CHILD WELFARE WORK IN ENGLAND[18]
The subject of child welfare, in its chief developments, cannot be
separated from that of Public Health, of which it forms a constituent
part, though I do not ignore the fact that child welfare is largely
dependent also on the extent to which child labor is exploited, and
to which expectant and nursing mothers,—as also other mothers whose
extra-domestic employment or whose employment for gain is within the
home itself,—involves neglect of young children.
Improvement in child welfare has occurred as the sanitary and social
progress of the country has advanced. Whereas in the decade 1871-80,
when money began to be spent more freely on elementary sanitary
reform, the expectation of life or mean after-lifetime at birth of
males was 41.4 years and of females was 44.6 years; in the years
1910-12 these had increased to 51.5 and 55.4 years respectively. The
greater part of the saving of life which this addition of ten years
to the average duration of life was the result of reduced mortality
in children under five years of age.
The first direct steps towards the reduction of infant mortality
were directed against epidemic or summer diarrhœa. Medical officers
of health have always been required in their annual reports to
summarize the vital statistics in their districts; and since 1905
a more detailed statement of infant mortality during each part of
infancy has been required. Annually, therefore, as well as when they
received the weekly returns of deaths from the local registrars,
there was forced upon their attention the fact that deaths of infants
under one year of age formed a high proportion of total deaths at all
ages (12.9 per cent. in 1917), and that of these infantile deaths a
large proportion were caused by diarrhœa, the number varying with
the temperature and the deficiency of rainfall in the summer months.
In 1912, a year of relatively small mortality from diarrhœa, this
disease caused 8.1 per cent. of all deaths under one year of age.
For many years past it has been customary for medical officers of
health to issue warnings as to summer diarrhœa, to arrange for the
distribution of leaflets of advice concerning the disease, and to
urge the necessity of more thorough cleanliness both municipal and
domestic during the summer months. Even before the early notification
of births became obligatory, in many areas the addresses of infants
were obtained from the registrars of births and special visits were
made to the mothers of infants during the months of June and July
and especially to the mothers of those infants who were known to be
artificially fed.
The reports of medical officers of health of many of the large
towns from 1890 onwards show that much valuable work was being
accomplished, and the way was being prepared for more general
measures against infant mortality.
The importance of municipal sanitation in aiding the elimination
of diarrhœal mortality is illustrated in the experience of many
towns, and strikingly by the comparative experience of Leicester
and Nottingham. The chief difference between the sanitary condition
of the two towns was that in Nottingham in 1909 pail closets still
served more than half the houses, while Leicester had abandoned this
system entirely, substituting water-closets. Between 1889-93 and 1909
the diarrhœal mortality in Leicester had declined 52 per cent.; in
Nottingham it had only declined 4 per cent.
Diarrhœa is not the only disease of infancy which can be greatly
diminished by improved public health administration. Tuberculosis
and whooping cough and measles figure largely in the infantile death
returns. Over 21 per cent. of the total deaths in infancy are due
to these three diseases and to diarrhœa. The amount of syphilis
appearing in the death-returns is small; but its actual amount is
much greater than the figures show. If pneumonia and bronchitis,
which account for 19 per cent. of the deaths in infancy, be
regarded—as they should—as infective diseases, then it may be said
that the problem of saving child life and securing the correlative
improvement in the standard of health of children who survive to
higher ages, _consists very largely in the prevention of infections_,
including diarrhœal diseases and acute respiratory diseases.
It follows from this that even if the limited and erroneous view
be taken that Sanitary Authorities are concerned only with the
prevention of infectious diseases, the reduction of infant mortality
is a duty devolving on these authorities, and cannot be effectively
carried out without their coöperation. Voluntary effort must
therefore always, in large measure, be directed towards stimulating
local authorities to perform their duties.
The influence of diarrhœal summer mortality on the progress of child
welfare work is further shown by the fact that among the earliest
efforts were those to provide pure cows’ milk to infants. In England
official Milk Depots for this purpose were never numerous; and
little voluntary effort went in this direction. There now remain
very few such Milk Depots; but many local authorities provide milk,
more particularly dried milk, to infants for whom it is specially
prescribed at Infant Consultations. Early investigations at Brighton
and elsewhere showed that the mortality of infants fed on condensed
milk,—chiefly of the sweetened variety,—was greater than that
of infants fed on fresh cows’ milk, and directed attention to
the supreme importance of domestic cleanliness in the prevention
of summer diarrhœa. The Milk Depots and the concurrent agitation
for purer cows’ milk served a useful purpose; though it cannot
yet be said that the cows’ milk ordinarily supplied in England is
satisfactorily clean.
It became evident ere long that the broadcast distribution of
instructions as to how cows’ milk might safely be stored and prepared
for infants had but a limited utility, and that the directions given
were liable to be misinterpreted by mothers as an encouragement to
abandon breast-feeding; and there is reason to believe that these
directions did sometimes have this effect. Hence the importance
of the work initiated by the late Dr. Sykes at the St. Pancras
School for Mothers, which brought into relief the importance of
encouraging breast-feeding by every possible means. In towns in which
the aided supply of milk was continued, advice as to its use was
also initiated; and thus gradually Infant Consultations, in which
the main element was the giving of individual advice and treatment
as required, superseded Milk Depots, and were established in very
large numbers where Milk Depots had never been started. These had
educational as well as medical and hygienic activities; and there
need be no dispute as to the relative value of these two aspects of
the work of Infant Consultations (also known as Schools for Mothers,
Child Welfare Centres, Baby Weighings, Mothers’ Welcomes, etc.); for
whether advice and instruction are given to the individual mother or
to mothers collectively,—or as is advisable in both ways,—it should
be exactly the advice which a physician skilled in the hygiene of
infancy as well as in the treatment of infantile complaints would
give to his individual patient. In this sense it remains true, as
Professor Budin, the distinguished founder of Infant Consultations
said: “An infant consultation is worth precisely as much as the
presiding physician.” This is true whether it is possible to arrange
for a physician to be present at each meeting of a Child Welfare
Centre; or whether, as has happened during the Great War in England,
nurses or health visitors trained under such a physician have given
hygienic advice in his absence.
_The Notification of Births_
For many years before the Notification of Births Act was passed, it
had been customary, especially in towns, to arrange for inquiry by
a sanitary inspector or female visitor into death occurring under
one year of age, and in many instances for the giving of systematic
advice to mothers concerning their infants. More than twenty years
ago the Manchester and Salform Sanitary Association had initiated
a system of home visitation by volunteer ladies and by women
workers paid by the Association who went from house to house, gave
elementary sanitary advice, and reported serious defects to the
Sanitary Authority. The City Council at an early stage showed its
appreciation of the importance of this work by giving grants towards
the expenditure incurred.
In order to enable early visits to be made, the town council of
Salford had begun as early as 1899 a system of voluntary notification
of births by midwives.
Prior to the stage at which early notifications of births was
obtained, the medical officer of health was dependent for his
information on the registration of births, for which an interval of
six weeks after birth was permitted before it became compulsory.
During this interval a large proportion of the total mortality of
infancy had occurred,—approximately one-fifth of the total deaths
in the first year after birth occur in the first week and one-third
in the first month after birth,—and the possibility of successfully
influencing the mother to continue breast-feeding had gone. The
action of the town of Huddersfield in 1906 in obtaining Parliamentary
power to secure the compulsory notification of births within
thirty-six hours of birth represented a rapid growth of opinion
based on experience in that and other towns to the effect that in
the absence of early information of birth the necessary sanitary
precautions and counsel as to personal hygiene could not be given
with the greatest prospect of success. This local pioneer work
doubtless facilitated the passing of the Notification of Births Act
in 1907.
Much important work followed the notification of births. Home visits
to the mother were regarded and continue to be regarded as the most
important part of this work; but there also grew up rapidly the
present system of Infant Consultations and similar organizations.
The Notification of Births (Extension) Act, 1915, not only made
the enforcement of this act universal, but it also empowered each
local authority administering the Act to exercise any powers which a
sanitary authority possesses under the Public Health Acts “for the
purpose of the care of expectant mothers, nursing mothers, and young
children.” In drawing the attention of Local Authorities to the terms
of the Act the Local Government Board, as well as earlier in the war,
deprecated false economy during the war. They said:
At a time like the present the urgent need for taking all possible
steps to secure the health of mothers and children and to diminish
ante-natal and post-natal infant mortality is obvious, and the Board
are confident that they can rely upon local authorities making the
fullest use of the powers conferred on them.
The Board in the same circular laid stress on “the importance of
linking up this work with the other medical and sanitary services
provided by local authorities under the Public Health and other Acts.”
The passing of this Act has been followed by an increasingly rapid
development of Maternity and Child Welfare work, and the Maternity
and Child Welfare Act passed in August, 1918, made it obligatory on
each Council exercising powers under the Act to appoint a Maternity
and Child Welfare Committee, which must include at least two women,
and may include persons specially qualified by training or experience
in subjects relating to health and maternity who are not members of
the Council.
In the circular letter sent out to local authorities explaining the
new Act, the Local Government Board reëmphasizes its previously
stated views that child welfare work was second only in importance
to direct war work, and was really a “measure of war emergence,” and
added:
although we have enjoined as local authorities the necessity of the
strictest of economy in public expenditure, we have urged increased
activity in work which has for its object the preservation of
infant life and health. We are glad to note that the great majority
of local authorities have realized the value of continuing and
extending their efforts for child welfare at the present time.
_The Causes of Child Mortality_
For detailed consideration of the causes of infant mortality and of
mortality during the next four years of life in England and Wales,
the reader may be referred to official reports by the writer.
No consistent and continuous decline had taken place in infant
mortality prior to 1900, although there had been marked reduction of
the mortality in each of the next four years of life. This difference
corresponds in the main with the facts that greater success had been
achieved in the general measures of sanitation and in the reduction
of prevalence of and mortality from such infectious diseases as
scarlet fever, diphtheria, and enteric fever, than in respect of the
special causes of mortality in infancy. These special causes may be
placed under three headings: First, infections,—acute respiratory
diseases, measles, whooping cough, syphilis, tuberculosis, and
diarrhœa; second, errors of nutrition, due largely to poverty, to
mismanagement, and to imperfect provision of facilities for healthy
family life; and third, developmental conditions present at the birth
of the infants. Under none of these headings had marked success been
achieved prior to 1900, though the steady work devoted to the subject
of diarrhœa had already begun to show fruit.
The statistics of infant mortality may be stated as follows:
_England and Wales_
Deaths of Infants under
Period 1 Year per 1,000 Births
1896-1900 156
1901-1905 138
1906-1910 117
1911 130
1912 95
1913 108
1914 105
1915 110
1916 91
1917 96
1918 97
The above are the crude rates, the infantile death-rate being stated
by the usual method per 1,000 births _during the same year_. Owing to
the great decline of births during the war, this method overstates
the infant mortality in recent years. In a table given in the
Registrar-General’s annual report for 1917, this unusual source of
error is corrected. When this is done, and the infantile deaths are
stated “per 1,000 of population aged 0-1,” the rates for the years
1912-17 inclusive in successive years became respectively
104, 117, 113, 111, 98, and 94.
In other words, there has been a steady and uninterrupted decline in
the death-rate of infants during the war.
This decline has followed similar declines in preceding years, and
it is to be noted that much of this decline occurred during the
period when the hygienic work effecting child-welfare was confined
to general public health measures. Thus it anticipated the more
direct and active measures adopted by voluntary societies and by
local authorities for the prevention of infant mortality. Comparing
the five year periods 1896-1900 and 1901-05, a decrease in the
death-rate of 12 per cent. is seen; comparing 1901-05 with 1906-10,
a decline of 15 per cent. occurred; comparing 1906-10 with the
average experience of the three years 1911-13 mortality declined 5
per cent.; comparing these three years with the average experience of
the five years 1914-18, during which war conditions prevailed more or
less, a reduction 9 per cent. was experienced. The actual reduction
during war time is greater than is indicated by these percentages,
when allowance is made for the statistical error indicated above.
The exceptional experience of the year 1911 illustrates one of the
chief sources of error in forming conclusions on the experience of a
single year. In this year the summer was excessively hot, and summer
diarrhœa prevailed to an exceptional extent; and the illustration is
important, as serving to remind us of the limitations of the value of
statistical tests and of the fact that increase of good work tending
to improve child life may be associated temporarily with increase of
total infant mortality.
_The Influence of School Medical Inspection_
In the development of child welfare work in England important place
must be given to the system of medical inspection of school children
initiated in 1907. The numerous physical defects found in school
children have led to the beginning of measures for remedial action,
confined in some areas to measures for securing greater cleanliness
and the treatment of minor skin diseases; but extending in other
areas to such measures as the remedial treatment of adenoids, the
cure of ringworm, the correction of errors of refraction, and the
provision of dental treatment. Perhaps the chief value of the system
of medical inspection of school children has been the fact that it
has demonstrated the extent to which children when they first come
to school are already suffering from physical disease which might
have been prevented or minimized by attention in the pre-school
period. The information thus accumulated has had much influence in
encouraging the institution of Infant Consultations, with a view to
the early discovery of disease or of tendency to disease.
_The Influence of Statistical Studies_
The intensive study of our national and of local vital statistics
has also had a most important bearing on the further development of
maternity and child welfare work. In successive official reports
it has been shown that infant mortality varies greatly in different
parts of the country, irrespective of climatic conditions; that it
varies greatly in different parts of the same town, in accordance
with variations in respect of industrial and housing conditions, of
local sanitation, of poverty and alcoholism; that the variations
extend to different portions of infant life, the death-rate in
infants under a week, or under a month in age, for instance, being
two or three times as high in some areas as in others; and that the
distribution of special diseases in infancy similarly varies greatly.
Intensive studies of infant mortality on these and other lines have
pointed plainly the directions in which preventive work is especially
called for; and have incidentally demonstrated the fundamental value
of accurate statistics of births and of deaths in the child welfare
campaign. Surveys of local conditions both statistical and based
on actual local observations form an indispensable preliminary to
and concomitant of good child welfare work; and it is to combined
work on these lines that the improvement of recent years is largely
attributable. To _act helpfully_ we must _know thoroughly_ the
summation of conditions which form the evil to be attacked.
One important result of investigations such as those already
mentioned has been to bring more clearly into relief the fact, which
previously had been partially neglected, that _child welfare work
can only succeed in so far as the welfare of the mother is also
maintained_.
This may imply extensions of work involving serious economic
considerations; but apart from such possibilities and apart from
questions of housing, and of provision of additional domestic
facilities for assisting the overworked mother, there is ample
evidence that medical and hygienic measures by themselves can do much
to relieve the excessive strain on the mother which childbearing
under present conditions often involves.
_The Course of Mortality from Childbearing_
The general course of mortality from childbearing (including deaths
ascribable to pregnancy) in England and Wales is shown by the
following table:
_Average Annual Death-rates per 100,000 births from_
Puerperal Other Diseases
Septic of Pregnancy
Diseases and Childbirth
5 years, 1902-06 185 228
5 years, 1907-11 152 215
3 years, 1912-14 148 233
2 years, 1915-16 151 239
It will be noted that although there has been a marked decline of
deaths from puerperal sepsis, the death-rate from other complications
of childbearing has not declined. The decline in puerperal sepsis
is general throughout the country, and evidences the greater care
in midwifery both on the part of doctors and of midwives. The
administration of the Midwives Act, 1902, has doubtless done much
to secure this. The death-rate from conditions other than puerperal
fever continues to differ greatly throughout the country. It is
highest in Welsh counties, Westmoreland, Lancashire and Cheshire
coming next in order of unfavourable portion; in many industrial,
including textile, towns it is also excessive. The general conclusion
reached by the writer in an elaborate official report on the subject
is that “the quality and availability of skilled assistance before,
during, and after childbirth are probably the most important factors
in determining the remarkable and serious differences in respect of
mortality from childbearing shown in the report.”—“The differences
are caused in the main by differences in availability of skilled
assistance when needed in pregnancy, and at and after childbirth.”
_The Midwives Act, 1902_
This Act forbade any woman after April 1, 1906, who was not certified
under the Act, from using the title of midwife or any similar
description of herself. It forbade after April 1, 1910, any such
woman from “habitually and for gain attending women in childbirth,
except under the direction of a qualified medical practitioner”; and
it forbade any certified midwife to use an uncertified person as her
substitute. The Act defined the limits of function of the midwife
by stating that the Act did not confer upon her any title to give
certificates of death or of still-birth, or to take charge of any
abnormality or disease in connection with parturition.
The Act set up the Central Midwives Board, giving it special
disciplinary powers over midwives. It also imposed on county councils
and the councils of county boroughs the duty of supervising the work
of midwives. For further details the Act itself and the Rules of the
Central Midwives Board made under the Act should be consulted.
The Midwives Act, 1918, gave further powers to the Central Midwives
Board and to local supervising authorities, and made it the duty of
the latter to pay the fee of a doctor called in by a midwife in any
of the emergencies for which Rules are made by the Central Midwives
Board, the fee paid to be in accordance with a scale prescribed by
the Ministry of Health.
As at least three-fourths of the total births in England and Wales
are attended by midwives with or without the assistance of doctors,
their work has great importance in relation to the reduction of
maternal disablement and mortality and to the prevention of early
infant mortality, and it is of happy augury that they are being
enlisted more and more in official work for safeguarding the health
of the mother and her unborn or recently delivered infant. An
important recent addition has been made to the rules of the Central
Midwives Board, which makes it obligatory on the midwife to notify
to the medical officer of health any instance, while the patient is
under her charge, in which for any reason breast-feeding has been
discontinued.
_Administrative Work._—Largely through the machinery provided by
the Midwives Act and the Notification of Births Act a system of
supervision of maternity and child welfare has been organized in
every county and county borough, and this has been responsible for
a large share of the improvement experienced in recent years. The
character and extent of development of the work varies greatly in
different centres; and as a rule the work is more fully developed
in county boroughs than in counties. In county districts it has
sometimes been found necessary to unite the offices of assistant
inspector of midwives, infant visitor and tuberculosis visitor in one
adequately trained health visitor, thus saving time in travelling
by enabling the visitor to have a smaller district allotted to her
than if she undertook only one branch of work. In some counties the
school nurse’s work is also undertaken by the health visitor. In some
country areas arrangements have been made for infant visiting to be
carried out by district nurses who are also midwives.
_Voluntary Workers._—Much of the success so far achieved in improving
the health conditions of infancy and childhood has been secured by
coöperation between voluntary and official health visitors. Excellent
work has been done by local and other societies, particularly during
the last ten years, in educating public opinion and in direct
assistance to mothers and their infants. It is essential that such
voluntary work should have a nucleus of highly trained and well-paid
workers; but given this condition, a large amount of good work can be
accomplished by voluntary aid.
The main work has been that of the _health visitor_. The details of
this work, the conditions of qualification of workers, the number of
visits which it is desirable to make, the character of the advice
intended to be given at these visits are set out in an official
memorandum of the Medical Officer of the Local Government Board and
it is unnecessary to repeat this information in these pages.
A similar remark applies to the next most important development of
work, the institution of _Maternity and Child Welfare Centres_. The
conditions of work of these institutions are set out in the same
document.
_Training and Provision of Midwives_
The provision of additional trained midwives is a pressing problem.
The increased cost of living, longer training required, and the
rapid development of less laborious and more lucrative occupations,
have made it difficult to secure women to train as midwives, or to
continue to practise in this capacity after qualification. In many
industrial areas the older _bonâ fide_ midwife is preferred, although
it is the almost universal experience that the trained midwife more
quickly detects conditions endangering the life of the mother or
infant, and sends for medical help. In order to encourage further
the supply of practising midwives, the government gives grants
for increased remuneration to midwives newly appointed by local
authorities, sufficient to recoup them in the course of a few years’
service for the cost of their training.
At a recent date, of some 30,543 trained midwives on the Roll, only
6,754 were returned as being in actual practice as such.
In order to make midwives available for all women needing them, the
Board repays to local authorities and voluntary associations half the
cost of the provision of a midwife for necessitous women. During the
Great War a woman might receive assistance in her confinement from
several central sources; for in addition to the above
(1) If she was the wife of an insured person, or if she herself is
insured, she received under the conditions of the National (Health)
Insurance Act 30s. in cash, or if she is insured and the wife of an
insured person 60s. in cash.
(2) If she was the wife of a soldier or sailor and not entitled to
maternity benefit she received from 10s. per week up to £2 from the
Local Pensions Committee.
(3) If she was a munition worker she might be aided under a scheme
provided under the Ministry of Munitions.
(4) She also might obtain priority for the supply of milk, or obtain
free milk or milk at cost price under the Local Committee Board
Food Control Order, No. 1, 1918, empowering local authorities to
supply milk and food and an extra ration under the Food Controller’s
Order. In addition, after confinement she had available the ration
apportioned to the infant and its allowance of milk under the
priority scheme.
There was evidently need for simplification and unification of effort
in the above cases.
In many instances maternity nursing is required. The midwife may have
too many patients to be able to give this during the ten days in
which she is in charge of the patient; and even when she carries out
her duty in this respect in accordance with the Rules of the Central
Midwives Board additional help is required in the feeding and care of
the mother and infant, and in the care of the household. Often also
nursing is required for both mother and infant for a considerable
period beyond the ten days. For these persons the government gives
grants for maternity nursing and for “home helps.”
Even when all the above requirements are or can be fulfilled, there
remain a large number of cases of pregnant women, and especially
of unmarried women, who cannot be satisfactorily confined at home,
either because of their social or sanitary circumstances, or
because abnormal or complicated childbirth is expected. For such
cases hospital provision is needed. This is one of the most urgent
requirements of the present time.
Under present conditions, institutional lying-in provision is
chiefly voluntary in character; and the government has advised
local authorities to contract for its use, rather than wait for the
erection of special hospitals. In other instances houses are being
taken and adapted as maternity homes.
_Ante-natal Work_
The progress made in the organisation of ante-natal work is slow for
reasons which are fairly obvious. There has been difficulty under war
conditions in securing assistance from doctors and midwives. There
is the well-known difficulty as to notification of pregnancy, which
the government has not encouraged, except when the definite consent
of the mother has been previously obtained. The facilities for
help provided at the Centre have in some areas attracted patients;
and health visitors and midwives have done much in other areas to
persuade mothers of the advisability of safeguarding themselves
against possible complications, as well as of securing adequate
preparation for the lying-in period.
This subject is closely associated with that of abortions,
still-births, and deaths in the first two weeks after birth. One of
the most promising methods for securing the sound development of
ante-natal work consists in the investigation of still-births and
early infant mortality. When these inquiries are made mothers can
be induced to obtain medical advice not only at the time, but also
in the event of a subsequent pregnancy. The investigation at the
patient’s home of all such cases and assistance in prevention of
recurrence of unnecessary ante-natal, natal, and early post-natal
deaths have as great an importance as the building up of a successful
ante-natal clinic. The anti-syphilis work now being carried on will
help greatly in this direction.
_Dental Assistance_
There has been a large extension of dental assistance at Centres for
expectant and for nursing mothers, and for children, especially in
the metropolis and its vicinity. The government has lately extended
its grant to cover dentures for mothers who are nursing or pregnant,
if the medical officer of the Centre is satisfied that the woman’s
health will be materially improved by the denture, and that she is
unable to provide it for herself.
_Creches_
Creches and day nurseries may be expected to exercise influence in
educating mothers in the care of their children. For this purpose it
is very desirable to have the creche attached to or near an infant
welfare centre.
These creches, unless managed with the most rigid medical and
general cleanliness, are very apt to spread infectious diseases; not
merely such diseases as whooping cough, measles, and chickenpox,
but also catarrhal and diarrhœal diseases. In the prevention of all
of these the enforcement of the strictest cleanliness is essential,
especially during the summer months for the last named diseases. For
the prevention of catarrhal infections, it is essential that the
creche should be conducted, so far as practicable, on strict open-air
lines. Open-air creches give admirable occasional relief to mothers,
even when these do not go out to work. The “toddler’s playground”
is a blessing to all concerned, but the indoor creche may be, and
often is, mischievous. The risks are greatly reduced by insisting on
open-air conditions and by not allowing large groups of children to
come together. Smaller groups mean greatly decreased possibility of
cross-infection.
_Observation Beds at Child Welfare Centres_
At infant welfare centres infants are not infrequently seen who
fail to make progress while living at home, and who yet are not ill
enough to be sent to a hospital. This especially applies to cases of
defective nutrition. For these cases beds in connection with centres
have been found to be necessary for observation purposes and to
initiate further treatment. In some instances, especially for failure
of breast-feeding, it is advisable to admit the mother with the
infant.
On July 30, 1914, the Local Government Board sent a circular letter
and a covering memorandum by their Medical Officer which may be
claimed to have been the starting point of maternity and child
welfare work on a larger scale, more generally distributed throughout
the country, and more completely covering the whole sphere of
medical and hygienic work for this purpose than had previously been
envisaged. Although the country at that time might be said to be
already under the shadow of war, these documents had been previously
prepared, and their appearance four days before the declaration
of war was a coincidence. The chief burden of the additional work
to which local authorities were urged was that there should be
_continuity in dealing with the whole period from before birth until
the time when the child is entered upon a school register_; and the
memorandum contemplated that “medical advice and, where necessary,
treatment should be continuously and systematically available for
expectant mothers and for children till they are entered on a school
register, and that arrangements should be made for home visitation
throughout this period.” It was added that “the work of home
visitation is one to which the Board attach very great importance and
in promoting schemes laid down in the accompanying memorandum the
first step should be the appointment of an adequate staff of health
visitors.”
The main provisions of this memorandum are printed on page 135.
The increase of work since that date may be gathered from the
following table, which shows the increase each year in the number of
health visitors, of child welfare centres, and of grants given on the
50 per cent. basis by the Local Government Board and the Board of
Education.
_Amounts of Grants (pounds sterling) in Each Financial Year to Local
Authorities and Voluntary Agencies, on the Basis of 50 Per Cent. of
Total Approved Local Expenditure_
Financial Year Local Government Board Board of Education
1914-15 11,488 10,830
1915-16 41,466 15,334
1916-17 67,961 19,023
1917-18 122,285 24,110
1918-19 (estimated) 209,000 44,000
These grants do not cover the entire scope of child welfare work
carried out throughout the country, and their amount must not be
taken as a complete indication of the extent of this work.
The increase during the war period has been very great; and this can
be attributed to the desire to do everything practicable for mothers
and children, especially those belonging to soldiers and sailors
who were risking their lives for the country; and to the increased
realisation of the importance of preserving and improving our chief
national asset which consists in a healthy population. During this
period there was a great increase in the industrial employment of
women, including married women, in factories including munition and
other works. This increase it is believed amounted to a million and a
half workers.
Notwithstanding the many adverse influences, to which must be added
great overcrowding in many industrial areas, especially those in
which new industries were hurriedly started, and the increasing cost
of food and especially of milk with a scarcity of supply, it has been
seen that infant mortality remained low and on the whole declined
during the whole period of the war.
To what circumstances can this be ascribed?
It is unnecessary to assume that this result was entirely due to the
active measures favorable to maternity and child welfare which were
taken as an unexampled scale, though these measures can claim an
important share in the result.
A number of contributory factors were at work:
1. In none of the years in question did the summer weather favor an
excess of diarrhœal mortality. With this factor, however, eliminated
the infant mortality each year was lower than in previous years.
2. Although so many husbands were away from home, in a large
proportion of cases the wife, in virtue of her separation allowance,
was financially in a more favorable position than when she was
dependent on her husband’s wages or such portion of it as he allowed
her for the support of the household.
3. In addition, every soldier became an insured person, and his wife
was therefore entitled to the Maternity Benefit of 30 shillings on
the birth of a child, and an additional 30 shillings if she was
herself an employed person.
4. There can be no reasonable doubt that the restrictions on the
consumption of alcoholic drinks and the limitation of hours for
opening public houses were a factor in improving domestic welfare.
But attaching full value to these and other similar factors which
undoubtedly were at work, chief place must, I think, be given to
the awakening of the public conscience on the subject, and to the
concentration on the mother and her child which had been urged in
season and which now became a fact. An indication of the public
mind is given by the advice issued by the Local Government Board in
August, 1918, which is quoted on page 248.
FOOTNOTES:
[18] Extracted from addresses given at Conferences held by the
Children’s Bureau of the Department of Labor, Washington.
INDEX
Abbott, J., 2
Abbott, S. W., 2
Alcoholic drinks, 123, 149, 187
Anaesthetics, 77
Ante-natal work, 261
Bacteriological diagnosis, 85
Banks, N. P., 2
Biggs, H., 77
Bowditch, 2
Budd, Wm., 15
Burns, John, 44
Burton, R., 71
Care Committees, 237
Causation, 147
Causation, specific, 20
Cerebro-spinal fever, 23, 76, 126
Chadwick, 2, 3, 11, 12, 25, 52, 54
Chalmers, 70
Chapman, 221, 237
Character and health, 173
Childbearing, care of, 137, 254
Child mortality, causes of, 248
Child welfare work, 240
Cholera, 12
Colonies for consumptives, 235
Consumption, see Tuberculosis.
Contacts in tuberculosis, 212
Creches, 263
Decadence, 121
Democracy and public health, 47
Dental assistance, 262
Destitution (see also Poor Law), 31, 65, 87
Deterrence, principle of, 29
Diarrhœal diseases, 20, 241
Dirt and disease, 11
Dispensaries for tuberculosis, 216
” general, 218
Domiciliary treatment, 35
Education authorities and public health, 56, 58, 86
Educational propaganda, 130, 168
” work of sanatoria, 233
Enteric fever, see Typhoid.
Epidemiology, present limitations of, 22, 81
Eugenics and public health, 44
Expectation of life, 20, 74, 192
Factory hygiene and legislation, 8, 26
Farr, Wm., 2, 25
Fulton, J. S., 24
Gerhard, 15
Goodnow, 60, 63
Grants in aid, 56, 135, 265
Historical development of public health, 42
Holmes, O. Wendell, 16
Hospitals, see Institutional treatment.
” as housing auxiliaries, 38, 77, 79, 98
” and private practice, 146
Housing, 38, 79
” and tuberculosis, 203
Huddersfield, 246
Ideals of public work, 4
Ignorance and sickness, 168
Immunity to tuberculosis, 196
Industrial colonies, 235
Industry and public health, 50, 161
Infant consultations, 243
Infant mortality, 144, 250
Infant mortality and poverty, 153, 185
Infants, care of, 30
Influenza, 23, 76, 127
Inspectors of factories, 51
Institutional treatment, 37, 79, 98
Insurance and public health, 33, 59, 66, 88, 92, 95, 103
Intemperance, 149
Jefferson, President, 6
Jenner, Wm., 15
Kay, 2, 11
Koch, Robert, 192
” and segregation in tuberculosis, 201
Laissez faire policy, 6
Lay workers, utilisation of, 3
Loans for public health work, 14
Local Government Board, 53, 58, 77
Lowe, Robert, 28
Mackenzie, L., 57
Maclean, D., 31
Malaria, 147
Malthus, 6, 162
Malthusian hypothesis, 164
Massachusetts, 2, 4
Maternity benefit, 34, 95, 111, 134
Measles, 20, 126
Measurement of results in life saving, 19
Medical benefit, 34, 106, 110
Medical practice and public health, 27, 83
Medical officers of health, 63
Midwives Act, 255
Midwifery nursing, 260
Milk depots, 243
Mill, James, 6
Ministry of Health, 49
Mother and child, 132, 180
Murchison, Chas., 15, 17
National Health Insurance Act, 33, 59, 88, 104
National medical service, 32, 36
New England, 1
Notification of tuberculosis, 206
” of births, 245
Nursing, training of, 122
” public health work of, 126
Oastler, 177
Overcrowding, 7, 199
Over-population, 166
Owen, 177
Panel doctors, 215
Pasteur, 21
Percival, 177
Pettenkofer, Von, 13
Philanthropy and public health, 9, 37
Physical defects, 81
Pneumonia, 76
Poliomyelitis, 23, 76
Political pull, 102, 175
Poor law and public health, 27, 29, 31, 46, 49
Population problem, 163
Poverty, causes of, 31, 182
” control of, 46, 114
” tests, 139
” and sickness, 148, 162, 167, 184, 189
Preventive medicine, 99
Progress of public health, 1
Public health nurses, 128, 154
Racial immunity, 196
Red Cross workers, 127, 132, 143
Registrar-General’s returns, 18, 25
Relief _v._ prevention, 109, 190
Relief _v._ prevention, 48
Research, 24, 35
Resistance _v._ infection, 195
Respiratory diseases, 23, 125
Rumsey, 54
Rural conditions, 161
Sanatorium benefit, 34, 94, 111, 129, 214, 222
Sanatorium treatment, 228
Sanitation and infant mortality, 242
Scarlet fever, 20
Schools for mothers, 244
School medical inspection, 30, 57, 252
Scope of public health work, 44
Sedgwick, 16
Segregation of feeble-minded, 44
” in tuberculosis, 200
Sex teaching, 151
Shaftesbury, 177
Shattuck, L., 2, 3
Shop hygiene, 9
Sickness and pauperism, 67, 68
Sickness insurance, 10, 32, 65, 67, 87, 116
Sickness registration, 26
Simon, Jno., 2, 4, 5, 9, 12, 13, 22, 25, 28, 55
Smallpox, 21
Smith, Adam, 6
Smith, Southwood, 2, 9, 11, 12
Smith, Theobald, 2
Snow, Jno., 13
Socialization of medicine, 82, 102, 115
State treatment of disease, 112, 137
Statistical studies, influence of, 252
Still-births, 137
Syphilis, 137
Sykes, J. F. J., 244
Town living, influence on health, 43
Tuberculosis, 20, 23, 34, 76, 78, 129, 192
Tuberculosis and hospital treatment, 198
” and overcrowding, 199
” and housing, 203
” notification of, 206
Typhoid fever, 15
Typhus fever, 17, 20
Unqualified practice, 31
Urbanization, 7, 159
Venereal diseases, 30, 85, 131, 150
Victoria, Queen, 10
Vital statistics, importance of, 24
Voluntary agencies, 141
Walcott, 2
War, 81, 120, 158, 179
Water supplies and health, 16
Wells, 159
Whooping cough, 20
Women, work of, 122
” position of, 184
Transcriber’s Notes
pg 14 Changed groups of diarrhoeal to: diarrhœal
pg 19 Changed and that diarrhoeal to: diarrhœal
pg 20 Changed one-sixteenth to diarrhoeal to: diarrhœal
pg 34 Changed doctor or mid-wife to: midwife
pg 34 Changed in a sanatorum to: sanatorium
pg 42 Changed of the excessive diarrhoea to: diarrhœa
pg 49 Changed and the feebleminded to: feeble-minded
pg 89 Changed England was not actuarily to: actuarially
pg 101 Changed if the latters to: latter
pg 105 Changed for the benfits to: benefits
pg 114 Added period after: due to sickness
pg 115 Changed assistance by cooperative to: coöperative
pg 118 Changed period to comma after: Pre-school clinics
pg 145 Changed their satisfactory cooperation to: coöperation
pg 159 Changed rows of unsatistory to: unsatisfactory
pg 164 Changed power of finding enployment to: employment
pg 171 Changed she is over-worked to: overworked
pg 176 Changed facts, they villify to: vilify
pg 178 Changed more and more entagled to: entangled
pg 184 Changed accompaniments of overfatigue to: over-fatigue
pg 221 Changed Examination of a register kept for faciliating
to: facilitating
pg 228 Changed efficiency in a santorium to: sanatorium
pg 241 Changed caused 8.1 percent to: per cent
pg 246 Changed total deaths in ths to: the
pg 259 Added period after: Insurance Act 30s
pg 262 Changed that of abortions, stillbirths to: still-births
pg 262 Changed investigation of stillbirths to: still-births
pg 267 Changed it as he ollowed to: allowed
pg 268 Changed Antenatal work, 261 to Ante-natal
pg 268 Added period after: Enteric fever, see Typhoid
pg 268 Added period after: Hospitals, see Institutional treatment
pg 270 Sickness and pauperism had no page references added 67, 68
Table of contents used lectures, but refers to chapters
Many hyphenated and non-hyphenated word combinations left as written.