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BUREAU PUBLICATION N o. 233 â ÿ s t l î p r a î à f£ -J > a .i’ eai C i 'o ^ i ai Taxas 1 1 t ÿ ç g g S & S j b , T exas. S - - ' ; | f | k ÎKSmEr CHILDREN’S BUREAU U N ITE D STATES D E P A R T M E N T OF LABOR 1936 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis U N IT E D STATES D E P A R T M E N T OF LABOR 41 F r a n ces P e r k in s , Secretary C H IL D R E N ’ S B U REA U . . . Katharine F. Lenroot, Chief Infant Mortality in Memphis BY ELLA O PP E N H E IM E R , M . D . + * Bureau Publication No. 233 U N IT E D ST ATE S * G O V E R N M E N T P R I N T IN G O F F IC E W A S H IN G T O N : 1937 For sale b y the Superintendent o f Documents, Washington, D . C. - https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis * * Price 15 cents https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Contents Letter o f transmittal____________________________ Introduction___________________________________ General considerations____________________________ ~ t Trend o f infant mortality in M em phis.................................................... Comparison o f infant mortality o f Memphis with that o f other cities______ . . . Residence o f mothers in relation to infant mortality in Memphis_______ Trend o f births in hospitals in relation to infant mortality in Memphis.............. Maternal and child-health program in relation to infant mortality in M em phis. Economic and social conditions and social services in relation to infant m ortality. Neonatal mortality and associated phenomena in Memphis_____________ *** . 3 9 20 31 32 37 4Q Where infants were born and where they died during the neonatal period in 1933 and ................................................................................................................................................................................... _ _ _ _ _ .......................... Prenatal, natal, and postnatal care in Memphis__________________ Results o f prenatal care_________________________________ ^ 4j aa Possible reasons for high and apparently rising mortality from natal and pre natal causes____________ _____________________ _ Conditions apparently associated with high neonatal death rate from other than natal and prenatal causes__________________________ cr Mortality in the second to twelfth month and associated phenomena____ 5g Where infants o f nonresident mothers died in thesecond to the twelfth m onth. Where infants o f resident mothers died in thesecond to the twelfth m onth. . Causes o f mortality in the second to the twelfth month________________ Public facilities for care o f infants....................................................... Limitations to the effectiveness o f infant-health supervision in Memphis______ Inadequacies in provision for care o f sick infants........................................ Special groups in Memphis in relation to infant mortality_________ ge Infants o f unmarried mothers_________ Infants in institutions __ k— Summary________________________ ____________ ^ 58 59 59 gn 62 53 gjj ksn g Recommendations_____________________________ Appendix 1. The resident infant mortality rate o f Memphis_____________________ Appendix 2. Tables.................................................................................... 77 Charts M ortality in the first year o f life among white and colored infants; Memphis Tenn., 1923-34....................................................................................................... 2 M ortality in the first month o f life among white and colored infants; Memphis Tenn., 1923-34................................................................................................ 4 M ortality in the second to the twelfth month o f life among white and colored infants; Memphis, Tenn., 1923-34...................................... ..................... g M ortality in certain periods o f the first month o f life among white and colored infants; Memphis, Tenn., 1927-34......................................._..................... 7 in https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IV C O N TE N TS Page 5. — M ortality in the first month of life from natal and prenatal causes and from all other causes among white and colored infants; Memphis, Tenn., 1927-34— 6. — M ortality in the second to the twelfth month o f life from gastrointestinal diseases among white and colored infants; Memphis, Tenn., 1927-34_______ 7. — M ortality in the second to the twelfth month o f life from natal and prenatal causes among white and colored infants; Memphis, Tenn., 1927—34------------8. — M ortality in the second to the twelfth month of life from respiratory diseases among white and colored infants; Memphis, Tenn., 1927-34------------------— 9. — M ortality in the first month and the first year of life in cities with 250,000 to 350.000 population, 1934___________________________________________________ 10. — M ortality in the second to the twelfth month of life in cities with 250,000 to 350.000 population, 1934_______________________________ ___________________ 11. — M ortality in the first year of life among white and colored infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34--------------------------------------------12. — M ortality in the first year of life among white and colored infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34--------------------------------------------13. — M ortality in the second to the twelfth month of life among white and colored infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34________ 14. — M ortality in the first month of life from all causes, and from natal and prenatal causes, among white and colored infants in cities with 250,000 to 350,000 population and 25,000 or more colored population, 1934-----------------------------15. — M ortality in the second to the twelfth month of life from specified groups of causes among white and colored infants in cities o f 250,000 to 350,000 popula tion and 25,000 or more colored population, 1934-----------------------------------------16. — Crude mortality and mortality among infants born to resident mothers in certain periods o f the first year o f life, b y color; Memphis, Tenn., 1934----------------------17. — M ortality in certain periods of the first year of life from specified groups of causes; Memphis, Tenn., 1927—34----------------------------------------------------------------18. — M ortality in certain periods of the first year of life from specified groups of causes among white infants; Memphis, Tenn., 1927—34------------------------------19. — M ortality in certain periods o f the first year of life from specified groups of causes among colored infants; Memphis, Tenn., 1927-34_____________________ 20. — M ortality in certain periods o f the first year o f life among white aad colored infants o f resident mothers; Memphis, Tenn., 1930-32 and 1934___________ 21. — Proportion o f white and colored infants born in Memphis, Tenn., and of those born elsewhere dying in Memphis in certain periods of the first year of life, 1 9 3 0 -3 4 ................................ - ............ .................................................................... .. 22. — M ortality in certain periods o f the first year of life among white and colored infants born in Memphis, Tenn., and among those born elsewhere; Memphis, Tenn., 1930-34................................................................................................... ............ 23. — M ortality among white and colored infants born in Memphis, Tenn., and dying in the city in certain periods of the first year of life compared with crude mortality in Memphis and in three Southern cities, 1930-34__________________ 24. — Proportion of live births b y color to resident and to nonresident mothers; Memphis, Tenn., 1927-34__________________________________________________ 25.— Live births to resident and to nonresident mothers; Memphis, Tenn., 1927-34 26. — M ortality in the first month and the first year of life among white and colored infants born to residents of the entire city, the old city, and the area annexed in 1928 and 1929; Memphis, Tenn., 1930-32_________________________________ 27. — M ortality among white infants in each ward of Memphis, Tenn., 1930-32_ 28. — M ortality among colored infants in each ward o f Memphis, Tenn., 1930-32_ 29. — M ortality among white and colored infants, by wards, according to varying housing indexes; Memphis, Tenn.,, 1930-32________________________________ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 10 11 12 13 14 15 16 17 18 19 22 23 24 25 26 27 28 29 30 33 34 35 36 38 CONTENTS 30. — Proportion of white and of colored women first attending prenatal clinic o f M em phis General Hospital in specified periods o f pregnancy; 1926, 1929, and Jan uary 1 to April 30, 1934____________________________________________________ 31. — M ortality from puerperal causes among mothers o f white and o f colored infants; Memphis, Tenn., 1927-34__________________________________________________ — M ortality from puerperal causes among clinic patients and among nonclinic patients, white and colored; Memphis General Hospital obstetric service, 1932-34................ 32. 33. 34. 35. 36. — Stillbirths and mortality in the first day of life among white and colored infants; Memphis, Tenn., 1927-34___ — M ortality rate from stillbirths to white women delivered in hospitals and at home; Memphis, Tenn., 1927-34___________________________________________ V 44 45 45 47 4g — M ortality rate from stillbirths to colored women delivered in hospitals, and to those delivered at home b y white physicians and b y colored physicians; Memphis, Tenn., 1927-34__________________________________________________ 50 — Stillbirth rate and incidence of premature births among clinic patients and among nonclinic patients; Memphis General Hospital obstetric service, 1932-34___________________________________________________________________ 51 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Letter of Transmittal U n it e d States D e pa rtm e n t o f L a b o r , C h il d r e n ’ s B u r e a u , Washington, August 19,1936. M a d a m : This report is presented as an example of the degree to which an analysis of Census statistics and local studies, in the light of a careful appraisal of public-health and clinical facilities for maternal and infant care, may make possible an understanding of those con ditions in a city which are associated with a high infant mortality rate and point to concrete measures which are indicated to improve it. In the fall of 1935 Dr. Oppenheimer submitted the report to those in Memphis who had requested the study and discussed with them what could be done to put into effect the measures recommended. As a result a Director of Maternal and Infant Hygiene has been appointed in the Memphis Department of Health and a beginning has been made in carrying out many of the recommendations. Respectfully submitted. K a t h a r in e H o n . F r an ces P e r k in s , Secretary o f Labor. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis F . L e n r o o t, Chief. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A Infant Mortality in Memphis Introduction Memphis, Term., was reported by the United States Bureau of the Census as having the highest infant mortality rate of any city of 100,000 or more population in the United States birth-registration area in 1932. In 1933 and 1934 its infant mortality rates reached an even higher level than in 1932. Local concern over this situation led to a request to the United States Children’s Bureau to make a study of the causes of the high infant mortality rate of Memphis and recommendations as to measures for decreasing it. The following joined in the request: The Mayor of Memphis, the Superintendent of the Department of Health, the President of the Shelby County Medical Society, the Superintendent of the Memphis General Hospital, the Professor of Pediatrics at the University of Tennessee (who is also Chief of the Pediatric Service of the Memphis General Hospital), the Dean of the Medical School of the University of Tennessee, and the President of the Memphis Chamber of Commerce. This report presents the findings of a brief investigation made in the spring of 1935 the purpose of which was to determine, to the degree possible on the basis of available data, the outstanding factors in the high infant mortality rate in Memphis, and to make whatever immediate recommendations seemed indicated as to activities which might be expected to lower it. It represents in no sense a complete analysis of the infant-mortality situation in Memphis, but only what was possible with the material available. Because similar causes are responsible for maternal deaths and many deaths in early infancy, maternal mortality and facilities for maternal care were also considered. The investigation also had the purpose of determining what kind of further studies, if any, were indicated in order to clarify the problem and to point the way toward the development of a program for maternal and infant health in Memphis which would adequately meet specific local needs. The conclusions of the report are based on analysis of the United States Bureau of the Census statistics for Memphis since 1927 and of local statistics made available by the Memphis Department of Health; on 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 IN F A N T M O R T A L IT Y IN M E M P H IS material culled from reports and studies that had been made locally which seemed to have a bearing on the problem; on information gathered in Memphis from interviews with those responsible for the public-health, medical, and social services, from discussion of local problems and needs Chart 1.— Mortality in the First Year of Life Among White and Colored Infants; Memphis, Tenn., 1923-34. Source: 1923-26, M em phis Department o f H ealth; 1927-34, U. S. Bureau o f the Census. with obstetric and pediatric medical groups and with the public-health nurses and nurses in charge of maternity and pediatric wards of hospitals, and from visits to hospitals, health centers, institutions caring for unmar ried mothers, orphanages, and day nurseries. Conditions described represent the situation in the spring of 1935. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis General Considerations Trend of Infant Mortality in Memphis Trend in mortality in the first year. From 1923 to 1927 the infant mortality rate in Memphis 1 decreased appreciably, but since 1927 it has been increasing to such an extent that the United States Bureau of the Census rate for 1934 was 40 percent higher than the rate for 1927. In both 1933 and 1934 the rate was even higher than in 1923. When the trend in the rates for white and for colored infants separately is considered, it is found that the rate for white infants, though always much lower than the rate for colored infants, had shown a smaller decrease (16 percent) from 1923 to 1927 than the rate for colored infants (36 percent), and from 1927 to 1934 had increased 45 percent as against 32 percent for the colored. (Chart 1. See also table 1, p. 81.) This in crease brought the 1934 rate for white infants considerably above even the 1923 figure, whereas the rate for colored infants did not approach the high rate of 1923 by a considerable margin. The upward trend in infant mortality in Memphis is in contrast to the trend of the general death rate for the same period, which for both white and colored has been slightly downward from 1929 to 1933. G e n e r a l D eat h R a t e s , 1 M em ph is , T e n n ., 1927-33 Y ear 1927____________ 1928____________ 1929_____ ______ 1930____________ 1931_____ ______ 1932____________ 1933____________ Total 18.2 18.6 18.9 17.3 16.6 16.8 16.7 W hite (2) IS. 5 15.8 13. S 13.6 13.6 13.3 Colored (2) 23.6 23.8 23.5 21.5 22.0 22.0 1 Deaths from all causes per 1,000 estimated population. a N ot reported. 1 Infant mortality rates for Memphis based on U. S. Bureau o f the Census statistics and comparable with other cities are available only since 1927, when Tennessee was admitted to the United States birth-registration area. Statements in the Survey o f Health Problems and Facilities in Memphis and Shelby County, Tenn., for the year 1929 made b y the American Public Health Association, and in an unpublished Survey and Appraisal o f Health Activities in the C ity o f Memphis, Tenn., 1931, b y H. E. Handley, M . D ., indicate that between 1922 and 1927 birth registration in Memphis was sufficiently complete to make the rates issued b y the local department o f health reasonably valid. 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 IN F A N T M O R T A L IT Y IN M E M P H IS Trend in neonatal mortality. Before 1928 the neonatal death rate (mortality among infants in the first month of life), like the total infant mortality rate, had been de creasing appreciably (the 1927 rate was 22 percent lower than that for Chart 2.— Mortality in the First Month of Life Among White and Colored Infants; Memphis, Tenn., 1923—34 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 Source: 1923-26, Memphis Department o f Health; 1927-34, U. S. Bureau o f thè Census. 1923), but since 1927 the trend in the mortality during the first month of life, as well as in the entire first year, has been upward. The neonatal rate for 1934 was 67 percent higher than the neonatal rate for 1927. (Chart 2. See also table 1, p. 81.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL C O N S ID E R A T IO N S 5 The neonatal rate for white infants in the earlier period (1923—27) had decreased slightly (9 percent), while the neonatal rate for colored infants had decreased markedly (37 percent). This corresponds to the trend during this period in the total mortality rates for white and for colored infants. From 1927 to 1934 increases appeared in both white and col ored neonatal mortality, the rate in 1934 being 59 percent higher than in 1927 for white infants and 73 percent higher for colored infants. So great has been the increase in neonatal mortality since 1927 that the 1933 and 1934 rates for all infants and for white infants were appre ciably higher than they were even in 1923. The rates for colored infants had again reached approximately the same level as in 1923 (chart 2). Trend in mortality in the second to the twelfth m onth. For infants surviving the first month the mortality rate during the second to the twelfth month had shown a decrease in 1926 and a further marked decrease in 1927 from previous years. Since 1927 there has been wide variability from year to year in mortality in the second to the twelfth month with apparently neither an upward nor a downward trend. The rate for 1934 (46.9) was slightly higher than that for 1927 (41.0), though lower than that for 1923 (57.6). The mortality among colored infants in the second to the twelfth month in 1927 was markedly lower than that for the period 1923-25. Since 1927 there has been much variability, but a slight downward trend since 1930. The 1934 rate (61.9) was about the same as that for 1927 (61.2), having increased over the minimum rate of 54.5 in 1932, which was very much lower than the rates of previous years. Mortality in the second to the twelfth month among white infants showed a slight decrease during the 1923-27 period. Since 1927 it has shown a general upward trend that has brought the 1934 rate (37.4) practically to the level of 1923 (38.3). (Chart 3. See also table 1, p. 81.) Sharp increase in infant mortality in 1933 and 1934 over 1932. Chart 1 shows that the infant mortality rate rose sharply in 1933 over 1932 and that the 1933 increase was maintained in 1934. The increase in 1933 and 1934 over 1932 was almost all in the neonatal period, although there was a slight increase in the second to twelfth month period in both 1933 and 1934 (charts 2 and 3). The 1933 and 1934 increase over 1932 in the infant mortality rate was greater among white than among colored infants, and this difference was accentuated in the neonatal rates. For the second to the twelfth month the rates among white infants remained practically stationary in 1933 and 1934 as compared with 1932, while those among colored infants went up slightly. Causes of upward trend in neonatal mortality. A detailed study of neonatal mortality by periods of the first month of life reveals that the marked increase in neonatal mortality in 1933 and 1934 as compared with previous years occurred during the period between https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 IN F A N T M O R T A L IT Y IN M E M P H IS the end of the first week and the end of the month. (Chart 4. See also table 2, p. 81.) Mortality during this period among white infants had been higher in 1930 to 1932 than in 1927 to 1929, and among the Chart 3.— Mortality in the Second to the Twelfth Month of Life Among White and Colored Infants; Memphis, Tenn., 1923-34 Source: 1923-26, M em phis Department o f H ealth; 1927-34, U. S. Bureau o f the Census. colored it had been higher in 1929 to 1932 than in 1927 and 1928; but the increase in 1933 and 1934 over 1932 was almost threefold among white infants and twice as great or more among the colored. The earlier death occurs, the more likely it is to be associated with natal and prenatal pauses rather than with external environmental https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL 7 C O N S ID E R A T IO N S conditions. That environmental conditions are largely responsible for the marked upward trend in neonatal mortality in Memphis, especially in 1933 and 1934, is suggested by the large increase in mortality during the period between 1 week and 1 month o f life, and this suggestion is corroborated when neonatal mortality in Memphis is analyzed by cause. Although natal and prenatal causes, which largely predominate, have shown an upward trend among both white and colored infants since Chart 4.— Mortality in Certain Periods of the First Month of Life Among White and Colored Infants; Memphis, Tenn., 1927-34 F ira t Day o f Life Colored W hite Seethe per 1,000 live births 0 20 40 0 Seaths per 1,000 live births 20 40 00 Second to S ix th Day of Li w h ite Colored Second Week, to F ira t Month of Life W hite Colored Source: U. S. Bureau o f the Census. 1927, the percentage increase in the neonatal rates from natal and prenatal causes in 1934 over 1927 accounts for only two-fifths of the increase in the neonatal mortality rates. In 1933 the increase over 1932 in the neonatal rate from natal and prenatal causes accounted for only about one-fourth o f the increase over 1932 in the total neonatal rate, while 1934 showed an increase as compared with 1932 in the total neonatal rate in spite of a decrease in that part of the rate due to natal and prenatal causes. The marked increases in the neonatal rates in 1933 and 1934 are due in very large part to striking increases in the mortality from other causes than natal and prenatal. These increases are apparent among both white and colored infants but are more striking among the white infants. (Chart 5. See also table 3, p. 82.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 IN F A N T M O R T A L IT Y IN M E M P H IS Deaths per 1^000 live b irth s Chart 5.— Mortality in the First Month of Life From Natal and Prenatal Causes and From All Other Causes Among White and Colored Infants; Memphis, Tenn., 1927-34 Source: U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL 9 C O N S ID E R A T IO N S Causes associated with upward trend among white infants and slight down ward trend among colored infants in the second to twelfth m onth period. Study of the causes of mortality in the second to the twelfth month period makes it clear that the upward trend from 1927 to 1934 in mortality among white infants surviving the first month was associated largely with increasing mortality in this period of the first year from gastro intestinal diseases and from natal and prenatal causes. The slight down ward trend apparent since 1930 among colored infants surviving the first month was associated largely with decreasing mortality in the second to the twelfth month from respiratory diseases and epidemic and com municable diseases; gastrointestinal diseases show marked variability from year to year. (Charts 6, 7, and 8. See also table 4, p. 82.) The upward trend in infant mortality in Memphis since 1927 has been largely the result o f a marked increase in neonatal mortality among both white and colored infants which has been associated in small part with an increase in mortality from natal and prenatal causes and in large part with an increase in mortality from other than natal and prenatal causes that was especially great in 1933 and 1934 as compared with previous years. , , Comparison of Infant Mortality of Memphis With That of Other Cities Infant mortality, 1927-34, in Memphis and in other cities of 250,000 to 350,000 population. Comparison of the infant mortality rates of Memphis with those of 15 cities of comparable size (charts 9 and 10; see also tables 6, 7, and 8, pp. 83-84) shows that the Memphis rates for all infants have exceeded those of other cities of its size, not only in 1934 but in a number of other years since 1927. The Memphis mortality rates for colored infants, with few exceptions, have been higher than the mortality rates for colored infants in cities with 25,000 or more colored population for which colored and white rates are given separately; the rates among white infants in these cities have been lower than the Memphis rates in each year since 1930. The mortality among white infants in Memphis, with few exceptions, has been even greater than among all infants in cities of comparable size that have less than 25,000 colored population and do not have white and colored rates listed separately. Trend in infant mortality in Memphis and in three other Southern cities, 1928-34. Although the Memphis infant mortality rate ranked high among the rates of all cities of its size in 1927 and 1928, it was not strikingly differ ent from that o f Birmingham in 1927 and 1928 nor from that of Louis ville in 1928; it was close to that of Atlanta in 1928 (the Atlanta rate for 1927 is not available). It is, therefore, especially noteworthy that a striking divergence has developed between the infant mortality rates 64535°— 37----- -2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ' \ 10 IN F A N T M O R T A L IT Y IN M E M P H IS D eath s per* 1,000 in fa n t s s u r v iv in g th e f i r s t m o n th o f life Chart 6.— Mortality in the Second to the Twelfth Month of Life from Gastrointestinal Diseases Among White and Colored Infants; Memphis, Tenn., 1927-34 1927 1928 Source: U. S, Bureau o f the Census« https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1929 1930 1931 1932 1933 1934 GENERAL 11 C O N S ID E R A T IO N S D e a th s p e r l?000 in fa n t s s u r v iv in g t h e f i r s t m on th o f life Chart 7.— Mortality in the Second to the Twelfth Month of Life From Natal and Prenatal Causes Among White and Colored Infants; Memphis, Tenn., 1927—34 1927 1928 Source: U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1929 1930 1931 1932 1933 1934 12 IN F A N T M O R T A L IT Y IN M E M P H IS D e a th s p er 1,000 in fa n ta s u r v iv in g th e f i r s t m on th o f life Chart 8.— Mortality in the Second to the Twelfth Month of Life From Respiratory Diseases Among White and Colored Infants; Memphis, Tenn., 1927-34 1927 1926 Source; U. S. Bureau of the Census, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1929 1930 1931 1932 1933 1934 GENERAL C O N S ID E R A T IO N S 13 of these three cities and of Memphis since then— a divergence which has occurred in the rates for the first year, the first month, and the second to the twelfth month of life and in the rates for each of these periods Chart 9.— Mortality in the First Month and the First Year of Life in Cities With 250,000 to 350,000 Population, 1934 Deaths p e r 1,000 live b irth s 40 w m F ir s t y e a r 60 120 F ir s t month Source: U. S. Bureau o f the Census. of the first year among white and colored infants separately as well as among all infants. Although all the rates of the three cities combined except the colored neonatal rates rose in 1933 and 1934 over 1932, the Memphis mortality rates in 1934 were higher than those of the three cities by the following percentages (table 9, p. 85): https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 IN F A N T M O R T A L IT Y IN M E M P H IS Percent First year o f life. W h ite .. Colored. 46 37 43 First month W h it e Colored. 55 45 55 Second to twelfth month. White______________ Colored_____________ 37 28 33 Chart 10.— Mortality in the Second to the Twelfth Month of Life in Cities With 250,000 to 350,000 Population, 1934 Deaths per 1,000 infants survivin<£.the f i r s t month of* life 0 Mem p h is, Tenn.. A tla n ta , 6a. L o u is v ille , Ky. Oall a s , Tex. Birmingham, Ala Denver, Colo. H ouston, Tex. C o lu m b u s, Ohio Toledo, Ohio A R ro n , Ohio J e rs e y City, N.J« P ro vid en ce, R.l, 5 t . Paul, Minn. O ak lan d , C a lif P o r tla n d , Ore, R o c h e s t e r , N.Yi Source: U . S. Bureau o f the Census« https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 40 00 80 100 J * « k Chart 11.— Mortality in the First Year of Life Among White and Colored Infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34 264 90 80 D e a th s p e r 1,000 live b i r t h s / ^ —C s m 70 * 60 * SO 40 30 G E N E R A L C O N S ID E R A T IO N S 100 White ad — Hemphia anintai ham » Aìrt m .— •mB m LO jisvìlie «m maAnt an a;isvBirmini hanij LC ou ilio 0 là 1327 1328 1323 1330 1331 Source: U. S. Bureau of thè Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1932 1933 1334 1927 1928 1329 1930 1931 1932 1933 1934 1927 1928 1929 1930 1931 1332 1933 1334 Ol Mortality in the First Year of Life Among White and Colored Infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34 IN F A N T M O R T A L IT Y IN Deaths p e r 1,000 live b ir t h s Chart 12. M E M P H IS Source: U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL deaths per 1,000 Infanta surviving the first rhònth.of life Chart 13.— Mortality in the Second to the Twelfth Month of Life Among White and Colored Infants in Memphis, Atlanta, Birmingham, and Louisville, 1927-34 C O N S ID E R A T IO N S 1927 1928 1929 1930 1931 Source: U. S. Bureau o f thè Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1932 1933 1934 1927 1928 1929 1930 1931 1932 1933 1934 1927 1928 1929 1930 1931 1932 1933 1934 18 IN F A N T M O R T A L IT Y IN M E M P H IS Charts 11—13 show the upward trend since 1928 in the mortality rates for the first year and the first month in Memphis in contrast to the downward trend in the rates fo r the first year and relatively stable rates fo r the first Chart 14.— Mortality in the First Month of Life From All Causes and From Natal and Prenatal Causes Among White and Colored Infants in Cities With 250,000 to 350,000 Population and 25,000 or More Colored Population, 1934 20 T o ta l Deaths per 1,000 live b irth s 40 60 Memphis Memphis resident ao 100 S3SSSS3SSSSS W h ite Memphis Memphis resident Memphis resid en t Houston ssssssss S88S Birmingham A tlan ta D a lla s Columbus Louisville SS sssssss All causes HI Natal snd prenatal causes Source: Memphis resident rates, M em phis Department o f H ealth; all others, U. S. Bureau o f the Census. month in the three Southern cities combined. The picture o f variability in the Memphis rates fo r infants in the second to the twelfth month period stands out against a marked decrease in the three Southern cities combined https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 19 during the period 1928-32. Although the second to twelfth month mortality in the three cities combined showed a marked increase in 1933 and 1934 this rate was still much lower than the second to twelfth month rate of Memphis in these years. , Chart 15.— Mortality in the Second to the Twelfth Month of Life From Specified Groups of Causes Among White and Colored Infants in Cities With 250,000 to 350,000 Population and 25,000 or More Colored Population, 1934 Deaths p er 1,000 infants surviving the.G r'at/n on th .of*. life* 0 Total: r Memphis; Tenn. M Memphis resident; 20 40 ---- 1... i l i .60 . 11,1111 1i 11 1111 SO .100 i ...........> l m & *W )e/ / A Atlanta, ©8. W&(XX//A/7777\ Louisville, Ky. Dallas; Tex. W Ê^ZZZXZZA Birmingham, Ala. M E 2 3 E 3 3 S 1 Houston,Tex. W & & /A //A sa sg jg a i W h ite : Memphis,Tenn. Memphis resident Louisville, Ky. W XS(///À/7m Atlanta Ga. V M X / M S/ M Dal las,Tex. m ò W A / sd Columbus, Ohio tm zB it Birmingham, Al». )^ 9 Y A Y / À Houston, Tex. Colored : Memphis,Ten h. Memphis resident ÏÏZZÆZZZZZI Houston,Tex. M üS6ÖÖÖÖÖÖOVy///Ai//////A Da11as, Tex. — YZ/Z/A /A Lo u isville, Ky. 1 I I I Birmingham,Ala. W R E*Z 3B S22Z 22!L I Columbus, Ohio I Natal and prenatal causes K&8 Respiratory d iseases G astrointestinal diseases ['//A All othAr and unknown or il I-defined Source: M em phis resident rates, Memphis Department o f H ealth; all others, U. S. Bureau o f the Census. Causes of neonatal mortality in Memphis and in other cities of comparable size. Differences between Memphis and the other eities of its approximate size appear both in neonatal mortality and in the mortality from the second to the twelfth month; but the marked excess of the Memphis neonatal mortality rate in 1934 over that even of the city next highest is https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 IN F A N T M O RTALITY IN MEMPHIS noteworthy, and the reason for the difference is evident when the causes of neonatal mortality in Memphis and in the other cities are compared. Such a comparison of the mortality from natal and prenatal causes and from other causes during the first month of life in Memphis and in cities with separate rates for white and colored in 1934 is shown in chart 14 and in table 11 (p. 86). Although the Memphis neonatal mortality from natal and prenatal causes among white and in most instances among colored infants was higher than that of the cities with which it is compared, the marked difference in neonatal mortality between Memphis and the other cities in 1934 was due to the fact that mortality rates from other than natal and prenatal causes among both white and colored infants were more than twice as high in Memphis as the highest rate from such causes in any of the other cities. Causes of mortality in the second to the twelfth m onth in Memphis and in other cities of comparable size. In the second to twelfth month period the most striking difference in causes of mortality between Memphis and the cities with which it is compared is in mortality from gastrointestinal diseases among white infants, which in 1934 was very much higher in Memphis than in any of the other cities except Louisville. It is of interest that many of the other cities have, like Memphis, a high mortality from respiratory diseases among colored infants in the second to twelfth month period, and that among the colored many of the cities have at least as high a mortality as Memphis from gastrointestinal diseases. Mortality from natal and prenatal causes among colored infants during this period of the first year of life was higher in Memphis in 1934 than in the other cities. (Chart IS. See also table 12, p. 86.) Residence of Mothers in Relation to Infant Mortality in Memphis Memphis is the trading and hospital center for a large area in western Tennessee and in Arkansas and northern Mississippi— an area very poorly equipped with health and medical services. Infants are brought to Memphis for medical care, and some of these die there. Women from elsewhere come to Memphis for delivery, and some of the infants born to nonresident mothers in Memphis die there early in life. Memphis cannot be relieved of all responsibility for these deaths unless it is demonstrated that they are due to causes entirely beyond the control of those in the city who care for these patients. Careful inquiry must be made as to conditions in Memphis that may have a bearing on the deaths occurring among the newborn infants of nonresident as well as of resident mothers, for the same influences may be responsible for some deaths in both groups. A similar inquiry must be made regarding deaths of nonresident sick infants brought into Memphis for care. But if women come into hospitals in the city for delivery without having planned for it and without affording the physician opportunity https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL C O N S ID E R A T IO N S 21 to give them adequate prenatal care, or if they come in an emergency, the city cannot be held responsible for a lethal outcome provided the care given under the circumstances meets accepted standards. The same holds true when sick babies are brought from outside the city for hospital care. Many infant deaths can be prevented by care early in illness; delay is often fatal, and the city certainly cannot be held respon sible for the deaths of infants brought in seriously ill and beyond effective medical help. It is, however, important first of all to determine whether deaths and births of infants of nonresident mothers affect what may be called crude infant mortality rates (based on all infant deaths and all live births in the city) to distinguish them from rates based on residence. Are the deaths and births of nonresidents responsible for the unusually high infant mortality of Memphis compared with other cities ? If so, do they affect both the rates for the first month and the rates for the second to the twelfth month? D o they affect the rates among colored and white alike? Mortality among infants of resident mothers in Memphis. Comparison of infant mortality rates based only on deaths of infants of resident mothers and on live births to resident mothers in Memphis, with crude infant mortality rates would reveal the degree to which the births in Memphis to nonresident mothers and the deaths o f such infants, and also the deaths in Memphis of infants not born there, are influencing the crude rates. A study of such resident infant mortality rates over a period of years would indicate the extent to which their trends have followed those of the crude rates. Comparison of resident and crude infant mortality rates in 1930-32 and in 1934. Unfortunately, reasonably valid mortality rates for infants of resident mothers are available only for the years 1930-32 combined and for 1934. Resident mortality rates by cause are available only for 1934.2 For both these periods the resident infant mortality rates for all infants and for white infants were significantly lower than the crude mortality rates. The resident neonatal mortality rates were slightly lower than the crude rates, but the differences were not statistically significant. The resident mortality in the second to the twelfth month of life was, however, significantly lower for all infants and for white infants than the crude mortality for these months. (Chart 16. See also table 13, p. 87.) For the neonatal period resident mortality rates from natal and prenatal causes and from other causes were not significantly different in 1934 from the respective crude rates. N or were there significant differences between the resident and the crude mortality when the figures fo r the first month were broken up into different age periods. 2For detailed discussion o f resident infant mortality in Memphis see Appendix 1, p. 77. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 IN FA N T M ORTALITY IN MEMPHIS , , In the second to the twelfth month period however the strikingly lower resident rate in 1934 from gastrointestinal diseases among white infants suggests that the upward trend in the crude mortality from this cause among white infants o f this age period may he associated with nonresident deaths from these diseases. (Charts 17—19. See also table 13, p. 87.) Changes in resident neonatal mortality rates, 1930-32 and 1934. It is especially significant that the neonatal mortality rates among the infants of resident mothers increased in 1934 as compared with 1930-32, Chart 16.— Crude Mortality and Mortality Among Infants Born to Resident Mothers n Certain Periods of the First Year of Life, by Color; Memphis, Tenn., 1934 D e a th s p er 1,000 live b irt h s T o ta l 0 20 40 60 00 100 ISO 140 is o Crude ra te R e sid e n t ra te W h ite Crude ra te Residen t rate C o lo re d Crude ra te Residen t r a te Deaths p e r 1,000 in fan ts surviving th e f i r s t m onth o f lif e F i r s t ^year F i r s t m on th Second to tw e lfth month .Resident rate Source: Crude rates, U , S. Bureau o f the Census; resident rates, Memphis Department o f Health. as did the crude neonatal mortality rates. (Chart 20. See also table 16, p. 89.) Although actual mortality rates among infants of resident mothers are available only for 1930-32 and 1934, data are available for analyzing separately the effect of (1) the deaths of infants not born in Memphis on the crude rates for the years 1930 to 1934, inclusive, and (2) varying pro portions of births to nonresident mothers in Memphis and the early deaths of such infants for the years 1927 to 1934. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL C O N S ID E R A T IO N S 23 Influence of deaths in Memphis of infants not born there on crude infant mortality rates. Deaths o f infants not born in M em phis in relation to the total number of infant deaths.— Infant deaths in the first month of life in Memphis are largely those of infants born in the city. Deaths of infants born else where form a small and practically negligible proportion of deaths during this period. Since 1930 from 95 to 98 percent of the neonatal deaths (92 to 96 percent of the white and 98 to 100 percent of the colored) have been of infants born in Memphis. For the second to twelfth month period, however, the situation is quite different. Deaths of infants not born in Memphis have formed a steadily https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 IN F A N T M O R T A L IT Y IN M E M P H IS increasing proportion of deaths occurring in the city. Of the deaths in the second to the twelfth month they formed 12 percent in 1930, 37 per cent in 1934; of the deaths of white infants, 29 percent in 1930, 53 percent \\ S.N in 1934; of the deaths of colored infants, 1 percent in 1930, 21 percent in 1934. (Chart 21. See also table 17, p. 90.) E ffect o f deaths o f infants not horn in M em phis on crude infant mortality rates.— The influence of deaths of infants not born in Memphis on the infant mortality rates since 1930 is shown in chart 22. This shows clearly that the infant mortality, particularly among white infants, has been raised appreciably from 1931 on by deaths in the city of infants not born there. It also shows that the rise in infant mortality among both white and colored in 1933 and 1934 as compared with 1932 is asso https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Ik * Chart 19.— Mortality in Certain Periods of the First Year of Life From Specified Groups of Causes Among Colored Infants; Memphis, Tenn., 1927-34 64535 F i r s t ; Y e a r of* L r P e Deaths per 1,000 live b irth s C ru d e ? __________^ 2 _________ tfL_________ ^ F i r s t M o n t h o f lL if e Deaths per 1,000 live births _________ ®° 0 20 40 60 70 0 Second to T w e l f t h M o n t h o F L ifte Deaths per IjOOO infants surviving th e f i r s t month o f life 20 40 ^ 60 70 GENERAL C O N S ID E R A T IO N S Resident ,934 H H ^ I R&&} G a s t r o i n t e s t i n a l d i s e a s e s g g g g g g g g g M B R e s p i r a t o r y d is e a s e s |y.y,| A ll o t h e r c a u s e s Source: Crude rates, U. S. Bureau o f the Census; resident rates, Memphis Department o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ^ ^/S////Av/77777\ | m N a t a l an d p re n a ta l c a u s e s 26 IN F A N T M O R T A L IT Y IN M E M P H IS dated with an increase in mortality among infants born in the city. (See also table 18, p. 91.) The deaths of infants not born in Memphis have obviously had no significant influence on the neonatal mortality rates. In the second to twelfth month mortality, however, they have exercised a large influence Chart 20.— Mortality in Certain Periods of the First Year of Life Among White and Colored Infants of Resident Mothers; Memphis, Tenn., 1930-32 and 1934 Mortality inthe First Month and the First Year of Life D e a th s p e r 1,000 liv e b i r t h s 20 q 40 60 80 100 120 ISO T o ta l V/////////77À 1 9 3 0 -3 2 V//////ZZA White 1 9 3 0 -3 2 1934 C o lo r e d 1930-32 V ////////777k 1934 |gfg First month IL— !."H F irst y e a r M ortality in th e Second to the Tw elfth Month o f Life life 0 D e a t h s p er 1,000 in f a n t s s u rv iv in g t h e f i r s t m o n th o f 20 40 60 80 100 120 130 T o ta l 1 9 3 0 -3 2 W h it e 1 9 3 0 -3 2 1934 Colored Source: M em phis Department o f Health. on the rates for white infants and an apparently increasing influence in recent years on the rates for colored infants. Comparison o f mortality among infants born in M em phis with crude infant mortality in three Southern cities 1930—34.— Comparison of the , mortality among infants born in Memphis with crude infant mortality in three Southern cities from 1930 to 1934 (chart 23) reveals that the mor tality among infants born in Memphis has been considerably higher than the crude mortality among all infants in the three cities in every year of the period. This is true also for the mortality among colored infants, and the difference has become greater recently. However, the mortality https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL C O N S ID E R A T IO N S 27 among white infants born in Memphis has been only slightly higher, except in 1933, than the crude rate for the three cities. The great difference in neonatal mortality between Memphis and the three cities in 1933 and 1934 is not appreciably lessened by the elimina tion of mortality among infants not born in Memphis, either for the total or among white and colored separately. For the second to the twelfth month, however, mortality among infants born in Memphis was slightly lower than in the three cities in 1933 and 1934. For the second to twelfth month period the Memphis rate for white infants born in Memphis has https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 IN F A N T M O R T A L IT Y IN M E M P H IS Chart 22.— Mortality in Certain Periods of the First Year of Life Among White and Colored Infants Born in Memphis, Tenn., and Among Those Born Elsewhere; Memphis, Tenn., 1930-34 been lower than the crude rate for the three cities throughout the period 1930-34, and in 1933 and 1934 very markedly lower. In 1933 and 1934 the second to twelfth month mortality of colored infants born in Memphis was very close to the crude rate for the three cities, although in previous years it had been much higher. These comparisons suggest that part of https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Mortality Among White and Colored Infants Born in Memphis, Tenn., and Dying in the City in Certain Periods of the First Year of Life Compared With Crude Mortality in Memphis and in Three Southern Cities, 1930-34 GENERAL C O N S ID E R A T IO N S Deaths per 1,000 live birtha Chart 23. bO https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CO 30 IN F A N T M O R T A L IT Y IN M E M P H IS the very marked difference between the infant mortality of Memphis in the second to the twelfth month, particularly among the white infants, Chart 24.— Proportion of Live Births, by Color, to Resident and to Nonresident Mothers; Memphis, Tenn., 1927-34 Percent 20 Total 40 60 80 100 1927 1928 1929 1930 1931 S3SSSS 1932 1933 1934 White 1927 ü 1928 1929 1930 1931 1932 1933 1 1934 Colored 1927 1928 1929 1930 1931 1932 1933 1934 m i l To resident m others To nonresident mothers Source: Memphis Department o f H ealth. and the three Southern cities with which it has been compared may be the effect of the very large proportion of deaths of infants not born in Memphis. (This suggestion is based on the premise that the rates from https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 31 the second to the twelfth month in the other cities are not so markedly influenced by nonresident deaths as in Memphis— a premise that merits investigation.3) Deaths in M em phis o f infants not horn in the city during the years 1930 to 1934 had practically no influence on the high and rising mortality rates in the first month o f life. They were however responsible fo r more than one-fourth o f the mortality o f white infants in the second to the twelfth month in 1930 and fo r slightly more than one-half o f this mortality in 1934; fo r practically none o f the mortality o f colored infants in the second to the twelfth month in 1930 andfo r approxim ately one-fifth o f this mortality in 1934 , , . Extent to which neonatal mortality rates were influenced by births to non resident mothers in Memphis and deaths in Memphis of infants born there of nonresident mothers. Births in Memphis to nonresident white mothers have made up from 16 to 22 percent of the total white live births in the city since 1927. (Chart 24. See also table 19, p. 91.) Even if the neonatal mortality among infants born in Memphis of nonresident mothers were sufficiently higher than among infants of resident mothers to raise the total neonatal mor tality significantly (and available evidence indicates that it is not), the relatively slight changes in the proportions of such births from year to year would eliminate them as a significant factor in the rising neonatal mortality rates among white infants. Births in JVlemphis to nonresident colored mothers are so few that they are obviously insignificant as a factor in the high and rising neonatal mortality among colored infants. Since 1927 they have made up from 1 to 7 percent o f the total live births; since 1930, only 1 to 3 percent. Births in M em phis to nonresident mothers and the deaths o f their infants do not account fo r the high and rising neonatal mortality among both colored and white infants. Trend of Births in Hospitals in Relation to Infant Mortality in Memphis The percentage of births (live births and stillbirths) occurring in hos pitals in Memphis between 1927 and 1934 (see table 20, p. 92) has in creased for the white from 66 percent in 1927 to 79 percent in 1934 and 8 In order, if possible, to clarify this point letters were written to the health officers of Louisville, Birmingham, and Atlanta, requesting details such as were obtained from M em phis as to births and deaths o f infants in these cities in accordance with the mother’ s residence. Birmingham was the only city which was able to furnish this information. Comparison o f the Birmingham and Memphis data reveals that since 1931, and especially in 1934, the Memphis second to twelfth month rate has been influenced to a greater degree by the deaths o f infants o f nonresident mothers than that o f Birmingham, although the deaths among white infants o f nonresident mothers appreciably affected the rates o f both cities. (For Birmingham figures see tables 40 and 41, pp. 102-103.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 IN F A N T M O R T A L IT Y IN M E M P H IS has averaged 40 percent for the colored. The rising neonatal mortalityrate among colored infants cannot therefore be said to be associated with an increasing proportion of hospital births. With the information available it is not possible to say whether the increase in the neonatal rate among white infants is associated with increased hospitalization. Maternal and Child-Health Program in Relation to Infant Mortality in Memphis Development and adequacy of maternal and child-health program, 1921-29. Although in 1927 to 1929 infant mortality in Memphis was relatively high, it had declined in 1926 and 1927 from much higher levels. This decline accompanied the development o f a maternal and child-health program launched by the city department of health in 1921 under specialized medical direction. This program involved (besides the development of a free milk fund 4 for babies in need of it, the licensing and control of midwives, and the supervision of maternity homes and infant boarding homes) the rapid growth of a generalized public health nursing service in the health department, which devoted a large propor tion of its activities to maternal and infant-health supervision, and the establishment of prenatal and infant-health clinics at the Memphis Gen eral Hospital as a cooperative undertaking of the health department, the hospital, and the University of Tennessee Medical School. In 1928 the director of maternal and child health in the health department resigned, and there has been no specialized medical supervision and direction of this work since that time.5 In 1929 a survey o f health problems and facilities in Memphis by the American Public Health Association pointed out that clinical and nursing services for maternal care in Memphis, although adequately planned and on the whole effective in relation to the needs of the average community, were somewhat below the amount required by a population in which maternal and neonatal mortality and stillbirth rates were above the average; that the major deficiency of the service for infant hygiene was the lack of adequate medical clinic care; and that while the division of publichealth nursing had made notable accomplishments in the past in spite of the handicap of a small staff, the imperative need for intensification of nursing in the fields of tuberculosis and child hygiene demanded an immediate program of expansion. 4 The Cynthia M ilk Fund, collected b y one of the Memphis newspapers. 8 Until the summer o f 1935, when a director o f maternal and child health in the Memphis Department o f Health was appointed. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 33 The need of an expanded maternal and child-health program in relation to annexation of wards 34, 35, and 37 to 50, inclusive, in 1928 and 1929. These comments on the deficiencies and needs of the maternal and child-health program in Memphis are o f especial significance in view of the fact that in 1928 the city annexed ward 37 and in 1929 wards 34, 35, Chart 25.— Live Births to Resident and to Nonresident Mothers; Memphis, Tenn. 1927-34 5,000 4,500 To resid en t mothers 4,000 3,500 3,000 2,500 2,000 1,500 1,000 To nonresident mothers 500 1927 1928 1929 1930 1931 1932 1933 1934 1927 1928 1929 1930 1931 1932 1933 1934 Source: M em phis Department o f Health. and 38 to 50, inclusive, increasing the population approximately 25 per cent. The additional direct responsibility brought to the city by these annexations in relation to infant welfare is apparent in the increased number of resident births occurring in 1930 and the years immediately following. (Chart 25. See also table 19, p. 91.) The additional territory brought with it an even greater infant-mortality problem than existed https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN F A N T M O RTALITY IN MEMPHIS 34 in the old city. This is shown in chart 26, which compares the infant mortality o f the old city and the annexed territory for the years 1930-32, and even more vividly by the maps showing mortality among white and colored infants by wards for 1930-32 (charts 27 and 28). Even after the addition o f this new territory, which brought with it a higher infant mortality rate than that of the old city, Memphis did not expand its health services for mothers and babies, which the survey of 1929 had considered inadequate to the needs o f the old city. Specialized Chart 26.— Mortality in the First Month and the First Year of Life Among White and Colored Infants Bom to Residents of the Entire City, the Old City, and the Area Annexed in 1928 and 1929; Memphis, Tenn., 1930-32 deaths per 1,000 live birtha total o 20 40 60 60 100 ISO M0 l6'o E n tire c it y Old c it y W hite E n t ir e c ity Old oit^y Annexed area C olo red E n tire c it y Old c it y Annexed a rea wsm Firat year Hi F ir s t month Source: M em phis Department of Health. medical direction and supervision, which had existed from 1921 to 1928, was lacking. The 1929 survey of the American Public Health Associa tion reported that to provide an adequate public health nursing service for the old city a minimum of 44 staff nurses in the health department was necessary, in addition to supervisors, and that, if the needs of the annexed territory were similar to those of the old city, 52 staff nurses would be the minimum required. The needs of the new territory were obviously greater than the needs of the old, yet the number of staff nurses in the division o f public-health nursing of the health department, which was 34 in 1929, remained 34 in 1934.6 Moreover, since 1929 the 8 In 1930 the Metropolitan Life Insurance Co. set up its own nursing service. Previ ously its nursing work had been done b y the city nurses. In 1934 the Metropolitan Nurs ing Service maintained 7 staff nurses. In comparison with 1929, therefore, there are in reality 41 staff nurses doing generalized nursing in the city instead o f 34. T he estimate o f the need o f a staff o f 44 nurses in the city department o f health for the old city and 52 for the enlarged city was, however, exclusive of nurses doing the work o f the Metro politan Life Insurance Co. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL C O N S ID E R A T IO N S 35 Chart 27.— Mortality Among White Infants in Each Ward of Memphis, Tenn., 1930-32 D e a t h s p e r 1,0 0 0 liv e b i r t h s L e s s th a n 50 X//X 50 - 74 7 5 -9 9 100-124 I I L e s s th a n . 50 liv e b i r t h s Source: M em phis Department o f Health, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 IN FA N T M ORTALITY IN MEMPHIS Chart 28.— Mortality Among Colored Infants in Each Ward of Memphis, Tenn., 1930-32 D ea th s per 1,000 live b irth s le'/A Y//\ L ess than 50 50 - 74 7 5 -9 9 8&S 100-124 flH 125 or more I— I Less than 50 live births Source: M em phis Department o f Health, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis GENERAL CONSIDERATIONS 37 major and prolonged economic depression has increased the need for health services for mothers and babies in both old and new sections of the city. There is ample evidence that both the health department, particularly the division of public-health nursing, and the Memphis General Hospital obstetric and pediatric services have carried increasing loads caused by the annexation of territory and the depression (see pp. 34, 39), but it is obvious that their efforts have not been adequate to cope with the situation. Economic and Social Conditions and Social Services in Relation to Infant Mortality Economic and social conditions. The association of high infant mortality rates with unfavorable eco nomic and social conditions is well recognized.7 That such an associa tion occurs in Memphis has been brought out in a very interesting study recently made by the superintendent and the sanitary engineer of the Memphis Health Department of the influence of housing on residual typhoid fever and on infant mortality,8 which demonstrated that wards having the lowest housing index had the highest infant mortality rate (chart 29). The indexes were based on three factors— persons per room, percentage of dwellings not in good repair, and percentage of living units with outdoor toilets; they were calculated by averaging the figures representing the numerical rank of the ward for these three factors, the poorest ward being rated 1, the next poorest 2, and so on. Just what direct role economic conditions, particularly since 1929, may have played in the rising infant mortality rates in Memphis it is impos sible to say. In 1934 only Louisville among the 16 cities of 250,000 to 350,000 population had a monthly average number of cases per 10,000 population receiving public unemployment relief that was lower than Memphis (see table 22, p. 93), so that on the surface it would appear that Memphis has been less affected by the depression than many other cities of its size. Yet the demands on the Cynthia Milk Fund, which for years has provided milk for needy babies, have become so great that milk is allotted only for short periods of time, and no more than a pint a day is allowed for any one child. M any of the babies receiving this milk are in relief families. Very little is allotted to colored babies. Because large numbers of families could not afford retail prices for cod-liver oil, money has been advanced recently for its purchase in large quantities. It has been bottled and sold at cost to patients at the well-baby clinic 7 Examples are: Causal Factors in Infant Mortality, pp. 125-164 (U. S. Children’ s Bureau Publication N o. 142, Washington, 1925) and Infant M ortality and Economic Status, Cleveland’ s Five-City Area, b y Howard Whipple Green (Cleveland Health Council, Cleveland, Ohio, 1932; mimeographed). 8 Graves, L. M ., M . D ., and Alfred H. Fletcher, F. A. P. H . A .: Housing Problem in a Southern City, with Special Reference to Its Influence on Residual Typhoid Fever and on Infant M ortality. American Journal o f Public Health, vol. 25, no, 1 (January 1935), pp. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 00 00 Chart 2 9 — Mortality Among White and Colored Infants, by Wards, According to Varying Housing Indexes; Memphis, Tenn., 1930-32 Deaths p e r 1,000 liv e b irth s 20 40 60 X (12 0-12 » wards) . 13-24 . QI2 wards) . 25-37 (13 wards) C olored Source: Housing Problem in a Southern C ity (see ftn. 8, p, 37), p. 25, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 80 100 120 140 160 IN F A N T ' M O R T A L IT Y IN M EM P H IS W h ite Group index GENERAL CONSIDERATIONS 39 of the Memphis General Hospital and occasionally is given away to those in need. The city nurses tell of many families with babies which have no ice, have had their water supply cut off, and do not even have a nursing bottle. That the standards of living of large numbers of families in Memphis, as elsewhere, have been lowered as a result of the depression admits of little doubt. Nearly half of a small sample of 62 families studied there by the United States Children’ s Bureau in 1934 were living on half or less than half of their former incomes.9 Social services. It is well recognized that neither health services for the prevention of disease nor medical services for its treatment can function efficiently if underlying basic necessities of living are lacking or inadequate. Here the social services of the community come in as important cooperating agencies with the health and medical groups, to provide supplementary relief where it is indicated and to help with constructive rehabilitation. Social services, including relief for those in need, from public funds had never been available in Memphis and Shelby County except for mothers’ aid until the fall of 1933, when Federal funds were made avail able for unemployment relief. Private social agencies there, as else where, have had tremendous cuts in budgets— they never were adequate— so that at a time when the need for social services is greatest, when there seems every reason to believe that many families not on unemploymentrelief rolls as well as those on these rolls are without some of the basic necessities of living, there has been little or no possibility for muchneeded help from either public or private sources. , , The annexation o f territory bringing with it a high infant mortality rate and the depression have increased appreciably the need fo r additional fa cili ties fo r maternal and infant-health supervision in M em phis—facilities apparently inadequate to meet the needs o f the old city in 1929. The health services have been handicapped further especially since the depression by the inability o f many fam ilies to procure the basic necessities o f living. , , 8 Lenroot, Katharine F .: Children o f the Depression; a study o f 259 families in selected areas o f 5 cities. Social Service Review, vol. 9, no. 2 (June 1935), pp. 212-242. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Neonatal Mortality and Associated Phenomena in Memphis From the discussion so far, it is apparent that the high and rising neonatal mortality which has occurred among infants of resident mothers to approximately the same extent as among all infants in Memphis presents the most outstanding problem for consideration. A closer study of neonatal mortality and related matters is therefore indicated, par ticularly in relation to conditions in Memphis with which it may be associated. Two aspects of neonatal mortality in Memphis obviously call for con sideration, both separately and in their relation to each other: The mor tality from natal and prenatal causes, which are the predominant causes of neonatal mortality, and the mortality from other causes in the neonatal period, which, although relatively small compared with that from natal and prenatal causes, has shown an upward trend during the period 1927 to 1934, with markedly higher rates in 1933 and 1934 as compared with previous years. Where Infants W ere Bom and W here They Died During the Neonatal Period in 1933 and 1934 Although in Memphis 63 percent of the infants born alive in 1933 and 1934 were born in hospitals (78 percent of the white infants and 41 percent of the colored), 88 percent of the deaths of infants in the neonatal period occurred in hospitals— 92 percent of the deaths of white infants and 84 percent o f the deaths of colored. Thirty-seven percent of the live births occurred in homes during this period (22 percent of the white and 59 percent of the colored). Y et only 12 percent of the neonatal deaths occurred in homes (8 percent of the white infants and 16 percent of the colored). Furthermore, although only 24 percent of the births occurred at the Memphis General Hospital (14 percent of the white and 40 percent of the colored), 60 percent of the neonatal deaths occurred there 38 per cent of the white and 84 percent of the colored; and although 64 percent of the births of white infants occurred at the other hospitals, 55 percent of the neonatal deaths among white infants occurred in these hospitals. (See tables 23 and 24, pp. 93-94.) When rates are computed on the basis of live births and deaths in hospitals and homes in Memphis the neonatal mortality in the Memphis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis N E O N AT A L M ORTALITY 41 General Hospital in 1933—34 is found to be approximately three times that of the other hospitals. (See table 25, p. 94.) The mortality in the first day and that from one day to one week are approximately twice as high in the Memphis General Hospital as in the others, but the mortality for one week to one month is more than six times as great in the Memphis General as in the other hospitals. This relation holds for the white as well as for the white and colored combined; for the colored the Memphis General is the only hospital, so that comparison with other hospitals is obviously impossible. The rates just cited are based on crude data for the births and deaths in hospitals and homes— all the births and all the deaths. Closer study of the deaths in 1934 reveals that the deaths, especially those in the latter part of the neonatal period, in the Memphis General Hospital were not all of infants born there. Some were of infants born at home; a few were of infants born at other hospitals; some were o f infants born at the Mem phis General Hospital who had gone home and reentered the hospital before death. The elimination of these deaths, however, does not lower very appreciably the Memphis General Hospital rate. Two conclusions seem justified by the above analysis: (1) That the neonatal mortality in Memphis was appreciably heightened in 1933 and 1934 by the excessive mortality at the Memphis General Hospital; (2) that it is largely the very excessive mortality from the second week to the first month occurring in the Memphis General Hospital in 1933 and 1934 that accounts for the very high Memphis mortality rate from the second week to the first month in those years. The Memphis General Hospital is the hospital which provides free care for residents o f Memphis who cannot afford private care. It provides delivery care also for nonresident as well as resident white unmarried mothers staying at the Beulah and Bethany maternity homes in Mem phis, and for colored residents of Shelby County who need hospital care. The other hospitals in Memphis in general do not provide free care for residents o f the city, although they do provide a certain amount of free care for white nonresident patients. While the neonatal mortality in the other hospitals in the city is rela tively high, it is apparent that the major problem in relation to the high neonatal mortality in Memphis lies with the group receiving public care. Prenatal, Natal, and Postnatal Care in Memphis Prenatal, natal, and postnatal care for those residents of Memphis who cannot afford private care is provided cooperatively by the public health nursing division of the Memphis Department of Health, the Memphis General Hospital, and the University of Tennessee Medical School. Industrial policy holders of the Metropolitan Life Insurance Co. receive prenatal and postnatal nursing care from the ^Metropolitan/ Nursing Service. 64535 °— 37- -4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 42 IN F A N T M O R T A L IT Y IN M E M P H IS A relatively large proportion of the activities of the staff nurses of the division of public-health nursing is devoted to prenatal home visits. Weekly prenatal clinics are conducted at the Memphis General Hospital— one for white and two for colored patients. The medical service for these clinics is provided by the obstetric staff of the Memphis General Hospital and the University of Tennessee Medical School. The nursing service for the clinics is provided by the public health nursing division of the health department. The Memphis General Hospital obstetric service main tains an in-patient hospital service for the delivery of all primiparae and of multiparae with any actual or potential complications, and a homedelivery service for the delivery of multiparae with no apparent complica tions. Home deliveries are conducted by the University of Tennessee medical students with the assistance of two experienced health-depart ment nurses who attend all home deliveries. These two nurses in their spare time assist at the prenatal clinics, and the nurse in charge of the prenatal clinic relieves each of the delivery nurses one-half day a week. In addition, seven of the district nurses carrying the lightest case load and working fairly close to the hospital assist at the clinics. Postpartum care for mothers delivered at home and postnatal care for the babies are given by the district nurses of the public health nursing division of the health department. Number of births cared for by the Memphis General Hospital obstetric service, 1930-34. Five hundred and five more live births— 223 more white and 282 more colored— resulted from deliveries by the Memphis General Hospital obstetric service in 1934 than in 1930. Tw o hundred and one of these were hospital deliveries— 77 white and 124 colored; 304 were home deliveries— 146 white and 158 colored. The increased burden of this service is shown by the fact that its proportion of the city’ s live births increased from 33 percent in 1930 to 45 percent in 1934— from 12 percent of the births of white infants in 1930 to 21 percent in 1934 and from 69 percent of the births of colored infants in 1930 to 83 percent in 1934. The proportion of live births that occurred in the Memphis General Hospital increased from 18 to 23 percent— for the white, from 9 to 13 percent and for the colored, from 33 to 39 percent. The proportion of live births resulting from deliveries in the home by the hospital obstetric service increased from 15 to 22 percent— for the white, from 3 to 8 percent, and for the colored, from 36 to 44 percent. (See table 26, p. 95.) Prenatal care given to patients delivered by the Memphis General Hospital obstetric service. The proportion of women delivered by the Memphis General Hospital obstetric service who received prenatal care increased slightly between 1930 and 1934 in spite of the increased number cared for by the service— for the total, from 88 to 90 percent; for the white, from 76 to 84 percent; https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis N E O N A T A L M O R T A L IT Y 43 and for the colored, from 91 to 93 percent. (See table 27, p. 95.) The proportion of women delivered in the hospital receiving prenatal care increased from 78 to 82 percent— from 67 to 75 percent for the white and from 83 to 85 percent for the colored. It is of interest that during the years 1932 to 1934 between 16 and 18 percent of the white mothers having live-born infants and 75 to 79 percent of the colored mothers in Memphis received some prenatal super vision at the Memphis General Hospital. (See table 28, p. 96.) Moreover, there has been a tendency toward earlier registration at the prenatal clinic. Analysis for the first 4 months of 1934 of the month of pregnancy at which patients first attended the prenatal clinic shows that 81 percent had registered before the seventh month of pregnancy— 72 percent of the white and 84 percent of the colored. These figures compare with 53 and 58 percent registration of white and colored respectively before the seventh month in 1929 and 29 percent registration of the white and 34 percent of the colored before the seventh month in 1926.10 It is signifi cant, as indicating increased public appreciation of the importance of early prenatal care and probably the result of educational work by the public-health nurses, that 39 percent of the white and 48 percent of the colored patients had registered even before the fifth month in the first 4 months of 1934, as* compared with 25 and 20 percent for white and colored respectively in 1929.11 (Chart 30. See also table 29, p. 96.) It is significant too that the average number of visits per patient to the prenatal clinic has shown a slight but steady increase— from 2.6 in 1929 and 1930 to 3.2 in 1934. (See table 30, p. 97.) The marked increase in the volume of work undertaken by the clinic is evident in the increase of 86 percent in the number of visits to it in 1934 over 1929. Prenatal home-nursing visits by health-department public-health nurses. The number of prenatal home visits made by the public-health nurses of the health department has also increased markedly since 1929— from 9,266 in 1929 to 13,878 in 1934, or nearly 50 percent. In addition, between 9 and 10 thousand additional prenatal home visits were made annually in 1932, 1933, and 1934 by nurses on work-relief projects who were assigned to the health department. The supervisor of the public health nursing division in the health department stated that these visits were of value chiefly as a check-up on prenatal-clinic attendance. In 1934, as might be expected, the average number per patient of prenatal home-nursing visits by regular health-department nurses decreased from the 1929 figures both for white and colored combined and for the colored. For the white there was a slight increase. In 1929 the average number of visits to both white and colored patients was 4.4, to 10 Survey o f Health Problems and Facilities in Memphis and Shelby County Tenn., for the Year 1929, made for the committee on administrative practice o f the American Public Health Association b y W . F. Walker, D r. P. H ., secretary, and D orothy F. Holland, Ph. D ., p. 56. « Ibid., p. 57. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 44 IN F A N T M O R T A L IT Y IN M E M P H IS white patients 3.3, and to colored patients 4.9. In 1934 the average number of visits to both white and colored maternity patients was 4.0; to white patients, 3.8; and to colored patients, 4.1. Thus the total volume of prenatal care, both in the clinic and in prenatal home-nursing visits, has greatly increased. The care received by Chart 30.— Proportion of White and of Colored Women First Attending Prenatal Clinic of Memphis General Hospital in Specified Periods of Pregnancy; Memphis, Tenn., 1926, 1929, and January 1 to April 30, 1934 T o ta l 1926 1929 J a n u a ry I to A p r i l *^30,1934 W hite 1926 1929 January Ito A p ril 30,1934- G o lo r e d 1926 W W ///Æ 1929 L/'v'-y J a n u a r y I to A p r i l 3 0 ,1 9 3 4 '//'/'•'/-// ' '///.•'/.'//'•'/.'//.'y' *ssssss/-/////s/sy/Ss'. v.v. B efo re \¿2Í f if t h month m F ifth and s ix t h months | Seventh to n in th month Source: 1926 and 1929, Survey o f Health Problems and Facilities in M em phis and Shelby County, Tenn. (see ftn. 10, p. 43); Jan. 1-Apr. 30, 1934, Memphis General Hospital. individual patients in terms of the average number of visits to the clinic and of the average number of home visits by the regular nurses of the health department has shown some improvement in the former and a .slight falling off in the latter. Results of Prenatal Care The effects of prenatal care, which implies in the largest sense adequate provision for delivery care, are looked for in reduced maternal mortality, stillbirth mortality, and mortality of live-born infants from natal and prenatal causes. Usually natal and prenatal causes affect especially the neonatal death rate. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis N E O N A T A L M O R T A L IT Y 45 Maternal mortality. Maternal mortality in JMemphis among both white and colored is very high and has shown marked variability from year to year since 1927. (Chart 31. See also table 31, p. 97.) The slight decrease shown in the Chart 31 — Mortality From Puerperal Causes Among Mothers of White and of Colored Infants; Memphis, Tenn., 1927-34 D eaths p e r 10,000 liv e b ir t h s 40 00 120 160 200 220 T o ta l 1927 1928 1929 1930 1931 7Z IZ 1932 V Z ??/////////7Z77A 77////////A 7?//////////A7777A 1933 1934 W hite 1927 1928 1929 7///////////777777A 1930 1931 W////////////7&.I 1932 1933 UZZZZZZZZZZA VZZZZZZZZZZZZZA 1934 Colored 1927 1928 7Z7?/,////////////;a a ;////7z >x 1929 1930 1931 7ZZZ&ZZZZZZZZ& 1932 1933 1934 gaaaaagaggagggaaggggaaagggg W k/ tt All puerperal c a u se s ■ Puerperal septicemia Source: U. S. Bureau o f the Census. rates when the periods 1927—30 and 1931—34 are compared is not suffi cient to be statistically significant. (See table 32, p. 97.) It is also of interest that maternal mortality for the period 1931—34 among both white and colored women in Memphis exceeded that of Atlanta, Bir mingham, and Louisville. (See tftble 35, p, 99.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 46 IN FA N T M ORTALITY IN MEMPHIS Material is not available for analyzing maternal mortality in Memphis in detail. However, from the annual reports of the Memphis General Hospital obstetric service it has been possible to compute the mortality from puerperal causes among patients cared for by this service and the mortality among patients receiving prenatal-clinic care and among those not receiving such care. Maternal mortality among patients cared for by the Memphis General Hospital obstetric service. Mortality assigned to puerperal causes per 10,000 live births among patients cared for by the Memphis General Hospital obstetric service is Chart 32.— Mortality from Puerperal Causes Among Clinic Patients and Among Nonclinic Patients, White and Colored; Memphis General Hospital Obstetric Service, 1932-34 Total Clinic patients Nonclinic patients Whit© Clinic patients Nonclinic patients Colored C linic patients Nonclinic patients Source: Annual reports, Memphis General Hospital obstetric service. high. But the relatively low mortality among women who received care at the prenatal clinic, as compared with the mortality among all patients cared for by the service and the greatly excessive mortality among non clinic patients, is noteworthy. (Chart 32. See also table 36, p. 99.) The nonclinic patients of course include emergency cases and cases of very early termination of pregnancy, which for the most part do not occur in the clinic cases. In view of the fact that from 1932 to 1934 live births to colored clinic patients formed 75 to 79 percent of the colored live births in the city, the relatively low maternal mortality among these patients is an indication of a retarding role played by the service on colored maternal mortality in the city. The almost unbelievably high maternal mortality rates among the nonclinic patients of the Memphis General Hospital obstetric service— practically all of whom were admitted to the hospital in emergency— https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis * N EO N ATAL M ORTALITY 47 indicate the importance of bringing this group of patients, small as it is, under good prenatal and natal care. Mortality from stillbirths and of infants in the first day of life. There has been a definite downward trend in stillbirth mortality among the colored. Although there has been much variability from year to year Chart 33.— Stillbirths and Mortality in the First Day of Life Among White and Colored Infants; Memphis, Tenn., 1927-34 AO d e a th s per 60 1,000 live b irt h s SO 100 120 140 Total V7777///////A \////////7777X V //////////////À yyyyyyyyyyvA yyyyyyyyyyyjA vyyyyyy7777\ xyyyyyy/yAi yyyyyyyyyyyyk yyyyyyyyyyi V77777777777TX 'yy7777yyy777X yyyyyyyyy77A yyyyyyyyyx yyyyyyyyym vyyyy777A Colored 1932 * ■ ■ ■ ■ ■ ■ ■ ■ 771 Stillbirths and m ortality * 2 3 )n th e f i r s t day 6 f liffc ■ ■ . , : i i ku k . ■ Stillbirth» Source: U. S. Bureau o f the Census. in the stillbirth mortality among the white, the 1934 rate is significantly lower than the 1927 rate. (Chart 33. See also table 37, p. 100.) When one analyzes the trend of stillbirth mortality in hospitals and homes, it is apparent that the white stillbirth mortality in hospitals, although greatly in excess of the stillbirth mortality in homes, has shown a downward trend in the period 1927-34, except for a marked increase in 1933. The white stillbirth mortality in homes has not, however, shown a downward tendency during this period. What decline there has been, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 48 IN F A N T M O R T A L IT Y IN M E M P H IS Chart 3 4 — Mortality Rate from Stillbirths to White Women Delivered in Hospitals Stillbirthe per 1,000 live births and at Home; Memphis, Tenn., 1927-34 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis N E O Ñ A T A L M O R TALITY m 49 therefore, in white stillbirth mortality results from the downward trend for hospitals. (Chart 34. See also table 38, p. 100.) It is of interest that the white stillbirth mortality in the Memphis General Hospital is not significantly different from that in the other hospitals. Among the colored, although hospital stillbirth mortality has been lower from 1929 to 1934 than in 1927 to 1928, the decline in the home stillbirth mortality has been much more marked. The very great height of the home stillbirth mortality among cases cared for by colored phy sicians is apparent— it was higher than the hospital mortality in every year except 1932 and 1933— as is the effect of this mortality in raising the total home stillbirth mortality among the colored. The striking decline in home stillbirth mortality among the colored patients cared for by white physicians is especially significant in view of the fact that all but an insignificant number of the births to colored women delivered at home by white physicians are attended by medical students on the home-delivery service of the Memphis General Hospital, assisted by health-department nurses (chart 35). All the patients cared for on the home-delivery service of the Memphis General Hospital have had prenatal care at the clinic.12 Because many of the deaths of infants in the first day of life are very closely allied in cause to stillbirths, it seemed worth while to consider together the changes in mortality from stillbirths and from deaths of infants in the first day of life. The mortality of colored infants in the first day of life has shown some variability but was lower in 1933 and 1934 than in any previous year of the period 1927-34. The rate for white infants also fluctuates, but there appears to have been a slight downward trend since 1929. (Chart 33. See also table 37, p. 100.) When mortality from stillbirths and deaths in the first day are considered together, most of the variability is ironed out among the colored, and there appears a definite downward trend. The mortality among the white is characterized chiefly by variability (chart 33). The striking downward *trend in the combined mortality from still births and deaths in the first day among the colored may be considered evidence of significant accomplishment on the part of the public health nursing division of the health department and the Memphis General Hospital obstetric service. This service delivered 69 percent of the colored live births in the city in 1930 and 83 percent in 1934; it had more than 90 percent of the colored patients delivered under prenatalclinic care. (See tables 26 and 27, p. 95.) It is not possible to compare the stillbirth mortality among women receiving prenatal care from the Memphis General Hospital obstetric 12 The home stillbirth mortality among patients delivered b y colored physicians is obviously not strictly comparable with that among patients delivered by white physicians, as the latter are for the most part uncomplicated cases cared for b y the Memphis General Hospital obstetric service. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 50 IN F A N T M O R T A L IT Y IN * M E M P H IS Chart 35.— Mortality Rate From Stillbirths to Colored Women Delivered in Hospitals and to Those Delivered at Home by White Physicians and by Colored Physicians; Memphis, Tenn., 1927-34 1 |927 1928 1929 1930 1931 1932 1933 1934. 1 The stillbirth rates among women delivered b y midwives are excluded because the number o f live births to such women was less than 100 in each year from 1931 to 1934. Source: M em phis Department o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEONATAL 51 M O R T A L IT Y service with that among women in the city as a whole, who may or may not have had prenatal care, because the obstetric service in its annual reports considered as stillbirths fetuses of 7 or more months’ gestation; whereas the health department enumerates as stillbirths, under the State law, all dead-born fetuses of 5 or more months’ gestation. Figures obtained from the obstetric-service reports, however, show nearly four times the incidence of stillbirth mortality (according to the definition used by the service) among women delivered by the obstetric service who did not attend the prenatal clinic as among those delivered by the Chart 36.— Stillbirth Rate and Incidence of Premature Births Among Clinic Patients and Among Nonclinic Patients; Memphis General Hospital Obstetric Service, 1932-34 S t i l l b i r t h s p e r 1,000 liv e b ir t h s 0 1 30 60 '•.... i .............'«. - 90 , 120 . 150 • Total Clinic patients Nonclinic patients Total Clinic patients Nonclinic patients Source: Annual reports, M em phis General Hospital obstetric service. obstetric service who did attend the clinic. (Chart 36. See also table 36, p. 99.) Many early infant deaths are caused by prematurity, which is often closely related in cause to stillbirths. The higher incidence of premature births among women delivered by the Memphis General Hospital obstetric service not receiving prenatal care as compared with those receiving prenatal care is also shown in chart 36 and table 36 (p. 99). Possible Reasons for High and Apparently Rising Mortality From Natal and Prenatal Causes In spite of the slightly downward trend in mortality among infants in the first day of life, practically all of which is due to natal and prenatal causes, these causes have shown a slight upward tendency as a cause of https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 52 IN F A N T M O R T A L IT Y IN M E M P H IS mortality in the first month of life, which suggests that proportionately more infants surviving the first day have been dying from natal and prenatal conditions. Obviously, possible reasons for the rise in mortality from natal and prenatal causes merit careful consideration, as does the possibility of a further decline in stillbirth mortality. Deaths from natal and prenatal causes include deaths from syphilis, from prematurity, from injuries at birth, from congenital debility, and from congenital defects of various kinds. Syphilis is a well-known cause of stillbirths and premature births. The Memphis General Hospital obstetric service reports evidence of syphilis in 39 percent of women who had miscarriages in 1931—33 and in 40 percent of those who had stillbirths and 26 percent of those who had premature deliveries during the period 1930-34. Although the deaths actually attributed to congenital syphilis on the death certificates are relatively few, it is well known that congenital syphilis is often unrecognized, and many infants who die from other causes may have congenital syphilis as an underlying debilitating and predisposing factor. That this may well be true in Memphis is indicated by the fact that in 1934, among infants of resident mothers who died, 27 percent of the cases for which there were reports as to tests for syphilis in the mother recorded its presence— 13 percent among the white, 31 percent among the colored. The Memphis General Hospital obstetric service plans to do routine tests for syphilis on all pregnant women who register at the prenatal clinic, and all positive cases are referred to the dermatological clinic for treatment. That this procedure has been one of the most potent factors in reducing the Negro stillbirth rate and the infant death rate from con genital syphilis admits of little doubt. But many women still register too late in pregnancy for beneficial effects for the child to be reasonably assured through treatments, although it is true, of course, that even a few treatments are often helpful; and though effort is made to have the tests routine, some women apparently do not get them. The much higher stillbirth rate among colored infants delivered by colored physicians makes one wonder whether syphilis unlooked for and inadequately treated during pregnancy may not be an important factor here. (Chart 35. See also table 38, p. 100.) Many difficulties in the way of these women getting consistent and regular treatment present themselves. The question of carfare is a vital one for many of them who are either on relief or bordering on desti tution; the fact that there is only one clinic a week for them and that it is in the daytime creates difficulty for working women, many of whose families are dependent upon them for support. The high incidence of syphilis among pregnant colored women is evidence of a high incidence among the population as a whole, and a https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis n e o n a ta l m o r t a l it y 53 vigorous educational social-hygiene campaign with expansion of public facilities for treatment of syphilis would undoubtedly contribute appre ciably toward lowering the stillbirth and infant mortality rates. Stillbirths and premature deliveries are frequently associated, in addi tion to syphilis, with other prenatal and natal factors, such as the toxemias of pregnancy and complications during labor. Adequate prenatal care will detect a large proportion of the toxemias early, and early treatment will in many cases prevent their development into serious conditions which are hazardous to the life of both mother and baby. Prenatal study will also determine whether there is likely to be obstruc tion in the birth canal, make possible planning for the kind of delivery indicated, and so prevent many of the stillbirths and birth injuries which are the result of long, difficult labors due to so-called dystocia not recog nized and not planned for. Other pathological conditions, too, often extremely hazardous to both mother and child, may usually be detected early through prenatal super vision, and treatment can be planned which will reduce the hazards to a minimum. Prenatal care is but the beginning and may represent effort wasted, in part at least, if women are subjected to unnecessary hazards during labor and if the best medical judgment is not called into play in deter mining procedures necessary when abnormal conditions develop. Many stillbirths and birth injuries, as well as deaths of many babies soon after birth, are the result of such abnormal conditions. Some of the drugs, such as morphine and scopolamine, used to produce painless or partially painless labor, although apparently harmless to the mother, must be looked to as a possible cause of some stillbirths and some early deaths of newborn infants. These drugs are widely used in Memphis. The question whether they may not be too widely used should be given careful consideration. But, apart from this, careful observation and prompt treatment, by modern methods o f artificial respiration, of the newborn infant whose breathing is feeble, occasionally of the apparently stillborn, has been demonstrated to prevent a certain number of deaths of the newborn and to counteract the effect on the infant of narcosis of the mother. The reduction of prematurity through the treatment of prenatal syphilis and the early detection and treatment of the toxemias and other condi tions have been discussed. It is significant that the Memphis General Hospital records indicate that the incidence of premature births was more than twice as high among those who had not registered for prenatal care as among those who had. (Chart 36. See also table 36, p. 99.) In all communities, however, the number of premature births from unknown causes continues high, and deaths of infants from prematurity form the highest percentage of deaths in the neonatal period. On the other hand, modern methods for the care of the premature have demonstrated that many of them can be saved. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 54 IN F A N T M O R T A L IT Y IN M E M P H IS The failure of the death rate from natal and prenatal causes to decline, in spite of other evidences of the beneficial effects of the public prenatal care that has developed in Memphis, gives interest to speculation whether this failure may not be accounted for in part by an association between low vitality in the newborn and undernutrition in the mother. There are no concrete data for Memphis to prove or disprove this association, but according to the supervisory nurses at the Memphis General Hospital many of the women coming to the hospital fot delivery in recent years were in wretched general condition and obviously hungry. The results of both prenatal and natal care received by patients under the health department and the Memphis General Hospital obstetric service, as shown by the mortality among those receiving this care and as reflected in the city’s stillbirth mortality and the mortality among infants in the first day of life, particularly the colored, have already been discussed. The very high mortality among patients delivered at the Memphis General Hospital who did not have prenatal-clinic care and who for the most part were brought in as emergency cases, the high inci dence of stillbirths and premature births among this group, and the high incidence of stillbirths among colored infants delivered by colored physi cians are indications of the need for further education of the public and of the medical profession. The colored physicians are keenly aware of their need of continuous education in prenatal, natal, and infant care. A t a meeting which a group of them requested the writer to attend, they expressed concern over their lack of opportunity for postgraduate clinical training. It is of significance that a communication o f this desire for instruction to the dean of the Medical School of the University of Tennessee has resulted in a plan to arrange for clinics for colored physicians in maternal and infant care. Many of the patients admitted to the Memphis General Hospital as emergency cases are of the group whose only opportunity for care lies through public provision. They will have to be reached and educated by the public-health nurses and persuaded to go to the clinic for prenatal medical supervision. This means an increased public health nursing staff and more prenatal-clinic facilities. For it must be pointed out that although there has apparently been some improvement in the quality and an increase in the quantity o f prenatal care, this has been accom plished almost entirely by an increased case load on the part of the nurses and the clinic which appears to have overreached their capacities. Undoubtedly more maternal and infant lives among the present group of patients could be saved if the nurses had more time for educational work, both at home and at the clinic, and for necessary follow-up of clinic cases and if there were opportunity at the clinic for more careful medical supervision. Such supervision is important for all patients for the early detection and prompt treatment of the toxemias of pregnancy, and espe https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis N E O N A T A L M ORTALITY 55 dally important for those patients receiving antisyphilitic treatment. Undoubtedly, too, although only cases apparently free from complications are chosen for the home-delivery service, there would be much better results in this service if there were direct medical supervision of the medical students conducting deliveries, and if patients having complica tions such as postpartum hemorrhages received at least emergency treat ment in the home whenever possible before being subjected to the addi tional shock of transfer to the hospital when such transfer is indicated. This supervision should include the care of the newborn baby in the home. Apart from other considerations, sound policy dictates the need for such direct medical supervision. With regard to the possibility that more adequate provision for artificial resuscitation of the newborn and for the care of the premature might reduce the death rate from natal and prenatal causes, it was the impression of the writer that these matters needed more careful study, but did offer a field for endeavor in Memphis, as practically everywhere at the present time, through which some saving of life in early infancy might be effected. Conditions Apparently Associated With High Neonatal Death Rate From Other Than Natal and Prenatal Causes It is the deaths between the first week and the first month of life and from other than natal and prenatal causes which account for the large increase in the neonatal death rate in 1933 and 1934 over previous years. (Charts 4 and 5, pp. 7-8. See also tables 2 and 3, pp. 81-82.) Most of the deaths of infants 1 week to 1 month of age in 1933 and 1934 oc curred at the Memphis General Hospital and were those of infants who were born there and remained there until death. A few were of infants who were born at home under the home-delivery service of the Memphis General Hospital and were taken to the hospital immediately after birth, either with the mother who was hospitalized for one reason or another or because of the condition of the child. A few were admitted to the hospital a short time before death, having become ill at home. A few had been discharged from the hospital and readmitted in serious con dition, usually shortly after discharge. M ost of these deaths of infants from 1 week to 1 month o f age were due to infections— variously diagnosed as respiratory, gastrointestinal, and unknown— the majority apparently from an epidemic which occurred to a limited degree in St. Joseph’ s Hospital in 1933 and to a large degree in both 1933 and 1934 in the new born wards of the Memphis General Hospital. At St. Joseph’s Hospital in 1933, the recognition of an epidemic among the newborn, though the cause was not determined, was met by closing the obstetric and newborn wards for a time and establishing the service https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 56 IN F A N T M ORTALITY IN MEMPHIS in a different section of the building. This resulted in the prompt subsidence of the excess of deaths of the newborn after the first week of life from acute infections. Inadequacy of isolation facilities in the maternity and newborn wards of the Memphis General Hospital. At the Memphis General Hospital during a similar epidemic it was not thought possible to close the wards, although every effort was made to isolate patients. The dearth of running water in convenient places in both the wards in which maternity patients are cared for and those in which the newborn are housed in the Memphis General Hospital must be considered a factor of great importance in this connection. It seems likely that some infections were transmitted as a result of the frequent inability of the nurses to wash their hands thoroughly when they went from one patient to another. It is apparent that the increase in the number of births at the Memphis General Hospital has resulted in serious overcrowding in the maternity wards and in the nurseries for the newborn, and in overloading of the nursing staff as well. The obstetric and pediatric staffs and the nursing staff of the hospital recognize most keenly the need for more space and more nursing personnel. Facilities for the proper isolation of infected women on the maternity service, as well as washing facilities, are inade quate. The same nurses take care of infected and noninfected patients. The delivery-room nurses do no nursing on the ward, but they admit all patients, some of whom are infected. The wards are frequently much overcrowded,, particularly for 2-week periods four times a year when patients who at other times would be scheduled for home delivery by medical students are brought into the hospital for delivery. Although the mortality among the prenatal-clinic patients is relatively low, the mortality among the so-called nonclinic patients in the hos pital is extremely high, and many of these women have infections. Every woman who is pregnant is admitted to the obstetric ward, and the case is later referred elsewhere for treatment if indicated— abortions, surgical cases, and infections such as pneumonia and typhoid. Efforts are made to isolate infections, but the same nurses take care of the in fected cases and the noninfected cases delivered on the ward. At the time of the writer’s visit to the hospital there was in the ward a prenatal patient with a breast abscess, which had been opened and drained; also a patient who had been admitted 2 weeks postpartum with multiple abscesses. The case records of maternal deaths in the annual reports of the Memphis General Hospital obstetric service contain a few examples of infections without adequate explanation. It may well be that con ditions just described afford such an explanation. The newborn nursing service is separate from the obstetric service but in neighboring quarters, and the possibility of cross infections must be https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NE O N ATA L M ORTALITY 57 borne in mind. But apart from this, washing facilities are inadequate, A and the space is entirely inadequate for the isolation of infected infants. Space and nursing facilities for isolation and treatment of such infections are absolutely essential. Facilities for the care of the premature are also inadequate, and many premature infants die from infections. Provision of more adequate facilities, therefore, for isolation of infected maternity cases and for the protection of the newborn from infections is the outstanding need at the Memphis General Hospital. Social problems. In 1934, for which period brief case histories of all infant deaths are available, a certain number of infants became ill from infections shortly after they went home, and died in the first month of life either at home or on readmission to the hospital. This points to the great importance of a closer tie-up between the hospital and the public-health nurses, so that home-nursing visits are made immediately and the mothers given instruc tion in caring for the babies. This situation also suggests the importance of adequate social-service facilities, coordinated with the public health nursing service, for aid in providing the minimum requirements for a wholesome home environment for mothers and newborn babies in need of such aid. Again, examples of babies under 1 month of age becoming very ill at home and dying either there or at the hospital soon after admission, who have had no nursing visits for a relatively long period, indicate the need of informing families as to the services which the nurse can offer and instructing them clearly how to get in touch with her early. 6 4 5 3 5 ° — 3 7 -------- 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Mortality in the Second to Twelfth Month and Associated Phenomena Although it is obvious that the outstanding problem in Memphis is the neonatal one which has just been discussed, the death rate among infants from the second to the twelfth month of age offers a fertile field for improvement. For this period of life the deaths of infants not born in Memphis form a large proportion of the total deaths, particularly among the white infants. In 1934 there were only four infants— two colored and two white— dying in the second to the twelfth month of life who had been born in Memphis of nonresident mothers and had remained there until death; all other infants of nonresident mothers dying in the second to the twelfth month had come from outside the city. Of the total deaths in the second to the twelfth month of life in 1934, 37 percent were of infants born outside the city— 53 percent of the white and 21 percent of the colored. (Chart 21. See also table 17, p. 90.) But in spite of the relatively high proportion of deaths of infants born outside the city the death rate among infants of resident mothers; particularly the colored, is high for this age period. Where Infants of Nonresident Mothers Died in the Second to the Twelfth Month Inasmuch as the deaths of infants of nonresident mothers from the second to the twelfth month of life are almost entirely those of infants who come from outside the city for care because of illness, the question of importance in relation to this group is whether their deaths are the result of inadequate care in Memphis. All the deaths of white infants in this group in 1934 and 20 out of 24 deaths of the colored in 1934 occurred in hospitals. (See table 39, p. 101.) The kind of care to be considered, therefore, relates, for all practical purposes, to hospital care. A study of available information as to deaths of these nonresidents in 1934 makes it evident that for the large majority Memphis had practically no oppor tunity to give care in time, for they came in desperately ill— in many instances moribund— and died shortly after admission to the hospital, 58 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M ORTALITY IN THE SECOND TO T W E L FTH MONTH 59 Where Infants of Resident Mothers Died in the Second to the Twelfth Month In 1934 almost two-thirds of the deaths in the second to the twelfth month of infants of resident mothers occurred in hospitals, a slightly higher proportion of the white than of the colored. (See table 39, p. 101.) Again, 21 out of 43 white resident deaths and 47 out of 79 colored resi dent deaths occurred in the Memphis General Hospital— evidence, as for the neonatal deaths, that a very large proportion were among infants needing free care. Of the colored infants who had died at home more than half had been delivered by the Memphis General Hospital obstetric service, so that the proportion of colored infants needing public care was even larger than is indicated by the Memphis General Hospital deaths. Among white infants who had died at home the same is true, although not to the same degree as for the colored. Causes of Mortality in the Second to the Twelfth Month The respiratory diseases take the highest toll among the infants of resident mothers in Memphis during this period of the first year. (Charts 17—19. See also table 13, p. 87.) They account for approximately one-third of the mortality in the second to the twelfth month among both colored and white. The death rate from them is two and one-half times as high among the colored as among the white. The greatest opportunity therefore, for reducing the mortality in this period of the first year lies in control of respiratory diseases. In connection with the excessively high death rate from respiratory diseases among the colored infants, the possibility of tuberculosis as an important underlying cause must be borne in mind, in view of its very high incidence among the colored population in Memphis. Mortality from gastrointestinal diseases forms a relatively small pro portion of the mortality among resident infants, but these diseases are largely preventable causes of death. Deaths from natal and prenatal causes during this period include deaths from congenital syphilis, which are in large part preventable. A striking finding with regard to the resident infants who died in 1934 was the very large proportion of colored babies who had been entirely breast fed. Many of them were babies old enough to have had the neces sary vitamin-rich foods, such as orange or tomato juice and cod-liver oil— and additional foods, such as cereals and vegetable broths. One wonders to what degree they received these foods. One wonders also about the quality of the breast milk. In other words, was there an underlying nutritional inadequacy among many of these colored breast fed infants who died of respiratory diseases, which lowered their resistance to infection? https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 60 IN FA N T M ORTALITY IN MEMPHIS The relatively large number of infants dying in the second to the twelfth month whose mothers had syphilis— infants whose deaths were attributed to other causes than syphilis— suggests the importance of more intensive observation and treatment of young babies for syphilis, and brings up again the need for more adequate facilities for this purpose. Public Facilities for Care of Infants The high incidence of deaths in the second to the twelfth month among those receiving public medical care is evidence that adequate public facilities for the prevention o f disease and the care of sick infants are of primary importance in reducing the death rate during this period of the first year, as they are in the neonatal period. The first question for consideration in this connection therefore concerns the nature and adequacy of such facilities in Memphis. Child-health centers. Child-health clinics, conferences, or centers are the means by which communities have endeavored to provide facilities for medical super vision of babies and preschool children for those who cannot afford to get such supervision privately, in order to promote normal growth and development and so far as possible to prevent disease and unnecessary deaths. Indeed, some communities have considered child-health con ferences so essentially educational in nature that they have put no finan cial limitations on the people who might attend them but have considered the conferences a public activity for the public good analogous to the public schools. Such clinics or conferences should be under medical direction, preferably that of a physician specializing in pediatrics, with nursing assistance in the actual running of the clinic and for what is generally called follow-up— the interpretation of the doctor’s advice to the mother and giving her what practical assistance is necessary in teaching her how to carry it out. Child-health centers in Memphis until 1929 were limited to the Mem phis General Hospital, where three such conferences are held each week— one a so-called 6-weeks clinic, where mothers come for postpartum exami nation for themselves and their babies; the other two, a colored and a white well-baby clinic. These conferences were organized by the depart ment of health about 1922, and both medical supervision and nursing service for them have continued under that department. N o other child-health center for white children existed in the city until 1929, when one was established at the Baptist Good Will Home. In 1932 the Regina Health Center and a center at the Jewish Neighborhood House were established. In 1934 a center in the Highland district, and in 1935 one in Hollywood and one in the Gaston center were set up. These neighborhood health centers have developed largely through the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M ORTALITY IN THE SECOND TO TW E L FTH MONTH 61 leadership of the health department under the sponsorship and with the cooperation of various community groups. They now number six in addition to the one at the Memphis General Hospital. Private physi cians give voluntary service at all these centers except Hollywood and the Memphis General Hospital, where they are staffed by a physician employed on part time by the health department. The health-depart ment public-health nurses of the districts in which the centers exist furnish the nursing service for these conferences. The following state ment, issued by the city health department, describes the policies and organization of the centers for white children: Child-welfare clinics are educational and intended to provide periodic medical supervision and immunization against the preventable diseases (diphtheria and smallpox) for infants and preschool children whose parents are unable to pay for the services of a private doctor. For children under 6 years of age only. Sick children are not admitted. No prescriptions written, medicines or treatments given. Sick children are referred to family doctor or in indigent families to Memphis General Hospital or its out-patient department. The cooperating agency is expected to assume responsibility for the following: The services of an adequate staff of physicians, preferably one a pediatrician. (Not more than four, each to serve once a month.) The clinic space and its equipment which can be very simple, inexpensive, and home-made as an educational demonstration. At least one lay worker who will help with records, act as hostess, etc. Clinic to be held same day and hour once each week in the early afternoon, if possible. The health department will assume responsibility for the following: Follow-up work in the homes. Clinic records. Medical supplies and immunization material. The services of a publi<?-health nurse at each clinic. The duties of the nurse will be assisting the doctor, giving group instruction to mothers on problems of infant and child hygiene; interpreting the doctor’ s orders and instructions to the parents. Since 1930 five additional centers for colored babies have been estab lished— one at a community center, the other four at public schools. Colored physicians who volunteer their services for these centers spend at least six consecutive clinic sessions at the colored well-baby clinic of the Memphis General Hospital. Recently the colored well-baby clinic at the Community Center has been taken over by the physician employed by the health department, who conducts the Memphis General Hospital and the Hollywood center. The visits to these permanent colored clinics (exclusive of the six weekly well-baby clinics at the Memphis General Hospital) have grown from 269 in 1932 to 4,702 in 1934. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 62 IN F A N T M O R T A L IT Y IN M E M P H IS The response of both white and colored parents to the establishment of these permanent centers is indicated by the growth in the number of visits to them. At the well-baby clinics of the Memphis General Hos pital the number of visits has increased from 891 in 1929 to 2,615 in 1934; at the other well-baby clinics the number of visits has grown from 520 in 1929 to 6,778 in 1934. (These include some preschool children, but the largest proportion are infants.) Home visits by health-department nurses for health supervision of infants. The public health nursing service of the Memphis Department of Health has devoted a considerable proportion of its time to home visits for health supervision to babies in Memphis. Such visits began in 1921 with 120 visits; by 1925 they reached 6,202; in 1926, 20,164; in 1929, 21,916; in 1930, 24,211. Since then there has been a gradual yearly in crease so that 27,021 visits were reported in 1934. Facilities for medical care for sick infants in families unable to afford private care. Medical care for sick babies whose parents cannot afford private care is provided by the Memphis General Hospital and the University of Tennessee Medical School; nursing care for sick babies in their homes is given by the health-department public-health nurses, who give a limited amount of bedside care to the sick as part of their generalized nursing program. The Metropolitan Life Insurance Co. nurses also give bedside nursing care to sick babies who are insured with the company. That the health educational work of the public-health nurses in the home, the supervision o f well babies at the well-baby clinics, and the care given sick babies in the Memphis General Hospital and its out patient department have been important influences in reducing the death rate from the second to the twelfth month admits of little doubt. The question may well be asked why the reduction in the infant death rate during this period of the first year has not been greater. • Limitations to the Effectiveness of Infant-Health Supervision in Memphis It is quite apparent that although the development of neighborhood child-health centers since 1929 represents a very important forward step, these centers as at present organized are limited in their effectiveness. This fact makes it impossible to judge whether the number is adequate. In the first place, in a number of them four physicians volunteer their services and rotate so that each physician serves only 1 week in a month. Although an effort is made to have patients see the same physician, once a month is frequently too long an interval for effective supervision, partic ularly in the first 6 months. Again, the effectiveness of the centers is limited by the fact that there is no coordination of the medical services in the different centers, with the opportunity which such coordination https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M ORTALITY IN THE SECOND TO T W E L FTH MONTH 63 would provide for regular staff conferences to discuss common prob lems and ways and means of meeting them, and to develop standards of procedure. In most of the centers, too, an excellent opportunity for group educa tion through posters, demonstrations, and other means is missed because, the space used being available only for the time of the conference, equip ment cannot be set up. This is particularly true of the colored centers. The public-health nurses apparently make an adequate number of home visits to infants under a year, according to the appraisal-form standards of the American Public Health Association. One wonders about the quality o f some o f the visits, in view of the lack of a specialized nursing supervisor for child health and of specialized medical super vision. The supervisor of the public-health nurses was of the opinion that the nurses greatly needed both specialized nursing supervision and medical supervision, particularly the latter. Inadequacies in Provision for Care of Sick Infants The in-patient pediatric service o f the Memphis General Hospital cares for sick infants whose parents cannot afford private care. It is housed in a separate well-built and well-equipped building. The isola tion unit of the Memphis General Hospital is equipped to care for children with communicable diseases. The only obvious improvement in equipment which seemed indicated was the provision of additional cubicles, particularly for children after the initial isolation period, so that the chances of cross infections might be minimized. The desirabil ity, too, of a hospital situated in the suburbs to which children could be sent for convalescence merits serious consideration. It would lessen the time o f children in the hospital and would also send them home in much better general condition. The care o f sick infants, particularly infants not seriously ill who do not need hospital care, presents a serious problem in Memphis. All preventive efforts stress attention to early symptoms of disease in order to prevent serious illness and death; ^et the pediatric out-patient depart ment o f the Memphis General Hospital is the only institution in the city caring for such infants, and it is open only 3 days a week. There are no facilities for medical care for babies who are ill on other days unless they need hospital care, in which case they can be taken directly to the re ceiving ward of the hospital. Social problems. Again, as was stated early in this report, it must be borne in mind that neither health services for the prevention of disease nor medical services for its treatment can function efficiently if underlying basic necessities of living are lacking or inadequate. Conferences with the district nurses regarding the problems they met in the families visited left an https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 64 IN FA N T M ORTALITY IN MEMPHIS impression of great want, particularly among the colored. The nurses especially pointed out families in frequent need of milk, ice, fuel, and nursing bottles, and of car fare for visits to the clinic. They also pointed out the need for educating families as to methods of spending their income to the best nutritional advantage. Many of the colored mothers worked out, and the babies were left during the day to be cared for by older sisters and brothers— themselves but children. Obviously to meet such a situation various measures are necessary, including development of more adequate relief, permitting mothers of infants to remain at home, and some simple training of older girls and boys in the essentials of infant care— something analogous to little mothers’ clubs. The nurses stated that needs of families on relief were reported to the emergency relief offices but that they were not always met. The emergency relief executive in an interview showed appreciation of the need, but explained her dependence largely on appropriations from State and Federal governments and the obvious necessity of keeping relief within the funds available. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Special Groups in Memphis in Relation to Infant Mortality Infants of Unmarried Mothers Infant-mortality studies have shown that the mortality of infants of unmarried mothers is generally very much higher than that of other infants.13 The death rate among this group, however, has been very much reduced in those places where social measures have been adopted for the protection of mothers and infants under conditions which assure the kind of care young infants need, and where recognized standards of care have been set up and carried out for those infants who for various reasons have not been kept with their mothers. The three maternity homes in Memphis caring for white unmarried mothers— the Bethany, the Beulah, and the Ella Oliver— submitted records of 196 births in 1933 and 1934. The number of infants born to girls staying at these maternity homes does not, however, represent the total number of births to unmarried mothers in Memphis* as a number are cared for privately. Statistics showing the total number are not available at the present time. Many of the unmarried mothers who seek refuge in Memphis are nonresidents. The girls at the Bethany and Beulah homes are taken to the prenatal clinic of the Memphis General Hospital for prenatal supervision and to the Memphis General Hospital for delivery. The girls at the Ella Oliver Home are delivered there, as it has its own delivery rooms and equipment. Any physician chosen by the girl may deliver her at the home. In practice, most of the deliveries are done by one physician. There were no maternal deaths of girls under the care of these homes in 1933 and 1934. The Bethany reported the loss of a large number of infants in 1933-34 in the “ epidemic” at the Memphis General Hospital. The number of deaths of infants reported by these homes obviously does not necessarily give a complete picture because of the varying length of time the infants are kept at the homes. A number of years ago the mater nity homes agreed, at the request of the health department, to keep mothers and infants together in the maternity homes for at least 3 months, whenever this was possible. In practice this is not generally done. At 13 See Causal Factors in Infant Mortality, p. 181 (U. S. Children’s Bureau Publication N o. 142, Washington, 1925). 65 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 66 IN FA N T M ORTALITY IN MEMPHIS the Beulah Home it was stated that although an effort was made to keep the girls for 6 months, most of the infants are placed with the Tennessee > Children’ s Home Society— usually at 3 to 6 weeks of age. At the Ella Oliver Home it was stated that the girls usually stay about 1 month after delivery, but that their infants are generally placed with the Tennessee Children’ s Home Society before the mothers leave. At the Bethany Home the superintendent stated that they try to keep mothers and infants together for 3 months for breast feeding but that it often does not work out that way. The Tennessee Children’s Home Society accepts on court commitment or on parental surrender dependent and neglected children not above the age of 7 years for placement for adoption. Pending such placement it cares for children in boarding homes. Supposedly only children physically and mentally sound and eligible for adoption come within the program of the organization, but in practice any child under the age specified may be received at least for care pending decision as to eligibility for placement. The organization has an agreement with the Memphis Family Welfare Society and the Memphis Children’ s Bureau that when children are found not placeable in free family homes, they can be turned over to these organizations for care. Often the Tennessee Children’ s Home Society works out a plan with relatives or with institutions for the care of such children. Most of the infants taken over by the Tennessee Children’ s Home Society are children of unmarried mothers. An illegitimate child can be transferred to the society by his mother, who, if she is of age, can sign a surrender of the infant which gives the organization legal custody. Sur renders by girls who are minors must be approved by the court. Infants from outside Shelby County (unless the parents are living in Shelby County at the time of surrender) are transferred to the Nashville Re ceiving Home of the society. Infants kept under the direction of the Memphis branch are those who are born in Shelby County or whose parents are living there at the time of surrender. Many of these are nonresident girls who come to Memphis for delivery. Because of the large number of infections in the newborn ward of the Memphis General Hospital, the executive of the Tennessee Children’ s Home Society stated that she preferred to receive the infants who were born there early, before they developed thrush or some other infection. Many of the mothers apparently sign their infants away before birth, and when this is done the Tennessee Children’ s Home Society is free to take the infant when it chooses. This organization has a number of boarding homes in which it places the infants under its care. Those for very young infants were said to be homes of graduate nurses. One pediatrician supervises the feeding for mulas in most cases, and a number of other physicians are on call for sick- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SPECIAL GROUPS IN RELATION TO IN F A N T M ORTALITY 67 ness. On July 2, 1935, the executive of the society in Memphis stated that no infant had died since the beginning of the calendar year. There is in Memphis a social agency devoting itself to problem girls of 16 to 25 years of age— the Church Mission of Help. Most of its cases are unmarried mothers. It attempts to work out with the girl and her infant a plan best suited to the individual. An effort is made not to dispose of the infant permanently for a year, either by having the mother keep the infant or by making arrangements for its temporary care if the mother cannot care for it, so that the mother may have an opportunity to demonstrate her ability to care for the child. If this is done, the agency continues to put in relief if necessary to keep mother and infant together. There were periods, however, in 1933 when the community fund was practically bankrupt, in which relief could not be gotten for this purpose, and it was necessary to put children in institutions and to release them for adoption when otherwise they might have been kept with their mothers. Of 87 infants born alive to unmarried mothers, who were under the care of the Church Mission of Help in 1933 and 1934, 23 had died, 28 were living with their mothers, 1 was with relatives, and 22 were adopted. The rest were temporarily in the well-baby nursery at the Memphis General Hospital, or in boarding homes or orphanages. Many unmarried mothers receive no help whatever from a social agency. For example, the Bethany Home is the only one of the three maternity homes which attempts social case work with the girls who come to it for care. This is done through the Church Mission of Help, to which all cases admitted to the Bethany Home are referred, except those sent in by the Travelers Aid, which handles dependency cases of nonresidents. The experience of a few States has demonstrated that the best method of assuring that all unmarried mothers are given the assistance that they need in planning for and caring for their children is to make it the duty of a public department, preferably of a county welfare department with responsibility for public services for children, to see that such services are available in all cases. The problem of the care of unmarried mothers and their infants is obviously not an isolated local one in Memphis but one which needs to be approached from the point of view of State planning and legislation. Memphis might well provide the leadership for such planning and legislation in Tennessee. The first and most urgent need is that maternity hospitals, institutions, and boarding homes for infants be licensed and supervised by a public agency, which should help to develop adequate standards of care. Tennessee has laws which authorize licensing and supervision of institu tions caring for children by the State department of institutions and licensing of maternity hospitals by the secretary of state on the recom- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 68 IN F A N T M O R T A L IT Y IN M E M P H IS mendation of the State department of institutions, but the State is not providing staff for these purposes. There is no legal provision for the licensing of boarding homes for infants. During the time when there was a medical director of maternal and child health in the Memphis Department of Health, boarding homes were systematically inspected; there was no specific legal authority for such inspection, however, and inspection has lapsed since the resignation of the director of that service in 1928. Infants in Institutions Orphanages. There are few infants cared for at the two orphanages in Memphis— the Porter Home and Leath Orphanage and St. Peter’ s. These seem to play no role in the high infant mortality rate of Memphis. Well-baby nursery at the Memphis General Hospital. The so-called well-baby nursery at the Memphis General Hospital is a small ward in the pediatric hospital, which cares only for well infants. Every effort is made to protect the infants from infections and to pro mote normal growth through supervised feeding and individual attention and “ mothering.” When it was first established a number of infants placed in it died from respiratory infections. Since then, however, there has apparently been much improvement in the care of infants there. The Church Mission of Help reports that it places many infants there for temporary care with excellent results. At the present time this nursery cannot be said to be contributing to the high infant mortality of the city, but there seems to be a real question as to the advisability of keeping well infants in a hospital— even though they are in a ward of their own. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Summary General considerations. Infant mortality in Memphis, high in 1927 compared with that of other cities of its size, has shown an upward trend since then. This upward trend has been largely the result of a marked increase in neonatal mortality among both white and colored infants. There has also been an upward trend in mortality in the second to the twelfth month among white infants. Although the mortality in the second to the twelfth month among colored infants has shown mainly variability with a slight down ward trend since 1930, the rate among them for this period of the first year in 1934 was higher than that among colored infants in most com parable cities. The increase in neonatal mortality has been shown to be associated to a small degree with increase in mortality from natal and prenatal causes, to a greater degree with a large increase in mortality from other than natal and prenatal causes, which was especially marked in 1933 and 1934 as compared with previous years. The neonatal mortality of infants of resident mothers was not significantly different from the crude neonatal mortality in the years 1930-32 combined or in 1934. The high crude mortality in the second to twelfth month period among whitednfants is apparently associated with the large number of deaths of nonresident white infants which occur in Memphis, for the resident mor tality among white infants surviving the first month was significantly lower than the crude mortality among such infants, both in the 1930-32 period and in 1934. Deaths of nonresident white infants from gastro intestinal diseases apparently play a predominant role in the high crude mortality of this period of the first year among white infants. The maternal and child-health program under specialized medical direction, which had been started in Memphis in 1921, apparently was a factor in the declining infant mortality of Memphis previous to 1928. Since 1928 specialized medical supervision has been lacking. Moreover, although in 1929 the available clinic and nursing services were considered by the American Public Health Association inadequate to meet the needs of a city with unusually high maternal and infant death rates, the needs of Memphis for expanded facilities were greatly increased by the annexa tion of a large territory at the end of 1929, which brought with it higher infant mortality than the old city. In addition, the depression has increased the need for health services in Memphis, as elsewhere. More over, it seems clear that social services in Memphis have not been able to meet the needs of many families for basic necessities, without which health services cannot function effectively. 69 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 70 IN FA N T M ORTALITY IN MEMPHIS Neonatal mortality and associated phenomena. Although neonatal mortality is relatively high among all groups in Memphis, the major problem in relation to neonatal mortality there lies with the group receiving public care. This care is provided cooperatively by the public health nursing division of the Memphis Department of Health, the Memphis General Hospital, and the University of Tennessee Medical School. Since 1930 the number of patients cared for by the Memphis General Hospital obstetric service in both its in-patient and its out-patient delivery service has increased appreciably. In 1934 it cared for 21 percent of the white infants born alive in the city and for 83 percent of the colored infants born alive. Although there has been no increase in personnel, there has been a large increase in the volume of prenatal care given as shown by attendance at the prenatal clinic of the Memphis General Hospital and by home-nursing visits made by the department of health nurses. The prenatal and natal care given by the health-department public health nursing service and the Memphis General Hospital obstetric service seems to have been an important factor in at least holding down the maternal mortality and reducing the stillbirth mortality and mortality among infants under 1 day of age, particularly among the colored. The group of women not receiving prenatal care from this service but delivered by it or admitted to the hospital shortly after delivery, although very small, had an extremely high maternal mortality and a high stillbirth mortality and incidence of premature births compared with those who had had prenatal care. However, the mortality in the first month of life from prenatal and natal causes (which include practically all the deaths in the first day) has increased. Improved prenatal care, both quantitative and qualitative, may be expected to decrease this mortality through more regular and intensive treatment of prenatal syphilis, more attention to the nutrition of the pregnant women, and more adequate supervision of the toxemias. Better postnatal care of the infant— particularly of the newborn, to prevent deaths from asphyxia, and of the premature— also offers hope for reduction in mortality from natal and prenatal causes. The high mortality among infants from 1 week to 1 month of age and from other than natal and prenatal causes in the first month in 1933 and 1934— due mostly to infections— was associated largely with deaths which occurred at the Memphis General Hospital and for the most part deaths of infants who were born there and remained there until death. In 1933 St. Joseph’ s Hospital had a relatively large number of deaths during this period of the first month, but the recognition of their cause as infections resulted in the temporary closing of the obstetric and newborn wards and a subsidence of the epidemic. With the increase in the number of maternity cases hospitalized at the Memphis General Hospital, there has been no comparable increase in space in the maternity and newborn wards of the hospital. Insufficient https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUM M ARY 71 facilities for adequate isolation of infections among cases in the maternity and newborn services seem to account for failure to control an epidemic at the Memphis General Hospital similar to the one at St. Joseph’ s Hospital and for the marked increase in 1933 and 1934 in neonatal mortality in Memphis from other than natal and prenatal causes. Mortality in the second to twelfth m onth and associated phenomena. A large proportion of the mortality in the second to the twelfth month in Memphis, particularly among white infants, is due to the deaths of nonresident infants. Most of these infants die in the hospitals in Memphis. In 1934 a large majority of them were brought in desperately ill— frequently moribund— and died shortly after admission to the hospitals. Mortality among resident infants in Memphis in the second to the twelfth month is largely among the group needing free care. The most outstanding problem in this period is the high mortality from respiratory diseases among the colored. The possibility of syphilis as an under lying factor in many of the respiratory deaths must be borne in mind in view of its high incidence among the mothers of the infants who died, as also must the possibility o f nutritional deficiencies and of tubercu losis. The prevention of gastrointestinal diseases and more attention to and treatment o f congenital syphilis as such offer further opportunity for reducing the mortality from gastrointestinal diseases and natal and prenatal causes in this period of the first year. Neighborhood child-health centers, which have been developed since 1929 to supplement the centers previously established at the Memphis General Hospital, represent an important advance in the protection of infant health in Memphis, but many of them are limited in their effec tiveness by the lack of continuity of medical supervision and lack in many instances of facilities and equipment for educational work with parents. The public-health nurses of the health department make a relatively large number of home visits for infant-health supervision. The desira bility of improving the quality of this supervision through the provision of a specialized nursing supervisor for child health seems evident. Facilities for hospitalizing at the Memphis General Hospital sick infants who cannot have private medical care seem reasonably adequate, but there is serious need for the provision of facilities for medical care in the early stages of illness. The pediatric out-patient department of the Memphis General Hospital, which is the only place where ambulant cases who cannot afford private care can get treatment, is open only 3 days a week. The lack in the homes of such basic needs in the care of infants as milk, ice, fuel, and nursing bottles, the frequent lack of carfare for clinic visits, and the fact that many infants, particularly among the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 72 IN FA N T M ORTALITY IN MEMPHIS colored, must be left at home during the day by working mothers, to be cared for as best they can by brothers and sisters, indicate the importance of considering ways and means of meeting the serious social problems which affect the care and the health of babies. Special groups in relation to infant mortality. For the unmarried mothers who seek care in Memphis for themselves and their infants, there appears to be real need for the development of a constructive social program under State leadership. Pending the development of an adequate program, which would necessarily include provision for both social and health aspects of the problem, the authority to license and supervise local maternity homes and hospitals and insti tutions and boarding homes for infants from the point of view o f health should be given the local health department by city ordinance. Ulti mately supervisory authority should be vested in State agencies. The care of infants in orphanages seems to play no role in the Memphis infant-mortality situation, nor at the present time does the care of well babies at the so-called well-baby nursery of the Memphis General Hospital. It seems inadvisable, however, as a matter of policy, to care for well babies in a hospital. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Recommendations It is apparent from this brief investigation that a more detailed and probably a continuing study over a period of years is necessary as a basis for evaluating the various factors which may be influencing the infant mortality rate at a given time, and also as a basis for the develop ment of a well-rounded effective program for preventing unnecessary infant deaths. Because of the relatively high proportion of births in Memphis to nonresident mothers and of deaths of nonresident infants there, and because of the large number of unmarried mothers who come to Memphis for care, the study should include— for a time at least— all births in the city and probably also all nonresident sick infants who are brought in to Memphis for care, as well as those who die. It should include a study of maternal care as well as the care of the newborn at least in all the hospitals in the city. It should include a few basic eco nomic and social items as well as health and medical ones. Such a study would best be part of the activities of the health department with the coop eration of the medical profession, the hospitals, and the social agencies. This brief investigation has shown clearly, however, the need for specialized medical supervision of maternal and child-health activi ties to coordinate the work in the city, to direct the continuing study, and to develop an adequate program for maternal and child health in Memphis, which would include both educational health measures aimed at prevention and adequate provision for the care of the sick. Such a program should be developed with the cooperation of medical and public health nursing groups, health and social agencies, and the general public.14 In addition, certain recommendations as to concrete measures to be taken immediately in the development of the maternal and childhealth program can be made as a result of the findings of this investi gation. They are: 1. The immediate provision of more space and facilities in the maternity pavilion of the Memphis General Hospital, particu larly for the care of the newborn. 2. The provision of medical supervision for individual cases on the home-delivery service of the Memphis General Hospital. The entire dependence of the home-delivery service of the Memphis General Hospital and the health department on medical students of the University of Tennessee is a situation which should be remedied. Among other things such direct medical supervision, would eliminate by making unnecessary the periodic great overcrowding at the hospital which occurs 14A director o f maternal and infant hygiene in the Memphis Department.of Health was appointed in the summer o f 1935. 64535°— 37----- -6 73 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 74 IN FA N T M ORTALITY IN MEMPHIS when the patients scheduled for home delivery by medical students are brought to the hospital during periods when the students are not available. The cost of such medical super vision might well not exceed the cost of hospitalization. 3. The development of much closer working relationships between the hospital, the public-health nurses, and the social agencies in order that the basic minimum needs of mothers and infants not otherwise provided for may be met promptly. If community funds are inadequate for the provision of workers and the meeting of minimum material needs this should be pointed out to the public so that an effort can be made to meet the situation constructively. 4. The provision of some form of medical care in their own homes, in daily clinics, and by public physicians for those infants not seriously ill whose families cannot afford private care. 5. The provision of more permanent quarters for childhealth centers, so that they can be really educational in the larger sense; the provision of more continuity in medical super vision of these centers, preferably through payment of pedi atricians for their services. The medical as well as the nursing service for these centers should be under the jurisdiction of the health department. 6. The provision of more prenatal-clinic sessions. 7. The provision of more adequate facilities for the treatment of syphilis. 8. The legal authorization of the health department to license and supervise maternity homes, institutions, and boarding homes for infants. There seems little doubt that the various needs which have been pointed out can gradually be met in Memphis through the coordination and development, and in some cases the expansion, of already existing agencies. Some recommendations can and should be carried out imme diately; others should follow the most careful consideration of what would be the best plan in the light of the specific problems and the resources in Memphis. Because of the close interrelation between the services of the health department, the Memphis General Hospital, and the University of Tennessee, it seems especially desirable, indeed neces sary, that these three agencies seek together to plan for the best method by which the necessary increased health and medical services for mothers and babies may be provided. It seems also necessary and desirable that the medical profession as a whole, the community social agencies, and representatives of important lay groups be brought to counsel together so that there may be intelligent understanding of the need and public sup port for what may be necessarily increased expenditures to meet it. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 'm - f R E C O M M E N D A T IO N S 75 Recommendations as to Memphis Department of Health activities. The first step indicated is the appointment of a director of maternal and child health— one with special training and interest in pediatrics, obstetrics, and child health 16— whose function will be to study continu ously and to point out conditions inimical to the health of mothers and babies and to develop, with the cooperation of other branches of the health department, the medical and nursing professions, the hospitals, the social agencies, and the public, ways and means of remedying them through a well-rounded program of maternal and child health, adapted to specific needs in Memphis. A budget adequate to develop such a program should be provided. Such a program would include: 1. The development of an adequate number of permanent prenatal and child-health centers with facilities and equipment for educational work with parents at these centers, and with continuity of medical supervision. 2. The gradual expansion of the public health nursing service, with the provision of specialized nursing supervision for maternal and child health. 3. The development of increased facilities for the treatment of syphilis, particularly among pregnant women and among children. 4. The development of nutrition work, particularly among low-income families, who need help in learning how to spend their money for food to the best advantage. 5. The authorization of the health department by city ordinance to license and supervise maternity homes and institutions and boarding homes for infants. Recommendations as to the Memphis General Hospital. 1. More adequate space and facilities in the maternity pavilion for maternity cases and for the care of the newborn, with special considera tion of the need for adequate isolation facilities both in the wards caring for maternity patients and in those caring for newborn infants. Special provision for the care of premature infants is essential. There is imme diate need for hot and cold running water in convenient places, in both the newborn and maternal sections, in order that nurses may and will wash their hands before going from one patient to another. 2. More cubicles in the pediatric section would be advantageous. 3. When feasible, the question of a convalescent children’s hospital should be given serious consideration. 4. The well-baby ward of the hospital should be abolished. Recommendations as to cooperative activities of the Memphis Department of Health, the Memphis General Hospital, and the University of Tennessee Medical School. 1. The close cooperation which has always existed between the city health department and the hospital in the maintenance of the prenatal 18 Such an appointment has been made. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 76 IN F A N T M O R T A L IT Y IN M E M P H IS and 6-weeks postpartum clinics and the well-baby clinics through the attendance of the public-health nurses at the clinics is very desirable. The public-health nurses, however, should not have complete responsi bility for running the prenatal clinics; hospital nurses should be provided for this, so that the time of the public-health nurses can be spent in educational activities with the patients. A t the present time the me chanics of managing the clinics absorbs all the time of the public-health nurses assigned to them. 2. Crowded prenatal-clinic sessions and the need for more sessions have been pointed out. The difficulty of providing for extra service with the present medical personnel, which is voluntary except for the resident in obstetrics, has been pointed out by the obstetrician in charge of the clinic. This is a matter for joint consideration and planning by the University of Tennessee Medical School, which provides the medical service for the hospital, the Memphis General Hospital, and the health department. In connection with this, consideration should be given to the feasibility of establishing outlying prenatal clinics as part of the hospital and health department set-up, rather than merely increasing the number of sessions at the hospital. 3. More convenient and adequate provision should be made for the treatment of syphilis, especially syphilis in pregnant women and in children. 4. The home-delivery service should be under direct medical supervision. 5. Well-trained social workers should be appointed for work in the prenatal clinics, in the obstetric and pediatric departments of the hospital, and among cases referred by doctors and nurses as needing help, to act as liaison officers with the community social agencies in order that families with children who are without the minimum basic necessities for health protection may be effectively and quickly aided. 6. Careful consideration should be given to ways and means of pro viding early medical care in their homes for babies not ill enough for admission to the hospital. Probably the most satisfactory method of providing this would be through a service provided by the hospital and the University of Tennessee Medical School. Recommendations as to social problems. 1. Every effort should be made to stimulate community interest and sense of responsibility so that funds are provided both to develop the necessary health program and to assure the provision for minimum basic needs when necessary— without which provision many preventive and curative activities are limited in their effectiveness. 2. The social aspects of the care of unmarried mothers and illegitimate or otherwise dependent and neglected infants should be given careful study in relation to the development of an adequate State program that meets accepted modern standards. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Appendix 1.— The Resident Infant Mortal ity Rate of Memphis From the data available it is not possible to formulate an'accurate resident infant mor tality rate according to the accepted definition o f the term. In order to arrive at such a “ resident” infant mortality rate, it is necessary to know: (1) The number o f births to resi dent mothers; (2) the number o f deaths o f infants born to resident mothers; (3) the number o f births to nonresident mothers; (4) the number o f deaths o f infants born to nonresident mothers in Memphis; (5) the number o f deaths o f infants who were not born in Memphis or if born in Memphis o f nonresident parents had returned home and reentered Memphis before their death; (6) the number o f births to resident mothers outside Memphis; and (7) the number o f deaths o f infants o f resident mothers outside Memphis. Information on the last two points is not now available, but all this information will be made available for all cities under the plans o f the United States Bureau o f the Census, so that it will be pos sible to compile city resident rates that will be comparable. It is however, possible to estimate the probable effect o f births and deaths of infants of nonresident mothers in Memphis and the deaths o f infants not born in the city, on the Mem phis picture, for the years 1930-32 combined and 1934. In order to have a clear picture o f the situation and the basis on which conclusions to be presented here have been reached, it is necessary to consider the method used b y the health department in classifying births and deaths as to residence, and the question o f the validity o f the residence statements on birth and death certificates. Method of classification of infant births and deaths by the Memphis Depart ment of Health as resident and nonresident. For a number o f years births have been classified as resident or nonresident according to the address o f the mother given on the birth certificate. Until 1934, however, all deaths in Memphis o f infants who had been born there and had resided there until death were classified as resident; all deaths in Memphis o f infants who were not born in Memphis or who were born in Memphis but had returned home outside o f the city and reentered M em phis before death were classified as nonresident. The so-called resident infant deaths, therefore, included the deaths o f infants born in the city to nonresident mothers and classi fied as nonresident births. In other words, infants born in the city o f nonresident mothers were eliminated from the resident births, but when any o f these infants died they were in cluded in the resident deaths. The so-called resident infant mortality rate computed yearly b y the city previous to 1934 has, therefore, obviously been erroneous. This method of classification has resulted in resident rates that are probably somewhat higher than ac tually obtain; it is impossible to estimate the degree o f excess. In 1934, instead o f considering as nonresident only the deaths o f those infants not born in the city, there were added to this group the deaths o f infants born in the city o f nonresi dent mothers. This latter method o f classifying the deaths as well as the births o f infants born in the city o f nonresident mothers as nonresident, will obviously give a more accurate picture o f the infant death rate o f actual residents in Memphis living in Memphis at the time o f death. 77 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 78 IN FA N T M ORTALITY IN MEMPHIS Validity of residence as given on birth and death certificates and its effect on resident infant mortality rate. A very important question which has been raised concerns the validity of the residence as given on the birth and death certificates. Because free care at the Memphis General Hospital, except in serious emergencies, is supposed to be limited to residents o f Memphis and Shelby County and to nonresident indigent unmarried women staying at maternity homes in the city, it was felt that many individuals who came to Memphis to get free hospital care, either at the time o f or shortly before their babies’ birth, either gave fictitious addresses or addresses o f relatives or friends which made them appear as residents o f Memphis when they were in reality nonresidents. This, too, was thought to be the case with some o f the babies dying who were not in reality residents o f Memphis. In other words, the number of births listed as resident (in the sense that they were births to resident mothers only) was probably higher than in actuality, and possibly also the number o f infant deaths. The only way in which an absolutely accurate number o f births to resident mothers can be obtained is by inquiring for every birth specifically not only as to the residence o f the mother but also as to the time when the mother came to Memphis. This has not been done. The same holds true for the deaths of infants o f resident mothers, though the latter would be taken care o f automatically if the birth-certificate information is correct. In 1934, however, a study was made b y the health department o f the death o f every infant under 1 year o f age in Memphis during that year, the original schedules o f which were made available to the Children’ s Bureau for analysis. A special effort was made to determine residence accurately b y inquiring as to the actual date on which the child had come to the city; if the child had been born there, the date on which the mother had come to the city. A comparison o f infant death certificates for 1934 with the birth certificates revealed that o f the 517 infants who died in Memphis during the year 428 (194 white, 234 colored) had been born in Memphis. The address o f the mother was given on the birth certificate as Memphis for 382 (154 white, 228 colored) of these 428 births. The special inquiry revealed that the original birth-certificate classification was correct for 354 births (93 percent); but the birth certificate had given a Memphis address for the mother in 28 instances (14 white, 14 colored) in which she was nonresident (table A ). It is significant, as indicating that the problem o f validity o f ^residence” is practically limited to the first month, that 24 o f the changes from the resident to the nonresident classification were for infants who died under 1 month o f age and the other 4 were for infants only slightly over 1 month old— who, indeed, had never left the hospital where they were born. T able A . — Result-of inquiry regarding residence of mother for infants dying in Memphis, Tenn., whose birth certificate stated mother to be a resident of city; 1934 1 Infants dying in M em phis wh<pse birth certificate stated m other to be resident o f city Inquiry s bowed— Period o f life Total M other resident Number TO TAL Second t o twelfth m onth_____________________ 354 9 2 .7 28 7.3 232 122 9 0 .6 9 6 .8 24 4 9 .4 3 .2 154 140 90 .9 14 9 .1 109 45 97 43 8 9 .0 (a) 12 2 11.0 228 214 9 3 .9 14 6 .1 147 81 135 79 9 1 .8 97.5 12 2 8 .2 2. 5 1 Compiled from figures supplied b y Memphis Departm ent o f Health, a Percent not shown because number o f deaths was less than 50. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Percent 382 C O LO R E D Second t o twelfth m on th --------------------------------- Number 256 126 W H IT E Second t o twelfth m onth--------------------------------- Percent M other nonresident (2) A P PE N D IX 1.---- RESIDENT IN FA N T M ORTALITY RATE 79 The official birth-certificate and death-certificate addresses were changed b y the Memphis Department o f Health from resident to nonresident for these 28 cases and for 1 more (the twin o f a colored infant who died whose residence had been changed from resident to non resident). It is apparent that the numbers o f resident live births as finally listed b y the health department for official use were, therefore, only slightly and insignificantly different from the numbers as compiled from the original birth certificates— less than 1 percent as a whole and for both white and colored (table B). B.— Live births to mothers certified as resident, number as corrected after inquiry of infant deaths, and estimated number of live births to resident mothers on basis of inquiry; Memphis, Tenn., 1934 1 T able Live births t o resident mothers Color N um ber cer tified t o resi dent mothers N um ber as corrected after inquiry Num ber esti m ated on basis o f inquiry T o ta l........................................................................................... 3,982 3,953 3,673 W hite________________________________________________________ 2,195 1,787 2,181 1,772 1,995 1,678 1 Compiled from figures supplied b y Memphis Departm ent o f Health. It is apparent also that the resident infant mortality rate computed on this basis is prob ably lower than the actual rate, as reallocation as to residence has been made for all the deaths but not for all the births— only for the births o f the infants who died. Whether the same percentage change in residence classification would occur if all births were carefully inquired into, it is, o f course, impossible to say; it seems likely, however, that the change would not be so large among those who lived as among those who died, in view o f the probability that an abnormal condition prompted some of the mothers o f the infants who died to seek care in Memphis. Nevertheless it seems justifiable for purposes o f study to consider the group o f births studied as a sample— to apply the percentage distribution of resident and nonresident births among it to the total number o f 1ive births, and compute the resident infant death rate on this basis. Such an estimate would seem to be a closer approximation o f the actual situation than either the original figures o f the health depart ment or the corrected figures o f the special study. For 1934, therefore, the mortality rates among infants o f resident mothers have been computed on the basis o f (1) resident infant deaths and resident live births as on the original birth and death certificate records, (2) resident infant deaths and resident live births as reallocated b y the health department following a study o f infants who died in the city during the year, and (3) resident infant deaths as reallocated b y the health department following the study o f deaths and resident live births estimated on the basis o f percentage distribu tion o f resident and nonresident births among 428 deaths o f infants born in the city that were made the subject o f special study (table C). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN FA N T M ORTALITY IN MEMPHIS 80 T a b l e C . —Mortality in certain periods of the first year of life 1 among all infants born in Memphis and among infants born to resident mothers, 1934 Resident rates based on records 3 Period o f life Crude rate 3 Originally certified W hite - - ...................... - ............................. W hite — .................. ....................... .......... Corrected after inquiry o f deaths 4 Estimated o n basis o f inquiry 112.4 95.9 89.6 96.4 92 .5 142.7 70.2 127.6 6 4 .2 120.8 70.2 127.5 68.7 64.3 58.7 63.2 57 .2 86.2 4 9 .7 82.3 44.5 7 6 .2 4 8 .6 80.5 46.9 33.8 32.8 35.5 37.4 6 1 .9 2 1 .6 4 9 .4 2 0 .6 48.3 22.7 51.2 1 First year and first m onth, deaths per 1,000 live births; second t o twelfth m onth, deaths per 1,000 infants surviving the first m onth o f life. . J Com piled from figures supplied b y U. S. Bureau o f the Census; rate based on all live births in Memphis. 3 Compiled from figures supplied b y M emphis Department o f Health. 4 Official resident rates o f Memphis Department o f Health. The differences among these various resident rates are of no statistical significance. The lowest are the official rates of the health department— and, as has been mentioned, they are probably too low. In other words, although the special study o f infant deaths revealed that certain births and deaths were classified as resident instead of nonresident because of inaccurate reporting on the birth and death certificates, the actual effect o f these inaccuracies on the resident infant mortality rate, at least in 1934, is apparently negligible, and the resident rate based on original birth- and death-certificate records probably is reasonably valid. Comparison of crude infant mortality rates and mortality rates of infants of resident mothers. Comparison of the crude rates and the rates for infants of resident mothers in Memphis for 1934 (table C) reveals that, as would be expected, for both races combined, and for white and colored separately, no matter which resident rate is used, the crude rates were higher for the total infant mortality and for both the neonatal and second to twelfth month mortality separately. The difference was greater for the white than for the colored, and for both white and colored it was greater for the second to twelfth month period than for the first month. The differences between the crude rates and the rates for infants of resident mothers among the colored for the whole year, the neonatal period, and the second to twelfth month period were not statistically significant. Among the white the differences between the crude rate, the rate for infants of resident mothers for the whole year, and for the second to twelfth month period were statistically significant. Those for the neonatal period probably were not, for the resident white neonatal rates as estimated on the postulate that residence is probably as poorly certified for all infants born in Memphis as for infants who die, is not significantly lower than the crude white neonatal rate. (The official healthdepartment resident rate, which, as was previously stated, is probably lower than the actual rate, is significantly lower than the crude rate.) There happens to be available as a result of a special local study of infant mortality b y wards a resident infant mortality rate for the period 1930-32, computed on the basis of live births to resident mothers in Memphis and deaths in Memphis o f infants of resident mothers as recorded on the birth and death certificates. A comparison o f these with the crude rates for 1930-32 reveals much the same differences as were found in 1934 between the crude and resident rates in the second to the twelfth month but in the neonatal rates an even smaller difference for the white and no difference for the colored. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Appendix 2.— Tables T able 1. —Mortality Period o f life in certain periods of the first year of life 1 among white and colored infants', Memphis, Tenn., 1923— 34 2 1923 First year_______ 1925 107.4 106.8 105.5 W hite___________ 76.3 Colored_________ 169.6 First month___ 1924 6 9 .9 166.2 68 .8 172.6 1926 1927 1928 1929 97.2 80.5 89.8 7 2 .7 141.2 6 3 .9 107.9 67.3 130.1 1930 1931 95.3 102.0 102.3 73.0 137.0 80 .8 138.6 82.9 137.0 1932 1933 1934 96.0 111.4 112.4 76. 2 9 3 .0 126.7 140.1 92 5 142.7 52.8 W h ite____ ______ Colored_________ 51.3 47.9 36. 5 75.1 45.8 41.1 39.5 79.5 45.1 3 6 .4 69.1 37. 5 6 0 .8 60.4 55.5 3 5 .9 4 9 .8 49.1 3 8 .7 5 6 .6 55.8 49. 5 8 0 .7 71.2 5 1 .2 6 2 .9 68.7 4 0 .6 6 4 .4 4 2 .6 76.3 62. 0 8 5 .6 57 2 8 6 .2 Second to twelfth month____ 57.6 58.5 60.5 53.9 38. 3 9 7 .9 41.0 3 4 .7 9 8 .4 3 3 .6 111.3 46.8 36. 6 8 5 .6 37.2 2 9 .0 6 1 .2 2 9 .7 7 7 .9 49.2 55.9 24.8 61.1 42.6 3 1 .2 80.8 43.2 46.9 4 4 .0 7 7 .7 35.1 54.5 33.1 59.5 37 4 6 1 .9 W hite___________ Colored_________ 1 Fir»1 year and first m onth, deaths per 1,000 live births; second to twelfth m onth, deaths per 1,000 infants surviving the first month o f life. H eai^ mi923-2r6 in 8uppUed b y U ‘ S' Bureau o f the Census, 1927-34, and b y the Memphis Department o f T a b l e 2 . —Mortality in certain periods of the first month of life 1; Memphis, Tenn., 1927-34 * First week Year First m onth Total First day week to first month Second t o sixth day TO TAL 1927......................................... 1928________________ «1929.................................... ... 1 9 3 0 ..._____ ___________ 1931_______________ 1932_______ _____ _ 1933_______ _____ 1934_______________ 41.1 45.1 6 0 .4 55.5 49.1 55 .8 71.2 6 8 .7 34.8 3 6 .7 4 9 .6 44.5 34.9 43 .2 39 .0 40 .0 26.9 27.2 3 2 .7 27.9 26 .7 2 8 .2 25.1 2 2 .6 7 .9 9. 5 16.9 16.5 8.3 15.0 13.9 17 .4 6 .3 8 .4 10.8 11.0 14.2 12.6 32.3 2 8 .7 3 5 .9 3 8 .7 49. 5 51.2 4 0 .6 4 2 .6 6 2 .0 57.2 32.3 31. 5 45. 7 42.5 3 2 .0 3 5 .4 41 .2 3 6 .0 2 5 .8 2 2 .4 2 9 .4 2 7 .7 26.1 22 .9 2 6 .7 22.3 6 .5 9 .1 16.3 14.8 5 .9 12.5 14.5 13.7 3 .6 7 .2 3. 8 8 .7 8 .6 7 .2 20. 8 21.2 4 9 .8 56. 6 80 .7 6 2 .9 6 4 .4 76.3 8 5 .6 86.2 3 9 .0 4 6 .2 5 6 .8 4 7 .9 4 0 .2 55.3 35.5 46.1 28.8 35.8 38.8 2 8 .4 2 7 .8 36.5 2 2 .6 23.1 10.2 10 .4 18.1 19.5 1 2 .4 18. 8 12.8 23.1 10. 8 1 0 .4 2 3 .9 15.0 24.2 21.0 50.2 40.1 W H IT E 1927.............................................. 1928.............................. 1929.............................. 1930_____________ 1931______________ 1932.......................... .. 1933_____________ 1934__________ . COLO RED 1927.......................... 1928______________ 1929_______________ 1930.............................. 1931______________ 1932___________________ 1 9 3 3 .................. ........ 1934................. ..................... 1 Deaths per 1,000 live births. Compiled from figures supplied b y U. S. Bureau o f the Census. 1 81 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 82 IN FA N T M ORTALITY IN MEMPHIS T a b l e 3 . —Mortality in the first month of life 1 from natal and prenatal causes and from all other causes; Memphis, Tenn., 1927—34 2 A l l ca u ses Y ear N a ta l a n d pre n a ta l cau ses A ll o th er cau ses TOTAL 1937 Ï9 2 8 1929 1930 Î9 3 Î 1932 1933 1934 ................... - .......................- .................... - ............... ........................................ ............................................. .......................................................................- - - - _____________ ________ ______________ ________ .............. ............................................................. ..........................................................................- ............... ............... _ .............. ......................... -- 4 1 .1 4 5 .1 6 0 .4 5 5 .5 4 9 .1 5 5 .8 7 1 .2 6 8 .7 3 5 .9 3 8 .4 5 1 .4 4 7 .5 3 9 .0 4 9 .1 5 3 .1 4 6 .1 5 .2 6 .7 9 .0 8 .0 1 0 .2 6 .7 1 8 .2 2 2 .6 3 5 .9 3 8 .7 4 9 .5 5 1 .2 4 0 .6 4 2 .6 6 2 .0 5 7 .2 3 2 .3 3 3 .7 4 3 .3 4 5 .1 3 3 .3 3 8 .6 4 7 .9 4 1 .7 3 .6 5 .1 6 .2 6 .1 7 .3 3 .9 1 4 .1 1 5 .5 4 9 .8 5 6 .6 8 0 .7 6 2 .9 6 4 .4 7 6 .3 8 5 .6 8 6 .2 4 2 .0 4 6 .8 6 6 .5 5 1 .8 4 9 .0 6 5 .3 6 1 .2 5 2 .7 7 .8 9 .8 1 4 .2 1 1 .1 1 5 .4 1 1 .1 2 4 .5 3 3 .5 WHITE 1977 1928. 1929 1930 1931 1932 1 93 3 1934 ....................................................................... ................................... .............. .................................................................. ............ ................... - .................................................- .................. _______________________ __________________ ................... .................................................................................. ................................................................................................... - - ______________________ _ ______________________ * COLORED 197.7 1928 1929 1930 1931 .................................................................................................. ............................. ................................................................ _________ _______ ______________________ _____________ ________ ________________________ 1932 1933 1934 __________ _______________ ___________________________________ ...................... .................................................................. ........................ .............. ............ ..................- ............................ 1 Deaths per 1,000 live births. 2 Compiled from figures supplied b y U. S. Bureau o f the Census. T a b l e 4 . —Mortality Year in the second to the twelfth month of life1from specified groups of causes; Memphis, Tenn., 1927— 34 2 A ll causes Natal and prenatal causes Respiratory diseases TOTAL 1927...................................... 1928...................................... 1 9 2 9 . . . ............................. 1930____________________ 1931____________________ 1932.........................- .......... 1 9 3 3 ........... ................... 1934____________ _____ Gastro intestinal diseases Epidemic and com municable diseases All other and unknown or ill-defined diseases 4 1 .0 4 6 .8 37.2 4 9 .2 55.9 4 2 .6 4 3 .2 4 6 .9 6 .1 9 .0 5 .5 9 .5 8 .9 12.0 9 .0 8 .9 14.4 16.3 13.7 15.1 16.7 11.0 11.8 13.1 8.0 8 .8 5 .3 8 .2 1 1 .4 7 .4 6 .9 11.7 6 .4 3 .4 5 .0 6 .0 8.5 4 .4 3.1 4 .0 6 .1 9 .2 7 .7 10.4 10.5 7 .9 12.4 9 .4 2 9 .0 2 9 .7 24.8 31.2 4 4 .0 35.1 33.1 37.4 4 .1 5 .6 4 .7 6 .4 4 .5 9 .0 7.5 6 .1 7 .2 8.3 8 .4 6 .8 13.1 6 .4 5 .0 8 .0 6 .8 5 .6 2 .9 8.1 10.0 9 .0 6 .3 12.6 5 .3 3 .4 5.1 2 .7 8.3 3 .7 2 .5 3.1 5 .6 6 .8 3 .6 7 .2 8.2 7.1 11.7 7 .7 61.2 77.9 61.1 80.8 77.7 54. 5 59.5 6 1 .9 9 .5 15.2 7.0 14.8 17.0 16.8 11.4 13.2 26.5 31.0 23.9 2 9 .7 23 .4 18.6 22.7 21.0 10.1 14.5 9 .8 8.3 13.9 4 .8 8 .0 10.2 8 .2 3 .4 4 .9 1 1 .9 8 .8 5 .4 4 .0 5 .4 6 .9 13.8 15.4 16.0 14.5 9 .0 13.4 12.0 WHITE 1927____________________ 1928............................... .. 1929................................. .. 1930____________________ 1931______________ _____ 1932..................................... 1933............................... .. 1934____________________ COLORED 1927................................... 1 9 2 8 . . - . - ........................... 1929..................................... 1930.............. ....................... 1931_____________ _______ 1932...................................... 1933..................................... 1934................ ..................... 1Deaths per 1,000 infants surviving the first m onth o f life. 2 Compiled from figures supplied by U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 83 A P P E N D IX 2 .---- TABLES Infant mortality1 from specified groups of causes; Memphis, Tenn., 1 9 2 7 -3 4 2 T a b l e 5. Cause of death T o ta l. Natal and prenatal causes____________ Respiratory diseases__________________ Gastroi ntesti na 1di seases_____________ Epidemic and com m unicable diseases. External causes_______________________ All other causes_______________________ Unknown o r ill-defined diseases. •.____ W h ite . Natal and prenatal causes____________ Respiratory diseases_______ ._________ Gastrointestinal diseases______________ Epidem ic and com m unicable diseases. External causes_______________________ All other causes______________________ Unknown o r ill-defined diseases______ 1927 1928 1929 80.5 89.8 95.3 102.0 102.3 96.0 111.4 4 1 .8 14. 9 8.1 6. 3 . 0 .9 r 4 .7 3 .6 4 7 .0 18.1 9.1 3 .7 1. 6 6 .5 3 .7 5 6 .6 1 4 .6 5 .4 5 .2 1 .6 8. 8 3 .2 56. 5 17.1 8 .8 5 .9 1 .6 6.1 5 .9 4 7 .4 19.1 12.1 8.3 1.5 7 .6 6 .4 6 0 .4 11 .7 7 .6 4 .3 0 .9 7.2 3 .9 6 1 .4 15.5 10.8 3.3 1 .7 11. 7 6 .9 54.3 23 .0 16.5 3 .7 1. 3 9 .1 4 .3 63.9 67.3 73.0 80.8 82.9 76.2 93.0 92.5 36.3’ 7. 6 6. 5 5. 4 39.1 10.1 6. 5 4 .0 0 .4 5 .8 1 .4 4 7 .8 8.3 2 .8 5 .2 . 0 .7 7 .6 0 .7 51.2 8 .7 8 .7 2 .6 0 .6 6 .8 2 .3 3 7 .6 15.8 10.6 7 .9 1 .7 7.3 2 .0 4 7 .2 6 .8 8 .9 3 .9 1.1 7 .2 1.1 5 4 .9 7.5 11.0 2 .4 2 .4 1 0 .6 4 .3 4 7 .5 14.8 16.2 2 .9 0. 7 8.3 2 .2 107.9 130.1 137.0 138.6 137.0 126.7 140.1 142.7 l i 4. 4 2 .5 Colored . N atal and prenatal causes___________ Respiratory diseases_________________ Gastrointestinal diseases_____________ Epidem ic and com municable diseases. External causes______________________ All other causes______________________ Unknown o r ill-defined diseases______ 5 1 .0 27 .0 10. 8 7. 8 0. 6 5. 4 5 .4 6 1 .2 32. 5 13.7 3.3 3 .9 7 .8 7.8 73.0 26.5 10.3 5. 2 3 .2 11.0 7 .8 1930 6 5 .7 31. 7 8 .9 1 1 .7 3 .3 5 .0 12.2 1931 6 5 .0 2 4 .8 14.8 8 .9 1 .2 8.3 14.2 1932 80.8 1 9 .4 5 .5 5 .0 0 .6 7 .2 8.3 1933 7 1 .6 28.110 .4 4 .9 0 .6 13.5 11.0 1934 112.4 64. 8 35. 7 17.0 4 .9 2 .2 10.4 7 .7 1 Deaths in the first year o f life per 1,000 live births. 2 Compiled from figures supplied by U. S. Bureau o f the Census. T a b l e 6. Infant mortality 1 in cities with 250,000 to 350,000 population and by color for cities with 25,000 or more colored population, 1927-34 2 City 1927 1928 Akron, O h io.. Atlanta, Ga.8. W hite___ C o lo r e d .. 62 Birmingham, A la . W hite_______ C olored_____ 78 58 111 95 74 127 Columbus, OhioW hite........... Colored____ 64 59 97 100 69 100 71 156 73 69 1929 64 94 75 128 1930 1931 1932 54 84 65 55 94 65 148 65 124 78 55 111 86 71 65 123 71 67 100 61 61 121 48 83 71 104 65 53 71 56 77 62 97 69 61 126 58 55 78 86 71 62 103 66 79 114 Denver, Colo.8. H ouston, Tex.4. W hite......... C olored___ M em phis, T en n . W h ite______ Colored____ Oakland, C a lif_____ Portland, Oreg_____ Providence, R . I ___ Rochester, N . Y ___ St. Paul, M inn_____ T oledo, O hio_______ 84 63 64 80 85 81 75 129 108 80 64 108 90 67 130 S3 47 63 63 49 62 47 43 63 61 54 65 66 67 72 93 74 77 67 144 95 73 137 102 102 81 139 47 43 47 41 53 51 43 56 66 63 46 70 1 Deaths in the first year o f life per 1,000 live births, i Conapilfd front figures supplied b y U. S. Bureau o f the Census. . ^ ° lorado and Georgia were admitted to the birth-registration area in 1928. * lexas was admitted to the birth-registration area in 1933. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 70 72 67 63 96 66 1934 47 83 64 113 Dallas, Tex.4. W hite__ Colored . Jersey City, N . J . Louisville, K y ___ W h ite_______ C olored_____ 1933 69 54 67 61 55 61 45 105 41 63 68 45 125 66 45 71 102 60 98 91 96 76 127 111 83 137 112 93 140 92 143 41 36 59 54 44 56 40 34 60 48 39 62 38 38 55 51 46 59 40 36 50 42 43 53 68 84 IN FA N T M ORTALITY IN MEMPHIS T a b l e 7.— Mortality in the first month of life 1 in cities with 250,000 to 350,000 population and by color for cities with 25,000 or more colored population, 1927-34 2_________ 1927 C ity 1928 1929 1930 1931 1932 1933 1934 38.0 3 8 .6 57.9 4 4 .8 8 3 .4 38.7 54.1 4 3 .8 72.8 35.5 52.8 4 0 .7 76.3 34.1 51.0 43.1 66.5 2 7 .8 44.2 36.9 5 7 .0 34.2 51 . 5 4 1 .9 67.3 29 .0 47.1 42. 2 5 6 .0 45. 5 37.3 58 .9 52.3 44 .0 6 4 .8 4 8 .9 4 5 .2 5 4 .5 . 4 7 .5 32.9 6 8 .4 42.3 37.3 5 0 .7 4 1 .4 33.1 53.1 4 5 .2 38.7 53.3 4 8 .6 40.4 5 9 .7 37.3 41.8 41.1 4 0 .6 3 3 .8 3 4 .6 45.8 4 2 .9 39.3 5 5 .6 3 2 .7 38.5 34.3 5 2 .2 4 9 .8 4 4 .4 4 3 .8 3 8 .6 36 .0 33 .6 34.2 27.1 5 3 .0 34.7 4 0 .4 30 .8 6 3 .9 Colored____________------------ 32.7 36.7 36.6 37.5 3 8 .4 4 2 .4 40.3 57.3 34.9 33.5 32.3 4 2 .0 37.9 3 6 .6 35.0 48.1 4 2 .2 39.3 33.1 78.1 28 .0 4 1 .4 36. 4 71.3 2 3 .4 37.0 31.8 67.3 27.0 37.6 36.9 42 .0 Memphis, T en n -------------------------W hite .................... ........ Colored____________________ 41.1 35.9 4 9 .8 45.1 38.7 56.6 6 0 .4 49.5 80.7 55.5 51.2 6 2 .9 49.1 4 0 .6 6 4 .4 5 5 .8 42. 6 76.3 71.2 62. 0 8 5 .6 6 8 .7 57.2 86. 2 Toledo, Ohio____________________ 30.0 29.2 38.0 38.3 30.1 39.6 29.5 2 9 .2 32.0 35.4 35 .6 41.6 2 8 .6 25.2 41.0 40.0 31.0 43.5 26.9 2 9 .4 32.8 34.1 29. 1 35.1 2 6 .0 24.9 38.6 33.9 2 9 .4 3 4 .4 27. 8 22.3 36.3 31.0 26 .4 41 .8 22.0 28.2 37. 5 34. 6 32.1 41.1 27.6 24.3 34 .4 3 2 .9 2 8 .9 32.9 W hite ____________ Birmingham, A la -----------------------Colored_________________ _ Columbus, Ohio-------------------------- Jersey p it y , N . J ------------------------ 1 Deaths per 1,000 live births. 1 Compiled from figures supplied b y U. S. Bureau o f the Census. 3 Colorado and Georgia were admitted to the birth-registration area in 1928. 4 Texas was admitted t o the birth-registration area in 1933. T a b l e 8.— Mortality in the second to the twelfth month of life 1 in cities with 250,000 to 350,000 population and by color for cities with 25,000 or more colored population, 1927-34 2 1927 C ity W hite W hite ' 1929 1930 1931 1932 W hite ____________________ 18.6 26.3 20.2 37.2 13.5 32.9 23.5 4 8 .6 19.2 37.5 30.1 51.3 2 4 .8 31.3 44.3 27.1 7 9 .4 34.2 21.3 55.7 4 5 .0 30.9 66.9 41.5 21.0 73.5 31.7 22.6 45.3 24.2 16.8 36.9 2 4 .6 16.7 36 .0 26.5 18. 5 36.8 30.2 22 .9 40. 2 27.3 32.1 3 1 .7 3 1 .4 28.7 .26.8 24.6 45. 4 40.9 61.8 26.1 34.2 28.3 54.1 43.1 4 1 .4 51.0 32 .4 34 .4 2 1 .7 28.2 18.3 55.2 2 9 .7 2 8 .9 14.7 65.0 31.8 30.4 28.3 4 4 .0 48.2 4 0 .7 35.8 76.3 3 3 .4 39.3 34.9 69.1 35.0 3 1 .7 2 9 .0 5 0 .6 32.8 3 9 .6 3 4 .7 71.5 26.8 26 .8 2 5 .9 32 .7 18.3 29.8 29.2 33.2 18.5 34 .7 32 .2 51 .4 41.0 29 .0 61.2 4 6 .8 2 9 .7 77.9 37.2 24.8 61.1 49 .2 31.2 80.8 55.9 44.0 77.7 4 2 .6 35.1 54.5 4 3 .2 33.1 59. 5 4 6 .9 37.4 6 1 .9 23.3 18.0 26. 2 26.0 19.0 23.6 18.2 13.9 32 .4 26.2 18.6 24.8 18.6 17.8 25.9 24.0 15.6 27.2 20.2 11.6 20.5 17.6 14.2 21. 8 15.4 10.9 21.5 20.5 15.2 2 2 .6 12.7 11.7 24.2 17.8 13.0 2 0 .9 16.4 9 .7 17.7 16.9 14.3 18. 5 13.2 11.5 15.9 9 .4 14.3 20.5 1 Deaths per 1,000 infants surviving the first m onth o f life. . 3 Compiled from figures supplied b y U . S. Bureau o f the Census. _ 3 Colorado and Georgia were admitted t o the birth-registration area in 1928. 4 Texas was admitted t o the birth-registration area in 1933. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 1934 20.1 34.6 23.1 57.9 W hite W hite .1 ___________________ 1933 20.5 43 .0 2 5 .7 77.8 26.3 41 .7 32.1 59.5 ___________ _________________ 1928 A P P E N D IX 2 .---- T A B L E S 85 T a b l e 9.— Mortality in certain periods of the first year of life 1 in 3 cities 2 with 250,000 to 350,000 population and 25,000 or more colored population, 1928-34 3 Period o f life First year . . . ... W hite____________ Colored_________ First month. _ _. W hite_________ C o lo r e d _________ Sefcond to twelfth month W hite________ __ Colored____ ____ 1928 1929 1930 1931 1932 91.5 83.8 79.1 73.2 138.2 68 2 122.8 75.6 61.5 122.9 6 2 .4 109.4 50.5 44.9 45.4 4 2 .6 70.5 39.1 59 .4 36.1 68.3 43.2 40.7 32.0 72.9 30.3 6 7 .4 1933 1934 67.2 73.1 77.2 56. 5 91.5 60. 5 9 9 .8 67 6 99. 5 44.2 42.4 3 7 .4 6 1 .6 44.6 35 .7 5 7 .6 44.3 36.7 61.3 39.5 55.5 35.4 32.9 26.3 58.6 25.9 29.8 26.1 50.9 2 1 .6 36.0 34.3 24. 7 41.1 29 2 46.5 1 First year and first month, deaths per 1,000 live births; second to twelfth month, deaths per 1,000 infants surviving the first m onth o f life. uui f Atlanta, Ga., Birmingham, A la., and Louisville, K y. (com bined). 3 Compiled from figures supplied b y U. S. Bureau o f the Census. T a b l e 10. Infant mortality,1 by cause, in cities with 250,000 to 350,000 population and 25,000 or more colored population, 1934 2 City Memphis, Tenn.— Crude___ Memphis, Tenn.— R esident. A ll causes N atal and prenatal causes Respira tory dis eases _ Gastro intestinal diseases Epidemic and com municable diseases A ll other and un known or ill-defined diseases 112.4 8 9 .6 54.3 44.3 2 3 .0 23.0 16.5 8 .9 3 .7 3 .5 14.8 9 .9 82.9 77.3 58 .0 71.3 71.0 , 4 5 .7 49.8 35.5 4 1 .0 38.2 35.1 13.9 9 .1 9 .6 11.2 12.3 10.8 8.3 4 .2 4 .2 9 .6 8.1 12.2 5.1 4 .0 2 .5 2 .9 2 .0 4 .0 9 .9 10.1 6 .1 6 .7 7-4 8-9 M emphis, Tenn.— C rude___ Memphis, Tenn.— R esident. 9 2 .5 6 4 .2 47.5 3 6 .7 14.8 12.8 16.2 6 .9 2 .9 2 .8 11 2 5 .0 Atlanta, G a______ Birmingham, A la . Columbus, O h io .. Dallas, T e x ______ Houston, T e x ____ Louisville, K y ____ 71.0 6 2 .4 5 5 .0 6 1 .6 45.1 3 9 .4 4 2 .9 34 .7 37.3 31.6 3 4 .8 9 .5 5.1 8 .8 7 .8 3 .8 9 .0 8 .9 4 .4 3 .4 7.3 4 .1 1 1 .8 5 .0 1 .8 2 .7 2 .5 1 .8 3 .7 8.1 8.1 5 .3 6 .8 3 .8 8 .7 Memphis, Tenn.— Crude___ Memphis, Tenn.— R esident. 142 .7 120.8 6 4 .8 5 3 .6 35. 7 3 5 .6 17.0 11.3 4 .9 4 .5 20.3 15.8 Atlanta, G a______ Birmingham, A la . Columbus, O h io .. Dallas, T e x ______ H ouston, T e x ____ Louisville, K y ___ 104.4 97.5 7 7 .9 103.5 124.8 91.3 57.1 5 9 .2 4 0 .6 5 3 .0 54.5 3 7 .7 21.9 14.4 14.6 22 .4 33.2 23.2 7.1 4 .0 9 .7 17.4 18.2 14.5 5.1 7 .0 1 .6 4.1 2 .5 5 .8 13.3 13.0 11.3 6 .6 16.3 10.1 Atlanta, G a ______ Birmingham, A la . Columbus, O h io .. Dallas, T e x ______ Houston, T e x ____ Louisville, K y ____ 68.1 68.0 1 Deaths in the first year o f life per 1,000 live births. 3 Com piled from figures supplied by the U. S. Bureau o f the Census and, for resident, b y the M emphis D epart ment o f Health. * H https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 86 IN F A N T M O R T A L IT Y IN M E M P H IS T a b l e 11.— Mortality in the first month of lifef hy cause, in cities with 250,000 to 350,000 population and 25,000 or more colored population, 1934 2 C ity Epidemic and com municable diseases A ll other and un known o r ill-defined diseases A ll causes N atal and prenatal causes Respira tory dis eases Gastro intestinal diseases 68. 7 58. 7 46.1 38.2 10.9 11.6 5 .7 4 .3 47.1 48. 6 3 2 .7 38. 5 4 0 .4 37 .6 42 .2 43 .9 29.3 34.8 35. 7 30.8 1 .4 1.3 1. 7 1 .2 2 .4 2 .7 1.0 57.2 44. 5 4 1 .7 32.1 7 .2 6 .0 4 .3 3 .2 42.2 4 0 .4 31.3 34. 3 30. 8 3 6 .9 37.7 3 7 .4 28.1 3 1 .6 29.5 31.0 1 .4 .4 1.5 1.1 .3 .2 .2 1 .7 2 .6 1 .2 1.0 .8 2 .0 1 .5 .2 1.3 2 .2 86. 2 76. 2 52 .7 45. 7 16.5 18 .6 7 .7 5 .6 56.0 59.7 42.2 52.2 63.9 42.0 5 0 .4 52. 7 37.3 45. 5 50.8 2 9 .0 1 .5 2 .5 3 .2 1 .7 8.2 7.2 .5 TOTAL Atlanta, G a ___________________ ________ Columbus, O h io____________ __________ Louisville, K y _________________________ .9 .2 .7 1 .7 6 .0 4 .6 0 .2 .2 .2 .2 2.4 3 .2 •1.3 1 .6 1 .6 2 .3 W H IT E Columbus, O h io_______________________ Louisville, K y _________________________ 4 .0 3 .2 1.0 COLO RED Louisville, K y _________________________ 9 .3 6 .2 .5 1 .7 2 .5 2 .9 3 .6 4 .0 1 .6 3.3 2 .5 2 -9 1 Deaths per 1,000 live births. ,, .. ^ i Com piled from figures supplied b y the U. S. Bureau o f the Census and, for resident, b y the Memphis D epart ment o f H ealth. T a b l e 12.— Mortality in the second to the twelfth month of life,1 by cause, in cities with 250,000 to 350,000 population and 25,000 or more colored population, 1934 2 City Epidemic and com municable diseases A ll other and un known or ill-defined diseases A ll causes Natal and prenatal causes Respira tory dis eases Gastro intestinal diseases 4 6 .9 32.8 8 .9 6 .4 13.1 12.1 1 1 .7 4 .8 4 .0 3 .8 ' 9 .3 5 .6 37.5 30.2 26.1 34.2 2 8 .9 3 4 .7 3 .6 6 .2 6 .4 6 .4 2 .6 4 .5 13.1 8 .2 8.1 10 .4 10.4 8.5 7 .8 4 .4 4 .2 9 .0 7 .7 10.9 5.1 4 .0 2 .4 3 .0 2.1 3 .9 8 .0 7.3 5 .0 5 .4 6.1 6 .9 37.4 2 0 .6 6 .1 4 .8 8 .0 7 .2 1 2 .6 . 3 .8 3.1 2 .9 7 .7 1.9 30.1 22.9 24.5 28.3 14.7 32 .2 1 .8 5 .7 6 .8 6 .0 2 .1 3 .9 8 .5 5 .0 7 .6 7 .0 3 .9 7.3 8 .2 4 .6 3 .3 6 .7 4 .2 1 0 .7 5 .0 1 .9 2 .5 2 .6 1 .8 3 .6 6 .7 5 .7 4 .3 6 .0 2 .6 6 .8 6 1 .9 48.3 13.2 8 .6 21.0 18.3 10.2 6 .1 5 .4 4 .9 12.0 10.4 51.3 4 0 .2 37.3 54.1 6 5 .0 5 1 .4 7 .0 6 .9 3 .4 7 .9 4 .0 9 .1 2 1 .6 12.7 11.9 21 .8 26.8 16.6 7 .0 4 .2 10.2 16.6 16.7 12.1 5 .4 6 .9 1 .7 4 .4 2 .7 6 .1 10.3 9 .5 10.2 3 .4 14.7 7 .6 TO TAL W H IT E COLO RED Louisville, K y _________________________ 1 Deaths per 1,000 infants surviving the first m onth o f life. .... . 3 Compiled from figures supplied b y the U. S. Bureau o f the Census and, for resident, b y the Memphis Depart m ent o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX 2 .---- TABLES T a b l e 13. 87 Mortality by cause, in certain periods of the first year of life 1 among all infants born m Memphis and among infants born to resident mothers, 1934 2 Period o f life All causes N atal and prenatal causes Respira tory dis eases _Gastro intestinal diseases Epidemic and com municable diseases 3. 7 3 .5 All other and un known or ill-defined diseases First year___________ M other resident. 112.4 89.6 54.3 44.3 23.0 23.0 16.5 8 .9 First m onth_________ M other resident. 6 8 .7 5 8 .7 46.1 38.2 10.9 11 .6 5 .7 4 .3 Second to twelfth m onth. M other resident____ 4 6 .9 32. 8 8 .9 6 .4 13.1 12.1 11.7 4 .8 J.8 4 .0 9 3 5 .6 First year______________ M other resident__ 92. 5 6 4 .2 47.5 36 .7 14.8 12.8 16.2 6 .9 2 .9 2 .8 11 2 5 .0 First m onth_________ M other resident. 57.2 44.5 4 1 .7 32.1 7 .2 6 .0 4 .3 3 .2 Second to twelfth m onth. M other resident____ 37.4 20 .6 6.1 4 .8 8 .0 7.2 12.6 3 .8 3.1 2 .9 7 7 1.9 142.7 120. 8 6 4 .8 5 3 .6 35 .7 3 5 .6 17.0 11.3 4 .9 4 .5 1 5 ~.8 First m onth_________ M other resident. 86.2 76.2 5 2 .7 4 5 .7 16.5 18.6 7 .7 5 .6 Second to twelfth m onth. M other resident____ 61.9 48.3 13.2 21.0 18.3 10.2 6.1 14 8 9 .9 6 6 4 .6 W H IT E 3 .2 C O LO R E D First year_______________ M other resident____ 86 20 1 9 1 6 2 5 .4 4 .9 12 0 1 0 .4 . . m o t i i i u m .i i , u c a i n s p e r j ,000 live births; second to twelfth m onth, deaths per 1,000 infants surviving the first m onth o f life. 8 Compiled from figures supplied b y the U S. Bureau o f the Census and, for resident, by the Memphis D epartment of Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T a b l e 14.—Number of deaths, by cause, in certain periods of the first year of life among infants whose mothers were resident and infants whose mothers were nonresident in Memphis, Tenn., 1934 1 M other resident Cause o f death Deaths in second t o twelfth month Deaths in first m onth Deaths in first year M other nonresi dent T otal M other resident M other nonresi dent M other resident Total.............................. ......... 517 354 68.5 163 31.5 316 232 73.4 84 26.6 201 122 N atal and prenatal causes_______________ Respiratory diseases_____________________ Gastrointestinal diseases_________________ Epidem ic and com municable diseases_. . . A ll other and unknown oi ill-defined dis eases___________________________________ 263 113 63 22 175 91 35 14 6675 80.5 5 5 .6 88 22 28 8 33.5 19.5 4 4 .4 214 55 21 1 151 46 17 7 0 .6 8 3 .6 63 9 2 9 .4 16.4 49 58 42 21 24 45 18 14 56 39 6 9 .6 17 3 0 .4 25 18 31 21 160 97 60.6 63 39.4 98 43 43.3 117 20 11 1 70 13 7 59 .8 47 7 4 1 4 0 .2 24 23 29 11 10 15 8 6 11 7 11 4 17.4 156 135 86.5 21 13.5 103 79 N atal and prenatal causes_______________ Respiratory diseases_____________________ Gastrointestinal diseases------------------------Epidem ic and com municable d is e a s e s ... A ll other and unknown or ill-defined dis eases______________________ . . . _________ Colored................................... N atal and prenatal causes_______________ Respiratory diseases_____________________ Gastrointestinal diseases_________________ Epidem ic and com municable d is e a s e s .... A ll other and unknown or ill-defined dis eases----------------------- ----------------------------- 141 43 40 12 140 80 28 15 6 22 11 259 214 122 70 23 10 95 63 20 . 8 34 28 54.3 118 5 6 .7 61 15 25 6 82.6 45 45.7 11 7 7 .9 9 0 .0 27 7 3 2 22.1 10.0 6 1 Compiled from figures supplied b y the M em phis D epartm ent o f H ealth. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 1 97 35 10 81 33 10 14 11 7 4 83.5 16 2 3 16.5 60.7 7 7 .6 79 25 13 24 7 39.3 2 2 .4 10 43.9 55 56.1 14 8 21 5 7 76.7 24 25 35 13 10 14 30 10 8 11 5 3 2 20 17 3 3 Percent not shown when number o f deaths was less than 50. 23.3 IN FA N T M ORTALITY IN MEMPHIS Num ber P ercen t2 N um ber Percent 2 N um ber P ercen t3 N um ber Percent * N um ber P e rce n t3 N um ber P e rce n t2 258 M other nonresi dent T otal T otal White...................................... 00 A P P E N D IX T a b l e 15 .—Mortality 2 .-----T A B L E S 89 in certain periods of the first month of life1 among infants horn to resident mothers; Memphis, Tenn., 1934 2 First weefe First month Color T otal T otal__________ W h ite______ Colored________ Fi ret day Second to sixth day Second week to first m onth 5 8 .7 1 8 .7 13.7 26.3 7 6 .2 1 7 .9 19.8 9 .6 18.6 17.0 37.8 1 Deaths per 1,000 live births. a f « H n Z ir y d off T a t h 8sUreS * * * M em phis Departm ent ° f H ealth; rates based on figures corrected T a b l e 16.—Mortality in certain periods of the first year of life 1 as shown by crude and resident mortality rates; Memphis, Tenn., 1930-32 and 1934 1930-32 1934 Period o f life Crude rate 2 First year__________ W hite____;_______________ Colored__ ____________ First month____________ W hite___________________ Colored_______________ ___ Second to twelfth month W hite.................... Colored______________ 100.2 if7-------- ' https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 90.2 Crude rate 2 112.4 80.1 134.0 6 3 .7 127.6 53.5 51.5 68.0 4 4 .9 4 0 .4 67.1 49.3 40.8 46.9 24.3 6 4 .9 3 7 .4 6 1 .9 36.8 7 0 .9 P" ‘ ■C00 b i" h ,i < * » “ > “ 2 Compiled from figures supplied b y U. S. Bureau o f the Census. 6 4 5 3 5 °— Resident rate 3 « * * * — Resident rate (as originally certified) 3 95.9 92.5 142.7 70 .2 127.6 68.7 64.3 57.2 86.2 4 9 .7 82.3 33.8 21.6 49.4 a . a - * , per 1,000 ¡ . f a « , . T able YJ.-Place of birth of infants dying in certain periods of the first year of life in Memphis, Tenn., 1930-341 Infants dying in first year of life Year Born elsewhere Num ber Percent Number Percent TOTAL W H IT E 1930. 1931. 1932. 1933. 1934. 1930. 1931193219331934. . Compiled from Born elsewhere Num ber Percent Num ber Percent 34 491 484 441 466 517 457 416 375 404 428 93 245 250 213 237 258 213 193 162 194 194 87 77 76 82 32 246 234 228 229 259 244 223 213 210 234 99 95 93 92 90 2 7 85 87 13 25 Born in city Born elsewhere N um ber Percent N um ber Percent Total T otal . „ P P « bp the M om phi. D o p o n m o o . o f H o .I.h . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis B o m in city 265 233 257 300 316 259 226 245 290 301 98 97 95 97 95 6 7 12 1U 15 2 3 5 3 5 155 125 119 159 160 149 119 109 151 148 96 95 92 95 93 6 6 10 8 12 4 5 8 5 8 108 138 141 156 110 107 136 139 153 100 99 99 99 98 1 2 2 3 1 1 1 2 1 . 226 2S1 184 166 201 103 1 For c o m o .p o .0 m « » „ . r e . f o , B i n m « * . » , * 1 .., « b l . « . P- 102. 198 190 130 114 127 IN FA N T M O RTALITY IN MEMPHIS Born in city Total 1930. 19311932. 1933. 1934- In second to twelfth month In first m onth T otal A P P E N D IX 2.---- TABLES T a b l e 18. 91 Mortality in certain periods of the first year of life 1 among all infants dying in the city and among infants born in Memphis, Tenn., 1930-34 2 , T otal W hite Colored Year Born in city T otal T otal Born in city T otal Born in city F IR S T Y E A R 1930............................. 1931________________ 1932 ______ 1933 .......... 1934_________________ 100.2 101.7 9 5 .5 109. 7 111.9 9 3 .3 8 7 .4 8 1 .2 9 5 .1 9 2 .6 7 8 .8 82.1 7 6 .0 91 .8 9 2 .4 68 .5 6 3 .4 57 .8 7 5 .2 6 9 .5 137.3 136 .4 125.8 137.3 141.8 136.2 130.0 117.5 125.9 128.1 54.1 4 8 .9 5 5 .7 7 0 .6 6 8 .4 5 2 .9 47 .5 53.1 68.3 6 5 .2 4 9 .9 41.1 4 2 .4 6 1 .6 57.3 4 7 .9 39.1 3 8 .9 58.5 53.0 6 1 .4 6 2 .9 76.2 84. 5 8 5 .4 6 1 .4 6 2 .4 75 .1 83.3 8 3 .7 4 8 .8 5 5 .4 4 2 .2 4 2 .0 4 6 .7 4 2 .7 4 2 .0 2 9 .8 2 8 .9 2 9 .5 30.5 42. 8 3 5 .0 32.2 37.2 21.7 25.3 19 .7 17.8 17.5 8 0 .9 78.4 5 3 .8 5 7 .6 6 1 .6 ? 9 .7 72.1 4 6 .0 4 6 .5 4 8 .5 F IR S T M O N T H 1930............................. 1931________________ 1932______________ 1933_________ 1934________________ SECOND TO T W E L F T H M ONTH 1930........................... .......... 1931_____________ 1932__________________ 1933________________ 1 9 3 4 ................... ....... 1 First year and first m onth, deaths per 1,000 live births; second t o twelfth m onth, deaths per 1,000 infants surviving the first m onth o f life. .* Compiled from figures supplied by the Memphis D epartm ent o f Health. For corresponding figures for Birmingham, A la., see table 41, p. 103. T a b l e 19.—Live births to resident and nonresident mothers; Memphis, Tenn., 1927-34 1 Live births Year T o resident mothers T o nonresident mothers Total Num ber Percent N um ber Percent TOTAL 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 4 ,3 8 4 4, 332 4 ,4 6 6 4 ,9 0 0 4,761 4 ,6 1 6 4 ,2 4 9 4,6 2 0 3,736 3,751 3,730 4,405 4,2 0 6 4,105 3,721 3,953 85 87 84 90 88 89 88 86 648 581 736 495 555 511 528 667 is 13 16 10 12 11 12 14 2,743 2,7 7 8 2,913 3,108 3,045 2,804 2,581 2,793 2,1 7 4 2,2 7 7 2,288 2,622 2,508 2,327 2,0 8 9 2,181 79 82 79 84 82 83 81 78 569 501 625 486 537 477 492 612 21 18 21 16 18 17 19 22 1,641 1,554 1,553 1,792 1,716 1,812 1,668 1,827 1,562 1,474 1,442 1,783 1,698 1, 778 1,632 1,772 95 95 93 99 99 98 98 97 79 80 111 9 18 34 36 55 s W H IT E 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. C O LO R E D 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1 Com piled from figures supplied b y the M em phis D epartm ent o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 5 7 1 1 2 2 3 92 IN F A N T M O R T A L IT Y T a b l e 20 .—Proportion IN M E M P H IS of births in hospitals; 'Memphis, Tenn., 1927-34 1 Live births and stillbirths In homes In hospitals Year Total Percent Num ber N um ber Percent TO TA L 4, 821 2,6 6 4 2,650 2,923 2,960 3,058 3,026 2,803 3,060 57 58 62 57 61 63 63 63 1,995 1,939 1,813 2,197 1,949 1,805 1, 663 1,761 43 42 38 43 39 37 37 37 2,855 2, 876 3,034 3,212 3,140 2,896 2,690 2, 873 1,873 1,900 2,2 0 9 2, 309 2, 372 2,211 2,042 2,2 8 4 66 66 73 72 76 76 76 79 982 976 825 903 768 685 648 589 34 34 27 28 24 24 24 21 1,804 1,713 1,702 1,945 1,867 1,935 1, 776 1,948 791 750 714 651 686 815 761 776 44 44 42 33 37 42 43 40 1,013 963 988 1,294 1,181 1,120 1,015 1,172 56 56 58 67 63 58 57 60 4 ,6 5 9 4 ,5 8 9 4,7 3 6 5,157 5,007 4,831 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. W H IT E 1927-, 1928.. 192 91930.. 19311932.. 1933.. 1934. COLO RED 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1 Compiled from figures supplied by the M emphis D epartm ent o f Health. T a b l e 21.—Mortality in certain periods of the first year of life 1 among infants born to residents of entire city, of old city, and of annexed territory; Memphis, Tenn., 1930-32 2 Period o f life Entire city Old city Annexed territory TOTAL 9 0 .2 51.5 82.5 49.1 111.1 5 7 .8 6 3 .7 4 0 ,4 6 0 .9 4 0 .2 7 1 .9 40 .8 127.6 67.1 115.0 62.5 157.3 7 8 .0 W H IT E COLO RED 1 Deaths per 1,000 live births. . , -. , , i Com piled from figures supplied b y the M emphis Department o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX 93 2 .-----T A B L E S T a b l e 22.—Average monthly number of cases receiving general public relief and average monthly relief per case during 1934 in Memphis and certain other urban areas included in the Children's Bureau summary of monthly relief trends Average m onthly number o f cases Area included State and urban area Per 10,000 population Number T a b l e 23 .—Place 12,994 22,403 27,274 IS, 599 11, 380 14,103 13, 362 11,385 3, 381 6 ,9 0 4 12,258 17,667 6,1 6 6 13,192 13,679 23,649 County. A rea__ C ou n ty. _____do. _____d o . _____d o . _____d o . C it y ___ _____d o . County. _____d o . _____d o . C it y ... _____d o . County. _____d o . Akron, O hio_____ Atlanta, G a _____ Birmingham, Ala Colum bus, O h io . Dallas, T e x _____ Denver, C olo___ H ouston, T e x ___ Jersey C ity, N . J Louisville, K y ___ M em phis, T e n n .. Oakland, Calif__ Portland, Oreg _ _ Providence, R . I . Rochester, N . Y . St. Paul, M in n . . Toledo, O h io____ Average monthly relief per case $21.12 462.0 652.5 632.1 432.0 3 4 9 .4 489 .9 371.9 359.5 109.9 225.3 431.5 522.3 243.7 402.0 477.1 813.5 17. 73 12.87 19.95 13.38 26.00 13.34 26.24 20.65 A J . Jw 22. 54 31.91 38.60 28. 87 18. 63 of birth and attendant at birth of infants born alive in Memphis, Tenn., 1930-34 » Live births. 1931 1930 Place of birth and attendant at birth 1934 1933 1932 Num ber Per cent dis tribu tion Num ber Per cent dis tribu tion Num ber Per cent dis tribu tion N um ber Per cent dis tribu tion Num ber Per cent dis tribu tion T o ta l..................... 4,900 100 4,761 100 4,616 100 4,249 100 4,620 100 H o s p it a l - - .__________________ 2, 814 57 2,916 61 2, 877 62 2.661 63 2,931 63 M em phis G eneral__________ Other hospitals_____________ H om e_________________________ 868 1,946 2,0 8 6 18 40 43 977 1,939 1,845 21 41 39 1,172 1,705 1,739 25 37 38 1,088 1,573 1,588 26 37 37 1,069 1,862 1,689 23 40 37 Physicians________ _______ W h ite___________________ M em phis General_____ Other physicians______ M idw ives__________________ 1,922 1,578 725 853 344 164 39 32 15 17 7 3 1,751 1,440 737 703 311 94 37 30 15 15 7 2 1,663 1,435 876 559 228 76 36 31 19 12 5 2 1,542 1,343 855 488 199 46 36 32 20 11 5 1 1,638 1,421 1,029 392 217 51 35 31 22 8 5 1 ' White...................... 3,108 100 3,045 100 2,804 100 2,581 100 2,793 100 H ospital______________________ 2, 224 72 2,294 75 2,138 76 1,956 76 2,215 79 Memphis General__________ Other hospitals-------------------H om e_______ - ________________ 282 1,942 884 9 62 28 359 1,935 751 12 64 25 438 1,700 666 16 61 24 388 1,568 625 15 61 24 359 1,856 578 13 66 21 Physicians (w hite)_________ Memphis Oeneral_____ Other physicians________ M idw ives------- ----------------- 873 81 792 11 28 3 25 ( 2) 740 98 642 11 24 3 21 ( 2) 657 147 510 9 23 5 18 ( 2) 621 198 423 4 24 8 16 ( 2) 575 227 348 3 21 8 12 Colored................... 1,792 100 1,716 100 1,812 100 1,668 100 1,827 100 - 590 33 622 36 739 41 705 42 716 39 M emphis General- _______ Other hospitals____________ H om e________________________ 586 4 1,202 33 ( 2) 67 618 4 1,094 36 ( 2) 64 734 5 1,073 41 ( 2) 59 700 5 963 42 ( 2) 58 710 6 1,111 39 (*) 61 1,049 705 644 61 344 153 59 39 36 3 19 9 1,011 700 639 61 311 83 59 41 37 4 18 5 1,006 778 729 49 228 67 56 43 40 3 13 4 921 722 657 65 199 42 5_5j 1,063 846 43 802 39 4 44 12 217 48 3 58 46 44 2 12 3 H ospital___________________ Physicians__________________ W h ite ............ .................— Memphis General_____ Other physicians_____ M id w ives. ________________ ( 2) 1 Compiled from figures supplied b y the Memphis Department o f Health and annual reports o f the M em phis General H ospital obstetric service. J Less than 1 percent. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 94 IN F A N T T a b l e 24.—Percentage M O R T A L IT Y IN M E M P H IS of deaths in the first month of life, by place of death; Memphis, Tenn., 1933-34 1 Deaths in first month W hite Total Colored Place o f death Number Percent distribu tion T o ta l----------------------------------------- 616 H ospital______________________ ________ Percent distribu tion Number Percent distribu tion Num ber 100 319 100 297 543 88 294 92 249 84 Memphis General______ _______ Other hospitals___________________ 368 175 60 28 120 174 38 55 248 1 84 H om e_________________________________ 73 12 25 8 48 16 100 1 Com piled from figures supplied b y the M emphis D epartm ent o f Health. 2 Less than 1 percent. T a b l e 25.—Mortality in certain periods of the first month of life 1 by place of death; Memphis, Tenn., 1933-34 2 First month First week Place o f death Total Total Total___________ ____________ _____ ______ H ospital__________ _________________________________ Memphis General________ ____________ _____ Other hospitals__________ ___________________ H om e__________________________ __________________ First day Second to sixth day Second week to first month 69.5 39.4 23.8 15.6 30.1 97.1 170 .6 50.9 22.3 55 .3 8 3 .0 3 7 .8 12.2 3 3 .8 50.1 2 3 .6 6 .7 21.5 32.9 14.3 5 .5 41.8 8 7 .6 13.1 10.1 White______________________________ 59.4 38.9 24.4 14.5 20.5 H ospital________________________________ ________ Memphis G eneral_____________________________ Other hospitals___________________________ ____ H om e_____________________________________ ________ 70.5 160.6 5 0 .8 2 0 .8 46 .0 84.3 37.7 14.1 28. 5 52. 2 23 .4 10.0 17.5 32.1 14. 3 4 .2 24.5 76.3 13.1 6 .7 Colored____________________________ _____ H ospital___________________________________________ Memphis General_____________________________ Other hospitals________ ____________________ H om e_________________________________ ___________ 85.0 40.1 22.9 17.2 44.9 175. 2 175.9 (*) 23 1 82.3 82.3 (3) 11.1 49. 3 4 8 .9 (3) 4 .8 33.1 33.3 (3) 6 .3 9 2 .9 9 3 .6 (3) 12.1 1 Deaths per 1,000 live births. 2 Com piled from figures supplied b y the M em phis Department o f Health. 3 R ate n ot shown because number o f live births was less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX T a b l e 26. 2 .-----T A B L E S 95 Percentage of live births in Memphis attended by physicians of the Memphis General Hospital obstetric service, 1930— 34 1 Live births Attended b y M emphis General H ospital obstetric service Total Total Num ber In hospital Percent Num ber I n home Percent Number Percent TOTAL 1930....................... 1931________________ 1932.............................. 1933____________ 1934..................... 4,900 4,761 4,6 1 6 4,249 4,6 2 0 1, 593 1,714 2,048 1,943 2,098 33 36 44 46 45 868 977 1,172 1,088 1,069 18 21 25 26 23 725 737 876 855 1,029 15 15 19 20 22 3,108 3,045 2,804 2,581 2,793 363 457 585 586 586 12 15 21 23 21 282 359 438 388 359 9 12 16 15 13 81 98 147 198 227 3 3 5 8 8 1,792 1,716 1, 812 1,668 1,827 1,230 1,257 1,463 1,357 1,512 69 73 81 81 83 586 618 734 700 710 33 36 41 42 39 644 639 729 657 802 36 37 40 39 44 W H IT E 1930__________ _____ 1931_______________ 1932................................ . 1933..................................... 1 9 3 4 ......................... C O LO R E D 1930..................................... .. 1931_____________________ 1932................... ..................... 1933____________________ 1934_______ _______ 1 Com piled from annual reports o f the Memphis General Hospital obstetric service. T a b l e 27.—Deliveries in hospital and in home by Memphis General Hospital obstetric service and registration at prenatal clinic, 1930— 34 1 A ll deliveries Registered at clinic Year Hospital deliveries N ot registered at clinic Total Registered at clinic N ot registered at clinic Num ber Per cent Num ber Per cent Total H om e deliv eries * Num ber Per cent Num ber Per cent 1,704 1,795 2,155 2,041 2, 245 1,497 1,581 1,895 1,797 2 ,0 2 9 88 88 88 88 90 207 214 260 244 216 12 12 12 12 10 947 1,041 1,263 1,167 1,197 740 827 1,003 923 981 78 79 79 79 82 207 214 260 244 216 21 21 21 18 757 754 892 874 1,048 375 467 597 597 620 284 365 466 467 522 76 78 78 78 84 91 102 131 130 98 24 22 22 22 16 275 353 448 399 392 184 251 317 269 294 67 71 71 67 75 91 102 131 130 98 33 29 29 33 25- 114 149 1,329 1,328 1,558 1, 444 1,625 1,213 1,216 1,429 1,330 1,507 91 92 92 92 93 116 112 129 114 118 9 8 8 8 7 672 688 815 768 805 556 576 686 654 687 83 84 84 85 85 116 112 129 114 118 17 16 16 15 15 657 640 743 626 820 TO TAL 1930_____ _________ 1931______________ 1932........................... 1933................ .......... 1934______ ________ 22 W H IT E 1930........................... 1931______________ 1932........................... 1933.......................... 1934.................... .. 1Q 8 228 COLO RED 1930........................... 1931______________ 1932_______ _______ 1933........................... 1934______ ________ * Com pijed from annual reports o f the M em phis General H ospital obstetric service. 1 A ll registered at clinic. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 96 T IN F A N T M O R T A L IT Y a ble 28.—Live IN M E M P H IS births to mothers registered and to mothers not registered at the prenatal clinic of the Memphis General Hospital, 1932— 34 L ive births T o mothers registered at prenatal c u n ic a Year T o mothers not registered at prenatal clinic Total » Num ber Percent Number Percent TO TA L 1932____________ ________________ 1933........................ ....................... 1934____________________ 4,6 1 6 4,249 4,620 1,821 1,733 1,952 39 41 42 2,795 2,516 2,668 61 59 58 2,804 2,581 2,793 460 460 510 16 18 18 2,344 2,121 2,283 84 82 82 1,812 1,668 1,827 1,361 1,273 1,442 75 76 79 451 395 385 25 24 21 W H IT E 1932......................................... 1933............................................................. 1934............................................................. C O LO R E D 1932........................................................... 1933........................ ........ .............................. 1934............................ ............ ........ ............ 1 Compiled from figures supplied b y the M emphis Departm ent o f Health. a Com piled from annual reports o f the Memphis General Hospital obstetric service. T a b l e 2 9.—Month of pregnancy in which patient first attended prenatal clinic of Memphis General Hospital, 1926,1929, and Jan. 1-Apr. 30,1934 Patients registered M onth o f pregnancy o f first attendance 19261 19291 Jan. 1-A pr. 3 0 ,1934 a Number Percent distri bution Number Percent distri bution Number Total................................... 858 100 1,394 100 3 1,712 100 First and second m onths______________ Third m onth__________________________ Fourth m onth_______ ________________ Fifth m onth_______________________ _ . Sixth m onth__________________________ Seventh m onth________________________ Eighth m onth_________________________ N inth m onth__________________________ 15 24 48 77 114 179 202 199 2 3 6 9 13 21 24 23 67 82 143 202 297 278 197 128 5 6 10 14 21 20 14 9 252 222 303 310 301 200 98 26 15 13 18 18 18 12 6 2 Percent distri bution White............................................ 220 100 340 100 377 100 First and second m onths______________ Th ird m onth__________________________ Fourth m onth_________________ _______ F ifth m on th ___________________________ Sixth m onth__________________________ Seventh m onth________________________ Eighth m onth________ _____________ N inth m onth__________________________ 6 5 11 16 26 43 52 61 3 2 5 7 12 20 24 28 25 23 37 41 53 65 50 46 7 7 11 12 16 19 15 14 35 56 57 56 66 60 33 14 9 IS 15 15 18 16 9 4 Colored................................ 638 100 1,054 100 1,301 100 First and second m onths. ____________ Third m onth__________________________ F ourth m onth____________ ___________ Fifth m on th ___________________________ Sixth m on th __________________________ Seventh m onth________________________ Eighth m onth_________________________ N inth m onth__________________________ 9 19 37 61 88 136 150 138 1 3 6 10 14 21 24 22 42 59 106 161 244 213 147 82 4 6 10 15 23 20 14 8 213 165 244 251 225 134 58 11 16 13 19 19 17 10 4 1 1 Survey o f Health Problems and Facilities in Memphis and Shelby County, Tenn., for the Y ear 1929; made for the com mittee on administrative practice o f the American Public Health Association. a Com piled from figures supplied b y the prenatal clinic o f the Memphis General Hospital. 3 Includes 34 patients for whom color was not reported. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX 2 .-----T A B L E S 97 T a b l e 30.—Number of patients attending prenatal clinic of Memphis General Hospitalt total number of visits, and average number of visits per patient, 1923-341 Patients attending prenatal clinic Year 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. Total number o f visits to clinic Average number o f visits per patient 942 1,383 1,535 1,455 1,726 1,695 1,835 2,029 2,165 2,365 2,469 2,755 2 .1 2.2 2 .4 2 .7 2 .5 2 .7 2.6 2.6 2.8 2 .9 3.1 3 .2 1 Compiled from figures supplied b y the public health nursing division o f the Memphis Departm ent o f Health. T a b l e 31.—Maternal mortality;1 Memphis, Tenn.,1927— 342 ►eral Year Puerperal septicemia 1 Other puer peral causes 1927. 19281929. 1930. 1931.. 1932.. 1933.. 1934.. 122 165 160 114 108 133 108 139 66 79 61 43 72 48 55 57 57 86 99 71 36 85 53 83 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 94 145 152 87 92 111 110 119 54 80 66 26 79 36 51 54 40 65 87 61 13 75 59 65 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 168 202 174 161 136 166 104 170 84 78 52 72 59 66 61 60 84 124 123 89 77 100 43 110 1 Deaths assigned to puerperal causes per 10,000 live births. 3 Compiled from figures supplied b y U. S. Bureau o f the Census. T a b l e 32.—Maternal mortality; 1 Memphis, Year Tenn., 1927— 30 and 1931—342 A ll puerperal causes Puerperal septicemia Other puer peral causes TO TAL 1927-30___________________ ______________________ ___________ _ 1931-34.......................... ............................................... ..................... .. 140 122 61 58 78 64 119 108 56 56 63 • 52 176 145 72 62 104 83 W H IT E 1927-30............................... ......................... .......... ................................ 1931-34................................................................. .................................. COLO RED 1927-30................................................ .................................. ................. 1931-34.................................................................................................. .. 1 Deaths assigned to puerperal causes per 10,000 live births. 1 Compiled from figures supplied b y U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 98 T IN F A N T a ble M O R T A L IT Y IN M E M P H IS 33.—Maternal mortality 1 in cities with 250,000 to 350,000 ‘population and by color for cities with 25,000 or more colored population, 1927-342 1927 C ity W hite W hite W h ite ' _________________ __________________ 1929 1930 1934 1933 1932 1931 92 75 104 98 118 90 96 103 83 51 104 80 149 78 95 69 148 63 92 78 117 41 61 54 73 73 74 70 82 104 89 129 122 108 142 144 143 146 113 111 117 125 81 198 107 76 151 82 71 95 93 77 114 98 79 79 106 101 121 99 79 58 151 76 75 68 99 122 96 71 92 101 79 78 52 145 58 74 59 113 49 54 50 85 67 73 61 160 45 64 64 64 63 77 70 124 69 82 78 108 62 85 84 92 41 74 61 148 41 78 74 101 122 94 168 165 145 202 160 152 174 114 87 161 108 92 136 133 111 166 108 110 104 139 119 170 66 60 76 54 51 90 64 52 74 86 72 102 31 57 101 53 50 95 38 49 75 60 57 86 57 37 59 39 53 85 48 41 57 45 60 57 31 55 62 47 74 86 47 63 80 48 62 73 - ...................... W Eite ' ....... ..........................- 1928 1 Deaths assigned t o puerperal causes per 10,000 live births, a Com piled from figures supplied b y U. S. Bureau o f the Census. * Colorado and Georgia were adm itted to the birth-registration area in 19Z8. Texas was adm itted t o the birth-registration area in 1933. t T a b l e 34.—Maternal mortality 1 in cities with 250,000 to 350,000 population reporting throughout the period 1931-34 2 City All puerperal causes Memphis, T en n .. Birmingham, Ala. Columbus, O h io.. Denver, C o lo ____ Atlanta, G a _____ Louisville, K y ___ Toledo, O hio____ Akron, O h io _____ Providence, R . 1. St. Paul, M in n ... Jersey C ity, N . J Portland, O re g ... Oakland, C a lif .. Rochester, N . Y . 1 Deaths assigned t o puerperal causes per 10,000 live births. * Com piled from figures supplied b y U. S. Bureau o f the Census. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Puerperal septicemia 122 102 99 82 81 80 75 65 64 62 53 49 46 44 58 42 47 44 36 39 36 29 29 33 24 16 19 19 Other puerperal causes 64 60 52 38 45 41 40 35 35 29 29 33 27 26 A P P E N D IX 99 2 .-----T A B L E S T a b l e 35.—Maternal mortality 1 in cities with 250,000 to 350,000 population and 25,000 or more colored population reporting throughout the period 1931—342 A ll puerperal causes C ity Puerperal septicemia Other puerperal causes TO TAL Memphis, T en n __________________ Birmingham, A la _________________ Atlanta, G a ______________________ Louisville, K y ____________________ 122 102 81 80 58 42 36 39 64 60 45 41 108 76 74 68 56 31 36 22 52 46 39 46 145 139 113 104 62 59 58 60 83 80 55 43 W H IT E M em phis, T en n __________________ Birmingham, A la _________________ Louisville, K y ____________________ Atlanta, G a ______________________ CO LO RED M em phis, T e n n ___________________ Birmingham, A la __________________ Louisville, K y ______________________ Atlanta, G a ________________________ 1 Deaths assigned t o puerperal causes per 10,000 live births. 2 Compiled from figures supplied b y U. S. Bureau o f the Census. T 36.—Live births, maternal mortality,1 stillbirth mortality, and premature births among clinic and among nonclinic patients delivered by the Memphis General Hospital obstetric service, 1932—34 2 a ble Deaths assigned to puerperal causes Registration at clinic Number Total...................................................... Clinic patients___ __ __________ N onclinic patients_______________ White......................................... Clinic patients__________ :________ N onclinic patients___ ________ Colored...................................... Clinic patients_____________________ N onclinic patients__________ Stillbirths Premati] re births Rate per R ate per R ate per 10,000 1,000 1,000 Num ber N um ber live live live births births births 70 115 230 38 361 59 6,081 26 44 47 765 167 63 30 110 282 79 51 137 5, 506 575 18 108 36 21 92 53 1,747 3 15 21 473 ■ 52 120 62 4,334 23 29 1,124 (3) (3) 194 (3) (8) 45 (8) (•) 1 Deaths assigned t o puerperal causes per 10,000 live births. * Compiled from annual reports o f the Memphis General Hospital obstetric service. 9 Inform ation not available. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Live births 269 (8) (*) *’ 258 100 T a ble IN F A N T 37.—Mortality from M O R T A L IT Y IN M E M P H IS stillbirths and in the first day of life;1 Memphis, Tenn., 1927-34* M ortality rates from - Year Stillbirths and deaths in the first day 6 1 .9 5 8 .8 59.0 55.1 48.5 46.1 50.9 43.9 26.9 27.2 32.7 27.9 2 6 .7 28.2 25.1 6 6 .4 57.2 70.3 62.5 55.5 55.5 68.3 51.1 4 0 .7 34.7 4 0 .8 34.8 2 9 .4 3 2 .6 4 1 .6 28 .8 2 5 .8 22 .4 2 9 .4 2 7 .7 26.1 22.9 26.7 22.3 97.1 28 .8 35.8 38.8 28.4 27.8 36.5 86.0 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 125.9 137.9 131.8 118.5 110.5 103.4 1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. Deaths in first day 9 1 .7 83.0 75.2 74.3 76.0 66.5 88.9 1927. 19281929. 193019311932. 1933. 1934- > Stillbirths 22.6 102.1 9 3 .0 90 .2 82.7 6 6 .9 65 .4 67 .0 88.1 9 0 .0 22.6 23.1 1 R ate per 1,000 live births. — , , „ . 2 Com piled from figures supplied b y U. S. Bureau o f the Census. T a b l e 38 —Stillbirth mortality,1 by place of birth and attendant at birth; Memphis, Tenn., 1927-34 2 Place o f birth and attendant at birth 1927 1928 1929 1930 1931 1932 1933 1934 43.5L 62.7 59.3 60.5 52.4 51.7 46.6 51.1 H ospital----------------------• Memphis G eneral-. Other hospitals-----H om e_________ ________ W hite physicians.-. Colored physicians. M idw ives__________ 65.2 81.1 55.0 59. 5 39.9 130.3 7 4 .6 6 6 .4 97.9 47.2 4 9 .8 31.2 138.9 53.7 5 6 .4 67 .9 5 0 .4 67.1 40.1 158.1 145.0 51.9 80.6 39.1 53 .2 32.3 139.5 73.2 4 8 .7 74.7 3 5 .6 5 6 .4 34 .7 147.9 ( 3) 51.8 75.9 35.2 38.0 30 .7 78.9 ( 3) 53.4 62.5 47.0 47.2 43 .2 70.4 ( 3) 44.0 68. 3 30.1 42. 6 26.7 152.1 ( 3) White............. 40.8 35.3 41.5 33.5 31.2 32.8 42.2 28.6 49.9 48.5 50.1 24.0 24 .6 42.2 38.9 4 2 .9 22.0 2 2 .4 47.4 35.1 49.3 26.1 26.5 38.2 39.0 38.1 21.5 2 1 .8 34.0 27.9 35.1 2 2 .6 23.0 34.1 34.2 34.1 28.5 28.9 4 4 .0 33.5 46. 6 36.8 3 5 .4 ( 3) 31. 2 4 7 .4 28.0 19.0 19.1 99.3 102.3 95.9 85.4 67.9 64.7 66.2 103.2 93.5 ( 3) 96.3 74. 5 130.3 84.3 132.9 123.3 ( 8) 79 .6 4 8 .7 138.9 6 0 .6 85.1 82.2 ( 3) 103.9 61.5 158.1 159.7 103.4 100.7 (?) 76.5 45 .4 139. 5 7 8 .4 102.8 100.8 ( 3) 4 3 .8 32.1 78.9 ( 3) 79 .4 7 8 .6 ( 3) 5 4 .0 4 9 .9 7 0 .4 ( 3) 83.8 7 8 .9 ( 3) 5 4 .9 3 1 .9 152.1 (?) Total............... H ospital-----------------------Memphis G eneralOther hospitals-----H om e_________ ________ White_ physicians- M idw ives_________ Colored.......... H ospital-----------------------Memphis G eneralOther hospitals----H om e_________ ________ W hite physicians-Colored physicians. M idw ives_________ 88.Q 102.9 101.9 ( 3) 79.5 47.1 147.9 1 Stillbirths per 1,000 live births. „ . 2 Com piled from figures supplied b y the Memphis Department of Health, s R ate not shown because number o f live births was less than 100. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis (3) 101 A P P E N D IX 2.---- TABLES T a b l e 3 9 . —Place of death of infants dying in certain periods of thefirst year of life who were born to resident and to nonresident mothers in Memphis, Tenn., 1934 1 Place o f death Total....................... H ospital_____________________ First year First month Nonresident Resident Total Second to twelfth month First year First month Second to twelfth month First month First year Second to twelfth month 316 201 354 232 122 163 84 79 427 273 154 271 192 79 156 81 75 289 138 189 84 100 54 212 59 144 48 68 11 77 79 45 56 32 43 90 43 47 83 40 43 7 3 4 517 White...................... 258 160 98 140 97 43 118 63 55 Hospital-._______________ 232 146 86 114 83 31 118 63 55 95 " 137 62 84 33 53 56 58 35 48 21 10 39 79 27 56 12 43 26 14 12 26 14 12 Colored................... 259 156 103 214 135 79 45 21 24 H ospital_____________________ 195 127 68 157 109 48 38 18 20 194 1 127 67 1 156 1 109 47 1 38 18 20 64 29 35 57 26 31 7 3 4 1 l Com piled from figures supplied b y the Memphis Departm ent o f Health. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T able 40 .—Place of birth of infants dying in certain periods of the first year of life in Birmingham, Ala., 1930— 34 1 .............................................................. - ........... 1 ■; ■ t— 1 ■■ ------ O to Infants dying in first year o f life Total In first month In second to twelfth month Year Born in city Born elsewhere Born in city m Percent Number Percent Born in city Born elsewhere Total Num ber Percent Number Percent Number Percent Number Percent TO TAL 1930...................................................................... 1931................................. ................................__ 1932...................................................................... 1933..................................................................... 1934........... .............. _......................... .............. 404 336 322 320 366 .364 306 289 285 334 90 91 90 89 91 40 30 33 35 32 10 9 10 11 9 255 216 205 205 231 252 214 201 197 227 99 99 98 96 98 3 2 4 8 4 1 1 2 4 2 149 120 117 115 135 112 92 88 88 107 168 171 142 143 170 136 149 119 117 143 81 87 84 82 84 32 22 23 26 27 19 13 16 18 16 106 119 96 98 110 103 118 92 91 106 97 99 96 93 96 3 1 4 7 4 3 1 4 7 4 62 52 46 45 60 33 31 27 26 37 236 165 180 177 196 228 157 170 168 191 97 95 94 95 97 8 8 10 9 5 3 5 6 5 3 149 97 109 107 121 149 96 109 106 121 100 99 100 99 100 1 1 1 1 75 77 75 77 79 37 28 29 27 28 25 23 25 23 21 53 60 (») 62 29 21 19 19 23 61 90 7 10 62 70 89 93 8 11 W H IT E 1930............................................................ 1931._____________________________________ 1932...................................................................... 1 9 3 3 ........... ........ ............................................... 1934______________ _________ __________ _ (2 ) 47 40 (J) (*) 38 IN C O LO R E D 1 Compiled from figures supplied by the Birmingham Department o f Health. 2 Percent not shown because number o f deaths was less than SO. https://fraser.stlouisfed.org # Federal Reserve Bank of St. Louis 87 68 71 70 75 For corresponding figures for M em phis, Tenn., see table 17, p. 90. M E M P H IS 1930______ _________________ ______________ 1931................................................................... .. 1932...................................................................... 1933______________________________________ 1934__________________________________ IN F A N T M O R T A L IT Y Number Born elsewhere , A P P E N D IX 103 2 .---- T A B L E S T a b l e 41.—Mortality in certain periods of the first year of life 1 among all infants dying in the city and among infants born in Birmingham, Ala., 1930-34 2 Year Total Colored W hite Total Born in city Total Bora in city Total Born in city FIRST YEAR 1930 ......................... ................................. 1931 1932 ______ _______ 1933 1934................................................................ 7 7 .7 65. S 6 4 .9 70.5 77.3 7 0 .0 5 9 .6 58.3 6 2 .7 7 0 .6 5 4 .7 53.1 4 8 .9 56.5 62 .5 44.3 46.3 4 1 .0 4 6 .2 5 2 .6 110.8 86.3 87.5 88.1 97.5 107.0 82.1 82. 7 83.6 9 5 .0 FIRST MONTH 1930 ________________ 1931 ................................. 1932 ______ _______ 1933 1934................................................................ 4 9 ,0 42.1 41 .3 45.1 4 8 .8 4 8 .5 4 1 .7 40.5 4 3 .4 4 8 .0 34.5 3 7 .0 33.1 38.7 4 0 .4 33 .6 36.7 31.7 35.9 39.0 7 0 .0 50.7 53.0 53.3 6 0 .2 70.0 50.2 53.0 52.8 60.2 30.1 2 4 .4 24 .6 26.5 30.0 22.7 18.7 18.5 20.3 2 3 .8 20 .9 16.8 16.4 18.5 2 3 .0 I 'L l 10.0 9 .6 10.7 14.2 4 3 .9 37.4 36.5 36.8 39.7 39.9 33.6 31.3 32.6 3 7 .0 8ECOND TO TWELFTH MONTH 1930 ....... ..................... ................................. 1931 1932 ________________ 1933 ....... ............ ........ 1934. — ------------- -------------------------------- I fir s t year and first m onth, deaths per 1,000 live births; second to twelfth month, deaths per 1,000 infants surviving the first month o f life. . _ . „ , , c c f 1 Com piled from figures supplied b y the Birmingham Department o f Health. For corresponding figures for M em phis, Tenn., see table 18, p. 91. o 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 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
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