HC Deb 30 April 1936 vol 311 cc1117-36

Order for Second Reading read.

4 p.m.

The Minister of HEALTH (Sir Kingsley Wood)

I beg to move, "That the Bill be now read a, Second time."

The main purpose of this Bill is to establish an adequate service of salaried and trained midwives, so as to ensure that every expectant mother, whatever her circumstances, will be able to obtain the services of a qualified midwife; and the Bill is also designed to raise the status of the midwifery profession by providing adequate salaries and sure prospects to those entering the new service; and also—this is a matter to which I am sure the House will attach importance—to ensure further facilities for their instruction. I do not think it is necessary for me to say very much about maternal mortality. Although lately there has been some improvement, during the last 10 years nearly 3,000 mothers in England and Wales have died each year in giving birth to children, and the failure of the maternal mortality rate to yield to the sustained attacks which have been directed against it has been a matter of national concern, especially in contrast with the outstanding results which have been achieved in reducing the mortality of young children. The women who die are in the prime of life, at an age when the general death rate is relatively low, and the death of a mother, perhaps more than that of any other member of a family is not only a tragedy in itself, but means disaster to the whole family life of a home.

We naturally do not want to exaggerate, still less to instil unnecessary fear, and it is right that we should state publicly the fact that motherhood is a natural event, and that death or departure from the normal occurs only in a small proportion of cases. Having said that, I would add this: Few health matters exceed in importance the necessity of providing a safe and healthy motherhood, especially when we remember the large amount of suffering, incapacity and ill-health, as well as death, which occurs as a result of complications arising from childbirth.

I would say a word about the actual problem itself. Most hon. Members who have studied this matter will agree with me when I say that it is still a difficult and baffling problem. For instance, in England and Wales the local authorities in 1926–27 were spending on maternity and child welfare services some £2,000,000 per annum. That expenditure has steadily increased, and last year over £3,000,000 was so expended. Yet the maternal mortality rate has not yet been substantially reduced. It affects all classes of the community. It varies from place to place, and we are not yet in a position to speak with certainty and authority as to all its causes. But I believe it is beyond question that to place at the disposal of the mothers of the country an adequate service of well-trained midwives is of premier importance and will be a real contribution—I put it no higher than that—to the reduction of the present toll of motherhood.

The case for these proposals is in fact to a large extent based upon past experience and the results already obtained by the services of salaried midwives who work under close and sympathetic supervision. Where domiciliary midwifery services are provided on a properly organised basis by the salaried midwives of voluntary hospitals and nursing associations, the maternal mortality rate is well below the national rate. I would like to give the House two instances in support of that statement. If one looks at the reports of the Queen's Institute for Nurses it shows that the Queen's Nurses and village nurse midwives attended over 60,000 confinements every year in the homes of patients, and the average mortality in these cases over a period of 10 years is about two per 1,000 births, compared with a figure for England and Wales of just over four per 1,000 births. These figures, for a variety of reasons, are not in all respects comparable, but they are a sufficient guide to give us confidence that our new service may do much to reduce the national rate.

The other case I would refer to is the case of West Ham. A recent investigation into maternal mortality in West Ham shows that in that borough, with a population of 276,000, the average maternal mortality rate during the 10 years 1924–33 was only 2.48 per 1,000 births. The great majority of domiciliary confinements in West Ham are conducted by salaried midwives attached to voluntary maternity hospitals or nursing associations. During 1934, of the 2,823 confinements in the homes of the women, 1,924 were conducted by the salaried midwives of the voluntary organisations, 262 by independent midwives and 637 by doctors. The voluntary organisations which provide the service of salaried midwives work—this is a point well worth noting—in co-operation with and receive financial support from the local authority. The maternal mortality rate in West Ham is, I suggest, another testimony to the results which may be obtained from the service of salaried midwives working under the control of voluntary hospitals or nursing associations and in close co-operation with the local authorities' maternity services. In my judgment such instances confirm the unanimous conclusion in the final report of the Departmental Committee on Maternal Mortality, in which it is stated: There are few more important matters than the provision of an adequate service of salaried midwives. Let me say a few words about the position of the midwifery service in this country at the present moment. It is by no means satisfactory. It has for the most part been a poorly remunerated service, without much status and little prospects —prospects which are, if things are allowed to remain as they are, by no means improving. It is an overcrowded profession. Except for a small minority, the practice of the independent midwife does not afford a living wage, and the reasonable livelihood of the few is often obtained only by attendance on an unreasonable number of cases, involving much physical and mental strain. There are too many part-timers. There are also midwives who continue to practise—I am making no reflection at all upon them, because we know their necessity—when they are past their work. There is another and greater aspect of the matter. There are numbers of unqualified women and there is nothing to prevent them from attending, and charging for their attendance, as maternity nurses on women in childbirth.

Finally, to complete my short summary, there is a lack of co-ordination between the work of the independent midwives and the health services in many areas. I have seen it said that the passing of this Bill may see the disappearance of Mrs. Gamp. I do not know whether Mrs. Gamp, the best of creeturs as she described herself, with her taste for pickled salmon and various kinds of liquid refreshment and an occasional pinch of snuff, ever really existed, but I do recall one of her most forceful observations: Our charges is but low. Sir, considerin' the nater of our painful Bdooty. At, any rate, I hope we shall see the end of conditions like that. I would say at once that in these proposals there is no reflection upon the admirable work done by many competent independent midwives up and down the country. The midwife occupies a particularly responsible position, very often a hard one, 'and I hope that these proposals may mean some substantial improvement in her lot and general conditions. I should like, for the consideration of the House, to put what I think a salaried service will mean. I attach particular importance to the fact that a salaried service will bring midwives into close association with public health services, and for the midwife herself it will mean the removal of anxiety as to personal income, provision for holidays—as far as I can gather she rarely gets a holiday at present—a better allocation of time, ensuring more adequate attention for the patient and, I hope, a higher standard and better training all round. One word about the machinery of the Bill and how it is proposed to put these proposals into effect. The Bill provides, after a careful consideration of the recommendations of the General Council on Midwifery, to which we owe so much in connection with these proposals, that the organisation of the new service shall be entrusted to the local authorities who are the local supervising authorities under the Midwives Act.

I have no doubt that we shall be able to discuss this matter in Committee, but I should like to say at once that the reason which has actuated myself and the Parliamentary Secretary in suggesting this in the Bill is that we believe that by utilising these authorities the new service will be organised on a basis which I regard as essential to its success, that is, on a wide and comprehensive basis and also—a matter to which I am sure hon. Members will attach importance—that mothers in urban areas, at any rate, will have as far as possible a choice of midwife. We shall be able to discuss other reasons at later stages of the Bill, but I wanted to mention these two important matters at once. Each local supervising authority is required to secure the whole time employment of a sufficient number of midwives for attendance—I want hon. Members to note this particularly—not only as midwives but as maternity nurses to meet the needs of the area for domiciliary midwifery, and the authority will carry out this duty by making arrangements with voluntary organisations or, where necessary, by themselves employing midwives. I should like again to emphasise that co-operation with the doctors and with voluntary hospitals and agencies is essential to the success of this proposal, and I am sure I can say that it will be forthcoming. Where the local supervising authority is not a maternity and child welfare authority co-operation with the authority and in particular with the work of ante-natal clinics is, of course, no less important.

Let me say a word about London. The case of London has been specially considered. I submit that it is necessary that the new service in London shall be comprehensive and organised on a wide basis, too. One of the difficulties in London will be to work out a scheme which will include the service of salaried midwives already provided by a number of voluntary hospitals. These services naturally take no account of borough boundaries and it is not uncommon to find that midwives working for voluntary hospitals in London work in three or four or five different boroughs. It is therefore essential that the arrangements in London should be entrusted to a body which can plan for London as a whole. I should like to call attention to the fact that about 25 per cent. of all confinements in London take place in London County Council hospitals, at which there are ante-natal clinics and where specialists in all branches of maternity work are available. Salaried midwives appointed by the London County Council will therefore have this fine service at their back, and it will be possible for them to enlarge their experience by taking duty in hospitals when they are not engaged in domiciliary work.

Let me add one word about the position of voluntary organisations under these proposals. I attach importance to the work of voluntary organisations especially in connection with the mid- wifery services, and I am sure that every hon. Member, whatever his view may be on matters arising from proposals of this kind, will agree that they have done magnificent work in connection with midwifery practice and matters of that kind. One of the main principles of the Bill is designed to ensure that efficient voluntary organisations shall have a proper and adequate share in locally co-ordinated schemes, and all organisations which employ salaried midwives must at once be consulted when the Bill is passed and the proposals have to be put into operation by the local supervising authority about the arrangements for the new service. The voluntary associations will have the right, if they are dissatisfied with any arrangements which are contemplated, to make direct representations to the Minister of Health, who has power to direct the authority to make proper arrangements in the circumstances. It will be the duty of whoever occupies my position to use this power so as to secure that the services of voluntary organisations which employ efficient salaried midwives shall be fully used, to see that proper agreements are entered into and proper payments made so as to secure an adequate service and extensions wherever desirable and practicable of their work.

A word of explanation on the question of fees and salaries in connection with this service. The local authority will fix the salaries of midwives employed by them and the fees to be charged for their services, and in recovering such fees they will have regard to the financial circumstances in each case. For instance, if the circumstances do not permit of the payment of the whole charge they will recover such part, if any, as the mother or the person legally liable is able to afford. As regards the salaries of the midwives and fees to be charged in relation to the work of voluntary associations, that will be a matter of negotiation between the local authority and the voluntary organisations, but the local authority will be asked to fix their grants to voluntary organisations on a basis which will ensure that the salaries and fees will correspond closely to those adopted by the local authority.

I have been asked to state what will be the position, if the scheme is sanctioned by the House, of the midwives at present practising, and the House no doubt will want to give careful attention to this matter. I think the position may be summarised in this way: that a midwife who is practising at the present time could apply for a salaried post or she could continue in an independent practice if she so desires. On the other hand, if she surrenders her certificate within three years of the coming into operation of the scheme she will receive compensation equivalent to three times her average annual emoluments for the preceding three years. There are also a number of old or infirm midwives unable, I am afraid, to perform satisfactorily their duties, and in these cases the local authority may call upon the midwife to retire, in which case she will receive as compensation a sum equal to five times the net annual value of her practice during the previous three years. If such a midwife objects to the requirement by the local authority as to retirement she will be able to appeal to the Minister of Health, and any midwife who is dissatisfied with the amount of her compensation is able under the Bill to appeal to the county court. There is also a provision in the Bill to which I invite the attention of hon. Members, that in suitable cases the local authority, instead of paying compensation in a lump sum, will be able to purchase for the midwife an annuity terminable at the age of 70 or at death if that occurs before she reaches that age.

Continuing the catalogue of the position and prospects of midwives under the Bill, I hope that a number of the midwives who are appointed in this service will in the course of time be appointed to the post of supervising midwife, because it is upon their zeal and efficiency that the success of the salaried service will largely depend. Arrangements are also provided for under the Bill which will enable midwives to keep up-to-date by attending from time to time post-certificate or refresher courses. Finally, I would like to make this statement, because I have had a number of letters in relation to it, as I daresay my colleagues here have also. I should like to explain that the receipt of compensation or the payment of an annuity provided for in the Bill will, of course, in no way affect the title of a midwife to a contributory pension.

I have also taken power in the Bill to deal with the position, to which I have already referred, of unqualified persons. At present any unqualified woman may nurse a woman in confinement if a doctor has been engaged, and she works nominally under his supervision and direction. I do not hesitate to say that there is no doubt that such employment is dangerous both to the mothers and to the children. No doctor who works with an uncertificated woman can always be sure that he will be at hand at the critical time, and it was unanimously agreed by the Departmental Committee that the practice of attending a confinement in such circumstances did not conform to a reasonable degree of security, even in normal cases. In the Bill the Minister of Health is empowered, when an adequate salaried midwifery service is in being, and not before, in any area or county district, to make an order under which it will be an offence for any person who is neither a midwife nor a registered nurse to receive remuneration for attending as a nurse a woman in child-birth or at any time during the 10 days immediately after the birth. I hope the House will regard that as a real and necessary provision for the success of this service.

I should also like to say a word about the position of medical practitioners. The Bill does not in any way prejudice their position, but I think the general practitioner should benefit considerably when the provisions of Clause 6 become operative, as he will always be sure of the assistance of a certificated midwife, whereas at present he has to rely in many cases upon the services of an untrained woman. In areas where such a course is customary, mothers will no doubt continue to engage doctors, as now, for their confinement, and it is intended that not only the doctor but the mother, wherever practicable, shall have a free choice of midwife to act as maternity nurse, and that nothing should be done which would in any way interfere with her preference for a particular doctor. I know I can rely upon the good will and co-operation of the general practitioners of the country, which is indeed so essential to the success of this Measure.

I now want to say a word or two about finance. There are, of course, additional liabilities to be incurred by the local authorities in connection with these proposals. There are two main obligations put upon the local authorities under this Bill. The first is an obligation to provide, or to secure the provision of, a service of salaried midwives, and the second obligation is to pay compensation to midwives in the circumstances set out in the Bill. The local authorities are to be assisted by grants from the Exchequer in both cases. Of course, the compensation liability is not of permanent importance to local finance, and it is proposed that the authorities shall receive a grant from the Exchequer equal to 50 per cent. of the compensation paid in each of the three years.

The obligation in relation to the service of salaried midwives is of a permanent character. The House will recollect that in 1929—I am sure the right hon. Gentleman opposite will remember those days, as I do—we replaced the payment of specific grants in respect of certain of the public health services by block grants, and the effect of the system of block grants is that additional local government expenditure increases the national block grant pool—that is what we know, in familiar jargon, as the general Exchequer contribution—available for distribution to the local authorities in the ordinary course by an amount equal to about 23 per cent. of such additional expenditure. Members who were in the House at that time will remember that the matter was debated as to what would happen if a new service came into being, and the House took the precaution, by Section 135 of the Act of 1929, of declaring that it was the intention of the Act that, in the event of material additional expenditure being imposed on any class of local authority by reason of the institution of a new service, provision should be made for increased contributions by Parliament. Clause 4 of this Bill contains the temporary provisions to give effect to that intention, and in due course, as I shall mention in a minute or two, a permanent addition will be made to the block grant pool.

The associations of local authorities have expressed to me the view that during the stage under which this service is being set up it will be preferable for the Exchequer assistance to each authority to be related in some way to the expenditure of that authority, and provision is therefore made in the Bill that during a preliminary period of five years there shall be a grant to each local authority directly related to its own expenditure and also at the same time to its relative capacity to meet that expenditure. Of course, the total Exchequer assistance to the new service—I want the House to realise this—will be approximately half the total additional cost, and the grant to each authority will be one-half of the authority's additional expenditure, scaled up or down in proportion to the extent of the needs of the area. Under this arrangement the grants will range from 80 per cent. of additional expenditure in the case of the poorest areas to 23 per cent. or so in the case of the richest areas. For instance, Sunderland and Merthyr Tydfil will receive something in the nature of 80 or 85 per cent., while places perhaps a little bit better off, like Bournemouth, Eastbourne, or Hastings, will get 20 per cent.


What about county boroughs?


And counties?


I will give four illustrations both of counties and of county boroughs, if the House would like them. To take four counties, Middlesex will receive about 31 per cent., Kent 40 per cent., Hereford 65 per cent., and Glamorganshire 77 per cent. Of the county boroughs, Brighton will receive 24 per cent., Bristol 41 per cent., Liverpool 52 per cent., and Gateshead 76 per cent. [An HON. MEMBEtR: "What about the West Riding?"] The West Riding figure will be 61 per cent. At the end of this five years period the Exchequer contribution towards the cost of the service is provided by an addition to the block grant representing approximately half the additional cost of the new service. As regards the midwives employed by voluntary organisations, the additional expenditure to be taken into account for the calculation of the Exchequer grant will be the excess of the amount of the contributions made by each authority to such organisations over the contributions which are already being made in respect of those services to the organisations. I do not think I need describe at length the other Clauses in the Bill. They provide for certain Amendments in previous Midwives Acts and for securing the periodical attend- ance of certificated midwives at courses of instruction to be provided.

I would like to make this final observation to the House in moving the Second Reading of the Bill. I regard the proposals in the Bill as a useful contribution to the solution of the problem of maternal mortality, but I would like to say that in my judgment we must continue vigorously the other methods of attack upon which we are engaged. I shall, I can assure the House, endeavour to encourage the local authorities, wherever necessary, to con-tine to develop their maternity services. A communication was addressed to the authorities to this end quite recently, urging them to review the position of their service and to take any necessary steps to complete their local organisation and ensure its efficient working.

I am glad to say this afternoon that progress is being made. For instance, ante-natal clinics, to which I know Members in all parts of the House attach great importance, have increased by 20 per cent. since 1931, and they increased by 103 last year. I think it is a very satisfactory thing, to all who are interested in this important side of health work, that the total number of attendances of women at these clinics reached nearly 1,000,000 in 1934. The number of maternity beds, I am also glad to say, increased by some 10 per cent., and the number of women admitted to them by 30 per cent. There are now 405 of the authorities who provide ante-natal facilities, either themselves or through voluntary agencies, and I am glad to say that post-natal facilities are also increasing. There are also—and I know this is a matter which is of public interest especially at this time-—393 maternity and child welfare authorities which are supplying milk either free or at less than cost price to necessitous expectant mothers, and I am also glad to know that a large number supply food of other sorts and, in some cases, meals at convenient centres. I hope that will all go on, and I shall do my utmost to encourage it.

I would also like to say that in bringing forward these proposals, I recognise it may well be that other steps may be necessary. Hon. Members may remember the statement I made in the House a little while ago in relation to a more special line of attack which is in progress, namely, a series of special investigations that have been undertaken and are now being pursued in a number of administrative areas., primarily those in which the rates of maternal mortality have been persistently above the average for a period of years. We are also having investigations made for the purpose of comparison in some areas comparable in general characteristics with the areas of high maternal mortality, but in which the rates have been relatively low. The aim of these investigations has been, in the first place, to give assistance to the local authorities to devise any immediate practical improvements which may suggest themselves, but also, and more particularly, to see whether we cannot obtain any further material which will help us to elucidate the underlying causes of high maternal mortality rates in general.

This is in my judgment, and I know in that of hon. Gentlemen opposite, a very important, a very difficult and a very laborious task, and I have no wish to push the investigators, but rather to allow them to make a careful and patient inquiry. I hope that their investigations will be concluded by the end of this year, when they will be made available by me, and we shall then be in a position, in the light of these inquiries, to see what further should be done by local authorities, hospitals, voluntary bodies, doctors and midwives to deal with this very difficult problem. But I hope that the House will agree with me that we shall be acting in the best interests of motherhood by proceeding immediately with these proposals, neglecting none of the good work which is now being pursued and seeking any other means which expert investigations may show to be desirable.

Therefore, in moving the Second Reading of this Bill, I am very mindful that we have to continue steadily and in certain places increase our work in the many ways in which local authorities and voluntary organisations are now engaging. I am also not unmindful that we must neglect no well-considered further plans for new schemes which will help to save the lives of the mothers and care for their health; but believing that the proposals in this Bill do not brook delay and that they may make a considerable contribu- tion to this difficult and complex problem, I ask the House, if they will, to give this Bill a unanimous Second Reading. Matters of detail and aspects of administration will no doubt be the subject of careful examination when the Bill is in Committee. I know there are no party divisions on this matter and that it is a subject which concerns all, and I ask the House to take this further step having an object which is dear to all of us, the safety of the mother and the improvement in so vital a respect of our national health and well-being.

4.50 p.m.


I think the House will welcome this occasion, because the right hon. Gentleman the Minister of Health so rarely addresses the House. He does not do so as frequently as he did when he sat on this side. We are, however, glad that he has at last emerged from his long twilight sleep, and that we have some offspring from his period of semi-retirement. I agree with him about the importance of the problem of maternal mortality. Maternity is by far the most dangerous occupation in this country, even more dangerous than that of the miner, and many of us have spoken on platforms about the dangers and rigours of the miners' lives. It is still the tragic fact that, in spite of all that has been done, childbirth is to the mother far more dangerous than even the most dangerous of occupations, and I imagine that it is a problem which successive Ministers of Health have regarded as the most stubborn which they have had to face. It is a problem which has given rise to investigation after investigation and special inquiry after special inquiry —such as the right hon. Gentleman is now undertaking—and it has claimed the attention of the health section of the League of Nations. It is a problem which has baffled us up to the present time. One would have hoped that when the right hon. Gentleman was not concerned with the means test regulations, with foreign affairs or with the Budget, and has had so long to prepare his plans, he might have produced a larger baby.

The Bill is one which I welcome for what it is worth, but it is very restricted in its character. I do not propose to take the time of the House in outlining the powers already possessed by local health authorities, but this Bill is in fact noth- ing more than a rather slight extension of the existing law, making it a little easier for local authorities to carry out the powers which they already possess. For that we are grateful, but even if the Bill, when it is on the Statute Book, is carried fully into effect, it will only go a short way towards a solution of the problem. After all the experimentation of past years, the time has now arrived not for small piecemeal measures, but for a far-flung comprehensive policy and an attack on this problem on a wide front. In the case of rearmament the Government are thinking in terms of an additional expenditure of £300,000,000, but in this problem they are thinking in terms of pence. From 1931 to this year the expenditure on the Navy has been increased from £50,000,000 to £80,000,000 a year. All that the Bill offers, to quote the financial memorandum is that: The total additional expenditure of the authorities"— in careful, cautious words— may ultimately amount to approximately £500,000 per annum. That is a very significant contribution to a great constructive service, compared with the willingness with which hon. and right hon. Gentlemen spend money on the destructive services.

What is this problem? It is this: We are losing in England and Wales each year 3,000 mothers through their performing a perfectly natural function. We now know, on testimony which nobody would dare to contradict, that half of those deaths could be prevented. This House is responsible for the murder of 1,500 mothers each year. It is a social problem for which this House is responsible. But what is perhaps even worse, in the sociological effects, is that the causes and factors which are responsible for the deaths of 3,000 mothers leave their mark on mothers who linger on, and the problem of maternal morbidity is as important as that of maternal mortality.

We know that this problem can be dealt with. The right hon. Gentleman himself quoted the case of West Ham, one of the oldest Labour boroughs in this country, a borough which has never stinted expenditure on public health services, which has never put the life and the health of its people before a penny on the rates, which has been lampooned in the Press and castigated in this House for its extravagance, but which has spent its resources in improving the lives of its people. Even there, poverty-stricken as West Ham is, where circumstances are as bad as they can be, the maternal death rate and consequently the maternal damage rate is only half that which it is in the rest of the country.

Let me take the case of a hospital which the right hon. Gentleman knows very well, the East End Maternity Hospital, which deals with people whose social environment is not perhaps what it ought to be. In the seven years from 1921 to 1928 there were in that hospital 17,500 confinements and the death rate was 68 a 1,000—less than one-sixth of the average rate for the country. When I say that we in this House are guilty of social murder for permitting the deaths of these mothers, irresponsible hon. Members opposite protest; but what the East End Maternity Hospital can do, what West Ham can do and what other authorities can do, ought to be done by the country as a whole.

Maternal morbidity is a question about which we do not know as much as we know of maternal mortality. I welcome the substantial reduction in recent years in the infant mortality rate, not only because of the saving of life, but because a diminution in the death rate means a diminution in the damage rate. I find that in a "follow-up" of the cases of 2,000 mothers who had attended an antenatal clinic in Edinburgh, 30 per cent. were found to be suffering from various complaints and disabilities which required treatment. If that is typical of the country as a whole—and I am not saying whether it is or not, because I do not know—it means that for every mother who dies, 65 others suffer some impairment of health as a result of pregnancy and confinement. That is a serious problem and one with which this Bill is connected.

What are the causes of this state of affairs? I know that the hon. Member for St. Albans (Sir F. Fremantle), who is sure to speak in this Debate, will tell me that maternal mortality is not a special affliction of the poor. We know that it is not, but I am bound to say that poverty has a bearing upon the problem. The Minister and his predecessor were both reluctant to admit the existence of malnutrition in our midst. They cannot go on denying its existence, and it is a little unfortunate flat the right hon. Gentleman in this Measure should now have to try to undo, by good nursing, what the Government have been doing by creating malnutrition. This Bill cannot repair the damage caused by malnutrition. You may provide the best midwifery service possible but at the stage where that service begins to operate it is far too late to undo the effects of malnutrition. The Health Section of the League of Nations has drawn attention to this aspect of the problem. A report on high maternal mortality in certain areas, published four years ago, pointed out: Anaemia and malnutrition not only tend to unfit a woman for the strain of child bearing, but lower her resistance to septic infection and may predispose to disease during pregnancy. The report of the Departmental Committee on Maternal Mortality in the same year said: We cannot expect a low maternal mortality rate unless women subjected to the strain and stress of the physiological function of childbirth are themselves healthy and physically fit to undergo it. They go on to say that that proposition is a truism, but it is a truism which the right hon. Gentleman seems to have been very loth to accept. I want, therefore, to draw the attention of the House to the general handicap which poverty is to many working-class mothers. It is true, as I have admitted, that maternal mortality is not confined to the poor, but I am bound to say that the evidence shows that conditions of life among the poor are to some extent responsible for the high rate of maternal mortality. The report on high maternal mortality in certain areas to which I have referred, says: The exceptionally bad housing conditions, together with unemployment, poverty, and a low standard of living have probably debased the general health. Under such conditions it is the women who suffer most; their capacity to resist infection or physical strain is likely to be below the average. The medical officer of health for Smethwick three or four years ago reported an increase in the maternal mortality rate in that town, and attributed a considerable proportion of those deaths to poor nutrition on the part of the mother. The late Chief Medical Officer of the Ministry of Health, Sir George Newman, in one of his reports pointed out that a factor in this problem is neglect of the nutrition of the mother during pregnancy, and particularly her diet. I would not have the courage, myself, to read to working-class housewives in the poor districts what Sir George Newman says on the subject of diet. 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. I agree, but over large tracts of this country working-class mothers cannot live up to that standard and they suffer in consequence. I do not think we can escape from the effects of this creeping paralysis of malnutrition merely by establishing a midwifery service. I frankly and fully admit that this country has gone a long w ay in the direction of developing its public health services but, in spite of the powers given to local authorities, so far we have made little impression on this problem. The right hon. Gentleman has given us his word that he will do his best to see that the existing powers are more fully exercised by local authorities. He has promised, rather vaguely, that if further measures are needed, he will be prepared to consider them.

The first step, it seems to me, is to make sure that expectant mothers are properly fed. I urn very glad the right hon. Gentleman gave a pat on the back to those authorities who are providing milk and other forms of food for expectant mothers. I hope he will communicate with his right hon. Friend the Minister of Agriculture on the desirability of making more milk available for expectant mothers, because it is clear that if during pregnancy women do not receive proper nutrition, they will be handicapped in their hour of trial. There ought to be more effective ante-natal care than there is to-day. The right hon. Gentleman mentioned a figure of 1,000,000 visits to ante-natal clinics. That is only a fleabite. I am not certain about the number of births per year, but I imagine it to be in the region of 700,000.




I cannot keep count of the fall in the birth-rate. Let us say roughly 600,000 and rule out all who need not go to these 'clinics and the figure of 1,000,000 visits seems to show two things: First, there are areas of the country that are not properly served by ante-natal clinics and, secondly, large numbers of women do not make use of the opportunities which the clinics provide. But ante-natal care is clearly, as the right hon. Gentleman would admit, a very important part of the problem. Then there is the question of care at childbirth. Here the Bill will help. I shall have a few unkind words to say about the Bill in a moment but let me admit that here it will help. There is then the problem of the provision of more maternity hospitals, which will be within the reach of working-class housewives. It is essential that behind the midwife there should be the services of the most skilled gynaecologists in this country and some provision to that end ought to be part of the Bill. This is only half a structure, even as regards the provision of care during childbirth. But what we equally need is care after childbirth. The Bill provides a 10 days' service. Many years ago, in the days of high enthusiasms immediately after the War, there was a Washington Maternity Convention under which, if it were ratified, women engaged in industrial employment would be required to remain away from work six weeks before and six weeks after childbirth. Industrial employment is better regulated than and in most cases not so heavy a strain as housework, and if it is regarded as industrially advantageous to keep mothers away from industrial employment for six weeks after childbirth, what argument is there against keeping the housewife away from her ordinary normal duties during a similar period.

What is also important during the period of confinement and afterwards is the provision of help for the mother in the home. I know that the law provides that local authorities can appoint home helps to go round in these cases. Many local authorities do not make such provision and one of the troubles of the working-class mother is, not any feeling that the midwife is not looking after her properly, but the worry of the home. She lies in bed with the family purse under the pillow and every penny that is spent on the household she has to give out to somebody. There are the children to be cared for also. What the midwifery service demands, as a corollary of the scheme, is the proper provision of home help.

The right hon. Gentleman's scheme is but a little scheme. It does certain things. It will help to secure a more adequate service of trained qualified midwives. For that the country will be grateful. It will do something to improve the status and conditions of service of midwives. That also is important. They have never received the honour due to them, and I am glad to think that this Bill will do something to improve their status as an important profession. It will, as the right hon. Gentleman has pointed out, prohibit the employment for pay of untrained nurses and the Sairey Gamps of a dying generation. These things are all to the good.

Then I part company with the right hon. Gentleman, as he would expect me to do. I do not like the principle, which he emphasised, of providing further public money for voluntary organisations. There may have been occasions in the past where that has been necessary, but our municipal services now are capable, if they are spurred on to it, to undertake this responsibility. I very much fear that the right hon. Gentleman's bias will be on the side of the Lady Bountifuls and the voluntary organisations rather than on the side of the local authorities. I regard that as a mistake. Then the Bill provides for the services of a midwife for only 10 days. Ten days has been selected because working-class poverty requires the midwife's services to be dispensed with at the earliest opportunity. I could take the Minister to towns in the north of England where, in the case of normal childbirth, the midwife went at the end of a week and the mother was glad to get rid of her because of the cost. Ten days has become the practice through poverty, not because of medical knowledge on this question, but because in the vast majority of working-class homes they desire to get rid of these additional costs at the earliest possible moment. It is not right to expect a woman, having undergone a trial of that kind, to be expected after 10 days to be up and about and to carry all the responsibilities of the household.

I am sorry that the right hon. Gentleman has not been more generous in this respect. I would have liked him to have rounded off the scheme for providing midwives with a parallel scheme in the same Bill and as part of the same service for the provision of home helps. There is a certain amount of interest in this problem, but there is not sufficient interest. We shall never banish the graver social evils, such as maternal mortality, which are eating at the vitals of our national life, unless we show the same enthusiasm, the same patriotic spirit, the same generosity for the constructive social services as we are prepared to do in such full measure when it comes to the destructive agencies of war. No nation can spend its money twice. I pointed that out in the Budget Debate. Every million pounds that goes into bombs and aeroplanes is a million pounds taken out of the lives of the people somehow. Every increase of expenditure on armaments will be met by a demand for a diminution of expenditure on the social services.

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