The rule is that women shall be delivered in quarters, provided there be
decent accommodation. At a number of the larger stations, where suitable
married quarters have not yet been fully provided, there are female
hospitals, attached to which, as we have already seen, is a delivery and
lying-in ward, with the usual offices. In the specially constructed
hospitals the wards are of a good size, well-lighted, warmed and
ventilated. If all the beds were occupied, the space would be 1,300
cubic feet per patient. But this is an event which rarely or never
happens, so that there is always plenty of room and good ventilation.
If[19] a woman requires admission, her husband applies to the medical
authorities for a ticket. No woman with a disease considered to be
infectious is admitted. The women usually follow their ordinary
avocations until obliged to proceed to hospital by imminent labour. They
are taken there in cabs, all the necessary arrangements for the lying-in
having been made, if possible, by previous intimation. The woman is
delivered in the delivery ward, and is thence transferred to the
lying-in ward. As a rule, the lying-in pavilion in these female
hospitals is distinct in all its arrangements for nursing from the
pavilion for general cases. Infectious cases are not received into the
same hospital, except at Aldershot.
In these hospitals for soldiers’ wives the time which elapses from the
admission to the discharge of the women is usually ten, and in some
cases twelve days.
At Aldershot four ‘Sisters’ are now at work in the soldiers’ wives’
hospital. One was trained as midwife, and took charge of the midwifery
cases early in 1867. The Sister midwife has sole charge of the lying-in
women for five or six days. They are then passed into a third ward, and
are nursed by the Sisters who attend the ordinary cases (which are,
however, of course in a separate ward).
The Sisters do not help the midwife, as a rule. Only the Superior, on an
emergency, and one for scrubbing floors periodically, enter the
midwifery wards (i.e. the delivery and lying-in wards).
In 1869 Aldershot had no fatal case among the lying-in women.
[The ‘infection wards’ are nursed by ordinary nurses, and in cases of
children by the parents.]
It will be seen, therefore, that at Aldershot the midwife has nothing to
do with the general cases, and the matron is not now the midwife. Both
there and at Woolwich the lying-in nursing is quite separate from the
general nursing.
The medical officer remarks, as to the two deaths in 1869 at Woolwich:
‘Two cases of puerperal peritonitis after bad labours, requiring
instrumental and other assistance, died, but the disease did not extend.
My opinion is that the coldness of the wards, though objectionable, has
a great deal to do with the comparative immunity hitherto enjoyed as
regards the germination and extension of contagious diseases.’
It need scarcely be said that these new hospitals are models of
cleanliness.
In the Colchester Hut the patient is received into a separate
compartment, of which there are four, where she is delivered and remains
until discharged to quarters.
It is very rarely indeed, if ever, that all the four compartments are
occupied simultaneously. The average stay is ten days; the average
number of deliveries a year under 50.
This hut does not form part of a hospital. It is a separate
establishment, solely for lying-in women, as such accommodation should
always be.
_Note._—There is another reason, though it may be termed a fanciful one,
for altogether disconnecting lying-in institutions with general
hospitals, and even with the name and idea of hospital. It is this:
there must be a certain death-rate in a general hospital, receiving as
it does fatal diseases and fatal accidents, as long as men and women
have fatal diseases and fatal accidents.
But lying-in is not a fatal disease, nor a disease at all. It is not a
fatal accident, nor an accident at all.
Unless from causes unconnected with the puerperal state, no woman ought
to die in her lying-in; and there ought, in a lying-in institution, to
be no death-rate at all.
It is dangerously deadening our senses to this fact—viz., that there
ought to be _no_ deaths in a lying-in institution—if we connect it in
the least degree with the name of hospital, so long as a hospital means
a place for the reception of diseases and accidents.
In French statistics, this confusion of ideas, were it not ghastly,
would be ludicrous. ‘Admissions,’ under the head ‘Malades,’ include not
only the lying-in women, but the new-born infants, which appear to be
‘admitted’ to life and to hospital together, as if life were synonymous
with disease, so that, e.g. 4,000 ‘Admissions,’ in such a year, to the
Paris Maternité would mean 2,000 deliveries, 2,000 births—[and—how many
deaths?]
_RECAPITULATION._
In summing up the evidence regarding excessive mortality in lying-in
institutions and its causes, it appears:—
1. That, making every allowance for unavoidable inaccuracies in
statistics of midwifery practice, there is sufficient evidence to show
that in lying-in wards there reigns a death-rate many times the amount
of that which takes place in home deliveries.
2. That a great cause of mortality in these establishments is
‘blood-poisoning,’ and that this arises from the greater susceptibility
of lying-in women to diseases connected with this cause. From whence it
follows that in many lying-in wards, as at present arranged and managed,
there must be conditions and circumstances apart from those belonging to
the inmates personally, which aid in the development of this morbid
state.
3. That the risks to which lying-in women are exposed from puerperal
diseases are increased by crowding cases in all stages into the same
room or under the same roof; by retaining them for too long a period in
the same room; by using the same room for too long a period without
cleansing, evacuation, rest, and thorough airing: but that the
death-rate is not always in proportion to the number of lying-in cases
which have passed through the hospital.
It follows from this that, other things being equal, a high death-rate
may take place in a small hospital constantly used up to its capacity as
well as in a large hospital constantly used up to its capacity.
4. That there are superadded causes in some establishments which add
greatly to their dangers. Among these may be reckoned the following:—
(_a_) Prevalence of puerperal fever as an epidemic outside the
hospital.
(_b_) Including midwifery wards within general hospitals, thereby
incurring the risk of contaminating the air in midwifery
wards with hospital emanations.
(_c_) Proximity to midwifery wards of post-mortem theatres or other
external sources of putrescence.
(_d_) Admitting medical students from general hospitals or from
anatomical schools to practice or even to visit in midwifery
wards without special precautions for avoiding injury.
(_e_) Treating cases of puerperal disease in the same ward, or under
the same roof, with midwifery cases.
(_f_) Permitting the same attendants to act in infirmary wards and in
lying-in wards, and using the same bedding, clothing,
utensils, &c., in both.
(_g_) Most probably also—especially in certain foreign hospitals—want
of scrupulous attention to ventilation, and to cleanliness in
wards, bedding, clothing, utensils, and patients, and in the
clothing and personal habits of attendants.
In short, the entire result of this enquiry may be summed up, in a very
few words, as follows:—A woman in ordinary health, and subject to the
ordinary social conditions of her station, will not, if delivered at
home, be exposed to any special disadvantages likely to diminish
materially her chance of recovery. But this same woman, if received into
an ordinary lying-in ward, together with others in the puerperal state,
will from that very fact become subject to risks not necessarily
incident to this state. These risks in lying-in institutions may no
doubt be materially diminished by providing proper hospital
accommodation, and by care, common sense, and good management. And hence
the real practical question is, whether it is possible to ensure at all
times the observance of these conditions.
The great mortality in lying-in hospitals everywhere is no doubt a
strong argument against such a result being attainable; so much so that,
in the absence of this security, the evidence in the preceding pages
appears sufficient to warrant the question being raised, whether
lying-in hospitals, arranged and managed as they are at present, should
not be forthwith closed?
Can any supposed advantages to individual cases of destitution
counterbalance the enormous destruction of human life shown by the
statistics?
Without vouching for the entire accuracy of Le Fort’s data, they may
still be taken generally as showing approximately the penalty which is
being paid for the supposed advantages of these institutions. It is
this: (see Table XV.) for every two women who would die if delivered at
home, fifteen must die if delivered in lying-in hospitals. Any
reasonable deduction from this death-rate for supposed inaccuracy will
not materially influence the result.
TABLE XV., _abstracted from_ TABLES III. _and_ X., _showing Comparative
Mortality among Lying-in Women in Hospitals and at Home_.
┌──────────────────────────────────────────┬──────────┬──────┬────────┐
│ │ │ │ │
│ │ │ │ Deaths │
│ │ │ │ per │
│ │Deliveries│Deaths│Thousand│
├──────────────────────────────────────────┼──────────┼──────┼────────┤
│Total for all hospitals │ 888,312│30,394│ 34│
│Total delivered at home │ 934,781│ 4,405│ 4·7│
├──────────────────────────────────────────┼──────────┼──────┼────────┤
│Excess of deaths per thousand delivered in│ │ │ │
│ hospitals │ │ │ 29·3│
└──────────────────────────────────────────┴──────────┴──────┴────────┘
The evidence is entirely in favour of home delivery, and of making
better provision in future for this arrangement among the destitute
poor.
_CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE
IMPROVED?_
Must we, then, surrender the principle of lying-in institutions
altogether, and limit the teaching of midwifery nurses solely to bedside
cases at home, notwithstanding the well-known difficulties of teaching
pupils at the beginning of their course elsewhere than in an
institution? We will try to reply to this question; and, in doing so,
perhaps some light may be thrown on another question, viz.: how to
improve existing lying-in establishments so as to reduce the mortality
in them.
Evidence sufficient has been collected to show that no one panacea will
enable us either to possess a perfectly healthy building, or to improve
existing hospitals.
Much has been written about the saving effect of small hospitals; but it
is certain, from what has been already said, that the small-hospital
idea is not sufficient of itself. It is, however, a very important idea,
because all hospital problems are simplified by subdivision of the
buildings. So far as we know, every one who has carefully studied the
subject has given a preference to small lying-in establishments over
large ones; but we should certainly be disappointed if we trusted to
smallness of size alone for reducing the mortality.
The evidence further shows that in any new plan infirmary wards must be
kept quite detached from lying-in wards. They should be in another part
of the ground, and should be provided with their own furniture, bedding,
utensils, stores, kitchen, and attendants.
The same arrangement, at least in principle, should be carried out at
all existing lying-in establishments, and every case of disease should
at once be removed from the lying-in wards to the infirmary, and be
separately attended there.
In our proposed midwifery school the whole attendance would be supplied
by midwives and pupil midwives, with a physician accoucheur, to make his
visit twice a day, to be sent for in time of need, and to give
instruction to the pupil midwives by lectures and otherwise; and in this
way we should escape the dangers of introducing medical students.
Applying the same principle to lying-in wards to which medical students
are admitted, there can be no doubt that a responsibility of the very
gravest kind attaches to all teachers and managers of lying-in hospitals
who do not satisfy themselves that students admitted as pupils have
nothing to do, either with general hospital practice, or with anatomical
schools, during the period. Midwifery instruction should be treated as a
matter quite apart.
What has been already said need scarcely be repeated, about the dangers
of connecting midwifery wards with general hospitals. The simple facts
are sufficient to show that all midwifery wards of this class should be
at once closed.
As a general result of this enquiry, applicable to all lying-in wards,
the evidence shows that very much indeed of the success depends on good
and intelligent administration and management.
Suppose that all these precautions could be carried out, will the cost
and difficulty of giving effect to them necessarily lead to the
abolition of all accommodation for midwifery cases, or for teaching
midwifery?
We reply, No. The facts already adduced clearly show what may be done in
this matter.
They prove, in the first place, that lying-in women should, as a rule,
be delivered at home. And, as a consequence, that whatever provision may
be made for cases of special destitution, or for midwifery teaching,
such provision should be assimilated as far as practicable to the
conditions which surround lying-in women in fairly comfortable homes.
These conditions are realised, and in some instances no doubt improved
on, in the better class of workhouse lying-in wards, and of lying-in
huts for soldiers’ wives.
The favourable results arrived at in many of these institutions appear
to show that a little more care would lower the death-rate still
further.
In every instance where it is considered necessary to organise lying-in
accommodation by voluntary effort, the same principles should be kept in
view.
The success which has attended Waterford Lying-in Hospital, already
mentioned, shows how much may be done in rendering such accommodation a
real boon to the poor.
A single hut, like the Colchester Hut, erected in a needy locality,
would supply, and that safely, all the accommodation wanted. But for a
training school of midwives and midwifery nurses other accommodation is
required, and of a far more costly character.
It is true that any sort of building may be leased or bought and
altered, or added to, and told off as a training school; but after what
has been said, to take such a course would be to ensure killing a
certain number of mothers for the sake of training a certain number of
midwives. If we are to have a training school at all, we must, before
all things, make it as safe for lying-in women to enter it as to be
delivered at home; and having made up our minds what is necessary for
this purpose, we must pay for it.
CHAPTER II.
_CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND TRAINING
SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES._
To apply all this experience to the construction and organisation of a
school for midwives and midwifery nurses[20] is the next thing:—
Everybody must be born, and every woman, at least in this kingdom,
is attended at the birth of her child by somebody, skilful or
unskilful. Except in the case of multiple births, there are
therefore as many attendances as there are births in the Returns of
the Registrars-General.
This it is which makes the subject of midwifery nursing of such
paramount importance.
Lying-in is an operation which occurs in England to seven women out of a
hundred annually. In 1868 there were 786,858 children born alive in this
country, wherefore for the midwives and midwifery nurses to be trained
there will always be occupation and custom enough; whereas the
occupation and custom for a surgical operator is, it is to be hoped,
comparatively small, except in Franco-German wars. Even there we may
trust that 7 out of 100 had not to undergo an operation. Certainly to 7
out of every 100 annually a surgical operation in England does not
occur.
Between midwifery nursing and all other hospital nursing there is this
distinction, viz.: the operator is herself the nurse; and the
head-operator (or midwife) ought to be a woman, and _is_, in Paris and
Vienna, and elsewhere.
Lying-in patients are to be compared to surgical (or operation)
patients, _not_ to medical patients, and _should_ be perfectly well in
health.
Since lying-in is not an illness, and lying-in cases are not _sick_
cases, it would be well, as already said, to get rid of the word
‘hospital’ altogether, and never use the word in juxtaposition with
lying-in women, as lying-in women should never be in juxtaposition with
any infirmary cases.
As to amount of work, necessary administrative conveniences and the
like, a lying-in institution is to be compared to a surgical, _not_
medical hospital, or rather to a hospital for operations.
It has been already shown that great improvements are required in the
manner of keeping midwifery statistics, and that many data are wanting
for this purpose. It would be altogether wrong to deal with these
statistics on the same principles as if they were general hospital
statistics. Lying-in is neither a disease nor an accident, and any
fatality attending it is not to be counted as so much per cent. of
inevitable loss. On the contrary, a death in childbed is almost a
subject for an inquest. It is nothing short of a calamity which it is
right that we should know all about, to avoid it in future. A form of
record is appended (Table XVI.), which appears to afford the means of
registering the required information.