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natal work for expectant mothers was carried out in the clinics. This was natural
because the service was free, it was good, it was done in well-designed and equipped
premises, and with a staff who could give the proper time and devotion to it. On
the whole the results were excellent. There was little inducement for practitioners
to do the work as there was no pay in it for them. Only a minority who looked
after their own booked patients provided ante-natal care for them.
The Practitioners Come In
When the new health scheme came into force in 1948 it made provision for
practitioners who did ante-natal and confinement work to be paid for it. Since
then the whole situation has changed. Now, of course, there is greater inducement
for practitioners to attract the mothers to their care for the fees they bring. Hence
the ante-natal work of the local health authority clinics has tended to become less
and less. Trained midwives have always considered midwifery to be an independent
profession. Before 1936, midwives received private fees from their
patients, so they had to arrange to get proper ante-natal care for them. This was
important to ensure all would go well at the confinement. After 1936 when the
midwives came on to the staffs of the local authorities and were paid salaries, it was
still important for their patients to receive ante-natal care at the clinics, but the
incentive for midwives to book patients for themselves rather than work with
general practitioners as maternity nurses was less than formerly.
Come to the Hospital
Some hospitals have always run obstetric departments. When the service
of obstetricians to hospitals was free, they were not so keen to spend all their time
inside the confines of the hospital, but relied a good deal on the prestige obtained
from the hospital appointment to attract fee-paying patients to themselves outside.
But when the service became nationalised in 1948 and hospitals began to employ
full-time or nearly full-time obstetricians it became a matter of pride and prestige
for them to attract to the hospitals as many patients as possible, because their
standing and rank had a great deal to do with the number of doctors and beds they
were in charge of. There thus grew up a sort of tripartite war. On the one side
there was the traditional pull of the midwives booking their own cases and obtaining
ante-natal care for their patients in the local authority clinics; second there was the
new incentive for general practitioners to book patients because of the attraction
of the fees; and third there was the pull of the obstetric units of hospitals wanting
to book patients in order to extend their departments and build their hospital
empires. And to this day this division of the services still obtains. Or course,
one important attraction of the hospitals service is that patients admitted there get
not only their medical services free but also their board and lodging, and this is
quite a consideration nowadays with the high cost of living. If a woman can save a
fortnight's board and lodging and obtain her rest and recuperation in pleasant
surroundings and without detriment to her home arrangements, she is well favoured.
Liaison
Now with a view to trying to straighten things out a bit, we had a meeting a
little while ago at the West Middlesex Hospital, which was attended by practitioners,
hospital consultants, and local authority medical officers. We tried to
thrash out what the basic pinciples should be. Eventually, after two long discussions,
we arrived at the following principles. As soon as a woman becomes
pregnant she should seek the advice of her family doctor who should advise her on
the best course of action in her particular case. The alternatives for her are to
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