Dáil Éireann debate -
Thursday, 23 Apr 1931

Vol. 38 No. 2

Midwives Bill, 1931—Second Stage.

General Mulcahy

I move: "That the Bill be read a Second Time." The Midwives (Ireland) Act of 1918 had for its purpose the arrangement for the better training and better regulation of the practice, general supervision and control of midwives. It arranged for the setting up of a Central Midwives Board consisting of three persons nominated by the Minister, one of them being a medical practitioner, four representatives elected by the doctors resident in the Saorstát, and four representatives of the midwives appointed by the Minister after consultation with the nurses' associations. The Act transferred to that Board the control of midwives generally and the making of regulations in regard to their training, practice and general control. It forbade the use by any person other than a person certified by the Board of the name "midwife" after the 1st of January, 1919, and after the 1st of January, 1924, it forbade the practice of midwifery by uncertified persons. The provisions of the Act of 1918 provided that a person who did not habitually and for gain practise midwifery could do so on odd occasions. There was a loophole in that and, as a result of the experience of the Central Midwives Board, this Bill is brought before the House on their advice and at their request for the purpose of tightening up the description of persons entitled to practise midwifery and, in the second place, to extend the powers to them under their regulations by which they can prescribe a type of badge which midwives, desiring to wear a badge for identification purposes, shall be able to wear.

The Act of 1918 made it possible that so long as a person did not practise midwifery habitually or for gain she could, though unqualified, attend cases. In practice it has been found that midwifery work is carried on habitually and for gain by persons who are not fully qualified. The amendment proposed in the Bill as well as reiterating the types of qualified persons who may practise midwifery, stipulates that any person attending a woman in childbirth, she being unqualified, shall be guilty of an offence unless she can satisfy the Court that such attention was given in a case of sudden or urgent necessity. It also has a provision by which persons, being persons undergoing training with a view to becoming duly qualified midwives, can give such attention as part of a course of practical instruction in midwifery recognised by the Medical Registration Council or the Board. Such persons may also practise midwifery in these circumstances though not qualified. Recent statistics in regard to mortality amongst women directly attributable to childbirth in 1929 are the lowest recorded in this country. The death rate per thousand in 1927 was 4.51, in 1928 4.93 and in 1929 4.14. The average rate for the decennial period up to 1928 was 4.88. The downward tendency is due to the better control of midwives under the Central Midwives Board and to the additional supervision provided by the county councils by the presence of the county medical officer of health.

Dr. Ryan

It appears to me that the Minister, when speaking about a loophole in the Principal Act, did not point out how it arose. I think that this Bill, like the Principal Act, is likely to lead to unqualified persons practising midwifery. As the Minister said, after January 1st, 1924, no person could habitually and for gain attend a woman in childbirth unless she was qualified. That was the wording of the Principal Act. If the law could not be enforced in that case and if it could not prevent unqualified women from practising habitually and for gain I do not see how it can prevent them practising under paragraphs (c) and (d) of Section 2.

Paragraph (e) says that any person who satisfies the Court that such attention was given in a case of sudden or urgent necessity will not be guilty of an offence under the Bill even though she is not a qualified midwife. I think it will be very difficult for any one who is prosecuting in a case to prove that a woman was not called in a case of sudden or urgent necessity. It could be arranged in such a way that if an unqualified woman wants to establish a practice, she would be called in in cases of sudden or urgent necessity. Paragraph (c) of sub-section (2) says that a person shall not be guilty of an offence if she gives such attention under the direction and personal supervision of a duly qualified medical practitioner. As we know, there are some very soft-hearted medical practitioners in this country and they have a certain amount of sympathy for those women who have made their living up to the present out of the practice of midwifery but who are not qualified. I am inclined to think that such practitioners in some cases will be found to lend their name to these women who can say, if they are taken up in any particular case, that they are under the supervision of a certain doctor. They will thus be able to evade the provisions of the Act.

That has been the complaint of some of the midwifery organisations, that doctors are not as particular as they should be about the qualifications of midwives. If they have not been particular in the past there is no reason why they should be particular under this Bill. They need only say, if any question is raised, that the woman was working under their personal supervision. I do not know how you are going to define "personal supervision." I do not think that it is necessary that the doctor should be present all the time during which the midwife, or supposed midwife, is present. If she is able to get the sympathy of a qualified medical practitioner she will be able to practise. In that way I do not think that the Bill is an improvement on the Principal Act which it sets out to amend. I also doubt whether the regulation and control of midwifery have had the effect on mortality to the extent mentioned by the Minister. Surely neither the Minister nor any one else should make such a sweeping statement as to say that the decrease in mortality is altogether due to the control of midwifery.

General Mulcahy

I did not say "altogether."

Dr. Ryan

The Minister said it was due to that. At the same time we have been improving hygiene and other things in this country, and the lying-in hospitals here in Dublin have been claiming that they are turning out better medical practitioners for the country. I am sure that the young medical practitioners would claim that they are better than the old practitioners, and that the decrease in mortality is due to them and not altogether due to the midwives. I do not deny that there may have been a certain improvement as a result of the control of midwives, but it is not altogether perhaps due to that. We should not give all the credit to the midwives and none to the young medical practitioners who are claiming that they are practising the art of midwifery better than it was practised some years ago.

The Minister states also that this Bill is going to effect the elimination of handywomen from midwifery practice, so that henceforward we shall have none but qualified midwives. Is the Minister sure that there are sufficient qualified midwives to carry on the profession satisfactorily? I know that in certain parts of the country, as a result of my own experience when I was in practice there, and as a result of complaints which I have received since from particular districts in my own county, that midwives can only afford to spend a minimum amount of time with women in childbirth, and that then they have to go on to other cases. Afterwards they are unable to visit each case more than twice in the following week. That is not sufficient attention, and the reason is that we have not got sufficient midwives in the country. If this Bill is going to have the effect which the Minister hopes, and which we all hope it will have, I think there are not sufficient midwives to cope with the work.

Another reason why there is not such competition for the position of midwife in dispensary districts is the very small salary offered and the great disparity in the salaries offered in different places. I got a list some time ago of the salaries paid to midwives in the different areas. In some cases the salaries go down as low as £32 per annum. That is the lowest I saw, though I am informed that as low as £25 is paid in some districts. In no case does the salary exceed £68 per annum. I think even the maximum figure is a poor salary for a midwife, who has to spend a certain amount of time in qualifying for the profession. She has to give all her time to the profession, and has to incur a considerable amount of expense in the way of travelling, purchasing uniform, instruments, and so on which she requires.

The attitude of the Minister and of the Local Government Department in regard to midwives is not at all in keeping with their attitude in regard to other classes. For a position such as medical officer of health of a county, they insist on a good salary being paid. They insist also on a good salary being paid for civilian jobs such as secretaries of county councils. The Local Government Department or the Minister have not in any way helped to get these midwives, who have nobody to take their part, a decent living. I would agree with the object which the Minister has in view, but I do not believe that the Bill as worded is going to do what the Minister expects it will do—namely, the elimination of unqualified women from the practice of midwifery.

Dr. Tubridy

I agree with the principle of the Bill and with Deputy Dr. Ryan. I want to point out to the Minister and to the House that there is no provision to cope with the amount of extra work which will fall on the already overworked maternity nurses in the country districts. Of course, towns and cities are well catered for by the outdoor staffs of the maternity hospitals. In the dispensary districts in congested areas, however, the general rule is that there is only one maternity nurse appointed. I do not see how one nurse can travel thirty or forty miles per day, as I have seen them, and succeed in attending all the maternity cases throughout these wide, scattered areas. The Minister should make provision in some way for an extra supply of maternity nurses, because at present the practice is that one nurse is supplied to a district, no matter how extensive the district is or what the population may be. The county councils apparently are satisfied that one nurse is sufficient. Any dispensary doctor in practice in a county district, in the West of Ireland, at all events, knows that one nurse is not able to cope with the amount of work to be done. Things are not quite as bad in Co. Galway as they are in Co. Mayo—the salaries are not as low as they are in Mayo. If this were a question of dealing with an organised trade union body, and that the members were being treated in this scandalous fashion, I am sure you would have the Labour Party speaking in favour of these people. I expect the Labour Party now to give some assistance in asking the Minister to remember the conditions under which these nurses have to work.

I think that it is a scandalous thing in Mayo to offer a salary of £35 per annum to a qualified nurse who has to live away from home, supply herself with a bicycle and other necessities, and very often work eighteen hours continuously throughout the day. Even those who are employed on the schemes for the relief of unemployment get 27s. per week, a wage that is little enough to live on, and to expect a maternity nurse with no private practice to live on £35 per annum is absurd. I think that the Minister should insist that county councils provide a sufficient supply of nurses and that decent wages should be paid to them. In some areas in the county which I represent the minimum wage paid is £1 per week. That is about the average, but it is less than that in the counties adjoining. I think the Minister should insist on increased salaries in districts in which the nurses appointed can have no hope of any private practice, and should also insist, if possible, that these nurses, who spend a certain time in poor districts where no private practice is available, should be transferred to the better districts according as appointments there become available. Also, in order to get suitable candidates to come forward for these positions, along with giving a decent salary, some pension scheme should be suggested by the Minister. I think that if that were done you would have a better type of person entering into this profession, and you would get more satisfactory work and the results gained by the Minister would be even better than they are in reality.

Mr. G. Wolfe

I think it is a mistake to suppose that the genus known as Sarah Gamp is extinct. I am afraid that, far from being extinct, the handywomen does a roaring trade in some districts; in fact, I have heard that they are far more popular than the properly trained nurse that is available. These people, I am given to understand, are extremely smart. They are quite aware that they may not exact a fee, but there are other ways of getting money besides demanding it. It is well known what they expect to get in the way of a present, and the present. I believe, is invariably forthcoming. I think that is an undesirable state of affairs.

I have also heard that in a very large number of cases, in certain districts, the doctor is only sent for when there is every probability of the patient going to die. That is the sort of thing that ought to be stopped. I do not know whether the Bill makes it strong enough. I think the Minister said that the person guilty of such a thing is guilty of an offence, but the punishment should be stated; it should be of a nature to prevent anything of the kind. Very deplorable cases have occurred in this instance just as in the case of people who deal with cancer and that sort of thing. They do not accept money but they get a present. Moreover, as Deputy Dr. Ryan said, there are not enough qualified midwives in certain districts. I rather think that is the case. I think they ought to have sufficient remuneration to enable them to get about their work and to get over the country because the state of affairs in certain districts at present is deplorable. I think it ought to be put in this Bill beyond yea and nay that this handy-woman business, so far as humanly possible, should be stopped and only in very extreme cases should an unqualified person be called in to attend under any circumstances. I hope the Minister will see the Bill strengthened in that particular before it leaves the draftsman.

Dr. Ward

I think we are all in agreement as to the necessity of the Bill and we will be all very anxious to see the intention of the Bill effected, but I am in thorough agreement with Deputy Dr. Ryan that the Bill, as it stands, does not effect the intention. Sub-section (3) appears to me to be the most serious part of it. It sets out that every person who attends a woman in childbirth shall be guilty of an offence unless "such person gives such attention under the direction and personal supervision of a duly qualified medical practitioner."

The phrase "under the direction and personal supervision of a duly qualified medical practitioner" is extremely wide and open to a wide interpretation. To my knowledge it has been interpreted at present as meaning that a man can supervise and personally direct and remain as his own surgeon. That is the practice under the law as it stands at present and unless there is alternate wording that will continue to be the practice. I have known medical men who authorise the class of woman mentioned here to attend at childbirth without ever having seen the patient at all. There is a possible danger that such a handy-woman may be a particular favourite of a doctor and he may, in certain circumstances, authorise her to attend, but if a crisis arises, and that particular doctor is not available but another doctor is sent for, no other doctor will go in on such a case and the patient's life is lost. The Minister may be aware that such cases have arisen. I am personally aware that recently such a case did arise under very unfortunate circumstances. Under this sub-section (c) the onus is really being put on the doctors to put these handy-women out of practice. I do not think that is fair. They should be put out of practice by legislation and the onus should not be put on the practitioner to accept the responsibility for refusing a case that has not been taken up by a properly qualified midwife. I cannot see there is any necessity for paragraph (c). If a doctor is present presumably anybody can attend. Paragraph (e) reads "such person satisfies the Court that such attention was given in a case of sudden or urgent necessity." I think some such paragraph as that will be required and it may be possible to make the wording more rigid in the Committee Stage. If, in the Committee Stage, the Bill is not amended the entire effect will be nullified.

Dr. O'Dowd

Like the other Deputies who have spoken I, more or less welcome this measure and I hope that the Bill, when it is passed, will have the effect the Minister intends it should have, but it is undoubtedly the desire of the Minister and of every Deputy in this House to improve the practice of midwifery. If we want to do away with the handy-woman it will be necessary to have a nurse in practically every case.

The practice at the present time in many districts is that a neighbouring woman or someone else is called in. She sends for a doctor and when the doctor arrives he has not time to procure a properly qualified nurse. I am glad to say that I do not know and I never heard of the practice, to which Deputy Ward referred, in the part of the country from which I come, that is, that a medical practitioner would authorise an unqualified person to take a case for him or under his supervision. I am glad to say that I never knew of a case like that in Roscommon. The Minister should remember, as Deputy Ryan and Deputy Tubridy pointed out, that the work of district nurses will be enormously increased under the Bill. At the present time, on an ordinary bicycle, which she is compelled to use, a nurse cannot possibly do her work satisfactorily. When the work is increased she will be totally unable to deal with it. District nurses are now paid a miserable pittance and are compelled to use ordinary bicycles because they cannot afford any other means of transport. Until the Minister takes some steps to see that midwives are paid a decent wage which will enable them to do their work properly I fear this Bill will defeat his object. In counties in which there are county medical officers of health the district nurse has to visit each day for nine days every case she attends. She has to keep a chart for inspection by the county medical officer of health when he calls on her, showing the pulse and the temperature for nine days after confinement. If she has two such cases in a district concurrently and has to travel say, five miles each way to one, that means that she has to travel over twenty miles. That is sufficient work for that day but if a third case occurs she will not be able to attend to it unless better transport facilities are made available. I do not claim that in every district an extra nurse would be wanted but in some areas in the congested districts probably an extra nurse would be required. Certainly, in every district the district nurse should have a salary that would compensate her for the work she does and that would enable her to provide herself with better transport facilities than she at present enjoys.

Mr. T.J. O'Connell

I did not intend to intervene in this debate, but to leave it to the doctors who are present. I want, however, to utter a word of warning with regard to the suggestion that the provisions should be made more rigid than they are. I do not wish to be taken as being in favour of an unqualified person acting as a nurse, but, in view of what Deputy Ryan and Deputy Tubridy said, we should not make the provisions so absolutely rigid that a neighbour would be afraid even to go to a house on such an occasion, lest she might be committing an offence and be liable to a fine of £10. There was the suggestion that paragraph (e) should be deleted. If that were done we know that many occasions would arise when a poor woman in a time of trouble might be left entirely alone and without the help of a neighbour, although that might be an extreme case. If it was the general opinion that if a neighbour went to the assistance of a woman, she was committing an offence, and was liable to be brought up in order that she might satisfy the Court that it was a case of urgent necessity. I think that would be wrong.

I know districts where the nurses have too much work to do. This Bill will have the effect of increasing their work very considerably. I think it would be well if a close examination was made of the amount of work that a district nurse is called upon to perform. That could be done, and I am sure is being done, in counties where there are county medical officers of health. I presume that matter will be dealt with, and I suggest that it is worthy of examination. It is my ex perience that the ordinary working nurse is not able to do efficiently all the work that she is called upon to do. In some places there are Jubilee nurses, and they make the work a little less difficult. I agree with Deputy Tubridy that the remuneration that these nurses receive is entirely inadequate. They can depend on the support of all parties to help them to get better remuneration. It is the experience of those who are members of public boards, especially when nurses are looking for better remuneration, that their request is always supported by Labour representatives.

I might add that the nurses are not entirely blameless themselves, because if they were better organised they would be able to obtain better conditions and better remuneration. Some of them, I am sorry to say, do not take kindly to the idea of being trade unionists, even though it might mean that they would secure better remuneration. To expect a person to do the work that is expected from a district nurse for 14/- or 15/- a week is absurd. I agree with Deputy Tubridy and Deputy Ryan that the Minister for Local Government should not leave the matter entirely in the hands of local authorities, any more than he does in the case of medical officers of health or any other county officials. I think it is part of the Minister's duty to see that people who have to do very essential work should be adequately remunerated, and I hope, now that the scope of the nurse's work is being extended under this Bill, that that is one of the things the Minister will give attention to.

General Mulcahy

I would not like Deputy Ryan to think that by praising the results of the work of the Central Midwives' Board I was eliminating all the others, including the young doctors, who are helping in the matter. I hope the Deputy did not raise the point seriously. With regard to a tighter drawing of the provisions in the Bill, the Central Midwives' Board consists of four doctors, who are elected by doctors resident in the country, and in addition, of four qualified midwives, representing the Midwives' Association and practitioners in midwifery, as well as three persons, including one medical officer, nominated by the Minister for Local Government. It is an institution responsible for the training and outlining of the practice of midwifery and controlling midwives in the country. That body has given a very considerable amount of consideration to this matter, both amongst themselves and with the Department. The matters dealt with in Section 2 of this Bill have been under their close consideration. They, as well as the Department, would, I am quite sure, welcome any changes that would more effectively deal with the work they have in hands. I think, however, that it will be found on further examination that the section may be left as it is. If we take out paragraph (e), as Deputy Ward suggests——

Dr. Ward

No, paragraph (c).

General Mulcahy

I thought that the Deputy said that while (c) might go that (e) would be necessary.

Dr. Ward

To retain.

General Mulcahy

I understood that was what the Deputy said.

Dr. Ward

What I meant to convey was that (c) must go but (e) or something approaching the present formation of (e) has to be retained. I do not think we could do without (e) as it stands, or something closely resembling it.

General Mulcahy

If (c) goes, then in the circumstances that have been suggested by some Deputies here there will be areas left in which it will be very difficult to get the assistance of any one in certain midwifery cases. If we take out (c) it would prevent any doctor, no matter how conscientious, making use of the older type of experienced woman in dealing with midwifery cases, and from what I have heard here I think that would be inadvisable. I think it will be necessary to retain (e). If, however, the wording can be improved, both the Central Midwives' Board and the Department will be only too pleased to welcome help from Deputies with that object.

A question has been raised with regard to the inducements to women to take up the profession, and it has been suggested that the Department does not take the same interest in their remuneration as it does in regard to the position and the remuneration of the county medical officers of health and other positions like that. The circumstances of midwives vary very much in different parts of the country. When dealing with a pivotal officer like the county medical officer of health or the secretary of a county council, we know the type of material in the market. We know the type of man we want, and we know the line below which, in the matter of remuneration, the proper man will not be attracted. Deputy O'Dowd suggested the effect on the general position of midwifery in any county that the county medical officer is likely to have. He is likely to awaken the conscience of the people as a whole as well as to awaken the conscience of the county board of health as to the number of midwives who are necessary to do the work there from his experience and knowledge. He would also be better able to awaken the public conscience as to the necessity for having this work done satisfactorily, and therefore paid at a proper remuneration.

There may not be cases in which the Department has interfered to the extent of actually fixing the remuneration of the midwife in any particular area in the same way as it has done with regard to the county medical officers of health or dispensary medical officers as a class. But the Departmental policy has been consistent in urging that in these areas where the remuneration is below the average—and the average lies between £50 and £60 a year—that their salaries be increased. The Department has been urging that all along. Mayo has been mentioned. There the provision with regard to the remuneration is particularly bad. We had to intervene some time ago and fix by Order a scale of dispensary doctors' salaries. Representations had been previously made to the Mayo County Council. Within the limits of our judgment we have done as much as we could up to the present to see that the scale of salaries in Mayo is improved.

The average number of cases that a midwife in a country district attends is only 25 a year. So that while there may be districts in which there is difficulty with regard to the small number of the midwives and nurses there must be large areas of the country where the wants are fully satisfied.

Dr. Tubridy

When you give that figure of 25 per annum I take it that you are referring only to cases in which free dispensary tickets are given?

General Mulcahy

Yes.

Dr. Tubridy

In a lot of cases a payment of 5s. or 10s. is given, so that actually in those areas the midwife may attend 100 cases.

General Mulcahy

I am only speaking now of the calls on their time that arise to them as employees of the local bodies. Even that will give a considerable margin to the midwives in most parts of the country for a fair amount of private practice as well. With regard to the points that have been raised as to the evasion of the present legislative intention, at any rate in the matter of better attention in midwifery cases, I am sure the Central Midwives Board is energetically surveying the whole position and dealing with it. The local supervisory bodies, perhaps, have not been as energetic as they might have been. Every midwife practising in the county council areas must notify the county council or the board of health that she is practising in that area within 24 hours after she has begun her practice, and must notify the fact that she is practising in that area annually after that. With that statutory provision with regard to midwives, with the Central Board doing its work, with the county councils being furnished more with the services of the county medical officers of health, the situation will be much more under review than it has been, in certain places at any rate.

We have confidence that we may find a proper balance as to the difficulties that exist at the present moment, and that require to be overcome. We have confidence also in the methods that we will take to bring about the idea that we hope to bring about. I do suggest that some of the irresponsibility in this matter that has been laid at the doors of some of the doctors must be very limited in its extent and that any irresponsibility or carelessness that there may be in that particular way must finish once there is more effective supervision by the county medical officers of health.

Question—"That the Bill be read a Second Time"—put and agreed to.

Committee Stage fixed for Thursday, 7th May, 1931.