H.—3la.

(2) The Case for Doctor-attendance. There are, however, many who consider that the ideal system is one in which the service of a practitioner, well qualified in obstetrics (though not necessarily limited to it as a speciality) are available for every mother during labour as well as in the antenatal and post-natal periods. They also can point to large groups of cases in which, under this system, an excellent and a safe service has been given. It is true that certain disadvantages associated with general practice have been suggested. The objection has been raised that the danger of contact with infection is greater in the case of the general practitioner than in the case of the midwife. This danger must not be overlooked ; but the extremely low incidence of sepsis in large groups of doctor-attended cases which have been recorded is clear evidence that, with proper care, the difference as between midwife and doctor in this respect is negligible. The charge is frequently made that owing to the exigencies of general practice there is much hurried midwifery ; whatever the justification for this suggestion may be in certain" instances, as a statement of general application it is an unwarranted reflection on the work of a very large body of conscientious practitioners. On the other hand, the personal control of the case by a competent doctor clearly has many advantages. Granted that the well-trained midwife can be trusted to conduct a normal case safely, yet there is an additional safeguard when the doctor himself assesses progress from time to time during the course of labour and is present at the delivery. This does not mean that the doctor must be prepared to spend hours of waiting in the first and second stages of labour performing a duty which a midwife or maternity nurse is quite competent to undertake ; the co-operation between nurse and doctor advocated by the exponents of this system definitely aims at avoiding non-essentials while ensuring that the doctor exercises general supervision of the first and second stages and is present at the delivery. A very important feature of modern maternity care is the great development of the use of sedatives and anaesthetics in labour ; such being the case, there can be no question that they can be used more safely and more effectively when controlled by the doctor. rt~is~E"very significant fact that, largely owing to this demand for pain-relief, an increasing number of women are seeking the services of a medical attendant even in Holland, where it is stated that only 60 per cent, of patients are now attended by midwives alone. The third stage of labour (immediately following the birth of the infant) is also a period of possible danger, and the presence of a competent doctor is undoubtedly a further security. The child's interests, too, are better served, since from time to time sudden emergencies in connection with the child arise in which the wider knowledge of a doctor may mean the difference between life and death. Finally, there is the important point that to be prepared for abnormal midwifery the practitioner must have a wide experience of normal practice. Tn New Zealand, as has already been indicated, the tendency is very definitely in the direction of combined attendance by doctor and nurse wherever the financial circumstances of the patient will allow it. Approximately 75 per cent, of the total confinements are attended by doctors, and there is a general consensus of opinion that the additional sense of security to be gained by a doctor's personal supervision is greatly to be desired. In framing a general policy for New Zealand, is this tendency to be encouraged or restricted ? The Committee is not impressed with the arguments of those who contrast the midwife system at its best with the doctor service at its worst. It is more concerned to decide which system at its best offers the fullest advantages from all points of view to the lying-in mother. If there have been in some instances in the past unsatisfactory features about doctor attendance, as can be freely agreed, the same can be equally definitely stated in regard to some types of midwife-attendance ; if it is possible to correct the faults , of the midwife system of the past, surely it is not impossible to do the same in the case of a doctor service. The question of real importance is the standard of training and practice of the attendants, whether they be midwives acting alone, or doctors and nurses acting together. Throughout this discussion emphasis has been laid on the necessity for competent obstetric help ; that being so, the implications regarding the training of medical students in midwifery are obvious, and every endeavour should be made to facilitate their training in the hospitals throughout the country. There are, and always will be, small and isolated communities where the doctor must work without other medical assistance ; it is therefore necessary that all medical practitioners likely to be engaging in such practice shall have reasonable experience in midwifery.

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