The full text on this page is automatically extracted from the file linked above and may contain errors and inconsistencies.
$, o 2 t\L& *3* (o U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAU JU LIA C . L A T H R O P , Chief MATERNITY AND INFANT CARE IN A RURAL COUNTY IN KANSAS By ELIZABETH MOORE 3» R U R A L C H IL D W E L F A R E SE R IES No. Bureau Publication N o. 26 WASHINGTON GOVERNMENT PRINTING OFFICE 1917 U S '8 c https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ADDITIONAL COPIES THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE "WASHINGTON, D . C. AT 10 CENTS PER COPY https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ■3 f e a - O tt-SA«* v £» CONTENTS. Page. Letter of transmittal............................................................ . . . . ............................................. Introduction...................................................... ....................................... ............................. Object of the survey......................................................................................................... Field of the survey...... ............. Method......................................................................... . ......................................... 5 7_10 7 g g 11-21 The county...... ............................................... Location and topography....................................................... . ..................................... 21 Soil and climate................: ............................. ........................................................ 22 History of settlement.................. 22 Present population......................................................................... 13-14 Nationality........ ................................................................................................... _ 23 Literacy and intelligence................................................ 23 Community centers................................................................ _.................. ......... 23 Density........................................................... ........................................... ; .............. 24 Means of communication............................................................................. , ................ " 24 15 Railroads.................................................................................................. 24 Roads..................................... 24 25 Telephones..................... ' . ......................................................„ ................................. Character of farm life....................................................................................................... 15-17 Size of farms............................................................................................................... 25 Chief crop................................................................. 25 Economic situation....................... 26 Tenantry............. . r .................................................................................................... 26 Health............................................................................................ 17-21 Vital statistics............................................................................................................ 27 Causes of infant deaths................................ 29 Contagious diseases................................................................................ . ................ 20 Public-health activities..................................... .......... ....................................... . 20 Findings of the survey...............................................................................................................22-45 Father’s occupation........................... 22 Place of confinement................................................................... 22 Maternity care.......................................................... 22-30 Attendant at birth.......................................................... 22 Midwives................................................................................. 22 Obstetrical service by physicians....................................................................... 23 Hospitals...................................................................................................................... 25 Nursing care and household help at confinement.......................... 26 Prenatal care.............................................................................................................. 28 Cost of childbearing................................................................................................ 29 Complications of confinement.......................................... '........................................... 30 Mother’s work........................................................................................................................31-40 Cessation of work before childbirth.................................................................... 31 Resumption of work after childbirth................................................................. 31 Usual housework and help..................................................................................... 32 The farmhouse......................................................................... 32 Water s u p p l y ................................... 32 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 CON TEN TS. Findings of the survey— Continued. Page. Mother’s work— Continued. 33 Other conveniences............. .................................................................................... 33 Boarding hired men................................................................................................. 34 Harvest and thrashing crews.......................... - .................................................... 39 Dairy work.................... ........................................................................................*' 39 Poultry raising.....................................................*.................................................... 39 Gardening........................ .......................................................................................... 39 Other farm work.................................................................. - ................................. • 40 Farm work during girlhood................................................................................. 40Infant welfare..................................................................................................................... 40 Infant mortality rate................................................................................................ 41 Causes of death....................................................................................... .................. 4 1 - 44 Feeding customs................................................................................ ; .................... Chart. Percentages of all babies receiving different kinds of feed 43 ing, by month of age.................................. ................................. .......... 44 Birth registration...............................................................- - ................................... 46 Summary and conclusions.....................................................................................*.............. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 45 LETTER OF TRANSMITTAL. U. S. D epartm ent C of L h il d r e n ’s abor, B ureau, Washington, June 25,1917. S i r : Herewith I transmit a report entitled “ Maternity and Infant Care in a Rural County in Kansas.” This report is the first in a series undertaken for the purpose of learning what safeguards are available for the physical welfare of mothers and young babies in typical rural communities. The study was made under the super vision o f Dr. Grace L. Meigs, the head o f the division of hygiene o f the Children’s Bureau. This series o f field studies is à direct sequence of the statistical report upon Maternal Mortality in the United States, made by Dr. Meigs last year. In that work the grave urgency of this subject is clearly shown. The outline for the inquiry was prepared chiefly by Miss Viola Paradise, research assistant, and the field work was done by Miss Elizabeth Moore and Miss Frances G. Valentine; the text was written by Miss Moore. Special mention should be made o f the assistance of the State board o f health, at whose request the study was undertaken; Dr. S. J. Crumbine, secretary of the board, secured the cooperation of physicians, social workers, and officials, and through the press made clear the purpose of the study. Mr. W. J. V. Deacon, the State registrar, prepared all the preliminary data needed as to vital sta tistics. Dr. Lydia A. Devilbiss, director o f the Kansas division of child hygiene, was of much assistance. The study is based upon inter views with individual mothers, and the general approval with which it was received is shown by the fact that not a single interview was refused the bureau’s agents. In the detailed statements given such changes have been made as prevent identification without impairing the accuracy of the illus tration. The bureau is indebted to Dr. J. Whitridge Williams, Johns H op kins University, for advice with regard to technical matters con nected with maternity care and especially for help in drawing up the standards suggested. Respectfully submitted. J u l i a C. L a t h r o p , Chief. H o n . W i l l i a m B. W i l s o n , Secretary o f Labor. 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY AND INFANT CARE IN A RURAL COUNTY IN KANSAS. INTRODUCTION. OBJECT OE TH E SU RVEY. In 1916 the Children’s Bureau began its projected studies o f ma ternal and child welfare in country districts. Three of these investi gations were undertaken during the year in selected areas in North Carolina, Wisconsin, and Kansas. In the latter two States the studies were planned and carried out upon the same basis and with the same purpose, and both are confined to a much more limited range of topics than the study in North Carolina. In Kansas, as in Wisconsin, the investigation is an extension of one phase of the study o f the causes o f infant mortality which the bureau has been carrying on in cities for the past four years. The one aspect of this wide subject which has been especially emphasized in these rural surveys is the conditions affecting the health of the mother during pregnancy and at the time o f childbirth. The points covered are the general living conditions o f the family, the work done by the mother, the care she received during pregnancy and at confinement, and the cost o f such care. The care and health of the babies during their first year o f life also are considered. This question o f the care o f the childbearing mother was selected for special attention out o f the many problems connected with in fant mortality because o f its great importance in connection with the loss o f infant life through premature birth, injuries at birth, congenital weakness, and associated causes, leading to stillbirths and to deaths in the first weeks o f life. Statistics show that this group o f causes is responsible for about two-fifths o f all infant deaths.1 T o this number should be added the loss from stillbirths2 and the unmeasured but very great waste o f potential life through miscarriages, making altogether a heavy charge against the prenatal and natal causes o f death. Obviously any saving at this period can be effected only through the mother, by bringing her and her baby through the period o f pregnancy in better health and by giving them 1 Deaths under 1 year of age in 1915 in the registration area, all causes, 1 4 8 ,5 6 1 ; malformations, premature birth, congenital debility, and injuries at birth, 61,082 or 41.1 per cent o f the total. M ortality Statistics, p. 645, Bureau of the Census, 1915. 2 In the seven cities in which infant mortality studies have been made by the Children’s Bureau the stillbirth rate was found to be 3.5 per cent o f the total legitimate births. 7 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 M A T E R N IT Y A N D I N F A N T CARE. both better care at the time o f birth. In addition to these general considerations, many letters coming to the bureau from country women, as well as many of those written to the Secretary o f A gri culture about the needs o f farm women, have made it evident that the problem o f securing adequate medical and nursing care at con finement is an extremely serious one for country mothers; that for many o f them such care is practically inaccessible, either because o f actual isolation or because o f the expense resulting from distance from physicians and nurses. Consequently it appeared that the bureau would be neglecting its obligations i f it delayed further the study o f the conditions surrounding maternity in rural districts. The information on which the Kansas survey is based was secured through interviews with mothers in the selected territory who had had children born within the two years preceding October 1, 1916. The object held in view in the use o f this information has been to present a picture o f maternity and infant care in the district stud ied; and no attempt has been made to show the relationship of par ticular conditions to the infant mortality rate, as has been done in the bureau’s city investigations. FIELD OF TH E SURVEY. The investigation was located in Kansas, partly because that State was considered typical o f a large area o f plains country west o f the Missouri River which had previously been untouched in the bureau’s w ork; and partly on account of the urgent invitation o f the Kansas State Board o f Health, which believed that a study by the Children’s Bureau would stimulate the rural communities o f the State to in crease their efforts on behalf o f mothers and babies. A certain county recommended by the secretary o f the State board o f health as typical o f the western farming country was chosen for investiga tion. The study was confined to the farming area of this county— the open country— all of which was covered in the inquiry; the one city and all the villages were excluded. METHOD. So far as possible a record was made concerning every birth— whether live birth or stillbirth— during the period o f two years from October 1, 1914, to September 30, 1916, occuring in families resi dent in the country districts of the selected county at the time o f the birth. As a first step toward securing these records the names o f the parents o f all babies whose births or deaths were registered were obtained from the State and local registrars’ offices. A canvass was made to find additional unregistered births. In all, 353 schedules were secured, representing 331 families; among these were 4 pairs o f twins, so that the records cover the history o f 349 confinements. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 9 None o f the mothers visited refused to give the desired informa tion, and almost always their cooperation was most cordial. A large proportion o f the parents had heard about the investigation through newspaper articles or from friends or neighbors and were ready to welcome the agents when they came. In all but 10 cases the main part o f the information was given by the mother herself, with supplementary information from the father in many instances! The remaining 10 records were furnished by others—6 by the grandmother, 2 by an aunt, 1 by the baby’s married sister, and 1 by the attending midwife, who was also a relative. Mothers who had had miscarriages but no live-born or stillborn children within the period of the investigation were not interviewed, and no records were secured for such miscarriages except in two in stances where the miscarriage resulted in the death o f the mother. These two are not included in the figures for the county. Further more, no attempt was made to secure records about illegitimate births. A birth certificate was found for only one illegitimate child in the country districts in the two years covered by the survey, and the agents heard o f no others in the course o f their canvass. Schedules were not secured for 78 of the registered births in the country districts, for the following reasons: In 60 cases the family had moved out o f the county; in 10, the family was not at home at the time o f the agent’s visit and it was impossible to revisit; in 8, the family could not be located. Among these births there was 1 still birth, and 5 of the children are known to have died. Instead o f reproducing here the schedule used the following typical story is given to indicate the kind o f information secured in an inter view. The names are o f course fictitious, and substitutions from other records have been made in order to prevent identification of the family. Mrs Green has a baby, Robert, 15 months old, who was born In September. H e weighed 9 pounds at birth and has always been well except for two attacks of diarrhea in the summer, when he was 9 months old, and a bad cold now. H e is still nursing, but his mother began to give him bread and milk, crackers and cereals when he was 6 months old. There are four children living, all in good health. Mrs. Green, who is now 35 was married when she was 22. The next year she had a stillborn baby, a girl! Two years later her oldest boy, now 10 years old, was born; the following year she had a three months’ miscarriage. These first three confinements occurred on a farm in eastern K a n sa s; for the first two Mrs. Green had a midwife and after the miscarriage her mother took care o f her. The last three children— a boy 8 years old, a girl of 4 years, and the baby— were all born on this farm and Mrs. Green had a doctor each time. The day after the stillbirth she called a doctor, because the baby was “ morti fied ” and she feared blood poisoning; he performed a curettage, but did noth ing for the severe laceration which had occurred. This laceration has given so much trouble since- the last baby was born that her present physician advises 3698°— 17----- 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 M A T E R N IT Y A N D I N F A N T GABE. an operation. The second pregnancy almost resulted in a miscarriage at three months and the third one did so. Although no serious complications followed, she was weak for a year afterwards. The last three confinements have been normal. Mrs. Green has suffered from nausea, varicose veins, and swollen hands and feet during every pregnancy, and especially during the last two. During the pregnancy for which the record was secured she had no prenatal care what ever. W hen the baby was born Mrs. Green was attended by the doctor from the nearest village, 7 miles away. She was in labor about 18 hours, during which time the doctor made two visits ; he also made one postnatal visit. This fee was $18. Mrs. Green stayed in bed 10 days. One o f her neighbors came in every day, washed the baby, and “ fixed up the bed ” ; otherwise her husband took care of mother and baby, and did the necessary housework for two weeks. He also did the washing (with the washing machine) during the winter, both the year before and the year after the baby was born ; he is too. busy to do much during the summer or fall, but he always carries the wash water from the windmill about 40 feet away, even in the busiest times. Except for such help as her husband and the boys can give, Mrs. Green does all the housework and the family sewing ; she does nothing outside the house except to care for the chickens. She is evidently a good housekeeper, as indicated both by her house and by the children’s neatness. Harvest occurred two and a half months before the baby was born, and Mrs. Green had six extra men to board for two weeks ; but she had a hired girl for that time. The thrashing crew came three weeks before the baby was born, just when the oldest boy was having the measles ; but Mr. Green arranged so that none of the men boarded at the house. In the summer after the baby’s birth she could get no help at harvest. It was then that the baby got diarrhea because she was unable to watch what he ate. That fall Mrs. Green cooked for the four grain haulers for three days. Aside from this she has not had to board any hired men. Mrs. Green has always lived in the country. A s a girl she helped with the housework from the time she was 10 years old, but “ never did a washing till she was 13 ” ; she also helped with the outdoor chores and “ drove teams ” in the fields from the time she was 8 years old. After she was 14 or 15 she frequently “ worked out ” among the neighbors for short periods, and the last two years before she was married she did housework in the city. She has never had any serious sickness, except pneumonia at the age of 1 2 ; but while she was working in the city she never felt well. The Greens have lived on this farm 9 years ; during this time Mr. Green has paid for one quarter section (160 acres) of good wheat land and has re cently purchased a second quarter, which is still heavily mortgaged. H e has built a good barn and granary and a comfortable five-room house. Mr. and Mrs. Green were both born in Kansas of native American parents. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A COUNTRY ROAD ACROSS TH E PLAINS. 1 A SMALL VILLAGE IN TH E W HEAT COUNTRY. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis DISKING TH E GROUND FOR TH E W HEAT. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis TH E HOME OF A PROSPEROUS LANDOWNER. A RENTER’S HOME, WHERE TH E FAMILY LIVES IN TH E GRANARY. 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A MODEST HOME W ITH RUNNING WATER FROM TH E WINDMILL TANK. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis TH E COUNTY. Before the findings of the survey are discussed a brief description is given o f the chief economic and social factors—such as the physical characteristics of the county, character of the population, means o f communication, type of farm life, and conditions affecting health— bearing on maternity and infant care in the area studied. LOCATION AND TOPOGRAPH Y. The county studied is situated near the southern boundary of Kansas, about one-third of the way across the State eastward from the Colorado line. In other words, it belongs in the western half o f the State, which has a semiarid climate and a comparatively sparse population. It is one of the larger counties in the State, being 30 by 36 miles in extent. With the exception o f the valley o f the Arkansas River, which crosses it from west to east, and the valleys of a few minor creeks, the whole county is a high, treeless, rolling plain— part of the Great Plains, which extend across half o f Colo rado and Kansas as well as adjacent States north and south, slop ing gradually eastward from the Rocky Mountains. Very little of this plain is absolutely flat, but the variations are slight except in the neighborhood o f the streams, where the ground often drops or “ breaks” abruptly. The landscape in most places gives an effect of limitless expanse in which the scattered homesteads, with their strug gling hedges, are often hardly noticeable. As one appioaches the villages the tops o f the grain elevators are visible on the horizon long before there is other sign of habitation. The general level o f the plain drops from between 2,600 and 2,700 feet elevation at the western border of the county to 2,400 feet near the eastern border; about half o f the river bottom is below the 2,40Q,foot level. SOIL AND CLIM ATE. The soil o f this high plain, comprising fully two-thirds o f the county, is what is called by the Bureal of S oils1 Richfield silt loam— a soil “ well adapted to the growing of wheat,” though “ the average yield o f wheat when calculated for a series of years is somewhat low, probably not exceeding 10 bushels, and for the average farmer this is barely within the limit o f profitable production.” The soil is undeniably fertile; it needs no fertilizer and in some places has produced wheat steadily for 30 years with no apparent exhaustion. 1 Reconnoissance Soil Survey of W estern Kansas, p. 58. ington, 1912, U. S. Bureau of Soils, W ash 11 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 M A T E R N IT Y A N D I N F A N T CARE. The reason why fertile soil, well adapted to wheat, gives such low average yields is largely a matter o f rainfall. In this part o f Kansas the average annual rainfall is only between 20 and 23 inches,1 and crop yields are uncertain because o f droughts. A good year, one of more than average rainfall, gives fine crops, while an unusually dry year may bring total failure. The selected county is just on the edge of what appears to be the profitable farm ing belt, at least under present methods o f farming; and there is a distinct difference in rainfall and in the resulting prosperity between the eastern and western ends of the county. Moreover, within the same year local showers will sometimes make a considerable differ ence in crops in neighborhoods not far apart. The Arkansas Kiver valley, which separates the northern from the southern half o f the county, presents very different conditions from the upland plains. The river itself carries little water in the channel; but it has a large subsurface-flow which irrigates the adja cent strips o f alluvial soil and makes them very valuable, especially for raising alfalfa. This strip of rich land is narrow, not more than a mile or two wide at most. North of this bottom is an irregular strip o f rough stony land rising steeply to the bluffs a couple o f miles back from the river. South of the river bottom runs a similar strip o f sand hills and sandy soil, largely worthless except for pasture. H ISTO R Y OF SETTLEM ENT. Most o f the land in the county, except in the northwestern corner, was taken up in quarter-section tracts by homesteaders about 30 years ago, at the time o f the western Kansas boom beginning in 1885. Few o f these early settlers are left, however, as nearly all were driven out during the dry years following the boom. It is a common saying that almost every quarter was taken up and relinquished six or seven times before it was finally “ proved up.” Much land went into the hands o f cattle ranchers and speculators after the boom, and *only in recent years has been put under cultivation again. East of the county seat the exodus was not so general as farther west; and in the eastern end o f the county there is a large German settlement which dates from the eighties. These families migrated from Ohio to Kansas as a group 30 year's ago and have remained largely separate from their neighbors ever since. They intermarry to a considerable extent within u the settlement,” and have their own churches. Although in the early days they went through very hard times, they held on to their land; and to-day this neighborhood has the best-developed farms in the county as well as the largest pro portion of home owners. 1 Reconrioissance Soil Survey of Western Kansas, p. 58. ington, 1912. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis U. S. Bureau of Soils, Wash M A T E R N IT Y A N D I N F A N T CARE. 13 Another and even more distinct community is formed by two small Amish colonies in the southern part of the county. These people are German in origin, a sect o f the Mennonite Church; they have a dis tinctive costume and strict rules as to simplicity of living and hold very little intercourse with outsiders. Within their own group they are closely bound together by relationship as well as by church ties. The Amish families in this county came chiefly from Indiana, most o f them less than 10 years ago. They are thrifty, and, in spite of having been poor in the beginning, they have made creditable prog ress toward farm ownership. A visitor is impressed by the unusual neatness and cleanliness o f most o f the homes, which go far to com pensate for their absolute lack o f adornment. German is still the language o f family life among these people, though they have been in America for generations. The women are hard workers, follow ing the German custom o f helping with the farm work in addition to the housework and care o f the children. PRE SEN T POPULATION. Nationality. As a whole this is a predominantly native American community. Out of the 662 parents in the families visited 505, or 76.8 per cent, were native white of native parentage, while only 19, or 2.9 per cent, were foreign born, 16 o f whom were German. Only 4 o f the parents could not speak English; these were Russian Germans, 2 o f the second generation. Literacy and intelligence. The population o f the county is also predominantly literate. The 1910 census shows only eight-tenths o f 1 per cent o f the native white population 10 years of age and over illiterate. Among the farming population there are practically no illiterates; in fact, only one was found among the parents in the families visited. The general level o f intelligence—o f interest in public affairs, in questions o f health, and in the education o f the children— also is high. A large propor tion o f the mothers had read some kind o f literature on infant care and were keenly interested in taking their babies to the various “ Baby Days ” held in the county. The country schools are o f the one-room type, but the buildings are well built and well kept; innova tions like playground apparatus are not uncommon, and a general interest in school efficiency is manifest. There is a high school in each o f the incorporated villages as well as in the county seat, and these high schools are well attended by country children. Community centers. The county seat, a city o f about 4,100 inhabitants, is the community center for the whole northwestern section of the county. Besides this one city there are three incorporated and three unincorporated vil https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 M A T E R N IT Y A N D I N F A N T CARE. lages. These are all small villages according to urban standards, ranging from 76 to 778 inhabitants. But the two largest are impor tant local business and social centers and boast o f “ city ” water sup plies. A ll o f these villages, in fact, except the smallest one, are important to their surrounding communities, providing churches, stores, physicians, and mail and shipping facilities. Density. According to the Kansas State census for 1915 this county had 13,152 inhabitants— an increase o f 15 per cent since 1910.1 The six villages, together with the county seat and the State soldiers’ home, had a combined population o f approximately 6,900,2 which leaves 6,250 people in the open country—that is, the area covered by the survey— or a rural density o f 5.8 persons per square mile. The density o f the rural population in the three townships on the eastern border o f the county is 7.6 per square mile, while in the four town ships on the western border it is only 4 per square mile, illustrating the increasing sparsity o f settlement as one goes westward. In the extreme northwestern township, which is the most arid and least thickly settled o f all, there were only 2.2 persons per square mile. M EANS OF COMMUNICATION. R a ilr o a d s . Two transcontinental railroads and two branch lines cross the county, with stations at intervals o f not more than 10 miles and one or more grain elevators at every station. Consequently the county is well provided with means o f travel; and the shipping facilities would be sufficient if it were not for shortages o f railroad cars, which often prevent the farmers from marketing their grain when they wish. Roads. The roads in this district, as throughout western Kansas, are usually in excellent condition, thanks rather to the climate and the nature o f the soil than to any work put upon them. No attempt is made to surface the country roads in any way (except fo r a few miles o f sandy road along the river which have been covered with cinders), and a "heavy rain makes them almost impassable. Such rains, how ever, are infrequent, and the dirt packs hard and smooth again in a surprisingly short time. Certain of the main roads are designated “ county roads ” and are kept well graded and dragged; the rest receive practically no attention except that necessary culverts are 1 The population more than doubled in the preceding decade, 1 9 0 0 -1 9 1 0 . (U. S. Bureau of the. Census.) “According to the State census the increase between 1915 and 1916 was 4 per cent. 2 Incorporated places from State census. Unincorporated places estimates. Soldiers’ home from commandant’s statement. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis , from postmasters M A T E R N IT Y A N D I N F A N T CARE. 15 built and kept up. But in this fortunate country a mere wagon track across the plains soon makes a good road. A large proportion o f the country families, especially among the land owners, have automobiles to enable them to take advantage of their good roads. Telephones. Telephone facilities extend throughout the county; more than twothirds of all the families visited had telephones in their homes, only four were farther than a mile and a half away from a telephone, and none had to go more than 3 miles to reach one. This is particularly advantageous in a community where the distances are so great and the homes so widely scattered. C H A R A C T E R OF F A R M L IF E . Size of farms. It has been shown already how sparse the population is—hardly one family to the square mile in the western part of the county and less than two in the eastern end. The census o f 1910 shows that o f the farms in the county three-fourths contained at least 260 acres and nearly one-third were as large as 500 acres. O f the farms visited two-thirds were farms o f 320 acres or more; and the consensus o f opinion is that 320 acres— a half section—o f reasonably good land is the least upon which a farmer can expect to make a comfortable living. A ll this means that next-door neighbors are often a mile or more apart, and “ tow n ” may be anywhere up to 20 miles away. Although houses may be easily distinguished from a distance o f 2 or 3 miles, yet from many places out on the plains there is hardly a dwelling in sight in any direction. Chief crop. Winter wheat is far and away the main crop o f this part o f the country. According to the report of the Kansas State Board of Agriculture for 1914 four-fifths o f the acreage o f planted crops in the county was in wheat; and 85 per cent o f the total crop values were due to the wheat crop. Oats and spring crops—corn, kafir corn, etc.— are raised on most farms, mainly for feed; but none o f these grains, nor all o f them together, approach anywhere near the impor tance o f the wheat. In fact, wheat stands in almost as predominant a relationship to the material well-being of the farmers o f this terri tory as cotton does in the cotton States. In discussing how he is getting along, almost any farmer or his wife will tell of his wheat crop— its acreage, yield, and price—with hardly a thought o f any thing else. The life o f the typical farm revolves around the wheat crop. W ork is active in the fall when the wheat ground is being plowed or disked and the wheat is being sown; after that there is not much to https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 16 M A T E R N IT Y A N D I N F A N T CARE. do, unless an unusual amount o f stock is kept on the farm or spring crops are raised, until the following June when the wheat again demands attention. At this time comes the great work crisis o f the year—the wheat harvest, employing from 3 to 15 men for two or three weeks—men whom the farmer must usually snatch from the incoming trains and whom the housewife must manage to board. Wheat thrashing usually follows some time in the summer, but lasts only a few days. I f spring crops are raised to any great extent, the busy season extends through a much longer period, from spring through corn husking or kafir thrashing, which often comes late in the winter; but there is no such time o f concentrated stress as the wheat harvest. Economic situation. At the time of the survey wheat crops had been satisfactory for the past few years, and wheat was bringing in the neighborhood o f $1.75 a bushel, which was then regarded as a phenomenally high price. Consequently a general atmosphere of good times prevailed in spite o f the total failure o f the corn crop in the current year. Aside from the car shortage there seem to be no marketing difficul ties, as farmers’ associations own cooperative grain elevators at nearly every railroad station. Average wheat crops for the current year ran about 13 to 15 bushels, though some farms produced as much as 20 bushels or more to the acre. Tenantry. A serious feature o f social conditions in this county is the large proportion o f farms in the hands of tenants. At the time of the 1910 census this proportion was 34 per cent o f the total; among the fami lies visited in the survey it was 38 per cent, not including those who rented land from their parents. In the decade between the 1900 and 1910 censuses the number o f tenant farms increased from 73 to 374, while the number in the hands of owners increased from 484 to 722; that is to say, the majority o f the newcomers were tenants and the proportion of tenants rose nearly threefold. A t present tenantry is distinctly more prevalent in the western or more recently settled half o f the county than in the eastern half. This fact seems to indicate— as do many individual histories—a wholesome tendency for the new settlers who start out as tenants to become landowners. Whether this tendency will continue in the face o f the rise in land values remains for the future to show. It must be borne in mind in this connection that many o f the older settlers homesteaded their land, but that now there is practically no free land left. A t present, the customary rental charge o f one-third o f the grain crop allows an enterprising and capable farmer to “ get ahead ” and buy land in the course o f time. But many of the renters move about from place to https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 17 place, forming a transient, unattached, thriftless element in the com: munity, their very names unknown to many o f the neighbors. For example, one family moved four times in 13 months, another three times in 7 months. The houses on most rented farms are decidedly inferior to those occupied by landowners; many o f them are poorly built and in wretched condition. And it frequently happens that, in addition to the handicap o f inadequate farm buildings, renters have insufficient capital to farm profitably, and their whole standard o f living is much below the general level. Many landowners rent land in addition to that which they own, in order to extend the scale o f their farming; but they are by no means in the same economic status as the tenants and are not so counted; for they are not transients, and they usually own the homes in which they live. For similar reasons those farmers who operate land belonging to their parents— an appreciable number among the younger folk— do not belong in the tenant class, whether or not they pay rent, for they have a permanent interest in the community and usually have the advantage o f farm buildings and dwellings such as an owner ordinarily puts up for himself but not for tenants. H EALTH . No investigation o f general sanitary conditions was included in this survey. It is worth noting, however, that the general climatic conditions the elevation and the dry atmosphere— are favorable to good health. So also is the character of the water supply. Prac tically all the water used throughout the county is taken from drilled wells more than 100 feet deep, which draw from uncontaminated ground-water strata.1 Open wells, such as are found in many coun try districts, are very rare. Hence, though the water is hard it is reasonably safe from pollution. V ita l statistics. The death rate for this county has been for several years somewhat above that for the State. But it should be noted that Kansas as a whole has a remarkably low death rate, about 2 per thousand below that for the rural part o f the registration States. Moreover, the rates for the county are stated by the secretary o f the State board o f health to be increased by the deaths o f patients brought from out side the county to the hospitals in the county seat. 1 Statement of the secretary of the State hoard of health. • 3698°— 17----- -3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 M A T E R N IT Y A N D IN F A N T CARE. T a b l e I .— Death rate per 1,000 population.® 1912 11.8 10.2 12.4 1913 12.4 10.fi 12.7 1914 13.5 10.5 12.3 1915 10.9 10.7 12.3 1916 13.5 11.7 a Derived from Second Biennial BeDort of the Central Division of Vital Statistics, Kansas State Board of Health, 1914r-15; from data furnished by the State board of health; and from Mortality Statistics, Bureau of the Census, 1913,1914, and 1915.' b Includes all places of less than 10,000 population in 1910 in the death-registration area. According to the State birth-registration figures this county has a birth rate which is not only one o f the highest in the State but also is considerably in excess o f that for the State as a whole, or for the birth-registration area o f the United States which was 24.9 per 1,000 in 1915.1 As shown in Table II , the rate for the county studied was 29 per 1,000 or higher every year for the past five years. O f the six other Kansas counties which had birth rates higher than 29 more than once in the four years 1912-1915, all but one are immedi ately adjacent to the one studied, so that evidently a high birth rate is characteristic o f this part o f the State. In each o f the past three years the county seat appears to have a higher birth rate than the rest o f the county; possibly this is due, at least in part, to more complete birth registration in the city. T able I I .—Birth rate per 1,000 population.a 1912 1913 35.4 29.0 22.5 21.0 1914 33.2 37.9 31.0 21.2 1915 29.9 35.8 27.2 22.2 1916 31.0 35.2 28.9 24.0 a Derived from Second Biennial Beport of the Central Division of Vital Statistics, Kansas State Board of Health, 1914-15, and from data furnished by the State board of health. Rates for the rural part of the regis tration area are not available. In this community a high infant mortality 2 rate does not accom pany a high birth rate. In contrast to its general death rate, the county o f the survey had in 1914 a lower infant mortality rate than the average for the State, and also in both 1914 and 1915 a rate lower than those found in other States. The rate for the birth-registration area o f the United States in 1915 was 100 per 1,000 births; only one State—Minnesota—had a rate lower than 85, while in 6 o f the 10 birth-registration States the rate was higher than 100.3 1 Birth Statistics for the Registration Area of the United States, p. 10, U. S. Bureau of the Census, 1915. 2 Infant mortality rate, as the term is used in vital statistics, means the ratio between the number of deaths under 1 year of age and the number of live births in the same period. 8 Birth Statistics for the Registration Area of the United States, p. 10, U. S. Bureau of the Census, 1915. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 19 M A T E R N IT Y A N D IN F A N T CARE. T able I I I .—Infant mortality rate per 1,000 live births.1 1914 Selected county. County seat. Rest of county. State of Kansas. 62 75 55 77 1915 71 88 61 70 1916 92 113 79 69 for the county. The figures in Table I I I show that the rate for the county seat was over one-third higher each year than that for the rest of the •county; but here again the real facts are obscured to' some extent by deaths o f children brought from the country to the city hospitals. It should be noted that the rates for the county and also for both subdivisions were higher in 1915 than in 1914, and much higher in 1916 than in either o f the preceding years; also that in this last year this county had a higher infant mortality rate than the State. Causes of infant deaths. In the two years 1914 and 1915, 22 o f the 53 infant deaths occur ring in the county were due to malformations and diseases peculiar to early infancy; outside o f the city 13 o f the 29 deaths were due to this group o f causes, or about the same proportion. In 1916, 14 out o f 39 deaths in the county and 7 out o f 21 outside o f the city belonged in the same group. Taking the three years together, or any one year, malformations and “ early infancy” are responsible for a larger number o f deaths than any other group o f causes; but they are not responsible for the sharp rise in the mortality rate in 1916. Both in the county as a whole and outside o f the city thfe number o f deaths from gastric and intestinal diseases in 1916 alone exceeded the number in the two preceding years. That is to say, in 1914 and 1915 there were 10 deaths from these causes in the county, but in 1916, 12 deaths ; and similarly outside o f the city, 4 deaths in the two years but 6 in 1916. In July, August, and September o f that year there occurred in and around the county seat an outbreak o f infantile diarrhea, which loomed large in the minds o f parents, •doctors, and nurses. In fact, 11 children under 2 years old died from diarrhea in these months; but only 4 o f these were under a year old, which number will not account for the high infant mor tality rate for the year. On the contrary, the records show that deaths from diarrheal diseases were excessive throughout the year and throughout the county. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 M A T E R N IT Y A N D IN F A N T CARE. Contagious diseases. During 1916 there were reported to the county health officer 229* cases o f measles, 28 of scarlet fever, 24 o f chicken pox, 10 of diph theria, 7 o f whooping cough, 1 o f infantile paralysis, and 87 o f sma pox. Measles seems to be unusually well reported; but the same can hardly be said of whooping cough, for the mothers visited told o f fully as much whooping cough as measles in their families. An epidemic o f measles which occurred earlier in the year in the city and in the southwestern quarter of the county was responsible for most o f the cases o f that disease reported. _ . The cases o f smallpox were due to two outbreaks in the spring, m the city and in one o f the villages. The latter was widespread, but no deaths resulted. ’ ... Compared with the fatalistic attitude common in many localities, the parents in this community seem as a riile to be careful in avoid ing exposure o f their children even to the milder contagious diseases.. A t the time o f the survey little trouble was experienced from any •o f the ordinary children’s contagious diseases, except for a diphtheria scare in the city from which only five or six cases developed. Public-health activities. In Kansas the county is the local unit for rural public-health ad ministration. The county board of health, consists of the county commissioners and a county health officer appointed by them. There are no township health officials, consequently the county officer has an extensive field to cover. . . A t the time o f the survey this county was fortunate m having an active, interested health officer— a local physician who had obtained special training for his duties by attending the course for county health officers given by the State board o f health. Unfortunately the low salary paid—$250 a-y e a r — threatened to deprive the county o f his services for the following year. The health officer’s duties embrace the inspection o f stores, restau rants, slaughterhouses, etc., the sanitary inspection.of schools, and the control o f contagious diseases. During his term the officer of this county had twice inspected the stores, restaurants, and slaughter houses throughout his territory and had visited “ about half a dozen ” of the 67 schoolhouses of the county. His activities were largely concentrated -on the prevention o f the spread of contagious diseases. He visited promptly every locality where there was an outbreak and had done much traveling for this purpose. In addition, he took an active part in the “ Baby Days ” held in the county. Obviously, he had performed far more service than the community was justified m expecting for the salary paid. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M ATERNITY AND IN F A N T CARE. 21 The social-service league o f the county seat employed a visiting nurse—who was a graduate o f the State board o f health’s training course for public-health nurses—during six months o f 1916 and expected to continue this work in 1917. The city and the county each contributed $15 a month toward the nurse’s salary 5 the remainder was raised by private subscription. Her work was confined almost entirely to the city. The most significant undertaking o f the year, from the standpoint o f children s health, was the series o f li Baby Days ” inaugurated by the visiting nurse and carried out by local physicians and dentists in the county seat and three of the villages. Young children were given physical examinations according to-a plan recommended by the State board o f health, in which the American Medical Association score card was used ; but no prizes were given. These examinations aroused a great deal o f interest throughout the county ; more chil dren were brought to each examination than could be admitted. At the largest meeting 60 children were examined by 4 physicians and 2 ■dentists. The spontaneous response to this opportunity, as well as the enthusiasm o f the doctors in face o f the arduous work involved, indicates a very promising field for public-health work. It seems probable that the project o f inducing the county commissioners to employ a public-health nurse for work throughout the county, which is being discussed in the city, would be received with fa For by the country constituency. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis FIN D IN G S OF T H E S U R V E Y . F A T H E R ’ S OCCUPATION. A ll but 3 o f the heads o f the 331 families visited were engaged in farming ; 317 were farmers, 2 farm managers, 8 farm laborers, and 1 had as his chief means o f livelihood the operation o f a thrasher. Five o f the farmers also worked as farm laborers part o f the time; 6 operated thrashers; and 9 had some other supplementary occupa tion. O f the 3 fathers not engaged in farming, 1 was a storekeeper, 1 a railroad station agent, and 1 a rural mail carrier. The small number o f families found who depended upon farm laborers’ wages is a reflection o f the extremely seasonal character o f farm work in this district. Wages are high during a few months in the busy season, but during the winter a laborer o f any kind finds, almost nothing to do; hence the bulk o f the hired labor is done by a migratory class. PLACE OF CONFINEM ENT. As has been stated, all the mothers with whom this study is con cerned were resident in the country districts o f the selected county at the time o f confinement. Some o f them, howevef— 17 in all—went for their confinement care outside o f the area covered in the survey; 3 o f these went to relatives outside o f the county, 10 went to hospitals in the county seat, and 4 stayed with relatives in the county seat or in one o f the villages in the county. Five others went away from their own homes in order to be with relatives but stayed within thecountry districts o f the county. M A T E R N IT Y CARE. Attendant at birth. Almost all (95 per cent) o f the 332 births in the rural districts were attended by a physician; but in 42 cases the doctor did not arrive until after the birth o f the child; and in 10 o f these not until' an hour or more afterwards. Twelve births were attended by a mid wife, 3 by a neighbor, and 3 by the father only; 1 was attended b y both a physician and a midwife. Midwives. Kansas makes no provision for licensing midwives; the only law in which the existence o f such persons is recognized is the birthregistration act. There are no professional midwives in this terri22 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D IN F A N T CARE. 23 tory, for no one could possibly make a living from the few obstetrical cases to which midwives are called. The 12 births mentioned above were attended by 7 different women, who are classed as midwives be cause they have had experience in this work, take charge of confine ment cases on their own responsibility, and are considered by the neighborhood competent so to do. Three o f these women had 2 cases each in the 2 years, and 1 had 3 cases; the others had only 1 each in that period. O f the 3 who were interviewed the first had attended 11 cases in 10 years, the second 6 cases in 10 years, the third 15 cases in 7 years. The last— a young native-born woman who had taken a course in midwifery—would gladly have had more practice; the others did the work primarily as a neighborly accommodation, making no regular charge but often receiving presents for their services. In the 12 families served by midwives, however, they have been an important factor and are evidently preferred to physicians. Out of 76 confinements in the history o f these families 53, or more than two-thirds, had been attended by midwives and only 18 by physicians; o f the 49 children born to these 12 families in this county 29, more than half, were delivered by midwives and only 13 by physicians. Obstetrical service by physicians. The county is well supplied with physicians. Twenty-five doctors attended the births included in this study; 10 o f them attended 10 or more cases each, or 273 cases in all. Eighteen o f these doctors are located in the county and the others in near-by towns in adjacent counties. The county seat has 8 practicing physicians; each o f the villages o f 100 population or more has at least 1, while the two largest each have 2. Probably no home in the county is more than 20 miles from a doc tor. A ll but four o f the families visited had a doctor within 15 miles when the baby was born; more than 80 per cent had a doctor within 10 miles and 32 per cent within 5 miles. Even 20 miles is not a prohibitive distance in this country o f smooth level roads where, under normal circumstances, the doctor’s automobile can cover that distance within an hour o f receiving a call. More than one mother remarked, in discussing the subject, that since the coming o f the telephone and the automobile distance made no particular difference in getting the doctor. Nearly half (19) o f the physicians, it is true, who were late in reaching their obstetrical patients came 10 miles or more; but two-thirds (13) o f these were less than an hour late— several only a few minutes. Some chance, such as a flood in the river, a winter storm, the doctor’s being “ out on a case,” a delayed sum mons, or a brief labor is more likely to be the cause of the doctor’s failure to arrive on time than is distance. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MAYERITCTY AN D IN T A N T CARE. 24 That distance is not a serious obstacle to securing medical care in this territory is further indicated by the fact that for 46 confinements some other than the nearest physician was called, from a distance averaging 7 miles greater than that to the nearest doctor. In \ 7 instances the attendant physician came from 15 miles or more away, though, as has been seen, only 4 families needed to send so far for a doctor. , . The fact that a physician can serve a large area makes a choice o f doctors possible to most families in the county a privilege not always available even in much more densely settled districts than western Kansas. This seems to be a factor in the general satisfaction with the medical situation. ~ , The available evidence tends to indicate a comparatively high stand ard o f obstetrical service at the time o f confinement. None o f the mothers complained o f neglect during the period covered by the sur vey. Instrumental deliveries were rare, only 16 cases out o f 349; and the stillbirth rate is low. W ith one exception all the lacerations which seem to have been severe were repaired. On the other hand, postnatal supervision o f obstetrical patients is much less common than might be expected from the general high level o f medical practice. In 136 out o f 314 confinements attended by physicians in the open country no return visit was made; in 128 cases one visit; and in only 48 cases more than one visit. In part this fail ure to make return visits depends on distance from the patient, for the proportion o f cases receiving no postnatal visits increases mark edly as the distance increases. (See Table IV .) In part, also, ibis a matter o f the habit o f individual physicians; some doctors make return visits to almost all their obstetrical cases, while others revisit almost none. • T able I V .—Number o f postnatal visits, by distance from physician. Mothers attended by physicians in country dis tricts, receiving specified number of postnatal visits. Distance from attending physician. No visits. Total. Num ber. 314 31~ 61 134 71 17 136 2~ 14 67 48 15 Per cent. One visit. More than one visit. Not re ported. 43 128 48 2 6 23 43 68 88 15 37 56 18 2 14 10 20 4 1 1 . The most common fee for attendance at childbirth is from $15 to $20 which was the charge in half o f the 266 cases for which this https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y AND IN F A N T CARE. 25 information was secured; in over three-fourths of the cases the physician’s charge was from $15 to $25. The fee is seldom less than $15 or as high as $30. Except in complicated cases the number of visits made by the physician does not seem to influence his charge, nor does the distance he travels unless it exceeds 15 miles. (This is true only of obstetrical fees, for the rate for an ordinary visit is usually based on a mileage charge.) Hospitals. The county has three hospitals—two of 16 and 25 beds in the county seat, and one o f 10 beds in one of the villages. A ll are physicians’ private hospitals. These hospitals reported caring for 60 obstetrical cases in 1916,1 the great majority in one hospital. Ten country mothers went to the hospitals for confinement during the two years o f the survey. Neither mother nor baby died in any o f these cases. Four o f these women went to the hospital as the most convenient arrangement. Two were in poor health, one with symp toms o f toxemia and the other much weakened by a miscarriage and repeated lacerations. The other four had more serious com plications, including one case of convulsions, one Caesarean oper ation, one premature birth following a fall, and one case where the doctor expected to use instruments; each o f these women was taken to the hospital from a distance of 10 to 16 miles, after labor began. On the whole, therefore, the hospital still seems to be gen erally regarded as a last resort; the custom of making use of hos pital facilities is hardly as well developed as might be expected in view of the community’s intelligence upon health matters and the availability o f hospitals. The ordinary hospital charge is $20 a week with physician’s fee ($15 for normal labor) in addition, or $25 a week including the doc tor’s services. This makes the usual expense of a confinement at a hospital amount to between $50 and $60. In this district, therefore, hospital care costs but little more than does care at home if the family pays for nursing instead o f relying on unpaid help. For example, one mother paid $50, including doctor’s fee, for two weeks at the hospital when her first baby was born; when the second baby came, she stayed at home, paying $18 for one visit from the doctor and $26 for a practical nurse who also did the housework for three weeks. O f course, where there are other children some provision must be made for the housework whether or not the mother goes to a hospital. 1 The reports cover 3,2 months for one hospital, 11 months for another, and 5 months for the third, which opened in July, 1916. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 M A T E R N IT Y A N D I N F A N T CARE. Nursing care and household help at confinement. Trained nurses are4not impossible to secure for those who can . afford them, since both o f the city hospitals give nurses’ training courses. Eighteen mothers who did not go to a hospital had a trained nurse, in most instances at the standard rate o f $25 a week, or a total expense in different cases of from $25 to $60. As might be expected, the incurring o f such an expense is confined to the more prosperous families; 16 out o f these 18 families belonged to the land-owning class; and in all o f them the father was farming at least a half section (320 acres) o f land. Several o f the doctors, when attending confinements, frequently take a. trained nurse or a hospital pupil nurse along with them to act as an assistant at the delivery; such a nurse washes the baby and makes the mother comfortable before leaving, but does not stay with the patient. One doctor who had a large practice- did this regu larly, making no extra charge for the nurse; other physicians usually charged $3 or $5. When, as often happens, the household provides only inexperienced assistance— a daughter or husband or a more or less incompetent hired girl—the services o f a nurse even for this short time are o f the greatest value both to the doctor and to the mother. In addition to the mothers who had a trained nurse, 53 others had at least partially trained care by a midwife or a practical nurse (usually called in this neighborhood an “ experienced woman” ). ¿Such attendants, however, are scarce and often difficult if not im possible to secure. In the great majority of cases the mother had to depend upon an untrained hired girl, a member of the family, a relative, or a neighbor. A very common arrangement is for a neigh bor to come in daily to wash the baby, while some member o f the household gives all the rest of the nursing care. The amount o f nursing done by the fathers is worth noting. In 16 cases the father took all the care o f the mother, though usually—but not always—some one else attended to the baby. One father said. « I have waited on my wife both times according to the doctor’s direc tions, thereby saving the price o f a nurse” ; this same father did the housework for two or three weeks after the first baby came; but the second time the family had a hired girl. . In two large families visited the father had delivered most of the children, and in another family the mother insisted upon his officiating at the last two births, because it worried her to have an outsider around. In 19 cases the father did all the housework while the mother was sick. As has been said, the absence of a competent “ experienced” nurse is often due not to considerations of expense so much as to difficulty in getting anyone to help. For instance, in one prosperous family the mother said that, as she could get no one to come in, she took care of https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 27 the baby herself from the day after it was born, while her oldest girl (15 years old) waited on her and brought her what she wanted. An other mother’s account was that her daughter o f 15 did all the house work and that she took care o f herself and the baby; the daughter brought things to the bed for her to wash and dress the baby with, and under her direction did whatever she could not do herself. In another instance a neighbor came in the day the baby was born and once afterwards to “ fix things up ” ; after the third day the mother got up and attended to the baby and even made the bed herself. About half o f the mothers visited had hired household help at the time of childbirth; nearly one-fifth had help during the latter part of pregnancy. Such help is rather more common on the larger farms (320 acres or more) than on the smaller ones, but usually absence of hired help is not to be attributed to poverty. Sometimes, it is true, the help which relatives can give seems sufficient; but more often the family would have had a hired girl if a good one could have been found. As in all country districts, household help is scarce; but the dearth does not seem to be as absolute as it is in many places, partly perhaps because the farmers are able and willing to pay fairly good prices for such help at times o f stress. So few women except trained nurses were employed to do nursing exclusively that they hardly count in an estimate of the nursing ex penses o f childbearing. Most o f the “ experienced women” and nearly all the hired girls who did childbed nursing did the house work also. The usual wage for a woman taking charge o f the house hold at such a time and doing more or less nursing was $1 or $1.50 a d ay; a girl doing ordinary housework without taking much responsi bility was commonly paid $4 or $5 a week. Considering only those (332) confinements which took place in the country we find that in 142 cases the mother had no expense for either nursing or household help at that time; that is, all such work was done by members o f the family, relatives, or neighbors. In the other 190 cases some expense was incurred for these services, either for nursing or housework, or both. In more than half of these cases where the cost was obtained this item in the budget was less than $20 ; in nearly two-thirds it was less than $25; in only one-eighth was it greater than $50. The amount spent depends mainly upon the length o f time for which help is kept; the figures given above cover a maximum period o f 12 weeks—6 weeks before and 6 weeks after confinement; but the minimum was sometimes as short as 3 days. As a matter o f fact, 19 mothers had help for more than 6 weeks before confinement and 18 for more than 6 weeks afterwards; but the ex pense for these additional.weeks has not been included in considering the costs o f childbirth. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 M A T E R N IT Y A N D I N F A N T CARE. Prenatal care. In one-third (119) of the pregnancies which occurred in the two years o f the survey the mother had some prenatal care from her physi cian. How adequate this supervision was, however, is a different question. In order to be able to classify the care received by mothers during pregnancy the following outline has been drawn up, after consultation with Dr. J. Whitridge Williams, professor o f obstetrics, Johns H op kins University, as representing a fair standard for adequate medical prenatal care: 1. A general physical examination, including an examination of heart, lungs, and abdomen. 2. Measurement o f the pelvis in a first pregnancy to determine whether there is any deformity which is likely to interfere with birth. 3. Continued supervision by the physician, at least through the last five months o f pregnancy. 4. Monthly examinations of the urine, at least during the last five months.1 Though this standard is no higher than is necessary to insure the early detection o f abnormal symptoms and conditions, it is not a standard which is generally attained in private or public practice, either in cities or in rural districts. Comparing conditions as reported by the mothers with this stand ard, we find that six o f the patients who are counted as having pre natal care because they sent the urine to the doctor for examination never saw the doctor at all during pregnancy, though in some in stances he sent them medicine. Sixty-nine patients who saw the doctor had no general examination. Fifty-nine had no analysis o f the urine. In no case was the pelvis measured with the calipers, in spite o f the fact that 42 of these patients were carrying their first babies. About two-fifths of the patients saw the doctor only once; in 28 o f these cases the one consultation with the doctor, with po general examination, was all the prenatal care given. In only two cases, neither of them a first pregnancy, could the care received be counted as adequate; in four other cases it would have been adequate, since there was continued supervision and repeated urinaly ses, except for the fact that the patients were primiparae and no measurements o f the pelvis were made. In 18 cases, none of which was a first pregnancy, there was a physical examination, one or more urinalyses, and some supervision, though not enough to make the care adequate; these are classed as having fair care. A l l the rest ( 99) of the women either were primiparae and had no measurements taken, or else they lacked one of the other essentials. For example, 1 See Maternal M ortality, pp. 1 2 -1 3 . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis U. S. Children’s Bureau publication No. 19. M A T E R N IT Y A N D I N F A N T CARE. 29 a women in her first pregnancy, in poor health and under the doctor’s care all the time, had no general examination and no urinalysis. Another mother, who sent the urine for examination daily during the last two months o f her first pregnancy, never saw the doctor until the time o f confinement. Another mother, who was bloated, vomited, and had dizzy spells all through her first pregnancy, went to the doc tor in the second month. He made no examination nor analysis o f the urine, though he told her she had kidney trouble; he merely gave her some medicine “ which did no good,” so she never went back. At eight months she had eclampsia. As a rule the mothers who feel, themselves to be in poor health during pregnancy are the ones who resort to the doctor. Among the 119 who had prenatal care, only 22 reported that they felt well during pregnancy; 34 had minor ailments such as backache, nausea, ■cramps, headaches, swollen hands and feet, or varicose veins; and the rest had some more serious trouble. Few women in this com munity recognize that it is wise to consult a physician during preg nancy whether or not they feel normally well. On the other hand the fatalistic assumption that a pregnant woman may expect to be thoroughly miserable is much less common than in many other places. Most o f these women, if they feel sick, make some attempt to get relief from the doctor even if only by sending for medicine. Doctoring with patent medicines is occasionally tried but is not common. The cost o f prenatal care in this community is difficult to deter mine, because it is frequently either included with the doctor’s ob stetrical fee or lost track o f in the general family bill. In the majority o f cases where a report could be obtained the cost was less than $5. Apparently no charge is ordinarily made for urinalysis; most consultations with the doetor take place at his office, for which the fee is never high; and only when some serious complication calls the doctor to the home is any considerable expense involved. That cost is' seldom a determining factor in calling upon the doctor is further indicated by the fact that in this district prenatal care is no more common among the well to do than among the poorer families. dost of childbearing. An attempt was made to find out how much it costs to have a a baby in this part o f the country. This estimate o f costs covers only the services connected with the birth—prenatal care, obstetrical fee, nursing, and extra household help for the confinement period— and does not include equipment o f any kind, such as medicine, nursing supplies, or the baby’s clothes. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 M A T E R N IT Y A N D I N F A N T CARE. The ordinary range o f the different items o f cost thus included has been already described. The total cost for these services was obtained for 249 cases1 (the other mothers being unable to give this information), and was as follows: Cost of confinement. Number of confine ments. 249 198 114 4 Total................ Less than $50........... . Less than $25___ No cost......... Less than $5. $5 to $9......... $10 to $14..., $15 to $19.... $20 to $24..., $25 to $ 2 9 ...____ $30 to $39........... . $-10 to $49........... . $50 to $59............. . $60 to $69.,.................. $70 to $ 7 9 '............... . $80 to $89................., $90 to $9^,............. .., $100 or more............. . 1 8 is BS 37 28 39 17 18 11 7 5 4 8 From these figures it appears that nearly half (46 per cent) o f the babies cost their parents less than $25; that four-fifths (80 per cent) cost less than $50; and that the expenses o f the birth o f the large majority (63 per cent) came to between $15 and $40. O f the 22 cases where the costs were markedly higher than the general rule—that is, $70 or more—2 were hospital cases with seri ous complications; in 4 cases the cost for physician’s services out side o f the hospital exceeded $25; in 7 cases a trained nurse was employed; and in 9 cases the expenditure for household help and nursing (exclusive o f trained nurses) was $50 or more. Apparently, therefore, unusually high expenses o f childbirth are much more apt to be due to the cost of nursing and household service than to medical fees. COMPLICATIONS OF CONFINEM ENT. Among the 349 confinements concerning whidh records were se cured in this study there developed 2 cases o f eclampsia. Four o f the children were stillborn. Sixteen deliveries were effected with in struments. One Caesarean section and 2 versions were performed. In the rural parts o f the county during the period studied 3 deaths occurred from puerperal septicemia, 2 following miscarriages, and 1 following a full-term birth. kSo far as could be learned, these were the only deaths in this area from causes connected with childbirth. During their whole child-bearing history the 3302 mothers had had 1,269 pregnancies, o f which 63 (5 per cent) resulted in mis1 Including confinements in a hospital, hut excluding others where the mother went away from the country district o f this county. 2 The history for one mother, secured from the grandmother, was too incomplete tQ use. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 31 •carriages and 23 (1.8 per cent) in stillbirths. O f the 1,216 children, carried to at least seven months’ term 73 were delivered with instru ments ; 48 o f these were first-born children. That is, 14.5 per cent of the first-born children o f these mothers and only 2.8 per cent o f the subsequent children were delivered with instruments. There was only one fully developed case o f eclampsia besides the two in the survey period, but in one other instance the doctor forced an eightmonths’ birth “ because he feared spasms. ” MOTHER’S WORK. The work which a mother does during pregnancy and within the first months after childbirth is a possible direct cause o f injury to her and to her baby. So, also, her ordinary duties and the work which she did in girlhood have an important influence upon her health, and presumably therefore affect her children’s vitality. As would be expected in a farming community, thé mothers o f this study did practically no work away from home; two laborers’ wives hired out for a few weeks to cook for harvest hands or thrash ers, but that was all. Consequently the problem of the work the mothers did during the period o f the survey resolves itself into a question o f housework and work on the home farm. O f these, house work is much the more important in this district. Cessation of work before childbirth. It already has been shown that about 1 in 5 o f the country mothers, had hired help with her housework during the last weeks o f preg nancy. Often such help is primarily a precaution to insure havingsome one on hand when needed, but in some cases the hired girl re lieves the mother o f most o f her work. Generally, however, preg nant mothers keep up their usual round o f duties until labor begins*, unless they are disabled by serious ill health. Besnmption of work after childbirth. In this community two weeks is well established as the shortest period that should elapse after confinement before a woman un dertakes any great amount o f work; and often the heavier house work such as washing and ironing, and the out-of-door chores, are not resumed for two or three months. Ten days in bed is the prevail ing standard for recuperation after childbirth, but normally a motherwho gets up after 10 days does no work within the fortnight. Less than 1 in 10 o f the mothers visited got up from bed before the tenth day ; less than 1 in 40 under a week. Pressure o f work doesnot often seem to be an important factor in inducing the women o f this part o f the country to get up too soon, for out o f 7 who were up in less than a week, 3 did no work for two or three weeks ; 3 did; https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 M A T E B N IT Y A N D I N F A N T CABE. some work after one week but had help for two or three weeks; only 1 did any o f her regular work within the first week, and she did nothing but the cooking during the first two weeks. Usual housework and help. Leaving out o f account the period immediately preceding and following confinement, we find that only 16 mothers—1 in 20—had a hired girl as a regular or usual assistant; 73 had a sister, mother, or daughter 14 years or older to help them; and 33 reported that they had more or less help from their husbands. The rest—about two-thirds o f the whole number—managed their housework alone or with some help from the boys or younger girls. The amount of work the mother has to do depends also to a- great extent upon the size o f the family. Moderately large families—of seven or eight people—are numerous, forming almost as large a proportion (28 per cent) o f the total as do the small families o f three or four (30 per cent). The typical family has several children who are too small to be o f any help to the mother but are, on the contrary, a decided addition to her burdens. The farmhouse. The typical farmhouse1 has from three to six rooms, most com monly four, all on one floor. Most o f the houses, except on some of the tenant farms, are fairly well built and in good repair; but many are needlessly inconvenient for the housewife. As one renter’s wife said when asked about conveniences, “ I mostly had inconveniences.” Occasionally one comes upon a farmer who has just taken hold o f his own land, and is temporarily housing his family in a one or two room shack; but such pioneer conditions are rare. Probably the most serious housing problem is the difficulty some renters have in finding any house to live in or, at lea^t, any decent accommodations. Room crowding is fairly common in these farm homes, and the inevitable confusion must add appreciably to the housewife’s labors. Nearly half (45 per cent) o f all the homes had more than one occu pant per room, counting all the rooms in the house and not in cluding the baby; one-sixth (16 per cent) had two or more occupants per room, which makes a distinctly overcrowded household. As might be anticipated, the homes on the smaller farms (under 320 acres) are more often crowded than on the larger ones. Water supply. Almost every farm is provided with a windmill; in spite of the fact that a drilled well with its mill is an expensive piece o f equipment, it is fortunately accepted as essential. And as the western plains are 1 A ll house Information is for the house where the parents were living when th e baby was horn. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 33 notoriously windy, the water seldom has to be pumped by hand; ex cept that, as one farmer explained, “ The wind ’most always gives out at harvest, just when you need the water most.” In the majority of cases the windmill is located within 50 feet of the house; nearly onefourth o f the houses have their mills within 25 feet. On the other hand* 1 in 8 o f the homes without water inside is 100 feet or more away from its water supply. For the most part, however, the carrying o f water is not such a task as in districts where it must be brought from a spring or creek. As the pumping power is already provided, it is comparatively easy to pipe water into the house; in a typical instance, where running water had recently been put in, the installation cost only $100. Never theless only 60 families, or less than 1 in 5, had water in the house when the last baby was born. But the idea o f installing “ water works ” is evidently spreading, for several families had made this improvement within the year; and more were planning to do so in the near future, especially when building new houses. One mother ex pressed a common sentiment when she said, “ We sure will have water when we are settled on a place to stay.” When people have water in the house they usually have running water from a tank filled by the windmill. This tank is sometimes in the house and sometimes on the windmill frame. But some builders have been so m i^uided as to arrange the tank under the house so that the water must be lifted into the kitchen by a hand pump. A num ber o f families have piped water available in the summer, but the tanks or pipes are not protected from freezing in the winter. One in four o f the landowning fathers had water in his house, but only 1 in 10 o f the renters. Other conveniences. Sinks for the disposal of waste water are as scarce as inside water, and even more markedly confined to the homes o f landowners. Eight een families had bath tubs—most, but not all, with running water; only 2 had water-closets. Although conveniences which are taken as a matter o f course in the ordinary city home—sinks, running water, set tubs, and lights—are scarce, the housewives are well supplied with other labor-saving de vices such as oil stoves, sewing machines, washers, and mechanical churns. Nearly every one has a sewing machine. Four in every 5 women have washing machines, and 1 in every 8 has a washing ma chine run by an engine. Boarding hired men. By far the most serious aspect o f the housework problem in this, community is the necessity o f boarding hired men. About one-third https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 34 M A T E R N IT Y A N D I N F A N T CARE. (114) o f the families visited kept a regular hired man for whom the housewife must provide for at least six months through the summer and fall. During their last pregnancy 263 mothers had occasional farm laborers to board. These extra hands appear for the busy sea sons, almost always for harvest and thrashing, often also for plowing and sowing in the fall, and sometimes for the spring work. One mitigating feature o f the situation is that it is not the custom in this district for the housewife to do the washing for the hired men, particularly not for men who are employed for only a short time. Even men employed for the season are usually expected to do their own laundry work. Harvest and thrashing crews. O f all the “ hands” the harvest crew is the greatest burden. Wheat harvest comes in the latter part o f June and the early part of July and ordinarily lasts for from two to three weeks, occasionally for a month; and life is strenuous during that time. The smallest number o f men who can handle the reaping is 3— called a half crew—which means 2 men besides the head o f the family, unless there are grown sons or brothers in the household. A standard crew for work with a header—the almost universally used type o f reaping ma chine— is 6 or 7 men, and this is the number most commonly em ployed; but the larger farms not infrequently need a double crew o f 12 to 15 men. T o have such a crew to cook for, even with the help o f a hired girl, for about three weeks in the middle o f summer is plainly no light task and is especially trying when it comes near the time o f confinement. The women recount that during harvest they have to begin work about 4 a. m. and get through about 10 p. m., with possibly a short rest after dinner. The work is acknowl edged to be so hard that hired girls regularly get more than their standard wages at this time—sometimes as much as $2 a day. The housework at thrashing time is not regarded as so arduous, even when a larger number o f men (thrashing crews usually number 12 to 15 men) has to be provided for, because thrashing ordinarily lasts only a few days, and “ you can get a lot o f things cooked up in advance to last that long.” Furthermore, many o f the thrashing outfits feed their own men—the “ machine men ”—from a* portable kitchen called the “ cook shack,” an arrangement which relieves the housewife o f all responsibility so far as these men are concerned. Then all she has to provide for, in addition to her family, are the few men who haul the grain; and when, as is often the case, the haulers are neighbors who are “ changing work,” she has to give them only their dinners. Obviously the cook shack is a great boon to the housewife. The reason it is not always employed is that https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 35 under the standard scale o f charges it constitutes a large addition to the farmer’s thrashing expense; he can save a good deal o f money hv getting an outfit without a cook shack and providing for the men himself. How the situation works out for a representative group o f farm mothers is shown in the following illustrations: On a farm o f 160 acres, where the family consisted of the father, mother, and two children o f 3 and 5 years, the baby was born in June, at the beginning of the harvest season. For a week before her -confinement the mother had to house and board 4 men; and when the actual harvesting began, 10 days after the baby was born, she had 16 men to board for 8 days. Six weeks later came the thrashing, with 5 men for 3 days. This extra burden o f work came at a time when the mother most needed her strength, at the end o f a trying preg nancy which was complicated by swollen feet, varicose veins, and dizzy spells. While the confinement was normal, the recovery was slow. Although for 2 weeks before and 3 weeks after the baby was born she had a hired girl who did most o f the work, and although . her sister came to help during thrashing, nevertheless the mother attributes her slow recovery to the fact that she had to work u harder than she would have liked ” after the baby was born. The mother on another 160-acre farm had 4 children, th$ eldest 8 years old. She was miserable with pain and nausea all through the latter months o f her fifth pregnancy, and was weak for more than a month afterwards. Harvest began the day before the baby was born. The two “ hands ” stayed 15 days; but they got part o f their meals at a neighbor’s, and the mother did not have to cook for them herself because she had a hired girl who did all the work for 2 weeks before and 5 weeks after the baby came. At thrashing time the mother had only two meals to give. In another case, on a farm o f 640 acres, the mother, who was badly bloated and troubled with headaches and vertigo during the last month o f pregnancy, had to board during that month 3 carpenters and 6 men for the barley harvest, in addition to the 1 man employed for the season. Though she had a hired girl for the last 2 or 3 weeks, she helped with the cooking up to the last day and had the care o f her three small children. The baby was born the very day the wheat harvest began; that day there were 15 hired men on the place. Harvest lasted 12 days; the next day the hired girl left; and the day after that came the thrashing, with 6 men to provide for. It is not surprising that the mother reported that she recovered her strength slowly. The baby on a 450-acre farm—the youngest o f 5 children under 9—was born in the winter. The mother had had a stillborn child less than a year before, and she vomited badly all through this last preg nancy. Every year she has 6 men for harvest in July for about 3 weeks, and 6 grain haulers in October for about 8 days; her husband keeps 1 hired man all the time and usually 2 all summer. The mother has had no help for the past three seasons. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 M A T E R N IT Y AND* IN F A N T CARE. The family on a 520-acre farm consisted o f 9 people; 2 boys were grown, but the oldest girl was only 12, and there were 3 children under 5. The last baby was bom in the fall, 3 months after harvest; the mother was troubled during pregnancy with pains and dizziness. Harvest brought 2 hired men for 10 days early in J u ly; later in the month thrashing brought 3 men fo r 2 days. The mother had no> help with the housework except her daughter. On a farm of 200 acres where the baby was born early in the fall the mother had 3 harvesters to board for 2 weeks in June; at thrash ing in August she had 4 men for dinner 2 days only. She had no help either time and she reported that she felt “ extra well ” through out the summer. In addition to her work for the men she had twolittle children, 2 and 3 years old, to care for. On a 160-acre farm the mother, whose baby was born late in the fall, boarded 6 men for 2 weeks at harvest beginning the last o f June; at thrashing in August she boarded 5 men for 2 days. She always has to be careful o f her strength during the early months o f pregnancy, but fortunately was in excellent health during the busy season. Her daughter o f 18 helps her with the housework;, she has only one other child besides the baby, but she is caring for twoo f her sister’s children. On a 3,80-acre farm the baby was born in the latter part o f May,, the sixth child in a family whose eldest was only 8 years old. The mother was in excellent health through her pregnancy and recovered from childbirth so well—“ felt better than ever before”—that she kept her hired girl only two weeks, after which she did all her regu lar work, including milking, gardening, and the care o f chickens. Harvest came when the baby was 3 weeks old, bringing 5 “ hands ” for 2 weeks; at thrashing, immediately after harvest, 2 haulers were boarded for 2 days. The mother had no help, with the housework during this time, but she did no milking or gardening through the harvest period; as far as possible she had “ got her work done upahead ” the first week she was up from bed. The mother on a farm o f 240 acres had three children, the oldest 7, before her last baby was bom. This birth occurred in the winter,, which made the trying latter months o f pregnancy—the mother suf fers from swollen feet and varicose veins—easier than i f it had come in the summer. In the previous summer she boarded 6 men at harvest for 6 weeks; and almost immediately after that she had the “ whole crew ” o f 12 thrashers to cook for for 3 or 4 days. From the time the baby was 3 weeks old she had 1 hired man to board; 6 harvest ers again in the summer, but for only 2 weeks; and 12 thrashers in August. She had help each summer, however. Another mother, whose baby was born in tjie fall on a 640-acre farm, had to board 4 harvest hands in July and 12 thrashers for 6 days in August in both the preceding and following summers; she had no outside help with the housework, but her 2 grown daughters do much o f the work. She was in good health throughout this time except for varicose veins during pregnancy. Another baby was bom. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 37 the second spring, and the varicose veins were “ worse than ever.” That year the mother had the usual 4 harvesters for 2 weeks when the baby was 10 weeks o ld ; but the thrashers brought a cook shack, so that she had only 3 or 4 grain haulers to provide for. The father keeps 1 hired man nearly all the time. This mother has 11 children, o f whom 5 were less than 10 years old when the last baby was born. .The baby on one 560-acre farm was born in the winter. The mother was troubled with vomiting throughout pregnancy. One hired man was employed steadily that year. The six harvesters stayed until the end of July, but the mother had help then. For the last three months before the baby was born she had a hired girl all the time and did no work except cooking and sewing. The cooking in itself was no light task during this period, as her husband thrashed three different times that fall, the last time only a month before the baby was born; and each time the mother cooked for the whole crew o f 12 to 14 men. Ever since this confinement—her first—she has been almost disabled with uterine trouble. The following summer there was 1 hired man before harvest; 6 harvesters for 2 weeks; and only 3 or 4 haulers for 3 days at thrashing, because the thrashers brought a cook shack. The mother could not get a hired girl that year, but her sister helped her through harvest and thrashing. A mother who lived on a 640-acre farm had four little children before this baby came, o f whom the oldest—twins—were only 4. -The baby was born in the winter, five months after harvest time, and the mother had good health all through her pregnancy except in the first two months. A t harvest that summer she had a hired girl to cook for the 7 men, but no help at thrashing in September, when she had to do the cooking for 15 men for 3 days. One man is employed all the time. The year following the baby’s birth the mother cooked for 3 harvesters and later for 3 haulers at thrashing, and then for 2 hired men until November; she could not get a girl at all that year, although the 2-year-old was sick at harvest time and the mother was barely able to struggle through with the work. This family plans to give up farming, partly because the harvest work is too hard for the mother and they have found it almost impossible to get household help. Four-fifths (272) of all the farm mothers worked for harvest crews, o f at least 3 men, either before or after confinement; 43 of them within 1 month o f confinement, 81 within 2 months, and 124 within 3 months. That serious harm may result from the strain o f such work is illustrated by the experience of two mothers during former pregnancies, in each instance a little over a year before the last baby was born. Each had a miscarriage that summer, one at 2 months and one at 5, which she attributed to overwork at harvest time. Both o f these women evidently were hard worker’s. One o f them had a gang o f carpenters in addition to the farm hands to provide for the summer of the miscarriage, and besides her own work she did the washing and baking for a bachelor neighbor. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 38 M A T E R N IT Y A N D I N F A N T CARE. It is markedly true o f this country that prosperity comes hard on the farmer’s wife, because prosperity here means practically always a larger farm and more wheat, and therefore more men to board for a longer time. One woman expressed the situation succinctly by saying: “ We have so many men because we farm so much land.” She had a double crew o f 15 harvesters to board both the year her baby was born and the year after, and 10 thrashers immediately after harvest; also 2 men through the rest o f the summer and fall, and a gang o f carpenters for a good part of both summers. Though she had a hired girl during harvest and thrashing, her work was nevertheless much heavier than that o f the wife on a quarter-section (160-acre) farm whose only “ hands” were a single crew of har vesters for a couple of weeks and a few haulers for two or three days. It also happened that in her case the difficulties o f the situation were aggravated by an uncomfortable pregnancy, with much vomiting, and a difficult instrumental delivery—the birth occurring two weeks after thrashing— resulting in injuries which troubled her for a long time afterwards. , ,, Another mother, whose husband farms a section and a halt (9b0 acres), had a crew o f IT men on the place for three months the sum mer her baby was bom and 1 or 2 men all the time. A third, on another 960-acre farm, had 4 men for a week, then 12 men for six weeks (finishing one week before her baby was b om ), and after that from 1 to 4 men for two months more until the next crop was sown. Each o f these women had a hired girl through the summer. Mothers’ work for harvest crews is not only heavier on the larger farms but also falls to the lot of a larger proportion o f the mothers. Where the father farmed less than half a section 72 per cent of the mothers had this work to do either before or after confinement; on farms o f from one-half to three-quarters o f a section the percentage o f mothers having such work was 85; and on farms o f over threequarters o f a section 87. This relation holds true o f all work for farm hands; where the farm was smaller than one-half section 79 per cent o f the mothers had to carry this burden during pregnancy; on the medium-sized farms, one-half to three-quarters of a section, 90 per cent; and on the larger farms (over 480 acres) 95.5 per cent o f the mothers had hired men to work for. Renters’ wives have many inconveniences to bear, but they fare a little better than owners’ wives when it comes to working for the hired men; 84 per cent o f the former boarded some hired men during pregnancy and 92.4 per cent of the latter. Farm laborers’ wives, o f course, usually escape this kind o f work, but sometimes they have to board some o f the employer’s hands. Summer work is likely to fall heavily upon the wife of the man who owns and runs a thrasher. There were 7 o f them among the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 39 mothers included in the survey. Among these 2 ran the cook shack for the husband’s crew for about 2 months ; 2 did the husband’s farm chores for 2 or 3 months while he was away with thè thrasher ; 1 had the crew to feed at the house most of the time for 2 months; and another had the crew at the house over Sundays all through the thrashing season. Dairy work. Dairying is a minor factor in agriculture in this part o f Kansas ; most farmers keep a few cows and many sell some butter or. cream, but very few make any large part o f their income from this source. Though half o f the women visited did some churning, the large ma jority o f these made butter only for their own use. Neither milking nor running the separator is customarily regarded as women’s work, and a goodly number o f the men even do the churning; in most fam ilies the mother does the milking only when the men are away or particularly busy, just as she would help with their other chores at such times. As the heaviest milk production comes in the winter while there is wheat pasture for the cattle, and as the men are least busy at this time, the situation works out very conveniently for the women. Poultry raising. The most common outdoor work done by the women is poultry raising. Almost every farm has its flocks o f chickens and turkeys. Eight out o f every 10 women visited kept chickens; and most of them raised at least 200 a year, while flocks o f 400 or more are not uncommon. Most o f the mothers do not regard the work o f caring for the chickens as onerous, for in this climate chickens seem to thrive with very little care except in the spring, and therefore do not aggravate the summer rush. Gardening. Less than half o f the mothers reported having done gardening during the period covered by the survey. Many had no garden (it is a discouraging task to try to raise vegetables in this climate), and in other families some one else—husband, children, or grandmother— took care of the garden. The men as a rule are helpful about doing the harder part o f the work, such as preparing the ground, and often the cultivating also. Other farm work. Other farm chores—feeding the stock, etc.— rarely fall to the lot o f the mother o f the family ; only 13 women reported doing this kind o f work. And field work is even more unusual, only 7 mothers having helped in the fields during the last pregnancy or the year https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 M A T E R N IT Y A N D I N F A N T CARE. following. One woman expressed the general standard when she said: “ I had rather do outside work than housework, but I won’t do both.” In this community few women would think o f neglecting their housework in order to help in the fields. E arn work during girlhood. The situation is very different when one inquires as to the work which these same mothers did when they were girls. Ninety per cent o f them lived in the country for at least two years o f their girlhood (after they were 10 years o l d ) ; and o f these, four-fifths did more or less farm work. About one-third o f the country girls did chores only—milking, gardening, care o f chickens, feeding stock—while nearly half o f them, in addition to their chores, did some work in the fields. For the girls raised in western Kansas this field work usually consisted of driving teams or herding cattle; but the list includes women who as girls did many other kinds o f work in other places. IN F A N T W E L F A R E . Infant mortality rate. The term “ infant mortality rate ” is used in the Children’s Bureau studies to mean the number o f children out of each 1,000 born alive within a given period who die before they are 1 year old. In the group o f 349 live-born children included in the survey, 175 were born at least a year before the agent’s visit; and o f these 7 had died before reaching their first birthday, giving an infant mortality rate o f 40 per 1,000, or 1 death for every 25 births. For the other 174 born within the year preceding the visit no definite rate can be computed, because some o f those who were still alive when they were visited may have died afterwards before they were a year old. There were 8 known deaths among this group, so that the infant mortality rate was at least 46 per 1,000. According to the death records of the county, no others o f these children died up to the close o f 1916, when all o f them were at least 3 months old and had therefore passed the age when most infant deaths occur. Hence it seems probable that the actual rate for this group would not be a great deal higher than this figure. An infant mortality rate o f 40 per 1,000 is the lowest found in any o f the Children’s Bureau studies and less than half o f the lowest rate found in any o f the cities studied; the rate found in the same way for selected country townships in Wisconsin was 54 per 1,000. It must be remembered that the figures upon which this rate is based are so small that one or two deaths more or less—which might easily have happened without any real change in conditions—would make a considerable difference in the rate. Still it is improbable that chance variation would bring the rate much above 50. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 41 The mothers o f these babies had had altogether 1,193 live-born children. Excluding the 174 who were born within a year of the date of visit, there remain 1,019 children in these families for whom the infant mortality rate can be computed. Among these children 56 died before they were a year old, which gives an infant mortality rate o f 55 per 1,000, or a little over 1 in 20. Evidently, then, the low rate for the survey period is not sporadic; the causes which produce a low rate among the babies in these country families have been in operation throughout the family history. It is encouraging that in a prosperous, intelligent, farming com munity the infant mortality rate can be brought so low as this. Nevertheless, the existing rate should not be regarded with com placency, for, as Sir Arthur Newsholme says, “ I f babies were well born and well cared for, their mortality would be negligible.” In other words, there is no inherent reason why any babies should die in a community which has all the advantages possessed by this county— country life, healthful climate, high standards o f living, a high level o f intelligence about matters o f health, and means where with to provide for its mothers and babies. Causes of death. O f the 15 deaths under 1 year of age which occurred in the group o f babies for whom schedules were secured, 2 occurred under 1 day, 4 under 2 weeks, and 6 under 1 month. Five o f the deaths were due to causes peculiar to early infancy, 5 to diarrhea and enteritis, 3 to respiratory diseases (1 of these was bronchitis following whooping cough), 1 to measles, and 1 to marasmus. Feeding customs. Practically all the babies in this study were breast fed at least for a few days. O f the 349 live-born babies 2 died before they were fed at all; only 2 were fed from the bottle from the beginning; and only 7 were weaned before the middle of the first month. On the other hand, 311 or 92 per cent of the 340 babies for whom the record covers the first month o f life were exclusively breast fed through the greater part o f that month, and another 20 or 6 per cent were partly breast fed. The proportion o f exclusively breast-fed babies then drops month by month to 71 per cent at 5 months and to 61 per cent at 6 months. After that the percentage naturally falls off more rapidly, but 23 per cent or nearly one-fourth of the babies were still exclusively breast fed during the ninth month, and a small number (8 per cent) had no, other food than breast milk until after they were a year old. Breast feeding in combination with other food is continued longer even than these figures would indicate. A t the end o f the ninth month only 19 per cent o f the babies were weaned, i. e., wholly taken https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 42 M A T E R N IT Y A N D I N F A N T CARE. off the breast, and at the end of 12 months only 30 per cent or less than one-third. In fact, for the majority breast feeding continues well into the second year; at the end o f 15 months 45 per cent or near] j one-half were not yet weaned; and at the end of 18 months 24 per cent or about one-fourth. Medical authorities agree that this custom of late weaning is not to be recommended. Though less dangerous than the opposite practice o f too early weaning, nevertheless it is not advantageous either for the mother or for the baby. In most cases the baby should be weaned by the end o f the first year. I f the feeding history o f these country babies in Kansas is com pared with that o f the city babies o f native mothers in Johnstown, Pa., and Manchester, N. H.—the first two cities where this study was made by the Children’s Bureau— and in Akron, Ohio, the larger of the cities o f the Middle West, we find that exclusive breast feeding is much more common through the first nine months in this Kansas county than in any o f these cities (with the exception o f the last three months in Akron), and, conversely, that artificial feeding is even more markedly absent. Since breast feeding, especially in the early months, is proved and acknowledged to be an important factor in protecting a baby’s chance o f life, this fact o f the unusual prevalence o f breast feeding probably accounts, in part at least, for the low death rate among this group o f country babies. T a b l e Y . —Breast and artificial feeding, by month and locality. Percentage of infants who were exclu Percentage of infants who were artifi cially fed. sively breast fed. Locality. During first month. During third month. During sixth month. During ninth month. During first month. County in Kansas___ 92.0 Manchester, N. H .1... Akron, Ohio1............. 81.7 87.9 83.2 66.9 60.9 73.3 60.8 41.1 36.3 54.5 23.3 11.8 17.1 27.7 15.4 8.1 2.1 During third month. 6.1 20.3 32.5 18.5 During sixth month. 12.5 26.1 47.4 26.9 Dining ninth month. 19.3 34.1 55.1 32.3 1 The percentages for Johnstown, Manchester, and Akron are given only for the babies of native-born mothers, because in the Kansas county practically all the mothers were native. A mother may be obliged for some reason to resort to supple mentary feeding or even to wean her baby altogether; but necessity does not excuse the giving o f solid food in the early months, as is often done by ill-advised mothers. The. mothers o f this community are on the whole careful in such matters. Only 10 babies (out of 310 whose feeding records for three months were obtained) were given any solid food before they were 3 months old, including as solid food gravy, or milk thickened with flour, crackers, etc. Only 59 (out o f 263) began to eat solid food before they were 6 months old. And 79 children (out o f 202) had no solid food until after they were 9 months old. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE, 43 PERCENTAGES OF ALL BABIES RECEIVING DIFFERENT KINDS OF FEEDING, BY MONTH OF AGE. — ----------------------------- Breast feeding. -------------------------------- Mixed feeding. --------------- ------------------Artificial feeding. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 44 M A T E B N IT Y A N D I N F A N T GABE. The use o f proprietary foods and condensed milk for babies is less common than in many localities. Twenty-four o f the babies of the survey were given condensed milk; 14, malted milk; and 26, other prepared foods. Cows’ milk, either whole or modified but without any proprietary preparation, was used as a regular feeding for 51 babies at some time before they began to take solid food. A large number, however, had no supplementary feeding—the breast milk being ample—until the mother considered that it was time to allow the baby to eat solid food, which, as we have seen, in most cases was not very early. Some o f the mothers in this county unfornately exercise worse judgment about what to give the baby than about when to begin artificial feeding. T oo many youngsters take “ tastes ” o f whatever the family has, or whatever they want, from the beginning. On the other hand, many mothers are careful about this also, beginning with a restricted diet o f milk and cereals, bread, or crackers, and only gradually extending the list o f what the baby may eat. A striking illustration o f the dangers o f artificial feeding, and also o f the close connection between maternal and infant welfare, is given by the history o f the baby whose mother died o f puerperal septicemia. He “ did finely ” the first 10 days while his mother was nursing him but never thrived on- artificial food. A ll sorts o f feed ing—except modified milk—were tried by the two women who took care o f him almost constantly under the advice o f one or another doctor; but nothing agreed. He “ just wasted away” ; and when the agent saw him he was “ a pitiful little skeleton, with hardly strength enough to cry.” Consequently it was no surprise to learn that he died the following day from marasmus. Birth registration. Kansas has a satisfactory vital-statistics law which requires (sec. 10, ch. 296, Session Laws 1911): “ That it shall be the duty o f the attending physician or midwife to file a certificate o f birth, properly and completely filled out, giving all the particulars required by this act, * * * with the local registrar o f the district in which the birth occurs, within 10 days after the date o f birth, and if there be no attending physician or midwife, then it shall be the duty of the father or mother of the child, * * * to notify the local registrar within 10 days after the birth of the fact that such birth oc curred * * *.” As has been explained, a canvass was made in the country districts to find babies whose births , had not been registered. The list of names so found was afterwards checked by the State registrar. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 45 In this way 351 unregistered births were discovered. Fourteen of the 350 children born in the county were born in town and all of these 14 were registered; but of the 336 births which occurred out in the country, these 35 or 10.4 per cent were unregistered. I f this county may be taken as a fair sample o f the completeness o f birth registration in Kansas, only a slight improvement would be necessary to bring the State up to the standard required for admission to the birth-registration area, viz, that at least 90 per cent of all births shall be registered. Twenty-six o f the unregistered births were attended by physi cians, 5 by midwives, and 4 by other people. As midwifery in this county is on such a nonprofessional basis, it is fair to say that the duty o f reporting all these 9 births where there was no physician devolved upon the parents. Six o f the 10 physicians who did the bulk o f the obstetrical work in this district reported all their births; and 3 o f the others were responsible for half .of all the failures to register. No record was secured as to promptness of registration except for the 19 births which occurred in September, 1916. A ll of these were registered; but 8 o f the 19 were registered more than 10 days after the birth took place, and therefore the requirement of the law on this point was not fulfilled. Township, village, or city clerks act as local registrars in Kansas and are required not only to secure complete registration from their districts but also to keep local records o f all births and deaths. According to the provision of the law (sec. 3, cit.), which authorizes the State board of health to establish registration districts, this county is divided into eight districts o f varying size. Five consist of only one township, while the largest contains five townships. Apparently the purpose is so to arrange the districts, by grouping the townships around the larger towns, that the registration office shall be as convenient as feasible to the local physicians. But this arrangement must interfere, where the districts are large, with the registrar’s ability to keep track of events through his own acquaintance. The problem of registration is further complicated by the fact that in some cases births are not registered in the dis tricts where they occurred but in the physicians’ home towns. This practice is unnecessarily confusing to the registrar o f the district in which the birth did occur, if he is making an effort to carry out his duties and see that the births in his territory are registered. 1 Including one which was registered several months after the canvass was made, pos sibly, therefore, as a result of the canvass; but excluding one which had been registered in the local office but the certificate not forwarded to the State registrar. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SU M M A R Y AN D CONCLUSIONS. The findings o f this survey o f the rural area of one county have a meaning not only for the county itself but also, because this county is a typical one, for large tracts of western farming country. The cir cumstances affecting the care of mothers in childbirth here have there fore a wide significance. The fact that every year in the United States thousands o f mothers die needlessly from childbirth compels attention to this subject. The favorable conditions described in this report suggest measures to be taken by other communities interested in the prevention of suffering and death of mothers and babies. The less favorable conditions reported will doubtless be recognized as typical o f large numbers of rural districts throughout the country. The farming population of this county is almost entirely o f native birth and predominantly o f native parentage. The general standard o f living and o f education and intelligence is high, especially among the two-thirds of the population who own land. For several years the all-important wheat crop has been satisfactory and prices high, so that the conimunity is in a prosperous financial condition. Con sequently most families are not debarred by poverty from obtaining such care for mother and baby as seems to them necessary. The infant mortality rate o f the group of babies studied in this district is low— 40 per 1,000 births. Though this is only half of the lowest rate found by the Children’s Bureau in any o f the cities it has studied, nevertheless the community should not rest satisfied with this record but should set as its aim the saving of all its babies. Nearly all the babies seen were strikingly sturdy, active, and appar ently well developed. It is significant that these indications o f good health occur in a community where only 1 baby in 5 is weaned before he is 9 months old, and where the mothers as a rule are careful of the feeding o f their babies and are interested in learning all they can about the best methods of infant care. The interest shown by the mothers o f the county in having their babies examined at the “ Baby Days ” indicates a field for further en deavor. Such examinations might well be held by physicians at regular intervals at accessible centers throughout the county. A county public-health nurse could assist the physicians at the “ Baby Days ” or baby-health conferences. She could also establish headquarters at the county seat and at accessible substations throughout the county in smaller towns and rural schools, where she could weigh babies and talk with mothers who wish her advice. Howl (to keep the baby 46 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis M A T E R N IT Y A N D I N F A N T CARE. 47 well through the hot summer; what to do before the doctor comes, in an emergency such as croup or convulsions; how to nurse a sick child or a mother and newborn baby at home—these are all questions about which women are anxious to learn all they can. The simple equipment necessary for these meetings and baby-health conferences throughout the county—scales for weighing the babies, exhibit ma terial, and apparatus for giving demonstrations—could easily be moved from one center to another if an automobile were available for the nurse’s transportation. The study shows that approximately 1 in 10 o f the babies in this county bom in the open country will be unable to get a birth cer tificate if one is needed later in life. Such a percentage is a fairly low one, but it shows that a still greater appreciation o f the impor tance of birth registration on the part o f parents and physicians is necessary. No community should be content until every birth is registered. Except at harvest the ordinary run o f work which the mothers have to do is not overhard. Although such conveniences as running water, sinks, and indoor toilets—which a city woman considers indispensable—are too often lacking, nevertheless mechanical laborsaving devices are fairly common. Few mothers do any field work or any farm chores except poultry raising and gardening. But at wheat-harvest time, and often at thrashing, there comes an almost overwhelming rush o f work because of the necessity o f boarding the crews. This is always a great burden and may be a serious matter if it happens at a time when the mother’s strength should be spared. Trained nursing care at confinement is seldom obtained. Only a few of the mothers went to a hospital at this time or had a trained nurse together with a helper for the housework at home. Even the so-called “ experienced” nurses are rare; most o f the mothers vis ited depended upon relatives, neighbors, or hired girls for their nursing care. * There is an evident need in this community for trained attend ants— competent women who have had some training and experience in home care o f the sick, and who can do the necessary housework for the mothers and the nursing under the supervision o f a trained nurse. In several communities it has already been proved that women can be found willing and anxious to do this work. Training courses have been established, and registries o f properly qualified and supervised trained attendants are conducted in several cities and towns. The supervision o f the work .of these attendants by registered nurses is an essential part o f the plan. Visiting nurses are acting in this capacity in several communities. A nurse, or a group o f nurses, employed by this county could well include this work of supervision in their program. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 48 M A T E R N IT Y A N D I N F A N T CARE. The situation as to medical care in connection with childbirth is better than in other country districts studied by the Children’s Bureau. Almost all the mothers were attended by a physician at confinement. Roads which are nearly always good made medical care accessible even in this country o f widely scattered farms. The necessary cost o f medical service is not prohibitive to the majority o f families. Hospitals, accessible to all parts o f the county by means o f the good roads, are available for complicated cases. The mother in the group o f families studied who had to be delivered by Caesarean section might have been lost, and her baby also might have died, if she had lived in a rural district where, either because o f distance or because o f impassable roads, no good hospital was within reach. The question o f the prenatal care obtained by this group of mothers is important. Only of late and to a limited degree has it been realized that expert supervision is necessary for every woman during pregnancy, if complications o f this period and o f confine ment are to be prevented or cured.' Such supervision is essential for the reduction o f the maternal mortality rate o f any community. That physicians should realize these facts is not enough; women and their husbands must realize them also. Otherwise women will not consult their physicians early and regularly during pregnancy, nor will their husbands be willing to pay for this added service. In this rural county one-third o f the mothers secured some prenatal care from physicians. In few cases was this care adequate or even fairly adequate; nevertheless, a beginning has evidently been made toward the realization that medical supervision during pregnancy is neces sary. During the last few years it has been proved that trained nurs ing service is invaluable in supplementing medical supervision dur ing pregnancy. I f this is true in the city, where it is comparatively easy to consult a physician, it is still more true in the country where the distance from the physician makes it more difficult to see him regularly. A nurse who has had special training and experience in prenatal work, and who is especially equipped to discern the danger signs o f pregnancy, can be o f great help to the prospective mother in the country and to her physician. She will advise the mother about daily details of her care o f herself so that she can avoid much discomfort and disability; she will urge her to see her physician early for a thorough preliminary examination and later when neces sary ; she will urge her to send samples o f urine regularly to be ex amined, or, if asked to do so, she will make examinations of the urine and report the results to the physician. Such prenatal work may be one o f the most important phases o f the duty o f a county public-health nurse. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis MATERNITY AND IN F A N T CARE. 49 The fact that in more than one-third, o f the confinements the mother did not receive a visit from the physician after the day of the birth, and the fact that in another third she received only one visit, are evidence that the importance o f after-care for the mother is also not realized. The Children’s Bureau in a recent publication1 has suggested a plan for securing adequate medical and nursing care for mothers and babies in a rural county, which should include: !• ^ rural nursing service, centering at the county seat, with nurses espe cially equipped to discern the danger, signs of pregnancy. The establishment of such a service would undoubtedly be the most economical first step in creating the network o f agencies which will assure proper care for both normal and abnormal cases. * * * 2. An accessible county center for maternal and infant welfare at which mothers may obtain simple information as to the proper care of themselves during pregnancy as well as of their babies. 3. A county maternity hospital, or beds in a general hospital, for the proper care o f abnormal cases and for the care of normal cases when it is convenient for the women to leave their homes for confinement. Such a hospital neces sarily would be accessible to all parts of the county. 4. Skilled attendance at confinement obtainable by each woman in the county. In the county studied progress has evidently been made in secur ing certain o f these suggested essentials for the care o f mothers and babies. It will be evident that in this county and others of similar type the next step may well be the establishment o f a nursing service for the rural parts o f the county. The ways in which a nurse could be o f help to the mothers of this district have been pointed out. -A. number o f public-health nurses in the United States are now em ployed by county boards o f supervisors or boards of education. Their work is no longer an experiment; its value has been definitely proved. In certain counties the work was established at first through private subscriptions; enough money was raised in this way to support a nurse for a period of 6 to 12 months; after the value o f the work had been demonstrated the county authorities appropriated money to continue it. This was in recognition o f the fact that public-health nursing is not a charity but is a measure for health protection to which all the people o f the community have a right. In one county in a Middle Western State a federation o f women was formed which included all the organizations o f women in the county—women’s clubs, ladies’ aid societies, and parent-teacher associations, as well as small neighborhood groups o f rural women. Largely through the efforts o f this federation a tax was levied by referendum vote and a 1 Maternal Mortality from All Conditions Connected with Childbirth in the United States and Certain Other Countries, p. 27. U. S. Children’s Bureau publication No. 19. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 50 M A T E R N IT Y A N D I N F A N T CARE. large sum of money provided for health work. Two nurses are now employed by this county. In many counties the nursing service has been established through the employment of a nurse for the rural schools, and this method has proved very successful. In other counties the nurse has begun her work as a tuberculosis nurse; in others as an assistant to the county health officer. Whatever the beginning of the work, the nurse soon finds that the assistance which she can give to mothers in the care of themselves and o f their babies is one o f its most important devel opments. In planning a rural nursing service two things are essential: 1. Every effort should be made to get the right nurse. The nurse employed should have had training in public-health or visiting nurs ing such as is given now in many training courses, and should also have practical experience. Nurses who have had hospital training only are not fitted to carry out public-health nursing successfully. 2. Ample provision must be made for transportation through the county. In Kansas, county boards o f commissioners have the authority to employ county nurses if they see fit. There is therefore no legal obstacle in the way o f this measure for the promotion of the public welfare, and this county could in no way better demonstrate its progressiveness nor more effectively protect the health o f its citizens than by providing such nursing service for the whole county. o https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
@FedFRASER