Introductory notes on lying-in institutions

The lying-in arrangements provided for soldiers’ wives are as follows:—

The rule is that women shall be delivered in quarters, provided there be decent accommodation. At a number of the larger stations, where suitable married quarters have not yet been fully provided, there are female hospitals, attached to which, as we have already seen, is a delivery and lying-in ward, with the usual offices. In the specially constructed hospitals the wards are of a good size, well-lighted, warmed and ventilated. If all the beds were occupied, the space would be 1,300 cubic feet per patient. But this is an event which rarely or never happens, so that there is always plenty of room and good ventilation.

If^[19] a woman requires admission, her husband applies to the medical authorities for a ticket. No woman with a disease considered to be infectious is admitted. The women usually follow their ordinary avocations until obliged to proceed to hospital by imminent labour. They are taken there in cabs, all the necessary arrangements for the lying-in having been made, if possible, by previous intimation. The woman is delivered in the delivery ward, and is thence transferred to the lying-in ward. As a rule, the lying-in pavilion in these female hospitals is distinct in all its arrangements for nursing from the pavilion for general cases. Infectious cases are not received into the same hospital, except at Aldershot.

In these hospitals for soldiers’ wives the time which elapses from the admission to the discharge of the women is usually ten, and in some cases twelve days.

At Aldershot four ‘Sisters’ are now at work in the soldiers’ wives’ hospital. One was trained as midwife, and took charge of the midwifery cases early in 1867. The Sister midwife has sole charge of the lying-in women for five or six days. They are then passed into a third ward, and are nursed by the Sisters who attend the ordinary cases (which are, however, of course in a separate ward).

The Sisters do not help the midwife, as a rule. Only the Superior, on an emergency, and one for scrubbing floors periodically, enter the midwifery wards (i.e. the delivery and lying-in wards).

In 1869 Aldershot had no fatal case among the lying-in women.

[The ‘infection wards’ are nursed by ordinary nurses, and in cases of children by the parents.]

It will be seen, therefore, that at Aldershot the midwife has nothing to do with the general cases, and the matron is not now the midwife. Both there and at Woolwich the lying-in nursing is quite separate from the general nursing.

The medical officer remarks, as to the two deaths in 1869 at Woolwich: ‘Two cases of puerperal peritonitis after bad labours, requiring instrumental and other assistance, died, but the disease did not extend. My opinion is that the coldness of the wards, though objectionable, has a great deal to do with the comparative immunity hitherto enjoyed as regards the germination and extension of contagious diseases.’

It need scarcely be said that these new hospitals are models of cleanliness.

In the Colchester Hut the patient is received into a separate compartment, of which there are four, where she is delivered and remains until discharged to quarters.

It is very rarely indeed, if ever, that all the four compartments are occupied simultaneously. The average stay is ten days; the average number of deliveries a year under 50.

This hut does not form part of a hospital. It is a separate establishment, solely for lying-in women, as such accommodation should always be.

Note.—There is another reason, though it may be termed a fanciful one, for altogether disconnecting lying-in institutions with general hospitals, and even with the name and idea of hospital. It is this: there must be a certain death-rate in a general hospital, receiving as it does fatal diseases and fatal accidents, as long as men and women have fatal diseases and fatal accidents.

But lying-in is not a fatal disease, nor a disease at all. It is not a fatal accident, nor an accident at all.

Unless from causes unconnected with the puerperal state, no woman ought to die in her lying-in; and there ought, in a lying-in institution, to be no death-rate at all.

It is dangerously deadening our senses to this fact—viz., that there ought to be no deaths in a lying-in institution—if we connect it in the least degree with the name of hospital, so long as a hospital means a place for the reception of diseases and accidents.

In French statistics, this confusion of ideas, were it not ghastly, would be ludicrous. ‘Admissions,’ under the head ‘Malades,’ include not only the lying-in women, but the new-born infants, which appear to be ‘admitted’ to life and to hospital together, as if life were synonymous with disease, so that, e.g. 4,000 ‘Admissions,’ in such a year, to the Paris Maternité would mean 2,000 deliveries, 2,000 births—[and—how many deaths?]

RECAPITULATION.

In summing up the evidence regarding excessive mortality in lying-in institutions and its causes, it appears:—

1. That, making every allowance for unavoidable inaccuracies in statistics of midwifery practice, there is sufficient evidence to show that in lying-in wards there reigns a death-rate many times the amount of that which takes place in home deliveries.

2. That a great cause of mortality in these establishments is ‘blood-poisoning,’ and that this arises from the greater susceptibility of lying-in women to diseases connected with this cause. From whence it follows that in many lying-in wards, as at present arranged and managed, there must be conditions and circumstances apart from those belonging to the inmates personally, which aid in the development of this morbid state.

3. That the risks to which lying-in women are exposed from puerperal diseases are increased by crowding cases in all stages into the same room or under the same roof; by retaining them for too long a period in the same room; by using the same room for too long a period without cleansing, evacuation, rest, and thorough airing: but that the death-rate is not always in proportion to the number of lying-in cases which have passed through the hospital.

It follows from this that, other things being equal, a high death-rate may take place in a small hospital constantly used up to its capacity as well as in a large hospital constantly used up to its capacity.

4. That there are superadded causes in some establishments which add greatly to their dangers. Among these may be reckoned the following:—

(a)

Prevalence of puerperal fever as an epidemic outside the hospital.

(b)

Including midwifery wards within general hospitals, thereby incurring the risk of contaminating the air in midwifery wards with hospital emanations.

(c)

Proximity to midwifery wards of post-mortem theatres or other external sources of putrescence.

(d)

Admitting medical students from general hospitals or from anatomical schools to practice or even to visit in midwifery wards without special precautions for avoiding injury.

(e)

Treating cases of puerperal disease in the same ward, or under the same roof, with midwifery cases.

(f)

Permitting the same attendants to act in infirmary wards and in lying-in wards, and using the same bedding, clothing, utensils, &c., in both.

(g)

Most probably also—especially in certain foreign hospitals—want of scrupulous attention to ventilation, and to cleanliness in wards, bedding, clothing, utensils, and patients, and in the clothing and personal habits of attendants.

In short, the entire result of this enquiry may be summed up, in a very few words, as follows:—A woman in ordinary health, and subject to the ordinary social conditions of her station, will not, if delivered at home, be exposed to any special disadvantages likely to diminish materially her chance of recovery. But this same woman, if received into an ordinary lying-in ward, together with others in the puerperal state, will from that very fact become subject to risks not necessarily incident to this state. These risks in lying-in institutions may no doubt be materially diminished by providing proper hospital accommodation, and by care, common sense, and good management. And hence the real practical question is, whether it is possible to ensure at all times the observance of these conditions.

The great mortality in lying-in hospitals everywhere is no doubt a strong argument against such a result being attainable; so much so that, in the absence of this security, the evidence in the preceding pages appears sufficient to warrant the question being raised, whether lying-in hospitals, arranged and managed as they are at present, should not be forthwith closed?

Can any supposed advantages to individual cases of destitution counterbalance the enormous destruction of human life shown by the statistics?

Without vouching for the entire accuracy of Le Fort’s data, they may still be taken generally as showing approximately the penalty which is being paid for the supposed advantages of these institutions. It is this: (see Table XV.) for every two women who would die if delivered at home, fifteen must die if delivered in lying-in hospitals. Any reasonable deduction from this death-rate for supposed inaccuracy will not materially influence the result.

The evidence is entirely in favour of home delivery, and of making better provision in future for this arrangement among the destitute poor.

CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE IMPROVED?

Must we, then, surrender the principle of lying-in institutions altogether, and limit the teaching of midwifery nurses solely to bedside cases at home, notwithstanding the well-known difficulties of teaching pupils at the beginning of their course elsewhere than in an institution? We will try to reply to this question; and, in doing so, perhaps some light may be thrown on another question, viz.: how to improve existing lying-in establishments so as to reduce the mortality in them.

Evidence sufficient has been collected to show that no one panacea will enable us either to possess a perfectly healthy building, or to improve existing hospitals.

Much has been written about the saving effect of small hospitals; but it is certain, from what has been already said, that the small-hospital idea is not sufficient of itself. It is, however, a very important idea, because all hospital problems are simplified by subdivision of the buildings. So far as we know, every one who has carefully studied the subject has given a preference to small lying-in establishments over large ones; but we should certainly be disappointed if we trusted to smallness of size alone for reducing the mortality.

The evidence further shows that in any new plan infirmary wards must be kept quite detached from lying-in wards. They should be in another part of the ground, and should be provided with their own furniture, bedding, utensils, stores, kitchen, and attendants.

The same arrangement, at least in principle, should be carried out at all existing lying-in establishments, and every case of disease should at once be removed from the lying-in wards to the infirmary, and be separately attended there.

In our proposed midwifery school the whole attendance would be supplied by midwives and pupil midwives, with a physician accoucheur, to make his visit twice a day, to be sent for in time of need, and to give instruction to the pupil midwives by lectures and otherwise; and in this way we should escape the dangers of introducing medical students.

Applying the same principle to lying-in wards to which medical students are admitted, there can be no doubt that a responsibility of the very gravest kind attaches to all teachers and managers of lying-in hospitals who do not satisfy themselves that students admitted as pupils have nothing to do, either with general hospital practice, or with anatomical schools, during the period. Midwifery instruction should be treated as a matter quite apart.

What has been already said need scarcely be repeated, about the dangers of connecting midwifery wards with general hospitals. The simple facts are sufficient to show that all midwifery wards of this class should be at once closed.

As a general result of this enquiry, applicable to all lying-in wards, the evidence shows that very much indeed of the success depends on good and intelligent administration and management.

Suppose that all these precautions could be carried out, will the cost and difficulty of giving effect to them necessarily lead to the abolition of all accommodation for midwifery cases, or for teaching midwifery?

We reply, No. The facts already adduced clearly show what may be done in this matter.

They prove, in the first place, that lying-in women should, as a rule, be delivered at home. And, as a consequence, that whatever provision may be made for cases of special destitution, or for midwifery teaching, such provision should be assimilated as far as practicable to the conditions which surround lying-in women in fairly comfortable homes.

These conditions are realised, and in some instances no doubt improved on, in the better class of workhouse lying-in wards, and of lying-in huts for soldiers’ wives.

The favourable results arrived at in many of these institutions appear to show that a little more care would lower the death-rate still further.

In every instance where it is considered necessary to organise lying-in accommodation by voluntary effort, the same principles should be kept in view.

The success which has attended Waterford Lying-in Hospital, already mentioned, shows how much may be done in rendering such accommodation a real boon to the poor.

A single hut, like the Colchester Hut, erected in a needy locality, would supply, and that safely, all the accommodation wanted. But for a training school of midwives and midwifery nurses other accommodation is required, and of a far more costly character.

It is true that any sort of building may be leased or bought and altered, or added to, and told off as a training school; but after what has been said, to take such a course would be to ensure killing a certain number of mothers for the sake of training a certain number of midwives. If we are to have a training school at all, we must, before all things, make it as safe for lying-in women to enter it as to be delivered at home; and having made up our minds what is necessary for this purpose, we must pay for it.