Attendants from the hospital, usually two undergraduate medical students, go to her home, sometimes accompanied by a nurse. Reports are sent to the physician at the hospital, on printed forms covering all important points to be noted in the patient's condition. Preparations are made for delivery, and if labor is not progressing satisfactorily the patient is seen at once by the resident physician. If necessary, the patient is transferred to the hospital or a member of the visiting staff is called so that the patient gets adequate care throughout.

The resident physician at the hospital knows the patient's condition and the progress of the labor through the frequent reports sent to him. He goes to her when he is needed and when he leaves she is in the hands of competent observers who can send for him when necessary. Following the confinement at the house there are visits by the doctor, the medical students, and the nurse until the patient is discharged.

There are several essential points of such an organized system of maternity care. Obstetrical diagnosis is desirable as early in pregnancy as possible. This means determining whether the woman can bear a child normally or whether she has some difficulty, such as a malformation of the pelvis, which would require special care or a surgical operation in the hospital.

Supervision and instruction during pregnancy is a desirable feature. This means periodical visits of the nurse to the mother's home to teach her to care for herself and to prepare for the coming child. Medical conditions must be watched during pregnancy, so the mother comes to the prenatal clinics for further examination by the obstetrician; periodical tests of urine, and so forth, are regularly made.

Delivery is under supervision. The medical student is allowed to deliver a case only under certain conditions, and must pass the responsibility to a graduate physician specially skilled in obstetrics, whenever specified conditions arise. Furthermore, the preliminary diagnosis and supervision of the patient have eliminated all those pathological or abnormal cases which could be foreseen.

Obstetrical emergencies are met either by determining them in advance and arranging for the delivery of the woman in the hospital, or when the emergency is unforeseen, by calling the resident or visiting physician, precisely that degree of skill being applied to each case which the case actually requires. The normal delivery of the woman who has already borne children almost takes care of itself, while an obstetrical emergency may require the highest degree of medical judgment and skill to save the mother and baby.

Postpartum care is given through nursing service in the home, and medical supervision is continued during the whole puerperal period. One of the most important parts of the system is the education of the mother of the family in both care during pregnancy and care of the baby after it is born.

The results of these systems of organized maternity service have been astonishingly good. In the outpatient service of the Boston Lying-In Hospital, students of the Harvard Medical School have year after year delivered 2,000 cases or so, with none or very few deaths. In Chicago the Lying-in Hospital, during nineteen years of operation, has cared for 24,764 confinements, with only eight maternal deaths

among the patients who were exclusively under its

care.

The contrast between these almost vanishing maternal death rates and the maternal death rate of about 5 to 1,000 in the United States as a whole, is due at bottom to the system of supervision. The care of the woman at confinement is fortunately a comparatively simple thing in the large majority of cases, but in a minority of cases the problem is difficult, often extremely difficult. The emergencies, when they occur, are grave, urgently threatening two lives. Some of these difficulties and emergencies can be foreseen and provided for in advance, so that they will not occur at all. A certain small proportion cannot be foreseen, and when these arise just that degree of skill and equipment which can cope with them successfully must be promptly on hand. Neither the unregulated midwife nor the general practitioner working alone in the patient's home can meet these requirements.

These systems have been largely taken advantage of by the foreign born. In Boston something like 3,000 cases a year are delivered in their homes or in the maternity hospitals through the teaching and hospital services connected with the Harvard and the Tufts Medical Schools. A large proportion of these cases are Jewish or Italian. The clientele of the Chicago Lying-In Hospital is largely Jewish and includes a considerable number from other foreignborn groups. In New York the same is true. The following figures from the study by Dr. LewinskiCorwin, previously mentioned, make an interesting comparison between races:

TABLE XXIX

THE KINDS OF MATERNITY CARE SECURED BY PATIENTS OF VARIOUS RACES IN NEW YORK, 1903-18

(Testimony secured from mothers during block canvass)

The cheapness of the maternity care offered by these organized systems is one of their great advantages. The medical students do the work for nothing. So do the visiting obstetricians. The resident physicians, who stand between the students and the visiting staff, generally receive nominal or moderate salaries, as they are securing valuable special experience. The only expenses to be met are for overhead, upkeep of the plants, and home-nursing service. Many of the patients can pay enough to cover a considerable porportion of these expenses, and some of them can pay enough to cover all. Consequently, the service can be, and is, offered at nominal rates, and the home deliveries are usually provided free when necessary.

The only obstacle to the indefinite extension of this almost ideal system is the limited number of medical students. During the last few years the annual number of medical graduates has been about 2,500 or 2,600. Even if each of these students were to deliver 20 cases in their homes-which is a very much larger number than students deliver in most medical schools -the total number of cases delivered by all the

medical students in the United States would be only about 50,000. This is about 2 per cent of the births in the United States. It is just about the number of births which occur each year in the city of Chicago.

The number of medical colleges is on the decrease rather than on the increase. There are at the present time 95 medical schools in the country, in about 60 different communities.1 For reasons of medical teaching efficiency they tend to be in large centers of population. There were in the United States, in 1917, 272 communities of over 25,000 estimated population.2 There were, according to the census of 1910, 2,173 communities of between 2,500 and 25,000. The rural area of the United States includes a little more than half the total population. The medical colleges and the medical students can develop a system and set a standard of medical care, but they can provide for only a minute fraction of the mothers of the United States in their time of need.

A PRACTICAL PLAN

The only effective maternity service thus far developed has been the out-patient teaching service, and the number that can be reached by this is limited by the number of medical schools. A practicable method of securing the advantages of this system without the use of the medical student has been suggested by Dr. A. K. Paine, as a member of the committee on

1 According to 1918 classification of American Medical Association.

2 Department of Commerce, Bureau of the Census, Bulletin 138, Table VI.