HL Deb 14 May 1895 vol 33 cc1130-41

Order for Second Reading read.


said, he need hardly assure their Lordships that he approached the performance of the task he had set himself under a deep sense of the responsibility which attached to him, not because he had any doubt or misgiving as to the strength of the case which he had to set forth, or that he had any doubt of the need, the clamant need which existed of reform in this matter; but owing to the feeling that he would not be able to do full justice to the strength of the case, and lest the excellence of the case be lost sight of through his failure adequately to perform his part. He would have preferred to see the Bill introduced by someone whose position arid previous experience and training would have been recognised as giving him a right to speak upon the subject. Personally, he approached the question as a layman and he hoped without prejudice, and unbiassed by any past controversies. In taking it up he endeavoured to ascertain the opinions of those who were entitled to express an opinion from technical knowledge, whether on one side or the other. He consulted, so far as he had the power, persons who held official positions. He had the opportunity of having two interviews with the present President of the General Medical Council, and he had also the advantage of the advice and counsel of many personal friends, members of the profession of Medicine, and well entitled to form an opinion on the subject. The information he had been able to get together led him to the conclusion that a case for this measure, or something like it, could be presented, which, so far as its main outlines were concerned, must carry conviction to every unbiassed mind. He supposed their Lordships would expect anyone who undertook to move the Second Reading of this Bill to prove to the House two things—firstly, that an undoubted evil existed; and secondly, that the remedy proposed proceeded on safe and wise lines, and would not bring in its train evils greater than those which now existed, or even any evils at all. As to the first point, he must rely largely on the evidence of others. Anyone who studied the Returns of the Registrar General would see that there were every year in this country between 800,000 and 900,000 births, and he thought it would surprise many of their Lordships when he said that more than half of those births were attended by midwives only, without any intervention on the part of a fully qualified medical man. Of course it was the case, but it would not lessen the interest their Lordships took in the matter that the great proportion of those cases must take place amongst the humbler or labouring classes of the community. It was also universally acknowledged that the great majority of the midwives who attended those cases were almost wholly, if not wholly, untrained, and were, in too many instances, lamentably ignorant of the important duties they undertook to discharge. In this country alone, amongst European countries, was no care or supervision exercised over the calling of the midwife. It was actually the fact that at the present time no conduct, however improper or disgraceful, would prevent any woman from undertaking and continuing this calling. Even the fact that a woman who had undertaken it had been convicted upon a criminal charge, would not justify any authority in intervening and preventing her continuing the practice. The state of matters consequent upon this was, by competent medical authorities, proclaimed to be that the mortality amongst mothers of the classes who chiefly employed these women was much greater than it ought to be, and much greater than it might easily be. In addition to that, the reports of the out-patient departments of many of the hospitals which were set apart for the treatment of diseases to which women were more peculiarly liable, were crowded with cases showing most lamentable results which had arisen from incompetent attendance during childbirth. In the case of children it was not too much to say that a very large proportion of the cases of ophthalmia, and of partial, and even in some instances of total, blindness, were due to the same cause. This was no new question. It had a long medical and Parliamentary history. They might search the Transactions of the General Medical Council for nearly a quarter of a century, and they would find constant references to it. That Council had, over and over again, committed itself to the support of a Bill which would run upon the lines of the one he had the honour to submit. They had resolved— (1) That this Council regards the absence of public provision for the education and supervision of midwives as productive of a large amount of grave suffering and fatal disease among the poorer classes, and urges upon the Government the importance of passing into law some measure for the education and registration of midwives. (2) That, if any department of Her Majesty's Government were constituted controlling authority in relation to local arrangements made under statute for the licensing and registration of midwives, the Medical Council would, if the Government Department so wished, be willing to advise as to the general rules of education, examination and discipline, which ought to be established in the matter. The first of those resolutions was proposed and the second was seconded by Sir Walter Foster, who was now Parliamentary Secretary to the Local Government Board. The College of Physicians had passed resolutions quite as strong. In 1891 they passed the following resolutions:— (1) It appears that there are from 10,000 to 15,000 midwives practising in England and Wales, many of them entirely uneducated and incompetent. This must be taken as an existing fact which cannot be ignored. (2) Midwives are under careful State Regulation in all the other principal countries of Europe, and, in the opinion of your Committee, the education, examination, and registration of midwives in Great Britain are urgently required in the interests of the women they attend. The usual organs of medical opinion had from time to time been equally emphatic. The Lancet had this in its editorial columns:— The records of our coroner's court within the last twenty years would furnish material enough to fill many columns of The Lancet with said illustrations of the fatal results caused by the ignorance, and, what is worse, by the persistent recklessness, of these women in refusing to send for medical aid when it is imperative. It is bad enough in large towns and cities, but what must it be in remote villages and hamlets far away from medical aid? Legislation is absolutely necessary to prevent ignorant and incompetent women from practising for gain to the danger of those women who employ them. A drunken old hag could not obtain a situation as nurse to a hospital or workhouse, but there is nothing to prevent her putting a brass plate with 'midwife' under her name on her door. In this simple fact lies the whole question to be solved. The British Medical Journal had not been behindhand in expressing a similar opinion. Frequent allusions were made to the same matter in the summing-up of coroners and in the finding of coroners' juries. The Home Office were so impressed last year with the importance of this branch of the subject that they sent a communication to the General Medical Council calling their attention to a letter from the Borough Coroner of Bridgwater in which that gentleman said that at an inquest held by him the jury appended the following rider to their verdict:— The jury desire strongly to censure Jane Rugg for not calling in medical assistance upon difficulties arising in the deceased giving birth to a child, and are of opinion that the Legislature should interfere to prevent women acting as midwives unless trained and certificated for such purpose. One more piece of evidence would be found in a recent charge of the Recorder to the Grand Jury at the Old Bailey. The Recorder said:— He regretted very much that the registration of midwives was not compulsory. To his mind registration was of the utmost importance, and he hoped that a Bill dealing with this subject, which had for some time been before Parliament, would eventually become law. Such a law was necessary in the interests of the poor, who might then look forward to the fact that if registration of a midwife; was compulsory, there would be some guarantee that she was able to perform her duties. Anyone at present could call herself a midwife, however ignorant she might be of the very first principles of her duties. The Parliamentary history of the matter was not less striking or important. In 1878 a Bill was introduced into the House of Lords by the Duke of Richmond, then President of the Council, but the part dealing with the Registratration of Midwives did not ultimately receive the Assent of the Legislature. In 1890 another Bill was introduced in the House of Commons, and proceeded as far as the Second Reading, but then fell a victim to a not uncommon practice; and those who opposed it, being unable to defeat it on its merit, had recourse to the device of talking it out. In 1892 and 1893 the House of Commons appointed a Select Committee to consider the question, which sat during two years. In 1892, the Committee reported as follows:— This evidence has shown that there is at present serious and unnecessary loss of life and health, and permanent injury to both mother, and child in the treatment of childbirth, and that some legislative provision for improvement and regulation is desirable. The Report of 1893 stated:— Your Committee are of opinion that a large number of maternal and particularly infant deaths, as well as a serious amount of suffering and permanent injury to women and children, is caused from the inefficiency and want of skill of many of the women practising as midwives, without proper training and qualification. Nothing, however, had been done, and no one with a candid mind could read the Report of the Committee without seeing that the following points were established beyond all possibility of doubt:—(1) That midwives did attend the women of the humbler classes in great numbers, and without the supervision of qualified medical men; (2) That midwives were a necessary class; (3) That in very large proportion they were quite untrained and uneducated, and therefore not fit for the important duties which they undertook to discharge; (4) That the mortality amongst the women whom they attended was greater than it ought to be, and that other injuries and evils followed from their want of skill; (5) That education and supervision would do much to reduce these evils, although they might not do away with them altogether. At present there was no proper authority exercised, and no proper standard of teaching. Before these could be secured, the Legislature must give the necessary statutory powers. He would quote the testimony of a man, whose name would be received with respect and attention, as one of the highest authorities in the country—Sir John Williams. Writing a few days ago, he said:— 64, Brook Street, Grosvenor Square, May 11. Dear Lord Balfour,—In common with a very large number of medical men, I am grateful to you for introducing into the House of Lords a, Bill for the Registration of Midwives. The large number of births attended by midwives alone, and the frequency of serious, and even fatal, results arising from ignorance on the part of midwives of the process of natural labour, make it most desirable that the poorer women of the country, who are unable to obtain the services of a medical man, should be able to secure the help of a midwife who has an elementary knowledge of midwifery. The mortality after childbirth is considerably greater than is generally supposed. This mortality is due to two classes of cases, one being preventable and the other not preventable. That due to preventable causes forms the larger section, and amounts to two-thirds or three-fourths of the whole. The preventable causes consist of infection and some forms of abnormal development and departure from the natural mechanism; and upon a knowledge of the means for preventing infection and an ability to distinguish abnormality at an early period depends success in preventing or reducing mortality. It cannot be doubted that the mortality of childbed among the poorer classes would be greatly reduced if the women attending them possessed the elementary knowledge to which I have referred. I am, my Lord, yours truly,—JOHN WILLIAMS. Could anything be more striking? According to this high authority, there was a large mortality due to preventable causes. It meant that this preventable loss of life might fall in the most tragic manner on otherwise happy homes. Let noble Lords think of the labouring man, in the prime of life, with steady and fairly paid work, and healthy children; and imagine the sudden loss, by preventable causes, of a useful life—a loss turning all the happiness and prosperity into misery and despair. He would next turn to the second part of the question—Were the proposals contained in the Bill a well-considered and wise measure of reform? The provisions were short and simple. First, they provided for the registration of midwives, and prohibited those who were not registered from using the title of "Midwife." The Bill did not prohibit unregistered women from practising as midwives; that could not be done. Common humanity would permit anyone to go to the assistance of a fellow-creature in pain or misery, and it was impossible to forbid that assistance being accepted. The Bill in this respect followed the precedent of former legislation. The Medical Act of 1858 prohibited any person from wilfully and falsely pretending to be or take or use the name of a physician, doctor of medicine, &c. The Dentists Act of 1878 provided that a person shall not be entitled to take or use the name or title of "Dentist," &c. Then, there was the Veterinary Surgeons Act of 1881, which provided that no person "other than a person who for the time being is on the register of veterinary surgeons," should "take or use the title of veterinary surgeon or veterinary practitioner." Parliament had actually taken more care of the animals under human charge than of women who were attended by midwives. Finally, there was the precedent of the Pharmaceutical Society. The right to use the title "Pharmaceutical Chemist" was restricted to certain persons by the provisions of the Pharmacy Act 1852, and the right to use the title "Chemist and Druggist" was restricted to certain persons by the provisions of the Pharmacy Act 1861. Therefore the Bill proceeded on the sound and well-considered lines of measures already accepted by Parliament. Next, the Bill formed a Board which would keep the register and admit midwives to registration after proper examination. The Board would also make rules for examinations and for the guidance and control of midwives in their calling. In all these matters, the Board would be subject to the control of the General Medical Council, and the Bill in this part differed a little from the original draft published in some of the medical papers, one reason for this was that it had been altered to meet the wishes of the President of the Medical Council himself. Then certain privileges were given to those on the register—such as the use of the title of "Midwife," the right to recover fees by law; and it imposed penalties for fraud and for disobedience of the rules. All those specialists on the diseases of women whom he had consulted, approved of the form in which the Bill was drafted. Some objections had been urged against the Bill, and one very prominently. It was that the Bill introduced a new class of medical practitioners—that it was going to put women on a different footing from men in this matter, because no man was a qualified practitioner until he had qualified in each of the three branches—medicine, surgery, and midwifery. But this was an objection that could not be sustained. The Bill did not turn these women loose without control. It simply provided that they should be so far qualified as to be able to recognise the limits of what they ought to attempt, and to recognise them early enough to call in a qualified medical man. It was impossible to prevent the women from practising, and was it better do what was possible in the way of improving their position, increasing their education, developing their facilities of training, and putting them under a certain control and supervision? If this Bill did nothing else, it would for the first time give the means and power to the people who employed the midwives of discriminating between those who were qualified to a certain extent and those who were not. There was no means of giving effect to the registration of midwives at present except by the action of a voluntary body, which had not been altogether popular. Another highly technical objection was that it used the expression "natural labour," which could not be defined in an Act of Parliament. The point he wished to impress on these objectors was that while, at the present time, midwives often did not know when labour was going on naturally and when it was not, the amount of attention and training to be given to them would enable them to know when the services of a medical man were necessary. He could fortify himself by an authority which he thought their Lordships would accept on this point. Two years ago, after the Report of the Select Committee was issued, The Lancet had a leading article on the subject. It cast a great amount of ridicule on those who took the objection to which he was referring. These were the words of the article:— We have not much sympathy with the remark that it is impossible to define 'natural labour.' We live in a practical world, and it is not impossible to lay down rules of conduct intelligible to women of any training that will enable them to know when to send for medical assistance, and enable those who supervise them to know when they have been culpable in not so sending. That was the answer which they gave to the objection, and they hoped that it would be regarded as a satisfactory one. There was, however, one objection which had not been raised which he felt bound to refer to for fear of misconstruction. It had not been actually suggested, but it was impossible to be blind to the fact, that it had been hinted that one effect of the Bill would be to take away business from medical men. Their Lordships knew the medical profession well enough, however, to believe that such an objection would not be raised by any large body of it. But if it were raised, it was an objection which Parliament would not listen to for a moment. He thought that their Lordships held the medical profession in far too high esteem to believe that any large body of doctors would raise a narrow-class interest of that kind against what he believed to be a great reform. So far from the Bill having this effect, however, he believed that the effect of this legislation would be to teach women when to send for medical advice, and the essence of the whole question was prompt and early attendance. This was no question of Party conflict; it was one of domestic reform. He believed it to be one of the greatest importance to a large class who were little able to help themselves. Some measure of this kind was a clamant necessity in the interests of public health, as well as in the interests of common humanity. The Bill would afford at least a chance to those most interested to know whether those they employed were possessed of reasonable knowledge and skill, or whether they were dangerously, and, he might add, criminally ignorant. There were the three proverbial courses before Parliament in this matter. To let the matter alone, a course which he thought no one would be found to defend; to prevent midwives altogether from exercising their calling, which he thought was not possible; or to accept some wise and well-considered reform, such as that which he had endeavoured to explain to their Lordships, and to the Bill enacting which he hoped most earnestly their Lordships would give a Second Reading.


said he took a great interest in this subject. They were all agreed as to the necessity for educating midwives, but there remained behind one consideration to which their Lordships ought to give attention. They ought to do justice to the 8,000 or 10,000 women who were at present engaged in this occupation—admitted to be a necessary one. The women, under this Bill, would not be able to obtain any education at all, be cause the Bill placed education almost out of their way. It raised the standard too much, and no doubt it was a measure which pleased the doctors very well. He did not blame the doctors; naturally they wished to exalt their art to the utmost; but the effect of the Bill would be to refer everything to a Council on which there were no lady doctors or laymen. A strictly professional Council would make regulations for the midwives. There was not a hint in the Bill of the recommendation of the Select Committee of the House of Commons that there should be local examinations, and that the local infirmary and local hospital should be utilised for the purpose of educating those women. Then, again, the Select Committee of the House of Commons recommended that the County Councils should have a controlling power; and they ought to have. It was, indeed, a local question. The whole Bill, however, was a centralised system of education in London of a most expensive character, quite unattainable by those poor women. He could not imagine anything wilder than the way in which that Bill was drawn. The Bill depended on the definition of midwife— a woman who undertakes to attend cases of natural labour with the direction and supervision of a medical practitioner. No such thing; a midwife never "undertakes." in a legal sense, or in any way, with the direction and supervision of a medical practitioner. This was a specimen of the little consideration which had been given to the details of the Bill. He thought that the object of the Bill was most excellent; but he trusted that it would be referred to a Select Committee, and that due care would be taken to see that midwives were properly represented on the Council. Above all, the examinations of midwives should be local, and the expense ought to be reduced to the lowest possible point.


said, the Government had no objection to the general principle involved in the Bill, though they considered that, probably, several Amendments might be necessary. If the noble Lord would put himself in communication with the Privy Council he thought that the suggested Amendments would commend themselves to him, as he hoped they would be found useful to the general public. There was certainly a large amount of ignorance among the midwives engaged in cases of natural labour throughout the kingdom; and there wag, undoubtedly, also a great deal of preventible illness which would not occur if more competent midwives were engaged. At the same time, the Government had always found it extremely difficult to deal with the question on account of the interests involved. This was not the first or the tenth time that this subject had been before Government. It was considered two centuries ago very seriously by the Governments of the day; and during the time that the medical Acts were passing through Parliament in 1878 the Government prepared clauses which were objected to by the Medical Council on the ground that they thought the subject should not be mixed up with medical reform; therefore, the clauses for the protection of women from unskilled midwives fell to the ground. The noble Lord said that he was justified in trying to define what "natural labour" was which midwives, qualified or not, might attend. That was one of the points of weakness in the Bill. He admitted that it was extremely difficult to define. The Bill mentioned that they might attend cases of natural labour, but if it was unnatural that then the medical man should be sent for. He thought that there must be some definition of this kind, but cases of unnatural labour were not frequent. Out of 15,000 cases analysed 983 in the thousand were cases of natural labour, and only for the balance were midwives obliged to send for the medical man. Still it might cause a considerable amount of litigation, and persons would not know their powers under the Bill if it was left as vague as at present. Then there arose a serious question. The Bill provided that no one should call herself a midwife alone or with an adjective unless she had been examined, certified, and registered. Now midwife was one of the oldest words in the English language, and it would be extremely difficult for any Bill to create a monopoly in the use of the word, and to say that persons who were not registered should not call themselves midwives. It was an old Saxon word, which arose from the woman getting mede, a guerdon, or a reward for her services. Their Lordships could not, therefore, monopolise it for one class of persons—an educated class, who were to exercise an art with skill. They might say "registered midwives" or "qualified midwives," but to take the name of midwife, which was the common property of all women, engaged now or in the future in this work, would be exceedingly difficult without some restriction. He called attention to Clauses 8 to 12 simply because he feared that they enjoined so much and were so elaborate that in practice they would defeat the Bill and prevent its success. They would prove to be so costly in their administration that it would be exceedingly difficult to make the Bill work. He thought that the fee of two guineas for examination and registration was too high for persons of this class. He believed that more money would be obtained if a lower fee was taken and if the examinations were local as well as central. He assured the noble Lord that personally, as well as officially representing the Privy Council, he had much sympathy with the Bill; but he would ask the noble Lord to postpone its further consideration for a little while, so as to enable the Government to consider what Amendments they should put down before the Committee Stage.


said, that he cheerfully accepted the suggestion of the noble Lord who had just spoken, not only to confer with the Privy Council as to the details of the Bill, but also to consult him and other noble Lords before putting down the Bill for Committee.

Bill read 2a.