any environmental defects, since the mother's mental condition is as important as her physical condition, or is a part of it. The nurse helps to make arrangements for care at delivery and to secure hospital care if it is desired.

The patient is supposed to send word to the maternity station when she goes into the hospital, or to notify the nurse when delivery is expected, so that she can arrange for nursing care at home.

The Maternity Center Association considers maternity and prenatal work as a teaching proposition, and one afternoon a week the nurse has a demonstration lesson at the station where she instructs mothers (using a life-size baby doll) in the care of a baby, shows the proper layette, and so forth. One week the nurse gives this instruction or demonstration to the mothers; the following week the mothers show the nurse the proper way to do it. The nurse has patterns and shows them how to make the baby's clothes, how to make maternity clothes, or how to alter their own to meet the emergency.

The doctors and nurses appointed to the work are chosen for special qualifications: Public health and maternity experience, understanding and experience in handling foreign groups, in many cases knowledge of the foreign language—all being considered. Ignorance of a foreign language, however, is not an absolute bar to the engagement of a nurse, as interpreters can always be found and thoroughly competent, sympathetic, and experienced nurses cannot. This association is the only one of all those with whom we have been in touch which insists that its local station, doing prenatal or similar work, must have

either a paid interpreter or a doctor and nurse, both of whom speak the language or languages necessary.

The nurses co-operate with the midwives in their districts and report to them as to the condition of their cases, just as they do to physicians. Midwives are said frequently to report the names and addresses of women who have engaged them for their coming confinement. The nurses visit the midwife's cases as they do those referred by a physician.

The neighborhood response to the activities of the maternity centers thus conducted, seems to show that the plan of work makes itself known to the foreign-born mothers of the district and calls forth a rapidly increasing utilization of the service offered. The Maternity Center Association of New York is emphasizing the adaptation of its prenatal and maternity service to immigrants in a manner which should render its work of great interest to departments of health and private organizations throughout the country. The prenatal clinics supplement the work of the obstetrician, but since they do not provide for the actual delivery they cannot supplant the midwife.

MATERNITY SERVICE BY MEDICAL SCHOOLS

The only important substitute for the midwife which has been thus far developed on an extensive scale is the organized maternity service connected with the medical school, including a hospital and an outpatient system of care. This system is extraordinarily little known to the general public. Medical students must be taught obstetrics in some fashion,

and the best medical schools throughout the country have developed a maternity service, partly for this purpose and partly to benefit the mothers of the community who cannot afford to pay for private obstetrical care. When thoroughly developed, the system includes the following elements:

1. A maternity hospital, which may have paying and part-paying beds as well as free beds.

2. One or more “prenatal” or “antepartum" or "pregnancy" clinics, as they are variously called. One of these may be located at the hospital itself, and others in various parts of the city. At each of these clinics there is, at regular intervals, a physician well trained in obstetrics, with the necessary equipment and nursing service to make examinations of pregnant women.

3. A visiting-nurse service, conducted either by an outside district nursing organization or by the institution itself, for visiting patients in their homes during pregnancy (the so-called prenatal work), for attendance after delivery, sometimes for giving care at confinement, in the home.

4. The medical student who, under certain important restrictions and under supervision, delivers patients in their homes.

The operation of such a system has been succinctly described in a recent article, which may be quoted:1

The patient presents herself at the clinic. She is examined carefully and thoroughly. She is visited at her

1 Stephen Rushmore, M.D., and Alonzo K. Paine, M.D., “A Suggestion for the Improvement of Obstetrics," Boston Medical and Surgical Journal, November 20, 1919, pp. 615-618.

home by the nurse, who sees that everything needed at confinement is in the house. She visits the clinic for further examination and advice. When she falls into labor word is sent to the hospital and her record is reviewed.

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.