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·FROM THE MEMBERS OF THE AD HOC COMMITTIL ON MATERNITY AND CHILD WELFARE, то THE CHAIRMAN, CENTRAL ADVISORY BOARD OF HEALTH. Dated Simla, the 10th October, 1938. SIR, We have the honour to forward herewith for presentation to the Central Advisory Board of Health our report on Maternity and Child Welfare work in India, which has been prepared in accordance with a decision made by the Board at its meeting in June, 1937. In planning the report, the first step to be taken was the preparation of a questionnaire divided into sections which together covered the whole field of our enquiry. Copies of the question. naire were circulated to all those whose experience was likely to be of value to us and the statistical section, which had been drawn up with particular care, was made the subject of special reference to all provincial medical and public hcalth departments. It was hoped that the replies from oflicial organisations would provide fairly accurate figures susceptible of analysis and capable of presentution in such comparative form as would permit reasonally sound inferences to be drawn. We regret that our hopes in this direction have been to a great extent frustrated. It was indeed quickly brought home to us that in many cases little care lad been taken in preparing the replies to the questionnaire and that tlic statistical material given under the different hendings had been given little consideration before it was written up. The result was that the consolidated tables which were prepared from this materinl linre been cxcluded from our report because they rere found to be largely valueless for our purposo and we have been compelled to depend largely on material made LPIC

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TABLE OF CONTENTS
PAQES.
CHAPTER 1.-History of the maternity and child weliace movement in India
1-13
CILAPTER 11.-Alustration, organisation and supervision, -official and non.
official
14-22
CHAPTER IIL-Statistics relating to Maternzty and Child TVelfare
23–38
PTER IV --Maternity services
39-50
I.
CHATTEE V.Infant and child welfare services
51-61
CHAPTER VI -Traming of staff
..
62-70
CHAPTER VIL.-Legislation
77-80
CHAPTER VIII.-Summary of recommendations
81-85
Except whero otherwise stated, the figures in this report refer to the year 1936.

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·REPORT on Maternity and Child Welfare Work in India. CHAPTER I. HISTORY OF THE MATERNITY AND CHILD WELFARE MOVE- MENT. Development at the Centre, 1. The maternity and child welfare movement began in this country in the second half of last century, following closcly on the establishment of women's hospitals by Missions and by the Dufferin Fund Medical work amongst women early led to realisation of the conditions attending childbirth in India. These pioneer medical women were only too fre- Guently faced with tragedy arising from the fact that childbearing and labour vero conducted in unsuitable surroundings and by unskilled attendants in the form of indigenous or hereditary dais. Because the dai seemed to be the easier problem, the earliest efforts to raise the standard of inidwifery were directed towards improving her methods. The first training classes for dars were held about the middle of last century. The earliest teachers were men whose" praisetorthy efforts to teach the dais their business was no doubt looked upon by the pupils as both shocking and presumptuous." These efforts were suon abandoned, because of failure to change the dars' dangerous practices. "In 1866 a Civil Surgcon, Dr Aitchinson, opened a class for dais at Amritsar which struggled on through many vicissitudes and changes of teaclier and became in the cighties the well-known Amritsar Dars School of the Church of England Zennna Missionary Society under Miss IIewlett." Miss Iewlett was not only able to command the respect of the dais and to win their confidence and friendship, but slie had the foresight to realise that training must be followed by supervision. The success of the Amritsar scheme led to the forination of similar classes in other areas and, generally speaking, the attempt to train dais continuer in desultory and sporadic fashion until the beginning of the present century when the establishment of the Victoria Memorial Scholarships Fund in 1903 gave impetus to the safer midwiferye movement. The Victoria Memorial Scholarships Fund was founded by Lady Curzon following lier appeal for money to be devoted to the improvement of conditions of childbirth, The object of the Fund Inid down at its inauguration was " to train midwires in the female wanie of liospitals and female training schools in such a manner as will enable them to carry on 'Sex" Work of Madral womea la Indis" by Ralfour and Young.

·2 their hereditary calling in harmony with the religious feeling of the people and gradually to improve their traditional methods in the lights of modern sanitation and medical knotledge." In order to induce the midwives to take a course of training, it was proposed to give them scholarships for the period concerned. In addition, qualified female teachers tho under. stood the vernacular there to be sent to outlying districts and fecs would be paid to midwives who attended a course of elementary instruction At this stage, the women's hospitals were the only institutions in a position to undertake the training of midwifery pupils and the administration of the Victoria Dlemorial Scholarships Fund was entrusted to the Dufferin Fund Committee which had been founded in 1895 with the object of providing female medical aid to the women of India. The establishment of the Victoria Memorial Scholarships Fund followed closely upon the passing of the first Midwives Act in England in 1902. Efforts to promote the safety of motherhood preceded the adoption of measures to safeguard liealth during infancy and childhood, but in the early years of the present century the first welfare centres in India wero opened by enthusiastic voluntary workers, who had been in touch with social movements in the rest and were genuinely perturbed by the needless sultering and mortality amongst infants, young children and their mothers These centres were originally staffed by nurses or midwives, but it was soon realised that if the prork was to be educational and preventive, a special class of worker, similar to the health visitar in England, would have to be trained Many applications for trained workers of this kind were received by the Dufferin Fund office, but the demand could not be met e no training schools were in existence. The Dufferin Fund ofice, encour. aged by the Secretary of the Education Department, Government of India, formed an Association for the Provision of Icaith Visitors and Antemnity Supervisors, and, assisted by a gront of Rs. 6,000 from the Government of India, this Association was enabled to open a health school in Delhi in 1918. It was a bold venture, because funds were limited and the future position as uncertain, but the plan was sound and the faith of the promoters has since been aniply justified In the same year, Lady Chelmsford, on her arrival in India, immediately interested herself in tho welfare of the momen and children of the country Lady Chelmsford first Bouch the help of provincial Governments as the proposed to finnnce the work from governmental funds, but whilst the Governments werr sympa. thetir, they did not see their way to promise financial aid. A public appeal Tas, therefore, launched in 1919 and the Lady Chelmsford All-India Iscazue for Maternity and Child Welfare was founded the following year. The original objects of the Leagur were to give grants-in-aid to welfare contrcs, to pritarr pmpazonda material, to publish a quarterly journal, to appoint travelling naniner, to stimulate interest in maternity and child mellare to give technini ndrice to the voluntary committere niready at work t parts of the country. Ladis Matrmity and Child Welfare richihitinn held in Delhi further important stimulus to the not morement Thc retnally niganised by the office of the Dufterin Fund, was first month for the Association of Medical Women Yare merived from all parts nt the country and the n*** hier in publ. whilst the resulting dix.

·3 semination of infromation in min! ni them insibilities of maternity and child mellare noi laal in mare iragarrirent in thir ofaniuation and 1) in or thr cxn110 mllar contra The maintenance oil-routy central rain maile a hrary innuen tlir triativrir mill in!!!!, Laily (primenil.regur l'une ard, onlar to litrair all.116 s.al fundo fortal urik, tir am rof the L (*.chin! Irrir alt! Dulcriu Fundurin erillisin anil tlir Seriar: oftlichtern I'. trubnic: t!.r tilset of lenntary Secretary siile lasty (r...frl I.-25er Find Thir Victorinryal Selimlar hips Funil. well as the ratio fitir l'honninn millenlith Vinton and Valrmly ani, na ndio nilministri itin 1l. Durtin aril n pl.: * A; .nl . *. 1! (hir! Valira001ent, Wan Vaaliral Fruine, in ilir Adminisration and in the priniention of their Inice Durin: 1"11.1941-, tl.r Indian fired from Nispirty Bosal adal ron. rilerally lo fa furile au alire trate u Avgasallo.ml, 11.- Srirty loan to trail rund fore clujmie in which is uriperined incre mirli Irzilimairly Le derniel. Vatrnuty and challel polfarr armoil in ima stabla fick for this purwoe, lut in nier trato escrilappines, the Unirmits and Child Wilrnte Burrat. Initian lini (pra Syrly. mas mablired in 2!!and for tlic 1.30azrrent of all arhitin minerned with maternity mi. chili! trllarr Tir almittenti oftlin Victoria Imo. rial Scholarulupe un rnel tlir fondy ("helminal langue l'uned (incor. porating the matirin for this l'annivien ! llentils Viator and nirmmits Suivre) Tat enirium to thic Ilirean. Dr. Rath Young being appointed tlır fin: Director. This amalgamation frns of undoubted advantar to the motrinen: in India : tlir Indlinn Mal Crks Socirty had Loth funds nnil loral mochinery in its jtorincial and distrire lornuclire, stliilat the Duſterin Fund proviilat ndefitionni minnry and the prsirrs of an expert teclinical adviser. Army child welfare work had buy this time also comr inin biring, the Jimited income available, thich tras inninly derived from thr Coinınander. in-Chief's fund for unfaresorn expenditure, being administereilly a voluntary committee. Limited funds and the lack of trclinical guidance han licappre progress and in 1931 tlie Army Child Welfare Committee and the Maternity and Child Welfare Bureau agreed to nmnlgamatr. Tho Maternity and Child Welfare Bureau tonk over the trrhnical supervision of the work, along with the income, from the Indy Iirou oocl l'une for Army Child Welfare and assumed a certain degree of responsibility for arms child welfare. Ciril and arny child welfnre were thus brought under the control of a single central office The opening of the All-India Institute of Hygiene and Public Iealth in Calcutta provided the opportunity for which those most intimately concerned with maternity and child welfare had long been looking The Chief Medical Officer of the Women's Jelical Service drew up and subinitted to Government & scheme for a diploma in maternity and child welfare. It was agreed that one of the sis sections at the Institute should be devoted to maternal.child health and the first diplomn course was held in 1933-31 From 1933 until 1937, the Differin Fund gave the free services of u member of the Women's Medical Service as Professor of Maternity and Child Wellare in the Institute, since when the Central Government bare resumed responsibility for filling that post.

·4 Two recent events bear testimony to the widespread concern feit in respect of the continuing high maternal and infantile mortality rates in this country. At the annual cunference of Medical Research Workers held in Calcutta in December, 1935, a resolution was adopted which recommended the establishnient of an ad hoc committec to advise on research into the problems connected with naternal mortality and morbidity. This committec mct for the first time early in 1936 and, during the same year, under the auspices of the Indian Research Fund Association, the first of a acrics of investigations into the incidence and causes of maternal deaths was started in Calcutta. A second investigation was later begun in Bombay. The information yieldcd by these surveys may be expected to provide data on which the planning of sound and effective preventive eclicmes can be hanel with some confidence. The second event was the decision made by the Central Advisory Board of Ilcalth nt its inaugural meeting to appoint an ad hoc committee which allould review the trhole maternity and child walfare position in Inclin and report to the Board The present report lias been prepared in accordance with that decision. Development in the Provinces. 2 The hustory of the maternity and child welfare movement in the provinces is more or less similar to that at headquarters. Isolated welfare centres and dars' training classes were in the first instance started by voluntary workers In some prorinces, branches of the Victorin Jemorial Scholarships Fund and the Lady Chelmsford League Fund were later established under provincial committees and there have mostly followca the example of honenmarters and hayr joined forces with the provincial branches of the India 1.3 Ra Crnint lirinninn nnifiad control to bear tihar and Orissa, on all voluntary effor howeser, large and tirir individual identity, whilst both :: have remained outside llie reope of the Victorin Memorial Scholarships Funil The former line ained consistently and title considerable success at abolition of the indigenous dai; in the latter, the Lady Wilson Village Dai Inproromcat Fund inkes the plaer of the Victoria Jemorial Scholarships Fund, (a) Bombay-The maternity and child welfare movement in Bombny Presidency originated in Bombay city where the special problems created by the recruitment of labour for the cotton mills anil tlie inadequacy of the housing of the workers and early to the establishment of minternity hospitals and homes The first maternitr home to open it in 1845 bilim Gouernment of Bombay in the compound of the J. J. Inupital and other inspitals and homa, vilt fram fuis contrisited by philus thropie inelis iduals, followed in rapid - najnu built in TFC, mas the first women's and !! Moltri carlusively by merlical wonen. Alarna vale matrrnits arhaina mas Willingdon in 1911.12. the deselamat ng its main features Theº be 1 : Citr Junirinal Committee. Houdt hos,

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·6 Cases standing feature was the Hyderabad Dais' Improvement Scheme started hy Miss Piggott in 1918. This was not only important as a great pioneer citost, but it has influenced the development of maternity and child welfare in Sind down to the present day. At various times, too, a num bei of small naternity homes were opened, but, as the driving force in many instances came from a single individual, most of these had only a tref existence The Sind Provincial Branch of the Indian Red Cross Society was established in 1991 and its first maternity and child welfare activity was the opening, in 1924, of centres statīed by voluntary trorkers for the families of Indian troops in Karachi The first civil chill welfare centre, with a purse in charge, was opened in 1925 in Kiamari, an industrial village four miles from Karachi In 1926, Nawabshah district ne provided with a touring nurse, those duties were to educate the mothers in regard to safe midirifery, to give lectures to dais and to attend midwifery' This scheme achieved a certain degree of succes and, later on. three additional touring nurses were appointed A Provincial Organiser was appointed by the Sind Branch of the Indian Red Cross Society in 1930 to supervise and develop work through. out the province By this time, one welfare centre, tno maternity homes and four touring turses, who conducted an average of 10 casos parh per annun, were being maintained. The Society, 'Fuided by the success of Miss Piggott's Scheme, decided to concentrate on the training of indi. Classes for these women were started at Nawabshah in con. rcction with the inaternity home and at Mirpur Khas under a health visitor. The inost successful scheme as that at Sukkur which, by 1937, had des eloped into a residential institution known as the Lady Graham Nel Crose Dais Training School (c) ſadras --The history of the movement in Madras I'residency differs from that in other provinces in that the stimulus has frequentig come from oncial sources As carly as 1875, Government orders acre issuril requiring crery local fund board in the Presidency to emping a milife. trained under rules Inid down by Government, in trarh nativo tromen (indigenous vlnit). Later priprs (157-9.7) provided that a midriff should be employed in all local fund dispensaries and hospitals bring women's varit on that detached hout pasilions should lor stab. lished for lying in casa The response of the inis to this provision for their training was meagre and the profession has consequrntly passed largely into the banily of A non-indigenous place of women Threr and fuharjuent Government onlere kept local boding ahire to their responsi. Wilities and pareil the way for later terelopments 6cnous dais The Mariras Corporntinn maup efforts to introduce a system of home sisiting in the city in 1991 whrrebr adrien on health matters imuld be available to the motline in berl.ome, in the scheme proved of little value. A more comprensirr maternity and child welfare service as inaugu. rateel in 1917 ritka melical roman in charge and fonr missises to Assit pith confinocents The first contre was opened in 1918. The Fjerres of the change Inil to rapid transion and in 1939 there were inplea contra rarh in ehatempla medical tomar and staffed by hralth ristope noul mistiine Preratal care has made such progress that it ·is now possible for the staff to restrict attendance at labour nainly to booked cases. The Corporation spends Rs. 1.82,510 annually on its niatemity and child welfare services Voluntary work in the maternity and child welfarr field started in 1915 when the Jadras Presidency llcalth Association was formed. Slortly aftertrands, the sociation 110% dissolved, its activities being taken over by the Madras ilealth Propaganda Board and the Modras l'residency Maternity and Child Welfare Association. The latter isso. cintion under the leadership of Lady Willingilon encouraged mofussil conunittees to open centres in charge of midrives and nurses. Financial assistance was given by the Ixociation, but the mininstny was the local voluntary worker. In 1922. the Secretary to the Government of Indras convenci n conference which was attended by the Director of Public Health, the Health Oficer and the Superintendent of the maternity and child welfare scheme of Madras city and representatives of various institutions and societies conecrned with work amongst toinen and children. The conference rccoinmendrd the training of licalth visitors at the Corporation welfare contres, this to be in charge of the medical superintendent of the Corporation centres The first coure as orranised by the Maternity and Child Welfare Association in 1922 and classes were continued on similar lincs until 1929. As the students completed their training they were absorbed into the municipal scheinc ; at that time, there was no demand from the niofissi: for health risitors From 1929-30. a health sclionl was run by the Maternity and Child Welfare Association, but in 1930-31 it was closed for lack of a competent staff. A specinl division of the Provincial Branch of the Indian Real Cross Society, into which the Vaternity and Child Welfare Association had been incorporated, took over the School in 1931 and continued to main. tain it until March, 1938, when it was felt that the time had come for Government to assume responsibility for the training of health visitors. A training class under Government auspices was actually formed during the same year. With the closing of the Red Crose IIcaith School and the landing over to the Corporation of the molel centre, the Society severed its connection with maternity and child relfare in the city. The voluntary funds thus liberated are being used to promote the training of Nursery School teachers. The IIealth Propaganda Board has done invaluable work by prozuoting conferences on maternity and cliild welfare and the school medical services, thus broadcasting information and broadening the outlook of all concerned with the health of the mother and her children The Board receives a Government grant-in-aid. In 1923, the Director of Public Health drew up a memorandum ou maternity and child welfare which Government circulated to all local bodies urging them to make more use of their powers to provide for the health of mothers and children. The last paragraph of the Government crder reads: “The Government trust that local bodies as the responsible custolians of the public health of the areas within their respective jurisdictions, will lose no time in formulating and carrying into extect practical me ces on the lines set forth in the emo- ·8 33 1 randum appended to this order All local bodies are requested to report through the Director of Public Health not later than the 31st December, 1923, the action taken by them on this order. The Director of Public Health is requested to bring to the special notice of the Government any instances in which he considers that the action taken by a local body is not adequate. The local authorities took little or no action to implement the reconmendations made in the meinorandum until more direct and more contintous pressure was brought to bear on them by the creation of a maternity and could welfare department in the office of the Director of Public Ilealtlı and the appointnient of a woman Assistant to the Director of Public JIcaith for ninternity and child welfare in 1931. (d) Punjab-Dr Agnes Scott was the first to hold the appointment of ironnan assistant to the Inspector General of Civil Ilospitals, a post created by the Punjab Government in 1917. The first result of this appointment was the organisation of a Central Jadwives Board , the development of maternity and cliile welfare work was then taken up As it was foit flat the needs of tlie province would bent be secured by the establishment of a Kchool for the training of health visitors, in 1920 the services of two English lealth visitors were obtained for work in Lalıore. In the sanio year, a ceatre was opened in Sıla and placed in charge of a Delli-trained health visitor provincial branch of the Luy Chelmsford Lengue for Maternity and Child Welfare was constitutecl in 1922 and during the same year, niddel by a grant from Government, the Punjab Iicaltı Salool was opened in Lahore. In 1923, the provincial branch undertook an active propagandia campaign in order to extend its work and decided not only that all centre must be inspected but that none should be cligible for financial 125istanee unless the Coinmittre were satisfied with its lon: und with the discouumodation provided for the woman in charge. The work of organisation and supervision was entrusted to the Principal of the Ilealti Saloul and, by 1924, five welfare centres 30211 been opener The first the course of training for liralth vanitory were held in I'nglish, but as the applications for admission were few in mumlxry, thic Committeended to accept vernacular students for the third cour'hela in 192!-23 The response Lcios eo better, this experiment was not ropcatel In 1927, the Director of Public IIealth dress the attention of the Indy Chamford League Committer to the fact that the League's fuarls were almont entirely spent on the licalth School and asked that consideration might lie Buen to the proposal that the Selinol be taken over hy Closera. ment, so tha thic artisite, of the manne might be concentrated on the prorion of infart wolare contre, in the districts as a result, the liralth Selinul le are nissernment institution in 1997, being placed under the contor Director of Public Inaltii The inverunrnt this became Corrit to the encourariant of cull welfarr work and the next step asin pise prints in and to beral scheme This was done in 1925 lien a sim ol 91,60 pas an tiaral. The Jial.ilstins of the provincial branch of the Lady Chelmsford Leagne Laring ln N talen over by Government, the League was dissolved in 1929.

·The district branches of the league were, loncier, amalgamated in 1931 with the branches of the Indian Ice Cross Society and control of the centres was transferred to the latter organisation. The cconomie depresuon of 19:30 nearly resulted in tlic closure of the Ilealtl. Seli00l, but tlus deession was rescinded in response to a striking demanal from the Legislative ('ouncil on the general public. Altlıough expenditure iras drastically cut and grants-in-ald were reduced, the buinber of centres lins nevertlicles continued to increase slowly but steadily. Dais' trames classes, nidel by grants from the Victoria Heinorial Scliolarship Fund, mere held at all centres and, by 1930, the numbers pre. pared for the Indigenous Dais' Certificate of the l'unjali Centrn! Midwircs Board had become so large that the liovernment ordered the examinations to be conducted by the l'ublic llealtlı Department. Dais' Ixamination Boards were established in each district, examinntions being conducted by the l'rincipal of the Blealth School during her inspection tours. an Asstart lupectress of Welfare Centres, tinder the control of the Director of Public Health, was appointed in 1936. By 1937, 89 welfare centres and n large number of subsidiary centres were at work (c) N'-. F Prolinec.—Maternity and child welfare work liegen in the X-W F Province in 1923 as a result of propaganda initiated by the Lady Chelinsford Lengue. In that year a woman sub-assistant surgeon was appointed for domiciliary midwifery by the Peshawar municipal committeo and a velfare centre in charge of a health visitor was opened under volun. tary auspices in Dera Ismail Khan, A nars' training class was started in the Dera Ismail Khan centre and 30 wonien eientually passed the Punjab Central Midwives Board examination l'rom this class developed the Lady Bolton Dais' Training School which was opened in 1926. The dais live in the School for nine montby and receive training in indoor midwifery and pre-natal work at the niunicipal Zenana Ilospital and in outdoor midwifery under the health visitor. By 1929, all the disiricts and many of the Agencies were co-operating in the better midwifery" scheme by sending dais for training. After the course, the dais return to their districts where they are attached to the Emall civil liospitals and dispensaries. In 1936, the health centre and the dais' training school were taken over by Government and the period of training was extended to selve months. In the same year, a second Government training centre opened in Teshawar and placed in charge of an experienced midwife, wliilst in Kohat, in 1937, a health visitor was appointed by a voluntary committee and a training class was started for local dais. Impetus has been given to this scheme by payment of Government subsidies to trained dais working in rural areas The Superintendent of the School tours the province to select dais suitable for training and to supervice the work of the trained women. During more recent yeais piany applications for admission to the training schools have been received from better cducated women. (1) United Prouinces.--The maternity and child welfare movement brgan in 1923 under the auspices of the Lady Chelmsford League, the first centre being opened in Bareilly and the second in Allahabad, which becaine a training centre for midwives. By 1926, the number of centres in exist- Was ·ence totalled 26. In 1923, the training centre was transferred to Lucknow, where a health school was opened for the training of ficalth visitors. Because of lack of funds and the difficulty of finding employment for the health stors, the health school was abolished in 1932. Amalgamation of the Lady Chelmsford League with the Indian Real Cross Society took place in 1931. By 1935, there existed at least one (cutre at the leadiftiarters of each of the 48 districts in the province and, in addi. tion, 114 rural and 61 other urban centres had been opened, making a total of 223. At the present date, 293 maternity centres are at work, some of these being situated in remote hill tracts, sliere no skilled help other than that kii on by the assistant midwife is available In contradistinction, chuld Telfare (cuties number only 18, the development of this work being hampered liy the dearth of trained lıcalth visitors Considerable assist ance has tren given to the work throughout the province by local 2011- mittecs of momen voluntary workers. In the initial stages, funds were small, but in 1926, the Governinent care a grant of Rs. 50,000 and for the last four years the annual Government grant las been Rs. 1,22,600 The total expenditure in 1937 amouuted to Rs. 2,51,718, this including a grant from the Indian Red Cross Sociсty, local contı:butions and fees The training of indigenous dars has been carried out under the Victorias Menorial Scholarships Fand, the women being still paul tro annns for each lecture they attend and four innas for ciery maternity case reported in time to permit of its supervision by the health ritor In sorne districts, grants from the Silver Jubilee Fund have been set stile for the training of these dais and in the near future it is loped that the slais trained at welfare centres will be attached to Dufferin Hospitals for a few mncnths. The training of 89istant midsnes continues, about 23 women реге annurn being given instruction with fairly successful results, In 1933, a grant of one lakh was recived from the Silver Jubriec lund for the construction in Lucknow of a health school for the training of health visitors, midwives and dais. Various difficulties having been overcome, luding operations are now in progress (9) Bilar and Onsso.-as in other parts of India, maternity and chill welfare work has been on inportant development of recent years, although, so far, most of the activities are still confined to district headquarters there the personal efforts of oflicials and their wives havc pro. vided the impetus. It was only in 1923, ten years after the creation of the province, that the first nigte was made. In that year, on the ndrice of ile Inspector General of ('ivil Ilospitals, the Provincial Government started a natur. nity achiene in Patna, the staff consisting of a naternity supervisor and six millris Lach midwife was given a defined are: in which to work and slir attended all normal labour cases. Tlis tulene, homeser, had little to do srith the care and protection of infants and, in 192: Lady 117 ccler initiate?" The Bihar and Orissa Chill Wrlfare Fun!" watch locan work by maintaining two child sel fare centres in Gulrathigh and in Patna and by tinklinn" laby works" in 11. more important towns Centres at ('uitla' k n! Balasore were rjun in the follorin; year. These four centres ſanctioned fully, bu, in order to promote the extension of welfare actisitics all over success.

·the province, in 1925 the " Bilinr and Orissa Maternity and Child Welfare Society was established, the existing Fund licing mered into llo. new Society. The income of the Society is derived from four Tritt iunie, from interest on iniestments and from annual Government frants un 19 spent in making grauts-in-nid to welfare centres established throughout the province By 1937, a total of ciglit centres trerc at work in Bilar and two others in Orissa and it is hoped shortly to have at least one centre in cach district leadquarters and in the more important towns. Each centro is control.cd by a local committee working under the guidnnce and super. risior of the Provincial Society and is maintained partly by the Society funds and partly by local subscriptions and donations Prery contre is staffed loy a health visitor, assisted by a midwife, and is usted regularly liy the local woman duxtor. I're-natal work is one of the most important parts of the work. (la va for las ar lield 111 110 of the centre in the separation of Orissa, the centres situated in that piros inre arre taken over by 'n new Society, which lias since been formed. (h) Central I'rol'inccs.-The beginnings of maternity and child selfare vork in the Central Provinces and lerar mis laid By Dr. 41:1104 Henderson of the Scottish Mission Society who was a pioneer in the causo of providing relief to Indian women in this province. More than 25 years ugo, she realised the importance of training the indigenous dui and sorted a training class at lier own expense. When the Victorin Memorial Dni Training Fund was establislic, this scheme received an annual grant from this lund. In 1920, Dr. Sinclair, also of the Scottish Mission Society, with the help of the Deputy Commissioner of Yaypur formed a committee of comc of the Jeuding citizens of Nagpur and collected donations for maternity and child welfare work among the poorer classes in Nagpur city. No wcl. fare centre was established, but a midwife was employed to do home visiting The following year this committee obtained a grant from Goscrn. ment for thic salary of a woman doctor for one year and a welfare centre was started. At the end of the year the committee felt that this work ought to be taken up by the municipality and this was later accomplished. The municipality placed the child welfare work under its liealth departıncat, Government paying half the cost up to a maximum of Rs. 5,400 per annum. Two health sisitors one from the Poona Seva Sadan and one from Delhi were employed to run the centres, but welfare work up to this time was confined to Nagpur city. In 1926, the Indian Red Cross Society decided to organise maternity and cliild welfare work for the province and a special committee, desig- Dated the Provincial Welfare Committee, was placed in charge. Shortly afterwards a six months' course for training health visitors was drawn up and conducted under the aegis of the Red Cross Society. A liostel for the candidates who received a stipend of Rs. 20 per mensem, and a health centre for training in practical work, were opened close to the Robertson Medical School, Nagpur. The lectures were delivered by the doctors from the Dufferin and the Mure Memorial Hospitals and by private medical practitioners. A scheme to open welfare centres in every district of the province was formulated and propaganda done by enlisting the support of district officials and prominent non-officials who were interested in the work.

·Centres vele started by local committee, #lio inre half the crist of 191p. mont And twiteinnee irutu un collele lise them and fryn gronks na In loral Lorities, the remaining ball leing borne by the prosiliul Wlfare (mmtter The funds of the provincial Welfare (ommittre comprimid grants fnir llie jic ('ron Socirty and from Government Thir lalter la fu. tutel l»'ween Rs. 1.3,900 in 1929-30 and 1. 10,000 in 1931, the present Government frant lieing lux. 39,500. It will soon felt that the training for health visitors was not sari factory. In 1995 the Real ('ros, training ell, van Gowed down and the Nomir Health Scical for training health witon was narteil by Govern. menit. a woman lorenr with experiene e of maternity and child welfaro work was Ipointed as Superintendent, Xirry School for toddlers aligned to serve as a minden for the province was opened in 1923 and most of the health centres were organised te do vais' training on a comprelien te scale and pre-natal work where it was possible to get the help of a lady ductor. After a promising begin. ning, progress was checked by the financial depression of 1931 as Govern. mont may conipelled to reduce its grant By cffecting economics in iurious directions and reclucing tlie pay of the health visitors, welfare work in the province flas not only seen maintained but hns been cxpanded Thic previous three grudes of welfare centres were abolished and all put on the sam. Iriel Since 1926, when the number of centres totalled 91, all of wel were in urban areas, activities have been greatly expanderi, so that by 1935 as many as Gl urban and 20 rural centres were in existence. () Asan-Red Cross work began in 1921, but welfare work under the Lally (lielmsford League was conducted separately until 1932. The funds of the League being small, such work ns was done between thieso dates was financed by the Red Cross. A welfare centre was opened in 1927 in Shillong ; later on, centres Here institute in Jorhat, Norgong and Sylliet The training of dais has been spasmodically carried on at the Berry White Iluspital at Dibrugarlı, but more serious efforts were made Silchar and Sylhet. As regards midwives and nurses, a number of candidates holling scholu sinips have licen given training at Delhi and Calcutta. In respect of the training of health visitors, a few have been trained at Delhi and Calcutta, but since 1937 two lealth visitors are being trained annually in the Bengal Health School. (1) Bengal.-Although the Calcutta Corporation started maternity and child welfare work in 1909, this was of a rudimentary type and it was not until 1916 that the real foundation of maternity and child welfare services was truly laid. During this year the Caleutta Corporation opened two maternity units, each in charge of a woman sub-assistant surzeun designated as a health visitor. These centres ere, howerer, intended for domiciliary midwifery. Additional maternity units trere opened by the Corporation and by 1930 there were seven such units in existence. With the formation of the Red Cross Society in 1921 a child welfare committee was formed and the Society gave financial assistance to two clinics, l'iz., the St John Anbulance Baby Clinic and the National Indian Association (Ladies Branch). In the sabie year a Maternity and Child 1ນ ·13 Welfare Trust was establislio nt Dacca and a maternity centrc nt Asansol, whil: the l'rovincial Branch of the Indian Red Cross Society niso liclined the Carisal district society in the supply of lry milk and, during the fol. Towing year, opened a child welfare centre in north Calcutta with the lielp of a grant from the corporation, which was secured luge thic representativo of the Indian Red Cross Society on tlic Municipal Committee. In 1923, the Calcutta Corporatioll established the first of its four municipal maternity homes The Calcutta Baby Weck Ansociation, which was founded in 1911, also made a small grant for centrict mnternaty work. Whilst thic Provincial Branch of the Indian Red Cross Society lind depende mamly on voluntary workers for its welfare schemes, the neeit for letter trained staff had constantly been realised and in 1923 a lealth School for the training of health stars tras cstallislıcd in Calcutta by thic Society Tlic nurses working in the existing clinicy attended the School, but at the same time continued to perform their usual duties, so that tho first trained health visitors were not nvailable until 1926 Tlic lealth School was closed down in 1931 for various reason13, Previous to 1930, the Asansol Nines Board of Ilealth lind maintained three midwives whose main duty was to train and supervise the work of dans In that year, an extensive scheme was prepared and in 1936 thic Mines Board sanctionedi materinty centres for their two principal arcas, ris, Asansol and Ranigan), and now employ a male medical oficer inu several health visitors. In 1933, & inolei child welfare centre tras organised by the Professor of Maternity and Child Welfare at the All-India Institute of Ilygicnc and Public Health This clinic series as a training centre for medical women attending the course for the Diploma in Maternity and Child Welfare and, 1.uter, refresher courses for health visitors have been arranged. Some of tlice healtlı visitors were cinploy oil luy the l'rovincial Branch of the Indian Red Cross Society and placed in charge of centres with a defined area having a radius of about two miles. This contre which had previously beeu financed from voluntary funds tas taken over by tlic Central Government in 1937. The clinic at Darjeeling opened in 1924 was reorganised ; a hсalth visiting section was added and a woman health visitor and two qualified midwives were appointed. The Bengal Tiealth School, which lind been closed in 1934, was remodelled and opened in 1937 as the Sir John Arderson Health School. The course for the training of health visitors has now been extended from one year to 18 months and the rules for its control aro under the consideration of Government in order that recognition should be given to it by the Bengal Nursing Council. The clinic at Kaurapukur was established during 1938 for the purpose of giving practical training to candidates from the School in rural work During the last few years a considerable number of welfare clinics have been opened by different societies and bodies, including the Indian Red Cross Society. During the present year a Nursery School was instituted by the Servants of Humanity Society. Tom this... - ild welfare voluntary Branch of ul Jued Cross Society. L.2PHC ·CHAPTER II. ADMINISTRATION, ORGANISATION AND SUPERVIS10.- OFFICIAL AND NON.OFFICIAL. . Organization at the Cenire 1 'l him Yillgrosskoon eliat marrnity and child selfare rosk in Inden still in the lines of voluntary rhanbations The w.ly Corul turly working on an all India Bajan ilire Unternity and Child lleure Bureau of the Indian lid i'r Siner ty The policy of the Murrau s kontsert boy di cuinente reprenlatır of the medical and public health departments of the firserntent of India, army medical ani aile Drtive departments, voluntary orginisations and in seal work, Hum. -13 por frozep fund pownici indical interested and exprricaced It al welfare The Director of the Bureau is a medal wowan with Ichwallvouledge of both the clinical anul administrative aspects of weld furt work The annual incrime of the Burcan a lounts approximately 10 Fix, 1,30,000 anul 15 mamly derived frutti che insendeid caputal of the Victoria Mensorial Scholarships Fund, the Luids (felmsford League, prints from the Indian Red Cross Soutely and from Irmy leadquarters and an annual Government grant of Rs. 6.00 for the Lly Reading liealth School The income from this Victoria Memorial Scholarships Fund which amounts to approxunately li» 10.000 is almost wholly distributed in the form of grants. in-an to training schemes for indigenous dars and other romen who will subsequently take up muufory practice in the smaller touns and villages. Approximately RS 600 per annum spent on the promotion of schemes for the welfare of the families of troops considerable proportion of the remaining balance is expendel on grants to schools for the training of health usitors, nursery school teachers and nursery nurses Two scholarships are also providedi, tenable nt thic All-India Institute of Ilygiene and Public Iicalth by medical spomen graduates taking the course for the diploma in Jaternity and Child Welfare Apart from expenditure on the training of public liealth workers, certain grants-in-aid of maternity and child welfare schemes and the production of a variety of propaganda material, the main function of the Bureau is to act as a central office in respect of all matters connected with the well-being of the mother and her children. It endeavours to collect and record information about the work throughout India, to keep in touch with what is taking place in other countries and to co-ordinate and standardise the maternity and child relfare activities of provincial branches of the Indian Red Cross Society. This is done by means of personal visits made by the Director, by correspondence and by promoting conferences and health reeks In short, the Burean attempts to carry out in the mluntary field the work which is performed in England by the Maternity and Child Welfare Department of the Ministry of Health. The extent to which the Bureau can influence the trend of maternity and child welfare is of course limited by the volun. tary nature of the organisation. Advice is willingly given when asked for by public health departments or by voluntary organisations and workers, but advice cannot be offered nor can circulars drawing attention to re- ·16 cent advances be sent out unless imitations to do so arc recrired. The existing relationship between the Benu and thic bodies undertaking maternity and child welfare in the provinces is indicated in the following paragraphs whiclı niso give descriptions of the different provmcial organi. sations Organisation in the Provinces. . Jadrat.-(a) Gorronment. Multas Presidency enjoys the dis. tinetion of bring the only Province shere a meilical woman holds an om. cinl appointinent as Assistant Director of Maternity and Child Welfare in tlic oice of the Director of l'ullie Ilealt'. IXreept for this oficer's salary, no other part of the provincial public Pealtlı budget 14 carmarker! for watcrmty and child welfare work. I'miler mul oriler of tlır Madras Government, all local authorities proposing to allot sunels for maternity and chilil welfare are required to consult the public health department in regard to their schemes. (lovernment orilory regulnting the conditions of service and the qualifications of the ntnft appointal to those maternity and child welfare schemes which reicise oficial grants linse been suci. Sundard record forms have also been introclueel and standard plans aro nailable, tliese having been prepared by the Architect and Sanitnry Enmeer ty Government in consultation with the Director of Pubhe liealth The Director of Public Ilealth, Snuras, lins remarked that " with regard to work under Government and local boilies, it has been found by experience that dual control, which resulted when erecutive powers were jointly entrusted to both local brilies and voluntary asociations, created many administrative difficulties, (nused frequently dislocation of work and scrious indixipline in the ranks and resentment on the part of local bodies At a conference hiele in 1931 between the Surgeon General and the Director of l'ublic licalili anel the authorities of the Indian Red Cross Society, it wng agrred that the organisation, direction and supervision of work under the local bodies should be left tu tlic Dicctor of Public lIealth In G 0. No. 2314-P.II, dated 29th October 1931, the concrnment havo accordingly direxted that the inspection and control of work tinder local bodies should be left to the Director of Public Ilealth Thic Director of Public Health lias, however, stipulated that wulst he would be glad to receive the suggestions of voluntary workers, is regards work curricel out by local bodies, the representatives of voluntary associations should not make recommendations and suggestions directly either to local bodies or to their officers in thic field but only to him (Director of Public Ilealth). This safeguard is necessary in order to prevent clashing and overlapping. This policy has been accepted by local bodies whose allotments for maternity and child welfarc work have increased from Rs. 1,23,781 in 1931 to Rs. 2,40,961 in 1937. As stated above, the work under them lag also pru. ceeded on more satisfactory lines.". () l'oluntary.-The Madras Provincial Branch of the Indian Red Cross Society includes maternity and child welfare work in its programme. The composition of the maternity and child welfare sub-committec of tho Provincial Branch corresponds closely to that of the Maternity and Child Welfare Bureau, Indian Red Cross Society, and the advice of the Director of Public Health and his woman Assistant Director are thus securel. Tho

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·17 ment of Inspectress of health centres and l'rincipal of the health school since 1927 ; a second assistant Inspectre's Hils appointed in 1936. Thic former acts virtually as an assistant for maternity and child welfare to the Director of Public I lealth The two women who hase held thic post of organiser of maternity and child welfare work since its establishment in 19:27 linse done admirablo work, both by Amusing interest in the opening of welfare centres, and later, lyv nrcuring the employment of trained health visitors and midwives. Tlie Punjab provides an annual grant of Rs. 53,800 for maternity and cliild welfare in its public health budget. Out of this sum, Rs. 25,000 is distributed in the form of grants-in-aid to centres, w bether managed by voluntary or official bodies, provided the public licalth department is satisfied with the standards of work and thic qualifications of the staff. The balance of Ils 25,800 is espended by the public health department in thic maintenance of the training selinol for health visitors and on the cataries and allowances of the staff attachcıl to leadquarters. (b) Toluntary.--The Provincint Branch of the Indian Ral Cross Societs spends approximately Rs 10,000 cach year on mnternity and child welfare Thic Organising Secretary of the Branch is a layman but techni. cal advice is obtained from tlic Inspectress of health centres who also inspects the Red Cross child welfare centres (c) Local Organasafions --- Local Boilies and I'oluntary – Iunicipal and district boards in the Punjab spend Rs 72.972 and Rs. 33,003 respec. tively per annum on welfare centres, whulst district Branches of the Indinn Red ('ross Society spend Rs 25 000 to Rs 30,000 per annum on maternity and child welfare work Welfare centres now total 88 Thirty-six ot these are run by municipal boards and local bodies, 13 ly voluntary associations, 31 by the combined efforts of local bodies and voluntary organi. entions and one in association with the Government health school. In addition, the N.W Railway has four centres of its own Oficinls are ordinarily represented on local committees, the Deputy Commissioner, in many cases, being president and the district medical officer of health being the secretary The Director of Public Health is not only regularly asked for advice regarılıng the work, but he is required to approve of a health visitor's qualifications before she can be appointed to a centre. Moreover, Government will not give a grant, until the work of the centre has been approved by the Director of Public Health 4. The United Provinces.-(a) Government and Toluntary --The United Provinces Governnient provides Rs. 1,22,600 in its public lealth budget for maternity and child welfare, but the trhole of this grant is landed over to the United Provinces Branch of the Indian Red Cross Society In addition, the Provincial Branch of the Red Cross Society expends Rs 24,656 annually on welfare Fork A medical woman acts as Director of the Maternity and Child Welfare Section of the Red Cross Society and works under the direct control of thie Director of Public lIcaltb, who is Vice-Chairman of that Society. TIorever expedient this method may have been in the past. when public health departments were neither suſficiently developed nor suitably staffed, it would seem to be open to argument whether the policy of ·18 daheraton, to a voluntary wirty, the provincial arranisation of maternity and cul selfupran ilir admini-tration of Governinant grunts in-aid alionlil le cont!nute! (h) Lil Biodlirs ani! Voluntary in the districts, welfare work is conducted lis' thun dastrict branches of the Indian Red Cross Society, their total expenditure amounting to Rs 1,13,097 per annun. Grants are also fiton los municipalition, and local borrels, since thene Bxwbies, as a rule, do not ornnis separate solemnes. lu onlir to secure all posibile cooperation, thie Dufferin anii Blissien luospital authorities are invited to brcone mern ben of the local commuters in order that they may actively assist in the supervision of the welfare trork in their arras 5. Bombay.- (a) Governmrnt and Teluntary --Maternity and child weinte work in wit organised by the oficial public health departuent. The Government has puien prants to the Bombay Presidency Infant wcl. fure Suciety of Ils. 1,000 during 1933, 1936 and 19.37 for the lealth Visitors' Institute, The expenditure during 1936 of the Bombay 'residency Infant Wel. fare Sociсty was Rs. 1,21,791 and that of the Bombay Mofussal Maternity, Child Welfare and Health Council was Rs 19,876— making a total of R$ 1,41,628. Jarl organisation maintains its own health school, (1) Local Bodies and Voluntary -Junicipalities are stated to spend as inuch as R 67,632 per annum on maternity homes wlulet the expendi. ture of the district branches of the Bombay Mofussil Council on similar homes amounts to Rs. 63226 per annum. The centre maintained by the Mofussil Council are ordinarily unspeeted by a medical man who works in ac honorary capacity, but officers of the medical and public health departments also make inspections, 6 Dilar.-(a) Government and Voluntary - Maternity and child welfare work in this province is organised by a combination of the meitical department and the provincial Jnternity and Child Welfare Society. The Inspector General of Civil IIospitals is the Honorary Secretary of the Society and the Director of Public Ilealth is one of the members (0) Local Bodies and Toluntary. In the mofussil areas, the Society Forks through district committees, the civil surgeon of the district being a member in each case. 7. Bengal.-(a) Government. The Director of Public Health reports that the Bengal public health department has not so far provided any maternity or chuk welfare serzice and has only taken an indirect interest in its development. The activity of the department has been confined to (a) the giving of grants for training of dars to local boards and munici. pnlities and to certain voluntary organisations snch as the Bengal Jicalth Welfare Committee of the Provincial Tranch of the Indian Red Cross Society, the Dacca Maternity Trust and the Sarojnalını Dutt Memorial - Association, (b) the giving of a grant to the Bengal Ilealth Welfare ·19 Columuttee for exhibition and propagandn in connection with maternity and child welfare vorh ; and (c) propaganda work in the province through tiro cincrin parties which tour tlirough the province. For these Inst, pirovasion to the extent of Rs 18,000 19 made in the budget of tlic Director of Public Ilcalth. 10) Voluntary.- in 1936, the work of tlic provincial branch of the Indian Red Cross Society was reorganised and a committee called the Bengal Health Welfare Committee, under thic cliairmanslup of the Director of l'ublie licalth, was formed to co-ordinate the work of various sub-committees appointcal to administer the (alcutta child welfare centres, llic Sir Jolin Anderson Ilealth Seliool and the district centres. The honorary secretary of the two foriner committers is a medical woman and it is hoped that she will later also be able to tour the province and advise on the work of the moussil centres The provincial branch of the Red Cross Society sprends Rs. 36.157 per annum on maternity and child welfare work, this in. cluding the maintenance of the above licalth school. Meantime, efforts are being made to nfiliatc all centres in the l'resi. dency to the provincial brancli of the Indian Red Cross Sociсty, not so much because it is felt that they necd guidance, but because it will further the collection of data on the existing provision and because the annual reports and occasionnl presence of a district representative at the Coin. mittee will be a stimulus to the Committee. The District Maternity and Child Welfare Committee was constituted in 1937 and includes represculative members from cach centre in addition to technical experts. (c) Local Bodies and l'oluntary.-It lias been reported that 22 muni. cipal boards and local bodies have organised their own maternity and child welfare schemes, but no further information is available beyond that runi. cipal expenditure on this work totals Rs. 42,516, wlulst that of district boards amounts to Rs. 7,195 per annum. Eleven mofussil centres are afli. liated to the Indian Red Cross Society. 8. The Central Provinces --(a) Government and Voluntary. The situation in the Central Provinces 18 similar to that in the United Provinces. The Government grant of Rs. 32,500 is made over in toto to the provincial branch of the Indian Red Cross Society and in addition the Government provides Rs 7,994 per annum for the maintenance of the health school. Maternity and child welfare work is organised by a welfare conimittee of the provincial Red Cross Society, whose members include the Inspector General of Civil Hospitals and the Director of Public Health. The hono. rary secretary of the committee is the superintendent of the health school. The superintendent who is a medical graduate, but who possesses no public liealth qualification, is not only expected to take charge of the training of pupil health visitors but is for all practical purposes in executive control of all welfare works in the province. It is obvious that, if the superintendent does justice to health school work, slic cannot effectively supervise the organisation and developinent of mofussil welfare centres and, vice versa, during her tours of inspection, the training of the pupil health visitors suffers It is difficult to believe that one woman can in practice fulfil both of these functions.

·() Local Bodies and Profiintary. In his reply to the questinnnaire thie Dirretur of Public Ilealth states that “liranchey are organised and controlled by rillaer () the District Red Cross Conmittees or (n) local committere lorking independently. Junicipal and Notifiral Area Com. miters are invariably repreinfect on the local welfare committere and are usually the chief contributors towards the running expense of the infant teliam (intre In ito cave, ??, Saapur and Jubljutpore, the local wel. turi committee is coinpool entirely of municipal members There are no officinl coinmittees administering any welfare centres, but officials are dirrelly represented on such committees and talie an active part in its Tarinis nctivities" 'The expenditure of municipalities on maternity anıl child welfare srork is klatril to ninoint tn Ns 13,012 per annum ani that of local boards to Rs. 500 per annum. ..-n awninsnartor lor the Inspector (icneral of Civil IIospitale, Publie Ilealth, the Superintendent of the ical oficer- of healthy Welfare work in le direct charge of the medical officers of licat ; 11 Atakan.........: le superusinn of the local medical officer of lealth In many arens, Assistant purgeons and nssistant medical officers of the medical department are made members of the local welfare committees and in such cases they take an active part in the conduct and maintenance of the centres. 9. North-West Frontier Prouini In this province, maternity and child welfare work has not developed to any great extent The public henith department inaintains the training selinols for dais and for these Government gives n grant of Rs 26492 The Prouincial Branch of the Indian Rel Cross Society also assists the schools and municipal and local bonrils contribute small amnunts towards their maintenance The Superintendent of the Dera Ismail Khan dare training school is a qualified health visitor and in addition she tours the proviner to inspact the work of the dars who have passed out from the school and to select Tromen for admission to the next course of training Rrcently the Superintendent of the raie' training school has been transferred to Peshawar ns Provincial Organiser 10 Sini (aGovernment and Voluntary — Jaternity and child welfare work is organised by a special committee of the Provincial Branch of the Red Cross Society, the Director of Health Services and Inspector General of Prisons being Chairinan. Ile inspects at intervals all institu. tions under the Red Cross Society which are concerned with maternity and child welfare work, but the provincial organiser of the Society is a lealth visitor, although only a part of her time is available for maternity and child welfare work, The provincial Gorernment gives no grant to the Indian Tried Cross Society for piateri is 1,000 per annum to the • internity homes in K: ( Cross Society allots I's 12,507 per annum to maternity and child welfare vork.

·21 11. Iesam.-As internity and child wellarc work is not organised directly by the Gorrrnment, the Red Cross Society has accepted respon. sibility for this neinity but no salaried organisers are employell dod 80 far little progress ling been made. The Cosernment gives no grant to any voluntary organsation for this purpose and no information is avail. able regarılıng the expenditure incurred either by the Red Cross of liy local bodies 19 This review of provincint innternity and child welfare organisa. tjons makes it enklerit that these hnve ilcycloped along different lines in different parts of the country In Assam, Bengal, United Provinces, Central l'rovinces NWP Province and Sind, the work is still dono by the Inelian Red Cross Society and in Bombay, Bibar and Orissa by utlier Voluntary organisations. In the Prınjab and Madrne Presidency, tho work is now largely organised and directed is the omicini public health departments. As the general campaign develops, the tendency will probably L. for Ciovernment and local authorities to take over the work in increasing meisie This is the usual sequence of cventy wlien schemos initinted his voluntary effort deselop beyond the resources of the voluntary associations concerned and is one which may be taken 19 cicar evidence that the initial voluntary effort lias achieved its purpose. Nor need the voluntary workers necessarily assume thint they are no longer required : there will always be score for their continued in. terest and assistance. On the other hand, even where Government medical and public health departments liave assumes full responsibility for this work, tliey should take erery possible opportunity of cnlisting the voluntary workers who can be expected to supplement the more official actities in many useful directions. In those prorince, where no official organisation has yet been developeil, the Director of the Maternity and Child Welfare Borezu of the Indian Red Cross Society continues to pay visits and to advise the volun. tary associations concerned. On the other hand, in Madras and in the Punjab, the Bureau maintains contact with the work only through grintsin-aid to health schools or to schemes for the training of dais and its Director neither makes visits nor offers advice, unless she is askoret to do so The role hitherto played by the headquarters Burean in the maintenance of a crtain uniformity in the standard of training at the health schools is mentioned here, only to draw further attention to the present trendi. Courses of training in provincial health visitors' schools will probably in future be regulated by the Nursing Councils established in certain provinces under the Nurses Registration Acts. As these Nursing Councils come into being in the remaining provinces, the present role of the headquarters Bureau will in consequence become more and more restricted In the interest of uniformity in the standards of training, it is to be hoped that the various provincial Nursing Councils will keep in close touch with each other. It might indeed he desitabile to form a central body for this purpose. There is little doubt that greater advance in the development of maternity and child welfare work has been made in those provinces where a technical organising and supervisory expert bas been appointed, whether hy Government or by a voluntary organisation ·22 ithe most successful schemes seem to be those undertaken by a combination of voluntary and ofiicial effort; the driving force and convation of the former implementing the additional financial support and the adınaustrative guidance of the latter. Equally succesful work may be done by local authorities aided by voluntary support or los voluntary effort assisted by public funds Victhods will vary in differont «listricts, a uli are not equally fortunate in possessing capable and enthusiastic oluntary workers On the other hand, many local auflio riley linse now come to realise the necessity for cxpenditure in this field of public health work and they should be able to obtain expert assistance in planning their welfare scheines This expert assustance, wliether 11osed by a Government department or by a voluntary organisation, is essential of progress is be made along correct lines. The Punjab organisation, namely, official direction of both volmtary and other clemes, provision of Government grants-in-aid rnel ad. ininistration of the centres either by local authorities or by voluntary budlics, is one which works smoothily and efficiently and which muy vo commended to other provinces and States There are lotations to the employment of non-medical women in the inspection and control of centres. The organisation of schem“, and the general direction of welfare activities would appear to be more suitably placed in the hands of a woman medical officer, whilst the supervision of bealth visitors, midwives and dars is best carried out by an experienced health visitor Norling under the control of that medical officer The system of prants-in-nid from provincial resources would scem to require development in many provinces These not only stimulate local bodies to improve their services, but gire public health departments a nieasure of control and supervision which thuis report shows to be urgently required linele other circumstances, the only pressure which can be brought to tear on local authorities is that of persuasion and numbers of local schemes in consequence have developed along lines which cannot be said to be satisfactory.

·23 CHAPTER III. STATISTICS RELATING TO MATERNITY AND CHILD WELFARE. 1. Indian vital statistics relating to inotliers and infants are per haps subject to cien wuer margins of crror than those of the general population The absence of medical certification and the inct that milage chauhidars are the agents for registration of vitn! statistics in rural areas are factors responsible for inaccuracy i mortality sintistics At every nige pers! These facts made it essential to define maternal Niortanty in a simple manner casily understandable by the villago registrar. Until recently, the definition in force was that cvery death of a woman occurring within 11 days of confinement should be considered as a case of inaternal mortality On the other hand, tlie inclusion of "all maternal deaths duung pregnancy or Inbour, or within four wecks nfter the termination of pregnaney or later if the illness originnted luring pregnancy, labour or puerperium considered to provide greater accuracy buy the Departmental Committee on Maternal Mortality nud Morbidity of the Ministry of Health, England. Apart from omissions, tlıcrefore, the prerions definition must have been responsible for a furtlicr larve error in the recordel figures of this country. In the next place, registration of births is known to be more defcctise than that of deaths and, when the sex ratios at birtli for different provinces are compared, it is fairly clear that, in some arcas, omission to register female birthis is much more common than in the case of malcs. ► ) Was TABLC I. Proportion of males born to every 100 femcles. Province. 1924-28. 1929-33 1934. 1935. 1930. N. W.F.P. Punjab Delhi 130 112 108 130 112 108 129 112 107 131 112 100 130 112 109 ủ, P. Buhar and Orissa Bengal 112 104 108 112 104 108 113 106 108 113 106 112 113 106 108 Assam CP Bombay 107 105 108 106 105 108 107 106 108 106 105 108 107 105 106 $ Sund Madras Coorg 104 107 118 105 107 116 105 108 119 105 114 115 125 105 108 113 Ajmer-Berware Not Available.

·24 2. Table I shows considerable consistency in respect of the sex ratio at birth in individual provinces. At the same time, North-Western India hias systcuatically recorded a higher proportion of male births than other parts of the country. The figures given by Neusholme for a number of European countries slow a much smaller range of variation, the smallest and largest figures quoted by him being 103 and 10C male chililien per 100 females born. When countries like England and Italy, which Are racially different, show only relatively small diſferences in this ratio, it is doubtful of the much larger variations found in India can be explained in terms of racial difference alone, Lven in countries where, registration of vital statistics is satisfactory, the figures for still-births are admitted to be incomplete. In Indin, there is no duabt that the recorded figures give little indication of actual fucts. 3. Such statistics as were available have been examined in the light of these preliminary remarks Morbidity statistics for the gen. eral community can be obtained only from hospitals and the subsequent discussion is mainly confined to mortality figures WAS Three types of figures were avarlable for study (1) those contained in public health reports, (2) those collected by special inquiries, and (3) those given in reply to the questionnaire which sent to all provincial Directors of Public Ilealth and Administrative Medical Officers The fruien given in health reports cannot be relied on as a true picture of existing conditions for reasons already given. On the other hand, whilst special inquiries provide more accurate data, in view of their restriction to limited areas, the inferences to be drawn from them are probably not entirely applicable to the country as a whole. The figures given a reply to the questionnaire have been found in many cases to be even less reliable than tliose contained in provincial health reports. In spite of these limitations, an attempt lias been made in the following paragraphs to utilis such statistics as seem to throw light on the extent and nature of the problems associated with maternity and infant and child life in this country. Maternal mortality and morbidity. 4 Naternal mortality.—There seems no doubt that child-bearing exacts a toll of lives in India at least four to five times greater than in those countries where serious attention has been given to the protection of motherhood During 1936, maternal mortality rates recorded in the cities and larger tons ranged between 2.6 and 37.4 per 1,000 births For the different provinces, maternal mortality rates recorded over the six-year period 1931-36 are given in Table II. These, it will be seen, show variations estending from 1.0 to 19.8 per 1,000 births It may be taken that the lower rates, at least, give a very misleading picture of the actual position.

·Tani.c. II. Jaternal mortalliy rates per 1,000 registeret births, 1'in 1011. 1973 191.1 1031 10.01. 1970. N.W.PI. l'unjab 12 5.4 Delhi .. 30 70 10 1.4 13 U r. Bibar Orze53 77 Bengal C.P. Bombay 87 os 97 60 38 DO 70 GR 70 12.9 Sind Madras Augam 87 13 7: 19 st 70 17 01 80 15 15 in Xot Available For 7 towny :l'or 17 trwne cinly I number of special enquiries conducted in different parts of India have, however, yielded more reliable figures. A few year ago Sinjor General Sir John Megaw carried out an investigation into certain public health aspects village life in India by collecting from a lor nur.. ber of rural dispensary doctors, distributed all orcr British India, figures which gave a internal mortality rate of 21 5 per 1,000 live buths During a more recent inquiry conducted in Calcutta, Dr Ncal Edwards found the rate there to corespond with that of General Megaw, wulst Madras City during 1930-31 Dr Lakshmanaswami Mudaliyar found the rate to be 16 6 per 1,000 live and still-births An earlier enquiry conducted by the Madras public health department in 1927-28 in four of the largest municipalities of the province, cxcluding Madras, showed that the rate was 18.5 per 1,000 live births. These several findings suggest that the maternal mortality rate for this country as a whole is probably somewhere near 20 per 1,000 live births, as compared with the 1936 figure of 4.9 per 1,000 live births in England and Wales Atention has already been made of the fact that a maternal death was previously defined as a death occurring within 14 days of confinement In order to bring the definition more into line with inodern practice, instructiuis were issued in 1937 to the effect that all deaths occurring within one month of childbirth should be classified under this heading Dolenver, as mothers, in the case of still-births, are equally exposed to the risks associated with maternity, all Directors of Public Ilealth were asked to calculate their maternal mortality rates on the combined figure for live and still-births ·20 Prior to the issue of these instructions, the most varicd practices seem to have been in force. For example, in the 1936 report vi the Director of l'ublic llealth, Central Provinces, the maternal mortality rate was said to be calculated on the combined figures for live antal stuli. births, and was given as 7.75 per mensem. In Annual Form VI (a) of the njipendices to the report, however, the rates for local areas were apparently calculated on the total population of these areas Simi. larly, in the Jadras report for 1936, Statement No. 6 of the appendices gives cleaths from childbirth as rates per 1,000 of the population Aguin, in the United! linees report for 1936, the maternal mortality iite for the province as a whole is given as 7:52 ; but when the rate is calcu- Inted from the total lise births plus still-birtlis and the recorded maternul dcatlıs, this found to be only 1 25 per mulle and on live births alone to be 1.27 per mlle In Delhi, Bombay, Bengal and Sinil the rates were calculated on live births only, whilst the report for Assam docs not hot l.ou the figure was reached In the public liealih reports of N.-W. F. Province, Bihar and Orissa, no maternal mortality rates were given at all The Punjab report states that the maternal mortality rates, in areat stel by health centres, varied between 3-9 and 12.0 per 1,000. 5 l'anses of meternal nortality --Unfortunately, no general statement can be made in tlus connection, but figures are available from one or tro restricted ulcas During her enquiry in Calcutta, Dr Neal Edwards was able to classify the causes of 701 deaths from puerperal causes attributable to child bearing which occurred between June, 1936, and June, 1937, and these are set out in Table III For comparative purposes, the table also includes figures collected by Dr Edvarils from 99 women's bospital distributed all over India These liospital figures lave, however, their limitations in that the institutions are situntoil in the larger towns andlities, so that the patients were mainly drawn from urban areas and helded only a small number of delayed and normal cases from the su iounding country In addition, figures relating to a bospital population cannot be considered as representative of the genaral coinmunity. TABLE III. Causes of maternal mortality, Calcutta 39 women's hospi. tala in India (1936). No. of deaths. Percentage No of of total deaths. Percentage of total 33 Abortion (septie) Abortion (non-septic) 19 2.67 4 0-57 5 070 Ectopic gestation 0.86 0.93 ·27 31 woming', hoopis tale in India (1030). Calcults. Xo. of death, I'montar of total. daithe I'rttago of inta). -1 Other secilents of pronancy 1.00 0:43 Parferal humorrhamm 7! 10:36 62 11 33 319 231 Puerporal sepe19 Albumipuna anteclama 17-07 105 11.21 ? Other toxsmiss. 11 3:32 Em lohim and rudden death 3.39 3-71 00 12.00 Other acculents of chillbirth Other pucrperal conditions Anama 10 143 1 0.14 107 23.33 129 18.00 Total 201 99.80 711 03.80 in The two sets of figures show considerable similarity. l'ucrperal sepsis, anæmia and toxæmlas of pregnancy constitute thic most promuent CAUSCS In both, wulst hæmorrhage also occupics a lugh place * Other accidents of childbirth" form a defintely lugher percentnge in the hospitals Aroup, but this is to be expected because abnormal and serious cases suoner or later find their way into hospital A comparison of these figures with those of other countries is interesting. Les conducted in England and in Scotland may be cited Whilst anemia per se only very rarely is a cause of death these countries, the figures in Table IV for some of the other piportant causes makc interesting comparisons. TABLE IV. Dlaternal deaths due to certain carises eIpressed as percentages of toler maternal deaths. England and Wales 39 Final Women's Calcutta Report Hospitals Special (1936-37) of Depart- Scotland inquiry menta! (1929-33). (1936) (1931). Committee (1932). Sepsis 31 9 32-5 34-2 36.3 38 Eclampsis 145 10-5 11 10.6 Other toræmias of pregnancy 5-6 7.2 10.6 58 12 Ante-partum hæmorrhage 4-6 67 8.1 8.1 Post-partur hæmorrbage 4-8 3.3 6.7 5 ADæmias 23:3 0 05 + 0 08 in India . 8 60 180 *Iacluding pre-eclamptio toxænla. Negligible.

·28 аге It may bic noird in the first place, that the figures for the 39 women's hopitals in India are not strictly comparable with the otliers borealise the latter relate to the general population whilst the former deal only with liospital groups The Indian, English and Scottish enquiries all shou bit sopsis constitutes the commonest cause of death. Nur are the percentages of India under thuis licad, very different from theme of England x) Scotland or of that of New York City vlucht Dr. Ixtuarits als Froles As Dr Neal Edwards has pointed out," while the maternal morixlity rate in India is many times higher than in West. ern countries, the proportion of deaths from sepsis is strikingly similar and this in spite of the fact that a far larger number of deliveries in this country is attended by untrained fromen tho make no use of modern methods of asepsis and antisepsis Eclampsia is responsible for a higher proportion in Calcutta thian in England and Scotland while other toximias of pregnancy relatively lower than in the latter two countries In respect of ante and post-iartuni hæmorrhages only small variations occur, 6. Maternal nurluidty - Munro Kerr* has pointed out that the outstanding causative factors of disability arising from pregnancy and childbirtlı arc. (1) toxæmia ; (2) infection ; and (3) trauma. In considering the question of maternal morbidity, account must be taken not only of the inmediate but also the remoter disabilities that follos dildbearing. In the words of Munro Kerr the main question is " what has it cost the motlier in health to produce the family she has when that family is compete '" The tosamias of pregnancy, although their etiology remains largely obscure, are stated by Junro Kerr to take a toll of 20-26 per cent of maternal deaths in the sluape of hyperemesis, nephritis, uclampsia, cerebral hæmorrhage and accidental bæmorrhage" Further thcir contribution to ill health of varying duration is still greater As regards infection, the relative importance of infective lesions of the cirolnet:ye tract may be gathered from the following classification of 533 cases, warng 2,700 women who passed through the waris of the Royal Samarit.in IIospital, Glasgow, during 1928-32 The figures in Table V are quoted by Afunro Kerr. TABLE V. Lesion or group. Nurnber of C&ses. Percent. age of the total. and with 152 146 103 59 57 16 28 5 27.4 19.3 11.1 107 30 Inflammatory hypertrophy of certit. 1) Pelvic pentonitis and cellulitis $33 100 O *Maternal Mortality and Morbidity by J. M Monro Kerr (1933).

·23 Trauma as a cause of disability is important partly because of its immediate cfiects and partly because it frequently freecelry infection. Table VI gives Glasgow figures niso quoted by Junto Kerr ; these indicate the relative muluence of infection mul trauma is the production of Temote disablernent, TANJ. VI. Total patients l'urrpera! Infraction an etiological factor Truma in ch wrth en clinlogical factor. CAM showing both trauma ATH! infertion. 1029 (0 months only) 2,033 122(0-0) 1929 2,831 457 (213) 731 (390) 853 (30.10) 1,027 (361) SGD (30-396) 072 (31-07) 291 (103) 1930 2.560 -39 (106) Total .. 7,731 2,178 (29.1%) 3.730 (33.3%) 074 (8.7%) These cases are described as coming from " the centre of a densely populated area with a mixed type of population and therefore shoull be fairly representatire of the conditions existing in the general community.' It is to be noted that trauma constitute, the more common cause of permanent disablement As far as is known, fet figures of the kind are available in Indin In a paper read at the 7th Congress of the Far Eastern Association of Tropical Medicine held in Calcutta in 1927, Dr. Margaret Balfour discussed anæmia of pregnancy, eclampsia and osteomalacia as the diseases of pregnancy and labour in India. IIer sources of information were replies to (i) a questionnaire sent to a number of maternity wards in different parts of the country and (2) a similar questionnaire sent to maternity liospitals in Bombay city and (3) notes taken by herself in Bombay hospitals Tables VII and VIII are reproduced from her paper. TABLE VII Osteomalacia Eclampsia Adæmia. Community. Ratio Number of calce Number of of labour. cases Ratio per 1,000 labour ca9es. Number of cases Ratta per 1,000 labour cases Nambor of cases, per 1,000 labour cages, 5,167 Hindu Mohammedan .. * Others (mainly Indian Christiaa). 1,273 1,152 160 79 6 309 62.0 5-1 79 31 8 15 2 24 3 6.9 148 46 15 28 0 36 1 13-0 L2PHC ·30 Tante VIII Osteomalacis Eclampsia Angja Communty Number Number of of cases of tas labour, Ratio per Number Ratio Number Ratio of per of per CASES 1,000 Cases 1,100 labour labour cases. cakes labour cases 2,066 6 8 R3 40.1 Mohammelen 842 32 33 0 C C 03.8 79 801 21 VIL 3 30 48 6 Others' (tamly Indian Chrutian). The tables make it quite clear that all these discases occur most frequently among Diohammedan women, thulst the lowest incidences are to be met with amongst Indian Christians. The following figures (Table IX) collected by Dr. Neal Edvards from women's hospitale in Indin may be compared with those given by Dr. Balfour. TABLE IX. Contracted Pelvis. Osteomalacia Other types. Total contracted pelvis. Number of deliveries. Tate per Number of cages 1,000 deliverica. Number Rate per of 1,000 casea deliveries. Nomber Pate per of 1,000 caseg. deliveries. 1936 1935 1934 30,163 26,778 21,348 664 559 353 22 0 20 9 16 5 467 461 415 15.5 17 2 20 8 1,131 1,042 9017 37.5 39.9 42.2 Anæm18 Anemia of pregnancy Other Anemias Total Anæmias Eclampsia Namber ot delivenes Num. Rate per Num. Rate per Num. Rate per Nom. Rato per ber of 1,670 ber of ber of 1,000 ber of 1,000 cages deliveries. cages, deliveries cages, deliveries cases deliveries. 1,000 1936 1935 .. 30,168 26,773 21,319 581 467 $ 19.3 17.4 912 650 $ 30. 24.3 $ 1,493 1,14971 592 49 5 429 27-7 396 390 13 1 14 6 13-7 1931 $ 292 Includes 22 anclassified cases. Includes 103 unclassificd cases, Includes 32 anclassified cases Not avadable.

·31 The figures in Dr. Balfour's first tabic were collectal from differ. eat parts of India and are therefore comparable with thos given by Dr. Neal Eduards. The combined rates for the three communities in the former are 32 3.297.3 and 13.5 per 1,000 deliveries for ostroma. lacia, anumia and eclampsia respectively In the latter, the rates for contracted pelvis due to osteoinnincia are smaller but, when all forms of contraction are meluded, the mtes for all three yean archzier. Dr. Neal Edwards' rate for "all ananias in 1931 closely approxi. tuates to Dr Dalfuur's figure, although those for 1933 and 19.30 are definitely lugler For eclampsia, the two enquiries alsow little differ. CHICC Wlule, a, Dr Nial Edwards has pointed out, there is a lar: "Tsunal factor in l.dmg what constitutes contraction, figures publinical by her give some idea of the relative frequency of this condition in ditierent parts of India The distribution 18 undoubtedly influ. enced by thr prevalence of osteomalacia in the arcas concerned 71.0 following statencnt fires comparative figures for contracted pelvis in hospitals attaclied to certain teaching institutions Lady Ilardınge IIospital, New Delhi 1 in 11 deliverics. Agra Maternity Hospital 1 in 15 Cama IIospital, Bombay 1 in 33 Memorial Hospital, Ludhiana 1 in 41 Caste and Goslia Hospital, Madras 1 in 90 The incidence of eclampsia is known to vary considerably in different parts of ludia l'igures for women's hospitals during 1931 show that the cclampsia rate per 1,000 deliveries varied from 31.1 in the American Jission Hospital, Madura, Madras Presideney, to mil anons 746 deliveries at the Lady Hardinge Medical College at New Delhi. Badra, Trivandrum, Ilyderabad, Calcutta, Vellore and Poona recorded vates over 19 per 1,000 deliveries whilst in North- Western India, the cities of Delhi, Agra and Ludhiana reported much lower incidences It will be observed that, broadly speaking, the incidence of osteomalacia and of eclampsia vary inversely as one passes from the north to the south of India. The former condition has high prevalence in the north-trest of India and is rarely to be met with in Madras, whilst in respect of eclampsia the opposite occurs As regards anæmia, this condition is known to exist all over India, although in other countries little mention is made of it as cause of maternal death. In the Report on " Maternal Morbidity and Mortality in Scotland ", for instance, only 19 deaths were attributed to serere anæmia out of a total of 2,527 cases investigated, whilst an English Lquiry puuducted in 1934 recorded only four deaths from anæmia out of a total of 770. As the result of her Calcutta investigations Dr. Neal Edvard states that serere anæmias of both the macrocytic and microcytic të re, as well as inixed forms, are extremely common and, while some cases are associated rith poverty and malnutrition, many other dur among the well-to-do families that seem healthy and well-courland, She also recognises a relationship between "dysentery and diarriva and severe anæmia of pregnancy and considers that the developunit of anæmia might often be the result of intestinal infection. *Journal of the Association of Medical Women in India, Augus, Jool, e a ·32 Dr Dudaliyar, in a series of 436 maternal deatbs in Madras City, classified 50 or 11.5 per cent. as due to annania and drew attention to two forms of the disease, one a macrocytic type and another secondary to hookworm infection, The wide prevalence of anxmin as a complication of pregnancy de mands that further insestigations should be carried out iu different parts of the country in order that adequate preventive measures may be formulated. Enquiries are now in progress in Calcutta and among the women labourer of plantations in Asram and it is hoped these will throw further light on this serious problem. One or two points remain to be considered. A few years ago Sir John Megan estimated that maternal deaths in British India announter to approximately 2,00,000 per annum. It Juas already been pointed out that, from available evidence, the maternal mortality rate may reasonably be assumed to be 20 per 1,000 live births. In 1936, thirrumber of recorded live births in British India totalleil nearly 10 mllions Using these figures, we again urrive at the figure of 2,00 0:10 maternal deaths per annum. When it is to membered that iegklintion of births may be in defect to the cxtent of 20 per cent, it will be realised that the above total is a very conservative estimate of the toll paid by the women of this country in the discharge of their productive function. Death, however, is frequently only the final release from prolonged invalidism. No figures are available which might permit of an estimate of the amount of ill-bealth caused by cluld-bearing among the wounen of this country. If English figures may be taken as any criterion, it follows that at least 39 per cent of all Indian mothers suffer from dis abilities of greater or less degree Even that figure enables one to visualise the mannde of the problem to be faced in planning a pre ventive campaign for a healthy motherhood Foetal deaths, still-births and neo-natal deaths. 7. Foetal deaths, still-births and neo-natal deaths may be considered together because their causative factors are frequently the same. Reluble statistics for foetal deaths are not available even in countries here registrntion of vital statistics is satisfactory. According to Munro Kerr, however, at hag been estimated that 15 of every 100 conceptions termipate witfi preinature death of the foetus, while the incidence of still. birtli is generally considered to be about 3.3 per cent Taking these facts into consideration it would not seem to be an overestimate to place the foetal drath-rate at 185 per 1,000 conceptions" A valuable study of this question was carried out in this country by Dr. Christine J. 'i homson during 1929-30. Her report is based partly on post-mortem examinations of 200 cases of still-birth and neonatal death and partly on some 3,700 replies to a questionnaire addressed to 11ospitals all over India Figures for the principal causes of still-births and neo-natal deaths in the Presidency towns of Bombay, Calcutta and Dadras and the averoze for five British cities as given by Holland and Lane-Claypon (1926) an investigation covering 1,311 cases are given in Table X.

·33 Tim X Principal causes of still-births and neonatal deaths in percentages. Homley Curata. Fire British citive. 1. Complications of Labour 30 6 31.8 :. Arte partam emorttage 11 3 88 10 18. 3. Torx of pregnancy 171 13 : 12-4 4. Maternal states 192 11.0 16 3 5. Syphila 8.6 & Foctal states .. 10.3 7. Prematurity. per a 161 3 64 66 The percentages of " complications of labour" in the l’resszency cities approxiaate 10 that for Great Britain, but Dr. Thomson's report slots that in the Punjab, the United Provinces and Kashmir, there osteomalacia is prevalent, much higher ratios than the British figure are to be found. Ante-partum haemorrhage" is not so important a causative factor in this country as in Great Britain, but Dr. Thomson points out that, as in the West, it shows the same tendency to occur in multiparne and to bring about a premature termination of pregnancy.' The uneven distribution of the incidence of eclampsia has already been mentioned. "As in the West the bulk of the eclampic mothers are primipara." “ Slaternal diseases " seem to play a much more important part in India than in Great Britain ; this may be due to the prevalence of tropical diseases such as malaria. In Dr. Thona cn's opinion“ prematurity per se is a primary canse of considerable importance in this country. She pointed out that, " in the three large Presidency cities, 59-64 per cent of all dead-born children and cases of earls infantile mortality were prematureis boru." A preventive campaign against neo-natal mortality and foetal death presents a problem of great complexity. Whilst in Western countries remarkable progress has been made within the past few decades in the rednction of infantile mortality, most of that reduction has been effected amongst those infants who survive the first month of life. According to Blunro Kerr, at the present time half the infants who die in the first year of life perish before they are a month old. Death reaps n3 big a harvest in the first month of life as it does in the eleven subsequent months The qirtion of neo-natal mortality will be further coasidered along with that of infantile mortality.

·34 Infantile mortality. 8 In his annual report for 1930, the Public Health Conimisyoner discussed at soine length the question of infantile mortality and also fare graphs for British India and for the provinces showing the trend of infantile mortality rates during the period, 1892-1930. These graphs bare been extended up to 1936 and are appended. Their striking feature is a general decline from 1918 onwards Whilst the maternity and child welfare movement started in this country about 1918, this apparent decrease in mortality is much greater than can be attributed to the benef.cent efects of that movement. The Publie Health Commissioner in fact espressed the view that continuous improvement in the registration of birthis had played a greater part, The question, whether any significant reduction in infantile mortality bas occurred, has recently been investigated by the Department of Vital Statistics and Epidemiology of the All-India Institute of Dygiene and Public Ilealth, Calcutta Because, in view of improved registration, the infantile mortality rates of more recent years were not strictly comparable with those of an earlier period, the figures for the decennium 1926-35 were used and it was found that no significant decline was demonstrable for British India as a whole The same investigation made an interesting comparison between the rates of reduction of infantile mortality in British India and in England and Wales between 1912 and 1936. Means and ratios of infantile mortality rates of British India and England and Wales. Mean of India. England Ratio. 1912-16 201 102 1917-21 217 89 1922-26 191 2.6 97-31 176 67 2.6 1932-36 173 61 2.8 The average quinquennial infantile mortality in British India, in spite of an appreciable fall since 1912, is not 2.8 times that of England, although during the first quinquenninn given above it was only twice as high. The rate of fall has, therefore, been much slower than that of England 9. Table XI gires relerant figures for British India and the pro- Tinces in respect of the distribution of infantile mortality for the different age periods during the first year of life ; the percentages for England and Tales (1935) are also given for comparative purposes ·35 Tante XI, Deaths af varying periods in the first year of life in British India and the prouinces during 1936, (spressed as percentages. jo Death ander one werk 1-10pjo riuwwal ou under one month. 1Dealh, under one week 30 ล้านวม ม drathi andre lyrar. Datha under one month ، ایلید1لاد deaths un Irelyret. Deaths between ono to ix months prentof Jeethe urler 1 year Deathe lewens and 12 months torrent I supun 417p Ju Se Tofantile mimality rate -110'11 yrar 72 3 39 7 20 G 17 1 67.0 England and Wales (1935). Bntish Indis 608 23 3 47.3 31. 21 % 202.4 N. W. F. Province Punjab Delhi 61.7 85 6 58 8 18? 21 3 35 1 438 35 4 37 A 298 37 5 27 1 273 27 121 7 1594 169-8 United Provinces Bihar Orings 61.6 71 2 68 2 27 7 36 0 23 3 428 60 6 48 6 34 8 30 6 31 2 18 ) 17 3 148 6 118.0 109 B Bengal Central Provinces Bombay 56 0 43 7 56 1 32 1 20 8 21.7 66 5 47 7 39 6 28 3 27.4 30.1 16 2 21 D 25 3 170 9 235.0 166.1 Sind Madras Coorg 83 3 67 3 57 7 21 6 36 4 29 7 40 6 640 61 6 34 4 23 6 20 I 25 0 22.5 22 3 121 6 101.1 181.3 Assam Ajmer.Merwara 51.8 65.2 28.1 16.0 61.2 28 9 30 9 38 3 17 0 32.8 160.8 174 1 * The figures for England and Wales are published not for the first month of life but for the first four weeks. Although the periods are not equivalent, the discrepancies between the English and Indian rates are not likely to have been influenced to any great extent by thug factor. In comparing these percentages for British India with those for England and Wales it must be remembered that the error due to misstatements of age is likely to be greater in the former. Taking the figures as they stand, however, the percentage of neo-natal deaths to total infantile deaths is higher in England than in India, particularly during the first week of life In both countries, about half the mortality of children under one year takes place during the first month, whilst the second six months period records the lowest rate. Provincial rates for peo-natal mortality show considerable variation, the figures ranging between 28.9 per cent in Ajmer-Mervara and 56-5 per cent. in Bengal ·36 Causes of inlantilo mortality. 10. Table XII scts ont the chief causes of mortality in infants in Bombay City during the years 1932 to 1936. TABLE XII. 1932. 1033. 1931, 1935. 1936. All causes 6,298 8,320 8.253 8,453 8,916 21+ Small-pox Bleanleg Malaria 69 16 717 18 33 27 300 CO 9 3 147 250 27 2,685 167 414 19 3,019 186 455 40 3,384 146 425 41 3,230 114 839 48 3,651 .. Remittent and undefined fever Diarrhoea and enteritis .. Dysentery Debility, malformaatious and prepa. turo births. Respiratory diseases Convulsions Other causes 2,217 2,828 894 535 2,983 502 674 3,039 603 696 3,174 683 479 431 It will be noted that the largest figures relate to two groups of causes, debility, malformation and premature birth" and respiratory discases.' Dr. Christine Thomson's inquiry showed that prematurity is a very common cause of still-births and neo-natal deaths in this country. " Debility, malformation and prematurity ” all relate to pre-catal causes. whilst deaths due to “respiratory diseases are mainly influenced by adverse environmental conditions It might, therefore, be anticipated that a majority of the infantile deaths due to the first group of causes would take place within the first month or even the first week of life and that most of the deaths due to respiratory diseases would occur in subsequent months. This anticipation is verified by the following figures taken from the 1936 Bombay City Health report :- Age-periods. Under I week. 1 to 4 weeks. 4 weeks to 6 months. Sto 12 month Infantile debility, prematunty, mallormation, etc. 88-3 75.6 29-4 Respiratory diseases .. 1.0 38 46.7 672 ·37 The figures in this statement reprrent the percentagen, of the deaths from cach specific group of causes of the total number of deaths at the particular agc-period. The personinges for the first group dcclinc progressively as the infants from older, whilst those of the second group steadily increase. Child mortality, 11. A high rate of infantile mortality is also commonly nccompanied by a high death rate in the Inter Ages of child life, because discasc, when it does not kill, leares the infant maimed and more linble to infection. Table XIII sets out the mortality rates for children under 10 years at different age-periods for Batish India and for individual provinces in 1936. The corresponding rates for England and Wales in 1931 are also given for purposes of comparison. TABLE XIII. Under one year. of total deaths. % of total deathe. 8-10 years Mos 30% deaths Total under 10 years of total dcstbs. years. . 73 3.2 1.0 12.1 England and Walea (1934). . British India 1.620,816 25.4 | 2,144,375 17 9 344,152 54 3,109,34348 8 N-W.F.P. Panjab Delhi 9,372 174.144 5,024 22 2 31 O 30 8 7,027 16.6 90,174 17 1 2,700 16.5 2,370 30,532 621 5.6 64 3.8 18,778 300,850 8,346 63 6 51.1 U. P, Bihar Orissa 280,359 25.8 134,970 19 2 50,651 26.2 222,927 20 4 144,873 20 B 28,891 149 48.058 43,854 9,240 4 2 6.2 4 8 549,344 SD 2 323,297 46.0 88,782 45.9 Bengal C. P. Bombay 285,956 23-4 163,036 28 6 123,289 24.8 189,738 15.5 120,470 22 5 105,933 21-3 89,101 26,935 22,038 73 8.0 564,705 | 46.2 300,441 60.2 251,200 0.5 Sind .. 9,649 272,393 709 19.0 26 6 18 2 6,687 13.8 159,897 15 6 421 10 8 2,330 48,033 205 18,666 38.6 480,323 46.9 1,335 34.1 52 Bledras Coorg Assam Ajmer-Mierwara 36,152 23.2 4,090 29.0 25,113 2,965 16.1 21.0 10,823 437 70 31 12,088 7,492 46.3 53.2 Child mortality rates at the different age-periods are from three to five times higher in India than in England For the whole period 0-10 years, the death rate among children in India is four times as high as in England. The question has frequently been asked if the saving of weak and defective infants by intensive public health efforts is not detrimental to the welfare of the community by increasing the number of the unfit The experience of England, where remarkable progress in the reduction of ·38 infantile mortality has occurred during the past few decades, does not support this view, for this reduction has been accompanied by a corresponding decline in the mortality rates of subsequent age-periods. In the words of the Chief Medical Oficer of the Ministry of Health, " at Ages 1-2, 23, 3-4, and 4-5, the rate of mortality in 1926-32 was less than one-quarter of the corresponding rate in 1861-70 and less than one-half the rate of 1901-10. Even in the yenrs of adolescence, 15-20, where some slackening in the rate of decline is observed, the death-rate in 1921-30 was only 39 per cent of that registered in 1861-70. So far then as rates of mortality are to be trusted, it is certain that the spectacular fall of infant mortality within the century has not been associated with any deterioration of mortality rates at later ages. That improvement of the environmental conditions of infancy has been at the expense of later ages, is a proposition unsupported by any evidence." This brief review of infant, child and maternal mortality statistics has elucidated a number of salient facts which all go to support the belief that a high percentage of the deaths of mothers and infants is preventable. They also prove the necessity for a widespread preventive campaign. How that campaign should be planned is set out in succeeding chapters.

·39 CHAPTER IV. MATERNITY SERVICES. 1. Control of maternal mortality and morbidity, of forinl deathe, still-births and nico-natal deaths and builty lips in the proviainn of birtter maternity services. These services comprise the protection of motherhood during the pre-natal, natal and post-natal periods. l'or the sake of con. Tenience these aspects of maternity and child welfare are considered separately from the infant and child welfare sertices, bout the mesentin unity of the care of the mother in her enparity th wife, otpretant anil nursing mother and as guardian of the family's well-being moet le kept in mind. The maternity services are provided partly by inedical and public health authorities and partie diga soltındary Organisation Maternity helle in hospitals and dispensaries are as a general rule under the control of thic fedical department Maternity homes may be tinder the public health or the medical department, or both kinds of institution may be inaintained by voluntary organisation and be under the control of neither In thic same way, doctors and midwrtes may be employees of the medical depart. ment, the public health clepartment, voluntary bodies or in private practice ; some are under supervision by one nuthority, some by another and some completely independent and uncontrolled. Pre-ontal clinics are similarly distributed. Unity of purpose and intimate contact between the various departments is perhaps more vital in the field of maternity and child welfare than in any other sphere of medical and public lealth work, and the means of securing co-operation, co-ordination and continuity in the care of the mother require careful consideration. In this connection, it may be noted that, in two provinces, namely, the United Provinces and the Panjab, the post of woman assistant to the Inspector-General of Civil Hospitals has been created, whilst in Madras there is a woman Assistant to the Director of Public Health. At one time, the woman medical assistant to the Inspector-General of Civil Hospitals, United Provinces, was also the Director, Maternity and Child Welfare, under the Provincial Branch of the Indian Red Cross Society and was thus able to supervise all medical and public health work amongst women and children during her tours throughout the province. Effective contact between institutional midwifery and the domiciliary service is dependent on mutual co-operation between the provincial medical and public health departments The question whether one medical woman either attached to the medical or the public health department can direct and supervise both the curative and preventive aspects of medical work merits consideration Such an arrangement would facilitate the required co-ordination and would be economical of time, energy and money Given medical women with a sound knowledge of both aspects of the work this is a policy offering a reasonable solution to the question Pre-natal care 2. Adequate pre-natal care demands the examination of tbe mother at least once a month when, in addition to an assessment of her health, specific ·38 infantile inortality bas occurred during the past few decades, does not support this view, for this reduction has been accompanied by a corresponding decline in the mortality rates of subsequent age-periods In the words of the Chicf Medical Officer of the linistry of Health, " at Ages 1-2, 2-3, 34, and 4-5, the rate of mortality in 1926-32 was less than one-quarter of the corresponding rate in 1861-70 and less than one-half the rate of 1901.10 Even in the years of adolescence, 15-20, where some slackening in the rate of decline is observed, the death-rate in 1921-30 was only 39 per cent. of that registered in 1861-70 So for then as rates of mortality are to be trusted, it is certain that the spectacular fall of infant mortality within the century has not been associated with any deterioration of mortality rates at later ages That improvement of the environmental conditions of infancy has been at the expense of later ages, is a proposition unsupported by any cvidcnce" This brief reries of infant, child and maternal mortality statistics has elucidated a number of salient facts which all go to support the belief that a high percentage of the deaths of mothers and infants is preventable. They also prove the necessity for a widespread preventive campaign. How that campaign should be planned is set out in succeeding chapters.

·Institutional Midtrifcry, Calcutta, 1935-contd. No, stal crat Yo. of Obstetric laske medical Yo mill. witre. Irmarlo Name of Innti. tution, I're-natal clink. I're natal. Maternity. Oihrer Tailable Total. Graduatrs Lirvytiatrs. Total Illiterre Traineel. Pupil Corporation Maternity Hom 1. Baldeoda. No Xo 351 So 33 D 2. Kidderpore Yo Yo 24 No 4 13.001 Cortation certificate. 031 Board of T'IA. mination Aty wintru by Corporation 057 Vernacular training 204 3. Chetla Xo Xo 40 Xo 40 3 .. 4. Maniektola No No 20 1 3 6 (neptic) Four of the six hospitals accepting midwifery pupils and two hospitals training medical students have no pre-natal clinics. There is no doubt that pre-natal care should be a function of all teaching hospitals. It may not be practicable, for many years to come, to provide skilled attendance for all confinements, particularly in the rural areas, but it need not be considered impracticable to provide some facılıties for prenatal examination, so that the more serious abnormalities at least might be prevented. This, however, depends on the training given in pre-natal work. The prejudices of the mother, her carelessness about her own health and her ignorance of the value of pre-natal care or of the facilities provided are a serious handicap to adequate supervision. The most successful remedy lies in visiting the mother in the home. Home visiting 18 discussed in a subsequent chapter and it need be mentioned here only to stress its vital importance. It has unfortunately proved impossible, from the replies received, to construct a table showing the number of pre-natal clinics attached to maternity hospitals and homes or to welfare centres Not only are the replies incomplete, but several give the number of pre-natal sessions con. ducted during the year instead of the number of Clinics. About 20 per cent of the 528 velfare centres given in Table XIX (page 51) profess to look after the health of the expectant mother, but few have a visiting doctor and many are staffed by midwives who have little or no training in pre-natal work and are unaware of the technique of home visiting or the importance of preventive and constructive health measures Two types of pre-natal clinic are required. The central or con. sultative clinic where obscure conditions can be investigated and the treat- ·12 ment of disease undertaken and the outlying or subsidiary clinic where einphasis is laid on the promotion of health through the education of the mother in the hygiene of pregnancy and on the diagnosis and amelioration of minor degrees of all-health. The former corresponds to the hospital prenatal departinent and draws its cases from a wide district ; the latter to cliues held in maternity homes and welfare centres and coverille a circumscribed area round the centre or home. Systematic home visiting of all expectant mothers in the area is only possible in conjunction with the latter type of centre. The role of each type of clinic is distinct yet uutual co-operation and reciprocity is essential to secure this Some form of duplicate records is required to facilitate transference of the patient from one clinic to the other while providing for continuity and uniformity in the care of the mother, It is desirable that every teaching and large maternity institution should have attached to it a qualified health visitor. Whilst her duties cannot be so clearly defined as those of a health visitor in a welfarc centre, she will be fully employed in fork connected with the specialised type of patient sent to a woman's or maternity hospital and will also to some extent perform duties ordinarily carried out by a hospital almoner. She would not be concerned with the collecting of cases from outlying areas but would only attend to the cases after they come to the hospital outpatient department. Medical supervision of the expectant mother is by no means easy to arrange. For the medical staffing of the clinic the choice lies between the private practitioner, the doctor attached to the local hospital or dispensary and a touring maternity and child welfare officer. Obviously continuity of care in the pre-natal and intra-natal periods can best be eccured by the two former metliods, the services of the doctor responsible for the pre-natal examination being thus available when necessary for the actual confinement Where medical men or women with sound training and subsequent experience in obstetries are available, this method is to be encouraged. For other areas, the touring maternity and child welfare officer seems to be the only feasible solution. In this connection it is interesting to note that the Inspector General of Civil Hospitals, Punjab, in 1938 issued a circular laying down attendance at the pre-natal session hela in the welfare centre as one of the duties of medical women attached to institutions under the medical department. A considerable proportion of women attending the pre-natal clinics require admission to hospital for the treatment of the graver disorders of pregnancy or for intercurrent disease during pregnancy and for the adequate care of such cases special pre-natal wards are desirable. Information in respect of the number of beds, especially reserved for pre-natal cases, has not been made available, but the number is believed to be negligible and reference to Table XIV, wluch shows that pot a single hospital in Calcutta has a special provision, bears out this assumption, although these cases are on occasion admitted to the general or fyzicolo gical wards Intra-natal care. 3. For the actual conduct of maternity work, there are two types of services. (c) institutional and (b) domiciliary. These will be discussed separately, but close co-ordination between the two is essential.

·(a) Institutional midifcry.—Before reviewing the criting arriccs it has secnued desirable to try to estimntr the nunber of lis required for labour casce. These may be admitted to fincpital becauer of obvtetric abnormalities or poor general health ; others locausr liome conditions are upsuitable for the confinement. A proportion of mothers will work admission from choice and bed, are also required for prompam in whom labour may be prolonged or dangerous. Detailed informntion regarding the percentage of cases admitted under cach of these heade ja nlmost entirely lacking and the follotring estimate of requirements, based on Western experience, is purely tentative. The number of beds required will of course vary from province to province with the customs, binbile and education of the people ; tlie prevalence of osteomnlaca, celampain and anæmias ; and housing and other environmental conditions. For general guidance, however, some standard is desirable. 91 Munro Kerr in his " Maternal Mortality and Morbidity estimates that in industrial areas the minimum institutionnl accommodation should provide for 15-20 per cent of deliveries on account of abnormalitics. This does not include provision for primiparz or for fomen who clcct for tlieir own convenience to go to hospital Ilousing conditions in India are generally unsuitable and abnormalities associated with child. bearing common; the provision needed may therefore be estimated for urban conditions as 30-40 per cent of all confinements Tuis estimate, which may not be of general application, has been calculated as follows — Per cent. Provision for pre-natal and natal abnormalities. 10-15 Primiparæ 10-15 Women who elect to go to hospital 5 Unsuitable housing conditions 5 3040 Allowing each case an average of 12 days in hospital, one bed will accommodate 30 births per annum. On the further assumption that provision should be made for 30 per cent of births, the minimum requirement will be one bed for approximately every 100 births, although actual requirements may be considerably in excess of this figure. In Bombay city, for instance, where the women are more willing to go to hospital, about 70 per cent. of all registered births take place in hospital and one bed is available for approximately every 30 births. In rural areas, where less overcrowding and less general ill-health esist, a smaller number of beds will suffice provided a satisfactory domiciliary service is available.

·44 The replies to this section of the questionnaire give details of the various classes of hospital maintained in the different provinces and of the number of beds maintained in these institutions for midwifery cases. Table XV has been compiled from the answers received. Wide variations are seen, ranging from 48 and 13 maternity beds in the urban and rural areas respectively of Orissa to 2,436 and 199 beds in the urban and rural areas of Bombay Presidency. Although the questionnaire was drawn up with a view to eliciting information with a minimum of trouble, the figures submitted are in certain cases open to grave doubt. In consequence the table can only be regarded as giving a general view of existing hospital [Provision for maternity cases, TABLE XV. Utban. Rural. Namo of Provinco or Stato. Number of birthsin 1936. Number Ratio of Xamber Xumber Ratio of of Maternity of of Maternity Maternity bedo per birthsın Maternity beds per beds fico births 1938. beds. 100 births N. W.F. Province 10,401 1.1 86,894 003 Punjab 125,413 2,091 27 973,703 172 .02 Delhi 21,229 147 .7 9,630 M Nu! U.P. 201,439 750 1,626,169 102 -006 Bihar 30,087 253 .8 1,113,921 12 001 Or1868 5,631 48 .8 249,066 13 005 84,855 800 7 1,588,351 33 002 Bengal C.P. 76,962 245 574,306 15 002 Bombay 130,000 2,436 2.8 . 612,331 199 032 Sind 26,674 466 1.7 52,862 73 Mladras 149,988 1,051 1,509,637 262 017 Atgan 6,349 . 104 1.6 233,355 16 007 224 15 Hyderabad State Mysore State Jodhpur State 30,088 780 2-5 108,481 100 -09 10 If the standard of one bed per 100 births, regarded as reasonable in Vestern countries, be accepted, the figures in Table XV would show that provision is adequate in the urban areas of the N-TY. F. Province, the Punjab, Bombay, Sind and Assam, and fairly adequate in Delhi.

·15 Bihar, Orica, Jadras and Ilengal In some arens, A large proportion of the beds for maternity casu are shown as leing inaintained in getirral Tards, which must be regarded as only a makesliift nrrangement. On the other hand the provision of maternity leils in rural areas is utterly inne quate throughout the whole of India, although it must le remrinboral that the maternity bels in urban areas are also to n certain citrnt ly women from rural areas In most provinces, the minjority of these beds and provided in loy. pitals maintainel eitlier by Governinent, municipal boards or local ladies, but, in the United Provinces, the Duſterin Fund maintains 74 urban and 11 rural hospitals which provide 241 mm S matermly beli rompectively It must be remembered, however, thint the distribution of availabil.. liris is by no means umform As the result of a rapidly increasing demand for admission to maternity hospitals and maternity homes, small maternity homes organiscal by voluntary or private cffort are springing up all over India. Many of these are, unfortunately, sitech in unstable buildings and placed under the charge of illiterate as ineapalile of taking temperatures or of keeping records and with but a faint appreciation of asepsis and isolation. In England, it has been found necessary to register and inspect maternity homes in order to ensure a reasonable standard of equipment, staff and safety for the mothers Should the development of private maternity homes in India increase with the same rapidity in the future as it has in recent years, their supervision will shortly become a matter of some urgency Sutable control might be exercised by a system of licensing and by inspection conducted by governmental medical and public health departments The respective rôles of the maternity hospital and the maternity home are rarely fully appreciated, consequently maternity homes are frequently called upon to assume the functions of a liospital The role of the maternity hospital is to admit all emergency or unbooked cases, all major operations and to conduct a consultative pre-natal clinic It is desirable also that it should have warıls for well and sick children and a gynecological department The planning, equipment and staffing must therefore be of a higli order and the hospital consequently an expensive institution The maternity home sliould confine itself to the conduct of " booked' confinements which are expected to be normal thus doing away with the necessity for much theatre equipment, the frankly septic blocks and permitting of a smaller staff. liomes maintained by public bodies or by voluntary organisations should have a pre-natal department and may arrange a domiciliary service For these reasons it should work in a circumscribed area in distinction to the hospital which draws its cases from a whole district or province Medical women employed in institutional midwifery. 4. By means of the questionnaire, figures have also been obtained in respect of the number of medical women employed in maternity hos. L2Pac ·pitals and liomes. Table XVI pires details for the individual pro vinces : TABLE XVI. Number of modical women employed in hospitals or homes. Xung of ['rouince or State. Sumber of beds main. tuned for manifery cases. Graduates, Licentiates. Total. 121 6 16 X.-WW.F. 'rosince 10 2,263 Punjab 43 80 123 Delhi 12 147 8 852 78 Unite Province 104 212 Bihar 205 17 48 05 ORIEBA GI 3 9 12 Bengal .. 633 15 27 Central Provinces 260 15 23 Bombay 2,635 88 03 151 Sind 539 14 12 36 Madras 1,313 96 165 201 Assam 120 2 17 19 239 12 32 44 880 Hyderabad State Mysore State Jodhpur State 17 39 66 10 3 7 The largest numbers of medical women are employed in the UP the Punjab, Bombay and Madras In thic Punjab, UP. and Bombas most of these medical romen are and to be employed by non-official bodies, by which presumably is meant Missionary and Dufferin Hospitals Io Naciras, the Provincial Government emplost the majority Midwives employed in institutional midwifery. 5 Table XVII gives the numbers of midwives employed in hospitals and maternity homes in each provoke. Although it is desirable to have one midwife for every three beds, one to five may be regarded as a reason ahle provision According to the table, this proportion of one to three exists approximately in Bengal, the United Provinces, Bihar, the Central Provinces, Bombay and Madras. In some provinces, the figures indicate that the proportion approaches to one midwife for every two beds This ·seems too good to be true nnd in these instahes the replies can only lor. accepted with caution. A possible explanation is that picry midwife attached to the institution, ihether actually doing inidwifery or not, has beca included in the returns. TAI.E SII. Xame of l'rovince oriente. Yo ofled, inain. tinnel for miil. wilury cars. No, of middle employed in 1.0 sital and bomcı. l'roportion of trile toerer midwife X-W.T. Trovince 1:1 N 15 3 Punjab 2.263 187 Delhi 23 . 0.. United I'rorines 238 3.3 Bibar 87 30 Orissa 61 56 10 033 209 2.3 Bengal Central Provinces 260 130 Bombay 2,035 025 Sind 539 11.4 Madras .. 1,313 630 Assam 120 .. 39 3.0 239 32 Hyderabad Stato Mysore State Jodhpur State 880 163 53 10 33 0.3 As hospitals and their stafl's are expensive, before embarking on .. grueral policy of hospitalisation for maternity cases, provincial Governments and municipal and local authorities would be well advised to consider the developinent of domiciliary services Domiciliary Midwifery. 6 Domiciliary multifery is relatively casy to provide, cheaper to maintain and meets the requirements of the normal confinement even where home conrlitions are by no means ideal The midwife is, of course, the most important it in a clomirilir scheme and, if the figures can be accepted, Table XVIII shows how insufficient this staff is in most of the provinces.

·48 TABLE XVIII, Stals employed in tłomiciliary midtrifery by local bodies and voluntary associations. Yo of total births in 1936 Province or State Yo of med, Yo of midcal wonen Wiley, 1913 fu domic tant mg]. 1:3ry mod. wives and kifury. nurse dais Yo, of trained indigenous data. Xo of births рхг mylaufe 18 13 36 X. IP l'unjab 70,99* 1.097,115 30,379 5,923 1,(199,140 Delhi 3 30 133 573 UI Bihar Or19 1,897,599 1.144,009 254,637 303 30 30 23 2 6,9.49 20,439 8,499 10 Bengal CP Bombay 1,073,206 051,269 742,331 40 140 19 218 220 21 79,791 4,652 5,015 30 Sind Madras Aggam 79,536 1,050,025 239,701 35 17 16 430 33 4,971 3,782 7,203 70 HIyderabad State Mysore State Jodhpur State 163,226 136,569 40,806 419 2 326 J *Large numbers of nurse days and trained dais are available for private employment Under the Laglish Midwives Act of 1936, every local authority i bound to provide an adequate staff for domiciliary Inidwifery Whilst no dcfinte figure is lau down, one midwife per hundred births 19 becoming accepted as a reasonable figure The last column in Table XVIII shox how far India lage lieliind in this respect Some provinces report that as many as 70 per cent of births tak place without any skilled attention for tlie mother. This figure probabi: understates the case Table XVIII also shows that every province, witi the exception of Madras and Punjab, emploved trained dais in their dom ciliary midwifery organisation The midwife is capable of dealing only with normal cases; for others she requires assistance cither from private practitioners, from specialisti attached to women's hospitals or fron medical tromen with experience in maternity and child welfare work. Most of the provinces report that thi" ospitals and maternity homes are availabl: it is almost certain that their services are extent The replies to enquiries in respect of the numbers of medical roman employed in domiciliary midwifery short that apart from those emplorer in midwifery institutions, the provision is almost negligible, except in the U P., Madras and Bombay and even in these provinces the figures are very small, r1

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·htlet pre-nutal clwics, sterile equipment, medical skill and liospital admission. T'he midwives are also able to work in a ruster, so that periods of rest and leisure can be obtained, whilst contact with the lustitutioual stat keeps their kuowledge up-to-date. lodia has long been accustoined to look to Government to provide hospitals, dispensaries and medical reliel, so that it is lalily surprising that the employiuent of midwiles by its local authorities preceutu tue adoption of this policy in Englaud. Few Indiau luumapalilits, however, could aftord to finance a complete schemic from then own resources and it is to be noted that when, in 1936, England made domiciary midwery service universal and compulsory, local authorities were authorise to recover fees from those able to pay. Until some such scheine is adopted in India, existing deficiencies will have to be by midwives in private practice. Local bodies and voluntary associations which provide a dumiciliary midwifery bervice would be well advised to institute und entorce scale of tee which, while not being applicable to the genuinely poor, would constitut additional funds for expanding the domiciliary service. There is no rea reason why those able to pay for the services of a inidwife should not d so and, in those areas where this system has already been practised, X hardship has been caused and the families concerned lave shown them selves willing to pay. The introduction of a scale of fees of this kin' removes the unfair inethod under wluch a completely frec service injure the practice and income of private practitioners and private midwives. Most of the provinces have apparently been unable to give the number of registered midwives in private practice, but from the figures received it would appear that there are 574 in Bengal, 388 in Bombay and 2,41 in Madras According to a recent survey carried out by the publi health department in Madras, the provision of midwn es works out at 09 per 1,000 births in municipal and rural areas. These figures may b somewhat misleading, because a midwife may be registered in one pri vince and work in another, The income of the average midwife in private practice is ofte uncertain , in fact midwifery is frequently a secondary activity onl practised in order to supplement earnings from another Source. Fees too, are usually small and the tendency is for the midwife to book mor cases than she can deal with efficiently. Technically, she is at a di: advantage compared to midwives employed by local bodies and voluntar organisations owing to lack of adequate equipment and, moreover, it i difficult for her to make contact with midwifery institutions and clinic whilst under existing conditions there is no supervision of her work. Post-natal Clinics. 8. Systematic post-natal examination is so far practically unknot in India. The routine medical examination of mothers, for a periodo six to eight wenu. - f. abnormalitie at an early ar tion of chron in the preren this activit requires to be stressed not only in the teaching hospitals but in e Health visitors' school Moreover every welfare centre, as well as ever women's hospital, should hold organised post-natal clinics in the same vay as pre-natal clinics and health visitors and midwives should make every effort to induce the mothers to attend.

·31 CHAPTER V. INFANT AND CHILD WELFARE SERVICES. Introduction. 1. The review of the vital statistics relating to infantile nel chuld mortality contained in Chapter 111 shows that 13 Hr ernt. of the total registered deaths occur under the age of 5 CAN Little is known of Ilic clinical causes of deaths in lanes and cluso and still low all the social and ceonomic canses which influence the deatlı rate Research ou these problems is required before rette control teasures based on an understanding of the situation can be institute In a general way, it is known that defective sanitation, bacl housw and overcrowding, inadequate milk and food, carly turriage, high birth rates, miscrec social customs and such like are in large mensure responsible for high tuortality rates, but there is little doubt that a factor of outstanding importance is the lack of skill and knowledge of mothercraft on the part of the mother herclf This being so, the most hopeful method of control they in educating thic mother in the nurture of her chuldren and in the precautione to be taken to secure their healthy development The first line of defence is to provide more universal education for girls and to introducc mothercraft classes into the curriculun of girls' school, the second to establish maternity and child welfare schemes online designed to meet the mothers' need for knowledge of the simple rule of health Muteruty and child welfare is essentially an educational service provuling ailvice and instruction for mothers in the care and management of their own henith and that of their infants and young children Number of Welfare Centres 2. The figures for maternity and child welfare centres for 1936 in the different provinces have been coinpiled from the replies to the questionnaire and are given in Table XIX TABLE XIX Number of Centres. Province or State Urban or combined urban and rural. Rural. Total. N.-W.F. Province 3 Punjab 70 18 Delhi 21 10 U.P. 138 IBI Bihar 17 Orissa S 5 ·52 Ito riace or State Urban or combined urban and rural Rural. Total. Bengal 32 32 . CP. 66 16 72 Bombay 10 31 53 Sindi 2 9 Madras 89 100 107 Assam 5 5 .. 4 4 IIyderabad State Mysore State Jodhpur State 36 7 43 2 2 .. Table XX shows the different agencies under which the centres al maintained These have been compiled from the replies sent br" a1 ministrative officers to the questionnaire but here again the informatic supplied is certainly incomplete It is surprising to note that administr tive officers seem to be unaware of the preventive trork actually beir done in the areas for which they are responsible.

·TABLE XX. Number of Maternity and Child Welfare Centres run by : Industrial Concerns Total (Grand). Government and Local Bodies. Namoof Province or State. Voluntary Organi- Bations (including Missions). Combined Local Bodies & Volun. tary Organisations Combined Gort. & Voluntary Organisations, Total. U. R Total. U. R B Total R. Total. U. Total. R. Total. U. R. 3 70 IA RS 1 1 مر ج N.-W.F.P. l'unjab. I 19 34 36 (combined ' & 4 15) 13 (Y 3 21 10 3 Delhi 4 .. 18 4 22 2 2 179 121 CE 63 136 121 257 I 13 0 S U.P Bihar Oruss 5 9 4 4 10 10 21 21 Bengal. 1 1 C.P. 3 19 7 31 49 2 16 20 Bombay 17 14 22 : ? 3 - Sund . 1 5 5 (These In AOTTA 150 gr grita) 17 Madras. 94 153 12 35 > Assam 5 5 . :12 4 19 Hyderabad State Nytore Stato Jodhpar State 13 16 2 U stands for urban and stands for rural.

·64 In the U. P., the 2039 centres in existence are divided almost equa between urlinn and rural arca, and are entirely managed loy the Indi Red Cross Sociсty: On thr orlice hanel, of the 196 centres in Madr 158 are organised under oficial auspict, and only 33 are run by volunta orginations In the Punjal, the organisation les milway between th of the land that of Jadras; of 89 centres, 37 are under offic Management, 13 are under voluntary organisations, 4 are under Xoi Western Railıay, whilst 31 aro mannen hy combined official oluntary organi'a:ions Dellii Province is shown as posso sing 31 centi but 18 of them are in the cities of Old and Yes Delhi The Ben figures total 31, including one attached to the All-India Institute Ilygiene and Public llealth The il centres in the Central Provinces : distributed between rural and urban areas fairly evenly. With th exceptions, includma Boinhay which has 53 centres and Mysore which i 43, infant and child welfare vork has not yet developed beyond experimental stage Health Visitors. 3 Table SXI gives the total mban and rural births in each proti with the corresponding numbers of centres and certificatei hea visitors Esperience has proved that ong bealth visitor cannot deal with me than a population producing 200 to 240 births per annum It is clear t1 tie available organisation is far short of this figure in most provinces. TABLE XXI Urban or combined urban and rural Rural. Name of Province Or State. Births. Certificatod health Visitors Centres No of births per health visitor. Births Centres. Certificated health V131 LOTS No. of births per health 2 N-1 T.P. Punjab Delhi 10,404 125,443 21,229 3 70 21 3 70 20 3,468 1,792 1,06) 66,574 973.703 9,630 18 10 46,3 2,9 A UP. Bihar 261,439 30,097 133 17 8 22 13 121 3 372,3 Orissa 5,631 I. 5 1.883 1,620 159 2,314 | 1,113,921 219,066 9 428 ] 1,593 957 1,261 574,306 Bengal Central Pro. Vince. Bombay 81,855 76,962 25 56 9 61 16 2 12 794.1 47,8 130,000 19 19 6,819 612,331 34 612,3 Sind, 1 I 52,8 Badras Asean 26 674 149,99 6,319 7 88 5 4 58 2 6,669 52 562 2,500 1,507,637 3,174 233,355 2 109 11 137, 4 3 .. Flyderabad State Mysore State Jödlpar Stats 30,008 36 } 30,003 106,481 6 ·35 It lins long been recognised that the trainei licalili vstor holds n hey finsition in a welfare centre organation in the fult of this fact, it is disappointing to find that so many welfare antren in this country Aull days no trained liealtlı visitor on their statis For inintite, althou the UP. has 239 centres, only healtlı visiton are employed ('hel welfare work, in the real sense of the termi, cliput be properly urried out by muset and assistant midwives, such as are m charge of the majority of the U centres. The frict that the l'unjab, with its heruitria, emploss 91 cerita ficated health visitors sliutis that it is possible to abraun truncil woma. It is reported that the ' ' emplossa lacs, bumber 1 taoth sluts Out that most of their time is given ti malwilers 10 Itus IS 1107. lo ever, the primary ſunetion of a health visitor In adros residency is hralih visitors are emplosed mainly las local hocles, 1.3 arc einpiloyal by voluntary organisations Women Doctors - 4. Table XXII gives the number of centres in each proumer and the numbers of women doctors attached ·Provinco or State Namber of Maternity and Child Welfare Centres. Graduates witbont a Diploma in M. &C. W.or a D. 11. ment Pubuo Tealth Depart Graduates with a Diploma in ML&C Wora DPI Licentiates. Graduates without a Doploms 10 L. & C. W or a DP La al Bodice. Bunicipal Boards and Graduates with a Diploma in M & C. W. or a DPH Licentrates. TABLD XXII. Graduata withont a Diploma in M&C Wor & DIU Yoluntary Organisations Graduates with a Diploma in MACW of a D PII Nomber of Medical Women employed aa Jeaterauty and Child Welfare Work by- Licentiates Graduatca thout Diploma 10 SL & C. W or a DII fadastral Concerns Graluates with Diploma in AL & C W or a DP II. Licentiatek Graduates without Diplons in 31. & C. 1. or a DIIL. Total Goslati smith a Diploma 10 L. & C. \y or DPI Laccatiates, 99 ·1111 The number of women doctors engaged in the spillere of work is very small except perliapy in Madras, where 31 Prentiates are employed wder local bodies. There seems to be great sense for the employment of women doctors with special traimng in ilus lield of public health work Early departures from health are not always apable of detection even by a traweit henlth Testtur The di due tothy to be alrawn from obrious departure froin licaltlı can m most valsts only for male by a traincil vonian doctor It is for these prisons that fury welfare rentre reures to have a visiting doctor Func:ions of Welfare Centres 9 Maternity and child welfure work is essentially of an educational tinture The education of the mother bepas by militadual instruction in the home and this cannot be suitably carried out and the healinn visitor ays regular monthly home visits to all crpeetanj mothers and tu mfants under one year and continue, to visit once a quarter the chilieu betucci the ages of one and five years On the assumption that 200 birthy per annum occur in a health visitor's area, this irans that she must pay 2,100 uome visits to infants alone, whilst Guisits to each expertant mother means another 1,200 per annum, If the health visitor is to make these 3,600 visits, che must do at least 12 per day, assuming there nre 300 working days in her year. These calculations take no account of visits to children between the ages of onc and fire Wien climate anal other conditions are taken into account, it will he agreed that in addition to running her contre, the health visitor has a beavy task if she tries to work to this standard The health visitor's task is to deal with the general development of the child, the management of breast feeding, rlothing, bathing, tecthung, vaccination, meaning, the diet of the nursing mother, babit training, prevention of colds and minor dietetic and other disorders The motlier las to be persuaded to change century-old customs and habits She has to be in. structed in the hygiene of the home and its environment, in family budgeting and in a host of other matters regarding wluch the lealth visitor will te consulted once she becomes the tried counsellor of the family The same lesson has to be repeated again and again before new methods aro accepted and practised Mention has already been made of the fact that most of the existing welfare centres are staffed onls by mures or midwives instead of by trained bealth visitors Whilst the traimng of a nurse fits her for nursing under the general direction of a doctor her hospital experience gives ber little contact with degrees of health Much less is slie trained in respect of the advice to be given to the mothers and babies attending a welfare mentre Only too frequently, resort is had to the charitable distribution of milk and clothing or, worse still, to the dispensary habit of doling out medicines It is these practices which have handicanned so severely the development of real welfare work in this country until fully trained health visitors the centres are guided and controll preventive outlook Whilst the importance of home visiting cannot be over-emphasized, it must be stated that the welfare centre is an equally valuable adjunct to sound maternity and child welfare work The welfare centre itself makes ·68 fod the cconomical ise of the doctor's services and gives opportunities to tie mother to consult the health visitor between the routine home visits. lcre also can be carried out weigling tests and the more detailed examina- 1.01s aluch are not possible in the home In addition, individual instructan begun in the liome can be consolidated by more formal group teaching und demonstrations, whilst the doctor is able to confirm the health visitor's rievice and ensure that it is acted on. In this country, since medical treatment is not always readily avail. abte and the absence of facilities for treatment is a great handicap to welfare work. the treatment of minor ailments in the centre is legitimate. Gicat cart, however, must be taken lest the welfare work, which is primarily preventive in nature, develops mainly a curative character. The centra which usurps the function of thic hospital or dispensary does so to the detri n:ent of its own more fundamental work of promoting racial health and presenting discase, but also puts back the time when adequate medical facilities will be instituted Every emphasis should always be placed on teaching the mother how to carry ont the treatment at home, otier- #ase the centre quickly becomes converted into a dispensary and its value as a preventive institution is entirely lost Inadequate facilities for tac treatment of disease is a handicap to her is to take place, facilities for the relief This means for India a wide extensic inedical officers *** It is a regrettable fact that in the past hospitals and welfare centres have not co-operated in the most fruitful way for the benefit of the women and chuldren of the country. Each has the persons concerned for wliom both & fullest co-operation between the two. but they are complementary and neither can do without the belp of the other. The misunderstanding on the part of the public as to what welfare centres exist for is partly at least due to wrong methods of working. Where the right ones are tried, the public generally realises the work which the hospital and the welfare centre performs and where the one carries out what the other does not attempt". Voluntary Workers. 6. Good voluntary workers are always a valuable asset to a welfarc centre For instance, the clerical work involved in filling up and indexing cards takes up valuable time if it has to be done by the health visitor and relief, in this direction alone, leares her more free to attend to the technical duties for which slie has been trained In addition to work in the centres, voluntary workers are frequently able to enlist the sympathy of local residents and members of local bodies and thus ensure the collection and allotment of funds necessary for success They should also be of value in homc visiting and in carrying out propaganda work amongst women. But, in order to play a really useful part, the voluntary worker must in the first -place be prepared to give tine and energy to the work and make hersell incroughly familiar with its aims and objects Enthusiasm must always be accompanied by knowledge if the voluntary worker is to be of any real *Handbook for Health Visitorg -Young.

·09 assistance. Classes for voluntary worlioni miglit lor conducted either in connection with health schools or plannel by vtliar orkanisations engana in voluntary work. Carc of the child from 1-5 scars 7. The number of nursery chals taken from the replies to the quc. tionnaire total 33 This figure, like others already quofcil, must be acceptai only with considerable reserve The years one to five are critical cars in the club's levelopment Jot only is physeal bralth luble for belastnina loquatc dint, by insufficicney ut sleep, toy expertire lo informal diseases and by unsatis factory enronmental cond11100s but the elulis 12.mal cinntional and social development may be returded by lack of the necessars stimuli or by Parental ignorance Both physical licaltlı, and, to some extent, development of character cau be influenced through the maternity and child welfare scrum well-organised schemes, the health visitor should pay quarterly visits in the homes of all pre-school children in her area and the children can als attend the consultation clinics at the welfare centro In most instances, however, the health visitor is fully occupied with work amongst expectant nuothers and infants and the chuld between one and five years is neglected. Nursery Schools. 8. In such circumstances, the nursery school offers a method of providing for the healthy plysical and mental development of the child In liis report on the liealth of the School Child, 1936, Sir G Newman says .- " The purpose of the nursery school has long been recognised by, intelligent Cbservers who are concerned in the nurture and education of the children of the nation. The pursery pchool should scck to reacly the detects often mbetent in the contrious of Lome life It is a species of Montessori or McMillan School with bealth as its objective. The phys al care of these children comprises much more than mere physical acicise, wuportant is that 19 It wolves provision for free movement, in Bunlight, when possible, in fresh air alsass, out of-lours or indoors, regular periods for sioun aud rest in the horizontal position; trung in all dcsurable bodily debats, Tartu ularly personal clearlinest ; and arrangements for incals, including but... foud at regulur times The games, hard work and physical exereises undertaken should be to a large extent free and unl7wpereil, though not armless The chiluren should bor trained to play together as well as to play alone, to breathe properly, to use their Jinils freely with irery.150g control, to move quietly uſien ucussary Walling Lolring, ekipping, marelung, running and arm exer13es are particularly valuable Fullest .dvantage should be taken ot life in the open air wud all those activities for Lttle gardens, the care of birds in nature, as well as nalural on shoukl be maintained ge nunberg of little children of of medical officers, nurses and and ready to the prompt pre- Tentive treasures against intcction. The school swould also prouale definite traming of the ofcaing mind of ine child, seck to establishi well formed l wils, cultir.te aters ness tunc igemess, and noude for suitable training of the motor and sensory facul Much may be done also il sense-t1810.ag; ties of the child (including handwork) ag anzarils sight to teach 1lie child to notice broad rather thau fine diderences in colour, form acd size, as regards hearing, to listen with attention, to respond to questione and commenee to distinguish diferent sounds and to develop a taste" for picasant rounds instead of n0159; in touch, to enable the child to interpret shape, size and texture through his fogers and to use his hands and Gngers for manipulation, Swed Witn

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·61 With the possible exception of the last fitonip, none con le regardal as satifactory. Dlily cart by..! sluz i llurn !" "sygent lins this advantage over : ere that the time 18+ 11. truulee mudd, where the attendant is constientists and incils, the child benefits from a greater measure of runtherin; Gutulit ni mustrial areas are, hot. evex, selon Ideal auderful puthies Imaried out buren by a licalth voor viat. 1* r'nplu. Bryn of female labuur being a well-established prisilie in utrual concerns. # number of culltened emplosen hiile te-l the value of proline; creches for the childre? I till! She staten no lerni obilato lion in the intit !!!!!!!!!! | in Bomlas Presidency, many mills and instries hi in.lule tout $1011 16 the tue scom ripe for the best tale mus Itali ni ibat indir ilic rul unei Ly the Government of Bombay, mils ciuploying more th.111 100 women must have suitable accommodation for the use of clullren below the age of six years. Acreche is intended to take charge of children from carly infancy to 5 years. For the younger infants, attention to cleanlines, comfort, iccd. ins, safety and freedom from infection are the main requirements, bat even these require considerable knowledge and skill. The routine work may be entrusted to an untrained ayah, but the direction and supersawon of the subordinate staff should be in the hands of an cxperienced and qualified woman who in turn will work under the general direction of a medical officer. Very few of the existing creclics are organised in this way partly no doubt because of financial considerations but also partly to lack of suitably trained workers The arrangements for the older children up to 5 years should be simular to those of a nursery school Institutions for orphans and illegitimate children, etc 10 The replies to the part of the questionnaire dcaling with this aspect of child welfare are conspicuous by their absence The matter is of soine importance, because, whilst definite statistics of the mortality amongst infants and children in institutions or with foster parents are not available, the mortality rate is known to be excessive in one or two of these institutions The children admitted are very often handicapped from the start by bad heredity and by the physical hardships through which they have passed before admission and only the best medical and nursing skill and mothering can help them to recover health of body and mind Whilst many of these institutions are inanaged and financed by volun. tary committees and the arrangements for cleanliness and comfort of the children are above reproach, others lack even the minimum sanitary requirements and possess neither the amenities nor the companionship neces- Before the responsibility sary for the healthy development of the child of Government with regard to these institutions can be advantageously discussed or recommendations made for their supervision, much more in. This is a formation concerning conditions obtaining in them is required matter which should not be lost sight of by the Governments of this Pountry In any case, the control of these institutions is a question in which both medical and public health departments are closely concerned. L2PHC ·The essential characteristics of an efficient nursery school are set out in a pamphlet entitled " Variations within the Nursery School Movement" published by the Nursery School Association of Great Britain. Crêches 9. Another method of catering for the supervision of infants aui young children in the crêche or day nursery. According to the replies given to the questionnaire, 97 crêches are known to the medical and public health departments, but this figure is clearly an under-statement. Recent in. formation in regard to Bombay Presidency shows that there are 31 crêches 11 mills in Bombay city and 61 in mills in Almedabad. In other provinces. the provision of crêches las not advanced so far, but at least five are known to cxist in Bengal and others are to be found in Nagpur, Bangalore and Madras The greater provision in Bombay Presidency is accounted for in large measure by the appointment by the provincial Government in 1922 of u roman doctor for the purpose of investigating the conditions of women in.lustrial worl.ers in the Presidency Her enquiry showed “ that about 90 per cent of the infants born to industrial women workers had oprum administered to them in some form or other and that this was responsible for much of the atrophy group of diseases met with amongst infants **, whilst in that year there were only four crêches in Bombay city and a few in Sholapur and Ahmedabaci Shortly after the completion of this investigation, the Government of Bombay appointed a Woman Inspector of Factories to deal especially with the problems affecting women and children. Although the number of croche, has increased considerably since, the numbers are still far short of requirements Where a crêche is not available, infants and children of the working mothers are left in the charge of old or decrepit relatives or of the elder children of the family, the arrangement in neither case being satisfactory. The following figures were collected by the manager of one of the jate mills in Bengal after the passing of legislation prohibiting infants from accompanying their mothers to Tork They indicate the net arrang ments made for the care of 120 children of working mothers, In charge of an outsider on payment of 0-4-0 weekly .. 15 Unattended and playing outside 15 In charge of a small brother or sister 49 In charge of aged relatives 29 In charge of other relatives 12 . 120 ·61 With the possible creeption of the last prop, noue cau le regarlel 33 satisfactory Daily cur by all meali 141n los payment has this advantage over a urcer that the rul 121.4.11 be reluced and Flicre the attendant is cous collutis nondly, the child lynetits from a greater measure of otherm: ( onuite]ita mustrial areas are, ko.s. ever, seldom ucal 1. riu spill! this buinlou out children by a health vositus is de 1.1 The plong tin nt of lumale labour being a well-established 15.111 an. ancia trial till 11 111nber of colightened employer bare reel ihe value of proslink creches for the ciulur. 131 1 luer Suple, botell no linal obliction in the mil Hill's 'VI'! In lumbay l'residency, many mininta base molt HU - Sonndi tome scoms ripe 105 1 In lil mulle uim ulsus. It my in 11. that under ihe rulis old and is ilie Guvernment of Bombay, Inills employing more than 100 women must liave suitable accommodation for the use of children lelow the age of six years. creche is intended to take clarve of chuldren from carly infancy to 5 years For the younger infants, attention to cleanliness, comfort, f'ecdl. 10%, safety and frecdon from infection are thic m.lin requirements, but even these require considerable l.nonledge and skill The routine work may be entrusted to an untrained az alı, but the direction and supervision of ihe subordinate staff should be in the hands of an experienced and qualified woman who in turn will work under the general direction of a medical officer. Very few of the existing creches are organised in this way fartly no doubt because of financial con aterations but also partly to lack of suitably trained workers The arrangenients for the older children up to 5 years should be simular to those of a nursery school Institutions for orphans and illegitimate children, etc 10 with this aspect of child tatter is of some importan rtality amongst infants and children in institutions or with foster parents are not available, the mortality rate is krown be excessivo in one or two of these institutions The children admitted are very often handicapped from the start by bad heredity and by the physical hardships through which they have passed before admission and only the best medical and nursing skill and mothering can help them to recover health of body and mind Whilst many of these institutions are inanaged and financed by volun. tary committees and the arrangements for cleanliness and comfort of the children are above reproach, others lack even the minimum sanitary requirements and possess neither the amenities nor the companionship neces. sary for the healthy development of the child. Before the responsibility of Government with regard to these institutions can be advantageously discussed or recommendations made for their supervision, much more in. This is a formation concerning conditions obtaining in them is required matter which should not be lost sight of by the Governments of this country. In any case, the control of these institutions is a question in which both medical and public health departments are closely concerned. L2PAC ·62 CHAPTER VI TRAINING OF STAFF Medical Women, Hcaltlı Visitors, Midwives and Dais. Introduction, 1 It was fortunate that the promoters of the maternity and child wel tare inorement realiseid at an early in the importance of properly trained walls fur welfare hirmes The stabliment of the first training cour for health visitors (1918) artually precreet this formation of the Lady I helmyon Lecue Fund ins Maternity and Child Welf.ir (1920). The "edical woman, the incalth Ustor oil the trained inilufe must all Vailable if the masurun benefit is to be derived from the centres In viher sphere, it is well recognised that no degree of skill and kuion indge in the actual worker can compensate for cfective planning and administra- 110n In the placre of maternity and child wellne, however, this seems to have escaped notice anil the services of the health visitor lave been only too frequently rendered more or less ineffective liy misdirection 'under m-informed enthusiasm Special post-graduate training lins long leren considered necessary for the medical officer of health and, in the samc way, of the maternity and child welfare services are to be properly organised and integrated into hicalth departments Special training for the medical officers in charge is essential. Medical Women. 2 A course designed to fit medical women for administrative and exc. cutive posts in maternity and child welfare schemes was instituted in 1933 at the All-India Institute of Ilygiene and Public Ilealth, Calcutta, but un. fortunately so far only a few women have availed themselves of these facilities As the greatest urgency is to obtain trained metlical women for the higher administrative posts in large cities, districts and provinces the course has becn limited to graduates A further cogent reason for limiting the course to graduates is uncertainty as to the future of the licentiate medical schools On the other hand, sub-assistant surgeons are employed by Gorern. ancats and voluntary committees and in army child welfare work, whilst others are attached to dispensaries and small hospitals where they mny be arquired to undertake duties in connection with welfare pentrts and domiciliary milwifery. In Madras, tlie medical women employed under local bodies' schemes are given a sluort post-graduate course in maternity and child wcifare. Some knowledge of public lealth practice woull be of great service to medical women and the question of arranging adequate courses for those already appointel is one of some importance Public Health appointments under local bodies open to medical women are so far uncommon (see Table XXII) and the salaries of those in cristence compare unfavourably with the income of medical women in practice or in liospital posts The conditions of service anrl the qualfiications necessary for medical women taking up maternity and child welfare Tork ail require careful consideration and emoluments should include some com. pensation for loss of private practice.

·03 There can be 110 dloubt tlint, if maternity and chuld welfare sork is to be properly organised, the first purament i la linse n win of this status of Issistant Directus of l'uli ll. Ith in mach provitice and this appointment clioule le opens only those who possaillier a jublic health qualiticatwn us ini terudolstojuma in materials and chulil wel. fare and have been selerisa piknikut ne of publice for alth work. For ans amiboltol IV 21! ln al lock shemes a Momiji doctor's rule to al mihalos banh social training, if she is to her able to login 13 ndes lusikalile lines and to advise and use the lin1111511) Health Schcols and the Training of Health Visitors 3 Tirre are plen lealth-chools in Indin, their opening dates being Delli, 1'11" , Lahore and Malra, 1922, Namur, 1924. l'..., 1:03'; Bumbay, 1935; and Calcutta, 1937. Ilealth Schools were formerly in existence in Bengal and in the U. I'., but were closed on my to financial and other difficulties Thc schools in tlic Punjab, in the Central l'rovinces and in Madras are Government institutions ; the others are maintained by Toluntary organisations and all except Bombny receive Government grantsin-aid amounting to 20—30 per cent of the total expenditure. The Sladras School was maintained by the Provincial Branch of the Red Cross Society until March, 1933, and was re-opened by Government in August 1938. In Mysorc State, a niodific training course for hсalth workers has been established at the Closcpet Rural Icalth Unit That a matter so vital to the development of the maternity and chilil welfare movement as the training of health visitors should have remained so long in the hands of voluntary bodies may be taken als a testimony to the enthusiasm and determination of a number of far-seeing individuals, but, although this policy may still be espedient, conditions are changing fairly rapidly and no Government can afford indefinitely to shelve its responsi. bility in this sphere of preventive medicine, even although voluntary organisations are willing to continue to carry part of the burden On the other hand, voluntary committees, whilst realising the influence they cau continue to exert on the development of maternity and child welfare work, are now inclined to believe that the experimental stage is past and that the time has come for tbem to dcflect their resources in other directions. This trend will probably be accelerated by the new Nursing Registration Acts which provide for the better training and control of health visitors. 4. Qualifications for admission Qualifications for admission have ur to the present been similar in the Bengal, Bombay Dellu, Madras anů Punjab schools The students must be not less than 21 years of age have reacl up to matriculation standard, have a good knowledge of English anri rossess a recognised midwifery certificate In the Nagpur and Poong schools, a lower standard is accepted Provincial Varsing Councils arc Low engaged in drawing up regulations in respect of the training of health visitors and the general tendency is to require the same standard of general education for health visitors as for midwives This is a lower standard than matriculation, which is now required, and is therefore a retrnglade tter Selection of candidates will have to be exercised with care of the folmer standards of erlucational qualifications are to be maintained A criticism often levelled at existing courses of instruction for health visitors in India is the lack of training in general nursing In the first ·61 instance, general nursing experience was not laid down is essential becaus: the yllis islo utical to become health visitors would not face the lovz and strenuous training 10 ultid before they could obtain the mure's quali. fication 5 Qualifications of Superintendent --In five of the seven licalth scholy, the Supermtendent is an experienced and qualified health stor, with experience of maternity and chikl welfare work in other comtries In Dombay and Nagpur, the Superintendent is a malica! woman grailmato Jodical women luxe been appointed as Superintendents presumably because hcalth ritors were not available, but this cannot be regarded as an ideal arrangement. The ordinary day-to-d. 101itne of a lealtlı visitor's work in the centre and in bonne visiting is letter taucht ly a lealih stor than ly a doctor, just as routine bedside mrsm is better taught by members of the nursing profession 11 seclural outlook is supplied by tlie lecturers most of whom are women doctors, tutorial work should be done by a health visitor The Superintendent of the Nagpur School, in addition to her school duties, acts as provincial organer of maternity and child welfare schemes and in this capacity is frequrntly absent from the school, Tlus arrangement is entirely unsatisfactory , in snel circonstances neither duty can be adequately performed 6 Diplomas. The diplomas of the Lahore, Madras and Nagpur health chidols are not recognised by their provincial Governments and Are issued by the official Public Ilealth Departments The diploma of tle Lady Reading IIcalth School, Dellia, las similarly been recognised by tlic Central Government and is not signed by the Public Health Con. missioner to the Governinent of India, who is er-offimo ("hairman of the School Committee The certificate of the Bombay Ucalth School is issund and recognised by thic Bombay Nursing Council cstablished under the Nurses Registration Act and Bengal will also probably adopt the same policy ; that of Madras and the Punjab are recognised but not issued by the respective Nursing Councils. The certificate issued by the Poona Schonl and granted by the Seva Sadan Society was un-official. In the Central Provinces and Madrns, additional and superfluous diplomas have been given by the Indian Red Cross Society. In the near future, the inspection of health schools, the regulation of esaminations and the issue of certificates is likely to become a function of the Nursing Councils, but it may be necessary to form some central body whose duty it will be to maintain approximately uniform standards and to facilitate the reciprocal recognition of certificates The former function is undertaken at present, as far as may be, by the Maternity and Child Telfare Bureau, Indian Red Cross Society. Some control is exercised through grants-in-aid or, as in the case of the Punjab, by the fact that the Director of the Bureau has been external esaminer for the Maternity and Child Welfare diploma for many years In this connection, it 15 interesting to note that, in England the medical officers of the Ministry of Ilealth inspect the training schools and attend from time to time the examinations conducted by the Royal Sanitary Institute. The cert: ficate issued hy the Royal Sanitary Institute is endorsed by the Minister of Health and grants are paid to the training institutions by the Ministry.

·03 7. Jadium of instruction. Thic mcilium of instruction in English at all the health schools except Nagpur and Poona, although tutorial instruction is given in the vernacular of the l'unjnb 111 certain paris of India, the demand for verdeular tuninn fus liealth visitors hae increased rapidly in recent van make the pH dubliculties of Acquiring knowledge thirugh a low lines are generally admitted, there is myeli tu be sul for the institution of vernacular courses At the same time careful muleratins must be frien to the motive behind the demand 11 mis probabile that the real reiset 14 liunneini, not educational, and the demand is not for a lush Kradle torna. cular training but for the trainin; of un mfermr worker wlio will commade a lower lary The institution of tho grades of certificate is not in conformity with present trends whiclı aiın at abolishing the lower grade training for doctors, midtrics and nurses and thus course is therefore not to be lightly undertaken. The replies to the questionnaire were almost unanimously opposed to the institution of two grades Existing scales of salaries are no loubt relatively high and beyond the means of many local authorities, but tlus is largely due to tlıc difficulty of obtaining trained women and, so long as surply falls short of demand, the position will not change The low status of the nursing and midwifery professions in India is without doubt largely responsible for the con. tinued sluortage of suitable candidates for admission to health schools. The more intelligent and ambitious women students enter the teaching and uredical professions, because in both, social status and financial rewards are of a much higher order With the spread of education and with the growing tendency of individual communities to fill teachers' posts witli girls belonging to their own community, it seems possible that greater numbers will be compelled to adopt the nursing and midwifery professions. It may be, therefore, that the present demand for a second and lower grade of worker is transitory A second argument put forward in favour of vernacular courses 13 that girls of good education will not work in rural areas where the pro. blems are more urgent, whilst the general lack of social amenities and of adequate housing in the villages certainly makes rural work less attractive (thers liold that these obstacles are not insuperable and can be overcome hy the careful selection of pupil liealth visitors suited to village work The succeeding paragraph summarises the general trend of opinion as stated in the replies to the questionnaire If the health visitor is fitted by temperament, upbringing and character for rural work, a high standard of general education is an asset rather than a handicap The health visitor's post is a responsihle one. she has to make contact with all classes of people from the illiterate labourer's wife to the well educated members of her committee and she Irust carry weight with them all if anything is to be accomplished. It is only on the basis of a sound education that the intensive, special train- 'ing of the health risitor can be effective and that she will remai sufficiently convinced of the value of her trork to maintain her conviction in She needs initiative the face of opposition prejudice and indifference and ability to adapt her knowledge to varying conditions and people .and the rural worker needs these qualifications even more than the urban no ·66 She worker. Her responsibilities are greater because she works alone and will regularly be faced with situations which ncver arise in the totes where better developed health and medical services are in existence needs character and conviction in greater degree because misunderstand. ing und misrepresentation have to be met without the stimulation and support afforded by contact with other workers, poorly educated worker is, therefore, at a much greater disadvantage in a village than in a town The practical difficulties thich have to be faced in instituting verna. cular courses are as follows In inout provinces, there is more than oue mam vernacular, properly qualified lecturers in the vernaculars are difficult to secure and the medical officer of health may be an Indian from n110thci province Moreover, suitable text books in the different rernaculars do not as yet exist, nor do journals or other literature, so that the health visitor is unable to keep her knotyledge up to date after gradnation without using English Refreslier courses and regular supervision would obriate this difficulty in part, but these are seldom arranged Record keepmg presents another difficulty, as the inspecting officer, whether Indian or Englisht, may be unable to read the local vernacular records Until provmces are in a position to overcome these obstacles and to provide adequate supervision for the worker it would seem the better policy to continue the training on the present standard Eventually, it might be best for cach prosilice to maintain its own vernacular health schools and for a central All-India school to be instituted which would accept pupils from all over India for an English course, designed to give a more intensive and advanced training to those women who aspire to supervisory and teaching posts At present, experienced health visitors Teqnired for key posts, particularly in teaching posts, liave to be recruited frun abroad or suitable Indian candidates are sent abroad for advanced training, arrangements which are obviously expensive and are in other ways undesirable. The advent of vernacular scliools has been brought nearer by the decision of various Nursing Councils to require the same standard of general education for nurses, midwives and health risitors The standard is generally below that of matriculation and too low to enable the pupil to follow an English course This is an additional reason for hesitating over the iustitution of courses for a temporary inferior grade of worker. 8 Syllabus of course --The syllabuses of instruction in use in the duficient schools are fairly uniform and, since they have stood the test of time, little comment is necessary A recent tendency, hotcrer, is to riden the field of the health visitor's work and to bring under her care the school child and families infected with tuberculosis or venereal diseases In these spheres, some esperience of general nursing would be a great asset and sooner or later it will be necessary to consider the question of modifying the curriculum in such a way as to include esperience of general nursing At the same time, a health visitor's work is largely educational and social and, rhilst nursing experience Tould undoubtedly be an asset, four Tears spent in acquiring technical skill, which the health visitor will baro little occasion to apply, would unduly prolong the course and unneces sarily increase the cost to meet these difficulties Dr. Ruth Young, ·07 heu Director of the Ifurcau, direu apa selieme for a four years' tratto ing course for licalth ston She lins proposed that the first two year of this course should be devoted to the lonic sciences including bioloor, chemistry, physiology, anatomy, dietetics, together with periods of concent huning experience arranged by afiliation with hospitals, thic thurd year's course should include Training in mulwifers and in pre-natal and post-natal carc , and the fourth year would correspond more or less withi the present slinbus of the health schools Such n course would hava the advantage of screaming the present gap toetween leaving cliool anel admission to alle althou This papi-5 four years is one of the front handicaps to recruitment of lealtlı visitor, because most of the suitable girls have adopted other professions before they reach the age of 21 Thuis ideal might therefore, be kept in mind and even made the subject of expriment, but the present state of developnient of the nursing and maternity anul cluld welfare services liardly justifies aventure of the kind at the moment. 9. Practical training --Every health school except that in Poona lag Dow attached to it a welfare centre Tlie work of these centres is carried out by one or two trained health visitors who work under the direction of the health school superintendent and who assist in the day-to-day practical training of the students in lome visiting and in management of the centre. A period of residence and practical training in a rural village should be made a definite part of the curriculum in all health schools and those schools which have not yet organised this work should do so without delay. A further increase of the period of 2-3 weeks devoted to rural maternity and child welfare work would go far to remove the demand for special schools for rural workers The development of rural health units, such as are now to be found in the United Provinces, Dadras and Delhi, affords admirable opportunity for the essential practical field training of pupil liealth visitors and may be expected, also, to provide additional recruits from the ranks of the midwives employed in those units 10 Refresher courses --Refresher courses are held at the Lahore health school, but so far no other school has arranged this valuable and important part of its work. The value of the refresher course lies not only in the opportunities it affords of acquiring information on new develop. ments and new methods, but also in the mental stimulus provided by dis. cussion and exchange of ideas The attention of all health school com. mittees should be drawn to the necessity for holding at least one course This should not lay any undue burden on the staff The health visitors employed by Government local bodies or voluntary organisations who attend a refresher course, should be regarded as on duty and trarellin allowance should be granted. 11 Number of students -Table XXIII gives details of tlie numbers of health visitors trained annually and the approximate numbers trained up-to-date At the moment the facilities for training can almost cope with the demands for trained women but if rapid developments take place in the maternity and child welfare field, additional accommodation in health schools will have to be provided. "The Training of Health Visitors in India, by Dr Ruth Young, WBE, WAS each year ·68 TABLE XXIII. Yo, of fotspils train di annually. Yo. alredy trained and certificatrd. No. of tohools EnglL. Veruscilar, 1 . Delhi Punjabi CP Matay. Bengal Bombay Poons U P. ISS 112 77 36 10-13 9-10 8 S ::.:..:: 0 33 19 7 455 9 Total 59-63 (sinco 1932) Training of Midwives. 12 Perhaps no part of the problem of maternity and child wellare is of greater importance than the methods to be adopted in this country for the training of midwives. In Table XXIV an attempt has been made to present the information supplied in response to the questionnaire, but it is again a matter for regret that none has been given except by one or two of the provinces TABLE XXIV Number of Institutions training midwives No. of Training Institutions No. of Maternity Cases No of purita per annum. Name of Province or State, Senior Certifi. cate Junior Certifi cpte Class Clagg A B Hospital. Hospital Senior Junior, 3 3 North-West Frortier Provinco Punjab Deibi United Provincca Not available. 31 21 in 2 y eers 3,5392 6,931 43 3 036 3,439 976 2 9,763 4,303 Not available 25 5 1 27 3 6 Bihar 2 45 1,403 1,020 Notarainlble. Orissa 4 200 169 3 121 Bengal 2 9 19.731 Not available Central Provinces Bombay 6 27 307 473 67 31 150 810d 20,000 1,400 10 30 205 Madras Aggama Hyderabad State Bysore State Jodhpur State 18,257 45 2,697 2,697 6,850 10 27 :::

·09 Information subsequently rerenied from Jindras stated tlint there nre 6c en institutions for the training of lugler hratle uses in Englii, 39 for vernacular counes for malutes and 13 for the training of dars. Twenty-seven of these are MAN 331 hospitals. Ser can the figures fu: mumbers of maternity case as atlable fut instruirtional purpose betalen at their face value, because one of the battutions included are niso ased for the trainmg of medical students who have the fint claun on that clinical materiał For metano il repmried that the central l'ruriiicet has ( hospitals amuiting 2017 Cartes nu that these train 31 pupils for the benior midwifery eritate in other words the nverage number of cases per bospital is 50 anil the average per mduite 10 lor the junior certificate, there are 21 recognised hospitals, 173 cases and 67 pupils, giving on an average about 20 cascs per hospital and 7 cases per pupil Even if this supply of clinical material is increased by extern practice, the position is anything but satisfactory. The Orissa figure of 100 cases for 121 junior pupils is worse. Any hospital admitting less than 100 coses per annum cannot be regarded suitable as a training school and even this figure is far below accepted standards. The 1999 report of the Departmental Committee on the Training and Employment of Midwives, England and Wales, stntcs that “ne liesitate to specify what taight reasonably be regarded for practical purposes as an institution sufliciently large for training midwives But if it be defined as one with at least twenty maternity beds togetlier ritli an adequate number of deliveries in an attached extern district, this might perhaps, be accepted as a guide for the future" Such a hospital could conduct about 500 deliveries per annum Few hospitals in India approach this standard It should also be kept in mind that, although classes limited to one or two midwives may afford good opportunities for individual instruction. under such circumstances the pupils lack the stimulation of personal contacts and exchange of ideas. Moreover, these small classes are uneconomical both as regards tcaching staff and equipment Inspection and recognition of schools for midwives and regulation of the training courses till in future be vested in the Nursing Councils established under the Nurses Midwives and Health Visitors Registration Arts These Councils are still of too recent origin to be functioning properly, so that the standards of staffing equipment and accommodation triucl will marrant the recognition of a hospital as a training school have yet to be laid down although a ferr of the Councils, notably Bombay, Madras the Punjah and Bengal, alrcady have provincial standards The task of the Councils will be no easy one and will no douht be made the subject of review at an early date but it is greatly to be hoped that the standards adopted in the different prorinces will be of such uniformity that it will be possible to obtain reciprocity in the registration of midırıres under the different Acts. In this connection the recommendation of the 1979 English Departmental Committee on the Training and Employment of Midwives is interesting. The recommendation states that existing arrangements for the approval and inspection of training institutions arå teachers by the Central Midwives Board are unsatisfactory by reason of their extremely limited scope and that the whole of this work should be placed in the hands of the Minister of Health, on those behalf the majority of institutions recognised as training schools by the Board are at present inspected by officers of his Department, either in connection with grants ·70 -aid of midwifery services or the training of midwives, as part of the routine inspection of por las institutions." If uniformity of standards throughout India is to be attained, the establishment of a central authority for that purpose would seem to be t'ssential The manner in which such a central authority could be estaliished is a matter which does not come within the scope of this report. Tlte questionnaire did not ask for inforination or opinions in respect of the selection and training of pupil midwives It was considered that ro useful review of the position could be made until the Nursing Councils Tere in a position to provide the necessary data. 13. Number of pupil midwives to be trained annually ---Iu 1929, the population of Denmark was 3,518,000, total births numbered 63,297 and the birth rate was 18 6 During the same year, 1.063 midtires were in practice and, in order to maintain the suppls while prerenting over-cromedias of the profession, 21 pupil midwives were admitted annually for trainira. To provide one midwife for every 100 births in India, approximately 90.000 frould be required and, in order to maintain the necessary number, about 2,000 pupils should be trained every year. The occupational tables in the 1931 Census Report give the figure of 87,909 for women employed as midwives, nurses, compounders, vaccinators and masseuses, but only a fraction of this total are mnidiviyes Table XXV which has been compiled from replies to the questionnaire gives the numbers of midwives reported to be practising in eight province as only 6,193 No information was made available from the provinces which are omitted It is admitted that the totals in the Table are understatements and that no estimate of the crror can be made, but even so it is fairly obvious that there is a great shortage of trained midtrives in this country and that great efforts will be required before the supply will be adequate. One method of obtaining a larger number of candidates for training might be the award of stipends to midnifery pupils, as few Indian girls are prepared or are able to bear the cost involved These stipends might be given both by official and voluntary organisations Stipends are already provided in Madras Presidency by the Government for higher grades, by the Corporation of Madras and other local bodies for vernacular grades and by the Red Cross and Dufferin Fund for both grades The shortage of midwives for the maternity and child welfare services also led the Director of Public Health to rcqnest the authorities concerned to increase the number of training institutions for midwives with the result that the schools increased from four in 1931 to 44 in 1937. Another point which arises from the present dearth of trained women is the necessity for training the hereditary or indigenous dai The role of the dai is dealt with in a later section of the report.

·Tani.r. XXV, Sumber of practis uira's (tricluding junior midures and nurse daie but oming froinnil dala). 1 l'n Trovince Timortone! To! 1, *10 $ 12 Pap}18. Delhi Or1943 Bengal Bombay C. P. Madras .. Assam 3.933 1.017 1:1 Tois 30 Total British Indis Mysore State 391 14. The question whether domiciliary experience was inelund in the training course for midwives was answered in the negatire try the Punjab, Delhi, Bengal, Bombay and Sind and in the afirmatiic by the N-W F. 1'. C. P., Madras and Assam. Indras is the only mezir province which answers with an unqualified niirinntale, but no details of the arrangements hare been supplied in the classitant irra tramed under the Indian Red Cross Society auspices are given mainly domiciliary train ing and only a limitedl amount of hospital work In Bilar and Orissa, domiciliary experience is not speerfienlly mentioned in the syllabus of training,'' but is giren in some districts where the intern clinical material is inadequate. Domiciliary experience affords one method of remediumg a shortage of clinical material, but it has an even greater Talue as a means of inculcating self-reliance in the pupils and in teaching them how to adapt hospital methods to domiciliary practice wule they are under the strict supervi. sion of a trained and competent midwife Extern practice, however, demands additional staff both for teaching and for supervision and many existing schemes fall short in tjus respect Financial considerations are usually a greater stumbling block to the inauguration of domiciliary training than the social conditions winch are frequently offered as an excuse for failure to introduce the system 15 Refresher courses --Madras and Assau are the oniy two pravinces which so far have provided for refresher courses, Bengal, reply are not required under ing in the negatire, adds that refresher courses any rules at present." There can be no doubt of the desirability of hold. ing annual refresher courses for midwises, especially for those working in rural areas There a scheme for the training of pupil midwives is in of the dat is clealt with in a later section of the report + ·72 16 Examining Body.—The conduct of examinations and the issue of certificates is now carried out by Nursing Councils, State Medical Faculties, United Mission Boards, Medical Esamination Boards, Special Boards of Examiners appointed by provincial Governments or municipalitie, and by civi' surgcons Private organisations and institutions frequently issue their own certificates In some provinces, two examination boards are in existence, the United Mission Board and the official Examination Board. The Bengal Registration Act goes some way towards controlling the issue of irregular certificates by prohibiting the employment of unregistered midvives in any institution wholly or partially supported loy public funds, but private practice and employment by soluntary organisations and indivi. duals are still open to the unregistered, who under present circumstances suffer little disability It is more than desirable that the examinations for nurses, midwives and health visitors should be conducted by the provincial Nursing Councils This will facilitate uniformity of standards and reciprocity between the different provinces. 17 Nomenclature - Juch confusion is caused by the variations in nomenclature used for the different grades of midwives in different provinces Various factors have combined m the past to produce higher and lower grades in both the inedical and nursing professions, but the general ten lency now is to eliminate the latter In the field of midwifery, the ideal to be aimed at is undoubtedly one recognised standard for training schools and one midwifery diploma whether the medium of instruction be English or a vernacular In ven of the shortage of training facilities and of suitably educated candidates, abolition of the different grades of midwife may not at present he possible, but something shonla be done to clarify the position as much as possible by adopting a uniform and distinctive nomenclature for each grade eg,"midwife" and "assistant midwifer". The title dai' should not be used to describe a woman who has had an officially recognised training conrse in midwifery The term "midwife" has a fairly general application and has been used to describe a woman who has undergone " a training of 12 months' duration (6 months for trained nurses) including the personal delivery of 20 patients and the obstetric nursing of 20 to 50 patients" The course of training has recently been lengthened to 18 months in one or to provinces For the assistant, junior or vernacular midwife's certificate, whilst a lower educational qualification is accepted from candidates, the course is similar, hut is conducted in institutions where the standard of training and facilities for practical work are too low to warrant their recognition as schools for midwives Many hospitals train both grades concurrently, the juniors doing menial work and gaining experience by watching and assisting. This is a system which is to he deprecated The term "nurse-dai" is used only in the Punjab and denotes a trained dai who has passed an examination in nursing " The educational standard of the candidates is generally low and, although the training lasts two years and is usually giver in a hospital, the pupil only gets A mere smattering of nursing. In so far as the term suggests that the woman is a qualified nurse and midsife, it is a complete misnomer and

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·74 stubborn and more amenable to di-cipline. New methods of training, particularly in respect of increased emphasis on pre-natal or postnatal care, are essential. The principle of 'hands off' in the intranatal period cannot be overstressed The utal importance of supervision of the dars' practice and methods is a so brought ont unmistal ably in the replies The advantages of prenatal clinics, managed by a travelling woman doctor or a health vsitor, brave alıcally been pointed out and the sits of these trainol workers miglit be conveniently combed with supervision of the dais' day-to-day activities 19 l'acilities for training ---The majority of dais' training classes are licle in connection with welfare centres and instruction is given by llie health visitors working there Tahle XXVI summarises the position. Tadle XXVI Training facilities for dais. D:19 Trtin. zug School Welfare Centre Clueses. Hospital training No trail.net annually. 2 N-W T I. Pun ab I Bihar 1 89 42 0 3 15 20 31 459 6 200 (approx) 46 centre 47-6 at hospital 01140 CT Bombay Sind Aggam ::: 4 71 6 1 5 1 8 2 31 500 268 10 87 at ono school Thic chicf advantage of utilising the welfare centre is that the dais 1 ( to the centre, this difficulty is largely obviated, but the number of fully staffed welfare centres at the moment is insignificant Under the rules for the Victoria Memorial Scholarships certificate, at least 20 deliveries conchicted hy the dar must be personaily witnessed by the liealth visitor. I'niler the Punjab Central Midwives Board miles the number is only 10, much too small a number From her very upbringing and outlook, theoretical instruction is of little salne to the dai and the only way is to give her 61116cicnt practice in better methods so as to make these automatic Unless the per methods become second nature by repetition, they are likely to be forgotten as soon as the first emergency arises It is obvious that the number of rais which the health visitor can teach and prepare for examination is strictly limited A midwife working fulltime cannot properly conduct more than 100 deliveries per annum, that is, more or less ·76 a number syllicient for the 14truction of fise dans The lealth visitor line, of course, olier duties. This difficulty lia frit to the restabil:026nt of traininz schonls for dais, Table XXVI also gives figures for illit olarsiraming shouls, mul onc other exists in jner The dans l'in the 1980s ponts and thirr of training meludes rot only prontal ohtulikomeliary and stitutionat midwifery lut piratas mine in the top of child welfare ventre part from the staruulating and comfortline cont dels wohntens grups, llic Grafer facility of printed the newboy of port nal work and p3- Tall crperience, the labelsbeurt of 11.11n linus in economical in respect of teaching stafi 11:1299mmen u bolna be 1141 rachers and 11011r trening material can be prosulal The main dan berku nie the unwillingness of Vie averaxe das the late her bome was!! at the pion of the day, in the town which the will is situate 191 mer lleiros for trauliing pun The latter dificulti mught le Fitome hy probubuting unre. gistered practice ill the area in busl the webul warls and broug! the work of the pupul clars as an integral part of the local munnipal mid. wifery serices 20 ('ourse of Training - There is no uniformity in the course of train. ing prescribed for dars in the various provinces in the Punjab, training lasts one year and the day is required to conduct ten cases under supervi. sion. In Bombay, two standards exist, a primary and a sccondary The primary standard fixes no limit of time, but the dar must conduct eight cases and witness 20 Tlie secondary training is a residential course of six months given to tlais who show aptitude in the primary class In the lady Graham Dais Training School in Sind, the rules laid down for the Victoria Dlemorial Scholarships certificate are followed, namely, the conduct of 20 cases under supervision and a course of instruction lasting not less than one year. The training may be wholly domiciliary, wholly institutional or a combination of the two. The ideal to be aimed at is a course of one year, the conduct of a minimum of 20 cases undnr supervision, experience of domiciliary and institutional methods and attendance at a prenatal clinic. Erupliasis should be placed on the practical side of the work, the diagnosis of prenatal abnorma. lity and the principle of “hands off” during the confineinent One aspect of the work frequently neglected is the care of the mother and baby during the lying-in period, this deserves greater attention in future. 21 Certificates --Most of the provinces which ariange courses in conformity with the Victoria Memorial Scholarships rules use the Victoria Mcmorial Scholai ships certificate The Punjab Central Midwives Board issues i dar's certificate In the N-F Province, the certificate is issuci by the Inspector General of Cir) Hospitals and in the Central Pro- Sinces by the Public Health Department In United Pro. vinces, certificates are issued be the Indian Recl Cross Society and in Bombay the Lady Wilson Village Maternity Association previously gave certi. ficates It seems desirable to secure come uniformity of syllabus and certi. ficate throughout India The position of the dai is somewhat anomalous In most provinces the law ignores her, but at the same time voluntary organisations assisted from public funds, or even public departments themselves, are actively engaged in persuading her to undertake a course of training and in using the ·30 bribery to accomplish this encl. is the day has uo status cren after trala. ing, she naturally sees no advantage in submitting to contiol. The dai has been omitted from most of the Nurses, Visites and l[etu Visitors' Registration Acts, and sci in rural area, at Ic:at, slie cannot be replaced at in estat, although the fact remains that under certain municipal Acts she can be licenseil This position cannot be regirded as satisfactory. The role of the dar in the larger urban areas is cntircly (nierent, Here the probably could, and shonlei, be replaced. Many towns llave trained dars tar in excons of their necils and, as tranung courware lield cach year, new recruis regulats join the prote.ston. In the curbon areas where in numbers ot trained dars are available, pructice by untramend unegyleted women should be forcluliteci and thic funils nu. will allow atal for tiamng course su'll be dverled to strengthening the supervisory taff, so that the work of tne registered nais may be properly controlled and Nursery School Teachers. 22. The teacher holds the key position in every nursery school scheme. She willst be "part educator. part nurse and part sncial worker" therefore, needs not only special qualities of temperament and character, but special training All that neert de wc birre is that the present lack of training schools for these teachers 25 ad nerious lanılıcap to the develop ment of the movement A further point worth notmg is that the school staff must be larger than that for infant classes in elementary schools. Nursery schools arc nor being established in various parts of the country, and, in South India particularly, the nursery school movement has already gaineri considerable momentum. The training given to infant school teachers is not suitable for nursery school teachers and, if the new movement is not to be brought into disrepute by the employment of unsuitable staffs, special training classes for nursery school teachers will shortls lave to be arranged. It is understood that the Madras Provincial Branch of the Indian Red Cross Society hopes to start such a course in 1938, the services of a nursery school teacher trained in America having been secure os superintendent of the school Two training schools are stated to exist in Bombay Presidency Nursery Nurses. 23 This term denotes nurses engaged by individual families to look after the children under the general direction of their parents Institutions thich train Anglo-Indian girls for tlus purpose inciude the Kalimpops Home in the Darjeeling Ilills and the St. George's Home, Ketti, in the Nilgiris The latter institution has recently recruited to English women to organise and conduct a regular course. In connection with the Warne Baby Fold, Bareilly, a training course for Indian girls has been arranged.

·17 OIAPTER VII LEGISLATION Registration of births and deaths, 1. The Birthy Deatlis 20 latringes llentiration det of 1896 was the first legislatne measure of its kind and, with subsequent arendments, is the only one npplicable to the whole of Brush India This Act, lowerer, provides only for the l'oluntary registration of births and deaths. Fous prudences only have a far pirundled themselves with their own Births and Deaths Registration Acts, whilst others have trame rules for the pur. puse under the All-India Act of 1986 In a number of provinces, provision has been made in Municipalities and Local Buaris Acts, but, in most cases, these Acts do not puuke registration of births and deaths compulsory. Whilst, also, power is given in the provincial Acts tur the framing of byelaws in respect of registration of birthy and deaths, thus is not obligators The result is that, over large areas in most of the provinces, there is even today no compulsory ystem of registration. Thus defect has always been a great handicap to all public health departments in thcir efforts to improve the vaccination of infants and is even more so in respect of the development of maternity and child welfare work. Even in those limited areas where registration is compulsory, the provisions of the Acts are rarely enforced, so that generally speaking vital statistics are deplor. ably defectue. It is hoped that the facts and figures set out in Chapter III will have demonstrated the urgent need for more accurate figures and for more skilled classification and calculation of rates. These have made it obvious that the present machinery for the collection and tabulation of vital statistics requires to be completely overhauled, if not replaced Dependence on illiterate village officials for the collection of these important statistics permits of an initial error which is only too fre. quently intensified later by the machinery employed for the classification of events In Madras Presidency, for some years past, the final classification and consolidation of district and municipal figures is being carried out in the office of the Director of Public Ilealth, and this arrangement has resulted in considerable improvement The plan is one which may be commended to other Provincial Governments It may be added, lowever, that medical officers of health could themselves, even under present circumstances, do much to effeet improvement, whilst in the last resort a few judicious prosecutions for contravention of the law, where compulsory registration is in force, would bring to the notice of the people the neces. sity for compliance That this is so has been proved in Calcutta where prosecutions for failure to register have resnlted in much more accurate records pertaining to the area concerned Notification of Births 2. The term " notification of births" dlors not apparently carry the same significance in India as it does in England and Wales In England and Wales, under the Births and Deatlis Registration Acts, 1874-1926, a birtis must be registered by the official registrar vithin 42 days of its occurs reure. The registrar has no direct connection with the public health L2PIO ·78 department and his figures are transmitted to the Registrar General, not tu the medical officer of liealth. Under the Notification of Births Acts of 1907-15, births must be notified to the medical officer of health within 6 hours The purpose of the latest Notification of Births Act was to put tlie inedical oflicer of health in possession of information relating to the occurience of a birth at the earliest possible moment and at a time when measures to prevent departures from health sere most likely to be effecuse The time lag of 42 days between the birth and the registration meant that the child might be dead and buried before the health visitor even heard of the event and notification was instituted to remove this obstacle to effective maternity and child welfare work. Since, in India, 47 per cent of the deaths of children under one year of age occur within the first month of life, thc potential value of such legislation is obvious, provided the information can be utilised Several municipal Acts contain clauses under which the medical officer of health, if such an officer cxists, is the official Registrar of Births and Deaths and all births and deaths must be reported to lum. In the United Provinces, for example, some municipalities lave frained bye-laws under wluch all birtlıs and deaths must be reported to the medical ofiicer of health within three days of their occurrence. Other clauses enable local authorities to frame rules for the notification of births to the medical officer of health These measures, if suitably enforced, woulil go to improve present conditions and give the health authorities the early information which is so necessary in relation to maternity and chud welfare oik They must be made inore generally applicable, however, before they can be said to be of any gicat value. Here again, public health departments and medical officers of health might play a much more active part than they have in the past. Registration and control of Nurses, Midwives and Health Visitors. 3 Considerable legislative activity in connection with the registration of nurses, midwives and health visitors has occurred during recent years, but existing Acts are without exception provincial in nature. These include : () the Punjab Nurses Registration Act, 1932, (ru) the United Provinces Nurses, Midwives, Assistant Midwives and Health Visitors Registration Act, 1931, (711) the Bihar and Orissa Nurses Registration Act, 1935, (1v) the Bengal Nurses Act, 1931, (v) the Central Provinces Nurses Registration Act, 1936, (24) the Madras Nurses and Jidwives Act, 1926 (as amended by Act VII of 1931); and (li) the Bombay Nurses, Midwives and Health Visitors Act, 1935. Comment has already been made on the absence of provision for (a) the registration of dais and (b) the prohibition of unregistered practice ander many of these Acts. Defects in these respects are to some extent rompensated by clauses in Municipal and Local Self-Government Acts ·70 which enable local authorities to promulgate rulre los llin registration of licensing of dais and for the fire'sibution of unregistered pornclicc, bu! estension in tliep diretions is urgently nerasity Moreover, attention must again be drawn to the desirability of milising more frequently the pomers already pomecaci Tlie l'unjati and Bihar Icha contain prohibi. tire clause which can be applied nt the discretion of tlır local authority, but the local Govement has also power to apply these to nny arra chere the local autlicrity fnile ulin n rezonabile time to inkr appropriate inca. sures to promote safe multiſery It would make for greater progress if these powers were posnes-ed In other provincial Governments nnd if the powers already in critenee were more cotnmonly afipline If the supervision of private mulwires is to be anything more than nominal, their work must be supervised in some way The Bengal Act, for instance gives the provincial Gorernment pouer to make rules for the regulation supervision and restriction within limits of the practice of nurses, midwives 11 health visitors and to lay down the powers and duties of Supervisory Boards to be formed in every district Theso Boards hare not yet been formell and meantime this duty ha4 been delegated to the civil surgeon In regard to some of the other provincial Acts, the provincial Governments have the power to frame rulen for supervision of these tromen. but the method of carrying out this supervision has not been included in the Acts In order that the local supervising authority, who might be the local civil surgeon or the medical officer of health, should be aware of the numbers of midwives in domiciliary practice in their areas, it has been suggested that a system of licensing by the municipality or local board should be introduced. Qualifications and appointment of maternity and child welfare workers. 4. Although a number of Municipal and Local Self-Government Acts give powers to formulate rules regarding the terms of appointment and qualifications of maternity and child welfare staffs, very advantage has so far been taken of those powers Earlier sections of the report have already stressed the importance of obtaining the services of adequately trained and experienced medical women, health visitors and midwives It is to be hoped that, in future, less reluctance will be shown in the use of the powers already available in respect of these appointments Supervision of Private Maternity Homes and Hospitals. 5. So far as these institutions are concerned, no legislation exists in any province in India for their registration and inspection There can be no doubt that these institutions which are in the hands of private individuals or organisations should be controlled in some measure. It is probable that existing Municipal and Local Boards Arts give no poter either of inspection or supervision of these institutions, so that legislative amendments to existing Acts are necessary These amendments should provide for the liccusing of such institutions by the municipal and local boards concerned and for their supervision and control by means of guitable byelars, ·80 Powers to inciu expenditure on maternity and child welfare activities. 6. In India, certain municipal and local boards Acts give these local bodies power to incur expenditure on maternity and child welfare work, but the provisions are usually permissive This power ought to find a place in the public ficalth legislation of every province In exercising the existing powers, many municipal and local bodies find it difficult to provide sufficient funds from their ordinary revenues for this public health activity This difficulty is best met by the provincial Governments making grants-in-aid on condition that certain standards are maintained. In this way, maternity and child welfare vorh in the provinces rould be susceptible of rapid development and the standard would be maintained becanse local schemes would automatically be under the supervision and control of the official public health departments, which should have a woman medical officer of the status of an Assistant Director of Public liealth Several provincial Governments now provide this stimulus of grants-in-aid, but if these grants are to be expended to the best advantage, supervisory control of the kind suggested is essential. Factory Act and Maternity Benefit Acts 7. The Factory Act of 1934 regulates the hours of work for women and the employment of espectant and nursing mothers It also encourages the establishment of creches, although their provision has not been made compulsory except in Bombay under the provincial Act. Maternity Benefit Acts are now in force in several provinces and it is to be loped that other provinces, where industries liave developed, will shortly provide themselves with similar legislative measures For the proper administration of maternity benefit, some method of certification of pregnancy seems desirable, but at the moment welfare schemes under which this could be effectively done are insufficient in numbers 8 The replies to the questionnaire would indicate that the first essential is the proper application of legislation and regulations already in force Legislative measures which cannot be made effective are almost worse than useless ·81 OMAPTER VIII SUMMARY OF RECOMMENDATIONS, Administration, Organisation and Supervision 1. If maternity nud chuld welfare worl. is to be preporly organised in a province, the first requirement is to have a wegan mcilienl oficer of this status of Assistant Director of l'ublic lealth poussins either a pulslır health, qualification or preferably a diploma in maternity and clue wclinre Tork and also conderable esperience in the branel of public healtli voie. (l'ages 15, 21, 22, 63 ) 2 The experimental stage in the management of health schools or the training of health visitors in India having now been priscil, Coverh. Inents should take over the administration of health schools (Parc 63.) 3 For the larger and better organised municipal and local bodies schemes a woman doctor's services are essential (Page 63 ) 4 The Fork of a health school requires the whole-time services of Superintendent and in no case should the Superintendent of a provincial school be expected in addition to undertake tours of inspection of child weifare centres. (Pages 19, 61 ) 5 In order to play a useful part. voluntary workers must have knowledge of welfare work and classes for voluntary workers might be conducted in connection with health schools or planned by other organisations engaged in voluntary work. (Pages 58, 59.) 6. In order that the various provincial Nursing Councils should keep in close touch with each other, eg, in the interest of uniformity in the standards of training, the constitution of a central body scems desirable (Pages 21, 64.) 7. Government grants-in-aid should be provided in order to stimulate dcvelopment (Pages 22, 80 ) Statistics. 11 6 Directors of Public IIealth should consider the possibility of improying registratiop of still-births (Page 24 ) 9. The attention of Directors of Public Ilealth is recalled to the instructions issued in 1937 in respect of the classification of all deaths of " mothers occurring within one month of childbirth as maternal mortality" deaths In addition, Directors of Public Halth are remindeu that maternal mortality rates should be calculated on the combined fiquid for live and still-births, (Pages 23, 25 ) 10. The facts show that the principal causes of maternal mortality and morbidity rary markedly in different areas in India and that there is roon for further researches into these questions as also into the causes of infantile mortality. (Page 32.)

·82 Maternity Services. 11 Co-ordination between the medical and public health departments is perlaps more vital in the field of maternity and child welfare than in any other sphere of medical and public health work. (Page 39 ) 12 For adequate prenatal care the first essential is the sound training of inedical students and midwives This training should include instruction in the methods of edncating the expectant mother. For this pur. posc all teaching liospitals sliould have prenatal clinics. (Pages 40, 41.) 13. Two types of prenatal clinic are required: (a) consultatire, and (b) subsidiary , some form of duplicate records is also required to coordinate the work of the two and to facilitate transference of the patient from one clinic to the other (Pages 41, 42) 14. The practice of accommodatiog maternity cases in general wards is to be deprecated and a large number of maternity beds in separate maternity wards should be provided. (Page 45 ) 15 In order to ensure a reasonable standard of equipment, staff and safety for the mothers, maternity homes organised by voluntary or private effort should be supervised and inspected It is suggested that suitable control could be exercised by a system of licensing and by inspection conducted by governmental medical and public health departments (Page 45.) 16 Admissions to maternity homes should be confined to booked' cases which are expected to be normal. (Page 45.) 17. Although it is desirable to have one midwife for erery three beds, one to five may be regarded as a reasonable provision. (Page 46.) 18 Considerable increase in the numbers of domiciliary midwives is required (Page 48 ) 19. Additional female medical aid should be made more readily avail. able in all domiciliary midwifery schemes ges 48, 49.) 20. For the supervision of domiciliary midwifery the solution seems to he in the appointment of medical Tomen or health visitors with sound obstetrical experience (Page 49.) 21. Attention is drawn to the advantage of attaching midwives to a maternity hospital, a maternity home or a welfare centre. (Page 49.) 22. In all domiciliary midwifery schemes, families who are able to pay should be charged fees for the services of a midwife. (Page 50 ) 23. The value of postnatal examinations should be stressed in courses of instruction in teachung hospitals and in health schools. (Page 50.) Infant and Child Welfare Services. 24. As child welfare work in the real sense of the term cannot be properly carried out by midwives and nurses, the employment of a traincit Sealth visitor in each child welfare centre is a primary necessity. (Page 55.)

·83 25. Since carly departure from hicsfth are not always capable of detection even by a trained healthi usilor, care wellnre contre ryurcs tu base a visiting doctor. (l'age 37.) 26. Great care must be taken lest the sellate word, who is primarily pretentive in nature, develoju mininly a curatlle chiaracter Tlic centre should not usurp the function ut a livspital or dispensary, but, if sound development of welfare work is to take place, incilities ior tlic relics of sullerig must be mude available Is dans lur iudin a wide extension of rural dispensaries and rural merla al ultheis (l'uke o ) 27. In order to improve the health of clder children inore attention shuuld be paid to those beseen the nges of one to live ll'age 31.) 28. The employment of female bbous being a well-established practice in many industrial concerns an India and since no ligul obligation exists except in Bombay Presidency the compulsory provision of creches for the children of these women workers the lime sceins ripe for such provision being made compulsory by legislative cnactments While the routine work may be entrusted to an untrained ayah, the direction and supervision of the subordinate statt should be in the lands of an experienced and qualified woman. (l'age 61 ) 29. Official responsibility for institutions for orphans and illegitimate children, etc., should be shared by provincial medical and public health departments. (Page 61.) Training of Staff. 30. If maternity and child welfare services are to be properly organised and integrated into official departments, special training for medical officers in charge is necessary. (Page 62 ) 31. In order to attract medical women to the field of preventive medicine, and especially to that part dealing with maternity and child welfare work, the conditions of service should be improved. (Page 62.) 32. For the post of Superintendent of a health school, an experienced and qualified health visitor is most suitable (Page 61.) 33. It is desirable that the regulation of examinations and the issue of certificates to nurses, midwives and health visitors should be conducted by the provincial Nursing Councils In the same connection, attention is invited to the English Ministry of Health methods and to tlie desirability of forming some central body whose duty it will be to maintain uniform standards and to facilitate the reciprocal recognition of certi. ficates by different provinces (Pages 64, 69) 34. Some experience of general nursing is a great asset to the health visitor and the authorities of health schools should consider the question of modifying the curriculuni for health visitors' training in such a way as (Page 66.) to include experience of general nursing 35, In order to provide suitable practical training, every health school should have attached to it a welfare centre. (l'age 67.)

·84 21eas. 36. Arrangements should be made for a period of residence and practical training in a rural area as a definite part of the curriculum in every health school (Page 67.) 37. Every health school should organise annual refresher courses and lealth visitors, whether employed by Government or by voluntary organisations, who attend these courses, should be regarded as on daty und travelling allowance to and from the course should be paid to thein. (Page 67.) 38 No hospital with less than 100 midwifery cases per annum should be accepted as suitable for training purposes (Page 69.) 39. In order to obtain a larger number of candidates for training as midwives and health visitors and, since it is difficult to obtain Indian girls prepared to bear the cost inrolved, a system of awarding stipends should be more generally adopted both by official and voluntary organisatrons (Page 70 ) 10 In the training course for midwives, domiciliary expericace should be included, especially for those women who are to work in rural (Page 71 ) 41 As in the case of health schools, training institutions for midwives should conduct annual refresher courses, especially for those midwives who are working in rural areas (Page 71 ) 42 Owing to the confusion which is caused by the variations in nomenclature used for the different grades of midwife in different provinces, it is suggested that only two terms, viz, "midwife" and "assistant midwife" sbould be employed in future (Page 72.) 43. Under present circumstances many hospitals train both midwives and assistant midwives concurrently This is a system which is to be deprecated (Page 72 44. Whilst it is agreed that the training and employment of dars is essential to meet existing conditions, this should be regarded only as a temporary expedient Various suggestions have been made for the iniprovement of the courses of training reguired for these women and for their supervision and employment (Pages 73–76) 45 In the larger torns where adequate numbers of trained midwives are available, the licensing and recognition of dais should be discontinued (Page 76 ) Legislation. 46. Not only is improved registration of birtlis necessary in those areas which have their own Births and Deaths Registration Acts, but every province should adopt a compulsory system of birtlis and deaths registration In addition, more stringent enforcement of existing regulations should be practised, if necessary, by prosecution in selected cases 47 The urgent need for more accurate figures and for more skilled Classification and calculation of rates has been pointed out. These questions should be given every consideration by provincial public health departments. (Page 77.) (Page 77.)

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