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as such. Then women of the fine type who have entered the ranks of nursing during recent years will enter this branch of the same profession.

Specialization within the nursing field becomes constantly more common and more important. The various branches of visiting and public health nursing, hospital or institutional nursing, teaching, and administration-all are recognized as distinct types of work which demand special training. The curriculum of the training school must be amplified, made more flexible, and relieved of routine elements unnecessary to the best nursing as such. The latter part of the nurse's course must give opportunity for specialization.

Maternity care should be regarded as one of the definite branches of nursing, for which a certain number of those entering the profession should be trained during their undergraduate course. Postgraduate courses in this subject should be provided for women already engaged in nursing. The field of the maternity nurses will be so largely among the foreign born that their training should include instruction in the backgrounds of various races of immigrants and in the special technique of dealing with them in maternity work.

DISTRICTING THE SERVICE

Some points made by Miss Frances Perkins, of the Maternity Center Association of New York, in her study of a desirable standard of maternity service, should be incorporated in the proposed plan for organizing maternity care. She suggests that the

stations for prenatal and other service to mothers and babies should be regarded as neighborhood centers, and that each "should not be a formidable, official-looking place, but should rather be small, simple, and accessible." In a large community each such center should be organized to care for about 400 cases per year. This would mean one center for approximately each 12,000 or 15,000 population. This corresponds to the general standard for determining the size of a district for general health-center purposes discussed later.

This local center will be primarily the center for the nursing service, although the prenatal clinic will be held there by the obstetrical staff at the necessary intervals. The resident physicians and obstetricians who provide the medical service and supervision must be grouped into larger units, since it would not be economical to have each center for 400 cases a year maintain its independent staff.

Maternity work is of an emergency nature. The approximate date of each confinement can be determined in advance, but not the exact day or hour. It is highly important, therefore, to regularize the calls of both nurses and physicians as much as possible. Regularizing can be managed best when a considerable number of districts are so located as to make it possible to utilize slack time in one, when there happen to be few calls, to fill up the needs in another, where there happen to be many. If too small an area is taken, there will be periods with but few calls, but a large enough staff must be maintained to carry the peak of the load. This defect can be overcome by having many local areas for the nursing and

neighborhood service during the prenatal and postpartum periods grouped into larger units.

VISITING HOUSEKEEPERS ESSENTIAL

Visiting houseworkers should be an element in the plan, developed as fully as financial considerations permit. One of the real reasons for the midwife is the help that she gives in the home, and the decrease in this part of the midwife's work is a misfortune to many families. The mother cannot stay long enough in bed after confinement when there is no one to care for her family and children.

Houseworkers maintained on salary could be attached to each center. They should do their work [says Miss Perkins] under the charge of the nurse in charge of the case. They should prepare the patient's food, attend to her minor wants, as directed by the nurse. In addition, they should go out with the nurse and the doctor at the time of delivery, and at once assume responsibilities for the care of the home, including the children. The number of hours per day spent in household work for each patient will vary according to the circumstances and the need of the particular family. These houseworkers should be given certain definite training and instruction before they are sent out.

Miss Perkins estimates that about one houseworker should be provided for every one hundred cases delivered, but this will vary much with the character of the district. The extra cost of these houseworkers may be an obstacle. The amount will have to be worked out. Probably much of this service can be paid for by some families.

INTERPRETING

According to the practical experience of the Maternity Center Association, it will be highly necessary to have some one in each center able to speak each language prevalent in the district. Where nurses or physicians of the center speak the languages sufficiently well, paid interpreters need not be engaged. In some centers it will be necessary to engage them or to have a certain number of residents of the district on call for such service, to be paid when called. Usually the need can be met by selecting some one to do clerical or other work at the center who can speak some of the needed languages, supplementing what the nurses or physicians know.

ADVANTAGES OF THE PLAN

The four advantages to their plan are stated by Doctors Rushmore and Paine,1 as follows:

1. It may be employed in communities in which no medical school exists. These are often the communities in which the need for adequate care is the greatest.

2. It will greatly increase the number of women who get adequate prenatal and obstetrical care.

3. It will tend to improve the standards of obstetrical practice. Hospitals with obstetrical departments will become much more numerous. Physicians who are to be in charge of these departments will be selected because of their greater proficiency and by additional experience will make further progress. House officers will have more experience and better training and thus be better fitted when they enter independent practice.

4. It will greatly increase the supply of obstetrical nurses.

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

This plan would seem to be adaptable to a community of any size where a maternity hospital exists or where maternity beds can be made part of the existing general hospital. It can be applied to small communities, because the overhead costs of providing the expert care, such as the obstetrical and nursing supervisors, can be distributed over a large area. With the development of the automobile there would seem to be no essential difficulty in extending it even to rural areas. The well-trained physician in private practice has nothing to lose by such a system. In fact he would be the gainer by it, because if he wished he could utilize the prenatal nursing service and secure the consultation of the obstetricians of the clinics for his patients without losing his relation with his private case.

Another very important advantage of the plan in communities having many foreign born and many midwives would be that the plan would provide an acceptable substitute for the midwife, at a cost about equivalent to the usual rates for the midwife's services; and that by equipping the "maternity nurses" with proper training in dealing with the foreign born, very great steps could be taken in bringing immigrant mothers to utilize such a service.

Furthermore, an advantage not discussed by Doctors Paine and Rushmore will be very apparent in those communities where there are many midwives and wherein there is a system of licensing, regulating, and supervising the midwives in their practice. This supervision could and should be conducted through the local and central stations of the organized maternity service, to which the midwives would report.

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