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U. S. DEPARTMENT OF LABOR JAMES J. DAVIS. Secretary CHILDREN’S BUREAU GRACE ABBOTT. Chief INFANT MORTALITY AND PREVENTIVE WORK IN NEW ZEALAND By R O B E R T M O R S E W O O D B U R Y . P h. D . Bureau Publication N o. 105 WASHINGTON GOVERNMENT PRINTING O FH CE 1922 U, *5 https://fraser.stlouisfed.org t>*>" Federal Reserve Bank of St. Louis Owing to limited appropriations for printing, it is not possible to distribute this bulletin in large quantities. AD D IT IO N AL COPIES OF THIS PUBLICATION M A T BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D . C AT 10 CENTS P E R COPY https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 3 b>-l Le *5 # i CONTENTS. Page. Letter o f transmittal___________________ \ Infant mortality in New Zealand and elsewhere____________________________ 1 -7 Comparison with the United States_____________________________________ 2 Comparison with American cities studied by theChildren’s Bureau__ 4 Analysis of statistics of infant mortality, New Zealand____ ;___________ 8-12 Decline in infant mortality, 1872-1919_________________________________ 8 Decline in infant mortality in cities__________________________________ 8 Decline in infant mortality, by cause of death__________________ 9 Birth and death registration___________________________ 13-16 Notification and registration of births_________________ ________________ 13 Registration of deaths___________________________________________________ 14 Completeness of birth and death registration_____________ ;____._______ 14 Relation between general conditions and infant mortality_________________ 17-27 C lim ate_______________________________ 47 19 Racial composition of population---______________________ '_______________ L iteracy_______________________________________________ 20 Density and distribution o f population in city and country_________ Housing congestion_________ ^_____________________________________________ Birth rate— _____________________________________________ Proportion of illegitimate births________________________________________ Economic level o f the population______________________________________ ÿ. 20 21 23 24 24 Government activities relating to the welfare o f mothers and infants____ 27-46 General health protection_________________________________________________ 28-31 Organization o f the department o f health__________________________ 28 Sanitation and prevention o f infectious diseases— _____________ 29 30 Social hygiene_____ 1____________________ ____________________________ Government aid in health protection_______________________________ 30 Regulation of medical and nursing services____________________________ 31-35 Registration of medical practitioners_____________________ 31 Registration of nurses_______________ 33 * Registration o f midwives_____________________________ 33 H osp itals________________________________ 35-38 St.. Helen’s Maternity Hospitals____________________________________ 35 . Public general hospitals_____________________________________________ 37 Private hospitals_________________________ i __________ ._____ _________ ' 37 Control over milk supply________________________________ 38-41 Regulation of production of milk___________________________________ 38 Regulation of sale of milk_________ _____________________^_____________ 39 Wellington municipal m ilk ______________ 49 Maternity allowances_____________________________________________________ 44 43 Regulation o f boarding homes for infants__________ h i https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IV ILLUSTRATIONS. Royal New Zealand Society for the Health o f Women and Children_____ 46-52 Aim s and objects_______________ 46 Membership_________________ 47 Local committees_________________________;________________________________ 47 47 Central organization______ ______________________________________ '________ Training of nurses_________ 48 Kinds of work____________________________ ;___________________________ *____ 49 51 Extent of w o rk ___________________ ; _____„_________________________________ Conclusion_____________ : ________— ___________________________________________ 52 Appendixes____________________________________________ _______________ _________ 55 Appendix A.— Extracts from “ Report on the W ork of the Royal New Zealand Society for the Health o f Women and Chil dren ” ___________________________________________________ 57 B.— Regulations regarding storage and sale of milk________ 62 G EN ERAL TABLES. Table 1. Births, infant deaths, and infant mortality rates, by cause of death, New Zealand, 1872-1919-______________ I__________________ 2. Infants under 1 year of age in foster homes at beginning of year, and admissions and withdrawals during year, 1908-19183. Decline in death rate among children under 6 years o f age in foster homes, 1908-1918__________________________________________ 4. Infants under 1 year of age in exempted institutions at begin ning of year, and admissions during year, 1908-1918_____ _ 5. Decline in death rate among children in exempted institutions, 1909-1918___________________________________________________________ 6 . Medical practitioners on register, New Zealand, 1914-1919____ 7. Proportion of breadwinners in the population 10 years o f age and over,, by sex and age, New Zealand, 1916__________________ 8 . Economic status of breadwinners, by occupation group and sex, New Zealand, 1916____________________________________ 9. Proportion of illegitimate births, New Zealand, 1877-1919_____ , 67 ^ 70 V 70 70 71 71 71 72 72 CHARTS. :C ^ Chart I. Infant mortality rates, New Zealand and United States birthregistration area as a whole, Minnesota, and Pennsylvania, 1 9 1 9 ______________________________________ 1 _____________________ _ II. 2 Infant mortality rates, by cause o f death, New Zealand and United States birth-registration area as a whole, Minne sota, and Pennsylvania, 1919__________________________ III. Infant mortality rates, New Zealand and American cities studied by the Children’s Bureau_________ \_____________________________ J. IV . Infant mortality rates from principal causes, New Zealand and American cities studied by the Children’s Bureau___.____ 5 6 IL L U S T R A T IO N S . The St. Helen’s Hospital, Wellington, New Zealand_______________ Facing page 36 View of the grounds. St. Helen’s Hospital, Wellington, New Zealand____ Facing page 37 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis \L L E T T E R O F T R A N S M IT T A L . U . S. D epartment of L abor , C h il d r e n ’ s B u r e a u , Washington, February 9, 1922. There is transmitted herewith a report on Infant Mortality and Preventive Work in New Zealand, by Robert Morse Woodbury, Ph. D. As the infant mortality rate in New Zealand is lower than in any other country in the world and about half that in the United States birth-registration area, it is believed that this analysis o f condi tions in New Zealand will be read with interest by many Americans. Material on which the report is based was secured by Dr. Woodbury during a recent visit to New Zealand. Acknowledgment is made o f the very generous assistance o f the health department, the department o f education, the census and sta tistics office, and other Government agencies of New Zealand, as well as o f the Royal New Zealand Society for the Health of Women and Children in furnishing documents and information for use in pre paring the report. Respectfully submitted. Sir : G r ace A Hon. J a m e s J . D a v is , Secretary of Labor. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis bbott , Chief. ■ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INFANT MORTALITY AND PREVENTIVE WORK IN NEW ZEALAND. IN F A N T M O R T A L IT Y IN N E W Z E A L A N D A N D E L S E W H E R E . In 1919 the infant mortality rate for the yvhole of New Zealand, exclusive o f the native, or Maori, population,2 was 45.3 per 1,000 live births. Comparison with similar rates for other countries for the latest available years up to 1919, as given in Table I, shows that New Zealand had a lower infant mortality rate than any other coun try in the world. The rate in the United States in 1919 was 86.6, or nearly twice as high. New Zealand, therefore, possesses great interest for students o f infant mortality. What are the causes of this exceptionally low in fant mortality rate? Is it due primarily to health measures and infant-welfare work, or should it be ascribed mainly to especially favorable local conditions? In the following pages an analysis o f the statistics for New Zea land showing the decline in infant mortality from the various causes o f death is presented. The local conditions affecting infant mortal ity are described—those which favor permanently low mortality and those which have become progressively more favorable to low rates. Next an account is given o f various governmental and private health measures, in particular the special measures o f the health and edu cation departments and the work o f the Royal New Zealand Society for the Health o f Women and Children. In conclusion, the relation between these preventive measures and the decline in infant mor tality is discussed. 1 A paper summarizing the material presented in this, bulletin was read a t the annual meeting of the American, Child Hygiene Association a t S t Louis, October, 1920, and is printed in the Transactions o f the Eleventh Annual Meeting o f the American Child Hygiene Association, Oct. 11—18, 1920. 2 Birth and death registration statistics for the Maori population are still in an un satisfactory state. A s Maori are. counted those living as Maoris, i. e., in Maori v illa g e s; Maoris or half-castes who live as Europeans are included in the general statistics. 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 INFANT MORTALITY. T a b l e I .— Infant mortality rates for certain foreign countries and the United States, 1919. Country and year. Infant mortality rate. Chile (1919)___ Hungary (1915). Japan (1918)... Spain (1918)___ Germany (1919) Quebec (1919).. Italy (1917)____ Finland (1919).. France (19x9 . . . Scotland (1919).. Uruguay (1919). Ontario (1919)... 306 264 189 183 145 143 139 135 119 102 101 96 Infant mortality rate. Country and year. Denmark (1919).......................................... England and Wales (1919)................ ] Ireland (1919).............................................. United States (birth-registration area) (1919)............................ f . ....................... . Netherlands (1919)...................................... Switzerland (1919).................................... ]. Sweden (1916)............................................ ~ Australia (1919)......................................... Norway (1917).............................................. New Zealand (1919).................................... 1 Spumes; Statistical yearbooks or other official publications of the different countries. for 1919, or for latest available year. 92 89 88 87 84 82 70 69 64 45 Figures are given Comparison with the United States. In Table I I comparative infant mortality rates are shown by causes o f death for New Zealand and for the United States birth-registraCHART I. IN FA N T M O R T A L IT Y RATES, NEW ZEALAND AN D U N IT E D STATES BIRTHR EGIS TR ATION AREA AS A W H OLE , MIN N E S O TA , AN D PENNSYLVANIA. 1919 100.0 86.6 N EW ZEALAN D B IRTH REGISTRATION ARIA MINNESOTA PENNSYLVANIA tion area in 1919. The differences in rates from the different causes are striking. In the United States the rate from gastric and intes- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 3 N E W ZEALAND. tinal diseases was five and one-half times as high as in New Zealand; while the rate from respiratory diseases was over three times, and that from epidemic diseases exactly six times as high as in New Zealand. New Zealand evidently had the greatest advantage in the rates from these three principal groups o f causes. But even in the groups “ early infancy ” and “ malformations,” differences appear. In the United States the mortality rate from malformations was nearly one and one-half times that in New Zealand, while the rate from causes peculiar to early infancy was one-fifth higher than in New Zealand. The rate from ill-defined diseases in the United States was 2.7 deaths per 1,000 births, while in New Zealand but a single death was so classed. T a b l e II. — Comparative infant mortality rates, by cause of death, N ew Zealand cmd the United States birth-registration area, Minnesota, and Pennsylvania, 1919? Infant mortality rates, 1919. Cause of death. Another...................................................................................................I U .S . birthNew registra Zealand. tion area. Minne sota. Pennsyl vania. 45.3 86.6 67.0 100.0 3.1 3.8 4.6 25.2 1.6 17.1 12.8 6.3 30.8 9.6 2.7 7.3 8.3 8.8 6.2 28.1 7.5 1.5 6.5 24.7 17.8 7.9 30.7 9.7 1.0 8.3 6- 9 1 First column compiled from Statistics of the Dominion of New Zealand, 1919, Vol. I, pp. 53-62; remain der of table compiled from U . S. Bureau of the Census, Birth Statistics, 1919, pp. 37,288, and U . S. Bureau of the Census, Mortality Statistics, 1919, pp. 548, 552. Gastric and intestinal diseases include Interna tional List numbers 102-104; respiratory diseases, 89,91, and 92; malformations. 150; early infancy, 151-153; epidemic diseases, 6-10, 14, 18, 24, 28-35, 37; ill-deflned, 187-189; “ all other’' includes all not otherwise classified. Even in States in the birth-registration area where comparatively favorable conditions prevail, infant mortality was considerably greater than in New Zealand. T o illustrate this point figures are shown for Minnesota, the State which in 1919 had the lowest infant mortality rate for any State in the original birth-registration area established in 1915. To show the contrast within the area, figures are given also for Pennsylvania, which had the highest rate for any State in the original area. In Minnesota the mortality rate from gastric and intestinal diseases was nearly three times, while in Pennsylvania it was eight times, that in New Zealand. The mortality rate from respiratory diseases was over twice as high in Minnesota and nearly five times as high in Pennsylvania as in New Zealand. Similarly for the other causes o f death, in nearly every case Minnesota had a lower https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 IN FAN T MORTALITY. CH ART II.— IN FA N T M O R T A L IT Y RATES, BY CAUSE OF DEATH, N EW ZEALAND AND U N IT E D STATES B IR T H -R E G IS T R A T IO N AREA AS A W H OLE , MIN N E S O TA , AND PENNSYLVANIA, 1919. NEW BIRTH MINNESOTA PENN- ZEALAND REGISTRATION AREA NEW BIRTH MINNESOTA PENN- SYLVANIA ZEALAND REGISTRATION NEW BIRTH MINNESOTA PENN SYLVANIA ZEALAND REGISTRATION AREA GASTRIC AND INTESTINAL DISEASES RESPIRATORY DISEASES SYLVANIA AREA E A R L Y INFANCY rate than Pennsylvania, but the low rate in Minnesota was consider ably higher than the rate in New Zealand. Comparison with Am erican cities studied by the Children’s Bureau. In Table I I I a comparison is presented of the infant mortality rates in New Zealand as a whole and in its four principal cities for the year 1919, and in eight American cities studied by the Children’s Bureau for the years to which the studies referred. It will be noted that the mortality rates o f the four principal cities of New Zealand were only slightly above that for the whole country, and that all these rates were below, and in many cases far below, those in the American cities selected for special study. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 5 NEW ZEALAND. T a b l e I I I .— Comparative infant mortality rates, New Zealand and eight Am eri can cities studied b y the U. S. Children1» Bureau. Locality. Infant mortality rate.1 Locality. 45.3 49.2 59.6 51.8 45.4 A kron.. Johnstown..................................................... 111.2 134.0 .................................................... Infant mortality rate.1 165.0 130.3 96.7 84.6 122.7 85.7 103.5 1 The rates for New Zealand are for 1919; for the American cities studied by the bureau the rates are for births in a single year within the period Nov. 1 , 1912-June 30,1914, except Johnstown, 1911, and Balti more, 1915. In Table I Y these rates are analyzed by cause o f death. This com parison shows that over these American cities, as well as over the en tire United States birth-registration area, New Zealand had the greatest advantage in the mortality from gastric and intestinal disCHART II I.—INFA N T M O R T A L IT Y RATES, NEW ZEALAND AND A M ERIC AN CITI ES STU DIE D BY T H E C H IL D R E N ’S BUREAU. 165.0 NEW AUCKLANDWELLING-CHRIST-DUNEDIN SAGINAWAKRONBROCK- 8ALTI- WATER- NEW JOHNS- MANZEALAND TON CHURCH TON MORE BURY BEDFORDTOWN CHESTER eases. Its advantage was nearly as great in the case o f respiratory diseases. In the rate from causes peculiar to early infancy, on the other hand, New Zealand’s advantage was relatively slight. From gastric and intestinal diseases the mortality in New Zealand in 1919 was 3.1 per 1,000 births, as contrasted with rates averaging 10 times as high in the eight American cities. In Manchester, where the rate was highest, it was 63.3;, in New Bedford it was 48.3; while in the more favorably situated cities, Brockton and Saginaw, it was https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 IN FA N T MORTALITY. 12.4 and 8.2, respectively. New Zealand has evidently reduced its mortality from this group o f causes almost to the minimum possible. T able IV . — Comparative infant mortality rates, by cause of death, New Zealand and eight American cities studied by the U. S. Children’s Bureau. Infant mortality rates. Cause of death. New Eight Zea- . Amer Johns Man ican land, town. chester. 1919. cities.1 New Bed ford. Brock ton. Saginaw. Water- Akron. Baltir more. bury. All causes— . Gastric and intestinal diseases4___ Respiratory diseases. Malformations........... Early infancy........... Epidemic diseases3. . 45.3 111.2 134.0 165.0 130.3 96.7 84.6 122.7 85.7 103.5 3.1 3.8 4.6 25.2 1.6 All other.................... 6.9 32.4 19.6 4.3 36.1 7.1 2.5 9.3 32.8 26.7 3.4 39.6 11.6 7.5 12.3 63.3 26.2 9.0 39.6 3.2 7.0 16.6 48.3 27.8 4.6 29.0 8.9 2.7 8.9 12.4 13.2 5.0 37.2 8.3 5.0 15.7 8.2 10.2 4.1 37.7 5.1 4.1 15.3 41.0 18.2 4.7 38.7 8.4 1.9 9.8 20.4 10.2 4.0 28.9 5.8 4.4 12.0 29.1 19.7 3.6 37.7 6.7 0.6 6.0 1 Studied by the U . S. Children’s Bureau; rates are for births in a single year about 1913, except Johns town, 1911, and Baltimore, 1915. * Includes only International List numbers 102-104. * Includes, besides diseases ordinarily classified as epidemic, tuberculosis and syphilis. C H A R T IV.— IN FA N T M O R T A L IT Y RATES FROM PRINCIPAL CAUSES, NEW ZEALAND AN D AME R IC A N C IT IE S S T U D IE D BY T H E C H IL D R E N ’S BUREAU. 251 £ , ‘1 ! 38 3.1 MEW ZEALAND 8 AMERICA^ CITIES NEW ZEALAND 8 AMERICAN CITIES GASTRIC AND INTESTINAL DISEASES RESPIRATORY DISEASES https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND 8 AMERICAN C IT IE S EARLY INFANCY N E W ZEALAND. 7 The infant mortality rate from respiratory diseases was likewise remarkably low in New Zealand, 3.8 in 1919 as compared with rates ranging from 10.2 in Saginaw and Akron to 27.8 in New Bedford in the years studied. The average for the eight American cities was 19.6, or approximately five times the rate for1New Zealand. In the third important group, causes peculiar to early infancy, the mortality rates were more nearly equal. In New Zealand the rate was 25.2. In Akron it was 28.9, and in New Bedford, 29; but in the other American cities studied it was notably higher— 39.6 in Johns town and Manchester, 38.7 in Waterbury, 37.7 in Saginaw and Bal timore, and 37.2 in Brockton. For all eight cities the average mor tality from causes peculiar to early infancy was 36.1, nearly 11 points higher than in New Zealand. The important, though subordinate, group o f “ epidemic diseases ” showed a decidedly lower mortality in New Zealand than in most of the American cities studied. Thus in New Zealand the mortality rate from this group in 1919 was only 1.6, as compared with an aver age of 7.1 for the eight American cities. In Manchester, however, the mortality from epidemic disease was only 3.2; in Johnstown it was as high as 11.6. Ill-defined causes were practically negligible In New Zealand; as already stated, in 1919 only one death was so classed. For the eight American cities, on the other hand, the average mortality from causes unknown or ill defined was 2.5 per 1,000 births. I f these deaths had been properly assigned to definite causes, the mortality from the definite causes concerned would obviously have been some what higher than shown in the table. The comparisons given are, therefore, somewhat more favorable to the American cities than they would have been if the causes o f death had been definitely diagnosed in as large a proportion o f cases as in New Zealand. The group o f “ all other causes,” including, among others, menin gitis, infantile convulsions, and infantile paralysis, showed a much lower mortality in New Zealand than in the American cities. The only cause o f death which showed a higher rate o f mortality in New Zealand than in the eight American cities was “ malforma tions ” ; and the difference was slight, the rates being 4.6 for New Zea land as compared with 4.3 for the American cities. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 * A N A L Y S IS O F S T A T IS T IC S OF IN F A N T M O R T A L IT Y , N E W ZEALAND. Decline in infant m ortality, 1872-1919. In Table Y is shown the decline in infant mortality in New Zea land from 1872 to 1919. In order to eliminate fluctuations, rates are given for five-year periods. In 1872-1874 the rate was slightly higher than the 1915 rate for the United States. It declined in a period o f 45 years to less than one-half its former size. In the first five-year period the mortality rate declined 4 per cent, and in the next 10 per cent; from this point to about 1899 the fall was relatively slight. A fter 1900 it became more rapid; the five-year period from 1900 to 1904 shows a decline o f 7.7 per cent from the preceding period, while in the last five-year period under considera tion the percentage o f decrease nearly doubled that figure. In interpreting this decrease it should be mentioned that, from the point o f view o f prevention, a fall o f 10 points in the rate o f mortality is more easily secured when the initial rate is 100 than when the initial rate is only 60. The increase in the rate of fall dur ing the period 1910-1919 is, therefore, all the more noteworthy. T able V .— Decline in infant mortality rates, by periods; New Zealand, 1872-1919.1 Period. 1872-1874................... 1875-1879.................. 1880-1884................... 1885-1889................... 1890-1894................... Average annual Amount infant of mortal decrease. ity rate. 105.9 101.5 91.4 86.3 85.6 Per cent decrease. 44 10.1 5.1 .7 4.2 10.0 5.6 .8 Period. 1895-1899 1900-1904 1905-1909 1910-1914 1915-1919..J............. Average annual Amount Per cent infant of mortal decrease. decrease. ity rate. 82.7 76.3 69.6 57.0 48.6 2.9 6.4 6.7 12.6 8.4 3.4 7.7 8.8 18.1 14.7 1 Compiled from General Table I, pp. 67-69. Decline in infant m ortality in cities. Figures showing the decline in infant mortality rates for the four chief cities o f New Zealand from 1904 to 1919 are given in Table VI. In all four cities substantial reductions in the mortality rates took place during this 15-year period. The reductions were greatest in Christchurch, a city o f about 90,000 population in 1916, and in 8 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis * 9 FE W ZEALAND. Dunedin, with approximately 70,000, in both of which the 1919 rate was less than half that in 1904. Substantial reductions were also made in Auckland, with some 135,000 population, and in Wellington, a city o f about 95,000.® In both Auckland and Dunedin the rates o f infant mortality in 1919 were less than 50 deaths under 1 year o f age per 1,000 births. Dunedin had had a low rate for a number of years. Thus in 1909 its rate was 48.5; in 1911, 43.4; in 1912, 38.1; and for the three suc cessive years 1917, 1918, and 1919 its rates were less than 50— 40.2, 46, and 45.4, respectively. The rate for Christchurch during the same three years averaged only 51.3. T a b l e V I. — Decline in infant mortality rates, New Zealand cities, 1904-1919.1 Infant mortality rates.4 Infant mortality rates.4 Year. 1QO£ 1911....................... Year. Auck Well Christ land. ington. church. 70.1 91.5 85.8 97.2 81.9 61.9 79.0 63.0 95.3 96.2 71.9 117.8 81.7 84.2 84.6 73.4 103.0 89.0 74.4 126.2 67.8 62.8 69.4 62.9 Dune din. 93.0 67.1 72.6 95.4 74.5 48.5 79.1 43.4. 1912....................... 1913....................... 1914....................... 1915....................... 1916....................... 1917....................... 1918....................... 1919....................... Auck Well Christ Dune land. ington. church. din. 57.0 80.8 57.6 .71.7 59.2 61.0 57.7 49.2 61.3 60.2 82.6 57.2 65.1 56.6 71.2 59.6 60.0 63.5 68.2 54.2 66.7 49.3 52.8 51.8 38.1 73.4 54:3 72.3 54.7 40.2 46.0 45.4 i Sources: New Zealand Official Year-Book, 1914, p. 169; 1919, p. 163; and Statistics of the Dominion of New Zealand, 1919, Vol. I., p. 86. 4 Cities include suburban boroughs. Decline in infant m ortality, by cause o f death. Turning to the analysis of the fall in infant mortality by cause of death, Table V I I shows infant mortality rates for the several groups o f causes. In order to eliminate minor fluctuations, rates are given, as before, for five-year periods. One o f the most important causes o f decline in the general death rates for all ages since,the seventies of the last century has been the gradual control o f epidemic and infectious diseases. The effect is shown in the group o f diseases classed as epidemic, including scarlet fever, whooping cough, diphtheria, and measles. This group shows for infants in New Zealand a rapid fall from 14.7 in 1872-1874 to 8.8, 7.9, and 6.4, respectively, in the three following five-year periods. In 1890-1894 the rate from these diseases went up to 10.2, probably owing to an epidemic o f influenza, but since then it has fallen to 5.2 in 1900-1904, and to 2.4 in 1910-1914. In 1915-1919 it was 2.5. # s A t tbe census o f Oct. 15, 1916, Auckland had a population, o f 1 3 3 ,7 1 2 ; W ellington, 9 5 ,2 3 5 ; Christchurch, 9 2 ,7 3 3 ; and Dunedin, 6 8,716 within their respective “ metropolitan areas.” New Zealand Official Year-Book, 1919, p. 110. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 T able IN F A N T MORTALITY. Y I I . — Decrease in infant mortality rates, by cause of death, N ew Zealand, 1872-1919.1 Respiratory diseases (8698). Gastric and intestinal diseases (102-110). Infantile Malformations (150). Early infancy (151-153). External (155-186). 4.7 5.7 5.0 4.2 3.3 3.1 1.8 1.4 .9 .4 0.2 .3 .3 .4 .5 .6 .5 .5 .4 .4 1.7 1.6 1.3 1.3 1.3 1.2 1.2 1.3 1.4 1.1 12.5 12.3 12.2 10.8 11.3 10.4 10.0 8.4 5.8 4.5 23.2 22.3 18.0 20.0 17.0 18.5 16.0 15.5 10.0 5.3 10.0 8.2 7.9 6.7 6.4 6.4 4.5' 3.6 2.5 2.1 0.6 1.5 1.4 1.2 1.2 1.6 1.6 1.4 3.0 4.1 23.6 24.2 23.1 25.7 25.0 26.1 27.0 26.6 27.0 25.2 1.4 2.0 1.9 1.8 1.8 2.0 2.2 2.0 .7 .6 10.5 13.7 12.0 7.4 7.7 7.0 6.1 4.8 2.8 2.3 1 Complied from General Table 1, pp. 67-69. tional List numbers included in each group. 1j > Hi-defined (187-189). Encephalitis, meningitis, [ and infantile paralysis (60, 61, part 63). c convulsions (71). Venereal diseases (37,38). 1872-1874................................. 14.7 1875-1879............. ................... 8.8 1880-1884................................. 7.9 1885-1889.................. 6.4 1890-1894........................ 10.2 1895-1899................................. 5.7 1900-1904............................... 5.2 1905-1909........................ 3.9 1910-19Ì4........................... 2.4 1915-1919............................... 2.5 Tuberculosis (28-35). Period. Epidemic diseases (1-19). Deaths under 1 year per 1,000 births. 2.3 1.2 .3 .4 .2 .2 .1 .1 .1 .1 The figures under the causes of death refer to the Interna- Tuberculosis also showed a marked decline as a cause o f infant mortality as early as the seven ty and eighties. From 5.7 per 1,000 births in 1875-1879, the rate fell in 10 years to 4.2 and in the next 10 years to 3.1; in the period 1905-1909 it reached 1.4, and in the last 5-year period it was only 0.4. In other words, during this 40year period, the mortality from tuberculosis was reduced from nearly 6 per 1,000 to four-tenths of 1 per 1,000 births. The mortality from venereal disease—syphilis—meanwhile re mained practically stationary, or even slightly increased. Doubtless the mortality from this cause was much understated, owing to unwill ingness to certify to the facts in such cases. The mortality from the group “ encephalitis,4 meningitis, and in fantile paralysis ” also showed little change. A slight fall appeared from 1872-1874 to 1880-1884, but after that time there was little or no significant change. The infant mortality rate from convulsions decreased from 10 in 1872—1874 to 2.1 in 1915—1919. This decrease was doubtless due in part to a gradual improvement in the assignment o f deaths to the real causes instead o f to the final symptoms, and in part to an actual decrease in the death rate from the real causes themselves. The mortality rate from external causes remained practically con stant from 1872-1874 to about 1905-1909. From 2 in the latter period, the rate diminished to 0.6 in 1915-1919. The spread o f prohibition in local areas and the increasing control over the liquor * In the earlier years the term. “ encephalitis ” was frequently returned in death cer tificates, probably meaning either meningitis .or poliomyelitis, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 11 traffic may have had an influence in diminishing infant mortality from these causes. “ Other defined causes V showed a fairly steady decline from a rate o f 12 in 1880-1884 to one of 2.3 in 1915-1919. The rate for causes ill-defined or unknown diminished from 2.3 per 1,000 births in 1872-1874 to 1.2 in 1875-1879, and to an insignifi cant figure in the following periods, as the certification o f causes of death became more accurate. Coming now to the more important groups o f causes o f death among infants, the gastric and intestinal diseases, the respiratory diseases, and the causes peculiar to early infancy will be taken up in order. The group o f gastric and intestinal diseases5'is by far the most deadly to infant life, with the single exception o f the causes peculiar to early infancy. The decline in mortality from diarrhea and enteritis is, therefore, worthy o f especial attention. In the period 1872-1874, the rate of mortality from these diseases was 23.2 per 1,000 births. W ith some fluctuations the rate fell gradually to 15.5 in the period 1905-1909, a decline o f 7.7 points in 35 years, or an average o f 1 point every 5 years. From this period the fall was rapid. In the next 5 years the mortality decreased by 5.5 points, and in the last 5 years by 4.7 points more, approximately 1 point every year. In 1915-1919 the rate was only 5.3, and in 1918-19, the last years in the group, it averaged only 3.6 per 1,000 live births.8 Be tween the period 1905-1909 and the years 1918-19 the mortality from gastric and intestinal diseases was reduced by over three-fourths. The mortality from respiratory diseases in 1872-1874 was 12.5 per 1,000 births. For 10 years it maintained approximately* this rate; then it decreased gradually in the next 20 years to 10 in 1900»1904. From this point the decrease became more rapid. In 19051909 the rate was 8.4; in 1910-1914, 5.8; and in 1915-1919, only 4.5. During the last 15 years the rate was cut in two. The average an nual decrease in the rate during these last 15 years was over three times the average annual decrease during the preceding 20 years. The mortality from the third group o f causes, those peculiar to early infancy, showed no such tendency to rapid fall. It rose from 23.6 in 1872—1874 to 27 in 1900-1904, an increase which may perhaps 5 In this discussion the group o f gastric and intestinal diseases includesi International L ist numbers 102—110. * I t should he mentioned in passing that the dates for changes a s given do not pretend to be e x a ct In order to show more clearly the trend o f the rates, averages for five-year periods have been taken, and it is therefore difficult to state,, for example, if the average for 1 9 0 5 -1 9 0 9 is lower than that for 1 9 0 0 -1 9 0 4 , the exact year in which the de crease first took place. This is further complicated by fluctuations in temperature and weather conditions. Even with no causes tending toward a reduction in infant mortality, the rates vary from year to year w ith variations in tem perature; hence, if it is sought to find the exact point a t which a decrease commenced, it is necessary to take account of these variations during the period within which the decrease first appeared. 92832°— 22------ 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 IN FA N T MORTALITY. be explained by improvement during this period in the registration o f deaths at very early ages. At this point a change in the trend ap peared and the rate fell slightly during the next five-year period, reaching 26.6; it rose during the next period to the same rate, 27; as in 1900-1904, and fell again in 1915-1919 to 25.2. The further course o f the rates will show whether this decline which appeared in the last period can be considered as marking the beginning of a con sistent downward movement. The rate from malformation showed little change between the period from 1875 to 1879 and that from 1905 to 1909, averaging about 1.4. It rose in 1910-1914 to 3 and in 1915-1919 to 4.1. Reference to the rates for the individual years in General Table 1, p. 68, indicates that a marked increase in the rate first appeared in 1912 and that after that date the rate was maintained at a higher level than pre viously. Since the law requiring stillbirths to be registered was passed in the year 1912,7 it seems probable that the increase in the rate from malformations was due to a more accurate distinction be tween births and stillbirths, resulting since 1913 in the registration o f the live births and deaths o f a small number o f infants who for merly would not have been registered. In the analysis o f the fall in the infant mortality rates in New Zealand two periods may be distinguished. The first is from 1872 to about 1905; during this period the fall in the mortality from epi demic diseases, convulsions, tuberculosis, and ill-defined causes was continuous and rapid, and the fall in the mortality from gastric and intestinal and from respiratory diseases was slight. The second pe riod is from about 1905 to 1919; during this time the fall in the mor tality from gastric and intestinal diseases proceeded at a rate five times as great, and that from respiratory diseases at a rate over three times as great as during the preceding period. During these last 15 years the mortality from gastric and intestinal diseases was reduced to one-fourth its former rates, and that from respiratory diseases was cut in half. 7 New Eealand Official Year-Book. 1919, p. 115. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis B IR T H A N D D E A T H R E G IS T R A T IO N . Since the accuracy of these statistics obviously depends upon the completeness o f birth and death registration, the principal require ments o f the compulsory registration laws will be briefly stated and evidence will be presented relating to completeness o f registration. Notification and registration o f births. The law o f New Zealand requires both the notification and the registration o f the birth o f every infant, whether live or stillborn. Notification must be given within 48 hours after the birth has occurred if in a borough, or within 21 days if in any other locality, and is the duty o f the “ occupier ” o f the house in which the birth takes place, who is required to report the fact, the date o f occurrence, and the name and address o f the mother or father to the local reg istrar o f births and deaths.8 This notice must also be signed by “ some person, if any (other than the occupier), in attendance at the confinement.” Sixty-two days are allowed for the registration o f births. It is the duty o f the father or mother o f the child to register ; but, in case o f the death, absence, or inability of both parents, the occupier of the house in which the child is born, and all persons present at the birth, are required to give the particulars necessary for registration. Births which have not been registered within the 62-day period may be registered within 6 months after the date o f birth upon a statutory declaration of the facts made before the registrar by the parent or some person present at the birth ; but for this late registration a fee o f 5 shillings may be imposed. After 6 months, births can not be registered except after conviction for neglect o f one o f the persons responsible.9 In practice, on receiving notification o f a birth, the registrar sends to the father or mother, at the address given, a notice to appear at the local registry office before the end o f the two months to give the information required for registration. I f this notice is not heeded, 8 For the purposes o f the act, the “ master, keeper, chief officer, or other person in actual charge of any prison, hospital, lunatic asylum, or public or charitable institution shall be deemed to be the occupier thereof.” Section 38, Consolidated Statutes, births and deaths registration act, 1908, No. 16. 8 Consolidated Statutes, births and deaths registration act, 1908, No. 16, amended by Statutes, 1912, No. 18, and 1915, No. 56. See also discussion o f special registration law, p. 15. 13 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 IN F A N T MORTALITY. a second one is sent, to the effect that the birth must be registered before the expiration o f the six-months’ period. I f no attention has been paid to either o f these notices the information is turned over to the department o f justice, and the persons responsible for the neglect are prosecuted. Compulsory registration o f live births has been in force since 1855. The registration o f stillbirths10 has been required only since March 1, 1913. Both these statements apply only to white births. Separate regulations apply to births o f Maoris. Registration o f deaths. A death must be registered within three days if it occurs in a borough, or within seven days if in any other locality. The duty of registration lies with the undertaker in charge o f the funeral. The law provides also that burial o f the body shall not take place until a certificate o f the cause o f death signed by a registered medical prac titioner, a coroner’s order, or a registrar’s certificate o f registration has been obtained. Undertakers are required to notify the registrar of all burials performed by them. The police are required to investi gate any deaths that occur, and give notice thereof to the registrar, whereupon he may order the persons responsible for giving informa tion to appear before him. Physicians in attendance are required to certify to the cause o f death.11 The body o f a stillborn child may not be buried without a certifi cate that the child was stillborn, signed by a registered medical prac titioner who was in attendance at the birth or who has examined the body, or, if no physician was present or if a certificate can not be obtained, without a statutory declaration by the person responsible for registering the birth to the effect that the child was stillborn.12 Completeness o f birth and death registration. Registration of deaths is in general comparatively easy to enforce, since a death must be registered before burial is permitted. Omis sions, if any, would be much more likely to occur in the country dis tricts—the “ back blocks,” as they are called in New Zealand— than in the cities. In the country the difficulties of notifying the regis trar or o f finding an undertaker are often great, and it is easy to bury privately without danger o f detection. In the cities, however, it is difficult to avoid the provisions o f the law. But the infant m or tality rate in the four cities, where registration o f deaths on this hypothesis would be most complete, is nearly as low as in the entire Dominion. One may fairly conclude^ therefore, that the low infant 10 A stillbirth is defined as a dead-born issue of at least 28 weeks uterogestation. Statutes 1915, No. 56, sec. 4 (births and deaths registration amendment act, 1 9 1 5 ). 11 Consolidated Statutes, births and deaths registration act, 1908, No. 16, secs. 24ff. “ Consolidated Statutes, births and deaths registration act, 1908, No. 16, sec. 36, Statutes, 1912, No. 18, sea 4. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 15 mortality rate in New Zealand is not due to incomplete registration o f deaths, but reflects especially favorable conditions. I f registration o f deaths is nearly complete, the very fact that the infant mortality rates are low is strong evidence that registration o f births is also nearly complete. So far as could be learned no special canvasses or tests for unregistered births are made. It has been the custom, however, to pass from time to time special laws per mitting late registration o f births which, without such special laws, could be registered only after prosecution and conviction for failure to register. The last such special registration law was passed in 1915. By it the registrar general was authorized to register, on pay ment o f a fee o f 5 shillings, any births not previously registered. Such births, however, had to be registered within one year. About 500 births were added to the register under this special law. Since nearly 27,000 births occur every year, and about five years had elapsed since the last special registration law, the proportion o f births which had not been registered was apparently very low.18 Furthermore, the people o f New Zealand are familiar with the requirements o f the law and with the use of birth certificates as evidence o f age. Birth certificates are used in connection with the enforcement o f the school-attendance law and in connection with granting permits for children to be employed in factories and work shops. Toward the end of the war legislation providing for mili tary registration and conscription added other uses for birth cer tificates. The long period during which birth registration has been compulsory would justify an inference that the population is familiar with the requirements of the law, and the various ways in which birth certificates are used would tend to make parents regard regis tration of the births o f their children as an important duty. Under these conditions, it might fairly be expected that the vast majority o f births would be registered promptly and that a special registration law, allowing late registration without the usual penalties, would bring in a large proportion o f the delinquents whose children were still alive. Birth and death registration, then, is fairly complete at the present tiihe. The question remains whether the decrease in the infant mortality rate since 1875 is due wholly or in part to improved registration of births. It has already been noted that compulsory birth registration went into effect in 1855, or nearly 20 years before the period to which any o f the figures here used relate. The statis tics o f birth rates may be used to test improvements in registration. 13 For a discussion of the number of unregistered births in connection with the results o f the last census, see Report on the Results of a Census of the Population of the Do minion o f New Zealand, taken for the night o f the 15th October, 1916, p. 1 3 : “ Probably unregistered births do not exceed 100 annually.” https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 16 IN FAN T MORTALITY. Since these rates are computed from the births that are registered, a marked improvement in registration would appear in an apparent increase in the birth rate. But, as shown in Table V III, the ratio o f registered births to population reached its maximum in the period 1876-1880. A further reason for concluding that the fall in mortality rates is due to an actual decrease in the proportion of deaths rather than to an improvement in birth registration is that this fall has not been uniform for the different causes o f death. A change in the complete ness o f registration o f births would affect all causes uniformly. The figures show, however, that from 1875 to 1905 a rapid decline ap peared in epidemic diseases, convulsions, and tuberculosis, other groups showing smaller rates of decrease or remaining nearly sta tionary, while from 1905 to 1919 the decline in gastric and intestinal diseases and in respiratory diseases was marked. One may con clude'', therefore, that the decline in infant mortality rates shown by the figures represents a real achievement in prevention o f infant mortality. T a b l e V III. — Birth rates, by periods, New Zealand, 1871-1919.1 Period. Annual births per 1,000 popula tion. 1871-1875 187fi-1880 1881-1885 1886-1890. 1891-1895........................ 39.88 41.21 36.36 31.15 27.68 Period. 1896-1900........................ 1901-1905........................ 1906-1910........................ 1911-1915........................ 1916................................. 1 New Zealand Official Year-Book, 1919, p. 117. Zealand, Vol. I, p. 33. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Annual births per 1,000 popula tion. 25.75 26.60 27.06 25.98 25.94 Period. 1917................................. 1918................................. 1919................................. Annual births per 1,000 popula tion. 25.69 23.44 21.54 Figures for 1919 from Statistics of the Dominion of New R E L A T IO N B E T W E E N G E N E R A L CONDITIONS F A N T M O R T A L IT Y . AND IN In the following section the general conditions in New Zealand which might have had an influence on infant mortality are dis cussed. Among these conditions are: Climate, racial composition, literacy, density, proportion o f population living in towns, housing and overcrowding, the birth rate, illegitimacy, and economic condi tions. In analyzing the connection between these conditions and the infant mortality rate, the distinction should be kept constantly in mind between a factor such as climate, which is favorable to low mortality throughout the period, and a factor such as the increas ing proportion o f the population living in cities, the influence of which upon infant mortality is subject to a progressive change. These conditions, moreover, are to be distinguished from the activi ties o f the different governmental and private agencies directed toward prevention o f infant mortality, most o f which, such as the Royal New Zealand Society for the Health of Women and Children, influenced only the latter part o f the 50-year period. These activities are discussed later. Climate. The influence o f hot temperatures in causing heavy mortality from gastric and intestinal diseases is well known and is illustrated by the “ summer peaks ” o f infant deaths from these diseases in the United States death-registration area.14 To a less marked degree the deaths from respiratory diseases are piled up into a winter peak.” 15 Climate, therefore, has an important influence in determining the infant mortality rate. New Zealand has a climate exceptionally favorable for infant life. Though the three islands which compose the Dominion meas ure approximately a thousand miles from the north to the farthest south, the climate throughout is tempered by sea breezes, and the summers are cool and the winters mild. Perhaps the climate o f northern California is more similar to that o f New Zealand than is that o f any other part of the American Continent. Though the latitude o f Auckland (36° 50' S.) corresponds to a latitude south of Washington, D. C., the highest temperature on record was only 91° See Save the Youngest (revised), pp. 10, 11, TJ. S. Children’ s Bureau publication No. 61, 1921. , . 15 In the United States birth-registration area in 1919, out o f 17,637 deaths under 1 year from respiratory diseases, 8,42 7 , or 47.8 per cent, occurred in the three winter months of January, February, and March. Nearly one-fifth, of all these deaths occurred in March alone. Compiled from U. S. Bureau of the Census, Birth Statistics, 1919, p. 302. * https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 17 18 IHSTFAISTT MORTALITY. F. 5 and though the latitude o f Dunedin (45° 52r S.) corresponds to that o f Minneapolis, the coldest temperature ever officially recorded at Dunedin was 23°, or only 9° below the freezing point. In Table I X average summer and winter temperatures for the period from 1914 to 1918 for the four chief cities o f New Zealand are shown, together with comparative data for seven American cities. The most striking difference is the absence o f extremes o f temperature in the New Zealand cities. In this respect the climate o f San Francisco or that o f Seattle appears to be most similar to that o f the New Zealand cities; and in this connection it may be noted that in 1919 Seattle had the lowest infant mortality rate for any city o f its size in the United States birth-registration area, and that the rate of San Francisco was also relatively low. Table X , which gives the mean monthly temperatures for the summer months for the four cities in each year from 1914 to 1918, inclusive, shows that in 1918 the average daily temperatures during the hottest summer month, February—corresponding to August in the Northern Hemisphere— were for Auckland 68°, for Wellington 65.6°, for Christchurch 63°, and for Dunedin 61.3°. The maximum temperatures in the same year were, respectively, for Auckland 78°, for Wellington 79.3°, for Christchurch 83.9°, and for Dunedin 81°. The average daily temperatures in 1918 during the coldest winter month, July—corresponding to January in the Northern Hemis phere— were for Auckland 49.4°, for Wellington 45.5°, for Christ church 39.6°, and for Dunedin 40.3°. The minimum temperatures were for Auckland 35°, for Wellington 30.1°, for Christchurch 27.2°, and for Dunedin 28°. T a b l e I X .— Mean summer and winter and maximum and minimum tempera tu res; comparative data for four N ew Zealand and seven American cities 1914-1918.1 Mean temperature. City. New Zealand cities: Auckland................................................... Wellington........................................................ Christchurch................................................. Dunedin..................................................... American cities: Boston, Mass........................................................... New York, N . Y ............................................ Washington, D. C.................................... Chicago, 111............................................. St. Louis, Mo........................ . Seattle, Wash................................................... San Francisco, Calif........................................ Three summer months. Maxi Minimum tempera temperaThree ture in ture.in winter 5-year 5-year months. period. period. 66.1 63.3 60.8 58.4 52.8 49.4 44.1 44.8 68.9 71.0 74.5 70.6 77.5 62.2 58.9 29.1 30.9 34.6 25.9 32.7 40.7 51.4 91.5 102 106 102 89 i Figures for New Zealand compiled from the New Zealand Official Year-Book, 1914-1919: figures for American cities compiled from manuscript figures furnished by the Weather Bureau. Figures are de grees Fahrenheit. ^ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 19 The climate of New Zealand obviously must be regarded as ex ceptionally favorable to a low infant death date. The cool summers make the danger from gastric and intestinal diseases much less, and tend to increase the efficiency o f preventive measures relating to the milk supply. The problem, of the milk supply, even o f the larger cities, is relatively simple in a country favored by such climatic conditions. Similarly, the mild winters tend to lessen the danger from respiratory diseases. In mild weather mothers are less likely to think it necessary to keep their babies in tightly closed or over heated rooms; on the contrary, out-of-door life is more natural. Since there is no evidence that the climate o f New Zealand is undergoing any progressive change, the factor of climate must be regarded as favorable to a low infant mortality rate throughout the entire 50-year period.Racial composition o f population. An important factor in infant mortality is the racial composition o f the population. Studies of infant mortality in the United States, for example, have shown widely varying rates for infants o f white and colored mothers, and considerable variations in the death rates among infants o f mothers of different nationalities. In New Zealand the statistics do not include the Maori popula tion, as registration of births and deaths among the Maoris is as yet incomplete. The Maori population comprises about 4.3 per cent o f the total population of the Dominion.16 O f the inhabitants o f New Zealand in 1916, exclusive o f Maoris, an overwhelming majority, 98 per cent, were bom in the United Kingdom or in British possessions and were therefore presumably of English, Scotch, Welsh, or Irish stock. Nearly three-fourths, 72.3 per cent, were born in New Zealand, 12.8 per cent in England, 4.7 per cent in Scotland, 4.2 per cent in Australia, and 3.4 per cent in Ireland. O f the 1.7 per cent o f the inhabitants bom in foreign countries, 0.3 per cent were born in the German Empire, 0.2 per cent in Aus tria-Hungary, 0.2 per cent in Denmark, and 0.2 per cent in China. The total number o f Chinese in 1916 was 2,147. No significant change in the proportion of the population born in British possessions has taken place in the last 50 years. A consequence of the high proportion of the population bom in British possessions is that practically the entire population is Eng lish speaking. This is in marked contrast to the situation in the United States, where, in 1910, over 3,000,000 persons 10 years o f age and over, forming 4.3 per cent o f the total population and 22.8 16 In the census o f 1916, 4 9,776 M aoris and 1,099,449 whites were enumerated. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 IN FA N T MORTALITY. per cent o f the foreign white population of this age group, were unable to speak English. Literacy. A connection between literacy of the mother and infant mortality is suggested by the fact that the mother who can not read and write is limited to instruction and tradition transmitted by word o f mouth, while the mother who is literate can derive information from the printed page. Studies made by the Children’s Bureau in American cities have shown that the mortality rate among infants o f illiterate mothers is higher than that among infants of mothers who are literate.17 Statistics o f literacy show that New Zealand ranks very high in the proportion of its people who can both read and write. O f the population 10 years of age and over in 1916, only 1 per cent were uiiable to read and only 1.5 per cent were unable to write. In the United States, on the other hand, 7.7 per cent o f the population of the same age group in 1910 were unable to write. This high pro portion o f illiterates in the United States is due chiefly to high per centages o f illiteracy among the negroes and among the foreign born; but even among the native white o f native parentage the proportion was 3.7 per cent, or considerably higher than that in New Zealand.18 Since 1875 the different censuses in New Zealand have shown a gradual decrease in the proportion o f its inhabitants who were not able to read, from 3.1 per cent of the population 10 years o f age and over in 187419 to 1 per cent in 1916.20 D ensity and distribution o f population in city and country. The density o f population or the proportion o f the inhabitants living in densely populated areas appears to have an important in fluence upon infant mortality. In practically every country infant mortality rates are lower in rural than in urban districts. In the United 'States birth-registration area in 1919 the States with the lowest infant mortality rates—Washington, Oregon, Minnesota, Kansas, California, and Utah—were those less densely populated and with large proportions o f the population living in rural areas.21 17 See for example, Infan t M o rta lity : Results of a field study in New Bedford, Mass., based on births in one year, p. 20, by Jessamine S. W hitney. U. S. Children’s Bureau publication No. 68. lS Thirteenth Census o f the United States, Vol. I, Population, 1910, pp. 1185, 1187. 19 Compiled from Results o f a Census of the Colony of New Zealand, taken for -the night o f the 1st of March, 1874, pp. 186—188. 20 Compiled from Report on the Results of a Census of the Population of the Dominion o f New Zealand, taken for the night o f the 15th October, 1916, p. 66. The figures are not exactly comparable since the figures for 1874 exclude Chinese and relate to inability to read English, while those for 1916 include Chinese and relate to inability to read in any language. 21U. S. Bureau of the Census, Birth Statistics, 1919, p. 37. W ashington, 1921 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 21 The average density o f population in New Zealand in 1916 was 10.6 persons per square mile, or one-third that o f the United States in 1910, which was 30.9 persons per square mile.22 As compared with the States just mentioned, New Zealand’s density o f population ex ceeded that o f Utah (4.5) and Oregon (7 ), but was only two-thirds that o f California (15.3), less than two-thirds that o f Washington (17.1) or o f Kansas (20.7), and less than half that of Minnesota (25.7). ' . So far, then, as density o f population alone is a factor in high or low infant mortality rates, conditions in New Zealand tend to favor a low rate. On the other hand, the density o f population increased rapidly in the last 50 years, rising from 2.5 to 10.6 persons per square mile be tween 1871 and 1916. Yet during this period the infant mortality rate, in spite o f the increase in density, fell to less than half. The number o f persons per square mile varies so widely, from the sparsely settled rural or grazing areas to the well-populated cities, that the proportion o f the population living in cities is probably a better measure o f concentration in connection with infant mortality than average density. New Zealand had a slightly larger proportion of urban population than the United States. In 1916, 53 per cent o f the population o f the Dominion lived in cities and suburban areas of 2,500 or more population,28 whereas only 46.3 per cent o f the population o f the United States in 1910 lived in urban areas. In New Zealand, however, the largest city, Auckland, had less than 135,000 population, while in the United States 34 cities larger than Auckland contained 20 per cent o f the population. During the period from 1881 to 1916 the proportion o f the popu lation o f New Zealand living in “ boroughs”—including many of the small cities and towns as well as all the large cities—increased from 40 to 53 per cent.24 Evidently, therefore, the change in the propor tion of urban population can not explain any part o f the decrease in the infant mortality rqje. H ousing congestion. O f greater significance than density o f population, in its influence upon infant mortality, is the character o f housing conditions and in particular the degree o f housing congestion. In general, housing conditions in New Zealand, so far as they relate to lot occupancy and style o f house, are excellent. The pre vailing type o f house is the one-story cottage or bungalow, and even in the largest cities the house is generally surrounded by a small plat 22 New Zealand Official Year-Book, 1919, p. 1 0 4 : Thirteenth. Census o f the United States, 1910, Vol. I, Population, p. 42. , 23 Compiled from New Zealand Official Year-Book, 1919, pp. 108—111. 24 New Zealand Official Year-Book, 1919, pp. 1 0 4 -1 0 8 . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 IN FAN T MORTALITY. of land used as a flower garden or for vegetables. Nowhere is there any extensive overcrowding in tenement houses. The built-up areas devoted to business are relatively small, manufacturing establish ments are few, and transportation facilities permit those who prefer to live in the suburbs to travel back and forth to their work in the city center. Tables X and X I throw light upon the degree o f overcrowding in dwellings as expressed in terms o f the average number o f persons per room. In 1916, 57.6 per cent o f all the inhabited private dwell ings and tenements in the Dominion o f New Zealand had an average o f less than one person per room. Only 4 per cent had an average of two or more persons per room. According to Chapin’s stand ard,25 by which houses with over one and one-half persons per room are considered overcrowded, only 7.8 per cent of the houses in New Zealand would have been classified as congested. Room congestion was slightly greater in rural than in urban areas, as shown in Table X I. In all New Zealand outside the four “ metro politan areas,” which include the chief cities and their immediate suburbs, 12.8 per cent o f the inhabited private dwellings and tene ments had an average o f one and one-half or more persons per room, as compared with only 7.9 per cent in the metropolitan areas. Among the four cities, Christchurch appeared to have had the least room congestion, and Wellington the most. Comparative data in regard to housing congestion are not available for the United States. Data are also lacking for comparisons with previously existing conditions in New Zealand. T able X . — Average number of persons per room in inhabited private dwellings and tenements, urban and rural areas, New Zealand, 1916.a Inhabited private dwellings and tenements. Average number of persons per room. Metropolitan areas. New Zealand. Rural areas. Small cities. 238,066 129,937 25,067 83,062 28,261 19,647 20,225 14,929 Less than one per room.......... 137,139 One per r o o m .......................... 41,806 Over one but less th an one and one-half per room.............. 31,498 7,775 One and one-half per room. . . Over one and one-half but less 9,039 than two per room............... 9,539 Two or more per room............ 1,270 Not reported............................ 69,177 24,605 15,610 4,026 52,352 13,175 18,266 4,323 11,667 3,374 12,968 3,170 9,451 2,308 17,533 4,803 3,313 676 10,652 2,296 3,541 736 2,656 600 2,539 539 1,916 421 5,594 7,298 927 820 588 34 2,625 1,653 309 840 492 63 668 548 134 616 291 102 501 322 10 Total................................ 9 Total. Auck land. Welling Christ ton. church. Dune din. a Compiled from Results of a Census of the Dominion of New Zealand, 15th October, 1916, Part X I , Dwell ings» PP* / 26 Chapin, Robert Coit : The Standard o f Living Among Workingmen’ s Fam ilies in New York City, p. 80. Russell Sage Foundation. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 23 N E W ZEALAND. T a b l e X I .— Comparative overcrowding of housing accommodations in urban and rural areas, New Zealand, 1916.1 Cumulative per cent of dwellings with or exceeding specified average num ber of persons per room. Average number of persons per room. Metropolitan areas. New Zealand. Two or more:............................ Over oneand one-half or more. One and one-haK or more....... More than one.......................... One or more.............................. Less than one............................ Not reported............................. 4.0 7.8 11.1 24.3 41.9 57.6 .5 Rural areas. Small cities. 5.6 9.9 13.6 27.1 46.0 53.2 .7 2.3 5.6 8.3 21.5 37.6 62.3 .1 Total. Auck land. Well ington. Christ church. . 2.0 5.2 7.9 20.7 36.6 63.0 .4 1.7 4.7 7.3 19.8 35.1 64.6 .2 2.8 6.2 9.2 22.8 39.9 59.4 .7 1.4 4.5 7.1 19.7 35.4 64.1 .5 Dune din. 2.2 5.5 8.3 21.2 36.6 63.3 .1 1 Derived from Table X . B irth rate. The birth rate in New Zealand in 1919 was slightly lower than that o f the United States birth-registration area—21.5 as compared with 22.3 births per 1,000 population. In 1915, however, the rate in New Zealand was above that for the United States, 25.3 as compared with 24.9. Comparisons with European countries as shown in Table X I I , based on figures for 1914— a year in which the birth rate was not influenced by war conditions—reveal that eight European coun tries had lower birth rates than New Zealand. New Zealand’s rate (26) was higher than the rates for France (18), Switzerland (22.5), Belgium (22.6, in 1912), Ireland (22.6), Sweden (22.9), England and Wales (23.8), Norway (25.2), and Denmark (25.6). Following the period 1876-1880 the birth rate in New Zealand fell from an average o f slightly over 41 to 25.1 in 1899 and 21.5 in 1919.26 The rate in 1919 was doubtless somewhat affected by war conditions. T able X I I .— Birth rates in principal countries, 1914.1 Births per 1,000 popula tion. Country. England and W ales... United States birthregistration area (1915).......................... 18.0 22.5 22.6 22.6 22.9 23.8 24.0 24.9 Country. German Empire.......... The Netherlands......... Austria (1913)............... Spain............................. Births per 1,000 popula tion. 25.2 25:6 26.0 26.1 26.8 26.8 28.0 28.2 29.6 29.8 Country. Italy............................... Hungary (1912)............ Chile............................. . Jamaica....................... Ceylon............................ Rumania....................... Births per 1,000 popula tion. 31.0 33.8 36.0 36.3 37.5 38.9 40.8 42.1 1 Sources: Statistical yearbooks or other official publications of the different countries. In the four chief cities the birth rates were all less than in the entire Dominion, ranging in 1919 from 21.1 in Wellington to 17.9 in Dune29 New Zealand Official Year-Book, 1919, pp. 116-117 ; 1920, p. 21. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 IN F A N T MORTALITY. din.2t It is noteworthy that the cities stood in the same order in the size o f the infant mortality rate as they did in the size o f the birth rate, but that in all cities the infant mortality rate was higher than in the Dominion. That the correspondence between low birth rates and low infant death rates is by no means a close one is shown by the many differ ences in position o f the various countries in Tables I and X I I , the former giving the rank o f the countries in infant mortality rates and the latter their rank in birth rates. Proportion o f illegitim ate births. Since in all countries where they are available, statistics upon this subject show that the mortality o f illegitimate infants is much higher than that o f legitimate infants, the proportion o f illegitimate births has an important bearing upon the general infant mortality rate. As compared with those of other countries except the United States, the percentages o f illegitimate births in New Zealand are low.28 During the period under consideration this low proportion of illegitimate births was undoubtedly a factor in low infant mortality ; but since it did not decrease during the period it can have had no influence on the decrease in infant mortality. Economic leVel o f the population. Factors related to the economic well-being o f the population— family income, wages, standard o f life, employment o f mothers, etc.— appear to have an important influence upon infant mortality. For the cities studied by the Children’s Bureau, it has been shown that the higher the earnings o f the fathers the lower the mortality among the infants. The employment o f the mothers, which is more prevalent in the low-income groups, appears also to influence the infant mor tality rate.29 In this connection reference may be made to the strik ing contrasts in infant mortality rates in poor and in well-to-do sec tions o f large cities. Definite information on the economic conditions most directly related to infant mortality, such as the economic status o f families in which births occur and the proportion o f mothers who are employed either during pregnancy or within a year after childbirth, is unfor tunately not available for New Zealand. Even in regard to the genw New Zealand Official Year-Book, 1920, p. 23. 28 For a full discussion o f comparative rates see Illegitimacy as a Child-W elfare Prob lem, Part I, pp. 1 1 -1 6 , by Em m a O. Lundberg and Katharine F. Lenroot, U. S. Children’s Bureau Publication No. 66. For the New Zealand rates from 1877—1919 see General Table 9, p. 72. See reports on Infan t M ortality, Results o f field studies in Johnstown, Manchester, Waterbury, Brockton,, Saginaw, New Bedford, and Akron, U. S. Children’s Bureau Pub lications Nos. 9, 20, 29, 37, 52, 68, and 72 ; also Woodbury, Robert Morse : “ Infant mor tality studies o f thé Children’s Bureau,” in Quarterly Publications of the American Sta tistical Association (June, 1 9 1 8 ), pp. 3 0 -5 3 , and Save the Youngest, U. S. Children’s Bu reau Publication No. 61 (revised). 29 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 25 eral economic level of the population the information is not as defi nite as could be wished, and where data are available it is for the most part impossible to bring together comparative material or to give satisfactory evidence o f changes in the 50-year period under study. In general, the economic level of the population may be regarded as comparatively high, and therefore as favorable to a low infant mortality rate. O f the total male population 10 years of age and over in 1916, 84.1 per cent were gainfully occupied.80 This figure is slightly higher than the corresponding percentage, 81.3 per cent, o f gainfully occupied males in the United States,81 but it must be remembered that the census o f 1916 in New Zealand was taken after two years o f war and that except for war conditions the proportion gainfully occupied might have been somewhat smaller. Nearly three-tenths, 27.9 per cent, o f the gainfully occupied males were independent; that is, they were either employers or were in business on their own account. Over three-fifths were receiving wages or salaries.32 Only 1.7 per cent were unemployed in October, 1916, a proportion very low in comparison with the proportion unem ployed among trade-union members in England or the United States.83 The figures for preceding censuses were also very low, 2 per cent in April, 1911, and 2.5 per cent in April, 1906.34 There was little or no real poverty in the Dominion. The average rate o f wages in New Zealand was high in compari son with the cost o f living.35 The wages o f unskilled workmen were higher relatively than those o f skilled workmen.36 This was due in part to the effect of the operation o f the system o f compulsory conciliation and arbitration by which, on application o f a union o f workingmen or o f employers to a conciliation board or council for the district, minimum wages for a trade are determined by the board or council, or, on appeal, by the arbitration court. 0 30 Complied from Results of a Census of the Dominion o f New Zealand, 15th October, 1916, Part IX , Occupations and Unemployment, pp. 2 -3 . 31 Thirteenth Census o f the United States,, Vol. IV , Occupation Statistics, 1910, p. 65. In England and W ales in 1911, 83.8 per cent of the males 10 years o f age and over were gainfully occupied. (Census o f England and W ales, 1911. Vol. X , Occupations and In dustries, Part I, p. cxxviii, Cd. 7018.) For comparative figures for European countries based upon population o f all ages see Statistisches Jahrbuch fiir das Deutsche Reich, 1913, p. 13. 32 See General Table 8, p. 72, which gives also the distribution by occupation groups, and the proportion of employers and wage earners, etc., in each occupation group. 33 Report on the Results of a Census o f the Population o f the Dominion o f New Zealand, 15th October, 1916, pp. 4 -5 . For comparative figures for other countries than New Zea land see Unemployment Insurance, p. 15, by G. V. M. Turner. New South W ales Board o f Trade. W . A. Gulick, Government Printer, Sydney, 1921. 34 Report on the Results of a Census of the Population o f the Dominion o f New Zealand, 15th October, 1916, p. 136. 36 For a discussion of wages, see New Zealand Official Year-Book, pp. 8 0 9 -8 1 0 , also pp. 8 6 0 -9 3 5 , article entitled “ W ages and working hours in New Zealand, 1897—1919,” by G. W . Clinkard; for a discussion of cost o f living, see the same volume, pp. 771—807. . 33 Ibid., p. 916. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 IN FAN T MORTALITY. In regard to the proportion o f women at work, the percentage o f females 10 years o f age and over who were gainfully occupied in 1916 was 23.7 in New Zealand, as compared with 32.5 per cent in England and Wales in 1911, and with 17.1 per cent o f the native whites o f native parentage and 54.7 per cent o f the negroes in the United States in 1910. In interpreting these figures it should be remembered that the proportion o f women gainfully occupied in New Zealand in 1916 was probably abnormal, owing to war con ditions.37 Other facts which should be mentioned in this connection are the comparatively high proportion of homes owned, and the relatively large numbers o f savings-bank deposits. Over half, 52 per cent, o f the homes o f New Zealand in 1916 were owned by the families that lived in them; 23.9 per cent were owned without encumbrance, 23.1 per cent were mortgaged, and 5 per cent were being purchased on time payments. In the United States in 1910, only 45.8 per cent o f the dwellings were owned or partially owned by the families that lived in them.38 The Government o f New Zealand has fostered home ownership by means o f various acts providing fo r loans to settlers, and for the erection o f dwellings for workingmen.39 In this con nection mention should be made o f the land legislation adopted in 1893 and later by which provision was made for leasing, on liberal terms, lands still held by the Crown, and in particular for splitting up large estates for the benefit o f persons seeking to take up land. The number o f depositors in the Post Office Savings Bank and in private savings banks in New Zealand in 1919 was 61 to every 100 o f the population, and the average deposit in the Post Office Savings Bank at the end o f the year 1918 was £56 12s. 5d. ($275).40 Evidence in regard to changes in economic conditions is even more unsatisfactory than that in regard to general economic con ditions. In general it may be noted that an area o f prosperity pre ceding 1882 was followed by a prolonged depression which lasted for 10 or 15 years, and during which emigration exceeded immi gration; then prosperity returned, and immigration has since been flowing into New Zealand except when prevented by war conditions. So far as changes in wages are concerned, evidence based upon minimum hourly wages as fixed in awards under the conciliation and arbitration act indicates that real wages as measured by food prices 87 See notes 3 0 and 31, p. 25. 88 New Zealand Official Year-Book, 1919, p. 102. Thirteenth Census of the United States, Vol. I, Population,, 1910, p. 1295. 88 For a full account o f this legislation see New Zealand Official Year-Book, 1919, pp. 6 7 2 -6 7 8 . 40 Depositors in the Post Office Savings Bank as o f Dec. 31, 1918, and depositors in private savings banks as o f Mar. 31, 1919. Compiled from figures given in the New Zealand Official Year-Book, 1919, pp. 7 1 1 -7 1 4 . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 27 NEW ZEALAND. and rents increased from about 1901 until 1911, fell during the following years until 1918, and increased again in 1919. But this conclusion does not take into account the decrease in hours o f work, in consequence o f which weekly earnings for full-time work without overtime decreased.41 The favorable conditions just reviewed, climate, homogeneity of population, a high level o f intelligence, a low density, a low pro portion o f illegitimate births, favorable housing conditions, a high economic level, and absence o f extreme poverty, go far toward ex plaining the relatively low infant mortality rate in New Zealand. As an explanation o f the decrease in the infant mortality rate dur ing the 50-year period under study, they either do not apply, if no change or i f no improvement in the condition occurred, or apply only to a limited extent, since improvements in these conditions, where they occurred, were not pronounced. While on the one hand the conditions o f living have doubtless been growing easier as the privations and discomforts o f pioneering have given place to the conveniences o f a more settled life, on the other, the proportion o f the population living in cities, in which infant mortality rates are higher than in rural districts, has increased. However, the gener ally favorable conditions constitute a milieu in which measures of prevention will produce larger results than they would in com munities where conditions were not so favorable. G O V E R N M E N T A C T IV IT IE S R E L A T IN G TO T H E W E L F A R E O F M O T H E R S A N D IN F A N T S . The principal activities o f Government departments and agencies which relate to maternal and infant welfare include general publichealth protection, regulation o f medical and nursing services, super vision and control of hospital facilities, control over production and sale o f milk, the grant o f maternity allowances to members o f the National Provident Fund and o f Friendly Societies, and the regula tion o f boarding homes for infants. The subsidies granted by the Government to the Royal New Zealand Society for the Health o f Women and Children, the work o f which is described in a later sec tion o f this report, should be mentioned in this connection. In general the statements made refer to conditions as they existed in the early months o f 1920. Since that date, however, one Very important change has taken place in the health department in the creation o f a new division of child welfare headed by Dr. Truby King, whose work in connection with the Royal New Zealand Society will be described later. 41 Clinkard, G. W . : “ W ages and working hours in New New Zealand Year-Book, 1919, pp. 910, 913. 92832°—22----- 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Zealand, 1897—1919,” in 28 IN FAN T MORTALITY. General health protection. Organization of the department of health.—Early laws and ordi nances providing for quarantine, vaccination, control o f epidemic diseases, and sanitation were incorporated in the public health act, 1876, which established a central board o f health for the entire colony. A series o f amendments modified various provisions o f this act. All these were repealed and a department o f public health was established by the public health act, 1900. The present organization and authority o f the department of health are regulated by the health act, 1920, which provides for a central administrative department under the general direction o f the minister o f health. The chief administrative officers o f the depart ment 'are the director general o f health and his assistant, the deputy director general, both o f whom must be medical practitioners with special qualifications in sanitary sciencè. The department has seven separate divisions : Public hygiene, hos pitals, nursing, school hygiene, dental hygiene, child welfare, and Maori hygiene. School hygiene, dental hygiene, and child welfare are new in the department, although all three branches o f work had been commenced in the education department. The functions o f the department are defined in broad terms. They include administration o f the health act and all other public acts so far as their purpose is the promotion o f health, advice to local authorities with reference to carrying out the health functions with which they are charged, prevention o f infectious and other dis eases, research and investigation relating to matters^ o f public health and the prevention and treatment o f disease, dissemination o f in formation concerning public health, organization and control o f medical, dental, and nursing services so far as they are paid for out o f public funds, and generally securing the effective carrying out and coordination o f measures conducive to public health. The act provides for the establishment o f a board o f health com posed o f 11 members, as follows: The minister of health and the director general o f health ex officio; three medical practitioners, o f : whom one must be a member o f the medical board constituted under the medical practitioners act, 1914, and one a member o f the medical faculty in the University o f Otago; two persons, not medical prac titioners, representing the New Zealand municipal and New Zealand counties associations ; one civil engineer ; one chairman of a hospital board ; and two other persons, one o f whom must be a woman deemed to be representative o f the interests o f women and children. The duties o f the board are both administrative and advisory; it may require local authorities to provide sanitary works, to enforce the provisions and regulations under the act, and to make reports as. to diseases and sanitary conditions. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 29 For purposes o f public-health administration, the Dominion is divided into health districts, each under a medical officer o f health, who must possess special knowledge o f sanitary and bacteriological science. These medical officers are appointed by the Governor Gen eral o f the Dominion and are responsible to the director general of health. Sanitation** and prevention o f infectious diseases.— Certain in fectious and a list o f other diseases are declared by law to be noti fiable, and still others may be designated as notifiable by the Governor General by notice in the official gazette.42 The list o f notifiable in fectious diseases includes: Anthrax, cerebrospinal fever (cerebro spinal meningitis), cholera, dengue, diphtheria, erysipelas, enteric fever (typhoid fever, paratyphoid fever), leprosy, plague (bubonic or pneumonic), puerperal fever (puerperal septicaemia, puerperal sapraemia), scarlet fever (scarlatina), smallpox (variola, including varioloid, alastrim, amaas, Cuban itch, and Philippine itch), typhus, and yellow fever. Besides these notifiable infectious diseases the following are designated notifiable diseases: Actinomycosis anchylostomiasis (hookworm disease), bilharziosis (endemic hsematuria, Egyptian hsematuria), beriberi, hydatids, food poisoning (botulismus, ptomaine poisoning), chronic gLad poisoning, phosphorus poisoning, and tetanus. . . Notifiable diseases must be reported to the medical officer of health o f the district by the medical practitioner in charge of the case, or by the occupier o f the house if no medical practitioner is in charge. In case o f a notifiable infectious disease the case must be reported to the local governmental authorities as well. Extensive powers for dealing with infectious diseases are given to the medical officer and to the local authorities; these apply to infectious diseases, such- as measles, which are not designated as notifiable, as well as to the notifiable infectious diseases.42 The act prescribes the procedure o f quarantine and defines the powers o f port health officers, who are charged with the enforcement o f quarantine regulations. Local authorities, including borough and county councils, town boards in districts not forming parts of counties, and similar bodies, are required to carry out the provisions o f the act relating to sanita tion under the general direction o f the board o f health and the director general. The board o f health may require local authorities 12 The Health Act, F irst Schedule, 1920, listed the following as infectious but not notifiable; those declared notifiable by gazette notice since that date are marked with asterisks: Chicken pox* (varicella), encephalitis lethargica*, influenza, fulm inant in fluenza*, pneumonic influenza*, septicsemic influenza*, measles (m orbill), German measles (rubella), mumps (epidemic parotitis), ophthalmia neonatorum*, acute primary pneu monia*, acute poliomyelitis* (infantile paralysis), ringworm of the scalp (tinea ton surans), scabies (itch ), trachoma* (granular conjunctivitis, granular ophthalmia, granu lar eyelids), tuberculosis* (pulm onary), whooping cough (pertussis). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 IN FAN T MORTALITY. to provide drainage and sewerage works, waterworks, means for the collection and disposal of garbage, refuse, etc., mortuaries, and other sanitary works. Each local authority is required to appoint one or more sanitary inspectors, whose qualifications are prescribed in the law, for the work of inspection and o f enforcing the abatement o f nuisances and o f conditions dangerous to health. The act provides powers for the regulation o f building, for the regulation o f offensive trades, and for the prevention of pollution of watercourses, and authorizes local authorities to make by-laws to carry out its various provisions. The medical officers o f health act in cooperation with local authorities in enforcing these provisions. Social hygiene.—A social hygiene act was passed in 1917, and in 1919 a branch, known as the contagious diseases branch, was estab lished in the health.department to carry out the objects o f the act. The law provides that any person suffering from a venereal disease must consult a registered medical practitioner regularly until cured. Restrictions are placed upon the employment o f such persons in handling food for human consumption. None but registered medi cal practitioners may treat persons suffering from these diseases. The law further provides for treatment at public hospitals for cases o f venereal diseases w ^ i subsidies from the Central Govern ment o f three-fourths o f the cost. Special clinics have been estab lished in the four chief centers.43 In the absence o f a hospital, a private practitioner is appointed and paid by the department for treatment given. In its present form the law is difficult of enforce ment, but the provisions relating to subsidizing local public hospitals have tended to improve facilities for treatment. Government aid in health 'protection.— The Central Government grants local government bodies and private organizations liberal sub sidies in aid o f public-health protection. Local hospital boards are granted subsidies for the establishment and maintenance of hospitals. Contributions raised by local boards to meet capital expenditures are subsidized by the Central Govern ment pound for pound, while taxes for current expenditures are sub sidized according to a somewhat complicated scale, varying from 12s. 3d. ($2.97) to 24s. 3d. ($5.89) for each pound ($4.87).44 Income derived from voluntary contributions or gifts is subsidized by the Government at a rate o f 24s. ($5.84) for every pound ($4.87), and bequests are subsidized at a rate o f 10s. ($2.43) for every pound, not, however, to exceed £500 ($2,433) subsidy in respect o f any one tes tator. 43 For in New Vol. IV 44 For a brief description o f the work under this act, see “ Treatment o f venereal disease Zealand,” by S. M cW illiams, in New Zealand Journal o f Health and Hospitals (April, 1 9 2 1 ), pp. 8 5 -8 6 . details see fourth schedule, the hospital and charitable institutions act, 1909, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. m As already stated, special subsidies equal to three-fourths o f the cost are granted hospitals which provide special facilities for the treatment o f venereal diseases. In a few country districts which are unable themselves to support nurses or midwives the Central Government makes special provision by stationing there midwives or nurses and paying their salaries. The health department is reimbursed in part by fees from patients:. This service has only recently been established and its extent is not great.45 Mention should be made in this connection of the establishment and maintenance o f the St. Helen’s Hospitals by the central depart ment; a full description o f the work o f these hospitals is given below. The Government pays the entire cost o f maternity bonuses granted at the birth o f each child to members o f the 'National Provident Fund and o f approved Friendly Societies. Liberal subsidies are granted by the Central Government in aid o f the work o f the Royal New Zealand Society for the Health o f Women and Children, the work of which is described later. Regulation o f medical and nursing services. Registration of medical 'practitioners.—The early provincial ordinances regulating the practice o f medicine were incorporated in the medical practitioners act, 1867, which was repealed two years later by the medical practitioners act, 1869. According to the latter act, persons registered or entitled to register in the United Kingdom or qualified for practice by completing a regular course of medical study o f not less than three years’ duration were entitled to be registered in New Zealand. In 1905 the length o f the prescribed course o f study was increased to five years.46 'According to the medical practitioners act, 1914, a person is en titled to be registered as a medical practioner if he is a graduate in medicine and surgery o f the University o f New Zealand, or is on or eligible to be placed on the register o f the United Kingdom, or i f he has a diploma from an approved institution granted after five years’ study o f the subjects pertaining to a medical or surgical de gree or license. Applications are made to the registrar of births and deaths at Wellington or at one of the other principal cities. One month’s notice must be given for registration, and the applica tion must be advertised in the New Zealand Gazette and in a news paper near the place o f the applicant’s residence. The medical practitioners act o f 1914 established a medical board, including the inspector general o f hospitals and six other medical practitioners 45 Compare Public H ealth and Hospitals and Charitable A id Report, 1919. “ H - 3 1 ,” p. 11. See also “ State medical service,” by Dr. R. H . Makgill, in New Zealand Journal of Health and Hospitals, Vol. IV (January, 1 9 2 1 ), pp. 1—7. ^ M ed ical practitioners registration act, 1905, No. 31, sec. 4. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 INFANT MORTALITY. appointed by the Governor General for a term o f three years each, and this board deals with all questions relating to registration o f medical practitioners. In this connection mention should be made o f the medical school established in 1876 at Dunedin as part of The University o f Otago. In that year arrangements were made for tlie first two years o f a medical course; in 1883 steps were taken to complete the curriculum, and a full five years’ course o f instruction was provided.47 This school is the only school in New Zealand preparing students for med ical and surgical practice. In connection with the medical school the Batchelor Hospital at Dunedin provides facilities for the training of students in obstetrics.48 In 1904 the medical school was authorized to grant the degree o f doctor of public health in addition to the medical and surgical degrees;49 in 1912 this authority was vested in the senate o f the University o f New Zealand, of which the University o f Otago is a part. i According to census returns given in Table X I I I the number o f medical practitioners in proportion to population remained prac tically stationary from 1891 to 1901, but increased from 5-7 per 10,000 population in 1901 to 6.9 in 1911. In 1916, the proportion fell to 4.6 per 10,000. The small proportion in 1916 was doubtless due to the absence of many physicians in military and naval service. Besides these figures, which, relate to medical practitioners enumerated on the dates o f the different censuses, a register is kept of medical practitioners licensed to practice. The number on the register since January 1, 1914, is shown in General Table 6. For comparative purposes, however, the census figures, including only those present and enumerated in New Zealand, appear to be the more significant. T able X III. — M edical practitioners, N e w Zealand, 18 91 -1 9 1 6 .a M edical p ra ctitio n ers enu m erated in census D ate o f census. 1891................................................... 1896................................................... 1901................................................... M edical p ra ctitio n ers en u m erated in census. D ate o f census. N u m b er. P er 10,000 p o p u la tio n . 362 411 438 5. 8 5. 8 5. 7 N u m b er. 1906......................... 1911................. 1916 ............... 601 1 602 503 P er 10,000 p o p u la tio n . 6 « A6 a C om p iled from R esu lts o f a Census o f the D o m in io n o f N e w Z ealand, 5th A p r il, 1891, p . 246; 12th A p r il, 1896, p . 359; 31st M arch, 1901, p . 389; 29th A p r il, 1906, p . 450; 2d A p r il, 1911, p . 501; 15th O ctober, 1916, P art I X . O ccu p a tion s a n d U n e m p lo y m e n t, p . 73. 47 New Zealand Official Year-Book, 1896, p. 344. 48 New Zealand Official Year-Book, 1919, p. 214. See also Public Health and Hospitals and Charitable Aid Report, 1919, “ H—3 1 ,” p. 12, for change in regulations of the St. Helen’s Hospital, Dunedin, permitting admission of medical students into its maternity ward. 49 New Zealand Official Year-Book, 1907, p. 1 7 0 ; 1919, p. 205. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 33 Registration of nurses.—The nurses’ registration act was passed in 1901. The principal provisions o f the act, as incorporated in the con solidated statutes o f 1908, are as follow s: Nurses who have attained the age of 23 years and who are certified as having had three years’ training in a hospital, together with sys tematic instruction in theoretical and practical nursing from the medical officer and the matron o f the hospital, are entitled to regis tration after having passed a satisfactory examination under the act and on payment of the required fee. Any person who had received four consecutive years of training in a hospital prior to January 1, 1902, when the original act came into operation, was entitled to regis tration after passing the required examination and upon payment of the fee. Persons admitted to practice outside New Zealand may be registered if the training received is recognized by the minister as equivalent to the training and examination required of New Zealand nurses. Detailed regulations govern the course o f study and supervision o f hospitals where pupil nurses are trained. Registration may be canceled in case of conviction of a nurse o f an indictable offense or in case of grave misconduct. Registration o f nurses is not compulsory. Registered nurses, how ever, are given preference o f employment in vacancies occurring in hospitals under the control o f hospital and charitable aid boards. The number of nurses who passed the prescribed examinations during the 10-year period 1910—1919 was 1,411, and the number of nurses on the register March 31, 1919, was stated as 2,433.50 Registration of midwives.—Registration of midwives was first required under the midwives act, 1904, which also provided for the formulation o f a standard course o f training. That act provided fo r the registration o f women holding certificates in midwifery granted after completion o f the course o f training prescribed by the act, or holding certificates from recognized training schools o f mid wifery or from the Obstetrical Society in London, or other certifi cates approved by the registrar o f midwives. Certificates under the midwives act are granted to nurses who have attended lectures at a State maternity hospital or other institution approved by the registrar, for 6 months if the nurse is registered under the nurses’ registration act, or for 12 months in other cases, 50 New Zealand Official Year-Book, 1919, p. 215. The figure 1,411 is found by adding the numbers given as having passed the examinations in each o f these years ending Mar. 31 from 1910 to 1919, as given in the yearbooks 1910, p. 334 ; 1911, p. 422 ; 1912, p. 1 9 0 ; 1913, p. 1 9 4 ; 1914, p.. 2 0 1 ; 1915, p. 2 2 9 ; 1916, p. 1 5 3 ; 1917, p. 1 4 5 ; 1918, p. 1 8 2 ; 1919, p. 215. The number given as on the register Mar. 31, 1919, is greater, however, than the sum of the number 879 on the register Mar. 31,. 1910, and the number 1,311 entitled to registration by passing the prescribed examination during the period Mar. 31, 1910, to Mar. 31, 1919. Others may have been registered as having equivalent quali fications because of training received outside New Zealand. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 34 INFANT MORTALITY. who have attended at least 20 cases o f confinement, and who pass a, satisfactory examination. Persons who had already been practicing for a period of at least three years when the law went into effect were entitled to registra tion without examination, provided they satisfied the registrar that they were o f good character. Notice o f intention to practice midwifery must be given annually to the registrar. Registration may be canceled in case of conviction for an indictable offense or in case of malpractice or misconduct. The district health officer is constituted the local supervisory author ity over midwives in his district. The board o f health publishes a pamphlet of rules for the guidance o f midwives in which the principal points o f the act are summarized. There are, in addition, detailed specifications as to equipment and a detailed statement o f conditions under which medical help should be sent for. I f a midwife neglects or refuses to send for a doctor in any case so specified, her registration as midwife becomes sub ject to cancellation. Persons not registered as midwives who practice or use the name o f midwife are liable to a fine not exceeding £20 ($97). The pen alty does not apply to assistance rendered in cases o f emergency. The department o f health, when it receives information through the office of the registrar o f births or from any other source, that a person not registered as a midwife has attended a confinement,»no tifies the person of her liability to fine under the law and institutesprosecution unless it is shown that the case was in the nature o f an emergency. In Table X I V the number o f registered midwives and the num ber of trained and certified midwives are given for the period from 1907 to 1920. In 1918 slightly over half those on the register had been trained and certified, the remainder having been in practice at the time the act went into effect. The law thus provides, in practice, for the gradual substitution of trained midwives for those in prac tice at the time the act went into force, who may or may not have had adequate training. It thus definitely raises each year the level o f midwifery care available for the mothers o f New Zealand. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 35 NEW ZEALAND. T able X IV .— R eg istered m id w ives, N e w Zealand, 1 9 0 1 -1 9 2 0 1 R egistered m id w iv e s . R e giste re d m id w iv e s . Y ea r en d ed M ar. 31— Y e a r e n d ed M ar. 31— T o ta l o n register. 1907............................................... . 1908................................................... 1909................................................... 1910____v ....................................... 1911................................................... 1912................................................... 1913............... .................................. 890 996 1,004 1,155 1,017 1,098 1,1S9 T rained and certified. 104 *149 »149 283 341 415 504 T o ta l o n register. 1914....................................... 1915................. 1916................................................. 1917................................................... 1918................................................... 1919............................................. 1 9 2 0 .. ;.................................. T rained and certified. 1,278 1,373 1,431 1,497 1,519 4 2,508 6 2,638 595 690 742 842 888 989 1,119 1 Source: N e w Zealand O fficial Y e a r-B o o k , 1907, p . 442; 1908, p . 251; 1909, p . 254; 1910, p . 333; 1911, p . 421; 1912, p . 190; 1913, p . 194; 1914, p . 201; 1915, p . 229; 1916, p . 153; 1917, p . 145; 1918, p . 182; 1919, p . 215; 1920, p . 62. a I b id ., 1908, p . 251, g iv e n as for 1907, b u t th e figure d oes n o t agree w ith th at g iv e n in 1907 y ea rb ook , p . 442, for th e year 1907. 8 Stated as for 1908, b u t see p reced in g n o te . T h e figure giv e n i n th e n e x t y ea rb ook is for 1910. 4 I b id ., 1919, p . 215. E v id e n tly an error d u e t o a d d in g t o th e n u m b e r o n th e register th e p reced in g year th e to ta l n u m b er train ed a n d certified in stea d o f th e n u m b e r n e w ly certified less d eaths a n d w ithdraw als. S h ou ld p r o b a b ly n o t e xceed 1,620. 6 See p reced in g n ote. S h ou ld p r o b a b ly n o t e xceed 1,750. H ospitals. St. Helen's Materrdty Hospitals.—Under the midwives act o f 1904 the establishment o f one or more State maternity hospitals was authorized. They were designed not only to provide facilities for training midwives and maternity nurses but also to provide skilled assistance at confinement for wives of workingmen, at a moderate fee. The first o f these State maternity hospitals, or St. Helen’s Hos pitals as they are called, was opened at Wellington in the year 1905. Three others were opened soon after, one at Dunedin in October, 1905, one at Auckland in June, 1906, and one at Christchurch in April, 1907. More recently, in November, 1915, one was established at Gisborne, and in March, 1918, another at Invercargill. As already stated, the midwives act specified that nurses trained in St. Helen’s Hospitals, after completing a prescribed course o f training and passing a satisfactory examination, might be admitted to practice as midwives or maternity nurses. The fees for the course o f training are low—only £10 ($48.66) for the 6-month course for registered nurses, and £20 ($97.33) for the 12-month course for others. It should be mentioned in this connection that the depart ment o f health remits the fee for the course of training in case the woman, when qualified as midwife, serves for a period o f two years in some district which is in especial need o f the service o f a midwife and is unable otherwise to secure such services. The wives o f workingmen who have incomes o f less than £350 ($1,703.28) a year may avail themselves of the services o f these hospitals.51 A small charge, 30s. ($7.30) a week, is made for care during the confinement period if the confinement takes place in a 61 New Zealand Journal of Health and Hospitals, Vol. IV (January, 1 9 2 1 ), p. 14. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 INFANT MORTALITY. St. Helen’s Hospital; patients admitted for special treatment before confinement are charged £1- ($4.87) a week, while babies are re admitted for treatment at a rate of 10s. ($2.43) a week. The charge for a nurse’s attendance at confinement at the home o f the patient and 10 daily visits is £1 ($4.87). These hospitals not only provide for the confinement period but also give a certain amount of prenatal supervision and o f advice on the care o f infants. Their medical officers are in attendance at special hours on certain days, when any woman desiring medical advice during pregnancy may secure it free o f charge, whether she is registered to have her confinement at the St. Helen’s Hospital or not. Expectant mothers who have registered to have their con finements at the St. Helen’s Hospitals are urged to come in about the beginning of the seventh month o f pregnancy, and if any un toward symptoms are present a thorough examination by a physi cian is given. At these hospitals mothers are kept in bed at least 10 days and in the hospital at least 14 days after confinement. Afterwards they are visited at intervals by the hospital nurses, who give them advice as to the care and feeding o f their infants. This feature o f the work is, however, not systematic. Sometimes mothers are referred to the Plunket nurses, as the nurses o f the Royal New Zealand Society for the Health o f Women and Children are called.52 During the year ended March 31, 1919, as shown in Table X V , 1,123 confinements took place in the six hospitals, and 521 confine ments which occurred outside the hospitals were attended by St. Helen’s nurses. O f the total number o f births in the Dominion, about 1 in every 23 took place in a ¡St. Helen’s Hospital; including those outside the hospitals attended by the institution nurses, about 1 in every 16 was attended by a St. Helen’s nurse.53 T able X V .— B irth s attended B irth s a tte n d e d b y S t. H elen ’ s nu rses. Y ear en d ed M arch 31— 1 9 0 7 .... 1 9 0 8 .... 1 90 9 .... 1 91 0 .... 1 9 1 1 .... T o ta l. 718 822 1,128 1,185 1,182 O u tside I n S t. S t. H elen ’ s H elen ’ s H osp i H o sp i tals. tals. 564 662 806 865 827 154 160 322 320 355 6 y S t. H elen 's nurses, 1 9 07 -1 920 .a B irth s a tte n d e d b y S t. H elen ’ s n urses. B irth s a tte n d e d b y S t. H elen ’ s n urses. Y ear e n d ed M arch 31— 1 9 1 2 .... 1 9 1 3 .... 1 91 4 .... 1 9 1 5 .... 1 9 1 6 .... T o ta l. 1,346 1,374 1,298 1,204 1,361 O u tside I n St. St. H elen ’s H elen ’ s H o sp i H o s p i tals. tals. ' 886 920 803 794 798 460 454 495 410 563 Y ear ended M arch 31— 1 9 1 7 .... 1 9 1 8 .... 191 9 .... 1 92 0 .... T o ta l. 1,594 1,778 1,644 1,691 O u tsid e I n S t. S t. H e le n ’ s H e le n ’ s H o s p i H o s p i tals. tals. 1,071 1,248 1,123 1,139 523 530 521 552 a S ource: N ew Zealand Official Y e a r-B o o k , 1908,p .2 5 7 ; 1909, p .2 5 4 ; 1910,p . 333; 1914,p . 200; 1919, p . 214; 1920, p . 61. T h ere are slight discrepancies in th e figures fo r certain y ears; e. g ., th e figures fo r 1910 are given as 865 i n a n d 320 o u ts id e th e S t. H elen ’ s H ospita ls xn th e 1914 ye a rb o o k , w h ile th e y are giv e n as 875 a n d 328 in th e 1910 y ea rb ook (p . 333); a n d th e figures for 1913 are sta ted as 920 a n d 454 in th e 1914 y e a rb o o k , b u t as 909 a n d 452 in th e 1913 y e a rb o o k (p . 193). 52 See p. 48. 63 New Zealand Official Year-Book, 1919, p. 214. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T H E ST. H E LE N ’S HOSPITAL, W E L LIN GT ON , NEW ZEALAND. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Z-98 VIE W OF T H E GROUNDS, ST. H E LE N ’S HOSPITAL, W E L L IN G T O N , NEW ZEALAND. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 37 Public general hospital*.—Public general hospitals aie established by and are under the control of local hospital boards and are subject at all times to inspection by the director general of health or his deputies. Moderate fees are charged for care and treatment in these hospitals. The number o f public general hospitals increased from 36 in 1880 to 65 in 1919. Besides these, there were, in 1919, 4 fever and in fectious disease hospitals and 5 sanatoria. for consumptives.54 During 1919, 393 normal confinements occurred in public hospitals in addition to those which occurred in the St. Helen’s Maternity Hospitals.55 Special mention should be* made of the system o f medical, nursing, and hospital facilities provided, since 1909, for country districts. Cottage hospitals are established and maintained in a number o f the more remote districts by the hospital boards. Nurses are appointed for work in the country districts ; physicians are subsidized to take up practice-in districts where otherwise they would have difficulty in making a living. Besides this provision by the local boards, the Central Government maintains a number o f district nurses in the back blocks, as the remote country districts are called, principally in regions where the Maoris are in preponderance and district midwives, paid for wholly by the Central Government, are stationed in a number o f the smaller towns. In these ways the smaller communities have access to medical and nursing services which unaided they could not support. Private hospitals.—Private hospitals are regulated under the hos pitals and charitable institutions act, 1909 (No. 11). Under the provisions o f this act all private hospitals are required to be licensed. Application for license must contain a detailed description o f the hospital and a statement as to the uses to which the different rooms are to be put and the number and kind o f cases to be received. It is further provided that the resident manager o f the hospital, if not a registered medical practitioner, must be, in case of a licensed ma ternity hospital, a registered midwife ; in case o f a medical and sur gical hospital, a registered nurse; or, in case o f a hospital licensed both as a maternity hospital and as a medical and surgical hospital, a registered nurse who is also a registered midwife or who has as an assistant a registered midwife. A complete register of patients must be kept open to inspection. Licensed hospitals are subject to visit and inspection in the same manner as public hospitals. 54 S t a t i s t i c s o f N e w Z e a la n d , 1& 80, V it a l S t a t i s t i c s , p. 5 2 . N e w Z e a la n d O ffic ia l Y e a r B o o k , 1919, p. 2 12 ; 1920, p. 60. 55 S t a t i s t i c s o f t h e D o m i n i o n o f N e w Z e a l a n d f o r t h e y e a r 1£>19, V o l. I , p . 1 7 4 . B e s id e s t h e s e c a s e s o f n o r m a l l a b o r , 1 ,0 6 6 c a s e s ( d i s c h a r g e s a n d d e a t h s ) o f w o m e n w e r e t r e a t e d f o r d is e a s e s c o n n e c t e d w i t h t h e p u e r p e r a l s t a t e . I b id ., p . 1 7 4 . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 38 INFANT MORTALITY. The act defines as a private hospital any house in which two or more patients are received and lodged at the same time, other than institutions under the control o f hospital boards and hospitals wholly or mainly supported by the State. A license may be revoked in case the premises are deemed by the inspector general to be insanitary, in case the hospital is conducted in such a way that revocation is demanded in the public interest, in case the licensee or manager has been convicted of an offense against the act or any offense punishable by imprisonment, or if the licensee has failed to pay the annual fee. A t the close o f the year 1919 about 240 private hospitals were in operation.56 A number o f private hospitals provide maternity care, but un fortunately no complete statement o f the number of confinements or births that occur in them is available. During the year ended March 31, 1919, 238 confinements occurred in 6 maternity homes maintained by the Salvation Army in the larger cities;57 a large proportion o f the confinements in these hospitals were of girls illegitimately preg nant.58 Besides these, in the year ended March 31, 1919, the Batche lor Hospital, an institution connected with the Medical School o f the New Zealand University at Dunedin, cared for 126 confinements, the McHardy Maternity Home, Napier, 141; the Maternity Home, Blenheim, 82; and the Essex Maternity Home, Christchurch, 21, while in the Alexandra Home, Wellington, 99 births occurred.57 Recent returns from 178 private hospitals for the two-year period July 1, 1919, to June, 1921, show a total of 15,838 confinements, or an average o f about 7,900 confinements in these private hospitals each year.59 Control over m ilk supply. Regulation of production of milk.—In regard to milk supply, the department o f agriculture has supervision until the milk leaves the dairies, while the department o f health controls the storage and sale. The two principal acts regulating production of milk are the dairy industries act, 1908, and the stock act of the same year. The pro visions o f these two acts are enforced by inspectors under the de partment o f agriculture. According to the dairy industries act, 1908 (No. 37), and the regu lations thereunder, all dairies producing milk for sale have to be 66 New Zealand Official Year-Book, 1920, p. 61. 67 Public Health, and Hospitals and Charitable Aid Report, “ H —3 1 ,” p. 13. New Zea land, 1919. 68 Ibid., p. 12. See also Report on the Work of the Royal New Zealand Society for the Health o f Women and Children, p. 5, by Dr. Margaret Harper. Royal Society for the W elfare o f Mothers and Babies,'Sydney, N. S. W „ 1920. 69 Report of the Director General o f Health, New Zealand for the Year Ended 31st March, 1921, “ H -2 1 ,” p. 24. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND, 39 registered with the inspector of stock in the district. Registration is made only after inspection and approval o f the premises, and has to be renewed annually. Such premises are subject to inspection at any time. Among other things, the inspectors have power to order any unsatisfactory condition remedied, and to prohibit the sale o f milk from any dairy which does not come up to standard. Provision is made for supervision over construction of dairies, and plans for new dairies have to be approved before work is commenced. No person suffering fropa an infectious or contagious disease is allowed to han dle milk. Under the stock act, 1908 (No. 187), cattle suffering from infec tious disease may be condemned by an inspector. The owner is com pensated at half the market value. Upon request, or whenever there is reason to suspect the presence o f tuberculosis, cows are tested with tuberculin free of charge. No general testing for tuberculosis has been undertaken. Samples o f milk from herds supplying the chief centers are taken and examined for tubercle bacilli. In the years 1918-19 the results of these examinations were negative in alf cases. Regulation of sale of milk.—Under the sale of food and drugs act, which was passed in 1907, the oversight over the quality and condition o f milk sold was placed in the department o f public health. Under the authority o f this act, regulations were published in the official gazette in 1907 which for the first time in the Dominion laid down a standard for milk sold.60 The regulations in force in 1919 prescribed a standard for the per centages o f butter fat and of other solids, and a standard in regard to bacterial condition,61 besides provisions for securing cleanliness and freedom from contamination o f milk.62 In the administration of the sale o f food and drugs act, the de partment o f health had, in 1919, 31 inspectors directly under its supervision. Besides these, in many districts other inspectors work under the direction of the local hospital boards. The agents o f the department collect samples from the vendors of milk, the samples are submitted to analysis, and prosecutions may be instituted if the milk is found to have been watered, or to be below standard in the percentage of butter fat and other solids or otherwise not in good condition. Special bacteriological tests of milk are made, when requested, in the Dominion laboratory of the department of health. 80W att, Dr. M. H. (director, division of public hygiene, department o f health) : “ In fant mortality in New Zealand,” in New Zealand Journal of Health and Hospitals, Vol. IV (April, 1 9 2 1 ), p. 89. 61 The regulation in the m atter o f milk souring provides that the milk when sold must be in such condition that in the reductace test it will not decolorize the methylene blue in less than three hours. New Zealand Gazette, No. 40, Mar. 21, 1918. 62 The principal provisions of the regulations for the sale and storage of milk in force in 1919 are given in Appendix B. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 INFANT MORTALITY. During the year 1918, 50 convictions were secured for adulterated milk or for milk not up to standard, and fines of £654 4s. Id. ($3,183.67) were imposed. O f these convictions, 17 were in the Wellington district, 9 in Auckland, 6 in North Canterbury, and 5 in the Nelson district. In general, so far as could be learned, no system o f refrigeration o f milk either during transportation by rail or during delivery by milk cart was in use in New Zealand. The general practice, further more, was to sell from the can; the delivery of milk in bottles now so generally required in American cities, was practiced only in special cases, such as that o f the u humanized ” milk prepared for individual babies in Dunedin.63 In this connection, however, it is necessary to bear in mind the relatively short distances from farm to consumer, and the cool climate. 'Wellington municipal milk.—An interesting development o f the last decade is the taking over o f the milk supply o f Wellington by the municipality. Wellington is the most unfavorably situated city in New Zealand, so far as the milk supply is concerned, being cut off from the dairy districts by high hills. Practically all the milk has to come in by rail from distances ranging from 7 or 8 miles to 15 or 20. By an act o f November 4, 1919, the city council was given complete authority over the sale and distribution o f milk in Wellington. By authority of this act the city took over the handling o f the entire milk supply entering the city. In 1920 it was buying all the milk from the dairymen and, after Pasteurizing it, was selling it to the private dealers to distribute. A t the central Pasteurizing plant every precaution was taken to insure cleanliness 5 the cans in which the milk was received from the dairies and those in which it was sent to the distributors in the city were completely sterilized. Samples were taken daily o f the milk received from each dairyman, and were subjected to analysis for butter fat and to the “ reductace test ” for determining bacterial con dition; if milk was not up to the standard, the dairyman furnishing it was first warned and then, i f he still failed to meet the requirements, was dropped from the number o f producers selling milk to the city.' The city was divided into five districts, and the four principal com panies were each allowed exclusive rights in one o f these; in the fifth district a few small local distributors were allowed to sell milk and any o f the four companies as well. The city itself sold milk at retail at its central plant, and on request also delivered milk in quantity to the larger hotels and similar establishments. 63 See p. 60. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 41 The city is authorized, however, not only to purchase and Pas teurize, but also to distribute milk, and the arrangement for distri bution by private companies was intended merely as a measure o f transition. The plan provides that after three years the city shall take over the actual distribution o f milk to the private consumer and shall deliver the milk in bottles. During this transition period o f three years the difference between the price which the city charges the distributing companies and the price they are allowed to charge the public is so measured as to provide the companies compensation for the good will o f their business. M aternity allowances. Although the Government o f New Zealand has no general system, like the Australian, of maternity bonuses, it does grant allowances for births to members o f the National Provident Fund and, beginning with 1917, to members o f approved Friendly Societies, as the volun tary societies which provide benefits for their members in cases o f sickness, old age, or invalidity, are called. A brief description o f the provident fund and o f the conditions under which maternity allow ances are granted is therefore o f interest in considering the subject o f infant mortality. The National Provident Fund was established Dy an act passed, in 1910, and went into operation on March 1, 1911. Its chief purpose was to provide facilities by which New Zealand residents could accu mulate funds for pensions in old age. Any resident o f New Zealand over 16 and under 50 years o f age may join the fund provided his average income prior to joining does not exceed £300 ($1,460) a year. Besides pensions for old age, benefits are given in case o f incapacity for work, and to the widows and orphans o f members.64 These pen sions are paid from contributions by members o f the fund, to which a State subsidy is added. In addition to the regular benefits, a payment o f £6 ($29.20) is made, upon the birth o f a child, to any member o f the fund o f at least 12 months’ standing. This payment is made from a special Government grant for this purpose; no part o f the cost o f the maternity allowance is borne by the contributor himself. Among the conditions for the grant of the maternity allowance are the following: For the period o f 12 months immediately preceding the birth o f the child the joint income o f the father and mother must not have exceeded £300 ($1,460); and since becoming a contributor the applicant must not have been absent from New Zealand for a period o f 2 years at any one time, or 5 years in the aggregate (absence 84 Details o f the conditions under which pensions are granted may be found in the New Zealand Official Year-Book, 1919, pp. 702—7 0 4 ; the reference, however, does not incorpo rate changes made by the national provident fund amendment act, 1919, No. 26. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 42 INFANT MORTALITY, in the military force or public service, however, is excepted). Mater nity allowances are granted for legitimate births only. The provisions o f the original act of 1910 specified that the board in whose hands the administration o f the fund was placed might re duce the amount of the maternity benefit to the sum actually ex pended for medical services, including the services o f a medical prac titioner, midwife, and nurse. This limitation was repealed by an amendment passed in 1919, since in practice it was found that few persons spent less than the amount provided for medical service, and that therefore the full amount was granted in practically all cases. The board may still require a report o f the amounts expended in medical service. An important amendment to the law was passed in 1916 by which maternity allowances o f £4 ($19.16) were granted by the Government to members o f any approved Friendly Society upon approximately the same conditions as to members o f the provident fund. The amount was raised to £6 ($29.20) by an amendment o f October 31, 1919. Details o f the numbers o f maternity allowances granted during the years 1912-1918 are shown in Table X V I. Prior to 1917 mater nity allowances were granted for less than 2 per cent o f the births in New Zealand. In 1917 and 1918, when allowances were granted to members o f Friendly Societies, the proportion o f births for which maternity allowances were granted rose to nearly 16 per cent. T able X V I .— M a ter n ity benefits granted to m em bers o f th e N ational P ro vid en t F u n d or approved F rien d ly S ocieties, 1 9 1 1 -1 9 1 8 .* Cases receiving m ate rn ity benefits. Year, e n d e d D e c . 31 B irth s. T o ta l. N u m b e r. P e r cen t o f birth s. 1912 1913 1914 1915 1916 1917 1918 27,508 27,935 28,338 27,850 28,509 28,239 25,860 31 119 306 472 634 3,360 4,120 N ation al A p p r o v e d P roviden t F rie n d ly Fund. Societies. 0.1 .4 1.1 1.7 2 .2 11.9 15.9 31 119 306 472 634 677 668 2,683 3,452 1 S ou rce: M anuscript figures furnished b y cou rtesy o f th e N a tio n a l P ro v id e n t F u n d . The prime object o f the grant o f maternity allowances for mem bers of the National Provident Fund was the encouragement of thrift ; since the attempt regularly to lay by savings for old age was in many cases interrupted or made impossible by extra expenses in cident upon childbirth, allowances were granted to insured members https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 43 ° f the fund in order to enable them to continue with their regular contributions to the fund. Though practically all the money granted appears to have been expended for medical and nursing services, no information is available to show whether the grant o f maternity allowances has actually raised the level o f confinement and nursing care in the families which received them. Hegulation o f boarding homes fo r infants. The infant life protection act was first passed in 1896. It provided that infants under 4 years o f age boarded out for reward apart from their mothers should be placed only in licensed homes. The powers o f licensing and inspection were at first given to the police. It might be mentioned that this act was first passed on account o f the discovery o f a flagrant case of baby farming in which, after the premiums had been paid, the infants had been practically murdered. In 1907, in order to improve the system o f licensing and inspection, the powers o f administration were transferred from the police to the ■education department. A t the same,time the age o f infants to whom the provisions of the act applied was raised to 6 years. The act is administered by the special schools branch o f the education depart ment. The inspectors are all trained women with nurses’ certificates. Table X Y I I shows the number o f children under 4 years of age in foster1homes from 1898 to 1905, and the number of deaths among them. These rates are not infant mortality rates, since children up to 4 years o f age were included, and since a child was counted for each calendar year during which he spent even a short period in the home. Nevertheless the decrease in the death rate from 1898 to 1905 probably reflects a corresponding decline in the death rate among infants in foster homes, since the great majority o f deaths were undoubtedly o f babies under 1 year o f age.65 On account o f the absence o f data, no exact comparison can be made o f mortality among ^infants boarded out apart from their mothers before and after the enactment o f this legislation. 65 Thus o f the 184 deaths among children! under 6 years of age in foster homes from J.908 to 1918, 139, or 76 per cent, were o f infants under 1 year o f age. 92832°—22-----4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 44 IN F A N T M O R T A L IT Y . X V II .— D eclin e in death rate am ong children under 4 yea rs o f age in T able fo ste r h om es, 1 8 98 -1 905 .1 C h ildren u n d e r 4 years o f age in foster hom es. C h ildren u n d e r 4 years o f age in foster h om es. D eaths. D ea th s. Y e a r e n d ed M ar. 31— A t any tim e in year.. Y e a r e n d e d M ar. 31— N u m b e r. P e r 100 in hom es at a n y tim e in year. 829 27 3.3 872 943 26 29 3 .0 3.1 1902.............................. 1903............................... 1904.............................. 1905.............................. A t any tim e m year. 936 854 728 862 N u m b e r. «4 4 28 21 20 P e r 100 in h om es at a n y tim e in year. » 4 .7 3. a 2.9' 2. a i Source: C om m issioner’ s R e p o rts as abstra cted in N e w Zealand O fficial Y e a r -B o o k , 1900, P -1 20, 1903. 405- 1904, o . 261; 1906, p . 214; a n d 1907, p . 442. T h e reference m th e 1907 y e a r b o o k d oes n o t s p e cify t h e yea r to w h ic h th e figures, 862, e tc ., refer, Taut fro m sim ilar statem en ts in o th e r y e a rb o o k s it is in ferred that, t h e y refer t o th e year 1905. 1 N o t stated in source. . . . . ... • in ri9 » A n e p id e m ic o f scarlet fe v e r a n d m easles is cite d as a n e x p la n a tio n o f th e h ig h m o r ta lity in I9iw. d Table X V I I I shows the decline from 1908 to 1918'in the mortality among infants under 1 year of age who were boarded out in foster homes. For this period, during which the education department had charge o f the inspection and licensing service, the death rate per 1,000 infants in foster homes fell from 148 in 1908 to only 21 in 1918. These rates, which are based upon estimated average numbers o f infants under 1 year of age in foster homes, indicate clearly a strik ing decline in the infant death rates. It should be borne in mind, however, that since the majority of these infants were probably over 2 weeks o f age before they were boarded out, the mortality rate among them is not exactly comparable to an infant mortality rate for the entire first year of life.66 T able X V III .— D eclin e in .d ea th ra te am ong in f m i s under 1 y e a r o f age in fo ste r hom es, 1908—1918.a -------------------------------------------------- J In fa n ts u n d e r 1 ye a r o f age in foster h om es. In fa n ts u n d e r 1 year o f age in foster h om es. Y e a r. Y e a r. D eaths. E s ti m a te d average num ber.!» N u m b e r. P e r 1,000. 1913...................... . 154 187 156 150 168 173 22 19 19 8 10 11 143 102 122 53 60 64 i 1914.............................. 1915.............................. 1916.............................. 1917.............................. 1918.............................. D eaths. E sti m a te d average num ber.!» N u m b e r. P e r 1,000. 198 210 183 181 191 17 9 10 10 4 86 43 55» 55 21 a C om p iled fr o m R e p o rts o f E d u ca tio n D e p a rtm e n t, N e w Z ealand, E d u ca tio n ; Special S ch ools, a n d J u ven ile P r o b a tio n S ystem a n d In fa n t-L ife P ro te ctio n , 1909-1919. ~ b F o u n d b y averaging th e n u m b e rs o n th e b o o k s at th e b egin n in g a n d th e en d o f th e ye a r. T h e n u m b e r o f d ifferen t in fa n ts is m u c h greater th a n th is average n u m b e r. See G eneral l a b l e 2, p . 70. 66 Further details of admissions and withdrawals are given in General Table 2, p. 7 0 . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 45 NEW ZEALAND. Figures are also available showing the mortality among infants under 1 year o f age in institutions exempted from certain provisions o f the act.®7 Table X I X indicates that in these institutions a marked decline in the death ra,te has taken place during the period o f 1909 to 1918. The rate per 1,000 individual infants cared for fell from an estimated 230 in 1909 to 60 in 1918, a decrease o f nearly threefourths. I f the deaths are compared to the estimated average num ber o f infants in these institutions, the rate, which much more closely approximates an infant death rate, appears much less favorable; but the fact o f a marked decrease in the rate is clearly established. T X I X .— D eclin e in the death rate am ong in fants under 1 y e a r o f a ge in institu tion s exem p ted from certain p rovision s o f the infant life protection act, able 1909— 1918.1 In fan ts u n der 1 y e a r o f age in e xe m p te d institutions.2 In fan ts u n d er 1 yeafr o f age in e x e m p te d in stitu tion s.2 D eaths. D eaths. Y ear. A t any t im e in yea r.3 1909 _ 1910................. 1911 . . 1 9 1 2 ... 1913................. 5 237 253 265 261 201 P er 1,000 a t N u m b er. any tim e ih yé a r. 56 41 30 26 15 236 162 113 100 75 E sti m a te d average n u m b e r .< 6 76 76 81 69 59 Y ea r. A t any tim e in ye a r.3 1914................. 1915................. 1916................. 1917................. 1918................. 289 217 116 141 182 E sti P er m ate d 1,000 at average n u m ber.4 N u m b er. an y tim e in year. 26 8 4 12 11 90 37 34 85 60 76 72 39 35 54 1 F or exp la n a tion o f e x em p te d in stitutions, see n o te 67, b e lo w . 2 U p t o 1912 th e K a rita n e H o m e , th e h o sp ita l for in fan ts m ain ta in ed b y th e N e w Z e a la n d S ociety for th e H ea lth o f W o m e n a n d C hildren, w a s in clu d e d in th e p u b lish e d returns. I n th e a b o v e figures th e infants in this h osp ita l a n d th e death s a m o n g th e m h a v e been om itte d in order t o p u t th e series on a un ifo rm basis. * T h e su m o f th e n u m b e r o n th e b o o k s at th e b e g in n in g o f th e y e a r a n d th e n u m b e r a d m itte d d u rin g th e yea r. 4 T h e average o f th e n u m b e r o n th e b o o k s a t th e begin n in g a n d a t th e e n d o f th e y ear. 6 T h e n u m b er on th e b o o k s a t th e b egin n in g o f th e y ea r is assum ed eq u a l t o th e n u m b e r on th e b o o k s at th e end o f th e yea r. F o r further particulars, see G eneral T a b le 4, p . 70. A large proportion of children boarded out apart from their mothers are o f illegitimate birth. Table X X gives an idea of the present scope o f the New Zealand act in protecting the lives of these children by comparing the illegitimate children brought under the act in a given year with the number of illegitimate births in the same year. An approximate average of from one-sixth to one-fifth of the illegitimate children appears to have been boarded out, and thus come under the provisions of the infant life protection act. As stated previously, between 4 and 5 per cent of all births are illegiti mate. 67 The minister o f education is empowered to grant exemption to institutions supported wholly or in part by the Crown or biy public subscription, to relatives of the infant, or to persons as to whom the minister is satisfied the act should not apply. Exempted in stitutions must be open a t all times to persons appointed under the act, and no infant may be removed from the institution without official consent. (Report o f the Education Department, “ B -4 ,” 1909, p. 37 .) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN FAN T MORTALITY. 46 No statistics of mortality among all illegitimate children are avail able for New Zealand. But in other countries the mortality among the illegitimate is two or often three times as high as that among the legitimate. The New South Wales experience under an infant life protection act similar to that o f New Zealand suggests that the infant mortality rate has declined even more among illegitimate than among legitimate infants. In New South Wales a system o f infant-life protection has been in force since 1891, with amendments in 1904 and changes in regulations at other times, and the mortality rate among illegitimate infants fell from 276 in the period 18951899 to 108 in 1918. T a b l e N X . — P roportion o f illegitim ate births brought under the infant life pro tection Y ea r. 190R 1909 . 1910 1911 1912 1913.............................. Illegiti m a te birth s. 1,105 1,223 1,162 1,078 1,177 1,180 act, 1 9 0 8 -1 9 1 8 .1 C hildren o f illegiti m a te b ir th aged 12 m o n th s or less b ro u g h t u n der th e in fa n t life pro te ctio n a ct. N u m b er. P e r cen t. 2 343 2 276 2 2U 2 223 249 194 31 23 18 21 21 16 Y ea r. Illegiti m a te birth s. C hildren o f illegiti m a te b ir th aged 12 m o n th s or less b ro u g h t u n d er th e in fa n t life p ro te ctio n a ct. N u m b er. P er cen t. 1914.............................. 1915.............................. 1916.............................. 1917.............................. 1918.............................. 1,302 1,152 -1,146 1,158 1,179 276 250 217 207 181 21 22 19 18 15 1 Source: R ep orts o f th e E d u ca tio n D e p a rtm e n t, “ E -4 ,” E d u ca tio n ; S pecial S chools, a n d Ju ven ile P ro b a tio n S ystem a n d In fa n t-L ife P ro te ctio n , 1909-1919. 2 I n th e source th e term “ ch ild r e n ” is u sed u p t o 1911; in 1912 th e term “ illeg itim a te ch ild re n ” is in tro d u ced , a n d th e sam e figure is giv e n for 1911 as in th e 1911 report for “ ch ild re n .” R O Y A L N E W Z E A L A N D SO C IE T Y FOR T H E H E A L T H OF W O M E N A N D C H ILD R E N . The most important infant-welfare work done by any single agency is that o f the Royal New Zealand Society for the Health of Women and Children. This society was organized in Dunedin in 1907 by Dr. Truby King, and was formed to carry on work which he had already commenced for the better care o f very young chil dren. The work o f this society was described in an early bulletin o f the Children’s Bureau.68 A im s and objects. The aims and objects o f the society are stated in its annual reports as follows: 1. To uphold the sacredness of the body and the duty o f health; to inculcate a lo fty view of the responsibilities of maternity and the duty of every mother to fit herself for the perfect fulfilment of the natural calls o f motherhood, 68 New Zealand Society for the Health o f Women and Children: A n Example o f Methods of Baby-Saving Work in Small Towns and Rural Districts. U. S. Children’s Bureau Pub lication No. 6. Washington,. 1914. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 47 both before and after childbirth, and especially to advocate and promote the breast feeding of infants. 2. To acquire accurate information and knowledge on matters affecting the health of women and children, and to disseminate such knowledge through the agency of its members, nurses, and others, by means o f the natural handing-on from one recipient or beneficiary to another, gnd the use of such agencies as periodical meetings at members’ houses or elsewhere, demonstrations, lectures, correspondence, newspaper articles, pamphlets, books, etc. 3. To train specially, and to employ qualified nurses to be called Plunket nurses, whose duty it will be to give sound, reliable instruction, advice, and assistance, gratis, to any .member of the community desiring such services on matters affecting the health and well-being o f women, especially during preg nancy and while nursing infants, and on matters affecting the health and well being of their children; and also to endeavor to educate and help parents and others in a practical way in domestic hygiene in general— all these things being done with a view to conserving the health and strength o f the rising genera tion, and rendering both mother and offspring hardy, healthy, and resistive to disease. 4. To cooperate with any present or future' organizations which are working for any o f the foregoing or cognate objects. N. B.— The society was started as a league for mutual helpfulness and mu tual education, with a full recognition of the fact that, so far as motherhood and babyhood were concerned, there was as much need for practical reform and “ going to school” on the part o f the cultured and well-to-do as there was on the part of the so-called poor and ignorant. M e m b e rs h ip . Any one who subscribes a sum o f 5s. ($1.20) or more a year to the society is a member. Local committees. Members o f the society living in any locality may join together to establish a branch organization and, with the approval of the central council and the department of health, may establish Plunket rooms and maintain a Plunket nurse. The work o f each local branch is sup ported wholly by local subscriptions and donations, except for a subsidy granted by the health department, and is managed by a local committee o f 15 to 20 women elected by the members o f the branch. Each branch committee has an advisory board o f three or more physicians and business men. The branches contribute to the funds o f the central council and send delegates to the general conference of the society which meets annually. Outlying branches in rural com munities which can not afford to maintain nurses o f their own often secure part-time services o f the nurses in near-by cities. Central organization. At the general conference questions o f poljcy affecting the work o f the society and in particular the relations between the society and the Dominion Government are discussed and decided. The conference also elects a central council, consisting for the most part of Dunedin https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 48 IN FA N T MORTALITY. members but with representatives from other branches, which con ducts the business o f the society during the intervals between the meetings o f the general conference, including, among other things, the receipt and disbursement to the branch organizations o f the sub sidies granted by the Government toward the payment o f salaries of Plunket nurses. The central committee meets in Dunedin, and the Dunedin members constitute an executive committee. Except for a paid secretary o f the central council and for the nurses, all the work o f the society is volunteer. Training o f nurses. A very important feature o f the work o f the society is the training o f its nurses. The branch at Dunedin, the one which was formed first, maintains a special hospital for the training of all the Plunket nurses employed in the various branches. Two other branches, those at Christchurch and at Wanganui, also maintain special hospitals for babies, but do not train Plunket nurses. Plunket nurses, as they are called in honor o f Lady Plunket, wife o f a former Governor of New Zealand, who took great interest in the work o f the society, are all registered general or maternity nurses who have had a sort of postgraduate training in infant hygiene, feeding, and mother craft, at the special baby hospital, the Karitane-Harris Hospital, maintained by the society at Dunedin. In this hospital babies are received for dietetic treatment only. Nurses are given careful and thorough instruction in the general methods of care, par ticularly in the preparation of so-called “ humanized ” milk—a special kind o f modified milk—in clothing, hours o f sleep, and other details. The period o f training is three months for nurses with general train ing and six months for nurses with special maternity training only, These nurses pay a fee of £15 ($73) for their training, which is re funded, however, after two years’ service with the society as Plunket nurses. The title “ Plunket nurse ” is given to nurses only while they are in the employ o f the society. Besides the Plunket nurses, the society trains Karitane nurses. These are women without previous nursing training who have taken a course o f 12 months at one o f the Karitane hospitals and have passed a satisfactory examination. The fee for this course is £20 ($97.32). The Karitane nurses are trained to serve as nursemaids for babies or chil dren ; in a few instances during the war emergency a Karitane nurse acted as assistant to a Plunket nurse, but training as general or mater nity nurses is a prerequisite to becoming Plunket nurses. Karitane nurses are trained not only at the Karitane-Harris Hospital at Dune din but also at the Karitane Hospitals maintained by the branches at Christchurch and at Wanganui. In this connection it is o f interest to note that Dr. Margaret Harper, a physician sent in 1920 by the Society for the Welfare https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 49 o f Mothers and Babies of New South Wales to study the work of the Plunket Society, commented very favorably upon the thorough train ing given to nurses. In her report to the New South Wales Society she says: The training of the nurses in the handling of babies in general infant hygiene and what is known as mother craft is excellent. No detail is too small to be observed, and no trouble is too great to be taken in the training and feeding of the baby.69 K inds o f work. The principal line o f work followed is maintenance o f infantwelfare or baby-health centers, at which the specially trained Plunket nurses give free advice on all matters relating to the care o f babies except purely medical matters. The nurses do not give treatment or medicines of any kind for diseased or sick infants, but advise the mothers to call the family doctor. The mothers bring their babies to the centers for advice in regard to diet and care; from the centers the nurses also make visits to the homes. An important feature of the work is the general instruc tion given in regard to proper clothing, fresh air, and hours o f sleep. The policy o f the society is everywhere to encourage breast feed ing, but if that is not possible “ humanized ” milk is recommended and demonstrations as to the method of preparing it are given.70 No nurse is allowed, however, to suggest weaning a baby without the advice o f a physician; on the contrary, they are instructed to encourage the mothers to continue breast feeding. Mothers in all communities where Plunket nurses are stationed have, therefore, free for the asking, trained and skilled assistance in regard to all matters relating to the health and welfare of their babies, with the sole exception o f medical attention in case o f sick ness. They have also a very important aid in the nurses’ advice as to when a physician should be summoned. Mothers in other communities often ask questions by mail, and answering these inquiries is part of the work o f the Plunket nurses. It is worthy o f mention that inquiries have been received from mothers as far away as Australia who had heard o f the work o f the Plunket nurses. 68 Harper, Dr. M arg aret: Report on the W ork o f the Royal New Zealand Society for the Health of Women and Children, p. 6. (Extracts from this report are given in Appendix A, pp. 57—62. _ _ , 70 According to the method in vogue in New Zealand, “ humanized ” milk is prepared in the following way '• W hole cow’s milk is allowed to set for from four to six hours, then the tap is drawn off and mixed with the proper proportions of water, sugar of milk, and other ingredients. For very young infants whey may be substituted for water in the formula. The formula and the amount prescribed vary w ith the individual case. The term “ humanized ” is merely a popular variant o f “ modified.” https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 50 INFANT MORTALITY. The mothers are encouraged to come to the Plunket nurses before confinement, but as yet the amount o f prenatal work is not large. During 1919, only 859 new cases were reported of mothers coming for advice before the birth.71 Besides the individual work with mothers and babies, the society" supplies a column called “ Our Babies,” which is printed weekly in many o f the newspapers in New Zealand. As an example of the kind o f articles published Dr. Harper mentions the reprinting o f a lecture by Dr. Emmett Holt, of New York, to health officers, deal ing with health teaching in the schools. The society also distributes, at nominal cost, booklets and pamphlets in regard to the care of infants. . These pamphlets include The Expectant Mother and Baby’s First Month, Feeding and Care o f Baby, Natural Feeding o f Infants, The Story o f the Teeth and How to Save Them, and others. One o f these pamphlets, The Expectant Mother and. Baby’s First Month, has been taken over and published by the health department, and is distributed free o f cost to mothers on the registration of the births o f their babies. A feature of the work is that all apparatus and methods used, not only in the baby-health centers but also in the baby hospitals, are so simple that any mother can secure and apply them in her own homeIt should be emphasized that the society does not confine its work simply to the children o f the poorer classes but, on the contrary,, urges mothers in all classes to use the services of the Plunket nurses.. The work o f the society is, therefore, well known and appreciated among the well-to-do— “ the upper classes ”— and the desire to imitate, these classes becomes an influence in spreading the use o f its facilities, among those not so well off. It also helps in removing any feeling: that the work of the society is on a charitable basis. In this connection it may be in place to quote from Dr. Harper’s, report72 already mentioned: The conclusions which I have come to are as follow s: 1. That the success of the New Zealand society lies chiefly in the popularizing: the breast feeding of babies. An atmosphere has been created in which a mother is almost ashamed to have, to admit that her baby is not naturally fed. 2. That this end has been attained— (&) By the careful and detailed training (given as a postgraduate course) o f nurses in so-called mother craft, and especially in the dealing with difficulties, of breast feeding; and by the establishment of the Plunket centers from which these nurses work. 71 Figures furnished through the courtesy of the health department of New Zealand. The number o f live births in 1919 was 24,483, hence only about 3.5 per cent o f the mothers confined in 1919 received prenatal advice from the Royal New Zealand "¡Society for the Health o f Women and Children. 72 Harper, Dr. M arg aret: Report on the W ork o f the Royal New Zealand Society fo r the H ealth o f W om en and Children, p. 11. Issued by the Royal Society for the W elfare of Mothers and Babies of N. S. W . Sydney, 1920. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 51 ( b) By the educating of the public, by means of pamphlets, by the publication of the weekly column called “ Our Babies ” in the press. The public-health department publishes and distributes free of charge the society’s pamphlet, “ The Expectant Mother and Baby’s First Month.” In this way the same standards and ideas are circulated through the whole o f New Zealand. (c) B y the education of the members of the committees, and the spreading of the knowledge thus obtained through all classes of the community. (d) By the special training given in Dunedin to the medical students by Dr. W illiam s, the lecturer in pediatrics at the medical school, who is also one of the honorary medical officers in charge of the Karitane-Harris Hospital. The students are encouraged to go to the Karitane-Harris Hospital, and there come into direct contact with the practical side of the work. E xtent o f work. In regard to the growth and extent of the work o f the society, very little statistical information is available. The society has published annual reports, but the statistics presented are somewhat frag mentary. Branches were organized in 1907 and 1908 in the four principal cities. The number o f main branches maintaining Plunket nurses has gradually increased until in March, 1920, it was 30; in addition there were 45 subbranches in outlying districts, and local committees had been formed in a number o f other smaller places. The number o f Plunket nurses gradually increased to 28 in 1916, and to 46 in 1920. In the year ended March 31,1919, the total number o f babies cared for was 15,951, a figure which increased to 19,142 in 1920. This fig ure, however, includes not only infants brought for the first time under the care o f the society but also infants brought in at any time during the year who had been under care in a previous year. Babies are usually first brought under care before they are 1 year old, and very -rarely after passing the first birthday; but after having formed the habit of consulting the Plunket nurses mothers fre quently bring their babies, as they are urged to do, at intervals until the children reach 2 years of age. The number of infants brought under care for the first time may fairly be compared to the number o f births to show roughly the proportion of infants born in New Zealand who are brought directly under the influence o f the Plunket nurses. The figure for 1919, fur nished through the courtesy of the health department, to which the society makes monthly reports, was 6,454; when compared with the total number of births for that year, this gives 26.4 per cent, or over one-fourth of all the New Zealand babies, cared for by the society. The proportion was much higher in the cities in which most o f the work was centered. But even outside the four* principal cities over one-sixth o f all births in 1919 came directly under the care o f the Plunket Society, as shown in Table X X I . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 52 IN FA N T MORTALITY. It should be pointed out that the infants who are brought directly under the supervision of the Plunket nurses— about one-fourth of the infants born—probably include the great majority o f those most in need of such care; furthermore, a large proportion o f the re mainder are doubtless reached by the educational measures of the society and by the distribution o f pamphlets. T a b l e X X I . — P roportion o f in fan ts brought d irectly under care o f the P lunket S o c ie ty, 1919. B irth s, 1919.1 P la ce. In fan ts b ro u g h t u n der care for first tim e du rin g 1919. N um b e r .2 N e w Z e a la n d ................................................................ - ......................................... P e r cen t o f b irth s. 24,483 6,454 26.4 7,683 16,800 3,337 3,117 43.4 18.6 1 S tatistics o f th e D o m in io n o f N e w Z e a la n d , 1919, V o l. I , P o p u la tio n a n d V it a l Statistics, p p . 33 a n d 85. 2 F r o m m a n u s crip t ta b le furnished b y cou rtesy o f th e D e p a rtm e n t o f H e a lth o f N e w Z e a la n d . CONCLUSION. It remains to point out the relationship between the general health movements and the specific measures o f governmental and private agencies, and the reduction o f the infant mortality from the several causes. Certain influences have been operating steadily toward a decrease in infant mortality throughout the period. These influences include the gradual increase in medical knowledge of the best methods o f disease prevention, the raising of the level of training in the medical profession, the improvements in public sanitation, the gradual ex tension o f the public-health work in the Dominion as shown in the increase o f powers and the improvements in methods of administra tion in the health department, and the gradual education o f the public in methods of preventing disease and o f maintaining health. These movements are difficult to trace in their individual effects upon infant mortality, but their combined influence is written plainly in the gradual and steady improvement in the rates o f infant mortality from epidemic diseases and tuberculosis, as well as in the decline in infant mortality from respiratory and from gastric and intestinal diseases which occurred during the period from about 1875 to 1905. The marked acceleration in the rate o f decline in infant mortality beginning about 1905 points clearly to the presence o f new causes operating to produce it. The study of the work o f various govern mental and private agencies, so far as they affected infant welfare https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis NEW ZEALAND. 53 during the period under review, suggests three principal movements as responsible in the main for this acceleration. The establishment o f State maternity hospitals for the training o f maternity nurses was a very important beginning in a gradual raising o f the level o f maternity care available. The compulsory registration o f midwives and the voluntary registration o f nurses were further steps toward securing better maternity and general nursing service. The work o f the St. Helen’s Hospitals, although especially directed toward providing for better confinement care for the wives o f work ingmen, offers large possibilities for the reduction o f the infant mor tality rate from causes peculiar to early infancy—causes which are related to the care and condition o f the mother. The decrease of one-half in the infant mortality rate during the first month o f life secured in New York City by systematic prenatal supervision shows in a striking way what can be accomplished in the further reduction o f the rate from causes peculiar to early infancy.73 As yet, the St. Helen’s Hospitals provide nursing and confinement services for the mothers o f only about one-sixteenth o f the infants born in New Zealand, and have paid comparatively little attention to the need for prenatal care. Nevertheless, their work already appears to have had a slight influence on the mortality from causes peculiar to early infancy. The work o f infant-life protection is another important factor in the reduction o f infant mortality. This work reaches only in fants boarded out apart from their mothers; this group, for the most part o f illegitimate birth, is one in which infant mortality is gen erally high, and is therefore in especial need o f supervision. Since the improvement of the inspection service due to the employment o f trained inspectors for infants’ homes, the reduction in mortality among these infants has been marked. The most important influence in the reduction o f the infant mor tality 1?ate is undoubtedly the work of the Royal New Zealand So ciety for the Health of Women and Children. Organized in 1907 in Dunedin, its work spread to other cities and has gradually enlarged until in 1919 it reached directly through its infant-welfare centers over one-fourth o f all the babies born in New Zealand. Through its newspaper health articles and through its distribution o f pam phlets, including the distribution o f its principal pamphlet through the department o f health upon the registration o f births, the society also undoubtedly exerts an important influence over a large pro portion of those infants not directly reached by the Plunket nurses. 73Baker, 8. Josephine, M . D ., and Sobel, Jacob, M . D . : “ Control of infant morbidity and mortality in New York City,” in Monthly Bulletin of the Department o f Health City o f New York, Vol. X I (October, 1 9 2 1 ), p. 233. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 54 IN FA N T MORTALITY. The emphasis laid upon breast feeding and, in case breast feeding is not possible, upon “ humanized milk,” makes for a reduction in the mortality from gastric and intestinal diseases, while general instruction in infant hygiene, the value of fresh air, proper clothing, and other matters, doubtless exerts an important influence in reduc ing the mortality from respiratory diseases. These new movements, together with the conditions favorable to low infant mortality rates already described, are doubtless re sponsible for New Zealand’s position as the country with the lowest infant mortality rate. 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 A P P E N D IXE S, A P P E N D IX THE A .— E X T R A C T S ROYAL NEW FROM ZEALAN D “ REPORT S O C IE T Y ON FOR THE THE W ORK OF HEALTH OF W O M E N A N D C H I L D R E N ,” * B Y D R . M A R G A R E T H A R P E R . The Karitane-Harris Hospital consists of a cottage situated in one of the suburbs of Dunedin. The site is a beautiful one overlooking the harbor; the grounds are large, with flower gardens, trees, and lawns, and all the ap pointments are o f the simplest. The babies are accommodated in basket cradles, placed on a platform running round the walls o f the room. These cradles are light, and easily carried to the verandas, or on to the lawns. Wher ever the cots are placed, inside or out, a distance of 34 feet is maintained be tween them. This is done with the object of preventing any chance o f re spiratory or other infection from being carried from one baby to the other. There is an isolation room to be used if necessary, and a room where pre mature babies can be cared for. This latter is heated by steam pipes, and can be kept at a uniform temperature, with a suitable supply of fresh air. No in cubators are used. The premature baby is fed and cared for entirely in this room. I f the baby is too small and weak to suck, the mother is instructed in the art of expressing the milk, which is then given to the'baby in the way best suited to its condition. This expression of the milk by the mother herself is used in all cases where it is necessary to draw off the milk. The breast pump is never used, as anyone who has had experience knows it is diffi cult, I would almost say impossible, to increase or even keep up the supply o f breast milk by means o f the breast pump. B y using the proper manipulations it is possible to increase the supply o f milk, almost as if the breasts were being naturally stimulated by the baby. In one case the 24-hours supply was increased from 174 ounces to 304. In another case it was increased from 84 ounces to 264. The nursery is the room where the baby is taken to be washed, dressed, and weighed. Each baby has its own separate basket of cloths, etc. A kicking pen is used in order to give the babies freedom for awhile to exercise their limbs. There is a milk room, where the food for each baby for 24 hours is prepared, put into bottles, and kept cool until required. One nurse deals with this under the supervision o f the matron or sister. Each nurse has two weeks’ training in this department. The babies who are admitted are the premature, those suffering from mal nutrition due to want of care, and to errors in feeding. None are admitted with acute disease, although, as there is no children’s hospital, cases o f pyloric obstruction, which are suitable for dietetic treatment, have been admitted. I f operation is necessary, they are transferred to the general hospital. No tuberculous, syphilitic, or mentally deficient baby is admitted. 1 Issued by the Royal Society for the W elfare o f Mothers and Babies of N. S. W . Sydney, 1920. 57 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 58 IN F A N T MORTALITY. The average number o f babies in hospital is 12 (3 o f these with their m others), and the number of nurses 15. The eight-hour system is in vogue in New Zealand, so that 15 nurses are not too many to give the individual attention necessary to each baby. A s soon as the baby is gaining regularly in weight, it is discharged to its home and passes into the care of the local Plunket nurse. The average stay of the baby in the hospital is a fortnight. The short stay in hospital, the large number of nurses, and the cool climate lessen the risks which are always associated with institutions in which babies are admitted without their mothers. The mothers’ cottage is situated in the grounds at a little distance from the hospital. It consists of three bedrooms, a sitting room, and bathroom. Each bedroom has a bright and cheerful outlook, and there is a good veranda on three sides o f the cottage. Here mothers, who are having difficulty with breast feeding, are accommo dated, and to my mind this is the most interesting and valuable part o f the work. * * * * * * * Here the mother is relieved from all household worries and is free to rest. The average time for a mother’s stay is a fortnight. Sometimes mothers who are unable to leave their families come in for the week end when their husbands are at home. Even this short stay is beneficial in setting the mother on right lines. * * * ❖ I $ * * The'training o f the nurses in the handling o f babies in general infant hygiene and what is known as mother craft is excellent. No detail is too small to be observed, and no trouble is too great to be taken in the training and feeding o f the baby. No artificial food is used except cow’s milk modified to suit the requirements o f each baby. The nurses are thoroughly trained in this one method of artificial feeding. They are taught to think of the milk mixtures in terms o f the percentages o f the sugar, fat, and protein present, and to reckon the quantity required in calories. They are taught the requirements o f the normal baby, the average weights o f babies o f various ages, and from the weight of the child they calculate the number o f calories required. I f the baby is underweight and undernourished, the amount required will be less than for a normal baby o f that age. A s the baby improves and increases in weight, the amount o f food required approaches more closely to the normal for that age. ' Thus the nurse has a standard to which, i f the baby is badly nourished, she must try to raise it. I f it is overnourished and overfed, she can reduce its food to the proper quantity. The quality o f the food is reckoned in tbe percentages o f sugar, fat, and protein present, the quantity by the number o f calories. The advantages o f the method are: 1. That having the standard of mother’s milk we can modify animal milk, either fresh cow’s milk, dried milks, or condensed milk, so that they approach in composition the baby’s natural food. 2. That the nurses are in a position to teach mothers to feed their babies by their weights, so that the dangers of underfeeding and overfeeding may both be avoided. Intervals between the feeds are three hours, or in some cases four hours, from the beginning. The last feed is given at 10 p. m., the first at 6 a. m. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 59 STEW ZEALAND. I f the baby wakes during the night it is made comfortable, turned in the bed, and given a drink o f boiled water if necessary. Very soon the baby gets into the way of sleeping all night. Few babies will wake for a drink o f plain water. BR EA ST FEEDING. The fundamental lesson, however, which is impressed continually on the nurse in training is the absolute superiority of mother’s milk for the baby over every kind of artificial food, and that every mother can feed her baby, i f not entirely, for seven or eight months, at least, partially. Each nurse during her training has entire charge of mother and baby in cases where some difficulty has arisen in the breast feeding. In this way the nurse knows of her own experience the difficulties which may arise, and learns that they can be overcome, and how to overcome them. W hen her training is finished she has confidence not only in her own ability to help mothers but in the mother’s ability to nurse the baby if only she is put on the right lines. It is no matter o f hearsay or theory; it is a matter o f personal knowledge: “ her eyes have seen and her hands handled,” so that the nurse herself knows, and this is the first essential for convincing others. * * The training is simple. sense methods applied. * * * * * Every detail is considered and ordinary common- 1. The mother is taught the ordinary laws of infant hygiene; that the baby must have fresh air, exercise, not too many clothes, that it must sleep in its own bed, have regular bathing, that care must be taken of its skin, and so on. 'So that, to begin with, the baby is comfortable and healthy, with a healthy appetite. The baby is trained from the beginning to regular hours of feeding and of sleep. The intervals between the feeds are either three hours, to be soon lengthened to four, or in some cases four hours from the beginning. Whether three or four .hourly intervals are the rule during the day, the long interval at night— from 10 p. m. to 6 a. m.— is insisted on. B y these means the mother gets an unbroken night’s sleep and more freedom during the day, and thus the nervous strain o f domestic life is lessened and tlie mother is more able to nourish her baby. Once a mother has fed a baby with these longer intervals between the feeds, she will never return to the older methods. The baby is happy and comfortable, and when his meal time arrives he is hungry and ready for his food. In this way the sfipply of milk is encouraged. W ith regard to the mother herself— the diet, daily life, and exercise are regulated. D IET. Three good meals a day, with plenty of vegetables and fresh fruit. Any plainly cooked, good food is allowed, with a certain amount of milk, but not too large a quantity. Plenty of fluid, best taken in the form of cold water between meals. In some cases, in order to make sure of the mother’s taking a sufficiency o f water, it is recommended to take a tumblerful before each time the baby is fed. EXER CISE . Plenty of exercise. Some part o f which must be taken in the open air every day in the form of walking. 9 2 8 3 2 ° — 2 2 ------- 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 60 INFANT MORTALITY. LO CAL M E A SU R E S. I f the milk supply is not satisfactory, local stimulation is given in the form o f massage and sponging. The massage is given 10 minutes to each breast twice daily. The massage movements are from the surrounding parts toward the breast tissue, the idea being to increase the supply of blood carrying the nutrient material to the breast. Sponging is done with the same object. After the massage the sponging is done by the mother. She has a basin o f hot and a basin of cold water, and gives each breast 2\ minutes by the clock o f hot, then 2\ minutes cold, sponging— 10 minutes each breast. These measures are only necessary in cases where the supply o f milk has gone off, and where the desire is to increase the quantity. In ordinary normal cases, of course, such measures are not necessary. When they are used it is only for a short time until the supply is established agaiq. A ll that is necessary in the case o f a healthy mother who is prepared before the birth o f her child to nurse it is : 1. Regular stimulation of the breast at proper intervals by the baby. 2. Regular exercise and fresh air. 3. Nights of unbroken rest. 4. Good plain food. No overfeeding. 5. Plenty of fluid in the form o f water between meals. 6. A good, happy baby that sleeps well, and is not fretful. The aim o f this training is to establish what one may call a “ virtuous circle.” A mother who trains her baby to good habits, regular hours o f sleep and feeding, with its natural food, produces a good, happy, healthy baby, who sleeps well and is not fretful, and in its turn produces a calm and happy mother, who is able to give her baby its natural food even in these days of domestic difficulties. * * * * * * * In Dunedin, in connection with the society, there is a milk-modifying depot. It consists of a room in the distributing depot of one of the principal dairying companies. The milk is received unpasteurized about 10 a. m. There are two women attendants who receive it and Pasteurize it. Then it is passed over a cooling apparatus, then modified according to prescriptions for each child, and the 24-hour supply is bottled. It is then sent down to the dairy cooling chamber and kept there until next morning, when the 24-hour supply is sent out on the ordinary milk cart, with no cooling arrangements, and exposed to whatever heat there is in Dunedin. Hence the last o f the baby’s feeds is at least 48 hours old. There has been trouble with this milk, I was told, and certainly such a method would not answer in Sydney, where the heat is so much greater, and many people have no means of cooling down the milk, warmed up in the delivery carts. I f it could be delivered cold— by simple devices it could be kept cold— but even in this way too many loopholes for disaster are left. A s fa r as I could learn the milk supply of the towns in New Zealand was not good. There is only one delivery in the day, and the milk that comes in at 10 a. m. is not distributed until the next morning. In Auckland the Plunket nurses told me that by going direct to the depot at 10 a. m., the mothers, on the nurses’ recommendation, could obtain the fresh milk. But, of course, this was of very limited use, as few mothers have time to go any distance for their milk. * https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis * * * * * * N E W ZEALAND. 61 The conclusions which I have come to are as follow s: 1. That the success o f the New Zealand society lies chiefly in the populariz ing the breast feeding of babies. An atmosphere has been created in which a mother is almost ashamed to have to admit that her baby is not naturally fed. 2. That this end has been attained— (a ) B y the careful and detailed training (given as a post graduate course) of nurses, in so-called mother craft, and especially in the dealing with difficulties of b reastfeed in g; and by the estab lishment o f the Plunket centers from which these nurses work. (&) By the educating o f the public, by means of pamphlets, by the publication o f the weekly column called “ Our Babies ” in the press. The public health department publishes and distributes free of charge the society’s pamphlet entitled “ The Expectant Mother and Baby’s First Month.” In this way the same stand ards and ideas are circulated through the whole of New Zealand, (c) By the education of the members of the committees, and the spreading of the knowledge thus obtained through all classes of the community. \d) By the special training given in Dunedin to the medical students, by Dr. W illiam s, the lecturer in pediatrics at the Medical School, who is also one of the honorary medical officers in . charge of the Karitane-Harris Hospital. The students are encouraged to go to the Karitane-Harris Hospital, and there come into direct contact with the practical side of the work. Among other things, Dr. Harper recommended for New South Wales: The establishment o f a training school for nurses on lines somewhat similar to those on which the Karitane-Harris Hospital is carried on. The course o f training should be a postgraduate one, given only to nurses with midwifery or general nursing certificates. Later the question of training women as Karitane nurses may be considered, but in the meantime we should give all our attention to giving nurses the special training. In view o f the fact that the experience of those physicians in Sydney who are best qualified to judge is that hospitals which admit babies without their mothers sooner or later are visited by epidemics o f gastroenteritis, I should •recommend that only babies with their mothers should be admitted to this institution. This arrangement would allow the nurses to get sufficient expe rience in dealing with artificial food, as nearly all the cases where mothers are having difficulty with breast feeding the baby must have, at least tempo rarily, supplementary feeds of artificial food. The hospital should be as home like as possible, with plenty o f ground round it, so that the babies and mothers may have the benefit of fresh air and open space. The matron and sister should be nurses who are thoroughly conversant with the methods o f training in use at Dunedin. To begin with, the baby clinic nurses should be given the benefit of the special training. These nurses come from the various train ing schools in different parts of Australia, and in not one case have they had any training in dealing with babies. I f they come from a children’s hospital they know how to deal with sick babies, but of infant hygiene in general they know very little. For long I have felt that unless our nurses have some special training in “ mother craft ” much of their work is ineffective, and I may add that many of the nurses doing the clinic work at present feel the same. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 62 IN FA N T MORTALITY. Arrangements should be made so that the nurses at present doing the clinic work should be relieved in rotation, in order to go through the course o f training. A rule should then be made that no nurse would be, eligible for appointment to a baby clinic who has not been through the special course in mother craft. Later, when the clinic nurses have had their training (possibly at the same time, as only a limited number of clinic nurses can be freed at a tim e), mid wifery and generally trained nurses should be encouraged to go through the course. When the training school has been established, and there is some prospect of having a supply of qualified nurses, the advisability of forming committees of women in suburbs which the baby clinics will not reach might be considered. These committees could then employ nurses for their respective districts. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX B— R E G U L A T IO N S R E G A R D IN G S T O R A G E A N D S A L E O F M IL K . The regulations for the storing and sale of milk in force in 1919 were as follows.2 16. FO R SECURIN G C LE A N LIN E SS A N D FR EE D O M FROM CO N TAM I N A T IO N OF M IL K . (1 ) Every person who sells milk shall at all times keep clean every place in which such milk is sold, and all furniture, fittings, apparatus, and vehicles used in connection with the sale o f milk. (2 ) No person shall apply to his mouth any vessel or utensil which contains or which comes in contact with any milk for sale. (3) Every person who sells milk shall, so far as is practicable, protect such milk from dirt and dust, and from contamination by flies or any animal. (4 ) No person shall keep, measure, carry, or deliver any milk for sale, or cause or suffer any such milk to be kept, measured, carried, or delivered in any vessel which is not clean. (5 ) No person shall use any vessel with rough or broken or rusty edges or surface for containing, measuring, or carrying any milk for sale. (6 ) No person, shall use for containing, storing, or conveying milk for sale any vessel unless it is so constructed as to permit o f every part o f the interior o f the vessel being seen and adequately cleansed, nor unless it is provided with a lid or covering which shall protect the interior from dust, or rain, or con tamination by flies or any animal. (7 ) No person shall sell milk in any place in which is stored, kept, or sold any kerosene, vegetables, fish, meat (except vegetables, fish, and meat in her metically sealed packages), or any other substance by which milk is or is liable to be contaminated, j nor in any room which is used as a living room or kitchen, or as a sleeping room, or which opens directly off any sleeping room ; nor in any room which is in direct communication with or is liable to contami nation from any water-closet, pan closet, pit privy, urinal, stable, or pigsty, or which has in it any opening into any drain or sewer. (8 ) No person shall milk any cow or cause or suffer any cow under his control to be milked for the purpose of obtaining milk for sale— (а) Unless at the time o f milking the udder and teats o f the cow are clean; (б ) Unless the hands o f the person milking such cow are clean and free from all contamination or infection. (9 ) No person shall use or cause or suffer to be used for closing or for helping to close any churn, tin, or other vessel containing milk for sale, any rag or canvas, or any material which is liable to contaminate milk. (10) Every person who receives or delivers milk for retail sale shall, as soon as possible after emptying, cleanse or cause to be cleansed every part o f any vessel within his control in which such milk has been carried. (11) Every person who sells milk shall provide, for the purpose o f cleansing all vessels and apparatus under his control which come in contact with the milk, a suitable and sufficient supply o f cold and of boiling water. a Regulations under the sale o f food and drugs act, 1908, of Mar. 4, 1913 (published in the New Zealand Gazette, Mar. 6, 1913, p. 758ff.)„ pp. 34 - 3 5 . 63 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 G E N E R A L TABLES. G eneral T able 1.— B irth s, in fa n t deaths, and in fa n t m o rta lity rates, b y cause o f death, N e w Zealand,, 1 8 7 2 -1 9 1 9 .1 Deaths under 1 year of age. Year. Live births. Total (1-189). Epidemic diseases d-19). Tuberculosis (28-35). Encephalitis, meningitis, and infantile paralysis (60,61, part 63). Venereal diseases (37,38). Num Rate per Num Rate per Num Rate per Num Rate per Num Rate per 1,000 1,000 1,000 1,000 1,000 ber. ber. ber. ber. ber. births. births. births. births. births. 1872.......... 10,795 1873.......... 11,222 1874.......... 12,844 1875.......... 14,438 1876.......... 16,168 1877.......... 16,856 17 770 1878 . 18,070 1879.......... 1880.......... 19,341 18,732 1881.......... 1882.......... 19,009 1883.......... 19,202 1884.......... 19,846 1885.......... 19,693 19,299 1886.......... 1887.......... 19,135 18,902 1888.......... 18,457 1889.......... 18,278 1890.......... 1891.......... 18,273 1892.......... 17,876 18,187 1893.......... 1894.......... 18,528 18,546 1895.......... 1896.......... 18,612 1897.......... 18,737 18,955 1898.......... 18,835 1899.......... 1900.......... 19,546 1901.......... • 20,491 20,655 1902.......... 21,829 1903.......... 1904.......... 22,766 23,682 1905.......... 24,252 1906.......... 25,094 1907.......... 25,940 1908.......... 26,524 1909.......... 25,984 1910.......... 26,354 1911.......... 1912.......... 27,508 27,935 1913.......... 1914.......... 28,338 1915.......... 27,850 1916.......... 28,509 1917.......... 28,239 25,860 1918.......... 24,483 1919.......... 1,084 1,213 1,394 1,816 1,673 1,527 1,500 1,941 1,805 1,731 1,678 1,995 1,573 1,756 1,899 1,795 1,336 1,456 1,438 1,667 1,594 1,600 1,507 1,637 .1,439 1,354 1,510 1,806 1,469 1,463 1,712 1,770 1,616 1,599 1,506 2,228 1,761 1,634 1,760 1,484 1,409 1,653 1,456 1,394 1,446 1,360 1,252 1,108 100.4 108.1 108.5 125.8 103.5 90.6 £4t4 107.4 93.3 92.4 88.3 103.9 79.3 89.2 98.4 93.8 70.7 78.9 78.7 91.2 89.2 88.0 81.3 88.3 77.3 72.3 79.7 95.9 75.2 71.4 82.9 81.1 71.0 67.5. 62.1 88. 8 67.9 61.6 67.7 56.3 51.2 59.2 51.4 50.1 50.7 48.2 48.4 45.3 Ill 280 121 101 109 156 10.3 25.0 9.4 7.0 6.7 9.3 55 47 62 104 96 93 5.1 4.2 4.8 7.2 5.9 5.5 2 3 3 5 5 8 0.2 .3 .2 .3 .3 .5 27 20 14 23 30 26 2.5 1.8 1.1 1.6 1.9 1.5 219 100 154 147 216 145 121 160 158 101 69 125 240 132 229 193 168 70 57 82 160 105 58 123 205 60 37 53 284 53 59 127 30 26 75 70 76 93 55 96 20 12.1 5.2 8. 2 7.7 11.2 7.3 6.1 8.3 8.3 5.3 3.7 6.8 13.1 7.4 12.6 10.4 9.1 3.8 3.0 4.3 8.5 5.4 2.8 6.0 9.4 2.6 1.6 2.2 11.3 2.0 2.2 4.9 1.1 .9 2.7 2.5 2.7 3.3 1.9 3.7 .8 97 96 Irti 94 100 94 77 95 102 80 48 47 66 65 60 59 65 . 52 51 52 66 35 48 37 46 28 29 32 47 40 33" 37 17 29 20 16 10 12 8 15 11 5.4 5.0 5>4 4.9 5.2 4.7 3.9 4.9 5.3 4.2 2.6 2.6 3.6 3.6 3.3 3.2 3.5 2.8 2.7 2.7 3.5 1.8 2.3 1.8 2.1 1.2 1.2 1.3 1.9 1.5 1.2 1.4 .6 1.1 .7 .6 .4 .4 .3 .6 .4 3 8 .2 .4 30 27 1.7 1.4 6 7 4 7 5 12 5 7 4 8 6 12 13 12 10 9 13 12 11 11 11 7 14 17 10 12 11 7 16 11 8 10 12 8 10 11 10 8 .3 .4 .2 .4 .3 .6 .3 .4 .2 .4 .3 .7 .7 .6 .5 .5 .7 19 26 14 23 31 30 24 17 32 29 25 20 14 16 29 18 30 22 23 28 23 21 31 32 19 29 44 39 45 44 32 39 28 29 35 30 34 21 1.0 1.4 .7 1.2 1.6 1.6 1.3 .9 1.8 1,6 1.4 .1,1 .8 .9 1.6 1.0 1.6 1.2 1.2 1,4 1.1 1.0 1.4 1.4 .8 1.2 1.7 1.5 1.7 1.7 1.2 1.4 1.0 1.0 1.2 1.1 1.3 .9 .6 .6 .5 .5 .3 .6 .7 .4 .5 .4 .3 .6 .4 .3 .4 .4 .3 .4 .4 .4 .3 1 S ource: Manuscript table furnished by courtesy of Mr. J. W . Butcher, acting Govern ment statistician. The figures under the causes of death refer to the International L ist numbers included in each group. 67 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 68 IN F A N T MORTALITY, G eneral T able 1 . — Births, infant deaths, and infant mortality rates, by cause of death, N ew Zealand, 1872-1919— Continued. ' Deaths under 1 year of age. Year. Infantile convul sions (71). Live births. Number. 1872............ 1873............ 1874............ 1875............ 1876............ 1877............ 1878............ 1879............ 1880............ 1881............ 1 8 8 2 ....... 1883............ 1884............ 1885............ 1886............ 1887............ 1888............ 1889............ 1890 . . 1891............ 1892............ 1893............ 1894............ 1895............ 1896............ 1897............ 1898............ 1899............ 1900............ 1901............ 1902............ 1903............ 1904............ 1905............ 1906............ 1907............ 1908............ 1909............ 1910............ 1911............ 1912............ 1913............ 1914............ 1915............ 1916............ 1917............ 1918............ 1919............ 10,795 11,222 12,844 14,438 16,168 16,856 17,770 18,070 19,341 18,732 19,009 19,202 19,846 19,693 19,299 19,135 18,902 18,457 18,278 18,273 17,876 18,187 18,528 18,546 18,612 18,737 18,955 18,835 19,546 20,491 20,655 21,829 22,766 23,682 24,252 25,094 25,940 26,524 25,984 26,354 27,508 27,935 28,338 27,850 28,509 28,239 25,860 24,483 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 116 111 122 154 125 122 132 144 148 140 157 159 159 133 159 127 116 106 113 122 116 122 106 136 126 108 100 129 106 91 82 103 95 96 90 84 76 107 80 89 51 71 51 55 74 56 53 47 Respiratory dis eases (86-98). Gastric and intes tinal diseases (102-110). Malformations (150). Rate per Rate per Rate per Rate per 1,000 Number. 1,000 Number. 1,000 Number. 1.000 births. births. births. births. 10.7 9.9 9.5 10.7 7.7 7.2 7.4 8.0 7.7 7.5 8.3 8.3 8.0 6.8 8.2 6.6 6.1 5.7 6.2 6.7 6.5 6.7 5.7 7.3 6.8 5.8 5.3 6.8 5.4 4.4 4.0 4.7 4.2 4.1 3.7 3.3 2.9 4.0 3.1 3.4 1.9 2.5 1.8 2.0 2.6 2.0 2.0 1.9 117 142 178 251 160 170 159 287 263 245 217 245 201 234 241 190 178 192 174 244 190 260 165 278 115 182 142 260 157 226 251 251 164 236 181 286 155 190 178 175 140 173 126 144 134 115 112 107 10.8 12.7 13.9 17.4 9.9 10.1 8.9 15.9 13.6 13.1 11.4 12.8 10.1 11.9 12.5 9.9 9.4 10.4 Q. ñ 13.4 10.6 14.3 8.9 15.0 6.2 9.7 7.5 13.8 8.0 11.0 12.2 11.5 7.2 10.0 7.5 11.4 6.0 7.2 6.9 6.6 5.1 6.2 4.4 5.2 4.7 4.1 4.3 4.4 262 176 371 381 416 317' 326 414 385 356 290 476 226 390 467 467 225 357 340 337 386 235 249 286 366 320 369 388 321 256 858 336 414 337 278 572 461 301 390 283 216 251 213 151 209 176 82 101 24.3 15.7 28.9 26.4 25.7 18.8 18.3 22.9 19.9 19.0 15.3 . 24.8 11.4 19.8 24.2 24.4 11.9 19.3 6 9 7 20 42 26 16 23 31 26 26 19 28 18 23 26 25 24 18.4 21.6 12.9 13.4 15.4 19,7 17.1 16.5 20.6 16.4 12.5 17.3 15.4 18.2 14.2 11,5 22.8 17.8 11.3 15.0 10.7 7.9 9.0 7.5 5.4 7.3 6.2 3.2 4.1 20 16 29 19 38 29 so 28 24 30 34 34 35 31 21 27 32 41 59 58 51 117 89 98 132 108 120 82 112 0.6 .8 .5 1.4 2.6 1.5 .9 1.3 1.6 1.4 1.4 1.0 1.4 .9 1.2 1.4 1.3 1.3 .9 1.6 1.0 2.0 1.6 1.5 1.3 1.5 1.7 1,6 1,6 1.4 .9 Cl 1.3 1.6 2.2 2.2 1.9 4.3 3.2 3.5 4.7 3.8 4.2 3.2 4.6 69 NEW ZEALAND. G e n e r a l T a b l e 1 .— Births, infant deaths, and infant mortality rates, by cause of death, New Zealand, 1872—1919— Continued. Deaths under 1 year of age. Year. Live births. Early infancy (151-153). Number. 1872............ 1873............ 1874............ 1875............ 1876............ 1877............ 1878............ 1879............ 1880............ 1881............ 1882............ 1883............ 1884............ 1885............ 1886............ 1887............ 1888............ 1889............ 1890............ 1891............ 1892............ 1893---------1894............ 1895............ 1896............ 1897............ 1898............ 1899............ 1900............ 1901............ 1902............ 1903........... 1904............ 1905............ 1906............ 1907............ 1908............ 1909............ 1910 ....... 1911.......... . 1912............ 1913............ 1914............ 1915............ 1916 1917............ 1918 1919............ 10,795 11,222 12,844 14,438 16,168 16,856 17,770 18,070 19,341 18,732 19,009 19,202 19,846 19,693 19,299 19,135 18,902 18,457 18,278 18,273 17,876 18,187 18,528 18,546 18,612 18,737 18,955 18,835 19,546 20,491 20,655 21,829 22,766 23,682 24,252 25,094 25,940 26,524 25,984 26,354 27,508 27,935 28,338 27,850 28,509 28' 239 25 860 24' 483 264 256 304 423 399 359 373 443 414 398 473 435 503 547 522 488 422 477 451 457 486 470 416 452 461 431 535 564 443 559 644 604 597 640 626 695 711 668 716 669 738 792 762 693 690 694 704 616 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis External diseases (155-186). Other defined diseases Diseases unknown orili defined (187-189). Rate per Rate per Rate per Rate per 1,000 Number. 1,000 Number. 1,000 Number. 1,000 births. births. births. births. 24.5 22.8 23.7 29.3 24.8 21.3 21.0 24.5 21.4 21.2 24.9 22.7 25.3 27.8 27.0 25.5 22.3 25.9 24.7 25.0 27.2 25.8 22.5 24.4 24.8 23.0 28.2 29.9 22.7 27.3 31.2 27.7 26.2 27.0 25.8 27.7 27.4 25.2 27.6 25.4 26.8 28.4 26.8 24.9 24.2 24.6 27.2 25.2 13 16 22 31 23 36 38 36 40 36 34 32 37 35 32 32 39 30 24 32 34 29 43 39, 32 34 44 40 39 57 43 44 57 87 59 54 53 50 33 19 13 16 19 20 13 17 14 13 1.2 1.4 1.7 2.1 1.4 2.1 2.1 2.0 2.1 1.9 1.8 1.7 1.9 1.8 1.7 1.7 2.1 1.6 1.3 1.8 1.9 1.6 2.3 2.1 1.7 1.8 2.3 2.1 2.0 2.8 2.1 2.0 2.5 1.6 2.4 2.2 2.0 1.9 1.3 .7 .5 .6 ' .7 .7 .5 .6 .5 .5 81 123 170 295 237 199 181 228 275 231 212 278 158 158 157 155 116 122 99 108 134 133 227 143 145 . 110 113 140 198 93 104 117 125 117 130 132 108 118 79 91 36 115 59 68 68 73 49 51 - * 7.5 11.0 13.2 20.4 14.7 11.8 10.2 12.6 14.2 12.3 11.3 14.5 8.0 8.0 8.1 8.1 6.1 6.6 5.4 5.9 7.5 7.3 12.3 7.7 7.8 5.9 6.0 7.4 10.1 4.5 5.0 5.4 5.5 4.9 5.4 5.3 4.2 4.4 3.0 3.5 1.3 4.1 2.1 2.4 2.4 2.6 1.9 2.1 30 30 20 28 31 15 12 17 18 3 3 2 4 13 7 8 5 7 4 4 4 1 3 4 4 4 2 1 1 2 2 1 i 1 8 3 1 5 3 2 2 8 5 1 1 2.8 2.7 1.6 1.9 1.9 .9 7 .9 .9 .2 .2 .1 .2 .7 .4 .4 .3 .4 .2 .2 .2 .1 .2 .2 .2 .2 .1 .1 .1 .1 .1 .3 .1 .2 .1 .1 .1 .3 .2 70 INEANT MORTALITY. a b l e 2 . — Infants under 1 year of age in fester homes at beginning of year, and admissions and withdrawals during year, 1908-1918.1 G eneral T Infants under 1 year of age in foster homes. At begin ning of year. Year. Admitted during year.9 Total. 1908.................................................. 1909.................................................. 1910............... ................................. 1 9 1 1 ................................... ............ . 1912.................................................. 1913.......... ...................................... 1914.................................................. 1915.................................................. 1916.................................................. 1917................................................ ; 1918................................................. 108 200 173 139 160 175 171 225 194 172 4 190 Under 6 months, 6 months. under 1 year. 353 363 296 315 327 359 399 347 308 264 278 261 276 230 254 275 274 331 266 217 206 201 92 87 66 61 52 85 68 81 91 58 77 Withdrawn during year.8 Total. 124 166 143 118 142 149 151 131 114 122 101 Under 6 months, 6 months. under 1 year. 57 83 63 55 75 59 70 59 45 46 36 67 83 80 63 67 90 81 72 69 76 65 1 Compiled from Reports of Education Department, “ E-4,” Education: Special Schools, and Juvenile Probation System and Infant-Life Protection, 1909-1919. New Zealand. 2 Includes the children adopted with premium exclusive of those already on the books. * Includes removal by parent or guardian, death, adoption from licensed home without premium, grant of exemption to home in which child is placed, brought under operation of the industrial schools act. and other causes. 4 A t end of year, 192. , General T able 3. -Decline in death rate among children under 6 years o f age in foster homes, 1908-1918.1 Children under 6 years of age. Children under 6 years of age. Deaths. Deaths. In foster homes Per 100 at any in homes time Number. at any in year. time of year. Year. 1908 1909 1910 1911 1912 1913, 1,017 1,181 1,183 1,183 1,228 1,330 26 25 26 13 12 13 2.6 2.1 2.2 1.1 1.0 1.0 Year. 1914 1915 1916 1917 1918 In foster homes Per 100 at any in homes time of year. Number. at any time of year. 1,423 1,440 1,250 1,361 1,349 1.4 1.0 1.4 .9 .4 ui uxic uiiicüü ut xauuuauuii, -Ciuuuauou: special scnoois, juvemie vro Dation System and Infant-Life Protection, “ E-4,” 1909-1919. a b l e 4 . — Infants under 1 year of age in exempted institutions at beginning of year, and admissions during year, 1909-1918.1 General T Infants under 1 year of age in exempted institutions. Infants under 1 year of age in exempted institutions. Year. Year. A t begin Admitted ning of during year. year. 1909............................................... 1910............................................... 1911............................................. 1912..................................... 1913............................................... (2) 76 75 86 62 161 177 190 175 139 A t begin Admitted ning of during. year. year. 1914 1915 1916 1917 1918 233 121 68 112 141 •Source: Reports of the Department of Education, Education: Special Schools, Juvenile Probation System and Infant-Life Protection, “ E-4,” 1909-1919. 9Not given in source. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 71 N E W ZEALAND. Ge n era T 5. — Decline in death rate among children in exem pted institu able tions, 1909-1918.1 Deaths. Children in ex empted Per 100 in institu institu tions at Number. tions at any time any time in year. in year. 1909. 1910. 1911. 1912. 1913. 749 915 899 911 984 66 63 47 36 18 8.8 6.9 5.2 4.0 1.8 Deaths. Children in ex empted Per 100 in institu institu tions at any time Number. tions at any time in year. in year. Year. 1914............................ 1915............................ 1916............................ 1917............................ 1918............................ 944 1,026 939 1,136 955 37 11 9 15 15 3.9 1.1 1.0 1.3 1.6 1 Source: Reports of Department of Education; Education, Special S chools, Ju ve n ile P ro b a tio n . S yste m and Infant-Life Protection, “ E-4,” 1912-1919. The source does not s ta te th e age lim its o f ch ild re n in exempted institutions. Genebal T able — Medical practitioners on register, New Zealand, Medical practi tioners on register. Year beginning Jan.1— 1914............................ 1915................................. 1,240 1,268 Medical, practi tioners on register. Year beginning Jan.1— 1916.............................. 1917.......................... ¡>948 *962 1914- 1919.1 Year beginning Jan. 1— 1918 Medical practi tioners on register. 969 985 1919 1 Source: New Zealand Official Year-Book, 1918, p. 174; 1919, p. 207. * During 1915,340 names were removed from register; in 309 cases the letter of inquiry was not delivered but was returned to the registrar general; 20 ceased to practice, and 11 were reported dead. During 1916. 18 names were removed from register on the ground that the “ letter was not delivered and was returned to registrar general,” General T 7. —-Proportion o f breadwinners in the population 10 years of age and over, by sex and age, New Zealand, 1916.1 able Population 10 years of age and over. Males. Females. Age group. Breadwinners. Total. Breadwinners. Total. Number. Per cent. 10 years of age and over....................... 10-14.............................................................. 15-19........................................................... 20-24........... .......................................... 25-44.................................................. 45-64........................................................... 65 and over............................ .................. Unknown.......................................... .. Number. Per cent 422,115 355,049 84.1 422,461 100,255 23.7 55,532 45,012 30,419 169,080 91, 842 29,539 691 3,854 38,053 29,701 166,494 89,600 26,791 556 6.9 84.5 97.6 98.5 97.6 90.7 80.5 53,693 46,392 46,759 174,149 77,036 23,857 '575 1,578 22,953 22,994 36,702 12,368 3,539 121 2.9 49.5 49.2 21.1 16.1 14.8 21.0 1 Compiled from Results of a Census of the Dominion of New Zealand, 15th October, 1916, Part I X , Occu pations and Unemployment, pp. 2-3. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 72* G INFANT MORTALITY. e n e r a l T a b le 8 .— E con om ic sta tu s o f breadwinners, b y occupation group and se x , N e w Zealand, 1916.1 B r e a d w in n e r s . P e r c e n t w i t h s p e c i fie d e c o n o m i c s t a t u s . T o ta l. O c c u p a t io n g r o u p . Num b er. R e la W ork tiv e a s s is t i n g fo r in g b u t w a g e s or n o t re c e i v i n g s a la r y . w ages. I n b u s i ness o n ow n P er cen t Em a ccou n t d is t r i p lo y e r. b u t io n . (n o t an em p lo y e r ). C la s s i W age e a r n e r fi c a t io n u n e m in a p p l i p l o y e d . c a b le . U n s p e c i fi e d . MALES. 355,049 24,797 10,119 49,490 40,253 97,045 100.0 7.0 2.9 13.9 11.3 27.3 12.2 9.1 r 16.4 14.5 2.8 9.8 15.7 8.7 13,2 12.6 5.9 7.6 3.4 .2 1.2 .8 .2 .3 62.2 77.0 66.1 65.7 89.2 79.1 10'531 34.6 3.0 17.5 29.6 9.2 40.6 1.1 A g r i c u l t u r a l, p a s t o r a l , m in e r a l , a n a o t h e r p r i - ■ 1.0 1.1 .2 .6 .2 .5 3.8 2.8 4.3 .1 1.7 1.2 2.8 1.5 1.5 2.7 2.1 100.0 fem ales. 100,255 17,303 31,796 16,714 2,289 19,874 100.0 17.3 31.7 16.7 2.3 19.8 2.6 1.1 2.3 2.3 .6 2.4 7.9 12.7 3.6 7.7 .2 10.0 8.3 .5 3.7 4.7 1.5 .9 74.1 74.9 87.9 78.7 97.0 84.6 1.2 1.2 1.6 1.4 .6 1.1 5.0 8.3 .3 4.6 .1 0.9 1.3 .7 .7 1.0 9,685 2,613 9.7 2.6 8.4 13.4 62.6 12.9 .2 .8 100.0 1.7 A g r i c u l t u r a l, p a s t o r a l , m in e r a l , a n d o t h e r p r i - 1 S o u r c e : R e s u lt s o f a C e n s u s o f t h e D o m in i o n o f N e w Z e a la n d , a n d U n e m p lo y m e n t, p p . , . 45 General T able 15t h O cto b e r 1916, P a r t I X , O c c u p a t io n s 9 . — P roportion o f illegitim ate births, N e w Zealand, 1811—1 9 1 9 } Y ea r. 1*77 1Ä7« 1Ä79 1J&1 1Ä92 1KQ3 1394. 1398 1397 1898......................................................... I lle g it i m a te b ir t h s . 351 429 415 471 534 546 534 587 630 602 617 577 612 603 638 593 673 704 835 834 826 801 P er cen t o f to ta l b ir t h s . 2.1 2.4 2.3 2.4 2.9 2.9 2.8 3.0 3.2 3.1 3.2 3.1 3.3 3.3 3.5 3.3 3.7 3.8 4.5 4.5 4.4 4.2 1899......................................................... 1900......................................................... 1901......................................................... 1902......................................................... 1903......................................................... 1904......................................................... 1905......................................................... 1906......................................................... 1907................... ..................................... 1908......................................................... 1909......................................................... 1910......................................................... 1911......................................................... 1912......................................................... 1913. . . .................................................. 1914..................... ................................... 1915......................................................... 1916......................................................... 1917......................................................... 1918........................................................ 1919......................................................... i C o m p ile d f r o m S t a tis t ic s o f t h e C o l o n y ( D o m i n i o n ) o f N e w Z e a la n d , o https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis I lle g it i m a te b ir t h s . Y ea r. 1877- 1919. 829 906 937 921 994 1,029 1,082 1,132 1,157 1,105 1,223 1,162 1,078 1,177 1,181 1,302 1,152 1,146 1,159 1,179 1,138 P er cen t o f to ta l b ir t h s . 4.4 4.6 4.6 4.5 4.6 4.5 4.6 4.7 4.6 4.3 4.6 4.5 4.1 4.3 4.2 4.6 4.1 4.0 4.1 4.6 4.6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
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