Part 16

The training for the examination of the Central Midwives' Board is based on the method pursued in medical education in English-speaking countries, viz., there is not one uniform course, but each of the training schools attached to hospitals follows out its own plan of training, each hospital having been approved by the Central Midwives' Board as giving an adequate training for its examination. There are now seven maternity hospitals in London, where women students may train in midwifery. Of these, only one--the Clapham Maternity Hospital (with its training school founded by Mrs Meredith in 1885)--is, and always has been, entirely officered by women. Here the course advised is six months, viz., three months in the hospital (Monthly Nursing), and three months in the hospital and district doing Midwifery proper. During this time over 200 cases may be seen, and nearly 100 cases attended personally. The cost of this training is £35 to £40, which includes board and residence for twenty-six weeks. Students previously trained elsewhere may take one months' extra training at a cost of ten guineas. Private doctors and midwives may also take pupils if recognised as teachers by the Board.

Midwifery training is now required not only by those who are going to act as midwives, but also by most missionaries, all fully trained nurses (for matrons' posts or colonial posts) and by health visitors and inspectors before obtaining appointments.

But it should be borne in mind, especially in considering the present condition and future prospects of Midwifery as a profession, that even now a large though ever-decreasing proportion of registered midwives are still ignorant women who have never passed the Central Midwives' Board or any other examination, and have had no teaching from any one more experienced or better informed than themselves. For when the Midwives' Act came into force in 1903, it was necessary to move slowly, and so a clause was inserted, permitting women who had been in _bonâ-fide_ practice for more than one year before 1902 to continue their work under inspection and supervision (with many attempts at teaching them by means of simple lectures and demonstrations). This plan, or some similar one, was necessary, not only in the interests of the midwives themselves, a set of decent and kindly, if ignorant women, who would have been ruined by too sudden a change, but also because a large number of mothers in England would have been left with no one to help them in their time of need unless they were prepared to run the risk of breaking the law. This, until recently, respectable English women disliked to do.

It is important to remember this fact, when considering the present and future prospects of the midwife. The untrained woman used to charge 5s. or 7s. 6d. for her services, and the fact that her name had been enrolled on the Government Register, that she was subject to the supervision of an inspector, without having spent anything on her change of status beyond the 10s. registration fee, did not suggest the need of any particular change in her scale of charges. Thus 7s. 6d. per case, unfortunately still remains the very common fee for midwifery, though this now involves, under the rules of the Midwives' Board, not only the long hours of watchful care at the birth, but ten days of daily visits to supervise both mother and baby, with careful records of pulse and temperature, etc., kept in a register. Naturally, the general public who employ midwives--viz., the poorer classes--do not differentiate between the trained certificated midwife and the untrained _bonâ-fide_ midwife whose name is on the register, and thus the scale of charges remains very low and the profession, as one for educated women, is thereby greatly injured.

Granted an intelligent woman is willing to give six months' work and study and £35 to £40 for her training, what chance has she of earning a decent living? If she could command 15s. or 17s. 6d. per case afterwards, she could make a decent living, given fairly hard work and the acceptance of real responsibility. If she had 100 cases a year, she would earn £75 at 15s. per case, and so on. This rise in the fees payable to midwives has just been made possible by the National Insurance Act of 1911, the framers of which appear to have recognised the necessary result of the Midwives' Act of 1902. As the _bonâ-fide_ midwife, who has received no training, gradually dies out, it becomes necessary to provide the means of paying trained midwives, whom the people are obliged to employ in place of the old ones, but who would soon be non-existent were the means of paying them not also provided by the State.

A 30s. maternity benefit is now given for every confinement of an insured person or the wife of an insured person. As the patient may have free choice of doctor or midwife, it seems possible, now that it has been established that the benefit shall go direct to the mother or her nominee, that hereafter the greater part of it may be paid over to the person who can supply that most necessary item of the treatment, i.e., good and intelligent midwifery with nursing care of mother and child. Therefore, it is the right moment for the careful, well-trained popular midwife definitely to raise her fees to all "insured" patients, being still willing to help the poor at a low fee as before. It should be remembered that in about one-tenth of all her cases, medical help will be required, but this case could probably be guarded against by an insurance fund, if properly organised.

We frankly admit that as things now stand--apart from the possibility of the maternity benefit being made to help her--midwifery is financially but a poor profession. But to an enthusiastic lover of her kind, who has other means or prospects for her future than the proceeds of her profession, there is much that is attractive in this most useful calling.

Now let us turn to a consideration of the poor mother. Dr Matthews Duncan in 1870 put the puerperal mortality at 1 in 100 for in-patients and 1 in 120 for patients in their own homes--shocking figures for a physiological event! Miss Wilson, a member of the Central Midwives Board, stated in 1907 that the average mortality of English women, from puerperal fever, a preventable disease, is 47 in 10,000 or _1 in 213_, but that in three of the best lying-in hospitals this figure has been reduced to less than _1 in 3,000_. To quote Miss Alice Gregory in her article on this subject in _The Nineteenth Century_ for January 1908: "We feel there is something hopelessly wrong somewhere. It becomes indeed a burning question: By what means have the Maternity Hospitals so marvellously reduced their death rate?"

The answer is not now far to seek in the opinion of the writer, who has worked continuously at Midwifery since 1st May 1884. It is probably wholly contained in the three following points:--

(1) All that makes for scrupulous asepsis in every detail for the surroundings of the mother.

(2) The absence of "Meddlesome Midwifery."

(3) Pre-maternity treatment, a factor which the writer considers to be of great importance, and of which she would like to have much more experience.

By this is meant the building up of the future mother's health by improved hygiene and careful, wise dieting and exercising and bathing during the last three months of pregnancy, which enables many a stumbling-block to be removed out of the way. Hence, the utility of pre-maternity wards wisely used. This is, one knows, a "counsel of perfection"; but every expectant mother should and could be taught how to treat herself wisely at this time.

These three points are all in favour of the well-trained midwife.

(1) _Scrupulous Asepsis_, if intelligently taught, can be learned in six months' training, though one feels bound to add it requires moral "grit" in the character to make one unswervingly faithful in observing it. The midwife, too, should run no risk of carrying infection from others, as a doctor might do.

(2) "Meddlesome Midwifery" is not so much a temptation for the midwife as the doctor, though she also may want to do too much. Patience combined with accurate knowledge when interference is urgently needed, is part of her training.

(3) The midwife who becomes a wise friend to her patients will be just the one to whom the mother will gladly apply early, and who will know if it is advisable to send for skilled medical advice. Contracted pelvis, threatened eclampsia, and antepartum haemorrhage are typical cases, which lose half their terror if diagnosed and treated early.

If ever it is recognised that good midwifery is at the root of the health of the nation and the new maternity benefit is made to help in obtaining it, it will at once become worth while for educated and intelligent women to take to the profession seriously. A practice could then be worked by sets of two or three midwives in co-operation, and with proper organisation as regards an insurance fund for securing operative midwifery from medical practitioners when necessary.

There is ample room for a much larger body of trained midwives than exists at present, if the health and welfare of the nation are to be secured, while the women themselves could, under these conditions, earn a sufficient livelihood.

Trained nurses also specialise in midwifery. They take the full course of training described above, completing this by passing the Central Midwives' Board Examination. They do not practise for themselves, but work only under doctors, thus replacing the monthly nurse. The improvement in health and comfort of both mother and child, when nursed by some one thoroughly competent, is very marked.

The fees which they receive for this work are usually 12 to 14 guineas for the month, and in some cases may rise to 18 guineas.

XIII

MASSAGE

This work demands a healthy body and cheerful mind, a love of the work, endurance, and much tact in dealing with the nervous cases for which this form of treatment is found to be beneficial.

It may be undertaken either

(1) As a separate profession, or

(2) As an additional qualification by trained nurses.

The training must be good and adequate to ensure any success as a masseuse, so great care should be exercised in the choice of a school. The many training schools advertised are of varying degrees of efficiency, and those prepared to train in a few weeks, or by correspondence only, are obviously unsatisfactory.

On application to the secretary of the Incorporated Society of Trained Masseuses, information can be obtained with regard to the training schools in London and the Provinces where a course of instruction in massage is given, which is accepted by the society as adequate.

The society itself is an independent examining body which insists on a satisfactory standard for massage workers. It holds two examinations yearly and grants a certificate to successful candidates. No one may enter for the examination unless she can show that she has received her training at one of the schools approved by the society.

Adequate training in massage includes a course of not less than six months in Elementary Anatomy and Physiology, the Theory and Practice of Massage and a course of bandaging. Students usually attend the classes from 10 A.M. to 4 P.M., lectures being given in the morning, demonstrations and practical work on "model patients" in the afternoon hours.

Sufficiently advanced students are allowed to attend at hospitals or infirmaries to see--and themselves to carry out under the teacher's supervision--the treatment ordered for the patients by the doctor. In this way all students have opportunity during their training of seeing and giving treatment to the various cases which they may have to deal with as qualified masseuses when working under private doctors.

Some training schools give their own certificate after training, and this is useful as a guarantee of the training taken. It is not, however, such an assurance of efficiency to the medical profession or the general public as the certificate gained after examination by an independent examining body.

There is also a further examination held by the society once yearly in Medical Gymnastics. The minimum time to expend on this is a further six months after qualifying as a masseuse, so that it takes a year to gain the double qualification.

In addition to supplying the independent examination in these subjects, the society watches over the interests of the masseuses. All its members are bound to observe the rules of the society. The result of this is threefold.

(1) The doctor is assured that the masseuse will not undertake cases on her own diagnosis, but work only under qualified direction.

(2) The public is assured that the masseuse is a trustworthy woman as well as an efficient worker.

(3) The masseuse herself is protected from undesirable engagements. This is of considerable importance.

The training for the examination previously mentioned is from 10 to 15 guineas for those taking the course. There is generally some reduction made for nurses. The further course in Medical Gymnastics costs from 20 guineas.

From this it will be seen that the whole training is comparatively inexpensive; it is, however, not a profession to be entered lightly. London is already overstocked and the better openings at the present time are to be found in the Provinces, in Scotland and the Colonies. It is well to start, if possible, in a town where the masseuse is already known either to the doctors, or to some influential residents. Much depends on the individuality of the masseuse, and one who is prepared to give all her time to the work, taking every call that comes, may reasonably expect to make in her first year from £50 to £100. By the third year a steady connection should be formed, bringing in an income of £150 to £250. This cannot, however, be expected unless the masseuse has some introductions to start her in her work.

Fees in the country vary from 3s. 6d. to 7s. a visit, and in London and some other places they rise to 10s. 6d. for an hour or less.

Hospital and nursing-home appointments are most useful as experience for the masseuse in her first year; they should be tried before she finally decides where to start work. Such appointments are residential, and the salaries offered vary from £30 to £70 a year.

It must not be forgotten that, owing to the short and comparatively inexpensive training, very many women take up this work, so that the above excellent results are not realised unless the masseuse has good introductions. The value of a thoroughly reliable society such as that mentioned cannot be over-estimated, not only for its certificate, but also on account of the information it can give as to the respectability of posts advertised for masseuses. Many of these are unfortunately merely blinds for undesirable houses. [SUB-EDITOR.]

SECTION IV

WOMEN AS SANITARY INSPECTORS AND HEALTH VISITORS

The introduction of women into the public health service is a modern development, although they have been engaged in it longer than is usually known.

Women who are employed in Public Health Work hold office under Local Sanitary Authorities, and their work must not be confused with that of the Women Home Office Officials, who were first appointed in 1895; these inspect factories and workshops, but their powers and duties are of a different character. For instance, the Women Home Office Inspectors deal, amongst other things, with the cleanliness of factories, but not with the cleanliness of workshops, and with the heating of workshops, while the ventilation of the same workshops is under the control of the local sanitary officials.

Glasgow was the first county borough to utilise the services of Women Health Officials, for in May 1870 four "Female Visitors," afterwards known as Assistant Sanitary Inspectors, were appointed in connection with the Public Health Department. Their duties were: "by persuasion principally, to induce the women householders to keep the interiors of their dwellings in a clean and sanitary condition, and to advise generally how best this can be maintained." They possessed the same right of entry to premises as the men inspectors, and were required to hold the certificate of the Incorporated Sanitary Association of Scotland. They reported certain nuisances, but themselves dealt with others, such as "dirty homes or dirty bedding, clothing, and furnishing."

The work of Women Health Officials in England, dates from the passing of the Factory and Workshops Act of 1891, when certain duties with regard to workshops, which had previously been performed by the Home Office Inspectors, were laid upon Sanitary Authorities.

In the opinion of Dr Orme Dudfield, late Medical Officer of Health for Kensington: "It soon became apparent that, not only was systematic inspection necessary, but also that many of the duties involved were of so special and delicate a nature that they could not be satisfactorily discharged by male inspectors." He therefore recommended the appointment of two Women Inspectors of Workshops in Kensington. In the meantime the city of Nottingham had appointed a Woman Inspector of Workshops in May 1892, and in accordance with Dr Dudfield's recommendation two Women Inspectors were appointed in Kensington in 1893.

These ladies were appointed as inspectors of workshops _only_. They did not hold Sanitary Certificates, nor had they the status of Sanitary Inspectors. In practice, this entailed a visit by a male inspector every time it was necessary to serve a legal notice for the abatement of any contravention of the Factory and Workshops' Act. Therefore, when these ladies resigned upon their appointment as Factory Inspectors, it was decided to appoint the in-coming ladies as Sanitary Inspectors, with power to deal with these matters themselves. It was, however, Islington which appointed the first woman with the legal status of Sanitary Inspector in 1895.

By 1901, eleven women had been appointed in the Metropolitan area as Sanitary Inspectors, nearly all of them exclusively engaged in the inspection of workshops. Since that time the number of women appointed by Local Sanitary Authorities has increased considerably, both in London and the Provinces. The exact number outside London is only known approximately, as no register exists which is available to the public. It is to be hoped that this information may be obtainable from the last census returns. The figures with regard to London are published annually by the London County Council, and there are now forty-one Women Sanitary Inspectors in the Metropolitan area.

Sanitary inspectors in London, whether men or women, are required to hold the certificate of the Sanitary Inspectors' Examination Board, the examination for which is the same for men and women.[1] Outside London no definite qualification is required by the Local Government Board, but it is usual in county and municipal boroughs for a sanitary certificate to be demanded from candidates for the position of Inspector of Nuisances (the term used outside London for Sanitary Officials). Men and Women Sanitary Inspectors possess equal rights of entry to premises and equal statutory powers for enforcing compliance with the law.

The duties of Women Sanitary Inspectors have become very varied and numerous during the past ten years; they differ considerably according to locality and to the opinions of the local Medical Officer of Health. Broadly speaking, before 1905 women in London were mainly engaged in the inspection of workshops, whereas in the Provinces (with the exception of Nottingham, Leicester, and Manchester) they were engaged in house-to-house visitation in the poorer parts of the towns, with a view to the promotion of cleanliness, giving advice to mothers concerning the feeding and care of infants and young children, and the detection of sanitary defects. The inspection of workshops in the Provinces was a later development.

These varied duties have called for special qualifications, and, in addition to certificates in sanitation, Women Sanitary Inspectors usually hold qualifications in nursing or midwifery. The general education of the women who take up this profession is, on the whole, superior to that of the men. Most of the women have had a high school education, and many are University graduates, while the men, as a rule, come from the elementary schools.

The duties of a Woman Sanitary Inspector are sufficiently varied to avoid monotony, and may comprise any or all of the following:--

_A_. (1) The inspection of factories in order to see that suitable and sufficient sanitary accommodation is provided for women, in accordance with the requirements of the Public Health Acts.

(2) The carrying out of the provisions of the Public Health and Factory and Workshops Acts, with regard to the registration and inspection of

_(a)_ laundries, workshops, and workplaces (including kitchens of hotels and restaurants) where women are employed;

_(b)_ Outworkers' premises.

(3) The inspection of tenement houses and houses let in lodgings, and the enforcement of the bye-laws of the Sanitary Authority affecting these.

(4) House-to-house inspection in the poorer parts of the district.

(5) The inspection of public lavatories for women.

(6) The carrying out of duties and inspection concerning

(_a_) Notifiable infectious diseases, such as scarlet fever.

(_b_) Non-notifiable infectious diseases such as measles.

(_c_) The notification of consumption.

(7) Taking samples under the Food and Drugs Acts. (This work is rarely given to women.)

For many of the above duties, women are obviously better fitted than men, but for the following most important group of duties men are practically disqualified by reason of their sex:--

_B_. Health visiting. Work in connection with the reduction of infantile mortality :--

(1) Notification of Births Act, 1907. Visiting infants and giving advice to mothers about the feeding and general management of young children.

(2) Advising expectant mothers on the management of their health and as to the influence of ante-natal conditions on their infants.

(3) Work in connection with milk depôts and infant consultations.

(4) Promotion of general cleanliness in the home and discovery of sanitary defects

remediable under the Public Health Acts.

(5) Investigation of deaths of infants under one year of age.

(6) Lecturing at mothers' meetings.

(7) Organisation of voluntary Health Workers in the district and arrangement of their work.

_C._ The following duties may also be required in the Provinces:--

(1) Work relating to the administration of the Midwives' Act, 1902 (where the County Council have delegated their powers to the District Council).

(2) The inspection of shops under the Shop Hours Act, 1892-94, and the Seats for Shop-Assistants Act, 1899.

The work described under _C._ 1 and 2, is performed in London (except in the City) by special inspectors appointed by the London County Council, who also inspect employment agencies where sleeping accommodation is provided and carry out certain duties under the Children's Act.

(3) Work in connection with the medical inspection of school children (performed in London by the London County Council school nurses).