H— 31.

Briefly the initial work consisted of — (1) The registration of all maternity nurses in addition to the registration of midwives, which was already in force. (2) The adoption of a higher standard of training for midwives and maternity nurses under the control of the Nurses and Midwives Registration Board, acting with the advice of the Consulting Obstetrician. (3) The adoption of a standard aseptic technique as applied to the conduct of labour and the puerperium. (4) A system of inspection of all private and public maternity hospitals by a Medical Officer co-ordinating the work of the Medical Officers of Health and Nurse Inspectors for each district. (5) The establishment of a number of free public ante-natal clinics in charge of specially trained nurses acting under the direction of the Medical Officer of the hospital to which the clinic was attached, or the patient's own medical attendant. The activities of the Health Department to promote maternal welfare have been supplemented by the practising members of the medical profession, the British Medical Association, the Obstetrical Society, the Otago Medical School, and the Plunket Society, to all of whom a large measure of the credit for any results obtained must be accorded. Special acknowledgment is also due to members of the medical profession who responded to. the Consulting Obstetrician's efforts to reduce to a minimum interference with the natural course of labour. The Obstetrical Society has also done valuable work in bringing before the profession the necessity for better ante-natal care, and before the Otago Medical School the need for greater facilities for teaching the art and science of obstetrics. To promote the latter a fund of £31,700 was raised by public subscription and subsidized by a £10,000 grant from the Government. This fund was used to endow a Chair of Obstetrics at the Otago University arid provide travelling scholarships for the study of obstetric methods abroad. Since 1924 Hospital Boards have provided further facilities by increasing the number of maternity beds from 221 to 503 in addition to the establishment of more district maternity services conducted by registered midwives. The Plunket Society has established nine ante-natal clinics in connection with their infant-welfare clinics. The results of the activities above recorded are very clearly shown in the accompanying graph. It will be noted that the outstanding features are the marked decrease in deaths from puerperal sepsis following childbirth and an equally marked increase in the deaths from septic abortion particularly during the last two years. Puerperal Sepsis following Childbirth :— The steady and continuous decrease in the deaths from puerperal sepsis during the period following childbirth may be safely ascribed to the measures taken as outlined above. In order of importance I would place them as follows: (1) The teaching and application of the principles of surgical asepsis to the practice of obstetrics. (2) The reduction in vaginal examinations, internal manipulations, and instrumental deliveries, the rate of which latter, as shown by hospital statistics, has fallen from 14-5 in 1925 to 9-14 in 1931. The avoidance of instrumental deliveries has undoubtedly been made easier to the often harrassed general practitioner by teaching midwives and maternity nurses to relieve pain by the use of anaesthetics prior to the arrival of the medical attendant; and the reduction of vaginal examinations by teaching methods of palpation and rectal examination. as substitutes for the former more dangerous methods of the diagnosis and correction of displacements. (3) Almost entire elimination of epidemic sepsis from maternity hospitals, particularly by the exclusion of septic surgical cases from hospitals admitting maternity and other cases together. (4) By systematic ante-natai care detecting and eliminating septic foci in the expectant mother and by the same means detecting many abnormalities the correction of which helps to avoid a number of artificial deliveries. I regard the very steady reduction in the puerperal sepsis rate as a distinct encouragement to continue on the general lines initiated in 1924. Further development along these lines, together with the adoption of any new methods of preventing infection that scientific research may place at our disposal, should ensure a further reduction in this essentially preventable infectious disease. Septic Abortion :— The problem created by the rise in the death-rate from septic abortion is an entirely different one from that due to sepsis following childbirth. There can be no doubt that the majority of these cases are due to the practice of criminal abortion, the incentives to the practice of which are mainly social and economic. The economic factor is emphasized by the marked rise in the number of deaths occurring since the year 1928 and particularly in the period 1929-30. The fact that twenty-six out of thirty cases in 1930 and twenty-six out of twenty-nine in 1931 occurred in married women excludes sexual immorality as an important factor. Separate classification of the above two causes of death is of utmost importance for purposes of comparison with other countries. Unfortunately, England is the only country for which I have been able to obtain statistical results based on the separation of these two causes of death. In 1929 England's puerperal mortality-rate after excluding septic abortion was 3-96. The New Zealand rate for 1930 was the same and for 1931, 3-68. The means of decreasing this dangerous method of limiting families can best be dealt with by societies concerned with the welfare of women. If the enormous risk to life caused by criminal abortion was appreciated by those concerned it might cause some women at least to abandon that method of meeting a difficult situation.

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