Public health and insurance: American addresses

by Sir Arthur Newsholme

FOOTNOTES:

[17] The substance of two lectures at the Summer School on Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919.

CHAPTER X
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].