Chapter VIII: Part 8

In collecting the letters, the object was not to obtain accurate statistics, but a general picture of the conditions of life during the period of maternity. It is, however, possible to give fairly accurate figures showing the proportions of the number of still-births, miscarriages, and deaths from pre-natal causes and injuries at birth, to the number of live births.

Of the 400 cases, 26 were childless, and 26 did not give definite figures. The number of families to which the following figures refer is therefore 348.

Total number of live births, 1,396.

Number of miscarriages, 218 (15·6 per 100 live births).

Number of still-births, 83 (5·9 per 100 live births).

Total of still-births and miscarriages, 301 (21·5 per 100 live
births).

Of the 348 mothers, 148 (42·4 per cent.) had still-births or miscarriages. Twenty-two had both still-births and miscarriages, 37 had still-births, 89 had miscarriages. Of the 111 women who had miscarriages (including 22 who had still-births also)--

2 women had 10 miscarriages each.
1 woman had 8 miscarriages.
1 woman had 7 miscarriages.
3 women had 6 miscarriages each.
2 women had 5 miscarriages each.
6 women had 4 miscarriages each.
9 women had 3 miscarriages each.
17 women had 2 miscarriages each.
70 women had 1 miscarriage each.

Of the 52 women who had still-births (including 22 who had miscarriages also)--

1 woman had 5 still-births.
1 woman had 4 still-births.
3 women had 3 still-births each.
9 women had 2 still-births each.
45 women had 1 still-birth each.

_Infant Deaths._

Total number of live births, 1,396.

Total number of deaths under 1 year, 122 (8·7 per 100 live births).

Of the 122 deaths, 26 took place in the first week of life, 12 between the first week and first month, and 23 later, owing to ante-natal causes or injury at birth.

Thus, 50 per cent. of the deaths occurred either within the first month or from ante-natal or natal causes after the first month.

Of the 348 mothers, 86 (24·7 per cent.) lost children in the first year of life.

LOCAL GOVERNMENT BOARD MEMORANDUM

MATERNITY AND CHILD WELFARE

A complete scheme would comprise the following elements, each of which will, in this connection, be organised in its direct bearing on infantile health:

1. Arrangements for the local supervision of Midwives.

2. Arrangements for--

{ (1) An ante-natal clinic for expectant mothers.
{ (2) The home visiting of expectant mothers.
_Ante-Natal._ { (3) A maternity hospital or beds at a hospital,
{ in which complicated cases of pregnancy
{ can receive treatment.

3. Arrangements for--

{ (1) Such assistance as may be needed to ensure
{ the mother having skilled and prompt attendance
{ during confinement at home.
_Natal._ { (2) The confinement of sick women, including
{ women having contracted pelvis or suffering
{ from any other condition involving danger
{ to the mother or infant, at a hospital.

4. Arrangements for--

{ (1) The treatment in a hospital of complications
{ arising after parturition, whether in the
{ mother or in the infant.
{ (2) The provision of systematic advice and treatment
{ for infants at a baby clinic or infant
{ dispensary.
_Post-Natal._ {(3) The continuance of these clinics and dispensaries,
{ so as to be available for children
{ up to the age when they are entered on a
{ school register--_i.e._, the register of a public
{ elementary school, nursery school, crèche,
{ day nursery, school for mothers or other
{ school.
{ (4) The systematic home visitation of infants
{ and of children not on a school register as
{ above defined.

LOCAL GOVERNMENT BOARD, WHITEHALL, S.W.

_July, 1914._

SUMMARY OF THE NOTIFICATION OF BIRTHS (EXTENSION) ACT, 1915

The main provisions of the Act having reference to England and Wales are:

1. That the notification of births and still-births is made compulsory in all cases.

2. That the powers of Sanitary Authorities for dealing with maternity and infancy are extended to County Councils.

3. That a Committee or Committees may be set up for exercising these powers, which must include women and may include other than members of the Authority.

The clause referring to this committee reads as follows: “Any such powers may be exercised in such manner as the Authority direct by a committee or committees, which shall include women, and may comprise, if it is thought fit, persons who are not members of the Authority. Any such committee may be empowered by the Authority by which it is appointed to incur expenses up to a limit for the time being fixed by the Authority, and, if so empowered, shall report any expenditure by them to the Authority in such manner and at such times as the Authority may direct. A committee appointed for the purposes of this section shall hold office for such period, not exceeding three years, as the Authority by which it is appointed may determine.”

As regards Scotland and Ireland, the powers conferred are considerably larger, as the Local Authority “within the meaning of the principal Act may make such arrangements as they think fit, and as may be sanctioned by the Local Government Board for Scotland (or Ireland), for attending to the health of expectant mothers and nursing mothers, and of children under five years of age within the meaning of Section 7 of the Education (Scotland) Act, 1908.”

The clause as regards administration by committees including women applies also to Scotland and Ireland.

NOTIFICATION OF BIRTHS (EXTENSION) ACT, 1915

LOCAL GOVERNMENT BOARD,
WHITEHALL, S.W.
_July 29, 1915._

SIR,

I am directed by the Local Government Board to bring to the notice of the Council the provisions of the Notification of Births (Extension) Act, 1915, which has recently been passed.

The objects of this Act are to make universal throughout the country the system of the Notification of Births Act, 1907, under which early information concerning all births is required to be given to the medical officer of health, and also to enable local authorities to make arrangements for the care of mothers, including expectant mothers, and young children.

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.

_Notification of Births Act, 1907, to extend to every District._

The Act provides that on and after the first of September next the Notification of Births Act, 1907, described as the principal Act, shall extend to and take effect in every area in which it is not already in force.

In the case of a county district the principal Act will come into operation as if it had been adopted by the Council of the urban or rural district.

The principal Act provides that in the case of every child born within the district it is the duty of the father of the child, if he is actually residing in the house where the birth takes place at the time of its occurrence, and of any person in attendance upon the mother at the time of, or within six hours after, the birth, to give notice in writing of the birth to the medical officer of health of the district. This notice must be given in the case of every child which has issued forth from its mother after the expiration of the twenty-eighth week of pregnancy whether alive or dead.

The notice is to be given by prepaid letter or postcard addressed to the medical officer of health, giving the necessary information of the birth within thirty-six hours after the birth, or by delivering a written notice of the birth at the office or residence of the medical officer within the same time. The local authority is required to supply without charge addressed and stamped postcards containing the form of notice to any medical practitioner or midwife residing or practising in their area who applies for the same.

The Act also provides for penalties for failure to notify a birth in accordance with the Act.

It will be the duty of every local authority in whose area the principal Act comes into force by virtue of the new Act to bring the provisions of the principal Act to the attention of all medical practitioners and midwives practising in the area [Section 1 (3)].

The Board wish especially to call attention to Section 1 (2) of the new Act, under which the medical officer of a county district, for which the principal Act had not previously been adopted, will be required to send duplicates of any notices of birth he receives to the county medical officer of health as soon as may be after they are received. The early receipt of these duplicate notices is important, particularly in facilitating the inspection of midwives, and the Board trust that arrangements will be made under which the duplicates are as a matter of routine immediately transmitted to the county medical officer.

_Administrative Arrangements under the Act._

Section 2 of the Act provides that for the purpose of following up the information obtained under the powers of the principal Act and for facilitating arrangements for the care of expectant mothers, nursing mothers and young children, all the powers of the Public Health Acts may be exercised. These powers will be available not only to all sanitary authorities, but also to all County Councils other than the London County Council. In London the powers of the Public Health (London) Act, 1891, will be available for work undertaken in regard to the care of mothers and young children by Metropolitan Borough Councils.

It will be seen, therefore, that the Act definitely contemplates that the powers of sanitary authorities will be used to promote the care of mothers and young children.

The Board are anxious to insist 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. They have already in their circular letter of the 30th July, 1914, on the subject of Maternity and Infant Welfare, indicated generally the scope of the work which they consider should be undertaken, and an additional copy of that letter is enclosed.

As indicated above, the Act contemplates that arrangements for attending to mothers and young children may be made either by County Councils or by sanitary authorities. The Board recognise that the organisation must vary to some extent with local conditions, and that a considerable degree of elasticity is necessary. They are, however, of opinion that it will generally be desirable to formulate comprehensive schemes for counties and county boroughs, although in some cases portions of the services may be undertaken by the larger District Councils with advantage. The councils of counties and county boroughs are the local supervising authorities under the Midwives Act, 1902, and they are also entrusted with the initiation and execution of schemes for the treatment of tuberculosis; if the organisation of a maternity and infant welfare scheme is also undertaken by them, it will be practicable to secure the unification of home visiting for a number of different purposes.

In all cases, however, in which a general scheme is organised for the county, the work should be carried on in close co-operation with the sanitary authority, and any insanitary conditions found by health visitors should at once be reported to the sanitary authority. Although the Board consider that general schemes should be organised for the county as a whole, and that the County Council should, as a general rule, provide for health visiting, they are prepared, in suitable cases, to recognise the sanitary district as a proper area for a scheme.

_Co-operation with Medical Practitioners and Voluntary Agencies._

In the development of general schemes the Board desire that the services of hospitals and other efficient voluntary agencies should be fully utilised. They are also anxious that the co-operation of medical practitioners should be secured. The value of a Maternity Centre will be much increased by obtaining the co-operation of the medical practitioners in the area to be served by it, and in organising the arrangements it is desirable that they should be consulted.

_London._

In London the Act contemplates that schemes should be organised by the Metropolitan Borough Councils. Many of the services required can be provided by the various London hospitals and the numerous voluntary agencies now at work, and in some cases the chief need is to secure that such services are properly linked up with the work of the Borough Council. In other areas existing medical services will require supplementing and extending, and it will be for the Borough Councils to consider how this can best be done.

_Grants in Aid of Local Expenditure._

The Government have agreed to provide, by means of annual grants to be distributed by the Board, one-half the cost of the whole or any part of schemes for maternity and child welfare approved by the Board. The regulations under which these grants will be paid, together with forms of application for grants, have already been distributed to local authorities. A further copy of the regulations is enclosed.

_Interim Schemes._

Many local authorities have already prepared and submitted to the Board schemes for Maternity and Infant Welfare, embracing some or all of the items included in the Board’s memorandum of 30th July, 1914. The initiation of a complete scheme, however, involves time, and the Board do not desire that work should be delayed until a complete scheme can be formulated. They trust that those local authorities who have not already taken steps in this matter will do so before the onset of the hot weather, which brings with it special dangers to infants and children. The Board are of opinion that the local authority should in the first instance carefully consider whether the existing arrangements for home visitation are adequate. After the provision of health visitors the next step should be to arrange in populous centres for a Maternity Centre at which medical advice and treatment may be provided for mothers, including expectant mothers, and for children, whether ailing or not. Arrangements should also be made for defraying in necessitous cases the cost of providing the services of a midwife and of a doctor. The Board will be prepared to sanction such provision under Section 133 of the Public Health Act, 1875.

_Present Need for Maternity and Infant Welfare Work._

The importance of conserving the infant life of the population makes it desirable that steps should be taken in the directions indicated even at the present time when strict economy is required in the expenditure both of public bodies and of private individuals. It is not, however, intended that any large outlay should be involved in the provision of the services mentioned. No capital expenditure is needed, and the maintenance expenditure need not be heavy. The health visitors and many of the doctors required to work such a scheme will be women, and no labour need be employed which is required for the more direct purposes of the war.

_Committees._

The Act provides that the powers of a local authority may be exercised in such manner as the authority direct by a committee or committees, which shall include women, and may comprise, if it is thought fit, persons who are not members of the authority.

In any such committee it will be desirable to include working women, who might with advantage be representative of women’s organisations. Where no local women’s organisation exists, some central organisation might possibly assist by suggesting suitable women.

The Board consider that on any committee appointed for the purposes of the Act there should be a majority of direct representatives of the Council.

I am, Sir,
Your obedient Servant,
H. C. MONRO,
_Secretary_.

ADMINISTRATIVE POWERS OF LOCAL AUTHORITIES

The powers of County Councils[C] and Sanitary Authorities--_i.e._, County Borough and Borough Councils, Urban and Rural District Councils--for maternity and infancy work are derived from the following Acts:

1. Public Health Acts, 1875-1907. 2. Midwives Act, 1902.
3. Notification of Births Acts, 1907-1915.[C]
4. The Milk and Dairies (Consolidation) Act, 1915. (This Act will not
come into force till after the war.)

The following Maternity and Infancy work (with the exception of the supervision of midwives) may be carried out by special Maternity Sub-Committees (which must include women) of the above authorities:--

_Notification of Births._[C]

Every birth has to be notified in every area to the Medical Officer of Health for that area by the father of the child or the medical practitioner or midwife within thirty-six hours of the birth.

_Women Sanitary Inspectors and Health Visitors._

Properly trained and qualified women may be appointed to visit the homes and give advice on the care of mothers and infants.

[C] See summary of the Notification of Births (Extension) Act, 1915, on p. 198.

_Maternity Centres._

Skilled advice and minor treatment for the preservation of health may be given at Maternity Centres to expectant and nursing mothers and children up to school age.

_Supervision of Midwives._

County Councils and County Borough Councils alone carry out the supervision of midwives, through the Medical Officer of Health, who almost invariably has under him a fully qualified woman.

_Professional Attendance at Confinements._

A doctor or midwife may be provided to attend necessitous cases. The fee of a doctor called in under the Midwives Act may be paid.

_Maternity Hospitals for Complicated Cases and Infant Hospitals._

Hospitals may be maintained or beds paid for in existing hospitals or wards.

_Milk Depots._

After the war, depots may be set up by Sanitary Authorities (only) for the sale of milk for infants at cost price. (The Government grant is not available for these depots.)

GOVERNMENT GRANTS.

Government grants for maternity and child welfare work are now made, and half the cost of the whole or any part of schemes, approved by the Local Government Board, is now paid.

A sum of £50,000 has been voted this year (1915) for England and Wales, and no doubt corresponding sums will be available for Scotland and Ireland.

NATIONAL SCHEME

PROPOSED BY THE WOMEN’S CO-OPERATIVE GUILD

To insure effective care of Maternity and Infancy, it would be necessary to combine the administration of benefits under the Insurance Act with the services organised by the Public Health Authority.

_Maternity and Pregnancy Sickness Benefits._--These should be taken out of the Insurance Act, extended to all women (under the income-tax limit), and increased in amount. In addition to the 30s. maternity benefit, every mother should receive £3 10s. in weekly payments of 10s. for three weeks before and four weeks after confinement (or for longer periods if she prefers smaller weekly payments). During pregnancy she should be entitled to benefit varying according to her condition, from 2s. 6d. to 7s. 6d. a week, if her health requires it, subject to the recommendation of a maternity centre or a doctor.

Public Health Authorities should be empowered to administer these benefits through women health officers and maternity centres.

_Notification of Births._--Notification of births and still-births is now compulsory throughout the country, and in order to make it effective, an adequate number of Health Visitors should be appointed in every area.

_Women Health Officers._--The status of Health Visitors should be raised, their salaries being increased, and three qualifications being required--_i.e._, midwifery, sanitary, and nursing certificates.

_Midwifery and Nursing._--These services should be organised by the Public Health Authorities, which already supervise midwives. Longer training for midwives should be required, and an adequate salary secured to them by the Public Health Authorities. A charge of 10s. might be made to mothers employing them, to be remitted if the circumstances require it. This is the only method of meeting the present shortage of midwives, which is particularly serious in rural districts. It is also the only way of securing skilled attention for the women at a charge within their reach, and at the same time of securing adequate payment for midwives. Municipal midwives could be employed with a doctor.

The administration of the Treasury grant for nursing should also be placed under the Public Health Authority.

_Maternity and Infant Centres._--These centres should be places where expectant and nursing mothers and children up to school age can come for advice and treatment, so that they may be kept well and made well. Their organisation will depend on local circumstances, but it will be found desirable in most cases to open several centres, so that they may be near the people’s homes and serve the different classes of women in different localities.

Advice to expectant mothers might be given either at local maternity centres or at centres at hospitals.

It is important that treatment of a simple nature should be given with advice at maternity centres. Nourishment being often the treatment mothers most need, provision should be made for dinners for expectant and nursing mothers when ordered by the doctor. Simple talks on personal hygiene, infants’ clothing, etc., should be arranged, and saving-clubs organised.

_Medical Service._--It is desirable to appoint women doctors as municipal officers of the centres, but local practitioners may in some cases be advantageously worked into a municipal scheme. The provision of a doctor called in under the Midwives Act should be part of the scheme.

_Maternity Hospitals or Beds._--The dearth of such hospitals for abnormal cases is calamitous. The need for their existence is also pressing from the point of view of research, and they could be used as training schools for doctors and midwives.

_Maternity Homes._--These are required for normal cases. The few voluntary homes in existence in England are most valuable, and the experience of New Zealand shows that municipal homes could be made self-supporting. Private doctors might attend their patients in the homes.

_Milk Depots._--The difficulties of securing pure milk make it desirable to establish municipal depots for the supply of milk to expectant and nursing mothers and children. While every precaution should be taken not to undermine the practice of breast-feeding, there are cases where specially prescribed bottles would be useful.

_Household Helps._--The need for help in the home before, at, and after confinement is urgent, but in order to prevent untrained women doing midwifery work, careful supervision and an organised service under the public health authority are necessary. The experiments made by relief committees show the value of such a service.

_Women as Councillors._--Working women should be elected on to councils and serve on public health committees.

_Public Health Maternity Sub-Committees._--These committees should be largely composed of representatives of the women concerned. Such representation should be secured whenever possible through the following industrial women’s organisations: the Women’s Co-operative Guild, Women’s Trade Unions, the Women’s Labour League, and the Railway Women’s Guild.

Any parts of this scheme not at first taken over by Public Health Committees--_e.g._, Dinners, Household Helps--might be organised experimentally by the sub-committees with a view to ultimate inclusion in a municipal scheme.

_Ministry of Health._--In the future it will probably be advantageous to establish a Ministry of Health, with a Maternity and Infant Life Department, partly staffed by women.

* * * * *

It is essential that Government departments and Public Health Committees should be in constant communication with organised working-women, and be ready to welcome their co-operation, so that their needs and wishes may be freely consulted. It is by a partnership between the women who are themselves concerned, the medical profession, and the State that the best results of democratic government can be secured for the mothers and infants of the country.

* * * * *

To be obtained from the Women’s Co-operative Guild, 28, Church Row,
Hampstead, London, N.W.:

_The National Care of Maternity_ (leaflets for town and country),
1/2d. each, or 3s. a hundred.

_Hints to Expectant Mothers_, by Dr. J. W. Ballantyne, price 1d., or
6s. a hundred.

_Household Helps_, 1/2d. each, or 3s. a hundred.

BILLING AND SONS, LTD., PRINTERS, GUILDFORD, ENGLAND

Transcriber's Note

The following apparent errors have been corrected:

p. 27 "condiditions" changed to "conditions"

p. 163 "on stairs" changed to "on stairs,"

p. 185 "nine children" changed to "nine children."

p. 197 "infan s" changed to "infants"

p. 210 "etc," changed to "etc.,"

Punctuation in the list of Occupations of Husbands has been regularised.

On pages 194 and 195, dittos have been replaced with the relevant words.

The following are used inconsistently in the text:

afterbirth and after-birth

afterpain and after-pain

childbearing and child-bearing

childbirth and child-birth

Illustrations have been moved and may not match the locations given in the List of Illustrations and Facsimiles.

The following possible error has been left as printed:

p. 2 husband’s trades