HL Deb 14 July 1936 vol 101 cc769-92

Order of the Day for the Second Reading read.

VISCOUNT GAGE

My Lords, this is a Bill to amend and improve the operation of the existing Midwives Act and the measures existing for the regulation of midwives in this country. I think it is important to emphasise the limited scope of the Bill at the very start. There are some very complicated and insistent problems connected with maternal mortality, and a great deal of money is being spent on its prevention every year. In fact, the amount has been increased from £2,000,000 in 1927 to £3,000,000 today, and yet maternal mortality persists at an average of about four deaths per thousand births. This figure, which is a serious figure, but not necessarily alarming, has been causing much concern to the Ministry and its medical advisers. There are many theories put forward as to the cause. Although it is true to say that the average figure is four per thousand, actually there is considerable variation in different parts of the country, and attempts have been made to attribute this variation to bad housing, malnutrition, and similar causes. Although nobody would deny that bad economic conditions do play a part, they by no means explain why, for instance, the mortality at Bournemouth is, on the whole, higher than that at Birmingham.

One fact, however, has been established from prolonged examination of the work of existing organisations, particularly such organisations as the Queen's Nursing Institute. The conclusion of the Joint Committee and other competent observers is that where an adequate midwifery service exists, the statistics of mortality are always invariably lower than the average. It seems, therefore, that if we could succeed in grading-up all over the country the conditions of the midwifery service to those which exist in the better organised districts, we should succeed in reducing the incidence of maternal mortality as it has been reduced in those better organised areas. That is what we propose to do in this Bill. We propose to require certain authorities to provide that from the "appointed day" every expectant mother shall be enabled, as a minimum service, to receive in her home the assistance of a qualified certificated midwife.

So far I do not suppose any member of this House will object to that aim and object, but I am aware that in matters appertaining to medical services there is a difference of opinion between ourselves and noble Lords opposite on methods of administration. I do not think anybody, whatever his Party, would decry or minimise the services rendered by the voluntary associations or the voluntary hospitals, but noble Lords opposite are inclined to express the opinion that the time has come when these voluntary associations should be superseded by the State or municipalities. It is perfectly true that in maternity matters as in other medical services the gradual growth of these services has presented, and is presenting, some very diverse features, but we believe that the tradition and the public spirit which animate voluntary organisations are so valuable that every effort should be made to retain them with as little disturbance as possible. Accordingly, the machinery of this Bill is designed to secure that, although the supervising authorities should have the ultimate responsibility of seeing that certain standards of requirements are carried out, a large measure of elasticity should be given as to how to bring that about.

Some supervising authorities which are already well organised will obviously be less affected by this Bill than others, except that the Bill will ensure the maintenance of standards in the future; in others the authorities will be required to provide greatly improved and extended services. But when we consider the varying conditions in the country, how progress has been made, in some cases by well-organised services of domiciliary visits by qualified midwives, under perfectly good schemes, in other cases by a well-developed system of institutional treatment and by the admirable assistance given by the voluntary hospitals, I think your Lordships will generally agree that the Government have been wise in giving to the supervising authorities a considerable measure of discretion while insisting that the broad objectives should be achieved.

I should like now to outline the effect of this Bill on the three most interested parties—the midwives, the administrating authorities, and the mothers. Obviously, it is highly important that we should secure an adequate number of properly trained midwives. At present some midwives are certificated and are employed at a regular salary. Some are properly qualified nurses who do a certain amount of maternity work, also on a salary basis. Another class have certificates, but work in independent practice. Finally, there is—chiefly in the large centres of population—a class of women with no qualification whatever, who are really not midwives at all, but who do, under the supervision of a doctor, act as midwives and receive remuneration from the patients they attend. There are so many undesirable features attaching to the employment of this unqualified class that the Government have come to the conclusion that the time has come for their abolition. The Bill accordingly proposes that when, and where, the Minister is satisfied that adequate arrangements have been made under the Bill for a proper service, he may make an order making it a penal offence for an unqualified person to receive any remuneration for assisting in medical cases. The Bill also aims at making considerable changes in the class of the independent but certificated midwife. With the fall in the birth-rate the position of this class has become increasingly difficult. Competition has been severe, and in many places they are unable to make sufficient income to maintain them in circumstances appropriate to the importance of the work they are doing. We are aiming in this Bill at the reduction by a large number of these independent midwives. We hope to bring this about partly by absorbing a considerable proportion of them in the new extended salaried service, partly by offering them compensation for voluntary retirement, and partly by giving the supervising authorities power compulsorily to retire some of those who are older and more unsuitable—again with generous compensation. While reducing thus the number of this class, I think it would be just to pay tribute to the work of the certified independent midwives who have in the past few years often given their services with very little remuneration and considerable self-sacrifice.

On the other hand, we anticipate that the schemes to be submitted by the supervising authorities will provide in some cases for a considerably increased number of salaried midwives, and although we are not breaking the accepted practice of leaving the supervising authorities free to engage their employees on terms which they think fit, nevertheless we believe that the status and conditions of service, including provisions for superannuation, will be greatly improved. Further, we are making financial provisions to assist the supervising authorities to this end. All these suggestions follow the recommendations of the Joint Committee on Midwifery. Your Lordships will understand that these changes are to be brought about by the supervising authorities who have to submit schemes to the Ministry.

I may perhaps say a word or two about the position of those administrating authorities. It has not been by any means an easy task to determine what authorities should be made responsible. On the one hand you have the authorities which have hitherto been responsible for the Maternity and Child Welfare Act, and there is much to be said in favour of making those who are responsible for ante-natal and child welfare work equally responsible for the period of childbirth. At the same time it is essential, if the scheme is to operate efficiently, that the machinery should be capable of supporting economically the appropriate number of midwives to give them all sufficient work, sufficient leisure, proper supervision and opportunities for promotion. If the authorities who are entrusted with this work are too small, you might well have a position constantly arising where the midwives in one area were overworked and in another area, adjoining, where they had nothing to do, and, after much deliberation, the Joint Committee and the Standing Committee in another place decided in favour of the supervising authorities.

In particular, a great deal of discussion centred in another place on the question so far as it concerned London, where, of course, the borough councils are particularly important and responsible bodies, but the complications of making a scheme which preserved the present arrangements, whereby the voluntary hospitals have given such immense and successful assistance, were so great that it was decided by a large majority to adhere to the principle of the Bill—namely, that the supervising authority (in this case, the London County Council) should be responsible. I would like, however, in this connection, to emphasise this point, which is clearly brought out in the Bill, that when the supervising authority prepares its scheme it must consult not only the Welfare Council—that is to say, those who are responsible for ante-natal and post-natal treatment—but also the voluntary organisations. Indeed, the position of these other interested parties is statutorily safeguarded and they are given the right of appeal to the Minister if they consider their claims have been ignored. It is felt by my right honourable friend the Minister that where possible it is preferable, where services have to be extended, that this extension of services should take place by an extension of the scope of existing voluntary schemes, and that only where this is not possible should the supervising authority engage the new midwives themselves.

I may perhaps say a word about the finance of the scheme. It is apparent from what I have said that in most cases the supervising authority would be put, if unaided, to considerable expense. Under the Local Government Act it was laid down as a general principle that where new work and new expense was imposed on local authorities, special consideration should be given by Parliament in addition to the normal block grant increase, which is I think about 23 per cent., in respect of any new approved expenditure. This Bill will lay on the supervising authorities expenses in connection with the compensation of the retiring midwives, and it is proposed that grants of 50 per cent. of the temporary expenditure should be made from the Exchequer to cover that expenditure. Then there is a further liability in respect of the cost of the additional new salaried midwives, and here again the Exchequer will make a contribution based on a formula similar to that on which the block grant is calculated, so that the necessitous areas, such as Merthyr Tydvil and Sunderland, will receive about four times as much proportionately as the more prosperous centres, such as Eastbourne. It is rather difficult to say exactly how the financial arrangements will work out until the scheme is properly under way. I have, accordingly, no figures to lay before your Lordships. Although the intention is, after the first five years, to merge this special financial arrangement into the block grant scheme, it is provided in the Bill that Parliament shall have a further opportunity to review the arrangement at the end of the next quinquennium.

I have dealt with the midwives and with the local authorities and now I will say a word on the mothers themselves, who, after all, are the class we desire to benefit by this Bill. I can explain that quite simply. What we hope to achieve in this Bill is to enable every expectant mother, whatever her circumstances, to obtain the services of a qualified midwife in her own home, and she will be given some choice of midwife. In return she will be expected to make a contribution according to her means, but power is given in necessitous cases to scale this down to nothing at all. To summarise, the status and security of the midwives will be raised, the mother will get a greatly improved service, and the supervising authorities will be assisted financially to bring this about, while the position of the voluntary associations, as I have already stressed, will be safeguarded.

In conclusion I should like to call attention to one or two points in connection with the clauses of the Bill. Clause 1 is a most important clause. It places on the supervising authority the obligation to prepare a scheme. It should be noted that the scheme must provide for the whole-time employment of a sufficient number of midwives for attendance not only as midwives but as maternity nurses. I have already referred to the necessity for consultation with the interested authorities and voluntary organisations, and your Lordships will note that the supervising authorities are not required themselves to engage midwives unless they are not satisfied that existing arrangements can be extended or adapted to cover the midwifery requirements of the district. They are, however, given considerable latitude as to how to carry out the intentions of the Bill. Clause 2 deals with the notifications to the midwives, and Clause 3 with the recovery of fees. In that connection I must point out that the wording follows that of Section 14 (4) of the Midwives Act, 1918. Clauses 4 and 5 deal with the calculation of Exchequer assistance and compensation respectively. Your Lordships will notice that the midwife may appeal to the Minister if she is dissatisfied with the amount of compensation.

An important provision of Clause 6 is that which gives the Minister power to make it an offence, when he is satisfied that an adequate service is in existence, for any unqualified person to practise midwifery. The importance of this provision is that although the whole of this scheme is based on trusting the supervising authorities and giving them wide discretion, nevertheless it does give the Minister some control over their progress. The other clauses are self-explanatory. I might perhaps add that although the sketch of the Bill before your Lordships is somewhat slight in view of the great benefits that we hope to achieve from it, I hope that the principle will receive your Lordships' endorsement and that questions arising on it will be more of a Committee nature. I beg to move.

Moved, That the Bill be now read 2a.—(Viscount Gage.)

THE EARL OF ONSLOW

My Lords, I would like to say a few words on this Bill, especially as regards one particular clause. I have been connected with a lying-in hospital for about twenty-five years and I heartily welcome this Bill, which I am sure will have an excellent effect. My noble friend mentioned the question of maternal mortality. He attributed that unfortunate state of affairs to various causes. This Bill, as my noble friend said, is intended to enable every woman in the country to have a qualified midwife to attend her in her own home, but the question arises as to the efficiency of the midwives available to give that service. The hospital which I mentioned just now bought up just after the War—I think it was in 1919—the practice of a midwife who was retiring and took over two houses and put in a staff of instructors. They opened there refresher courses for midwives practising anywhere but mainly for those practising in country districts whose opportunity for keeping up to date was perhaps not so great as in the case of women practising in larger cities. That has been very successful, and the number of women attending these courses has grown very considerably in the seventeen years that the centre has been in existence. The class of midwives who take these refresher courses of instruction includes midwives of long standing, those who have been trained but have not actually taken up practice and want to refresh their memory and skill, and those who want to do some practical work before they start in practice on their own account. We have taken women from voluntary institutions all over the country.

Experience has shown that the original course, which was for one month only, was greatly improved when it was extended to two months. We find that a woman coming from a country district to London finds herself rather at sea and wants time to settle down. I am told that the ratio of advantage of the course is about twenty-five per cent. for the first month and seventy-five per cent. for the second month. Therefore, when refresher courses are instituted, as I trust they will be all over the country, I hope that local authorities will see that courses extend over two months, and if possible throe months, because I dare say that would be even better than two months. The system inaugurated in 1919 has had very beneficial results especially to those who had not had the opportunity of seeing the latest developments in their profession, those who practise in remote country districts. I shall be glad if my noble friend will tell us what arrangements are being made to institute refresher courses of this kind in provincial districts. It would be interesting to know what steps are being taken under Clause 7 because I regard that as one of the most important clauses in the Bill. All midwives should have the advantage of being able to take a course of this kind.

THE EARL OF LISTOWEL

My Lords, I am sure that many of you will rejoice with me that the noble Viscount who gave birth to this Bill in your Lordships' House should be blessed with such an easy delivery. It is indeed one of the few measures that can claim to be born in Arcadia. The Bill has had a smooth and easy passage in another place where it met with no opposition from any Party and it looks as if it were likely to receive as favourable a welcome in all quarters of your Lordships' House. We on these Benches are heartily thankful that the Government do seem at last to have recognised that the provision of adequate maternity services for the working-class population must be a public and a national responsibility, and cannot any longer be left to the well-intentioned but necessarily limited efforts of voluntary hospitals and nursing associations or to the private enterprise of medical practitioners and independent midwives. That is to us a very welcome turn in the policy of the Government as regards this particular branch of public health.

We are agreed that this measure is a small but substantial contribution towards the establishment of a national maternity service because it really does guarantee for all poor mothers, wherever they may live, whether in rural or in urban districts, the attendance of a qualified and certificated midwife at the time of childbirth. That I think is the essential change that is effected by this Bill. Hitherto the power of local authorities to provide midwives was merely optional. Now it is mandatory, and the larger local authorities from the passing of this Bill into law will find themselves under statutory obligation, assuming trained midwives are not forthcoming from other quarters, to see that there is a sufficient supply in their area to meet the needs of every working-class home.

But it is impossible for me to continue to shower bouquets upon the Government. We are, I think, justly entitled to complain that action in so urgent a matter should have been taken much earlier. For the last ten years there have been 3,000 deaths annually owing to difficulties and complications during childbirth, and approximately half of all those annual deaths have been preventable. This, I think, is what has been so profoundly shocking to the public conscience. I should like, if I may, to quote an important passage from the recommendations of the Departmental Committee on Maternal Mortality. This Committee of experts, of doctors, of those who are best acquainted with the subject, drew up a unanimous Report, and among its conclusions the following sentence appears: We are confirmed in the opinion expressed in our Interim Report that at least half the deaths which have come under review could have been prevented had due forethought been exercised by the expectant mother and her attendant, a reasonable degree of skill been brought to bear upon the management of the case, and adequate facilities for treatment been provided and utilised. That is to say that every year there have been about 1,500 unnecessary deaths owing to the lack of proper provision for mothers during this period of childbirth.

The figures to which I think the noble Viscount alluded and which appear at this point most strongly are those that give the mortality rate of four per thousand mothers for the whole country, and two per thousand in those cases where salaried and certificated midwives had been provided by the Queen's Nursing Association or by maternity hospitals. They show us more clearly, I think, than anything else the amount of damage that has been done by neglecting to provide the proper facilities. Now, the Official Report of the Departmental Committee on Maternal Mortality appeared in 1932. Why have we had to wait for four years for the Government to introduce a Bill? That means that every year 1,500 lives, approximately, have been sacrificed through the dilatoriness and inertia of our present Government.

This Report, which is, I suppose, the most thorough survey available on the subject, stresses other factors which are operative in producing the high rate of maternal mortality, besides the one that is alluded to and dealt with in this Bill. It mentions, for instance, besides the inadequate midwifery service at present in existence, under-nourishment, which is due to poverty. It stands to reason that a perfect state of physical health is necessary for the mother if she is to be able to stand the strain of childbirth, and that under-nourishment both diminishes her powers of resistance and produces certain minor ailments which in the case of the mother are peculiarly dangerous. I will refer to only one of these, and that is rickets. Your Lordships are fully aware that rickets is an ailment produced entirely by lack of proper diet in small children. It produces a malformation of the bones owing to a lack of minerals in the food, and this in women often has the effect of narrowing the pelvis. I should like to refer for a moment to what those who drew up this Departmental Committee's Report say upon the effect on maternal mortality of this peculiar complaint. They say: Rickets, now a preventable disease, has a most important bearing upon maternal mortality, and its prevention should substantially reduce the maternal death rate. It may be said that rickets is a comparatively rare complaint and therefore that no special steps need to be taken to cope with it. This is unfortunately not the case.

The medical officer of health of Stockton-on-Tees has just made a very interesting inquiry into malnutrition which shows that of 2,676 elementary school children in Durham whom he examined, 83 per cent. showed some sign, at any rate, of rickets. This is not peculiar to the poverty-stricken North; it is equally evident in the South, where at any rate conditions are better. There it was found that of 1,638 elementary school children in London, no less than 87.5 per cent. showed symptoms of rickets. This bears out the fact that we in this country are suffering from a problem that is not insoluble but which must be solved if we wish to lower really considerably the maternal death rate. We must be able to provide a proper diet of fresh milk, fresh vegetables and so on for small children in these early months and years when their bones are being formed. The figures of Dr. M'Gonigle, the medical officer of health for Stockton-on-Tees, bear out the statement of the distinguished expert on malnutrition whose report, which appeared a few months ago, made it perfectly plain that approximately half of the inhabitants of the country were suffering in some degree, at any rate, from under-nourishment. That, of course, is a factor in maternal mortality which the Government have not dealt with and which is naturally not touched upon in the present Bill.

There are, in the few moments at my disposal, two other important causes of maternal mortality and maternal morbidity with which I should like very briefly to deal. Recommendations as to how they should be dealt with by the Government also appear, very much underlined, in the Report of the Departmental Committee which was appointed in 1928 by the Home Secretary. The more important of these two factors is ante natal care. This Report stresses very strongly the inadequacy of the treatment that is provided at present in ante-natal clinics. What is absolutely indispensable, if we are to save many lives that would otherwise be lost, is that there should be a sufficient number of antenatal clinics for every expectant mother to be able to go to them and take advice, and that these ante-natal clinics should be staffed with doctors who have special knowledge of gynaecology and obstetrics or who are specialists in those subjects. That is the first and most fundamental change that we must see. The second is that we are bound, sooner or later, to provide a grant for expectant mothers which will enable them to provide a diet which every doctor would prescribe. Those of your Lordships who are married and have children know perfectly well that an expectant mother has to have a special diet. It is exceedingly important for her to obtain fresh milk, fruit and vegetables, and to obtain them in greater quantities, and a poor wife cannot afford those luxuries unless there is a special fund provided from the public purse. Those are the two steps forward which we must take and which the Government appear practically to ignore.

Finally, there is the last factor with which I shall deal, the question of postnatal care. It ought to be taken for granted that every mother at the end of the lying-in period should have careful medical supervision for at least six weeks, and unless this is provided it is perfectly certain that a great number of mothers will suffer for the rest of their lives from the ill-effects of giving birth to a child. We want that provision, and we want also the provision on a much larger scale than hitherto of home helps. I do not say that work in the home is in itself necessarily very injurious to a mother, assuming she has children or a husband who can do the harder manual jobs, but one has to remember that in the working-class home there is a strong, if not an overwhelming, temptation for the mother to rise from her bed of sickness before her time. She is anxious about preparing meals for the children, about the cleaning and tidying-up of the house, and it is very difficult for her to neglect her home, as she imagines, because there is nobody to do the work. I therefore think that in time we shall have to come to see that there is a provision of home help for a mother during the period that immediately follows childbirth. That is all I have to say on this very vital subject from the point of view of the whole working population of the country.

I should like to point out to the noble Viscount, because he raised the point himself, that we do not object to voluntary maternity hospitals and nursing associations—that we welcome the very valuable work they do. What we do object to is the using of them as screens for the deficiencies of the present system, and as excuses for public authorities not providing what private initiative is unable to give. What we hope to see is friendly co-operation between the voluntary associations and the local bodies who will have to work the Bill. There is no doubt that taken in the right spirit they can help one another to a large extent. This Bill is a step, if not a very long step, towards the provision of a really adequate and nation-wide maternity service, and it is a movement in the direction of providing in a larger measure for the great bulk of the population—for the working people—those benefits and facilities that at present are reserved almost exclusively for the well-to-do.

VISCOUNT MERSEY

My Lords, I am asked by Lord Gainford to say that the Liberal Party welcomes this Bill generally, although it may have been rather overdue. I should like, myself, to make certain observations on two points only. The first is that there has evidently been a good deal of consideration by the Government as to whether this supervision should be transferred from the borough councils to the county councils. I have had the advantage of consultation with the noble Viscount, and he assures me that the matter has been thoroughly thrashed out in another place, and that the conclusion the Government have come to is the best solution, and I am prepared to accept that statement.

The other point is as to Clause 6. Clause 6 says in effect that no woman other that a certified midwife or a State registered nurse shall attend a woman in childbirth. My advisers on this matter—I do not pretend to be an expert—inform me that the State registered nurse has not really got the qualifications necessary for a maternity case, and that a maternity nurse would be a much more effective person to employ than the ordinary State registered nurse. It is further said that out of 57,000 midwives now on the roll of the Central Midwives Board only 15,000 are practising. At present there are too many midwives trained, thus seriously interfering with the training of medical students, and State registered nurses are given no teaching of this nature in their general training and therefore are quite unfit to act as maternity nurses. I do not know whether that is only a Committee point, but I have mentioned it to the noble Viscount and I now venture to mention it again, in order that when he replies he may tell your Lordships what the position really is.

LORD JESSEL

My Lords, I wish to call your Lordships' attention in connection with this Bill to a piece of special machinery. When this Bill was presented to another place there was a long and very useful explanatory Memorandum which was printed and sent round with the Bill. When the Bill comes to your Lordships' House there is no explanation at all, and I would like to ask the Government whether in future, in cases of this kind, we should not be afforded the same generous treatment as is afforded in another place. There are several difficult matters in this Bill which were fully explained in the Memorandum, and I hope the Government in the future will see that we are equally well served in this matter as the members of another place. I may remind the noble Lord, who represents the Opposition, that during the time when his Party was in power we got a very good Memorandum from the Minister of Transport in which the places mentioned in an Order of the Ministry were inserted in the Orders of this House. I do not want to delay the House by referring further to this matter, but I think it is of importance.

The noble Earl who spoke for the Opposition began with pæans of praise for this Bill. In the middle of his speech he was rather critical, and I am afraid he dilated a little too much on questions which are not quite germane to the Bill, the question of rickets, for example, and he introduced the old controversy of the treatment of Park Lane and Poverty Corner. However, he did end by saying that his Party—and I was glad to hear him say so—had no objection to working with the voluntary hospitals and co-operating with the big welfare associations which do such good work in all parts of the country. If I might correct him in one matter, he was not entirely right when he said that this Bill had an easy passage in another place. It did not by any means. There was a great deal of controversy in the Standing Committee and the Bill had to be recommitted, in pursuance, it is true, of a pledge given by the Minister to the Opposition, as regards the number of days that a midwife should attend. The Bill was recommitted in respect of that pledge—namely, to increase the number of days from ten to fourteen, with a little elasticity if it was thought fit.

I think a great deal of alarm may have been occasioned among expectant mothers by some of the speeches that have been made in another place and up and down the country in respect of maternal mortality. The latest returns show nearly 600,000 births and a little over 3,000 deaths of women in childbirth. That is a large figure, no doubt, but you have to take into consideration that children are brought forth by many mothers who are naturally not fit, however well attended they may be by midwives or others. Also it is a curious thing that the position in life of the mother is no criterion. Some women bear children much more easily than others. I have known it in the same family; one woman, in exactly the same circumstances as another, has difficult parturition, when another finds it perfectly easy. In the same way, we find in the animal world that less well-bred animals have a much better chance in many cases than the more nervous highly-bred animals. I think it is rather a mistake to say that many of these deaths are due to want of care, because I believe that when they are investigated it is found that a great many of them are due entirely to the fact that nature is not the same in all cases and physical strength and physical attributes are different in different people.

I myself think this is a very good Bill. I am always rather interested to hear when those opposed to the Government, on whichever side of the House they are sitting, say it is a pity that this or that Bill was not brought in earlier. The fact is that we have now such a mass of legislation that only a certain number of things can be done at one time. At all events we have got the Bill, and we all welcome it, and I think it is a great step in advance, and a great social reform. There is one point to which I should especially draw your Lordships' attention. It was a question that was raised at considerable length and provoked considerable controversy in another place—the case of London. As regards statistics of maternal mortality London compares most favourably with the rest of the country. The figure for the rest of the country is 4.2 per thousand, whereas in London it is only 2.2, and we pride ourselves here in London on our ante-natal and post-natal services. The boroughs in every part of London have cither had a midwifery service instituted or have made arrangements with voluntary bodies to provide a midwife. What I regret is that now the London County Council is to be the supervising authority and we are going to have two authorities for the mother instead of one. That seems to many of us a great mistake. The Standing Joint Committee, which is composed of representatives of all the twenty-eight boroughs of London, very strongly objected to handing this matter over to the London County Council.

I might say for the information of your Lordships that the majority of the borough councils in London are not of my Party, they belong to the Party opposite, and by a very large majority they were against the County Council having this power. The London County Council very naturally, like all bodies which want more power to their elbow, decided—both parties—in favour of the powers being handed over to them. I must say that for the midwives it is contended that they would, by being put under the supervision of the London County Council, be all on one list, and there could be promotion, and they could go to refresher courses. On the other hand I am not at all sure whether this is going to be a good thing. There is, however, power in the Bill as far as I can understand, for the Minister to decide, after representations from a borough, as to whether the present system may be allowed to go on, simply with the supervision of the London County Council. I hope that will be so. In the City of Westminster, where we have been most successful in these matters, we have made arrangements with the Westminster Hospital. We did employ midwives, but we did not find them a success and now the system is much better.

I hope therefore that the Minister, when the matter comes before him and there is an appeal made to him by the boroughs interested, will take into consideration what has been done by these services in London of which we are all extremely proud. I hope that the same fate may not await the boroughs which overtook them some years ago when they approached the Minister on the question of the devolution of powers. Under the Act—I think it was the London Government Act of 1900—there was an appeal to the Minister when both parties were not agreed that certain powers should be devolved. The result was that after months of controversy the inspection of slaughter houses and the transfer of the Thames Embankment and certain small gardens of less than three acres were handed over to the City of Westminster at a cost of £12,000 a year to the City of Westminster. I hope that a better arrangement will be made this time.

The real truth of the matter is that the London County Council has got too much to do. I quite agree it is a good thing that it should have this supervisory power. It seems to me that the Ministry which the noble Viscount represents in this House might hand over a good deal of its supervisory power to the London County Council, and the County Council could hand over a good deal of the detailed work to the boroughs, which are quite competent to do it. I think that in this Bill a retrograde step is taken. I am not going to challenge it in Committee because I know very well I should not get much support, but I felt bound on behalf of the boroughs of London to make this protest, and, having done so, I wish the Bill God-speed during its remaining stages.

LORD BAYFORD

My Lords, I cannot follow my noble friend into the London controversy, but, taking the Bill as a whole, I think the noble Earl who spoke from the Front Bench opposite is quite right when he claims that it is a step towards making midwifery a national service. Although it may become a national service altogether in future, it ought never to be forgotten that some of the very best work that has ever been done by voluntary effort has been done in this cause. Some forty years ago midwifery was entirely haphazard. There was no supervision of it of any sort or description and it was then that in various districts people put their heads together and started district nurses who had a midwifery training.

I remember its being done nearly forty years ago in a remote part of the West Country. I remember the nurse being obtained. She was paid a salary that would be looked upon as wholly inadequate at the present time, but wherever she went she was entertained. She had to be put up by the patients or by their relatives, and as a means of transport she generally had to ride a horse—a matter which, I think, might present some difficulty to a good many of our present-day midwives. She certainly did a very great deal of good in that district. The same thing was going on all over different parts of the country, and by degrees various district nurses for whole counties or great parts of counties were brought together. But all that time it was purely voluntary effort; it was essentially a series of charitable associations. It is quite true that the subscribers were entitled to free treatment from the midwife, who was also a nurse, and their wives were entitled to midwifery treatment; but the fees collected in that way were not nearly enough to keep these associations going and to pay the nurse, so for a long time they remained entirely charitable associations. In a great many cases the county council stepped in and helped.

The system that we now have in my own county is that the County Council makes a very considerable subscription towards the county nursing association, but the executive power, the management of the whole system, is in the hands of the voluntary association; the inspector being, I think, paid half by the association and half by the County Council. We find that that system works perfectly well, but I do not want to disguise for a moment that if you had people out to make difficulties—if those who are managing on the side of the County and those who are managing on the side of the district nursing association were not getting on together—considerable difficulty might arise in working the system. This Bill, wisely, I think, supports the existing system as long as it can be continued, but you must not forget the difficulties with which these associations have to deal.

First of all, they have to find nurses to train. I am informed that that is by no means an easy job, and that it is getting harder and harder. If, as is rumoured, the period of training is going to be increased that will not only make it harder to find candidates for the nursing profession: it will also make it more expensive, because you have to pay all the time during that period and you are getting nothing for your money. I said I hoped the system would continue, but we have got to face the fact that it depends on being able to collect in the County a very considerable amount of money in the course of a year. That is getting more and more difficult. They have to rely very largely indeed upon getting subscriptions from those who get no benefit whatever from the nurse. I do not suppose that actual fees come to more than a slight proportion of the annual receipts. We have got to face the fact that in a great many districts eventually the local authorities may have to take the service over.

I want to say a word or two about one or two points in the Bill. First of all as to finance. The noble Viscount who explained the Bill was very candid about finance. I think he told us that on this point the Bill was not particularly intelligible. I wonder if he can enlighten us on this point—namely, whether it is the fact that the counties which have, up to now, spent most money on promoting the nursing service will come off worst in the matter of grants? In this House we cannot alter that, even if it is so, but as I read the Bill that seems to be the case, and it seems a little hard on those counties. As to the matter of fees, there is a clause in the Bill—I think Clause 3—dealing with this matter. Will any model fees be laid down? I suggest that it is worthy of consideration whether the Minister should not lay down some scale of fees or else ask the counties or the authorities to let him have their scale of fees before they actually put them into force. The danger I see is making the fees too low. You can always remit fees, you can always reduce them, but it is a fact that in these associations very often people who are perfectly well able to pay a considerable fee for the services of a midwife, by belonging to the association get off very cheaply indeed. If any scale of fees is laid down, as I think it ought to be, so as to get uniformity in the various counties, I hope that point will be taken into consideration.

Only one more point, and that is with reference to the provision in Clause 1 and Clause 2 as to women being employed as whole-time midwives. I think it must be the intention of the Government that that should include a whole-time nurse who gives part of her time to midwifery and part to other nursing services. That is a point that has been raised by the County Councils' Association. I think that it ought to be made clear, and I am putting down an Amendment on the subject which I hope the noble Viscount will look at with favour. I hope the Bill will have a fairly easy passage through this House because I am sure it is a Bill that will do good.

LORD ABERDARE

My Lords, I rise especially to try, if possible, to correct an impression which, I think, is prevalent as to the inadequacy of the fees paid to midwives generally. It is a fact that of the independent midwives, of whom we have heard there are far too many and only a few practise, most are inadequately paid; but it is a fact that those midwives who are paid by those. associations which are affiated to the Queen's Institute of District Nursing, although not as highly paid as one would wish, still are fairly well paid. But the chief point is that they are in regular employment. I do not wish to detain the House this evening, because the points which I had intended to make have been very well dealt with by the two noble Lords who have just spoken. I did wish, however, to congratulate the Government on bringing in this Bill, which I think is a very good Bill. I am sure the Government will give all credit to the Joint Council of Midwifery for their memorandum of last year on which, I think, they have based this Bill. I hope, too, that credit will be given to the Queen's Institute, the Central Midwives Board and the Midwives Institute for the suggestions and the Amendments, which they also got moved, all of which I think were adopted in another place.

I think that the Government are tackling this question in the right way by linking up the voluntary organisations with State effort. It seems to me that the human contact behind the voluntary effort in such a matter as maternal mortality and midwifery is of great value. I feel that the result of this Bill, although there will be a great deal of spade work to eliminate a certain number of midwives who have passed the age at which they may be expected to work, and to eliminate those who perhaps have not had sufficient training, will be that the status of the midwife will be raised and also that midwives will get a fairer reward for their services. The consequence of this should be—and I feel this is very necessary—that that status should be promoted, and that the remuneration should be sufficiently large to encourage women to come forward in increasing numbers to fill the very necessary places in this great profession. The feature of the Bill which pleased me very much was the encouragement given to expectant mothers to bear their children in their own homes. True, they have a choice of hospital if need be, but I think a great deal of encouragement should be given to mothers to have their babies in their own homes.

I was going to say one word on the question of publicity, which has frightened certain married women, but that point has been covered. I only hope that it [...] with good nursing [...] saved. The figure [...] to-night, of fifteen hundred lives per annum that might be saved, is not an over-statement. You have only to look at the figures for maternal mortality in England and Wales for the last two years. In 1934 the figure per 1,000 was 4.41, and in 1935, 3.98. Compare with this the cases, running to the number of 68,000, dealt with by the Queen's Institute of District Nursing, where the maternal mortality rate in 1934 was only 2.74 and in 1935, 2.56. This should be a source of great encouragement. A striking figure which I should like to give your Lordships is that for the last ten years, during which time 606,000 cases have been nursed by Queen's Nurses, the maternal mortality has been at the low average of 1.91 per thousand, which, in a rough way, compares, as far as I can make out, with the rest of the country of something over four per thousand. No wonder the Government have largely based their Bill on the results and experience of the Queen's Nurses and the village nurse midwives. I hope now that as a result of this Bill every expectant mother will have the chance of getting a midwife, that the status of midwifery all over the country will be increased, and that numbers of lives will be saved.

Finally, I should like to make an appeal to the Government to see whether the telephone could be installed free in the case of district nurse midwives, especially in the country. It is unnecessary for me to stress that point, or to give any reasons in support of it to your Lordships, as it seems to me the advantages are obvious. It seems a small expense, but at the same time it is a fact that even an expenditure of that nature is felt very much by the smaller district nursing associations, many of whom, as your Lordships well know, are in the Special Areas. I should like to congratulate the Government on this Bill and I hope it will receive unanimous support.

VISCOUNT GAGE

My Lords, I think we can congratulate ourselves on the successful reception given to this Bill. I made a few ineffectual efforts at the commencement of my remarks in the hope that I would be able to "head off" my noble friend opposite from discussing malnutrition and disease, which have really nothing to do with this Bill in particular, but I shall be very glad to hand him a very comprehensive answer to several points he [...] dealing with rickets, which can be extracted from my right honourable friend's speech on malnutrition in another place a few days ago. Perhaps we ought to congratulate ourselves on really being blamed for only half the maternal mortality of this country. My noble friend, I noticed, was kind enough to confine our liability as a Government to half only.

Some questions were asked by my noble friend Lord Onslow (and on a somewhat similar subject by my noble friend Lord Mersey) on the refresher courses. That is a very important aspect of the Bill. It is provided in Clause 7, as was pointed out, that these refresher courses should be held. My noble friend Lord Onslow wanted a little more information about the refresher courses, and he also asked other questions about the training of midwives under the new dispensation. It is a very important subject, as we fully admit, but I understand that the Central Midwives Board is at present formulating new provisions in its rules covering not only the training of new midwives but the details of these refresher courses. I can give an assurance with regard to schemes when they are laid, that my right honourable friend will consider the question of training in a general way and refresher courses in particular.

My noble friend Viscount Mersey referred to the large number of midwives on the roll who do not practise. We anticipate that the overcrowded condition of the midwives' roll will be greatly reduced by the scheme for voluntary and compulsory retirement. My noble friend Lord Jessel raised a point about a Memorandum. Inquiries are still being pursued as to who is responsible for the affixing of that Memorandum. I am not sure that it is not partly attributable to action in another place, but I would like to reserve any statement until that can be determined. I would point out to my noble friend that in London, as elsewhere, it is the desire of the Minister that successful arrangements that are operated to-day should be preserved as far as possible. I think he need have no fear that the schemes in which he is particularly interested—if they fall, as I am sure they within the category of successful shcemes—will toe in any way predudiced by this Bill.

My noble friend Lord Bayford referred to the scale of fees. I am informed that the actual drawing up of the scale of fees will not be done by identical methods all over the country and therefore it would be inapplicable to make a model scale of fees. We are endeavouring to trust local authorities as far as possible, but this is a subject of course on which my right honourable friend would require some information when schemes are submitted, and no doubt he will use his good offices to secure some change if he thinks it desirable. I think the other matters raised were largely Committee points and if they are raised at another stage I will do my best to answer them.

On Question, Bill read 2a, and committed to a Committee of the Whole House.