Infant and Maternal Welfare and the Rise of Social Medicine

Lecture 2: Birth and Death in Modern Britain: Infant Welfare to Incubator Babies

Slide aims

This week’s lecture explores the juxtaposition of birth and death in modern Britain, looking at the deaths of infants and young children. So the period when the end of life followed all too soon after the beginning of life. It does this largely by examining infant mortality and efforts to reduce it in late 19th and early 20thC Britain.

Its also interesting to reflect on the experiences of mothers and changing expectations of maternity in the 20thC, as childbirth came to be marked less by anxieties about the survival of mother and baby and more by choice and the desire to have a ‘good birth’ (consider this in the seminar).

By the end of the 20thC governments, policy makers and mothers are no longer absorbed with demands of nationhood and eugenic considerations as they were at the start of the century, though such influences have not disappeared entirely. Whereas the bête noire of those seeking to reform maternity services and improvement infant welfare at the beginning of the century was the woman who claimed to know about childbearing and childrearing because she had ‘born 12 and buried 8’, by the end of the century this became the ‘single welfare mother’, often depicted by the media as immoral, a drain on resources, and a poor ‘citizen’.

Worth reflecting too over the long twentieth century that – just as ideas of temporality have changed (ideas about different life stages and expectations attached to each one), so too have families changed. Though family size was already in decline at the end of the 19thC, this decline continued throughout the `2

20thC (idea of precious child). More births occur outside of marriage (34% in England and Wales in 1995) and lone parenting is more common, and families have become more varied, with 2 parents of the same gender becoming increasingly common for example.

This will not be our sole visit to the issue of childbirth and later in the module we will explore midwifery services in more detail.

The problem of infant mortality

Slide – figures of births and deaths

Interest in infant and maternal welfare was spurred on by the recognition that infant mortality was a problem of national importance, and indeed as we saw in last week’s lecture by the very notion that there was a problem of high infant mortality.

In 1857 the Registrar-General began to report the number of deaths of children under the age of one (deaths first registered in 1838) – giving formal recognition to infant morality statistics. So the ‘infant’ became a separate category and at the same time it became possible to record the very high death rates amongst infants which tended to increase rather than decrease.

As morality rates from most diseases were in decline (notably infectious diseases) the fact that infant mortality was actually rising (and birth rate falling particularly amongst wealthier and more educated classes) caused great anxiety (not just in UK but across Western Europe and other parts of Western World) and responded to by what became known as the ‘Infant Welfare Movement’:

1876-1899 birth rate fell 35.5 to 30.5 (per 1,000 population), so by 14% `3

1876-1899 infant mortality increased from 146 to 156 (per 1,000 live births), so by 7%

The two factors of declining birth rate and rising infant death rate, became source of national anxiety. As Anna Davin points out, this was something of a turnaround – during much of the 19thC political economists and politicians (following Mathus) had been concerned with the risks of excessive population growth, which he and others predicted would lead to exhaustion of resources, war, epidemic disease and other checks on population growth.

Slide – MOH quotes

In the late 19thC and beginning of 20thC emphasis was placed on the value of a healthy and numerous population. MOH for Marylebone pointed out in 1907 that

It is of concern to the nation that a sufficient number of children should annually be produced to make good the losses by death; hence the importance of preserving infant life is even greater now than it was before the decline of the birth rate. (also contrasting view!!!)

This was related strongly to ‘Empire concerns’ and anxieties about Britain’s place in the world, compared with the US, Germany and the new rival Japan. Concerns were also expressed about having a healthy population to populate and manage the Empire. ‘Population was power’ and children began to be seen as ‘a national asset’ or ‘the capital of the country’. Yet this clashed with what was happening in reality, with the population apparently in decline and there was also concern that those who you least wanted to reproduce, the very poor with poor or no education, and physically and morally wanting, were those most likely to have large families (eugenic concerns about the right kind of people reproducing). `4

After the Boer War (South African War), infant welfare became part of a national drive to improve the quality and quantity of the population and was included in the campaign to improve physical and ‘national efficiency’. This was expressed as concern about the next generation of workers and soldiers, and Britain’s apparent decline as a major economic and military power. Various measures followed, both at national and local level that were intended to improve the conditions of infancy and educate mothers. Represented an incursion of ‘state’ medicine and the relationship between the state and mothers was a focus of much discussion.

Social Medicine

The campaign to reduce infant mortality and improve the health of infants is also an early example of ‘social medicine’, which is particularly associated with the period 1880-1930s. Whereas infant welfare reform was largely to do with addressing national anxiety about population, it is also a period which saw the slow emergence of social responsibility and state responsibility for health. The field of social medicine seeks to understand how social and economic conditions impacted on health, disease and the practice of medicine. It saw the health of the population as a social concern and advocated that the governments should promote health by individual and state means (brokering new relationship between individual responsibility and state health – we’ll look in detail how this worked out between mothers and the state in the seminar).

Slide – social medicine

During the period 1880-1930 there was a notable shift from public health programmes that aimed to control disease towards ‘social medicine’, which incorporated a wide range of policies that aimed `5

 to improve social conditions

 provide health education

 provide new medical services

Public health and sanitary reform (which we associate with mid- to late-19thC) continued alongside social medicine, but there was a strong emphasis on the latter. Early 20thC health measures shared continuities with earlier periods – for example the destruction of slum areas and the development of model housing. Public washhouses were introduced and more houses had running water – baths and showers. However, for medical professionals involved in public health – the period from the 1880s saw a shift from interest in controlling infectious diseases towards improving the general health of the population. Public health experts now saw social issues as the prime determinants of health and they debated the effects of diet, unemployment, hygiene, housing and lifestyle on levels of disease, and became increasingly concerned with preventive medicine. MOHs, for example, became involved with a much wider set of issues, including infant and maternal welfare, provision of housing, workplace inspections, midwifery services, TB clinics, health education and school medicine, aso.

National efficiency, Empire concerns and eugenics

In the wake of the disastrous Boer Wars (South African Wars) (2nd one, 1899-1902) fears about the national standards in physical health reached a peak. Concern over physical efficiency first arose when attention was drawn to the poor quality of army recruits.

Slide - Boer War. Report 1904 `6

 In 1899 40% of the volunteers for the Boer War (so 4 out of 10) were found to be medically unfit. Men were rejected because their bodies weren’t strong enough to sustain the rigors of war. Some of the most common reasons recruits were rejected were rickets, skin disease, bronchitis and poor teeth.

 In the aftermath of the Boer War a specially appointed Committee on Physical Deterioration was created in 1903. The Committee was charged with investigating why so many army recruits were rejected on the grounds of health.

• In 1904 the Committee reported that they had found no evidence of long- term physical deterioration in the British population. The report of the Committee devoted much attention to the welfare of infants and school children, recognising that it was in the national interest to safeguard the next generation and thereby improve the quality of the population. The Committee made a small number of recommendations:

a) Medical inspections of children in schools

b) Free school meals for the very poor

c) Training in mothercraft.

Many of these changes became embedded in Liberal Reforms, and we’ll be looking more specifically at how these affected children in the next couple of lectures which look at child poverty and school medical services.

The government began to think in terms of national interest and national efficiency for which a healthy population was essential. This was driven by growing national and imperialist rivalries which cast the shadow of war over Britain and Europe and focused attention on the strength of the military, as well as the worries about `7 maintaining the British Empire. Historian John Pickstone argues that ‘welfare came back into fashion when fit citizens were required for the armed forces, for empire and for factories’. (‘Productionist’ phase of medicine)

At the turn of the 20thC, the health of the population became a primary concern for central and local government. The higher rate of reproduction among the lower classes was thought to be lowering the overall stock of the population, and there was considerable anxiety about rising levels of contraception and abortion. The science of ‘eugenics’ dovetailed with these debates. Eugenic rhetoric was concerned about the middle classes ‘limiting themselves out of existence’ (birth control and women abstaining from marriage and having careers) while the poor continued to ‘breed’ prolifically. They encouraged the better classes to breed more and those seen as physically or morally degenerate should be controlled (even by measures as extreme as sterilisation). The eugenicists claimed too that moral degeneration was weakening the race – and resulting in TB, syphilis, alcohol abuse, prostitution and ‘mental deficiency’. We will come back to the eugenics movement in a few weeks. So worries not just about quantity but also quality of population.

So to recap, around the beginning of the C20 infant life and child health took on a new importance in public discussion, reinforced by emphasis on the value of a healthy and numerous population as a national resource. The surge of concern about the bearing and rearing of children was also part of wider social and economic discourse about preventive medicine, physical efficiency and the relationship between family and state. Because government concerns centred on the need to improve the quantity and quality of population, maternal and infant welfare services received considerable attention earlier than most other health services. `8

Infant and Maternal Welfare

The relative health of an infant population provides an important index to the physical well-being of the larger community. Children belonged ‘not merely to the parents but to the community as a whole’; they were a national asset and the capital of the country; they were the citizens of tomorrow. The birth rate and infant health were matters of national importance – population was power.

Slides – infant welfare

Already in the closing decades of the 19thC MOHs anxiously observed and analysed infant mortality. By the 1890s some municipalities were distributing leaflets on infant care and providing instruction to mothers through visits to their home.

MOHs were particularly interested in the infant welfare work being done in France where leading campaigners promoted breastfeeding, the provision of pure modified cow’s milk when possible, weighed babies and gave advice on their care. With the aid of voluntary workers, often from the Ladies Sanitary Association, a few similar programmes had been started in Britain. France became a real leader in the field and placed huge emphasis on the provision of clean milk to infants when mothers were unable to feed them themselves. France was also responsible for developing the incubators (or isolette, based on similar equipment used to keep chicken eggs warm in the mid-19thC), and the practice first adopted by Dr Stephane Tarnier, who developed it to keep premature infants in a Paris maternity ward warm. He helped convince other physicians that the treatment helped premature infants and France became a forerunner in assisting premature infants, in part due to its concerns about a falling birth rate. Dr Pierre Budin, advocate of feeding with breastmilk and infant welfare activists is known as the father of modern perinatology (foetal/maternal `9 specialists) and his seminal work The Nursling (Le Nourisson in French) became the first major publication to deal with the care of the neonate.

In general more doctors – based in either public health or hospitals – became interested and more specialised in infant welfare. Programmes of individual communities such as Huddersfield were often inspired by individuals – in case of Huddersfield by Mayor Benjamin Broadbent and its MOH, S.G.H. Moore. Broadbent Mayor 1904-6 and Moore an ambitious MOH keen to make his mark on reducing morality in town. Huddersfield had high IMR – 167 per 1,000 in 1880s, above national average, and a low birth rate. Broadbent visited France and was interested in their programmes, which also emphasised nursery care. That element was lost from Huddersfield programme, which came to focus on home visiting by teams of voluntary women visitors, supervised by female assistant MOHs (so mixture of state and voluntary), and also the payment of a guinea to mothers if their child reached his or her first birthday! Other than this, offered little in way of material aid – common theme.

More broadly the infant welfare campaign focused very much on preventable diseases, especially diarrhoea and attributed high portion of infant deaths to ‘preventable conditions’, which could be resolved by improved mothering. Many local authorities also set up infant welfare consultations or clinics, and held Health and Baby Weeks, but most involved very little material aid. Emphasis was also placed on breast feeding (slide). (in fact preventable conditions was a flexible concept – so even with premature births or babies born with congenital conditions – this was blamed on the mother not taking good care of herself and being in poor health without analysing the poverty and want which produced poor health.). Broadly speaking, child and family poverty and environment were largely ignored. Yet the family – especially the mother – was to be responsible for the state good! `10

Infant welfare became area of active state involvement, yet focused mainly on educating mothers rather than providing material assistance (though as Liz Peretz has shown this varied from locale to locale, e.g. Tottenham in London provided good advice on modern methods of childrearing, though clinics, health visitors and magazines and offered more material assistance – by 1920 mothers could be prescribed milk, meals, cod liver oil, hospitals delivery, and home helps (strong Labour and cooperative presence), while conservative Oxford, with long voluntary tradition, offered much less practical and material aid. Many municipal authorities, however, experimented with schemes to supply hygienic milk cheaply for weaned infants who were at risk from the contaminated and adulterated milk normally on sale in working-class districts.

Legislative changes

The Notification of Births Act was passed in 1907. The act stated that the local MOH should be informed within six weeks of a birth so that health visitors could be sent to the family. The system of notification was made compulsory in 1915. Between 1910 and 1916, the Local Government Board issued regular reports on infant, and later maternal, mortality and the scale of local efforts to improve infant welfare during these years increased dramatically (also international congresses on subject). The loss of population during WW1 further increased awareness of the importance of infant life, and child and maternal welfare work was extended to include the ante-natal period. Again, state intervention was justified in terms of the national good and racial improvement.

In 1918, a Maternity and Child Welfare Act was passed, which required each local authority to set up a maternal and child welfare committee and enabled, though it `11 did not compel, local authorities to provide a full maternal and infant welfare service, including salaried midwives, health visitors, infant welfare centres, day nurseries, and the provision of milk and food for the most needy mothers and infants. When the Ministry of Health was created in 1919, one of its 6 departments was devoted to maternal and child welfare. The state’s interest in a Health Ministry stemmed from the need to secure the maximum standards of health for the populace.

Besides all of the official activity, there was still considerable interest in infant and maternal welfare on the part of the voluntary/charitable sector; clubs for mothers were set up in the second half of the 19thC and in the early 20thC such organisations as the Infants’ Health Society (1904) the National League for Health, Maternity and Child Welfare (1905) and the Women’s League of Service for Motherhood (1910) were established to improve maternity and infant care. Other organisations, notably the Women’s Cooperative Guild also focused on improving conditions for mothers, and campaigned for a maternity benefit.

Motherhood and education

Motherhood was a common feature in all discussions of infant mortality and child welfare, whether the focus was on the quality or quantity, on the encouragement and nurture of the fittest, or the preservation of all infant life.

Working –class mothers were frequently criticised and blamed for the decline in infant health and mortality – poor hygiene and diet – Slides Concentration on the mother also arose from a belief that diarrhoea (main cause of mortality), was due to contamination in the home from dirty feeding bottles, dummies and the like. Breast feeding advocated strongly. So if the survival of infants and the health of children `12 was in question, it must be the fault of the mothers, and if the nation needed health future citizens then mothers must improve their knowledge and skills.

The focus on mothers provided an easy way out. It was cheaper to blame them and to organise a few classes than to expand social and medical services, or pay maternity benefits (which were being introduced in other countries, notably France). And there seemed more chance of educating individuals, than of banishing poverty. The most general method of education was through leaflets on infant management handed out to mothers – sometimes organised by local authorities or voluntary societies. How far they were read or followed is impossible to know. Lectures to mothers were also tried, but it was difficult to assemble the appropriate audience. Infant consultations or infant welfare centres, the forerunners of today’s baby clinics, were set up, which advised mothers, weighed the babies and occasionally offered vitamins/milk to mothers. Many local authorities appointed lady health visitors, but visits were not always welcomed by new mothers – intrusion into working-class life by the authorities.

A number of voluntary agencies established Schools for Mothers. The first school for mothers started in St Pancras in 1907. By 1917, there were 321 voluntary societies known to the Local Government Board to be operating a total of 446 infant welfare centres. Most Schools for Mothers featured a combination of classes and health talks for mothers, and individual consultations with the mother about her infant, during which the baby was weighed and advice on feeding and management given by the medical officer. The main purpose of all these institutions was to pass onto the mother information about, a sense of responsibility towards and pride in, home and family. Advice on the clothing of infants was given and advice on feeding. `13

The social background of mothers attending the schools is not absolutely clear. The target audience was the upper working class, those classified as either poor with irregular earnings or poor with small regular earnings. Attendance at the schools was voluntary and news of a school was often spread by word-of-mouth. (one of points of Angela Davis’ article is that middle-class mothers felt they didn’t get enough advice or attention)

Regardless of the purpose of the schools and whether the education was the best way of preventing infant mortality, there is no doubt that they provided information, much needed nourishment in some cases, companionship, and a measure of reassurance for many women. Because GPs feared that the schools would impinge on their practice, no medical treatment was offered; mothers were referred to a doctor if more than advice was required.

It is hard to assess what part the education of mothers or the introduction of infant welfare centres played in the rapid decline of infant mortality after 1911 – proportion of mothers visiting schools was relatively small. The reasons for the decline in the infant mortality rate were as complex as the causes of infant death. The Ministry of Health and the Board of Education agreed that ‘the reduction in infant mortality is no doubt due to the combined action of various factors, but there can be no question that one of the weapons which has been most effective in this campaign is the education of the mother’. But also due to improved levels of general hygiene, rising standard of living and lower birth rate!

Slides – Women’s Cooperative Guild and conclusion

Conclusion `14

Infant and maternal welfare formed an important part of the shift from public health to social medicine in the late 19thC and early 20thC, even though the emphasis was on mothers and their roles. The Boer War marked a turning point in how the state viewed health, focusing attention on the importance of national efficiency and the physical strength of the population. Concern about infant and maternal welfare thus reflects wider social and economic and political preoccupations.

It is by no means clear that child and maternal welfare policies were primarily responsible for the fall in infant and maternal mortality. But there is little doubt that child and maternal welfare policies carried with them a strong ideology of motherhood. Official concern about population and mortality rates was couched in an unimpeachable rhetoric, which talked of the need to save lives and improve the quality of motherhood. The emphasis placed on better child-care and the importance of motherhood reinforced women’s traditional role in the home. When infant and maternal welfare workers spoke of the importance of women’s responsibility as mothers, they referred to all social classes, though there was little doubt that they thought working-class women to be in greatest need of instruction.

By 1950s infant deaths in decline. 154 babies out of 1,000 died in 1900 before their first birthday, this declined to 30 in 1950 and 9 in 1985.

20thC marked by changed expectations of mothers concerning experience of birth and more babies born in hospital after 1950s. With far fewer babies dying around childbirth or in the first weeks or months of life, expectations have been raised and attention of suppliers of maternity services shifted to improving infant health and also the experience of birth for mothers, to providing better ante-natal care and mothers became more interested in experience of childbirth itself (consumption/a good birth) than about the survival of the baby. With birth increasingly taking place `15 in hospital, more medical interventions have been introduced to ensure the survival of babies. Incubators as we have seen were first developed in the mid-nineteenth century but became common after the 1930s, recreating an environment similar to the mother’s womb for premature babies, and neonatal units were set up after the 1960s to care for very premature babies. Increasingly range of genetic and technological interventions increased possibility for monitoring baby’s progress and checking for ‘faults’. The question ‘is my baby all right’ less likely to be posed at moment of birth but rather during pregnancy itself.