HB 1323 .14 E8 Copy 1 INFANT MORTALITY. REPORT OF THE PUBLIC WELFARE COMMITTEE OF ESSEX COUNTY 1912 665 Broad Street Newark, N. J. ^ Transfer A P* 16 1919 ^ 0\ 'Where the white hearse goes most often, there you will find the weakest places in your municipal housekeeping. ' ' 'A baby who comes into the world has less chance to live one week than an old man of ninety ; and less chance to live a year than one of eighty." 'Infant mortality is an infinitely complex problem." 'The reduction of infant mortality is a public health problem. " ' 'The time to save the baby is before it becomes sick, not afterward. ' ' the ity irk / EVERY DOT REPRESENTS THE DEATH OF A BABY UNDER ONE YEAR OF AGE DURING SUMMER OF 1910 By Ccu'l'V 'f»" •»"<■•""' M ° p C °- / Special report of the work carried on by the Public Welfare Committee of Essex County for the Reduction of Infant Mortality in Newark together with A study of the problem in Essex County and a program for the City of Newark. By JULIUS LEVY, M. D. TRUSTEES. FRANK H. SOMMER, President S. Ervin Manness, Vice-President Emily S. Hamblen, Secretary John L. Rankin, Treasurer M. N. Baker Dr. Laban Dennis Edward Blau Rabbi Solomon Foster Dr. Wm. Buermann Dr. Miriam B. Kennedy Mrs. G. W. B. Cushing Rev. John J. Moment DEPARTMENTS. i. Research Theo. D. Gottlieb, Chairman 2. Juvenile Dr. Laban Dennis, Chairman SECTIONS. Research Health Dr. Julius Levy Infant Consultation Stations and Milk Supply Edward Blau Placing Out of Infants J. A. Cullen Matters of State Control J. J. Moment Fire Prevention S. E. Manness Labor Thos. J. McHugh Juvenile Education Achill Bippart Playgrounds and Recreation Centers Wm. S. Lamont Physical Environment of the School Child Dr. Theo. Teimer Commercial Recreation John J. Gascoyne Motion Pictures and Theatres Rev. Geo. P. Dougherty Illegal Employment and Entertainment of Minors Chas. A. MacCall SUB-COMMITTEES Legislative Richard D. Currier Publicity Mrs. E. Stern INTRODUCTION The purpose of this report is, first, to present a record of the Infant Mortality problem in Essex County, and more especially in Newark, with a study of some of the most important underlying causes; second, to state what has been learned and accomplished by the plan proposed by the Public Welfare Committee of Essex County, providing for infant con- sultation stations, the education of mothers, and the home modification of milk; third, to propose on the experience obtained here and elsewhere a plan of action commensurate with the complexity of the problem under consideration, a plan that, if properly carried out, will practically remove the infant mortality problem from private charity and philanthropy, and place it on a permanent and efficient basis. I wish to take occasion here to thank the doctors and nurses who have assisted me in the clinics and have worked so devotedly in the in- terests of the mothers and their babies; also those who by their financial aid and encouragement have made this experiment and study possible. FOREWORD. Of course you believe in conserving child life! This study and report is sent to you in an effort to transmute that belief into action. Is it too much to ask, in the name of the babies of the county, that little of your time needed for a careful reading? Be warned, at the outset that such a reading will pull at your heart- strings — and perhaps at your purse-strings. We owe the study and report especially to the now long continued work, in self-sacrificing spirit of service, of Dr. Julius Levy and to Mr. Edward Blau, Chairman of the committee directly in charge of the work described. The conclusion reached, that the problem of infant mortality can be most efficiently and economically met by establishing public depart- ments of child hygiene with broad but definite functions is that to which practically all have been forced, who have studied the problem. What of the time that must pass before the work is included among governmental functions, and public departments of child hygiene become an actuality? Can we in the meantime turn a deaf ear to the bitter cry of the children ? No ! The infant consultation stations now established must be maintained ; their work must be strengthened ; their number must be increased, and their sphere of activity extended ; the continued sale of pure milk, especial- ly for babies, at prices within the reach of those who are compelled to struggle to make wage and outlay meet, must be assured; visiting of the homes of the new-born and the education of the mothers must go on ; registration for wet-nurses, and homes must continue to be provided ; and the systematic training of midwives must be undertaken. Then, too, the gathering and study of data must go on. The campaign of education to create sentiment for the work as a governmental function must be pressed. So long as the work continues on the plane of private philanthropy appeal must be made to the people for financial aid. The appeal is now made to you. The study and report present facts and the results of a scientific study of the facts. This foreword may serve to re-enforce the heart interest of these facts. Won't you as you turn the last page look into the beaming faces' of your little ones ; then think of the little ones outside, and the homes unnecessarily saddened by the going out of the vital spark of some babe's life for want of a little knowledge ; for lack of the methods of care which that little knowledge would induce? And then — Give! PUBLIC WELFARE COMMITTEE OF ESSEX COUNTY, Frank H. Sommer, Chairman. Wiss Building, Broad Street, Newark, N. T. Infant mortality problem of greatest magnitude. *THE WORK OF THE PUBLIC WELFARE COMMITTEE OF ESSEX COUNTY FOR THE REDUCTION OF INFANT MORTALITY. The Public Welfare Committee of Essex County has taken up the infant mortality problem in the same spirit that it has studied other civic and social prob- lems in our county, with the same purpose to obtain first hand knowledge of the problem as it exists in our county, to become familiar with the adequacy and effi- ciency of existing activities and then, if it seems neces- sary, to evolve a plan and method of solution that will attempt to be commensurate with the problem and can be given permanence by adoption into some muni- cipal department. With this view in mind we attempted to demon- strate the efficiency of our plans in but limited areas, leaving the extension of the work to the day when the city shall take it over. Our survey of the infant mortality problem in Newark revealed the following facts : During the past decade there were more deaths from infants under one year of age than from tuber- culosis in all forms and at all ages. That is why the Section on Health of the Public Welfare Committee felt called upon to devote itself to this subject. While it was found that the greater part of these deaths occurred in about four districts, the clinics, hospitals, milk depots were often not in the centre of these districts and therefore not where they could do the greatest amount of good. It was found, further, that the doctors and nurses usually could not speak the language of the mothers, and so at best could have very little effect in eliminating what, I believe, is the greatest single factor in this problem — ignorance made hide-bound by prejudice. It was further found that, though modified milk- could be obtained at a milk depot, relatively very few mothers could avail themselves of it on account of the distance, and though certified milk has been sold here for more than fifteen years, practically all of the mothers in the districts of highest mortality were buy- ing very filthy store or bottle milk. The one fact, however, that was the most astounding of all, was that while there has been a reduction of infant mortality in Newark during the past ten years, and though certified milk has been introduced and a milk depot operated, the infant mortality from diarrheal diseases showed a very marked increase in the first half of the past decade and was actually higher at the end of the decade than at the beginning. The reduction of infant Ignorance is greatest single cause. Certified milk and milk depots reach only a small per- centage of the babies. Diarrhea increasing. * Paper read before the Pediatric Section of the Academy of Medicine of Northern New Jersey, October, 1912, by Dr. Julius Levy. mortality has been due to factors not directly influ- enced by milk supply and feeding. As a result of these and other studies and obser- vations, we were convinced that milk is not the great- est single factor in the infant mortality problem and that the distribution of modified milk is not the way to solve this complex problem. Indeed, I have long felt — and many other workers are voicing this same opinion — that the milk depot, in the first place, in- creases the number of artificially fed, and secondly, does not reach the infants that require it most — those with the most ignorant and indifferent mothers ; nor indeed when the mortality among infants is highest — before the third month of life. Our plan found its basis in the common knowl- edge, obtained both empirically and biologically, that mothers' milk is the only proper food foi infants ; that mothers can nurse their infants successfully in greater numbers and for longer periods than obtains to-day — that the failure to nurse wholly or partly is due, in large part, to ignorance, inherited prejudices and superstitious beliefs that are fostered by anxious grandmothers, ignorant midwives, and I am sorry to admit, indifferent doctors ; in a lesser degree to the equally preventable social and economic conditions of overwork, undernourishment, tuberculosis and other debilitating diseases. Our plan is nothing more than to try to induce mothers to accept our knowledge of the importance of maternal nursing and its rationale, of the hygiene of infancy, of the importance of ob- taining a clean tuberculin tested milk and then taking proper care of it in the home. Our method has for its fundamental thought that mothers can only be con- vinced of these somewhat recently emphasized facts by doctors and nurses who see the mothers frequently, know their customs, habits, and prejudices, speak their language — yes, and even their dialect. Our ulti- mate purpose is to conduct our work in such a manner that the public and the authorities will be convinced that infant welfare work is of such value and im- portance to the entire community that it shall become a part of the municipal activity for the conservation of public health. I will describe the work as carried out at one consultation station : As the district in which this station was opened was inhabited almost entirely by Italians, we obtained, after much difficulty, an Italian doctor and nurse to assist in the work. I wish to state that neither had any special training in pediatric work. I consider the ability to speak the language of the mother of most importance. Clinics were held twice a week, but the nurse was at the station every day at a certain hour to meet any mothers who wished additional informa- tion or had very sick babies. To enable mothers to Milt is not the greatest single factor. Maternal nursing and education are the two most im- portant factors in prevention. Doctor and nurse must speak native language of mother. Pure milk at rea- sonable price. Uirth records. Practically all mothers can nurse their infants. All mothers can be I aught to modify milk at home. obtain milk fit for infants at a reasonable price, ar- rangements were made with two milk companies to sell their nursery milk at nine cents a quart, one selling it from drug stores through the generous assistance of the druggists, and the other delivering it by wagon. After a little persuasive reasoning with the au- thorities we were permitted to copy the birth records, and with these in our possession our nurses were able to call on every baby in our district before it was two months and in most instances before it was one month old. The purpose of this early visit is to reach the mother while she is still nursing her infant, to explain the danger of giving anything in addition, to advise the mother to come to the station, have her baby weighed each week, and place herself under the direc- tion of the doctor. The doctor bent all his efforts to convince the mothers that they were nursing success- fully and that under no circumstances should they give anything to the baby without first consulting him. This constant emphasis on the ability of the mothers to nurse their infants is absolutely necessary to coun- teract the general impression that very few mothers can nurse their infants successfully for more than a few weeks or months, an idea for which the constant emphasis on milk modifications is partly responsible. The time comes when the infant requires addi- tional milk. We then introduce slowly one, two, or three bottles, always prolonging the maternal nursing as long as possible. Even when it seemed that the mother had very little milk and that she could not nurse successfully — which was much less frequently than the mothers claimed, and even than many doctors think — we did not wean, but ordered supplemental feeding, that is, that the baby be nursed every three hours and be given immediately in addition a bottle of milk. In this way we kept continually before the mothers our horror of artificial feeding and our faith in the wonderfully saving powers of their own nour- ishment. In this way I hope we will re-establish in the breasts of the mothers that faith in their powers and that high sense of duty to their infants' welfare thai will compel them to maternal nursing even though it be at the price of some social or physical disability — the lacteal secretion, I am convinced, is usually pres- ent. However, some babies must be artificially fed. Of course, all milk was modified at the home of the mothers by the mothers themselves. This may seem very remarkable indeed to some, but I assure you there is no difficulty where the method is simple, the instructions definite, a clean milk to hand, and the cases followed by doctor and nurse that speak the language of the mother. With the exception of a very few cases we required nothing but raw diluted whole milk, cane sugar, barley water and salt. This I would emphasize as the most impressive and important phase of our work, because in this way alone, it seems to me, can rational, intelligent milk modification come into general household and general professional knowl- edge, can mothers and doctors learn the cost of clean milk, its value and where to obtain it. The mothers obtain a working knowledge of an infant's capacity and digestion, and when they act without advice they will at least have some experience to guide them. In this work of home modification the emphasis is laid on clean milk, clean bottles and nipples, proper inter- vals, the avoidance of additional food, and not on the modification. Doctors and mothers must be weaned from the superstition that milk modification is so com- plex a procedure, even when most scientific, that only a baby specialist can understand it and only a trained nurse prepare it. Naturally, we have some grave cases of malnu- trition, marasmus and summer diarrhea brought to us. All these cases have been cared for in the homes of the mothers, by the mothers with the active supervision of the doctor and nurse. We were prompted to try this not only because infants under one year and suf- fering from nutritional disorders do very badly in all institutions, the mortality often rising to 30 or 40 per cent, in hospitals, and from 60 to 70 per cent, in infant asylums, and even in the worst types of cases is only 23 per cent, in private homes, but mainly because the experience of handling a sick infant has such a great educational value for the mother. From time to time young infants are left without a mother to care for them either through death, sick- ness which necessitates the removal of the mother to the hospital, or economic conditions which take the mother to the shop. The first condition we have tried to meet by the establishment of a county registry for the supervision of and placing out of infants. The second condition by trying to explain to the hospitals that by admitting a nursing mother without her infant they are increasing sickness and death ; I am glad to say that our hospitals have agreed to admit babies with their nursing mothers. The economic necessity that separates mother and infant is a bit of shortsighted social and economic policy that must cease, whether it be accomplished by means of pensions, insurance, or an entire change of government. The above are the most important things we have tried to introduce this summer. We intend to con- tinue this work for a time, but in addition we hope to establish classes for expectant mothers to teach them personal hygiene, for mothers to teach them the care of the home and their children, for the little mothers who are often the caretakers of the infants and always have great influence in the home ; classes and training for midwives, but only with the purpose of showing the way to the educational and health departments so Private homes preferred to hospitals and asylums. Tensioning' of mothers. Placing: out of infants. Education of little mothers, mofhers and midwives. that this work will be included in their activities. 1 will submit only a few of our statistical data: During the four summer months we had on record 509 cases, of which twelve died (including every case even though moribund or attending only a few hours. This gives a mortality of 2.3 per cent. If we omit two cases that were moribund and died after making only one visit, and one a breast-fed baby that died from status lymphaticus, our mortality is 1.9 per cent. Of all the cases under one month on admission (9 per cent, of the total) none were in very poor con- dition. Of all under two months (22 per cent, of the total) none were in very poor condition. No babies that were entirely breast fed were in very poor con- dition. Of the babies in very poor condition 81 per cent, had been artificially fed, 12 per cent, partially breast fed, 7 per cent, on general diet. Among the Italian mothers in our care at one station 98 per cent. had been delivered by midwives, and 19 per cent, of all their babes born died before two years of age. Department of I believe we are justified in the following conclu- chim Hygiene sions : A high infant mortality rate is of grave mo- an asset to the , ° . . - rr ■ community. ment not only on account of the pain, sutienng, worry, and economic loss it entails, but particularly because it is an evidence of the ante-natal, neo-natal and post- natal environments to which those that survive are also exposed. The physical resistance and mental ca- pacity of childhood, the moral stamina of adolescents, are directly influenced by the health and nutrition of the first two years of life. If we believe that the most valuable asset of this community is the health and character of its youth, we cannot longer question the urgency of making the conservation of infant life a special function of our municipality in a department of child hygiene in the city, county or state. *f£> 12 * \ ' EVERY DOT REPRESENTS THE DEATH OF A BABY UNDER ONE YEAR OF AGE DURING SUMMER OF 1910 By Courtesy of the Interstate Map Co. i Our Problem BORN WITH A HANDICAP. IMPROPERLY CARED FOR AFTER BIRTH. 13 THE EXPERIMENT. A statement of the work carried on by the Committee during the summer of 1912. Infant Consultation Stations — 147 Seventh Avenue — Fifteenth Ward. 226 Hunterdon Street (closed Oct. 1st), Fourteenth Ward. Beth Israel Hospital — Third Ward. Ferry and Richards Streets (open only one month), Tenth Ward. Number babies visited from birth records before one month old. . 497 Number babies visited from birth records over 1 month and under 2 months ■ • • • 200 Average gain per week of babies artificially fed on home modified milk ' ' 4 oz. Number of babies registered at clinics 509 Number of babies died .Mortality rate 2.3% Mortality rate, omitting babies under observation less than two weeks (7) 0.9' \ Mortality among children under 2 years of age, of same mothers, prior to opening of clinic 13.9 Number of visits to clinics 1,549 Largest number attending clinic any one day 40 Average attendance 15 Number clays by physicians at clinics 96' The clinics are held twice a week at each station. The nurses connected with each station are of the same nationality as the people of the district and speak their language. The doctors, to a considerable extent, also speak the language of the people. NURSES. Number of nurses — one head nurse, three in field : two speak Italian, one speaks Polish and Yiddish, Slavic and Russian. Visits to homes for registered babies 3,033 Visits to homes for new born babies 697 Visits to homes for instruction in home modification of milk. . . . 766 Total 4,496 Average visits per nurse per field working clay (6 working hours) 12 Average visits for each baby 6 Total working days 252 Divided as follows : Days spent in visiting 141 Hours spent in clinics, 440, or days 55 Hours spent at stations ( 1 hour daily) 28 Hours spent at lunch ( 1 hour daily) 28 Number of babies registered at each station, from June 10 to Oct. 1 : Total. Under care Oct. 1st. 147 Seventh Avenue 208 168 226 Hunterdon Street 154 119 - Beth Israel Hospital 127 122 began July 15th Ferry and Richards Streets. ... 20 one month only. From published reports about 500 babies are cared for by other agencies. This is about 5 per cent, of the total births. In New York in 1911 about 50 per cent, of the total births were under supervision. Of the 10.000 babies born each year in Newark, at least 3,000 babies ought to be under supervision. 14 MILK. On account of the quality of the general milk supply and the price of certified milk in Newark, it was necessary, by special arrangement, to obtain milk both fit for infants and reasonable in price. All milk used was kept under observation by the Board of Health and was bought by the mothers themselves from delivery wagons or from drug stores, at nine cents a quart. This milk is sold regularly at twelve cents and fourteen cents a quart, and had a bacterial count from 10,000 to 30,000 per C. C. This arrangement was made only in the districts where our stations are located, but many mothers, who did not attend the stations, bought the milk. Number bottles sold from drug stores, 23,023, equal to 161,161 feedings Number bottles delivered to house, 4,947, equal to 34,629 feedings Total, 27,970 " " 195,790 Number drug stores assisting 14 Largest number quarts sold in one week 1,168 Average number quarts sold per day 138 Largest number from one drug store per day 17 This method of supplying clean tuberculin-tested milk at a reasonable price can be quickly applied everywhere no matter what the character of the general milk supply may be. It brings the best milk quickly and surely where most needed, without charity or special private effort. In this way every baby can receive pure milk. MATERNAL NURSING. Relation of method of feeding to condition of babies. Good Fair Poor Very Poor % % % % Breast 87 11 2 Partially breast 67 24 . 7 2 Artificial 42 31 14 13 Nursing infants rarely suffer from malnutrition or from any other diseases during the first year. Relation of method of feeding to Diarrhea. Diarrhea Present Absent Breast fed only 25% 75% Partly breast fed 54% 46% Artificially fed 51% 49% Diarrhea is present in a large number of breast fed babies on account of too frequent feeding and improper handling. Diarrhea was present in more than one-half of those partially breast fed, on account of too frequent feeding and over feeding. Even mothers who nurse their infants require advice and instruction. Reports from Birmingham, England, for 1909, showed that of 1,242 babies that died from diarrhea only ten per cent, were breast fed. Babies fed otherwise than on the breast die from diarrhea at twenty- seven times the rate that breast fed babies die. The true solution of infant mortality lies in breast feeding, plus supervision. Society cannot afford to permit industrial, social, or economic conditions to prevent maternal nursing. IS PROPORTION AT CERTAIN AGES THAT ARE BREAST FED, PARTLY BREAST FED OR ARTIFICIALLY FED. Relation of age to method of feeding. Age. Breast Partly Artificially 1 to 4 weeks 85% 10%' 5% 5 to 8 weeks 71 % 23% 6% 9 to 12 weeks 68% 14% 18% 13 to 24 weeks 50% 29% 21% 24 to 52 weeks 10% 46% 44% This gives the feeding as it existed, when the babies came to the consultation station. Even at one month 10 per cent, were partly artificially fed, and 5 per cent, entirely artificially fed. At two months 23 per cent, were already receiving the bottle in part, and 6 per cent, entirely. This is, practically speaking, entirely preventable, as can be seen from figures gathered by Dr. Herman Schwartz, director of the Pediatric Department of Dr. Hill's Maternity Clinic, New York. Of 1,500 mothers he found only four who could not nurse, when encouraged by proper care and advice at and after the confinement. Of these 1,500 mothers. Of our 509 mothers. 96.9% nursed 1 mo. 95% nursed 1 mo. 89.1% " 3 " 81% " 3 " 77% " 6 " 79% " 6 " Notwithstanding many statements to the contrary practically all mothers can nurse their babies. He further shows the effect of careful supervision from birth on maternal nursing. Of 44 mothers who nursed a previous child months : 10 nursed the child under clinic care 8 months 9 nursed the child under clinic care 6 months 5 nursed the child under clinic care 5 months 4 nursed the child under clinic care 4 months 9 nursed the child under clinic care 3 months 4 nursed the child under clinic care 2 months 3 nursed the child under clinic care 1 month In the Public Welfare clinics we succeeded in inducing mothers, who were giving the bottle only, to partly nurse, and many that were partly nursing to breast feed only. But to accomplish all that is possible in this direction we must see the babies in the first week and the mothers before the babies are born. This is the most important work, from every point of view, for the welfare of babies and the reduction of infant mortality. It requires much prompter return of birth records, and makes it desirable that the vital statistics be in the hands of those whose duty it is to conserve infant life. This is not the case in Newark to-day. INFANT CONSULTATION STATIONS vs. MILK DEPOTS. The efficiency of stations is determined by the age of babies attend- ing. Of the babies registered at the Infant Consultation Stations 9 per cent, were under one month of age and 22 per cent, under two months. Most babies attending milk depots are over three months of age. Only 14 per cent, of the babies attending the New York Milk Committee milk depots were under two months. Since one-half of the babies dying in the first year die before three months of age, it is clear that not much can be accomplished unless they are reached soon after birth. 16 RELATION OF AGE TO CONDITION. Age Good % 1 to 4 weeks 87 5 to 8 weeks 78 9 to 12 weeks 84 13 to 18 weeks 83 19 to 24 weeks 74 25 to 36 weeks 64 37 to 52 weeks 65 52 weeks 51 Fair Poor Very poor % % % 9 4 18 4 2.3 9 4.7 3 8 6 11 11 4 26 2 8 26 7 2 38 5 6 In the first two months, 82 per cent, were in good condition, none in very poor condition. Between two and six months, 72 per cent, were in good condition, 5 per cent, in very poor condition. The figures point to the importance of prompt supervision from birth and of the desirability of a prompt notification act so the babies can be visited soon after birth. In this way only can we prevent early weaning, improper feeding, summer diarrhea and malnutrition. To accomplish this the birth records must be, in fact, as supposed to be in law, in the hands of those requiring them within five days after birth. MORTALITY RECORD OF CHILDREN UNDER TWO YEARS OF AGE PREVIOUS TO MOTHERS' ATTENDANCE AT CONSULTATION STATIONS AND PRO- PORTION DELIVERED BY MIDWIVES. Deaths -„ „ ,. , under Mor " Delivered Mothers Births years tality by of aee rate midwife Seventh Avenue (Italian) 206 476 95 19% 98% Hunterdon Street (Italian and mixed) 154 468 55 12% 91% Beth Israel Hospital 126 363 37 10% 56% Ferry Street (Slavic) 19 61 11 18% 74% The highest mortality was found among the Italians in the Fifteenth ward. Here, almost all the women are confined by midwives. Practically all of these carry on factory labor in the home. Most of those under our observation know very little of infant hygiene and the general rules of health. Of all the babies born to the 509 mothers before they attended the clinics thirteen per cent, died before reaching their second birthday. Of the same mothers only 2.3 per cent, of the babies under the care of the infant consultation stations died during the summer. Supervision alone causes a reduction in infant morbidity and mortality. i7 i8 DATA CONCERNING THE TWELVE FATAL CASES. If we omit the two cases of syphilis and one case of Status Lymphati- cus, all clearly beyond our influence, our mortality was 1.9%. If we omit, in additon, all cases that were under our care less than four days, the mortality is reduced to 1.1%. If we omit those under observation less than nine days, the rate would be 0.9%. Of the twelve fatal cases, only one at the outset of summer was breast fed and in good condition. This infant died from an irremediable, inherent defect. Of the remaining eleven, three were in fair condition and eight in poor or very poor condition, and before the hot weather had set in were from ten per cent, to fifty per cent, under weight. Two had been arti- ficially fed from birth and eleven had been artificially fed after the first month. Four of the twelve that died were without mother's care ; of these two were legitimate and two illegitimate. Of the former, one mother died and one worked in a factory ; of the latter, one mother deserted and one worked in a factory. The above facts show clearly that many factors other than milk and summer heat bring about the death of infants. These factors can be classed as social and economic rather than hygienic and sanitary. Fur- thermore, the}' prove that babies dying from summer diarrhea have been suffering from improper care and feeding before the summer began. Therefore, work must be conducted all year around and not during the summer alone. Above all, these cases show that for one reason or another, personal, social or economic, the babies were deprived of the breast and often of the mother's care as well. When this takes place the legitimate baby fares no better than the illegitimate baby. Of these twelve cases eleven could have been saved, first, by pre- vention or prompt cure of hereditary syphilis ; second, by active super- vision of the babies immediately after birth so that they would have been nursed and properly cared for ; third, by the keeping of mother and baby together, whether legitimate or illegitimate. EXPENSES JUNE TO OCTOBER, 1912. Salaries of head nurse and two nurses $860.00 One nurse is paid by the Board of Health. ($65.00 per month.) Expenses of nurses for sundries 30.39 Signs, index cards, charts 66.00 Furnishing of three Stations 24.00 Literature distributed 27.85 Equipment of Stations — scales, repairs, etc 20.25 $1,028.49 Owing to the hospitality of churches in the clinic neighborhoods, there was no expense for rent. Omitting the salary of the head nurse, the cost per baby, for the time actually devoted to it alone would be $1.10 for four months, or $.0130 per baby per clay for nurse. Costs about $4.00 a year to keep a baby alive and well. Costs about $50.00 to bury it. 19 •SJU3JEJ jo S33\r •Jaqioj^ •p 3 ;a tisapiiiO -o,v ■luog vo iiojpijiio -om uoqnjo g £ £ E £ £ E ' E "Xq p3.I3AIpQ £ 3 -g 3 ■§. -S •qjE3 a JO O C/3 3SnE^) U9AIQ < W en < U J ■-lauiuing jo lasuo t- < 4E uoij;puo3 o H C^i < te fe •}q8i3A\ Jspun ^ O 33E3U3DJ3J 2j S* f*i c O ■Suiluuo^ H < m •caqjjeiQ JO UOJJEJnQ ■pojaisiSa^ U3q,u uoiaipuoj qjE3Q JO 31EQ E» < < ,r, ^ uj •3>133A\ Ul 33\>' *3SE3 JO jaquin^T t< S «qi°K ggggSSS^^SsS E 3 cJi—s— ™Ec k. in = •D3J31Sl33a . . jj 3 3 "3 3 < 3 STUDY. STATEMENT OF THE PROBLEM OF INFANT MORTALITY IN NEWARK AND ESSEX COUNTY. TABLE 1. Number of deaths under one year for period 1901-1910 and in 1910. 1910 1901-1910 Newark 1,232 10,703 Orange 100 1,030 Montclair 94 843 East Orange 45 422 Belleville 41 250 Bloomfield 26 319 Iryington 26 177 West Orange 24 189 Essex County 1,631 14,457 TABLE 2. INFANT MORTALITY RATES : PROPORTION OF DEATHS UNDER 1 YEAR OF AGE TO 1,000 BIRTHS. 1910 1901-1905 1905-1910 Newark 123 155 130 Orange 119 156 126 Montclair 200 305 161 East Orange 75 110 87 Belleville 220 Bloomfield 90 190 132 Irvington Ill 127 107 West Orange 96 119 92 Essex County 121 157 128 Essex County (less 8 cities) ... ... 100 TABLE 3. PROPORTION OF DEATHS UNDER ONE YEAR TO TOTAL DEATHS. Newark 20.3 Belleville — Orange 20.0 Bloomfield 21.4 Montclair (Infant asylum Irvington 18.5 present) 30.9 West Orange 20.0 East Orange 15.4 Essex County — TABLE 4. PROPORTION OF DEATHS UNDER ONE MONTH TO DEATHS UNDER ONE YEAR. % % Newark 33.2 Bloomfield 32.9 Orange 34.7 Irvington 33.3 Montclair 23.3 West Orange 35.9 East Orange 41.9 Essex County 33.7 Belleville 36.4 Essex County (less 8 cities) (Rural) 40.3 TABLE 5. INFANT MORTALITY IS THE HEALTH PROBLEM OF GREATEST MAGNITUDE IN ESSEX COUNTY. Year 1910 Infants Tuberculosis Essex County 1,631 1,122 Newark 1,232 831 The number of deaths from tuberculosis at all ages and in all forms is less than the number of deaths among infants under one year of age. These tables show the great number of infants that die before they reach the age of one year. It exceeds all deaths from tuberculosis in all forms at all ages. Tt forms approximately one-fifth of the total number of deaths. In most cites one-third of all deaths under one year occur in the first month of life. In cities where infant mortality is low it will be found that it can be further reduced by attacking the factors influencing death in the first month. In East Orange 41 per cent, of deaths under one year of age are due to deaths under one month. It is the unanimous opinion that at least 50 per cent, of the deaths under one year are preventable. The preventable deaths represent con- ditions in which the surviving infants must continue to live. Many die in the second or third year, others carry their malnutrition and physical defects into school, industrial and family life. A conservative estimate can place this preventable loss in life, health, and general efficiency in the County of Essex alone at $100,000 a year. INFANT MORTALITY RATE IN NEWARK, 1901-10. Deaths under one year per 1,000 births. Certain Groups of Diseases Year Rate Respiratory G astro Intestinal Congential Debility All Others 1901 160 1902 163 30.3 29.1 38.7 64.7 1903 151 24.6 30.0 48.2 48.2 1904 162 27.9 43.6 38.6 51.9 1905 141 22.9 43.4 40.2 28.5 1906 143 28.8 46.7 46.3 21.2 1907 138 18.5 43.1 40.5 37.9 1908 133 23.3 55.5 38.6 26.6 1909 115 19.9 34.4 38.8 21.9 1910 123 25.4 34.4 34.0 29.1 , ( 1902-05 Average ll906-10 26.4 36.5 41.4 48.3 23.1 40.6 39.6 37.3 There has been a positive reduction in infant mortality in Newark in the past ten years. What has caused it? PROPORTION OF DEATHS UNDER ONE YEAR DUE TO DEATHS FROM DIARRHEA. 1903. 17.5 1 10 , 1906 37.3 | igy\ average 18.6 ^gQJ 39 7 j- average S/.i> 1904 25.7/ 0<70 1908 32.4 j „ , 1905 28.7 \ avera g e 2/ - 2 1909 30.0 f avera g e 301 1910 28.0 5 < o o X (3 I— I o fa H W W o o o t Q o o o It 5 I 5 23 The tables show that the proportion of deaths under one year due to diarrhea have increased 46.2 per cent, in 1904-5 over 1902-3, 101.5 per cent, in 1906-7 over 1902-3, 61 per cent, in 1908-10 over 1902-3. That the reduction of infant mortality in Newark has been due to a reduction in the number of deaths from those diseases other than those classed under respiratory, gastro-intestinal, and congenital debility ; namely, to the acute contagious diseases, meningitis, tuberculosis, syphilis, convulsions, diseases of the heart and kidneys, which showed a rate of 29.1 in 1910 against 64.7 in 1902. In the period 1906-10 there was an actual increase in the deaths due to diarrhea over 1902-06. There has been a very -slight decrease in those due to congenital debility and respiratory diseases. While there has been a reduction in Newark in the infant mortality rates, it is clearly not due to the activities established in Newark with the hope of influencing deaths from contaminated milk and summer diarrhea. In truth there has been an actual increase in deaths due to diarrhea. THE AGE OF THE INFANT IS OF FAR GREATER IMPOR- TANCE THAN THE QUESTION OF SUMMER HEAT OR SUMMER DIARRHEA. Newark, 1910. Proportion Number and proportion Total number of Number of deaths of d eat hs of deaths under 3 mos. deaths under dunnt' June, July, during- of age to deaths under 1 year of age Auir.. Sept. Summer one year 1242 497 40% 660; 53.1% During the summer period of four months, that is one-third of the year, 40 per cent, of the babies died, while during the first three months of life, that is one-fourth of the first year, more than 50 per cent, of the babies died. Age Incidence of deaths in the first year Total number of deaths under: 1 clay 1 week 1 month 2 months 3 months 1 year 140 285 456 560 660 1242 Of the deaths under one year, 11.2 per cent, occur on the first day, 22.9 per cent, in the first week. 36.7 per cent, in the first month, 45 per cent, in the first two months, 53.1 per cent, in the first three months. Of the deaths in the first month, 36.7 per cent, of the total under one year, only 6 per cent, are ascribed to diarrhea. These tables clearly direct our attention to conditions affecting infant life and death, acting before, at, or immediately after the birth. Contaminated milk and summer diarrhea are not the most important factors in infant mortality. 24 •5 ■si CO -J 5 ffi ifc * 3 t e -1 p k ^ f\ En / /' w o ' / / / / / / \ 1 c / \ 1 3 o c q c> o ~ «0 *) >*• K> «3 I ?> V bn -o ■ o O e v -t-> ■a 5 o 5 „