MIDWIVES BILL.

HC Deb 30 April 1936 vol 311 cc1136-225

Question again proposed, "That the Bill be now read a Second time."

5.32 p.m.

Mr. GREENWOOD

My somewhat rambling remarks had been drawing to a rather awkward end. Visits such as we have just paid give one time for further reflection, but I do not propose to develop my speech much further. There is only one other point I wish to make, but it is of very considerable importance. The national birth rate continues to fall and that is, perhaps, one of the most significant and important sociological facts of our generation. I am not saying whether that is a good thing or otherwise, but the fact that the birth rate is falling makes it all the more important to ensure that every child shall be well born. What this nation may in future lack in numbers it ought to be the aim of statesmanship to make up in quality. That has a very distinct bearing upon this problem of maternal well-being. This brick, this small brick, this useful brick will form part of a great fabric which is not yet completed, and, until it is, a heavy responsibility lies on Members of this House for every unnecessary death of a mother and for any unnecessary suffering among mothers.

Though this is a small brick we welcome it as one little addition to a structure which, when completed, will make it impossible for us to lose lives that might be saved. I hope the day will soon come when the fabric will be completed, and that the right hon. Gentleman will hurry on the work. I hope he may add brick unto brick to help us to build the fabric. We on this side shall not vote against the Second Reading of this Bill. I have explained our views upon it. We hope that the right hon. Gentleman will show a resiliency of mind in Committee which will enable my hon. Friends to put forward Amendments to improve the Bill. We welcome the Bill for what it is worth, though we are sorry that it is not better.

5.36 p.m.

Major HILLS

After the speech of the right hon. Gentleman opposite it may be for the convenience of the House if I deal with the Bill itself. The first part of his speech was of a type that is not uncommon. When you can find, nothing to say aganst a Bill talk about the other evils that exist in the world. There are always plenty of them, and you can always make a great case that it is not a perfect world, and then proceed to connect up all those evils with the action of the Minister in introducing the Bill. The right hon. Gentleman said at the end that it was a good Bill as far as it went. I submit that it is a very good Bill, and goes a very long way. I believe that a good midwifery service is the most effective weapon in reducing maternal mortality. There is nothing which can compare with it for effectiveness. I believe the present service can be very greatly improved and that this Bill will go a long way to improve it. First, the Bill provides a whole-time service, and a paid whole-time service, and that alone is a great advance. Then it improves the pay of the midwife and improves her status. It gives her a different position in the medical world. The old quarrel which existed some years ago between the doctor and the midwife is now composed. They have worked together, and doctors are now the first to recognise that midwifery is an essential part of the obstetric service. In fact, doctors would be the first to complain if there were a bad midwifery service. In that respect, I think, the Bill will do a very great deal.

I agree with the right hon. Gentleman opposite on one point. I notice that the 10 days specified for the attendance of the midwife is a minimum only. I should like to see that minimum raised. I know very well why the period of 10 days was fixed. Then the danger of the worst complications is over. Still, to give four days more, making it 14 days instead of 10, would avoid a great deal of post-natal trouble. I hope that when we get into Committee the Minister will accept an Amendment to that effect.

The Minister quite properly spent some time in explaining who was to administer this new Bill. May I thank him very sincerely for the alteration which he has seen fit to make in the Financial Resolution? By making that alteration the discussion as to who is to be the supervising authority under the Bill is postponed from the Financial Resolution to the Committee stage of the Bill, a more convenient occasion on which to take it. Let us consider the position in London first of all. The House knows, I think, that the London boroughs have extremely efficient health visitors. Their visits start after the midwife has departed, and they safeguard the health of the child for as long as five years. So the post-natal service is in the hands of the London boroughs, but the midwifery service is to be put into the hands of the larger authority, the London County Council, Not only the post-natal services but the ante-natal services are in the hands of the smaller authorities. They are extremely fine services in a great many of the London boroughs. Does the Minister think it is a good thing to have the ante-natal and the post-natal services run by the borough councils and the midwifery service in the hands of the London County Council? I want a good midwifery service, a self-respecting midwifery service, a midwifery service in which all the midwives will feel rather proud of what they are doing. I think you will get more efficiency and more actual service of the sort you want mothers to get if you allow the midwifery to be run by the smaller local authority.

The same observations apply to the country. Take the West Riding of Yorkshire. As the Bill stands, the service would be run by the county council there and by the county boroughs, and the non-county boroughs and the county districts, whatever their size, would not be able to undertake those services, except under certain conditions. Many smaller local authorities run very fine health services. They have health visitors, some towns have home helps and a great many are providing milk for expectant mothers. Some of these non-county boroughs are large and important towns. It is very hard for a town to become a county borough now, and so the trend in recent legislation has been to give suitable powers to the larger non-county boroughs and not always to place them under the county council.

I submit to the Minister, with great respect, but with great force, that a midwifery service should fulfil the following conditions: It should be near the home of the mother. The nearer you can bring this service to the home of the mother the better for her. The places which she has to attend, the clinics, should not be so large as to involve a long wait. think that would be agreed to. The third point is that the mother should, if possible, be treated by people whom she knows. All those services should be carried out by a smaller authority, and you should not put the non-county boroughs in the West Riding of Yorkshire under the county council, which sits far away in the town represented by the right hon. Gentleman opposite, the town of Wakefield.

I am not so foolish as to suggest to the Minister that there should be indiscriminate admission of all the non-county boroughs to these local services. I suggest for his consideration that the standard laid down by the Local Government Act of 1929 should be adhered to, and that the smaller authority should not be chosen unless they have a maternity and child-welfare committee, that they employ a whole-time medical officer and that their area Teaches a certain size in population. I do not know what size. The size under the Shops Act is 20,000. The three conditions which I have just outlined I regard as essential. As I hope to explain in the Committee, I feel very strongly about the decentralising of the service. In a great district like the West Riding of Yorkshire I believe, and I hope I can persuade the Minister to believe, that there would be a better and more effective service, one which would appeal to the people more and do more for them, if it were split up, rather than centralised under the county council.

I am aware that Clause 1 of the 8111Bill provides the larger local authorities, if they are made supervising authorities, with power to make arrangements with the smaller authorities. Such a Clause has often been inserted in Acts in the past, but. has not worked satisfactorily. It is far better to say in the Bill, in black and white, which is to be the authority to operate the power given by the Measure. The other course causes friction and difficulty; after all, Parliament should say which type of body it wishes to carry out such great powers. So much for that.

I have only one more point, but it is one on which there is very great divergence of opinion and upon which much can be said on either side. Clause 6 abolishes the maternity nurse who, in the old days, was known as the handy woman and who ofter usurps the midwife's function. If she endangers health she ought to go. I want to do away with unskilled service which takes the place of efficient service, but when I look at the Bill I am doubtful whether we can do without a secondary service. Let hon. Members remember that the Bill quite rightly sweeps away a large number of midwives who are engaged in small or inadequate practices, and reduces the remainder to a compact and whole-time service. That is a very good thing, an excellent thing, but I am told that the reduction in the number of midwives will be very large in some parts of the country. 1I am told that in one London borough the number will be reduced from 40 to nine. In that borough there are 800 confinements annually. Can we expect that the smaller service will give the attention that the larger number of midwives can give, attention which the mother requires? They cannot give service for longer than 10 days, after which somebody has to step in and look after the mother.

The question is, are we to abolish the maternity nurse or to train her? There is a strong case for abolishing the maternity nurse and for letting qualified people do their work. The maternity nurses are often not qualified and not in the. least fit for the job, but we should do better by training a body on the lines of the home helps now working in Birmingham, or of the after-care nurses who have been used. with great success in Holland. I think you want something. Does not the Minister think so? If the Bill remains as it is, does he not think that the after-service will be turned over to the old handy woman, the Mrs. 'Gawp, with all the old evils again? I am afraid it will. There must be someone, whether maternity nurses or after-care nurses, to carry on the good work of the midwives. I hope that the Minister will give that point full consideration.

Nobody can want a good maternity service more earnestly than does the Minister, and in the fight against maternal mortality he is playing a large part. I would like to make. a suggestion, which is entirely out of order. Would the Minister try to induce the Central Midwives Board, who are not under him, by the way, to increase the period of training of midwives to two years? If that could be done we could get a splendid service. I believe the Bill does a very good., deal, that it will raise the profession of midwifery to a higher degree of efficiency and will save the lives of many mothers and improve the health and future of many offspring.

5.56 p.m.

Mr. HOLLAND

Before I came to this House I was informed that here many stout hearts have been broken and not a few lives wasted. Whatever degree of truth there may be in that statement, I am not unmindful of the fact that this House, as has so often been the case, can be sympathetic when hon. Members have addressed it for the first time. I feel that the same sympathy will be forthcoming to-day, as I muster the best spirit I know and enter this den of not-too-unfriendly lions, in order to make a contribution to the discussion of the Bill.

I listened with great interest to the Minister, but I felt that his speech was of better quality than his Bill. I could not help feeling that he confessed to the House that the maternity services of this country were in a state of confusion, and I am sure he felt that the desired satisfactory midwifery services referred to in the explanatory Memorandum were not possible with the miserable amount of money at his disposal, and with the derogation of responsibility to the respective voluntary associations. Maternal mortality is one of the most serious matters to which this House can turn its attention. Apart from the devastation of war, no other human activity has such a tragic history. In these days of enlightenment, when scientific discovery and medical research should be the handmaidens of progress and happiness, it must be said to our shame that motherhood is still the most dangerous of occupations—if it may be so described. During the last five years, in spite of the reduction in the birthrate, the maternal mortality was roughly five per thousand.

I do not desire to bore the House, but I would like to make reference to the Report of the Departmental Committee of 1932 in which it is shown, as a result of an investigation of 3,432 deaths, that 45.9 per cent. of those deaths could have been avoided. The causes of the deaths were classified as follows: Lack or failure of ante-natal care, 15.3 per cent.; error of judgment, 19.1 per cent.; lack of facilities, 3.7 per cent. and negligence on the part of the patient, 7.7 per cent. I am sure that hon. Members would agree that those figures reveal a most serious situation. It is to be regretted that certain people have sought to commercialise that fact by offering it to the public as sensational news. There would be little cause for complaint if the same kind of lurid description of the causes of the high proportion of deaths were displayed in the same way, but that is not done.

The jerrybuilders and the slum landlords have much to answer for in this matter. Where local authorities have been enterprising, even more enterprising than the Minister of Health, the people who lift up their hands in pious horror as they read those startling figures have been willing to stampede public opinion against any increase in the rates, and to suggest that the local authorities must be saved from the Socialists. I have great resentment against the patronising attentions of the more favoured sections of the community who are, in my view, much too fond of lecturing the poor, and telling them what they should or should not do, in the circumstances with which we are dealing. I submit to the House that, given the facilities which should be their common right—a sufficiency of food, a decent dwelling-house, the necessary skilled attention in time of sickness—the working classes will be quite capable of managing their own affairs, and in the majority of cases would, indeed, be examples of motherhood to many who now try to teach them.

In my view, desirable as the salaried midwifery service will prove to be, it is only one very short step in the right direction. I submit that every mother should be in a position. to have the choice of a medical practitioner during the ante-natal period if she so desires, plus the attention of the midwife during the period of confinement. These advantages are only possible at the moment to a favoured section of the community, and because of poverty, working-class mothers must take great risks. Often during the period of convalescence they are all too soon engaged in the duties common to working-class homes. I myself was born in a miner's home of miner parents, and it may be that certain inherited instincts, plus the social environment of which I was a victim, are largely responsible for the convictions which I now hold. I do not apologise to the House for my Socialist convictions. They have taught me one thing, and that is that all human life is sacred; and the safeguarding of human life should receive prior consideration to any monetary expenditure which it involves.

I am fully aware that this great question of maternal welfare and infantile mortality is subject to differences of opinion among the medical profession, maternity nurses, and midwives themselves. The case has been made for and against domiciliary attention. Medical officers of health and medical practitioners argue the respective merits of domiciliary and institutional treatment, and, as an ordinary person taking an interest in these matters, I often find myself bewildered as to what really is the best course to pursue; but in my own opinion, if the average mother could be assured of knowledgeable treatment in her home, that would be the majority choice in normal cases. I shall support this Bill, weak as it is, simply because there is nothing better on offer. The dangers associated with maternity are one of the many illustrations of capita list neglect and indifference. The public will compare the readiness of the Government to spend huge sums on weapons of destruction with the stringency which they exercise when it comes to preserving life. This Bill is so limited in its scope that it represents but a small effort in the direction of a comprehensive attack on maternal mortality and maternal morbidity.

In my concluding words—and I thank the House for having listened to me so patiently—I would suggest that what is needed is a complete national maternity scheme, in which should be included supervisory clinics within easy reach of the mothers' homes, staffed by doctors with special knowledge and experience in obstetrics. There should be health visitors going into mothers' homes and, in a kindly and tactful way, offering their suggestions; there should be improved housing conditions to reduce the unnecessary amount of work in the home and provide healthy and quiet surroundings; and certainly there should be improved nutrition for the mother, and hospitals of rest with proper equipment and methods and with competent nursing and medical staffs. There is great leeway to make up before we obtain what the Minister desires as a. satisfactory midwifery service. I respectfully suggest to him that he should be far more enterprising, and, if I may say so, like the man who: Buckled right in with a trace of a grin On his face; if he worried, he hid it; He started to sing as he tackled the thing That couldn't he done, and he did it.

6.6 p.m.

Mr. KINGSLEY GRIFFITH

I should like very heartily to congratulate the hon. Member for Clay Cross (Mr. Holland) on the speech he has just made. He has passed through an experience which I think is almost as terrifying as motherhood, and he has done it with very great success. He has every reason to be proud of his first-born, and we shall all look forward to his future contributions to our debates. I should like also to congratulate the Minister on having escaped, on the whole, very lightly from the claws, if I may say so, of the right hon. Gentleman the Member for Wakefield (Mr. Greenwood). It is true that he was not exactly complimentary to the Bill, but at least he did not describe it as piffling, pettifogging, or even as the meanest Measure ever presented to the House. On the whole I think this is the Minister's lucky day, or else the right hon. Gentleman the Member for Wakefield is losing his grip.

If the Minister had presented this Bill to the House as a Bill for the abolition of poverty and malnutrition, I should have regarded it as extremely inadequate to that purpose; but it is, as the right hon. Gentleman the Member for Wakefield rightly said, a limited Bill. Indeed, it is limited by its title to amending the Midwives Acts, 1902 to 1926. No one would have recognised that fact in listening to the Minister. I prefer to deal with the Bill as it stands for the purposes for which it is intended, and from that point of view I quite agree that the right hon. Gentleman the Member for Wakefield is entitled to point out that there is only a speculative provision to the extent of £500,000, which may or may not be absorbed. In dealing with a Bill to provide employment it is perhaps correct to take the expenditure as a yard-stick, because it is possible to calculate more or less how many people are likely to be given employment by a given expenditure; but in the case of a Bill like this to reform a branch of administration I am not at all sure that it is a safe guide to say that only so much has been spent, and therefore the Bill cannot be of any use at all. I think there is a good deal more in it than the mere expenditure of money. Of course, if it can be shown that the service is being stinted, that on some definite point progress cannot be made because not enough money has been put down in the Financial Resolution, that is an entirely different matter, but I do not think that that case has yet been made out, though perhaps it may be made out as the Debate goes on.

I should like to welcome the Bill, because I think it will do something quite definite for the mothers, who in the past have had to put up with an inefficient service; it will do something for the midwives, who have suffered under most depressing conditions of employment; and I think also it will do something for the generations of the future, who may expect to get a better start in life. The Bill might almost be boiled down into a motto of "fewer and better midwives," because a great deal of it consists in pruning away what is of no service, as well as retaining what is good. I should rather like to have some kind of estimate from the Parliamentary Secretary, when he replies, as to how he thinks the number of midwives under the new system as a whole will compare with those who were employed before. I have a particular reason for asking that question, because it is obvious that, if there were the same number employed, there must be a much greater strain upon the educational services which now train midwives than there has been in the past.

The whole point, or at any rate a large point, in connection with the Bill, is that attention to the mothers is being given by people who are not qualified. There is to be more training, and one sees it specifically in the arrangement for "refresher" courses, which will obviously put a new strain upon the existing training facilities. I should like to ask the Parliamentary Secretary whether in view of the Minister the existing training facilities are going to prove sufficient to stand the new strain. I gather from the Report of the Central Midwives Board for 1935 that there are 180 institutions at present in existence for training midwives, and that in addition about 6.7 per cent. of the whole, or 1,027 in number, are privately trained. I wonder whether these facilities are going to be sufficient; I wonder whether the Minister is really satisfied with his training system as it exists at the present moment. I happened, in going through the report, to see the results of the examinations which were held in midwifery, and I was struck by the differences in the percentages of failures as between one district and another. For instance, I see that the percentage in Leeds was 32.9, while in Birmingham it was only 14.2. I am not going to accept for a moment any suggestion that people in the Midlands are more intelligent than in Yorkshire, but I would suggest that large differences like this—there are intermediate figures—seem to indicate that there is a considerable difference in the standard required in the training of midwives and giving them their certificates in various parts of the country. That is a matter which might well be looked into. I raise these points now because I do not think they could be raised in Committee. They are not directed to any particular Clause in the Bill, but are directed to the chance that the Minister is going to have to make a success of the whole scheme as it goes forward under these conditions.

I should like also to say something with regard to voluntary associations. Unlike the right hon. Gentleman the Member for Wakefield—perhaps it is a natural difference between parties from the party point of view—I am glad that the Minister is retaining and using to the greatest of his ability the voluntary system, and I should be very sorry to see it done away with. But it cannot be denied that the continuance of this new official system with the voluntary system side by side is going to raise some difficulties in administration, and I notice that the local supervisory authorities are asked to cooperate with the hospitals and nursing associations that are now concerned, in maintaining a salaried midwives' scheme. I should like to know whether the associations that are to be included in the scheme are to be regarded as fixed and limited to those voluntary associations that are now conducting midwifery services, or whether it is to be open to some nursing association that has not hitherto engaged in midwifery services to open out on that line and still to come into the scheme. I have been asked to ask this question on behalf of a certain nursing society, and I hope that I may get a reply to it.

There is a second question that I should like to ask with regard to voluntary associations. In Sub-section (3) of Clause 2 there is an outline of certain superannuation schemes which it is reckoned will be set up by the local supervising authorities, and I should like to know whether persons employed by the voluntary associations will be able to take part in those superannuation schemes, because it may very well be that they have no superannuation schemes of their own under their voluntary association. In the third place, there is in Sub-section (1) of Clause 7 a provision with regard to post-certificate courses which are to be supplied for the midwives under the new scheme. Will these be open to the midwives employed by the voluntary associations? I imagine there must be some financial burden upon midwives attending these schemes. They will have expenses to provide and substitutes may have to take their place. Will the scheme of the Bill give facilities of that kind to midwives employed by the voluntary associations in order that they may be helped to go through these courses These questions are relevant because I read that substantial equality of conditions of service throughout each area is one of the objects of the Bill. I take it that that means that there is to be equality of conditions of service amongst the new official class of midwives and those who are under voluntary conditions.

It always happens that, when Parliament devises some new form of social service, or some improvement in a social service which has to be administered locally, by the necessities of the case there is some kind of worry about the proportion of the burden. I quite agree that in a case like this a strong case may be made out for saying that this is fundamentally a local service, but look at it from a local authority's point of view, particularly an authority in an area which is badly hit and has many burdens. Of course, the Minister is thinking of the amount required for compensation. Everyone will agree that it has to be given. But there is a case for the State taking over the whole of the charge. After all, it is not the local authority, it is a State policy which is demanding that they should be included in the new scheme. I imagine that this initial expenditure in establishing the scheme might very well come 100 and not 50 per cent. upon State funds.

With regard to the additional expenditure, I am not quite clear what the provision is. Do I understand that, to start off with, we are going to have assistance given on the basis of block grants, that that lasts until 1942, and that after that it will stop? What system is to replace that in 1942, and why is there any need for any change? What I am trying to secure is that it shall continue to be the system. The Minister gave examples of allowances. He did not give the example of Middlesbrough. I thought it would not do for each of us to ask for the figure of our own locality, but the differences should be made in favour of localities which are hard hit financially. I should have thought that essential and I want to see it firmly established in the Bill. I am very glad to conclude my speech in a state of general benevolence towards the scheme. I congratulate the Minister and the Parliamentary Secretary on their labours, I wish them as short a confinement as possible in Committee and a happy delivery in the end.

6.21 p.m.

Sir FRANCIS FREMANTLE

I congratulate the hon. Member upon his presentation of certain points which are exceedingly valuable, and particularly because he brought us back to what really is the main matter of the Bill, namely, the question of midwifery as a profession. One leaves aside questions of poverty and malnutrition and comes to this question of the profession. I do not think it has been sufficiently impressed upon many of those who write to one on the subject and criticise it and bring forward proposed Amendments and comments on the Bill, that the real object before us is to establish and enlarge and improve, both in quantity and quality, the profession of midwives. Even those who have spoken to-day have not realised that the number of midwives is going to be cut down, probably to a half what it is at present, and that half is going to be much more hardly treated from a professional point of view and higher requirements demanded of it. All the speeches have taken it for granted—the Minister himself took it for granted—that the flow of recruits would come in, but is that the case? That is the real problem before us.

If we put ourselves in the position of young girls of good education and standing choosing a profession for themselves which is to be a whole-time service, what are the inducements to them to take up the great burden of training to go in for this extraordinarily hard and arduous life, with all its difficulties? It is only natural that they will say, even if their bent is towards nursing the sick, that they prefer to go in for general nursing rather than midwifery. This is one of the hardest professions, and the Bill makes it a little harder, and yet the financial scales, the conditions of service and so on are treated lightly. Those that are laid down, though better than they have been hitherto, are to my mind quite inadequate to bring in the right kind of persons, to reward them and, when they have experience of it, to recommend others amongst their acquaintance to come into the profession. We want to examine the Bill from that point of view.

Above all, I take the matter which is going to divide us very largely, Who is to be the right authority to supervise this service? It is very natural that we should at once say the midwife has so much to do with maternity and child welfare services, the conception of her profession is being extended to ante-natal and post-natal work; therefore, obviously she must be associated under the same authority for the whole business for her future profession. But it is obvious that that does not take into account the prospects of a young girl choosing a profession as such for a lifetime. If she is wanted to do that, you must give her a flexible future in which she will have a chance of varying her employment according to taste and fitness, physical and otherwise, for a service in which she is likely to have a large number of colleagues with whom she may compare notes, in which she will have a large service behind here of specialists, a service where they will be able to have officers of high class to do the superintending and supervision of the service, which after all, in the case of inspectors of midwives should be one of help, advice and support and comfort from a professional standpoint. That cannot be done by an authority which employs two or three midwives. It cannot be done with an authority which has a small rateable value and has no skilled superior officers. What can be done in that way can be done only by larger authorities. I trust, therefore, that we shall consider in Committee whether it is not better to put this new service under the county councils rather than under smaller authorities.

My right hon. Friend the Member for Ripon (Major Hills) recognised the difficulty and said he would not suggest that the ordinary maternity and welfare authorities as such should have the command of the service, but that it should be limited, in the same way as local education authorities, to 20,000 population and in other ways. In addition to that, in the future conception of the work of this service it must work in not only with the homes of the people, but with the hospitals. Certainly in London we shall hear a great deal about the larger service of public assistance and municipal hospitals which are under the larger authorities and with which the midwife will have to be in close relation. It is not simply a matter of maternity and child welfare authorities and the local supervising authority. The midwife, to do her work properly, has to work with various different authorities, with general practitioners and with all sorts of people and she must be able to work with the individuals and the individual authorities concerned.

Naturally one's thoughts go back to one's own experience in the War. Whether you belonged to a service such as the Army Medical Corps or the Engineers or the Artillery, wherever you were sent you had to work under the commanding officer of the particular unit. We medical men had to work under the control of the commanding officer of the unit to which we were sent, and, at the same time, we were under our own professional organisation with commanding officers right up to the Director-General of the Army Medical Service at the War Office. I hope that regulations will be made in the Bill, or afterwards, by which complete facilities will be given to midwives to work under all the different organisations, and that they will be trained and encouraged to work for the best of their profession wherever they are and in whatever circumstances.

There are nearly 60,000 midwives, and of those 18,000 gave notice of their intention to practise in the year before last, and out of that number only 16,000 practised. What is really wanted—and it is not dealt with in the Bill—is some kind of modification, as was mentioned by the hon. Member for West Middlesbrough (Mr. Griffith), of the sources of training for those women who want to put C.M.B. after their name. This is a most pressing problem both to medical schools and midwifery schools in London. There should be some kind of intermediate qualification of women who intend to be equipped, if necessary, for occasional demands made upon them for midwifery or maternity nursing.

It has been suggested in the course of the Debate that in view of the great reduction in the number of midwives it would be difficult to do away with the handy woman. My right hon. and gallant Friend suggested that we might revert to the home help. These are rather different words, but they have the same association. He means women with better training, such as those who are in Birmingham and elsewhere. It is laid down in the Bill that those who are to work in maternity under a doctor should be qualified under the Central Midwives Board or Nurses (Registration) Act. This is a small point upon which amendment will be required to be made later. It would not be possible for nurses who are in one of the specialised services to register. Nurses in the specialised service relating to fever eases have not been trained for this purpose. They must be on the general section of the nursing register, and that will require a minor Amendment in Committee. If that is allowed it will probably meet the case, and it will be an advance.

There is one point in regard to which I cannot see how the Bill can be worked. Provision is to be made entirely for whole-time midwives. This will be possible in busy towns, but impossible in country districts, if "whole-time midwives" means that they are to be midwives and nothing else. I do not think that that is intended, but that is how the Bill reads, and it is constantly referred to as such. It was brought to my notice to-day by a county medical officer in Wales who is one of the highest authorities in my profession on the subject of county council administration. He said that it will be impossible in a county district such as that in Wales to arrange a service of midwives for full-time employment in the mountain valleys and so on. They will have to continue the system of district nurses under the county nursing organisations, which have done such valuable work, where they are well trained as midwives, and where, by means of refresher courses from time to time, they are kept up to the mark.

My experience as a county medical officer of health goes back to the actual inception of this work as a result of the Midwives Act, 1902, which we owe to one who has passed out of memory now—Mr. Heywood Johnstone, who was Member for the Horsham Division of Sussex, whose wife carried out very good work for the Cottage Benefit Nursing Association after his death; and who did so much to get through, in face of the greatest possible difficulty, the first Measure for midwives passed by this House. After that, a series of voluntary associations took up the work as well as the different political parties. With our greater liberty and freer mention of what used to be considered unmentionable subjects, this matter has been more freely discussed and brought to the front.

A Joint Council on midwifery, a voluntary organisation, was set up, and on it the three parties in this House were represented. The hon. Gentleman the Member for Westhoughton (Mr. R. Davies,) the hon. Lady the Member for Anglesey (Miss Lloyd George) representing the Liberal party, and myself representing the Conservative party, representatives of the medical profession and of medical officers of health, of the local authorities, both the Municipal Association and the County Councils Association, and representatives of midwives and nursing services, formed this body and worked out the reforms for this Measure which finally took shape as a draft Bill. We are grateful to the right hon. Gentleman the Minister of Health for the way in which he received the suggestions of the Joint Council, and as a result the present Bill has emerged. Various points will have to be considered in Committee, but on the whole I believe that we are faced with a new chapter in the development of the service of midwifery. We should congratulate the Minister in having introduced a Bill which will enable us to reach this new chapter, and I hope that we shall see it become a very useful Measure.

6.40 p.m.

Mr. RITSON

I cannot range over the facts and figures and scientific appliances as can be done by hon. Members on the opposite side. I rather deprecate the right hon. Gentleman talking about Mrs. Gamp. I had no idea who she was. I looked at Dod, as I thought perhaps she was a Member of this House. But there used to be some good Mrs. Gamps, and some bad Mrs. Gamps. As a member of a large family I want to pay tribute to Mrs. Gamp. I never knew of my mother having a doctor in her life. Where I lived we had to depend upon the Mrs. Camps, whose work in some of our colliery villages could not have been better done by some of our best trained doctors. We used to have some remarkable women attending cases of this kind without reward and out of neighbourly kindliness. I can give instances in my own family circle where such a woman has been a good deal more useful, practical and helpful than any service we have at the present time. The Midwives Acts were passed. What has happened? In some of the larger colliery villages the doctor has thought that it was not his duty to be present because there was a midwife on the job. I hope that the Minister will look into that state of things. Leaving women alone with a midwife is not sufficient for me when we pay for the service of a doctor under Health Insurance. It is his job to be there.

I have done my best to try to persuade our women to have institutional treatment. That is a difficulty in working-class homes. It is difficult to get the women to appreciate and to understand it. Our women, in spite of what has been said against them, have always been highly moral living women, and they are terrified of any interference at such a time. They love their neighbours and relatives more than they love the doctor. The great difficulty to-day is to persuade these women to go into an institution. I can quote an example. I had a chairwoman and a vice-chairwoman of my Women's Federation in one of our villages. The chairwoman was the mother of 18 and the vice-chairwoman was the mother of seven. If things went on like that, it would be impossible for me to be beaten in my division. They were wonderful women, and the chairwoman told me again and again that she would never go into an institution. We are anxious to get women to have institutional treatment, but I am also anxious that the officers of the Ministry of Health should visit some of these places more frequently. I was at an inquiry some time ago when the matron had to admit after two hours cross-examination, in which I took part, concerning the high temperature of one of the patients, that a leaf had been torn out in case the official of the Ministry found the record of the high temperature and condemned the institution. We condemned that matron. There is another case which I can quote, which shows that doctors are too ready to get rid of these poor people. In this case the child was born as soon as the taxi-cab door was opened, and the mother died in the reception room of the hospital. The Minister of Health ought to see that every medical officer in every institution is thoroughly looked after in regard to matters of this kind.

I am thankful for the Bill, small as it is. Anything that will move along in this direction we shall welcome. As secretary of a very large lodge, in connection with which we have to look after the men, their wives and their families, I can remembers some tragic cases, and I hope that the hon. Member for St. Albans (Sir F. Fremantle) will stimulate the members of his profession, along with the midwives, to do everything possible for these people, who have certainly done more to build up England than ever your navies and armies have done. Many women are terrified of childbirth, and that is why there is more abortion than one ever dreamed of. The only way in which we can get rid of that and avoid the birth of so many weakly, rickety children, is to see that the Ministry of Health attends to these women before their confinement.

Anyone who is acquainted with the work of maternity homes will testify that one of the greatest difficulties which is experienced there in the treatment of many women is that they have not been properly fed. I suggest to the Minister of Health that assistance should be sent to the women in good time, and when it is found that there is anything wrong they should be encouraged to go to the maternity hospitals. Encourage the natal clinics to do their duty by the women, and always see that there is a good doctor there. It is better to spend an extra £200 a year on a good doctor than to save something on having a poor one. I attach much importance to the work of a tactful doctor and a tactful midwife. I am often more concerned with their tact than with their ability. I remember that on one occasion when I had to summon a doctor, he said to my wife: "Lie in bed for 21 days"—not the 10 days provided in the Bill— "you have never had any rest in your life, and this is the only opportunity and the best excuse you have." I have known women who have been confined and have got up on the third day in order to get their men ready for the pit.

I know that the Minister is sympathetic, and I want him to put his best foot forward in pressing on with this scheme and in getting the best people. It will pay very well in the long run, instead of having so many people in hospitals, con- sumption homes and cancer institutions. The cost may be great, but it will be a very good thing for the nation. I say to the Minister, go forward with the Bill and let us improve it if we can in Committee, but do not try to mix too many cooks with the broth. We have some very kindly people in our voluntary associations, but some of our people call them Nosey Parkers, not always deservedly. In a case like this you cannot have more than one cook on the job; it is too serious a matter. I hope that the Minister will rely more upon good experience than on experts. Let the work be done by people who know from experience the class of people with whom they are dealing, and their methods of life.

There was one good thing about the Mrs. Gamps and that was that they were very often women of ripe experience. They may have been present at the birth of the mother and even at the birth of the grandchild of the mother. She knew the temperament, understood the conditions and knew the methods of the family. I am more concerned for the help that we can get from experience than I am over the experts. I hope that the Bill will have a Second Reading without opposition, and that the Minister will not cease in his efforts. Minister after Minister will have to continue until this work is perfected. Instead of losing thousands of lives through maternal mortality and the loss of child life, let us see to it that we so improve the conditions that no mother will be afraid to go through the ordeal of childbirth, but will take it as a duty and feel that it is part of a great national function which is of benefit to the whole world.

6.58 p.m.

Mr. KEELING

I should like to congratulate the hon. Member who has just spoken on being the first Member on the benches opposite who has not mentioned armaments. This House has a heavy programme of legislation before it this Session, and it will certainly help the progress of that legislation if during the discussion of the Midwives Bill we do not devote much attention to the question of munitions.

I have been asked by the Westminster City Council, of which I am a Member, to give its views on the Bill, and those views are shared by almost all the other Metropolitan Borough Councils. In a Debate last week on the Shops Bill the hon. Member for Westhoughton (Mr. Rhys Davies) complained of the colossal conceit of the Londoner, who always seemed to think that every Bill should contain some special provision for London. Whatever may have been the case with that Bill, it is a fact that the London borough councils differ from the borough councils of the provinces for the simple reason that their relationship to the county council is different.

The committee of the Joint Council on Midwifery, whose report is the basis on which the Bill has been framed, had no representative of London on it. Furthermore, it did not take any evidence from London. That is a matter for regret. Under the Bill, as the Minister has stated, the London County Council is to be the authority for midwives, and its duty can be discharged in one of three ways. Either the county council will appoint its own midwives, or it will make an arrangement with the borough councils in their respective areas, or it will make an arrangement with voluntary organisations such as the hospitals and the nursing associations. The Bill provides that the county council shall submit its scheme to the Minister of Health and give a copy to each borough council, and that any borough council which feels aggrieved by the proposals will have the right to appeal to the Minister.

As I said the other day during the Debate on another Bill affecting London, the relations between the borough councils and the London County Council are excellent, and whatever may be the issue of the discussion on this Bill I am sure that the borough councils and the County council will do their best to administer it. I am equally sure that the Minister of Health, at any rate while the right hon. Member for West Woolwich (Sir K. Wood) Occupies that post, will hold the scales fairly between the two sides. The London borough councils much regret, however, that they have not been made the authorities for midwives under the Bill. They think that there are several reasons why they should be preferred to the county council. First of all, they are already the maternity and child welfare authorities in their areas and are carrying out most of the duties prescribed in the Bill. Secondly, the population of each London borough is larger than the population of a great many provincial county boroughs, all of which are to be the authorities for midwives under the Bill. Finally, and most important, the maternity services in London are far superior to those provided in the provinces. The Minister of Health has already referred to the good record of West Ham. In London as a whole the maternal mortality is little more than half that in the rest of England. Londoners may be forgiven for being a little conceited about that.

It is true that there are only three Metropolitan borough councils which are employing their own midwives, but there is a very good reason for that. Most of the boroughs find that they can provide midwifery service much better by making arrangements with the great London voluntary hospitals, whose maternity services are second to none, or with the nursing associations, than by appointing their own midwives. My right hon. Friend has referred to the excellent results obtained in West Ham by that means. In Westminster we provided our own midwives until a few years ago but we found that we could get better results by making arrangements with the Westminster Hospital and the nursing associations. Under such an arrangement the midwife works with the hospital as a base, and the organisation of the hospital is at her back to give her assistance.

My right hon. Friend mentioned that 25 per cent. of births in London take place in London County Council hospitals. But I should like to remind him that another 25 per cent. take place in the voluntary hospitals. He also pointed out that some London hospitals provide midwives for more than one borough, and he seemed to think that there would be overlapping if the borough councils were made the authority for midwives. All that I can say is that this system is at present in operation and does not occasion any difficulty in practice. The right hon. Member for Wakefield (Mr. Greenwood) deprecated the giving of money to voluntary hospitals and other voluntary organisations, but I should like to ask him why it is any worse to give money to one of the great London voluntary hospitals for midwifery than to give money to one of the London County Council hospitals. In efficiency and economy the voluntary hospitals of London have nothing to learn from the London County Council hospitals.

Many of the borough councils go much further than the Bill. They subsidise maternity beds in hospitals and arrange for gynaecologists to be available for consultation in serious cases. They also finance bacteriological services. Each of the London borough councils has also, of course, one or more maternity centres, with which the midwives work in close association. All these services are available free of charge when necessary. I ask my right hon. Friend to consider whether it is wise to authorise the London County Council to scrap all these services. What is required in London is not revolution or reconstruction but development.

The London borough councils welcome this Bill because it reduces the risks of motherhood, enhances the position of qualified midwives and hastens the disappearance of the handy woman. But they are firmly convinced that their object, which is the health of the mother and child, could best be attained by continuing to allow them to administer the domiciliary midwife service and leaving the London County Council to maintain the maternity hospitals and to exercise a general supervision. The division of functions at present between the London County Council with its institutions and the borough council with its midwives works perfectly well, and I can see no reason why it should be interfered with. I am aware that the Bill gives a right of appeal to the Minister if the London County Council does not make arrangements with the borough councils. The borough councils are not greedy, but they want a little more. They suggest that the Bill should provide that the London County Council, before importing any midwives into any borough, should satisfy the Minister that efficient arrangements in that borough cannot be made by the borough council, and I would ask my right hon. Friend to consider whether some Amendment to that end could not be made in Committee.

7.3 p.m.

Miss WILKINSON

I would like very much to enter into a discussion with the previous speaker about the relative merits of the voluntary hospitals and a considered county council scheme, but I wish to speak for only a short time, and I am sure that many of the experts who will follow will deal faithfully with the hon. Member. We realise to the full that this Bill cannot be a Bill to abolish poverty in the course of abolishing maternal mortality, and it is for that reason that we welcome the Bill as far as it goes. But this Government, particularly on these matters, has a habit of doing a little and then claiming that it has done a great deal. In so far as this Bill is drawn to meet one specific problem we welcome it, but it will not be long before we shall hear the Minister of Health, the Chancellor of the Exchequer and the Prime Minister claiming loudly what they have done to reduce maternal mortality because of the Midwives Bill. That is the reason why so many on this side of the House who have had much experience of what it means to have a child on the means test and to have to visit those homes, cannot let this Bill go by without saying that nursing and midwifery, however excellent, are no substitute for good food and conditions.

Of the 60,000 midwives on the roll, only about 16,000 are practising, and of these nearly half are in some way salaried, employed by hospitals, associations and institutions. One of the problems which this Bill has to tackle is the problem of the independent midwife. It is serious for her if the Minister is going to take too short a view of the period on which her service has to be judged, because, like a good many other professions that have suffered from depression during the last five years, midwifery to-day is almost in the position of a depressed trade. I feel very much when putting this the absence of certain women whom I wish were on these benches with me. This is definitely not my subject and I wish very much that women such as Dr. Edith Summerskill and Mrs. Jeannie Adamson, the chairman of our party, who have done so much on this subject and have great experience, were here to speak. From the profession's point of view, the independent midwives have been adversely affected by the fall in the birth-rate, by the increasing number of cases which have gone to hospital, and the consequent under-cutting and overlapping. The result is that the majority of independent midwives to-day are not earning as much as £100 a year. That is a serious thing, because this is a profession which asks not only for a high degree of technical skill and experience, but for much unselfish voluntary work, for which the midwife never can be paid.

In the poorer homes it is the midwife, who is nearly as poor as the people she is helping, who gets up in the middle of the night, who goes in and gets food ready and does everything she can to help her patients. It is a magnificently unselfish work, and she has not been paid anything like a right salary. For this self-sacrificing work she ought to be guaranteed a living wage. Salaries vary, but in some cases £1, 22s. or 27s. is all that is paid for a whole case. Where the home is so poor and the midwife has to collect her own fees out of sheer humanity she often does not collect them. That is why it is so important that the midwife should be a salaried whole-time servant, but it is equally important that the Minister when he comes to assess and advise what the grade of salary should be should not take just these last few years, when midwives have been working under the greatest difficulties, and make that a standard of payment for the future or for compensation.

This question of net earnings occurs in the Bill, and I would point out to the Minister that there are two ways in which you can regard net earnings. The Bill rather seems to assume that net earnings mean that the bad debts of the midwife will not be counted. The other side of estimating her net earnings is how much she has to pay out of her very meagre salary or earnings for expenses. For example, doctors are telling the midwives that they ought not to do housework, because if they have cuts or abrasions on their hands they are liable to infection. Thus they nearly always have to pay for domestic help of some kind, although they are women who normally would not do so. There is the cost of uniform, the heavy cost of laundry, the cost of dressings which they often supply and the cost of personal disinfection. For all these reasons if expenses are to be included in the amount of salary, I ask that a very generous and much more generous level than has yet been given should be given to these women.

We pay a tribute to what the voluntary organisations have done towards getting things started. I think that the importance of the voluntary organisations is the pioneer work they do, and the value they have in rousing public opinion on matters where public opinion is only too anxious to sleep. It is the voluntary work of women who had to face much greater difficulties than any woman has to face to-day which has forced these things on public attention, and would not have a conspiracy of silence on the sufferings which were going on. But there comes a time when the work of voluntary associations is almost done, and what has to take their place is a well-equipped, well-organised and well-endowed public institution. I hope that the voluntary associations will not be allowed to pull down the level of salaries and superannuation.

I would ask the Minister to consider generously the position with regard to the compensation of the older midwives. The hon. Member for Durham (Mr. Ritson) has spoken most movingly of the older women, who had great experience even if they had not as great a technical equipment as midwives have at the present time. It is suggested that the compensation should be based on the last three or five years. It is the woman compulsorily retired who will get it on the five years' basis. I wonder if it is not possible, before we get into Committee and the Minister commits himself, for him to consider extending the five-year basis all round. I ask that for this reason. It would be rather dreadful if some of the women who have been taking the required number of cases are forced to apply for public assistance. It is happening now, unfortunately, and it is not fair. These women have done such a great public service, and they have not had anything like the recognition which they ought to have, and just now, when the Minister and the Government are beginning to recognise the work these women are doing and are following on the work started under the 1902 Act, and making it into a profession, it would be an act of grace on the part of the Government if they applied a five-year basis of compensation all round. In doing so bad debts should not be deducted from the amount of compensation. Many of these bad debts are acts of great generosity on the part of midwives in colliery villages and in places like Jarrow, where under great difficulties a fine service is being maintained. It would be a pity if a midwife were to suffer in the future for her generosity in the past.

We want these women to get that recognition from the public as a whole that they ought to get. That will depend very much on the basis which is laid down now for the women who are to come into this service. The country is not unwilling that the very best that can be should be given to the women who will come in. An hon. Member opposite rather sneered at the uestion of armaments being brought in, but surely when you are spending hundreds of millions of pounds to destroy life you can spend a few thousands to save the new life which is coining in to replace those who may be killed. I doubt if we should have had the Bill at all if we were not now beginning a new pre-war period. In 1917, when our young men were being killed off quickly, this country began to realise that it could not afford an infantile death rate at the figure it was then. This is a pre-war Measure, and if it is necessary to take a generous view of the country's needs in the matter of Defence, an equally generous view should be held in preparing for the next generation.

7.17 p.m.

Mr. LECKIE

I have listened with great interest to what has been said in the very informative Debate we have had this afternoon. Many important points have been dealt with. May I join in the congratulations to the Minister for the able way in which he put the Bill before us, and for the great interest he has taken in this matter over a long period 1 So far as my own constituency is concerned, the town council of Walsall have given great attention to maternity work for many years. We have excellent doctors and health visitors, and excellent maternity clinics. Much good work has been and is being done. We certainly feel that we are quite abreast of other progressive towns in the way we have tackled this very vital question. I have been kindly supplied by the medical officer of health with some facts and figures showing the actual position of maternity services in my constituency. I find that the service, so far as midwifery is concerned, is adequate but that the work is badly distributed. The following figures may be interesting. Out of a total of 2,020 births notified in 1935, 699 took place in hospitals or in private nursing homes. Of the remainder 1,290 were notified by midwives in private practice, and no fewer than 751 out of the 1,290 were conducted by three midwives. That is an extraordinary fact. Another 510 of these cases were shared by 12 midwives who practise in Walsall, and 29 by nine midwives who practise in the immediate neghbourhood.

The problem we have to face, and I presume it is the same in all industrial communities, is a more equable distribution of cases. The three midwives who conducted the 750 cases are earning considerably more than they are likely to get under any local authority scheme which may be set up by the Bill, and that raises a very difficult point. If these three midwives come into the scheme, they will get no compensation for the considerable loss of money they will suffer, and if they stand out, the authority has no power to restrict their practice. I am told that these three midwives are popular and sought after, and this is evidenced by the large number of cases, they undertake. If they come into the scheme it will place the authority in a very difficult position. We desire to give a choice of midwife to expectant mothers and, therefore, we may have to say to them that they cannot have the midwife of their choice as she as already got her quota. That, of course, is a question which will have to be faced as soon as the Bill becomes law, which I hope will be soon. However, these are points which, I am sure, can be surmounted and we can discuss the details in Committee.

The Bill will certainly help to get rid of older midwives, but nothing is said about the age at which they are to retire. Some of these old midwives have done wonderfully good work, and those whom I have consulted do not consider that the Bill offers them adequate compensation. I should like to join in the appeal made by the hon. Member for Jarrow (Miss Wilkinson) that the Government will consider a more generous scale of compensation to those who are past work. I know of a case of one of our oldest midwives in Walsall who, although over 70 years of age, undertook 68 cases last year for which she received approximately £100. If she has to retire, she will suffer considerably in loss of income, and certainly everyone will agree that the compensation set down in the Bill is quite inadequate. I hope the Minister will consider a more generous scheme of compensation. The general purposes committee of the Association of Municipal Corporations has sent out a circular to all municipalities and one has been sent to me in which they raise no objection to the main principles of the Bill, but they do object to the provision that local authorities should be compelled to pay one-half of the aggregate amount paid by way of compensation to midwives who cease to practise.

It is felt very strongly that this should be a national charge. The compensation is brought about by an act of this House, and I do not think it is fair that this share of compensation should be placed on local authorities. It is unfair, because industrial towns will have to pay more compensation than non-industrial towns. In Committee I hope the Minister will consider this point. The Association of Municipal Corporations also contend that the Exchequer contribution should continue after 1st April, 1942, as set out in the Bill, for another five years, so that instead of a five-year average, it would be a 10-year average, which is a much fairer figure to take. That is a reasonable request. I hope that all these matters will be given due consideration. The Bill is a very hold step. The Minister was too modest in the claims he made regarding it. The right hon. Member for Wakefield (Mr. Greenwood) said that it was a brick in the edifice. I think it is a course of well-laid masonry in preparation for a coping-stone on our maternity services. The Minister has shown courage in attacking the question now, and in not waiting for the report of the special committees which have been appointed. I am glad that the House is going to back him up, because the Bill will go a long way in dealing with what is really one of the most baffling problems which municipalities have to face.

7.27 p.m.

Mrs. TATE

I want to endorse what has been so admirably said by the hon. Member for Jarrow (Miss Wilkinson) when she asked for better terms for those midwives who will have to go out of the service. The last three years have been almost impossible for the practising independent midwife, and now that we are improving the conditions of those who come into the service in the future, the least we can do in recognition of the extraordinary selfless work which has been done in the past is to see that the women who are now to be retired are adequately compensated. The work which some midwives do can never perhaps receive adequate remuneration. They get some part of their remuneration in the sheer love of their work, but at least let us see that they have some measure of justice and some appreciation for what they have done. We want to see conditions improved in the service, and I should like to ask the Minister whether local authorities have power to provide houses for midwives. The conditions under which they live are as important as the salaries they earn.

I welcome the Bill. I believe it is going to be a very important step, although only one step on the way, in dealing with the problem of maternal mortality. It is most regrettable, however, that the Central Midwives Board does not come under the Ministry of Health. It is under the Treasury. If the Ministry of Health is to be a really effective and constructive weapon in dealing with the health of the country, it should have charge of everything concerning the health of the people, arid anything as important as the Central Midwives Board should be under the Ministry of Health. The Bill is only going to be of value in dealing with the problem of maternal mortality if it means that in future we are to have a better trained midwifery service. The hon. Member for St. Albans (Sir F. Fremantle) would, I think, agree with me on that point. The right hon. and gallant Member for Ripon (Major Hills) asked that we might have two years' training for midwives. Personally, I say that if we cannot have two years' midwifery training, at least let us see that all midwives are also trained nurses. It seems rather curious that if you get in a nurse to nurse your child in some childish ailment, she has to have three years' training, but you let a woman, at what is admitted to be a dangerous and difficult time in her life, be nursed with her infant child, by a woman who has perhaps had no more than one year's training.

I know that to-day the medical profession deplore the propaganda that has taken place with regard to maternal mortality. They feel, and quite rightly, that the fear that is put into women may perhaps even add to the dangers of childbirth, but let us recognise that that fear is there because of the failure of the medical profession in the past. That has to be acknowledged, and what we have to do away with now is the causes that give rise to the fear. That can only be done by better training. It is quite useless to have better training for your midwives if you are not to have far better training for your doctors also, for, remember, the midwife is going to have to call in the doctor when she considers the case particularly difficult or in some way abnormal, and in very many cases to-day the doctor whom she has to call in has not got anything like the degree of skill and knowledge of the circumstances with which he is called in to deal possessed by the midwife who has to apply for his help.

The hon. Member for West Middlesbrough (Mr. K. Griffith) raised the question as to whether the training facilities of the country would be sufficient for the extra training that would have to be provided by the refresher courses and the larger number of midwives that it is anticipated will come into the service. I think it is a well known and well recognised point—and it was made by the hon. Member for St. Albans—that facilities for the training for the numbers of midwives who are in practice are probably there, but they are certainly not there for the number of people who take the Central Midwives Board's certificate. When the Minister spoke of the problem of maternal mortality being one which needed voluntary effort on the part of the whole country, I felt that he was really striking the right note. It is not only voluntary effort that is needed, but also common sense, and until you have the Hospital Appointments Board refusing to make it necessary for women who take the higher appointments in hospitals to have had a Central Midwives Board's certificate, you will never ensure that there is sufficient material for the midwives and the doctors to be trained on. That is the problem which has to be faced.

I very much deplore the tremendous play which hon. Members opposite have tried to make to-day with regard to the amount of money that is to be spent on the midwifery service as compared with the amount of money that is to be spent on armaments. They glibly talk of money being spent on weapons of destruction, but has it never yet dawned on their politically warped minds that the money which we are spending on armaments is spent to save life just as much as the money which we are spending on maternity services? If they were in power, with their incredible policy of rushing to war with no arms, there would not be very much life left in this country to save, and there would be no need for a Midwives Bill to-day, because women and children would be slaughtered in their thousands. It is a lamentable thing, when hon. Members opposite take a genuine interest is this terrible problem of maternal mortality, and when they can find so little fault with the Government's Bill, that the only thing they can do is to try to make propaganda about the money spent on armaments as compared with the money spent on maternity services. It is nonsense.

If the money spent on maternity services could have saved maternal mortality, I believe it would have been done long ago. To-day we are spending more on maternity services than we have ever spent before, and hon. Members opposite know as well as I do that the figures of maternal mortality are no lower than they were whet; we spent no money at all on this service. I am not saying that money does not need to be spent on it, but I do say that it needs spending in the right way and that the mere spending of money will do nothing whatever. You can judge not at all of the effect on maternal mortality by the amount of money you spend. The Government are spending some £20,000 a year at least on giving training to some of these women, who, I maintain, ought not to be allowed to take the midwifery examination because they never intend to practice midwifery, and that money spent on maternity services is absolutely thrown away. You will not get a real decrease in maternal mortality until you get a better trained medical service and a better trained midwifery service.

No country can afford, even looking at it from the very lowest point of view, to lose mothers or young children, and I look and long for the day when the public conscience will be sufficiently aroused to make it impossible that any expectant mother in this country shal be short of food. While the right hon. Member for Wakefield (Mr. Greenwood), who led off for the Opposition in this Debate with making so much play of the present position in regard to maternal mortality, it is a pity he did not remember to say that if that is the standard by which you are to judge, this country is ahead of the whole world, with the exception of Holland, and that is at least a tribute to sound Government. The right hon. Gentleman was very scornful of what was done by voluntary effort. When he deplored the money which was to be given to encourage it and spoke in glowing terms of the magnificent maternity record in West Ham, it was curious that he forgot to mention that the amazingly good maternity record in West Ham is very largely due to the work done by the voluntary hospital there, the Plaistow Maternity Hospital. It is a pity that he should try to give credit to the Socialist administration in West Ham when the credit is really due in so large a measure to the voluntary hospital which in the next breath he tried to decry. It is a curious way of trying to fight one's cause.

I very much welcome the fact that the Minister of Health has shown his appreciation of the magnificent work done by voluntary associations in the past. In the county of Somerset, a part of which I have the honour to represent, we have a very admirable service of Queen's nurses, and our maternal mortality rate is well below that of the country as a whole. I am very thankful that those voluntary services which have done so much are to be made full use of and encouraged, and I only hope that the efforts which have been made by the philanthropic public to raise money in support of those nursing associations will not, as a result of this Bill, in any way diminish, and that people will not begin to think that there is a less great need for help. I think that we are very often satisfied with far too low a standard of health for the nation as a whole, and when we discuss our maternal mortality rate we are very liable to console ourselves by thinking that we are, as I said just now, with the exception of Holland, the country in which that rate is the lowest in the world. That is not the point of view from which we should look at the question.

The only thing that matters is how many people are dying who ought not to die, and how many people are suffering from bad health, as a result of what ought to be a happy, comfortable, and natural function. That is all that matters, and I believe that we should forget all about the statistics in other countries and that the only thing we should keep our minds on is what the rate ought to be. The actual maternal mortality rate can be got down very easily, because it has been done in large parts of the country, to less than one death per thousand, and we should not rest satisfied until we get down to that rate. I am very glad that this Bill has been brought in, and I believe that it has been brought in by a Minister who has the gifts of imagination and of initiative. I believe that he will sympathetically reviews Amendments which are brought forward to improve one or other section of the Bill, and that under his guidance it will be, what we all hope it will be, a real corner-stone in building up a better service for maternity in this country.

7.42 p.m.

Mr. FRANKEL

I welcome this Bill as a very small step towards a State medical service, and I hope the House, in considering the Second Reading and in Committee, will be realistic in their attitude towards the practical details of carrying the Bill into effect. In London we are a little more fortunate than other parts of the country in so far as the maternal mortality rate is lower, generally speaking, in London than elsewhere. While approving of the general principles of the Bill, I have certain comments to make both on its omissions and, in my opinion, on some of the confused thought which is present in the Bill. A lot of comparisons have been made by hon. Members between voluntary organisations and local authorities. The hon. Member for Twickenham (Mr. Keeling), speaking from the height of the Westminster City Hall, roundly condemned the London County Council hospitals as compared with voluntary hospitals, and other hon. Members have also alluded to voluntary organisations in comparison with those publicly run. To my ears, that sounds strange in this House, which is responsible for the public authorities and which is generally responsible for the payments to the local authorities. It is this House which stands to be judged, in my view, on the excellency or otherwise of those local authorities, and if the local authorities' hospitals and institutions are bad, this House must bear its share of the responsibility.

Mr. KEELING

I did not criticise the London County Council hospitals: I merely praised the voluntary hospitals.

Mr. FRANKEL

The hon. Member attempted to compare the voluntary hospitals with the London County Council hospitals in a manner which I thought derogatory to the latter.

Mr. KEELING

No.

Mr. FRANKEL

Well, I accept the hon. Member's apology.

Mr. KEELING

Correction, not apology.

Mr. FRANKEL

It has to be remembered, in comparing voluntary hospitals with public institutions, that the voluntary organisations have to be praised for the great work they have done and are doing. But that great work was done in advance of the imagination of the House of Commons and the local authorities. It was clone because the public conscience demanded it, but there was no public money for it. Therefore, voluntary organisations in many respects were the forerunners of what are now public institutions. I am glad to say that during recent years a very great change has taken place. There is more enlightened public administration and more public money is spent on the hospitals and institutions of local authorities; and it will be seen that all over the country the number of admissions of patients, even in connection with maternity work, has grown tremendously in the publicly-controlled hospitals as compared with the voluntary hospitals and institutions.

It is interesting to note that hon. Members sometimes refer now to the voluntary institutions as a vested interest, and it is a fact that even in considering this Bill the Minister has had to give great thought and care to the vested voluntary institutions. I deprecate the fact that they should have become vested interests. Without wishing to detract in the slight- est from the great work, particularly propaganda work, which they have done on many occasions, and in which even now they are leading the way, with the public institutions following very far behind, I take the view that, as far as this House is concerned, we ought to take great pride in the local authorities controlling the health interests of this country. We ought to give them every opportunity of developing and of doing all sorts of work which is necessary to public health.

This afternoon I have heard mentioned by the Minister and by hon. Members on both sides of the House figures which make comparisons of the deaths per thousand in different districts and different maternity homes. For 11 years I have been interested in hospital administration and one of the things I have learned is that the figures concerning voluntary and publicly-controlled institutions cannot be compared. They are impossible of comparison, because the voluntary institution can refuse or accept a case at will, whereas the publicly-controlled institution is compelled to accept every case. I do not wish to say anything against the East End Mothers' Home, for it is an excellent institution and has done first-class work. I am in close contact with the work of the London Hospital and of other great voluntary hospitals in London, but even those in control of these great institutions would not deny that it is not unusual for a case to be refused. For instance, in cases of attempted abortion, a class of case which is probably responsible for a larger proportion of the deaths in maternal mortality than any other, it is not unusual for the voluntary institution to refuse them and they go to a publicly-controlled hospital, where they die.

Sir F. FREMANTLE

Does the hon. Member not realise that these big voluntary general hospitals take in all the worst cases they possibly can, and only refuse cases which they cannot accommodate, whereas the local authorities' hospitals are very often filled with chronic cases and are not nearly so useful a field for the acute cases?

Mr. FRANKEL

The hon. Member must have been completely out of touch for a number of years with what is happening in London hospital administration.

Sir F. FREMANTLE

Evidently you have never been in touch with the voluntary hospitals, if that is your view.

Mr. FRANKEL

I do not claim to have worked in a voluntary hospital, nor do I claim to have a medical degree, but for five of the eleven years during which I have been connected with hospital administration I have been responsible for the control of three East End hospitals, and for the last five years partly responsible for controlling 76 London hospitals and institutions under the county council. It is well known that it is not unusual for voluntary hospitals, for good reasons, to refuse these cases. I admit that the hon. Member is perfectly right in saying that the voluntary hospitals take very bad cases, but those cases have also to be interesting ones before they are accepted. They must be interesting from the point of view of the students and the surgeon. Therefore, I contend that in order to obtain a real analysis of the proportion of deaths in particular hospitals or institutions, it is necessary to go much further back than the actual place where the patient dies.

My main purpose in addressing the House is to try to find out what are the Minister's ideas in regard to the practical working of this scheme. Under the scheme, as has been mentioned, there are three ways in which a local authority can carry out its duties in this respect, and the method with which I am mainly concerned is that of the farming-out of those duties to voluntary organisations. I feel we ought to be sure, and to make some provision in the Bill to ensure, that this new service shall be in the hands of authorities who may be relied upon to take the responsibility for this supremely important work. In my opinion there should be no farming-out of this responsibility to smaller authorities or to voluntary organisations unless they are of proved capacity. We ought to be absolutely certain, and there ought to be some means of testing it, whether there is the possibility of this work being handed over to authorities not capable and not efficient enough to carry it out properly. In that respect it must be remembered, unfortunately, that it is not new in English local government to have laws passed by this House which are calmly thrown aside and never worked by many local authorities. This Bill is an example of that. If the laws which have already been passed had been taken advantage of by the local authorities this Bill might perhaps not have been necessary. What might have been necessary would have been a much larger extension of the powers which already exist; this is only a small extension of them. I want to safeguard against the possibility of the local authorities farming-out this responsibility to some voluntary organisation, without proper care and inspection, instead of bearing their own responsibility and making a real contribution to the problem of helping mothers and children.

I would like now to turn to another practical point. Under the laws as they at present exist, any county council or local authority which will have to operate this Bill is compelled by Statute to make charges according to the means of the individual. They have no option but to assess according to the means of the patient. In many parts of the country, when this Bill goes through, it will be worked by the voluntary organisations under the authority of a local authority. It is rather wrong to have to use the term "unfair competition" in regard to so serious a matter, but the vested interests concerned are so strong that one is compelled to do so. I would like to know from the Minister what provision there is in the Bill to ensure that there is no unfair competition from voluntary organisations in this respect. Will they, as well as the local authorities, be compelled to assess according to the means of the patient, or are we to have a repetition of that which exists in London today, where voluntary hospitals can or cannot, as they wish, charge patients? The London County Council is compelled to charge and assess according to the means. I suggest to the Minister that there must be some provision in the Bill to the effect that voluntary organisations shall be compelled to assess on the same terms as the local authorities which are working this Bill. I would much rather that neither of them had to do so, but that is not the issue at the moment. The local authorities will be compelled to charge and assess, and I think the voluntary organisations ought to be in the same position.

The question of refresher courses is also raised in the Bill. I would like the Minister to consider whether the Central Midwives' Board, on submitting their proposals for refresher courses to the Minister, ought to have the final word on that subject. May I suggest to him that the local authorities, which are very much interested and concerned, ought to be consulted with regard to refresher courses, for it is they who will finally be responsible? There are also certain omissions from the Bill, to which I think I ought to draw attention, although they have been casually mentioned already by hon. Members. The right hon. Member for Wakefield (Mr. Greenwood) pointed out that not only ought there to be salaried midwives, but salaried midwives with strong medical support. This Bill does not alter the fact that when a midwife is called in the patient must express the wish for a particular doctor. In the usual way that doctor might be a well-qualified man, but have no special technical qualifications in gynaecology, and I think that under this Bill the midwives ought to have the power to call in a real expert from the neighbourhood rather than any general practitioner, as is now the the case. That is an important point which ought to be borne in mind by the Minister when the Bill is in Committee.

On the financial arrangements I am sure there will be a number of Amendments in Committee. Hon. Friends and myself had some Amendments on the Paper for to-night, but I understand they will be taken in Committee. I would urge the House, in giving its assent to the Second Reading of this Bill, to bear in mind that it represents only a small step, although it is a step well worth taking and one which can materially help to solve the problem of maternal mortality. I wish, however, that the Minister had not been so timid and so responsive to what I have termed the vested interests. I wish his vision had been a little broader and that in this Bill he had attempted to join up all the public health services which affect ante-natal and post-natal work. I realise the difficulties involved, and I have not attempted to enter into the discussion concerning borough councils and county councils. Personally, I am a member both of a borough council and a county council. I do not think that any of us who belong to local authorities wish to stand out for the special importance of the authorities with which we happen to be connected, but we wish to be assured that the job will be done efficiently. That is the ultimate consideration.

If I thought the borough councils could do it more efficiently than other authorities, I would support them having it, but I think we want more fluidity than would be possible under such an arrangement. We do not want to have too many boundaries, and I think a borough is too small an area in dealing with a matter of this kind. We do not want to have people appointed for streets and roads and small districts. We want them appointed for counties, in such a way that they will be interchangeable and able to go wherever their services are most needed. I believe that to be the case, generally speaking, in the counties. I know that some of the borough councils are doing excellent work of this sort at the moment and I hope the Bill will not interfere with that work. I hope that in Committee we may be able to improve the Bill and that before long the Minister will be prepared to bring forward a larger and more imaginative scheme.

8.3 p.m.

Sir GEORGE JONES

I wish to join with previous speakers who have congratulated the Minister on the introduction of the Bill which will, I hope, do a lot to remedy what has been a serious defect in our public medical service up to the present. The mortality associated with child-bearing has been a matter of concern for many years to all social reformers and I think that this Bill represents a very important step towards the reduction of that mortality. It will, at any rate, ensure that, for the future an adequate domiciliary midwifery service will be available for everyone regardless of their financial means. The hon. Member for Mile End (Mr. Frankel) expressed some anxiety on the question of finance. As I understand it, the position is fairly simple. There will be a request for payment according to the means of the patient, but if the patient cannot pay anything there will be no demand for payment. I am glad that the Minister proposes to give such a generous subscription to the authorities towards the cost of administering the Measure. In times past we have put upon local authorities many duties which were really of a national character and have left too large a burden on the rates in respect of those duties. Here the Minister recognises that the scheme deals largely with a national problem and accordingly he is making a substantial contribution from the Exchequer towards the cost.

I wish to deal more particularly with the question of the authorities to whom the administration of this Measure ought to be entrusted. There are only two possible selections. One is the local supervising authority and the other is the maternity and child welfare authority. The Government have decided that the local supervising authorities are the proper authorities for this purpose, and, if I may respectfully say so, I think the Government are right in that decision. Those authorities have had considerable experience in administering the present Midwives Act. For many years they have been the disciplinary and supervisory authorities over the midwives in their areas. They have gained a lot of experience and they will be acquainted with the capabilities and the qualities of the various midwives in their areas. They include all county councils, all councils of county boroughs and councils of the larger non-county boroughs, who have applied to be made local supervising authorities under the Local Government Act.

Those bodies have the great advantage of comprising in their number all the most important municipal authorities in the country. Further, it is of importance to bear in mind that the provisions of the Maternity and Child Welfare Act are administered by all of them with two exceptions. Certainly their administration covers the greater portion of the country, as far as maternity and child welfare work is concerned. They are also the public hospitals authorities for their several areas. I suggest that in the administration of a scheme such as that embodied in the Bill, it is a great advantage that the authorities selected should have the experience which the local supervising authorities possess, and should be closely associated with the various other forms of public health administration, especially public hospital administration. I am sure the House recognises that the successful operation of the Bill will require the co-operation of all those associated with the medical services. There are few bodies more capable of carrying it out satisfac- torily than the local supervising authorities.

There are one or two other points to be borne in mind in regard to the authorities. The hon. Member for Mile End spoke of the desirability—as to which I fully agree with him—of having large areas of administration. Experience of the public health services shows that if you want efficiency, it is necessary to have a larger rather than a smaller area. In regard to the administration of such a service as this, it would be impossible in a small area to have a satisfactory number of salaried midwives. It will be necessary to have reserves available in cases of illness and holidays and to meet other emergencies, and that cannot be done except with the larger units. There is one point already mentioned by the Minister which is of great importance in this connection. We want, if possible, to allow the mother to have a choice as to the midwife who is to attend her. That point has been emphasised by other speakers, and I think it is clear that it would be impossible to meet it, unless we were dealing with comparatively large areas.

I wish to say a few words about London, because it occupies a special position in this connection. I think most people connected with London administration agree that it is desirable that there should be one authority for London under the Bill. Any other system would be bound to create chaos and lead to inefficiency. It is necessary to bear in mind that the London County Council is already the local supervising authority and public hospital authority for London. We start with the fact that the London County Council occupies that position. On the other hand, the metropolitan borough councils are maternity and child welfare authorities. They have not done much in the way of providing midwifery services. I am not, however, criticising them in that respect. I appreciate the arguments which have been put forward on that point but, broadly speaking, their activities and their experience in this connection have been comparatively limited.

We have this complication in London. An excellent domiciliary service has been organised by the voluntary hospitals acting independently of the borough councils and it would be a calamity if any- thing were done which would diminish the splendid work which the voluntary hospitals have been doing and are still doing. It is necessary in London, in my submission, that the scheme so efficiently carried out by the voluntary hospitals shall be fitted into the new scheme contemplated by the Bill. I do not think there will be any difficulty in doing so. The point is that it would be easy enough for the hospitals to arrange with one authority, say the London County Council, but no end of confusion would be caused if they had to make separate arrangements with the various borough councils in whose areas their midwives serve. It has also to be borne in mind that the London County Council occupy a prominent position already in regard to this question. The Minister has pointed out that 25 per cent. of the confinements take place in the London County Council hospitals. We all know that there is a very big organisation of ante-natal and post-natal clinics under the London County Council in connection with their hospitals and that they have the services of many specialists at their disposal. There is the further point that one authority for London, such as the London County Council, would enable midwives to have an opportunity of enlarging their experience and knowledge by attendance at the hospitals for purposes of study.

For all those reasons I hope that, whatever else happens, the Minister will stand by the proposal of the Bill under which the authority for London will be the local supervising authority or the London County Council. The hon. Member for Twickenham (Mr. Keeling) was a little apprehensive as to the position of the voluntary hospitals under the new scheme. As I understand the Bill, there is no need for anxiety on that score and the good work which the hospitals have been doing will not be interrupted or diminished. It will merely be brought into the scheme probably with greater resources available for it than are available at present. It will be necessary for the London County Council to draw a plan setting out the proposed administration. In drawing up that plan they will have to consult the authorities specified in the Bill including the metropolitan borough councils. Those borough councils will have the right to make objections to the scheme and finally the Minister will have the power to alter or amend the scheme as he sees fit. I think we can say that the position of the voluntary hospitals is adequately safeguarded under the scheme and that there is no need to be apprehensive of any interference with the excellent work which they have been doing. If this Bill goes through, as I am sure it will, I believe that the result will be to make yet another considerable advance in the administration of the public health services of the country.

8.15 p.m.

Major MILNER

I will not follow the hon. Member for Stoke Newington (Sir G. Jones) into the dreadful conflict that seems to be raging within the confines of the London County Council area. I am happy to think that no question of that sort will arise in the county borough of Leeds, which the Minister will, without question, approve as a supervisory authority under the Bill. I should like to join in the qualified chorus of approval which the Minister has received on the introduction of this Bill. It is true that it is very much overdue. I have the worst possible opinion of the right hon. Gentleman's political views, but I am bound to pay a tribute to his personal capacity and initiative in the Post Office and since he has been at the Ministry of Health. There are one or two preliminary matters which I should like to bring before the House before I discuss some of the details to which many local authorities and the associations of local authorities take some exception.

A good deal has been said during the Debate about the dangerous occupation in which women who have children have to engage, and I should be the last to minimise what must be the very difficult and painful trial through which they have to go, but I would express the hope that hon. Members and those who have responsibility in these matters will not over-emphasise the question of danger. I know the effect that that over-emphasis can have on a certain type of rather sensitive women, and I take the view, which I hope is the right one, that, while under present conditions it may be a dangerous occupation, it will under the conditions which we hope will be brought about, be a very natural and normal function. That is the impression which I hope all of us will try to give. This Bill is brought in with a view of setting up a really adequate domiciliary service of midwives to attend women in their own homes. I hope that that fact will not prevent those of us who hold that treatment in an institution is far better than treatment at home, urging it upon women in all classes. I am confident from my own experience that although she may have the best doctor and midwife at home, a woman is far more likely to have the necessary attention in the difficult circumstances that may arise if she were willing to leave home for the short period necessary and go into some institution. It is difficult and almost impossible for many working women to do that because of their home responsibilities to their husbands and other children. It is far better that they should go into an institution where there are day and night nurses and every possible convenience. I am reminded of a terrible case which once came to my notice in a house consisting of one room up and one down. In the downstairs room the family, including young children, had to have their meals and there was a young child who had been killed in an accident two or three days before lying on a table in the window close, to the table on which the family had their meals. In the other room upstairs was the poor mother passing through the throes of childbirth. How much better it would have been if it had been possible for her to go into an institution and have proper attention.

I regret that the service which will be provided under this Bill will not be in the real sense a national one. I had hoped that the status of midwives might have been made akin to that of civil servants, and that it might have been made much more of a national service, with the conditions of uniformity in other directions that would thereby accrue, than the kind of service that we are to have. It will be supervised, it is true, by competent local authorities, but it will not be equal to what a real national service would be. The Minister said that of course there would be obligations imposed upon local authorities. Why "of course"? There is hardly a piece of legislation passed nowadays that does not impose a duty on local authorities. I yield to no one in my admiration for the work which local authorities perform, hut if these duties are imposed on them, Parliament should provide them with the means to carry them out. In this Bill these duties have been imposed without the proper financial assistance to enable the local authorities to carry them out. The obligations will be permanent and will increase, and yet the financial assistance will not be sufficient. Its exact nature is not altogether clear. It appears to consist of contributions in the first five years of half the additional cost to which local authorities are put, and that half is modified by being scaled up or down in accordance with a preconceived formula which is extremely difficult for anyone to understand, and from which it is impossible to tell whether one's authority will be fairly dealt with or not.

The local authorities represented by the Association of Municipal Corporations and the County Councils' Association and also the London County Council claim, I think rightly, that the least contribution which ought to be made to any local authority under the Bill is a minimum of 50 per cent. I had certain Amendments to the Financial Resolution on the Order Paper, which I gather are not in order because they would increase the charge. I would urge upon the Minister and the Government the fairness of the Government making at least 50 per cent. minimum contribution. I would also ask on behalf of the authorities represented by these associations that the preliminary period during which that form of contribution is to be made should be extended to 10 years. After five years it is proposed that the contribution should be in the form of an addition to what is known as the block grant. I submit that it will not be possible to tell in such a short period as five years the exact extent of the obligations imposed on local authorities or the extent of the financial burden which is placed upon them. This service will naturally take some little time to build up. We hope that it will be built up quickly, but those local authorities for whom I may presume to speak do not think that it is a fair basis on which to compute the amounts which will be payable under the block grants to take such a short period as five years. I hope that the Government may be persuaded to extend the period.

There seems to be some doubt whether the whole of the additional expenditure which the local authorities are likely to incur under the Bill will be met by this contribution, and therefore I had put down an Amendment providing that it should include all expenditure incurred by local authorities in providing or arranging for the provision of courses of instruction and any payments made by the authority to a superannuation fund for midwives employed by them. I do not know whether the right hon. Gentleman is in a position to say whether those expenses will be included in the expenditure upon which the grant will be computed, but I hope he will be able to say that it will.

In passing, I should like very strongly to support the plea which has come from both sides of the House that the compensation paid to midwives who leave either voluntarily or compulsorily should be a national and not a local charge. It will occur only once. The Bill shows that the Government regard this service as a national responsibility, and in my submission that compensation, which cannot amount to a very great deal, might fairly be a charge on the Government. Finally, I am sorry to see the provision by which fees can be charged, apparently, to all classes of the community according to their means. I had hoped that this might be a free service, and that it would not be necessary to calculate means and to demand some contribution from quite poor people. I should also like the Minister to accept an Amendment stating that the services of the midwife shall be available for a period of at least 14 days instead of 10. With these few comments I would commend the Bill to the House.

8.28 p.m.

Captain ELLISTON

The only really adverse criticism of this Bill which we have heard is that it fails to do something which it was never intended to do. All we need concern ourselves with to-night is the principle that under the Bill every local supervising authority is required to provide an adequate domiciliary midwifery service within its area and that the Exchequer will make grants towards the cost. That provision represents, in the opinion of my hon. Friends, a great and important step in the measures we have taken to deal with the problem of maternal mortality. As the Minister has told us this afternoon, it has been proved over and over again that where a domiciliary service has been properly organised, either by a voluntary hospital or by a nursing association, the local rate of maternal mortality does fall below the national. It is useful to emphasise the significance of the domiciliary character of this service. It has been said in the House several times to-day, and has been frequently said outside, that the present campaign to save the lives of mothers is creating a sort of panic among many expectant mothers. They are becoming unduly alarmed about the dangers of childbirth, and yet, as the Minister has reminded us, childbirth has been described in a manifesto issued by the British Medical Association as, A natural physiological event and though involving complex and delicate processes, departures from the normal are rare occurrences. Very many competent authorities believe that normal confinements can be conducted more safely at home than in hospital, even, curiously enough, in houses where the accommodation is of a very primitive character. I have been surprised to hear many Members expressing a, preference for the removal of the mother to hospital, but the opinion certainly prevails amongst doctors that where the case is a straightforward one the majority of mothers are better and more safely dealt with in their own homes. This is on the assumption, of course, that they are assured of skilled advice and attention such as are provided in this Bill, General approval has been given to the view that County Councils are the proper authorities to be entrusted with the powers under the Bill, but it is the fact that, with a few understandable exceptions, all the representative public health authorities contend that where the local supervising authority is not responsible for administration under the Maternity and Child Welfare Act of 1918 the local authority which is administering that Act should also be responsible for the service of midwives provided under this Bill; in other words, that this midwifery service should be an integral part of the maternity and child welfare schemes.

The principle involved seems to have been recognised in the new Public Health Bill which is now being considered in another place, because it expressly authorises the Minister to transfer functions to the welfare authority if such transfer would conduce to the more efficient administration in the district of functions relating to public health. It can be argued that that would justify the placing of midwives under the maternity and child welfare authorities. The reasons for this claim seem obvious. The health visitors of the maternity and child welfare authority are able to give the health department early information of pregnancy, they provide ante-natal care in clinics, they provide consulting medical services for difficult cases and under the puerperal fever regulations and they provide those ancillary services which are so important in maternity work, such as the provision of milk and meals for necessitous mothers.

There is also the importance of securing close co-operation between the salaried midwives and the existing health visitors. It is thought that they would be better as colleagues under the same authority eventually enjoying, as I hope, equal status, because it is obvious that if we are to attract a type of educated and cultured woman to these improved maternity services they should be remunerated at least as well as the health visitors with whom they will be associated. The importance of this co-operation is emphasised when we consider the important part that the health visitor plays, or should play, in the maternity service. Under the Maternity and Child Welfare Act, the health visitor has to visit every house where there is a child under five years of age, and she becomes the friend and confidante of the family. She is probably the first to know when the expectant mother is approaching her confinement. Being herself qualified with a certificate of the Central Midwives Board, she appreciates the importance of ante-natal and medical attention. She warns the expectant mother to make preparations for her confinement in good time. She is taking into the home that education in health which is at last teaching the mothers, after many years, to go to the clinics and to the medical consultants who are available. It has been said to-day that we might extend the work of the clinics. The clinics have been there for many years, and the aim should be to persuade mothers to make the most of the advantages of them. In that work, the health visitor, in cooperation with the midwife, will play a very big part.

I intended to say something about the compensation to be paid to those very devoted women who have served the public as midwives in past years. It was pointed out in a letter in the "Times" the other day that most of them paid for their training and secured the certificate of the Central Midwives Board, and that in many cases they bought their practice. It seems only fair and reasonable, therefore, that if the local supervising authority takes over their practice, generous compensation should be given to them. Making every allowance for those midwives who have what we call a pin-money practice, such as those who continue to be midwives after marriage, taking a few cases, in what is practically part-time work, I suggest that in Committee we should consider very carefully whether we cannot do something more generous than is foreshadowed in the Bill for the bona fide whole-time midwives who have been such faithful servants of the public for many years.

The Bill is notable if for only one thing —the extermination of the handy woman. People have said many kind things to-day about those old ladies, but however amiable and kindly in the household they may have been, the fact must be recognised that they are a definite danger to the expectant woman. They would take on any job that came their way. I think it was Mrs. Gamp who said that she was as good at a laying-out as at a lying-in. They are engaged in all sorts of occupations which may be a definite danger to the lying-in mother. I do not think anybody in this country will mourn their departure. We have been told to-day about the things that the Bill fails to do, but the Minister was perfectly frank about it. This is only one step in the campaign to reduce maternal mortality and, even more important, maternal morbidity. We have been promised next autumn, or perhaps next winter the report of an investigation by medical officers of the Ministry, who are exploring all the possible causes of that mortality. There is no doubt that the result of those investigations will be that the Minister will be able to complete his scheme step by step. Most of us hope to see the time when medical supervision will be available for every mother throughout her pregnancy, when specialist and hospital treatment will be available in every case where necessary and when there will be help in the home while the mother is incapacitated. There should be a supply of dressings and all the other necessary services for the safety and comfort of the mother. All those things we hope for, but the point is, as has already been said this evening, that we do not yet know what measures are the most urgent and most necessary. We are still very much in the dark.

Nobody can give a satisfactory reason why maternal mortality at Burnley is 14.5 per 1,000 and at Rochdale only 5.66, or why at Liverpool it is 2.79 while at Sheffield it is 5.60; or why at Bournemouth it should be 6.98 and at Birming ham only 3.23. The right hon. Gentleman the Member for Wakefield (Mr. Greenwood) told us that the cause of maternal mortality is lack of food and malnutrition, but will anybody tell us that the mothers of Birmingham are twice as well fed as the mothers of Bournemouth? Are the people of Liverpool twice as well fed as the people of Sheffield? No, there are many factors, which the Minister is in course of examining, such as the effect of the birth-rate, the proportion of first births, the occupational circumstances of the mother, and the age group of the female population. All those have to be examined. We can confess at once that we do not know the controlling causes of maternal mortality. Certain steps have been found effective, and are now followed. It is sound that we should proceed in this matter step by step, making sure by adopting those measures first which are most likely to produce early results.

I think we are all determined, irrespective of political party, to deal with the problem of maternal mortality until we have achieved success. It may be that we shall have to extend National Health Insurance or the services of local authorities to provide further safeguards for the protection of mother life. Last year the deaths totalled about 2,500, but that is an insignificant figure in comparison with the number of women who suffered injuries in childbirth and who may have impaired health for years to come. The virtue of the Bill is that it is a first step in dealing with the problem as a whole. We congratulate the Minister of Health on having introduced it.

8.45 p.m.

Mr. W. H. GREEN

This subject has been one of great interest to me for many years. I do not know whether I shall be regarded as egotistical if I mention that 27 years ago I was serving on a maternity and child welfare committee in connection with the Metropolitan borough council of which I am still a member, and also, if I may be pardoned a further personal reference, that I am in the rather unique position of representing in this House a supervising authority and a maternity and child welfare authority; and, with the experience I have had of these matters, I welcome the present Bill. I felt that the Minister's speech in moving the Second Reading showed great sympathy and knowledge of the subject. Having said that, however, I must say I felt that one could only welcome such a. Bill provided we were assured that it was the very first step in what is going to be a long path towards the solution of a problem which I believe every Member of the House recognises as one of the most baffling and one of the gravest of all the problems with which we are faced. In my view it is a problem that requires a most courageous approach, and it is because I feel that this Bill is feeble and halting in its approach to the problem that I must in some senses be critical of it.

Perhaps there is no problem facing the country to-day which needs to be approached from so many angles as this problem of maternal mortality. It is not merely a medical question; it is not merely a question of the provision of midwives; it is a question of housing, it is a question of poverty, it is a question of malnutrition, and one would not be entitled to say that any one of these factors is the deciding factor in the maternal mortality which we all deplore. I believe, however, that the Bill approaches the subject in at least a helpful way, though one has no reason to get excited over its introduction, because after all, in some senses, it is but the co-ordination of services and powers which already exist. As an old borough councillor, I know that the borough councils at the present time have powers to develop salaried midwives services in their areas. This Bill will compel non-progressive authorities to do what they have had the power to do under previous Acts of Parliament.

It is very strange, and perhaps indicates the baffling nature of the problem, that, while we have reduced the risks to life in every other phase of human life, yet, with all our scientific research, with all our development of maternity and child welfare services, we have not only not succeeded in reducing maternal mortality, but its increase has been progressive over a long series of years, and I believe that the figure at which it stands to-day outrages the public conscience, at least of the deeper-thinking section of the community. There is no problem whose solution would be more welcome than the problem that we are discussing to-night. We have succeeded by our child welfare services in reducing infantile mortality from a common figure of 130 to 59, and we have increased the expectation of life; but in this one vital matter we seem to be baffled. Perhaps one aspect of the problem which is as serious as the actual deaths is that to which the right hon. Gentleman the Member for Wakefield (Mr. Greenwood) referred when he pointed out that, while between 3,000 and 4,000 mothers may die in childbirth, it is reasonable to suppose that many thousands linger on in lives that are largely maimed; and, while we have no statistics to prove the exact extent of this problem, it is in a very real degree dependent on the problem that we are discussing to-night.

I want in passing to say a word on the question, about which we have heard a good deal this evening, whether the Minister was right in providing in the Bill that the authority to operate the Measure should be the supervising authority. That is a question which is causing considerable concern in municipal circles in London. My personal loyalties might reasonably be supposed to be somewhat divided on this matter. My borough council have decided unanimously that in their view the London County Council is much the better body to administer the Measure, and to my mind every reason which carries weight seems to be on the side of the larger body undertaking this work. It seems to me to be most essential and desirable that the great hospital authority in London should be the authority to administer this Measure. I think that something like 13,000 of the 60,000 births which take place annually in London take place in London County Council maternity wards, and it would appear to me to be a great advantage that this municipal midwives service should be intimately linked up with the great hospital service of the London County Council.

The London County Council to-day have quite a number of specialists dealing with every phase of difficulty in connection with maternity work. They train midwives, they supervise midwives, and it seems to me reasonable to suppose that, if they are the administrative authority, the midwives would be attached to the various hospitals, and, when not actually engaged in domiciliary work, they would be gaining further experience in the hospitals of the authority employing them. Further, it seems to me that, the wider the area, the more efficient the service will be. In a small borough like my own borough of Deptford, where we might have five or six midwives, it might well happen that four of them would be engaged locally at the same time, and it would be much easier, if they were a unit of a larger service, to draft them to boroughs where they were needed. Therefore, it appears to me, as one who is both a borough councillor and a county councillor, that the London County Council would be much the better body to administer the Measure.

After all, what ground of complaint have the borough councils? They have had powers to engage municipal midwives, and only three metropolitan boroughs have taken advantage of these powers; the rest have entirely neglected the opportunity. As an old borough councillor, I sometimes wonder whether there is not a danger of borough councillors thinking rather of their powers, and the possibility of their losing some of their powers or of increasing some of their powers, when looking at the problems with which they are faced, rather than thinking which authority is likely to produce the better and more efficient service. I hope the Minister will stand by that provision. We have heard a good deal about the conflicting interests of the county council and the borough councils in connection with maternity services. I know the Minister will agree with me that there is a great deal to be said for that point of view. The whole of the maternity services of London, when we get a Government courageous enough to do it, will have to be thoroughly gone into and reorganised. There is a tremendous amount of overlapping between the powers of the borough councils and the powers of the London County Council as the supervising authority, and it would appear that the whole thing will have to be put into the melting-pot before we get the most satisfactory service.

There are one or two criticisms of the Bill of which, I hope, the Minister will take some note. The first is the question of the 10 days during which the municipal midwife may be in attendance. On both sides of the House, without exception, the total inadequacy of 10 days has been emphasised. It just gives the suggestion that we are trying to tackle this grave problem in a cheap way. I hope the Minister will seriously consider the question. The local authorities will have a grievance in the matter of the compensation. The Minister will say they always feel that when it is a question of the contribution that the Exchequer should make to local services, but local authorities of all complexions throughout the country feel that they have a grievance if this contribution is limited to 50 per cent. I should like to ask what is to be the retiring age for these municipal midwives. This is a question which some of us who have been intimately engaged in public health work are very concerned about. The ordinary health visitor retires at 65. We say that is far too late, and those who have had experience of the work of our health visitors will agree that tramping the streets, going from door to door and carrying out their arduous duties, their period of efficiency ends long before they reach 65. I imagine that the same point will arise here and that the age of retirement ought to be seriously considered. One almost feels envious of the position of a Minister who is able to take even this first step on the path which we hope will lead to safer motherhood. This Debate has indicated that we are not divided on questions of principle on party lines. The only division is as to whether the Bill goes far enough.

8.58 p.m.

Sir JOHN MELLOR

The hon. and gallant Gentleman the Member for South-East Leeds (Major Milner) complained that under the Bill very poor people will be required to pay fees. I think he cannot have noticed the second paragraph of Clause 3 (1), in which provision is made for a partial or total remission of fees to those who can ill afford them. I most warmly welcome the general provisions of the Bill and I feel that they are welcomed throughout the country, but I wish to join issue with the hon. Member who has just spoken and with the hon. Member for Stoke Newington (Sir G. Jones) with regard to the authority which is to administer the Bill. If it is confined, as it is at present, to the local supervising authorities, considerable misfortune will result. I feel, with many others, that there should be included among the authorities who will administer the Bill those county districts which have a maternity and child welfare committee under the Act of 1918 and a whole time medical officer and are of sufficient size efficiently to conduct the administration. At present the supervising authorities are the county and county borough councils and those authorities that were added by delegation under the Act of 1902, but there have also been added under the Act of 1929 33 county districts by order of the Minister. A large number of others have applied for orders and been refused. It seems to me that in the discrimination between those who have been granted and those who have been refused orders there has been great inconsistency, because in many cases there are higher rateable values and more midwives employed where an order has been refused than where it has been granted. Out of the 33 county districts which have been granted orders, only four have salaried midwives, whereas there are six authorities which have not been granted orders which have salaried midwives.

Under the Bill the county and county borough councils automatically become the administering authorities. That is not altogether satisfactory, because there are nine county councils and three county borough councils which have a rateable value of less than £320,000. Size and financial resources have been made a great point of in the question whether or not a particular class of authority should have power to administer the Bill. I take the figure of £320,000 because it happens to be the rateable value of the Royal town of Sutton Goldfield, which is in my constituency, and I suggest that that town has all the requirements to qualify to be a supervising authority. It has a maternity and child welfare committee, it has a whole time medical officer, it has salaried midwives and it is of adequate size. When one finds that that town is not considered qualified, but that there are a large number of county and county borough councils which are smaller and have less financial resources which are considered qualified, it is just to argue that the discrimination has been very inconsistent.

With regard to the question of whether the Bill is to be administered by very large authorities or by smaller authorities, there comes the question of proximity. It is most important that the supervising authority should be close at hand to the work which it is to supervise. That is most important, particularly, as has already been pointed out several times in this Debate, with regard to co-ordination of midwifery with ante-natal and with post-natal treatment. It is very unsatisfactory that a midwife should be employed by authority A and supervised by authority B. In the cases of the non-county boroughs which have been working a satisfactory service, it is a great pity that their duties should be now taken away from them and vested in some authority perhaps geographically distant, and probably out of touch with the work that has to be done. It would be most in the interests of efficiency and humanity that those county districts, which satisfy those three points which I have suggested, should be allowed to administer the provisions of this Bill.

9.7 p. m.

Miss RATHBONE

The Minister has good reason to be satisfied with the reception that has been given to his Bill. There has really been very little criticism of its main features. Such criticism as has taken place has been principally of a constructive kind and concentrated rather upon its limits and upon certain aspects of the financial provisions. I will not follow the hon. Gentleman the Member for Tamworth (Sir J. Mellor) into the question which he raised. It has been raised by several other hon. Members, and I leave it to anyone who is now, as I am no longer, a member of a local authority, except to say that on the grounds of general principle that, where uniformity is desired to be got into a service and where the work of the midwives will necessarily, in many cases, take them into the area of a good many authorities that in a sense points to the larger authority as being the more effective.

I want to direct attention for a few minutes to some of the points of criticism that relate to the interest of the midwives. As several speakers have pointed out, notably the hon. Lady the Member for Frome (Mr. Tate), though we have every hope that the Bill will result in a much better standard of salary for midwives, there is nothing actually in the Bill that guarantees the standard. Apparently whether the midwife is employed by a voluntary organisation or by the local authority, provided she is a whole-time salaried midwife, there is nothing to ensure either uniformity or adequacy in the scale of salary. That is the weak point. We are all agreed that the system of the payment of midwives by the job has completely broken down, and has resulted in the desperate impoverishment of the midwife in a large proportion of cases. There is a little danger, when you go from a very bad condition of things to a different arrangement, that the minds of those responsible will be too much influenced by the extreme lowness of previous standards. I mean that the new employing bodies may feel that the midwife has worked so very cheaply in the past that if they pay her a small regular salary, it will be enough. I hope that by means of regulations or otherwise the Minister will see to that point.

I see that the Joint Committee and, I believe, some of the other individual bodies represented on that committee, have put forward, as a sort of guiding principle, that the midwife should not receive less than a woman health inspector. That gives a very wide range, because I believe that the salaries of women health inspectors range from £150 to something like £350. I think that everyone will agree that the work of the midwife is not less skilled, is more arduous and much more anxious than the work of the health inspector, so that that is, at any rate, not too high a standard to suggest. It certainly should not be lower than that. I think that the question of the scale of salaries requires special care where midwives are employed by a voluntary organisation. The voluntary organisations have done admirable work in the past in the employment of nurses and midwives, but there may be some fear of inadequacy of salary. It may be difficult for the voluntary organisations without more assistance than they may get under the Bill, to raise the salaries to an adequate point.

Apart from that fear I do not share the mistrust expressed by some of the Members of the Opposition about the use that is being made of voluntary organisations under this Bill. I often think, when I listen to the speeches made by Members of the Labour party as they touch upon the question of the employment of voluntary organisations, they are suffering from a time-lag. Really, the days have gone past when we need to be told, as we were told by the right hon. Gentleman the Member for Wakefield (Mr. Greenwood) that this work should not be left to Lady Bountiful. The work of the voluntary organisations is on the whole now as fully organised, and as free from the spirit of patronage and interference with the private lives of those they employ as the work of the local authorities. I will quote a sentence from one of the most constructive Members of the Labour party, Sydney Webb. He has recognised, as many of the Members of the Labour party fail to recognise to-day, just the right place that the voluntary organisation can occupy in a service of this kind. He deprecates what he calls the parallel-bars theory of the relation between public and private action, and says: The better analogy is that of the extension ladder that draws out length after length to enable the worker to reach to greater heights.… The Public Authority and the salaried official can only do the work in gross; they are apt to be blunt and obtuse; to have no fingers, but only thumbs… We need the voluntary worker to be the eyes and fingers of the Public Authority… as the circumference of Public Authorities is extended the greater becomes the periphery. Where you have a service like this which has been built up upon long experiment by voluntary organisations, it would be a very great pity to throw away all that experience, especially in a matter where delicate personal relations come into play as much as they do in the midwifery service.

A futher point with which I shoud like to deal is the compensation for a retiring midwife. I recognise that from many points of view the suggested basis of compensation does not sound too bad—three years net earnings in the case of a midwife who retires voluntarily and five years in the ease of one who is compulsorily retired. That sounds perhaps all right if we compare it with the compensation given in the case of interference in industry by some new development, but we have to remember two things in connection with midwives. In the first place, there are the extraordinarily difficult conditions under which midwives have been working during recent years and the many cases in which they have been doing work for which they did not receive any pay. Let me give a few instances from recent letters addressed to the President of the Midwifes' Institute. One midwife writes We get no payment from the local authority for miscarriages, and the patients tell us that they cannot pay. I have had six this month. Another writes: I have done several cases and not received any fee. The local authority says that the father must pay when the mother is single, but often the father is not known, and I get nothing. Another says: In many cases I have to take 6d. and 1s. a week but many patients cannot pay at all. I myself paid to take my training. Another says: Nothing is paid for ante-natal work, and I nearly live with my patients. There were four patients last month, with 31 visits, for which there was no payment. In many cases the midwives have consented to do work without pay because they cannot bear to desert their patients. They know that in many cases the failure to pay has been involuntary, because of distress. It would therefore be a very great hardship if net payments are reckoned and no allowance is made for work that has been done for bad debts. I trust that the Minister will either make an Amendment or have such an interpretation of the Clause that it will work fairly. I do not know what the interpretation of net earnings is, but allowance should be made for bad debts.

The midwife has been for a long time in a curious position. In one sense she has been a public servant. She has had to be registered and to receive training at her own expense. She has been subject to inspection and supervision, and very often she has been made the scapegoat for the sins of other people. If a doctor has misbehaved and the local authority thinks there is a scandal, they drop down on the midwife but not upon the doctor, because a local authority is often frightened of the medical profession, which is so well organised and so articulate. They are not, however, frightened of the unfortunate midwife. She has had, so to speak, all the discipline of being a public servant but none of the status and none of the reward, and now that the time has come to make the midwifery service into a real public salaried service, the Minister should be very generous in his treatment of those women who have been doing a great public work without getting any pay from the public.

There are two further points in regard to compensation, apart from the question of whether the allowance of five years net earnings in one case and three years in the other is sufficient. It is proposed that the local authority may think it wise, instead of paying a lump sum, that they should pay an annuity which is to cease at the age of 70. Might not the woman herself be consulted as to which form of payment she would prefer? Moreover, is it not a strange proposal in the Bill that annuities should cease at the age of 70? One assumes that the only reason for that provision is that the old age pension will begin at the age of 70. The old age pension is 10s. a week. The Joint Committee suggested that a pension was a suitable form of compensation in the case of a woman compulsorily retired because of age or sickness, and they suggest that the pension should be sufficient to keep her in adequate comfort. Is it suggested that a pension of 10s. a week is sufficient to keep a woman in adequate comfort? If not, why is it provided in the Bill that where compensation is paid in the form of pension it is to cease at the age of 70? I hope the Minister will give us some assurance on that point.

But with all its defects and limitations the Bill will be a very great advance on the past. We all recognise that by itself it is not going to do a very great deal, although it may do something to relieve the problem of maternal mortality. It is only one brick, though a very important brick, in the edifice. We want not only a better system of home care but the whole question of housing and poverty should be dealt with and, what is perhaps more directly relevant than anything else, the extension of health insurance with de- pendants' allowances and medical services for the dependant of the unemployed person. In many cases it is the lack of medical service during the years when perhaps a husband has been sick and the woman has done all the work of the house and attended to the husband, that the woman's health has suffered considerably. There is no medical benefit for the woman dependant on an insured person, and when the man falls sick she gets no dependants' allowance. The health of many women has been undermined by lack of these provisions. However, the Bill is a Midwives Bill and we cannot expect it to do everything.

It is the culmination of half a century of effort. If I may make a personal reference, my earliest associations with this House go back to a date in the nineties when I used to look upon this Chamber from the grille which protected the Ladies' Gallery, while a little group, of which my father was one, was engaged in the House fighting for the first Bill for the registration and training of midwives, so that mothers might be saved from the drunken old Sarey Gamps of those days. It required courage in those years to work for a Midwives Bill, when even the mention of midwifery was the cause of ribald jokes in the House. That Bill did not pass into law until 1902, and we can be thankful to those women who fought for all those years for reforms of this sort, without even having a vote to help them in their fight. Some of those workers are still in the field, such women as Dame Rosalind Paget, who has sometimes been called the Florence Nightingale of the midwives.

We know that this Bill owes a good deal to others, and, if it is not indiscreet to say so, to none more than the lady who is the wife of the head of the Government, and whose unfailing and patient interest in the welfare of the mother has done so much to stimulate interest in this question. It is a good thing to have ladies of that sort in diplomatic circles, if not in the diplomatic service, and if social reformers could choose the wives of those in authority we might perhaps see greater progress. We are glad of what we get in this Bill, and we hope that the Minister may make some concessions in Committee. We realise that one of the great difficulties will be whether, when the Financial Resolution is passed, we shall be able to obtain that generous retiring allowance for the midwife which the right hon. Gentleman's nature will, I am sure, make him desire to secure.

9.27 p.m.

Mr. DUNCAN

The hon. Lady will not expect me to follow her at this late hour, but I will make one comment in connection with her speech, and that is on the question of the word "net." My right hon. Friend should give an answer to that question before the Committee stage of the Financial Resolution is passed, as it makes an enormous difference to the pension of the midwife according to the meaning that is put on that word, and whether it is to take into account the cases in which there has not been any payment, or is to be interpreted on the strict meaning of the word. If we take no action until after the Resolution is passed it will be too late to amend the Bill.

I welcome this Bill, which the right hon. Gentleman has introduced so clearly and persuasively. I have sat here six hours waiting to say that, and I say so no less sincerely now than if I had been successful in securing Mr. Speaker's eye. The right hon. Gentleman the Member for Wakefield (Mr. Greenwood) mentioned that this was a political question. I remember an election a few years ago in which it was made a party political question. In this Debate everyone will agree that although it is a political question it has not been made a party political question, and I hope that in Committee the Bill will be considered on its merits and not on party lines.

We should get this question of maternal mortality in its proper perspective. One or two hon. Members have said that this is a terrible tragedy and a scandal that must be stopped. The psychological effect of that on young women is liable to make them frightened of undergoing childbirth. The figures are roughly 580,000 births and only 3,000 deaths. That puts it in the proper perspective. Childbirth is a normal, physiological event in a woman's life and, although painful, a normal thing which 97 women out of 100 get over with no after-effects. Nothing should be said in this House which would give the impression outside to young girls, perhaps having their first child, that it is such a dangerous thing that they may try to avoid it. What is grave is that of the 3,000 deaths roughly half are preventable. If this Bill will do something to save 1,500 mothers a year it will be a great thing for the country.

May I refer briefly to the question of London? Many speeches have been made with regard to London, and I should like to explain the exact position in the London boroughs. I agree that in the Provinces the counties and the county borough councils, which are also the maternity and child welfare authorities, are to be the supervisory authorities under the Bill. In London there is a different position. The London County Council is the supervisory authority, and the borough councils are the maternity and child welfare authorities. In London the first thing that happens, as soon as it is known that a woman is about to have a child, is that she is visited in her home by the health visitor. All hon. Members do not realise the completeness of that service in London. The woman is invited to attend one of the ante-natal clinics which form part of the borough council's service. All arrangements for her safe confinement are made and supervised by the borough council organisation, but the moment labour begins the midwife is called in and supervision passes for 10 days to the London County Council, which supervises the midwife. The doctor or midwife is required by Statute to notify the registration officer within 36 hours of the birth. The borough health visitor does not visit the home for 10 days. If, however, puerperal fever occurs in the mother or any other infectious disease develops, the borough council must step in even before the 10 days are up in order to prevent the spread of infection.

The county council is concerned with a view to preventing the midwife spreading infection, while the borough council officers are required to prevent the spread of infection by other channels. The borough councils carry out the disinfection of the bedding and personal clothing of the patient and the duty of the London County Council is to provide for the disinfection of the midwife. Therefore, you have a lot of overlapping; in the duties of the borough councls and the county council. Ten days after confinement the health supervision of the mother and child passes back to the borough council and remains with it until the child is five years old or goes to school, when the papers are handed to the county council so that the child's life story can be handed to the education authority. That is what happens. I submit that, although there is overlapping, the scheme has been justified in the result. In 1932, while the death rate in England and Wales was 4.2 per 1,000, in London it was only 2.9. In 1933 for the country it was 4.5 and in London 3.6. In 1934 for the country it was 4.6 and in London 2.8. By getting rid of this overlapping even this percentage could be improved—the borough council being the authority for the purposes of maternity and child welfare, having to provide the health visitor to start with and the ante-natal clinic and then give up control for 10 days in order to avoid overlapping, coming in again with post-natal looking after the child up to the age of five years or when it goes to school, it should have the duty of looking after the midwife who is looking after the mother.

There is a case for the maternity and child welfare authorities in London, and are the borough councils, having charge of midwives instead of handing over the whole of this service to the supervision of the London County Council. My right hon. Friend said that there was one objection, that the voluntary hospitals are in different areas, and that it would be most inconvenient to negotiate with various boroughs and hospitals, and much easier to negotiate with one authority, the London County Council. I agree that from the point of view of the Ministry of Health it would be much better to negotiate with one authority, but I would point out that the negotiations which my right hon. Friend suggests will be difficult with voluntary hospitals in different areas, have in fact been going on for some time. Arrangements have been made by the boroughs in the past, and on the whole they are working satisfactorily to-day. Therefore there should be no difficulty in negotiating with voluntary hospitals who have nursing associations in different borough areas. My right hon. Friend said that 25 per cent. of mothers who have children are under the London County Council. In that case 75 per cent. are not under the London County Council.

There is a genuine fear among borough councils that the all-embracing London County Council, of which I was once a member, is tending to take away the work of borough councils and lessen their importance. I take a great interest in the work of the London County Council and also in the work of my own borough council, and I am trying to look at this matter from that point of view. I think there is a case here for handing over to the borough councils all the duties of the London County Council in the provision of midwives, and if some scheme can be arranged for a general supervision, a register of midwives, perhaps a training of midwives and a, general day-to-day administration, between all the authorities concerned, I should be satisfied. I think the bias should be towards the borough councils rather than towards the London County Council. If the borough councils can prove that their existing service or the service they propose will be satisfactory, then the London County Council should not in the ordinary course of events come in.

My right hon. Friend also said that only three borough councils have actually employed municipal nurses. The hon. Member for Twickenham (Mr. Keeling) answered that point very effectively. He said that the City of Westminster had employed salaried midwives in the past and had got rid of them, and had made better arrangements with the Westminster Hospital. The Borough of Kensington in the northern part have made arrangements with a voluntary hospital and in the southern area they have a municipal midwife. Incidentally, the maternity death rate in Kensington as a whole is just over 1 per cent. Therefore, I think there is a case for a consideration of this question by my right hon. Friend, and I hope he will not close his mind to the possibility of some Amendment being made in Committee to meet an objection which is felt by the vast majority of the boroughs in London.

On the benches opposite there have been two schools of thought with regard to midwives and maternal mortality. There is one school of thought which was ably put in a maiden speech by the hon. Member for Claycross (Mr. Holland), who said that he would like on balance to see domiciliary treatment rather than institutional treatment. There was the other school of thought put by the hon. and gallant Member for Leeds (Major Milner), who said that he would rather see more institutional treatment. I must come down on the side of the hon. Member for Claycross. I think it is most important, in these days particularly, that maternity should be looked upon as a natural physiological function and any question of taking people to hospital to have a child should be discouraged. What should be encouraged is that it should take place at home, if it is a normal case; and there should be efficient services to see that the case will be normal. There should be 100 per cent. attendance at an ante-natal clinic, with doctors there who can see that things are going to be all right, and with that, and with the midwife whom the mother wants and a doctor in case of trouble, we are going to make great strides in getting rid of this unnecessary maternal mortality. I like the Bill and shall support it wholeheartedly.

9.45 p.m.

Mr. E. DUNN

I, like previous speakers, have sat here for six and a-half hours waiting for the opportunity to make my little contribution to this Debate, and I do so because I believe that this Bill is intended to go right to the heart of one of the most important problems which this country has to face at the present time. I appreciate the fact that the Bill has its limitations, and they have been referred to by previous speakers, and I would have preferred that the Bill should have made a much wider survey of the whole incidence of maternal mortality than one finds represented in it. Nevertheless, I take this opportunity, together with previous speakers, of expressing my support and appreciation of what I believe to be, although in a, limited sense, an opportunity seized by the right hon. Gentleman the Minister of Health to approach this problem, and to secure, if at all possible —and I believe it is possible—a trained and qualified midwifery service for every mother in the country, whether she be the wife of a member of the wealthier section of society or, on the other hand, the wife of a member of the poorer section of the community.

I have listened to the whole of this Debate, and I should like to direct attention, late as it is, to what I believe to be the real problem which this Bill is intended to attack. The discussion appears to have centred round adequate training and an efficient midwifery service, and to that ideal and object I give my whole- hearted support. Although it is only the beginning and the forecast is not too rosy, yet, if this Bill really is directed at affording an efficient and a trained midwifery service for the mothers of this country, I believe that those mothers will welcome the Bill and support those who have introduced it. To that extent I want to offer my appreciation of the Bill.

I could not but feel somewhat disturbed at the reference made by the previous speaker to the fact that out of 580,000 births that had taken place in this country last year, only, as he put it. slightly over 3,000 deaths of mothers had occurred. I do not know whether this House appreciated the significance of that statement, but let me put it quite simply that only slightly over 3,000 women in this country last year gave their lives in consequence of childbearing, and if the hon. Member opposite does not feel any perturbation of mind and conscience on that matter, all that I can say is that he is of a different school of thought from that of the right hon. Gentleman who introduced this Bill. I suggest that the mothers of this country are seriously disturbed about this question, that they are more disturbed about it than they are on any other issue now before the country. If an efficient midwifery service is to have the effect, as it should have, of reducing the maternal mortality rate of this country by 50 per cent., then to that extent this Measure will have been a godsend and a blessing to the country.

This Bill is directed mainly against two very important human factors. One of them is this: There is an alarming fall in the birth-rate of the country. As a matter of fact, from 1911 to 1933 the birthrate has fallen by nearly 30 per cent. or, to quote the figures, from 881,138 in 1911 to 580,413 in 1933. In other words, for every three babies born in 1911, we have two babies born at the present time, so that there is an alarming fall in the birthrate of this country, and I suggest that this Bill is directed towards securing a trained midwifery service in order that the birth-rate may be prevented from falling even lower. If that is a true deduction, and a trained midwifery service can do anything in that direction, I suggest that even the provisions of this Bill itself might be described as not generous at all as far as the midwives of this country are concerned.

I should not have intervened in this Debate, particularly at this late hour, but for the fact that when I went to my constituency on Saturday of last week, I was met with this alarming and amazing incident: One of the best and brightest young women it has been my lot ever to meet, a woman of less than 30 years of age, was married to a young man who lost his employment. During the time that they have been married this young man has had only nine weeks' work. Last Thursday a baby was born. On Saturday the mother of the baby was taken to the hospital, and she went out of her mind and died, and I believe that to-day that young woman, one of the brightest and best I have ever met, has been buried. If people suggest that the incidence of unemployment, the economic factor, does not enter into the question even of the birth-rate itself, I cannot conceive what kind of a world they are living in. God forbid that I should say a single word that would not have the effect of helping towards a trained and efficient midwifery service, but coupled with that is this poverty and the economic factor.

I do not think the hon. Member for North Kensington (Mr. Duncan) placed sufficient emphasis upon the question of maternal mortality, nor do I think the right hon. Gentleman the Minister of Health can agree with the hon. Member's remarks. In 1911, 4,320 women died in this country in childbearing. That is equal to 12 deaths a day or one death every two hours. In 1918, 5,038 died—equal to 14 deaths every day or five in every four hours. In 1933, the figures had gone down a little, and were 3,436, which still meant 10 women's deaths in childbirth every day. Hon. Members who come from the mining industry are amazed at the fact that we are losing in this country a thousand men's lives a year in the production of coal, but here we have the amazing fact that in order to produce children between 3,000 and 4,000 women lose their lives every year. It is a scandal, and it behoves every Member of the House, on whatever side he may be, to do all that he possibly can to arrest this wreckage and wastage of human life that is taking place.

To put the matter in another way, I would remind hon. Members of the accident which took place at Gresford in 1934. The country ought to realise that every year there are 12 Gresfords mainly in the working-class homes of the country in order to produce children. I am glad that the Minister of Health has brought forward this Bill, limited though it be, with a view to trying to provide an efficient and trained midwifery service to grapple with this appalling problem. The hon. Member for North Kensington made light work of the fact that over 3,000 women are losing their lives in childbearing in this country. Does the House realise what that means? It means that if the coffins of the women who died in childbirth were placed head to toe in a line starting from Palace Yard and going to King's Cross, there might have been in 1934 and 1935 the sad sight of coffins along both sides of the street from Palace Yard to King's Cross.

I would like now to make one suggestion to which I hope the Minister of Health will give some consideration. Before doing so I would point out that I come from a very large family, and the handy woman was the midwife at the birth of each child. I cannot subscribe to the view that the important function of childbirth should be left in the hands of untrained women. I believe it is the duty of the State to delegate its responsibility to the largest authority possible, with a view to carrying on this work of. safeguarding the motherhood of the nation. I have been the Chairman of a hospital for six years, and during that period the hospital came to be known in the district as one where women, particularly in child-bearing, never died. If that can be accomplished in a municipal hospital, or in a voluntary hospital or organisation, my view is that we ought to rouse public opinion in the country in order to stop the wastage of human life which is taking place at the present time. The suggestion I would like to make to the Minister of Health is that midwives should in future be given special training in the newer anaesthesia appliances.

I make that suggestion because it is the common practice in Mayfair, and if it is the common practice there in the case of people who can afford it, and of their lives and those of their babies can be saved, I think that the ordinary midwife ought in future to be trained in that particular respect. The right hon. Gentleman will remember that at the end of last year I put to him a series of ques- tions on that important matter, and at the time he said the figures in regard to it were not available. I was then astonished to find that the leading anaesthetists of the country, almost without exception, wrote letters to me giving one occasion after another where this newer treatment, which is simple and safe, could be used by the ordinary midwife, and showing how, if there has been malnutrition—as there is in thousands of cases—the newer treatment eliminates the danger of the resistance of the mother being lowered at childbirth. I am assured by the best authorities in the country that not only would it enable hundreds of lives to be saved, but thousands of women would be enabled to regain strength and health far more quickly than they otherwise would.

I make that suggestion in all seriousness and in the hope that if it is at all possible the right hon. Gentleman will introduce it into some form of legislation in order that the training of midwives in future may be along those lines. With regard to the financial provisions of the Bill, I notice that the £500,000 suggested as the contribution of the Exchequer to the local authorities, nearly coincides with the number of births in the country in a year, and therefore we might put this down as the "£1 per birth Bill." I suggest, in regard to the incidence of the financial help suggested, that the Minister might regard this provision as being too modest for the training of an efficient midwifery service.

10.6 p.m.

Mr. MICHAEL BEAUMONT

I do not propose to follow the hon. Member for Rother Valley (Mr. Dunn) in all the ramifications of his speech but I wish on behalf of my hon. Friend the Member for North Kensington (Mr. Duncan), to repudiate the aspersions of callousness which were quite falsely cast upon him by the hon. Member. If the hon. Member had paid attention to my hon. Friend's speech he would have heard that he was not in any way uninterested in the fact that there were 3,000 deaths per year in child-birth. What he did say—and I think he is right—was that the important factor was not the comparatively small proportion of deaths to births but the fact that an enormous percentage of those deaths was preventible. That was the point on which he laid stress, and any suggestion that he was uninterested in the matter of maternal mortality is not to be left unchallenged.

Having said that, I wish to say something from the point of view of the voluntary associations—an aspect of the question which has not been dealt with so far in the Debate. I have had some connection with these associations, particularly with the Queen's Institute of District Nursing which has probably done more good pioneer work and more efficient organising than any other voluntary midwifery service in the country. Tributes have been paid by the Minister and others to the voluntary services for which those associations will be grateful. They are glad to have been consulted and they welcome the Bill as furthering the work which they have, in some measure, started. Naturally, we are not in agreement with the criticisms which have been leveled from the benches opposite at the voluntary services. I think that the provisions of the Bill dealing with that matter, constitute probably its finest feature.

I know that hon. Members opposite are apt to decry voluntary services and say that they do harm and are liable to render inefficient State or local authority services. I take the other view. With a considerable experience of State and local authority organisations I believe that they tend to introduce inefficiency and incompetence. In this case I think the Minister has succeeded in making the best of both worlds. Frankly, I welcome the fact that the proposed expenditure is modest, although hon. Members opposite have complained that it is not larger. I agree with a previous speaker who said that one could not judge the work done in a social service by the amount expended on it. Hon. Members opposite who have had much to do with both voluntary and State-aided social services and have done it nobly will agree that the services which cost the least money often do the most effective work.

Mr. E. J. WILLIAMS

Did not the hon. Member hear the Minister quote the figures about West Ham showing what had been done there in recent years? Surely that is concrete evidence.

Mr. BEAUMONT

I fail to see the relevance of the interruption. I merely said that it was not necessary to have large expenditure on a service in order to do good work, and I do not think the figures of West Ham have anything to do with that.

Mr. WILLIAMS

But the hon. Member was deprecating expenditure by local authorities and said we could not find where that money was giving concrete results. I said that the Minister had quoted West Hans.

Mr. BEAUMONT

I never said anything of the sort. What I said was—I now say it for the third time—that very often services on which small amounts are spent do more effective work than services on which large amounts are spent.

Mr. WILLIAMS

Give us examples.

Mr. BEAUMONT

I shall be delighted to give examples at the proper time, which is not now, but hon. Members themselves know that what I have said is perfectly true, and I am sorry to have been led away from my subject by a rather irrelevant interruption. As I say, we welcome the Bill and the way in which it is drawn. There are several Committee points but I do not propose to deal with any of them to-night except one, and that is the point alluded to by the hon. Lady the Member for the English Universities (Miss Rathbone) as to the right of local authorities to decide whether compensation to midwives shall take the form of an annuity or a lump sum. That is an entirely new provision and one of considerable danger as a precedent. That local authorities should be allowed to decide how people shall have their own compensation—their own money—is a revolutionary proposal. I would sooner that the compensated midwives should decide how the local authorities shall receive their money than that it should be the other way round, and I hope that something will be done in Committee to delete or to change materially that proposal.

I wish also to lodge a protest against the form of the Financial Resolution. It is, unfortunately, a growing practice in this House to take into a Financial Resolution and thus preclude discussion on subjects which ought properly to be discussed in Committee. I think I am right in saying that as this Resolution is drafted, it will be impossible to raise in Committee the question of compensation. Personally, I support the Government on the question of compensation, but I think it is a matter which the Committee ought to decide. As the Resolution was originally drawn it would not have been possible to raise at all the question of the operative authorities, and I thank the Minister for having altered it in that respect, but I protest against the growing habit of putting into a Financial Resolution points such as that which I have mentioned and also the question of grants for training. Those matters are important to the Bill and we should not be precluded from discussing them in Committee. I know that it may be said it is difficult to frame Amendments to deal with that because they would impose a charge, but it can be done.

There is a much more glaring example on the Paper in respect of another Measure, and if this habit of drafting Financial Resolutions in such a way as to prevent discussion on important points by the Committee is to go on, the only remedy will be to have a second Committee stage on the Financial Resolution. That would dissatisfy everybody, and I hope that the Minister and the Government will note this practice and will pay more attention to it. There is no excuse for it now that the Chairmen of Committees upstairs have the right to select Amendments. I do think that is a very serious and rather insidious, though I have no doubt quite unintentional, attack on the rights of private Members. For the rest I welcome the Bill very much for the reasons that have been advanced against it by the other side, for it is a reasonable Measure taking the voluntary services into account. I hope that it will work well. It is a statesmanlike Measure which will do good and be of benefit, if of modest kind, to the people of this country.

10.16 p.m.

Mr. RHYS DAVIES

The only title I have to address the House on a subject of this kind is that I unofficially represented the Labour movement on the Joint Council for Midwifery which issued the report upon which this Bill is based. Before I deal with the Measure, however, I might be permitted to say how pleased I was to hear the contribution of the hon. Gentleman the Member for Clay Cross (Mr. Holland) in his maiden speech. The remarks he made redound great credit on him and show that, he has a great deal of knowledge of this very difficult subject.

Those of us who studied this problem during the last 12 months or so were rather astonished to find out the facts, some of which have been given to-night and some of which have not. I was amazed to learn that there are women over 80 years of age practising midwifery. Nobody can convince me that a woman over 80 can do her duty properly in a confinement. I was astonished also to learn from the statistics that a great number of midwives in actual practice never attend more than 18 cases a year. When those of us who are interested in this problem came face to face with the facts and figures we found that, so far from this service as the Minister of Health said being just unsatisfactory, it is deteriorating. It is deteriorating in a measure because it is less attractive to women than some of the new occupations and professions which attract the same type of women. Consequently this report was propounded, in the first place, in order to elevate the midwife into a higher status; to raise her status to the point it ought to have reached long ago. Therefore, the first thing to do was to improve her salary.

It is strange, especially to those of us who sit on this side, that when the community is in a serious difficulty and is facing a stubborn problem, it invariably turns to the municipality to help it out of its difficulty. I should imagine that the main difference of opinion on this Measure lies in the queston as to whether voluntary organisations should receive public money for this new service. The answer to the hon. Member for Aylesbury (Mr. M. Beaumont) lies in the fact that the Bill intends to hand over the main tasks of midwifery to the municipalities because voluntary organisations have failed in the past.

Mr. M. BEAUMONT

Oh, no!

Mr. DAVIES

The hon. Member for Aylesbury always says "No" to anything I say, so I never take his "No" as a final answer. I repeat that it is very interesting to those engaged in public life to see this important fact emerging: that when the most enthusiastic exponent of voluntaryism in this country is up against a problem he always turns to the collective idea, as represented by the municipalities, to get him out of his trouble. That is what this Bill is doing. If the right hon. Gentleman had introduced such a Bill 25 years ago he would have been expelled from the Tory party. It shows the progress we are making towards municipalisation and, if I may say so, socialisation. He does not like the word "Socialism," so I will call it socialisation.

Another point to be remembered is that a number of midwives receive no payment at all. There is no money to pay them. To show how stubborn this problem of maternal mortality is I will endeavour to put it in its true perspective. The right hon. Gentleman was right when he said that municipalities have been spending increased sums of money, amounting to about £3,000,000 a year, in trying to overcome the problem. If hon. Members will look up the debates on National Health Insurance in 1911, when it was proposed for the first time to pay maternity benefit to the wives of insured persons they will find that it was then prophesied that the payment of 30s. on confinement would certainly help to reduce maternal mortality. But every attack on the problem up to now has apparently failed.

I am not a statistician, but I am sure that the statistics as they are now collected do not provide an accurate picture of what is happening. Deaths in confinement take place generally in the case of the first child. If the mothers of this country 30 years ago produced on an average four children, and 20 years ago produced on an average three children, and now produce on an average two children, I venture to say that until we get statistics of maternal mortality in respect of each child born the picture will rot be complete. I am sure I am right when I put it that way. Nevertheless, the situation is really very serious as it is.

I do not want to say very much to-night, but I would add these few further comments. The right hon. Member for Wakefield (Mr. Greenwood) was quite right when he said that the power to do all that this Bill proposes was there before the Bill was introduced, and unless I am mistaken the evidence we received on our committee was that only one large corporation had put those powers into operation, namely, the Bradford Corporation. We were told, too, that when the municipality did adopt these powers there was soon a decline in the maternal mortality rate. The right hon. Gentleman has done a very good service to-day in pointing out the excellent experience of the West Ham Corporation. If there is one thing which stands out above the rest in this Debate it is the justification of the point of view we put that voluntaryism will never grapple with this problem as effectively as public control.

Mrs. TATE

The hon. Member was not in the House when I made my speech, and perhaps he will allow me to remind him that a very large part of the tremendous success in West Ham is due to Plaistow Voluntary Hospital, which serves that area, and is therefore due to voluntary effort.

An HON. MEMBER

What about the subsidy?

Mr. DAVIES

I do not know West Ham as well as the hon. Lady does—

Mrs. TATE

Obviously not.

Mr. DAVIES

But I have lived a little longer than the hon. Lady. [Interruption.] I wanted to say that by way of complimenting the hon. Lady. I should not be a bit surprised to know that if there is any complaint about the treatment of women in the hospitals at West Ham, whether controlled by the municipality or by voluntary organisations, the mere fact that criticism in public can be brought to bear upon those institutions is always for the good in remedying those complaints.

Mr. FRANKEL

What about the subsidy? [Laughter.]

Mr. DAVIES

I do not know what there is to laugh at.

Sir K. WOOD

We are laughing at your Friends.

Mr. DAVIES

I do not need prompting. I always learn my piece very well beforehand. The hon. Member for St. Albans (Sir F. Fremantle) was right hi part when he said that this was a midwives' Bill because it raises the status of the midwives. I would point out to him, however, that this Bill would hardly have been introduced had it not been for the heavy maternal mortality. As usual, the hon. Gentleman was a little too professional in his speech.

The Bill will of course help the mother considerably, and I sincerely trust that after it has been in operation for a time all that has been said about it will come true. I am not, however, so sure about that. There are factors deeper than all those which have been referred to in this House in connection with this problem, but they are not for laymen to deal with. We are not paying sufficient attention to the woman before the day of her confinement arrives. I have sat on a local authority for 10 years and taken a little interest in public health. I am sure that the right hon. Gentleman will live long enough to see that this Bill, which merely raises the status of midwives by paying them a proper salary and giving them better training will not avail very much in reducing maternal mortality. The issue is, as stated, deeper than that.

Some of my hon. Friends have complained that women are not properly fed, and hon. Gentlemen on the other side are always trying to make out that our case on that score is not made out. We claim that malnutrition and unemployment must have something to do with this problem. Let me put it in a way which, I believe, will appeal to all parties in the House. A woman in confinement cannot be very happy if she knows that her husband has been unemployed for five or ten years, and that he does not seem to have any hope of getting into employment again. Putting it that way, I suggest that a woman cannot go through the ordeal of confinement in those circumstances as well as she could if her husband were in full employment and in receipt of a decent wage.

It is astonishing, as the right hon. Gentleman has said, that, in a great measure, we are mastering some of the chief diseases which have afflicted our people. I think I am right in saying that the mortality rates in this country are probably the best in the world with the exception of this one. I am informed that there are some countries in Europe which have better figures by far than we have in relation to maternal mortality. I gather that one of the Scandinavian countries has for years adopted the very principles laid down in this Bill, and, speaking from memory, I do not think that that country—I am not sure which it is—

Mrs. TATE

Holland.

Mr. DAVIES

I do not think that they hand over this work to any voluntary organisation whatsoever. We will, therefore, watch keenly the effects of the provisions of the Bill and their application to voluntary organisations.

We shall not, of course, vote against the Bill, because it proceeds along the road that we would like to travel ourselves. It is well, I suppose, that the right hon. Gentleman himself is in charge of the Bill. He is a very capable politician; he can make a statesman's mountain out of a political molehill, and that, I think, is what he has been able to do to-day. I am not going to throw bouquets at him, but I should like to point out that this Bill, after all, is not the product of any one party in the State. Members of all parties have been working at the problem for a very long time. Hon. Members have been paying tributes to some public men and women who have helped this cause forward. I would venture to pay a tribute to one person above all who, I think, has inspired most of what we are doing to-night, namely, Lady Williams, the Secretary of the Joint Council on Midwifery. So far as I know, she is probably more responsible than anyone else for fashioning what we are doing now.

Some day, other Members of Parliament will sit in this House and will meet the consequences of what we are doing to-night. I am satisfied that the Bill will without doubt do one thing—it will provide us with better nurses; they will have a better salary than they are getting now. The municipalities will thus be able to attract a better type of woman for this work, and all that is to the good; but in the end I am almost certain that this Bill by itself will not make the impression upon the maternal mortality rate that the right hon. Gentleman would have us believe.

10.34 p.m.

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

I am sure that my right hon. Friend has reason for satisfaction at the almost unanimous approval that has been given to this Bill. There were one or two exceptions from the Benches opposite, particularly in the case of the right hon. Gentleman the Member for Wakefield (Mr. Greenwood). Those who know him as well as I do—and I have had to follow him for the last three or four years—will realise what he can do when he is really enthusiastic about a Bill, but the remarkable thing about him to-day, as the hon. Member for West Middlesbrough (Mr. K. Griffith) pointed out, was the extreme poverty of his language. I have heard him fulminate, when he disliked a Bill, in terms that nobody in this House can touch, but to-day he was almost bankrupt in his attack. It was rather remarkable to notice that nearly every speaker from the Benches opposite started his speech by saying that this was only a small step, but, as each speech advanced, it was clear that the speakers could hardly contain their enthusiasm.

I should like to congratulate the hon. Member for Clay Cross (Mr. Holland) on his contribution to our Debates. I congratulate him not only on his speech but on his good political judgment, because he chose a, good Bill on which to make a good maiden speech. I was a little surprised at the hon. Member for Westhoughton (Mr. Rhys Davies). He remarked that he did not expect as much from this Bill as some other people. He was a member of the Joint Council that made this report and this is what he, as a. member of that council, said in describing the purpose of the Bill: A well trained, well informed, and intelligent service of midwives working in cooperation with the medical profession is therefore, of premier importance in any scheme for the reduction of maternal mortality and morbidity. He must, therefore, not blame the Government for putting into effect a Measure of premier importance. Let me re-state the case for the Bill. The present position as regards this vital service is very unsatisfactory. No one denies that. It is not satisfactory to the expectant mother and it is very unsatisfactory to the independent midwife. The midwife does not occupy that position in our public health services that she is entitled to by virtue of the very honourable and vital services that she performs. What we attempt to do under our scheme is to substitute for too intense competition among the independent midwives, very few of whom are getting an adequate living, an organised, salaried whole-time service, with regular and proper conditions of employment as regards remuneration, provision for sickness and relief as regards holidays. There will result a real status for the midwife and we shall strengthen what is at present the weakest link in the chain of our maternity service.

The right hon. Gentleman the Member for Wakefield asked what is the meaning of "for at least 10 days after childbirth," and so did many others. Those words refer only to a midwife who is acting as a maternity nurse, for this reason. The term of 10 days is fixed by the rules of the Central Midwives Board for midwives acting as such, and, therefore, it is not necessary to put it into the Bill, but there are no rules as to the period for maternity nursing and we take a step forward in saying that a midwife acting as maternity nurse shall attend on the mother for at least 10 days. Let the House note this fact; not 10 days, but at least 10 days. If in the circumstances of the case the doctor or midwife decide that there is need for further attention, they can give it. There is a considerable opinion among the medical profession that from the point of view of nursing, 10 days is not enough.

If the Central Midwives Board considered changing the rules with regard to midwives employed as such, we should necessarily have to change the rule here as regards the period of attendance of midwives acting as maternity nurses. The Amendment would then not only be necessary, it would also be desirable. The hon. Gentleman the Member for West Middlesbrough asked a number of questions. He asked how many salaried midwives would be necessary under the scheme of the Bill. It is very difficult to answer that question, but if the hon. Member will turn to the Schedule of the report he will see that the Joint Council of Midwifery estimate on certain assumptions that roughly 4,500 new salaried midwives would be necessary. He asked whether voluntary associations to be formed in future can be consulted by the supervisory authority and whether they can come into the scheme. The answer is, "Yes, certainly." What I think will usually happen, if one takes the case of the county council, which will normally be the supervisory authority in respect of an area not at present covered by a district nursing association, is that the county council will say to the county nursing association, "Can you cover this area?" and the existing nursing association may say "No, it is not being covered." In view of that the duty would then fall to the supervisory authority to frame the scheme itself.

The hon. Gentleman asks whether the training can be improved, and the answer is that we hope so. The hon. Lady the Member for Frome (Mrs. Tate) in her interesting speech, pointed out that so many places in training schools had been taken by those who had no intention of practising. Training places will be reserved for those who intend to practise. The hon. Gentleman opposite also asked about superannuation schemes and whether training would apply to those in the voluntary service, and the answer is, "Yes." There are per capital training grants in respect of those who receive training courses, and the arrangement will apply to a trainee whether the trainee comes from the salaried service or from the voluntary service. The supervising authority can make a grant to a county nursing association and include a sum towards the expenses of the association in running a superannuation scheme. Of the 62 counties some 60 are in varying measure covered by a network of district nursing associations and some 55 of the counties already have their own superannuation schemes.

The hon. Gentleman asked me to explain what he had failed to understand, namely, the finance of the scheme. When one talks about general Exchequer contributions one is apt to get very puzzled. The Financial Resolution authorises grants to all local authorities for each year during the third grant period, which starts from 1st April next. For the five years of that grant period the grants to the local authority will be on the basis of half the new expenditure incurred. That grant will be scaled up or down according to need. That need will be calculated according to a carefully devised formula. This provision has been well received by the House, because it is clear that in some of the Special Areas unless the grant was scaled up the local authority would have difficulty in starting the new service. The new expenditure will be calculated in relation to the expenditure incurred in the year ending 31st March, 1936. In the case of direct employment under a supervising authority there will be a unit of cost based on the average net annual cost throughout the country incurred in respect of the employment of a midwife. That unit has not yet been fixed, at the special request of the local authorities, who wished to have more information as to what salaries were being paid and what fees were being charged.

Let me give a simple example of the working of the plan, and any hon. Member who reads my speech in the OFFICIAL REPORT to-morrow will be able to work out the figures for himself. We start by realising that the Exchequer will assume responsibility for one half of the new expenditure. Take the county of Norfolk. We calculate first what is the weighted population. We then divide the weighted population by the actual population, and in Norfolk the quotient is 3.6. We do exactly the same for the whole country, calculating the weighted population for the country and dividing it by the actual population, and when we do that the quotient comes out at 2.7. You then take half your expenditure and multiply it by 3.6, which is the weighted factor, and divide it by 2.7, which is the aggregate weighted factor for the whole country. In the case of Norfolk instead of the grant being 50 per cent. the grant works out at 66 per cent. In the case of Middlesbrough it is over 80 per cent.

With regard to the administrative working of the scheme, there are divergencies of opinion between various London Members. The question was also raised by the right hon. Member for Ripon (Major Hills), in a very admirable speech. Let me state quite frankly that there are attractive arguments on each side. There are attractive arguments, as put by the hon. Member for Kensington, North (Mr. Duncan) for making the maternity and child welfare authority the authority for this scheme. But on balance, and considering the thing by and large, we have come down on the side of the larger authority, on the side of the hospitals authority, because this is in line with the whole trend of modern health administration. The House will remember that of the 62 counties every one is a supervising authority and of the 83 county boroughs every one is a supervising authority, and every supervising authority knows the efficiency of its midwifery service and these are the authorities to whom one naturally turns if one is starting a new service.

If you entrust this service to the smaller authority—perhaps a small non-county borough—it is difficult for that small non-county borough to provide a sufficient number of midwives so that there can be reliefs in case of sickness or holidays. In London the county authority, with all the London County Council hospitals behind them, where 25 per cent. of the births are delivered, should be the authority to administer this scheme. Should it be true that another 25 per cent. of births occur in voluntary hospitals that does not. upset our framework. The balance of the argument would still come down on the side of the larger authority, because arrangements will have to be made bringing in the voluntary hospitals and as the voluntary hospitals sometimes serve four or five boroughs, it is better that the larger authority should make the arrangements. My right hon. Friend the Minister is always sympathetic in considering an application under Section 62 of the Local Government Act, 1929, whereby a maternity and child welfare authority employing a whole time medical officer of health can itself apply to be made a supervising authority under the Act. I agree with the hon. Member for North Kensington (Mr. Duncan), who pointed out that there was at present a good deal of overlapping between the supervising authority and the maternity and child welfare authority. In future, where you have a Salaried service under a large supervising authority, you will be able to assure a much closer co-operation between the authorities.

Mr. DUNCAN

Does Section 62 apply to London?

Mr. SHAKESPEARE

No.

Mr. DUNCAN

It is Section 64 which applies to London?

Mr. SHAKESPEARE

The hon. Member for St. Alban, (Sir F. Fremantle) asked whether a midwife in the country could practise nursing and other health services. The answer is "Certainly". The phrase in Section 1 of the Bill is, "the employment of midwives as whole time servants," and in country districts it is the best economy that the village nurse should undertake general nursing in case of emergency.

Sir F. FREMANTLE

It is not only in cases of emergency that village nurses are at work. Midwifery may be only a small part of their services.

Mr. SHAKESPEARE

That is so. As long as the midwife gives whole-time service she can carry on doing nursing work in the ordinary way when not employed as a midwife. The hon. Member for Jarrow (Miss Wilkinson) hoped that the salaries to be offered will not bear any relation to the present low remuneration of midwives. The general idea is that the new service should be properly remunerated and bear comparison with the remuneration given to health visitors at present under local authorities. The question as to the meaning of the words "net earnings" in relation to the question of compensation, is really a Committee point, but let me say that what we intend by that phrase is that the compensation to midwives who retire voluntarily or compulsorily should be based upon the actual amount they have earned. We can do this in no other way. It is quite impossible to compensate on some hypothetical basis, on some assumption as to what the midwife might have earned if she had been in a different area. We have to find out the actual amount of her earnings.

Sir F. FREMANTLE

Are the actual earnings those paid in cash, or are they the book earnings, many of which have not been paid and may be bad debts?

Mr. SHAKESPEARE

Her earnings are the amount which she has received.

Mr. M. BEAUMONT

The Parliamentary Secretary has said that this is a Committee point. Shall we be able to debate it in Committee as the Money Resolution is drawn?

Miss RATHBONE

Why is it impossible? Surely the number of cases on a woman's book is known; that is not hypothetical.

Mr. SHAKESPEARE

If you are compensating a doctor you do so on his earnings and not upon the amount he might have earned if he had been in a richer area. The hon. Member for Walsall (Mr. Leckie) put the case of an aged midwife who had earned £100 a year. If she is compulsorily retired at age 60 she will receive £500, which will enable an annuity of 22s. 6d. per week to be paid to her. I cannot believe that that is not generous compensation. Hon. Members will realise that this is the first Bill which provides compensation in the case of the State setting up a service. The hon. Member for Frome asked whether local authorities will be able to provide houses for their midwives. The answer is yes. Local authorities have adequate powers to do that now. It may interest the hon. Member to remember that the first recorded house in the Bible is in connection with midwives. When a certain Pharaoh found that the children of Israel were too fertile he instructed two famous midwives to strangle the Israelite male children at birth and when these midwives refused because they feared God he gave them houses.

Mr. K. GRIFFITH

The Parliamentay Secretary says that the question of the net annual emolument is a Committee point. Is that true? In the Financial Resolution we have the words "the average net emoluments," and we shall have committed ourselves to that before we get to Committee.

Mr. SHAKESPEARE

I am not saying that Amendments can be moved to increase the charge, but that the definition of the word "net" can be considered in Committee. The hon. Member for Mile End (Mr. Frankel), who has had considerable experience in hospital administration, asked whether the voluntary associations would undercut the supervising authority, and the answer is "No," because, as he will see in Clause 1, the scheme must include areas which are served by either kind of authority, and it is not the intention that there should be any undercutting.

Mr. FRANKEL

Clause 1 does not cover the question of assessment.

Mr. SHAKESPEARE

The scheme to be submitted will, of course, cover that point, and the supervising authority will naturally take it up with the voluntary association. The hon. Member for Deptford (Mr. Green), whom I should like to congratulate on his very interesting speech, asked as to the date of retirement of a midwife. There is no date mentioned in the Bill, and naturally it would be a matter of arrangement between the supervising authority and the county nursing association, but there is this exception, that if the midwife takes direct employment under a supervising authority which has a superannuation scheme, that scheme as a rule makes provision for retirement at a certain age, usually 60, with a possibility of extension to 65.

Now I come to my hon. Friend the Member for Aylesbury. I think it is a great mistake to look at this scheme as though there were some conflicting interest between municipal authorities and voluntary associations. Those who have any knowledge of administration in this connection know that you can only get the best results when there is perfect cooperation and confidence, and it is really foolish to try to praise one at the expense of the other. Everyone knows that long before municipal efforts were begun in these matters, voluntary efforts had done magnificent work. Whatever you may say against the Durham County Council, you cannot at least say that it is anything but Socialist. The Durham County Council willingly and freely make a grant, what to? To the county nursing association, and work in perfect harmony with that association, and the miners are so interested in the county nursing association and the district associations that they will not even let their wives serve on the district committees. All these committees are served by the miners themselves when they come home from their shifts. They then get down to the business of these committees. I give that as an example of the harmony that does and should exist between municipal and voluntary efforts.

I think I have covered most of the points that have been raised in the Debate, so let me, in conclusion, agree with the point made by the hon. Member for Westhoughton that this is not the only solution of this problem. We only claim that this is the most urgent improvement that should be effected. We all rejoice that at long last this Bill provides a basis of just remuneration and recognition for those women who for a generation have performed this vital service of midwifery under almost impossible conditions. Everybody, to whatever party he may belong, will welcome not only the fact that this recognition is paid, but that we are organising a secure and salaried service to perform this very vital function.

11.5 p.m.

Mr. WOODS

There are one or two points which particularly concern the borough that I represent and if the Parliamentary Secretary makes a further reply, I should be glad if he would deal with them. They concern the contribution from the Exchequer towards additional costs. It is well known that in some areas the whole of this matter has been practically ignored or left to some voluntary organisations, whereas in ether areas there has been fairly considerable expenditure in connection with it. One of the things of which we are proud in Finsbury is our maternity service, which shows what results can be achieved in that direction. We are able to rejoice in the fact that during three of the last four years not a single maternal death has occurred in the whole of the borough, and in one year the figure was 1.9 per thousand. Such an achievement has been built up over a period of time and has involved expenditure.

I submit that it would not be fair to say to such a borough that its additional expenses will be infinitesimal and that therefore the grant it will get will be infinitesimal. If anything, such a borough ought to be rewarded for having been a pioneer. I am hoping that any additional expenses that may be incurred in Finsbury will be as a result of our bringing into operation a service which we feel is vitally necessary to complete the service; we are giving to our citizens, I would like to know whether in such a case the additional services will be dealt with generously. I would like to know further whether there will be any provisions for extensions of our service on the maternity side? We are anxious to make experiments and to extend it so that every mother after childbirth shall have adequate convalescence. We do not believe it is possible for the average mother in tae conditions which prevail in Finsbury, to have anything approaching convalescence in her own home. The results to which I have referred have been achieved in spite of the fact that there is considerable overcrowding in Finsbury, and I would point out that in a survey of overcrowding in the London boroughs which was recently made, Finsbury was. third on the list. If it is at all possible we want to have a real convalescence service so that the mother, with her baby, can go away and rid herself of the burden of domestic cares, and escape the sordidness of many of the homes in which the poor people have to live. I would like to know whether, in addition to the other grants, the Minister will be able to make any additional grants for such an extended service.

Question put, and agreed to.

Bill accordingly read a Second time, and committed to a Standing Committee.