GREAT THOUGHTS ON CHILD LIFE AND

CHILD WELFARE.

Under this heading are gathered quotations from the works of those who have formed ideals or dealt with actualities relating to child life and child welfare. It is hoped that many of our readers will assist in the compilation of this page by sending any helpful thoughts which they may have found of service in their own experience or discovered in the course of their general reading.

THE CHILD.

A MONTHLY JOURNAL DEVOTED TO CHILD WELFARE.

No. 4.

JANUARY, 1918.

Vol. VIII.

THE PROBLEM OF MATERNAL AND CHILD

WELFARE.1

By SIR JOHN BYERS, M.A., M.D., M.A.O.

Professor of Midwifery and of Diseases of Women and Children in the Queen's University, Belfast.

IN any discussion of the pressing problem of maternal and child welfare, the close association existing between mother and child must always be kept in mind, a circumstance made clear from the fact noticed in all countries--alike in their urban and rural areas-that about a half or a third (varying in different places) of the deaths that take place in the first year of life are met with in the first month after birth, and that as many deaths occur during pregnancy as during the first year of life. Since this terrible War began two features stand out prominently, especially in England, America, Belgium, and France the great concern for the protection of maternity, and the effort to secure that the infant is properly taken care of by its healthy mother in her own home rather than in any institution--circumstances again emphasizing the close association of mother and child.

The main reason why this question has become so acutely clamant is really the decline in population, for not only are fewer infants being born, but far too many mothers and children are dying from preventable causes; further, in this War we are losing the very best blood of the Empire and of the Dominions-the very flower of our manhood, the potential fathers of the next generation. I may give in support of these statements the following facts :

1 The first of a series of lectures delivered in connection with an exhibition on "Life-saving in War Time," in the Central Municipal Library and Museum, Belfast, on October 23, 1917.

Decline fn Birth-rate.

In England and Wales since 1876 (when the birth-rate was highest) the birth-rate has steadily declined, a diminution of 33 per cent. having been reached in 1914. Had the same rate of births continued from 1876 to 1914 there would have been 1,346,719 births instead of 878,882; in other words, if the births in 1914 had been as numerous as in 1876 there would have been 465,837 more babies. In Ireland there has been a steady fall in the birth-rate since 1909. In that year there were 102,759 births, while in 1916 (when the birth-rate reached its lowest) there were 91,437, a difference or diminution of 11,322. In Belfast the birth-rate has steadily fallen from 35 ̊5 per 1,000 of the population in 1890 to 241 in 1916. In 1895, when the population of Belfast was 295,000, there were 9,772 births; in 1916, with a population of 390,000, the births were 9,415-that is, a population of 95,000 more, yielded 357 fewer babies.

Maternal Mortality.

It has been calculated that, as a result of child-bearing in England, one mother dies to every 259 births, in Ireland one to 191 births, and in Scotland one to every 175 births. As the result of pregnancy and parturition, week by week, it is said sixty-seven deaths of mothers occur in England and Wales, of which twenty-four are ascribed to puerperal infections.. It is clear that a large number of such deaths are preventable, and especially those from puerperal infections (the old "puerperal fever "), from the fact that there has been a reduction of the child-bearing mortality in England and Wales experienced in recent years, by the marked variations noted in different parts of the country, and by the experience of maternity hospitals. In Ireland it is unfortunate to find that the rate represented by the deaths from puerperal septic diseases, and diseases and accidents of pregnancy and childbirth during the year 1916 (viz., 5'51 per 1,000 births), is o'22 per 1,000 above the average (5'29) for the preceding ten years, and is, with the exception of that for the year 1906, higher than the rate for any of those years. In England in 1903 the Midwives Act came into operation. Now the death-rate from puerperal septic diseases per million females living was for the previous three years as follows: In 1900, 121; 1901, 123; and in 1902, 118; from which it has fallen to 75 in 1914; while the deaths from the accidents of childbirth vary according to whether expert advice and attention are available, a circumstance which applies to the Highlands in Scotland, Wales, and to Con

naught in Ireland. Scotland has in recent years obtained a Midwives Act. What is required in Ireland are: a Midwives Act, more institutional treatment for pregnancy and confinement cases needing special care, and, notably in urban centres, maternity and pre-natal clinics. So far as Ireland is concerned, I can endorse in the strongest way what Sir Arthur Newsholme, K.C.B., writes me of England: "If I were asked what is the provision needing most urgently to be made at the present time, I should most unhesitatingly say that in this country it is maternity homes for mothers living under unsuitable conditions, where they could be confined away from noise and the risks of an early return to work, &c.”

The United States of America have recently had a very rude awakening on the question of maternity death-rates, for the Federal Children's Bureau in Washington reports: "More women between the ages of 15 and 45 years of age die in the United States from conditions incident. to maternity than from any other cause except tuberculosis; and since 1900, where the death-rate from tuberculosis, typhoid fever, diphtheria, croup, and from certain other preventable diseases has been greatly reduced, the available figures for the death registration area show no decrease in the proportion of mothers whose lives are yearly sacrificed as a result of ignorance and neglect " (Meigs). Taking the maternal death-rates per 100,000 of the population from diseases caused by pregnancy and confinement, Spain occupies the worst position with a rate of 196 per 100,000 of the population, while Sweden has the best place with a rate of 6'0; after Sweden come Norway (81), Italy (89), France (103), Prussia (10 ̊4), England (111), New Zealand (12'4), Ireland (129), Hungary (13'3), Japan (133), Australia (141), Belgium (148), Scotland (148), United States (149), Switzerland 152). These figures I have taken from Dr. Lobenstine's paper in the American Journal of Obstetrics for September, 1917.

Infantile Mortality.

In England and Wales in 1916 the infantile mortality (or the rate of deaths of children in the first year of life per 1,000 births) was 91, in Scotland 97, while in Ireland it was 83; but if we go back to 1904 we find that the subsequent yearly decline was rapid and steady in England and Scotland, but slow in Ireland, amounting to about onethird of that in England. If Ireland be divided into the "nineteen town districts" (that is, towns of over 10,000 inhabitants), and the remainder of Ireland, the infantile mortality was almost twice as high

in the towns as in the country. To put this in a clear way, for every 100 deaths of infants in 1916 in the "nineteen town districts," only 55 occurred in the remainder of Ireland--that is, the lives of 1,506 infants would have been saved in 1916 had the death-rate of rural Ireland been the same in the large towns. Of the Irish "county boroughs," Dublin (in 1916) had the highest infantile death-rate (153), Londonderry the lowest (92), while it was in Cork 94, Belfast 113, Limerick 122, and Waterford 133. It is interesting to record that in London, a city with a population of 4,237,387, the infantile mortality was 89 in 1916, while in Ireland, with a slightly larger population (4,337,112), and with a great rural area, the rate was only 6 points lessthat is, 83 per 1,000 births. In the report of a "Committee concerning Causes of Death and Invalidity in the Commonwealth" of Australia, recently published, there is a most interesting table showing the infantile death-rates under one year per 1,000 births of various foreign countries on the average of the latest five years for which information is available, and of the Australian States and New Zealand on the average of the years 1909-1913, which shows that Sweden (78), Western Australia (77), Tasmania (75), New South Wales (74) (68 (latest figures) in 1915), Commonwealth (72) (67 (latest figures) in 1915), Victoria (72) (68 (latest figures) in 1915), Norway (70), Queensland (67), (latest figures 63 in 1915), South Australia (65) (and (latest figures) 67 in 1915), and New Zealand (59, since dropped to 50 in 1915, with one of its principal towns, Dunedin, which has a population of about 60,000, with a rate of only 40 per 1,000 births), have all lower rates than in any of the three countries (England, Scotland, and Ireland) in the United Kingdom. European Russia has the highest infantile mortality (254), the German Empire has a rate of 176, Austria 203, Prussia 170, Spain 165, Japan 156, Italy 153, Belgium 141, France, 126, Switzerland 115, and Denmark 107. In Ireland, in 1916, the deaths of children under one year (7,627) were rather more than one-ninth of all the other deaths during the year, while in Belfast they (1,067) were about one-sixth.

Causes of Infantile Mortality.

The causes of infantile mortality may be grouped under two heads (1) The Congenital or Pre-natal, (II) and the Environmental.

The Congenital or Pre-natal Group.

Of the children dying under one year in Belfast during 1916 from stated causes, a little more than one-third died in the first month; in other cities the number amounted to a half, and the same fact was