NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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4. TRAINING AND EXAMINATION.
In practically all the nurses' training schools in British India the three
years' period of training for nurses has been adopted and most hospitals
work very closely on the syllabus laid down by the General Nursing
Council of England and Wales. This is recognised as being a very com-
prehensive one and is desirable for provinces having in view reciprocal
registration, for their nurses, with the General Nursing Council. Where
this syllabus is adopted there are two examinations. The Preliminary one
can be taken at any time after the completion of one year's training, but
is usually taken at the end of 18 months and the Final one on completion
of three years' training.
The examinations are conducted by
-
(a) The Provincial Government Examination Board,
(b) The Examination Board of the Provincial Nursing and Midwives
Council, and
(c) The Christian Medical Association Examination Boards.
The old system by which certificates were granted by the hospitals is
now obsolete and exists only in a very few places.
2. The period of training in Midwifery for general-trained nurses is
s i x m o n t h s a n d f o r w o m e n w h o h a v e n o t u n d e r g o n e n u r s i n g t r a i n i n g 1 8
months in Madras and Bengal and 12 months in other provinces.
In the Madras Presidency midwifery is a compulsory subject for all
nurses trained in hospitals controlled by Government and in training
schools under the control of the Christian Medical Association of Southern
India.
Since the Central Midwives Board, London, has recently increased
the period of training for midwives to one year for trained nurses and two
years for women without general nursing certificate and introduced a
register of applicants for training, to be approved by the Board, and two
examinations during training it is impossible for any province in India to
get reciprocal registration in midwifery wth the Central Midwives Board
London, until very drastic changes are made in the training provided in
this country.
In general it can be stated that while great improvements have been
made during the past few years in the proficiency attained by Indian
nurses, the syllabus and period of training cannot be considered as settled.
The conditions for reciprocity with the General Nursing Council demand
a standard both of preliminary education and of training which is not
easily attained under existing Indian conditions. Some authorities
consider that the demands for a knowledge of the basic medical services
have gone too far, while others realising the difficulty of combining
classes for theoretical teaching with practical nursing have advocated the
establishment of pre-nursing classes, which can be taken before a proba-
tioner joins her hospital; this is a proposal worthy of serious consideration.
18 2
5. CONDITIONS FOR APPROVED TRAINING INSTITUTIONS FOR.
NURSES AND MIDWIVES IN THE BOMBAY PRESIDENCY.
The rules of the Bombay Nurses, Midwives and Health Visitors Council
on this subject are so comprehensive and precise that no apology is
needed for giving a brief summary of them here.
General conditions.—The general conditions prescribed are that any
training institution in order to be approved by the Council should be
housed in a building suitable for a hospital with sufficient accommodation
and equipment for theoretical and practical training; be under the
management of a regularly constituted governing body with such financial
resources as to make due provision for its continued maintenance in an
efficient manner; agree to allow inspection to be carried out by persons
appointed by the Council; have all probationers under training resident
either on the premises of, or appurtenant to, the institution or any other
place approved by the Council; have at least one Resident Medical
Officer; maintain a ratio of one nurse to five patients; arrange for lectures
being given to probationers by qualified registered medical practitioners of
at least 3 years' standing and having sufficient practising experience to
teach the various subjects in which they are to lecture; and agree to
observe all the conditions prescribed or which may be prescribed by the
Council as to the engagement and training of probationers from time to
time.
Special conditions. —No institution, is approved by the Council as a
complete Training School for Nurses unless the trained nursing staff is
sufficient in number to give the probationers efficient training; it is in
charge of a Matron who is a registered nurse and midwife capable of
imparting instruction to probationers; the hospital provides experience in
the four main services—Medical, Surgical, Gynaecological and Children's
diseases; the total number of beds in these services may not be less than
75 and the daily average occupied not less than 60; where the work is
mainly surgical about one-third of the beds must be devoted to medical
work; where the work is mainly medical, about one-third of the beds
must be devoted to surgical work; and there must be at least 10 beds
each for Gynaecological and Children's diseases.
No institution is approved by the Council as a complete Training
School for Midwives unless the trained nursing staff is sufficient in number
to give the probationers efficient training; it has not less than 500
midwifery cases a year; it is in charge of a fully qualified registered
nurse and midwife capable of imparting instruction to probationers;
the minimum number of beds is 30 divided into ( a) antenatal and waiting,
( b ) lying-in-beds, ( c ) labour beds and ( d ) septic beds; it provides
experience in midwifery operations in caeserian section, forceps, internal
version, craniotomy and induction of labour; and it has a properly
organised ante-natal clinic.
183
6. SALARIES OF NURSES IN VARIOUS PROVINCES.
There is no uniform standard of salaries and allowances throughout
India at present. Each provincial Government has its own scale; to
some extent the variation is due to the different cost of living but not com-
pletely so. The salaries paid in the south are low as compared with
Delhi, Bengal and the Central Provinces, and this leads to a constant
migration of many of the best nurses.
It needs to be remembered that the work of a nurse is particularly
arduous, requires several years of study, entails both day and night duty
and the non-enjoyment of holidays as in other services. The stipends
of pupil nurses could in some cases be lowered but the fully qualified
nurses who are expected to take responsibilities in full should be well
paid.
184
CHAPTER VII.
Maternity.
A general review of the maternity service in India reveals the vast
magnitude of the problem. It is doubtful if it is generally realised that
even now the great majority of confinements in India are conducted by
indigenous dais or midwives. For ages the dai had been the genius
presiding over childbirth and her sway until recent years was undisputed.
The profession is hereditary; it passes from mother to daughter.
These women are, generally speaking, low in the social scale, e.g.,
in Madras and Bombay they belong to the "barber" caste while
in North India Mohammedan women of the lower classes practise
the art. They have no scientific knowledge of the mechanism of labour
or of the elementary principles asepsis. In any difficulty their only
remedy is force, with what disastrous consequences may be imagined.
Under these conditions is it any wonder the maternal deaths in India
arising out of pregnancy in. 1936 numbered over 160,000?
2. The tragedy is that probably 80 per cent. of those deaths were
preventable. During the recent inquiry into maternal mortality in
Calcutta, Dr. Neal laid down lower standards and, as judged by them,
the proportion of preventable cases in her series of 430 cases was as high
as 96·3 per cent.
3. It must also be stressed that along with this wastage of life a very
serious wastage of health takes place. In the annual report of the
Public Health Commissioner with the Government of India for 1935 it
was stated that "the percentage of women disabled as a result of preg-
nancy and labour may perhaps be taken as not less than 30 per cent. and
in a country where nearly ten million births are registered annually, the
percentage of women temporarily or permanently incapacitated must be
very large". On this estimate about 3 million women are disabled tem-
porarily or permanently every year. To the physical disabilities must also
be added the loss of happiness in the home life which must result from
this heavy mortality and morbidity.
4.
There is a great difference between the conditions existing in
Western countries and in India and it is only in large cities like Madras,
Bombay, Delhi and Calcutta that serious efforts have been made to
establish a connected chain of agencies concerned in maternal and infant
welfare. In small towns and in a large proportion of villages, the old
order still prevails.
5. Owing to lack of education in the public it is also clear the
maximum benefit from the services in existence is not derived. Further
the best midwifery schemes devised will be ineffective until there is a
general improvement in the general health and resistance of the people.
Little improvement in the mortality rate can be hoped for until the public
are better educated, the economic conditions of the people are improved
and the untrained and meddlesome indigenous dai is replaced by the
This Chapter is based on notes supplied by Dr. C. L. Houlton, Chief Medical Officer,
Women's Medical Service.
186
Fund, there is a domiciliary service under the United Provinces Branch of
the Indian Red Cross Society. A medical woman is in charge of the
Maternity Section and works under the control of the Director of Public
Health. The maternity centres are under the management of local Red.
Cross Committees, but are inspected regularly by the Director of the
Maternity Section. Indigeneous dais are trained at these Centres and do
most of the maternity work in the Province. This work is supported patly
by a grant from the Local Government and partly by the Victoria Memorial
Scholarship Fund and the Indian Red Cross Society. An act for the
registration of health visitors, nurses and midwives has recently been
passed.
10. Bengal has no organised maternity and child welfare scheme in
connection with the Public Health Department. The Local Government
assists voluntary bodies by giving (a ) grants for the training of dais and
( b ) grants for propaganda. In 1934 the Bengal Nurses' Act was passed
for the registration of health visitors and midwives, but this Act also
ignores the dais and has no penal clauses for malpractice.
Maternity Service. —Institutional. A certain number of beds are pro-
vided in the large mofussil hospitals and Calcutta possesses four special
women's hospitals, but the number of available beds is far below the
needs of the population. Domiciliary. The Calcutta Corporation main-
tains 7 maternity and child welfare clinics and 4 maternity homes.
The Provincial Branch of the Indian Red Cross Society also manages
a number of welfare centres. The vast majority of Bengal women are,
however, in the hands of untrained dais. The rural areas are almost
entirely uncatered for. The number of deaths due to child bearing in
Calcutta during 1935 was 322. The accuracy of this figure is doubtful.
Dr. Neal's enquiry between June 1936 and 1937 showed that during that
period there were 701 deaths directly due to child bearing. Similarly the
recorded figure of maternal deaths of 16,581 in 1936 in the whole Bengal
is not likely to be an underestimate. Untrained midwives, dirty sur
-
roundings, overcrowding, poor diet, ignorance and superstition are all
responsible for such high mortality.
11. Punjab.—There is no separate Maternity Service in connection
with the Public Health Department but the Punjab Government gives
grants-in-aid for approved schemes for maternal welfare work and finances
and maintains a Health School. The Superintendent of this School is
also Inspectress of the Health Centres. In this Province there is a
Registration Act for nurses, midwives and dais, but no penal clauses for
malpractice are attached. The great majority of confinements are in the
hands of dais, most of whom are untrained.
12. Delhi Province. —Institutional facilities are good in the city of
Delhi as there are three very good hospitals for women and the women
have become "hospital minded" as regards childbirth. The admissions
to hospital have risen from 593 cases in 1922 to 3,241 cases in 1936.
Efficient antenatal clinics are held in connection with all 3 hospitals.
In 1936 there were 257 trained dais practising in urban areas and they
187
were responsible for 3,494 cases. There is no control or supervision of
the dais after training and they are invariably found to revert sooner or
later to their old superstitions and time-worn customs.
Medical women are in charge of the Welfare centres in both Old and
New Delhi. The rural areas have practically no maternity service.
13. In the Central Provinces and Berar there is a Government Health
School in charge of a medical woman, who is also Directress of the
Maternity and Child Welfare Centres which are managed by the Indian
Red Cross Society. The institutional midwifery service is very meagr
e e v e n i n t h e l a r g e t o w n s , b u t t h e r e a r e a f e w f a i r l y g o o d h o s p i t a l s f o r
women under the Countess of Dufferin's Fund.
14.
In the North-West Frontier Province there are two centres for the
training of dais-one at Peshawar and the other at Dera Ismail Khan
- b o t h a r e u n d e r G o v e r n m e n t c o n t r o l .
15.
In Sind the midwifery service is partly institutional and partly
domiciliary. Karachi has a fairly large Dufferin hospital and several
maternity homes, but in the whole of Sind there are only 539 beds
available.
Health Centres have been opened in Karachi and Sukkur for the
training of dais, but the work is in its infancy. There is no registration
of nurses in this Province and in both urban and rural areas untrained
dais practise their hereditary craft uncontrolled and unsupervised.
16.
In Bihar, Baluchistan, Central India, Orissa, and Assam, mater
¬ n i t y s e r v i c e i s a l m o s t n o n - e x i s t e n t a n d t h e t a c k l i n g o f t h e p r o b l e m h a s
barely been started.
17.
One point which has come out clearly from the present review of
maternity welfare work is the lack of co-ordination between the work of
prevention and that of cure. In some cases there appears to be actual
antagonism. In those provinces where the welfare work is under the
control of the Director of Public Health it has been removed almost
entirely from the sphere of influence of the medical officers in charge of
Dufferin and other special hospitals for women. It would seem to be a
rational policy if the work were co-ordinated in each province by placing
it under a medical woman who would be inspecting officer of the welfare
centres and who would be also responsible for the supervision and
inspection of the hospitals for women. In this way economies would be
effected and efficiency would be increased as capable medical women in
the various hospitals could be given the responsibility for welfare schemes
which are now often in the charge of poorly trained sub-assistant surgeons
and health visitors.
2. FACILITIES FOR TRAINING.
1.
General Practitioners. —It is true that up to the present the general
practitioners of India have been responsible for very little midwifery and
therefore cannot be blamed for the high maternal mortality rate, but if
188
this state of affairs is changed in the future and more midwifery is under-
taken by the general practitioner, the results may be serious, as the
average male practitioner's knowledge of midwifery is rather limited.
This is due to the fact that apart from the colleges and two or three
medical schools, the training of medical students in obstetrics is poor,
owing to the great difficulty that is experienced in obtaining a sufficient
number of confinement cases in the teaching hospitals for the satisfactory
training of male students. Also post-graduate course for general practi-
tioners are rare, whilst facilities for specialist courses in obstetrics exist
only in the cities of Madras, Calcutta and Bombay.
Apart from the Medical School for Women at Ludhiana there are no
facilities for the training of medical students in domiciliary midwifery.
2.
Midwives. —The schools for the training of midwives are far below
the needs of the country. The standard of training in many of the schools
i s o f a l o w o r d e r a s ma n y o f t h e i n s t i t u t i o n s a r e b a d l y s t a f f e d a n d p o o r l y
equipped. Madras and Bombay Presidencies are the most advanced in
the training of nurses and midwives.
Legislation regulating the training and registration of midwives has
been passed in the Provinces of Madras, Bombay, Punjab, Delhi, United
Provinces, Bengal, Bihar and Orissa, and the Central Provinces, but the
working of the Acts, apart from those in Madras and Bombay, is still
in the initial stages and comparatively little benefit has yet resulted from
this legislation.
There seems little hope of getting rid of the dai in this country for
.many years to come and unless she is controlled by proper legislation little
progress in the improvement of the midwifery service of India can be
expected.
3. RESEARCH ON MATERNAL MORTALITY AND MORBIDITY.
Considerable knowledge of the diseases of childbirth is possessed by
individuals but very little active research has been carried out in this field
and very few articles on this subject have been published. Reliable
statistical data on the incidence and causes of maternal deaths is not
available in the reports of the Directors of Public Health. In view of
this and since many women's hospitals keep excellent records the Council
of the Women's Medical Association in India decided to collect and
publish these records with a view to making the material more widely
available and stimulating research. The figures from various women's
hospitals throughout India for 1935-36 have been classified by Dr. M. I.
Neal and published in the August issues of the Journal of the Association
of Medical Women in India in 1936 and 1937.
The first reasonably complete study of Maternal Mortality was made
by Dr. A. L. Mudalyiar in 1931-32 at the suggestion of the Surgeon
General, Madras. The survey was financed by the Corporation of Madras.
Contributed by Dr. Jean M. Orkney, W. M. S.
189
Dr. Mudalyiar's "Report on an investigation into the causes of Maternal
Mortality in Madras" was published in 1932.
2. At the Annual Conference of Research Workers in India held in
1935 proposals for the establishment of an Advisory Committee on
Maternal Mortality and Morbidity were adopted. The first statistical
survey under the auspices of the Indian Research Fund Association was
carried out in Calcutta by Dr. M. I. Neal during 1936-37 and the report
will shortly be ready for publication. Similar surveys are now in progress
in Bombay under the direction of Dr.J. Jhirad and in a rural area in
Bihar. These surveys are expected not only to provide data for further
research on the more important specific causes of deaths, but also, data
from which conclusions can be drawn and recommendations made for the
improvement and expansion of existing midwifery services.
3. Anaemias associated with childbearing are second only to sepsis
as a cause of maternal mortality and morbidity and it is not surprising
that the major part of other researches in this field during the past 3 years
has been concerned with the types, causes and treatment of anaemias of
pregnancy.
4 . T h e f o l l o w i n g a r e t h e m o r e r e c e n t l y p u b l i s h e d p a p e r s : —
1. M. I. Balfour . . .
1933 Maternity Conditions and Anaemias
in the Assam Tea Gardens. Jl.
Assoc. Med. Women in India
, Vol. 21. pp. 28/38.
2. Lucy Wills . . .
1934
Studies in Pernicious Anaemias of
Pregnancy—Part VT. Indian Jl.
of Med. Research—Vol. 21, p. 669.
3. L. E. Napier . . .
1935 Enquiry into anaemia of women.
(A short note published in the
Report of the S. A. B. for the year
1st April to 31st December 1935,.
p. 109).
5. The need for further statistical surveys, for research on the bacterio
-logy of puerperal sepsis, on taxaemias of pregnancy and for further work
on anaemia is unquestioned. Women's Hospitals provide abundant
material but the time of the medical staffs of these hospitals is too fully
taken up with routine duties to permit the work to be undertaken. There
is the further difficulty that opportunities for medical women to get an
insight into research methods and to develop a capacity for scientific
research are almost non-existent. The Council of the Association of
Medical Women in India, deeply conscious of their responsibilities in the
matter, have under consideration a proposal to establish a post-graduate
school and research department possibly in connection with the Dufferin
Hospital in Calcutta. The inauguration of this scheme would be a
tremendous stimulus to the scientific study of diseases associated with
child bearing and would do much to remove the relative neglect of
research on problems so vitally connected with the building up of a fitter
n a t i o n .
190
6. Other recently published papers are:—
4. K. N. Das and P. C. Maha
-lanobis . . .
1934 Maternity Statistics from Calcutta,
1850-1901. Sankhya: The Indian
Jl. of Statistics, Vol. I, p. 215.
5. C. Mehta . . .
1937 External version for Breech Presenta
-tions. Br. Med. Jl., Vol. I, p. 706.
4. MATERNITY HOMES OF BOMBAY.
The following note on the Maternity Homes of Bombay, which more
than any other province has adopted an institutional policy, has been
communicated by Dr. Sir Mangaldas V. Mehta, O.B.E., F.R.C.P.(I.),
F.C.P.S., F.C.O.G., Principal Medical Officer, The Nowrosjee Wadia
Maternity Hospital, Bombay.
"The position today is that in the City of Bombay there are 14 public
and free institutions with 486 beds, and 8 private semi-charity institutions
with 155 beds, while paying nursing homes are 61 in number with 667
beds. The total number of maternity institutions both public, private
charity with free beds, and nursing homes come to 83 with 1,308 beds.
The total number of births registered during the year 1937 was 37,795;
out of these 27,758 were delivered in maternity institutions in the City
during 1937, i.e., a percentage of 73.4 women confining in maternity
institutions out of the total birth rate of the City. I attach herewith
a comparative statement since 1929 to 1937 of the total birth rate, the
number of confinements in institutions and the percentage in Bombay
City.
"It will thus be clearly seen to what extent institutional maternity
service is organised and how it has reduced both infant and maternal
mortality in Bombay City.
"The dais are practically wiped out in the City, but their great strong
- h o l d i s i n t h e r u r a l a r e a s . T h e r e a r e s e v e r a l o t h e r f a c t o r s i n f a v o u r o f
institutional maternity service in the City of Bombay, viz., one tenement
rooms, poverty, unhealthy surroundings, breaking up of joint family
system chiefly amongst the middle class Hindus and last but not least
women having more faith in hospital treatment particularly the antenatal
care of expectant mothers in the antenatal clinics attached practically to
every maternity hospital or home.
"The Bombay Nursing Council has in this connection given a great
impetus to the establishment of more maternity institutions in the urban
and rural areas and insisted upon every maternity institution seeking
recognition to have antenatal clinics attached to it.
"As regards the rural areas, as long as there is no adequate supply
of trained midwives, inadequate funds, apathy of the District Munici
- p a l i t i e s a n d D i s t r i c t L o c a l B o a r d s , g r e a t i l l i t e r a c y a m o n g s t p e o p l e w i t h
their time-worn prejudices and superstitions and last but not least the
indigenous dais having a strong influence on the ignorant women, I am