Midwives Bill, 1943—Second Stage.

Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward)

I move that the Bill be now read a Second Time.

The object of this Bill is to make further and better provision for the enrolment, certification, control and training of midwives and for other purposes relating to midwives and the practice of midwifery. The existing law in these matters is contained in the Midwives (Ireland) Act, 1918, the Central Midwives Board Order, 1923, and the Midwives Act, 1931. The Act of 1918 provided for the constitution and establishment of a Central Midwives Board for Ireland and gave the board statutory powers in relation to the training of midwives and their registration in the roll of midwives to be kept by the board. The board were empowered to regulate and supervise the practice of midwifery, to take disciplinary measures in regard to midwives. A specified fee was to be paid to the board by every woman presenting herself for examination and certificate—such fees to be devoted by the board for payment of expenses. If in any year the income derived from fees was insufficient to cover the expenses of the board they were empowered to apportion the deficit between the councils of the several counties and county boroughs in proportion to rateable valuations, and the councils were required to pay the amounts so apportioned. Each county and county borough council was given supervisory powers relating to midwives practising within their district. They could investigate charges and had power to suspend midwives from practice in certain cases. The councils were known as local supervising authorities for the purposes of the Act and each council could act by themselves or through their medical officer.

As the statutory powers of the Central Midwives Board extended to the whole of Ireland it was necessary when Saorstát Eireann was established to provide for the exercise of their functions within the new State. This was done by means of an Order made in pursuance of the Adaptation of Enactments Act, 1922, entitled the Central Midwives Board Order, 1923. The Order provided for the establishment of a Central Midwives Board for Saorstát Eireann and conferred on the board all the jurisdictions, powers and duties of the Central Midwives Board for Ireland.

The Midwives Act, 1931, gave power to the Central Midwives Board to issue badges to midwives. It also prohibited unqualified or unauthorised persons from attending women in childbirth.

From time to time the Central Midwives Board have made representations for the amendment of the provisions of these enactments to meet administrative difficulties experienced by the board.

"(a) The Act of 1918 required the local supervising authorities to pay to the board the moneys apportioned to them within six months from the date of the receipt of the precepts or warrants for the amounts payable, or within such further period as might be agreed upon. Under this arrangement a period of at least six months might elapse before the board were paid the amount of the deficit shown in their accounts at the end of the year. The outstanding liabilities which went to make up the deficit might have been incurred early in the year. It can be readily understood that an embarrassing financial situation might thus arise. The board suggested that statutory provision should be made to enable the board to be placed in funds to meet expenditure pending the receipt of the amounts assessed on the local supervising authorities.

(b) The Act of 1918 required each woman presenting herself for examination and certificate to pay to the board such fee as the board with the approval of the Minister for Local Government and Public Health might from time to time determine but not exceeding the sum of one guinea. When this provision was made the period of training was six months and candidates for admission to the roll of midwives were required to pass only one examination. The period of training is now two years and there are two examinations. It is suggested that the board should be empowered to charge a fee for each examination.

(c) By the Act of 1918, the board were given power to decide upon the removal from the roll of midwives of the name of a midwife for disobeying the rules and regulations for the time being laid down by the board, or for other misconduct. The board were not, however, empowered to require witnesses to appear before them to give evidence in any proceedings for the removal of the name of a midwife from the roll. For the effective performance of the functions of the board it is essential that they should have this power and also that the procedure for the removal of a name from the roll should be specified in detail.

(d) When a local supervising authority, after investigation, establishes a prima facie case of malpractice, negligence or other misconduct on the part of a midwife practising within their district they are empowered to report the same to the Central Midwives Board but they have no power to suspend the midwife from practice pending the decision of the board and they have no means of preventing the midwife from practising even though they may have reported her for a serious offence. It is very necessary that the local supervising authority should be given this power.

(e) The Central Midwives Board also consider that they should be empowered to grant certificates of competency to teach midwifery."

When steps were being taken to draft a Bill embodying the amendments suggested by the Central Midwives Board, it was found difficult to provide amending provisions to harmonise with those of the Act of 1918 on account of the great contrast in terminology. It was therefore decided to draft a consolidating Bill to re-enact the provisions of the previous Acts and to provide for the suggested amendments.

The Bill now before the House provides for the establishment of a board to be styled and known as the Central Midwives Board, consisting of eleven members, seven to be appointed by the Minister, four of whom shall be midwives ordinarily resident within the State selected by the Minister after consultation with representative nursing organisations, and one at least of the remaining three to be appointed by the Minister shall be a registered medical practitioner. The other four members of the board are to be registered medical practitioners ordinarily resident within the State elected by the registered medical practitioners so resident.

Appointments and elections are required to be made quinquennially, as is the case with the existing board, and the election years are so fixed as to provide for continuity in the election periods provided for in the existing enactments and those proposed under the Bill. The members of the present board who are in office when the Act comes into operation will continue in office as members of the new board, and as the last appointment and election to the existing board will take place at the beginning of 1944 the first election year for the purposes of the new Act will be 1949. It is provided that a member of the board may resign his membership, while the Minister is given power to remove a member from office. The appointment and term of office of the chairman of the board are also provided for in the Bill.

The board are required, subject to the consent of the Minister, to appoint such officers and servants as they may from time to time think proper and to pay them such remuneration and allowances as they may from time to time determine. The power given to the board to grant retiring allowances or gratuities to any of their officers and servants leaving their service is a new provision.

The board must submit to the Minister a report of their proceedings each year and furnish to him and publish after the end of each year a statement of their receipts and expenditure, including liabilities, certified as correct by the Minister acting through a local government auditor. When this statement shows a balance against the board they are required, with the consent of the Minister, to apportion such balance between the local supervising authorities in proportion to rateable valuations, and post to each such authority a notice specifying the amount assigned to them. Each local supervising authority is required to pay one-fourth of the amount so assigned within one month, and the balance within three months, after the receipt of the notice. These time limits are fixed with a view to obviating the delay in payment of deficits to which I have referred earlier in this statement.

The only other point in connection with the finances of the board to which I propose to refer is the new power given to them by Section 20 of the Bill to set aside moneys for a fund to meet contingencies. It is considered desirable to provide such a fund. Various situations may arise involving substantial expenditure which could not be held over and dealt with in the annual deficit of the board.

The board are required to maintain and publish a roll of midwives and to keep the entries in the roll correct. The secretary to the board is charged with the custody and correction of the roll. Registration in the roll of midwives is governed by Section 24 of the Bill, under which the board are required to register in the roll every woman who: (a) applies for registration in the prescribed manner; (b) has completed the prescribed course of training; (c) has passed the prescribed examinations; (d) satisfies the board that she is of good character, and (e) pays the prescribed fee.

The board are also empowered to register a woman who has been trained in any other country provided that they are satisfied that the training and examination undergone in such country is of a standard not lower than that adopted by the board, and that the authorities in such other country certify or are prepared to certify women registered under the new Act on reciprocal terms. The board are prohibited from registering any woman in the roll of midwives whom they consider to be physically or mentally unfit to attend women in childbirth.

By Section 25 of the Bill the board are given power to remove the name of a midwife from the roll of midwives in accordance with rules to be made under the Act, and such rules must in particular make provision that where it is proposed to remove a name from the roll, proceedings in that behalf shall be instituted before the board, and that in such proceedings the defendant shall have an opportunity of answering the allegations made against her. The grounds upon which a name may be removed from the roll are:— (a) infamous misconduct or professional misconduct; or (b) conviction in the State of treason, or of a felony or misdemeanour, or outside the State of a crime or offence which would be a felony or misdemeanour if committed in the State; or (c) conviction of an offence under the Act; or (d) disobedience to the rules of the board; or (e) physical or mental unfitness to attend women in childbirth.

The board may take evidence on oath in any such proceedings, and require any person to attend and give evidence in relation to any matter arising in the proceedings, and to produce documents. The board may, in lieu of removing the name of a midwife from the roll, caution or reprimand the midwife, or suspend her from practice for a period not exceeding 12 months. A midwife may appeal to the High Court or to the Minister from a decision of the board to remove her name from the roll of midwives or to suspend her from practice.

Section 30 of the Bill gives power to the board to restore to the roll of midwives, for any reason which they consider sufficient, the name of any midwife which has been removed therefrom. In addition to the power of the board to suspend a midwife from practice in lieu of removing her name from the roll, they are empowered by Section 33 of the Bill, where proceedings have been instituted for the removal of the name of a midwife from the roll, to suspend the midwife from practice pending the decision in such proceedings.

Section 35 of the Bill contains the new power proposed to be given to the local supervisory authority to suspend a midwife from practice where, after investigating a charge against her of disobeying the rules of the board or of other misconduct, they report a prima facie case against her to the board. A local supervisory authority is also empowered by Section 36 to suspend a midwife from practice where they are of opinion that this course is necessary in order to prevent the spread of infection, and by Section 37 to suspend from practice any midwife against whom proceedings have been instituted in the District Court for an offence under the Act. A local supervising authority is required to exercise general supervision over the midwives practising in their district.

On the question of the education and training of midwives the Bill sets out the powers of the board in detail. The board may make provision for the courses of training and examinations to be taken by candidates for registration in the roll of midwives and for the approval by the board of lecturers and teachers in institutions in which the courses of training may be taken and for the conditions of admission to examinations. The board may, under Section 40, make provision for optional courses of training and examinations for midwives and for the granting of certificates and diplomas to midwives taking such courses and passing such examinations. This section will meet the wishes of the Central Midwives Board in regard to the grant of certificates of competency to teach midwifery, but their power under the section is not limited to the granting of such certificates.

Section 48 of the Bill extends the powers of the board by enabling them to require midwives to attend from time to time such courses of instruction as may be approved by the board or provided or arranged by them. This is a new power and it will enable the board to require midwives to attend post-graduate courses.

By Section 32 of the Bill the board are required to issue a certificate to every midwife whose name has been entered on the roll of midwives. Where the name is removed from the roll the certificate must be surrendered to the board. The board must return the certificate to the midwife if her name is restored to the roll. Where the midwife dies, the person having the custody of the certificate must return it to the board. Similar provisions are contained in Section 45 as regards badges issued to midwives. The section also contains an express prohibition against the unauthorised wearing of a midwife's badge, or the wearing of a coloured imitation of a midwife's badge, or the lending of a midwife's badge.

Section 42 of the Bill permits a midwife to add to her name the designation "State Certified Midwife". This is a new provision. The next section provides that it shall not be lawful for any person other than a woman registered in the roll of midwives to take or use the name or title of midwife either alone or in combination with any other words. A prohibition is contained in Section 49 of the Bill against the attendance on women in childbirth of unqualified or unauthorised persons.

A midwife is required by Section 46 of the Bill to give notice to a local supervising authority where she proposes to start practising in their district and also to give notice annually thereafter of her intention to continue practising in the district. If she attends a woman in childbirth outside the district of the local supervising authority she must give notice of such attendance to the local supervising authority in whose district she attended the woman. The midwife must also inform every local supervising authority within whose district she is practising of any change in her name or address.

Where a midwife attends at a childbirth in which any emergency occurs, she is required by Section 47 to call a registered medical practitioner to her assistance, and if the patient is one upon whom the midwife is attending in the course of her duties as midwife of a dispensary district she shall call to her assistance the medical officer of such district if he is available. Where the medical officer of a dispensary district attends a person eligible for medical assistance under the Public Assistance Act, 1939, in response to a call from a midwife in pursuance of this section no fee is payable to him by the local supervising authority in respect of his services. An appropriate fee may be paid by the local supervising authority in any other case. This section differs slightly from Section 22 of the Act of 1918, under which no fee could be paid to any medical practitioner called in by a midwife in an emergency to attend upon a patient who was entitled to medical relief under the Medical Charities Act.

The Bill concludes with transitory provisions essential to provide for continuity of administration between the existing board and the board provided for in the Bill.

Dr. O'Higgins

So far as the Bill carries out the purposes outlined by the Parliamentary Secretary—the securing of better attendance at childbirth, better training of midwives and more efficient supervision—every person in the House, and outside, will be strongly behind it. The greater portion of the Bill is undoubtedly designed to achieve these purposes and, so far as it is so designed, it should get the support of all, but very frequently when a Bill emanates from a great Department, it starts out to do one thing and then there is a little clause here and a little section there which end by doing possibly the very opposite. A person reading this Bill hurriedly would be inclined to approve of it without reservation. A person reading the Bill closely would see that the Bill, apparently designed to save women and children, is more specifically designed to save pounds and shillings.

Section 47 lays it down in a mandatory way to midwives that, if they require medical assistance, they shall call in the dispensary doctor, and then the words "if available" are added. Most of us here are familiar with dispensary districts. Let us take rural dispensary districts. A rural dispensary district may stretch from end to end over a distance of eight miles, and, in many parts of the country, over a far greater distance. There is a maternity case at the extreme end of the district. The nearest doctor may be just 100 yards away, while the dispensary doctor may be seven miles back. The Bill makes it obligatory on a midwife, if she requires assistance, to requisition the local dispensary doctor, if available. It is not known whether he is available or not until he is sent for and the Bill in this respect applies to the destitute poor. It is not a question of motor cars, of somebody running out a car and driving 5, 6 or 7 miles, but a question of somebody going on foot, on a bicycle or in a donkey and cart; and by the time the word comes back that the dispensary doctor is not available, hours have passed and possibly, if not probably, a life or two lost.

I am reading this section as it will be read by the ordinary midwife. Lawyers or experienced parliamentarians might argue that the paragraph is not so very rigid, that "if available" can mean "if conveniently available" or "if immediately available," and that a certain amount of discretionary power is left to the midwife. As the ordinary person will read that paragraph, there is an obligation on the midwife to ascertain if the dispensary doctor is available, and only when she hears that he is not can she get assistance from any other quarter, and all that risk is taken with human lives to save a fee of perhaps three guineas three times a year in a rural district.

I think the Bill would be improved by the removal of that section and that the situation could be met by an instruction to midwives, who are officers serving under the Department of Local Government, that there would be a responsibility on them to explain to and satisfy the county manager that there was adequate reason for requisitioning the services of a doctor other than the dispensary doctor. But, as the section stands, it will be read by nervous, inexperienced people—inexperienced in the reading and interpretation of Acts of Parliament—and it will be rigidly carried out by narrow-minded auditors and the dread of a surcharge by the auditor will lead to hours of delay in getting medical assistance for a woman in labour. I feel perfectly certain that the Parliamentary Secretary is not in favour of the section and that it was injected into the Bill by finance-minded officers in his Department. The Bill would be improved, lives would be saved, the lot of the midwife would be made less anxious and skilled assistance would be more readily available to the afflicted poor, if the section were dropped.

I know the background of this. There were certain abuses in the past, particularly in the City of Dublin, where dispensary midwives requisitioned the nearest doctor, and not always in an emergency, and fees had to be paid in a great number of cases, where another salaried officer was available for the job and his services were not requisitioned. The fact that there were some slight abuses in one part of the country which involved in all a few hundred pounds is no justification for worsening the lot of patients in childbirth and making more anxious the lot of the midwife away in a remote part of the country, up against a difficult case and generally by night.

If that nurse is to do her work efficiently and competently, we must be conscious of the fact that human beings are afflicted with nerves, and the less anxiety that presses on a midwife, the better she will do her job, and it will be an ease to both nurse and patient to feel that, if anything arises, they can command the services of the nearest doctor. A matter of £5 or £10 a year in a dispensary district when we are dealing with the lives of women and children should not be magnified to the extent which it is magnified here. If we were dealing with brood mares, if we were dealing with cows, there would not be the same tendency to make the job more difficult and relief less speedy for the sake of a possible saving of a couple of guineas per annum.

The Parliamentary Secretary knows better than I that in the country the districts are large and straggling, and that very often one doctor's dispensary district goes to within 100 yards of the next town. His place of residence may be miles away. A midwife up against a difficult case, a critical situation, where minutes if not seconds may make all the difference, will feel bound to send a cyclist or pedestrian perhaps six miles or seven miles, by night, to get the local dispensary doctor. That is a mistake. That is defeating the objects of the Bill. I think it is entirely unwise. I am encouraged in making these remarks because I feel that what I am saying will support the Parliamentary Secretary within his own Department in convincing others that this is not a Bill intended to save pounds or shillings or pence; it is a Bill designed to save human life, and there has to be a sense of proportion and a sense of realism injected into most of our Government Departments. If it is to be a Public Health Bill, or if it is a Medical Aid Bill, then the voices that must speak loudest inside that Department are the voices of those primarily charged as experts in that particular field. Their opinions and their voices and their views must not and should not be subordinated to the views of expert financial accountants.

We have in the same section of this Bill another provision aimed at saving or gathering in one or two or three guineas per annum. It provides that where a nurse, in an emergency, in a case that is not a destitute case according to the Acts, requisitions the services of a doctor in order to save two lives, that automatically is evidence of the liability of the husband, and that that statement itself should be sufficient evidence to get a rule of court that the husband must pay the fee. Every one of us knows that there is a big mass of our population in between the lower line of destitution and the upper line of those capable of paying a reasonable professional fee; that there are great numbers of people who are not, in the legal sense of the phrase, destitute people, people entitled to a dispensary ticket, but who are nevertheless not in a position to pay a professional fee. A midwife is called out on any such case and she finds that it is an emergency case; she must have medical aid. She requisitions the nearest doctor, and under this section the manager is bound automatically to collect from the husband. That may be a seven or ten acre farmer. That may be a struggling tradesman. That may be some very tiny shopkeeper— somebody who is just above the destitution mark, and not entitled to a dispensary ticket. The doctor is paid by the manager and the section entitles the manager to collect from the husband. Even the hands of a court are tied by this particular section. Auditors will come from the Minister's Department, and they will ensure that, if there is not a ticket to account for the case, the money must be collected. In the past, points such as that were left to the discretion of the board of health, nine or ten sensible, honest, local people, who knew the local circumstances, and who would say to their secretary: "Ah, well, so-and-so may not be a dispensary case, but he is not a person who can pay a fee." If this Bill stands as it is at the moment, the auditor will ensure that every effort is made to collect in 100 per cent. of the cases. I think that is unwise. I think it is merely a utilisation of a very good Bill by financial fanatics. The amount of money involved, as the Parliamentary Secretary knows, is not worth talking about. If we are to do good, do not let us always endeavour to do good through the medium of irritations, and particularly of, comparatively speaking, worthless irritations.

There are one or two other matters in the Bill that I do not understand, and to which the Parliamentary Secretary did not refer. Under an earlier section of the Bill the board is constituted, a board of quite clearly responsible people: so many members of the nursing profession, so many nominated by the Minister either from the nursing profession or from the medical profession, or both; and so many elected by the medical practitioners. Yet, Section 6 (d); without any explanation, reads: "The Minister may remove any member of the board." Now, they are elected or appointed only for 12 months, and surely if such a situation arises—I do not know what is the idea at the back of the section——

Dr. Ward

It is a five-year period.

Dr. O'Higgins

The Minister may remove them at the end of five years?

Dr. Ward

The period of office is five years—not 12 months.

Dr. O'Higgins

What set of circumstances would arise in the meantime to make it necessary or desirable for the Minister to remove them? If they should be removed—no one of us is perfect—I would suggest that the removal should be done by the board itself. It takes from the Bill to present a picture that those 11 people are only, as it were, time-serving creatures dependent on the pleasure of an individual; that if they do not carry out the will of an individual they are removable; that their tenure of office is not worth a day's purchase. I am not reading all those sinister things into the Bill at all, but that bald little section standing by itself is in my opinion entirely superfluous, and it is distinctly unwise to have it in the Bill.

I have one further word to say: this is one of a number of Bills and regulations that are going to increase the strain on the midwives of this country. It is going to subject them to more supervision. That is all to the good. That is in the interests of the public. It is going to subject them to far tighter control. It is going to make their livelihood far more precarious. It is going to have them operating under the fear of being removed from the register at any time. It will undoubtedly increase the number of rules under which they live, and, to that extent, increase their duties. Now, war or no war, the payment that is given to that body of women, Irish midwives, is a scandal to any State— salaries ranging from £40 a year or 15/- a week upwards, for qualified professional people, subject to all kinds of restrictions, subject to all kinds of supervisory control; salaries that were fixed in many cases in the last century, and in all cases prior to the rapidly increased cost of living arising from the emergency; salaries that were fixed, as the Parliamentary Secretary knows, at a time when most destitute cases were attended by handy women and when the midwife got the bulk of private cases and a very small percentage of the destitute cases. Since then, we ensured, by legislation, and properly so, that no handy woman would attend a person in childbirth. We increased the work of the midwives. We passed legislation and regulation, one after the other, to ensure that their attendance would be prompt, that it would be continuous, that they would carry out a system of notification within 24 hours, and that they would keep their records written up. The Central Midwives Board made many highly desirable regulations which increased the cost of the midwife's calling. It laid down that she should have so many white coats, so many sets of overalls, and that they were to be regularly laundered. Her salary for four weeks would not purchase the outfit or even the replacement of one of the articles which she is compelled to have. Yet the salary has remained the same.

I know that there are many midwives practising in this country at present who are practising on the verge of starvation. Since Christmas I visited a midwife who was in trouble and I could see the stamp of starvation on her face. I would debase my professional signature before I would sign the type of report that I should sign in that case if the woman was in her health. I have heard it said: "There is only a birth-rate of 15 per year in that district. We are paying at the rate of £3 for each case." That is not the point. If the poor of that district are entitled to have a midwife, it is not her fault that the birth-rate is so low. She should have a livelihood. If the birth-rate is so low as that, what is the prospect of private practice? In the next district the salary may be the same and the birth-rate may be 200 per year. Do you hear any of the same set of officials saying: "We only pay 15/- a case in the next district?"

Every place where the Minister's Department appoints a midwife the salary should go up as the birth-rate falls. A low birth-rate is an indication of the poverty of the midwife. There are districts not far from Dublin where there is not as much as £10 a year to be earned in private practice. If we are to overhaul the whole service of midwifery in the country—and I am glad to see it being done—if we are going to see that the standard of qualification is higher, that the degree of competency is increased, that the work is carried out under much stricter conditions, then one of the things that should occur to any of us is to ensure that a reasonable salary is paid to highly-qualified people for a very responsible and a very anxious type of duties.

Mr. Linehan

I entirely agree with what Deputy O'Higgins said about the question of payment.

An Ceann Comhairle

Will the Deputy allow me for a moment? This Bill does not deal with the payment of midwives. I do not know how far the Minister is responsible for their salaries. It is quite in order to make an incidental reference to the remuneration as Deputy O'Higgins has done. It should not, however, be the burthen of the debate.

Mr. Linehan

I understand. The only point I really wanted to make was that the fact that this Bill increases the length of training is an obvious reason for dealing with the matter. Just one other point. The fact which is known to everybody, as it was published in the public Press of this country, that one local authority was not able to obtain a midwife for a certain district, I think in Tipperary, because she could not live on the salary she was to get in that particular district, indicates how serious that problem is. I really wanted to refer to two points from the point of view of saving money to the board, the supervising authority and, possibly, on occasion, to the midwives themselves. If the Parliamentary Secretary will look at Section 22 (d) provision is made there for recovering sums which may be apportioned to any supervising authority and that amount may be recovered as a simple contract debt in any court of competent jurisdiction. There is just a possibility that that would lead to excessive costs, entirely unnecessarily. I put it this way to the Parliamentary Secretary. The wording "in any court of competent jurisdiction" obviously means that if the sum exceeded £300 the action would have to be brought in the High Court. If the sum exceeds £25 and is under £300, it would have to be brought in the Circuit Court. There is already a provision in regard to other matters that, no matter what the size of the sum is, where a local authority is recovering money off ordinary persons the action may be brought in the District Court irrespective of the amount of money involved. For instance, where a board of health, or the county manager as representing a board of health, seeks to recover money from the estate, we will say, of a person who dies in a county home and who is discovered to be in possession of certain assets, if the sum is £70 or £80 or £90, the local authority can bring that action in the District Court in excess of the usual jurisdiction. As this is a sum fixed by the board and apportioned on the local authority and there cannot be any doubt about the amount, or the rights or wrongs of the payment, I suggest that under that section the action could be brought in the lowest possible court which has jurisdiction in cases of simple contract and where the lowest possible costs would be involved.

I also think that that same point might apply to the question of appeals where a person is removed and the right of appeal arises under Section 28 of the Bill. That section sets out that the person concerned may either appeal from the decision of the board to the High Court or to the Minister, but not to both, within three months of the notification. Obviously again there the appeal from the decision of the board to the High Court, if the person concerned chooses to take that line of action, will be a very costly affair both to the board and to the person concerned. If I take first the case of a midwife who may feel that she has a grievance and has a just cause of appeal against the decision of the board, she would not be in very affluent circumstances and to my mind would find it extraordinarily difficult to obtain the necessary amount of money to bring an appeal of that sort to the High Court. I think there would not be any reasonable objection to altering the words "High Court" to "Circuit Court". The judges of the Circuit Court are of sufficient standing to be able to deal with an appeal of that nature. It would have the advantage that the costs to the person concerned would be very much less, because the case would be heard in her own district and would be taken within a reasonable time. It would also be an advantage to the board. In the case of an appeal to the High Court, if the decision was in favour of the board and costs were allowed to them, the board and the State or the local ratepayers would be involved in the expense of a High Court action with no possible hope of ever recovering one penny, even though they had been granted costs. I mention these two points because I honestly think that those two sections are made rather unwieldy by the fact that, in one case, there should be no necessity at all for having to bring an action for the recovery of the statutory payments due under the Bill, while in the other one, I think that the Circuit Court would be far enough to go to give a person a chance to appeal.

Mr. Corish

I would like to add to what Deputy O'Higgins has said in regard to the employment of a doctor. The section says that the medical practitioner must be the medical officer of the dispensary district, if available. One could understand that being insisted on if every dispensary doctor lived in the centre of his dispensary area; but everyone knows that that is not the case. In many cases, the dispensary doctor lives at the extreme end of a very long area, perhaps eight or nine miles in length. A good deal of harm could be done before a doctor of that kind could be got to the place where he was needed. I suggest to the Minister that he should give the nurse permission to call upon the nearest doctor to the particular case. Time and time again we have had cases in which doctors were summoned over a long distance, and unfortunately did not arrive in time. After all, it is very important to try to save the life of a child and of a mother, and every facility should be afforded to the nurse to get the nearest medical attendance. You, Sir, have told Deputy Linehan that the question of nurses' salaries is not a matter for the Parliamentary Secretary.

An Ceann Comhairle

I said it was not clear that the Minister's Department was responsible, but that the raising of that question seemed inevitable, while it should not become the main topic of debate.

Mr. Corish

I agree it should not be so, but the question of payment is very important. In the first place, as Deputy Linehan pointed out, the fact that these people will have to undergo longer training now makes it more necessary that they get a decent salary. Secondly, there will be such a lot of stipulations in regard to costumes and other attendant matters that more money will be required. The pay which nurses are receiving in hospitals and as maternity nurses is a scandal all over the country to-day, and the sooner the Minister for Local Government and Public Health does something about it the better.

Time and time again, various public bodies, when they had the authority, sent up recommendations for increases in nurses' salaries, and they were invariably turned down by the Minister or the Parliamentary Secretary. I suggest that, if we are to have a proper nursing service in this country, it is absolutey necessary that they be paid a decent wage.

Mr. Larkin

I think that the Bill is not only desirable but has been too long delayed. The sympathetic criticism of the Leader of the Opposition is based upon factual knowledge gained through his professional status. I wish to deal with the case more from the point of view of social control and social welfare, and I am particularly interested in Section 25. I know the difficulties that men and women in the profession have to contend with in local administration and I think it is their business to give all the help and advice they can give to the House and the Minister; but I am particularly concerned about the application of the section to midwives in areas such as Dublin, Cork and Limerick. I know of the gross abuses going on in and about the metropolitan area, and I think we are all too kind to the people who offend against this Section 25. It seems to me that there is a means of escape for people who are guilty of "infamous misconduct."

Section 25 says that if a midwife has been guilty of conduct which, in the opinion of the board, is infamous misconduct or professional misconduct, her name may be removed from the roll. When we realise what is happening every day in this city—I do not want to go very far in speaking of this: I did say something on another occasion and I was told that legislation was being brought in—it is easy to understand that this legislation has been too long delayed, in the attempt to deal with this cancer in the body politic. There are people, supposed to be professional women, in this area and the conduct which is carried on by them is well known in the public records of the criminal courts. I have a case in mind where there were five illegitimate births in one house which were not notified to the authority. The unfortunate creature who was the victim of the conditions under which she lives was brought to this house on three occasions, where she was delivered, and there was no record of the children. There were twins on two occasions and a single child on another. A single woman and a married man were concerned. There is no record in the courts or anywhere else of the births of those particular children. Of course, they did not live very long. They were removed from the particular place where they were brought into life, and within a few short months they had passed into death. That is only one of the cases which could be mentioned: there may be a larger list.

A woman in such a case as that takes it upon herself to treat in a professional way another woman and then, by a lack of attention to the ordinary conditions that ought to govern professional life, by the total omission of registration and by connivance—criminal connivance, if you like to call it so—for the purpose of getting rid of the responsibility of this or any other type of woman who gets herself into trouble, is relieving the girl of the guilt and of the responsibility of bringing up the child and also is allowing a vicious character to escape his responsibilities. It has been pointed out here that the ordinary person—a man married to a woman— might not be in a position to pay the professional fee; but what about a case such as this, which might be multiplied, where a gentleman who carried on that particular form of life destruction and soul destruction could escape all commitments? By paying a certain sum of money to a type of woman like this, who had neither professional honour nor sex honour, nor any decency at all, he is allowed to continue.

This Bill deals with very meritorious work. It is the most important work that any professional man or woman could be engaged in: it is a question of new life. I do not wish to labour this point, for fear somebody might abuse it elsewhere, but we in Dublin know that, if for no other reason than that, the Government and the Minister in charge of this Bill should receive the thanks of this House. The only thing is: how far we can help in making it watertight, thus preventing escape for any person who abuses the professional status.

There are things we have to deal with here, without giving publicity to them, for many reasons; but we know of the cases which have been dealt with in the criminal courts, where the evidence given would shock humanity.

If Section 25 of the Bill is enforced by a properly constituted board, it will be the greatest blessing ever conferred upon this city or any city of the same type. We are only concerned with our own nation, but we all know that, all over the world, there has been outrageous exposure of child murder. Unfortunately, possibly we have to take our share of the guilt in this city. It would be well if the Parliamentary Secretary, in carrying this Bill through with the approval of the House, could immediately enforce its provisions. I cannot see where there is sufficient power in this Bill, although I have read it through. It deals with the question of the midwife dying, but what about the patient dying and what about the new-born child dying?

There is no mandatory provision in the Bill, so far as I can see. There must be a record of the midwife dying —obviously, for the purpose of filling the vacancy; but I do not see any section where the midwife is bound in law, and under penalties that could not be evaded, to record the proceedings of every case which she handles. Whether a child is born alive or dead, it should be insisted on that an official record of the birth be kept.

Dr. O'Higgins

That is in the rules.

Mr. Larkin

I agree, but the point is that it is not in this Bill. As regards some of the cases that I have quoted, eminent medical men in this city have admitted the weakness there is in the matter of the registration of these children. There is no registration of the transfer of a child to a foster-mother, and there was no registration of death in two of the cases that I have quoted. Obviously, therefore, there must be some gap wherein the type of person that I have referred to can operate. I suggest to the Parliamentary Secretary that he ought to tighten up matters in that respect so that no means of manoeuvring will be left to this criminal type of person to operate, the type of person who has lost all sense of sex decency as well as of professional decency.

I congratulate the Parliamentary Secretary on bringing forward this much too long delayed measure. The criticism that has been offered by the Opposition is not criticism. It is sympathetic advice, and I hope it will be accepted in that spirit. I believe that it is the desire of every member of the House to help the Department in this matter, and to make this measure one of the greatest blessings that has ever been conferred on the country.

As regards the provinces where women cannot earn a decent livelihood at their professional work, that question, I think, could be easily solved if authority were given to the county councils. In the larger counties provision might be made for the employment of three or four women who would always be available with, of course, proper means of transport, when their services were required. Why argue about the expenditure of the few paltry pounds that would be needed to make such a service available? It is quite possible that if some of those children got proper attention at birth they might become shining and brilliant specimens of our race. They were denied that opportunity because in the areas in which they happened to be born the services of specialists were not available. Why should the provinces be denied the excellent means we have in a city like this?

Some of those difficult cases have to come to Dublin, but for the expenditure of a few pounds a specialist service could be provided in provincial centres. If necessary, why not have a mobile hospital, if you like, with a doctor and nurse? It is impossible for women with professional attainments to live under the conditions that prevail in many of the country areas. In those areas, too, there is no means of sterilising clothing. Many of the midwives serving in the country are highly trained, and their professional status demands that they should get proper recognition in the matter of remuneration. There is to-day a much closer affinity between the doctor and the midwife than there used to be in the old days. I do not know any doctor who would hestitate to recommend proper and adequate recognition for those women who render such valuable service to the community.

I welcome the statement that was made by Deputy O'Higgins. It was a most valuable contribution to this debate, and I hope that the Parliamentary Secretary will take cognisance of what he said. We here are the voice of the people who elected us. I hope, therefore, that the particular blot and stain on our provincial areas, to which reference has been made, will be completely wiped out, and that the conduct of those creatures who have been guilty of crimes against their own sex and their own profession will not only be checked but that it will be obliterated from the mind of man.

Mr. Connolly

The general tenor of this Bill is, I think, acceptable to all sections of the House. Parts of it will undoubtedly receive high commendation from all Deputies. The purpose of the Bill, in so far as it tends to raise the professional status of a very important section of the community, is highly commended by the Labour Party as such. The secondary purpose of the Bill should be, I think, to decrease, to some extent, the incidence of infantile mortality. For these two reasons I think the Bill should have an easy passage through the House. Everyone recognises the importance of a midwife and will acclaim any measures taken to give the members of that profession a rightful place in the community. The incidence of infantile mortality, particularly in cities like Dublin, was in the past a disgrace to civilisation.

At one period it ranked probably the highest in Europe, vying, I think, with some places in India. With a proper professional status for the midwife, and with proper safeguards such as are being taken in this Bill as to their efficiency and general knowledge, and with general control and supervision of them, we would, I think, be taking the first step anyway towards improving the chances of life for the vast mass of children, particularly of the poor in the big cities.

There is one part of the Bill which I should like to see extended and which, I think, deserves greater consideration and more amplification. It appears merely as a subsidiary part of the Bill. In the way it is framed it may not have any significance actually at all. Section 50, which permits the local supervising authority—in most cases, I suppose that will be the county council—to contribute to the cost of the training of candidates for the midwife's service will, I am sure, become an increasingly important part of the Bill if it is implemented in the proper spirit. This has relation to a great difficulty in the nursing profession in this country. Everyone knows that, so far as many of the daughters of working class men are concerned, it is almost impossible for them, owing to the cost of maintenance, and even though such girls may have a natural aptitude for nursing, to become a nurse in Irish hospitals, or to pay the fees required. The result is that some of the best nursing talent in the country, those who would in time become the best midwives, are exported. They are induced to leave the country by the better conditions and the higher wages that obtain in England, Scotland and Wales. Here, I think, there is provision made, if it is availed of by these local authorities, to contribute towards assisting such naturally talented young girls in working-class homes to become trained as midwives. That should enable us to increase the number of efficient members of this profession. It would be a great boon to the working classes and it would be welcomed, I am sure, by the midwives generally. It would enable us to attract the best type from the working classes who are anxious to enter the nursing profession and it would also enable us to keep those daughters of our race at home instead of having to export them. For these reasons, that it raises the status of the profession, that it will tend towards decreasing the incidence of infantile mortality, and because it makes provision for helping the training of midwives where the individuals are unable to do so out of their own resources, I welcome the Bill.

Dr. Ward

The discussion on the Bill has been helpful and it has been approached in a spirit that ought to help in the improvement of the measure, if it is possible to improve it. There is nothing of a contentious nature in the measure as it stands and nothing of a contentious nature has been raised in the course of the discussion. At the same time, I think I might inform the House that amendment along some of the lines indicated in the discussions is scarcely feasible. I might, perhaps, begin by eliminating the only question that might be, to some extent, contentious, on the ground that it is not appropriate to the Bill, and that is the question of the remuneration of midwives. It does not arise under this Bill, and we cannot discuss it or deal adequately with it here.

The Bill deals not only with midwives in the employment of local authorities, but with persons engaged in the practice of midwifery, regardless of whether they are in the employment of local authorities, in private practice, or working under the control of nursing organisations or other corporations. Deputy O'Higgins raises a question on Section 16. That section gives the Minister power, at any time, by Order, to remove any member of the board from office. The Deputy takes exception to that section, but I rather think that he must not have fully considered the implication of leaving such a section out of the measure. In the first place, it is the Minister who appoints the board. Having accepted that principle, it seems logical to contend that if, in any circumstances, a member of the board should be removed, the Minister is the appropriate person to remove him.

There are many circumstances under which it might not only be desirable but necessary to remove a member of a board. Deputy O'Higgins will be the first, I am sure, when his attention is directed to some of these circumstances, to admit the necessity for Section 16. A member of a board might become of unsound mind; he might become bankrupt; he might be imprisoned; he might leave the country— members of some hospital boards have been out of the country for years; they have nominally remained as members of the board, because the Minister or the appointing authority had no power to remove them. I think these examples are sufficient to satisfy Deputy O'Higgins and the House that such power is a necessary part of the machinery. It is merely machinery power, and it is only intended to meet such contingencies as I have mentioned.

I do not think Deputy O'Higgins was terribly concerned about that section, but he was concerned about Section 47. Section 47 does create some difficulty; in fact, considerable difficulty. Deputy O'Higgins and other Deputies, I think, would like to give the midwife an unlimited discretion in case of emergency in the matter of calling in a doctor to her assistance. At first glance that would appear to be a desirable arrangement, but it does not at all fit in with our existing code under the Public Assistance Acts. Deputy O'Higgins talks about the need for having the best possible assistance available to the destitute poor, and with that sentiment we are all in full agreement. But, under the public assistance code, the dispensary medical officer is responsible for maternity cases in his district in much the same way as he is responsible for any other type of case where a person is entitled to public assistance. The dispensary midwife is a subordinate officer of the dispensary medical officer. A woman in childbirth can, if she so desires, have the services of the dispensary medical officer in the first instance in preference to the services of the midwife.

Under that code, if the dispensary medical officer is summoned to attend a woman in childbirth, a poor person who would be entitled to public assistance, he goes there and, if he is satisfied that the case will probably pursue a normal course, he sends for the midwife and leaves her in charge. If any emergency arises later on she sends for him. When we relate that position under the public assistance code to the possible conditions that would obtain if we give the midwife the uncontrolled right to select a doctor when she anticipates difficulties, I think that we might well reach a state of confusion in our administration that would be far from satisfactory from the point of view of the persons most intimately affected, namely, the sick poor.

Deputies may know, especially medical Deputies who have been in the dispensary service, that it sometimes happens that the relationship between the local midwife and the dispensary doctor is not of the best. We realise that the dispensary doctor in the exercise of his duty may from time to time find it necessary to reprimand a midwife for the manner in which she discharges her duty. I have known men to do it. In my own experience I have known unpleasant relations to exist between the dispensary doctor and the midwife. If, under this Bill, we give a dispensary midwife in a public assistance case the right publicly to call in a doctor, other than the dispensary doctor, or to declare that the dispensary doctor is not a fit and proper person to attend a critical case, I think we will be bringing a share of trouble upon ourselves. That is a discretion we ought not to put into the hands of the dispensary midwife. I am sure Deputy O'Higgins would be satisfied if he were assured that in no case of urgency or emergency would a woman in childbirth be left without the services of a doctor, if she required them. That is what we are all aiming at. The question is how we are to achieve that objective.

I do not think Section 47 will seriously handicap us in that regard. If the dispensary doctor is available there is onus on the midwife to call him in in a dispensary case, but if he is away, as in the case quoted during the debate, eight or nine miles, or if in fact he is not available the midwife will be at liberty then to call in another doctor. Determination of the question whether she had taken reasonable steps to ensure whether or not he was available will be a matter for the local supervising authority. I feel sure that in such circumstances they would take a commonsense view. If the midwife faced by an emergency sent to the doctor's residence an urgent message that he was wanted and, if he was not there, and she then called in the nearest available doctor, I do not think the local supervising authority or any responsible Minister would find fault with her for acting in that way.

This section has given rise to considerable discussion with the Central Midwives Board but from a somewhat different angle. Section 47 (1) reads:

"Where a midwife attends at a childbirth in which any emergency specified in rules made under this Act occurs, she shall...."

The section as drafted puts the onus on the Central Midwives Board of taking consequential disciplinary action if a midwife fails to call in the dispensary medical officer. I think a very strong case could be made against placing the Central Midwives Board in that position. It is proposed to amend that section in this way:—

"Provided that nothing in the section will restrict the Minister's right to insist upon the dispensary medical officer being called in in accordance with regulations made under the Public Assistance Act."

We cannot give such power under this Bill as would deprive the Minister of the power he has under the Public Assistance Act. I propose to move an amendment along these lines on the Committee Stage when we can, if necessary, discuss the matter again.

Deputy O'Higgins made a point regarding the determination of who might be entitled to public assistance and who might not. The determination of the right to public assistance is entirely a matter for the local authority. While most local authorities have established some kind of uniform approach to such cases there is no statutory limit set to the receipt of public assistance. The local authorities have full discretion, having fully considered the circumstances of each case on its merits, as to whether or not a person is entitled to public assistance. The law does not put any restriction upon them and the Minister has no statutory power to put any restriction on them.

Deputy Linehan raised a point on Section 22 as to the recovery of debt from a supervisory authority. I will look into the question of the appropriate court in such cases. On first examination it does appear as if it might involve hardship. It is a recommendation of the Central Midwives Board. Perhaps it would be convenient to the Central Midwives Board to have a case heard by the High Court.

Mr. Linehan

I was only thinking of the accused.

Dr. Ward

I do not know if that would be a consideration. I can see that if a case was before a local district court it would inconvenience the Central Midwives Board.

Mr. Linehan

My suggestion was to this effect: when the Land Commission sue a farmer for annuities in the District Court there is a provision in the Land Act that the certificate of the Land Commission showing that the amount is due shall be admitted as evidence. It is a statutory payment that can be recovered. You could have a certificate of this board as to the amount due and let that be accepted as evidence. That would be a form of procedure that could not be contested.

Dr. Ward

The Deputy also raised a question on Section 28 concerning appeals from the decisions of the board. I will look into that to see if the rights of the accused are adequately safeguarded.

Mr. Larkin

In Section 28 you could not deny the right to go to the High Court.

Dr. Ward

This is a question of what court the applicant should go to in the first instance. It is conceivable that a case might be appealed from one court to another. The Bill provides that the trial would take place in the High Court in the first instance. I do not quote this as an excuse for having it in the Bill, but in fact Section 12 of the Act of 1918 provides that any woman thinking herself aggrieved, by any decision of the board to remove her name, might appeal either to the Hight Court or to the Department of Local Government.

Mr. Larkin

There was a question of charging an individual for professional duties.

Mr. Linehan

There are two sections, and Section 22 deals with the point Deputy Larkin raised. Section 28 deals with a different matter.

Dr. Ward

It also arises in connection with the point raised by Deputy Larkin on Section 28, regarding a case where the midwife appeals,

Mr. Larkin

You cannot deny her that right.

Dr. Ward

We are all in general agreement and I shall look into the matter between now and Committee Stage. Coming to Deputy Larkin's views on Section 25, I quite appreciate, the force of his arguments to-day, but many of the abuses, which he did not feel free to discuss openly for obvious reasons, can be dealt with under the existing law. The trouble is that for some reason or other the existing statutory provisions do not appear to be fully enforced. Whether that is the fault of the people who know things and who do not come forward to put the law into operation or whether it is due to some other cause, I am not in a position to say, but this Bill does substantially improve the position, from two points of view, in relation to the matters the Deputy has in mind.

Mr. Larkin

I agree.

Dr. Ward

Under the existing law the local authority has not power to suspend a midwife from practice, even pending the investigation of certain charges that may be made against her. The Bill provides for that authority now. When this Bill becomes law, the local authority can take the initiative by suspending her pending an inquiry into the charges made. The next point is this, and it is important: the Central Midwives Board while they had power to hold inquiries and to take certain disciplinary action in certain circumstances, had no power to compel the attendance of witnesses or the production of documents at a hearing. In that way they were completely handicapped in any proper trial when charges such as those we have in mind were made. Now the fact that we are arming them with the necessary statutory authority to compel the attendance of witnesses and the production of any documents that may be available, should go a long way towards remedying the abuses that have been mentioned.

The last reference that it is necessary to make arises out of Deputy Connolly's contribution with particular reference to Section 50. Section 50, as Deputy Connolly properly points out, gives the local supervising authority statutory authority to contribute to the cost of training of candidates for midwives' certificates. Such a provision is welcomed by Deputy Connolly speaking for the class of the community he represents and such a provision, I am sure, is welcomed by every Party in the House, but beyond giving the local authority statutory power to initiate what might be a very valuable service, there is nothing further that can be done in the legislation. We cannot make it mandatory on a local authority to subsidise candidates for training as midwives. We give them statutory power to do it subject to the Minister's approval. If local authorities consider it a useful activity, presumably they will take advantage of the provision and the only restriction on the action of a local authority under Section 50, in subsidising candidates for training as midwives, will be such as might be involved in the Minister's sanction.

Mr. Larkin

Where will the money be provided from?

Dr. Ward

The money will be raised in each instance from the rates. If the rating authority feels any enthusiasm for this social service, I do not think that the Minister will be very difficult to deal with in the circumstances.

Question put and agreed to. Committee Stage ordered for Wednesday, 1st March, 1944.

Dáil Éireann díospóireacht - Wednesday, 16 Feb 1944