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SAVE the YOUNGEST
Seven charts on
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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
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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.
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Federal Reserve Bank of St. Louis
(2)
Washington, 1918.
3 (o 2. ■!
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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,
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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 )
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INFANT MORTALITY THERMOMETER,
DEATHS UNDER I YEAR OF AGE PER 1,00» BIRTHS
%
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CHILDREN’S
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bu r ea u . u s. department
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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)
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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
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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.
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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.
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<8)
'DEATHS UNDER ONE'YEAR‘OF_AGB
GROUPED BY CAUSES
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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.
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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.
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( 12).
Washington, 1914,
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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)
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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.
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WASHINGTON : GOVERNMENT PRINTING OFFICE : 1921
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