question and bring legislation before the House without a minute's delay, because we are convinced of the gravity of the situation.

Mr. RHYS DAVIES

The hon. Member understands that the report of the Government actuary which he is expecting will have nothing to do with the problem that we have been arguing to-day about the rights of the 110,000 persons under the national health insurance scheme. There is no actuary's report expected on the national health insurance scheme, because the societies are bound by the quinquennial valuation. Are we to expect legislation in respect of contributory pensions, legislation to safeguard the interests of these persons under the national health insurance scheme as well? That is the problem.

Mr. SHAKESPEARE

I was dealing with one aspect of it, and, if the hon. Member will allow me to proceed, I will deal with the cognate question of arrears and so forth. The House will not expect me, in fact I am not in a position to do so, to go further than to say that at the earliest possible moment we shall introduce legislation to modify the existing arrangements.

Mr. JOHN

What does that statement really mean?

Mr. SHAKESPEARE

I have explained that I cannot possibly make any further statement. As regards the question of arrears, here again hon. Members must realise that provision was made in the Act of 1932 that in so far as the position of approved societies permitted, the position might be improved owing to the better financial position of the country, the fall in unemployment and the increase in the income of contributors, and provision was made to deal with it by regulation. To what extent we can ease the position as regards arrears and make a relaxation as to how many weeks and so forth arrears might be excused, is a matter we are now urgently considering. It is cognate to the other questions of medical benefit, etc., and it is a question that I can assure the hon. Member for Gorbals (Mr. Buchanan) we are considering most anxiously.

Not only that, but the approved societies have sent in schemes which we are discussing with them, but I am sure the House will not expect me to say anything further on that matter except that we are seized with the gravity of the position and will do our best to find a solution that will not put an undue burden on the approved societies, which are not one body but consist of 7,500 financial units. I hope that I have covered most of the points raised in the debate. As regards maternal mortality, I can assure hon. Members that we are doing everything in our power to lessen it. As regards the other point, I have made a definite promise on behalf of the Government, and I hope the House will accept what I have said in the spirit in which it has been offered.

Mr. G. GRIFFITHS

Will the hon. Member answer the question I put to him as to how a diabetic person is to get insulin?

Mr. JANNER

What is the hon. Member prepared to do in order to bring to the notice of the people as a whole the suggested means of co-operation, so that prospective or future mothers will know how they may co-operate with the doctors and nurses? I suggested that there might be some kind of information given in the schools or the clubs.

Mr. SHAKESPEARE

In regard to the first question I think that is dealt with by the public assistance committee. As regards the point put by the hon. Member for Whitechapel, when the report has been received and we have considered it with experts, we must then endeavour to enlist public opinion in the effort, either by education in schools, through the provincial Press, or through the National Council of Women. I am sure that the hon. Member's suggestion is on the right lines. It is only by an informed and instructed public opinion that the necessary steps will be taken by women themselves to make this experiment a success.

Mr. G. GRIFFITHS

How can a diabetic person get insulin from the public assistance committee if he is under the Unemployment Assistance Board? If he is under their scale the public assistance committee dare not touch him.

Mr. SHAKESPEARE

If he is a diabetic, I presume he is under medical attention.

Question, "That the Bill be now read a Second time," put, and agreed to.

Bill read a Second time, and committed to a Committee of the Whole House for To-morrow.