MATERNITY SERVICES (SCOTLAND) BILL. (Hansard, 27 April 1937)

§ LORD STRATHCONA AND MOUNT ROYAL
My Lords, I beg to move that this Bill be now read a second time. The main purpose of the Bill is to improve the standard of domiciliary midwifery in Scotland. It is based on the recommendations contained in the Report on Maternal Morbidity and Mortality in Scotland published by the Department of Health for Scotland in 1935, and these recommendations were in general affirmed by the Committee on the Scottish Health Services which reported in 1936. The Report of 1935 stressed the urgent need for making available in the home, to expectant mothers who could suitably be 32 cared for there, a comprehensive maternity service covering antenatal and postnatal care as well as competent attendance at confinement. The Bill accordingly aims at providing a domiciliary midwifery service of high standard, securing adequate nursing, medical and specialist obstetrical services for women confined at home.
The Bill covers a wider field than the English Midwives Act of last year. Scottish medical men take a much larger part in midwifery practice than their English confrères. The Bill takes account of this fact and is therefore not limited to a midwife service only. Under the arrangements proposed, every expectant mother who desires to be confined in her own home will be entitled to obtain the services of a midwife and a doctor. If the need arises, the doctor will be at liberty to call for the advice or help of an obstetrician of recognised standing. In some districts, such as parts of the Highlands and Islands, it may not, however, be practicable to make specialist help readily accessible. A thorough system of antenatal and postnatal care will be a fundamental feature of the scheme. The idea is to have a co-ordinated service of the midwife and the doctor acting in co-operation with the assistance, if need be, of the expert obstetrician. Local authorities are required to submit their proposals for providing the services of mid-wives to the Department of Health for approval. The midwife service may be provided, first of all, by arranging with voluntary associations employing midwives, or with midwives in private practice; or secondly, by setting up a local authority service of salaried midwives; or thirdly, by a combination of two or more of these systems. Authorities are required to consult with the voluntary associations in their areas and with any organisation which has the right to speak for the practising midwives. If dissatisfied with the arrangements proposed by an authority, these bodies may make representations to the Department.
As to the medical arrangements, local authorities will be free to select the type of arrangements they prefer for securing the medical services so long as the services are adequate. In some areas medical arrangements, other than those relating to obstetricians, may be made with all general practitioners in the area who are willing to take service on the terms 33 offered by the local authority. In other areas the antenatal and postnatal examinations may be carried out at the authority's clinics and arrangements made either with all practitioners or a limited number of those in the area to provide the intranatal service. No insuperable difficulty is anticipated in securing the services of qualified obstetricians in most areas. Adjoining areas may in some cases find it desirable to combine for the purpose of this specialist service. As in the case of the midwife service, the local authority is required to consult with any local organisation representing the medical practitioners in the area before submitting their proposals for the Department's approval, and any such organisation, if dissatisfied, may make representations to the Department.
The remuneration of midwives and doctors participating in the service will be a matter for negotiation between the local authorities and those with whom they propose to enter into agreement or their representatives. As these fees will be payable by the local authorities, one of the beneficial aspects of the scheme will be the elimination of "bad debts," which have hitherto been a source of much worry, particularly to midwives, who have been ill able to bear the loss. As regards the fees to be charged by the local authority to those who apply for the services, the Bill provides for the grading of the charge according to ability to pay. No fee will be charged to the necessitous. In the case of insured women, the wives of insured men, and others in like economic circumstances, it is expected that the inclusive charge for the whole range of services to be provided will not be much, if at all, higher than they pay at present for the services of a midwife alone.
Midwives who are not absorbed into the service under the Bill may wish to retire from practice. If they do so within three years after the passing of the Bill, they will be entitled to compensation equal to three times their average annual income from practice during the preceding three years. Many midwives have remained in practice after they have become unfit, owing to age or infirmity to carry out their duties in a satisfactory way. In these cases the local authority is empowered within three years of the commencement of the Act to require the midwife to retire, subject to a right of appeal 34 by the midwife to the Department of Health. Those who are so compelled to retire will receive compensation equivalent to five times their average annual income from practice for the preceding three years.
I do not propose, my Lords, to deal in detail with the finance of the scheme. One-half of the estimated additional expenditure imposed on local authorities by the Bill will be met by the Exchequer. In apportioning the grant among the authorities, each will receive 50 per cent. of its estimated additional expenditure, scaled up or down in proportion to the needs of the area as determined by the "weighted population" formula ascertained for the purposes of the block grant under the Local Government (Scotland) Act, 1929, as proposed to be amended. Local authorities will also receive from the Exchequer one-half of the compensation paid by them to retiring midwives.
There is one matter to which I must make special reference. Clause 6 of the Bill, the object of which is to prevent the attendence of unqualified persons on women in childbirth, contains a proviso excepting from the prohibition medical students and pupil midwives attending as part of their course of training. Fears were expressed, while the Bill was under discussion in another place, that under this exception it might be possible for students and pupil midwives in the early stages of their training to undertake the delivery of women, and the Secretary of State for Scotland undertook to look into the question whether there was any possibility that this might occur. In pursuance of that undertaking, the Secretary of State arranged that a conference should be held between the Department of Health and representatives of the University medical schools and of the maternity hospitals engaged in the training of midwives. The conference was held last Friday. The representatives of the training bodies assured the Department that the fears which had been expressed were groundless. As regards medical students, they pointed out that the effect of the recommendations of the General Medical Council was that no student could undertake any practical midwifery work until the latter part of the fourth year of his curriculum, and that before undertaking any domiciliary 35 case he must have had adequate theoretical and practical instruction in midwifery, including the witnessing of demonstrations and the delivery of women under qualified supervision, in a maternity hospital or ward. They assured the Department that the arrangements for training in every Scottish University are such as to ensure the safety of the patients, and have been recognised by the General Medical Council as complying with their requirements.
As regards pupil midwives, the rules of the Central Midwives Board for Scotland secure that the pupil, before undertaking any domiciliary case, shall, in addition to having received sufficient theoretical and practical instruction, including demonstrations, have delivered, under qualified supervision, five patients in a maternity hospital or institution giving a course of training which has been approved by the Board. No pupil midwife is trained in Scotland otherwise than in accordance with these rules, which are subject to the approval of the Department of Health for Scotland. It is clear, therefore, that neither medical students nor pupil midwives are sent out to the homes of the people until they have been properly tested out in the maternity ward, and have satisfied their teachers that they can be trusted with outside cases.
In view of the assurances which have been received from those responsible for the control and supervision of the courses of training, and for the observance of the conditions laid down, I feel justified in submitting that the Minister has discharged the undertaking that he gave. This House and those members of the House of Commons who voiced the apprehensions to which I have referred can rest assured that the great Universities and the maternity hospitals which have been approved as training bodies, as well as the General Medical Council and the Central Midwives Board for Scotland, are no less anxious than Parliament that the arrangements for training should be carried out in such a way as to safeguard the life and health of mothers and infants at every point.
It will be gathered from my brief description of the contents of the Bill that it is designed to secure a concerted 36 attack on the problem of maternal morbidity and mortality, which has long been disturbing the Government and all who are concerned about national health. The provisions of the Bill are flexible enough for adaptation to the varying needs of localities, while securing a general advance in the standards of home midwifery. Every effort will be made to secure the full co-operation, not only of the midwives, the practitioners and the specialists, but also, by suitable educative effort, of the women themselves. The Bill is submitted for a Second Reading in the hope that it will be favourably received by noble Lords of all shades of opinion as an earnest and constructive attempt to deal effectively with a problem of long-standing intractability. I beg to move.

LORD STRABOLGI
My Lords, may I first of all congratulate the noble Lord on his feat, which must be almost a record, I think, of introducing in quick succession three important and intricate Bills, and explaining them to the House with such ability and lucidity? All of them have a strong Socialistic tinge and therefore are the more acceptable to those for whom I speak in this House. With regard to the Bill immediately before your Lordships, I only want to ask one or two questions, and to make some brief general comments upon this very important Bill, which I believe, speaking personally and on behalf of those whom I represent in this House, we welcome very heartily indeed. If I understand aright, a midwife who is not perhaps up to date, or who is old and infirm, who retires voluntarily, receives the equivalent of three years earnings. If she does not voluntarily retire, but is compulsorily retired because it is thought she is not sufficiently up to her work, she receives five years earnings. If I read the Bill aright, obviously no one is going to retire voluntarily and receive three years earnings when by holding on until compulsorily retired she will receive five years earnings. I think, whether it be three or five years, it is not very big compensation to pay a woman who for many years may have trudged over the Highland roads or footpaths attending to women to the best of her ability. It is not very high compensation by way of pension or 37 grant to her, and I think that is the only blot which I see on the Bill.
The other question is this. I know parts of the Highlands very well, including the very beautiful part from which the noble Lord takes his title, and I know his property up there also. I have visited houses in the Highlands which are practically inaccessible for months in the year. I am thinking of shepherds' cottages in the middle of deer forests, where I have seen some of the most beautiful children I ever saw. The cottages are hundreds of feet above sea level and remote from everywhere, and they are visited once a week by a school mistress, under another Socialistic but excellent provision. Of course these children are a tribute to the excellence of the Highland air and to the magnificence of the Highland race. How are the provisions of this Bill to be applied in these cases, if the mother continues, as is to be hoped, to bear children? She is to have the services of some qualified doctor or gynæcologist and midwife, but you cannot get to those places in the winter, and it is very difficult in the summer. The usual means of transport is a pony, and I see the Bill is compulsory and not voluntary. I dare say that can be got over, but you cannot use aeroplanes in the present state of flying, because there are no landing places. Nevertheless I imagine that something is proposed.
With regard to the Bill itself, I welcome it very much. This is a very long step towards what my Party has advocated and continues to advocate, and will presently put in force—a State medical service. It is a very much larger step than is contemplated for England, and I congratulate the Scottish Office upon its courage, and also the noble Lord on introducing the Bill in this House. I hope the Bill will pass through all its stages as rapidly as possible, and will do much for what I consider to be the offspring of the finest race in the world.

§ LORD STRATHCONA AND MOUNT ROYAL
My Lords, it would be discourteous if I did not make some reply to the noble Lord who has just spoken. He mentioned the question of compulsory retirement of midwives. I understand that the scale laid down was recommended by the General Council of Midwives themselves. It is obvious that a midwife who is compelled to retire is 38 presumably more infirm and unable to carry on her work, and therefore is more entitled to a larger degree of compensation. She has, of course, been at her job for a longer time than the others referred to. With regard to the question of isolation, I appreciate the difficulty of the point which the noble Lord has put. I do not think the question of compulsion applies to those areas, but I will inquire and communicate with the noble Lord. He is aware of the admirable services which are done by the district nurses in those districts of Scotland, and I take it that they will for the time being carry on the noble work which they now carry on in very exceptional and severe circumstances.