The full text on this page is automatically extracted from the file linked above and may contain errors and inconsistencies.
U. S. DEPARTMENT OF LABOR J A M E S J. D A V I S . Secretary CHILDREN’S BUREAU G R A C E A B B O T T . C h ief MATERNITY AND CHILD CARE IN SELECTED RURAL AREAS OF MISSISSIPPI By HELEN M. DART R U R A L C H IL D W E L F A R E SE R IES N o. 5 Bureau Publication N o. 88 WASHINGTON GOVERNMENT PRINTING OFFICE 1921 % 6 a. 7 a,L •s sc i î i https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Owing to limited appropriations for printing it is not possible to distribute this bulletin in large quantities. Additional copies may be procured from the Superintendent of Documents, Govern ment Printing Office, Washington, D. C., at 10 cents per copy. O m https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis u, s i ? % c. _ <Z - 4 © o CONTENTS. Page. Letter o f transmittal---------------------------- — .--------------------------------- ---------------5 Introduction------------------------------------------------------------------------------------ ------------- - -----7 -8 7 -8 Scope and method o f the survey---------------------------------------r------- ¿X .-----------Selection of counties— ----------------- :— — L ----------------------------------------7 Sources o f information--------— --------------------------------— -------------8 Main features in social and economic background of families visited------- 9 -2 0 Population---------- ------------------------------------------------ i— i -------------------—--------- u - " 9 -10 Urban and rural population--------------------------- -------------------- --------------- 9 Density o f population.----------------------------------------- --— — — -------------0 Means o f communication--------------------------------------------------------- — -------------- 10-11 Railroads---------------------------------------------------------------------— ------ j----------10 Roads and mail service----------------------------------------- -— - — ---------4%— 10' Telephones _________ jl—J --------------------------------— — ---------------- -— 10 Farming conditions------ _■------------------------—--------------- — — - — — — ------- - 11-15 S o ils ------------------------------------------------------- ---------------— — — ------------------11 Climate____________________ ,j------------------------------------------------ —*----------- U Crops apd live stock---------- --------------------------— — — i---------- ;■--------------l2 Plantation system o f land tenure--------------------- --------------------------— — 12 Tenure and acreage-------- *---------------------------- — ----------------— - — — 13 Removals from farm to farm ----------------------- — -— — — -----------------14 Occupation of chief breadwinner______ _______ :------------------- — -------- ; 15 Illiteracy and education----------------------------------------------:-f— --------------- 15-16 Illiteracy-------------------------- _— -------,-----------------------------------------------— 15 Schools_______i ------------------- --------------- .— ---------------------------------------- — 15 Home demonstration and agricultural agents-------------- -l— -----------16 Public health work in the county--------------------------------------- \— ----------------10 Housing and sanitation---------------------------------- *— --------------------------------------18-20 Houses__- _________________ — ------- --------------------------- ---------------- '----------18 Overcrowding— -------------------------------------- ----------------------------------- --------18 Screening-------------------------------- ?------- — >---------------------- — *------------- --------19 W ater su pply-------- ---------------------------------------------------------- *•----------— — 19 Privies------------ ------------------------- ^ ----------------—---------- :— 20 Maternity care—.----------------------- ----------------------------------------— - - - — - - - ■ — S ------ 21-34 --------------21 The need for education;----------------------------------i - ^ 4 — — J.------- — • Maternity care available-------- — ;-------------- ------ ------------- ---------------------------- 21-23 H ospitals--------------------------------------------------- — ------- ----------- ----------—— 21 Physicians-------------------------------- ----------------------------------------— — ------21 Midwives--------------------------------------------------------------- -------- *■-— — -— — "21 Maternity histories o f mothers visited------------ — — - — ----------- - - — 23 Prenatal care-------------- — i ------- ------------------------- -----------^----------------- —-------- - 24-26 Mothers receiving prenatal care--------------------------- a -------------------------— 24 Analysis of care given--------------------------------------------------------------------- — 25 Use of home remedies during pregnancy----------------- —'— --------- — 25 Information through reading--------------------------------------— -------------— 26 Attendant at confinement— --------------------- ---------------- -------- ------------------------ 26-28 Kind o f attendant— .------ ----------------------------------- 1— --------------------------26 Distance from attendant-------------------------------------------------------------------— 28 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 3 I "51 S t 4 CONTENTS. Maternity care— Continued. Care o f the mother after delivery___________ __________ Medical care______________________________^ __v__— Nursing care_____________________ ____________________ 4 Days in b e d ___ ________________ .__________________— Costs of confinement____ __________ ______ _____________ w '__ Total costs and free service___,___ ^________ __________ Costs item ized________ ___________________ _____k ____ ikl. Cost of confinement and economic status of family Maternal m o r ta lity .-_______ ___ - __ ________________ _______ Maternal deaths in the county___ ________________ Deaths from causes other than childbirth-._________ Mothers’ work in relation to ehildbearing— - ____ , ____________ Usual farm and household w o rk _l____ ___________________ Farm work— _____ _________i_______________ _______ Household conveniences and household help____ ____ W ork during pregnancy and after confinement___________ Kind of household help secured-;____________ ___ Relief from work before confinem ent---______ l___ Resumption of work after confinement______________„ Effect of farming season on mothers’ work___ J-____ Care of children___________________________ j ____ _______________ Birth registration______________ ________ ____ _______ ____ i__ Instruction in infant care__________________________________ Feeding customs_____________________ .______________________ Breast feeding___ ________________________|_____________ Solid food and family d ie t-____ M ___ L _ _ _______ Children’s illnesses_____________ ________ .__________ Medical care________ i________________________________ Nursing care_'______________ ___ ___ _____________________ r_ Deformities_________ _____________ ___ g___________ __ ! , Accidents_______4_,________________ .________ _________ Illnesses________ ____ --__________________ ____ |________ m Home remedies for children_____________________ _____ Infant deaths_____________ .____________j_____ i______ _______ Medical care________________ ________ - ;___ |____ ■____ ___ _ Causes o f death____ _________ ___ ___ ____________ .______ Children’s health conferences--.__________'_____________________ Previous public health work__.______ ____________ Attendance and places o f meeting_____ :_______ _______ __J_ Examination of children— ___ _ i ________ ______________ _ Exhibits_________ ________ - ___ __ ¿j...__— __ _______ __________ Results o f the conferences_____ ____ _______________ Summary ----------------- ----- W_________ _________________ & __ X______ Conclusions_____ ________ ____________— __ ____ __ — In d e x ____________*_______________ — ____ \______ ____ t ___Ik - ILLUSTRATIONS. P late I. The conference at a country schoolhouse. P late II. An examination at a Negro conference. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Page. 2 8 -3 28 29 30 31-33 31 31 32 33-34 33 34 35-41 35-37 35 36 37-41 38 38 39 40 41-50 41 42 ■12-4; 42 43 43 -4 7 43 44 45 45 46 46 47-50 48 49 50-52 50 51 51 51 52 53 55 57 LETTER OF TRANSMITTAL. U n it e d S tates D epartm ent of L abor, C h i l d r e n ’s B ureau, Washington, June 14,1921. S i r : I transmit herewith a report entitled “ Maternity and Child Care in Selected Rural Areas o f Mississippi.” This is one o f a series o f studies o f child welfare in rural areas undertaken by the Children’s Bureau. The study was made under the general direction o f the Hygiene Division o f the Children’s Bureau. The report was written by Miss Helen M. Dart, who was in charge of the field work. Dr. Frances Sage Bradley was in charge o f the children’s health conferences held in connection with the inquiry. The Children’s Bureau wishes to express its appreciation of the generous cooperation given by Dr. W. S. Leathers, secretary, Missis sippi State Board o f Health; Dr. R. W. Hall, director o f the State Bureau of Vital Statistics; local physicians; school authorities; and members o f the Woman’s Division o f the Council o f National Defense. Respectfully submitted. J u l i a C. L a t h r o p , Chief. Hon. J a m e s J . D a v i s , Secretary of Labor. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY AND CHILD CARE IN SELECTED RURAL AREAS OF MISSISSIPPI. INTRODUCTION. The present report upon Maternity and Child Care in Selected Rural Areas o f Mississippi is one o f a series o f studies o f the con ditions affecting maternity and child welfare in rural sections o f the United States begun by the Children’s Bureau in 1916. That there is urgent need for the study o f such problems and for the adoption o f measures that will eventually lead to an amelioration o f the conditions that give rise to them has already been shown in previous reports of the bureau1 and need not be restated here in detail. A survey was undertaken under the direction o f the Hygiene ¡Division o f the Children’s Bureau in the spring o f 1918 at the request o f the Mississippi Board o f Health, and the secretary o f the board, in advocating the establishment o f a bureau o f child welfare, stated: This phase of health activity in Mississippi has been neglected in the past. No special provision has been made for conserving the health o f the children of the State. There is no greater need in Mississippi to-day than the study of infant mortality with the hope o f reducing deaths among children less than 2 years o f age. * * * W hen it is known that thousands o f children die in Mississippi from preventable causes before reaching 2 years of age, it is imperative that steps be taken to check and control this slaughter o f the innocents.2 . SCOPE AND METHOD OF THE SURVEY. Selection of counties.—A county in the southern part o f the State, where some public health work had already been done by the Mississippi State Board o f Health, in cooperation with the Inter national Health Board (formerly the Rockefeller Sanitary Commis sion), was chosen as the field for a series o f children’s health con fer-' ences, which included the examination by a Government physician o f children under 6, simple talks to parents, stereopticon views, and ex1 Children’s Bureau Publication No. 26, Maternity and Infant Care in a Rural County Kansas; Children’s Bureau Publication No. 34, Maternity Care and the Welfare of ■«Ibung Children in a Homesteading County in M ontana; Children’s Bureau Publication No. 46, Maternity and Infant Care in Two Rural Counties in Wisconsin; Children’s Bureau Publication No. 33, Rural Children in Selected Counties of North Carolina. “ Report of the State Board of Health of Mississippi, .Tune 1, 1915, to June 30, 1917J p. 17, Jackson, Miss., 1918. 7 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 M ATERN ITY ARTD CHILD CARE. hibits relating to child care. For the intensive survey o f maternity and infant welfare a county in the northern part o f the State was selected which was typical o f the “ hill country ” of that part of the State in respect to the conditions o f child care, general economic and farming conditions, and racial and industrial distribution o f popula tion. Comparatively little public health work had been done in the county, and while it was not progressive in this respect, neither was it the most backward in the State. The study was Confined to rural communities in the northern county; the two county seats, towns of about 500 and 4,500 inhabitants where strictly rural conditions did not prevail, were not included in the area studied. Sources of information.— General information was secured from the county health officer, the county superintendent o f schools, the county agricultural agent, the home demonstration agent, from physicians, and from many other responsible persons in the county. But in this, as in all similar surveys made by the Children’s Bureau, the information most pertinent to child and maternity care was secured through personal interviews with individual mothers by the woman agents o f the bureau. Effort was made to secure interviews with the mother o f every baby born in the area studied between April 1,1916, and April 1,1918. Information was obtained in regard to 685 babies (299 white and 386 colored) born to 675 mothers (295 white and 380 colored). In a few cases in which it was impossible to see either the mother or the father, information was secured from relatives and others in a position to know the facts sought. The local registrars for births and deaths helped in finding all the babies within the scope o f the survey, and death certificates for all babies whose deaths had been registered were secured at the beginning o f the work. Since birth registration was incomplete, a house-to-house canvass was made o f the county. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MAIN FEATURES IN SOCIAL AND ECONOMIC BACK GROUND OF FAMILIES VISITED. The county in which the intensive survey was made is located in the northern part o f the State and is typical of the “ hill country ” o f Mississippi with rolling hills, open fields, broad fertile river bot toms, and a good deal o f cut-over woodland. POPULATION. The census o f 1910 showed that the percentage of Negroes in Mississippi, 56 per cent, was greater than for any other State in the Union,1 and in the county studied more than half the total popula tion o f 22,959 was Negro.2 O f the mothers interviewed 56 per cent were Negro, and only 1 mother was foreign bom. Urban and rural population.—About 20 per cent of the population was urban, owing to the fact that there was one city o f 4,649 inhabi tants.3 In spite o f its size it exerted very little more influence for progress than did the other county seat, a village o f about 500 in habitants. The population o f the county exclusive of these two towns was about 17,800 in 1918. Scattered over the county there were eight small towns in which living conditions were essentially rural. They varied in size from 10 to 475 inhabitants and contained from 1 to 12 stores. None o f these towns had more than one physician in regular practice, and three had no physician at all. A ll but one had post offices and all but two were on the railroad. O f these two, one was about 7, the other about 9 miles from a railroad station. In none o f them was there a town water supply or sewerage system. Density of population.— In 1910 the density o f the rural popula tion o f the State was 84.3 persons per square, mile, o f the county 35.2 persons per square mile.4 In the open country it was seldom more than a quarter o f a mile from one house to the next, and even in the rougher parts o f the county it was unusual to visit a family who had no neighbors in sight. This was quite different from the county 1 Thirteenth Census, 1910, Population, vol. 1, p. 135. a Estimated for Apr. 15, 1918, on basis of Thirteenth Census, 1910, Population, vol. 2, p. 1058. 8 Estimated for Apr. 15, 1918, on. basis of figures given, Thirteenth Census, 1910, Popu lation, vol. 2, pp. 1035 and 1058. 4 Thirteenth Census, 1910, Population, vol. 2, pp. 1044-1058. 48532°— 21------ 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 9 10 M ATERNITY AND CHILD CARE IN studied in Montana, where it was unusual to find families living less than one-half mile apart. Most o f the Negroes lived on the river bottoms as tenants on the large plantations, while the whites lived in the hills where the plantations had been broken up into small farms. MEANS OF COMMUNICATION. Railroads.—Two divisions of the Illinois Central Railroad crossed the county from north to south. Stations were only from 4 to 7 miles apart. None o f the families visited lived more than 10 miles from a railroad station. The large markets were St. Louis and Memphis. Shipments o f cotton, hay, cattle, hogs, and other produce were arranged for in carload lots by the county agricultural agent. Only a very small part o f the stock and grain raised in the county was used by the local market. Roads and mail service.— On account of the many hills and gullies even the public roads were winding and had many steep grades. The soil was so sandy that the roads dried quickly, and so loose that they washed out easily and needed constant care to keep them in condition. However, the main roads were usually very good and well graded, and practically every part of the county was accessible by automobile. Even in bad weather the roads were seldom impassable for more than a few days at a time, and only a few instances were reported where a father had difficulty because of bad roads in getting a doctor or midwife to attend a confinement. According to the southern custom, most o f the houses were not on the main road but back on the plan tations. The roads leading to them were private and not so well worn or well kept as the public roads. Some o f the houses were 1-| or 2 miles from the main road; a few were almost inaccessible by automobile even when the weather was good, because the roads lead ing to them were rough and steep or the bridges insecure. Good roads made possible daily mail delivery for every part o f the county. No place in the county was more than 3 miles from a rural mail delivery route and most places were not so far away as this. Telephones.— Telephone lines followed most o f the main roads. O f the 675 families visited, 84 white families and 2 colored had telephones in the homes. Nearly one-half were less than a mile from some neighbor who had a telephone, 182 were 1 to 3 miles distant, and only 20 o f the families (19 o f them colored) were reported as living over 5 miles from a telephone. Only 4 mothers reported trouble in getting a physician for confinement because the telephone service was cut off. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 11 FARMING CONDITIONS. Over four-fifths of the land of the county was in farms,5 but it was estimated by the county agricultural agent that about one-half o f this land was still unimproved, although more was being brought under cultivation each year. Much o f the land under cultivation had not yet been cleared o f stumps, and in many fields the trees had been girdled instead o f cut in order that the land might be immedi ately planted in cotton or corn. Nearly one-half the farm acreage o f the county was in woodland.6 Soils.—-The soil of the bottom lands, though liable to overflow, afforded some o f the best farming land o f the State, while the upland soil was probably more suitable for grazing than for any other pur pose. T o quote from the State geological survey: Most of this region has been long in cultivation. The* high, well-drained condition of the surface, the healthfulness of the climate and the fertility of the soil at an early period in the State’s development invited settlement. In the antebellum days, under slavery régime, these lands were owned and worked in large plantations. A s elsewhere in the State, cotton was the staple cropi with just enough corn to supply the needs of the plantation. The methods of cultivation were very exhausting to the soil. Crops were, year after year, taken off the land and nothing returned to it.7 The report states further that the exclusive cultivation o f cotton exhausted the humus and other elements o f fertility. Since the Ciyil W ar the exhaustion o f these lands had been more rapid than ever before, and careless terracing or circling o f the hill slopes had caused many o f them to wash out badly. It was only within the past few years that agricultural methods had begun to show im provement. Climate.— Hot weather usually continues unbroken from the latter part of May to early October, and farmers count on a frost-free growing season o f about seven months. The temperature does not rise any higher than it does' in some northern States, but the longcbntinued unbroken heat and the humidity makes the climate more enervating. Only occasionally in a severe winter does the ther mometer drop below zero. The rainfall is well distributed throughout the year but the heaviest occurs in the late winter and early spring. The total precipitation for the year 1917 was 53.98 inches.8 The snowfall is slight, even in the northern part o f the State. The prevailing winds are from the south. Tropical storms and thunder showers which ^cause great damage to crops are not infrequent. 5 Thirteenth Census, 1910, Agriculture, Vol. VI, pp. 870—871. 8 Thirteenth Census, 1910, Agriculture, Vol. VI, pp. 870—871. 7 Mississippi State Geological Survey, Bulletin No. 12, p. 213, Jackson, Miss., 1915. 8 Climatological data, Mississippi Section Annual Summary, 1917, p. 101. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 M ATERNITY AND CHILD CARE IN Crops and live stock.— Until 1911, when the boll weevil appeared in the county, cotton was by far the most important crop and a large v part o f the foodstuffs consumed was imported. With the dwindling o f the cotton crop to about one-third its former size, other crops had assumed a greater relative importance and more attention had been given to stock raising. Diversified farming had reacted beneficially on the people as well as on the soil. They no longer staked a whole year’s effort on one crop nor depended on the market value o f that crop to buy their foodstuffs. One o f the illiterate colored farmers said that he and his fellow tenants on the plantation had been much more prosperous'and independent since each household had begun to raise its own grain and meat, and garden produce. For the first time in years they had been able to get out o f debt at harvest time. There were as yet few stock or dairy farms, but practically every farmer in the cohnty was raising a few hogs and cattle for market, and a few farmers were shipping milk to a creamery outside the county. About three-fourths o f the families visited owned some cattle and about the same number were reported as keeping hogs. Some mules and houses and a few sheep and goats were raised for the market. The number o f sheep had decreased considerably since the law requiring the fencing o f pastures made their upkeep more expensive. O f the 674 families reporting, 280 o f the white and 279 o f the colored families had milch cows. In 46 cases the family did not own the cow, but had the use of her as part o f the rental contract or in return for some service. Fifteen white and 100 colored families neither owned, hired, nor had the use o f a cow. It must be taken into consideration, however, that not all the families reporting cows had fresh milk all the year round, and the importance o f milk in the children’s diet needed emphasis here as in many other farming districts. Plantation system of land tenure.—The conditions of tenant farm ing in the area studied were peculiar to the plantations o f the South, the form of tenure having been developed there in the reconstruction period to supplant slavery conditions. To quote from the special study o f plantation areas in the South made by the census in 1910 : A large proportion of the tenants in the South actually occupied a very different economic position from that usually occupied by tenants in other parts of the country. The plantation as a unit for general purposes o f administration has not disappeared, and in many cases the tenants on plan tations are subjected to quite as complete supervision by the owner, general lessee, or hired manager as that to which the wage laborers are subjected on large farms in the North and W est, and indeed in the South. W here t h i^ is the case a tenant is very similar in his economic position to the hired farm laborer, practically the only difference being that he confines his work to a https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED EUKAL AEEAS OF MISSISSIPPI. 13 particular parcel of land which he works by himself and that he is paid by a share of the crop instead o f by wages.9 Along with the plantation system o f land tenure was the credit system peculiar to it. From the time, early in the year, when the tenant signed the contract until the crop was marketed the landlord “ carried ” him. Unless the planter wished to supply the tenant from his own commissary, he arranged credit for him through either a bank or a store for a weekly or monthly allowance for food and clothing, though in many cases the arrangements were less system atic. This advance, with interest, was deducted from the tenant’s share o f the crop at harvest. Since the- colored- tenant was usually ignorant and often illiterate, the bookkeeping was completely in the hands o f the landlord; and there was, without question, some exploitation. One tenant working in partnership, with another re ported that after deductions had been made for the debts incurred for her living expenses she received $5 and 3% loads o f com as earnings for the year’s work. Tenure and acreage.—The plantation system necessitated a large proportion o f tenant farmers. Fifty-six per cent o f the white families on farms were tenants and 89 per cent o f the colored. O f the families who were reported as having farms, 75 per cent were tenants, 22 per cent owners, while for the remaining number the form of tenure was too irregular to be classified because the farmers were working farms belonging to their relatives, who in the majority of cases lived with the family but took only a minor part, if any, in the management and operation o f the farm. Altogether only 45 farmers were renting on a cash basis or were paying a standard rent o f a fixed amount o f produce (usually a bale o f cotton), while by far the greater proportion (over 80 per cent) o f the tenants were renting on shares. Thirty per cent o f the white and 68 per cent o f the Negro tenant farmers were renting on half shares. Economically these were the lowest in the scale. The farm implements and work animals they used were owned by the landlord. More than four-fifths o f the ten ants o f this class owned neither a horse nor a mule; about two-fifths owned no cattle; and nearly one-third owned no pigs. A quarter share rental was reported by 67 tenant farmers and 54 were paying one-fourth o f the cotton and one-third of the corn. Cash and stand ard-rent tenants received but little supervision, but the share tenants were supervised with regard to the planting, cultivation, and harvest ing o f the crops. i Most o f the small farms were in the rougher, parts o f the county, while the rich bottom lands were held by large plantation owners. 9 U. S. Bureau of the Census, Plantation Farming in the United States, p. 7, ton. 1916. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Washing 14 M ATERNITY AND CHILD CARE IN The number o f small farms was large, but most o f the land in the county was in large holdings. F or the 121 farm owners for whom acreage was reported, 21 had farms o f less than 50 acres, 28 had farms of 50 to 100 acres, and 35 had farms o f 100 to 175 acres. There were 11 farms o f 500 acres or more, and 2 o f 1,000 or more. Farms be longing to colored farmers averaged smaller than those belonging to white farmers. The average size o f farms among tenants was much smaller than among owners, because it was not customary for a man to rent more land than he and his family could work by their own labor, and furthermore rented farms included little unimproved land, while practically one-fralf o f the land o f the owned farm was not under cultivation. O f the tenants reporting acreage, 42 had farms of from 10 to 20 acres; 116 (nearly one-half) had farms of from 20 to 30 acres; and 57, farms o f from 30 to 50 acres. There were only 20 tenant farms of more than 50, acres and none o f more than 260 acres. Removals from farm to farm.—As may be expected in a section where the proportion o f tenant farmers is large, there was consider able moving from one farm to another. Nearly one-third o f the families visited reported that they had lived in their present dwelling less than a year. Seventy-five families (1 in 9) had lived on the average less than a year in a place during married life, and nearly one-half o f the families visited had lived on an average less than three years in a place. One mother said she had moved so many times she could not keep count of the number, while in another family the older daughter said they had moved every two years since she could remember. Families who move every year or two do not stay in one neighborhood long enough to get the full benefit of the schools, churches, and other community enterprises, and they have little interest in community projects, such as the building of a county hospital or the employment o f a county nurse. Removals were naturally more frequent among tenants than among farm owners. As the share tenant was supplied not only with a house but with most of his furniture, farm implements, and stock, moving was a relatively simple operation, in many cases consisting o f loading all his household goods and family into a one-horse wagon and moving over to another farm without losing any time from work. The most shifting element of the population was the white tenant farmer. Only about 1 in 8 had stayed for an average o f three years or more in one place. On the whole removals among the colored families were but little more frequent than among white families^ The tendency to remain for a long time on one farm seemed to be stronger among the Negro than among the white families, consider ing the fact that the proportion o f tenant families was much greater among the Negroes. Many spent their whole lives on one plantation. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED BUBAL ABEAS OF MISSISSIPPI. 15 Occupation of chief breadwinner.— In 93 per cent of the families visited the chief breadwinner was a farmer, farm manager, or farm laborer. Only 39 per cent o f the white and 9 per cent o f the colored farmers were farm owners. O f the remaining 7 per cent nearly onehalf were railroad employees and the rest were professional men, merchants, salesmen- postal employees, or skilled mechanics. In 2 white and 16 colored families the mother was the chief breadwinner; 13 o f these mothers were farmers, and 1 was a farm laborer. ILLITERACY AND EDUCATION. Illiteracy. Illiteracy and low standards o f education were serious enough in this part o f the State to present a real obstacle to better health work. Many a mother refused to take the Children’s Bureau pamphlets on Infant Care and Prenatal Care because she could not read and had no one who could read them to her. The percentage of illiteracy was much greater among the Negro than among the white parents, and the percentage o f illiteracy among fathers was higher than among mothers. O f the white families visited, 9 fathers and 8 mothers were reported as illiterate, while o f the colored families 110 fathers and 100 mothers were thus reported. In 5 white and 48 colored families neither parent could read or write. The figures for illiteracy indicate to only a small extent the ignorance which existed among most o f the white tenant farmers and Negroes. These people had very few books and subscribed for practically no magazines or papers, and were unable to use readily the means which the more intelligent and progressive farmers employed to counteract the isolation o f rural life. Schools.— The schools o f the county were handicapped by the lack o f a compulsory education law.10 When school attendance is volun tary it is likely to be irregular. The-school session came in the months when it was least likely to interrupt farm work, and this made the term fall within the period o f bad weather which caused much irregularity o f attendance. The term, too, was so short that many children forgot between terms what they had learned, and many left school with only a slight knowledge o f reading and writ ing. The term for rural schools for white children was five months in the southwestern part o f the county and five and a half months 10 A compulsory education law requiring 60 days’ attendance, with exemptions, went into effect Sept. 1, 1918. This law was applicable only to those counties which elected vto come under its provisions. (Mississippi Acts of 1918, ch. 258.) A new law requiring « 0 days’ attendance, with exemptions, went into effect Aug. 1, 1920. This law applied to the entire State, but permitted any county to release itself from the provisions of the act by a majority vote of the qualified electors at an election held for that purpose. (Missis sippi Acts of 1920, ch. 156.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M ATERNITY AND CHILD CARE IN 16 in the northeastern, the difference being due to the additional income in the northeastern part o f the county from the Chickasaw fund. Terms in the colored schools averaged about four months. Three or four districts levied a special tax for a longer term. Teachers o f the first or highest grade ( “ grade” being based on educational require ments and type o f examinations passed) were required, to have only a common-school education. Practically all o f the white teachers were o f the first grade, with salaries averaging $50 a month. Most o f the colored teachers were of the third grade, with salaries ranging from $16 to $25 a month.11 The rural schoolhouse served to some ex tent as a social center for the community. Some of the schoolhouses were well-constructed buildings, while some were rough, unceiled frame houses with uncomfortable homemade benches. Several o f them had no toilet facilities' whatever. A t the time of the survey the county had no consolidated schools, but in one or two localities there were good prospects that such schools would soon be established. Home demonstration and agricultural agents— The home demon stration agent of the county, employed under the joint supervision of the State and the United States Department of Agriculture, worked with the women and girls to promote better methods o f household economy. She organized in close cooperation with the schools canning ciubs, poultry clubs, and home economics clubs. An important part o f her work was the promotion of better care and more intelligent feeding o f babies and children. The first publichealth nurse in the county will find her work made easier by the or ganizations already formed and methods already put in practice by the home demonstration agents. The agricultural agent worked with the men much as the home demonstration agent worked with the women. He made a scientific study o f the soils of the county, advised the farmers in methods o f cultivation and stock raising and promoted cooperative seed buying and the cooperative sale o f farm products. PUBLIC HEALTH WORK IN THE COUNTY. The county was at the time o f this survey the unit o f administra tion in public-health work in Mississippi. One of the physicians resident in a county was appointed as health officer. His duties were to make monthly statements o f mortality statistics •compiled from the reports o f the registrars o f the- various voting precincts o f the county, to enforce quarantine regulations, and to act as assistant sanitary inspector in enforcing the rules o f the State board o f healthin regard to the sanitation of public buildings, markets, milk depots, ii Statement of county superintendent of schools. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 17 etc.12 He was charged also with the enforcement o f the law passed in January, 1916, for the prevention o f blindness in the new born, which involved the recording o f all cases o f ophthalmia neonatorum, and the registration of the midwives of the county and their in struction in the use o f the prophylactic measures prescribed by the law.13 Most of the county health officers o f the State worked only on part time and had to depend upon private practice for their living. Salaries o f these part-time officers varied from $150 to $1,800 a year. The officer o f the county studied received about $300 a year. In re viewing the results o f this type o f organization the secretary o f the State board o f health wrote as follow s: In many of the counties the part-time man achieves results for which he is by no means compensated. In the main, the part-time county health officers of Mississippi have been, so fa r as the system will permit, reasonably effective public-health workers. But * * * this business o f conserving the public health requires the undivided and aggressive effort o f those who serve in this capacity.14 Special emphasis had been laid upon campaigns against the dis eases peculiar to the region— pellagra, malaria, hookworm, and soilpollution diseases. Special effort to reach rural districts had been made through the Division o f .Rural Sanitation.15 In 1914 a study o f the dietary causes o f pellagra was made in cooperation with the United States Public Health Service in two orphanages in Jackson.16 Intensive work had also been done on malaria. In 1910 the State board o f health, in cooperation with the counties and the International Health Board, formerly the Rockefeller Sanitary Com mission, began a State-wide survey of hookworm and soil pollution. None o f the intensive health work had been done in the county studied because it is not situated in the part o f the State where these diseases were most prevalent. The preliminary survey had shown that the infection from hookworm based on the examination o f 570 children in the county was only 2.3 per cent.17 Nevertheless, the propaganda attendant upon this work in other parts o f the State had undoubtedly had some influence. The local physicians had done some educational work in connection with their practices. One physician said that when he began to practice, most o f his time was taken up with treatment o f malaria. His insistent warnings against 12 Report of the Board of Health of Mississippi, 1915-1917, pp. 166-201. Jackson, Miss., 1918. 13 Report of the Board of Health of Mississippi, 1915-1917, pp. 301-302. Jackson, Miss., 1918. 14 Report of the Board of Health of Mississippi, 1915-1917, pp. 21-22. Jackson, Miss., 1918. 15 Report of the Board of Health of Mississippi, 1915-1917, pp. 29-30. Jackson, Miss. 1918. 16 Report of the Board of Health of Mississippi, 1915-1917, pp. 309-310. 17 Report of the Board of Health of Mississippi, 1913-1915, p. 26. 48532°— 21— 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 M ATERNITY AND CHILD CARE IN mosquitoes had resulted in the screening of many o f the homes in his community and a decrease in the prevalence of malaria. Another, in connection with his typhoid cases, had raised the standards o f sani tation and cleanliness in some o f the country homes. HOUSING AND SANITATION. Houses.— The three-room one-story house with a wide, open pas sage from front to back and chimneys for fireplaces at each end o f the building was the type o f farmhouse most often seen. Some times-a porch extended across the whole front of the house, some times a kitchen was built on at the back. Many o f the larger houses were built on much the same plan, while the smaller houses had a chimney at only one end. Many o f the cabins were o f rough boards or logs with generous cracks between. Only about 4 per cent o f the houses were plastered on the inside, and about 30 per cent were finished with ceiling. A few o f the board houses were finished with a second layer of boards on the inside; some were not even clapboarded. Many were papered with newspapers to keep out the cold. - Some o f the poorer cabins had no glass windows, but merely holes in the walls fitted with wooden shutters; when these shutters were closed the house was dark except for the light that came in through the cracks. Comparatively few houses were painted; some were whitewashed inside and out. The houses among the Negroes were on the whole much poorer than those o f white families, many of them being old ramshackle cabins in wretched condition. Less than 1 per cent were plastered and only 21 per cent were ceiled. For the greater part o f the year such houses were comfortable, but in the few winter months there was real suf fering from the cold. Over 96 per cent o f the houses were set up on piles so that the .circulation o f air underneath might make them cooler and drier; unless this space under the house was inclosed, chickens, pigs, cats, and dogs used it as a shelter. The houses of the prosperous white planters were comfortably furnished, but many of the tenant cabins had only the most necessary things— a bed, a few chairs, and a table. In some houses rough homemade benches took the place o f chairs; homemade cradles, beds, and tables were often seen. „ Overcrowding.—It is surprising to find that there are as serious instances o f overcrowding in the country as in large cities, but the fact that there is no crowding of one house against another does not insure plenty o f room inside the house. When a family o f 8 mem bers or more lives in a house o f two rooms or less (17 o f the f amilies were thus reported), there is bound to be crowding, lack o f privacy, and inconvenience for the housekeeper, no matter how much space there may be outside the house. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 19 The size o f the families varied from 2 persons to 16; about 85 per cent o f the white families had from 3 to 8 members ; most o f the Negro families had from 3 to 11 members. Fifteen colored families had 12 or more members, 4 had 14 or mole. The house most commonly found had three rooms, but many o f the families visited were living in smaller quarters ; 15 families had only one room, and HT, or 17 per cent, had two-room houses. Less than one-half o f the families visited were living in houses o f four rooms or more. Forty per cent o f the families visited reported 2 or more persons per room ; 10 white and 70 colored families were living with 3 or more persons to a room. About one-third o f the white families re ported 2 to 3 persons per sleeping room ; about one-fourth 3 to 4 persons per sleeping room; 28, or nearly one-tenth, reported 4 to 5 persons per sleeping room. There were 27 instances o f 5 or more per sons per sleeping room. Only 23 per cent reported less than 2 per sons per sleeping room. Overcrowding o f sleeping rooms in Negro families was still more evident. More than two-thirds reported 3 persons or more per sleeping room, and only 6 per cent less than 2 persons. In 43 families (over 11 per cent) there were 6 or more persons per sleeping room ; 6 cases were found o f 8 in one sleeping room, 3 instances o f 9, and 3 cases o f 10 persons sleeping in one room. Screening.—-Even in northern Mississippi the climate is such that screening against mosquitoes is desirable as a precaution against malaria. Flies should be kept out o f the house to guard- against con tamination o f food, and in the summer screens are very desirable to keep chickens and live stock out o f the house. In one o f the homes visited, a goat was wandering around inside the house, and in other cases chickens had come in and made themselves at home on the beds. Only 23 per cent o f the white families and 3 per cent o f the colored families were living in houses screened at all doors and windows. One o f the fathers said that he had done his best to screen the house, but there were so many cracks in the walls and floor that flies and mosquitoes came in anyhow. Water supply.—The geologic formation was such that good water was easily obtainable.18 Flowing wells varying in depth from 160 to 200 feet were found at both county seats and along the river bot toms. Among the families visited, 41 reported a drilled well, in many cases an artesian well, as the source o f water supply; 156 families reported springs; 9 secured their water from a river or ¿peek; 16 used cisterns; 109 had bored wells; and 344 (51 per cent) had dug wells. The artesian wells furnished much the cleanest water, since they were drilled to a considerable depth and the piping kept 18Crider, A. F„ and Johnson, L. C .: Summary of the Underground Water Resources of Mississippi, p. 39. Water Supply and Irrigation Paper No. 159, U. S. Geological Survey Washington, 1906. ’ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 M ATERN ITY AND CHILD CARE. out surface water; river or creek water was liable to pollution from animals and fowls, and was usually m uddy; springs, unless carefully protected, were likely to be dirty; and many o f the dug wells were insufficiently protected from surface pollution. The bored wells were subject to much the same dangers from surface water as dug wells, but the opening was so much smaller that animals or insects were less likely to get in. Many of the dug wells were equipped with a windlass or pulley, which made them easier to use, but did not insure any more cleanliness. Eight families had water in the house, and in 21 cases the source o f water supply was on the porch. For more than one-third o f the families the source o f water supply was less than 25 feet from the house; for more than one-half, less than 100 feet. On the other hand, about one-third of the families had to go, 100 yards or more, and 53 had to go a quarter o f a mile or more. Negro mothers reported on the whole longer distances from water supply. A few did* not have wells on the premises, but had to go to a neighbor’s for water; in some cases one well served a group o f tenant houses. Privies.— The disposal of human excreta is a particularly important problem in the South, where special precautions are needed against soil pollution diseases. The survey showed that this problem had hardly been touched in the area studied. Among white families, 61 per cent had no toilets whatever ; among Negro families, 85 per cent had no toilets. O f the 166 families who had privies, 143 reported the open-back type, in which the refuse is unprotected not only from flies but also from chickens, pigs, and other domestic animals. Only two families had water-closets. The State board o f health was doing effective Work in rural sanitation, but thus far little o f it had touched the county studied. The report o f the State board o f health for 1913 to 1915 19 showed the results o f an investigation of sanitary conditions in over 500 rural homes of the county; 303 had openback privies and 270 had no privies. This gave the county a sanitary index based on the type o f privies found o f 5.2 on the scale o f 100. The fact that this index was about the average for the whole State indicated that the problem was State wide. 19 Report of State Board of Health of Mississippi, 1913-1915, p. 27. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY CARE. THE NEED FOR EDUCATION. In Mississippi as well as in other parts o f the* country ignorance o f the value o f good maternity care was largely responsible for the lack o f it, and several physicians in the county stated that the most important factor in getting adequate care o f this kind was to educate the mothers to recognize the need o f it. One physician said that when he heard incidentally that mothers were having swollen feet and other dangerous symptoms during pregnancy, he could not con vince them o f the necessity o f reliable medical advice, and they con sidered visits to him unnecessary. The board o f health attributed the high maternal mortality rate in the State to the fact that “ a very large majority o f the confinement cases among the Negroes are * attended by Negro midwives, in which case little protection is afforded "the patient, consequently the death rate from this cause is unusually high. It is also trtle that a large percentage o f the confine ment cases in this State as a whole are not attended by licensed phy sicians.” 1 MATERNITY CARE AVAILABLE. Hospitals.— A t the time o f the study the hospital nearest the county was located at Memphis, Tenn., nearly 100 miles away, and the nearest one that received patients free o f charge was at Jackson, over 100 miles away. Distance and expense made hospital care im possible for the great majority o f mothers and children o f the county. Only one o f the 675 mothers scheduled had been confined in a hospital. Physicians.—-At the time o f the survey there were 14 physicians in regular practice in the county, and, in addition, there were 3 or 4 who had retired from active practice, 4 or 5 who had enlisted for war work, and 1 or 2 who held no licenses but occasionally helped their neighbors in case o f illness. Midwives.— There were probably over 100 midwives practicing in the county during the period covered by the survey, and 87 o f these ^(8 white and 79 colored) were interviewed by the agents o f the Children’s Bureau with the object o f finding out the status o f mid wifery in the county. In respect to education, the white mid wives 1 Report of the Board of Health of Mississippi, 1915-1917, p. I l l , 21 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 M ATERNITY AND CHILD CARE IN were superior to the colored, as all could read and write, while twothirds o f the colored midwives were illiterate ; but on the whole the white midwives di$ not differ either in training or practice from the Negro midwives. The informations gleaned from the interviews dis closed the fact that none o f the midwives had had adequate training, and most of them lacked even the elementary education that would make such training possible. Various accounts were given as to the training received to fit them for midwifery and the reasons for adopting this practice. Some o f them had been taken to confinement cases and taught by phy sicians; some were midwives because their mothers and grand mothers had been; others had become experienced in handling emer gencies or in bearing their own children; while still others said that they had been “ called by the Lord.” Many o f them believed in various superstitions such as “ Girls come at the full moon and boys on the new moon,” and “ Babies born on a wasting moon haven’t all their senses.” One midwife always cut the cord long because she had heard the saying, “ Long cord, long life.” Many o f the midwives were very o ld ; and decrepit, before-the-war “ aunties had more prestige among their neighbors than any o f the younger midwives. One o f those interviewed said: “ I ’m not going out on night cases any more, because I ’m getting old- and can t keep awake. Some o f their methods were amazingly primitive. Over ninetenths used no antiseptics whatever in making preparations for de livery; one said: “ No washing is necessary if grease is used plenti fully.” Various questionable expedients were used to bring the afterbirth; some o f the midwives used a method o f warming the patient suddenly by putting her over a bucket o f hot ashes or burn ing feathers, while two advocated putting an umbrella or a black hat over her face. Some o f the more intelligent ones knew that childbed fever was caused by uncleanliness and tried to guard against it, but among many the old custom still held o f not changing the bed coverings for at least three days. Many of them said that they always called a doctor when any complication occurred, but several told o f attending cases o f ad herent afterbirth, severe hemorrhage, breech presentation, prolonged labor, and stillbirth without the aid o f a physician, and it is probably true that many o f them failed to recognize minor complications and mild cases o f childbed fever. The midwife’s most dangerous fault was her failure to recognize her own limitations; ignorance pre vented her from recognizing cases where the attention o f a physician was imperative, and in many cases it fostered a fatalistic attitude which was manifested in such expressions as “ Women are born to suffer and it’s wrong to interfere,” and “ I f the baby is born to die, nothing can be done.” https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 23 Several o f the more intelligent midwives said that they would be glad to have a county nurse to advise them and to teach them better methods o f practice. A t the time o f the survey there were no rural county nurses in the State, and practically nothing had been done in the area studied in regard to the supervision of midwives beyond urging them to register births. In 1916 the State legislature passed a bill for the prevention o f blindness from inflammation o f the eyes o f the newborn, and the State board o f health (1917), in the enforcement o f the law, required that all midwives register with the county health officer at least once a year; that all midwives as well as physicians use a 1 per cent solution o f silver nitrate in the eyes o f every newborn baby, and report cases o f inflammation of the eyes within six hours after they had been observed. A t the time o f the survey the law was not being enforced in the county, as was shown by the fact that only 3 o f the 87 midwives interviewed reported having used any drops in the eyes at birth. MATERNITY HISTORIES OF MOTHERS VISITED- The maternity histories obtained from the mothers showed frequent pregnancies and large families. It was customary for girls to marry early and to begin bearing children when quite young. Almost onetenth o f the mothers whose ages at marriage were reported had been married before they were 16 years o f age; one-third o f them before 18; and slightly over three-fifths before 20. Very early marriages were more common among the colored mothers than among the white; about 1 in 8 had married before the age o f 16 (two at less than 14) , and nearly two-fifths when less than 18. O f the white mothers 13 said they had been less than 17 years old at the time o f their first confinement, and 102 under 20. O f the colored mothers, 79 reported the first confinement at less than 17 years, and 227 under 20 years. About 1 in 7 o f the mothers visited had been under 20 when the baby scheduled was born, and 28 o f these had had two or three previous confinements. Nearly one-half (318) were in the age group 20 to 30 years; less than one-third were in the group 30 to 40 years. More than one-half o f all mothers had had four or more pregnancies, and nearly one-fourth had had seven or more. Eighteen per cent o f the white mothers and 28 per cent o f the Negro mothers had had more than 6 pregnancies. One white mother and 9 Negro mothers had had more than 12 pregnancies. Sixty-four o f the 380 Negro mothers were unmarried at the time the baby scheduled, was born; 52 had never been married; 6 had been married at some time previous;,6 were married after the baby was born. H alf these mothers were under 20 years o f age, 7 were under 17 years o f age. F ifty per cent had had one or more pregnancies previous to the birth o f the baby scheduled. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 M ATERN ITY AND CHILD CARE IN PRENATAL CARE. Mothers receiving prenatal care— The figures relating to prenatal care point plainly to the conclusion that lack o f prenatal care was due in large measure to ignorance o f the need for it. Only 116 mothers, about 1 in 6, had any prenatal care whatever, and o f these only 9 had care because they thought that pregnancy was in itself a reason for seeking medical advice. In only 9 cases o f the 116 could the care received be classed as fair, and in only 1 case was the prenatal care adequate.2 O f these 10 mothers who had adequate or fair care, all had either had difficulties in previous confinements or such illness during pregnancy that attention from a physician seemed imperative. The standards o f maternity care were much lower among the Negroes than among the whites, the proportion o f Negro mothers receiving some prenatal care being just about half that for the white mothers. Only 45 o f the Negro mothers, 12 per cent, had any care at all, and only 1 o f these had fair care; 10 had a physical examination and 3 a urinalysis. While illness seemed to have been responsible for prenatal care in the majority o f cases, it can not be assumed that all mothers who felt the need o f care sought a physician. One white mother said that she did not feel well all through her pregnancy, though not sick enough to call a doctor. One o f her older daughters was strong enough to do the housework so the family could get along. Another mother said she suffered a great deal from varicose veins but did not see a physician. Still another had no prenatal care, even though hardly able to be about during the last three months o f pregnancy. Although ignorance .of the need o f good prenatal care was in a large measure accountable for its lack, yet there were other factors that entered in, such as family income, distance from doctor, and traveling facilities. It is significant that the proportion o f mothers receiving prenatal care was. highest among f amilies in which the chief breadwinner was not a farmer, and that they lived in or near towns, not far from a doctor. The heads o f these families were for the most part ministers, doctors, merchants, salesmen, skilled mechanics, and railroad employees in the towns; over three-fourths o f them were white. ' 2 Prenatal care was classed as : Adequate, if there had been a monthly urinalysis, fifth to ninth months; if the mother had been under the supervision of a physician fifth to ninth months; if an abdominal examination had been made, and, m the case of a first child if pelvic measurements had been taken. Fair, if urinalysis had been made but less than’ five times at monthly .intervals, if the mother had had some supervision by a Dhvsician, and if an abdominal examination had been made, and, m case of a first c ild, if pelvic measurements had been taken. Inadequate, if there had been visits to a phy sician, but no urinalysis, no abdominal examination, or, in the case of a first child, no pelvic measurements. Urinalysis with no visits to physician was also counted as inade quate care. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 25 Analysis of care given.— In the majority of cases o f women receiv ing some kind o f prenatal care the matter ended when the mother had seen a physician. There was no realization of the importance o f urinalysis, still less o f abdominal and pelvic examination. Study o f the number o f visits, urinalysis, and kind o f physical examina tions made brought out the fact that 9 o f the 116 mothers receiving care had urinalysis only, and did not see a physician personally. O f the 107 mothers reporting visits to or from a physician, 53 reported a single visit. Less than one-third o f the 116 mothers had one or more urinalyses made during pregnancy, and 92 per cent o f these mothers were white. It is interesting to consider some o f the few cases in which the need o f such care was realized. One mother had learned through reading and through consultation with a trained nurse that monthly urinalysis should be made, and accordingly sent specimens to her physician during the last five months o f pregnancy, although she did not see him personally. In another instance the grandmother who came to stay with the mother insisted upon urinalysis because she had heard that serious complications might result from kidney trouble. One mother during pregnancy had convulsions which her physician said were caused by kidney trouble and necessitated regular urinalysis, but she insisted that they were caused by a sunstroke she had had as a girl, and refused to send specimens after the second time. Her attitude is typical o f a large proportion of mothers visited. In one case a mother who had had alarming symptoms dur ing pregnancy had been told by her physician to send specimens o f urine for examination, but her husband, more through ignorance than ill nature, refused to act as messenger. Only four o f the mid wives reported it as their custom to see the mother during pregnancy; six said they might make some examina tion if they happened to see the mother before confinement. There were often chance meetings, o f course, during which the mother casually sought advice; some mothers consulted the midwife when they came to engage her, and some called her in when they were not feeling as well as they thought they should; but for the great ma jority o f confinement cases the midwife was summoned only after labor had begun. Use of home remedies during pregnancy.— Aside from the advice which can properly be classed as prenatal care, some mothers learned something about prenatal care through reading or took medicine not prescribed by a doctor. Two were instructed by a trained nurse. A few consulted midwives, but in the majority o f cases the advice given could not be considered any better than that which might have been given by any experienced neighbor. Advice was also picked up 48532°— 21-------4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 M ATERNITY AND CHILD CARE IN from various other sources. One mother used liniment purchased « from an agent who was canvassing the county; while another said she had written to a firm in a northern city for medicine. More than one-half (most of them Negroes) o f those who used home remedies said that they took some kind of patent medicine. One mother said she had taken six bottles o f a patent medicine during her last pregnancy, and another said that she had taken “ more patent medicines than she could mention ” during the 10 years she had been “ complaining.” Simple home remedies, such as castor oil, magnesia, calomel, kerosene, and camphor, were also used, and several Nep?o mothers said they took teas o f various kinds, such as “ tansy tea” or “ pepper tea.” . . Information through reading.—Thirty-two white mothers and 14colored had read something about the care needed by a pregnant woman. It can not be supposed, however, that the literature read was really instructive in every case, for almost none o f the books mentioned were standard. Several were general “ doctor books,” which dealt with many subjects besides childbirth; others were pamphlets or almanacs* published as advertisements; while many others were advertisements designed primarily to promote the sale o f patent medicines. More than one-half o f the Negro mothers who said they had received some instruction through reading had only read advertisements o f this kind. Probably only the 19 mothers who read the current women’s magazines and farm papers received on the whole up-to-date and authoritative instruction. ATTENDANT AT CONFINEMENT. Kind of attendant.— Only two-fifths o f all the mothers studied were attended by a physician at confinement, while nearly thr^e-fifths were attended by midwives. The remainder, only per cent, were at tended either by their husbands or by other women who were not midwives. One mother had no attendant at all. In a few instances some attempt was made to secure a physician, but the call did not reach him on account of interrupted telephone service or bad roads. In several of these latter cases the mother was attended by a wholly inexperienced person or by a Negro midwife. One mother told of being alone with her sister and husband when the baby was born. Her husband,' realizing that the baby would be born bef ore the doctor could possibly arrive, called in his wife’s sister. She knew nothing about confinement cases, but “ risked cutting the cord.” Others told o f very similar experiences. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OE MISSISSIPPI. 27 Number and per cent distribution o f scheduled' mothers o f specified race ac cording to attendant at confinement. R a c e o f m oth er. T o ta l m oth ers. - W h ite . A tte n d a n t a t con fin em e n t. P er ce n t N u m b er. d istrib u tio n . N egro. P er cen t N u m b er. d istrib u tio n . P er cen t N u m b e r. d istrib u tion . T o t a l co n fin e m e n ts .............. 675 100.0 295 100.0 380 100.0 P h y s ic ia n ......................... M id w ife ............ O ther w o m a n ............ F a th e r ....................... N o n e .............. 266 382 24 2 1 39.4 56.6 3.6 .3 .1 234 48 12 1 0 79.3 16.3 4.1 .3 32 ' 334 12 1 1 8.4 87.9 3.2 .3 .3 The choice between physician and widwife seemed to depend in some degree upon custom. Seventy-nine per cent o f the white women were attended by physicians, while nearly 88 per cent o f the colored mothers were attended by midwives. One instance was found o f a hi egro family who lived in town only a few blocks from a physi cian, but sent 3 miles into the country for a colored midwife. The proportion o f native white mothers attended by a physician at confinement was the highest that had been found in any rural district studied by the Children’s Bureau except the one surveyed in Kansas. However, it was lower than any o f the cities studied by the bureau. A physician had been in attendance at every confinement for about two-thirds o f the white mothers, but for only 3 per cent o f thè Negro mothers. Moreover, 11 o f the 13 Negro mothers had had but one confinement. The custom among the Negroes seemed to be to call a physician only when some complication arose which the midwife could not handle. There were, however, 23 white mothers who had never had a doctor at confinement, and 14 o f these had had three or more pregnancies. O f the total confinements to all mothers (3,017), 64 per cent were attended by midwifes or other women and 35 per cent by physicians. O f the remaining 1 per cent o f the confinements reported, 16 were attended by the father and for 11 there was no attendant. The difference in the choice o f attendant might have been *due partly to the difference in economic well-being between the white and colored families. On the whole, the Negro families were much poorer than the white, and since the midwife’s fee was so much lower than a physician’s the choice o f attendant was in many cases conditioned by the family’s ability to pay. The percentage o f mothers, both white and colored, who were attended by a physician https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 M ATERNITY AND CHILD CARE IN at confinement was much higher among those families living on farms o f their own than among farm tenants, and was lowest among the half-share tenants. Distance from attendant.—Another factor that entered into the choice of attendant at confinement was the distance the physician had to travel to reach the patient. Sixty-six white families were living 7 miles or more from a doctor, and on the other hand 155 white families, more than half, were less than 5 miles from a doctor. For white families the proportion o f mothers attended by physicians was lower for those living 7 miles or more from a doctor than for those living nearer, and the proportion o f cases attended by midwives was higher. In this connection, however, transportation facilities and the condition o f the roads must be taken into account. A ll mothers, both white and colored, who lived in the more remote parts o f the county ran greater risks at confinement than those in or near towns, because o f the time and difficulty usually involved in getting a physi cian in an emergency, but under favorable conditions it was usually possible even fo r families living far from town to get a physician in time. There were, however, instances o f unfortunate coinbinations o f circumstances which prevented the mother from securing a physi cian for confinement. One mother told o f difficulty at confinement be cause the first physician they called was ill and the next one was away on another case, so that she was alone with her husband and a neigh bor when the baby was born. Another mother told o f failure to get a physician because a man had taken down some of the telephone wire to repair his wagon. Still another had a. baby born in January when a severe storm was raging. The telephone was out o f order and her husband had to go through the storm to use a neighbor’s telephone. He succeeded in reaching the doctor, but the latter was delayed by having to heat water in order to start his car, and when he finally reached his patient the baby had been born two hours. By that time the grandmother had cut the cord and rendered the other necessary services. There were many midwives scattered through the different sections of the county and probably no family lived more than 2 or 3 miles from one. CARE OF THE MOTHER AFTER DELIVERY. Medical care— Only one-third of the 266 mothers who were'at tended by a physician at confinement reported any: after care by a physician; 46 received but one visit, 25 received three or more, and only five reported more than six visits. O f the 25 confinements for which the physician made three or more visits, 14 were cases in which either the mother or the baby was in a serious condition after delivery. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED BUBAL ABEAS OF MISSISSIPPI. 29 In 6 o f the 11 remaining cases the family was living less than a mile from the attending physician, and in 3 other cases the mothers were the wives o f prosperous farmers. Nursing care.— One of the most serious obstacles to good maternity care was the scarcity o f nursing care. There was no trained nurse working regularly in the area, and most o f the practical nurses were midwives whose practice was largely among Negro mothers. Very few o f them were really competent. Only 7 mothers o f the 675 secured trained nurses, and less than one-fourth reported care by a practical nurse or midwife. It was also very hard to find anyone who could be hired to do the housework during the mother’s lying-in period, and in the majority o f cases the person who nursed the mother had most o f the responsibility for the housework, too. This scarcity o f help many times resulted in poor care for the mother and made her feel that she ought to get up at the first possible moment-. One mother who had stayed in bed only a week explained that it was her custom to stay longer but that this time she could get no nurse; she was worried because the baby was not doing as well as he should, and she felt that she must get up to attend to him. Another said she had been unable to get either a trained or a practical nurse, even though all her children had whooping cough when she was confined. She finally secured a colored woman to care for her and do the housework. In another family the father nursed the mother while the older daughters, girls o f 12 and 16, did all the housework and washihg. One woman told o f a miscarriage brought on by'overwork in nursing her husband and her father at a time when no woman could be found to help with either the nursing or the housework. Less than one-fourth of the midwives interviewed reported that they stayed in the mother’s home a day or more after delivery; most o f them stayed only a few hours. The majority o f midwives went to see the mother afterwards from one to five times, but most o f the care given during the lying-in period was for the baby rather than for the mother. In about 1 case in 7 most o f the nursing was done by the father. In about 1 case in 5 the nurse did not stay with the mother con stantly, but came in for a few hours during the day. This practice was most common among the midwives, but there were other cases in which the mother depended upon daily visits from some neighbor for nursing care. In most cases such care was gratuitous—a neigh borly service to be repaid only in kind. One mother said that her mother came in several times a day, but that it was a busy time on the farm and she was left alone much o f the day with only the children to wait on her. Another said she secured a colored woman https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 M ATERNITY AND CHILD CARE IN to come and stay with, her, and one o f the neighbors to come in for an hour or so every day to bathe her and the baby. In 72 cases the nurse left before the mother was able to be up, and in only 17 cases did the nurse stay until after the mother was able to be up for most o f the day. In nearly two-fifths o f all cases no extra person was called in, but the mother was cared for by some member o f the household. Only about 21 per cent of the mothers had paid nursing care, and only 13 per cent paid for all nursing care received. The quality o f nursing care was on the whole much poorer for Negro mothers than for white. None had a trained nurse. Less than one-third had nursing care by a midwife or practical nurse, and one-third o f these mothers had practical nurses who made only a few visits and did not stay in the mother’s home. The percentage o f mothers nursed only by their husbands was larger among Negro than among white families. Four had only such care as could be given by a child under 14 years o f age— in one instance a little girl 5 years old. Tw o Negro mothers had no nursing care at all. Need less to say, these mothers got up as soon as possible after confinement. Days in bed.—As a result o f the scarcity o f nurses, the pressure o f work, and the inadequate supervision by physicians and midwives, many mothers did not have the rest in bed after delivery that is considered essential. O f the white mothers visited, there were 20, or 7 per cent, who stayed in bed less than a\ week, and nearly 60 per cent who stayed in bed 10 days or more. O f the Negro mothers, 150, or 39 per cent, stayed in bed less than a week, and 30 per cent 10 days or more. One Negro mother explained rather apologetically that she had stayed in bed for a week after the last baby was born, because the weather was so cold. Ordinarily she stayed only three days. In spite o f the custom among many of the Negro mothers of staying in bed only a few days, some still held to the tradition that the mother should “ stay in her month.” One said that she had been told by the midwife who attended her-first confinement to stay in bed for a month, and she had followed this advice at each o f her four subsequent confinements. The season o f the year in which the confinement occurred deter mined to some extent the length of time which the mother spent in bed. One Negro mother explained that she stayed in bed for only four days with a “ summer-time baby,” but with one born at any other time o f the year she stayed in bed longer. During the busy spring and fall seasons the mother was likely to feel that she ought to help if she possibly could, and even if she did not go into the fields for work herself she might try to release for field work those who were helping with the nursing and housework. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED BUBAL ABEAS OF MISSISSIPPI. 31 &OSTS OF CONFINEMENT. The •costs of confinement tabulated for this study include the attendant’s fee, the cost o f prenatal care, the cost o f hospital care, and the combined cost o f nursing care and help with the housework; expenses for medicine and for extra supplies or transportation are not included. Total costs and free service.— O f the white mothers who reported the cost o f confinement, 62 per cent gave totals ranging from $10 to $25, and 16 per cent reported an expense of $25 or over. O f the colored mothers who gave information on this point, 65 per cent reported a total cost o f less than $5 and 25 per cent a cost o f less than $2.50. These costs average lower than those found in any other rural district surveyed. In Kansas 54 per cent reported an expense o f $25 or over for confinement, while in Montana physicians’ fees alone were usually over $25 for confinement, prenatal care, and postnatal care. Forty-six mothers, 16 white and 30 colored, reported no money whatever paid out for the services specified. Analysis o f cost by different items of expense shows that most mothers received free service o f some kind. Forty received free care from the attendant midwife, and 4 paid nothing to the attend ant physician. In 488 cases (three-fourths o f the total reporting) there was nothing paid out for either nursing or housework. In such cases by far the largest item o f expense was that for the attendant at confinement. Other costs rarely equaled or exceeded the attendant’s fee, and in a great many instances it was the only expense incurred. Costs itemized.— It was customary for the physician to charge a fee for confinement and, in addition, regular fees for each pre natal or postnatal visit, rather than a lump sum to cover all care during pregnancy and confinement. The physician’s usual fee for a normal delivery was $10 or $15. O f those who reported the phy sician’s charge for confinement alone, 193 (87 per cent) paid from $10 to $25, and only 16 paid over $25. The expense averaged higher i f prenatal care had been given.' Five o f the nine mothers who re ceived fair prenatal care (see p- 24) paid a physician $25 or more. About 1 in T o f the mothers reporting inadequate care paid over $25. F or the confinement fee alone only about 1 mother in 14 o f those who reported paid $25 or over. None o f the mothers who paid the attendant physician less than $10 received any postnatal care; ap proximately 28 per cent*of those who paid $10 to $25 received post natal care; and 10 of the 16 mothers who paid over $25 received postnatal care. The distance which the physician had to travel seemed to be a factor of no importance in the expense. Distances https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 M ATERNITY AND CHILD CARE IN were small compared to those found in Montana,3 where the phy sician’s fee for mileage was sometimes greater than his fee for service. No instance was discovered in this study o f a physician’s making a charge for transportation or mileage. Approximately two-thirds o f those reporting payment to a mid% wife paid her less than $5 and in only 3 instances was the charge over $10. It is natural, therefore, that the poorer and the more ignorant families should employ the midwife rather than the physician whose fees were higher. One Negro mother stated frankly that she had tried both and preferred the midwife because she did more and charged less. The midwife’s fees varied somewhat ac cording to the difficulty o f the case, the distance from the patient, and the ability o f the family to pay. One midwife said she charged more for boys than for girls because wboys are harder to handle and mothers want them more.” In many cases there were informal arrangements such as exchange o f services, and payments in chickens, pigs, grain, and other prod uce instead o f money payments. One mother said she gave the midwife a bottle o f snuff (valued at 25 cents) for confinement care, including nursing and help with the housework. About one-half o f the white mothers and almost 95 per cent o f the colored who reported on costs o f confinement said that they went to no expense for nursing and housework; some o f these may be included in the 71 who paid the midwife a lump sum for confinement and nursing, or in the 34 who paid her a lump sum for confinement, nursing, and housework. Many families settled the debt on a neighborly give-and-take basis which involved no money payment. One father worked his sister’s crops a few days to pay her for helping his wife at confinement; another gave his w ife’s sister a bottle of snuff in return for her serv ices. Negro help was often paid in left-overs from the table, milk, or second-hand clothing. Rates per week for nursing and house work varied from 50 cents to $5 or (in a few cases) more. The usual prices were $1.50, $2, or $2.50 a week. Nearly one-half the 136 white mothers who stated a definite charge for nursing and house work reported less than $5, 26 reported costs o f $10 to $25, and six reported costs o f over $25 for these services. O f the 20 colored mothers who paid for nursing and housework, 9 paid less than $2.50 and only 5 paid $5 or more. Cost of confinement and economic status of family.— The percent age o f white families who reported a total confinement cost o f $25 or more was higher among farm owners than among farm tenants, and higher among owners o f the 100 to 500 acre plantations than among the farm owners as a whole. More than one-third o f the white half3 U. S. Children’s Bureau Publication No. 34, Maternity Care and the Welfare of Young Children in a Homesteading County in Montana, pp. 49, 50. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 33 share tenants reported charges o f less than $10, while about one-fifth o f all white families reported charges o f less than $10. The percent age o f those receiving free care was much higher among half-share tenants than among any other economic group. In general the mothers o f the well-to-do white families got better care than the mothers in the poorer families because they were better able to pay for it. The doctor’s bill was a big item to the poorer tenant, and in many cases ignorance and poverty combined to make him feel that a physician’s services during pregnancy, and at confinement were an unjustifiable expense to be incurred only in cases o f unusual emergency. One/Negro mother had been miserable throughout her pregnancy; she could scarcely walk, her feet were swollen, and she had to kneel in order to hoe. She seemed pitifully eager for relief, but said she could not afford to have a physician. “ I f I had a doc tor, then when winter came there would be nothing for clothes. P oor families can’t have such things as doctors.” This mother had been hurt by a falling tree two months before the interview, but was still doing her house and field work, although unable to walk without the help of two homemade crutches. Share tenants usually depended upon the landlord to advance credit for the doctor’s bill and to deduct it, with interest, from the crops sold at harvest time. MATERNAL MORTALITY. Maternal deaths in the county.— Three mothers of the 675 for whom information was secured for this study lost their lives in childbirth, two from puerperal septicemia and one from hemorrhage following confinement. The care received by the three mothers who died was, on the whole, no better and no worse than that received by most o f the mothers visited whose confinements did not terminate fatally. None o f the three mothers had received any prenatal care. A ll did their washing, housework, and other chores up to the time o f confinement and none had trained or even partly trained nursing care. Only one was attended by a physician at confinement, and in this case the mother died o f hemorrhage which began after the attending physician, the only doctor within a radius of 8 or 9 miles, had hur ried away on another call. One of the other mothers was attended by a neighbor because the physician who was sent for had to come 5 miles over rough roads and was an hour late; she died o f puerperal septicemia about four weeks later. The other case was that of a Negro mother whose baby was bom while the father was on his way for the midwife. She did not arrive until two hours later, when she found the mother and baby shivering on the floor. The mother died a few days later. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 34 M ATERN ITY AND CHILD CARE. By the death o f these three mothers 13 children were left mother less. Eleven were white and 2 were colored, and 10 o f them were under 7 years o f age. Deaths from causes other than childbirth.— Eleven mothers who had been confined during the period covered by the survey died from causes other than childbirth before the date of the inquiry, 10 of them within eight months after confinement. In nine o f these cases pregnancy and childbirth may be considered a contributing factor in hastening death. Five died from tuberculosis, all of them colored women. One mother, also colored, died o f pellagra, the mortality from which is relatively high among women o f childbearing age.4 The death of one white mother four days after the delivery o f a stillborn child was ascribed to pernicious malaria. Two mothers, one white and one colored, died from nephritis, one about two months after the baby was born, the other about four months after. Two o f these mothers had prenatal care o f “ inadequate ” grade (see p. 24) ; the others had none at all. Four were attended at confinement by physicians, 5 by midwives. The deaths o f these women left 40 children motherless. O f the last babies o f these mothers, 1 was stillborn, and 4 o f the 8 live-born babies died under 4 months o f age. One died o f an intestinal disturbance two weeks after the mother’s death. Another died while his mother was on a journey to see a doctor 30 miles away. One baby whose mother was too ill to nurse him “ just got peakeder and peakeder and finally was nothing but skin and bone.” The fourth death was that of a tuberculous mother who had been unable to nurse the baby. 4 Report of the Board of Health of Mississippi, 1915—1917, p. 344, Jackson, Miss., 1918. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis •V MOTHERS’ WORK IN RELATION TO CHILDREARING. USUAL FARM AND HOUSEHOLD WORK. Farm work.— Most of the mothers had been reared in the country and were used to doing farm chores and field work as well as house work. Women reported doing almost every kind of field work which was to be done— plowing, harrowing, hoeing, chopping, and cotton picking. About 85 per cent o f the white 'mothers reported that their principal occupation before marriage had been farm work o f some kind, and about 70 per cent had done field work; 8 per cent had been teachers, and a few had been employed in stores, cotton mills, or offices. Nearly all the colored mothers had done field work before marriage; a few had worked as domestic servants. About fiveeighths of the mothers did field work during the period covered by the survey, and practically all of these), had done farm work o f some kind before marriage. Somewhat more than one-fourth o f the mothers who, as girls, had worked in the fields were relieved o f field work during the period studied, this being due in some instances to poor health, in others to pressure o f household work, or to highetr in come which made it unnecessary for the mother to work in the fields. One father said he had taken work as a farm laborer rather than as a tenant so that his wife would not have to work in the fields. The importance of the different kinds o f chores as indicated by the number o f mothers reporting them was as follow s: (1) Care o f chickens, (2) care o f garden, (3) carrying water, (4 ) churning, (5) milking, (6) care o f stock, and (7) running the cream separator. Only one-tenth o f those who reported doing chores were doing less than three o f those listed above, and more than one-half were doing five or more. On the whole, the Negro mothers had fewer chores to do than the white mothers, probably because a smaller proportion o f the Negro families kept cows, pigs, or chickens. It was customary in most families for the women to take care of the chickens, and for the men to attend to feeding the cattle and work animals. Most o f the mothers who reported care of stock took care of the pigs only. About 79 per cent o f the white mothers carried water for house hold use; for nearly one-half o f these women the source o f water supply was less than 25 feet from the house, but for more than one*fourth it was 300 feet or more from the house. About 54 per cent had a pulley or windlass to draw up the water bucket; about 40 per 35 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 M ATERN ITY AND CHILD CARE I N cent had to dip water from the spring or pull it up from the well by hand; only 6 o f the 222, the total number reporting, had a pump. Eighty-five per cent o f the Negro mothers reported carrying water as a regular chore. The distance averaged a little higher than those reported by the white mothers, as more than two-thirds carried water' 25 feet or more, for two-fifths the source o f water supply was 300 feet or more from the house, and about 1 in 8 had to carry water a quarter o f a mile. The proportion (49 per cent) o f mothers reporting no equipment for drawing water was higher among the Negroes. Household conveniences1 and household help.— Housekeeping in most homes was rather primitive. Some o f the houses were very barely furnished, with two or three splint-bottomed chairs,, a bed, a bench, and a rough-board table. Some mothers did most o f the cooking at an open fireplace. O f the white mothers, only 15 per cent had more than two household conveniences, and 20 per cent had none at all; o f the colored mothers, none had more than two, and 56 per cent had none at all. The abundance o f cheap colored labor had induced many white families to hire cheap hand labor rather than to purchase labor-saving devices. Sewing machines were the only modern convenience in general use, yet only 75 per cent o f the white mothers and 42 per cent of the colored mothers had them. Eight white mothers had water in the house, and 2 o f these had a bath and sink also; 14 mothers had washing machines and 13 had .refrigerators. Many said that they kept food cool by letting it down in the well, putting it in the spring, or in a tub o f cold water. Kerosene lamps were used for lighting in all the homes visited. Eighty-six families had telephones and 14 had automobiles. In only 77 homes were there screens at all. the doors and windows. While screening is primarily . a health pre caution, it also saved the mother much annoyance from chickens, pigs, dogs, and cats, which otherwise came in at will. It was not unusual for the agent’s interview with the mother to be interrupted while the pig was pushed out o f the door or the chickens “ shooed ” away from the table. Forty-three per cent o f all mothers reported that they had some help with the housework all the year round (as distinguished from help during pregnancy and confinement). Three-fourths o f these mothers received help from some other member o f the household— a mother, sister, or grown daughter, who was living with the family. 1 Conveniences tabulated were as follows: Water in house, bath, sink, washing ma chine, sewing machine, refrigerator or ice box, iceless refrigerator, fireless cooker, bread mixer,, vacuum cleaner, oil stove, furnace, gas or electric lights, engine for household use, telephone, screens for all doors and windows, and automobile. While an automobile is. not strictly a household convenience, it was so classed because it made it so much easier for the mother to,get to market, to see her neighbors, and to reach help in time of trouble. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OE MISSISSIPPI. 37 Such arrangements were seldom made on a money basis, and were usually independent of the economic status o f the family. O f the 123 white mothers who usually had help with the housework, nearly half had hired help. While the proportion o f Negro mothers who usually had some help with the housework was slightly higher than among white mothers, none o f them hired such help. For many families the only housework for which outside help was hired was laundry work. About 88 per cent o f all mothers reported that they did their own washing. The washing was usually done out o f doors near the well or spring; the water was heated in a large iron kettle over the outdoor fire and the clothes were boiled over this fire. Under the system o f tenant labor on the large plantations the planter’s wife was not responsible for boarding or housing the field hands. The tenant farmers and most o f the farm laborers lived in houses by themselves and boarded themselves. Hired men who lived with their employer’s family on a basis o f social equality were prac tically unknown, since the great bulk o f hired labor was Negro. Even the domestic servants usually lived in separate houses with their own families. WORK DURING PREGNANCY AND AFTER CONFINEMENT. The health o f the mother and baby may be impaired by excessive work during pregnancy or too soon after confinement. Ordinary housework and the lighter farm chores are a very good form of exer cise i f they are not carried to the point o f fatigue, do not involve heavy lifting or straining, and are not resumed too soon after de livery. It is important, therefore, to know what period o f rest the mother had before delivery and how soon after confinement she had to resume full responsibility of her usual work. The time which these mothers actually spent in bed has already been dis cussed (see p., 30). Mothers who could not afford to hire help and were unable to make other arrangements could not secure the desirable period o f rest before and after the baby’s birth. Pressure o f work in the busy eotton-picking season, when all hands are in the fields, often made it hard for the mother to get help. Emergencies similar to the following were not unknown: A mother confined in January said that during the latter part o f her pregnancy her husband was taken ill, and the family was obliged to move to make room for other tenants. The mother had to assume the whole burden o f moving and settling in the new home. She cut enough wood to last throughout the period of her confinement, and when labor pains began she was building a hogpen. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 38 M ATERN ITY AND CHILD CARE IN A few o f the white mothers left home for confinement, in most cases to stay with relatives, where facilities for maternity care d if fered little from those in their own homes, but where they could secure a more complete relief from responsibility for the housework during the period o f confinement. Kind of household help secured.—Many o f the mothers reported that it was difficult to get reliable persons to help with the housework while they were incapacitated. Only 28 per cent o f the white mothers and 5 per cent o f the colored reported hired help for house work. Over 35 per cent o f all mothers reported free help given by an outsider. Neighbors were usually ready to come in to help when they were needed. One mother said that she and her sister who lived near had agreed that when either was pregnant the other would do the washing for both families. While there were no mothers who reported no help at all with the housework, five o f the white and nine o f the colored mothers said that the only help they had was from a child less than 14 years old. Such help relieved the mother o f the actual work, but it did not relieve her o f the respon sibility. In 9 per cent o f the white families and 14 per cent of the Negro families, the housework was done by the husband or son; 21 per cent o f the white mothers and 41 per cent o f the Negro mothers reported help given by some other adult member o f the household. Relief from work before confinement.— O f the white mothers less than one-fifth reported any relief from housework before confine ment and less than one-tenth reported a relief o f one month or m ore; about 96 per cent did some farm chores during pregnancy and 80 per cent reported no cessation before delivery. I f the mother’s work was lightened at all during the latter part o f pregnancy it was likely to be done by relief from washing or field work. About 76 per cent o f the white mothers did the washing during pregnancy, and 29 per cent o f these stopped one month or more before the baby was born. Eighty-four white mothers, less than 30 per cent, re ported field work during pregnancy; 39 o f these had a rest o f three months or more before confinement; 4 had from a week’s to a month’s rest; and 18 worked in the field up to the day o f confinement. Cessation o f work before delivery was. even less common among the Negro mothers. Approximately 93 per cent reported that they did their usual housework up to the time labor began; 89 per cent had no relief from farm chores; 79 per cent had none from washing, and nearly 40 per cent did field work up to the time o f confinement. One o f the Negro mothers who was confined in the cotton-picking season said she worked in a field 2 miles from home during the last day of her pregnancy; she “ just did make it hom e” that night, but was unable to get supper for the family. O f the 320 Negro mothers who https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED BUBAL AEEAS OF MISSISSIPPI. 39 did field work during pregnancy, only 70 stopped one to three months before confinement, and only 79 three months or more. Approximately 75 per cent of the white and 94 per cent o f the colored mothers did housework, washing, and chores during preg nancy, and o f these 62 per cent o f the white and 79 per cent o f the colored reported no cessation o f any o f the three kinds o f work before confinement. Twenty-nine per cent o f the white and 81 per cent o f the colored mothers did field work in addition to their housework, washing, and ehores, and o f these mothers 20 per cent o f the white and 42 per cent o f the colored reported no cessation before confinement. The one mother who had no one to attend her at delivery hoed corn the whole day before confinement. She came home a little early and the baby was born. Her husband was still in the field and she could not get word to him. Approximately 75 per cent o f the white mothers reported cessa tion o f some kind o f work (housework, washing, chores, or field work) a month or more before confinement, and nearly 50 per cent a cessation o f three months or more. Among Negro mothers nearly 50 per cent reported relief from at least one kind o f work a month or more before confinement, and 27 per cent a relief o f three months or more. Resumption of work after confinement.—Among white mothers, 83 per cent reported that they resumed their usual housework less than six weeks after confinement; 19 per cent resumed it less than two weeks after. Only about 1 in 7 had a relief from housework of six weeks or more after confinement. One mother said that although she always had a hard time at confinement, she had to be up and doing all her housework within a week afterwards. Another mother who had a difficult delivery had been obliged to get up to look after the other children when the baby was 1 week old. The weather was very cold, but the family had to move when the baby was 3 weeks old because someone else was taking possession. About 75 per cent o f the white mothers began to do chores less than six weeks after con finement, and nearly one-half o f these began at less than four weeks. Nearly 40 per cent began to do their washing within the first six weeks; about 32 per cent o f the 145 white mothers confined in the first year of the period did not do their washing in the year after the baby was born. Only seven o f the white mothers worked in the field during the first six weeks after confinement. Slightly over one-fifth did field work in the year after confinement. The proportion of mothers who resumed housework and chores in the first six we'eks after confinement was approximately the same for white and Negro. Sixty-two per cent o f the colored mothers be gan to do their washing less than six weeks after confinement, and https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 M ATERN ITY AND CHILD CARE IN 14 per cent began less than four weeks after. Twenty-two per cent did field work in the first six weeks after confinement. Following the tradition expressed by one mother who said, “ I stayed out o f the field my month,” all but six did no field work during the first four weeks after confinement. The mothers who had no rest from work before confinement were also the ones who had to begin work soon after confinement. About 75 per cent o f the white and 80 per cent o f the Negro mothers re ported not only no relief from housework before confinement, but also resumption at less than six weeks after. Thirty-six per cent of the white mothers resumed their housework, washing, and chores less than six weeks after the baby was born, and 2 per cent had also re sumed field work. Fifty-seven per cent o f the Negro mothers had resumed housework, washing, and chores less than six weeks after confinement; slightly over 10 per cent resumed it at less than four weeks. In addition, field work had been resumed by 18 per cent o f the Negro mothers at less than six weeks after the baby’s birth. Many mothers gave accounts o f the ill effects o f heavy work. One said she thought her baby had been born prematurely because o f the heavy work she had been doing in the field in addition to her house work, washing, and chores. She stayed in bed 10 days after the baby was born, and in three weeks began to work in the field again. She endured the strain for a week, then had to give up, and was inca pacitated for a month. Effect of farming season on mothers’ work.—In agricultural communities the work in the house is intimately correlated with the work in the fields, and pressure o f work in the busy farming season is likely to mean additional work for the mother. Even if she does not go into the fields to work herself, her husband and older children have less time in which to help with the chores and housework. One mother who was confined in the winter said that although she was up in six days, she stayed in the warmest room most of the time for the next two weeks, while her husband did the housework. Another said that although she was feeling well, her husband did the work for three weeks after the baby was bom , because he had no work to do in the fields at the- time. 1 The climate was such that for only about two and one-half months in the year was it impossible to work in the fields. The busiest sea sons were in May and June (hoeing time for cotton and corn), and in October and November (picking time in the cotton fields). Each season was likely to spread over two weeks before and after, and it varied with the weather and the size of the crop. Accordingly, the slack season may be considered as extending from the middle o f https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED BUBAL ABEAS OF MISSISSIPPI. 41 June to the middle o f September, and from the middle o f December to the middle o f April. In, the case o f white families the extent to which the mother might be relieved o f overstrain during pregnancy and the weeks following confinement usually depended on the financial ability of the family to hire help, though in some instances economic conditions made no difference one way or the other; because the mother had relatives who came to help h er; or because she was wholly incapacitated and had to be relieved whether she could afford it or n ot; or because at the time no help could be secured. Very few Negro families could afford to pay money to relieve the mother o f her usual duties during pregnancy and after confinement. CARE OF CHILDREN. The connection is more or less obvious between the various subjects o f the study taken up thus far—maternity care, work of the mother, housing and sanitation, and economic conditions— and the question of the welfare o f the child. The lack o f specialists and hospital facili ties was as serious for the babies as for the mothers, and poorly built, insanitary houses made living conditions dangerous for the one as well as for the other. In this section of the report infant deaths and those elements o f child care not already touched upon— feeding customs, care o f sick children, home remedies used for children, etc.—will be considered. BIRTH REGISTRATION. Complete birth registration is a prerequisite to any adequate study o f infant mortality and child welfare. Since 1912, when the State passed a law establishing a bureau of vital statistics under the State board o f health, and providing for the registration o f births and deaths, the board o f health had been working toward complete regis tration, but at the time o f this survey no part o f the State had been admitted to the birth-registration area, and only the five largest cities to the death registration area. Only 50 per cent o f the births in cluded in this study were registered. One of the'greatest obstacles to good birth registration in the county was the difficulty o f getting the midwives to register births. Many o f the colored midwives were illiterate, and therefore had to get some one else to fill out the certifi cate or report by word o f mouth when they happened to go to town. Often the names were written on old crumpled slips of paper and were almost illegible. While the midwives were responsible for the greater part o f the .unregistered births, only 76 per cent o f the births attended by physicians were registered. Only 71 per cent o f the infant deaths were registered. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 42 M ATERN ITY AND CHILD CARE IN INSTRUCTION IN INFANT CARE. A general lack of knowledge of child care prevailed among the mothers visited, as very few of them had received any instruction in this matter beyond what they learned from their mothers or from their own experience. Only 20 had received some instruction from a physician and 2 had been advised by a trained nurse. Fifty-eight had learned something o f infant care through reading, but the high percentage o f illiteracy and low standards o f education prevailing in the county made instruction through reading practically unattain able for a large proportion o f mothers in poor white as well as in Negro families. The literature read, however, was not- really in structive in all cases, for while 2 had read books by Holt, 1 a bulletin from the Department o f Agriculture, and 25 current magazines and papers, the rest'had read only advertising pamphlets or almanacs or “ doctor books ” o f one kind or another. Many mothers were very glad to receive the Children’s Bureau pamphlet on Infant Care. * The methods o f caring for children were in accordance with the customs handed down by other generations. The midwife’s advice was often sought, especially in regard to the care o f the baby during the first few days of life, and the midwives were credited with being responsible for encouraging dangerous methods of feeding and the use of filthy and dangerous home remedies. FEEDING CUSTOMS. The almost universal custom o f breast feeding among the country mothers in the county studied probably counteracted in many in stances methods o f feeding unwise in other respects. The tendency o f the mothers was to nurse their babies not only through the first year, but also through most o f the second year or even longer. A rti ficial feeding was haphazard and unscientific. In many cases it in cluded the whole range o f family diet— meat, corn bread, pie, etc. Some mothers did not use cow’s milk because the “ bitter weed ” that the cows ate made the milk bitter in taste, although not, so far as could be learned, unwholesome. Breast feeding.— The often-repeated criticism of the feeding cus toms o f rural mothers that they feed their babies from the table at too early an age and delay weaning too long held true in the case o f the mothers included in this study. Only 14 per cent o f all infants, both white and colored, for whom information was secured, were weaned before the middle o f the twelfth month; two-thirds were nursed through the greater part o f the fifteenth month; nearly onehalf through the eighteenth month; and one-fourth through the greater part o f the twenty-first month. Nine infants were nursed through the greater part of the twenty-fourth month or longer. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 43 One instance was found at one o f the children’s health conferenceso f a child six years old who was still nursing. The Negro mothers showed a tendency to wean their babies a little earlier than the white mothers; by the middle of the eighteenth month 63 per cent o f the Negro babies had been weaned as com pared with only 41 per cent of the white babies. O f the babies re ceiving exclusive breast feeding, the percentage was higher in each month o f age for white than for colored babies; for babies receiving some breast feeding, at the sixth month the percentage was slightly higher for Negro than for white; and at 9 months the percentage (92) was about the same for both races. Solid food and family diet.— Artificial feeding may be necessary in some cases at an early age, and, while not so good for the baby as breast feeding, does not necessarily obviate the possibility of normal development. Experts generally agree that fresh, clean, modified cow’s milk is the best substitute for mother’s milk, and that no solid food should be given during the first six months at least. Only one-fourth o f the babies studied were receiving a strictly liquid diet at 2 months. The solid food included bread or crackers soaked in milk, gravy, or cereals, and did not necessarily include the kind o f food eaten by the older members o f the family. H ow ever, many mothers reported that the baby at an early age was given “ tastes” o f everything that the mother ate. One mother said with pride that her baby had eaten “ everything” since she was 11 days old and had had all tjtie meat she wanted since 2 months old. Another said there was nothing too hot with pepper or too sour for her 14-months-old baby to eat. Eight per cent o f the mothers reported that the baby had been given family diet when less than 1 month old, 15 per cent at 2 months, and over half at 7 months. Only about 6 per cent were reported as 12 months or more o f age before receiving family diet. The tendency to give the baby solid food or family diet was more pronounced among colored mothers than among white. At the fourth month 60 per cent o f the colored babies were receiving solid food as compared with slightly under 35 per cent o f the white babies. Under the eighth month the percentage o f colored babies receiving family diet was higher than that o f white babies receiving solid food. A t the end of the twelfth month nearly 80 per cent o f the colored babies were receiving family diet as compared with about 60 per cent o f the white babies. CHILDREN’S ILLNESSES. Medical care.— The accounts given by the mothers of their chil dren’s illnesses indicated the difficulties in caring for sick children in these rural districts. Children’s specialists and hospitals were https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 44 M ATERN ITY AND CHILD CARE IN too far away and too expensive to be thought of by any but the most prosperous parents, and many o f the poorer families living in remote parts o f the county hesitated to call a doctor unless the child seemed very seriously ill. As one mother said: “ A farmer only gets money twice a year, and if the children get sick between seasons they have to get along.” One mother said that her baby began to have indigestion at two months; he vomited frequently and had spasms. These symptoms continued for over three months, but the doctor was called only once. Another mother said that her baby had been ill for three weeks with some trouble in the head; she bathed the baby’s head with camphor and put sweet oil in her ears but did not call a physician. Only the two county seats had more than one physician, and families out o f reach o f one or the other of these towns often had to send 15 or 20 miles for the nearest physician available. Although under ordinary circumstances a doctor could be secured in two or three hours at most, there were, o f course, times when this was not possible, and sometimes serious complications developed »so rapidly in babies and young children that even a short delay proved serious or even fatal. The baby o f a family living 4 miles from the doctor in a house back in the woods, almost inaccessible from the main road, became sick when 6 days old. The father consulted the physician by telephone, and medicine was sent, but the baby died the following day. Nursing care.— Trained nurses were no more available for sick children than they were for mothers at confinement, and, as in other rural areas, home care was the rule when children were ill. Emer gencies frequently arose when there was really acute need for trained, or even practical, nurses. One mother said that when the baby, was born both the father and the other children had measles. It was an unusually severe winter. No nurse could be found nor could they get domestic help. A neighbor came in once a day for a little while, but she was too busy with her own family cares to do much. The oldest child died about a week after the baby’s birth. In another case, all the members o f a family were ill at the time o f the mother’s con finement. The father, though convalescent, was not able to do much, and as a last resort his brother came in and did the housework. In another family the mother and four children were ill with malaria. The father had to do the nursing and housework himself while he hired cotton pickers to take his place in the fields, field laborers being much easier to find than nurses and housekeepers. Situations similar to these described were likely to be brought about whenever the mother was incapacitated. Many mothers had no one who could take their place as nurse, because relatives and https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 45 neighbors were entirely occupied with their own family affairs, and furthermore many o f the women, although willing to do their utmost, lacked skill and experience in the proper care o f children seriously ill. Deformities.— Several children needed special attention on ac count o f some deformity. One white baby had deformed feet. The father had given up his farm and secured work with the railroad in order that he might earn money and perhaps secure a railroad pass to take the child to a specialist and have the deformity corrected. A mother was most anxious to know what ought to be done for her year-old baby who had a deformed hand and wrist. She brought the child to one o f the children’s health conferences, and the Gov ernment physician said that some manipulation and massage would do a great deal o f good, but unfortunately there was no one in the county who could do it. One baby had club feet and his father, a Negro farm hand earning $19.50 a month, had never taken him to a physician. Another Negro boy about 6 years old had a stiff knee and back so that' he could not stand upright and could scarcely walk. His mother said that his condition was caused by paralysis from which he suffered while teething. The family owned a small farm on the river bottom, but had never considered it possible to take the boy to Memphis or Jackson. In several other cases similar to these the need for special medical attention seemed imperative if the children were to have a fair chance in life. A public health nurse could do much toward teaching parents that it is possible to have deformities corrected and toward making the necessary arrangements with specialists and hospitals. Accidents.— Children everywhere are liable to injury from acci dents o f one kind or another. But in Mississippi accidents occur ring'while the parents are absent in the fields are far too common. The secretary o f the board of health, in commenting on the large number o f deaths from burning, said: “ This carelessness which resulted in the death and suffering o f so many- children for the last two years * * * should be given thorough study' and means provided, if possible, to reduce this unnecessary mortalityl” 2 As the open fireplace was used for cooking in many o f the cabins, the danger from fire was serious at all times o f the year. It was not uncommon to find a little baby left alone in its; crib while its mother was off in the fields at work. One colored mother told o f the death o f her oldest son from burns. She had no one to leave him with while she went out in the field to plant potatoes. Presently she heard him scream, and rushed back to find his clothing all afire. In one family visited, the baby had no toes on the right foot. The mother ex2 Report of the Board of Health of Mississippi, 19151-1917, p. 107. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Jackson, Miss., 1918. 46 M ATERNITY AND CHILD CARE IN plained that she had left the baby on the floor while she went o u t, for a little while, and that when she came back she found that the baby, then 6 months old, had crawled to the fireplace and one little foot was in the coals. The custom o f leaving infants in the care o f older children too young to accompany their mothers to the field is bound to lead to serious results. During the hoeing season the Children’s Bureau agents often found no one at home but a little 6 or 7 year old child in charge-of one or two'younger children. Sometimes he could point in the'direction in which his mother had gone, sometimes he did not seem to know where she was. One mother left the baby with the older children while she went to work. The baby’s dress caught fire and he was badly burned. Accidents o f other kinds occurred while older brothers or sisters were tending the baby. One baby had been sick since the older children in their play let him fall out o f bed while the mother was working in the field. Another mother said her baby had been very sick when 12 months old. She thought “ the children might a’ dropped the baby” while she was in the field. Such accidents as these described were more common among Negro babies because the Negro mothers did more field work than the white mothers. Some mothers tried to solve the problem by taking the babies with them to the field, but with no shelter from the hot sun this arrangement did not seem very satisfactory. Illnesses*—The accounts of children’s diseases given by the mothers did not differ very much from those given by mothers in other parts o f the country. Colds, indigestion, and colic were mentioned fre quently. In the winter previous to the survey there had been mild epidemics o f measles and whooping Cough with no effective quaran tine regulations. The children were, o f course, liable to the diseases peculiar to the South—malaria, hookworm, and pellagra. * One physician said he had noticed a decided tendency among mothers to attribute almost any illness which children had to “ worm s” and to persist in the belief contrary to the doctor’s diagnosis. Several mothers said that their children had had worms and that they had used various home remedies, turpentine, soot tea, castor oil, etc. Home remedies for children.—The great extent to which the mothers in the area “ doctored ” their children presented one o f the most serious phases of child care. Home remedies have a legitimate place in every household, but stories told by many o f the mothers indicated a widespread tendency toward overdosing and unwise se lection o f drugs for the home medicine chest. Patent medicines were in common use, particularly among white mothers. ^The colored mothers made frequent use o f teas o f one kind or another. More or less superstition was evident in the remedies recommended by colored mothers. The midwife instead of the doctor was frequently https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. ; 47 „summoned in case of illness, and she was often responsible for the extravagant use o f home remedies. INFANT DEATHS .3 ' B i any locality where the birth and death registration is as incom-N plete as in the rural areas surveyed by the Children’s Bureau, it is impossible to discover all births during a given period even by a house-to-house canvass. The number o f omissions is probably pro portionately greater for stillborn infants and babies who died early in the period included in the canvass than for the others. The re turns are especially likely to be incomplete in districts similar to the county studied in Mississippi where many families live on farms re mote from the traveled roads, and a large part o f the population is shifting and illiterate. As a consequence, infant mortality rates for the area studied, while as accurate as any that could be secured, are somewhat lower than they would be if returns for deaths had been as complete as for births. On the other hand, figures based not on a canvass but on birth and death registration alone are likely to exag gerate death rates since death registration is usually more complete than birth registration.O f 155 white children born alive to the mothers interviewed, 12 died in the first year o f life. This number includes only children bom between A pril 1, 1916, and March 81, 1917, the first, year o f the period covered by the study, since most of the children born later than that were less than 1 year old at the time the information was secured. The infant mortality rate for these white children was 77.4,4 a rate lower than was discovered in any o f the cities surveyed, but high as compared with rates for other ‘rural districfs studied. The rate found in Kansas was 40 to 1,000 live births; 5 the rate among white infants in the lowland county o f North Carolina was 48.1;6 in the mountain county o f North Carolina the rate was 80.4;6 the rate in Wisconsin was 54.7 The rate in Montana (although based upon, an incomplete record o f deaths) was 71 per 1,000.8 3 Detailed information, in regard to maternal and infant care was secured only for the last confinement of each mother; in considering infant deaths, however, all the births occurring in the two years covered by the survey were included. Thus while detailed information was secured for only 664 live births, 699 live births occurred to the mothers ' visited during the two years covered by the survey. Six deaths occurred among these 35 nonschedule births. i As in previous studies made by the Children’s Bureau the rate is computed on the basis of the number of deaths at less than 1 year of age among infants born in the given period. BChildren’s Bureau Publication. No. 26, Maternity and Infant Care in a Rural County in Kansas, p. 40. 6 Children’s Bureau Publication No. 33, Rural Children in Selected Counties of North . Carolina, p. 36. 7 Children’s Bureau Publication No. 46, Maternity and Infant Care in Two Rural Coun ties in Wisconsin, p. 69. 8 Children’s Bureau Publication No. 34, Maternity Care and the Welfare of Young Chil dren in a Homesteading County in Montana, p. 70. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 48 M ATERNITY AND CHILD CARE IN The accuracy o f the infant mortality rate for Negro infants is open . to more question than the rate for white, because o f the greater ob stacles to a complete canvass among Negro families. Therefore, for purposes o f comparison, infant mortality rates are more sound which are based upon the whole maternity histories o f the white and Negro mothers while resident in the area. Even these rates are likely to-be an upderstatement of infant mortality, because mothers who had had many confinements often became confused as to the number and may have forgotten at the time to tell o f the babies who died in early infancy. Since this was particularly true o f Negro mothers, the fig ures show also an understatement o f the difference between rates for white and Negro infants. The rate among white infants was 61.2 per 1,000 live births, while the rate for Negro infants was 107.3— a differ ence o f 46.1 in favor of infants born to white mothers. Medical care.— One o f the most' significant aspects o f infant mortality was the small proportion o f deaths attended by physicians. Information was secured as to the attendant at death for 43 o f the babies who died at less than 1 year of age; only 15 were attended at death by a physician. Only 5 o f the 9 white babies who died under 2 weeks o f age were attended at death by -a physician, and only 4 o f the 6 who died over 2 weeks o f age were attended by a physician. O f the 28 Negro babies who died at less than 1 year o f age, only 6 were attended by a physician. The proportion o f deaths not attended by physicians was too1large to be explained entirely by bad roads, poor telephone service, the distance o f the family home from the physician, or by the fact that in some instances Jhe baby died so suddenly that there was no time to call a physician! Parents often failed to realize that their children were sick, and did not appreciate the necessity o f securing the best medical care possible for them. One baby was sick for two days before death; her mother said a she seemed to have griping in the stomach and the stretches.” The mother cut red onions and bound them on the child’s hands and feet, but did not call a physician. Another Negro mother said she thought her baby died because she “ couldn’t keep the hives out on him.” She said the baby was born “ puny ” because she had hoed right up to the time o f confinement in very hot weather. This mother had had no prenatal care, a midwife had attended her at confinement, and no physician had been called for the baby. A white mother whose husband had not been able to get a physician for her confinement said that her baby had not been normal from birth, and he died when 6 days old. Sha seemed satisfied with the midwife’s explanation that “ the hives went in on it.” This family https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. 49 -.lived only 3 miles from a town with six physicians in it. One colored mother said that her baby had a hemorrhage from the navel shortly after birth, and that by the time they had brought the.midwife ^)ack to tie the cord again, the baby had bled to death. Two colored babies died o f whooping cough without the attention o f a physician. Causes of death.— Discussion of the causes of death is hampered at the outset by lack o f complete registration. F or 14 o f the 49 in fant deaths occurring in the period no death certificate was filed, and in 20 instances, although a death certificate was filed, no cause o f death was entered on it. For only 15 cases could a physician’s certificate showing cause o f death be secured. Eight o f these deaths were due to natal or prenatal causes (four o f the eight to prematur ity), and five to gastro-intestinal diseases. Among white infants who died under 2 weeks o f age the death rate per 1,000 live births was 40. The stillbirth rate, based on all births in the area studied, to mothers interviewed was 2 per cent for white infants and 4 per cent for Negro. About one-tenth o f all pregnancies o f both white and colored mothers resulted in miscar riage, a stillbirth, or a live-bom infant that survived less than, 2 weeks. Obstetricians agree that most o f the deaths under 2 weeks o f age are due to prenatal and natal causes and can be prevented in large measure by good prenatal care and skilled care at confinement. In rural communities, where few mothers receive any prenatal care at all and where skilled help is not available, it is to be expected that the number o f deaths in early infancy will be comparatively large. Eeports on prenatal care were secured from 40 mothers whose babies were stillborn or died under 2 weeks o f age. Only eight had any care, and only one had care that could be classified as fa ir ; five o f those who had care sought medical advice because they were ill during pregnancy. Information was secured also in regard to the kind o f attendant present at 21 o f the confinements resulting in a live-born infant who survived less than 2 weeks. Six o f the 9 confinements of white mothers were attended by a physician and 3 by a widwife or other woman; 2 o f the 12 confinements o f Negro mothers were at tended by a physician and 10 by a midwife or other woman. A ll 10 stillbirths to white mothers and only 1 o f the 11 stillbirths to Negro mothers were attended by a physician. Improper feeding also contributed to infant mortality in the county. One o f the registered deaths occurred when the baby was •ijL about 2^ months old, about 2 weeks after the mother’s death. Cow’s * milk had been used to supplement breast milk and the baby had been given solid food some time before his death. Another baby at 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 50 M ATERNITY AND CHILD CARE IN months o f age had tastes o f everything the family ate. The motherv said that the baby had been bitten by mosquitoes a few days before its death and she attributed death to malaria rather than to improper feeding. Another baby weaned at 3 months o f age died about four weeks later. The mother said-she had tried cow’s milk and then malted milk. She thought that the baby had measles, but the cause given on the death certificate was ileocolitis. Another mother said: “ The baby was fine and healthy, but he had one o f the spells I had at confinement (convulsions) and died o f that and whooping cough.” CHILDREN’S HEALTH CONFERENCES. In order to promote interest in child welfare, a series o f children’s health conferences were held in two counties in the State—in the county in which the intensive survey was made and in another located in the south central part o f Mississippi which contains a city o f more than 10,000 inhabitants known as one of the wealthiest cities in the South. This city was very progressive; it had well-paved streets, substantial public buildings, luxurious homes, good schools, and a good city hospital o f 40 beds. Outside this city, however, the county was no more progressive than neighboring counties. PREVIOUS PUBLIC HEALTH WORK. An intensive sanitary survey of the southern county by the International Health Board (formerly the Rockefeller Sanitary Com mission), in cooperation with the State board o f health, had been completed in January, 1918, shortly before the children’s health con ferences began. As part o f the work of the survey many persons were examined and treated for hookworm and many inoculated against typhoid. The survey also included a campaign for sanitary privies both in the city and in the rural districts of the county, and special attention was given to an educational campaign against pellagra.9 The extensive public health work done through the sani tary survey made it possible to arrange for a series o f children’s health conferences with a minimum o f effort and with some assur ance of response from the parents. During the previous year a birth registration test had been made in the city which disclosed the fact that about one-third o f the births in the city were unregistered. The births o f 22 per cent of the children brought to the children’s health conferences were definitely reported as unregistered. 9 Report of the Board of Health of Mississippi, 1915-rl917, pp. 47 48. 1918. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Jackson, Miss., ■THE C O N F E R E N C E A T A C O U N T R Y S C H O O L H O U S E . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SELECTED RURAL AREAS OF MISSISSIPPI. _ 51 ATTENDANCE AND PLACES OF MEETING. The aggregate attendance at the 35 meetings held in the two counties was about 3,000. In both counties meetings were held in towns and in the country. Meetings were held in the courthouses o f the county seats, in the country schoolhouses, in churches, one in an open-air pavilion in the picnicking center, and in one o f the smaller towns the proprietor o f a store suspended business for the afternoon and expressed pleasure in turning over his store “ to the use o f Uncle Sam.” The babies were examined on the counter and stereopticon slides were shown in a dark corner at the back o f the store. At some of the night meetings families straggled in late; having worked all day in the fields, they had then dressed the chil dren, hitched up the horses, and driven to the conference. EXAMINATION OF CHILDREN. A t these meetings children under 6 years o f age were examined by a Government physician, and the results o f the examination, together with special recommendations in regard to the care o f the child, were written out and given to the person bringing the child -for examination. In all, 544 children were examined by the physi cian, 375 white and 169 colored. I f the examination revealed defects that needed special medical attention, the parents were told what was wrong and were advised to consult the family doctor. Measures were also recommended to promote better physical development. The ad vice given to many mothers concerned feeding alone. The physician explained to these mothers that they had been giving their children too much food, feeding them too often, or allowing them too much starchy food ; and regularity o f feeding and a well-balapced diet were recommended. A t the end o f one o f the conferences one mother was heard to say emphatically that she would never have another case o f “ summer complaint ” among her children. EXHIBITS. An exhibit was shown at some o f the conferences o f miniature models illustrating the proper clothing for a baby, baby’s bed and mother’s bed, and the equipment needed for bathing a baby and for preparing its food, and charts were shown illustrating various phases' o f child welfare. A small model of an iceless refrigerator and a homemade fireless cooker excited much interest. For conferences held at night, when neither models nor charts could be shown to advantage stereopticon slides were. used. The men who attended the meetings often showed gTeat interest in the exhibits, and said they were going to make play pens and separate beds for their babies and fireless cookers and iceless refrigerators for their wives. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 52 M ATERN ITY AND CHILD CARE. RESULTS OF THE CONFERENCES. The value o f the conferences was primarily educational. The instruction received by individual parents was probably of no less importance than the impetus given to systematic public health work for mothers and children. The advisability o f securing a full-time public health nurse for the county was widely discussed, and at many o f the meetings the local committee circulated a petition to the county supervisors asking that such a nurse be employed. This movement was indorsed not only by parents but also by physicians and others prominent in the county. Several o f the leaders among the colored people desired to secure a nurse to work among the colored people alone. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUMMARY. Thé intensive survey o f maternity and child care was made in a farming section typical of northern Mississippi. Over one-half o f the population was Negro, and three-fourths of the farmers visited x were tenants. -, Six hundred and seventy-five families were visited, and most o f these were living in poorly constructed houses far too small to accommodate the whole family with any degree o f comfort. Very few were plastered or ceiled on the interior, and about 40 per cent o f the families were living two or more persons per room. Study o f sanitary conditions disclosed the fact that only about one-fourth o f the families had a privy o f any kind, and of these over fourfifths had the insanitary open-back type. Only 11 per cent of the houses were adequately screened against flies and mosquitoes. Although it was possible to obtain good water by drilling deep wells, many families were using water from dug wells and from springs which were not well protected against surface pollution. Investigation of the status o f maternity care showed that the low standards were due in large measure to ignorance o f the need of it, to the scarcity o f physicians and nurses, and to poverty. There were 14 physicians in active practice in the area studied; there was no trained nurse working regularly in the county. The nearest hos pital was 100 miles away. There were about 100 midwives practic ing in the county, but a large majority o f them were untrained, ignorant, and careless, and their methods were primitive and insani tary. While 79 per cent of the white women were attended at con finement by physicians, nearly 88 per cent o f the colored women were attended by midwives. Only 116 o f the 675 mothers studied received any prenatal care; 9 o f these received care that could be classed as fair, and only one received really adequate care. Less than one-tenth o f the mothers attended by a physician received three or more calls from the doctor during the lying-in period ; only 7 mothers had trained nurses ; and less than one-fourth had care by a practical nurse or midwife. Most o f the mothers had great difficulty in securing anyone to do the nurs ing or help with the housework, and the majority had to depend on relatives and neighbors. The lack o f conveniences made housework* a rather strenuous task, and almost all o f the mothers were used to 53 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 54 M ATERN ITY AND CHILD CARE. doing farm chores and field work as well as housework. As it was so very difficult to hire help, many o f the mothers had neither adequate relief from work before confinement nor a sufficient period o f rest afterwards. Children as well as mothers suffered from the lack o f skilled medi cal and nursing care. F requently the parents failed to recognize that children were seriously ill, and they were content to use home remedies and advice from neighbors rather than to secure the best medical attention possible. Analysis o f feeding customs showed that while the custom o f breast feeding, was almost universal the mothers tended to nurse their babies too long and give them solid food or the regular family diet too soon. Although about 85 per cent were wholly or partially breast fed during the first year, at the age o f 6 months 65 per cent were receiving solid food and 47 per cent were given what the rest of the family ate. One-fifth o f the children were still partially breast fed at 2 years o f age. Incomplete birth and death registration handicapped the authori ties in studying the problem o f infant mortality. Standards o f living were lower and the inadequacy of maternity and child care more extreme among the Negroes than among the white families. Only 8 per cent o f the Negroes were farm owners, and about 57 per cent were half-share tenants—the lowest in the scale economically. Their homes were smaller and more crowded than those o f the white families and sanitation was not so good. The per centage o f illiteracy was high (26 per cent) among Negro mothers. Few Negro mothers had received any prenatal care or been attended by a physician at confinement. A larger proportion of Negro than o f white mothers did field work, and they had less relief from work before confinement and a shorter period of rest afterwards^ Children’s health conferences were held in two counties for the purpose o f stimulating interest in public health activities. Children were examined by a Government physician, and exhibits were shown. The meetings had a large attendance and much interest was aroused. In view o f the conditions found to exist in the county it was evi dent that the most necessary steps in securing better care for the mothers and children were : The employment of a public health nurse •for the county, and a county or district health officer on full time ; the establishment o f a county hospital, with free care available for those unable to pay; provision for the training and supervision o f midwives; and the enforcement o f the birth and death registration laws. In addition, it seemed imperative that steps should be taken .to deal effectively with the problem o f illiteracy which existed to a serious degree among the poor white and Negro families. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CONCLUSIONS. The conditions revealed by this inquiry are by no means peculiar to the county studied ; they are more or less typical o f those existing in many rural communities. They call for a general constructive program for the conservation o f the lives and health o f mothers and babies, and of older children as well. Among the essential hygiene features o f such a program are : 1. A county public health nurse (preferably one for white and one for colored), who, by doing educational work thrpugh the schools, clubs, and other organizations and by practical demonstrations o f home nursing and preparation o f food for babies, could accomplish much toward improving maternity and child care.. 2. ' A well-trained public health official, devoting his entire atten tion to health problems in the county or the district o f which it might form a part. 3. A county hospital conveniently located for all residents o f the county. 4. The birth and death registration laws strictly enforced. 5. The law to prevent blindness in the new-born strictly enforced. 6. Midwifery practice controlled. 55 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INDEX Accidents : Page. liability of children to_________ 4 5-46 unavailability of medical care in time of^_._____ i ___ __ 43—46 Acreage and tenure. See Farming conditions. Artificial feeding. See Feeding, arti ficial. Attendant, confinement. See Care, confinement. Birth registration: enforcement of__________ 41, 50, 54, 55 incomplete_________________ 8, 47, 50, 54 reasons for____________ \___ 41 law providing for (19 1 2)__ 41 Blindness in newborn, prevention of (law passed Jan., 191 6 )---------------------------- 1 7 ,2 3 ,5 5 Breast feeding. See Feeding, breast. Bureau of vital statistics, law estab lishing (1 9 1 2 )_____ 41 Campaigns, health. See Health cam paigns. Care, confinement : a tte n d a n tfactors entering into selec tion of— custom___ _____________ 27 distance.________ L_______21, 28 economic condition of fam ily__________ 2 7-28, 32 kind of__________________ 2 6 -28 , 49 per cent distribution of mothers of specified race according to________ i____ 27 costs and free service___________31—33 Care, « m b é m é Mi p o s tn a ta l medical attention, inade quate --------------------------21, 28-29 nursing care,scarcity of_____ 2 9 -30 , 44 resumption of work after con finement___ 30, 37, 39-40, 41, 54 Care, prenatal : analysis of care given_____ .____ 25, 53 inadequacy of________ ._________ _ 24, 49 factors responsible for____ 21, 24 inadequacy of relief from work- 40, 54 information through reading___ 26 use of home remedies__________ 25 Childbearing. See Mortality, ma ternal, causes of. See also Work of mothers in re lation to childbearing. Children in study, number of_______ _ 8 Children’s health conferences." See Health conferences, chil dren’s. Colored people. See Negroes. Paga Communication, means o f ___________ 10 Compulsory school-attendance law, lack of_____________________ 1 5-16 Confinement : care during. See Care, confine ment. costs of________ ____ .____________ 31-33 length of_ I ----------------------------- Death registration, incompleteness o f ------------------------41, 47, 49, 54 Death registration area, cities ad mitted to__________ ;______ 41 Deaths. See Mortality. ' Deformities. See Illnesses, deformi ties, and accidents. District health officer. See Public health officer (county). Economic status of family, relation of, to cost of confine ment______________________ 32-33 Economic and social background of families visited___________ 9—20 Education : children— lack of compulsory schoolattendance law___________ 15 length of school terms-------15-16 mothers—instruction by home demon stration and agriculture 16 agents---------- ^___________ need of instruction— in infant care_________ 42 in maternity care__21, 24, 53 See also Illiteracy. Examination of children, medical. See Medical examination e f children. 57 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 Conveniencies on the farm, lack of__36, 53 Costs of confinement : by economic status of family.— 32-33 itemized___________________________ 31-33 total, and free service_________ 31 Counties, selection of. See Scope and method of the survey. County, population of. See Popu lation. County public health nurse. See Public health nurse (county). County public health 'officer. See Public health officer (county). Cows, milch, percentage of families 12 having________ ______ ,____. Crops and live stock. See Farming conditions. Cultivation of land, extent of____ __ 11 INDEX. 58 P age. Exhibits in child welfare: nature of------------------------------ -— 7—8, 51 results of------------ -------,— ;---------- 51—52 Families, number interviewed---------8, 53 Farmers: owners— economic status------------------ 1 3,1 4 percentage o f ---------------------13 Negro------------ - -------- -— 15» 54 15 w hite-- ------------------------size of farms-------- r — - — — H tenants— economic status-------------- 12—13, 54 illiteracy ----------------------------15 length of tenancy— -------------- 14—15 percentage of------------------------ 13, 53 Negro__________________ 13 w hite__________________ 13 size of farms worked---------14 Farming conditions: climate------------------------------------- — H crops and live stock-------------------12 _ 14 removals from farm to farm----soils______________ —-----— ----------11 tenure and acreage------------------------ 12-14 Feeding: artificial— liquid food— percentage of children receiving, by age---43 solid food— kinds of----------------------- - 42—43 percentage of children receiving, by age---- 43, 54 breast, prevalence of- 42—43, 54 improper, relation of, to infant mortality------------------------49 mixed, extent of--------------------- -— 43, 54 Free medical service in confinement cases--------------------------------31 Gastro-intestinal diseases. See Mor tality, infant, causes of. Government physician. See Physi cian, Government. Health campaigns: agencies responsible f o r -----------50 •nature o f ----------------------------------- 17, 50 results o f ------------------------- --------- 17 >50 Health conferences, children’s : activities— examination of children— by whom examined- 7, 51, 54 number examined------51 exhibits_________ s----------------51, 54 attendance---------------------------*-----51, 54 location----------------------------------- — '7, 50. places of meeting-----------------------51 purpose------------------------------- -------- 50, 54 results---------------------- •— :------- — 51-52 Health officer, county. See Public health officer (county). Health program suggested as result of study------------------------- — 54, 55 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Page. Health work, public. See Public health work. Hemorrhage. See Mortality, ma ternal, causes of. Home demostration and agriculture agents. See Education. Home remedies, use of— during .pregnancy----------— ---------25—26 for children--------------------------------- 4 6-47 Hookworm, campaign against---------- 17,50 Hospitals : county, need o f ---------------- ----- — 54, 55 inaccessibility o f ------------------ 21, 43, 53 Housing and sanitation : _ congestion---------------18—19 average number of persons per room__ -----------------------19, 53 average number of persons per sleeping room ---------19 privies— sanitary, campaign for------50 type of_____ _—------- ■;---------- 20, 53 jt screening--------------- ------------- — 19, 53 types of houses---------------------------------18,53 water supply------------------------- 9 .1 9 , 53 See Mortality, infant, causes of. Illegitimacy, extent of—------------------23 Illiteracy, extent o f -------------------- 15, 42, 54 Illiteracy of midwives. See Mid wives. Illnesses, deformities, and accidents of children. home remedies used------------ — - 46 medical care--------------------------------- 43—44 nursing care------------------ ------ -— 44-45 Industry, principal-----------------11-12 Information obtained by mothers, sources o f : in infant care---------------- ------------16, 42 26 in maternity care------------International Health Board (in cooperation with the State board of health) : campaign by — l-------------50 survey by—r.— !s?ii------ 17, 50 Ileocolitis. Land, cultivation of---------------------------H Land tenure,, plantation system of— 12-13 Literature, instruction of mothers through: in infant care-----------------------------42 in maternity care---------------------26 Live stock. See Farming conditions. Lying-in period, care during. See Care, confinement. Mail service. See Communication, means of. M alaria: campaign against------ .------—-----pernicious. See M o r t a l i t y , maternal, causes, of. Marriage, average age at----------------— Maternal mortality. See Mortality, maternal. 17 23 INDEX, 59 N egroes— Continued. pregnancies, frequency of____________ 23 tenants— average size of farms 14 worked— _________________ economic position_________ 1 3 , 5 4 length of tenancy__ J;_____ 14-15 Nephritis. See Mortality, maternal, eauses of. Nursing care, unavailability of____ 29-30, 44, 53 Mortality, maternal: causes of___ ___________________ 3 3 -3 4 relation of midwife attendance to------------------------------------- 2 1 - 2 2 Mothers in study, number of_______ 8 Mothers, unmarried,number of______ 23 Negroes: babies - in study— feeding customs________:___ 4 2 -4 3 number-.____________________ 8 farm owners— 14 average size of farms______ number___ ____________ 15, 5 4 housing and sanitary conditions o f ---------------- --------- - 18-20, 54 illiteracy, extent of_____________ 15, 5 4 marriage, average age at_______ 23 mothers as economic heads of families, number________ 15 mothers interviewed, percent age___________ 9 percentage in county____________ 9 , 5 3 percentage in State_______________ https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Pellagra, campaign against_________ 17, 50 See also Mortality, maternal, causes of. Physician, Government, examination of children by_________ 7 , 51, 5 4 Physicians : infant deaths attended by_____ 48 mothers attended b y -_______ 26-28, 4 9 number of, in county________ 21, 44, 53 unavailability o f _________________ 4 3 - 4 4 Plantation system of land tenure___ 12-13 Population (census of 1910) : county (Negro, ^ rural, urban, w h ite )___________________ 9 State (Negro, white)____________ 9 Postnatal care. See Care, postnatal. Pregnancy : care during. See Care, prenatal. use of home remedies during___ 2 5-26 work during— ---------- --------- 3 7 -3 9 ,4 1 See also Mortality, maternal, causes of ; see also Ma ternity histories. Prematurity. See Mortality, infant, causes of. Prenatal care. See Care, prenatal. Privies. See Housing and sanitation. Program, health, suggestions for___ 54, 55 Public health nurse (county), need of — — ---------- 23, 29, 52, 54, 55 See also Nursing care. Public health officer (county) : appointment of_____ _£ _ _______ i 16 duties o f ________________ „ 16 need of full-time____________ 17, 5 4 , 5 5 salaries of______________ __;_____ 17 Public Health Service, United States, cooperation of, in study of pellagra______________ 17 Public health work : activities— campaigns against diseases- 17, 50 investigation of sanitary conditions_____ , _____ 16, 20, 50 administration— health officer, appointment 16 o f -----— — -----------------------duties of ------------------------16-17 salaries of______ £i _— 17 sanitary inspector. See above, health officer. Puerperal septicemia. See Mortality, 9 maternal, causes of. ■ 60 INDEX, Page. Railroads. See Communication, means of. Reading, instruction through.: in infant care___________________ in maternity care -------------------Registration : births. See Birth registration, deaths. See Death registration, midwives. See Midwives, regis tration of. Roads, condition of. See Communi cation, means of. Rockefeller Sanitary Commission. See International Health Board. Rural county nurse. See Public health nurse (county). 42 26 Page. Specialists, unavailability of------------ 4 3 -4 State board of health : bureau of child welfare advo cated b y _________________ 7. campaign and survey by (in co operation with the Inter national Health Board) _ 17, 50 16 rules by— ---------- ------- — ----------Stillbirths, percentage of— -------------49 Telephones. See Communication, means of. Tenant farmers. See Farmers; ten ants. Tenure and acreage. See Farming conditions. Trained nurse. See Public health nurse. See also Nursing care. Tuberculosis. See Mortality, mater nal, causes of. 50 Typhoid, campaign against-------------- inspector. See ' Public health officer. Sanitation. See Housing and sani United States Public Health Service. tation. See Public Health Serv School attendance. See Education. ice, United States. School terms. See Education. -V ita l statistics, bureau off See Bu Scope and method of the survey : reau of Vital statistics. selection of counties------------------ 7, 8, 9 8 sources of information-------------W ater supply. See Housing and Screening. See Housing and sani sanitation. tation. Weaning, ages of--------------------------- — 42Selection of counties. See Scope and Work of mothers in relation to child method of the survey. bearing : Social and economic background of after' confinement— families visited-------------9 -2 0 resumption of work---------- 30, 37, Soil-pollution diseases, campaign 39-40, 41 against----------------------------17 before confinement— Soils. See Farming conditions. nature of work---------------------- 38—39 Sources of information : relief from w ork---------- 37—38, 41 obtained by the bureau— usual farm and household See Scope and method of work— the survey. assistance, kind of---------------- 36—37 obtained by mothers— conveniences, lack of----------36 in infant care-------------- -— 42 nature of------------------------------- 35-37 in maternity care-------------- -- . 26 Sanitary o https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis