The Elements of Child-protection

by Sigmund Engel

Since the middle of the eighteenth century there has, in nearly all the countries of Europe, been a decline in infant mortality, in the case alike of boys and of girls; this fall in the infantile death-rate is greater than the fall in the general death-rate. Although the data available justify this general statement, it is necessary to point out that authentic statistical data bearing on the question exist only in the case of small and isolated areas, such as individual towns; national registration of such particulars is of much more recent date than the middle of the eighteenth century.

Certain Contributory Causes.—The influence upon infant mortality of certain causes commonly regarded as important is in fact small. Statistical data prove beyond dispute that local and climatic factors exercise no direct influence at all upon the infantile death-rate; such influence as these factors do exercise is an indirect one, operating through the effect which climate and locality may have upon social conditions. The same qualification applies to the influence of race and of religion upon infant mortality. There are differences in the infantile death-rates as between Teutons and Slavs, and as between Christians and Jews; but these differences are in no way directly dependent upon the differences in race or in religion, and they must be ascribed to the differences in social conditions. Fertility is well known to exert a decisive influence upon infant mortality; but variations in fertility are not the direct effect of any differences in race or creed; they are a consequence of the varying social conditions in which those of the respective races or creeds actually live. Thus it is only in certain social conditions that Slavs are more fertile than Teutons, and Jews more fertile than Christians. The constitution of the parents exercises a considerable influence upon infant mortality; but the parental constitution must be regarded as largely dependent upon the social environment in which the parents themselves have grown to maturity.

The Chief Causes of Infant Mortality.—Among the commonly enumerated conditions affecting infant mortality the following are conspicuous: the proportion of infants reared by artificial feeding instead of being suckled; work for wages by the mothers of infants; the general intelligence of the lower classes of the population, and their knowledge of the care and management of infants; the general state of the public health, including such conditions as the degree to which the general population is enabled to avail itself of the medical knowledge of our time (in all the countries claiming to be “civilised,” bald official statistics prove beyond dispute that a large proportion of the children dying before attaining the age of one year die without having ever received any medical treatment whatever); the number of illegitimate births, &c. But all these conditions are in essence nothing more than social conditions. Thus we are practically justified in saying that the determining factors of infant mortality are social conditions and nothing else. With striking unanimity, those who have made a special study of this question formulate the conclusions summarised in the following paragraph.

The infantile death-rate is higher among the lower classes than it is among the upper. Within the limits of those making up what are termed “the lower classes,” the infantile death-rate is higher in proportion as the social conditions are unfavourable. The figure attained by the infantile death-rate depends above all upon the social circumstances and the earning capacity of the parents. Inasmuch as an infant does not possess the faculty of spontaneous change of place or of other spontaneous activity, since it is unable even to express its needs in an intelligible manner, its fate depends upon the soil in which it grows—its very life depends upon its environment. Such, from the social standpoint, is the essential characteristic of the age of infancy. The infant born of well-to-do parents has better chances of life than the infant born of poor parents, for the former lives in more favourable circumstances, and receives in every respect a better upbringing. It is a demonstrable fact that most children that die succumb, not from inherited weakness, but owing to the errors and defects of their upbringing.

The materials available in proof of this proposition are ample and incontrovertible. Whatever the place, the time, and the other conditions submitted to investigation, and whether the investigated materials be large or small, we are led invariably to the same conclusions. In the bourgeois (middle and upper) classes, only 8 per cent. of the children die during the first year of life, but among the proletariat the infantile death-rate is 30 per cent. Even more significant, if possible, are the following facts. The infantile death-rate is higher among illiterate wage-earners than it is among literate wage-earners; it is higher among casual labourers than it is amongst wage-earners permanently occupied. In the strata of the population above the manual workers, we find that the infantile death-rate is lower as we pass from strata in which social conditions are comparatively bad to strata in which they are comparatively good. The infantile death-rate and the income of the parents vary in inverse ratio. The differences in the infantile death-rate as we pass from the poorer quarters of our towns to the richer quarters tell always the same tale.

The Great Number of Children.—The chief cause of high infant mortality and of high child mortality among the lower strata of the population is the great size of their families. The number of conceptions, pregnancies, and births varies directly as the infantile death-rate. If out of a certain limited income more children have to be maintained, the share of each in the commodities purchasable out of that income necessarily diminishes. The income of the manual worker is so small that, even if his family is quite a small one, it is exceedingly difficult for him to provide out of that income what he and his wife and children need for the satisfaction of elementary vital needs. With every additional child comes a further limitation of supplies for each individual member of the family. Not only does this have a directly unfavourable influence upon health, inasmuch as each child receives a smaller share of dwelling-room, food, &c. In addition, as more and more children are born, the worth of the individual child in the eyes of the parents diminishes.

The mother’s health is apt to suffer from the rapid succession of conceptions, pregnancies, and deliveries. For various reasons this is disadvantageous to the children. A woman thus affected will subsequently bring more weakly children into the world; the mother whose health is poor is unable to give as much time and pains to the rearing of her children as she would if she were well and strong; many women whose health has been broken by unduly frequent pregnancies die during a subsequent pregnancy or delivery.

But may it not be that the relationship between a large number of births and a high infantile death-rate is the reverse of that which we have suggested? Is it not possible that the great mortality among children may be the cause of an increase in the number of conceptions, pregnancies, and births? It is true that certain purely psychological factors may contribute to such a causal sequence. To a certain degree a high infantile death-rate has such an effect. For if a woman gives birth to a diseased or a still-born child, or if one of her children dies, the parents are more likely than would otherwise be the case to desire to have another child, and the wife will be more ready to undertake the troubles of another pregnancy and the risks of another delivery.

The most important means for the diminution of child mortality is to improve the conditions of working-class life. It is indisputable that the more prosperous members of the working class have fewer children on the average than those who are not so well off; that in any region in which an improvement has taken place in the conditions of working-class life a fall in the birth-rate has ensued; that the poorer the condition of any stratum of the proletariat, the larger is the average family. An increase in the average working-class income will lead to a proportionately greater decline in the death-rate of infants and young children. For this increase in income will operate in two ways: in the first place, if the number of children remain the same, the rise in income will ensure for each child a larger share of the necessaries of life; and, in the second place, with the rise in income the size of the average family will diminish, and this will reduce the child mortality. Inasmuch as the height of the infantile death-rate depends mainly upon the great infant mortality among the lower strata of the population, every effort at reform in this direction must begin at the lower end of the social scale.

Child Mortality in the Towns.—A connection appears to exist between density of population and the death-rate: if the other conditions remain unchanged, the death-rate increases pari passu with increasing density of population. The question whether in the towns child mortality is higher than in the country districts has not yet been decisively answered; and it is equally uncertain whether from the hygienic standpoint the existing rural conditions are better than the urban. It appears probable that child mortality is higher in the towns than in the country districts; it is more doubtful, however, if the same can be said of infant mortality. The statistical data available on this question must be subjected to a stringent critical examination. The infant mortality which truly belongs to the towns appears smaller than it really is, for the reason that a proportion of the infants born in the towns are placed in the care of foster-parents living in the country, and some of these die in the country. It is equally true that many people from the country die in hospitals and other institutions in the towns; but this applies much more to adults than to children.