Prenatal Care and Obstetrics, of Boston. We may quote from the statement made by Doctors Paine and Rushmore:1

The scheme proposed for discussion by the committee is the substitution for the medical student of graduate and undergraduate nurses, preserving in other respects the system now in use in many hospitals.

There would then be in a municipal or other hospital an obstetrical department as a center to which all cases needing hospital care could be sent. Prenatal clinics would be established here and at substations in the district if necessary. Patients at their homes would be cared for by physicians from the hospitals, who would be assisted by nurses as they are now assisted by medical students. If transportation were provided by automobile, the number of cases seen and cared for would be greatly increased for a given amount of effort.

THE COST OF A COMMUNITY PLAN

The cost of this plan of service is important, since its field of action would be the large number of cases now covered by the midwife and the smaller, but important, number who now receive no care, or get medical charity at the hands of physicians or institutions. In their committee report, Doctors Paine and Rushmore made estimates which are worth quoting in detail.

The following items of nurses, physicians, supplies, and automobiles must be included in the cost of such a system. The estimates are on the basis of 5,000 deliveries cared for during a year:

1 Stephen Rushmore, M.D., and Alonzo K. Paine, M.D., "A Suggestion for the Improvement of Obstetrics," Boston Medical and Surgical Journal, November 30, 1919, pp. 615–618.

Nurses.-Needed for antepartum visits, for attendance at confinement, and for postpartum visits.

Antepartum visits.-Each patient should be visited once at her home by the nurse to see that she has made proper preparations and has the necessary supplies on hand. For normal cases no other visit is necessary, as the patient reports at the clinic for observation and examination. It is estimated that the patients needing special care, as in toxemia, bleeding, and so on, will require 3 visits each on the average, and will constitute about 5 per cent of the total number of patients. Of these patients needing special care, a considerable number will be actual in-patient cases, and will have to be transferred to the hospital. If 4 visits per patient were necessary, it would make 1,000 extra antepartum visits, making a total of 6,000 antepartum visits.

If the year be reckoned as comprising 300 nursing days, this gives 20 visits per day, which would require the whole time of 2 nurses.

Five thousand births in the course of a year gives an average for one day of 13 plus, which may be regarded as 14. Eight hours may be allowed as the average time that would have to be spent with each case. With an eighthour day this would be 14 nurses for a day's work. If 2 nurses attended each case, 28 would be required. Of these one half would be graduate nurses, the other pupil nurses.

Postpartum visits.—Averaging a visit a day for 10 days, there would be 14 visits for the first day, increasing each day until on the tenth day there would be a maximum of 140 visits, the daily number from that time on. Postpartum visits would require an hour for each and would therefore require 18 nurses a day.

It is estimated that 5 supervisors would be required for this total of 48 nurses.

Cost: 14 graduate nurses and 5 supervisors at

$100 per month....

34 pupil nurses (average $42 per month)..

Total per month...

Total per year..

$ 1,900

1,428 $ 3,328

39,936

Physicians.-There would be a consulting or visiting staff and a resident staff, only the latter involving expense. Probably 6 men would be necessary for the resident staff. They would be on 24-hour shifts. Thus, 3 men would be taking confinements for 24 hours, making an average of about 5 a day. For the next 24 hours these 3 men would be making postpartum visits, on the third and tenth days of the puerperium, attending to the antepartum clinics, keeping up records, and would have one undisturbed night for sleep. Each man would have one evening and afternoon off in six.

Cost: 6 at $36 per month (average)..

per year..

$ 216
2,592

It might be well if these men were salaried and the term of service might well be a six months' service.

Supplies. The cost of supplies would not be very great, as many of the supplies are provided by the patients, purchased under the direction of the nurse or doctor. A dollar per patient would be ample $5,000.

Ambulance-automobile.-In order that a physician shall be able to take care of five cases a day, on the average, and to enable nurses to attend cases promptly at any time of the day or night in any part of the district, automobile transportation would be necessary. It is estimated that four ambulances or other automobiles would be required.

The average cost per month of one ambulance at the Boston City Hospital is $365 (all costs, including drivers on 8-hour shifts).

This would make an average cost per case (5,000 cases) of $13.02. It may be that the allowance for automobile service is too generous, since less expensive machines than ambulances could be employed, except for emergency cases requiring transfer to a hospital. These are relatively few. We might safely reduce the automobile expense to $12,500. On the other hand, the physicians' and nurses' salaries seem unduly low. In many communities the visiting staff should have fees, and the resident staff should have salaries of $75 to $100 per month. Ten thousand dollars should be allowed for medical salaries. The cost of hospital care for 250 cases (5 per cent of 5,000), at an average of $50 each, would be $12,500. Finally, overhead supervision and incidental expenses would have to be allowed for. This would be less if the maternity care system were part of a larger organization. Four thousand dollars to $7,500 should be sufficient. The total of all would be between $90,000 and $100,000, or between $18 and $20 per case. This figure is presented more for purposes of discussion than as a substantiated estimate.

A considerable proportion of the recipients of this care could pay this amount, since they pay as much as this now to midwives. It should be considered not a charity, but a public service.

It would be essential for the successful operation of this plan that a sufficient number of the right type of women be secured as nurses and that the proper training be given. The term "midwife" must be abandoned for the term "nurse," with the prefix "maternity" or "obstetrical." "Maternity nurse would seem to be the best title. After all, the great

est drawback to midwifery in this country is that which nursing faced in its "Sairy Gamp" stage. Nursing, before the time of Florence Nightingale, had many Sairy Gamps. Miss Nightingale's greatest service was so to dignify the profession, so to touch the imagination of the community-and especially

of womankind-that nursing became a vocation which could draw the finest types of womanhood. The care of the mothers of our nation at the time when they are bringing babies into the world is a worthy and inspiring service, and must be dignified