H.—3la.

It is not, however, suggested that all general practitioners should be encouraged to practise midwifery, but there should be no difficulty in every community of any size in making available a number of well-trained practitioners who, without going to the length of full specialization in obstetrics and gynaecology have given special study to maternal and infant care, who are competent to give up-to-date service, and into whose hands the midwifery will naturally pass. Without any regulation or restriction of the rights of practice, this tendency is very definitely developing in New Zealand. In the larger towns, in addition to a group of practitioners of this type, there should be opportunity for certain practitioners to practise full specialization in obstetrics and gynaecology, thus developing the consulting and teaching sides of the service. The Committee is completely in accord with this tendency to partial and full specialization and believes that it is along these lines that the best maternity service will be developed in New Zealand, provided that it can be put within the reach of all. It is the opinion of the Committee, after full investigation, that, although the midwife system as it operates in this country is giving a safe and efficient service, the combined system of doctor and nurse attendance can give a still more efficient and a more satisfying service. Already, as has been indicated, some 75 per cent, of all cases are attended by both doctor and nurse. Is it possible to bring this combined service within the reach of all ? The Committee is of the opinion that this could be assisted in several ways :— (1) In communities with a sufficiently dense population the development of the larger public maternity hospitals to a size which would allow of the maintenance of a resident house surgeon would help materially. While not expert obstetricians, these house surgeons, if selected in the way advised, would be thoroughly qualified to supervise or administer fuller pain-relief and to act promptly in the emergencies which have been referred to, while they would act in close co-operation with the senior staff in all complicated cases. In a similar way the house surgeons in the larger public hospitals with maternity annexes could be used to give this service in close co-operation with the Superintendent or visiting staff ; this course is already adopted in some hospitals. Such a system would also be of the greatest benefit to the maternity service as a whole by giving opportunities for post-graduate training in midwifery, under supervision, to a number of doctors preparing to enter the wider field of practice. (2) In smaller hospitals provision could be made for the doctor-attendance of indigent cases by the Superintendent or by members of the visiting staff ; this plan is also in operation in some hospitals. (3) In the event of provision being made for doctor and midwife attendance under a health-insurance plan, many of the difficulties would be solved, with the additional advantage that many women, now unable to afford it, would be in a position to have the services of the doctor of their own choice. See reservations by Doctors S. G. de L. Chapman and T. L. Paget. 3. HOSPITALIZATION OR DOMICILIARY ATTENDANCE. A second primary consideration is the extent to which hospitalization or domiciliary attendance is to be recommended. It is found that the proportion of cases confined in hospitals or maternity homes varies greatly in different countries. Whereas in England and Wales only 15 per cent, to 25 per cent, of the total confinements take place in hospitals, in New Zealand 81-75 per cent, are so conducted at the present time. It will thus be seen that while in England and Wales hospitalization is largely restricted to abnormal cases, in New Zealand the greater proportion of normal midwifery, as well as the abnormal, takes place in hospitals. On this matter there is a good deal of difference of opinion. Those advocating the policy of domiciliary attendance for normal cases in Great Britain assert that the results where hospitalization is practised have been less satisfactory than under the system of attendance in the homes. The serious danger in hospitalization is the risk of transference of septic infection, and there can be no doubt that the inefficient hospital is a menace. If, therefore, the general maternity hospital standard is not a high one, it can be conceded that domiciliary practice will probably be safer. On the other hand, there are those who maintain that if adequate steps are taken to safeguard the patient through attention to equipment and staffing, the introduction of a standard aseptic and antiseptic technique, rigid inspection, and the insistence on accurate record-keeping and notification of abnormal cases, then the hospital system is safer than a domiciliary one. It is their opinion that it is a simpler matter to introduce completely satisfactory methods of maternity care into hospitals than it is into the average home. Once assured of the safety from the point of view of sepsis, the advantages of the hospital from the medical point of view are many, especially in the case of first births. This is not disputed

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