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U. S. DEPARTMENT OF LABOR JAMES J. DAVIS, Secretary CHILDREN’S BUREAU GRACE ABBOTT. Chief INFANT MORTALITY RESULTS OF A FIELD STUDY IN GARY, IND„ BASED ON BIRTHS IN ONE YEAR By ELIZABETH HUGHES 0 Bureau Publication No.. 112 WASHINGTON GOVERNMENT PRINTING OFFICE 1923 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis U- s % ° * CONTENTS. Letter of transmittal............................... •........................................................................ ........... Page. vn Introduction.........................................................................................y ........... ............................... 1 -3 Selection of Gary, I n d .......................................................................................................... 1 M eth od ..................................................................................... 2 Infant m ortality rate...................................................................................................................... Cause of death................................................................................ 4 4 -1 1 Gastric and intestinal diseases....................................\ ........................................... 5 Causes of death peculiar to early in fa n c y ............... ...... ................... ............... ........ 7 Malformations...................... 9 Respiratory diseases............................................................................................................... 9 Other communicable diseases.............................................................. 11 Other causes of d e a t h ..................... 11 A ge at death....................................................................................................................................... 12 S tillb irth s..................................................................................... 15 F eedin g........................................................................... 17-24 E xte n t of different types of feeding...................... ......................................................... 17 Death rates and type of fee d in g ............. .................... ..................................... ............. 18 Computed annual death rate and type of feeding.................................................... 19 T yp o of feeding and cause of death................................................................................ 19 Supervision of and reasons for w eaning........................... ............................................ 20 N ativ ity of mother and feeding customs................... .................................................. 21 Incom e, and feeding m ethods........................................................... 23 Maternal m ortality and maternity care........................................... ................................... .. 25-40 25 Maternal m ortality................... Care during pregnancy....................................................................................... 26-33 Household help and w ork.......... .......................... ................. ................................... 26 Mother’s gainful em ploym ent during pregn ancy............................................ 27 28 Prenatal care and instruction................................... Care during confinement p eriod .. . . 1............................................................................. 3 3-40 A ttendant at b irth ................................................................... 33 Nursing fcare........................................... 37 Days in Bed and household h e lp ............................................................................. 38 Age of mother and order of b irth............................................. ................................................ 41 Interval between b irth s'.____•...................../ ......... .................................................................... 44 Plural births.............*........................................................................................................................ 46 S e x ___ . / . ____ N . ..................................................................................... 47 Incom e......................................... 4 8-53 Earnings of chief breadwinner................................................... 48 Supplementary earnings....................................................................................................... 49 Mother’s em ploym ent and earnings................................................................................ 50 E m p loym en t of chief breadwinner..........................: ..................................................... 51 Infant m ortality rates and earnings of chief breadwinner.................................... 52 N ationality.......................................................................................................................................... 54-58 Infant mortality rates b y nationality............................................................................. 54 Non-Epglish-speaking nationalities................................................................................ 55 Mother’s ability to speak E n glish ..................................... ................... . . ...................... 55 Years in the U nited States.................................................................................................. 56 Literacy of m other...................... i ................................................ ....................................... 57 m https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CONTENTS. IV Page. Maternity histories.......................................... : ............... . . . - ...............................- ....................59-62 Infant m ortality r a te .. . ........................... ........................................................................... Age of mother and order of b irth...................................... .............................................. 59 60 Interval between births................................................................................. .<■.................. 61 Earnings and infant m ortality rate..................... ..................................................... .. 61 Civic and social factors........................... ...................................................................................... 6 3-79 Birth and death registration............................................................................................... 63 Housing....................... 64 T h e subdivisions of G ary............ ........................................................................................ 65 Department of health and charities......................................... 69 M ilk su p p ly .......... ..................................................................................................................... Collection and disposal of garbage and other waste................................................ 71 73 Sewers and sewage disposal................................................................................................ 75 W ater su p p ly................... 76 Streets and alleys..................................... 77 Infant welfare............................................................................................ - ............................ 78 Summary and conclusions.......................................................................................................- - 81-84 Infant mortality rate and cause of death............................................................ 81 Nationality of mother and infant m ortality....................................................... 81 Feeding and infant m ortality........................................................ 81 Maternal mortality and m aternity care........................ - ..............- — ------- 82 Earnings of chief breadwinner and infant m ortality..................................... 83 Civic and social factors................................................................................................ 8 3 -8 4 83 Birth and death registration........................................ Housing and other civic factors...................................................................... 84 Infant-welfare work.............................................................................................. 84 A p p e n d ix...........................................- —............................ - .......................... .......... ........................ 8 5-89 M ethod of procedure.............................. ........................................... ..- - - - . Infant mortality rate................. - 8 5-89 85 L ive births excluded................................................ 87 Stillbirth rate...... ................... . ........................- ...........- .......... .......................... - - - - 88 Stillbirths e x c lu d e d ..................................................................................................... In d e x ................................................................................. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 89 117 GENERAL TABLES. Page. Table 1. Registration of birth, b y attendant at birth; live births in Gary in 1916............................ ............................................................................................... 93 2. Infant mortality rates, b y cause of death; comparison of deaths among infants b o m in Gary in 1916 with infant deaths in the birth-registration area in 1916......................................................................... 93 3. Cause of death, b y month of life; deaths among infants b o m in Gary in 1 9 1 6 . . . ........................................................ .................................................... . . 94 4. Cause of death, b y calendar month of death; deaths among infants b o m in Gary in 1916........................... .......................... ................. ................... 5. M onthly death rate b y type of feeding, b y month of life and n ativity of mother............................................................................................................. 94 95 6. Reason for weaning, b y physician’s advice, and infant’s age at weaning; infants weaned under 15 m onths................................................ 97 7. Supervision of feeding or access to instructive literature in first year of infant’s life, b y color and nativity of mother; infants par tially or exclusively artificially fed............................................................. 99 8. Prevalence of artificial feeding with fresh cow’ s m ilk, with con densed m ilk, and w ith proprietary foods before and after weaning under 15 months of age, b y color and nativity of mother; infants born in Gary in 1916............................. ............. ............................ .................... 99 9. Age at weaning of infant, b y medical supervision of weaning and earnings of chief breadwinner; infants bo m in Gary in 1916............ 100 10. Prevalence of artificial feeding with fresh cow’ s m ilk, with con densed m ilk , and w ith proprietary foods before and after weaning under 15 months of age, b y annual earnings of chief breadwinner; infants b o m in Gary in 1 9 1 6 „ .................................... ................................... 101 11. Duration of household help during pregnancy, b y kind of house hold help and color and n ativity of m other; births in Gary in 1916. 102 12. Source of instruction in prenatal care, b y color and nationality of mother; confinements in Gary in 1916........................................................ 103 13. Grade of prenatal care, b y color and nationality of mother; con finements in Gary in 1916................................................................................. 103 14. Grade of postnatal care, b y attendant at confinement; births in Gary in 1916................................ ...................................................................................... 104 15. Duration or nursing care at confinement, b y color and nationality of mother; confinements in Gary in 1916................................................... 104 16. Duration of household help during lying-in period, b y kind of house hold help and days in bed; births in Gary in 1916................................. 105 17. Duration of household help during lying-in period, b y kind of household help and color and nativity of mother; births in Gary in 1916......... ................................................ ................................... ............... 106 18. Num ber of days in bed following confinement, b y annual earnings of chief breadwinner; births in Gary in 1916........... ' . .............................. 107 19. Duration of household help during lying-in period, b y kind of house hold help and earnings of chief breadwinner; births in Gary in 1 9 1 6 .................................... ....................................................................................... v https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 108 VI GEN E R AL TABLES. Page. T a b l e 20. Prematurity, b y order of pregnancy and age of mother; births in Gary in 1916 .......................................................................................................... 109 21. Interval from preceding confinement, b y condition of preceding issue; births in Gary in 1916 second and later in order of issue........ 109 22. E m ploym ent of chief breadwinner, b y color and nativity of mother and earnings of chief breadwinner; births in Gary in 1916................ 110 23. Aggregate fam ily earnings, b y earnings supplementary to those of chief breadwinner; births in Gary in 1916................................................. I ll 24. E m ploym ent of mother, b y color and nativity of mother and earn ings of chief breadwinner; births in Gary in 1916.................................. I ll 25. E m ploym en t of mother, b y annual earnings and color and nativity of mother; births in Gary in 1916................................................................... 112 26. Infant mortality rates,_ b y literacy and color and nationality of mother; births in Gary in 1916....................................................................... 113 27. Infant m ortality and stillbirth rates, b y earnings of chief bread winner and literacy of mother; births in Gary in 1916.......................... 113 28. Literacy and nationality of mother, b y age at 1916 confinement; births in Gary in 1916 to foreign-bom white mothers........................... 114 29. Infant mortality and stillbirth rates, b y age of mother and order of pregnancy; births from all pregnancies...................................................... 115 30. Cause of death, b y month of life; deaths among infants b o m in Gary in 1916............................................................................................................ 116 CHARTS. Ch a r t I .— Deaths from respiratory and from gastric and intestinal diseases, b y month of d eath .......................................................................................... io I I .— Deaths b y month of life........................................................ ............................ 12 H I .— Infant mortality rates, b y earnings of chief breadw inner................. . 53 M AP. M a p .— Gary, I n d ...................................................................................................faces p a g e .. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 65 LETTER OF TRANSMITTAL. U. S. D epartm ent of L abor, , C h il d r e n ’s B u r e a u , Washington M ay 13, 1922. : There is transmitted herewith a report on infant mortality in the city of Gary, Ind., the ninth in the bureau’s series of reports on infant mortality. This study is part of a general investigation of the welfare of infants and children of preschool age made while Miss Julia C. Lathrop was chief of the Children’s Bureau. Separate reports will present the findings with reference to the health of the children of preschool age, the conditions under which they live, and the general care they were receiving. The investigation was directly in charge of Estelle B. Hunter; Dr. Robert M. Woodbury was responsible for the interpretation of the statistical findings, and has written the appendix on Method of Procedure; Elizabeth Hughes, who has written the main body of the report, was the supervisor of the local field work. The bureau desires to acknowledge with thanks the assistance of its statistical committee— Professors Walter F. Willcox, Irving Fisher, Thomas S. Adams, Robert E. Chaddock, J. W. Glover, and Edith Abbott— in the planning of the inquiry; and the cooperation on the part of the mothers, public officials, and local organizations of Gary which made the carrying out of the plan possible. Respectfully submitted. Sir G race Hon. Ja m e s A bbott, Chief. J. D a v is , Secretary o f Labor. VII https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INFANT MORTALITY, GARY, INTRODUCTION. SELECTION OF GARY, IN D . In 1913 the Children’s Bureau began the first of its field inquiries into the subject of infant mortality and the social and economic conditions surrounding infant life in typical American cities.1 This report presents the findings of the ninth unit in the series. The studies preceding this were made during normal times of peace; the babies considered in this report, though bom in 1916 before the United States became an active participant in the World War, completed their first year, or whatever part of it they survived, in a community which was devoting much of its energy toward furthering war-time production of steel. In 1906 there appeared upon the southern shore of Lake Michigan the gigantic mills of the steel corporation and the nucleus of the town of Gary in which the men employed at the mills were to live. An unpeopled waste of shifting sand dunes and marshes in 1906, by 1910 its population was 16,802.2 In 1917 the population was estimated by the Bureau of the Census at 56,000,® or practically the same as that returned in the census of 1920, 55,378.4 The city is young, rapidly growing, and progressive. Ever since its inception, the city and its method of meeting civic responsibilities have continued to hold the interest of the public. Industrially, Gary is unusually homogeneous; the steel industry overshadows all other activities. In point of number of nationalities represented, its citizenship is exceedingly diverse. The foreign bom constitute over one-half the entire popu lation. The study of infant mortality under these conditions is therefore of especial interest in comparison with cities previously studied by the bureau. In spite of Gary’s rapid growth and progressive spirit the city possessed a high rate of infant mortality.5 In 1917, for cities in the 1 Between 1913 and 1918 studies were made in Johnstown, Pa.; Manchester, N. H .; Brockton, Mass.; Saginaw, Mich.; New Bedford, Mass.; Waterbury, Conn.; Akron, Ohio; and Baltimore, Md. 2 Thirteenth Census of the United States, 1910, Vol. II, Population, p. 568. 3 U. S. Bureau of the Census, Birth Statistics for the Birth-Registration Area of the United States, 1917, p. 24. 4 Fourteenth Census of the United States, 1920, Vol. I, Population, p. 83. 6An infant mortality rate is the number of deaths under 1 year of age per 1,000live births. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 . I N F A N T M O R T A L IT Y . birth-registration area,6 the infant mortality rate was 100,7 while Gary’s rate for the same period was 142.8 M ETH O D. As in former studies of infant mortality the Gary study is based upon births that occurred in the city during a selected year, 1916, and upon the deaths under 1 year of age among this group of children. The year 1916 was chosen because by January 1, 1918, when the study was begun, all the children born in 1916 would have completed a full year of life if they had not died before reaching their first birthdays. Three principal sources of information were used. The first was the birth and death records of infants born in Gary in 1916. The names, addresses, and facts about the parents and the children were transcribed to schedules to be used in home interviews. A second source of information was a house-to-house canvass of the city which was made prior to the interviews in the homes. In view of the fact that in 1916 Indiana had not been admitted to the birth-registration area, such a census was necessary in order to supplement the list of registered births. It yielded, furthermore, up-to-date addresses for the parents of children born in 1916 and also added a considerable number of new names to the list of births in the selected year. Finally the most important source of information was the home interviews. The mothers of children born in Gary in 1916 were interviewed by the women agents of the bureau, and information was secured in regard to infant feeding during the first year of life, the mother’s maternity history, the mother’s employment history, and the family income, and housing conditions. Study of the registration records of Gary showed 1,499 live births and 68 stillbirths that occurred in the city during 1916. The house-to-house canvass of the city disclosed 183 unregistered five births and 3 unregistered stillbirths, making the total live births, both registered and unregistered, 1,682; the total stillbirths, 71; and the total number of births, both live and still, 1,753. As in other studies of infant mortality, not all the births known to have occurred in the city during the period selected could be used in the detailed study. «In the birth-registration area are included only States in which, in the judgment of the Bureau of the Census, at least 90 per cent of the births are registered. In 1917 the birth-registration area comprised: Connecticut, District of Columbia, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Utah, Ver mont, Virginia, Washington, and Wisconsin. U. S. Bureau of the Census, Birth Statistics for the Birthregistration area of the United States, 1917, p. 7. 1 1bid., p. 23. « Ibid., p. 24, Table I. 8aIncludes 44 registered only as deaths. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IHD. 3 For 290 infants, the information called for on the schedule could not be obtained because the families into which these children were #born had moved away from the city before the date of the canvass. Twenty babies were born in Gary to mothers who resided outside the city but had come to Gary hospitals for confinement. In 40 cases the families could not be located. In 2 cases the data secured seemed too incomplete and unreliable to be included. Four still births of less than seven months’ gestation were excluded in order to conform to the definition of stillbirth adopted in all the bureau studies.9 Four births out of wedlock were excluded on the ground that the conditions surrounding such births are not the same as in normal families. Deduction of exclusions from the total number of births for the period, 1,753, leaves as a basis for study 1,353 live births and 40 stillbirths (of seven or more months’ gestation). This number in cludes those born during the calendar year 1916 to married mothers in families which lived in Gary during the year following the birth, and which were living in Gary at the time of the canvass.9a Before the canvass started in February, 1918, residents of Gary had been made familiar with the character and plan of the proposed inquiry through the newspapers, the schools, and the pulpit. Constant and intelligent cooperation on the part of the city, its officials, its organizations, institutions, and citizens attended every step of the inquiry. Individual mothers gave most generously of their time. Of all the mothers interviewed, none refused to answer the questions upon which this report is based. This widespread civic interest and ready individual contribution to a study of infant and child life in the community are unmistakable evidences of the high esteem in which the child and his welfare are held in Gary. 9A stillbirth, as defined by the Children’s Bureau, is a dead-bom issue resulting from seven or more months’ gestation. I f the period of gestation was reported as less than seven months, the birth, even though registered as a stillbirth, was classed as a miscarriage and, as such, excluded from the study. #a For a more complete discussion of the exclusions -«e Appendix, p. 85-89. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INFANT MORTALITY RATE, Among the 1,353 infants born alive in Gary in 1916 who were in-, eluded in the detailed study, 169 deaths under 1 year of age occurred, giving an infant mortality rate of 124.9.10 CAUSE OF DEATH. The causes of these 169 deaths as stated on the death certificates show the diseases which were directly responsible for this loss of infant life. They suggest, furthermore, the economic and social factors responsible for the relative importance of the different diseases as causes of death in infancy. Such environmental influences as hot weather, unsupervised artificial feeding, poor sanitation, lack of medical and hospital care, improper housing, poverty, and ignorance are important factors governing the incidence of disease. The group of diseases to which the largest number of infant deaths among babies born in Gary in 1916 was due, comprised the gastric and intestinal diseases.11 To these diseases were attributed 68 of the total 169 deaths or 40.2 per cent. Next in rank were the causes of death connected with early infancy—premature birth, congenital debility, and injuries at birth—which were responsible for 34 deaths, or one-fifth the entire number. Respiratory diseases were third in order of importance and the cause of 27 deaths, or 16 per cent of the total. Other communicable diseases accounted for 15 deaths (8.9 per cent); malformations, for 11 (6.5 per cent); and all other causes, for 14 (8.3 per cent). T a b l e I .— In fa n t m orta lity rates, by cam e o f death; live births in G a ry in 1 9 1 6 . Infant deaths. Cause of death.« Number. Malformations................................................................................................... All other causes.................................................................'.............................. Per cent Infant distri mortality bution. rate. 169 100.0 124.9 68 27 11 34 15 14 40.2 15.9 6.5 20.1 8.9 8.3 50.3 19.9 8.1 25.1 11.1 10.4 a For classification according to detailed International List, see General Table 2, p. 93. 10 For method of computing infant mortality rate, see p. 85. 11 The classification of causes of death used here is that used b y the U. S. Bureau of the Census (see Mor tality Statistics, 1916, p. 483), and comprises the diseases most important in the first 12 months of life. The term “ gastric and intestinal diseases” includes only the diseases of this type which are most impor tant among infants; i. e., diseases of the stomach, diarrhea, and enteritis. It does not encompass all “ diseases of the digestive system” as classified under this heading according to the detailed Internationa; List. So, too, “ respiratory diseases” includes only those respiratory diseases most important among infants; i. e., acute bronchitis, broncho-pneumonia, and pneumonia. “ Communicable diseases,” similarly, is limited to those of this group which are most important among infants. See General Table 2, p . 93. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis I N F A N T M O R T A L IT Y , G AR Y, IN D . 5 GASTRIC AND INTESTINAL DISEASES. The infant mortality rate from gastric and intestinal diseases in Gary was 50.3, or almost exactly double that for the same group of diseases in the birth-registration area, 25.4, in 1916. In both birth e d death-registration areas the gastric and intestinal diseases occu pied second place among the causes of death of babies. In Gary they held first rank. Gary’s rate from this group of diseases alone was practically equivalent to New Zealand’s rate, 51, from all causes for the same year. An examination of the distribution of the 68 deaths in Gary from gastric and intestinal diseases, according to the calendar month in which death occurred, shows the mortality to have been greatest in July, August, and September, though no month was free of deaths from this cause. In these three months alone 41 of the 68 deaths took place, the highest number for any one month being reached in August (Chart I). Since deaths under 1 year of age of infants born in 1916 might have occurred in either 1916 or 1917, the mortality in this group from gastric and intestinal diseases may have been influ enced by the temperature conditions of the summer months of these two years. Of the 50 babies dying in 1916 from gastric and intestinal diseases 32 died in these months; 9 of the 18 deaths in 1917 from the same causes occurred in the period, July through September. The concentration of deaths in these hot summer months shows the effect of hot weather in increasing the mortality from gastric and intestinal diseases. The summer of 1916 showed for the vicinity of Gary unusually high temperatures, which were exceptionally prolonged. These, to gether with a lowered rainfall, were apparently favorable to the production of a high infant death rate from diarrhea and enteritis. On 25 12 days in July, August, and September the temperature was 90 or over. Though 1917 did not equal 1916 in extremes of heat and deficiency of rainfall, it nevertheless produced 12 days when the tem perature was 90° or over. The accompanying tabular statement shows means of temperature and rainfall for 1916 and 1917.13 . " Figures are taken for the nearest station of .the Weather Bureau, at Whiting, Ind., and mav be con sidered representative for Gary also. y « U. S. Bureau of the Census, Mortality Statistics, 1917, p. 58: Death rate from diarrhea and enteritis under 2 years of age per 100,000 population. In Gary, Ind., in 1911 the death rate was 380.9: in 1915 410 75 2 ? m ± ? m ! ’ 16i 3‘ The dMerence in “ er heat rainfall in 1916 and 1917 apparentlyftj mshes a partial explanation of the relative rates from diarrhea and enteritis in these two years. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 I N F A N T M O R T A L IT Y . M ean, m axim u m , and m in im u m m on th ly tem peratures and m on th ly p recip ita tion , at W h itin g , In d ., in 1 9 1 6 and 1 9 1 7 . Temperature (° F.). Temperature (° F.). 1916 June__ , ............. Mean. Maxi mum. 77.0 75.8 64.4 53.6 42.6 25.0 29.0 24.0 34.2 47.5 60.2 63.0 102 100 92 89 76 64 60 52 73 80 90 86 Precipi tation Mini (inches). mum. 0.56 1.04 1.89 3.40 1.72 3.33 5.01 1.01 2.61 1.08 441 7.94 59 50 33 29 13 —10 —7 —5 7 24 37 48 1917 July.................... August............... September......... October.............. November......... December.......... January............. February........... March.. I............ April.................. May.................... June................... Mean. Maxi mum. 72.2 72.0 64.6 45.4 42.2 21.5 23.0 20.2 37.8 45.4 52.2 640 97 94 87 70 71 50 45 48 77 84 89 88 Precipitation Mini (inches). mum. 50 51 40 19 21 -1 2 -1 2 —12 10 28 31 40 12.94 11.92 2.87 4.56 0.26 2.49 1.49 0.42 3.16 1.72 2.33 13.34 i Figures are for Hammond, Ind., those for Whiting for June, July, and August, 1917, being unobtainable. In Table II the rates of mortality from the several causes of deaths are shown according to the nativity of the mother. A striking con trast is noted in the rates from gastric and intestinal diseases. Among infants of foreign-bom mothers the mortality rate from these dis eases was 61.5, or 24 times the rate, 25.5, among infants of native white mothers. The mortality from gastric and intestinal diseases is largely, if. not wholly, preventable. This preventability is illustrated in part at least by the figures showing the reduction in the infant death rate from diarrhea and enteritis in the death-registration States from 37.7 in 1910 to 23.2 in 1917,14 and again by the fall in the infant mortality rate from gastric and intestinal diseases in the birth-registration area as of 1915, exclusive of Rhode Island, from 24.6 in 1915, to only 19.0 in 1919.15 It is illustrated further in the wide variation in the mortality from these causes in different areas. Thus in the cities studied by the Children’s Bureau, Saginaw, Mich., had an infant mortality rate from gastric and intestinal diseases of only 8.2, while at the other extreme, Manchester, N. H., had a rate of 63.3, higher even than that for Gary. New Zealand’s rate of 2.7 in 1918 shows the possibilities of reduction in the mortality from gastric and intestinal diseases. 14 The following table shows the death rate from diarrhea and enteritis per 1,000 estimated mid-year popu lation under 1 year of age in the death-registration States of 1910 (exclusive of North Carolina), 1910 to 1917: Death rate per 1,000 infants under 1 year of age. Cause of death. 1917 23.2 1916 24.1 1915 22.6 1914 24.7 1913 28.1 1912 26.2 1911 29.0 1910 37.7 TJ. S. Bureau of the Census, Mortality Statistics, 1917, p. 64. M Compiled from Birth Statistics, 1916, p. 21; 1919, pp. 24,288; and Mortality Statistics, 1915, pp. 647-657. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IND. 7 The methods which have proved most effective in reducing the death rate of infants from gastric and intestinal diseases are educa tion and instruction of mothers in the care of babies, with special attention to proper feeding and insistence upon medical supervision of babies who can not have the benefits of breast milk; provision of pure-milk supply and supervision to see that its excellence is main tained, and improvement of community sanitation and housing CAUSES OF DEATH PECULIAR TO EARLY INFANCY. The infant mortality rate in Gary from causes of death peculiar to early infancy among babies bom in 1916 was 25.1, half that from gastric and intestinal diseases. In the birth-registration area in 1916, premature birth, congenital debility, and injuries at birth— the three causes grouped together under early infancy—produced an infant mortality rate of 33.7. Contrary to what was true for gastric and intestinal diseases, comparison with the registration area is in this instance favorable to Gary. Of the 34 deaths from causes connected with early infancy, 30 occurred before the end of the first month and 28 before the end of the first two weeks of life. Two-thirds of the deaths under 1 month of age from causes connected with early infancy were attributed to prema ture birth, which was the largest single cause of early death. Con genital debility, a term used to describe a baby's lack of vitality from birth, claimed 9 babies within the first 14 days of life, 2 in the second month, 1 in the fifth, and 1 in the seventh month. Injuries at birth caused the death of but 1 child, which occurred in the first few davs after birth. T a b l e I I .— In fa n t m orta lity rates, b y cause o f death, and color and n a tiv ity o f m otherliv e births m G ary in 1 9 1 6 . ’ Deaths among infants born in 1916 to— Native white mothers. Cause of death. Foreign-born white mothers. Num Infant Num Infant Num Infant ber. mortal ber. mortal ber. mortal ity rate. ity rate. ity rate. All causes.................................. Gastric and intestinal diseases Respiratory diseases............... Malformations.......................... Early infancy................... ’ ” ........................... Premature,birth....... " ................................. Congenital debility..................................... .Injuries at birth................................... .*"* Epidemic and other communicable diseases’. ’ External causes........................... . ........ . Diseases ill defined or unknown " : ............. All other causes.............. 1Rates not shown where base is less than loo. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Negro moth ers.1 169 124.9 37 96.6 128 133.5 4 68 27 11 34 20 13 1 15 1 8 50.3 19.9 8.1 25.1 14.8 9.6 0.7 11.1 0.7 5.9 3.7 9 6 4 13 9 3 1 4 23.5 15.7 10.4 33.9 23.5 7.8 2.6 10.4 59 19 7 20 11 9 61.5 19.8 7.3 20.9 11.5 9.4 i 1 2.6 10 1 7. 5 10.4 1.0 7.3 5.2 5 2 i i 8 IN F A N T MORTALITY. If the infant mortality rate from causes connected with early infancy for babies of native white mothers is compared with that for the babies of mothers who were foreign born; an interesting and marked contrast is presented. The rate for infants of native white mothers was 33.9; for infants of foreign-bom mothers, 20.9. The mortality rate from premature birth for babies of native white mothers was a trifle more than twice that for babies of foreign-bom mothers. This excess may be due in part to a higher proportion of first births among those to native white mothers, since, as will be shown later, the proportion of premature births is especially high among first births. Variations in the mortality from causes peculiar to early infancy in the birth-registration area as a whole,16 similar to those just discussed for Gary, raise the question whether these com paratively low rates in the first days of life among children of foreignborn mothers of certain race groups may not be explained in part by racial differences in the difficulty of labor or in the vitality of babies at birth.17 Since the causes of death peculiar to early infancy are chiefly pre natal or natal in their origin, it is evident that, to be successful, measures to control them must be initiated before the birth of the child. Experience has proved that both infant and maternal life are conserved by instruction of a mother in the care of herself prior to the birth of her child, by medical supervision during the prenatal period, and by skilled medical and nursing service at confinement. Only b y such supervision dining pregnancy and b y skilled assistance during confinement is it possible to reduce to a minimum the danger of com plications of pregnancy and confinement. With such skilled assist ance and supervision, much of the mortality within the first month of life is preventable.18 In 1916 there was no provision b y the city of Gary, and but little through private agencies, for prenatal clinics and instructive nursing service for pregnant women.19 The city’s infant mortality rate from 16 See U. S. Bureau of Census, Birth Statistics: 1916, pp. 16,17; 1917, pp. 15,16; 1918, 24-26. W Cf. Birth Statistics, 1918, p. 26. is Carnegie United Kingdom Trust Report on the Physical Welfare of Mothers and Children (England and Wales), Vol. I, pp. V III and IX . In a note on the report Sir Arthur Newsholme says: “ Of the total deaths of infants during the first year of life one-fifth occur dining the first week, and one-third occur during the first month after birth. Here again local variations show the extent te which preventable mortality prevails. For instance, in Workington, Dewsbury, Batley, Chesterfield, and Tynemouth, two to three times as large a proportion of the infants born die in the first week after birth as in Leyton, Hey wood, or Hornsey. The conditions leading to this excessive maternal and early infantile mortality are complex; but two stand out as most important. These are the lack of skilled medical, nursing, and ancillary domes tic assistance; and the fact that such assistance as is obtainable is given under unsatisfactory domiciliary conditions. * * * Maternity homes are urgently needed, and I know of no social work so likely as the provision of such maternity homes to give immediate results in saving maternal and child life, in diminish ing chronic invalidism of mothers, and in enhancing the national welfare.’ ’ 19 See p . 28 ff. for discussion of the prevalence of prenatal care among the groups of mothers studied- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GAR Y, IN D . 9 causes connected with early infancy (25.1) already lower than that for the birth-registration area, might be still further reduced through the establishment of organized help and prenatal and confinement care for mothers. M ALFORM ATIONS. The infant mortality rate among Gary babies from malformations was 8.1 as against a corresponding rate of 6.8 for the birth-registration area. Just as the mortality from causes peculiar to early infancy was higher for babies of native white mothers than for babies of foreignbom mothers, so here, too, the rate for babies of native mothers (10.4) was less favorable than that (7.3) for babies whose mothers were bom outside the United States. A similar difference in rate of infant mortality in favor of the children of foreign-born mothers is shown in the birth-registration area when the rate from malforma tions among the white children of foreign-born mothers (5.6) is com pared with the rate (7.7) for white Children of native mothers.20 Of the infants who died because of malformations six died within the first two weeks after birth ; three others failed to survive the second, one the fourth, and one the seventh month of life. As a cause of death, therefore, malformations swell the losses during the days immediately following birth. Of all causes of death, malforma tions are least controllable and least preventable by scientific effort. RESPIRATORY DISEASES. Acute bronchitis, broncho-pneumonia, and pneumonia were to gether responsible for the infant deaths of 27 babies born in Gary in 1916. The infant mortality rate from this group of diseases was 19.9; in the birth-registration area as a whole the infant mortality rate from similar causes in 1916 was 15.9. A glance at Chart X, shows that an increased number of deaths from respiratory diseases occurred during the months January, February, and March. This is in agree ment with the findings of other studies, namely, a greater incidence of respiratory diseases in the late winter and early spring, In the case of respiratory diseases, as in that of gastric and intesti nal, the mortality rate for babies with foreign-bom mothers (19.8) was higher than that for babies whose mothers were native white (15.7). The difference, however, was not so large as in the birthregistration area as a whole, where the figure for white infants of foreign-bom mothers was 21 and for white infants of native mothers only 11.1.21 The infant death rate from the principal respiratory diseases in the death-registration States of 1910 decreased from 19.5 in 1910 to 20 U. S. Bureau of the Census, Birth Statistics, 1916, p. 17. 21 TJ. S. Bureau of the Census, Birth Statistics, 1916, p. 17. 106137°— 23------ 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 IN F A N T MORTALITY. 16.2 in 1916;22 while in the birth-registration area as of 1915, exclu sive of Rhode Island, the infant mortality rate from these causes de creased from 16.6 in 1915 to only 14.5 in 1919.23 Whatever serves to increase the infant’s power of resistance also serves to minimize the power of the respiratory diseases to fasten Chart I.—Deaths from respiratory and from gastric and intestinal diseases, by month, of death. Number of deaths. -------- Gastric and intestinal diseases. .........Respiratory diseases. death. themselves upon him. The importance of educating mothers is again apparent, as well as the necessity for making each mother 23 TJ. S. Bureau of the Census, Mortality Statistics, 1916, p. 57: Death rate per 1,000 estimated mid-year population under 1 year of age from acute bronchitis, pneumonia, and broncho-pneumonia in the deathregistration States as of 1910 (exclusive of North Carolina): 1910 to 1916. Cause of death. 1916 2.4 4.2 9.6 1915 2.5 4. 5 10.1 1914 2.6 4. 8 9.9 1913 2.9 5.3 9.9 1912 3.1 5.7 9.3 1911 3.0 5. 6 8.6 !3 Compiled from Birth Statistics, 1915, p. 21; 1919, pp. 24,288, and Mortality Statistics, 1915, pp. 647-657. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 11 G AR Y, INT). realize the value of breast milk and fresh air in developing and main taining her child s ability to withstand disease, the danger of exposure to severe weather of an insufficiently clothed infant, and the danger in permitting a baby to come in contact with persons suffering from colds. OTHER COMMUNICABLE DISEASES. Of the 169 deaths among infants bom in Gary in 1916 about 1 death in 11 was attributed to other communicable diseases.24 The infant mortality rate was 11.1 in Gary and 8.9 in the birth-registration area, a comparison again unfavorable to Gary. Measles and whooping cough were responsible for 8 of the 15 infant deaths in Gary from this group of diseases. A fatalistic attitude is still prevalent with refer ence to these children’s diseases and the necessity for each child to undergo both illnesses sooner or later. The real menace which both diseases offer to the life of a baby is not yet sufficiently appreciated by the majority of mothers, consequently too small an effort is made to protect babies from exposure to measles and whooping cough. OTHER CAUSES OF DEATH. Other causes of death besides the ones already discussed, produced an infant mortality rate of 10.3 in Gary and practically the same rate (10.1) in the birth-registration area in 1916.25 The preceding discussion has shown how the excess of the infant mortality rate among infants bom in Gary in 1916 (124.9) over the infant mortality rate in the birth-registration area in the same year (101.0) was distributed among the different groups of diseases mili tating against infant life. The heaviest contributor to this excess was the largely governable and preventable gastric and intestinal diseases. 24See Table 2, p. 93. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 25Idem. AGE AT DEATH. Chart II shows that the first weeks of life are the ones fraught with the greatest peril. The curve indicating the number of infant deaths in Gary begins with a precipitous descent and drops from 56 deaths during the first month to 16 in the second; from the third on, it Number Month of life. 1 2 3 4 5 6 7 8 9 10 11 12 hovers near an average of 10 deaths per month, save in the eleventh month, when it sinks to its lowest number, 4. Had the high loss during the first four weeks been maintained for each succeeding month of the first year, but half the babies born in Gary in 1916 12 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis in f a n t m o r t a l it y , gary, in o . 13 would have survived 12 months. Fortunately, no other period of infancy makes such severe demands upon the human organism to adjust itself to so new and different an environment as do the weeks immediately following birth. The lessening in number of deaths was marked between the first and the second three months of the first year and the fall in the remaining half of the year was steady. In Gary 82 babies (48.5 per cent of the entire number dying) perished before the end of the first quarter of the first year of life; 34 more (20.1 per cent) succumbed before six months had passed; 29 (17.2 per cent) died in the third, and 24 (14.2 per cent) in the fourth quarter. If these percentages are compared with corresponding percentages for the birth-registration area, a larger proportionate loss in the first three months (59.8 per cent) is disclosed in the registration area. T a b l e I I I .— A g e at death; deaths am ong in fa n ts horn in G ary in 1916 and in fa n t deaths m the birth-registration area in 19 1 6 . Infant deaths. Gary. Age at death. Birth-registration area.1 Per cent Per 1,000 Per cent Per 1,000 Number. distribu live Number. distribu live tion. births. tion. births. Total................ 169 100.0 124.9 82,734 100.0 101.0 Under 1 month...... Under 1 d a y ... 1 day, under 2........ 2 days, under 3.......... 3 days, under 7........ 1 week, under 2 ... 2 weeks, under 1 month. 1 month, under 2 . 2 months, under 3........ 3 months, under 6. 6 months, under 9. 9 months, under 12.. 56 24 3 2 8 8 11 16 10 34 29 24 33.1 14.2 1.8 1.2 4.7 4.7 6.5 9.5 5.9 20.1 17.2 14.2 41.4 17.7 2.2 1.5 5.9 5.9 8.1 11.8 7.4 25.1 21.4 17.7 36, 111 12.133 3,997 2.989 5,657 4,766 6,569 7,425 5,968 13,837 10,679 8,714 43.6 14.7 4.8 3.6 6.8 5.8 7.9 9.0 7.2 16.7 12.9 10.5 44.1 14.8 4.9 3.6 6.9 5.8 8.0 9.1 7.3 16.9 13.0 10.6 B irfhltetìsti?1916,0“ 4U' S' BureaU ° fthe Census- Mortality Statistics, 1916, Table II, pp. 483-525, and This larger proportionate loss in the first three months in the birthregistration area merely reflects the differences already noted in the relative rates from the several causes of death. The rate from causes peculiar to early infancy in Gary was lower than in the birth-registra tion area and practically all the deaths from these causes occur within one month of birth. The rate from gastric and intestinal diseases, on the other hand, was nearly twice as high in Gary as in the registration area, and about two-thirds of the deaths from these causes in Gary occurred during the last nine months of the first year of life. The mortality rates in Gary and in the birth-registration area for the first three months of life were practically identical, 60.6 and 60.5. The excess of the mortality rate for the first year in Gary, 124.9, over that in the birth-registration area, 101.0, was brought about by an https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 I N F A N T M O R T A L IT Y , G AR Y, I N D . excess of the rate in Gary among babies who had successfully come through their first three months. T a b l e I Y . — A q e at death, by color and n a tiv ity o f m oth er; deaths am ong in fa n ts born in G ary in 1916. —---------- . Deaths among infants bom in 1916— All mothers. Age at death. Number. Total................................. Native white mothers. Foreign-bom white Negro mothers.1 mothers. Per 1,000 Per 1,000 Per 1,000 Number. live Number. .live Number. live births. births. births. 169 82 87 121.9 60.6 64.3 37 23' 14 96.6 60.1 36.6 128 133.5 4 57 71 59.4 74.0 2 1 Rate not shown where base is less than 100. Within the city itself a contrast similar to the one just noted between Gary and the birth-registration area was found in connection with the mortality rates for infants of native white and for infants of foreign-born mothers. During the first three months of life the mortality rate among babies of native white mothers was 60.1 and among infants of foreign-born mothers, 59.4. During the first year of life the mortality rate among babies born in 1916 to native white mothers was 96.6 and to foreign-born mothers, 133.5. The difference in the rates for the first year of life is evidently due entirely to a difference in the rates in the two groups between 3 and 12 months of age. Reference to Table IV shows that the excess in the rate between 3 and 12 months of age among infants of foreign-born mothers is largely accounted for by the very heavy mortality from gastric and intestinal diseases, the rate in this group being over 2£ times that among babies of native white mothers. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis STILLBIRTHS. The causes underlying deaths prior to or at birth are closely analogous to many of those responsible for the death of live-born babies within the first two weeks after birth, a fact which gives pertinence to a discussion of stillbirths in connection with a study of infant mortality. An appreciation of the importance of prenatal and natal condi tions in relation to loss of infant life may be gained from considera tion of all infant losses due to conditions existing before the birth of the child rather than to adverse postnatal environment, feeding, or care. For Gary this group is composed of 40 stillbirths and 38 of the deaths of infants under 2 weeks of age; and constitutes well over a third (37.3 per cent) of the total loss (209) of infant life. If the total deaths from causes peculiar to early infancy (34) and from malfor mations (11) are grouped with the stillbirths (40) the proportionate loss clearly ascribable to prenatal and natal conditions is 40.7 per cent. Stillbirths formed 2.9 per cent of the total births in Gary in 1916. The stillbirth rate did not vary for births to native white and to foreign-born mothers, being in both cases 2.8. It is interesting to note that the highest stillbirth rate (4.4) was found among babies to Polish mothers, the same nationality group in which the highest infant mortality rate (148.3) obtained. If, however, births from all pregnancies to the entire group of mothers are considered the still birth rate is 3.0; for babies of native white mothers, it is 3.4; for those of foreign-born mothers 2.9; and the rate for babies of Polish mothers (3.3), though higher than the rates for the babies of Serbian and Croatian and of Slovak mothers, was lower than those for babies of German (4.7), Italian (3.9), or Lithuanian (3.4) mothers. (Table VI.) T a b l e V .— S tillbirth rates, b y color and n a tion a lity o f m oth er; births in G ary in 19 1 6 . Color and nationality of mother. Total births. Stillbirths. Number. Per cent.1 Total........................................................................................ Native white............................................................................................... Foreign-born white................................................................................... L Polish............ .................................................................................... Serbian and Croatian................................................................................ Slovak........................................................................................... / All other___ .................................................................................... Negro2.................................................................................. 1,393 394 987 275 162 135 415 12 2.9 2.8 4 2.5 2.2 1Not shown where base is less than 100. 2The negro mothers were all native. 15 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 16 IN F A N T MORTALITY, GARY, IN D. T a b l e V I .— S tillbirth rates, b y color and n a tion a lity o f m oth er; births fr o m a ll p reg nancies. Births , all pregnancies. Stillbirths. Color and nationality of mother. Total. Number. Per cent.1 Serbian and Croatian.................................................................... .......... Lithuanian and Lettish....................................... .................................... ' 4,714 142 3.0 1,054 3,632 1,023 605 515 254 243 232 150 610 28 36 105 34 17 12 10 2 8 7 15 1 3.4 2.9 3.3 2.8 2.3 3.9 0.8 3.4 4.7 2.5 1 Not shown where hase is less than 100. A partial indication of the extent of loss of life before birth is afforded by these data relating to stillbirths. It must be remem bered, however, that they give no gauge of the number of losses due to miscarriage at less than seven months’ gestation. Moreover, the registration of stillbirths is imperfect and the methods employed to discover unregistered live births are found to be less effective in tracing stillbirths. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis / FEEDING. Among the factors inimical to infant life, improper feeding is of great importance. Breast milk, because of its cleanliness, purity, composition, and adaptability to the changing needs of "the growing organism of the baby, is superior to any other form of infant food, and medical authorities agree that the use of any substitute is attended by risk to the infant’s health. The danger to which the very young child may be exposed through insanitary surroundings, or through the mother’s poverty, carelessness, or ignorance, will be minimized if the child is breast-fed and aggravated if artificial feeding is adopted. Of the 1,353 babies born alive in Gary in 1916, 31 died before they could be fed. The discussion of feeding as affecting infant life is, therefore, limited to examination of the methods used among the 1,322 babies surviving long enough to receive food. Classification has been made on the basis of those breast fed exclusively; those in part artificially fed, i. e., the babies receiving some other food in addition to mother’s milk; and those artificially fed, i. e., infants receiving no breast milk. The difficulty of presenting such a sub ject as infant feeding by means of tabular analysis is ever present because feeding is so eminently a changing process. When one or more types of feeding were employed during a given month, that type which predominated the greater part of the month was chosen as representative. Because there is general agreement that after the ninth month of life exclusive breast feeding is not only no longer necessary but not even advisable, the analysis in the tables has been largely limited to the first nine months of the first year of life. EXTENT OF DIFFERENT.TYPES OF FEEDING. All but 91 (7 per cent) of these 1,322 babies are known to have been wholly breast fed during the first month of life, while 58 (4.4 per cent) were artificially fed during this period. More than threefourths of the infant survivors in each of the first four months were exclusively breast fed. The decrease in breast feeding from month to month was steady except during the seventh month, when the percentage of breast-fed infants was reduced by over 15 per cent from the percentage in the preceding month. In the majority of cases where the feeding was changed from exclusive breast feeding, the babies became part of the group having breast milk supplemented by artificial food. By the end of the first three-quarters of the year slightly over one-third (35 per cent) of the babies surviving were still exclusively breast fed; less than one-fourth (23 per cent) were receiving no breast milk; and 42 per cent, a little over two-fifths of the entire number alive, were having 17 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 I N F A N T M O R T A L IT Y . mothers milk supplemented by some other form of food. VII). (Table T a b l e V I I . — T yp e o f feed in g , b y m onth o f life ; in fa n ts born in G ary in 19 1 6 . Infants born in 1916 surviving at beginning of month. Exclusively breast fed. Month of life. Partially breast fed. Artificially fed. Feeding not re ported. Num ber. Num ber. Total. Num ber. Fourth..................... Fifth........................ Eighth..................... U,322 1,297 1,281 1,271 1,258 1,247 1,237 1,223 1,215 1,231 1,152 1,080 987 910 836 636 542 430 Per cent. 93.1 88.8 84.3 77.7 72.3 67.0 51.4 44.3 35.4 Num ber. 26 48 68 114 154 210 368 428 507 Per cent. 2.0 3.7 5.3 9.0 12.2 16.8 29.7 35.0 41.7 Per cent. 58 91 128 164 188 195 227 248 273 4.4 7.0 10.0 12.9 14.9 15.6 18.4 20.3 22.5 7 6 5 6 6 6 6 5 5 Per cent. 0.5 .5 .4 .5 .5 .5 .5 .4 .4 1 Excludes 31 infants who died not fed. DEATH RATES AND TYPE OF FEEDING. The relative advantage which the breast-fed infant has over the infant artificially fed is brought out strikingly in Table V III, which presents the monthly death rates per 1,000 for infants exclusively breast fed, in part artifically fed, or wholly artificially fed in the dif ferent months of life. Up to the ninth month the death rate in every month among the artificially-fed infants at least quadrupled that among those exclu sively breast fed. The rates for the infants receiving partial breast feeding occupied a mid-position and for the most part exceeded the monthly rates -for the purely breast fed and fell short of those for the infants receiving no breast milk. From this it may be argued that even partial breast feeding affords an appreciable protection to the infant. T a b l e V I I I . — M on th ly death rates, b y typ e o f feed in g ; in fa n ts b o m in G ary in 1 9 1 6 . Month of life. Second.............................................................................................. Third................................................................................................ Fourth.............................................................................................. Fifth............... .................................................................................. Seventh............................................................................................ Deaths in month per 1,000 Deaths in infants. month per 1,000 survivors at begin Exclu sively Partially Artifi ning of breast cially fed breast month. fed. fed. 1 18.9 12.3 7.8 10.2 8.7 8.0 11.3 6.5 5.8 6.7 15.4 7.8 5.6 5.1 5.5 2.4 4.7 3.7 4.7 3.5 38.5 20.8 14.7 8.8 4.8 5.4 2.3 6.3 69.0 54.9 23.4 42.7 31.9 35.9 39.6 20.2 18.3 9.5 i The rate is per 1,000 infants who lived long enough to be fed. The rate per 1,000 live births is 41.4; 31 infants died not fed. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IND. 19 COM PUTED ANNUAL DEATH RATE AND TYPE OF FEEDING. It will be recalled (see p. 4) that among the 1,353 live births in 1916 there were 169 infant deaths, making the infant mortality rate for the city 124.9. In other words, of 1,000 infants born alive, 125 died before the first birthday. If the monthly death rates for’ all infants (Table,VIII) are applied to 1,000 infants who lived long enough to be fed and the losses in each month subtracted successively to learn the number of survivors at the beginning of the next month, the end of the twelfth month will show 896 of the 1,000 infants alive and 104 dead. In a similar manner the number of deaths in the first year of life among 1,000 infants breast fed or among 1,000 infants artificially fed can be computed from the monthly death rates for the respective types of feeding. Such a computation serves to bring out in a striking manner the comparative merits of breast, partially artificial, and wholly artificial feeding. Had the group of 1,000 been breast fed the entire first year of life only 64 would have died; if partially breast fed, 109 would have died before the end of a year; while if the entire 1,000 had been subjected to the hazards of purely artificial feeding 310 deaths would have resulted. In other words the mortality rate for exclusively artificially-fed babies in Gary averaged 5 times that for exclusively breast-fed babies and almost 3 tunes that for partially breast-fed infants. TYPE OF FEEDING AND CAUSE OF DEATH. As would be expected, the greatest excess in mortality among infants artificially fed is caused by gastric and intestinal diseases. The mortality rates from these diseases varied from 2 to over 12 times as high among infants artificially fed as among infants breast fed. Artificially-fed infants are subjected to increased hazard from ill adapted and improperly prepared food. Another measure of this extra hazard is offered in a comparison of the actual deaths among the exclusively artificially-fed babies with the number of deaths that would have occurred if they had been breast fed. If the rates of mortality from gastric and intestinal diseases that prevailed among breast-fed infants had prevailed also among the artificially fed, only 4 deaths instead of 32 would have occurred in this group. The mor tality rate from these diseases among the artificially fed was therefore on an average 8 times as high as among breast-fed infants. Not only was the mortality from gastric and intestinal diseases among artificially-fed babies greater than among breast-fed babies, but the mortality from all other causes of death, including respiratory and other communicable diseases, was also markedly greater among the artificially fed. A computation similar to that given above shows that if the rates of mortality from all causes except gastric https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 IN F A N T MORTALITY. and intestinal diseases prevailing among breast-fed infants had pre vailed also among the artificially fed, only 7 instead of 30 deaths would have occurred among them. The mortality from these causes among the artificially-fed infants was thus about 4 times as high as among breast-fed infants. This bears out the statement made in the discussion of the mortality from respiratory diseases that breast feeding affords a definite protection against respiratory and other infections.26 SUPERVISION OF AND REASONS FOR WEANING. Since breast feeding tends markedly to increase and artificial feeding to lessen the infant’s chance of survival, as the rates just cited so clearly demonstrate, the reasons why 58 babies were arti ficially fed in the first month of life are of interest, although it must be remembered that the reasons given are the mothers’ statements which might not always correspond with physicians’ diagnosis even in cases where physicians were consulted. Ten mothers stated that they were ill and unable to nurse their babies; 10 more reported breast infections or other reasons connected with their health. In 30 cases the mothers reported that the milk ceased or was insuffi cient; in 3 cases that it disagreed with the child; in 1 case that the infant was ill, and in another that the infant refused to nurse. Of the 58 infants, 32 were never breast fed or were weaned within the first 15 days after birth by advice of physician; for 26, or 45 per cent, the action was taken without physician’s counsel. Of the 384 infants weaned before the end of the ninth month, 148, or 39 per cent, were weaned on the advice of a physician, while 236, or nearly two-thirds, were weaned without such advice. For inf ants, weaned before the end of the ninth month the inade quacy or the complete cessation of the supply of breast milk was the reason far more frequently reported than any other. Of these 384 infants, 155, or two-fifths, according to the mothers’ statements, were no longer nursed because of failure or insufficiency of mother’s milk. In over two-thirds of these cases the infants had been deprived of breast milk even before they entered upon their fourth month.27 Doubtless wider dissemination of knowledge of the importance of breast feeding and of the factors which promote it would serve to lower the proportion of mothers whose supply of breast milk shrinks prematurely or disappears. ** The computations in this section are based on figures given in Tables 5 and 30, pp. 95-96,116. 27 About three-fifths of the babies weaned at or before the end of three months were weaned because the mother’s milk ceased or became insufficient. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 21 GARY, IN D . T able IX . P revalence o f artificial feed in g , by color and n a tiv ity o f m other; in fa n ts born in G ary in 1 9 1 6 . Infants bom in 1916 surviving at end of— Three months. Six months. Nine months. Color and nativity of mother. Artificially fed. Total. Num ber. Per cent.1 Artificially fed. Total. Num ber. Per cent.1 Artificially fed. Total. Num ber. Per cent.1 Total............................ 1,271 125 9.8 1,237 188 15.2 1,208 268 22.2 Native white.............. Foreign-born white............... Negro............................ 360 902 9 54 70 1 15.0 7.8 355 873 9 78 107 3 21.9 12.3 348 851 9 98 167 3 28.2 19.6 1 Not shown where base is less than 100. NATIVITY OF M OTH ER AND FEEDING CUSTOMS. Only about one-half as large a proportion of babies of foreign-bom mothers as of babies of native mothers were artificially fed at 3 months of age, the proportions being 7.8 per cent and 15 per cent respectively (Table I X ) ; at 6 months the proportion was one-eighth for foreign born to about one-fifth for native; through the n in th month the ratio between the groups remained practically the same. Other things being equal, therefore, it would be expected that the mortality among infants of foreign-born mothers would be less than among infants of native white mothers, since a larger proportion of the infants of foreign-born mothers were breast fed. A study of General Table 5, however, reveals that the death rates of infants of foreign-born mothers were higher each month than those for children of native mothers. If annual rates are computed as described previously for the breast fed and for the exclusively arti ficially fed in each nativity group, then of 1,000 breast-fed infants of native mothers 39 would have died before the end of the first year, while a similar group of infants of foreign-born mothers 71 would have died during the same period. Of 1,000 artificially-fed babies of native mothers 265 would have died before the end of the first year, while of the same number of artificially-fed babies of foreignborn mothers 333 would have died. In other words, whether breast fed or artificially fed, the children of the foreign-born mothers faced a greater hazard than the children of the native white mothers, when children receiving the same type of feeding are compared; but whether of native or of foreign-born mothers the babies artificially fed had a markedly higher rate of mortality than breast-fed babies The feeding customs of the native and the foreign-bom mother were no doubt different in many respects. Some of these'differences, like the greater prevalence of breast feeding among infants of foreign- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 IN F A N T MORTALITY. bom mothers, tended to lessen while others contributed to increase the mortality rates among these infants as compared with those among infants of native mothers. Probably one such influence tending to make artificial feeding less fatal to the infants of native mothers was the accessibility and us,e of helpful supervision and advice. Of the babies either partially or wholly artificially fed, 313 were children of native and 729 were children of foreign-bom mothers. Of the children of native mothers 63 per cent were receiving some supervision, while only 30 per cent of children of the foreign-born mothers received this care. As might have been expected, the foreign-born mother either could not or did not avail herself of advice on infant feeding through consulting books, pamphlets, or magazines to the same extent as did the native mother. Over one-fourth of the native mothers who artificially fed their babies read literature on infant feeding while only slightly more than one-twentieth of the foreign-born mothers reported that they received guidance from this source.28 The substitutes for breast milk in common use are fresh milk, condensed milk, or some one of the patent infant foods which in this report are designated proprietary foods. The most widely used substitute in Gary among native and foreign-bom alike was fresh milk. Of the babies of foreign-bom mothers one-fourth had received no fresh milk under 15 months of age; a somewhat larger propor tion of the babies of native white mothers (31 per cent) were given no fresh milk during this period.29 Apparently the foreign-born mothers tended more toward feeding their children fresh milk before weaning them than did the native mothers, who seemed rather to make relatively greater use of fresh milk as infant food at or after weaning their babies. Condensed milk and proprietary foods were used less by foreignborn than by native mothers (General Table 8, p. 99), proprietary foods were less popular than condensed milk, which in turn was much less used than fresh milk. Greater similarity of custom in infant feeding according to nativity of mother is shown in the giving of solid food than in the use of any of the liquid foods. Of the infants of native white mothers 16 per cent and of the infants of foreign-bom mothers 19 per cent received no solid food under 15 months of age. Under 9 months of age 40 per cent of the infants of the foreign-born and 32 per cent of the infants of native white mothers had received some solid food. This indicates a tendency among foreign-bom mothers to give their babies solid food earlier than native mothers,30 but many native as well as 28 See General Table 7, p . 99. 29 General Table 8, p. 99. 89 Solid food has been considered any food other than breast milk,fresh cow’s milk, condensed or evapo rated milk, proprietary foods, and orange orfruit juice. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 23 GARY, IN D . foreign-bom mothers seemed to believe it necessary to accustom the baby to take solid food at an early age. One native mother began to feed her 3-months-old boy a mixture of molasses and butter, and gravy and bread “ to get him used to eating.” Another gave her child, 3 months old, “ chewed rations” of whatever she herself ate, including meat, potatoes, gravy, bread, cake, and eggs. In general, such soft foods as oatmeal, farina, cornflakes, mush, soup, eggs, soaked crackers, and gravy on mashed potatoes or bread constituted the solid food diet. Having secured softness for the baby’s diet, some mothers recognized little further cause for exclusion of an article as unfit. There were, for example, the Italian mother who gave her 6-monthsold baby ginger snaps soaked in milk; the native mother who gave her 5-months-old child cornflakes, oatmeal, potatoes, bread and butter and tea; the Polish mother who gave oatmeal with bacon grease to her 8-months-old baby and cut off his supply of cow’s milk; the Croatian woman who began to give her child coffee, bread, and soup when he was 7 months old; and the Slovak mother who gave her infant coffee and cereals from 4 months on. T a b l e X . — A g e at which so lid fo o d was first given , by color and n a tiv ity o f m oth er; in fa n ts b o m in G ary in 1 9 1 6 . Infants born in 1916 to— All mothers. Age at which solid food first given. Num ber. Per cent distriburion. Native white mothers. Num ber. Per cent distri bution. Foreign-bom white mothers. Num ber. Per cent distri bution. Negro moth ers.1 Total............................................. 8 1,322 100.0 371 100.0 940 100.0 11 Not given under 15 months................... Not reported, if given............................ Given under 15 months......................... 245 10 1,067 6 16 105 375 272 287 6 18.5 0.8 80.7 0.5 1.2 7.9 28.4 20.6 21.7 0.5 61 2 308 2 1 24 93 86 100 2 16.4 0.5 83.0 0.5 0.3 6.5 25.1 23.2 27.0 0.5 181 8 751 4 15 80 278 185 186 3 19.3 0.9 79.9 0.4 1.6 8.5 29.6 19.7 19.8 0.3 3 3 months, under 6 ........................... 6 months, under 9 ........................... 9 months, under 12.......................... 12 months, under 15....................... Age not reported.................................... 8 1 4 1 1 1 1 Per cent not shown where base is less than 100. 8 Excludes 31 infants who died not fed. INCOM E, AND FEEDING M ETH O DS. In regard to the age at which infants were weaned slight differ ences of custom were observable among the various earnings groups.31 3i The earnings of the chief breadwinner in the family during the calendar year 1917 were taken as basis for division of families into income or earnings groups, in the belief that these earnings formed as good and dependable a means of determining economic status of families as could be secured in an investigation of this sort. A threefold classification has been made into families where the annual earnings of the chief breadwinner fell below $1,050; those where he earned $1,050, but less than $1,850 in a year; and those where his earnings reached $1,850 or over. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 IN F A N T MORTALITY, GARY, IN D. At the end of the first three months a slightly smaller proportion 8.3 per cent, of the infants belonging to the lowest income group had been weaned than in either the middle or the highest'-group, 10.2 and 12.2 per cent, respectively. At the end of the first nine months about two-tenths of the infants in each of the lower earnings groups had been weaned, as compared with slightly over three-tenths of those in the highest earnings group.32 In all income groups fresh milk was the prevailing type of artificial feeding, condensed milk ranked second, and proprietary foods were least commonly used. The proportion of infants receiving each form of artificial food was greater in the highest income group than in the lowest.33 T able X I .— S u p ervision o f feed in g , b y a n n u a l- earnings o f ch ief breadw inner; in fa n ts p a rtia lly or exclu sively a rtificia lly fe d . Infants bom in 1916 artificially or partially artificially fed during first year. Feeding su pervised. Annual earning.! of chief breadwinner. Feeding not ' supervised. Supervision nof reported. Total. Num ber. $1 OfiO mider fl,850... No earnings, no chief breadwinner, and not Per Num ber. cent.1 Per Num cent.1 ber. Per cent.1 1,053 421 40.0 631 59.9 1 0.1 304 539 153 93 233 76 30.6 43.2 49.7 210 306 77 69.1 56.8 50.3 1 0.3 57 19 38 1 Not shown where base is less than 100. As might be expected, the artificially-fed babies in the lowest income group received the least feeding supervision. For 69 per cent of the infants artificially fed in the group whose breadwinners’ annual earnings were under $1,050 the feeding was not supervised; when the annual earnings were $1,850 or over, only 50 per cent of the babies artificially fed were not supervised. With increase of income, therefore, the added supervision of feeding doubtless tended to offset the ills accompanying the greater use of artificial feeding, an important consideration in view of the much higher death rates which obtained among artificially-fed babies. ** General Table 9, p. 100. 83 General Table 10, p. 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNAL MORTALITY AND MATERNITY CARE. MATERNAL MORTALITY. Seven mothers of babies included in this study died within 1 year after confinement in 1916, 3 of them from causes connected with childbirth. Of the 7 children bom to these mothers only 2 sur vived 12 months, though 3 of the 5 who died were outlived by their mothers. One mother who developed active tuberculosis, following upon the birth of her child, was forced to wean her baby in the fifth or sixth week because of her own ill health. The baby died when a little over 9 weeks old and the mother’s death occurred about a fortnight later. Another mother who had con vulsions at the time of confinement was ill and bedridden until her death about 4 months-afterwards. The baby, born prematurely, lived only 4 weeks. Another infant whose mother died of tuber culosis 9 months after the baby was born lived but a month; the cause of this infant’s death was given on the death certificate as gastroenteritis. The mother of the fourth baby died of puerperal septicemia 16 days after full-term delivery. The baby, a healthy child at birth, was breast fed at home 9 days, spent the next week in the hospital to which the mother had been removed, and was then placed by the father, in an infant asylum where he died at the age of 4 i months. The fifth child and the mother both died less than a day after the baby’s premature birth. The close interrelation between maternal welfare and infant wel fare, between maternal mortality and infant death, requires no elaboration. The practically stationary death rate of mothers in this country from causes connected with childbearing serves, how ever, to indicate the need of giving further consideration to the causes of maternal mortality.34 Table X I I presents what it cost in mothers’ lives to give birth to the children bom in the registration area in 1916, in Indiana in 1917, and in the city of Gary in 1916. In the registration’ area one mother died for every 161 babies bom alive as compared with one for every 138 in Indiana and one for every 140 in Gary. The proportion of 84 Figures published b y the Census Bureau for the years 1900 to 1919 (17.0 per 100,000 population) show steady maintenance of the maternal death rate since 1900. “ And physicians remind us thatthe women who die in childbirth are few beside those who suffer preventable illness or a lifelong impairment of health. The loss involved is immeasurable. It does not stop with the loss o f vigor and efficiency to the mother. It extends, in general, to the well-being of her home and her children; and, in particular, to the motherless infant who faces a peculiarly hazardous existence.” Sixth Annual Report of Chief, U. S. Children’s Bureau, p. 12. 106137°— 23------ 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 25 26 IN F A N T MORTALITY. this loss due to puerperal infections is also brought out in Table X II. The death rate from puerperal septicemia, like the rate from all causes connected with pregnancy or childbirth, shows little reduction from year to year,35 yet puerperal sepsis as a cause of death is very largely preventable.35 Gary’s maternal mortality rate (5.9) from childbed fever in 1916 was more than twice that in the registration area, though the city’s rate from all other puerperal causes compared favorably with that for the registration area. CARE DURING PREGNANCY. The care, supervision, and assistance given mothers during preg nancy and confinement are important both because of their connection with the questions of maternal mortality and well-being and on account of their inseparability from the problems of infant mortality. T a b l e X I I .— M aternal m orta lity rates, by cause o f death, f o r the birth-registration area, 1 9 1 6 , In d ian a 1 9 1 7 , and G a ry, 19 1 6 . Deaths from diseases of pregnancy and confinement. Area. Popula tion as of July 1, 1916. Total. Live births, 1916. Puerperal septicemia. All other. Per Per Per Per Per Per Num 100,000 1,000 Num 100,000 1.000 Num 100,000 1,000 ber. popu live ber. popu live ber. popu Uve. lation. births. lation. births. lation. births. Birth - registration area1.................... 33,013,280 818,983 5,091 Indiana2- ................ 22,835,492 263,144 458 Gary *...................... 8 40,548 1,682 12 15.4 16.2 29.6 6.2 2,066 7.3 226 7.1 10 6.2 8.0 24.7 2.5 3,025 232 3.6 5.9 2 9.2 8.2 4.9 3.7 3.7 1.2 1U. S. Bureau of the Census, Birth Statistics, 1916, p. 4; Mortality Statistics, 1916, Tables 8 and 9. 2 Figures for 1917. tT.S. Bureau oftheCensus, Birth Statistics, 1917, p. 23; Mortality Statistics, 1917, p.334. 3 Population estimated: U. S. Bureau of the Census, Mortality Statistics, 1916, p. 215. Household help and work. Somewhat over half the births in Gary in 1916 (51.5 per cent) were to mothers who reported no help with their housework during pregnancy. Only 12, less than 1 per cent, had no household duties for that period. Native white mothers received help with household duties to a much greater extent than did foreign-born mothers.37 Fifty-eight per cent of the native white mothers and 32 per cent of the foreign bom had household help for at least a month. 35 U. S. Bureau of the Census, Mortality Statistics, 1917, Table II, p. 96: Death rate from puerperal septicemia per 100,000 population: Annual average 1901 to 1905,6.3; annual average 1906-1910,6.8; 1914,7.1; 1915, 6.3; 1916, 6.7; 1917, 6.9. 36 U. S. Bureau of the Census, Birth Statistics, 1917, Table I, p. 24; Mortality Statistics, 1917: Table 5, p. 239. In Indiana cities in 1917 maternal mortality from puerperal septicemia ranged from 1.9 to 12.8 per 1,000 live births, a variation indicative in a measure of the degree of possible preventability and the extent of needless and prodigal loss existing. 37 General Table 11, p. 102. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 27 GARY, ISTD. Mother’s gainful employment during pregnancy. It happens not infrequently that the duties of the mother in a small household are not arduous, even though they include cooking, cleaning, washing, and ironing, as well as general care. If, however, a mother undertakes gainful work in addition to her usual home duties and the care of her family, the sum total of strain and effort entailed may become so great as to be harmful. T a b l e X I I I . — E m p lo ym en t o f m other during pregn an cy, and hind o f w o rk ; births in G ary in 1 9 1 6 . Total births. Mother’s place of employment during pregnancy and kind of work All mothers.............................. Mother not employed during pregnancy___ Mother employed during pregnancy... Away from home.......................... At home only......................... Keeping lodgers........................... Other................................... Per cent Number. distribu tion. 1,393 100.0 984 409 50 359 344 65 70.6 29.4 3.6 25.8 24.7 4.7 Of the births in Gary, 409 (29 per cent) were to mothers gainfully employed during pregnancy and only 50 (3.6 per, cent) were to mothers employed outside their own homes. All but 65 of the mothers gainfully employed during pregnancy kept lodgers. Foreignbom mothers, who, as already pointed out, had less household help than the native white mothers, had the larger proportion gainfully employed in any way. They, too, were the ones most frequently keeping lodgers. Lodger keeping among the foreign born usually increased greatly the amount of work for the housewife. The “ lodger” might be simply a “ roomer,” but he was more often a man for whom the mother cooked as well. Not uncommonly, in addition to preparation of the lodger’s food and care of his room, h is laundry and mending were done by the mother. Sometimes each man bought his own food and the mother cooked it, the number of articles prepared by her being limited only by the individual tastes and de mands of her lodgers. Where all these functions were performed by one mother for several persons there can be no question that the amount of physical energy demanded of her for the tasks of lodger keeping was large and in many cases it was excessive. The mothers of 279 infants (68 per cent of the total whose mothers were gainfully employed) did not cease work even within two weeks of confinement, and the mothers of 256 infants continued gainful work up to the very day or hour of confinement. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 IN FA N T MORTALITY. T a b l e X I V .— In fa n t m orta lity and stillbirth rates, b y in terval betw een m other's ceasing ga in fu l w ork and confinem ent and color and n a tiv ity o f m other; births in G ary in 1 9 1 6 . Interval betweencessation of gainful work and confinement and color and nativity of mother. Stillbirths. Total births. Live Number. Percent1 births. Infant Infant deaths. mortality rate.1 All mothers........................................ Not employed.............................................. Employed................................................... Interval: Under 1 day.................................... 1 day, under two weeks................. 2 weeks, under 1 month................. 1 month, under 2............................ 2 months and over.......................... Not reported................................... Native white mothers........................ 1,393 984 409 40 25 15 2.9 2.5 3.7 1,353 959 394 169 116 53 124.9 120.9 134.5 256 23 11 20 90 9 394 8 3.1 34 3 3 5 8 137.1 11 2.8 248 23 10 19 85 9 383 37 96.6 Not employed.............................................. Employed.................................................... Interval: Under 1 d ay .................................... 1 day, under two weeks................. 2 weeks, under 1 m onth................. 1 month, under 2............................ 2 months and over.................... . Not reported................................... Foreign-born white mothers............ 315 79 8 a 2.5 307 76 29 8 94.5 36 6 5 7 22 3 987 i 3 28 2.8 35 6 4 7 21 3 959 128 133.5 Not employed............................ ................. Employed.................................................... Interval: Under 1 d ay .................................... 1 day, under 2 weeks...................... 2 weeks, under 1 month................. 1 month, under 2............................ 2 months and over.......................... Not reported................................... Negro mothers. . . : ............................ 658 329 16 12 2.4 3.6 642 317 84 44 130.8 138.8 219 17 6 13 68 6 12 7 3.2 30 3 i 4 6 141.5 1 4 212 17 6 12 64 6 11 Not employed.............................................. Employed.................................................... 11 1 1 10 1 3 1 1 1 5 l i 1 2 1 2 1 Not shown where hase is less than 100. That gainful employment of mothers during pregnancy, a higher stillbirth rate, and an increased infant mortality rate were coincident is demonstrated in Table X IV , which shows that the infant mortality rate was highest among babies whose mothers ceased gainful work less than a day before their babies were born. Prenatal care and instruction. The importance of prenatal care receives lamentably little recogni tion from mothers, who fail to be impressed by the pregnancies and confinements presenting serious difficulties because the greater num ber of pregnancies terminate favorably. Realization that expert med ical supervision is not only wise but necessary for all pregnant women if the possible complications of pregnancy are to be combatted and those of confinement foreseen and guarded against has come slowly, and as yet but partially, to mothers and fathers even in our most en lightened communities. Yet, skilled prenatal and confinement care is admittedly a prerequisite to an attack upon the maternal mortality rate and the death rate of babies from causes connected with early infancy. The prenatal care received by mothers in Gary in 1916 has been classified into three grades, designated A, B, and C. For the purpose https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, I2TD. 29 of the study, to be classified as Grade A the prenatal care given a mother must fulfill all four of the following requirements: 1. Monthly urinalysis at least from the fifth through the ninth month of pregnancy. 2. Medical supervision at least for the last five months. 3. Physical examination, preferably including examination of the heart, the lungs, and the abdomen, but at least providing examina tion of the abdomen. 4. Measurement of the pelvis in a woman bearing her first child in order to discover the existence of any malformation which might make birth difficult or impossible normally. If the prenatal care given a mother failed to meet all these require ments it was classified as Grade B if it fulfilled all four of the following less stringent tests: 1. At least one urinalysis. 2. Some medical supervision. 3. An abdominal examination. 4. Pelvic measurements if the mother was a primipara. Mothers who had had urinalysis or had made visits to physicians or clinics were classified as having had prenatal care of Grade C if the care failed in one or more particulars to satisfy the requirements of the higher grades. Seven-tenths of the mothers had no prenatal care whatever; of the remaining three-tenths, 33 (2 per cent of the entire number of mothers) had care of Grade A ; 54 (4 per cent) had Grade B care; and 318, almost one-fourth (23 per cent), received care which failed in some essential and could only be classed as Grade C. T a b l e X V .— Grade o f prenatal care, by source o f in stru ction in prenatal care; con fin e m en ts in G ary in 1 9 1 6 . Confinements in 1916 of mothers— Receiving prenatal care of specified grade. Source of instruction in prenatal care. Receiving no pre natal Total. care. 8 Total..................................... 21,376 966 Not reported whether prenatal in- [C. Total. P pO O Prenatal instruction...................... Physician only........................ Physician and nurse.___. ___ Physician, nurse, literature... B. A. Not re ported Grade whether un care re known. ceived. "3 CD O ÍH gt <D ’S CD V CD -M 1 U & © pQ Ph & . P< £ 70.2 406 29.5 924 924 100.0 9.3 406 90.0 451 42 283 1 0.4 281 99.3 6 6 10 10 94 93 24 10 14 1 3 2 31 30 1 F h CD pQ -+-5 1o ■ F h' <d Ph CD pQ Fh "3 pS CD O .*C•< D Ph 4-i d CD Q F h CD pQ •I h * CD . CD u Ph* & 33 2.4 54 3.9 318 23.1 1 0.1 4 0.3 33 7.3 20 7.1 1 2 10 54 12.0 318 70.5 29 10.2 231 81.6 1 4 3 5 62 21 14 2 1 0.2 1 0.4 3 0.7 1 0.4 1 1 •t 1 1 Not shown where base is less than 100. 2 Includes 17 confinements which resulted in twin births and 5 instances where mother had two con finements in 1916. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 IF F A O T MORTALITY. No one of the three mothers who died from causes connected with childbirth had even a modicum of prenatal care. The mother who died of “ septicemia following Cæsarian section” had had two children still-born because, as the father said, she was “ built too little.” Yet recourse was not had to a physician until after serious trouble had developed. The death certificate stated as contributory cause of death “ septic before operation, three days.” Another mother died of “ acute dilatation of the heart following delivery of child.” The delivery was instrumental as well as premature. There had been absolutely no consultation of a physician earlier in preg nancy. The third mother was delivered b y a midwife. Septicemia developed; physicians were then summoned, and the mother removed to a hospital. In two of these instances the baby as well as the mother died. Two hundred and fifty-seven confinements, somewhat less than a fifth (19 per cent) of the entire number, were at the termination of first pregnancies. Of these mothers, 129 (50 per cent) had some prenatal care, a proportion noticeably above that for the whole group (30 per cent). Among mothers bearing their first child, however, the percentage receiving Grade A care was no greater than among the group as a whole, while that for mothers receiving Grade B care was smaller, and the proportion with Grade C care was twice as high as for the entire group. Probably failure to take pelvic measure ments was responsible for placing relatively more of the first preg nancy mothers in the lowest grade of prenatal care. T a b l e X V I .— Grade o f 'prenatal care, b y order o f p reg n a n cy; confinem ents in G ary in 1916. Confinements in 1916 of mothers— Receiving prenatal care of specified grade. Receiving no pre Grade natal un C. A. B. Total. care. known. Order of pregnancy Not re ported whether care re ceived. Total..................................... a 1,376 966 Second............................................ Fifth . 257 283 251 180 138 95 69 47 21 32 3 70.2 406 29.5 128 49.8 129 50.2 176 62.2 104 36.7 181 72.1 69 27.5 143 79.4 37 20.6 114 82.6 24 17.4 75 20 5 64 10 37 1 20 6 26 1 2 CD © u <D Ph *©4 rQ tí 8 fH CD Ph 33 2.4 54 3.9 318 23.1 6 16 6 1 2 1 6 21 12 5 5 1 1 2.3 5.7 2.4 0.6 1.4 2.3 7.4 4.8 2.8 3.6 18 117 45.5 66 23.3 51 20.3 31 17.2 17 12.3 18 1 9 1 6 1 d © u <D Ph 1 Number. Ph fl |Number. »-i CD Ph Í3 s S-4 © 1Number. d 8. Number. |Number. Per cent.1 Number. Total. d © O U © P< 1 0.1 4 0.3 1 0.4 3 1.1 1 0.4 1 Not shown where base is less than 100. * Includes 17 confinements which resulted in twin births, and 5 instances where mother had two con finements in 1916. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 31 GARY, IND. Eighty-eight per cent of the births were reported to have been attended b y no complications.38 Of the remaining 12 per cent (168) which were accompanied by complications, half were to mothers receiving some prenatal care; about one-twentieth to mothers who had Grade A care; one-twentieth to mothers with Grade B care; twofifths to mothers whose care during pregnancy was of Grade C. Like mothers approaching their first confinement, mothers who experienced or feared some complication of pregnancy or confine ment showed a greater tendency to seek prenatal supervision and help than was shown by the mothers as a whole or b y those whose pregnancy was normal and presaged no difficulty for confinement. Even anfong mothers suffering some complication, however, 9 out of 10 either had no prenatal care or care of Grade C, a fact indicating an unmistakable need for educating mothers regarding what to seek and to demand in the way of care and supervision during pregnancy and at confinement. T a b l e X V I I .— Grade o f prenatal care o f m other by com plications o f pregnancy and con fin em en t; births in G ary in 19 1 6 . Births in 1916 to mothers— Receiving prenatal care of specified grade. Complications of pregnancy and con finement. Total. Receiv ing no pre Total. natal care. A. B. Not re ported Grade whether care re un known. ceived. C. Total........................................... 1,393 980 409 33 54 321 1 No complications................................. Complications...................................... Prematurity only......................... Prematurity with: Stillbirth..................... ........... Stillbirth and instrumental delivery............................... Instrumental delivery............ Convulsions............................. Instrumental delivery and convulsions.......................... Full-term births: Stillbirth only........................ Stillbirth, convulsions, and instrumental delivery......... Stillbirth and instrumental delivery............................... Stillbirth' and Caesarian section....................................... Instrumental delivery........... Caesarian section.................... Convulsions............................ Not reported1................................ 1,224 169 48 896 84 29 324 85 19 24 9 4 46 8 253 88 15 1 7 1 6 1 1 6 3 1 17 6 3 3 1 3 1 1 1 14 3 1 1 1 8 4 1 68 2 5 1 1 22 1 5 3 1 4 4 46 1 6 1 4 1 6 1 39 1 1 Period of gestation not reported; delivery instrumental. Approximately one-third of the mothers had recognized a need for instruction in prenatal care and endeavored to secure it. Of these, 3« The complications reported upon were instrumental delivery, Caesarean section, convulsions, prema ture delivery, and stillbirth. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 IN F A N T MORTALITY. 29 per cent were advised and instructed by physicians and a small number (27), by nurses. About 1 mother in 10 found help through books or magazine articles. Usually this was in addition to instruc tion b y word of mouth from doctor or nurse, but 2 per cent of the mothers relied upon literature alone. (Table X V .) Native mothers sought advice and instruction more frequently than foreign-born mothers. Only 25 per cent of the native white mothers had no instruction in prenatal care from doctor, nurse, or literature; 84 per cent of the foreign born were without such instruc tion. The foreign-born woman is much less likely to seek out physician or trained nurse inasmuch as she relies in the New World as in the Old upon the services of a midwife or upon the advice of neighbors, relatives, and friends.39 The same tendency holds with reference to prenatal care. Less than 1 per cent of the foreign-born mothers had Grade A care while 7 per cent of the native mothers secured the best grade of supervision. Approximately seven-eighths of the foreign born had no medical care whatsoever, while but onefourth of the native white mothers suffered such complete lack.40 From the point of view of maternal mortality it is significant that all three of the deaths from causes connected with pregnancy and con finement were deaths of foreign-born mothers who, as already stated, had no prenatal care. Where no widespread system of free maternity care and instruction is operative, it may be expected that the size of the family income will influence more or less the extent to which mothers in different income groups will aspire to prenatal instruction and care and be able to satisfy their desires. When the family income, as represented by the chief breadwinner’s earnings,was under $1,050 per annum, only 14 per cent of the mothers had any prenatal instruction and only 12 per cent received any pre natal care. In the highest income group where annual earnings were $l,85Q,.or over, 65 per cent of the mothers had prenatal instruction and 62 per cent prenatal care. The intermediate group, with annual earnings of chief breadwinners $1,050 but less than $1,850, occupied a mid position also in the proportion of mothers securing prenatal instruction (34 per cent) and prenatal care (31 per cent). The mothers in the lowest earnings group having Grade A care during pregnancy constituted 1 per cent; in the mid-group, 2 per cent; and in the highest group, 7 per cent. The three maternal deaths from childbirth were of mothers in families with less than $1,050 for a yearly income. All conditions of family and individual life are likely to be less favorable when the income is low; housing inferior, ignorance of sanitation and hygiene greater, and power to satisfy physical wants reduced. 39 General Table 12, p. 103. <° General Table 13, p. 103. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 33 GARY, IU D . T a b l e X Y I I I .— P revalen ce o f prenatal care and in stru ction in prenatal care, by an n u al earnings o f ch ief breadw inner; con finem ents in G ary in 1 9 1 6 . Confinements in 1916 of mothers— Annual earnings of chief breadwinner. Total. Receiving no prenatal care. Receiving prenatal care. ' Not reported whether care received. Receiving Not Receiving no instruc instruction reported tion in whether in prenatal prenatal instruction care. care. received. Num Per Num Per Num Per Num Per Num Per Num Per ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 29.5 4 0.3 924 67.2 451 32.8 1 46 11.7 221 30.7 115 62.2 24 i i i i 0.3 0.1 0.5 337 473 64 50 55 140 248 34.4 121 65.4 27 1 Total.............. » 1,376 966 70.2 «406 392 721 185 78 345 499 69 53 88.0 69.2 37.3 Under $1,050........... $1,050, under $1,850 $1,850 and over....... N6 earnings, no chief breadwinner, and not reported. 86.0 65.6 346 0.1 1 Not shown where base is less than 100. * Includes 17 confinements which resulted in twin births, and 5 instances where mother had two confine ments in 1916. * Of the 33 instances of adequate care included here, 4 were in the earnings group “ under $1,060,” 14 in “ $1,050, under $1,850,” 13 in *‘$1,850 and over,” 2 in “ earnings not reported.” CARE DURING CONFINEMENT PERIOD. Attendant at birth. The foreign-born mother/ it has been seen, secured much less help and supervision from physicians during pregnancy than did the native white mother. For confinement care her custom was to resort to the help of a midwife rather than to engage a physician to attend her. The reasons for this preference for the midwife doubtless in cluded, besides the desire for a woman attendant at confinement, appreciation of the greater amount of nursing service and household help which the midwife rendered in conjunction with the lower fee which she charged. Slightly more than seven-tenths of the mothers of foreign birth had no attendant other than a midwife. Fifty-one others (5 per cent) had both a midwife and a physician, the latter having been called in usually because labor had been long or difficult or because the confinement presented complications. Among the native white mothers but 13 per cent had no attendant except a mid wife, and 3 per cent had both physician and midwife. The propor tion of native white mothers who were attended by physicians ap proximated nine-tenths while the proportion of foreign-born mothers attended by physicians but slightly exceeded two-tenths. Hospital confinements constituted 22 per cent of the total among the native white, and but 4 per cent among the foreign born. As a group, there fore, the foreign born had confinement care which was less skilled and much less capable of meeting successfully any abnormal con ditions which might arise during, or immediately following, delivery. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 34 IN F A N T MORTALITY. T a b l e X I X .— A tten d a n t at confinem ent and tim e o f arrival^ o f attendant, b y color and n a tiv ity o f m oth er; con finem ents in G ary in 1916. Confinements in 1916. * Attendant and time of arrival, and place of confinement. Nathit y of mother. Total. Native white. Num ber. Per Num cent ber. distri bution. Foreign-horn white. Per Num cent ber. distri bution. Per Negro.1 cent distri bution. 392 100.0 972 100.0 12 Confinement in hospital.................................... 125 ÖTT s i 22.2 35 3.6 3 Physician..................................................... 120 2 3 8.7 0.1 0.2 86 1 21.9 0.3 31 1 3 3.2 0.1 0.3 3 Confinement not in hospital............................. 1,251 90.9 305 77.8 937 96.4 9 Physician only............ ............................... On time................................................. 393 381 12 754 737 16 1 32 30 2 58 55 3 14 28.6 27.7 0.9 54.8 53.6 1.2 0.1 2.3 2.2 0.1 4.2 4.0 0.2 1.0 242 234 8 51 49 2 61.7 59.7 2.0 13.0 12.5 0.5 0.5 0.5 10 9 1 2.6 2.3 0.3 15.0 14.7 0.3 71.9 70.4 1.4 0.1 3.1 2.9 0.2 4.9 4.7 0.2 1.4 5 4 1 4 4 2 2 146 143 - 3 699 684 14 1 30 28 2 48 46 2 14 Total......................................................... 21,376 Midwife only............................................... On time................................................. 100.0 1 Per cent not shown where base is less than 100. a Includes 17 confinements which resulted in twin births and 5 instances where mother had two confine ments in 1916. One per cent of the physicians and 1 per cent of the midwives sum moned to attend mothers reached the mothers only after delivery but in time to perform part of the services required, namely, delivery of the placenta or tying and cutting the cord. A small number of physicians (13) were not able to reach the mothers in time to render any of these services. Thirty-two mothers (2 per cent) had for attendant a relative, neighbor, or friend, sometimes pressed into service because labor was so short no professional help could be secured, sometimes because either mother or father thought professional services a needless expen diture. One father, for example, said he became disgusted with doctors during his wife’s earlier pregnancies because she went to them for little headaches, the doctors did nothing, and he always had big bills to pay. This father, however, after delivering the mother himself, sent for a doctor when the baby was 7 hours old, upon the advice of a fellow section hand, to make sure everything was all right. He also stayed home from work 12 days to care for the mother. Fourteen women (1 per cent) had no attendant of any kind at confine- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IND. 35 ment, but did everything for themselves. In a few of these cases the birth occurred so quickly that the attendant was unable to reach the mother before delivery. In some cases the mother was alone and could not send for help and in others no effort was made to procure assistance though the father was at home. (Table X IX .) Since slightly more than seven-tenths of the 1,371 mothers con sidered were born outside the United States, most of them in coun tries where it is customary to employ midwives at confinement, it is not surprising that about six-tenths of all the mothers were delivered by midwives. As might be expected, Gary with its large foreign population had a number of midwives. The Indiana State medical law, passed in 1897, provides a State board of medical registration and examination. According to the law which went into effect in 1899, an applicant for a certificate to practice midwifery in the State was required to present a duly attested diploma from an obstetrical school approved by the board or to pass a satisfactory examination. A midwife who had been practicing in the State 10 years preceding 1897 might secure a certificate to continue her vocation by submitting affidavit prior to July 11, 1899. No provision had been made for the supervision of midwives after certification.41 The official register of midwives licensed to practice in the State in 1916 did not contain the names of 17 who attended some of the births in Gary in 1916. The number of mothers who were attended b y un licensed midwives was only approximately 5 per cent of those who had midwife attendants. If to these mothers are added those who reported a midwife attendant but failed to disclose her name, the percentage, though doubled, is still low. No unlicensed midwife attended any large number of births; usually she had taken charge of but a single confinement. On the whole, then, it appears that the State law was functioning in Gary to such an extent that in 90 per cent of the 817 confinements attended by midwives in 1916 the atten dant midwives had been licensed to practice. Nearly half the births attended by unlicensed midwives were not registered, while of those attended b y licensed midwives, 89 per cent were registered, a show ing only slightly below the percentage of registered births among those attended by physicians. Postnatal care has been classified into grades A, B, C, and D on the basis of the number of visits made by the attendant subsequent 41 The examination fee was fixed at $10; at the time of this study, 1916, the examination might be written in whatever language the applicant desired but an additional $10 fee was required for translation. By 1919 the privilege of using any language but English had been withdrawn and a possible source of deception done away with. Indiana, Acts of 1897, p. 255, as amended; Bums’ Annotated Statutes 1914, secs 8401 to 8408. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 IN F A N T MORTALITY. to the visit at delivery and the period of time covered by them. For the highest grade of care (grade A) it was necessary that the attend ant make at least daily visits through the fifth day of the lying-in period, and call again the seventh or eighth day, and once more on the tenth or eleventh day, giving a minimum of seven visits. The lowest grade required merely one visit besides the visit at delivery. Grades B and C are intermediate. Of the 517 babies whose mothers were attended by physicians only 30 per cent received grade A, 34 per cent grade B, 26 per cent grade C, and 6 per cent grade D care. For mothers of 763 babies where a midwife was the only attendant, the postnatal care was distributed as follows through the different grades: Grade A, 26 per cent; B, 71 per cent; C, 2 per cent; D, three-tenths of 1 per cent. When a physician and midwife both attended the delivery the after care during the confinement period suffered, probably because neither attendant felt undivided responsibility. Of the 66 babies born to mothers who had 2 attendants (doctor and midwife), 25 were to mothers to whom no return visits were made; and among the different grades of care the largest number (15) fell into grade D.42 The figures just cited show the midwife custom in caring for mother and baby. Usually for 7 or 8 consecutive days after delivery the mid wife makes a daily visit during which she gives nursing service to both mother and child. The final examination of a maternity patient 4 to 6 weeks after delivery is coming to be recognized as one of the standards of good practice which an obstetrical attendant should meet.43 Of the mothers who bore babies in Gary in 1916, 1,215 (or 88 per cent) had no such final examination from attendant physician or midwife; 54 mothers (4 per cent) who were attended by physicians received examinations 4 weeks or more after delivery; an additional 13 (about 1 per cent) received examinations before their physicians discharged them, but were discharged less than a month after delivery. Fiftytwo mothers (about 4 per cent) reported receiving final examinations from midwife attendants. In view of the midwife’s more restricted obstetrical knowledge and training these examinations were un doubtedly less thorough than those given b y physicians and afforded correspondingly less protection to the mothers. « General Table 14, p. 104. 43Minimum Standards for the Public Protection of the Health of Children and Mothers, p. 436; Standards of Child Welfare, Children’s Bureau Publication, No. 60. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 37 GARY, IND. Table X X . F in a l exam ination o f m other b y attendant before discharge; confinem ents in G ary %n 1 9 1 6 . Total confinements in 1916. Final examination of mother by attendant before discharge. Percent Number. distribu tion. Not reported whether examination made.. ................................... m en tfto m 6 .COnflnementS Which resulted in twin births and 5 instances where mother had tv 100.0 90.9 88.3 2.6 4.9 3.9 0.9 3.8 0.4 ? ' 11,376 1,251 1,215 36 67 54 13 52 6 1 .............................. ................................... ....................... ........................................ ................... O o 0 Total............. No examination....... Physician or midwife attending _ No physician or midwife attending. Examination by physician. . . 4 weeks or more after delivery. Less than 4 weeks after delivery... Nursing care. The kind and extent of nursing care given a mother d u r in g the period are extremely important. The mothers of about one-tenth of the babies born in 1916 were cared for in hospitals, and a similar group was cared for by trained nurses at home. The mothers of 7 per cent of the infants were cared for by practical or student nurses; those of a little over a fifth of the babies were de pendent upon untrained outsiders or members of the family; and in fully half the cases the mothers were dependent upon midwives for nursing care. It has been noted that the training of attendants at birth among foreign-bom women was usually inferior to that of attendants at confinements of the native mothers. The nursing service which foreign-born mothers had during the lying-in period was also of a less skilled type. Well over a third of the babies of native mothers and only about an eighth of those of foreign mothers were bom in hos pitals or in homes where a trained nurse was employed for the con finement period. Midwife care was the highest type of nursing service received by two-thirds of the foreign-born and by only one-tenth of the native white mothers. T able X X I. K in d o f n u rsin g care received b y m other during lyin g -in period, by n a tivity o f m o th er; births in G ary in 19 1 6 . Births in 1916 to— Kind of nursing care during lying-in period. All mothers. Native mothers. Foreign-bom , mothers. 1 Per cent Per cent Per cent Number. distribu Number. distribu Number. distribu tion. tion. tion. Total....................... Trained nurse............... Midwife................. Practical or student nurse......... Other, (outsider)................. Other (member fam ily)___ Not reported.............. 1 Includes 12 native negro mothers. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1,393 130 146 711 101 244 59 2 100.0 9.3 10.5 51.0 7.3 17.5 4.2 0.1 1406 92 61 42 75 120 16 100.0 22.7 15.0 10.3 18.5 29.6 3.9 987 38 85 669 26 124 43 2 100.0 3.8 8.6 67.8 2.6 12.6 4.4 0.2 38 IFFAiTT MORTALITY. A difference similarly favorable to the native mother was found in the aggregate length of time which nursing care of any type covered. Of the foreign-bom mothers, 57 per cent had ceased to have nursing care within 10 days after delivery; while 56 per cent of the native mothers received nursing care for two weeks or longer.44 In progressing from the lower to the higher income groups, the amount of nursing care received by the mothers showed a steady increase. For example, nursing care lasting for two weeks or longer was received by the mothers of 30 per cent of the babies in the lowest earnings group, 40 per cent in the mid group and 58 per cent in the highest group. Conversely, when the income was low the mothers of 1 baby in 10 had nursing care less than a week as compared with 1 in 30 when the income was high. T a b l e X ^ I I .— D u ra tion o f n u rsin g care f o r m other, b y annual earnings o f ch ief bread w in n er; births in G ary in 1 9 1 6 . Births in 1916. Duration of nursing care. Annual earnings of chief bread winner. Total. Less than 7 7 days, less than 10. days. 10 days, less than 14. 14 days and over. Duration not re ported. Num Per Num Per Num Per Num Per Num Per ber .i cent. ber. cent.1 ber. cent.1 ber. cent.1 ber. cent -1 Total..................................... 1,393 2 109 7.8 403 727 185 44 55 6 10.9 7.6 3.2 878 4 Under $1,050.................................. $1,050, under $1,850....................... $1,850 and over.............................. No earnings, no chief breadwin- 36.8 217 15.6 552 39.6 3 0.2 186 46.2 260 35.8 38 20.5 53 121 34 13.2 16.6 18.4 120 289 107 29.8 39.8 57.8 2 0.3 512 28 9 36 • 1 1Not shown where base is less than 100. . 2includes one infant whose mother died at childbirth, and one whose mother died four days after delivery. 8Includes 6 births in families where there was no chief breadwinner and 11 in families where there were no earnings. Days in bed and household help. A mini mum of 10-days’ rest in bed after a normal delivery is commonly recommended b y obstetricians and resumption of house hold duties is discouraged under a fortnight. Seven hundred and forty-six mothers (54 per cent) remained in bed less than 10 days after delivery. Native mothers are much more likely to observe 10 days as a requisite rest period following parturition than are foreignbom mothers. No native women in the group studied spent less than a day in bed after delivery, but two Polish and two Slovak mothers rested less than 24 hours following the birth of their babies. One-eighth of the foreign mothers were up within 4 days, more than << Cenerai Table 15, p. 104, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 39 GABY, IND. one-fourth within a week, and only a third spent 10 days (the mini mum recommended) or more, in bed. Three-fourths of the native white mothers, on the other hand, spent at least 10 days in bed following confinement. T a b l e X X I I I .— N um ber o f days in bed fo llo w in g con fin em en t, b y color and nation a lity o f Toother; con finem ents in G ary in 1 9 1 6 . Confinements in 1916. Number days in bed following confinement. Color and nationality of mother. Total. Less . 1 day, 4 days, 7 days, 10 days, 14 days Not re than 1 less less less less and day. than 4. than 7. than 10. than 14. over. ported. © rQ T o t a l................... Native white................... Foreign-bom white......... Polish....................... . Serbian and Croatian Slovak........................ All other.................... Negro............................... *1,376 392 972 272 159 135 406 12 1© S ©-t Ph 5m * ©' fc d o© © P* (H ¡25 t-4 © d pQ © o Sh © Ph S h 4^ © © d g ^rO & © o © »•< *4 © © Pi fc Pi fc d © © © Pi © rû d © «-o t-4 © P-1 4 0.3 120 8.7 170 12.4 452 32.8 289 21.0 336 24.4 *5 0.4 4 1.0 15 3.8 75 19.1 183 46.7 115 2a. a 4 0.4 115 11.8 155 15.9 371 38.2 103 10.6 219 22.5 2 0.7 45 16.5 58 21.3 84 30.9 15 5.5 67 24.6 16 10.1 18 11.3 60 37.7 19 11.9 43 27.0 2 1.5 15 11.1 23 17.0 64 47.4 6 4.4 25 18.5 39 9.6 56 13.8 163 40.1 63 15.5 84 20.7 1 3 6 2 5 0.5 1 0.4 3 1.9 1 0.2 1 Not shown where base is less than 100. mentsin^l916^ con®Jlemerl*'s which resulted in twin births and 5 instances where mother had two conflne* Includes 3 instances where the mother died as result of childbirth. A mother may know that it is wise to rest the prescribed number of days after her baby’s birth, yet believe that for her it is imprac ticable not to resume activities sooner. Mothers of 1,271 babies were confined at home," in only 4 cases did the mothers have no household help during the lying-in period, while the mothers of 1,252 babies had assistance with housework for at least part of the time after delivery. Mothers of 121 babies remained in bed less than 4 days after the babies’ birth, although half of them had house hold help of some sort for a week or more. ' The mothers of all but 15 of these babies (12 per cent) were dependent upon the unpaid help of either a neighbor or member of the household, and accordingly might have felt obliged to get up as soon as possible. When, as in 9 cases, the mother stayed in bed less than 4 days in spite of the fact that hired help was kept from 1 to 4 weeks, it would appear that she herself had small regard for her own welfare and safety. For the most part, however, there seemed to be some relation between the length of time the mother rested in bed and the portion of the lying-in period during which she had help with her housework.45 <5 General Table 16, p . 105 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 in f a n t M o r t a l it y , g a r y , in d . In approximately one-third of the homes there was paid house hold help during the confinement period, but it was customary both in homes of the native white and those of the foreign-born mothers for neighbors or members of the family to assume extra tasks while the mother was incapacitated. Paid assistance was relatively less frequent among foreign-bom mothers, however, who also showed a tendency to dispense sooner with any additional help secured because of confinement. Almost half of the native white mothers kept house hold help for at least a month after delivery; almost half the foreignborn mothers, on the contrary, had help for less than two weeks, and the proportion among them keeping assistance for a month or longer was less than half that among native white mothers. Family income apparently had some effect upon the length of time which the mother spent in bed after her baby’s birth as well aa upon the time she kept help with housework. More than threefifths (65 per cent) of the mothers in families in which the chief breadwinners earned less than $1,050 in a year observed less than the 10-day period in bed after delivery, and about one-half (51 per cent) had household help less than two weeks. When the income was $1,850 or over, 36 per cent got up before the tenth day and only about one mother in six (16 per cent) had household help less than a fortnight.47 __________________ _ _ 46 General Table 17, p . 106. 47 General Tables 18 and 19, pp. 107,108. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis AGE OF MOTHER AND ORDER OF BIRTH. A mother’s age at the time her child is born may exert an influence over the infant’s chance of survival. A very young mother suffers the disadvantages of physical immaturity, inexperience in the proper care of herself during pregnancy, and ignorance regarding the proper care of her baby. On the other hand, a woman who has borne many children may suffer physical disadvantages from repeated child bearing although she may be able to counteract them by the knowl edge which she has secured from experience and instruction. The highest infant death rate in Gary in 1916 (187.1) was found among babies born to mothers less than 20 or to women 40 years of age or over.48 Babies born to mothers in the twenties had the best likelihood of living 12 months, for the mortality rate among these children was only 106.7, The mortality rate for infants bom to mothers in the thirties (132.3), while it showed a notable rise above the lowest rate, fell far short of the highest. The stillbirth rate also was lowest (2.2) among babies born to mothers in the twenties. The proportion of dead-born infants was highest (4.5 per 100), however, among the births to women in the thirties. Subdivision according to mother’s nativity, though it renders the numbers too small to permit calculation of all the rates, shows that the trend in each nativity class is similar to that in the group as a whole. T a b l e X X I Y . — In fa n t m orta lity and stillbirth rates, b y age and color and n a tiv ity o f m oth er; births in G ary in 19 1 6 . Age of mother at birth in 1916 and color and nativity of mother. Total births. Stillbirths. Number. Percent.« Live births. Infant deaths. Infant mortality rate.“ All mothers........................................ Under 20 or 40 and over.............................. 20 to 29.......................................................... 30 to 39.......................................................... Not reported................................................ 1,393 143 824 396 30 40 4 18 18 2.9 2.8 2.2 4.5 1,353 139 806 378 30 169 26 86 50 7 124.9 187.1 106.7 132.3 Native white mothers........................ Under 20 or 40 and over.............................. 20 to 29.......................................................... 30 to 39............. ............................................ 394 11 2 6 3 2.8 383 55 235 93 37 10 18 9 96.6 b 57 Foreign-born white mothers............ Under 20 or 40 and over.............................. 20 to 29.......................................................... 30 to 39.......................................................... Not reported.......................................... . 987 c 83 678 296 30 28 2 12 14 959 81 566 282 30 128 15 66 40 7 133.5 Negro mothers.................................... Under 20 or 40 and over........................ 20 to 29....................................................... 30 to 39......................... ................................ 12 3 5 4 1 u 3 5 3 4 1 241 96 1 2.5 2.8 2.1 4.7 76.6 116.6 141.8 2 a Not shown where base is less than 100. 6 Includes 46 to mothers under 20. c Includes 60 to mothers under 20. 48In other studies both the groups “ under 20” and “ 40 and over” showed high rates; the groups are combined in this report on account of the small number of cases. 106137°— 23------ 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 41 42 IN F A N T MORTALITY. Two hundred and fifty-eight babies were born as the result of first pregnancies. Of these births, 8 per cent, according to the mothers’ statement, were premature, a proportion higher than was found to obtain for any succeeding pregnancy. First births to women under 20 years of age formed about a fourth (26 per cent) of the. total first births, but included almost half the first pregnancies which termi nated at less than normal term. Of all births in 1916 to mothers under 20 or 40 years of age or over, 1 in 10 was reported to have occurred prematurely; of births to mothers in the twenties, 1 in 22; and of those to mothers in the thirties, 1 in 28.49 The 53 babies born at less than full term— less than 4 per cent of the live births— contributed 36, or 21 per cent, to the total of 169 infant deaths. If all the babies in Gary had been bom at full term the infant mortality rate would have been reduced from 124.9 to 101.6, or nearly one-fifth. T a b l e X X V .— In fa n t m orta lity and stillbirth rates , by p eriod o f g esta tio n ; births in G ary in 1 9 1 6 . Stillbirths. Period of gestation. Total births. 1,393 11 26 29 1,326 1 Live births. Infant deaths. Number. Percent.1 40 7 6 27 2.9 2.0 1,353 169 11 19 23 1,299 1 11 11 14 132 1 Infant mortality rate.1 124.9 101.6 i Not shown where base is less than 100. Infants bom of first pregnancies had a mortality rate of 140.6; sec ond bom 104.3; third born 104.8. For fourth born the rate rose to 142 but sank to 115.1 for children fifth in order of birth. Babies bom of sixth or later pregnancies had a rate of 142.3. The still birth rate was high for first pregnancies (3.5), although it was exceeded by the rate, 4.4, secured when sixth and later pregnancies were combined. Infant mortality rates by order of birth to native white and to foreign-bom mothers showed substantially the same trend. In inter preting the differences, however, between the infant mortality rates for all babies of native white mothers (96.6) and for all infants of foreign-bom mothers (133.5), the higher proportion of first births « General Table 20. o . —. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IND. T able X X Y I . 43 In fa n t m orta lity and stillbirth rates, by order o f ‘p regnancy and color and n a tiv ity o f m oth er; births in G a ry in 1 9 1 6 . Order of pregnancy and color and nativ ity of mother. Stillbirths. Total births. Number. Percent.1 All mothers. 1,393 Order of pregnancy: First................................ Second........................... Third........................ Fourth.................... Fifth.................... Sixth and later............. Not reported................... 1,353 258 285 253 182 140 272 3 Native white mothers.................. Order of pregnancy: First............................. Second.................... Third............................. Fourth......................... Fifth........................... Sixth and later............. Foreign-bom white mothers.. Order of pregnancy: First.................................. Second...................... Third........................ Fourth........................... Fifth................... Sixth and later.............. Not reported.......... 394 ' '** Infant deaths. Infant mortality rate.1 169 124.9 139 260 140.6 104.3 104.8 142.0 115.1 142.3 383 96.9 278 248 11 120 107 64 31 26 46 2 987 28 134 174 188 149 114 225 3 Negro mothers................... Order of pregnancy: First........................... Second................... Third...................... Fourth.................... Sixth and later................... 40 Live births. 2.8 115 105 62 31 26 44 2.8 131 10 1 4 4 1 2 1 1 130.4 76.2 1 6 128 185 143 12 15 8 3 4 133.5 145.0 118.3 124.3 139.9 132.7 139.5 n 1 Not shown where base is less than 100. and of births to young mothers among the infants in the native white group should be borne in mind. Fourteen per cent of the babies of foreign-bom mothers as compared with 31 per cent of those of native white mothers were first-born children; 5 per cent of the babies of foreign-bom mothers as compared with 12 per cent of those of native white mothers were bom to mothers when under 20 years of age. (Tables X X IV and X X V I.) The unfavorable tendencies which at tached to first births and to births to young mothers as shown in this study tended to raise slightly the mortality rate for babies of native white mothers as compared with the rate for babies of foreign-bom mothers. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INTERVAL BETWEEN BIRTHS. Births other than first births comprised 1,135 (82 per cent) of the total. The rapidity with which pregnancy succeeds pregnancy and birth follows birth is a factor influencing infant mortality. One birth in 10 in Gary came within 15 months after its immediate predecessor, and 1 in 5 occurred after an interval of less than 18 months. The in fant mortality rate among babies born within 15 months after their mothers’ previous confinement was 169.1, a rate considerably in excess of even that for children of first pregnancies. When the inter val between births stretched into two years or more the infant mor tality rate fell to 102.8. Among the native white mothers 6 per cent of the births came within the shortest interval; foreign-born mothers bore 12 per cent of their babies less than 15 months after a previous pregnancy had terminated. The lowest infant mortality rate among babies of native white as among those of mothers of foreign birth occurred when the period between the last two confinements was at least two years in length. The very low rate for this interval among infants of native white mothers (62.9) deserves notice. T a b l e X X V I I .— In fa n t m orta lity and stillbirth rates, _by in terval fr o m 'preceding con fin em en t and color and n a tiv ity o f m oth er; births in G ary in 1 9 1 6 . Stillbirths. Interval from preceding confinement and color and nativity of mother. All mothers........................................ Infant mortal ity rate.1 Infant deaths. Live births. Total births. Number. Per cent.1 40 1,393 2.9 1,353 169 124.9 . 35 23 17 39 52 3 140.6 169.1 125.0 128.3 102.8 No preceding confinement........................... Under 15 months......................... ................ 15 months, under 18..................................... 18 months, under 24.............................- — 24 months and over l ................................... 258 139 142 309 522 23 9 3 6 5 16 1 3.5 2.2 4.2 1.6 3.1 249 136 136 304 506 22 Native white mothers....................... 394 11 2.8 383 37 96.6 No preceding confinement........................... 120 23. - 36 65 147 3 5 4.2 2.7 15 4 3 6 9 130.4 1 1 4 115 23 35 64 143 3 987 28 2.8 959 128 133.5 131 112 100 236 361 19 19 19 13 32 42 3 145.0 169.6 130.0 135.6 116.3 18 iuuiitliS) under 2124 months and over v ................................. Foreign-bom white mothers............. 3 3 5 4 12 1 2.2 15 months, under 18..................................... 18 months, under 24................................ . 24 months and over %.................................... InLei vdl not reported-.................................. 134 115 105 240 373 20 Negro mothers................................... 12 1 11 4 4 1 i 4 2 1 3 1 1 4 2 1 No preceding confinement........................... Under 15 montlis................................. . , 4.8 Ì .7 3.2 62.9 1 1 1 — i Not shown where base is less than 100. 44 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 45 IN F A N T MORTALITY, GARY, IND. In Table X X V III births have been grouped according to the annual earnings of the chief breadwinner in the family and the interval since the preceding confinement. The lowest earnings group, which had less than $1,050 per annum, contained the smallest percentage (15 per cent) of children born as the result of first pregnancies; it com prised the largest proportion (12 per cent) of infants bom less than 15 months after an earlier issue. In the highest earnings group 22 per cent of the births were first issues; only 6 per cent came at less than a 15-month interval from preceding births. Lowest, mid, and highest groups had a practically similar proportion of births coming at an interval of at least 18 months. T a b l e X X V I I I .— In terva l fr o m preceding con finem ent, by annual earnings o f ch ief breadw inner; births in G ary in 1 9 1 6 . Births in 1916. Annual earnings of chief breadwinner. Interval from preceding confinement. Total. No earn ings, no chief bread Per Per Per Per winner, Num cent Num cent Num cent Num cent and ber. distri ber. distri ber. distri ber. distri bution. bution. bution. bution. not re ported.1 Under $1,050. $1,050 and un81,850. 81,850 and over. Total............................. 1,393 100.0 403 100.0 727 100.0 185 100.0 2 78 No preceding confinement.. . Under 15 months................... 15 months, under 18.............. 18 months, under 24.............. 24 months and over............... Not reported.......................... 258 139 142 309 522 23 18.5 9.9 10.2 2.2 37.5 1.7 60 50 38 87 158 10 14.9 12.4 9.4 21.6 39.2 2.5 147 69 81 164 259 7 20.2 9.5 11.1 22.6 35.6 1.0 41 11 19 38 74 2 22.2 5.9 10.3 20.5 40.0 1.1 10 9 4 20 31 4 1 Per cent not shown where base is less than 100. 2 Includes 6 births in families where there was no chief breadwinner and 11 in families where there were no earnings. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PLURAL BIRTHS. Among the 1,353 live births in Gary in 1916 were 33 twins, of whom but 15 survived a year; 1 twin was stillborn. Infant mortality among twins is very high, and the child who is the product of a single birth has a much greater expectancy of living a year than has a child who is one of twins. To all the mothers in the city for whom complete maternity histories were secured, 100 live-born twins had come. Of these, 46 died in infancy, making the mortality rate for plural births 460, a rate eloquently expressive of the added hazard to which a child born a twin is subjected. The influence of the mortality rate among plural births in Gary in 1916 is shown by comparing the mortality rate for single births (114.4) with that for live births (124.9), in which are included plural issues as well. Plural births added but 33 to the 1,353 live births and yet contributed 18 of the 169 infant deaths. ■One per cent of the live births to native mothers and 3 per cent of those to foreign-born mothers were twins. Comparison of the infant mortality rates for single births in the two nativity groups— native white 92.3, foreign born 120.4— and the rates for all births, inclusive of plural— native white 96.6, foreign born 133.5 reveals that a part of the difference was due to the influence which the larger proportion of plural births exerted upon the mortality rate among infants with foreign-born mothers. T a b l e X X I X .— In fa n t m orta lity rates f o r sin gle and p lu ra l births, by color and n a tivity o f m oth er; births in G ary in 1 9 1 6 . Singie or plural birth and color and nativity of mother. Total births. All mothers......................................................... Single births.................................................................. * Plural births............................................... —.............. Native white mothers......................................... 1 Not shown where base is less than 100. 46 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Infant deaths. Infant mortality rate.1 1,393 40 1,353 169 124.9 1,359 34 39 1,320 33 151 18 114.4 383 37 96.6 379 4 35 2 92.3 394 390 4 Negro mothers..................................................... Live births. Still births. n n 987 28 959 128 133.5 957 30 27 1 930 29 112 16 120.4 12 1 11 S 4 12 1 11 4 SEX* Vital statistics show, almost invariably, a preponderance of male over female births and an infant mortality rate among males which is in excess of that for females. In the birth-registration area in 1916, for example, for every thousand live-born girl babies there were 1,057 live-born male infants. The males died in infancy at the rate of 111 per 1,000; the females, at 90 per 1,000.50 The figures for births and infant deaths in Gary are in practical conformity with this gen eral experience. There were 659 female and 694 male live births; the infant mortality rate for girl babies was 115.3, while for boy babies it was 134.0. Male births exceeded female both among native white and foreign-born mothers. Among infants of native mothers the mortality rate for males very greatly outran the death rate of females; among infants of foreign-born mothers the rate for males fell slightly below that for females. T a b l e X X X .— In fa n t m orta lity rates, b y sex o f in fa n t and color and n a tiv ity o f m oth er; births in G ary in 19 1 6 . Sex of infant and color and nativity of mother. All mothers........................................................................... Native white mothers.......................................................... Foreign-bom white mothers................................................ Total births. Live births. Infant deaths. Infant mortality rate.«» 1,393 1,353 169 124.9 721 672 694 659 93 76 134.0 115.3 394 383 37 96.6 204 190 196 187 25 12 127.6 64.2 987 959 128 133.5 512 475 494 465 65 63 131.6 135.5 12 11 4 5 7 4 7 3 1 a Not shown where base is less than 100. 60 U. S. Bureau of the Census, Birth Statistics, 1916, p. 16. 47 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INCOME. Family income has been shown to be one of the most significant environmental factors influencing infant life. Prolonged inadequacy of income ushers in poverty with its attendant evils— insufficient food and clothing, poor housing and sanitation, lessened ability to secure proper medical care and attention, and increased need for the mother to seek gainful employment to add to the earnings of the natural breadwinner in the family. Consequently, the part which adequacy of income plays in governing the new-born child’s chance to survive should not be minimized. EARNINGS O F CHIEF BREADWINNER. Financial responsibility for the family is usually assumed b y the father. In determining the economic status of families, therefore, the father’s annual earnings constitute perhaps the best index of the standard of living of the family. In 98 per cent of all the families into which babies were born in Gary in 1916, fathers were the chief breadwinners. A few families (2 per cent), however, by reason of the father’s death, desertion, or incapacity were dependent upon the earnings of some other member who took up the responsibility for the maintenance of the home. In these families classification has been made, accordingly, on the basis of the annual earnings of the chief breadwinner, that is, the person upon whom the baby and the family were mainly dependent for financial support.50® The calendar year 1917 was chosen as the year to which the annual earnings relate, on the ground that the amount of the earnings could be more accu rately and easily secured for this period (which corresponded with the year for which incomes are commonly reported for tax purposes) than for the precise 12 months following the birth of the infant in 1916. The earnings for this period doubtless afford as fair a basis for classi fication of families into income groups as the earnings for the year following the birth. All reports of earnings, therefore— those of chief breadwinner, other supplementary earnings, and the monetary contribution of mothers through gainful employment— pertain to the calendar year 1917. Ordinarily, income from supplementary sources was less regular and more difficult to secure accurately than the chief breadwinner’s so« in the tabulations, the mother was never classified as chief breadwinner, and if no person other than the mother assumed financial responsibility for the family it was considered as having no chief bread winner. General Table 24 shows the proportion of mothers in each nationality group who were em ployed, and the relation of mothers’ employment to earnings of chief breadwinners. 48 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 49 IN F A N T MORTALITY, GARY, IN D . earnings. The majority of mothers who worked kept lodgers and could state the gross receipts only. The gainful employment of the mother usually indicated a need for supplementing the father’s wage, but whether she worked at home or in the factory, the fact that the tune and service she could give to home and children were necessarily lessened, tended to offset the benefit from the addition made to the family resources. Income from investments, on the contrary, was found usually where the chief breadwinner’s earnings were in them selves sufficient to meet the needs of the family; not only was the amount of net income difficult to obtain, but in these cases the earn ings alone usually furnished a fair indication of the standard of living. The chief breadwinners for 29 per cent of the babies earned less than $1,050 in a twelvemonth; for an additional 52 per cent their annual earnings reached $1,050 but fell below $1,850. The proportion of babies of foreign-born mothers in families where the chief bread winner s earnings were below $1,050 was 3^ times as great as the pro portion among babies of native white mothers. The proportion of babies of native white mothers in families where the chief breadwinner’s annual earnings were $1,850 or over was more than 3 times as large as the proportion among babies of foreign-born mothers. Slightly oyer one-fourth of the babies of native white mothers, as compared with less than one-twelfth of those of foreign-born mothers, had chief breadwinners whose yearly earnings equaled or exceeded $1,850. 4 T able X X X I . A n n u a l earnings o f ch ief breadw inner, by color and n a tiv ity o f m oth er' births in G ary in 1 9 1 6 . ’ Births in 1916 to— All mothers. Annual earnings of chief breadwinner. Num ber. Total. Under $1,050...,................... $1,050, under $1,850............... $1,850 and over....... .............. No earnings, no chief bread winner and not reported__ io Native white mothers. Per cent Num distri ber. bution. Foreign-born white mothers. Per cent Num distri ber. bution. Negro mothers. Per cent Num distri ber. bution. 1,393 100.0 394 100.0 987 100.0 12 403 727 185 28.9 52.2 13.3 41 225 104 10.4 57.1 26.4 358 495 80 36.3 50.1 8.1 4 7 1 2 78 5.6 24 6.1 54 5.5 Per cent distri bution.1 U U U C I JLUU. Includes 6 instances of **no chief breadwinnerand 11 of wno earnings.* SUPPLEMENTARY EARNINGS. Nearly two-thirds (64 per cent) of the families had no earnings besides those of the chief breadwinner. If the families are classified according to the earnings of all members of the family, the income group under $1,050 embraces only 23 per cent of the entire number https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 50 INFANT MORTALITY. the mid group contains 53 per cent and the highest group 18 per cent, instead of 29, 52, and 13 per cent, respectively, when the families are classified according to the earnings of the chief breadwinner.51 The proportion of families in which the chief breadwinner’s earn ings were not supplemented varied according to the amount of the breadwinner’s contribution. When his earnings were below $1,050, 56 per cent of the babies were found in families which had no supple mentary earnings; in the next higher income group, 67 per cent; in the highest, 72 per cent. In short, the more adequate the chief bread winner’s earnings, the smaller the tendency, the less the need to add to them by the earnings of other members of the family. Mothers were less likely to be gainfully employed if the chief breadwinner's earnings were high, though even in the highest income group 29 per cent of the mothers were employed. In the lowest income group the percentage was 41.52 M O TH E R’S EM PLOYM ENT AND EARNINGS. Slightly over one-third of the 1,393 babies born in 1916 had mothers who were gainfully employed during all, or part, of the year 1917. B y far the largest proportion of these mothers (86 per cent) were en gaged in keeping lodgers. Since in these cases it was impossible to determine the expenditures incidental to furnishing room and board, or to secure a statement of net income, the gross earnings usually represented considerably more than the real addition made to the family resources. Of the mothers gainfully employed 47 per cent earned less than $200 in the year, 40 per cent earned $200 or over, while in 12‘per cent of the cases earnings were not reported. Gainful employment was a little more common among foreign-born than among native white mothers. Likewise the proportion of foreignborn mothers who kept lodgers (32 per cent) exceeded the proportion of native white mothers (24 per cent).53 Employment of mothers outside the home was not of frequent occurrence in Gary. Steel, the chief industry of the city, did not afford many openings for women outside the clerical positions and in few factories in the other industries was woman labor common. A special inquiry was made into the question of the relation between infant mortality and gainful employment of the mother within one year after the birth in 1916. If a mother is gainfully employed only after her baby dies, the baby’s death obviously can not be ascribed in any way to that employment. But if a mother’s employment takes her away from the child or lessens the care she can give him, the infant’s chance of life may be lessened. The mothers of 391 infants (28.9 per cent) commenced or resumed gainful work 61 General Table 23, p. 111. ** General Table 24, p. 111. 68 General Table 25, p. 112. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IND. 51 during their babies’ lifetime and before the babies’ first birthdays. In the overwhelming majority of these cases (91.6 per cent), however, the mother’s work was in her own home and consisted for the most part of keeping lodgers or boarders; in only 33 cases did the mother’s work take her out of the home, and in only 25 of these did it result in separation of mother and baby. The effect upon infant mortality of the mother’s gainful employ ment during the year after the infant’s birth may be shown by the following calculation. Among the entire group of 391 infants, 40 deaths occurred before the end of the first year of life, 2 of them among the infants whose mothers worked away from home. If the average monthly death rates for the city had prevailed among these infants from the time their mothers commenced or resumed work until the end of the year, only 33 deaths instead of 40 would have resulted. This difference, although suggestive of a greater mortality rate among infants of employed mothers, is hardly large enough to be conclusive. In general, gainful employment of the mother during the infant’s lifetime was for the most part at home, and the mother’s employment away from home after the birth in 1916 was a negligible factor in the city’s infant mortality rate. EM PLOYM ENT OF CHIEF BREADWINNER. As might be expected in a city in which the basic industry was steel, the greatest proportion of wage earners were employed in the steel mills. Gary, however, has had in its brief history a whole some development of trade and commerce and other industries essen tial to steady growth as a community, with the result that a consider able number of its wage earners were employed outside the steel indus try. Of the babies born in 1916, 87 per cent were in families having chief breadwinners who were wage earners, practically two-thirds of whom were connected with the production of steel. Of the infants of foreign-born mothers slightly over seven-tenths (71 per cent) were dependent upon workers in the steel mills. The proportion of babies of native white mothers whose chief breadwinners were employed in other industries than steel was more than double the proportion among babies of mothers born outside the United States. A comparison of the earnings of employees in steel with those of employees in other industries shows for the most part a similar dis tribution among the three earnings groups. A slightly larger propor tion of the wage earners in the steel industry were in the highest earnings group. The difference in earnings in favor of the steel industry was more marked in the foreign-bom group. In the foreign-born group of wage earners in other industries than steel (47 per cent) had earnings of less than $1,050, and only 1 per cent https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 52 INFANT MORTALITY. had earnings of $1,850 and over, as compared with 37 per cent and 7 per cent, respectively, of wage earners in the steel industry.54 INFANT MORTALITY RATES AND EARNINGS OF CHIEF BREADWINNER. Among the 392 live-bom infants in the lowest earnings group 54 deaths under 1 year of age occurred, giving a mortality rate of 137.8; 90 out of the 708 babies in the mid group died under 12 months of age, making an infant mortality rate of 127.1; of the 179 in the highest income group, 16 died in infancy, establishing a mortality rate of 89.4 for the group which was best favored financially. In these figures appears again the coincidence between low income and high infant mortality rate which has so persistently recurred in the studies made by the Children’s Bureau.55 T able X X X I I .— In fa n t m ortality rates, by annual earnings o f ch ief breadw inner and color and n a tivity o f m oth er; live births in G ary in 19 1 6 . Total live births. Annual earnings of chief breadwinner and color and nativity of mother. All mothers...................................................................................- ........ Native white mothers........................................................... - ............... Foreign-born white mothers................................................................. Infant mortality rate.1 Infant deaths. 1,353 169 124.9 392 708 179 274 54 90 16 9 137.fr 127.1 89.4 383 37 96.6 41 219 100 23 5 23 6 3 105.0 60.0 959 128 133.5 348 482 78 51 48 65 9 6 137.9 134.9 11 4 3 7 1 1 2 1 i !N ot shown where base is less than 100. 2Includes 5 instances of “ no chief breadwinner” and 11 of “ no earnings. Division according to nativity of the mothers shows for each nativity class the same movement from higher to lower infant mor tality rate with increase in the earnings of the chief breadwinner. Among the infants of native white mothers the rate in the highest ^ earnings group (60.0) was a little less than half that in the lowest (121.9). The rates among babies of foreign-born mothers, th ou g h t they do not fall so markedly, nevertheless display a steady descent as the breadwinner’s earnings rise. (Chart III.) 6<Percentages are based upon birtbs. 66 Save the Youngest, U. S. Children’s Bureau Publication, No. 61, p. 15. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IND. Ch a r t III.—Infant mortality rates, by earnings of chief breadwinner. 140 130 120 110 100 90 80 70 -------------2 60 $1,050 and under $1,850. Infants to all mothers. Infants to native white mothers. Infants to foreign-born mothers. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis $1,850 and over. NATIONALITY. The 1910 Census, made four years after Gary was founded, showed that 49 per cent of the city’s population was native white, a like proportion foreign bom, and 2 per cent colored. Austria-Hungary, Russia, Italy, and Germany had contributed the largest quotas to the foreign-bom population, though practically every European country was represented in the cosmopolitan body making up Gary’s citizenship.5^ In 1916, 987 babies were born in Gary to foreign-born mothers of 28 distinct nationalities. The leading nationality groups in point of numbers were from the countries most largely represented in the city’s population in 1910—Poles, Serbians and Croatians, Slovaks, Magyars, Italians, Lithuanians, and Germans. T a b l e X X X I I I .— In fa n t m ortality and stillbirth rates, by color and n a tion a lity o f m oth er; births in G a ry in 1 916. Stillbirths. Color and nationality of mother. Total births. Live births. Infant deaths. Number. Percent.1 Infant mortality rate.1 Total....................... 1,393 40 2.9 1,353 169 124.9 Native white.................... Foreign-bom white.......... Polish........................ Serbian and Croatian. S lovak...................... All other*.................. Negro................................ 394 987 275 162 135 415 12 11 28 12 4 3 9 1 2.8 2.8 4.4 2.5 2.2 2.2 383 959 263 158 132 408 11 37 128 39 20 15 54 4 96.6133.5 148.3 126.6 113.6 133.0 . 1 Not shown where base is less than KX>. * Including 64 Magyar, 60 Italian, 54 Lithuanian and Lettish, 41 German, 36 Rumanian, 24 Greek, 22 Great Russian, 20 Bohemian, 20 Danish, Swedish or Norwegian, 19 Ukrainian or Ruthenian, 14 Irish, 8 Slovenian, 7 Canadian (not French), 6 English, Scotch, Welsh, 6 Jewish, 5 Bulgarian, 3 Spanish, 2 Assyrian, 1 Dutch, 1 French, 1 Albanian, 1 foreign-born white, nationality unknown. INFANT MORTALITY RATES BY NATIONALITY. The contrast between the infant mortality rate for babies of native white mothers (96.6) and that for infants of foreign-born mothers (133.5) has already been noted. Only three nationality groups— Polish, Serbian and Croatian, and Slovak—were large enough to warrant the computation of infant mortality rates. The rate among the babies of Polish mothers (148.3) was greatly in excess of that for either of the other nationalities and notably higher than that for the babies of all foreign-born mothers. The stillbirth rate (4.4) was also high for the Polish group. Since births to these mothers constituted 28 per-cent of the entire number of babies bom to foreign women, the high infant death rate among babies of Polish motherwas undoubtedly strongly instrumental in raising the general infant mortality rate for babies of foreign-born mothers. 66 Thirteenth Census of the United States, 1910, Vol. II, Population, p. 568. * \ 54 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN FA N TM O R TA LITY ,G A R Y ,IN D . 55 NON-ENGLISH-SPEAKING NATIONALITIES. With the exception of 20 births to mothers from the British Isles and seven infants whose mothers were of Canadian origin other than French, the foreign-bom mothers belonged to non-English-speaking nationalities. Of the mothers of non-English-speaking nationalities 67 per cent were of the different Slavic races, and therefore possessed the racial customs, culture, and ideals characteristic of these races. Moreover, although Lithuanians, Rumanians, and Magyars— 16 per cent of the non-English-speaking nationalities, as represented among the births in Gary in 1916— are not Slavic peoples and do not speak Slavic languages, nevertheless in customs and habits they have many points of resemblance to the Slavs. In Gary there was but little segregation of different nationalities into distinct colonies; a few blocks predominantly Polish had been dubbed “ Little Poland,” but Poles were living in other parts of the city as well. Certain subdivisions of Gary were chiefly foreign, as the South Side, or Tolleston, for example, but a single block, or even a single tenement in these subdivisions, might contain families of various nationalities living side by side. In religious life, perhaps more than in social and economic custom, ' the different national groups held themselves distinct. There were Polish, Slovak, Croatian, Lithuanian, Magyar, Ruthenian, Rumanian orthodox, Russian orthodox, Italian, German, and Jewish congrega tions. Practically every nationality had, in addition, its societies, clubs, or associations for social, protective, fraternal, or educational purposes, and a person of almost any nationality could find without much search a store or bank wherein he could make his wants known in his native tongue. On the other hand the very youthfulness of Gary, the general feeling there that change and growth were normal, could scarcely h#ve failed to permeate even the most foreign sections and tend there also, to break down connections with the past and foster the adoption of new customs and ideas. To this was added the very real influence which the public schools of the city exerted, not only over the children attending them, but over the adults, the foreign-speaking men and women who enrolled in the manual training shops and night classes of the schools, who used the schools’ swimming pools and baths as well as the instruction offered in English, cooking, sewing, foundry work, and other subjects. M O TH E R S’ ABILITY TO SPEAK ENGLISH. Of the 1,393 babies, 44 per cent were born to mothers unable to speak English. Inability to speak English was of significance so far as it might constitute a social and economic handicap, curtail a https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 56 INFANT MORTALITY. mother’s opportunity to use the community’s medical, social, and educational resources to the fullest degree, or close to her ways of obtaining valuable information on the care of her home and children. The babies of Polish women had the highest proportion of mothers (83 per cent) who could not speak English; among the Serbians and Croatians the proportion was slightly less than three-fourths (74 per cent), while among the Slovaks only half the infants had mothers incapable of conversing in English. It is to be noted that t^,e infant mortality rate was highest among babies of Polish mothers— the women least proficient in the English tongue— and that while the infant mortality rate for babies of mothers of non-English speaking nationalities was 134.8, when this group was subdivided further according to mother’s ability to speak English, the mortality rate for infants whose mothers had not acquired the language was 145.2, whereas the rate for infants whose mothers had learned to use English was but 116.1. Apparently the mother’s inability to speak English was found aligned with other forces inimical to infant life. T a b l e X X X I Y . — In fa n t m orta lity rates, by m oth er's a b ility to speak E n g lish , and color and n a tion a lity o f m oth er; births in G a ry in 1 916 to fo reig n -b o rn w hite m oth ers. Total births. Ability to speak English, and color and nationality oi mother. Per cent Number. distribu tion. Live births. Infant deaths. 987 959 128 27 24 2 Infant mortality rate.1 133.5 960 100.0 935 126 134.8 346 614 275 47 228 162 43 119 135 67 36.0 64.0 336 599 263 45 218 158 41 117 132 39 87 39 116.1 145.2 148.3 31 142.2 126.6 382 184 198 52 68 388 189 199 100.0 17.1 82.9 100.0 26.5 73.5 100.0 49.6 50.4 100.0 48.7 51.3 66 66 8 20 4 16 15 7 8 20 32 13ff. 8 113.6 136.1 108.7 161.6 1 Not shown where base is less than 100. YEARS IN THE UNITED STATES. Foreign-born mothers of slightly more than one-tenth of the babies had been in the United States less than five years. Since the nation alities found were chiefly from the countries of southeastern Europe, they were almost wholly of the “ newer immigration” and displayed, but little individual differences in length of residence within the United States. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 57 G AR Y, IN D . T able X X X V . In fa n t m orta lity rates , by years o f residence o f m other in the U n ited S ta tes, ana eolor and n a tion a lity o f m other; births in G a ry in 1 9 1 6 to fo r e ig n -b o m w hite m others. Years of residence in United States and color and nationality of mother. Total births. All foreign-born white mothers___ Less than 5 years........... 5 years and over........... Not reported.......... Polish....................... - Live births. Infant deaths. Infant mortality rate.1 987 959 128 133.5 108' 872 7 107 845 7 17 111 158.9 131.4 148.3 275 263 39 Less than 5 years............. 5 years and over............ 22 253 21 242 6 33 136.4 Serbian and Croatian............ 162 158 20 126.6 19 '143 19 139 3 17 122.3 135 132 15 113.6 9 122 4 9 119 4 2 13 109.2 All other................ 415 406 54 133.0 Less than 5 years........... 5 years and over................ Not reported.............. ____ _ _______ 58 354 3 58 345 3 6 48 139.1 Less than 5 years........... 5 years and over......... Slovak...................... Less than 5 years............... 5 years and over................ Not reported............ 1 Not shown where base is less than 100. One in 6 of the babies whose mothers had been in the United States less than 5 years and 1 in 8 of those whose mothers had been in this country for a longer period, died within 12 months after birth. Each of the 3 most numerous foreign nationality groups showed a lower infant mortality rate among the babies whose mothers had had a more extended residence within the United States. Besides making possible the acquisition of English and the methods of child care which are best suited to this country, lengthened residence also had a tendency to better the economic status of the family and thus to enhance the infants’ likelihood of living beyond infancy. Length of residence was apparently a factor in reducing the mortality rate among infants of foreign-born mothers toward the level of the rate among infants of native mothers. LITERACY OF M OTH ER. Only 2 native white mothers said they were unable to read and write. There were, however, 361 babies (37 per cent) whose foreignborn mothers could not read and write in any language. The percentage of illiteracy, gauged simply by the mother’s statement as to her ability to read and write in any language, was greatest among the Serbian and Croatian women. Approximately two-fifths of the Polish mothers could not meet this crude test as to literacy. Among the Slovaks somewhat over one-fourth of the babies (27 per 106137°— 23------ 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 58 IN F A N T MORTALITY, GARY, IND. cent) had illiterate mothers. When the numbers were not so small as to make the calculation of infant mortality rates undependable, the babies with mothers who could not read and write showed a higher mortality rate than did those whose mothers were literate. This was especially true in the case of Polish mothers.57 Illiteracy, like inability to speak English, was of significance chiefly because it restricted the mother’s opportunity to acquire knowledge by limiting her to the spoken word as the sole medium of instruction. The mother’s illiteracy, furthermore, tended to be associated with ignorance and a lower economic level. Of the babies of illiterate mothers 24 per cent had chief breadwinners whose earn ings totaled less than $1,050 per annum, while 44 per cent of those infants whose mothers could not read and write had chief bread winners in the lowest income group.58 The proportion of illiteracy was less among the younger foreignborn mothers. Slightly over one-fourth of the mothers under 25 could not read and write, as compared with one-half of those 35 years of age and over.59 57 General Table 26, p. 113. 68 General Table 27, p. 113. 69 General Table 28, p. 114 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY HISTORIES. In addition to the information gathered with special reference to the question of infant mortality among the babies born in Gary in 1916, mothers were asked to report the sequence, duration, and out come of their earlier pregnancies as well, their ages at the time each successive birth occurred, and, for the children who had died, the causes of death and the children’s ages at time of death. The data secured in maternity histories corroborate and supplement certain findings based on the data regarding infants bom in 1916. The 1,393 births in Gary in 1916 included in this study represented births to 1,371 mothers, since in 17 cases of confinement twins were born, and in 5 cases the mothers had been confined previously within the year. Twenty-two maternity histories were omitted because they were incomplete or included births out of wedlock. To the 1,349 mothers remaining, the total births, both live and still, of at least seven months’ gestation numbered 4,714. INFANT M ORTALITY RATE. Among the 4,572 children born alive to these 1,349 mothers 637 deaths under 12 months of age had occurred, making the infant mortality rate for all babies l>orn to these mothers 139.3. This rate was considerably in excess of that (124.9) among babies born in 1916. The complete maternity histories contained a larger proportion of first births as well as a larger proportion of births to foreign-born mothers than did the 1,353 live births in the selected group. Because infant mortality among first births and among births to foreign-bom mothers was high, a larger percentage of these among the births from all pregnancies would tend to raise the mortality rate. T a b l e X X X V I .— In fa n t m orta lity and stillbirth rates, b y color and n a tion a lity o f m oth er; births fr o m a ll pregnancies. Births, all'pregnancies. Total Color and nationality of mother mothers. Stillbirths. . Total. Number. Per cent.» Total......., ................ 61,349 Native white....................... Foreign-born white............. Polish............................ Serbian and Croatian... Slovak........................... Magyar........................... Italian............................ Lithuanian and Lettish German.......................... All other...... ............... i Negro.... ............. ................. Live births. Infant mor tality rate. Infant deaths. . 4,714 142 3.0 4,572 637 139.3 1,054 3,632 1,023 605 515 243 254 232 150 610 28 36 105 • 34 17 12 2 10 8 7 15 1 3.4 2.9 3.3 2.8 2.3 0.8 3.9 3.4 4.7 2.5 1,018 3,527 989 588 503 241 244 224 143 595 27 100 532 153 104 68 45 33 38 14 77 5 98.2 150.8 154.7 176.9 135.2 186.7 135.2 169.6 97.9 129.4 a Not shown where base is less than 100. ras^ncomplete O T u S t e b ? 01“ th6re wereiUegitmate births Prior t o 1916 and 3 whose maternity history 59 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis • 60 IN F A N T MORTALITY. The mortality rate for all infants of native white mothers, 98.2, was but very slightly different from that, 96.6, for babies of these mothers^ in 1916. The rate for babies of foreign-born mothers, 150.8, on the contrary, was noticeably above the rate, 133.5, for babies of these mothers in the selected year. It is interesting to note that among the different nationalities, the mortality rate for babies of German mothers, 97.9, almost identical with that for infants of native white mothers, accompanied the highest stillbirth rate, 4.7; that the rate of 135.2 for all babies of Italian mothers accompanied a stillbirth rate of 3.9; whereas an identical rate, 135.2, among babies of Slovak mothers was attended by a stillbirth rate of only 2.3. The excessive infant mortality rate for babies of Magyar mothers, 186.7, was found coexistent with a very low stillbirth rate, 0.8. Other high rates were those for babies of Serbian and Croatian mothers (176.9), Lithuanian mothers (169.6), and Polish mothers (154.7). AGE OF M O TH E R AND O RD ER OF BIR TH .81 Among all live births included in the maternity histories, the rate of mortality during the first year of life was greatest for babies of mothers under 20 and those 40 years of age or over (163.9), and least among babies whose mothers were in the twenties (129.9). The rate^ for infants bom to mothers when in the thirties was intermediate (144.1). While the range of variation was not so extreme as in the corresponding rates among babies bom in 1916 to mothers of these ages (see p. 41), the ranking was the same. The percentage of still births (2.3) was lowest among births to mothers under 20 and those 40 or over and highest (4.5) among babies born to mothers in the thirties. Among babies born in the selected year the highest still birth rate fell likewise among births to women in the thirties; the lowest, however, was to mothers in the twenties. Among all babies included in the complete maternity histories, infant mortality rates according to order of birth confirm the trend shown when births in 1916 alone were under consideration (p. 42). Infants bom of first pregnancies had a high mortality rate of 147; the rate fell among second-born infants to 124.2; rose for the babies third in order of birth to 132.8; for fourth, to 151.1; sank to 142.9. for fifth-bom infants; and increased slightly to 145.3 for those offspring of sixth and later pregnancies. o See General Table 29, p. 115. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 61 GA R Y, IN D . INTERVAL BETWEEN BIRTHS. Over seven-tenths of the total births to the 1,349 mothers followed an earlier pregnancy. Babies bom within 15 months of the time when their mothers had been previously confined showed a mortality rate in their first year of 183.9; when the interval from a preceding birth lengthened to 15 but less than 18 months the mortality rate fell to 157.4. When at least two years elapsed between confinements the infant mortality rate sank to 99.5. This again parallels and confirms what held true among the births in 1916. About 1 in 8 of all births to foreign-bom mothers came less than 15 months after a preceding pregnancy had terminated; among all births to native white mothers approximately 1 in 14 occurred after so short an interval. T able X X X V I I . In fa n t mortality^ and stillbirth rates, by interval fr o m precedina con fin em en t and color and n a tiv ity o f m oth er; births fr o m a ll 'pregnancies. Interval from preceding confinement and color and nativity of mother. StiUbirths. Total births. Number. Percent All mothers. 142 No preceding confinement.................. ■Interval from preceding confinement: Under 15 months............ 15 months, under 18............ 18 months, under 24...................... 24 months and over.....................] N ot reported....................... ! ! ! ! ! ! Native white mothers. No preceding confinement................. Interval from preceding confinement: Under 15 months....................... 15 months, under 18................. 18 months, under 24...................... 24 months and over................“ *" Not reported............................. Foreign-bom white mothers. N o preceding confinement................. Interval from preceding confinement: Under 15 months........................... 15 months, under ¿8................... 18 months, under 24...................... 24 months and over................1... Not reported.................................. Negro mothers. 3.0 Infant deaths. Infant mortality rate.i 637 139.3 533 413 849 1,387 125 98 65 113 138 37 183.9 157.4 133.1 99.5 296.0 98.2 Live births. 4,572 1,265 557 429 862 1,426 132 4.3 3.7 1.5 2.7 5.3 1,054 371 77 88 161 346 11 3,632 105 1,018 100 4.0 356 35 0.6 2.9 83 160 336 2.9 925 2.9 477 340 697 1,073 120 4.0 3.2 1.7 2.7 5.8 28 147.0 73 14 11 17 24 4 106.3 71.4 3,527 532 150.8 458 329 685 1,044 113 6 150 167.0 84 58 95 112 33 183.4 176.3 138.7 107.3 292.0 27 N o preceding confinement................... Interval from preceding confinement: Under 15 months............................ 15 months, under 18....................... 18 months, under 24....................... 24 months and over........................ Not reported...................... •........... 1Not shown where base is less than 100. EARNINGS AND INFANT M O R TALITY RATE. An important question is: Do infant mortality rates for all babies show a tendency to rise with fall in family income similar to that evidenced among babies born in 1916 ? Since the only information https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 62 IN F A N T MORTALITY, GARY, ÏN B . on earnings relates to the year* 1917, this question can be answered only on the assumption that the earnings in 1917 are roughly indica tive, for the groups as a whole, of the economic status of the families' over the period of the mothers’ maternity histories. Of course in an individual case in which the mother’s pregnancy record extends over a number of years, the economic status may have been changed considerably; but for some families which have moved upward there are others that have fallen back; the assumption simply means that classifying the families into income groups based on fathers’ 1917 earnings gives a result that is broadly correct for the period covered by the maternity histories. In the lowest income group, the infant mortality rate for all babies was . 166; in the mid group, 139.5; and in the highest, 78.8. T a b l e X X X V I I I .— In fa n t m ortality and stillbirth rates, by annual earnings o f chief breadw inner; births fr o m all 'pregnancies. Births, all pregnancies. Total Annual earnings of chief bread mothers. winner. Stillbirths. Total. Number. Per cent. Live births. Infant Infant deaths. mortality rate. Total.................................. il,349 4,714 142 3.0 4,572 637 139. ' f Under $1,050................................ $1,050, under $1,850..................... $i;850’and over........................... N o earnings, no chief bread winner, and not reported.............. 369 706 180 1,445 2,383 545 49 57 12 3.4 2.4 2.2 1,392 2,330 533 230 325 42 166.0 139.5 78.8 94 341 24 7.0 317 40 126.2 1 Excludes 19 mothers who had illegitimate births prior to 1916 and 3 whose maternity history was incomplete or unreliable. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CIVIC AND SOCIAL FACTORS. BIRTH AND DEATH REGISTRATION. The Indiana State vital statistics law as amended in 1913 re quires births and deaths to be registered within 36 hours by the physician or other person in attendance. The enforcement of the law is centralized in the State board of health; in Gary the city health officer is in charge of enforcement locally and for this purpose is designated as a State official. The State was admitted to the l Q i y ^ g ^ a ^ n area iU 1900 and t0 the birth-registration area in The material secured during the study, which included a house-tohouse canvass of the entire city, showed that birth and death registra tion in 1916 was Tar from complete. Death registration was more complete than birth registration, but in a total of 211 deaths of infants bom alive, 7 were found in which the death was not registered, v Of the total 1,353 live births included in the study, 195, or 14.4 per cent, had not been registered. This percentage is probably an understatement of the proportion of unregistered births, since others may have occurred which were not discovered by the canvass.62 Failure to register 7 (or 3 per cent) of these unregistered live births was attributable to hospitals; 32 (or 14 per cent) to private physicians; 117 (or over half the entire number) to midwives; in 71 cases (31 per cent) there was no professional attendant at the tune of birth or information as to the attendant was lacking. Of the live births included in the study which were attended by midwives 15.1 per cent were not registered, while of those attended b y physi cians in hospitals, 6.1 per cent, and of those attended by physicians outside of hospitals, 7.3 per cent, were not registered. v In practically all the cases in which neither physician nor midwife was in attend ance the birth had not been reported to the registrars. Complete birth registration can be secured only through wider publicity, and through cooperation on the part of physicians, mid wives, and health authorities. In case of persistent neglect or re fusal on the part o f physicians and midwives to report births, prosecuP ' 87’ fOT a mOTe COmplete discussion of evidence regarding birth registration Stillbirths of 7 or more months gestation are required by law to be registered as both births and deaths but since for purposes of admission to the birth and death registration areas the completeness ofregistra’tmn oflive births and of deaths (exclusive o f stillbirths) is used as the criterion,the discussion above his been based upon the registration oflive births and of deaths oflive bom infants. The requirement for double registration of stillbirths is not observed uniformly. Thus, 8 stillbirths were registered as deaths £ ¿ 2 as births while 60 were registered both as birthsand deaths as required bylaw Three stillbirths were found which were not registered either as births or deaths. 63 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 64 IN F A N T MORTALITY. tions may prove necessary to enforce the law. In Gary during the three or four years prior to the study no prosecutions had been made for neglect to register births. In July, 1914, the registrar of births in Gary adopted the practice of giving a certificate of birth registration to the parents of each child whose birth was registered. This practice has met with a considerable degree of success wherever it has been tried in stimu lating parents to secure prompt birth registration for their children and in spreading information in regard to the birth-registration law among all classes of the population. The importance of complete birth registration must not be under estimated. Complete registration of both births and deaths under 1 year of age is essential to an accurate knowledge of the infant mortality rate. Registration of, births is coming to be everywhere more useful in furnishing a means of proof of age in connection with compulsory school attendance, employment certificate laws, employ ment in dangerous trades, voting privileges, not to mention its value in establishing inheritance and in proving nationality. One import ant use is furnishing the basis for visits of the health officer to insure that the provisions of the infant-blindness law, for the prevention of ophthalmia neonatorum, are observed.83 M> A HOUSING. Laws and ordinances applicable to housing in Gary include the city tenement-house law of the State and a number of local ordi nances. The city’s chief dependence in control of housing at the time of this study was the city tenement-house law of the State, which was passed in 1913; this law applies to all tenement houses, including apartment houses, in which two or more families live. In regard to tenement houses already built when the law went into effect, the law requires that water-closets, at least one to every two families, must be provided; basement water-closets are prohibited; water must be supplied on each floor. If a tenement is found unfit for habita tion, or dangerous to health, authority is given to the board of health to order the house put into good condition or vacated. Fire escapes were required to be provided for all tenement houses of three or more stories. With reference to new tenement houses the provisions of the law are much more strict. Connection with water and sewer mains must be made if the mains lie within 100 feet; limits are pre scribed to the proportion of the lot that may be covered by buildings; each tenement must be provided with a yard; rear tenements are prohibited; further regulations cover other particulars such as the arrangement of rooms, window space, separate water-closets within «B o o k of Instructions to Health Authorities, Infant Blindness Law, p. 126. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IND. 65 each apartment or tenement, and fire escapes for tenements three or more stories in height. Provision for enforcement is made by a system of permits and inspections. City ordinances provided for permits for building, and for building inspection, and laid down specifications relating to fireproof construc tion, window space, and light and air shafts. The enforcement of housing regulations was in charge of a department of buildings, headed by a commissioner. The principal weakness of the State law and the city ordinances lay in the absence of regulations applicable to one-family dwellings. Furthermore, in Gary many tenements constructed before the State law of 1913 went into effect already incorporated serious housing evils. Since the demand for housing accommodations in Gary has consistently exceeded the supply of desirable quarters, many tem porary makeshift structures have continued in use and the condem nation and abandonment of unfit dwellings has been retarded. Housing conditions in Gary may be considered as largely influ enced by the circumstances of its founding. Practically all the housing is of recent origin. The city grew rapidly, but local ordi nances to govern building were slow to appear, with the result that during the early period of growth building was little regulated, either by city ordinance or by State law. Housing was begun under the auspices of the land company, a subsidiary company to which the steel corporation gave the. task of providing shelter for the em ployees of the steel mills. In certain subdivisions, the development of housing has remained largely in control of this subsidiary company. But although the company’s housing developments, as shown later, resulted for the most part in well-built and attractive residence areas, in other parts of the city less satisfactory housing conditions arose. THE SUBDIVISIONS OF GARY. Those who planned the city of Gary found their chief problem in leveling the shifting hills of sand which covered the chosen site on the southern shore of Lake Michigan. The mills secured a lake frontage of 7 miles,64and the spacious harbor in which huge ore steam ers now anchor was constructed. The Grand Calumet River, paral leling the lake shore, was made to flow in a new channel half a mile from the one it had formerly occupied, and formed a fine of division between the mills and the city designed to house the mills’ employees. Besides the river, ribbed bands of railroad tracks already converging toward Chicago, lying to the northwest, separated mills and city. The city itself was laid out on the simple but unlovely gridiron plan. Straight south from the mill gates runs Broadway, the principal 84 Gary, Indiana, 1917-18, p. 4. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 66 I N F A N T M O R T A L IT Y ; north and south thoroughfare, and intersecting it at right angles is Fifth Avenue, the main east and west business street of the city. The subdivisions of the city nearest the mills— the First Subdivision, Kirk, and Ambridge— were largely developed by the land company for the companies whose mills lay to the north just beyond the railroad tracks and the river. Before opening a district for residence, streets were laid out and paved, sewers and water mains were constructed, and attractive dwellings with modern improvements were erected. For the most part, the company houses exhibit a pleasing variety of architecture. In the section of the city just south of the Grand Calumet are the attractive red-brick, frame, or brick-and-frame houses built for the employees of the steel company and the work men of the bridge company; and the structures in plaster and cement, very different in plan and appearance, in which the workmen of the sheet and tin plate mills and their families dwell. In contrast to these groups of homes are the more stereotyped and ugly small -frame houses sheltering the employees of the freight railroad which serves the mills and has its great yards north of the Grand Calumet River. Besides the dwellings erected by the land company, many houses, apartment buildings, and business blocks were erected inde pendently, but subject, when building was done upon companyowned land, to certain salutary restrictions.65 At first a number of two-family frame houses were rented by the land company to foreign-bom laborers employed in the mills. Per haps because these families were unfamiliar with such modem con veniences as bath, toilet, and sink, or perhaps because they over crowded their houses with lodgers, the company before long refused to rerent to these first tenants, put the buildings into good condition, and then rented them to Americanized workmen only, leaving the foreign-bom laborer to house himself and his family as best he could. The result of this policy was to concentrate the foreign-born workmen in the South Side and Tolleston, subdivisions which display bad housing conditions. • A number of long, one-story frame buildings, cheaply constructed and designed to bring in a maximum return in rental, which were built on the South Side, perhaps epitomize the worst ills of uncon trolled housing. They were planned for lodging houses, and divided into two-room, or more rarely three-room, apartments. These small apartments were occupied by families, however, with consequent overcrowding. When two such long buildings occupy adjoining or “ shoe-string” lots with only a narrow passage between, used in common by the tenants of both buildings, the congestion is great, and but little relief is afforded by the small yards left at the end of each lot. Two adjoining houses of this type supplied but a single 60Including uniform buildingline and modern type of building. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IN D. 67. water faucet and four privies for the use of 12 families. In another instance a single flush toilet was provided to accommodate nine families. Inadequate at all times, during cold weather it was rendered useless, due to its location at the end of the last apartment where it was not protected against freezing. Apartments in such houses were found occupied by both colored and white families of different nationalities, as well as by groups of lodgers. From the point of view both of morals and of sanitation such buildings are not in accordance with decent housing standards, and their continued existence should not be tolerated. The possibility of using a single lot for more than one house was not overlooked in the haphazard, little-regulated building of Gary’ s South Side and examples of rear houses are not lacking there. One rear house abutting directly on the alley faced upon a small, cluttered yard, flanked with coal sheds and closed at its other end by the back of the house occupying the front of the lot. Six of its rooms were occupied by a Spanish family of 6 and their 6 lodgers, and its base ment, containing three rooms, housed a Polish family and lodgers, 8 persons in all. These 20 individuals were dependent upon a single toilet under the outside steps leading from the yard to the first floor. It was dark, dirty, ill ventilated, and its walls and door had been disintegrated by dampness. Portions of the South Side had city water, while other sections were still using well water at the time this study was made. Some houses had baths, indoor toilets, gas, and electricity and were in every way modem; others lacked all these features. Privies were still far too numerous. Certain districts of the South Side embodied many of the primitive conditions of pioneer life, where, for a nominal yearly fee of a dollar or two, one might have squat ters’ rights and put up oner’s own shelter or occupy the cast-off abode of a family which had prospered and been enabled to move into a house. Tumbledown shacks, made of scraps of boards unevenly pieced together, having roofs patched with tin cans and pierced by stovepipe or tile, were clustered together in the sand alongside more pretentious and stable, though less picturesque, tar-paper structures, which might even disport brick chimneys. The wind, ever busy with the sand, frequently made rebanking of shacks necessary, especially when winter struck. Gardens were not possible because of the character of the soil, but the desire of an agricultural, foreignborn people to possess chickens, ducks, geese, or pigs could be satis fied. In the construction of pens for domestic fowls and animals ingenuity had full play. Their frequent proximity to the living quarters of the families was undesirable. The heat in these low buildings during summer was intensified by the glare of the sun upon the hot sand; the water supply was a well https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis .68 I N F A N T M O R T A L IT Y . common to many, and the toilet was often but a single privy for several families. In short, the South Side as a whole, in 1918, exemplified the need of community supervision over housing conditions, especially in dis tricts largely inhabited by citizens of foreign birth. More closely akin to the South Side than any other section of the city was Tolleston, an older town, which became part of the city of Gary in 1910. In foreign population it ranked next to the South Side; in much of it, living conditions were rural. Wells were in use where city water had not yet been piped, and outside privies were still to be found. Clark and Pine were also rural sections. The city sewer and water systems had not been extended to them, and they were sparsely populated. West Gary, another subdivision not at all thickly settled, was tending to become a good residence section and, though water and sewer systems had not yet reached it, some houses in it were being fitted with modern plumbing. Ridge Road and Glen Park, subdivisions lying farthest to the south, were separated from the bulk of the city by the Little Calumet River and they were characterized by a different physical contour and a greater degree of vegetation and beauty. Their population was mostly native white and many houses were modem family residences well constructed and situated. Lincoln Park, just north of the Little Calumet River, closely resembled the South Side and Tolleston in the character of its housing and population. It suffered more than any other subdivision from periodic inundation by the Little Calumet, a stream which might almost be considered to have no banks— so unbrokenly flat and marshy is the land on each side of the small river’s shallow bed. In sanitary development, in economic status of families and in nativity of population, certain subdivisions grouped themselves together. Ambridge and the First Subdivision, with predominantly native white population, with more uniformly excellent housing, wider extension of sewers and water mains, and general high economic level formed a group in contrast to Lincoln Park, the South Side, and Tolleston, where the greater proportion of the population was of foreign birth, yard privies and well water were still used by many, housing was much less favorable and the economic status of the bulk of families lower than in the sections chiefly native white. In the one group, excellence of housing and sanitation was found co-existent with other factors favoring a low death rate among babies; in the other, unsuitable housing and community failure to develop municipal sanitation and hygiene to a high degree were allied with forces antagonistic to infant life. Among the five births in Ambridge and the First Subdivision, 27 infant deaths occurred, resulting in an https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 69 GARY, IK'D. infant mortality rate of 90.6 for these parts of the city. In Tolleston, the South Side, and Lincoln Park 942 babies were born alive and 133 deaths occurred under 12 months of age, giving an infant mortality rate of 141.2. The contrast in the infant mortality rates from the gastric and intestinal diseases as shown in Table X X X I X was even more marked. In the sections where housing ills were greatest and where the yard privy lingered, the infant mortality rate from gastric and intestinal diseases was 63.7; in the sections preponderantly native white where community progress had been greater the corresponding rate was 23.5. T a b l e X X X I X .— In fa n t m ortality rates fr o m a ll causes and fr o m gastric and in testin a l diseases, b y su bd ivision o f c ity ; live births in G ary in 191 6 . Infant deaths. Subdivision of city. Gastric and intes tinal diseases. Live births. Total. First Subdivision............................ ............................ Clark, Pine, and Cavanaugh........................................ Not reported........................ ......................................... 1,353 169 36 262 63 27 729 186 6 5 39 2 25 6 3 104 26 Infant mortality rate.i Infant Number. mortality rate.i 124.9 68 50.3 95.4 7 1 2 46 12 26.7 142.7 139.8 63.1 64.5 1 2 i Not shown where base is less than 100. The welfare of infant and mother has long been recognized as a test for judging the excellence of a city’s community life because especially upon babies and mothers do the failures of municipal endeavor fall. Among the elements in a city’s work for health and hygiene, besides its housing, are its water supply, milk supply, sewer system, system of garbage collection and disposal, street cleaning and paving, as well as its agencies more immediately concerned with infant and child welfare. All of these have interest and merit study as criteria of community vision and community recognition of responsibilities. DEPARTM ENT OF HEALTH AND CHARITIES. At the time of Ibis study, chief responsibility for civic health and sanitation in Gary was centered in a department of health and charities headed by a board of health of four physicians, one of whom acted as secretary. The health staff included besides the board of health, one sanitary inspector, one food and milk inspector, a plumb- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 70 IN F A N T MORTALITY. mg inspector, a city bacteriologist and chemist, a nurse, and a city matron. The secretary of the board of health was the city health officer; neither he nor any member of the board was giving full-time service to city health work. Part-dime service and inadequate recom pense were faults inherent in the State law regulating health work throughout the cities, towns, and counties in Indiana. In 1918, in cities of the second class, to which group Gary belonged, salaries of members of boards of health did not exceed $100 per annum and the secretary of a board might not be paid in excess of $1,000 a year for his services.66 As already mentioned, the health officer was in charge of vital statistics in the city. Recognizing the importance of prompt record ing of births and deaths, he began in July, 1914, to send a certificate to the parents of each baby whose advent was reported to the health officer by the attendant at birth. In the opinion of the health officer, these certificates had been the means of securing more complete registration not only of births in the current year but of earlier births which had failed of record. During the 3 or 4 years preceding the study no use had been made of prosecution to enforce the law requiring registration of births. The health department had recognized the value of a good supply of pure milk in reducing infant mortality and worked toward the elimination of dirty and unfit milk. This subject is discussed further in the following section. The city of Gary was handicapped in making provision for nurses on its health staff. During the summer months of 1918, however, a city-paid trained nurse was employed, as part of the police staff, to do infant-welfare work and to give educational service to the mothers living in Gary’s South Side where the summer toll of infant deaths was especially high. Another trained nurse, who was on the staff of the health depart ment, visited cases which came under the supervision of the depart ment because of contagious diseases.67 The members of the department of health and charities other than members of the board of health were full-time employees reporting every two weeks to the board’s secretary. The municipal laboratory presided over by the city chemist was equipped for the making of chemical and bacteriological tests of milk and water, tests for tuber culosis, meningitis, diphtheria, hookworm, typhoid, and trachoma, as well as for venereal diseases. ■ _____ j_____ ' : ' ■ - ............ ............. *% ____ ______ 66Indiana Yearbook, 1918, p. 856. 87 The mayor’s annual message to the city council, 1919, said: “ I am of the opinion that laws should be enacted which would authorize cities of this magnitude to employ a full-time physician and surgeon at the head of our health department and also a corps of trained nurses. During the past year we have had a trained nurse on our police department, and I assure you that the work she has done and the results obtained have been remarkable.” https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis G AR Y, IN D . 71 The sanitary inspector with his deputy established and maintained quarantine; investigated insanitary and uncleanly premises of home dwellers or business places, public nuisances of any sort which were reported, and overcrowding in rooming houses; inspected privies and toilets; ordered the provision of garbage cans and containers; and initiated prosecution of offenders against the city’s sanitary regula tions, wherever necessary. The inspector was hampered in better ing sanitary conditions by the inadequacy of the building ordinances and the fact that the State housing law did not apply to one-family dwellings. In spite of having no power to compel the removal of yard privies belonging to one-family houses he had succeeded by persuasion in reducing markedly the number of outside closets. M ILK SUPPLY. In 1918 Gary citizens were receiving their milk supply from 126 different farms through 13 licensed city dairies. An ordinance passed inl908 provided that it should be unlawful for Person, firm, or corporation to engage in the sale of milk within the town of Gary without first procuring a license granted by the town clerk upon presentation of a certificate from the secretary of the board of health. B y a subsequent ordinance each milk dealer had been further required to furnish to the secretary of the board of health the < name and location of every dairy, farm' or other place where the milk which the dealer was offering for sale had been produced.68 The ordinance provided further that milk should contain 3.6 per cent of butter fat and 8.4 per cent of solids not fat, but the State law fixed 3.25 per cent as the minimum for butter fat and 8.5rper cent for milk solids exclusive of fat.69 The pure food and drug law of Indiana of 1907 forbade the manu facture, sale and offering for sale of any adulterated or misbranded foods or drugs. It defined adulterated milk as milk to which water or any foreign substance had been added; milk produced by sick and diseased cows; milk from which the cream or part thereof had been removed; milk which was not of standard quality; milk collected and kept or handled under conditions which were not cleanly and sani tary; milk which contained visible dirt, or less than 8$ per cent of milk solids exclusive of fat and 31 per cent of milk fat; or milk to which color or preservative had been added.70 •The State law further provided 71 against the use of any building for stabling cows for dairy purposes ‘ V hich was not properly con structed, well lighted, well ventilated, and provided with a suitable solid floor of plank, cement, or other impervious material that can be 88 Ordinances, City of Gary 1913, p. 119. 89 Pure Food Laws of State of Indiana, p. 3; Ordinances, City of Gary, 1913, p. u s . 70 Pure Food Laws of State of Indiana, p. 3. 71Ibid., p. 30. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 72 IN F A N T MORTALITY. readily cleaned.” It held that all milking rooms and stables were to be “ thoroughly clean and in good repair and each milk cow clean and groomed.” All milk as soon as drawn was to be removed from the stable to a milk room, separate from the place in which cows were kept, and used exclusively for the handling and keeping of milk and cream. The milk room must be of sanitary construction, and equip ped with facilities for straining, cooling and storing milk and for “ washing and sterilizing all utensils and apparatus in which milk is removed, stored and delivered.” 72 All milk was to be cooled to 60° F., or below, within one hour after milked and kept at such temperature until it left the farm, or, if retailed to consumer, until it was delivered: By city ordinance milk and cream had to be Pasteurized and clari fied before Pasteurization by means of centrifugal clarifiers or separa tors.73 Pasteurization required subjecting the milk to a temperature of at least 145° F. for 30 minutes, or 165° F. for 30 seconds. Imme diately after Pasteurization, milk or cream must be cooled to 50° F., or below. Records which would show the temperature of the milk and cream during Pasteurization were to be kept by “ some form of self-recording thermometer to be available for inspection.” All cans, bottles, or other containers must be sterilized by live steam or hot water at a temperature of at least 170° F. All milk and cream must be sold to retail or wholesale trade in the original container, which must show the name of the filler or packer, and bear the word ‘ ‘ Pasteurized ” or ‘ ‘ raw. ’ ’ Labels or caps must, moreover, bear the name or trade-mark of the person or firm originally filling the bottles and be stamped to show the day of the week the milk or cream con tained in the bottles was received from the producer. It was thus required that milk or cream sold in Gary should be Pasteurized and bottled.74 # The enforcement of the provisions of both city and State rulings regarding milk in 1918, lay in the hands of a food and milk inspector who was both a State and city offical and a member of the city depart ment of health and charities. This inspector had supervision over the 13 city dairies, the vehicles, the milk cans, and the stores dispens ing milk, and over the farmers selling it to the city; in addition, he collected samples of milk and cream for analysis. He endeavored to make monthly visits to the 126 farms supplying the city, timing his visits for no exact day but, as far as possible, so that milking would be in process on his arrival. The city dairies he visited weekly and obser ved the records of the thermometers which indicated the tempera« Ibid., p. 31. 73city Ordinance No. 543 regulating the production and sale of milk passed Jan. 1 7 , 1916. 74An exception to the requirements for bottling was that restaurants and hotels might receive milk or cream by the can. None but bottled milk orcream might be peddled on the city streets. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis G AR Y, IN D . 73 tures at which Pasteurization had been effected. Stores and vehicles he inspected as frequently as his other duties would permit.75 Gary milk and cream were examined for bacterial count, total solids, and butter fat weekly by the city chemist and bacteriologist. His report for 1918 showed 500 chemical examinations; 514 bacterio logical examinations of milk and cream, and 175 special chemical examinations of milk. Reports based on his analyses were published weekly in the city papers giving the percentage of butter fat, the bacterial count per cubic centimeter in the milk of each dairy and describing the milk as f 'dirty, ’ ’ l 'slightly dirty, ’ ’ or ' 'clean. ’ ’ During 1918 there was considerable dissatisfaction with the quality of the milk supply in the city and a feeling that the bacterial count ran too high. Mothers not infrequently, as their reason for not feed ing their babies milk, stated that the supply was dirty. For a time the city newspapers failed to publish the weekly reports, but publication was resumed at the request of women interested in knowing about the quality and purity of milk they were buying. A movement was started in 1918 for the purchase of milk from near-by farmers to be delivered by truck, a plan which would obviate many of the disad vantages resulting from the "lon g haul.” B y the end of the year, 160 to 200 of the 600 or 700 cans of milk used daily were being received by truck. j The duties of the one food and milk inspector were numerous and there was a growing realization that additional inspectors were necessary to watch over the city ’s milk supply. City ordinance and State law were together comprehensive in regulatory power 76 and, had provision for their enforcement been more adequate, should have insured to Gary a milk supply both safe and satisfactory. COLLECTION AND DISPOSAL OF GARBAGE AND O THER WASTE. During the period covered by this study of infant mortality and up to May, 1918, the City ordinance regulating the removal and disposal of garbage specified that no person, firm, or corporation might collect and remove garbage without first securing a permit from the secretary of the board of health. Such permits could be granted only to qualified applicants 18 years of age, or over, who were properly equipped for such work. Each owner of a dwelling house was required to furnish a suitable and sufficient metal container with tightly fitting cover. A city incinerator was maintained for the dis posal of the garbage which the city itself collected 11 75 Statement of food and milk inspector. 76 In the ordinance requiring Pasteurization the provision permitting the alternative method of heating milk to a temperature of 165° F . for 30 seconds was not in accord with the most approved practice, and in 1921 this method had been abandoned. 77 Ordinance No. 23, Mar. 22,1910; Ordinance No. 212, Apr. 15,1912; Ordinance No. 538, Dec. 20,1915, 106137°— 23------ 6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 74 IN F A N T MORTALITY. In April, 1918, a new ordinance was passed to become effective on and after the 15th of May and to repeal all previous ordinances on the subject.78 The new ordinance stipulated that separate receptacles should be provided for garbage, for waste in the form of tin and metal, for glass and earthenware, and for ashes. By the provisions of the new regulation, the city assumed complete responsibility for collection of garbage and forbade the use of the streets and alleys of Gary by any person or corporation for the purpose of removing and transporting garbage. Before the end of the year, collections were being made daily in the business section; three times a week in more thickly set tled residence districts; and twice a week in sparsely settled regions. By keeping garbage free from other forms of waste the city was en abled to contract for the sale of all garbage collected. In the operation of this system of contract, however, care must be exercised in selecting, the party to the contract if evils are to be avoided. It would appear unwise to grant the right to purchase garbage for feeding swine on a farm located within the city limits. Even if contract were made with a farmer outside the city, it would be desirable, especially if close to the city, that the farmer should be equipped to handle the garbage in a satisfactory way. The first contract made under the new ordinance system considered these points and was not attended by evils. The city also shouldered» the burden of collecting ashes, glass and earthenware, and tin and metal waste. This duty, like that of gath ering garbage, was placed in the department of public works under the supervision of the street commissioner. Collections of ashes were made once in two weeks in residence and once a week in business districts. The sale of these forms of waste also was authorized, and accordingly carloads of tin cans collected were sold. The ashes were utilized in constructing alleys. Although Gary possessed no city dump there were different places on undeveloped private property which the city in common with private individuals was allowed to use for dumping purposes. The street commissioner inspected these dumps regularly to see that nothing was deposited which would be a menace to the city’s health. A t the time of the completion of the field work of this study in October, 1918, the change to the regulations of the new ordinance had not yet been wholly completed and some of the evils of the older system lingered. By the end of 1918, however, considerable im provement had been made in regularity of collection of all forms of waste, and the consequent increased cleanliness of alleys was notice able. is Ordinance No. 697, Apr. 17,1918, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IN D. 75 SEWERS AND SEWAGE DISPOSAL. Gary’s sewerage system in 1918 included 82 miles of sewers, of the combination sanitary and storm type. In the built-up portions of the city sewer connections were possible in practically 95 per cent of the area. A large part of the 31 square miles included within the city limits, however, was still rural in character, a fact which must be borne in mind when comparing the 137 miles of improved streets with the miles of sewer mains. Disposal of sewage consisted in allowing it to flow untreated into the Grand Calumet and Little Calumet Rivers. The sewage, small in amount, from the two southernmost residence districts, Glen Park and Ridge Road, was emptied into the Little Calumet; the sewage from the rest of the city, together with the waste from the mills, was all emptied into the Grand Calumet. It was probably owing to the large volume of water with which the sewage was diluted that this method of sewage disposal apparently involved little that was unpleasant for Gary. In 1918 some difficulty was encountered, however, in connection with the outlet for the sewers serving Broadway between Fifth and Eighth Avenues; the outlet was submerged, and failed to function properly. The city was giving its attention to this problem and a satisfactory solution was expected.79 The sewer system was so constructed that the sewage, not only from the outlet into the Little Calumet but also from the three outlets into the Grand Calumet, could fibe diverted to special locations for septic tanks and filtration beds at any time.” 80 During 1917, 875 permits were issued for service connections to the public sewers.81 According to the State housing law, tenement houses were held to be accessible to public sewer if the sewer main ran within 100 feet of any outside line of the lot upon which the tenement house stood. The erection of tenement houses which did not connect directly with 79 Annual Report, City Engineer, 1917, p. 4, * * * Needed relief will be secured when the submerged condition of the outfallis remedied. This can be done by lowering the water surface of the Grand Calumet River or by installing a pumping station at the river. The recent activities of the commissioners of the sanitary district of Chicago in connection with the disposal of the sewage from this city through their Calu met Sag Channel may offer the solution by the first method. This department (i. e., the city engineer’s department) is gathering data to prepare plans for a solution by this second method. ’ ’ Connecting the Grand Calumet with the Sag Canal and hence with the Chicago Drainage Canal would mean diverting the sewagefrom the Calumet region eventually into the Mississippi River. At present Gary sewage discharged into the Grand Calumet after being carried approximately 25 miles reaches Lake Michigan at the South Chicago, HI., outlet of the river. It is believed that the current of the river does not permit the emptying of Gary sewage into the lake nearer Gary through the river outlet at Indiana Harbor. B y additionalindustrialand domestic sewage from other parts of the Calumet region the Grand Calumet becomes grossly polluted before reaching South Chicago and constitutes a grave nuisance and source of contamination to the water supplies of Hammond, East Chicago, and Whiting. 80Annual ReP°rt of the Heads of the Departments of the City of Gary, Indiana,for the Year Ending Dec31,1914, p. 61. 9 81 Annual Report, City Engineer, 1917, p. 5, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 76 I N F A N T M O R T A L IT Y . a sewer had been forbidden since 1913.82 As has been mentioned, there was in 1918 no city ordinance to supplement the State law and give adequate regulations for one-family houses. WATER SUPPLY. A water company, since May, 1907, has had the right and privi lege of installing, acquiring, maintaining, and operating a water works plant in Gary. Lake Michigan is the source of the city s water supply through a tunnel 6 feet in diameter which extends miles from shore.83 The water enters this intake at a depth of 40 feet. Coming from such a distance in the lake and at such depth the water shows the effect of storms only when they are exceptionally severe and stir the lake very unusually. The city engineer stated that no system of filtration was necessary and that thereThad been but few instances in the history of Gary when the city water had not been clear. The capacity of the system was more than sufficient for the city’s needs. The average daily pumpage at the time this study was made was 5,738,344 gallons.84 In 1918 the contents of a large concrete water tower of 500,000 gallons capacity lasted little more than an hour, whereas when the city was small the tower contained a day’s supply.85 No storage system was in use but purification was secured by the introduction of liquid chlorine into suction wells.88 The report of the city chemist showed 99 examinations of the city water made b y him in 1918. In addition, the water company had examinations of the water made at irregular intervals. All tests were favorable and showed that the city was in possession of a very satis factory water supply. In fact Gary city water met the high standards set by the United States Public Health Service and had been certified for use on interstate carriers. There were, in 1918, 80 miles of water mains in the city. It was estimated that 80 per cent of the population of Gary could secure city water. To the outlying rural parts of the city Pine, Clark, and West Gary— the water system had not yet been extended. Some sections of the old town of Tolleston still lacked service. In the districts of Gary to which the city water supply had not yet reached the driven well was the ordinary source of water. Such 82 Housing law of State of Indiana, acts of 1913, sections 7 and 35. 83Taylor, Graham R .: Satellite Cities, p. 183, New York, 1915. 8« Indiana Year Book, 1918, p. 398. 85 Statement of an official of the water company. 8« An average of 1.8 pounds chlorine per million gallons was used, Sept. 30,1917, to Oct. 1,1918, m Gary. B y a rule made by the State board of health in October, 1917, “ the superintendents of all waterworks plants operating or maintaining chemical precipitation or purification plants ” are required to submit a report to the water department of the State board of health on Monday of each week, giving the following facts:“ Daily pumpage, pounds of chemicals and grains per gallon used each day, any unusual condition that may have affected pumpage, character of raw water, and the quality of the treated water during the week pre vious ftTiriing Saturday at midnight.” Indiana Year Book 1918, pp. 396-398. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis G AR Y, IRTD. 77 a well consisted of a pipe, with a sieve over its lower end, driven into the sand to a depth of perhaps 20 feet until a supply of ground water was tapped. A common iron pump attached to the upper end of the pipe made the well complete. Such wells did not present so great chance of contamination by seepage of surface water into them as would dug wells with imperfectly fitted tops or platforms. By the time surface water had filtered through the sand to the depth of the sieve at the end of the pipe there had been opportunity for the surface water to become greatly purified. In its well water as in its city water Gary was fortunate. The typhoid-fever record of a city may be taken as indicative of the excellence of its water. But one death from typhoid occurred in Gary in 1917, and but 16 deaths in 1918. Gary had never had an epidemic traceable to its water supply.87 STREETS AND ALLEYS. In Gary a street must be paved if it is to be of much real value? since travel through loose sand is too laborious to be practicable. The 137 miles of improved highways within the city in 1918, there fore, represented by far the largest proportion of the streets. Only in the less-settled and less-frequented parts were unpaved sand roads used. With the exception of the main thoroughfares, Broadway and Fifth Avenue, which yrere of greater width, Gary streets were uni formly 60 feet wide, while alleys for the most part were half as wide. Approximately 50 per cent of alleys in the built-up sections of Gary were paved.88 During 1918 the ashes collected by the city were used to construct cinder alleys in the Ambridge and the Tolleston districts. As already stated, both water and sewer mains had been laid in the alleys, so that repair or extension work on the mains did not involve tearing up the streets. As is the case in all windy cities, the streets of Gary, in spite of the efforts of an efficient street-cleaning force, sometimes looked dirty and littered. Even in the thickly built-up sections a high wind could still displace a considerable amount of loose sand. In Gary’s earlier days it was found that paved streets and sidewalks might be come covered over with sand drifting from neighboring lots. A c cordingly the Gary council declared it a public nuisance to permit “ loose sand to be carried onto the streets, alleys, sidewalks, and pavements” and provided a penalty for the property holder who allowed sand from his lot to remain upon the adjoining street and walk.89 87 Statement by city engineer, an official of the water company; and the city chemist. 88 Statement of city superintendent of streets. 89Ordinance No. 113, Oct. 26, 1909. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 78 I N F A N T M O R T A L IT Y . Improvement in the condition of alleys due to the new system of city garbage and rubbish collection was marked in most parts of the city but perhaps less widespread on the South Side and sections where the paving of alleys had not progressed far. Successful en forcement of the provisions of the new method depends upon incul cating in the rank and file1of citizens increased knowledge of their responsibilities and upon their intelligent cooperation with the civic agencies intrusted with collecting garbage and rubbish and with keeping streets and alleys clean. Beauty of lawn and shade trees had indeed been bought with a price in Gary since, in most of the city, grass-covered yard and curb lawn had been won only by overlaying the sand with black earth and pa tiently and painstakingly fostering the formation of sod. The re mark that the number of inches of black dirt on top of the sand in his yard might be taken as a measure of a householder’s financial status in the community was not without its element of truth. INFANT WELFARE. During the years 1916 and 1917 comparatively little infant-welfare work was being done in Gary. One infant-welfare station was con ducted under the auspices of Neighborhood House, a settlement in the midst of the foreign-bom community on the South Side. The work, conducted in cooperation with physicians, consisted in educat ing the mothers in the proper care of babies. Babies were weighed and measured and given physical examination; mothers were taught modification of milk according to the formulae prescribed b y physi cians. General instruction in the hygiene of infancy was accompa nied by emphasis upon the fundamental principles of the care of milk and other food. Some prenatal work was done, both with mothers visiting the station and with mothers in their homes. A Little Mother’s class for girls of foreign-born parentage met once a week to leam proper ways of bathing, dressing, feeding, and putting a baby to sleep, as well as how to care for an infant’s clothing. Milk was dispensed from Neighborhood House but not without cost except to those designated b y the charity association. The privilege of securing milk kept fresh and cool on ice was appreciated by mothers who had no home facilities for preventing milk from souring. The city in 1918 gave $50 to the settlement for ice, to be distributed to families who were unable to purchase it. Late in 1918 Friendship House, another settlement house on the South Side, resumed infant-welfare work it had largely discontinued during 1916 and 1917. Besides these stations, a third center for infant-welfare work on the South Side had been opened under the charge of the visiting https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis G AR Y, IN D . 79 nurse for the employees of one of the steel companies. This station not only undertook teaching of infant care, but also held a clinic twice weekly for- examination and treatment of sick babies. In 1918 this station was reaching about 50 families. The work of the health department, besides the activities already discussed, included in 1916 .and 1917 the enforcement of the provi sions of the infant blindness law. The city matron’s work was also partially concerned with infant welfare, since in cases of extreme poverty or of abandonment she often provided outfits for newly arrived infants; this work, however, was incidental to her general philanthropic and charitable work. In 1918, the city took a greater interest in infant welfare. A citypaid nurse was put in charge of the work of the infant-welfare sta tion at Neighborhood House already mentioned, and the city matron reported daily to this station for work dining the summer months. Since 1918 Community House in the First Subdivision has also become a center for infant welfare. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUMMARY AND CONCLUSIONS. This study of infant mortality and of conditions in the city of Gary affecting babies bom in 1916 contributes further evidence of the importance of social and economic factors in infant mortality. Infant mortality rate and cause of death. Among 1,353 babies born alive 169 deaths under 1 year of age occurred, and the resulting infant mortality rate was 124.9. Fourtenths of the deaths were attributed to gastric and intestinal dis eases; one-fifth to causes connected with early infancy; and one-sixth to respiratory diseases. Gary’s infant mortality rate from gastric and intestinal diseases, 50.3, was almost double the corresponding rate for the birth-registration area. Loss from causes connected with early infancy gave Gary a specific infant mortality rate (25) half as large as the one from gastric and intestinal diseases, and somewhat less than the rate in the birthregistration area. * The infant mortality rate from respiratory diseases in Gary was 19.9; from the group of “ other communicable diseases” it was 11.1. These rates were both higher than the corresponding rates, 15.9 and 8.9, in the birth-registration area. Nationality of mother and infant mortality. Of the births in Gary in 1916, 71 per cent were to foreign-bom mothers. The principal nationalities were the Polish with 19.7 per cent, the Serbian and Croatian with 11.6 per cent, and the Slovak with 9.7 per cent. The infant mortality rate among babies of native white mothers was 96.6 and among infants of foreign-bom mothers, 133.5. The babies of Polish mothers had the highest rate, 148.3. The mortality rate from gastric and intestinal diseases among the infants of foreign-bom mothers was 2\ times as high as among those of native white mothers and the rate from respiratory diseases wâTs slightly higher; the rate for “ other communicable diseases” was identical in the two groups, while the rates from malformations and from early infancy were considerably lower among the infants of foreign-born than among those of native white mothers. Feeding and infant mortality. Of the infants who lived to be fed, 93 per cent were exclusively breast fed and only 4 per cent were exclusively artificially fed in the 81 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 82 I N F A N T M O R T A L IT Y ; GARY, I N D . * first month. The proportion breast fed gradually diminished and the proportion artificially fed increased month by month; in the ninth month only 35.4 per cent were exclusively breast fed, 41.7 per cent were partly breast fed, and 22.5 per cent were exclusively artificially fed. During the first 9 months of life the mortality among the artifi cially-fed infants averaged 5 times that among the exclusively breast fed and about 3 times that among the partly breast-fed infants. The mortality from gastric and intestinal diseases among the arti ficially-fed infants was relatively much greater, on an average 8 times as high as among breast-fed infants. The mortality from other causes, including respiratory and “ other communicable” diseases, was also higher among the artificially-fed infants, and averaged about 4 times as high as among the babies exclusively breast fed. The mortality among babies of foreign-bom mothers was greater than among babies of native white mothers among both the exclusively-breast fed and the exclusively artificially-fed infants. Native mothers fed their babies artificially earlier and more exten sively than mothers of foreign birth. Supervised feeding of babies was about twice as frequent among infants of native mothers— a fact which accounts in part for the greater safety which attended the use of artificial feeding by these mothers. Examples of unwise feeding of infants were far too common, and served to illustrate the need of educating mothers in acceptable and safe methods of feeding their babies and caring for articles of food. Maternal mortality and maternity care. Seven mothers died within a year after confinement in 1916, three from causes connected with childbirth. The care, supervi sion, and assistance that mothers receive during pregnancy and confinement have bearing not only on maternal health and well being but also upon infant welfare. Of the mothers giving birth to children in Gary in 1916 seven-tenths had had no prenatal care; only about one-fiftieth had had care that could be termed adequate. Native white mothers secured better care than foreign-born mothers. About seven-eighths of the foreign-born women had no medical supervision whatever, while among native women this group con stituted only two-eighths. At confinement and for the lying-in period the foreign-born woman depended much more generally upon midwife services than did the mother born in the United States. About nine-tenths of the native white mothers, but two-tenths of the foreign-born mothers had phy sician attendants. Of the native white mothers 22 per cent and of the foreign-bom mothers only 4 per cent were confined in hospitals. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis G AR Y, IN D . 83 Prenatal and confinement care received by the foreign-bom mothers as a group was less skilled than that which native white mothers sought and obtained. Gainful employment of mothers outside the home either during pregnancy or after confinement when their babies were still very young was not widespread. Only 3.5 per cent of the mothers worked away from home during pregnancy, and only 2.4 per cent after con finement during the life of their infants prior to the first birthday. Lodger keeping, on the contrary, was frequently carried on by mothers during pregnancy. Gainful employment of mothers during preg nancy was associated with increased infant mortality and stillbirth rates. The highest infant mortality rate occurred among babies whose mothers continued gainful work up to within a few hours of confinement. Earnings of chief breadwinner and infant mortality. A decline in the infant mortality rate with a rise in the earnings of the chief breadwinner in the family was again demonstrated in this study. When the chief breadwinners’ earnings were under $1,050 a year, the infant mortality rate was 137.8; when chief bread winners’ earnings reached or exceeded $1,850 per annum, the infant mortality rate fell to 89.4; among babies to native white mothers when earnings were in the highest group, the mortality rate sank to 60. Over one-third of the babies of foreign-born mothers, and only one-tenth of those of native white mothers, had chief breadwinners in the lowest earnings group; somewhat more than one-fourth of those of native white, and somewhat less than one-twelfth of those of foreign-born mothers, had chief breadwinners whose annual earn ings at least equaled $1,850. From the point of view of infant welfare, low family income is important because of other unfavorable factors— ignorance, poor housing, and inability to purchase medical and nurs ing service— with which it tends to be associated. Civic and social factors. B irth and death registration .— Good vital statistics records are a prerequisite to ascertaining the status of infant well-being in a com munity. In 1916 about 1 baby in 7 was not receiving public record of birth in Gary, and for 1 in 30 of those who died under 1 year of age no death certificate was found. The city was attempting to secure public cooperation in birth registration by mailing a certifi cate to the parents of each child whose birth was registered. So far as the registration of births in 1916 was concerned, midwives in fail ing to report one-eighth of the births they attended were more serious offenders against Indiana’s law for birth registration than were physicians, who failed to report one-twelfth of the births they attended. Midwives not on the official register of those licensed by https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 84 I N F A N T M O R T A L IT Y , G AR Y, IN D . the State to practice were largely responsible for lowering the record of midwives as a whole. The law is explicit in requiring licenses for those who practice obstetrics and in providing for the prompt regis tration of births. Improvement lies in better enforcement. H ou sin g and other civic fa c to rs .— Poorer housing, less development in municipal sanitation, lower average in economic status, and pre ponderance of the foreign born were characteristics of the South Side, Tolleston, and Lincoln Park subdivisions. More uniformly better housing, superior development and extension of sewers and water mains, higher general economic level, and predominantly native white population were features of the First Subdivision and Ambridge. The infant mortality rate for the babies bom in the first group of subdivisions was 141.2; in the second, 90.6. City officials were aware that the building ordinances did not cover the one-family house and that the city’s chief dependence in regulat ing building was the State law of 1913 directly concerned with tene ment houses. Extension of sewers and water mains and the paving of streets were being pushed forward. The installation of a new system of garbage and rubbish collection by the city in 1918 was salutary. Gary was still suffering in 1918 from having only a part-time city health officer, inadequately salaried, and no nursing staff sufficient to its work. Need for changing the State law governing city health departments was recognized. Infan t-w elfare w ork .— During the years 1916 and 1917 compara tively little infant-welfare work was being done in Gary. In 1918 the city detailed a nurse to assist in this work during the summer months. This provision was totally inadequate to meet the needs of Gary’s population. Gary needed additional infant-welfare stations and additional public-health nurses. In conclusion, much of the mortality among infants in Gary was preventable. The heaviest toll was taken by the gastric and intes tinal diseases, and it has been repeatedly demonstrated that the mor tality from these causes can be largely reduced by the encourage ment of breast feeding, improvement of the milk supply, improve ment of community housing and sanitation, and especially by the instruction and education of mothers in the proper methods of infant feeding and care through the establishment of infant-welfare stations. Experience has shown that mortality from causes peculiar to early infancy can be reduced by education of mothers in the principles of prenatal care and personal hygiene during pregnancy and by skilled care at confinement. By carrying forward and extending work already commenced in Gary, through infant-welfare stations, prenatal clinics, and public-health nurses, it should be possible within a few years to reduce the infant mortality rate to a very low figure. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis APPENDIX. M ETH O D OF PROCEDURE. Infant mortality rate. An infant mortality rate expresses the probability of a live-bom infant dying before his first birthday and is usually stated as the number of deaths under 1 year per 1,000 five births.1 The usual approximate method of finding the infant mortality rate for a certain area is to divide the number of registered deaths of infants under 1 year of age occurring in a given calendar year by the number of registered live births in the same year. The number of deaths thus secured includes not only deaths of infants bom in the same calendar year, but also some deaths of infants bom in the preceding year or in a different area; it excludes deaths of infants included in the group of births if the death occurred either in a different area or in the following calendar year. The two numbers— of deaths and births-— do not refer to the same group of infants. To avoid this inaccuracy, the method employed by the Children’s Bureau is to follow each infant born in a given selected year in a certain area for a period of 12 months. The deaths among these infants are then compared to the births. In this way the deaths include no infants not included in the births, and the true probability of dying in the first year of life is secured. The chief difficulty, in practice, in computing infant mortality rates arises from the incompleteness of registration of births and deaths. Two methods are available for treating the original data to make them more serviceable. One is to exclude the least accurate material, where it is known to be incomplete or inaccurate; the other is so to supplement the original data that the figures used include all the evidence applicable to the groups studied in the city. Certain groups for which the information was inaccurate or in complete were excluded in this study. The groups for which the rates •were most open to question and most difficult to obtain were illegiti mate births, births in families that moved away, and births to non resident mothers. The first of the groups that were excluded from the general analysis was the group of illegitimate births. The information secured was probably not so complete as for legitimate births; futhermore, it related to an abnormal family group. 1Stillbirths are omitted from both births and deaths. 85 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 86 INFANT MORTALITY. Births to mothers who moved away in the first year of the infant’s life formed the second group of exclusion. The information as to the number of deaths that occurred in this group was not complete. Obviously, if the infant moved away from the city after the first few weeks or months of life, his death, if he died, would not be registered in the city. Deaths registered in the city of infants bom to mothers who later moved away also had to be excluded; otherwise the rates would be biased b y the exclusion of live births only, with no exclusion of infant deaths to correspond. A third group of exclusions was the births to nonresident mothers. These were excluded not only on the ground that in most cases the infant did not live in the city during his entire first year of life but also on the ground that the conditions under which nonresident mothers lived prior to coming to the city might have been different from those of the average mother in the city. In order to make the rate as characteristic of the city as possible these births were ex cluded. Births to mothers who could not be found were also excluded. In such cases the probability was that the mother had moved away. No reliable information could be secured about these cases and hence the only safe policy was to exclude them. In practice, since the visit of the agent of the bureau to the mother to secure the information called for on the schedule always was made after the first anniversary of the birth of the child— in some cases a year or more afterwards—births were excluded if the mother had moved away from the city prior to the agent’s visit or could not be found at the time of the visit.2 The data submitted in the report apply, therefore, to births in the city during the selected year to resident married mothers who lived there during the child’s first year and were found at the time of the agent’s visit. Though the records for births to resident married mothers were much more complete and satisfactory than for all births in the city, the difficulty of the incompleteness of registration still remains. In Gary a house-to-house canvass was made to supplement the list of names secured from the birth register. This procedure was plainly necessary, since Gary was not in the birth-registration area in 1916. The canvass was undertaken not so much to complete the record of children born in Gary during the selected year as to complete the record of such children who lived in Gary during the first year of 2The rulings in two special cases might he mentioned: (1) I f the mother died during the child’s first year, the birth was included if the infant (or, in case of death, his family) had lived in the city during the first year after his birth. (2) In a few cases mother and child were away from the city for a part only of the child’s first year but later moved back and were found by the agent. These cases were excluded in case of removal, a temporary absence not exceeding three months, such as absence during a summer vacation, not being considered a removal. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GARY, IND. 87 life. Obviously it would be more difficult to secure records for children whose mothers moved away from the city before the end of the first year of life, or for children who had died. The omission of such births from the canvass would not have' affected the validity of the canvass for the purposes of this study. All the names secured either b y birth records or b y the canvass were used as a basis of visits to mothers, and those cases for which the information secured showed that the child had been born in Gary in the selected year and had lived in the city during his lifetime up to the first birthday were included in the detailed study. Incidentally the canvass greatly facil itated the work of finding the mothers, for it gave the correct ad dresses of most of the mothers to be interviewed. Live births excluded. With the foregoing explanation of the method of procedure in mind the significance of the exclusions and the rates for the excluded groups may be more easily grasped. During the selected "year there were 1,682 known live births in Gary; of these, 274 had moved out of town and no trace of 32 could be found, making a total of 306 which were excluded on grounds of removal or lack of information. Forty deaths occurred in this group, giving a rate of 130.7. Of these 306 live births, 31 were unregistered. The majority of the 31 unreg istered births were discovered through death certificates. The true number of unregistered live births to mothers who moved away from the city was probably greater than the number discovered, since, as suggested previously, it was difficult to locate unregistered live births through a canvass made after the families had moved away; on the other hand, the true number of deaths under 1 year of age was probably also somewhat greater than the number registered, since the deaths registered in the city did not include deaths which might have occurred outside the city after the families had moved away. In two instances the births were excluded on account of incomplete or unreliable data; in one of these cases the infant died. Among the 19 live-born infants excluded on account of nonresi dence of the mother, one death occurred in the city. In most cases the mother probably left the city soon after the birth of the child. The mortality therefore understates the true mortality for this group. Two births were excluded on the ground of illegitimacy; neither of these babies died. From the figures light may be thrown upon the completeness of the registration of live births in Gary. If the deaths of infants whose births were not registered are compared with the total deaths in the city of infants whose births occurred in the selected year, the figure of 21.8 per cent is obtained as an index of the proportion of live births unregistered. This index gives the true proportion only in case the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 88 I N F A N T M O R T A L IT Y . mortality in the groups where registration was faulty was the same as the average. The mortality rates are usually high in the foreignborn and low earnings groups among which registration is probably less complete. This percentage, therefore, represents a maximum statement of the number of live births unregistered. Another method of determining the proportion of live births unregistered is b y com paring the unregistered live births which were discovered b y the can vass or in other ways with the total number of live births. There were 227 unregistered births discovered or 13.5 per cent of the total number known to have occurred im the city in the selected year. A fairer comparison, however, is of the 195 unregistered live births to mothers who were resident in the city not only at the time of the birth but also at the time of the agent’s visit, with the 1,353 live births in the same group; this gives a percentage of 14.4. The true percentage of unregistered births probably lies slightly above this figure, but below the figure given by the first method. T a b l e I . — R egistered and unregistered live births in G ary in 1 9 1 6 , in fa n t > deaths, and in fa n t m ortality rates f o r births included in a n d fo r births excluded fr o m detailed a n alysis, by reason f o r exclu sion . Births Births Births Births Un regis Total. regis unreg Total. regis unreg Total. Regis tered. tered. tered. istered. tered. istered. 1,682 Reason for exclusion: Nonresidence or lack of informa tion. Data incomplete or unreliable. Infant mortality rate.1 Infant deaths. Live births. Inclusion or exclusion of live birth, and reason for exclusion. 1,455 2227 211 165 «46 125.4 113.4 202.6 124.9 127.7 120.0 87.5 153.8 12a 4 87.8 124.1 85.0 1,353 329 1,158 297 195 32 169 42 139 26 30 16 327 296 31 42 26 16 32 28 2 19 247 1 4 6 1 1 34 3 1 1 21 3 19 274 2 1 Not shown,where base is less than 100. 3 Includes 2 not registered as deaths. 27 1 13 2 Includes 44 registered only as deaths. Stillbirth rate. Stillbirth rates are obtained b y dividing the stillbirths b y the total number of live and stillbirths. A stillbirth is defined as a dead-born issue of seven or more months’ gestation. Miscarriages, or deadbom issues of less than seven months’ gestation, were excluded. A policy of exclusions was followed similar to that for infant mor tality. Stillbirths to nonresident mothers were excluded because of the possible effect of conditions not characteristic of Gary; like wise, stillbirths to mothers who moved away prior to the visit of the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GABY, IF D . 89 agent. In the latter case, not only was information difficult to obtain, but also there was the same chance of omission of births as in calculating the infant mortality rate. In Indiana the law requires registration of stillbirths of seven or more months of gestation. A stillbirth must be registered both as a death and as a birth. It frequently happens, however, that a stillbirth is registered as a death but not as a birth. It is obvious that such an omission is one of carelessness only, as ordinarily a physician would register both. The number of unregistered stillbirths is difficult to determine. In the course of the canvass in Gary three cases of still birth were found which were registered neither as births nor as deaths. Stillbirths excluded. There were 60 registered stillbirths and 11 unregistered stillbirths3 known to have occurred in Gary in the selected year; 4 of those registered were excluded because they were found to be miscarriages of less than seven months’ gestation. Twenty-five stillbirths were excluded because the mothers had moved out of the city or were nonresidents, or because they could not be found. In these cases it could not be determined definitely whether the birth was a still birth or a miscarriage. Two stillbirths were excluded on account of illegitimacy. There were 40 stillbirths to mothers resident in the city both at the time of the birth of the child and at the time of the agent’s visit. The stillbirth rate for the included group was found b y dividing the number of stillbirths, 40, by the total number, 1,393, of births included in the study, giving 2.9 as the percentage of stillbirths. No rate has been formed for the nonresident, not found, or removed groups because it could not be ascertained from the records whether or not the birth was a stillbirth or a miscarriage. T able II. S tillbirth s 1 in G ary in 1916 included in and excluded fr o m detailed a n alysis, by reason f o r exclu sion . Inclusion or exclusion of stillbirth, and reason for exclusion. Total. Included................................................... Excluded.......................................... Reasons for exclusion: Nonresidence or lack ofinformation. Not found................................... Data incomplete or unreliable... Nonresident................................ Removed....................... •............ Miscarriage........................................ Illegitimate........................................ ° Includes miscarriages if registered as stillbirths. 3Includes 8 registered as deaths, but not as births. 106137°— 23------ 7 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Still births <* (total number). 71 40 31 25 8 1 16 4 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL TABLES 91 1TTT v Jj . 3 'JJ * https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis TT) A T 1 m E O ïï& m h 0P ÏE X â S Irn ; tu; https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL TABLES T a b l e 1.— R egistra tion o f birth, by attendant at birth; live births in G ary in 1 9 1 6 . Live births. Attendant at birth. Registered. Unregistered. Number. Per cent. Number. Percent. 1,353 1,158 85.6 195 14.4 Total. Total........................................ Physician (at hospital).......................... Physician (not at nospital)....................... Midwife.......................................... Other, none, or not reported.............. 115 439 753 46 108 407 639 4 93.9 92.7 84.9 ' 7 32 114 42 6.1 7.3 15.1 T a b l e 2.— In fa n t m ortality rates} by cause o f death; com parison o f deaths am ong in fa n ts born in G ary in 191 6 w ith in fa n t deaths in the birth-registration area in 191 6 . Infant deaths in— Abridged Interna tional List No.1 Cause of death.2 List No.1 24 25 102,103 104 20 Part of 23 22 Part of 33 89 91 92 150 Part Part Part Part of 33 151[1] of 33 }l51[2], 152[2], 153 of 37 of 37 152[1] Part Part Part 5 6 7 8 9 of 12 of 12 of 37 13 14 15 of 37 35 38 6 7 8 9 10 14 18 24 28,29 30 31,32,33,34,35 37 155 to 186 187,188,189 17 Part of 37 19 61 71 79 Infant Infant mor mor tality Number. tality rate. rate. 169 124.9 Num ber. All causes........................ Part Birth-registra tion area, 1916. Gary. Detailed Gastric and intestinal diseases3........... Diseases of the stomach................. Diarrhea and enteritis.................... Respiratory diseases*4.............. Acute bronchitis................... Broncho-pneumonia............... Pneumonia............................. Malformations................ Early infancy.................... Premature birth........................ Congenital debility........................ Injuries at birth.............................. Epidemic diseases and other com municable diseases.5 Measles...................................... Scarlet fever..................... Whooping cough............................. Diphtheria and croup.................... Influenza................ .*................. Dysentery................... ................... Erysipelas.................................. Tetanus................................ Tuberculosis of the lungs.......... Tuberculous meningitis___ Other forms of tuberculosis.......... Syphilis......................... External causes........................ Diseases ill defined or unknown.. . All other causes......................... Meningitis....................... Convulsions............................. Organic diseases of the heart. . . Other..................................... 68 3 65 27 1 16 10 11 34 20 13 1 15 3 1 1 1 1 8 5 1 4 50.3 2.2 48.0 19.9 7 11.8 7.4 8.1 25.1 14.8 9.6 7 U .l 20,834 1,145 19,689 13,092 2,088 7,804 3,200 5,583 27,586 15,846 8,316 3,424 7,329 3.7 1.5 2.2 1,175 45 1,824 418 693 161 464 77 447 673 203 1,149 887 768 jj .7 .7 1.5 7 5 .9 3.7 .7 2.9 626 1,030 278 4,721 25.4 1.4 24.0 15.9 2.5 9.5 3.9 6.8 33.7 19.3 10.2 4.2 8.9 .1 2.2 J) .8 1.4 1.1 8.1 .8 1.3 5.8 „A ? * 1? numbers indicate the classification in the abridged and detailed lists, respectively, of the Manual of the International List of Causes of Death. i.ncI|ided in this list are those used by the Ü. S. Bureau of the Census (see Mortality statistics, 1914, p. 660) m classifying the deaths of infants under 1 year. They are those causes of death aI 6 5?°?^ important at this age. The numbers of the detailed and abridged Inter national Lists wall facilitate their identification. In order to make discussion of the figures easier, these causes of death have been grouped m 8 main groups. , °The term “ gastric and intestinal diseases” as used in the tables and discussion, includes, as above shown, only the diseases of this type which are most important among infants, i. e., diseases of the stomach, aiamiea, and enteritis. It does not include all “ diseases of the digestive system” as classified under this heading according to the detailed International List. *“ Respiratory diseases,” as used in the tables and discussion similarly includes only those of the respir atory diseases which are most important among infants; i. e., acute bronchitis, broncho-pneumonia, and pneumonia. It does not include all “ diseases of the respiratory system” as classified under this heading according to the detailed International List. * Epidemic and other “ communicable diseases” as used in the tables and discussion includes only those of this group which are most important among infants. 93 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 94 IN F A N T MORTALITY. T a b l e 3.— Cause o f death, by m onth o f life ; deaths am ong in fa n ts b o m in G a ry in 1 916. Deaths among infants bom in 1916. Twelfth. Eleventh. Tenth. Eighth. Ninth. Sixth. Seventh. Fifth. Fourth. 169 156 16 10 13 11 10 14 8 7 9 4 11 12 2 6 30 20 9 1 1 7 2 5 3 7 2 1 5 3 6 3 8 2 1 1 5 5 2 4 3 1 1 3 4 2 9 4 68 27 11 34 20 13 1 15 1 8 5 External causes................................................ Diseases ill defined or unknown..................... All other causes................................................ Second. First. Total. All causes................................................ Gastric and intestinal diseases........................ Respiratory diseases........................................ Malformations.................................................. Early infancy................................................... Premature birth........................................ Congenital debility................................... Injuries at birth......................................... Third. Ooccurring in specified month of life. Cause of death. 1 2 1 2 1 1 2 1 3 2 1 1 2 2 3 2 1Includes 45 deaths under 2 weeks, 6 ascribed to gastric and intestinal diseases, 1 to respiratory diseases, 6 to malformations, 28 to causes connected with early infancy, 3 to diseases ill defined or unknown, 1 to some “ other cause.” T a b l e 4 .— Cause o f death, by calendar m onth o f death; deaths am ong in fa n ts born in Gary in 1 916. Deaths among infants bom in 1916. December. November October. September. August. July. June. April. May. February. March. Total. January. Cause of death. Allcauses......................................... 169 13 13 19 18 13 10 18 22 15 13 9 5 Gastric and intestinal diseases.................. Respiratory diseases.................................. Malformations............................................ Early infancy............................................. Premature birth.................................. Congenital debility.............................. Injuries at birth................................... Epidemic and other communicable diseases. External causes.......................................... Diseases ill defined or unknown............... All other causes.......................................... 68 27 11 34 20 13 1 15 3 5 1 6 4 2 1 1 12 . 4 1 2 1 1 2 1 3 2 1 2 1 1 18 3 2 5 3 3 2 x 1 1 2 1 2 4 2 2 5 3 2 11 2 2 1 1 5 4 2 6 5 1 3 4 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1 8 5 1 1 1 1 2 1 1 9 2 2 1 3—L 2 1 1 9 1 2 1 2 2 Month of death not reported. Occurring in specified calendar month. 1 T a b l e 5 . — M on th ly death rate by tyjpe o f feed in g , by m on th o f life and n a tiv ity o f m other. Infants born in 1916. Month of life and nativity of mother. Exclusively breast fed. Partially breast fed. Subsequent deaths. Infants Infants Subsequent deaths. Infants Subsequent deaths. survivsurvivsurviving ing ing at In year. In month. at In month. at In month. beginbeginbeginrung ning ning Per Per In Per In Per of of of speci Num cent Num 1,000 speci year Num 1,000 speci year. Num 1,000 of sur sur sur fied fied fied ber. ber. ber. ber. sur vi month. vi month. vi month. vivors. vors. vors. vors.1 All mothers: First month....... 21,353 Second m onth... 1,297 Third month___ 1,281 Fourth month... 1,271 Fifth month....... 1,258 Sixth month...... 1,247 Seventh m onth.. 1,237 Eighth m onth... 1,223 Ninth month___ 1,215 Tenth month___ 1,208 Eleventh month. 1,199 Twelfth month.. 1,195 Native mothers:3 First month....... 394 Second m onth... 373 Third month___ 370 Fourth m onth... 369 Fifth month....... 366 Sixth month...... 365 Seventh month.. 364 Eighth m onth... 360 Ninth month___ 359 Tenth month___ 357 Eleventh month. 355 Twelfth month.. 355 169 113 97 87 74 63 53 39 31 24 15 11 12.5 8.7 7.6 6.8 5.9 5.1 4.3 3.2 2.6 1.9 1.3 0.9 256 16 10 13 11 10 14 8 7 9 4 11 41.4 12.3 7.8 10.2 8.7 8.0 11.3 6.5 5.8 7.5 3.3 9.2 1,231 1,152 1,080 987 910 836 636 542 430 41 20 17 16 13 12 11 7 6 4 2 2 10.4 5.4 4.6 4.3 3.6 3.3 3.0 1.9 1.7 1.1 0.6 0.6 21 3 1 3 1 1 4 1 2 2 53.3 8.0 2.7 8.1 2.7 2.7 10.9 2.8 5.6 5.6 345 320 298 269 246 227 173 150 118 26 19 11 7 5 2 19 10 8 5 4 4 4 1 19 9 6 5 5 3 2 2 2 1 6 17.4 1 3.4 2 1 26 48 68 114 15.4 7.8 5.6 5.1 5.5 2.4 4.7 3.7 4.7 210 368 428 507 6 12 16 30 41 55 94 111 137 11.6 6.7 ................. , 2 5.6 1 Rate not shown where base is less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 107 75 56 43 ...1 ........... 6 6 6 7 5 7 9 10 11 10 6 5 1 1 2 2 2 2 2 2 2 1 1 Not fed. Artificially fed. 1 1 1 1 8.8 1 2 1 4.8 5.4 2.3 4 1 5 Subsequent Infants Subsequent deaths. Infants surviving ing at In month. at beginDied beginning at ning In Per once. In In of of speci year. Num 1,000 speci year. month sur fied fied ber. vi month. month. vors.1 58 91 128 164 188 195 227 248 273 30 40 1 1 3 Includes 31 infants who died not fed. Feeding not reported 69 78 82 96 98 103 23 31 35 36 33 29 24 18 13 9 7 6 4 5 3 7 6 7 9 5 5 3 2 6 10 9 8 9 7 6 5 4 4 2 1 1 3 3 31 23.4 42.7 31.9 35.9 39.6 20.2 18.3 2 1 1 1 1 1 1 1 5 5 5 12 3 1 1 2 2 1 7 6 5 6 6 6 6 5 'am ‘ahvd Total. 19.4 1 i 1 1 1 1 1 1 1 1 1 1 3 Including 12 native negro. CD Oi CD T a b l e 5 . — M on th ly death rate by typ e o f fee d in g , by m on th o f life and n a tiv ity o f m other— Continued. a Infants born in 1916. Exclusively breast fed. Total. Month of life and nativity of mother. Twelfth month.. Not fed. Artificially fed. Subsequent deaths. Subsequent deaths. Subsequent deaths. Subsequent deaths. Infants Infants Infants Infants surviv surviv surviv surviv ing ing ing ing In month. In month. In month. In month. at at In year. at at begin begin begin begin ning ning ning ning In In In of of of of Per Per Per Per Per year. speci year. speci speci year. speci 1,000 1,000 1,000 cent Num sur Num 1,000 Num Num Num fied fied fied fied sur sur of sur ber. ber. ber. ber. month. month. month. month. ber. vi vi vi sur vi vors. vors. vivors. vors. vors. 959 924 911 902 892 882 873 863 856 851 844 840 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 128 93 80 71 61 51 42 32 25 20 13 9 13.3 10.1 8.8 7.9 6.8 5.8 4.8 3.7 2.9 2.4 1.5 1.1 35 13 9 10 10 9 10 7 5 7 4 9 36.5 14.1 9.9 11.1 11.2 10.2 11.5 8.1 5.8 8.2 4.7 10.7 886 832 782 718 664 609 463 392 312 88 65 48 38 31 22 15 10 7 5 2 13 9 14.7 10.8 6.4 6.9 7.5 3.3 2.2 2.6 6.4 2 1 1 2 2 1 ::::::: 6 20 36 52 84 113 155 274 317 370 3 7 8 9 8 4 J. 1 1 1 1 1 2 1 3 1 4 6.5 7.3 3.2 28 51 73 95 110 113 131 150 170 13 22 27 27 26 23 19 14 9 7 6 1 2 3 4 5 6 7 3 2 2 Subsequent deaths. Infants surviv ing at Died begin at ning once. In In of speci year. month. fied month. 19 45.5 53.1 53.4 33.3 17.6 Feeding not reported. 6 5 4 5 5 5 5 4 4 4 4 4 2 1 1 1 1 1 i i I N F A K T M O R T A L IT Y , Foreign-born mothers: Partially breast fed. T a b l e 6. R ea son f o r w ean in g, b y p h ysicia n ’s advice, and in fa n t’s age at w ean ing; in fa n ts w eaned under 1 5 m on th s. Infants bom in 1916 weaned under 15 months. Total. Reason for,1 and advice on, weaning. Breast milk poor or disagreed with child....... Breast infected.................... Other reasons connected with mother' s health.. Condition of infant................ Illness of infant................... Refused or unable to nurse (not ill)........ Age....................................................................... Separation of mother and child.......... Other causes of separation............ All other known reasons.......... ............................... Reason not reported.................... Weaned by physician’ s advice.......... Reason for weaning: Condition of mother............ Pregnancy............................ Supposed pregnancy......................................... Breast milk poor or disagreed with child... 1 Per Un 15 Num cent der days 1 ber. dis 15 under mo. tribu 1 mo days tion. 845 100.0 529 62.6 145 17.2 32 3.8 60 7.1 31 3.7 182 21.5 19 2.2 60 7.1 34 0 20 2.4 29 3.4 238 28.2 3 0.4 2 0.2 1 0.1 18 2.1 0.9 53 20 10 3 30 7 3 3 3 12 1 1 1 1 2 9 1 2 22 2 3 2 1 1 20 1 2 3 4 24 1 1 1 7 2 5 3 5“ 3 12 3 1 2 1 2 1 3 2 1 1 32 30 63 63 ’ 58 173 88 78 1 35 26 10 1 6 26 40 17 1 3 4 8 46 20 , 2 6 1 7 33 22 4 3 29 12 4 2 25 14 2 3 1 2 73 30 5 7 3 9 5 1 25 2 2 21 17 96 4 2 90 6 54 3 1 1 10 11 M ï4 p 4 6 5 10 1 2 2 171 77.7 13 5.9 3 1.4 46 20.9 21 9.5 64 29.1 30 33 * 16 1 2 14 15 1 h 5 2 5 1 10 1 1 8 2 4 8 Ò 3 4 6 4 1 3 4 1 1 9 1 3 2 1 20 4 2 14 9 3 3 1 1 i 11 1 1 3 5 1 53 1 1 51 1 2 48 2 2 3 1 2 16 5 1 1 10 2 16 12 11 27 9 2 11 8 6 1 16 7 2 1 1 2 1 1 6 1 4 3 2 1 2 1 i i 2 * Includes 15 cases where infant was never breast fed. 5 Includes 1 case where infant was weaned more than once. 1 2 Ex act age not re port ed. 31 1 2 1 220 100.0 9 10 11 12 13 14 mos. mos. mos. mos. mos. mos. 39 1 1 As stated by mother. 2 Includes 5 cases where infant was never breast fed. 8 Includes 2 cases where infant was never breast fed. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 3 4 5 6 7 8 mos. mos. mos. mos. mos. mos. mos. GARY, Total................................ Reason for weaning: Condition of mother................... Pregnancy.................... Supposed pregnancy............... Age at weaning. 1 i 1 1 81 CD ~3T CO T a b l e 6 . — R ea son f o r w ean in g, by p h ysicia n ’s advice, and in fa n t’s age at w ea n in g ; in fa n ts weaned under 15 m onths — Continued. 00 Infants bom in 1916 weaned under 15 months. Age at weaning. Total. Reason for, and advice on, weaning. Weaned without physician’s advice..................... Reason for weaning: Condition of mother.................................................. Pregnancy............................................................ Supposed pregnancy........................................... Illness of mother.................................................. Breast milk poor or disagreed with child.......... Breast milk ceased or insufficient...................... Breast infected.................................................... Other reasons connected with mother’s health. Condition of infant.................................................... Illness of infant.................................................... Refused or unable to nurse (not ill)................... Age....................................................................... Separation of mother and child................. .......... Mother’s employment........................................ Other causes of separation.................................. All other known reasons............................................ Reason not reported.................................................. «3 12 10 45 29 2 13^2 09 fi 2 jj 8625 100.0 358 132 29 14 10 57.3 21.1 4.6 2.2 1 fi 7 11 48 7.7 242 38.7 1.6 10 23 3.7 209 33.4 3 0.5 2 0.3 1 02 16 2.6 6 1.0 3 Includes 2 cases where infant was never breast fed. 6 Includes 3 cases where infant was never breast fed. 1 1ncludes 1 case where infant was never breast fed. https://fraser.stlouisfed.org Y Federal Reserve Bank of St. Louis 1 1 1 1 2 2 2 Ex act age 12 14 11 13 10 9 7 8 2 4 5 6 3 not mos. mos. mos. mos. mos. mos. mos. mos. mos. mos. mos. mos. mos. re port ed. 1 1 2 1 2 1 2 1 1 1 1 1 1 71 1 1 1 1 1 1 1 2 5 3 1 2 2 2 2 1 1 1 2 11 1 9 4 11 1 8 2 5 1 3 1 26 8 15 18 23 17 5 28 21 28 47 51 47 146 872 73 23 8 14 16 17 13 1 3 4 2 17 10 29 14 1 2 2 6 38 18 2 2 1 6 27 21 4 57 27 4 22 10 3 23 14 2 2 5- 24 9 4 1 1 g 2 1 26 6 4 3 2 9 1 1 1 2 3 1 3 9 - 9 1 1 3 2 1 4 15 1 2 12 1 20 1 2 17 3 3 32 io 4 83 1 71 1 7 1 I 12 1 1 2 12 2 2 1 1 1 16 8 6 2 4 1 2 1 1 1 32 1 1 1 1 1 9 1 1 1 2 7 2 15 85 4 2 79 4 3 5 45 2 48 2 2 3 81 45 1 1 8 Includes 1 case where no report as to advice on weaning was obtained. 9 Includes 10 cases where infant was never breast fed. 19 Includes 4 cases where infant was never breast fed. 2 46 2 I N F A N T M O R T A L IT Y . Reason for weaning—Continued. Breast infected............... .................................... Other reasons connected with mother’s health. Condition of infant.................................................... Illness of infant...................... . ........................ Refused or unable to nurse (not ill).................. Age....................................................................... All other known reasons............................................ Reason not reported.................................................. Per Un 15 1 der days Num cent dis ber. tribu 15 under mo. 1 mo. days. tion. GAR Y, TNT), 99 T a b l e 7.— S u p ervisio n o f fe e d in g or access to in stru ctive literature in first year o f in fa n t’s life, by color and n a tiv ity o f m oth er; in fa n ts p a rtia lly or exclu sively artificially fe d . Infants born in 1916 partially or exclusively artificially fed at some time during first year. Supervision of feeding or access to instructive literature. Num ber. Total.................................................... No supervision or literature.............................. Supervision or literature................................... Medical supervision................................... Physician only.......................... Physician and nurse......................... Physician, nurse, and literature.......... Physician, nurse, other person, and literature............................................ Physician and other person................. Physician, other person, and literature. Physician and literature...................... Supervision by nurse................. Nurse only............................................ Nurse and literature............................ Supervision by other2................ Other only............................................. Other and literature............................. Literature only................................. Native white mothers. Total. Foreign-born white mothers. Per Per Per Negro.1 cent Num cent -Num cent distri ber. distri ber. distri bution. bution. bution. 1,053 100.0 313 100.0 729 100.0 11 2 632 421 305 231 11 2 60.0 40.0 29.0 21.9 1.0 0.2 116 197 148 96 5 i 37.1 62.9 47.3 30.7 70.1 29.9 20.9 18.1 5 6 5 3 0.3 511 218 152 132 0 1 2 7 6 46 14 10 4 45 35 10 57 0.2 0.7 0.6 4.4 1.3 0.9 0.4 4.3 3.3 0.9 5.4 2 2 5 37 5 3 2 14 9 5 30 0.6 0.6 1.6 11.8 1.6 1*0 0.6 4.5 2.9 1.6 9.6 4 1 8 9 7 2 30 25 5 27 0.5 0.1 1.1 1 4! 1 3.4 i 1 1 Per cent not shown where base is less than 100. 2Includes 1 “ not reported.” 0.1 1 3.7 2 Any person other than physician or nurse T a b l e 8 .— P revalence o f artificial feed in g w ith fresh cow ’s m ilk , w ith condensed m ilk , and w ith 'proprietary fo o d s before and after w eaning under 1 5 m onths o f age, by color and n a tiv ity o f m oth er; in fa n ts b o m in G ary in 1 9 1 6 . Infants bom in 1915 to— Type of artificial feeding given under 15 months before or after weaning. * All mothers. Num ber. Total......................................................... 21,322 Cow's milk (fresh): None given under 15 months..................... Not reported whether given....................... Given, beginning under 15 months............ Before weaning..................................... At or after weaning.............................. Not reported whether before or after weaning............................................. 100.0 371 2 356 4 962 595 365 26.9 0.3 72.8 45.0 27.6 2 0.2 81.7 0.4 17.9 6.4 11.5 Proprietary foods: None given under 15 months...................... 2 1,188 Not reported whether given....................... 5 Given, beginning under 15 months............ 129 Before weaning..................................... 47 At or after weaning.............................. 81 Not reported whether before or after weaning............................................. 1 89.9 0.4 9.8 3.6 6.1 i Per cent not shown where base is less than 100. Foreign-bom white mothers. Negro Per Per Per moth cent Num cent Num cent ers.1 distri ber. distri ber. distri bution. bution. bution. Condensed milk: None given under 15 months...................... 2 1,080 Not reported whether given....................... 5 Given, beginning under 15 months............ 237 Before weaning..................................... 84 At or after weaning............................. 152 Not reported whether before or after weaning............................................. 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Native white mothers. 100.0 940 100.0 114 30.7 257 143 114 69.3 38.5 30.7 238 4 698 450 246 25.3 04 74.3 47.9 26.2 2 0.2 796 5 139 57 81 84.7 0. fi 14.8 6 1 8.6 1 0.1 867 69 27 41 92.2 0 47.3 %9 44 1 0.1 276 74.4 95 27 68 25.6 7.3 18.3 0.1 0.1 311 1 59 20 39 83.8 0.3 15.9 5.4 10.5 4 2 Excludes 31 infants who di«d not fed. 11 4 7 2 5 8 3 3 10 1 i io o in f a n t m o r t a l it y . T a b l e 9. — A g e at w eaning o f in fa n t, by m edical su p ervision o f w eaning and earnings o f ch ief breadw inner; in fa n ts b o m in G ary in 1 9 1 6 . Infants born in 1916. Weaned. Earnings of chief breadwinner. Total surviv ing. B y physician’s Without physi advice. cian’s advice. Total. Num ber. Per Num cent.1 ber. Num Per cent.1 ber. Per cent.1 SURVIVING A T END OP 3 MONTHS. Total....................................................... -, 1,271 128 10.1 67 5.3 61 4.8 Under $1,050....................................................... $1,050, under $1,850.........- ................................. $1,850 and over...................1............................ 372 659 172 52 16 31 67 21 6 3 8.3 10.2 12.2 16 38 10 2 1 4.3 5.8 5.8 15 29 11 4 2 4.0 4.4 6.4 SURVIVING A T END OF 6 MONTHS. Total......................................................... 1,237 189 15.3 92 7.4 97 7.8 Under $1,050....................................................... $1,050, under $1,850............................................ $1,850 and over................................................ 355 645 172 49 16 46 97 36 6 4 13.0 15.0 20.9 19 50 19 3 1 5.4 7.8 11.0 27 47 17 3 3 7.6 7.3 9.9 SURVIVING A T END OF 9 MONTHS. Total........................................................ 1,208 270 22.4 102 8.4 168 13.9 Under $1,050....................................................... $1,050, under $1,850......................... ................. $1,850 and over.................................................. 347 630 167 48 16 72 133 51 9 5 20.7 21.1 30.5 19 55 23 3 2 5.5 8.7 13.8 53 78 28 6 3 15.3 12.4 16.8 SURVIVING A T END OF 12 MONTHS. Total........................................................ 1,184 443 37.4 138 11.7 305 25.8 Under $1,050...................................................... $1,050, under $1,850........................................... $1,850 and over.................................................. 339 618 164 48 15 125 217 81 14 6 36.9 35.1 49.4 22 75 33 5 3 6.5 12.1, 20.11 103 142 48 9 3 30.4 23.0 29.3 SURVIVING A T END OF 15 MONTHS. Total........................................................ 1,162 766 65.9 182 15.7 584 50.3 Under $1,050....................................................... $1,050, under $1,850........................................... $1,850 and over.................................................. 326 610 164 47 15 213 385 130 27 11 65.3 63.1 79.3 30 97 43 8 4 9.2 15.9 26.2 183 288 87 19 7 56.1 47.2 53.0 No earnings and no chief breadwinner........... 1Based on total survivors. Not shown where base is less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 101 G AR Y, UND, T a b l e 10 .— Prevalence o f artificial feed in g w ith fresh cow 's m ilk , w ith condensed m ilk , and w ith prop rieta ry fo o d s before and after w eaning under 1 5 m onths o f age, b y annual earnings o f ch ief breadwinner; in fa n ts b o m in G a ry in 1 9 1 6 . Infants born in 1916. Annual earnings of chief breadwinner. Total. Under $1,050 Type of artificial feeding given under 15 months before or after weaning. $1,050, un der $1,850. Per Per Per cent Num cent cent Num distri Num distri distri ber. ber. ber. bu bu bu tion. tion. tion. Total................................... ..-......... 2 1,322 Cow’ s milk (fresh): None given under 15 months............. Not reported whether given.............. Given, beginning under 15 months... Before weaning............................ A t or after weaning...................... Not reported whether before or after weaning.................... ........ 100.0 382 100.0 691 100.0 177 100.0 2 356 4 962 595 365 26.9 0.3 72.8 45.0 27.6 95 2 285 180 105 24.9 0.5 74.6 47.1 27.5 203 2 486 321 164 29.4 0.3 70.3 46.5 23.7 39 22.0 19 138 64 73 78.0 36.2 41.2 53 30 23 2 0.2 1 0.1 1 0. ß 566 2 123 43 80 81.9 0.3 17.8 6.2 11.6 134 75.7 60 43 14 29 24.3 7.9 16.4 12 3 9 623 2 66 25 41 90.2 0.3 9.6 3.6 5.9 150 1 26 10 15 84.7 0.6 14.7 5.6 8.5 68 1 0.6 Condensed milk: None given under 15 months............. 2 1,080 Not reported whether given.............. 5 Given, beginning under 15 months... 237 Before weaning......................... 84 At or after weaning...................... 152 Not reported whether before or after weaning........................... 1 81.7 320 0.4 3 17.9 ' 59 6.4 24 11.5 34 83.8 0.8 15.4 6.3 8.9 0.1 1 0.3 Proprietary foods: None given under 15 months............. 21,188 Not reported whether given.............. 5 Given, beginning under 15 months... 129 Before weaning.................... ....... 47 At or after weaning...................... 81 Not reported whether before or after weaning............................ 1 89.9 0.4 9.8 3.6 6.1 347 2 33 9 24 90.8 0.5 8.6 2.4 6.3 0.1 1 Per cent not shown where base is less than 100. 2 Excludes 31 infants who died not fed. * Includes 5instances of “ no chief breadwinner” and 11 of “ no earnings.” https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis No earnings, $1,850 and no over. chief bread win ner, Per and cent not Num distri re ber. bu port tion. ed.! »72 4 3 1 INFANT MORTALITY. 102 T a b l e 11.— D u ra tion o f household help during pregnancy, by kind o f household help and color and n a tivity o f m other; births in G ary in 1 916. Births in 1916. Kind of household help during pregnancy and color and na tivity of mother. No house hold help during preg nancy. To tal. No. All mothers........................ No household help...................... No household duties...................... Household help............................. Adult doing work other than laundry................................ Hired................................ Outsider, not hired.......... Member household......... . Laundry only......................... Child only............................... Not reported. ; ....................... Native white mothers............ No household help........................ No household duties.................... . Household help............................. Adult doing work other than laundry................................ Hired................................ Outsider, not hired......... Member household......... Laundry only........................ Child only.............................. Foreign-bom white mothers. N o household help...... ................. No household duties.................... . Household help............................ Adult doing work other than laundry............................... Hired............................... Outsider, not hired........ Member household......... Laundry only........................ Child only.............................. Not reported.......................... 51.5 720 99.9 38 2.7 12 Per Per No. ct.1 No. ct.1 Per No. Per No. No. ct.1 ct.1 Per No. ct.1 1,393 65 4.7 136 9.8 416 29.9 0.4 14 1.0 ~1 .1 "ié ’¿!0 662 5.7 9.7 20.1 61.6 379 157 107 115 224 58 9.0 9.6 12.1 5.2 1.8 11.6 12.1 20.6 2.6 19.0 16.6 29.0 13.0 59 26.3 2 .. 57.5 58.0 36.4 76.5 59.8 2 1.9 3.3 30 7.6 60 15.2 43.1 1.8 10.9 20.7 60.0 2.5 14.4 17.7 57.5 1.7 34 3.4 75 7.6 24.6 6.6 19.7 63.0 10.8 20.5 57.4 8.5 1 394 28.2 6 1.6 3 1.9 1 .9 3.1 Ill 13 275 181 87 57 37 987 61.0 602 602 100.0 4 381 195 70 49 76 132 53 1 Negro mothers2..................... No household help....................... Household help............................ Adult doing work other than laundry............................... Outsider, not hired......... Member household......... Laundry only........................ 1 Not shown where base is less than 100. 2 The negro mothers were all native bom. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Household help preceding con finement. House hold House help hold early help 1 2 3 weeks, month, months in preg not re Less ported. nancy than 2 under under and only. 1 3 weeks. over. month. months. 25 2.5 3.0 11.4 58.3 1.3 1.0 1.5 1.5 G A B Y , IN D . T a b l e 12. 103 Source o f in stru ction in prenatal care, b y color and n a tio n a lity o f m other • confinem ents in G ary in 1 9 1 6 . ’ Confinements in 1916 of mothers of specified nationality. Total con finements in 1916. Source of instruction in pre natal care. Foreign-born white. Native white. Total. 'S0 ¡•3 ö O <3 o © 0 O.Q Total. 0,0 * 1,376 100.0 392 100.0 972 100.0 272 100.0 No prenatal instruction. Prenatal instruction___ Physician only............... Physician and nurse....... Physician, nurse and lit erature.......................... Physician and literature. Nurse only...................... Nurse and literature............. Literature only............... Not reported whether prena tal instruction received.... 100.0 135 100.0 406 100.0 924 67.2 451 32.8 283 20.6 6 .4 24.7] 75.3 45.4 1.5 84.4 15.5 10.4 89.3 10.7 6.3 .7 2.3 20.4 2.3 .1 1.3 1.5 .3 1.9 1.1 10 94 24 3 31 Ne gro» Serbian Polish. and Croa Slovak. All other tian. 6.8 1.7 .2 2.3 3.3 93.1 6.3 5.0 92.6 7.4 5.9 74.9 25.1 16.7 .2 .4 3.0 2.5 .5 .4 2.6 2.2 1 Per cent not shown where base is less than 100. mentstad19167 coafllleiaents which resulted in twin births and 5instances where mother had twoconfine- T a b l e 13 .— G rade o f prenatal care, by color and n a tion a lity o f m oth er; con finem ents in G ary in 1 9 1 6 . Confinements in 1916 of mothers— Keceiving prenatal care of specified grade. Not re ported. Total......................... Native white............... Foreign-born white........ Polish............ Slovak....................... All other...................... Negro.......................... 113 28.8 276 846 87.0 125 12.9 252 92.6 20 7.4 149 93.7 9 5.7 127 94.1 8 5.9 318 78.3 88 21.7 7 - 1 Not shown where base is less than 100. m en S n dl9S!67 confinemeilts wMch » ■ * * * https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 3 8 t-t & 54 3.9 318 23.1 00 /» ^ 1 .7 .6 3 .7 3 8 © (U Number. 1 PU "3 8 3 Ph Number. "3 8 © Wheth Grade er prena untal care known. received. C. Number. B. Number. Number. Number. *1,376 966 70.2 406 392 972 272 159 135 406 12 A. Total. Percent.1 | Number. Total. Percent.1 Color and nationality of mother. Receiv ing no prena tal care. 3© © S ©-4 PU -- ¡¡J— 1 0.1 4 0.3 — 37 9.4 211 53.8 1.6 103 10.6 4 1.5 14 5.1 1 .6 7 4.4 1 7 7 5.2 10 2.5 75 18.5 1 4 1 .3 3 1 .8 .1 1 .6 ■ twin births and 5 instances where mother had two confine- 104 I N F A N T M O R T A L IT Y . T a b l e 14.— Grade o f postn a ta l care, b y attendant at con fin em en t; births in G a ry in 1916 Births in 1916 to mothers— Attendant at confinement period. Receiv ing no care by attend after Total. ant delivery. Receiving specified grade of postnatal care. Total. No. Per ct.3 No. Grade B. Grade A. Grade not re Grade ported.1 D. Grade C. Per No. Per No. Per No. Per No. Per Per ct.3 ct.3 ct.3 ct.3 ct.3 No. ct.2 Total.................................. 1,393 48 3.4 1,349 96.6 363 26.1 736 52.8 161 11.6 48 3.4 37 2.7 517 66 763 33 14 8 25 1.5 509 98.5 156 30.2 177 34.2 132 25.5 1 41 11 10 763 100.0 195 25.'6 540 70."8 16 ’ ¿.'i 11 32 9 2 31 6.0 15 2 *0*3 13 2.5 4 10 "Ì.3 10 Physician and midwife.............. Midwife only.............................. No attendant.............................. 1 14 100.0 1Includes 21 cases in which attendant at confinement was member of household and 2 cases in which mother died during confinement. 3 Not shown where base is less than 100. 3Includes .1 case with physician and “ other” in attendance. T a b l e 15 .— D u ra tion o f n u rsin g care at con fin em en t, b y color and n a tion a lity o f m other; confinem ents in G ary in 1 9 1 6 . Confinements in 1916 of mothers with nursing care. Color and nationality of mother. Total con fine ments in 1916. Less than 7 days. 7 days, less than 10. 10 days, less than 14. 14 days or over. Duration not reported. Per No. Per Per Per Per No. cent.1 cent.1 No. cent.1 No. cent.1 No. cent.1 Total.................................. 31,376 3108 Native white.............................. Foreign-bom white.................... Polish................................... Serbian and Croatian.......... Slovak.................................. All other............................... 392 972 272 159 135 406 12 5 102 48 15 7 32 1 7.8 506 36.8 216 15.7 543 39.5 3 0.2 1.3 10.5 17.6 9.4 5.2 7.9 52 449 132 63 78 176 5 13.3 46.2 48.5 39.6 57.8 43.3 113 28.8 102 10.5 18 6.6 20 12.6 9 6.7 55 13.5 1 221 317 74 59 41 143 5 56.4 32.6 27.2 37.1 30.4 35.2 1 2 -.3 .2 2 1.3 1Not shown where base is less than 100. 3 Includes 17 confinements which resulted in twin births and 5 instances where mother had 2 confine ments in 1916. 3Includes 1 mother who died at childbirth; 1 who died 4 days after delivery. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 105 GABY, IN D. T a b l e 16.— D u ra tion o f household help during lyin g -in p eriod, b y k in d o f household help and days in bed ; births in G a ry in 1 9 1 6 . Births in 1916. Total........................................ 1,393 __ 7 0.5 168 12.1 Mothers in hospital for confinement. 122 3 2.5 7 ~ b .l No household duties........................J 15 No household help (confined at home)................................... ......... 4 4 Household help................................. 1,252 12.9 In bed less than 4 days___ ____ 121 59 48.8 Household help— Adult doing work other than laundry.............. 116 58 50.0 Hired....................... 15 6 Outsider, not hired. 40 21 61 Member household. 31 Child only...................... 5 1 In bed 4 days but less than 7 days____ ______ ____________ 171 65 38.0 Household help— Adult doing work other 167 thanlaundry, i .......... 63 37.7 Hired....................... 40 9 62 Outsider, not hired. 26 65 Member household. 28 Laundry only......... . 1 Child only............... . 3 2 In bed 7 days but less than 10 days.................... ...................... 437 29 6.6 Household help— Adult doing work other than laundry.............. 426 28 6.6 Hired....................... 139 8 5.8 171 Outsider,not hired. 11 6.4 116 Member nousehold. 9 7.8 Laundry only................ 1 Child only.......... ........... 6 Not reported. ,\............ 4 1 In bed 10 days but less than 14 days.......................................... 239 4 1.7 Household help— Adult doing work other than laundry....... . 235 4 1.7 Hired....................... 93 3 Outsider, not hired. 102 Member household.. 40 1 Laundry only................ 1 Child only...................... 1 Not reported.................. 2 In bed 14 days and over............. 282 4 1.4 Household help— Adult doing work other than laundry_______ 277 4 1.4 Hired....................... 115 2 1.7 Outsider, not hired. 105 2 1.9 Member household. 57 Laundry only................ 1 Child only............ '.....! 2 Not reported............ 2 Number days in bed not re ported................. ..................... 2 1 Not shown where base is less than 100. 106137°— 23-------8 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Per cent.1 Per cent.1 Number. Number. Per cent.1 Per cent.1 .1 Number. 1 Number, j Per cent.1 A © o u Ph u Number. 1 Percent.1 Number. Number. No Household help during lying-in period. house House hold hold help help Less 1 week, 2 weeks 4 weeks, during 6 weeks not re Kind of household help during less less less lying-in 1than or over. ported. lying-in period and days in bed. week. than 2. than 4. than 6. Total period. 384 27.6 411 29.5 117 8.4 298 21.4 9 1 7 4 28 2370 5 X T 65 53.3 1 J j 10 0.6 "5 X I 3Y4 29.9 381 30.4 110 8.8 223 17.8 30 24.8 19 15.7 1 .8 12 9.9 3 .2 30 25.9 5 10 15 18 15.5 4 8 6 1 47 27.5 33 19.3 11 6.4 15 8.8 47 28.1 16 10 21 32 19.2 10 17 5 1 11 6.6 4 14 8.4 i 4 9 218 49.9 109 24.9 28 6.4 52 11.9 1 .2 215 50.5 106 24.9 54 38.8 44 31.7 89 52.0 47 27.5 72 62.1 15 12.9 1 2 1 2 28 12 14 2 48 11.3 20 14.4 10 a a 18 15.5 1 1 .2 .7 1 .4 1 .9 1 9 7.8 9 5 2 1 6.6 8.6 s, 9 17 4 59 24.7 83 34.7 33 13.8 60 25.1 57 24.3 23 22 21.6 12 81 34.5 33 43 42.2 5 1 33 14.0 14 16 15.7 3 60 25.5 90 20.6 19 1 1 1 20 7.1 137 48.6 37 13.1 83 29.4 19 6.9 137 49 5 12 10.4 44 38?^ 7 6.7 61 58.1 32 37 13 4 19 16 5 1? 11.4 6 80 28 9 38 3t3 0 23 21.9 19 1 2 1 1 i 1 106 IN F A N T MORTALITY, T a b l e 17 .— D u ra tion o f household help during lyin g -in p eriod , by kin d o f h ousehold help and color and n a tiv ity o f m oth er; burths m G a ry m 1 9 1 6 . Births in 1916. Kind of household help during lyingin period, and color ana nativity of Total. mother. Household help during lying-in period. No houseduring* lyine-in period. Less than 1 week. 2 weeks, 1 week, less than 2. less than 4. 4 weeks or over. Household help not reported. Per ium- Per 'ium- Per 'ium- Per 'ium- Per 'ium- Per ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 7 1,393 Total. 0.5 No household help 10 and not reported.. 15 No household duties 1,368 Household help....... Adult d o i n g work o t h e r than laundry. 1,319 Hired........... 444 Outsider, not hired......... 513 M ember household. 362 19 Laundry o n ly .. . 21 Child only.......... 9 Not reported.... Native white.. No household help and not reported.. No household duties. Household help........ A d ult doing work o t h e r than laundry.. Hired........... Outsider,not hired......... M ember household. Laundry o n ly ... Child only.......... Not reported..., Foreign - born white............. No househQld help and not rep orted .. No household duties. Household help........ A dult doing work o t h e r than laundry.. Hired........... Outsider, not hired......... Member household. Laundry o n ly ... Child only.......... Not reported___ Negro. 0.6 8 168 12.1 384 27.6 411 29.5 415 29.8 168 12.3 1 383 6.7 28.0 2 409 13.3 29.9 12 403 80.0 29.5 5 .4 164 31 12.4 7.0 376 112 28.5 25.2 399 141 30.3 31.8 376 158 28.5 35.6 4 2 .3 .5 62 12.1 141 27.5 191 37.2 117 22.8 2 .4 71 19.6 123 34.0 67 6 1 3 18.5 101 13 14 27.9 16.5 126 32.0 191 48.5 3 3 4 1 1.0 4 6 1.5 65 3 9 382 6 1.6 1 64 16.8 1 125 32.7 7 184 48.2 3 .8 361 153 6 4 1.7 2.6 60 27 16.6 17.6 121 44 33.5 28.8 172 78 47.6 51.0 2 .6 158 1 .6 26 16.5 71 44.9 58 36.7 2 1.3 50 15 3 3 x .3 394 2 .5 1 7 36 11 1 6 4 2 2 16.4 316 32.0 283 28.7 219 22.2 3 162 16.6 316 32.4 1 282 28.9 5 214 21.9 2 .2 948 289 158 27 16.7 9.3 313 85 33.0 29.4 276 96 29.1 33.2 199 79 21.0 27.3 2 .2 348 61 17.5 112 32.2 119 34.2 56 16.1 70 22.5 116 37.3 61 19.6 64 2 13 20.6 987 4 .4 162 1 311 4 18 6 12 No household help and not reported.. Household help........ A dult doing work o t h e r than laundry. Hired......... Outsider, not hired....... 1 2 9 3 2 5 3 2 5 3 2 1 5 1 3 1 3 1 Member household 1 Not shown where base is less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1 1 1 GA R Y, IN D , 107 T a b l e 18.- -N u rn ber o f days in bed fo llo w in g con fin em en t, b y annual earnings o f ch ief breadw inner; births in G ary in 1 9 1 6 . Births*in 1916. Number of days in bed following confinement. Annual earnings of chief breadwinner. Total. Total........................................ 1,393 Under $1,050............................... $1,050, under $1,850......... $1,850 and over....... .............. No earnings, no chief breadwinner, and not reported........................... 403 727 185 Less than 1 day. Not re 1 day, 4 days, 7 days, 10 days, 14 days ported. less less less less or than 4. than 7. than 10 than 14. over. 0.3 120 8.6 172 12.3 12.9 8.3 3.2 13.4 12.8 8.6 457 32.8 290 20.8 38.5 31.5 24.3 *78. 1Not shown where base is less than 100. *Includes 6 instances of “ no chief breadwinner” and 11 o f “ no eamings.; https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12.7 22.0 35.1 24.8 0.7 0.1 108 I N F A N T M O R T A L IT Y . T a b l e 19. — D u ra tion o f household help during lyin g -in period , by k in d o f household help and earnings o f ch ief breadw inner; births in G a ry in 1 9 1 6 . Births in 1916. Kind of household help and annual earnings of chief breadwinner. No house hold help during Total. lying-in period. Household help during lying-in period. Less than 1 week. 2 weeks, 1 week, Less than 2. less than 4. Household 4 weeks or over. reported. Num Per Num Per Num Per Num Per Num Per Num Per ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 0.5 168 12.1 384 27.6 411 29.5 415 29.8 8 0.6 4~~ 1.0 65 15.5 145 34.5 114 27.1 91 21.7 1 0.2 3 413 65 15.7 145 35.1 114 27.6 3 88 21.3 1 0.2 401 104 64 9 16.0 8.7 143 38 113 35 28.2 33.7 80 21 19.9 20.2 1 1 0.2 1.0 154 23 14.9 52 33.8 52 33.8 27 17.5 32 22.4 53 37.1 26 18.2 32 22.4 1 7 Not reported___ 143 1 9 2 $1,050, under $1,850.. 727 3 4 0.6 5 3 All m oth ers... 1,393 Under $1,050............. 2420 No household help and not reported. No household du- 4 Household help— Adult doing work other than Outsider, not Member houseLaundry o n ly ... N o household help and not reported. No household duHousehold help___ A d u lt doing work other than laundry.. Outsider, not M ember household. Laundry o n ly ... Not reported___ No household help and not reported No household duHousehold help___ A dult doing w o r k o t her than laundry. Outsider, not Member house hold. Laundry o n ly .. Not reported___ Earnings not reHousehold help... A dult doing work other than laundry Hired.............. Outsider, not Member house hold.............. Laundry only.. 7 4 1 1 1 89 0.4 35.7 36.5 12.2 203 1 27.2 31.6 198 28.4 2 228 32.0 7 191 26.8 2 0.3 27.9 230 2 10 712 89 12.5 1 202 685 221 86 17 12.6 7.7 199 63 29.1 28.5 222 78 32.4 35.3 177 63 25.8 28.5 1 0.1 282 32 11.3 77 27.3 110 39.0 62 22.0 1 0.4 18.7 52 8 6 28.6 27.6 103 55.7 1 2 1.1 2 101 55.5 1 0.5 97 63 55.7 1 0.6 182 12 9 6 185 37 20.3 59 32.4 5.4 3 19 10.3 3 10 34 4 2 51 1 1 2 182 10 5.5 19 10.4 51 28.0 174 95 10 3 5.7 18 7 10.3 48 22 27.6 59 6 7 23 22 20 5 2 1 1 4 3 2 12 3 1 61 4 17 16 23 1 61 4 17 16 23 1 59 24 4 2 16 .4 16 6 22 11 1 1 18 1 5 6 6 17 1 1 1 7 4 5 1 1 1 1 1 1 iNot shown where base is less than 100. * Includes 6 instances of “ no chief breadwinner” and 11 of “ no earnings.1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1 109 GAR Y, IN D . T a b l e 20.— P rem a tu rity, by order o f p ‘ regn an cy and age o f m oth er; births in G ary in 1 916. Births in 1916. Age of mother. Total. Prematurity and order of pregnancy. Number Percent distri bution. Under 20. Total................................... 1,393 100.0 99 824 396 44 30 Premature.................................... Full term...................................... Not reported................................ First pregnancy........................... Premature.............................. Full term ... . ........................ Second pregnancy............ .......... Premature.............................. Full term................................ Third pregnancy.......................... Premature.............................. Full term.............................. '. Not reported.......................... Fourth pregnancy....................... Premature............................ . Full term............................ . Fifth pregnancy........................... Premature.............................. Full term............................... Sixth or later pregnancy.............. Premature.............................. Full term............................... Order of pregnancy not reported. Full term............................... 66 1,326 1 258 21 237 285 8 277 253 10 242 1 182 10 172 140 3 137 272 14 258 3 3 4.7 95.2 0.1 100.0 8.1 91.9 100.0 2.8 97.2 100. d 4.0 95.7 0.4 100.0 5.5 94.5 100.0 2.1 97.9 100.0 5.1 94.9 12 87 37 787 3 41 30 66 10 56 28 2 26 5 173 11 162 215 6 209 193 6 187 14 381 1 17 20 to 29. 30 to 39. 5 40 and over. 2 17 ' 37 37 45 4 40 1 44 1 43 68 2 66 184 7 177 1 1 128 8 120 62 1 61 53 48 Not re ported. 1 2 4 1 1 4 9 1 9 8 1 7 5 2 5 28 2 26 1 1 5 7 2 5 7 1 1 T a b l e 21.— In terva l fr o m preceding con finem ent, b y'co n d ition o f preceding issu e; births in G a ry in 1 916 second and later in order o f issu e. Births in 1916 second and later in order of issue. Interval from preceding confinement. Condition of preced ing issue. Total. Under 11 months. 12 months, under 15. 15 months, 18 months, under 18. under 24. 24 months and over. Not re ported. Num Per Num Per Num Per Num Per Num Per Num Per ber. cent.1 ber . cent.1 ber. cent.1 ber. cent.1 ber. cent.1 ber. cent.1 Total............... 1,135 42 Miscarriage............... 49 Stillbirth“ ................. 35 Live birth................. 1,049 Survival.............. 936 Infant death....... 113 Condition not reported.................... 2 9 5 28 15 13 3.7 97 2.7 1.6 11.5 6 11 80 55 25 1 Not shown where base is less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8.5 142 7.6 5.9 22.1 3 8 131 114 17 12.5 309 12.5 12.2 15.0 5 6 298 283 15 27.2 522 28.4 30.2 13.3 13 5 504 464 40 46.0 23 2.0 13 48.0 49.6 35.4 8 5 3 2 0.8 0.5 2.7 110 I N F A N T M O B T A L IT Y . t T a b l e 22.— E m p lo ym en t o f ch ief breadw inner, b y color and n a tiv ity o f m other and earn in g s o f ch ief breadw inner; births in G ary in 1 9 1 6 . Births in 1916. Annual earnings of chief breadwinner. Total. Employment of chief breedwinner and color and na tivity of mother. Under #1,050. Per cent Num dis ber. tribu tion. 1 Num ber. All mothers. Employer..........................-. Own account........................ Professional. , ............... Other.............................. Wage earner......................... Steel................................ Other.............................. Not reported.................. Not reported whether em ployer or wage earner........ Native white mothers.. Employer............................. Own account........................ Professional................... Other............................. -Wage earner......................... Steel............................... Other........ ..................... Not reported whether em ployer or wage earner....... F o r e i. gn-b o r n w h i t e mothers.............................. Employer............................. Own account....................... Professional................... Other........; ................... Wage earner......................... Steel............................... Other................ ^........... Not reported................. Not reported whether em ployer or wage earner....... Per cent Num dis ber. tribu tion. 1 1,393 100.0 403 100.0 106 62 7.6 4.5 14 15 3.5 3.7 54 3.9 86.9 65.8 20.9 14 372 277 95 3.5 92.3 68.7 23.6 8 ,210 916 291 3 0.6 0.2 1.1 394 100.0 33 14 5 9 343 208 135 8.4 3.6 1.3 2.3 87.1 52.8 34.3 1 $1,050 under $1,850. 0.2 727 Per cent Num dis ber. tribu tion. 1 Per cent dis tribu tion. 1 100.0 185 100.0 4.3 3.4 42 7 5 131 112 19 22.7 6.5 3.8 2.7 70.8 60.5 10.3 104 100.0 25 671 507 162 2 3.4 92.3 69.7 22.3 0.3 12 No earn ings, no chief bread winner, and not reported.i 2 78 0.5 225 4.0 2.7 17.3 4.8 4.8 6 210 120 90 2.7 93.3 53.3 40.0 77.9 61.5 16.3 495 99.9 1.0 987 100.0 358 100.0 73 47 3 44 856 700 153 3 7.4 4.8 0.3 ■ 4.5 86.7 70.9 15.5 0.3 13 11 3.6 3.1 0.3 10 332 260 72 92.7 72.6 20.1 11 1.1 Negro mothers. 12 Own account......... Other............... Wage earner.......... Steel................ Other...... ........ 11 1 2.8 4.4 3.8 19 454 380 72 2 0.6 1 1 1 Per cent not shown where base is less than 100. 2Tnfbidps 6instances of “ no chief breadwinner” and 11 of “ no earnings. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1,850 and over. 3.8 91.7 76.8 14.5 0.4 80 54 111 GAHY, IN D , T a b l e 2 3 .— A ggregate fa m ily earnings, by earnings su p p lem en ta ry to those o f ch ief bread w in n er; births in G ary in 1 9 1 6 . Births in 1916. Aggregate family earnings. Supplementary earnings. Total. Under SI,050. Num ber. SI,050 under SI,850. Per Num cent.1 ber. $1,850 and over. Per Num cent.1 ber. Not reported. Per Num cent.1 ber. Per cent.1 Total...................... .... 1,393 320 23.0 738 53.0 257 18.4 78 5.6 N o supplementary earnings.. Supplementary earnings....... N ot reported..................... 889 448 56 224 81 15 25.2 18.1 484 242 12 54.4 54.0 134 117 6 15.1 26.1 47 8 23 5.3 1.8 1 Not shown where base is less than 100. T a b l e 24 .— E m p lo ym en t o f m other, b y color and n a tiv ity o f m other and earnings o f chief breadw inner; births in G ary in 1 9 1 6 . Births in 1916. Annual earnings of chief breadwinner. Total. Employment and color and nativity of mother. Under SI,050. $1,050, under $1,850. $1,850 and over. Num ber. Per cent dis tribu tion. Num ber. Per cent dis tribu tion. 1,393 100.0 403 475 917 1 34.1 65.8 (9) 165 237 1 394 100.0 117 277 29.7 70.3 987 100.0 .358 Employed....... .................. Not emploved................... Not reported.................. 352 634 1 35.7 64.2 .1 145 212 1 Negro........................ . 12 4 7 1 Emploved......................... Not employed.................... 6 6 2 2 3 4 1 All mot hers.................. Employed............................. Not employed........... Not reported.................. Native white................... Employed........................ Not employed............... •Foreign-bom white......... Num ber. Per cent dis tribu tion. Num ber. 100.0 727 100.0 185 100.0 278 40.9 58.8 .2 226 501 31.1 68.9 54 131 29.2 70.8 30 48 41 225 100.0 104 100.0 24 18 23 64 161 28.4 71.6 29 75 27.9 72.1 6 18 100.0 495 100.0 80 54 40.5 59.2 .3 159 336 32.1 67.9 24 56 24 30 1Per cent not shown where base is less than 100. 2 Includes 6 instances of “ no chief breadwinner’ ' and 11 of “ no earnings.” 8 Less than one-tenth of 1 per cent. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis No earn ings, no chief Per bread cent winner, dis and tribu not re tion. ported.1 112 I N F A N T M O R T A L IT Y . T a b l e 25 .— E m p lo ym en t o f m other, by annual earnings and color and n a tiv ity o f m other; births in G ary in 191 6 . Births in 1916. Mother’s annual earnings in 1917. Total. Employment and color and nativity of mother. None. Num ber. Per cent dis tribu tion.1 All mothers.................. 1,393 100.0 Not employed........................ Employed.............................. Lodgers............................ Other work only............. Not reported.......................... 917 475 409 66 1 65.8 34.1 29.4 4.7 (2) Native white mothers. . . 394 100.0 277 100.0 Not employed........................ Em ployed............................. Lodgers........................... Other work only............. 277 117 93 24 70.3 29.7 23.6 6.1 277 100,0 F o r e i g n - b o r n white mothers........................ 987 100.0 634 100.0 Not employed........................ Employed.............................. Lodgers............................ Other work only............. Not reported.......................... 634 352 313 39 1 64.2 35.7 31.7 4.0 .1 634 100.0 Negro mothers................ 12 6 Not employed........................ Employed^............................. Lodgers............................ Other work only............. 6 6 3 s 3 6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis $200 and over. Per cent dis tribu tion. Num ber. Per cent dis tribu tion. Num ber. 917 100.0 225 100.0 191 100.0 917 100.0 225 1Q7 28 100.0 191 100.0 59 12! 4 12 6.3 26 Num ber. 1Per cent not shown where base is less than 100. 2Less than one-tenth o i l per cent. Under $200« Per Not re cent ported. dis tribu tion. 60 67 35 15 67 57 10 35 31 4 10 155 100.0 154 100.0 44 155 139 16 100.0 89 7 10.3 154 100.0 43 7 4.5 1 ===== 3 2 3 1 2 1 1 — 1 1 GARY, IN D . T a b l e 26.— .I n fa n t m ortality rates, by literacy and color and n a tion a lity o f m other- births m G ary m 1 9 1 6 . Total births. Literacy and color and nationality of mother. Live births. Infant deaths — All mothers....... 1,353 169 124.9 119.9 139.6 .................................. .................................. 1,029 1,001 351 120 49 37 96.6 ...................... 392 381 2 36 1 94.5 ............ . .................. .................................................... ............... .............. 625 609 349 1 263 160 103 Illiterate............ Not reported.......... Native white mothers Illiterate..... Foreign-born white mothers Illiterate......... Not reported___ Polish Literate......... Illiterate..... Serbian and Croatian Literate............ Illiterate......... Not reported..... Infant mortality rate.1 1 275 168 ............... ................. ............ Literate............ Illiterate......... A llother........ Literate............ Illiterate....... 87 1 135 .......... .............. ................... ............ ............ 36 415 Negro mothers___ Literate....... « 74 83 1 132 97 35 406. 278 128 133.5 80 48 131.4 137.5 39 20 19 20 10 10 148.3 125.0 184.5 126.6 15 9 6 54 41 13 113.6 12 11 4 12 11 4 133.0 147.5 101.6 1Not shown where base is less than 100. T a b l e 27. In fa n t m ortality and stillbirth rates, by earnings o f ch ief breadwinner and literacy o f m oth er; births in G ary in 1 916. literacy of mother. Stillbirths. Total births. Number. Per cent. Total. Under $1,050.......... . $1,050, under $1,850. $1,850 and over....... not reported. . . Literate mothers. Under $1,050.......... .......... $1,050, under $1,850.. J ................. $1,850and over.............. No earnings, no chief breadwinner, and not reported.................„ .. Illiterate mothers. Under $1,050...................... $1,050, under $l,85o! ............... $1,850and over............... . . I ! " ! ! ! ! ! " No earnings, no chief breadwinner, and not reported.......... ............. 1,393 40 2.9 1,353 169 124.9 403 727 185 11 19 6 2.7 2.6 3.2 392 708 179 54 90 16 137.8 127.1 89.4 2 78 4 74 9 1,029 28 2.7 1,001 120 119.9 245 555 176 8 14 5 3.3 2.5 2.8 237 541 171 37 62 15 156.1 114.6 87.7 53 1 52 6 3B3 12 3.3 351 49~ 139.6 158 171 9 3 5 1 1.9 2.9 155 166 8 17 28 1 109.7 168.7 25 3 Literacy not reported.. 1 $1,050, under $1,850. 1 22 1 I t ■ * Not shown where base is less than 100. Includes 6 instances of “ no chief breadwinner” and 11 of “ no earnings. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Infant Infant deaths. mortality rate.1 births. 3 I 114 I N F A N T M O R T A L IT Y . T a b l e 28 .— L iteracy and n a tion a lity o f m other, by age at 1916 con fin em en t; births in G ary in 1916 to fo r e ig n -b o m w hite m others. Births in 1916 to foreign-bom white mothers. Age of mother. Literacy and nationality of mother. Total. Under 20 years. 20 years, 25 years, 30 years, 35 years, 40 years, No and under under under under report. 25 years. 30 years. 35 years. 40 years. over. Total................................. *987 50 304 274 216 80 33 30 Literate...................................... Illiterate..................................... 625 361 1 38 12 219 85 173 100 1 126 90 41 39 18 15 10 20 Polish................................... 275 16 92 73 i 54 25 9 6 Literate......................... Illiterate...................... 168 107 ‘ 9 7 164 28 43 30 34 i 20 12 13 4 5 2 4 Serbian and Croatian.......... 162 6 49 46 33 13 8 7 4 19 2 6 2 5 Literate......................... Illiterate....................... 74 87 1 4 2 29 20 » 19 26 1 114 19 Slovak...................... ........... 135 7 41 38 28 11 3 7 23 5 6 5 1 2 3 4 Literate......................... Illiterate........................ 99 36 6 1 30 11 30 8 Magyar................................ 64 8 20 12 18 2 3 1 Literate......................... 59 5 8 18 2 12 15 3 2 3 1 Italian.................................. 60 4 17 15 14 6 2 2 3 1 11 2 4 2 31 29 3 1 13 4 18 7 Lithuanian and Lettish___ 54 2 9 19 12 8 2 2 Literate......................... 19 35 2 4 5 5 14 4 8 2 6 1 1 1 1 41 16 11 8 4 2 37 4 15 1 10 1 *7 1 4 1 1 12 All other.............................. 196 7 60 60 49 11 4 5 Literate......................... Illiterate........................ 138 58 16 1 146 14 46 1 14 26 8 23 19 2 4 1 14 1 Includes one twin birth. 1 Includes one twin birth resulting from second confinement in 1916. * Includes one birth resulting from second confinement in 1916- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 116 I N F A N T M O B T A L IT Y . T a b l e 30 .— Cause o f death, b y m onth o f life ; deaths am ong in fa n ts born in G a ry in 1 916 Deaths among infants born in 1916. Cause of death. Month of life. All other causes. Gastric and intestinal diseases. Total. Total. Total............................. Fiftb Total. 11 2 72 32 27 12 2 15 29 5 6 6 4 6 3 2 5 3 8 11 5 2 2 3 1 2 1 1 2 1 1 1 3 2 1 138 «66 25 125 16 10 13 11 10 14 8 7 9 4 11 10 27 8 4 4 3 2 1 1 1 1 7 6 8 5 4 1 3 1 29 2 1 2 2 3 5 3 3 4 1 3 1 Excludes 31 infants who died not fed. s Includes 1 infant for whom type of feeding was not reported. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Artifi Breast Partly breast. cially fed. fed. fed. Artifi Breast Partly breast cially fed. fed. fed. 2 1 2 2 1 1 _______ *6 2 2 4 1 3 1 7 2 3 INDEX Adulteration of milk, law regarding, 71. Age at death: Analysis of infant mortality by, 12-14. Causes of death reflected by, 13,14. Contrast with birth-registration area, 13. Age at which solid food was given, by nativity of mother, 22-23. Age of mother and order of birth, 41-43. Alleys and streets, 77-78. Ambridge subdivision, housing in, 66, 84. Analysis: Milk, 70, 73. Water, 70, 76-77. Artificial feeding. See Feeding, artificial. Ashes: Collection of, 74. Utilization of, in construction of alleys, 74, 77. Attendance at birth, 33-37. B y midwife, according to nativity of mother, 33,35. B y physician, according to nativity of mother, 33. B y time of arrival of attendant and nativity of mother, 34-35. No attendant, 34-35. Other than physician or midwife, 34. Attendance after birth, 35-38. Bacteriological tests: Milk, 70,73. Water, 70,76-77. Birth: Attendants at, 33-37. Certificate of, influence upon registration, 70,83. Order of, by age of mother, 41-43. Birth-registration area: Gary not included in, at time of study, 86. Indiana not included in, at time of study, 2. (Admitted 1917, p. 63.) . Infant mortality rate for— Comparison with rate for Gary in 1917,1-2. Variations in, from causes peculiar to early infancy, 8. Maternal-mortality rate for, as compared with rates for Gary and Indiana, 25-26. Requirement for admission to, 2 (footnote 6). Births: Excluded from study, 2-3,85-86. Mortality rate for, 87-88. ^legitimate, excluded from study, 3,85,87. Interval between, as influencing infant mor tality, 44-45. Live— Exclusions among, 2-3,87-88. Illegitimate, excluded from study, 87. Registered— Canvass to supplement, 2,63,86-87. Mortality rate, 88. Number in Gary, 2. Unregistered— Method of determining proportion of, 88. Mortality rate, 88. Number disclosed by canvass, 2. Births—Continued. Plural— Mortality among, 46. Premature— B y age of mother, 42. Infant mortality rate from, 7-8. Per cent as result of first pregnancies, 42. See also Early infancy, causes of death peculiar to. Registered— Comparison between, by licensed and un licensed midwives, 35, 83-84. Registration— Canvass to supplement, 2, 63, 86. Importance of, 64. Incompleteness, 2,63. Computation of infant mortality rates affected by, 64,85. Law pertaining to, 63. Enforcement of, 70, 83-84. Stillbirths excluded from discussion, 63 (footnote). S t illDefinition of term in study, 3, 88. Exclusions from study among, 3, 88, 89. Registration, 2, 3,15,16, 63 (footnote), 89. See also Stillbirth rate. Blindness, infant, prevention of, enforcement of law regarding, 64, 79. Board of health: City. See Health and charities, department of. See also Health officer, city. State, enforcement o f birth and death regislfra* tion law centralized in, 63. Breast feeding, 17, 18,20, 82. Bronchitis, acute. See Respiratory diseases. Broncho-pneumonia. See Respiratory diseases. Building, regulation of, 64-65, 67, 75-76, 84. Canvass, birth and death registration supple mented by, 2, 63, 86-87. Care: During confinement, 26, 33-40, 82-83. Relation to infant mortality, 8,15,26. During pregnancy, 26-33. Relation to infant mortality, 15, 26, 28, 82. Causes of death: Classification used in study, 4 (footnote 11). Communicable diseases (other than speci fied), 11. Early infancy, causes peculiar to, 7-9. Gastric and intestinal diseases, 5-7. Malformations, 9. Respiratory diseases, 9-10. See also Mortality, infant. Certificate o f birth given to parents, influence upon registration, 70, 83. Characteristics of Gary, 1. Chemical tests: Milk, 70,73. See also Milk supply. Water, 70. See also Water supply. 117 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 118 INDEX. Childbirth: Maternal deaths from causes connected with, 30, 32, 82-83. Children’s Bureau: Method of computing infant mortality rate, 19,85. Studies of infant mortality previously made by, 1 (footnote 1). City health officer. See Health officer, city. City ordinances. See Ordinances. Civic and social factors, 63-79, 83-84. Birth and death registration, 63-64, 83. Garbage, collection and disposal, 73-74. Health and charities, department of, 69-71. Housing, 64-65, 84. Infant welfare, 78-79, 84. Milk supply, 71-73. Sewers and sewage disposal, 75-76. Streets and alleys, 77-78. Subdivisions of Gary, 65-69. Water supply, 76-77. Clark subdivision: Housing, 68. Water supply, 68,76. Clinic, baby .establishment of, for employees of steel company, 79. Communicable diseases: Definition of term in study, 4 (footnote 11). Mortality from, 4,7,11. Feeding in relation to, 19. See also Gastric and intestinal diseases and Respiratory diseases. Community House (First Subdivision): Infant-welfare work under auspices of, 79. Complications of pregnancy or confinement, by grade of prenatal care, 31. Confinement care, 26,33-40. Congenital debility. See Early infancy, causes of death peculiar to. Contagious diseases, nurse employed by health department for, 70. Cooperation: Of city officials, etc., in study, 3. Of mothers in study, 3. Death: Age at— Analysis of infant mortality by, 12-14.. Causes of death reflected by, 13,14. Contrast with birth-registration area, 13. Causes of. See Mortality. See also Mortality. Death rate. See Mortality rate. Death registration area: Indiana admitted to, in 1900, 63. Deaths: Infant— Excluded, 86. Registration of, 63, 64, 85. Maternal, 25-26, 82. See also Mortality. Definitions: Diseases (communicable, gastric and intestinal, respiratory), 4 (footnote 11). Infant mortality rate, 85. Miscarriage, 3,88. Stillbirths, 3, 88. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Department of health and charities, 69-71, 79. See also Health officer, city. Department of public works, 74. Description of Gary, 1, 65-69. Diarrhea, climatic conditions as affecting, 5. See also Gastric and intestinal diseases. Diseases: Classification, 4 (footnote 11). Communicable (other than specified), 11. Number of infant deaths attributed to, 4. Gastric and intestinal, 5-7,14,19,69,84. Number of infant deaths from, 4, 5, 81. Ophthalmia neonatorum, prevention of, en forcement of law regarding, 64, 79. Respiratory, 9-10,19. Number of infant deaths from, 4, 9, 81. Disposal: Garbage and waste, 73-74, 84. Sewage, 75-76. Dumps, 74. Early infancy, causes of death peculiar to: Mortality from— Analysis of, 7-9. B y nativity of mother, 8. Number of deaths, 4, 7. Prevention, methods of, 8, 84. Rate compared with that in birth-registra tion area, 7,8. Earnings: Chief breadwinner— B y nativity of mother, 49, 83. "Economic status determined by, 48. Employment of mother as influenced by, 48, 49. Feeding supervision by, 24. Housing as related to, 32,48. Infant mortality as related to, 52-53, 83. Interval between births by, 45. Mother’s employment as related to, 48, 49. Prenatal care as affected by, 32-33. Supplementary earnings by, 49-50. Mother, 50-51. See also, Employment of mother. Economic factors influencing infant life, 4, 48, 81, 84. Education of mother in prenatal and infant care, importance of, 7, 8, 10, 20, 22, 31-32, 70, 78, 79, 82, 84. • Employment: Chief breadwinner— B y kind of work and earnings, 51-52. Mother (gainful employment)— After birth of infant— B y kind of work and earnings, 50-51. Earnings of father as related to, 48, 49. Infant mortality as related to, 50-51. During pregnancy— B y kind of work, 27, 83. Infant mortality as affected by, 28, 83. Interval between ceasing work and confinement, by nativity of mother, 27-28. •Rngiish, ability of mother to speak, infant mor tality rate by, 56. IN D E X , Enteritis, climatic conditions as affecting, 5. See also Gastric and intestinal diseases. Epidemic and other communicable diseases, 4, 7 11. S ee also Gastric and intestina, diseases and Respiratory diseases. Exclusions from study: Births, 2-3, 85-87. Live births, 87-88. Still births, 3,88, 89. Deaths, 86. Feeding: Artificial— Number of infants receiving, in specified month of life, 17,18,81-82. Prevalence, b y nativity and color of mother, 21. Relation to mortality from gastric and intestinal diseases, 19,82,84. Relation to mortality from respiratory and “ other communicable” diseases, 82. Supervision, 22. B y earnings of chief breadwinner, 24. Breast— Importance of, 17,18, 20. Number of infants not receiving, in speci fied month of life, 17,20. Number of infants receiving, in specified month of life, 17,18,82. Customs— Difference between native and foreign bom, 21-23, 82. Variations in specified income groups, 23-24. Mixed— Number and per cent of infants receiving, in specified month of life, 17-18, 82. Solid food, age at which infant received, by nativity of mother, 22-23. Type— B y nativity of mother, 21-23,82. Extent of different types, 17-18. Mortality rates by, 18-20,81-82. Number of infants surviving at specified months of life by, 17-18. Fire protection, legislation relating to, 64,65. First subdivision: Housing in, 66,84. Infant-welfare work in, 79. Food, solid, age at which given, by nativity and color of mother, 22-23.. See also Feeding. Foreign bom : Housing conditions of, 66-68. Subdivisions inhabited by, 66,68, 84. See also Nationality of mother. Friendship House, infant-welfare work of, 78. Gainful employment of mother. See Employment of mother, gainful. Garbage: Collection and disposal, 73-74,84. Ordinances regulating, 73-74. Gastric and intestinal diseases: Definition of term in study, 4 (footnote 11). Infant mortality from— Analysis of, 5-7.. B y nativity of mother, 6-7,14. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 119 Gastric and intestinal diseases—Continued. Infant mortality from—Continued. B y subdivision of city, 69. Climatic conditions as affecting, 5-6. Comparison with rate in— Birth-registration area, 5. New Zealand, from all causes, 5. Specified cities, 6. Feeding as related to, 7,19, 84. Number of deaths, 4, 5, 81. Prevention, methods of, 6-7,84. Glen Park subdivision, housing in, 68. Health officer, city: Duties of, 63, 70. Part-time employment of, 70,84. Salary, inadequacy of, 70, 84. Health work, regulation of, faults in State law re garding, 70, 84. Health and charities, department of: Activities, 69-71, 79» Personnel, 69-71. See also Health officer, city. Histories, maternity, 59-62. Hospital confinements, 33,37,82. Household help: During lying-in period, 38-40. During pregnancy, 26. Housing: Congestion, 66, 67. Fire protection, legislation relating to, 64,65. Foreign-born laborers, 66-68. Income as related to, 32. Infant mortality as affected by, 68-69. Laws pertaining to, 64-65, 75-76. Enforcement of, 65. Weakness in, 65, 75-76. Sanitation, 64, 66-69. Infant mortality in relation to, 68-69. Law relating to, 64. Subdivisions, conditions by, 66-69. Toilet facilities, 67, 68. Type of houses, 65, 66. Unfit dwellings, power of board of health to order vacated, 64. Illegitimate births: Excluded from study, 3,85. Illiteracy of mother, influence upon infant mortal ity rate, 58. Income, 48-53. S ee also Earnings. Industries in Gary, 51. Infant blindness, prevention of, enforcement of law regarding, 64, 79. Infant mortality. S ee Mortality, infant. Infant-welfare stations: v First SubdivisionCommunity House, 79. Need for, 84. South Side— * Friendship' House, 78. Neighborhood House, 78, 79. Visiting nurse for employees of steel com pany, .79. Infant-welfare work, inadequacy of, in Gary, 78-79, 84. 120 INDEX, Injuries at birth, 7. S ee also Early infancy, causes of death peculiar to. Inspection: Plumbing, 69-70. Sanitary, 71. Instruction of mother in prenatal and infant care, importance of, 7,8,10,20,22,31-32,70,78, 79, 82, 84. Interval between births, 44-45. B y earnings of chief breadwinner, 45. Interval between mother’s ceasing gainful work and confinement, by nativity and color of mother, 27-28. Intestinal diseases. See Gastric and intestinal diseases. Kirk subdivision, housing in, 66. Laboratory, municipal, functions of, 70. Law: Relating to— Blindness, infant, prevention of, 64,79. Health work, weakness in, 70,84. Housing, 64-65, 75-76. Midwifery, practice of, 35, 83-84. Milk supply, 71-73. Registration of births and deaths, 63-64,84. Registration of stillbirths, 63 (footnote), 89. Sewage, 75-76. See also Ordinances. License: Requirement of— For practice of midwifery, 35, 84. For sale of milk, 71. Lincoln Park subdivision, housing in, 68,84. Literacy of mother, in relation to infant mortality, 58. Little Mother’s class, activities of, 78. Live births. S ee Births, live. Lodgers, family earnings supplemented by keeping of, 27, 50-51, 83. Lying-in period. S ee Confinement period. Malformations, mortality from, 4, 9. Maternal mortality. S ee Mortality, maternal. Maternity histories, 59-62. Measles and whooping cough: Mortality from, 11. S ee also Communicable diseases. Method of procedure in study, 2-3, 85-89. Midwives: Attendance at birth, 33, 35, 82. Licensed, number of births registered by, 35. Licensing, State law pertaining to, 35. Milk: Breast—Substitutes used, 22. Dispensing of, from Neighborhood House, 78. Milk supply, 71-73. Bacteriological and chemical tests, 70,73. Miscarriages: ’ Excluded from study, 3,88. Mixed feeding. See Feeding, mixed! Mortality: Infant— „ Causes, 4-11. B y nativity, 6-9. Classification used in study, 4 (foot note 11). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Mortality—Continued. Inf ant—Continued. Causes—Continued. \ Communicable diseases, other than specified, 4,11. Gastric and intestinal diseases, 5-7. Malformations, 9. Other than those discussed, 11. Peculiar to early infancy, 4,7-9,84. Reflected by age at death, 13-14. Respiratory diseases, 9-10. Economic and social factors in relation to, 4, 48, 81, 84. Employment of mother dining pregnancy as related to, 28, 83. Feeding in relation to, 17-24,81-82,84. Housing conditions as related to, 68-69,84. Length of residence of foreign-bom mothers in the United States as related to, 57. Literacy of mother as related to, 58. Prenatal conditions as related to, 8,15,26. Prevention of, important factors in, 4,7,8, 10, 84. M aternalCauses, 25-26. Relation to infant mortality, 25-26,82. Mortality rate: Infant— B y age at death, 12-14. B y age and nativity of mother, 41. B y earnings of chief breadwinner, and nativity of mother, 52-53. B y interval between births, 44. B y length of residence of mother in the United States, and nationality of mother, 57. B y nationality of mother, 54, 81. B y nativity and color of mother and cause of death, 6,7. B y order of birth, 42, 43. B y order of pregnancy and nativity of mother, 42-43. B y period of gestation, 42. B y sex of infant and nativity of mother, 47. B y subdivision of city, and deaths from all causes, and from gastric andintestinal dis eases, 68-69. B y type of feeding, 18,19-20. Definition of, 85. For birth-registration area in 1917,1-2. For births included in study, 4. For excluded groups, 87-88. For Gary in 1917,2. For plural births, 46. From causes other than discussed, 11. From causes peculiar to early infancy, 7-8, 81. From communicable diseases, 11, 81. From gastric and intestinal diseases, 5-7,81. From malformations, 9, 81. From respiratory diseases, 9-10. Incomplete registration as affecting, 64, 85. Method of determining, 19,85. . Maternal— For birth-registration area, Indiana, and Gary, 25-26. Mothers, instruction in prénatal and infant care, importance of, 7,8,10,20,22,31-32, 70, 78, 79, 82, 84. INDEX, 121 Nationality of mother: Polish group: Care during confinement period, 38-39. Infant mortality rate, excess in, 15,54,56,81. Infant mortality rate (pp. 54,81) by— Stillbirth rate, excess in, 15. Births from all pregnancies, 59. Population of Gary, 1. Mother’s ability to speak English, 56. Postnatal care: Mother’s length of residence in the United Classification by grade of care, 35-36. States, 57. According to type of attendant, 36. Literacy, 57-58. Pregnancy: Care during, 26-33. Stillbirth rate, 15-16,54,59. See also Nativity of mother. Employment of mother during, 27-28. Household help during, 26. Nationalities, non-English-speaking, 55. Infant mortality rate by order of, 42-43. Nativity of mother: Premature births: Age at which infant died, 14. B y age of mother, 42. Age at which infant received solid food, 22-23. Infant mortality rate from, by nativity of Care during confinement period, 33-35, 37-40, mother, 7-8. 82-83. Per cent as result of first pregnancies, 42. Care during pregnancy, 26,32 See also Early infancy, causes of death peculiar Cause of infant death, 6-9. to. Earnings of chief breadwinner, 49. Prenatal care: Employment of mother, gainful, during preg B y nativity of mother, 32,33,82,83. nancy, 27-28. Given by infant-welfare station, 78. Feeding customs, 21-23, 82. Grade— Infant mortality rate by— B y complications of pregnancy and con Age of mother, 41. finement, 31. Earnings of chief breadwinner, 52. B y order of pregnancy, 30. Interval between births, 44,61. B y source of instruction, 29. Order of pregnancy, 42-43. Prevalence, by earnings of chief breadwinner, Plural births, 46. 32-33. Sex of infant, 47. Prenatal conditions, relation to infant mortality, Literacy, 57-58. 8,15. Stillbirth rate, 15-16,28,59. Prevention of infant blindness, enforcement of law See also Nationality of mother. concerning, 79. Neighborhood House, 78. Prevention of infant mortality: Non-English-speaking nationalities, 55. From causes peculiar to early infancy, 8,84. Nonresident mothers: From gastric and intestinal diseases, 6-7,84. Infants of, excluded from study, 3,86,87. From respiratory diseases, 10. Mortality among, 87. Possibility of, as shown by decrease in rates Stillbirths to, excluded from study, 88,89. from certain causes in birth- and deathNurse: registration areas, 6,9-10. Employed by health department to visit con Procedure in study, method of, 2-3,85-89. tagious cases, 70. Employed by police department for infantRate: welfare work, 70,79. Death. See Mortality rate. Nurses, need for, on health department staff, 70,84. Stillbirth. See Stillbirth rate. Nursing care: Registration: Duration, 38-39. Births— Kind, 35-37,82. Canvass to supplement, 2,63,86-87. Certificates mailed to parents in order to Occupations. See Employment. SeeaZso Industries. secure cooperation, 64,70, 83. Ophthalmia neonatorum, prevention of, enforce Importance of, 64. ment of law regarding, 64,79. Incompleteness, 2,63. Ordinances: Computation of infant mortality rates Regulating— affected by, 64, 85. Building, 64-65. Law pertaining to, 63,64, 84. Weakness in, 65,76,84. Enforcement of, 70. Garbage, removal and disposal, 73-74,84. Number of registered births attended by Milk, production and sale, 71-72. licensed midwives, 35. Sand, removal from streets, 77. Stillbirths excluded from discussion for See also Law. purpose of accuracy, 63 (footnote). Partially breast fed. See Feeding, mixed. Deaths— Pasteurization of milk, 72-73. Canvass to supplement, 63. Physicians, attendance at birth by, according to Importance of completeness, 64. nativity of mother, 33,82. Incompleteness, 63. Pine subdivision, 68,76. Effect upon computation of infant mor Plural births, 46. tality rates, 64, 85. Pneumonia. See Respiratory diseases. Law pertaining to, 63. 106137°— 23------ 9 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 122 INDEX, Registration—Continued. Incomplete, infant mortality rates affected by, 64, 85. Stillbirths— Imperfection in, 16. Law regarding, 89. Number included in study, 3,15,89. Number registered and unregistered, 2, 89. Registration areas. S ee Birth-registration area and Death-registration area. Residence of foreign-bom mothers in the United States: Length of residence b y nationality of mother, 56-57. Infant mortality raté by, 57. Respiratory diseases: Definition of term in study, 4 (footnote 11). Mortality from— Analysis of, 9-10. B y nativity of mother, 9. Climatic conditions as affecting, 9. Feeding as related to, 10,19. Number of deaths, 4,9,81. Prevention, methods of, 10. Rate compared with that in birth- and death-registration area, 9-10. Ridge Road subdivision, housing in, 68. Sanitation, 64,66-69. Infant mortality in relation to, 68-69. Inspection of, 71. Law relating to, 64. Scope of inquiry, 2. . Selection of Gary, 1-2. Sewers and sewage disposal, 75-76. Sex of infant and nativity of mother, analysis of births and infant mortality rate by, 47. Social and civic factors, 63-79,83-84. Birth and death registration, 63-64,83. Garbage, collection and disposal, 73-74. Health and charities, department of, 69-71. Housing, 64-65,84. Infant welfare, 78-79,84. Milk supply, 71-73. Sewers and sewage disposal, 75-76. Streets and alleys, 77-78. Subdivisions of Gary, 65-69. Water supply, 76-77. Social and economic factors, relation to causes of infant mortality, 4,81. Solid food, age at which given, by nativity and color of mother, 22-23. South Side subdivision: Housing in, 66-68, 84. Infant-welfare stations established in, 78-79. Nurse (city paid) employed in, 70,79. Statistics, vital, health officer in charge of enforce ment, 63, 70. Stillbirth: Definition of term in study, 3, 88. Stillbirth rate: B y age and nativity of mother, 41. B y interval between births, 44. B y interval between mother’ s ceasing gainful work and confinement, 28. B y nationality of mother, 15,16,54. o https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Stillbirth rate—Continued. B y order of pregnancy and nativity of mother, 42-43. B y period of gestation, 42. Employment of mother dining pregnancy as affecting, 28. Method of determining, 88, 89. Stillbirths: Exclusions from study among, 3, 88. B y reason for exclusion, 89. Registered— Number included in study, 3,15, 89. Number registered and unregistered, 2, 89. RegistrationImperfection in, 16, 63 (footnote). Law regarding, 63 (footnote), 89. Street commissioner, duties of, 74. Streets and alleys, 77-78,84. Study: Cooperation in— Of city officials, etc., 3. Of mothers, 3. Procedure in, method of, 2-3,85-89. Subdivisions of Gary, 65-69. Foreign population of, 66,68, 84. Housing conditions, 66-69, 84. Summary and conclusions, 81-84. Supervision: Artificial feeding, 22. During pregnancy, 26, 28-32. Of midwives, no provision for, 35. Tenements: Laws pertaining to, 64-65. Enforcement of, 65. S ee also Housing. Tests, laboratory: Diseases, 70. Milk, 70, 73. Water, 70,76-77. Toilet facilities, 67,68. S ee also Housing. Tolleston subdivision, housing in, 66,68, 84. Twins, infant mortality rate among, 46. Type of feeding. See Feeding, type. Venereal diseases, laboratory tests for, 70. Vital statistics law, enforcement of, 63,70. Waste, collection and disposal of, 73-74,84. Water supply, 66,67,68, 76-77. Analysis, 70, 76-77. Source, 76. Weaning: Reasons for, 20. Supervision of, 20. Welfare stations, infant. S ee Infant-welfare sta tions. Welfare work, infant, inadequacy of, in Gary, 78-79,84. Wells, source of water supply in certain sections, 76-77. West Gary subdivision: Housing, 68. Water supply, 76. Whooping cough and measles: Mortality from, 11. S ee also Communicable diseases.
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