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Causes of Infant Mortality in the United Slates. It is probable that the variety of race groups in the United States has had a marked effect upon infant mortality. Statistical studies on this point are not readily available but the report of Dr. W. H. Guil- foy of New York City is worthy of mention. Dr. Guilfoy shows that out of every thousand infants born of mothers of Russian- Polish or Austro-Hungarian nationality, over 920 survive the first year of life ; of Italian mothers 897 ; of native mothers 894 ; of German mothers 885; of Irish mothers 881. Other significant results of this analysis show that the nationality of the mother seems to be a pre- dominant factor in deaths from congenital diseases under one year of age per 10,000 births reported. This rate in children born of Italian mothers was 295, of Russian mothers 320, Austro-Hunga- rian mothers 284 and native-born mothers 544. This clearly indi- cates that measures for the reduction of infant mortality in the United States in the future must take into consideration the high death-rate from congenital causes of infants of native-born parentage. The effect of nationality upon deaths by infectious diseases is shown in the fact that children of Italian mothers present the highest mortality in the group, with a rate of 58 ; children of Irish mothers rank next with a rate of 7; children of native-born mothers 38; children of Austro-Hungarian mothers 36. In respiratory diseases, race seems again to play an important part. The death-rate of infants of Italian mothers from acute respiratory diseases is more than three and one-half times that of children of German mothers, almost three times that of children of Russian, Austro-Hungarian and Irjsh mothers, and a little more than double that of native- born mothers. In diarrhoeal diseases, the racial aspect is shown as follows: The death-rate of infants of English mothers is 91 per 10,000 births, children of native-born mothers 80, children of Irish mothers 72, children of Italian mothers 70, children of Austro- Hungarian mothers 52, and children of Russian mothers 30.

The influence of race, as shown by these figures for New York City, would seem to indicate that the highest death-rate from con- genital causes in infancy is among children of native-born mothers, the highest among infants from infectious diseases among children of Italian mothers, the highest rate from respiratory diseases among children of Italian mothers, and the highest rate from diarrhoeal diseases among children of English and native-born mothers.

Figures for the United States Registration area for 1919 are of interest in this connexion: Rates Classified According to Country of Birth of Mother, 1919.

Total rate 86-6

United States. 77.7

Austria, including Austrian Poland 112-6

Hungary 89-3

Canada ............ 99- 1

Denmark, Norway and Sweden 66-8

England, Scotland and Wales 73-2

Ireland 87-4

Germany, including German Poland 78-1

Italy 87-7

Poland '.'.'. 124-4

Russia 73.5

Other foreign countries \ 104-8

Negroes (United States) 134-3

Age Groups as Factors in Infant Mortality. The well-known fact that people are susceptible to their environment in inverse propor- tion to their age is graphically demonstrated in the case of the infant death-rate by examination of age subdivisions of the first year of life. It is evident that the new-born infant is extremely susceptible to its environmental conditions and that intrauterine factors have an effect in making the infant mortality rate unusually high during the first few days or first month of life. It must be remembered that the intrauterine infant's environment is its mother and that anything that affects her health inevitably reacts upon the infant.

Rates in the U.S. Registration Area 1919 by Subdivisions of First Year.

United States (total) 87-0

Under one day is-i

One day ...

Two days 3.2

Three to six days {3.0

One week .... c.c

Two weeks '.'.'.'. 3.=

Three weeks but under one month. . ! 2-8

One month g.e

Two months j C.Q

Three to five months \ I?. 7

Six to eight months ' jg.i

Nine to eleven months [ \ 7.0

Sanitation and Environment. Statistics regarding the effect of sanitation and environmental conditions on the infant death-rate are difficult, when not impossible, to obtain. Clinical and practi- cal experience must be drawn upon to prove that lack of proper sanitation and poor hygiene cause infant deaths. It is generally accepted by child hygienists that the main factors in high rates are poverty and ignorance. The more definite causes of infant mor-

tality due to lack of sanitation may be classified as those of social, economic and general environment. Although the direct relation of sanitation to the infant death-rate cannot be proved statistically, it has been proved many times by the marked fall in the infant death-rate when sanitary conditions in a community have shown improvement. The sanitary conditions affecting the infant death- rate may be classified from another point of view as decent housing, proper standard of living, opportunities for recreation and fresh air, clean water supply and clean milk supply.

Studies made by the Children's Bureau at Washington show that the infant death-rate is definitely affected by overcrowding, and that the number of people living in a room can be shown to have a direct statistical relation to the rate. Overcrowding has a direct relation to the economic condition of the family and is reflected in its general standard of living. Such factors, therefore, are not easily separated, but statistical studies have shown uncleanliness, overcrowding, lack of ventilation and lack of decent hygiene in the home are directly responsible for many infant deaths. In the same way, poverty can be shown to be allied to the rate by the fact that the rate bears a close and regular relation to the amount of wages received by the family. In the Johnstown report of the Children's Bureau, U.S. Department of Labor, definite figures are given in this regard. The results of that investigation showed that when the father earned less than $521 per year, the infant death- rate was 255-7; where the father earned more than $1,200, the in- fant death rate was 84. But wages must be considered again in relation to social and sanitary factors, as a decent standard of liv- ing may be maintained on a low wage-rate while a high wage-rate does not necessarily include conformity to hygienic requirements.

Poverty reacts upon infant mortality in still another direction. Insufficient earning capacity of the father usually forces the mother into industry. Statistics relating to the health of mothers who are industrially employed during their child-bearing life or during the period of pregnancy would seem to indicate that employment of these women, in itself, has no deleterious effect upon the infant. More detailed studies and more careful analysis of the studies al- ready made would seem to indicate that the high rate in towns where women are industrially employed to any great extent is due not so much to the effect of the mother's industry upon the child, as to the conditions of poverty in the family that have forced the mother into industrial pursuits. In order to show conclusively that employment of women is a factor of importance in increasing the infant mortality rate, a further study should be made as to the effects of certain types of industry upon pregnant women. Prob- ably one of the most harmful results of the employment of women, so far as infant mortality rates are concerned, is the fact that returning to the industry too soon after confinement is not only harmful to the health of the mother in relation to future pregnan- cies, but reacts disastrously upon the infant in that the latter usually is deprived of breast feeding.

Type of Feeding. It has long been recognized that infant death- rates from diarrhoeal diseases are very markedly affected by the feeding employed. It has been proved beyond doubt that the infant death-rate from diarrhoeal diseases can be much reduced by the wider use of breast feeding and by the provision of safe, clean milk for use in artificial feeding. The relation of breast and artificial feeding to infant mortality is graphically shown in cer- tain studies made in New York City. One such study, covering deaths of 1,065 infants from diarrhoeal diseases, showed that 17% of those who died had been breast-fed exclusively, while 83% had been artificially fed, either with cows' milk or some form of prepared infant food. In order to determine the extent of breast feeding among well children, a further study was made covering about 4,000 children between 3 and 12 months of age. In this study it was found that 79% of the babies were breast-fed exclu- sively while the remaining 21 % were fed with bottled milk, or bot- tled milk and breast feeding combined. The- experience of the Bureau of Child Hygiene of the Department of Health of the City of New York has shown that about 80% of the tenement population of that city nurse their babies exclusively, and that four-fifths of the high death-rates of infants from diarrhoeal diseases occur in that group of the infant population that is not breast-fed.

Milk. Reduction of the infant death-rates in the various com- munities of the United States has followed very closely the improve- ment of the milk supply and the tendency towards general pasteur- ization of milk. The use of raw milk which has not been sufficiently protected in its production, transportation and in its care in the home is undoubtedly one of the most important factors in the causation of high death-rates from diarrhoeal diseases which occur so commonly among artificially fed infants. For these reasons any efforts which are directed towards obtaining a safer supply of milk for children may be classed as measures for the reduction of infant mortality.

^Congenital Diseases. Under the group classified as "congenital diseases " in the following table have been listed all deaths of infants from prematurity, feeble vitality and accidents of labor. This group, furnishing as it does over one-third of the total deaths dur- ing the first year of life, is of immense importance. Some cities, notably Boston and New York, have demonstrated that by the employment of public health nurses for the supervision of women