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SAVE the YOUNGEST Seven charts on and In f a n t M M a ter n al o r t a l it y , with e x p l a n a t o r y comme nt CONTENTS. W hen will the thermometer fa ll?__________________________ ___________________ The first year o f life is the dangerous age------------------------------------------------------Save the youngest----------------------------------------------------------------------------------------------Take care o f the mothers-------- --------------------------------------------------------------- --------This high peak is unnecessary— J------------------------------------------- ----------------------The youngest most need our care----------------------------------------------------- _ -----------Poverty is the baby’s greatest enemy--------------------.-------------------------- _________ Page, 2 4 6 8 10 12 14 C h arts. Maternal mortality rates------------ ___--------------------- |---------------------------------------Infant mortality thermometer______ ______________ -_________ Deaths under 1 year o f age, by monthly age groups______________ .________ Deaths under 1 year o f age, grouped by causes--------------------------------------------Summer peak o f infant deaths_______________________________________________ Comparison of infant deaths in 1910 and 1918_______________________________ Infant mortality rates, according to fathers’ earnings_____________________ 83669’ —21 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis (1) 3 5 7 9 11 13 15 WHEN W ILL THE THERMOMETER F A L L ? In our country in 1919, 17,800 mothers lost their lives from con ditions caused by childbirth. The mercury in the thermometer on page 3 shows that the United States ranks seventeenth, respecting maternal mortality, in a list o f 17 countries. The intelligence and the conscience o f our people are challenged by this high rate. The death rate from conditions connected with childbirth rose from 6.1 per 1,000 births in 1915, to 6.2 in 1916, 6.6 in 1917, and to 7.4 in 1919. In 1918 the rate rose to 9.2, and the number o f deaths to 23,000, an increase due largely to the epidemic of influenza which was especially dangerous to expectant mothers. The maternal mortality thermometer here shown indicates that the United States permits many thousands o f mothers to die from pre ventable causes every year. Out of the 17,000 women who died in 1917 from childbirth about 7,000 died from childbed fever, a disease almost entirely preventable; the remaining 10,000 died from causes also to a great extent preventable. In 1917 childbirth caused more deaths among women 15 to 44 years old than any other disease except tuberculosis; it caused in the same year among the same age group more than five times as many deaths as typhoid fever. During the 17 years from 1900 to 1917 the typhoid rate has been reduced to one-third the former rate, the tuberculosis rate markedly reduced, the diphtheria rate reduced more than one-half. In other countries there has been a decrease in the death rate from child birth, but in the United States no indication o f a decrease in the maternal death rate has yet appeared. And physicians remind u s.th a t the women who die in childbirth are few beside those who Suffer preventable illness or a lifelong impairment o f health. The loss involved is immeasurable, " i t does not stop with the loss o f vigor and efficiency to the'mother. It extends, in general, to the well-being of her home and her children; and, .in particular, to the motherless infant who faces a peculiarly hazardous existence. For example, in two o f the cities included by the Children’s Bureau in its study of .infant mortality, the'm ortality rate among babies whose mothers died during the year following birth is com pared with the rate for all the babies in the city. In Waterbury the rate among the motherless babies is three times the average tor the c ity ; in Baltimore, fine times the average for the city.* Our enemies are chiefly ignorance and poverty—from a community point o f view perhaps mostly ignorance. “ Public health is purchaseable,” and a community can, to a large extent, determine its own death rate. Individuals should be educated to demand, and com munities to supply, as a minimum protection, public health nurses; prenatal centers; clinics, such as dental and venereal clinics; mater nity hospitals or wards in general hospitals; training, registration, and supervision o f midwives; training, registration, and supervision o f household attendants; education o f the general public in the significance o f and necessity for maternal and infant health. * Sixth Annual Report of the Chief, U. S. Children’s Bureau, p. 12. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis (2) Washington, 1918. 3 (o 2. ■! Ll » “o ' &/ m a te r n a l m o r t a l it y rates per looo births Latesi available figures upto 1317^ ♦— UNITED STATES N ew Zealand. Australia, Spaivi. -, Scotland 4---- Switzerland t Tmolanrl FranceEn¿>Iand anol V iales. Japan. N arwai/ . Swedetj— » Hungary Rnland irussia .TheNetherlands CHILDRENS BUREA U.U.S. PE PART MENT OFLABOR, https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE F IR ST Y E A R OF LIFE IS THE DANGEROUS AGE. On the thermometer o f infant mortality the United States has a better relative position than on the thermometer showing maternal mortality, but, even so, six countries have better rates than ours. It is true o f this thermometer, as it is also o f the one on page 3, that its level is not fixed but is constantly changing, falling with the increase of prenatal work carried on by various agencies o f infantwelfare work, improvement o f living conditions, and the like; or rising when unfavorable conditions are not controlled. The war emphasized the fact that the annual loss o f young life from preventable causes is an important world-wide problem, and even under the strain of war European countries made special efforts to safeguard children. In England these efforts resulted in reducing the infant mortality rate- to the lowest point in her history. The essentials o f the methods employed in England were as follow s: 1. Compulsory notification o f births within 36 hours. 2. Government aid for approved local maternity and infant wel fare work, amounting to not more than 50 per cent of approved ex penditure. ■ , v 3. Publication o f a Government plan for such work, including the details o f antenatal, natal, and post-natal work. 4. Great increase o f health visitors, the number o f whom was 600 in 1914 and 1,607* in 1920. The ¡board recommends that there should be at least one to every 400 births. In 1917 there were 850 welfare centers in England and Wales; in April, 1920, they had increased to 1,754, o f which 1,061 were munici pal or county and 693 voluntary. The classic example o f *how a young and vigorous country can reduce its infant death rate in New Zealand. Since about 1905 its infant mortality rate from gastric and intestinal diseases has been cut to one-fifth; the rate from respiratory diseases has been cut in half, and it has made a beginning in the reduction o f the mortality from diseases o f early infancy. It now has an infant death rate o f 45. The United States could reduce its too high rate by establishing eertain minimum standards, such as prompt and accurate birth registration; children’s health centers, including nutrition clinics; provision for public health nurses; special dinies; children’s hos pitals or beds in general hospitals; State registration and supervi sion o f all chiM-earing institutions; general educational work, in cluding a compulsorybourse in (M id Hygiene in public schools. 8 The total number of health visitors in 1920 was 3,359, but many had duties in addition to maternity and infancy work. The total service for this work was computed as equivalent to the whole time of 1,607 visitors. (4 ) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis INFANT MORTALITY THERMOMETER, DEATHS UNDER I YEAR OF AGE PER 1,00» BIRTHS % €> CHILDREN’S https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis bu r ea u . u s. department (5) L-i. i ?tfi «J M r-!-.'. OF LABOR $ r&M SAVE THE YOUNGEST. In 1918 more than 100,000 babies in the United States died before they had completed their first month o f life.4 W hy do five times as many babies die in the first month o f life as in the second and nearly twelve times as many as in the twelfth ? Because the parents were not healthy or the mothers were not given proper care and protection during thé months of pregnancy. We pile up this tall black monument because we allow mothers to be underfed, or overworked, or both ; because we let them struggle along without necessary medical and nursing care. How can this high column be cut down? According to many authorities at least one-half o f these babies perished needlessly; others put very much higher the proportion o f those who might have been saved. We can cut it down by good prenatal care. This care will include complete physical examination by a physician as early in pregnancy as possible; internal examination and pelvic measurements before seventh month in the case o f a first child; examination o f urine every four weeks during early months, at least every two weeks after sixth month, and more frequently if indi cated; Wassermann test, when indicated; instruction in hygiene o f maternity and supervision throughout pregnancy; confinement at home by a physician or a properly trained and qualified attendant, or in a hospital; nursing service at home at the time o f confine ment and during the lying-in period, or hospital care ; daily visits through fifth daÿ, and at least two other» visits during second week by physician or nurse; at least 10 days’ rest in bed after a normal delivery, with sufficient household service to allow the mother to recuperate ; examination by physician not later than six weeks after delivery. A pertinent illustration may be given from the figures o f the New Y ork Maternity Center Association. Among 4,496 women who were supervised throughout pregnancy and for a month after the baby was born the proportion o f babies dying before the end o f the first month was only 42 per cent that o f the city as a whole. These mothers lived under the usual low-income handicap; yet, with the help and care given them, they were able in a large number o f cases to bring healthy babies to birth. In addition, the proportion o f stillbirths was reduced nearly one-half; and the proportion o f mothers who died was less than one-third the general rate for the United States. > This figure is an estimate based on the number who died in the death registration area which included 78 per cent of the population. ( 6) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis DEATHS UNDER ONE YEAR OF AGE} BY MONTHLY AGE GROUPS DEATH REGISTRATION AREA MORTALITY ST A T IST IC S 1910. TOTAL 193,855 ' Two fifths ©fall the infants dying the firstly ear of^ifa die during "the ti rst three weeks after birtk. Chief Causes.^ Income insureier\t forfanrnfyneeds.' Venereal disease of the parents. Health condition of mother during pregnancy' Unskilled assistance during confinement./ , Lack of c a r e d u rin g t h e lying-in p e r i o d . ^ CHILDREN’S BU REAU ^U -S D EPARTM EN T OF LABO R J s9q https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ( 7) bahuhni v T AK E CARE OF THE MOTHERS. The chart on page 9 should be read in connection with the chart on page 7. As explained on that chart, deaths in the first month of life are due chiefly do the unfavorable conditions surrounding the mother during pregnancy—conditions whieh include poverty, ignorance, venereal disease, and lack o f medical and nursing care. This chart indicates plainly that the prenatal and natal causes claim the highest number of victims—a number closely corresponding to the deaths in the first month o f life. I f infant mortality is to be controlled the work for that purpose must begin in the prenatal period, and must include proper medical and nursing care for the mother at the time o f childbirth. The second column is the monument to the babies who die, for the most part, in the heat o f summer. The death rate from digestive troubles is decreasing, but there is still need for widespread education o f mothers in the feeding and general hygienic care o f their babies. Many babies whose deaths are classed under gastrointestinal diseases actually died from neglect or from the mother’s ignorance o f proper care and feeding. The importance o f breast feeding-should be im pressed upon the mother. |pj§ The public health nurse offers the solution o f this problem. “ More money for more nurses” is the plea o f every board ¡engaged in infant-welfare work the country over. The third column should be studied Ip connection with the chart ©n page 15. The diseases o f the respiratory tract, bronchitis and pneumonia, reap their grim harvest largely in the poor, ill-ven tilated, crowded homes, where good food, cleanliness, and fresh air are almost unknown, and where even the rudiments Of "decent living are too often beyond the reach o f the family’s resources,The fourth column shows what number die frodi the various epidemic diseases, such as measles and whooping cough. The idea, still too prevalent, that a child might just as well have these dis eases and “ get them over w ith” should be destroyed, and in its place should be established the habits o f cleanliness and health Which would protect the child from the danger o f these epidemics.5 The remaining column includes a wide variety o f causes, such as accidents and other external conditions. W ork now being done in the United States, England, and other countries demonstrates that each o f these formidable columns, par ticularly the first two, can be greatly reduced. Any community, in the light o f present-day knowledge o f health and preventive methods, can practically determine its own infant mortality rate. * In 1918, influenza accounted fojr „nearly half the deaths from epidemic diseases. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis <8) 'DEATHS UNDER ONE'YEAR‘OF_AGB GROUPED BY CAUSES U.S, RE6ISTRATI CMIAKijV \ l 9 IS. \ ,OeoAks Related .to Natal and/ [Intestinal lf*r«natal Causes.) iOvscases^ t5 l i t i M £ r r s T B U K e M V u . S . . O t P A R T p l £ r i T j ) ( v U A S 0 R • ' W if- iSW-0 <&h p ; ' ¿mQ ¡||fj ■:•; vnh-3-i'.. v :> i'T lifg. f§||§ in https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis :.£tsOSSa j.tio:iu?3:ar ;».s3 TH IS H IGH P E A K IS UNNECESSARY. Excessive heat is a grave menace to the health and life o f babies. They must battle not only with the immediate, weakening brought about by heat, but also with a possibly infected milk supply. In hot weather the public milk supply is easily infected with disease germs, which multiply with tremendous rapidity. I f the milk supply is poor, the dangers are enormously increased by the heat. Even if the milk is clean when it reaches the home, it can be kept so only by great care. Unfortunately, the public milk supply is often not ade quately protected from dirt; many families have no ice; and many mothers lack knowledge of how to take proper care o f the milk in the home. Hot weather is thus a time o f great hazard to infant life, as this chart testifies. However, it is in the decrease of the deaths from the summer diarrheas that the most striking work for the reduction o f infant mortality in this ^qd in other countries has been and is being done. The methods of reduction in this field are now well understood. They consist essentially in such things as— 1. Insistence upon breast feeding for at least the first six months o f the baby’s life. 2. Instruction o f the mother in the best methods of infant care, particularly breast feeding and, later, artificial feeding. 3. Improvement o f the milk supply and the spread o f popular knowledge regarding its care and use, jg Because o f the way in which babies went down before, the sum mer heat, a rich merchant o f Brooklyn w#s led to establish milk stations in that city about 2 6 'years ago. Infant deaths .decreased rapidly with each year that these milk stations supplied poor mothers. By the multiplication o f infant-welfare stations, visiting nurses, and various forms o f educational work for mothers, New York City has lowered its “ summer peak,” and its infant mortality rate has been reduced from 111.6 infant deaths per 1,000 live births in 1911 to 82 in 1919. The work necessary to cut down the “ summer peak ” is being done by a large number o f children’s health centers throughout the country by means o f an increasing number o f public-health nurses and by the distribution of free educational literature on these sub jects. The result is shown in the reduction in the infant death rate after the first month or two o f life, as illustrated in the decrease in the number o f infant deaths in the chart on page 13, comparing the year 1918 with 1910. ¡iO ) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis m m m 'ftA K o f m rm v o f a t h s . fnôw öiarsäa amd agrcarts g« u s mmnmsTRMm m £a -jæ& Auaust ?3,822'. íí&wemtíf ¡¿as» g f «.ASßK, m> https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE YOUNGEST MOST NEED OUR CARE. The chart on page 13 furnishes a none too encouraging answer to the question, uAre the bad conditions shown by these charts growing better as the years go on ? ” The solid line shows the number o f infant deaths in 1910 in the various months o f the first year o f life. The dotted line shows the same for 1918, and the line o f dots and dashes shows the death in 1918 less the deaths due to influenza. The actual number o f infants that died in the first month o f life was greater in 1918 than in 1910. However, our population was greater in 1918 and the total number o f births sufficiently larger to make the death rate per 1,000 births in the first month o f life probably slightly better in 1918 than in 1910. This chart shows strikingly what can not be too strongly emphasized, that the first month o f life is the most hazardous. The distance between the two lines after the first month shows by the perceptible decline in the deaths o f older babies that the efforts made during the past 10 years to “ save the babies,” to “ cut down the summer peak,” etc., have borne good fruit. But looking at the high black monument on the chart on page 7 and then at this chart, we cap see plainly that we are not attacking the problem at the root. England has long recognized that the pro vision o f prenatal care is fundamental to really intelligent childwelfare work; and her program published in 1914 included prenatal and obstetrical care, hospital and lying-in accommodations, and sys tematic instruction o f women in the hygiene o f pregnancy. Espe cially in rural areas was the need felt for more and better accom modations for child-bearing women. Government grants were made to relieve the situation, to maintain more small hospitals, and to pro vide physicians. Assistance was also given by furnishing domestic help and by providing for the care o f the older children during the mother’s absence. Prematemity and convalescent homes were also established in some places. In 1918 the maternity and child-welfare act establishing many measures for the protection o f child-bearing women was passed. Such legislation is advantageous in that it brings Government assistance to large rural areas where isolation and modest tax re turns make it impossible for local authorities to provide public-health nurses, adequate hospital accommodation, consultation welfare cen ters, or other needed facilities. It can bring to these areas stimulus and aid for infant-welfare work similar to that which we have given our own country districts for scientific farming, home economics, the health o f domestic animals, and good roads. W ork for infant welfare is coming to be regarded as more than a philanthropy or an expression o f good will. It is a profoundly important public concern which tests the public spirit and the democracy o f a community. There is, perhaps, no better sign o f the modernness o f a city’s administration than the proportion of its income which is assigned to the protection o f infancy and childhood.® • Second Annual Report of the Chief, U. S. Children’s Bureau, p. 8. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ( 12). Washington, 1914, txmmmsmor » PFf fa itt d e a t h s A ffi is s m DEATH’ RFGÌSTRATlOrt S'TATE S OTflW'O' CEXCÜ3SIVC 0T (W im CMC0UR&, ,\b Jv -.v . ■■ '■■• j - v:. >/. ■ ii .%& V V -.Ï ": C fin* iV OVUKJ . I . j., \{) O,:. . ‘ V V'- £!$îg ti;. «¿j rj 1. :;r;■ i; ' "îïïÔSiEÏ til • https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PO VERTY IS THE BABY’S GREATEST ENEMY. The greatest proportion o f baby deaths occurs in families with the smallest income. Most o f the child-bearing women in the homes recorded in this chart have undoubtedly been denied, in very large measure, the care necessary to insure healthy babies and healthy mothers. The poorer the family, the greater the hardship o f the mother and the greater the menace to the child. Income plays a chief part in determining the location o f the home as well as the kind o f home. Unfavorable location and overcrowding are bad housing conditions that accompany low income. In the study o f infant mortality made in Waterbury, Conn., by the Chil dren’s Bureau, the mortality rate for children born in rear houses or houses on alleys was 172, while the rate for children born in houses located on the street was 120.6. The study in Manchester, N. H., showed the infant mortality rate to be 123.3 where the persons in a room averaged less thap one, and 261.7 where they averaged two but less than three. Low income often drives ¿he mother to work to add to the family budget. Many times this entails less care for the baby, the substi tution o f bottle feeding for breast feeding, and other untoward conditions. In Manchester, N. H., it was found that the mortality rate for babies whose mothers were employed outside the home was about twice the average rate in the city. Poverty may be accompanied by ignorance. It is important to remember that poverty lacks the defense against ignorance which is at the disposal o f the well-to-do mother. Sir Arthur Newsholme says that the designation o f maternal ignorance as the chief factor in child mortality is “ a comfortable doctrine for the well-to-do person to adopt j but he states that we have little reason for think ing that the ignorance o f the working-class mother is much greater than that o f mothers in other classes o f society. The ignorance o f the working-class mother is a menace because she is socially helpless unless the community will take the responsibility o f providing ade quate medical and nursing care, adequate teaching o f maternity and infant hygiene, adequate provision for decent housing and sanitation, and adequate income for the father. The fathers o f 88 per cent o f the babies included in the Children’s Bureau studies made before the war earned less than $1,250 a year * 2T per cent earned less than $550.' As the income doubled the m ortality rate was halved. (14) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis IN F A N T M O R T A U J Y R A T E S A C C O R D IN G T P F A T H E R S E A R N IN G S H U F W S FROM SEVEN CITIES STUDIED f f i U S J H U *B i5 BUREAU^ Under $ 4 5 0 >450 to $549 1550 to $649 650 to $849 $850 to $1049 ;I050 to $1249 ►1250 and Over. The baby death rate rises as the fathers^ earnings tall. OS) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis WASHINGTON : GOVERNMENT PRINTING OFFICE : 1921 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis