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THE CHILD WELFARE MOVEMENT
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THE CHILD WELFARE MOVEMENT
BY
JANET E. LANE-CLAYPON, M.D., D.Sc.
DEAN AND LECTURER ON HYGIENE, AT THE HOUSEHOLD AND SOCIAL SCIENCB DEPARTMENT OF KINC'S COLLEGE KOR WOMEN, UNIVERSITY OF LONDON
LONDON G. BELL AND SONS LTD. 1920 ^^njk^
PREFACE
This work is intended to be a handbook for those who wish to understand something of the machinery for the conduct of work for Maternity and Child Welfare.
It makes no effort to be a comprehensive text-book on either Local Government or Child Hygiene in any of its branches. These matters form part of the frame- work of the book, but the aim has been to give only such aspects of both these subjects as appeared neces- sary for an intelligent understanding of the work under consideration.
The book has been written under pressure of other work, which has rendered much revision of the origiual manuscript impossible for lack of time. The subject- matter of the book has been dealt with for some time past in lectures to students of the Household and Social Science Department of King's College for Women. Now that the College is undertaking the training of health visitors under the recent Board of Education Regulations, a short text-book on matters with which all health visitors should be familiar seemed opportune, and the request to write a handbook served to supply the necessary stimulus. The opinions expressed have been formed primarily as a result of four years' work practically all over the country, when serving as Medical Inspector for Child Welfare under the Local Govern- ment Board.
It is believed that record has been made of opposing
vi PREFACE
views whenever there is known to be a definite school of thought of opposite tendencies.
It is usual, however, in life to find that the cause of divergence of views is due primarily to inadequacy of explanation. This arises especially in connection with Child Welfare work, when, for example, those with urban experience only, discuss matters with those working in rural districts. The conditions are so different in these areas as to justify apparently opposite views. When the district under discussion is specified, it will usually be found that any remaining difference of opinion is on unimportant matters only, or due to the fact that one side contemplates an ideal regardless of cost or feasibility, and the other envisages such development as may be capable of accomplishment under existing powers and conditions.
No attempt has been made throughout the book to deal with the work of the Poor Law Guardians, either under the Poor Law or under the Children Act of 1908. While theoretically, no doubt, many phases of their work fall under the general meaning of Child Welfare work, it is not included under what is ordinarily under- stood by this term.
Further, it is probable that the whole Poor Law system will now be short-lived, and as Public Health workers are not closely concerned with its working as at present carried out, it appeared unnecessary to deal with it.
The chapters on Local Government are inserted with the view of explaining certain points in the machinery, upon which information is not readily accessible.
They are not intended to form a treatise on Local Govenmient as such.
I am indebted to St. Katharine's Royal College at Poplar, and to Dr. Harold Waller their Medical Officer, for permission to print samples of their record cards. To the Controller of His Majesty's Stationery Office for
PREFACE vii
permission to reproduce the Act and Circulars which form the subject-matter of Appendices III., IV., V. (A) and (B), and VIII. The documents are not printed by Authority.
Further, I desire to acknowledge with many thanks the permission given by the Medical Officers of Durham County, Hertfordshire, and Birmingham to reprint the subject-matter of Appendices VI. and VII.
I am also greatly indebted to Mr. H. 0. Stutchbury, of the Ministry of Health, for kindly reading many of the chapters, especially those on Local Government, and for numerous valuable suggestions ; and to Dr. Major Greenwood, who was good enough to read over the chapter on Infant Mortality.
J. LANE-CLAYPON.
March 1920.
CONTENTS
rAOB
Preface . . . ' . . . v
CHAP.
I. Introductory ..... 1
II. On Notification of Births in Relation to
Child Welfare .... 8
III. The Work under the Notification of Births
Acts . . . . . .16
IV. The Relation of the Child Welfare Visitor
to Charitable and Social Organisations . 27
V. Points in the Arrangements and the Condi- tions of Work of an Infant Visitor . 30
VI. The Child Welfare Cbntrb . . .38
VII. The Centre (conti7iued) . . . .52
VIII. The Centre (continued) . . .69
IX. The Organisation of Child Welfare Work
IN Urban Areas . . . .81
X. The Combined Duties of a Visitor in the Different Local Authorities in Urban Areas . . . . .88
XI. Child Welfare Work in County Areas . 91
b ix
X CONTENTS
CHAP. FAOB
XII. Thb Training of Health Visitors . . 101
XIII. The Position of Voluntary Agencies in
Child Welfare Work .110
XIV. Other Phases op Child Welfare Work , 115
XV. The Control of the Practice of Midwifery 125
XVI. Pre-natal Work . .137
XVII. Attendance at Birth and Maternity Nursing 147
* XVIII. The Provision of Maternity Care by
Institutions . . . . .159
XIX. On the Present Provision op Midwives . 167
^ XX. Infant Mortality . .176
XXI. Notifiable Diseases in Relation to Mater- nity AND Child Welfare, with Notes on Measles and Whoopinq-Couoh . .188
XXII. Local Government Areas . . 194
XXIII. Local Government Authorities : their
Powers and Duties .... 202
XXIV. Notes on the Machinery op Local
Authorities ..... 214
XXV, The Sources of Money for Local Govern- ment PUBPOSES .... 222
XXVI. The Future .230
CONTENTS xi
APPENDICES
I. Sample Record Cards and Leaflets . . . 235
II. Figures showing the Ailments among School
Children 241
i III. Maternity and Child Welfare Act, 1918, with
Circulars 4 and 11 . . . .242
IV. Circular by the Ministry of Health on the Training
of Health Visitors . . . .263
V. (A) Extracts from the Board of Education Regu- lations for Nursery Schools . . . 270
(B) Ministry of Health Circular on Day Nurseries . 282
VI. (A) Scheme for a Trained Midwifery Service in
Durham County .... 288
(B) Scheme of Payments and Pensions for Mid- wives in Hertford:shire . . . 294
VII. Housing and Sanitary Conditions in Relation tu
Mortality Rates in Bii-mingham . . 303
VIII. Extracts from the Ministry of Health Circular on
Measles and German Measles . , .316
THE CHILD WELFARE MOVEMENT
CHAPTER I
Introductory
The rapid growth of the child welfare movement has tended to the concentration of attention on the activities of the movement, so that the causes which led to the movement, and the principles underlying it are some- times passed over by those engaged in the work.
In common with the initial phases of other movements, the cry for improvement in the condition of infants and children was made by a few pioneers many years before a sufficient impetus had been given to the work to secure its public discussion. It is probable that these pioneers did not themselves appreciate the greatness of the work they felt constrained to begin. Different methods were used in the several different countries, but the primary cause of the effort was the same in all — namely, an attempt to reduce the number of deaths among infants. There is no reason to suppose that the death-rate among infants was higher at any time during the nineteenth century than it had been in earlier times — on the con- trary, such evidence as there is shows that in all prob- ability the number of children who survived and reached adult life, as compared with those that died, was considerably lower in the preceding centuries. The number of both births and deaths was almost
2 THE CHILD WELFARE MOVEMENT
certainly less during the last half -century than previously. ! As civilisation progresses the value placed upon life is ' increased, and a high death-rate comes to be regarded as a blot on the nation and produces efforts to bring about its reduction. A reduction in the number of births appears also to be a natural accompaniment of ad- vancing culture.
The keeping of accurate registers of births and deaths is comparatively recent in this country, and it is prob- able that, apart from a few of the smaller and more advanced European countries, only Great Britain, France, and Germany possess records which may be regarded as sufficiently accurate for all practical pur- poses. Even for these countries the figures dealing with similar matters cannot be compared with one another, since the bases of their preparation are not necessarily the same. Speaking generally, there is a close relation- ship between the vitality of a nation and its rate of in- crease. The rate of increase is clearly determined by the excess of births over deaths. Where the excess becomes very small, it behoves a nation to take active steps to preserve its future. In France, for many years before the war, there had been no appreciable excess of births over deaths and the population had remained almost stationary, but with a tendency to decrease. In other countries where figures are obtainable there was still a large excess of births over deaths, but ths excess was diminishing fairly rapidly.
It was necessary either that there should be a re- duction in the number of deaths or an increase in the number of births, or, in the opinion of some, both these changes should take place. The first efforts were made towards a reduction in the rate of mortality among infants. It is probable that many of those who took part in the beginning of the movement were^ actuated fully as much by philanthropic motives as by an appre- ciation of the need of the work. In France, however,
INTRODUCTORY 8
the early efforts were a direct response on a small scale to a known need, and the same must be said of the similar efforts of local authorities in this country. The aim was the prevention of preventable deaths among infants.
In England in the 'seventies and 'eightiesthe first efforts were directed to the visitation of infants in their homes. In France in the 'eighties, the movement commenced by encouraging breast-feeding among the mothers who were confined in a maternity hospital and by giving them suitable advice. The name of Professor Budin will always remain associated with this, the first infant consultation {consultation des nounrissons). The success achieved by this infant consultation led to the estab- lishment of similar organisations for artificially-fed babies, and, in addition to the advice, a supply of good milk was provided either free or at a small charge. These institutions were known as gouttes de lait. It should be noted that medical advice was given to the mother as to the way she should feed her child with the milk. The provision of food for the hungry makes a powerful appeal to most people, but, as will be shown, the provision of milk for infants, without instruction as to the method of using it, does not produce the satis- factory results which had been anticipated.
Milk depots for the supply of milk, without, however, the medical advice, found some footing in this country. The first depot was opened at St. Helen's in 1889. Al- though certain of the depots opened rather later by Liverpool, Battersea, Lambeth, Leicester, and a few other boroughs are still open, for the most part they have been closed, or, as at St. Helen's, have become depots for the provision of dried milk when ordered by the medical officer of the infant consultation. (For further details see pp. 56 et seq.)
Belgium started in yet another direction and opened schools for mothers. During the early years of the
4 THE CHILD WELFARE MOVEMENT
present century the movement, as represented by one or more of the above methods of work, spread into the western nations of Europe. The progress became very rapid about the year 1906 and after. In this country, the local authorities developed home visitation, aided by the Notification of Births Acts of 1907, and a con- siderable number of them opened centres for infant consultations. At first many of the centres which were started in different places were supported and managed by voluntary agencies, and some home visiting was also undertaken by them. It is almost a practice in this country for voluntary effort to take the first steps in any new branch of work, and the country usually re- frains from spending public money, either taxes or rates, upon experiments. As the movement has grown, the local authorities have continually taken over more of the work of the voluntary societies, wlio have either joined in with the official work of the district or have diverted their energies to new developments.
During the last ten years the general movement has spread widely, until, at the present time, there is hardly a country, however primitive, that is not stirred by the need for improving the condition of its children. The experience gained has led to the continual introduction of fresh branches of work and of new methods. Organis- ations have been started and grown with almost in- credible rapidity until the varieties and complications of activities are almost bewildering.
The development of home visitation and work at the centre, whether by infant consultations or by schools for mothers, showed that new branches of work must be opened up if satisfactory results were to be obtained. The home visiting without work at the centre was proved to be insufficient, and the work at the centre required close co-ordination with the home visitation. This is necessary in order that the medical officer may be cognisant of the home conditions on the one hand,
INTRODUCTORY 5
and that the health visitor on the other hand may know the advice which should be given in carrying out her work in the home. The schools for mothers realised the need for medical advice in addition to their classes, and the infant consultations found it necessary to make arrangements for assistance for the mothers in regard to advice as to clothing and instruction in the care of infants generally.
At the same time that the work for infants was de- veloping, the medical inspection of school children was introduced and its importance recognised almost at once. The inspection showed a deplorable condition of ill-health among children entering school, and brought into prominence the urgent need for super- vision of children in the early years of life. It was, how- ever, realised that care must be extended still further backwards and that many of the aihnents arising in young children before they attend school have their origin in defects of health diu"ing infancy, which again in many cases are due to ignorance on the part of the mother or to unsatisfactory environment of one kind or another. There can be no question that the work of school medical inspection has afforded a very powerful stimulus to the child welfare movement.
Then, again, those concerned with the work soon dis- covered that if their efforts were to be effective it was not sufficient to deal with the child after birth. The care of the children before and at birth has been shown to be a most essential feature of the work, and this clearly involves the care of the mother. For some years past pre-natal work has been recognised as an essential feature of child welfare work. There are, however, certain inherent difficulties comiected with it which have prevented the rapid expansion of the work.
Further, it has become increasingly evident that the care of the mother at the confinement is an immensely important factor in child welfare work. Such care
6 THE CHILD WELFARE MOVEMENT
brings the child welfare movement at once into close touch with those who are concerned in the practice of midwifery, and it is to be hoped that the co-opera- tion necessary to secure the most satisfactory con- ditions for the infant and its mother may form a leading feature in child welfare work in the immediate future.
Investigations into the causes of infant mortality have shown the immense complexity of the problem of the prevention of infant deaths. The conditions of employment of the parent, the home conditions, general sanitation, feeding, etc., all play a part in the health of young children.
The child welfare movement has also brought into prominence the need for further curative measures in many directions. At the present time there appears to be a distinct tendency for the child welfare move- ment to expand on the curative side of medicine. It is perhaps not unnatural that there should be this ten- dency in view of the large amount of ill-health for which at present inadequate provision is made. At the same time, it should never be forgotten that child welfare work is essentially preventive : its object is to preserve the health of healthy infants, and to give such advice as may assist the mother in bringing up her child so as to avoid all unnecessary ailments or disease.
Preventive work is at all times more difficult, and in some ways less attractive than curative, but its im- portance can hardly be exaggerated : it is the essence of public health work.
Child welfare work should, however, be linked up with curative measures, since all disease cannot be prevented, and adequate treatment is necessary to secure a return to health. The various activities and their relationship to other agencies will be considered fully under separate headings in subsequent chapters. It may safely be said that at the present time no
INTRODUCTORY 7
country is so fully covered by organisations for child welfare as England and Wales, and in no other country have the State and the local authorities together produced such complete arrangements for carrying out improvements in the health of the children of the nation.
While much was being done before the war, under the pressure of that upheaval undreamed-of develop- ments have occurred. The country is still assimilating the lessons learned in the furnace, and the time to strike is when the iron is hot. It behoves us to increase our efforts, and to fill up the gaps in our organisations and in our knowledge. There is much ignorant talk and loose thinking on child welfare work in all its branches. It does not perhaps impede the progress of sound work, but, if only the energy thus employed were directed oa informed lines, it is impossible to say how greatly k might assist.
Certain aspects of information have not been readily accessible hitherto. This book will be only one of many, but it is hoped that it may prove a slight addition to the literature upon the subject, and may at least aid the rising generation in their efforts to learn about the needs of their fellow- citizens.
CHAPTER II
On Notification of Births in Relatiojt to Child Welfare
The early workers in the cause of infant weliare found themselves face to face with a grave difficulty at the very commencement of their work. This difficulty lay in the absence of information as to the whereabouts of the infants who were to be the objects of assistance.
The workers set before themselves the prevention of infant mortality by means of advice as to the care of the infant and the improvement in the general conditions of the home.
There were two methods of finding the homes where babies had been recently born — the one by direct house- to-house visitation, and the other by applying to the Registrar of Births.
Up to 1837 there had been registers of baptisms kept in the various churches and chapels, but these records were admittedly far from being complete. In this year the registration of all infants within forty-two days after their birth became obligatory on the parent.
The Manchester and Salford Ladies' Health Society seems to have been the pioneer agency in child welfare work. The society was founded in the 'sixties by ladies who were impressed with the unhealthy con- ditions of the poorer homes. They did not themselves undertake the visiting, but employed other women to do this. These were untrained, but at that time there was little in the way of training which could be taken
by women. The towns were divided into districts, and
s
ON NOTIFICATION OF BIRTHS 9
each worker visited in her own district. It was, how- ever, soon realised that the method of house-to-house visitation involved much loss of time and energy since in many houses there were no infants, and the society was concerned with infants only.
After a while it was arranged that the Registrar of Births should supply to the society lists of the births registered in order to reduce the difficulty. The regis- tration is confidential, and special permission from^the Registrar-General was necessary to secure the informa- tion. Even then, however, it was found that in quite a number of cases the child had died, or its parents had removed from the neighbourhood before it was possible to visit.
Some years later other towns in Lancashire appointed women who had been trained as sanitary inspectors to undertake similar work on similar lines. These women carried out much valuable work, but it was impossible to cope with the problem with any real effect, so long as the whereabouts of the children were not more accurately known.
It was realised that a more effective method of dealing with the position must be introduced, and that some- thing must be done to secure notification of the homes where infants had been born at an earlier period of their lives tlian that compulsory for registration.
The first effort at notification of births seems to have been made in Salford in 1889. In that year the medical officer of health asked all the mid wives practising in the district to notify to him at once the names and addresses of the women they attended. This informa- tion was then passed on to the visitor for the district. In 1906 Huddersfield obtained parliamentary powers for the compulsory notification of births to the medical officer of health.
This was followed in 1907 by the passing of the first Notification of Births Act, introduced by Lord Robert
10 THE CHILD WELFARE MOVEMENT
Cecil as a private Bill. The measure was taken over by the Government of the day and passed into law under the guidance of Mr. John Burns, then President of the Local Government Board.
This Act was an adoptive Act, and must be distin- guished from the Notification of Births (Extension) Act of 1915, which is considered later.
The Act of 1907 permitted Local Authorities to adopt a system of compulsory notification of births, subject to the consent of the Local Government Board.
The Notification of Births Act might be adopted by any Local Authority. Such local authorities are county boroughs and counties, other boroughs, includ- ing Metropolitan boroughs, urban and rural district councils. (Cf. Chap. XXII.)
The detailed procedure was as follows : — The adoption being decided upon by the council (usually on the re- commendation of the health committee), the town clerk applied to the Local Government Board for per- mission to adopt the Act. The permission was at first given only if the Board were satisfied that pro- vision was being made to utilise the information ob- tained by home visitation, and after such proposals had been duly advertised in the local papers. These conditions being satisfied, the Local Government Board, with the concurrence of the local authority, fixed the date on which the Act would come into force.
Although the Act gave power to the county coimcils, except the London County Council, to adopt the Act, the Local Government Board did not at first encourage these authorities to undertake the work. It is, however, precisely in the scattered districts which are found in country areas that the work is most difficult to carry out. A number of smaller districts were willing to do something to improve the condition of the babies born in their area, but were unable or unwilling to employ
ON NOTIFICATION OF BIRTHS 11
some one specially for this purpose. Events have shown that the county council is the proper authority to take on the work, at all events for the less populated areas within its boundaries. A few county councils, notably Warwickshire and Worcestershire, who were most determined to get the work started, succeeded in persuading all the districts within their purview to adopt the Act,'and then to arrange with the county council to do the work. This policy did not, however, tend to promote the adoption of the Act in rural areas, and after a few years it was found necessary to secure the adoption of the Act by county councils wherever possible.
When adopted and in force, the Act required the parent, or any other person present at the birth, or in attendance upon the mother within six hours after the birth of the child to notify, within thirty-six hours, the occurrence of the birth to the medical ofl&cer of health for the district. Failure to notify might involve a penalty not exceeding £1.
Notification is required of all viable children whether alive or dead, that is, of all children born after the twenty-eighth week of pregnancy.
It is important to note that the duty of notification was primarily laid upon the parent, because it has often been contended that the duty was laid upon the doctor or the midwife in attendance, and great objection raised to the absence of a professional fee for notification.
The error has no doubt arisen from the fact that doctors and midwives are the only persons authorised by law to attend births, and are registered and known. Tt is therefore easier to draw the attention of doctors and midwives to the requirements of the Act than to inform the parents. Moreover, the Act provides that notification forms shall be provided by the local authority free of charge and prepaid for the post so as to avoid any expense to the person notifying.
As it would be impossible to send one to the parents,
12 THE CHILD WELFARE MOVEMENT
who are not known beforehand, it was evidently necessary to send the forms to the doctors and midwives, who could then either hand the form to the parent or fill it in themselves. The notification form is either a folder or a postcard addressed to the medical officer of health. A sample folder is shown below.
THE ROYAL BOROUGH OF KENSINGTON.
NOTIFIOATION OF BiRTHS ACT, 1907.
No. 3662.
/ hereby give you notice of the birth of a child * at
{Address)
State whether born alive or dead
Sex Date of Birth
Name of Parent
Parentis occupation
Name and address of the person giving the notice
Doctor's Name
Midxvife's Name
Dale of -Notice
* This notice applies to any child bom " after the expiration of the twenty-eighth week of pregnancy, whether alive or dead."
Notification of Births Act, 1907.
suboiary of the provisions of sectio^ one.
The " duty " of notifying a birth to the medical officer of health devolves, in the first instance, upon the father of the child, if he be living in the house at the time of the occurrence of the birth ; and if not, then upon " any person in attendance upon the mother at the time of, or within six hours after the birth." The notice must be " given by posting a prepaid letter or prepaid postcard . . . within thirty-six hours after the birth " ; or by delivering a *' written notice of the birth at the office or residence of the medical officer within the same time." The notification is in addition to, and not in substitu- tion for, the requirements of any Act " relating to the registra- tion of births," and it applies to any child born " after the expiration of the twenty-eighth week of pregnancy, whether alive or dead." Liability to penalty not exceeding twenty shillings is incurred by any poi-son who fails to give notice of a birth in accordance with th<f Act.
ON NOTIFICATION OF BIRTHS 18
Slight variations occur in the forms used in the diff- erent areas, but the differences are not important. The Act only allows a halfpenny to be spent on postage for each form. Some local authorities used halfpenny postcards, but the publicity involvedproved an objection, and some form of folder is commonly used.
The majority of births are now attended by mid wives (cf. p. 147), and it has been found that the notification forms are in most cases filled in by the midwife in attend- ance ; the medical practitioners fill in a proportion of the notification of births attended by them, and the small remainder are dealt with by the parents or some other person present at the birth.
A comparison of the births notified with those regis- tered shows, in most districts, that all births are not notified. The percentage of notification varies from 80 per cent, to 90 per cent, in most areas, while a few claim that complete notification is secured. The cases not notified are usually those among better-to-do persons occurring in doctors' practices.
The notifications are carefully preserved in the Public Health Department, the information given entered in a register and the appropriate visitor supplied with the details necessary for her work (cf. p. 19).
The Act was adopted at once by a large number of great towns, and certain of the Metropolitan boroughs. In 1909 it became compulsory for the Metropolitan area by order of the Local Government Board.' Rapid extension of its adoption took place in 1912-14, and in 1915, 80 per cent, of the whole population of England and Wales had come under the Act. The Notification of Births Extension Act of 1915 brought in the remaining 20 per cent, compulsorily. In effect the remaining 20 per cent, of the population were almost entirely in rural areas, there being then only an insignificant number of towns which had not adopted the Act. The rural districts had special difficulties in carrying out any work
14 THE CHILD WELFARE MOVEMENT
under the Act, and had therefore not applied for its adoption.
The Act of 1907 carried with it no powers to spend money out of the rates on work undertaken under the Act, and no Exchequer grants were available (for further information, see Chap. XXV). The only way in which it was permissible for local authorities to pay the salaries of the visitors employed by them, was to regard them as sanitary inspectors. A Bill (The Health Visitors' Bill), introduced by Mr. Burns to remedy the difficulty, failed to secure passage through the House of Commons. Power to employ health visitors was given to the Metropolitan boroughs by the London County Council General Powers Act of 1908.
Those local authorities whose accounts are subject to government audit ^ found themselves in a somewhat ambiguous position until the Act of 1915 gave definite power to levy rates for infant welfare work. In 1914 Exchequer grants became available, but there was no clear parliamentary authority for the spending of rates on infant welfare work. Many of the larger local authorities had undertaken considerable annual expenditure for this purpose, and much work was being carried on before the Act of 1915 was passed.
Apart from the activities of local authorities, much work was being done by voluntary agencies. This was especially! the case in certain towns where the local authority was either unwilling or afraid to incur ex- penditure. In some of these, the names and addresses of the infants whose births were notified were passed on for
* The aooounts of county oonnoils, of certain of the municipal boroughs, the Metropolitan bon)Ugh8, the urban dlBtricts and rural districts are audited by govommcnt auditors attached to the Local (}o\ernment Board (now the Ministry of Health), whose duty it is to disallow all expenditure for which there is no statutory authority. Those members of the authority who give instructions for any unauthorised expenditure are liable to bo surcharged and to be required to repay the money.
ON NOTIFICATION OF BIRTHS 15
visiting to the voluntary agency. In others, the local authority employed a visitor to pay the first visit, and the voluntary agency was supplied with notes of those requiring visiting. A great variety of arrangement obtained, but during the past few years the work of home visitation under the Notification of Births Acts has been taken over almost exclusively by the local authorities, and in the provinces at the present time there are few areas where voluntary agencies undertake this work. In London, however, there are several districts where voluntary agencies do the visiting after notifi- cation.
The notification of births forms the nucleus around which centres the great mass of infant welfare work. It is true that it is frequently too late after the birth to repair defects in both mother and child, and that, wherever possible, care should be begun at a much earlier period. At the present time, however, ante- natal care can only be effectively carried out in a com- paratively small proportion of cases. Alteration and development in many directions are necessary before ante-natal work will replace or render unnecessary the notification of births.
In addition to the notification of births, the notifi- cation of infectious and infective diseases is also of importance to child welfare work. As such notifi- cations are carried out on different systems, it will be more convenient to deal with them under other headings (see Chap. XXI).
CHAPTER III
The Work under the Notification of Births Acts
The initial duty under the Notification of Births Act is the home visitation. Under the Act all births should be notified, whether occurring among rich or poor. If the better-to-do inhabitants are visited as well as the poorer ones, the cost will evidently be greater than if only the latter were regarded as in need of advice. It is contended that the former can afford such assistance as they may need and hence should not be visited. It often happens, however, that those who might be regarded as outside the range of visiting by the health visitor, are glad to avail themselves of her assistance, and it is difficult and probably undesirable to make any distinction in the visiting. In some districts it has been decided that all houses where a birth occurs shall be visited, of whatever social standing, but in many places the visiting is confined to houses below a certain rental. Before the war a rental of £30 per annum was fre- quently taken as the limitation above which no visits were paid. In every case, however, this was left to the discretion of the locality guided by the advice of the medical officer of health. In each town the streets are well known to the Public Health Department, and little difficulty has usually been experienced in determining the areas and houses to be visited. Very often requests are made for visiting by those who had not been regarded as ))cing in need of assistance. About 80 per cent, of all births fall within the range of
i6
NOTIFICATION OF BIRTHS ACTS 17
infant visiting. This figure may appear to be unduly high, but in fact it is remarkably constant, since where there is a large better-class population the birth-rate among them is usually low, the births occurring mainly among the poorer classes. In a few districts the per- centage of births requiring visits is considerably above 80 per cent., and may reach 90 per cent, or more.
When the visiting is carried out by a voluntary society it is usual for the society to have a district allotted to them and the medical officer of health sends on to them only the births which he considers suitable for visiting. In some cases the visitor of the authority pays the first visit, and then sends on the name and address to the voluntary agency.
Date of the First Visit. — Either a doctor or a midwife attends every birth, and each is responsible for giving advice to the mother during the period usually recog- nised as the length of attendance.
Doctors usually remain in charge for fourteen days after the birth, and midwives for ten days. The doctor does not, however, usually attend every day, and can hardly reasonably be expected under the present conditions to give the time needed for detailed advice to the mother as to the hygiene of the child, especially in many of the poorer cases. The midwife is expected to attend frequently, and in the case of a great many midwives the necessary advice and care are no doubt given. There are, however, still a number of midwives in practice who are not capable of giving the advice required, since they are themselves untrained, and when they are in attend- ance at the birth it is usually felt that the visitor should visit at once on receipt of the notification.
The medical officer of health decides the date at which the first visit shall be paid, having regard to the qualifications of the person who is in attendance. It is unusual to visit doctors' cases within fourteen days unless a request for this is made on the notification form, or it
18 THE CHILD WELFARE MOVEMENT
is known that any special practitioner is glad of the assistance of the \asitor. There is no rule as to the date of the visit in midwives' cases, and the practice varies according to the views of the medical ofl&cer of health and the known capacity of the individual midwife. Probably, however, in the aggregate the visits are most frequently paid after the period of the midwife's attendance has ceased.
The health visitor has no legal right of entry to a house. She can enter only by the permission of the occupier. The sanitary inspector has the legal right of entry in the performance of his or her duties, and efforts have been made at intervals to secure a similar right for the infant visitor. So far, however, this has not been received with enthusiasm either by the Local Government Board or by most of the local authorities. It is felt that if the visitor needs legal powers to enable her to get into the home, her advice will probably not be followed, and, since she needs to be on friendly terms with the mother, it is preferable for her to obtain entrance by tact alone. In practice a suitable visitor very rarely fails to obtain admission.
Leaflets. — A great many local authorities distribute leaflets on bow to look after the baby, and these are sometimes sent by post at once on receipt of the notifica- tion, and sometimes distributed by the visitor at her visit. The value of these leaflets is much debated. Some people no doubt read them, but many do not, or if they do, make no attempt to follow the instruction. Then again, the instruction given differs widely in different districts, and unfortunately the advice given in the leaflets is by no means always the best, being often of the old-fashioned type. Thus, in London, in adjacent streets, the mothers may receive different or even opposite advice owing to the boundary line between two districts falling in that area. The leaflets vary from small slips of paper with a few salient maxims, to
NOTIFICATION OF BIRTHS ACTS 19
large cards filled with, advice which can be hung on the wall, and are sometimes booklets of considerable size. Their value probably varies with the character of the population and with the degree to which the visitor feels able to draw the mother's attention to them.
Record Cards. — One of these is provided in each case.^ In the larger public health offices, the name, sex, date of birth, address, and any further information obtained from the notification form is usually filled in by the clerical staff. The record cards show almost as great variety as the leaflets. The object of the card is to record such information about the child as may be considered of value in connection with its health. This will include the place in the family, the number of other children, the general condition of health of the parents and children, the conditions of the home, whether airy or confined, sanitary or insanitary, the methods of feeding the child, and other relevant matter. It is evident that all the information cannot be gained at one visit, but must be obtained gradually. As the visitor gets better acquainted with the mother, she usuallyihas no difficulty in gaining any information she needs. In fact, she usually receives far more than is required for her record card. '^
It is not advisable to fill in the cards while paying the visit. The information should be memorised and written down on the record card outside the house, preferably round the street comer. Some local authorities provide neat little^ cases or satchels for each visitor and a fountain pen, so^that the card can be filled up while on a round, thus saving the time which would be re- quired later at the office if notes are to be copied on the cards. Space is provided on the cards for notes as to the progress of the child at subsequent visits, and it is very desirable that the record should be continued up to the age at which the child attends school. The card, * Samples are shown in Appendix I.
20 THE CHILD WELFARE MOVEMENT
or an abstract of it, should then be available for the school medical' ojficer, and^will be of the greatest assist- ance in deaUng with health questions while the child is at school. Where the child attends a child welfare centre, arrangements are necessary to render the in- formation obtained at the visits available for the medical ofl&cer at the centre, and also that informa- tion obtained at the centre should be available for the visitor (cf. pp. 46 and 47).
(For a sample record card see Appendix I.)
The Duties of the Visitor. — Health visitors appointed by the local authority form part of the staff of the Public Health Department and are imder the medical officer of health. In most large towns there will be assistant medical officers of health, and in this case one of the assistants will probably be specially appointed to supervise the child welfare work. Sometimes an assistant medical officer of health is appointed ex- pressly for this work, and may also be the medical officer of the child welfare centre or centres.
A health visitor should always remember that it is her duty to carry out the instructions of her chief loyally whether his directions correspond precisely with her own \aews or not. It is usual for a definite time to be set apart when the visitors can see the medical officer. These interviews afford a valuable opportunity to the medical officer of hearing the information a visitor may have to impart about her district, and of giving the advice of which the health visitor may be in need in regard to any special case.
The date at which the visit is paid will affect the duties of the visitor. If paid early after notification, while the mother is still in bed, the most important duty will be to make inquiries about the feeding and to per- suade the mother to breast-feed the child, but it will usually be undesirable to remain more than a few minutea. It is often po88il)Ie to note the sanitary con-
NOTIFICATION OF BIRTHS ACTS 21
ditions of the premises at the first visit, since this does not disturb the mother. One examination is not suffi- cient, but the visitor, throughout the period of her visiting, be it long or short, should see that insanitary conditions are noted and dealt with. At subsequent visits she will become more closely acquainted with the affairs of the family. While always ready to listen, the visitor should not appear inquisitive, and any infor- mation obtained is strictly confidential and must on no account be communicated to neighbours. Some people consider it advisable that the visitor should inquire into the wages earned by the father or by the other members of the household, if any. This inquiry is, however, often very naturally resented, and sometimes the woman herself does not know what her husband is receiving. The object of the inquiry is to ascertain what the mother is able to afford for the child, and whether the money is sufficient but is being misspent. A tactful visitor is nearly always able to judge whether the mother is able to afford all that is necessary for the child without asking about the family income.
It is well to remember that, in a sense, the visits are in the nature of an intrusion and that the visitor is admitted by courtesy and not by right. She should therefore refrain, unless in very special cases, from behaviour which she would not adopt on any friendly visit to her own acquaintances.
The Sanitary Condition of the Premises. — The visitor must note the general condition of the house or dwelling : the condition and cleanliness of the walls and floors : the arrangements for ventilation and presence of any overcrowding : the water-supply : the nature of the sanitary arrangements : the condition of the backyard or garden, if any : the arrangements for the disposal of refuse : the facilities for getting air for the child : for the storage of food, especially for the infant's milk, if artificially fed. There will also be other points which
22 THE CHILD WELFARE MOVEMENT
will present themselves to the experienced visitor. When defects are present, the visitor must endeavour to get them remedied. Ordinarily, she will report de- fects in sanitation to the medical officer of health or to the sanitary inspector, but certain of the above matters can often be remedied by the people themselves if they are persuaded of the desirability for doing so.
She should be sufficiently acquainted with the law and with local practice to be aware which of these matters require reporting and which do not.
Where the visitor is qualified as a sanitary inspector she can, if desired, deal with the defects herself. This may, however, lead to difficulty with the landlord, and, in general, it is the practice for the visitor to hand over any procedure which may be necessary to the recognised officer. In view of the present housing conditions, the people are frequently afraid of any repre- sentation being made to their landlord, lest they should be turned out in favour of other more complaisant tenants, and often beg the visitor not to let the landlord be annoyed by requests for improvements.
In some few places the practice of allowing the visitors to deal with sanitary defects discovered by them obtains, and has been found to be entirely unobjectionable. At the same time, the majority of medical officers of health seem to prefer that the sanitary defects should be referred to the sanitary inspectors, and this view is taken by the Ministry of Health in a recent circular on child welfare.
The Hygiene of the Infant. — The visitor should be prepared to give advice as to the feeding of infants both before and after weaning, and of young children. She should be fully acquainted with the technique of breast-feeding, and should do her utmost to secure this for the mfant. Failing the natural method, she should be able to advise simple methods of artificial feeding, and should instruct the mother in the necessary
NOTIFICATION OF BIRTHS ACTS 23
details. Further, the clothing, bathing and general cleanUness of the child, its sleeping arrangements by- day and by night, the amount of fresh air it obtains, the ventilation of the room or rooms it may occupy, and the state of the bowels and of the skin all fall within the province of the visitor. Where there is an infant welfare centre in the neighbourhood, and this is usually the case at the present day, the visitor should invite the mother to attend, and should tell her the day and hour when the centre is open.
In a few places the visitor is provided with a hammock which can be suspended from the hook of a spring balance. The baby (usually with its clothes, since the mother does not want the trouble of undressing it) is placed in the hammock, and the weight entered on the record card. Apart from the error of the clothes, which will inevitably differ at each visit, the child rarely remains still in the hammock, and the level of the pointer oscillates on the scale, rendering it impossible to read with any degree of accuracy. Such a method as weighing is of Uttle or no value, and weighing is best omitted from the duties of a visitor on her district.
There is a superstition which is very prevalent in many parts, to the effect that if a baby is weighed it will die. The origin of this beUef has, so far, it is beUeved, not been explained, but it seems possible that it may be a survival in an altered form of the dread of punishment similar to that visited on Israel and Judah after the numbering of the people by David.
A health visitor must reaUse the importance of de- tecting early indications of oncoming trouble. If, for example, the child is not thriviag, or its progress from being quite satisfactory becomes less so, she should not wait until the trouble, whatever it may be, has got well established, but should endeavour to ascertain what it may be that is the cause of the lack of progress. It may be that on careful inquiry she may find that the mother
24 THE CHILD WELFARE MOVEMENT
has been giving different food, or has failed to give the child fresh air, and so on. If, however, there is no apparent cause she should endeavour, if possible, to per- suade the mother to bring the child up to the centre to see the doctor, or if this is already being done, she should advise that the mother should not fail to attend on the next possible occasion. Where the child is clearly ill, it will probably be advisable to recommend the mother to seek the advice of her own doctor, but some centres consider that the child should be sent on to the family doctor from the centre rather than by the health visitor.
A visitor must in no case undertake treatment as distinct from hygienic advice.
Social and Industrial Conditions, etc. — A visitor will need to know about the conditions of work, etc., which concern the famihes she is visiting. In a rural area the life is bound up ^vith the various seasons, with the weather, the kind of crops most prevalent in the particular districts, etc., and the visitor will do better and more intelUgent work if she makes herself acquainted with these and similar matters.
Most districts have conditions which are common to other districts of similar type, and also other special conditions peculiar to the locality.
In the towns or industrial areas she will need to know about the conditions under which the men and women, the boys and girls, work : of the chief types of amusement available, the social organisations to which they may or should belong. For instance, in a mining area, the work of the housewife is rendered very arduous by the shifts worked by her husband and perhaps by a lodger or relation living with them. In other districts there will be other difficulties connected especially with the pre- vailing employment of the inhabitants.
She should know something at least about the question of insurance under the National Insurance Act, of trade
NOTIFICATION OF BIRTHS ACTS 25
unions and their rules, of clubs of various kinds, in fact, all that affects the lives of those she visits should be of interest to her.
Certain of the above matters are technical and not easy to understand without explanation. Such ex- planation should now be given in the training for health visiting which requires instruction in social and economic conditions.
The visitor is dealing with the complexities of human life, and the more she is able to enter into the varied conditions of the Ufe of those among whom she visits, the greater will be the value of her speciaUsed work.
Other Matters. — The formidable list of subjects already enumerated does not, however, complete the duties of an infant visitor. As she becomes friendly with the mother she will find that her advice is asked on all kinds of matters, some of which may have only an indirect bearing on her work. She will often need to bring to bear all her past experience in order to answer the questions put. In some homes circumstances are found which present very real difficulty to the visitor. Here and there a mother is found who seems to have no affection for her children, who are neglected and wretched. The efforts and persuasion of the visitor may, with patience, succeed in effecting astonishing transformations. Occasionally, however, it may be necessary for more drastic treatment to be adopted. In such a case, the medical officer of health may con- sider it advisable to refer the case to the officer of the National Society for the Prevention of Cruelty to Children, a procedure which often secures good results.
There are few visitors of experience who have not in their memory cases which have required continual and persistent visiting, advice and cajoling, in fact, all forms of inducement for a prolonged period before that realisation of her duties in the mother has been pro-
26 THE CHILD WELFARE MOVEMENT
duced whicli makes her secure healthy conditions for the child.
The visitor must remember that she is not a mis- sioner but a health agent. Her duty is not to condemn or to preach. She will inevitably find immoral con- ditions among some of those she visits, but except in so far as those conditions may cause direct injury to health they are not her concern. Voluntary workers may find it difficult to refrain from advice and admoni- tion in these matters, but the health visitor must dis- creetly avoid any interference in the lives of those she visits. If this is realised she will often be given oppor- tunity of assistance which she would otherwise miss.
Whoever would do useful work among the poorer classes must try and understand the views upon various matters held by those among whom the work is to be done. It is too frequently forgotten that the life of those who live in humble circumstances is altogether more primitive than is usually the case in the classes from which the workers are most often taken. Differ- ent classes of society are prone to condone different faults. It is always easier to see the faults of those among whom we have not been brought up ; but, ex- cept in so far as health may be concerned, it is no more the duty of the health visitor to expatiate to those she visits upon their faults, than if she were visiting her own friends. A friend who is inclined to chide is not likely to receive confidence or to be allowed to give aid or advice.
CHAPTER IV
The Relation of the Child Welfare Visitor to Charitable and Social Organisations
At the present time the whole attitude of many thought- ful persons is undergoing, or has already undergone, much change from that of some twenty years ago or less. The old idea of giving money or other material assistance to cases of obvious poverty without further inquiry has now nearly passed away. It is recognised that apparent poverty may be due to other causes than lack of income, and that investigation is needed, be- cause indiscriminate and unsuitable gifts are more^likely to do harm than good. The official^recognised organisa- tion for public relief is the Poor Law, but, from various reasons, mostly well known, recourse is only had to the Poor Law by those who are unable to obtain help in any other way, or who have been proved impossible to aid from other sources. Until recently, at any rate, the Public Health Department has not had power to give material aid in any form, and material aid has usually been regarded as undesirable. All forms of work which tend directly to prevent disease are now coming to be regarded as a duty which has to be carried out by public bodies, and as conferring benefits, which are the right of the public and in no sense charity.^ Every visitor among the poor will not fail to meet
^ It is impossible to say how far the present position of the Public Health Department may be modified if, and when, the abolition of the Poor Law comes to pass.
87
28 THE CHILD WELFARE MOVEMENT
cases of poverty where common humanity appears to demand instant material aid. In one or two towns the infant visitors have been allowed to collect money, and to distribute it among cases which appear to be necessi- tous. Ordinarily, however, it is agreed that material relief should in no case be given by the infant visitor. In the first place, the inhabitants of her district should not regard her as a source of aid in apparent poverty, which will be the case if she distributes relief, and, secondly, such reUef is palKative only, and may be directly detrimental unless given with due knowledge of the family circumstances. The visitor is hardly ever a trained relief worker, and does not therefore know the best means of affording lasting aid. Organisations of various forms, to which cases can be referred, exist in nearly all districts. It is sometimes said that certain well-known organisations are too slow or too particular in their methods, but even if this statement be deemed justifiable, there should be no difficulty in arranging for speedy relief apart from the infant visitor. The visitor should be well acquainted with the various possible sources of aid in her district, and she should refer the needy cases to whichever of these sources appears to be the most appropriate to each case as it arises.
The provision of free or cheap dinners or food for mothers and of milk for infants is a very debatable point. So long as such aid is provided only on medical orders, and this is clearly understood by the recipient, little or no objection need be raised from the point of view of reUef. It will nearly always be a temporary measure to tide over a special period in the life of either child or mother. The distribution without much in- vestigation of free orders for milk for infants needs to be closely watched lest it should tend to encourage artificial feeding.^
* It l» greatly to be ho])ed that the present high prices of milk may produco greater attention to breast-leeding on the part of
CHILD WELFARE VISITOR 29
Again, there will be cases where it may seem that letters for some convalescent home or rest home for mothers with some form of aid for a child are required. The infant vistor should not herself take any steps to pro- vide such aid, but she should possess a sufl&cient know- ledge of the aim and objects of the manifold charitable and social organisations, both generally and in her own district, to be able to direct the mother or herself to make application to the appropriate agency, either directly or through the chief health visitor, according to circumstances. It has often happened that a well-mean- ing ignorant visitor has expended much time and trouble in securing what appeared to her to be the right form of assistance, when the case was well known to existing appropriate agencies who either had already made similar arrangements for aid, or who knew that the proposed form of aid was entirely unsuitable for the particular case. Overlapping of effort should be avoided and no one set of workers should trench upon the field of others.
all concerned and that it will not lead to an increased supply of free or nearly free milk for artificial feeding.
CHAPTER V
Points in the Arrangements and the Conditions OF Work of an Infant Visitor.
It is assumed in tliis chapter that the visitor under- takes no other work than that connected with infants. In the earher years of the movement it was common in the towns to allot to the health visitor other duties beside those arising under the notification of births. The ^\ork in connection with and arising out of the medical inspection of school children, and the work among tuberculous persons were the most important of the other activities. In the towns, however, the visitors are now increasingly being given only the work among mothers and children under school age. In the counties, on the other hand, owing to the relatively scattered position of the population the tendency is to place a variety of duties upon the health visitor for each district. It is easier, however, to deal first of all exclusively with the work among infants and after- wards to consider the modifications (cf. Chaps. X and XI).
The arrangements made for the work of the visitor will depend a good deal on the nature of the district, whether the population is congested or scattered. In a large town it is usual to employ a number of visitors, of whom one is the chief visitor. The town is then divided into districts and a visitor allotted to each. The size of the district will depend upon the average number of births which occur in the year. As a rule, the
WORK OF AN INFANT VISITOR 31
poorer the district, the smaller it will need to be. In addition to the number of births, the facilities of transit will be considered and the areas arranged so that there is the least waste of time in getting to and about the district.
The chief visitor may have a small district of her own if she has time, but in a really large town it will probably only be possible for her to supervise and arrange the work of the other visitors and to visit especially difficult cases when her assistance is requested.
The notification of the births will be handed to the visitor of the district who will be responsible for visiting. Although it may be the nominal practice to visit doctors' cases on the fifteenth day and midwives' cases on the eleventh, it is not always possible for this to be done without undue loss of time, unless the area worked by one person is very small and congested. A visitor learns to arrange her work beforehand, so that there are a number of visits to be paid in adjacent streets, and it may cause the loss of eight or ten visits if she is obUged to pay a single visit in a district where no other visits happen to be due. The less congested the area, the more difficult it is to adhere at all strictly to any set day for the first visit.
Opinions differ widely as to the frequency with which visits should be paid. It is usually agreed that much must be left to the discretion of the visitor. There will be a number of cases where an occasional visit is all that is necessary. The mother may be well-to-do and the child well cared for. In such a case the visitor may pay a quarterly visit or she may ask the mother to send a card if there is anything she would care to see her about. It is rather surprising to find how much advan- tage is taken in some districts of this offer : it might have been thought that the trouble of writing would have acted as a deterrent.
Again, there will be other cases where much assistance
32 THE CHILD WELFARE MOVEMENT
is needed and where weekly or more frequent visits will be necessary if any improvement is to be effected. Then there are the cases where fairly regular visits are desirable. Some people consider that monthly visits are too fre- quent for the average case, while others regard a fort- night as the longest interval which should be allowed to elapse at any rate in the early months after birth. There can be no rule laid down — much depends upon the character of the people and of the visitor and each case must be dealt with on its own merits. Again, as the child grows older fewer visits will be necessary. If the visiting is continued up to school age, as should be the case, it may roughly be computed that the number of visits in the four years from one to five will be about equal to those necessary in the first year alone.
It has been found that on the average a visitor en- gaged only with children under one year, can undertake the visiting for approximately twice as many births in the year as one who continues visiting up to school age. Here, again, however, there will be much variation. The most recent circular upon the subject issued by the Local Government Board allows 400 births to one visitor. Certainly not more than 200-250 children up to school age can be dealt with by one visitor. At first, under the Notification of Births Acts, it was a not in- frequent practice for one visit only to be paid, subse- quent visits not being regarded as falhng into the same category. Later, as the work developed, it was reaUsed that one visit without re-visits was waste of effort and visits were usually continued up to the end of the first year.
In 1915 the Local Government Board regarded 500 births as the number which could be allotted to one visitor. Great consternation and doubt were expressed by many councils at the immense number of visitors who would be necessary under such a proposal It is now generally known that much effort is wasted if the
WORK OF AN INFANT VISITOR 88
visiting ceases at the end of the first year and in some places already the aim is to allot not more than 250 births per annum to each visitor and to require visiting up to school age.
The number of visits which can be paid in the day or the year will again depend on the nature of the dis- trict, on whether the visits are early visits or late ones — as a rule early visits take longer than those paid when the child is older. Ordinarily a visitor will not be able to accomplish more than fifteen to seventeen visits in the day under favourable circumstances. When the homes visited are not grouped, or when there are several first or early visits, it will not be possible to pay so many. Again, much will depend upon the distance from her office, which is usually the Public Health Department, and which may be some distance from the district to which the visitor is allotted — also whether she bicycles or walks or takes a tram, etc.^
Then, again, the amount of office work required will affect the number of visits paid. If the visitor has to spend an hour or more copying notes and records either before going out or after returning from her work, there will be less time for visiting. The hours available for visiting are ordinarily rather limited. The tidy mother does not like to be found at her work, and she likes a little time for clearing up after the children (if any of school age) have been got off to school There- fore usually it is best not to visit much before 10 a.m. unless the visitor knows the mother, and is sure of her welcome. Then, visits should not be paid during the dinner hour, especially if the husband comes home to dinner ; moreover, preparations for dinner are necessary,
1 It is usual where the tramways are owned by the Corporation to give free or reduced tickets to the visitors when using the trams for their work. Their travelling expenses incurred in connection with their work are paid. It is usual also to provide the health visitor with an annual sum for the upkeep of her bicycle, and in Bome cases the bicycle itself is provided.
3
84 THE CHILD WELFARE MOVEMENT
and the housewife who has just left time to get dinner ready may not be pleased at a ten minutes' interruption at a critical moment in her culinary arrangements. In the afternoon, of course, they are often out, and the chil- dren return from schoolat 4 p.m., or earher in some places, in the winter. Visits paid at inconvenient times do not conduce to a welcome or to obtaining good results. A certain number of visits will often be abortive, the mother being out, but after a little while the habits of the district or of particular women get known, and the visitor develops an instinct for finding the mothers at home.
In a scattered area, or in the country, it is impossible to arrange for more than occasional visits owing to the distance apart of the homes. Much will naturally depend upon the size of the district the visitor has to work, but generally very different standards of frequency are adopted in towns and in country districts.
Where there is a child welfare centre in the visitor's district, arrangements are usually made for her to attend the centre. It is sometimes urged that by doing so the visitor cannot pay as many visits as are required for her cases. Both from the point of view of the visitor as well as of the mother, it is essential that she should arrange to attend the centre. She will be more success- ful, because more interested, in persuading the mother to come up if she knows she will be there herself, and the mother will feel less strange if the visitor is there to welcome her. Again, it acts as a stimulus to the visitor and, if she is present at the consultation, as should be the case, she is better able to see that the advice given at the consultation is carried out.
The Ministry of Health are now advising local authorities to arrange as far as possible tliat each visitor shall be attached to a centre, and that the area served by the centre shall be coterminous with the visitor's district, or where the centre serves the districts of two
WORK OF AN INFANT VISITOR 35
visitors, separate sessions should be allocated to the different districts. The centres would thus be small centres, and their primary function would be the giving of medical advice. There would thus be many small centres, each serving a particular locality, and a few larger centres where other activities are available, serving the districts of a number of visitors.
Still-Births. — A feature of the visitor's work which obtains almost universally among the staffs of local sanitary authorities is the visits paid in regard to still- births. The problem of still-births is very intricate. It was not usual to register children who were born dead, but notification of all viable children {i.e., after the twenty- eighth week of pregnancy) is required whether the child is born dead or alive. Formerly, the still-born child was not infrequently taken to the undertaker, who placed it in any cofl&n which was about to be taken to the cemetery, and the child was buried without further ado. But, with the notification of still-births, the practice ceased, and tbe medical officers of health required the visitor to pay visits to the homes of all still-births, and to make special inquiry into the occurrence. Although, doubtless, some still-births are unpreventable, it is probable that a fair proportion could be prevented, and in certain cases no doubt a still -birth is not regarded as a misfortune.
In one large town no burial of a still-birth may take place until the body has been seen by the visitor for the district, or by the chief visitor, and a permit for burial received from the Public Health Office. Accurate figures as to the number of still-births are only avail- able for a few towns. The midwives usually notify all the cases occurring in their practice, but it is well known that this is not the case in doctors' practices. Hence the still-births notified do not give a correct figure. The only method of obtaining the true figure is from the returns of the cemeteries, through the certificates of death. The figure of 3 per cent, which has been widely
86 THE CHILD WELFARE MOVEMENT
published as the average figure for still-births is subject to the limitation of available information mentioned above.
Ante-natal Work. — Experience has shown that visits paid at the times above described are very often too late. The child has been taken ofi the breast, and efforts to restore natural feeding are unsuccessful, or no effort at all has been made by the mother to undertake this duty, and artificial feeding is firmly estabUshed when the visitor arrives. Again, unsatisfactory clothing has been provided, and the money having been spent, no more is available — ailments in the mother or conditions in the home could have been attended to had the visits been commenced before the child was born. These and other considerations have led to the demand for ante-natal visits on the part of the visitors.
There can be no doubt of the need for ante-natal care, but it is questionable whether it can be regarded as falling within the purview of the work of the visitor. When a doctor has been engaged, ante-natal visits should not be paid without his consent and approval, although the nature of the ante-natal care given by the visitor or by a midwife should not include anything in the nature of treatment. Under her Rules (cf. pp. 129 et seq.) the midwife is responsible for her patient as soon as she has been engaged to attend the confinement. In the case of trained midwives, there can be little doubt that ante- natal visits should be carried out by them, but where the midwife is herself untrained the position is very different.
There is the difficulty of knowing wliere the cases are that require ante-natal visits, since there is no definite means of ascertaining their whereabouts. A visitor who knows her district will probably not have much trouble in knowing of the majority of cases, but she must be careful not to interfere with the midwife or doctor engaged by the mother. Apart from these con- siderations it is evident that she must have had experi-
I
WORK OF AN INFANT VISITOR 87
ence in maternity work, and know what advice to give. Thisfat once raises the whole question of the training of visitors as midwives. It is generally agreed that without a midwifery training, they cannot undertake ante-natal work, but also the mere training in mid- wifery is not enough, and actual practical experience in midwifery on the part of the ante-natal visitor must be regarded as essential. The visitor should have been a practising midwife if she is to undertake this work. This subject is considered further in later chapters.
The Ministry of Health have recently stated that ordinarily the midwife should do the ante-natal work for her own cases, although at the present time, where all midwives are not trained, this may not be possible.
CHAPTER VI
The Child Welfare Centre
Reference has already been made to the child welfare centre as exemplified by the infant consulta- tion and the school for mothers. At the outset these branches of work were very simply arranged, and did not overlap one another. The primary function of the infant consultation was the medical advice to the mother on the means she should employ to preserve the health of her child. It was not usual for the attendance to be continued after the child had reached one year of age.
The school for mothers was intended to be educational, the object being to instruct mothers in these matters which relate to the welfare of infants generally, and not to the particular child of the individual mother.
It was soon found that neither of these activities was self -sufficient. At the infant consultation it was realised, for example, that the clothing of the children was often quite unsatisfactory, and that the mother had no idea how to make proper garments. Many of them did not sew at all, and had never cut out a garment in their lives. They did not know how to mend or alter, how to prepare the food for the growing child after weaning, and were frequently ignorant of the rudiments of housecraft.
At the schools for mothers, on the other hand, it was found that the mothers were not able to adapt the in- formation given on general lines to their own children,
38
THE CHILD WELFARE CENTRE 39
but were continually asking for advice on special points. It was gradually recognised by the schools for mothers that they needed an infant consultation, and the infant consultations on their part realised that they needed some arrangements for the instruction of the mothers in the care of infants and of the home generally.
The functions of the two varieties of centres thus tended to approximate, but it was only rarely that any change of title was made, and in many instances schools for mothers were started whose work was essentially that of an infant consultation, but the title " school " happened to appeal to those who were responsible for commencing the work.
At an early stage in the movement it was found that if the work was to be as useful as possible, it would be necessary for the homes of those attending the centres to be visited. The establishment of centres and the in- itiation of the work under the Notification of Births Act commenced about the same time.^ The home visitation was at first only undertaken by the large towns which adopted the Act as soon as it became operative. Even then the visits paid were by no means frequent, and often amounted to one visit only. In many districts there were at first no arrangements at all, t\e Act not having been adopted by the authority of the district.
In some areas there was visiting and no centre, and in others there was a centre and no notification of births. In the latter cases the visiting had to be done from the centre, if it was done at all. In the early years the centres were, with very few exceptions, commenced and worked by voluntary workers. Usually a number of ladies banded themselves together to form a com- mittee, which was responsible for all matters connected
1 The first infant consultation in this country was started by Dr. Eric Pritchard at Marylebone in 1906, and the first school for mothers by a number of ladies in St. Pancras about the same time.
40 THE CHILD WELFARE MOVEMENT
with the centre. The cost was not great in those early days.
The accommodation usually consisted of not more than two rooms of small size, for which a rent of perhaps 2s. 6d. a week was charged for the one afternoon it was opened. All the workers were voluntary, and the doctor was asked to give his or her services. As time went on and the work increased, it became impossible for the visiting to be done by the ladies themselves. In some districts it was arranged that the visitor under the Notification of Births Act should attend the centre and undertake the visiting of the homes of those attend- ing as a part of her ordinary work. In other places it happened that there was no official visitor, or that the ladies preferred to keep the visiting under the control of the centre. In this case it was common to employ a trained visitor who worked with the centre only. She visited those mothers and only those who attended the centre, for the primary reason that the whereabouts of the others were not known. It often happened that the centre could undertake more work than it was actually called upon to perform be- cause the centre was not known outside a very limited area. Quite commonly the medical officer of health was asked to supply information as to the address of more mothers if the Notification of Births Act had been adopted for the district.
The medical officer of health was often wilUng to send on lists of the births in a given area, which area was then regarded as allotted to the centre, on the under- standing that the centre then assumed responsibihty for all the births so notified to them, and that they furnished such information about the children as might be called for.
Only in rare cases, however, were the first visits paid from the centre. Usually these were paid by the Council's visitor in order that the condition of the home,
THE CHILD WELFARE CENTRE 41
etc., might be ascertained and reported to the PubUc Health Department. Speaking generally the dual system of visiting does not work out very satisfactorily. The centres often failed to keep in touch with those infants whose mothers did not bring them to the centre, so that they received no visits at all. They have been handed over to the centre, but the centre, finding that they do not attend for medical advice, gradually ceases visiting. Those who do not attend a centre are fre- quently more in need of visiting and advice than those who do, and in this way many cases in real need of advice may be neglected. It is seldom that a centre can afford to provide a staff of sujSicient size to visit cases other than those who form the clientele. The mass of homes whence the mother does not attend at a centre must be visited by the official workers employed by the Council under the Notification of Births Act.
Another arrangement sometimes made was that the centre should send weekly or fortnightly lists of the infants who were being visited by them, and it was then understood that the visitor from the Pubhc Health Department would not visit in those homes. Any line of demarcation is, however, always likely to leave gaps, and as a result a certain number of the children are not visited regularly.
The only satisfactory method of visiting is for the ofi&cial health visitors to be responsible for all the visiting and for them to attend the centre and be*thus personally in touch with it.
On other grounds also it is essential that the visitors should attend the centre in their own district, whether the centre be worked by a voluntary agency or by the Council. If the visitor does not know what advice has been given by the doctor at the centre, it is probable that much of the advice will be wasted. The mother often wants assistance in carrying it out and the visitor
42 THE CHILD WELFARE MOVEMENT
cannot help her adequately unless she knows what advice has been given. Then again, it is good for the visitor herseK. She gets a variety of work and is kept up-to- date and alert by contact with the other activities of the centre in addition to the fact that she learns by hearing the advice given by the doctor.
It is difl&cult to emphasise too strongly the need that the visitor should attend the centre. The two branches of work — home visiting and consultation — are not separ- ate parts of the work but are interdependent, and any system which does not secure the closest co-operation will fail to effect the best work. The visitor will take more interest in the work if she follows the infant in all its phases of care, while the mother will be drawn closer to the visitor if they meet at the centre. Even if the visitor has to pay rather fewer visits in the week the time devoted to work at the centre is well spent.
At the present time hardly any visiting is done by voluntary agencies outside London. The development of the work at the centre itself has been a determining factor in the handing over of the visiting to the ofl&cial visitor. The fimds of a voluntary society do not ordin- arily admit of the employment of more staff than is neces- sary to actually carry on the work at the centre.
The large present-day centre has moved far from the simple activity of the infant consultation. It will be interesting now to study shortly the reasons for this development. The need for the infant consultation and the teaching of the mothers has already been con- sidered, and the other phases have arisen as the work expanded. In some districts one activity came first and in others different work was taken up in different order, but now many centres in large towns have a number of these activities at the same centre.
It was found that many mothers were unable to attend the centre owing to the fact that they had several children under school age who could not bo left at home
THE CHILD WELFARE CENTRE 48
alone. If these cliildren were brought to the centre in considerable numbers the disturbance caused was great. They could not reasonably be expected to sit still during the whole session and inevitably they made a good deal of noise. So a " toddlers' room " had to be arranged where these small children could be taken on arrival and cared for during the time the mother was at the centre. Ladies are usually wilhng to take charge of these little ones, and a list of those undertaking this duty should be arranged for each session.
The need for medical supervision of those children under school age is now fully realised and provision is made at many centres for their examination and for advice as to their hygiene. Such examination need not take place frequently, but it is found better to arrange the work among older children on a different day from that among children of one or two years of age. The practice varies considerably according to local circum- stances, some centres keeping those under two years in one category while others make the dividing line earlier. Others again do not make any clear division.
Then it was found that many of the children were suffering from some mild nutritional disturbance which would yield to a few days in hospital with regular feeding, etc. Hence arose the desire for some accommoda- tion whereby these children might be supervised for a few days and got into good habits. It is quite im- possible at present to send these children into an ordinary hospital as the accommodation is hopelessly inadequate for even serious cases of illness. Hence certain centres have started so-called " observation wards " where they can keep the cliildren for a few days. In some cases these wards are used also for children who, from one cause or another, have no one to look after them for the time being. This may be due to the mother's illness or some other cause. These beds should not, however, be used for cases of serious illness.
44 THE CHILD WELFARE MOVEMENT
Another branch of work is that among the mothers themselves, expecially before the birth of the child. Ante-natal work is increasing and its importance is being realised. This branch leads into the whole sphere of maternity and midwifery work, and some centres now employ midwives of their own.
The provision of dental care has been found to be one of the most valuable branches of work at a centre. This is needed for all ages, for the mothers and for the children who, too soon after cutting their first teeth, show signs of dental decay and before they reach the age to attend school have already in many cases sustained permanent injury to both teeth and jaw.
A large centre may therefore be a veritable hive of activities, but it is advisable that there should also be numerous smaller centres where the ordinary infant consultation with its advice and instruction for mothers is offered without all the expensive varieties of work of a large centre. The various phases will be dealt with in more detail in the next chapter, only those forms of work which are found in nearly all centres being dealt with in this chapter.
Accommodation Required. — ^T wo rooms is the least number required for even a small centre, and three are desirable. For a centre where more than some ten or twelve children attend at a time, three rooms must be regarded as essential. Sanitary accommodation and a place for keeping perambulators are also necessary. One of the rooms will serve as a waiting-room where the mothers sit on their arrival. There should be some method of warming the waiting and other rooms in winter, and adequate ventilation should not be forgotten. Another room is needed as a private consultation room for the doctor who will see the infants one by one. The children are weighed, either in the consultation room or in the third room, according as is preferred by the doctor. In any case, the remaining room should be
THE CHILD WELFARE CENTRE 45
available for undressing the children before they are seen by the doctor. The consultation room should have a good light, and this requisite will probably determine which room shall be allotted for this purpose.
White overalls or coats should be worn by all the workers, and hats should be removed. Some form of receptacle which can be easily washed should be pro- vided for the clothes of each child so that there is no mixing of garments. Only a few children will be in the undressing room at once, some of them waiting for the consultation and others dressing after it is over. In some cases the consultations are held in the morning, but the majority of centres are open in the afternoon. At many centres, especially where the agency respons- ible is voluntary, it is not unusual to provide tea and a bun or biscuit at a small charge.
Weighing. — It is essential that the children should be undressed for weighing and for the medical examina- tion. No accurate figure for the weight can be obtained if some or all of the garments are left on. It is argued by those who approve this method that the mothers bring the children up in the same clothes on each occasion 80 that the error in weight due to the clothing is always the same. It is difficult to see how such a statement can be made seriously, since not only must the clothing change from week to week, but it should be different in winter and summer, and, moreover, as the child grows, it will need new and larger garments. There is no virtue in weighing as such ; its object is to note the progress of the child. It is especially valuable when the progress is slow or absent, when an ounce or two either way may be of much importance in deciding the advice to be given. Care should be taken with the weighing and a good balance used. The Post Office balance, which only weighs to within about four or more ounces, especially when the child is moving in the scale pan, is of little or no value for this purpose. Weighing which is care-
46 THE CHILD WELFARE MOVEMENT
less or inaccurate may as well be omitted. There is more difficulty in accurate weighing than might be supposed, and most people have a sort of personal equation which makes their reading rather different from that of others ; wherever possible, therefore, the same person should weigh on each occasion.
The undressing also enables the state and nature of the clothing to be seen. The kind of clothing provided is frequently quite unsuitable, and may be improved by appropriate assistance and advice. Moreover the mother will be more careful in regard to cleanliness if she knows the child is to be undressed. It is sometimes argued that there is little to be gained if the cleanliness is for one day in the week only, but at least one clean day is better than no clean day and may be the fore- runner of others.
The scale pan should hold a piece of wool or a blanket to keep the infant from feeling the cold of the metal, and a fresh piece of clean paper over the blanket should be used for each child. The blanket or wool must be of known weight.
Record Cards. — Various forms of medical records are kept at child welfare centres. The object of the record is to provide information as to the condition of the child at its first attendance, together with such details as are necessary of its place in the family and home conditions, and to which additions may be made on each occasion of the child's attendance. When the centre is large, a system of card indexuig will be neces- sary, and this will be kept either in the waiting-room or in some further adjoining room. On the arrival of the mother the record is found, or a fresh one prepared if it is a first attendance, and placed ready for the doctor, and handed to him or her when the infant concerned is in theJ[consuJtation room. It is usual, also, to give the mother a card on which the baby's weight is entered and notes of the instructions she has been given.
THE CHILD WELFARE CENTRE 47
(Samples of such record cards are shown in Appendix I.) The information obtained by the visitor on her visits after the notification of the birth may be used for the details of home conditions, etc., and any alteration in these noted.
The record cards should not be fuller than is really necessary. A card that requires much time and leaves space for all manner of details will, in all probability, not be filled up as carefully as one which, being less elaborate, can be properly dealt with in the time avail- able. It is not necessary that any more than the salient features should be recorded in ordinary cases.
The record cards should be available (or copies of them) for the school medical ofiicer when the child attends school. It is the only means whereby an accurate record of the child's previous health history can be obtained. The record card would, for example, show at a glance the ailments which it had suffered from including the infectious diseases and would furnish valuable data for research on all these points.
It will evidently take some years before such records are generally available, but their importance is very great and no time should be lost in getting the whole system of records in hand.
Frequency of Attendance. — The medical officer de- cides the frequency of attendance at the consultation. A good arrangement is for the date of the next attend- ance for consultation to be written on the record and on the mother's card. It may be that the doctor will wish to see the child every week for the first two or three weeks of its attendance, and that unless some unforeseen difficulty occurs, the visits can then be lengthened to fortnightly, or later, monthly, or, as the child gets older, quarterly visits. It is found, however, that in many cases it is advisable to allow the mothers to attend as frequently as they wish on the special afternoon, as it conduces to attendance on the consulta-
48 THE CHILD WELFARE MOVEMENT
tion days. The baby can be weighed by the workers but not sent to the consultation room unless some untoward event has supervened which renders this necessary.
Clothing. — Child welfare work has brought into prominence the question of clothing, but it is doubtful whether the full importance of proper clothing is even now properly appreciated. While details can be sought for in the text-books on infant hygiene, a few remarks upon this matter will hardly be out of place here. It looks almost as if there were no age at which clothing is more oppressive than during the early months, or perhaps years, of childhood. The unfortunate infant is obliged to wear exactly what its mother or nurse thinks would be good for it, or ornamental for the out- side garments. The child wants freedom to stretch its arms and legs, freedom of movement for its chest and body, but custom has prescribed that the clothing of the infant shall do its utmost to hamper the poor Uttle mite in its efforts to grow healthy and to develop on the lines intended by nature.
To take the undergarments first. Who has not seen the terrible article known as a binder ? Some bandage is necessary until the child has parted from the remains of its umbilical cord, but not afterwards. The practice of days gone by still persists in many homes of sewing a
Siece of flannel as tightly as it is possible round the ab- omen of the miserable infant. Sometimes the binder is so tight that the child literally cries with the pain, as is evinced by the sudden cessation of the cry when the binder is released. Even if this degree of duress is avoided the binder is uncomfortable, and usually works its way up towards the chest where, becoming crumpled up in layers over the lower part, it effectively prevents the expansion of the chest m breathing. If it should remain in the position intended by the nurse or mother, it tends to produce internal discomfort, and is by many
THE CHILD WELFARE CENTRE 49
regarded as one of the causes of constipation in infants. If the binder be knitted, as is now sometimes the case, the wool may shrink, and the binder become hard and excessively tight for the infant. But custom has pre- scribed it, and, tight or loose, comfortable or uncom- fortable, it is placed on the often stoutly resisting child.
Then there is still in some parts, the horrible little cotton shirt with short sleeves, which is followed by another binder, stiff and starched this time, and extend- ing over the greater part of the distance between the arms and legs of the unfortunate infant. Binders have nothing to recommend them, and should be omitted from the infant's wardrobe. The writer remembers attending a consultation where needles and cotton were actually provided by the centre for the sewing up of these instruments of torture after the weighing.
Then there is the flannelette petticoat with cahco bodice, as soon as the child is a little older, which, owing to its lack of warmth, has to be duphcated and reduph- cated until sometimes as many as four or more of these garments are piled on the child to keep it warm. The outer and outdoor clothes are little better. The long frock with heavy embroidery and frills, stretching over the toes and weighing them down, the short sleeve tied up with ribbon, the thick peUsse, the padded bonnet without any ventilation, and the woollen veil, which effectually negatives any benefit the child might obtain from being in the fresh air, should all be dropped in favour of more hygienic garments. The ideas of many on the subject of clothing are still tainted with suggestions of the dark ages, and that not alone among the poorer classes.
The child wants to be kept warm in winter by a few woollen garments. A woollen vest with long sleeves, a longer woollen garment, extending so as to enclose the feet, and an upper garment of reasonable length and weight will suffice for indoor wear. Napkins should be
4
50 THE CHILD WELFARE MOVEMENT
of soft material, such as Turkish towelling, and should be washed between each use. In summer the clothes should be modified to the change in temperature. One cause of trouble for the poor mother is the custom of wearing long clothes up to about two months old, when a fresh set of short clothes has to be provided. The now prevalent fashion of so called three-quarter length garments can be used from birth onwards imtil the child begins to walk, by which time they will, in all proba- biUty, be worn out. Unfortunately the clothing is provided before the child is bom, and the mother is reluctant and often unable to change it. Good progress has, however, been made with the mothers who attend many of the centres. Model garments should always be on view, and the workers be prepared to show the mothers how the garments can be made. Where classes are held, some mothers will be able to attend them, but many will be unable to do so. These last can be aided by helping them to cut out or to put the pieces together. In other centres, paper patterns are sold for Id. Again, rolls of flannel, etc., may be bought at wholesale prices, and sold in quantities for single garments at cost price. There are many methods in practice for helping the mothers with the clothing of the infant, and all are valuable. At some centres the mothers can pay in small sums weekly, and then purchase material as they need it.
p.- Talks or Lectures. — These are also not infrequently arranged, and may be given by the doctor or by some of the visitors. Long talks should be avoided. Probably ten to fifteen minutes is as long as it is possible to retain the attention of most mothers who attend, whose schooldays are long past, and in whom the power of concentrated attention is small. Opinions vary con- siderably as to the value of lectures.
Classes. — It is often diflGicult for a mother with one or more young children to attend classes. These are more
THE CHILD WELFARE CENTRE 51
easily attended by mothers with children at school. A large attendance is seldom obtained, but even if only a small number of mothers attend, these may be able to help those who are unable to do so.
Various classes are held, often differing at the same centre year by year. They will include cooking, laundry, mending, cutting-out, sewing, knitting, millinery, etc.
In some districts a fully trained Domestic Economy teacher is provided, who devotes her whole time to this work.
CHAPTER VII
The Centre {oontinued)
In addition to the phases of work ah:eady described, there are a number of other branches of assistance with which it is very desirable that centres, in at any rate large populous areas, should be associated, although not necessarily carried on at the centre. Such are ante- natal work, arrangements for securing aid from the various social agencies, and of food or milk for neces- sitous cases of mother and children, and also of dental care, the importance of which is difficult to over- estimate. Further forms of aid are dealt with in the next chapter.
Ante-natal Work. — ^As the development of child welfare proceeded, it became clear that it was not sufficient to deal with the child after birth. The health of the mother during pregnancy, and the conditions obtaining at the birth are known to exercise all-im- portant effects on the future health of the infant. The conditions present at the birth of the child fall essentially within the purview of the doctor or midwife, since they alone are authorised to attend and take charge of con- finements. These conditions can, however, be modi- fied by care before the time of confinement. There are many matters calling for attention. The mother's health, the presence or absence of ailments, whether directly connected with the pregnancy or not, her habits of life, her food, clothing, exercise, etc. : the provision
THE CHILD WELFARE CENTRE 58
for confinement, both for herself and for the baby : the baby's clothes, sleeping place, etc. In fact, as in the case of child welfare work, ante-natal work has both preventive and curative aspects.
Every mother should be placed in the path of health, both for herself and for her infant. Many are ignorant, and do not know what they should do, nor how to do it. They are usually very glad of advice and assistance, if tactfully given by the right person. While many women do not need treatment at all during their preg- nancies, it can hardly be denied that a general medical examination is advisable. Often some slight chronic trouble is present, which may produce trouble or difl&culty during or after labour. Among these are cardiac disease, bronchitis,, bad teeth, chronic septic trouble in any part, etc. Such matters clearly demand medical care, but the patient does not always know of their presence and may not regard them as deserving of any attention. In such a case the condition will ordinarily not be discovered until it is too late to avoid the consequences of neglect.
When a doctor is engaged to attend the case, a com- plete routine examination is not usual unless the mother complains of some ailment.
If a midwife is engaged she must refer cases of ailments to a doctor, but she will find it difificult to persuade many mothers of the desirabihty of the trouble and expense of the medical examination unless there is some definite complaint. Power to pay doctors' fees in cases of pregnancy was conferred by the Maternity and Child Welfare Act, but so far, no special fee has been fixed, and arrangements for providing it are, at present, very limited indeed. The task of advising the mother how to secure adequate and suitable provision for the confinement should be, and is regarded as, the duty of the midwife in those cases where one is engaged. But, in the present conditions (see Chap. XVII) many mid-
54 THE CHILD WELFARE MOVEMENT
wives cannot afford the time which would be required, and, moreover, the untrained midwives are usually not in a position to offer such advice.
These considerations have led to the demand for ante- natal care at the child welfare centres, and this is pro- vided at a considerable number of them.
Great care should be taken, however, to co-operate with the doctors and midwives practising in the dis- trict. In some districts where co-operation has been established from the first, the centre has proved of great benefit to all concerned. The midwives have felt that they were receiving due consideration, and that they were in no danger of losing their cases. Unfor- tunately, these important considerations have not always been borne sufl&ciently clearly in mind at all centres, and much opposition has been aroused among the doctors and the midwives of the district.
Ante-natal work has undoubtedly been brought into prominence by the efforts of the centres who are in a position to see the disastrous effects of the neglect of ante-natal care in all its branches, and there is no more vital need for child welfare than adequate care of the mother before, during, and immediately after child- birth. While the centre has a place in this, and can do most valuable work, it is a late arrival in the field of midwifery work, and more good will probably result by endeavours to improve existing agencies than by trying to take over a part of their work. The centres feel that they can achieve more in a short time than is likely to be the case if the ante-natal work is left to be gradually undertaken by midwives and hospitals. It is true that the progress with these agencies taken over the whole country is bound to be slow, but it is doubtful whether the process of, as it were, superposing ante- natal work over a structure which, although imperfect, already exists, and should be made to bear it, will fulfil the purpose intended. Ultimately the work must be
THE CHILD WELFARE CENTRE 55
done by doctors and midwives, either in the home or in hospitals, as a part of the medical service of the country. There is room for all, but the shortest cut on a steep path is not always the quickest. Much technical matter is bound up with ante-natal work, certain aspects of which will be dealt with in connection with the work of midwives.
The Provision of Dinners for Mothers. — At most centres in a poor district need will arise among a few mothers for the provision of a good meal. Such pro- vision, when made, is confined to expectant or nursing mothers, and is designed to secure a healthy child, and, later, to maintain breast-feeding. Some people dis- approve altogether of this provision on the ground that the aid is purely temporary, and that, in many cases, the mother could perfectly well afford to provide her- self with adequate food, but that she is either too ignorant of cooking or generally unwilHng to exert herself, and it would be better to persuade her to look after herself than to feed her. Doubtless these criticisms are just, but there are cases where the mother is too depressed, or too ignorant to be able to manage for herself during pregnancy. Very careful investiga- tion should, however, be given to each case lest the system should degenerate into mere charity.
In some places the dinners are provided elsewhere than at the centre, or arrangements are made with a cheap restaurant or the invalid kitchen to feed special cases. The beneficial effect secured by providing a good meal, even four times a week, is surprising, and may enable breast-feeding to be continued for the full nine months. ^
^ Although adequate food conduces to breast-feeding, too much food appears to have the contrary effect. Women of the better- to-do classes who are persuaded of the importance of eating largely to maintain the mammary secretion, do not obtain successful results. The process is a natural one, and an ordinary diet should be pursued as far as possible. The motlier should eat sufficient,
56 THE CHILD WELFARE MOVEMENT
The meal usually consists of either a good thick soup with vegetables, and perhaps suet dumphng, or meat, with potatoes and vegetables, followed by a good plain pudding, sometimes with stewed fruit. The menu will vary greatly with the opportunities for buying food. The sum paid by the mother is generally about 50 per cent, of the cost price, and may be much less — a few dinners are often given free. Under the Maternity and Child Welfare Act of 1918, money may be obtained from the rates for the provision of food for mothers. It is usual to require a certificate, either from the medical officer of the centre or from an experienced health visitor, for admission to the dinners.
The Provision of Milk. — There is probably no branch of child welfare work which has attracted more atten- tion than the provision of milk forartificially-fedchildren. The dishke of hunger is a primitive instinct, and the appeal for food finds an echo in the hearts of most people. How much more is this the case when the only food required is milk, as is the case with young children in the early months of life.
The provision of milk was one of the main early aspects of the child welfare naovement, and only after many years was the fallacy appreciated. There were two errors — one, the most important, concerned the whole question of artificial feeding. There was a wide- spread belief that the human species was becoming effete and unable to provide breast-milk, so that artificial feeding was necessary. The experience gained during recent years has shown that nearly all women can breast-feed their babies if they are taught how to manage the feeding. The mammary gland is still capable of function, but it has often been asked to put up with treatment which defeated the object in hand. Probably the two-hourly feeds, still, alas ! advocated by many,
but over-feeding hnB been found to luivo a dotrimental offoot on the Bupply of broiut-milk.
THE CHILD WELFARE CENTRE 57
have done more than anything else to discourage breast- feeding. The milk depot encouraged the belief that artificial feeding was necessary and eased the path to the mother. It undoubtedly tended to discourage breast-feeding — there was ordinarily no medical super- vision, and the mother not unnaturally thought that as the milk was specially provided it must be good, and she might be spared the trouble of breast-feeding, seeing that all was ready prepared for her.
The other main source of error arose from the tendency to regard the feeding as the most essential need for the well-being of the infant. While it is, of course, true that the child will die if it is not fed, it may also die, even when receiving sufficient food, if its general con- dition and surroundings are unsatisfactory. Milk depots, originally believed to be a prime factor in child welfare, have been found to be only an accessory feature.
The early milk depots provided pasteurised milk in bottles of different sizes according to the age of the child. There were standard mixtures and standard quantities to the feed. The depot cannot make up special feeds for each child, the labour and time required are pro- hibitive in cost. Yet the more experience is gained with regard to artificial infant feeding, the more clearly does it appear that each child must be considered in- dividually. There is no standard amount or standard mixture which is exactly suitable for children of different ages or of different weight. The six or seven stock mixtures of the milk depot of fixed amount, and ar- ranged for a definite number of feeds in the day, are not satisfactory.
The milk depot cannot be run without considerable expenditure of money. The mother cannot ordinarily afford to pay more than the cost price of the milk itself. In addition to the initial outlay on plant, there is the cost of labour, of the fuel for_^the pasteurisation, the
58 THE CHILD WELFARE MOVEMENT
continuous wear and breakage of bottles in the process of heating, the rent of the depot, etc.
Even when worked with regard to economy, the milk depot is an expensive matter, and the money available would be better employed in other branches of child welfare work.
The expense of the milk depots, and the fact that they did not appear to be producing the efEect anticipated, prevented their development on a large scale in this country. Also, it was realised that very few mothers were able or willing to send regularly to the depot for the milk, and that, at intervals, the child was fed as the mother might decide, from milk obtained at any dairy. The milk depot is not educative. It does not teach the mother how to feed her baby even artificially, and rather discourages breast-feeding, unless proper medical super- vision is arranged for.
If cow's milk is supplied in any form, it should be on the advice of a doctor only, and should only be given on the condition that the child is brought up regularly for medical supervision.
The pasteurised milk depot gradually gave way to dried milk as this commodity was placed on the market. At the present time only a very few places provide any other form of milk, and the majority of centres make some arrangement for the provision of such mUk.
This is not the place to embark upon a discussion on the merits or demerits of dried milk as a food for infants, but a few remarks may not be out of place. Usually the milk is purchased wholesale and sold at cost price retail. A considerable saving to the mother is thus effected. The use of dried milk has now been very large for a number of years, and much experience in its use has been gained. Yet, although there have been many years of experience on the question of artificial feeding for infants, the details are still the subject of warm dis-
THE CHILD WELFARE CENTRE 59
cussion, and no agreed system is advocated by those concerned.
There is probably no one subject in medical literature which has formed the subject of more discussion than milk in its various aspects. One school of thought pressed for the use of raw milk, and another for the use of sterilised milk, and so on. Now we have the discussion on dried milk as against other forms of cow's milk. It is hardly likely that any one form of artificial feeding will find acceptance with all advocates, just because the whole procedure is artificial.
A breast-fed baby has, as it were, greater license. It can take more milk than it really wants, and with- in reasonable limits no harm results. Its digestive organs can deal with varying quantities of the natural food. But cow's milk, of which the constituents, while similar in type to those of human milk, are yet different in composition, requires much more care if the digestive organs are not to be upset. Over-feeding with cow's milk will lead to a degree of indigestion which is not found in breast-fed babies, and ""a host of other troubles follow in its wake. It^has^lbeen justly said that a baby lives on its alimentary canal in the early months of life. If the functions of that complicated organ are deranged, the whole organism suffers, and may die as a result.
There is a school of thought that regards all dried food as unsatisfactory, because certain so-called " vital " properties are believed to be destroyed in the process of drying, or even of the heating in pasteurisation. This remark at once leads to the much vexed question of the extent of heat employed in heating milk, and on this matter there is great confusion in the literature, both of thought and of language. It may therefore be well to set out the true position. Pasteurisation means that the milk, or whatever substance is under consideration, is heated to a temperature considerably below boiling
60 THE CHILD WELFARE MOVEMENT
point, and 180^ Fahrenheit is the usual figure given in this country. As soon as the temperature is reached, or at most, after two minutes at this temperature, the milk is rapidly cooled by the use of cold or of iced water, and should subsequently be kept at a low temperature until it is used.
In conversation the term " pasteurisation " is frequently used to denote any form of heating milk where a low temperature is subsequently applied. For in- stance, it is applied where the milk is raised practically to boiling point, and even when such a temperature is maintained for prolonged periods.
Then again, the term " sterilisation " is applied when really pasteurisation is meant. Many people call milk which has been heated in any way " sterilised," whereas this term should only be applied to milk which has really been rendered sterile. Sterility is difficult to obtain with milk, and a temperature above boiling point will be re- quired. Again the term " boiled " is often used without any comment as to the method used, that is, whether boiled over the flame or in a jacketed pan, and without any reference to the length of time of boiling. All these matters make a difEerence.
There is no advantage at all in heating milk beyond the temperature required for pasteurisation. The object of heating is to kill certain germs which may be harmful. These are killed by pasteurisation, and the other varieties, while reduced in number, are not all killed even by boiling. The pathogenic germs reach the milk from two main sources, the cow herself and the workers on the farm or dairy. A great many cows in this country are suffering from tuberculosis, and the bacilli are passed out in the milk. Although with pre- cautions much can be done in a good dairy farm towards eliminating this disease, it is hardly possible with our present methods to state definitely that any given specimen of milk contains no tubercle bacilli. Again,
THE CHILD WELFARE CENTRE 61
cows suffer from inflammation of the udder, and in such cases streptococci are found in the milk which may cause bad sore throats in those driuking it. Both varieties of bacteria may be passed into the milk when there is no obvious disease in the cow when examined by the veterinary surgeon.
Then again, the milkers, or those handling the milk at later stages of its transit, may be carriers of disease, such as tuberculosis, enteric fever, or diphtheria, and outbreaks of scarlet fever have been traced to the milk supply. Many possible sources of infection can be removed almost entirely with due care, but it will probably not be possible to be certain that there is at no time a source of infection among the workers. The dangers from the cow are even more real, because infection with tuberculosis is widely spread in many herds.
Some heating of the milk is essential in order to remove the risk of harmful bacteria. No milk should be taken raw. But, as already explained, pasteurisation if properly carried out is sufficient. The heating should be carried out after the milk has been put in the recep- tacle from which it will be taken by the individual and not before. It is sufficient to heat the receptacle in a vessel of water, and to allow the water to boil for two or three minutes. The milk does not reach the temperature of the water. The receptacle should then be plunged into cold water, and remain there until required for use.
There has been, and still is, much discussion as to the detrimental effect of heating milk. Certain substances known as " vitamines " are necessary for the mainten- ance of health. Their absence may cause infantile scurvy and possibly rickets. These substances, which are present in small amounts in milk, are stated to be destroyed by heating. But here much confusion has been caused by the lack of definition in regard to the length of time the milk has been heated. In some of the experimental work undertaken, the milk was heated
62 THE CHILD WELFARE MOVEMENT
for an hour at boiling point, and was then found to have suffered the loss of some of the vitamine-content. But, if pasteurised, it appears that no appreciable loss is incurred. There is nothing to be gained by heating beyond this point, so that from this aspect, pasteurised milk can be safely used ; nor is the food value of the milk reduced — in fact, heated milk is found to be more easily digested than raw milk.
In the processes of drying milk may, for a few seconds, be exposed to a temperature somewhat above that used in pasteurisation. The special methods employed reduce the time of heating, and it ^has not]|yet been shown that the vitamine-content' of dried ;^milk is reduced appreciably below that of the original milk. It is not unlikely that some small loss may occur. Practical experience has, however, shown that dried milk can be used for infants with excellent results, if proper precautions are taken. Over-feeding with dried milk, and its subsequent digestive disturbances, seem to occur more readily than with pasteurised milk. But this may be due to the instructions on the tins of the milk, which often advise a great deal too much milk and too many feeds. Although the mother may be told to follow the doctor's instructions, and not those on the tin, it does not follow that she will do so, and many women think that the more a child can be got to take, the better it will be. Hence unfortunate results may occur owing to the excess of zeal. It is so easy just to add a little more of the powder, and the directions printed on the tin will appeal to the mother.
Some doctors advise that fruit juice, of one kind or another, should be taken with dried milk after the first few months. It is very doubtful how far this is necessary, but many children who are fed artificiallv seem to improve more rapidly with the addition of fruit juice or of a small amount of fruit puree after about six months of age.
THE CHILD WELFARE CENTRE 68
The report issued by the Local Government Board * on the use of dried milk, shows that dried milk properly- used is a satisfactory artificial food for infants. It cannot, however, be too clearly stated that no known artificial food can adequately replace natural feeding.
Dried milk has the advantage of being comparatively sterile, and of keeping for some time after the tin is opened, also only the amount needed at each feed is used, and there is no waste involved.
Milk is undoubtedly a necessity for children up to about eight or nine months of age, but the milk should be that of its own species, namely, mother's milk. It is probable that breast-feeding is now more common than it was a few years ago, but there are still too many chil- dren who are fed artificially : for these cow's milk in some form is necessary. After the age of eight or nine months milk gradually ceases to be a necessity as the child's organs become able to digest other food. Its value as a foodstuff decreases, and the child needs variety of food. Milk is not a foodstuff of great value for adults. No other species of young take milk after weaning, and there is no real need whatever for the human infant to do so. We have got accustomed to the idea of milk, and to regard it as a necessity for children and for cooking. But at the present price of milk especially, much better food value can be obtained with other less costly foods. The statements as to the immense quantities of milk often said to be necessary for children are quite erroneous.
Then again, so much is talked of the value of milk for expectant and nursing mothers. There is no special value in milk for mothers ; any other good nourishing dietary will do equally well, or better. It sometimes seems that people are under the impression that milk taken by the mother is utilised directly by the mammary
^ Report tu the Local Government Board by F. J. Coutts, M.D. (Food Reports, No. 24).
64 THE CHILD WELFARE MOVEMENT
gland for its secretion, and mothers are advised to drink milk half an hour before they feed their babies. Milk, like all other good foodstiiffs, is broken down into the simple substances, and the mammary secretion, like the other secretions, requires building up from simple bodies.
A number of local authorities are preparing to spend considerable sums on the provision of milk for mothers and infants. It is well known that infant mortality was low during the worst cotton strike, when, although poverty was great, the mothers stayed at home and breast-fed their babies, and the same effect is stated to have been produced in Germany during the recent war. It is hoped that local authorities will pause before spending large sums of money on milk. There is no doubt the money could be better employed.
The following letter, which appeared in The Times on 3rd September 1919, is of interest in this connection: —
"Milk for Children
" To the Editor of ' The Times '
"Sir, — You wiU remember that during the war we were accused of murdering German babies through the reduction of milk supply attributable to some extent to our blockade. The current number of the Eevue Internationale de la Croix Rouge shows that infant mortality in Germany decreased, especially in the big towns. In 1914, 15*1 per cent, of infants died within the first year in the whole of Germany ; in 1916, 148 only. In the towns of over 15,000 inhabitants the figures were 14*1 and 13-3 per cent. In Switzerland in towns of over 10,000 inhabitants the fall was from 9 9 to 6-9 per cent. Here follows the explanation : —
'* ' Comment expliquer ce fait curieux outrement que par la p6nurie du lait en tomps de guerre et I'augmen-
THE CHILD WELFARE CENTRE 65
tation par compensation de Tallaitment maternel.' The whole article is written to prove the greater life- chance of the mother-fed infant. It looks as if the coming scarcity of milk in England may induce English mothers to nurse their own children (if they can), and 80 give them a better start in life, besides diminishing our present mortaUty rate of 10-7. — Yours faithfully,
"W.A.B."
Dental Work. — This is undertaken at a fair number of centres, and in other places some arrangement is made, either with a local dentist, or with a school clinic or hospital for providing such treatment for cases sent on from the centre.
The vital importance of sound, clean teeth is being increasingly recognised among all classes. The utterly deplorable state of the mouth of large numbers of people requires remedying before we can hope to be- come a healthy nation. A decaying tooth is, in fact, an open sore, the exudation from which, being con- tinually mixed with saliva, is for the most part swal- lowed, but also infects all parts of the mouth and lips and fouls the breath. Bad teeth are a source of great danger to the possessor. Small, or in bad cases, large doses of toxic material are being continually absorbed, and afiect the condition of the whole body. Waller ^ has shown that the removal of bad teeth in a nursing mother effects a tremendous improvement in the growth of the child, and increase"* the mammary secretion. It is horrible to contemplate the effect on an infant of being frequently kissed by a mother whose very breath is infective, and most people who have had to do with child welfare work will recall cases where the dummy teat, in itself a vicious thing, has been rendered actively harmful by being previously sucked by a mother with a foul mouth. The mother has got so ' Lancet, November 1916.
5
66 THE CHILD WELFARE MOVEMENT
accustomed to tlie condition of her mouth that its dis- advantage to the infant does not occur to her.
Dental care should be regarded as an important branch of ante-natal work. The old idea that it was dangerous to give gas to a pregnant woman has been found by Waller ^ not to be correct, and the bad teeth constitute a risk to the mother of Septic complications at the confinement. Any septic spot will be liable to cause trouble after a confinement, and bad teeth have been found to be the cause of death in a number of cases. In addition, there is the great improvement of health which follows on the removal, either by ex- traction or stopping, of the decaying spots.
The provision of dentures will be necessary in a number of cases, and may require a great deal of trouble. It is usual to endeavour to obtain a part of the money at least from the mother herself ; there are also, in some places, voluntary funds, and the centre, if neces- sary, will find some of the cost, and can receive a part repayment from State funds.
The cost of establishing a separate dental depart- ment is considerable, owing to the special fittings and instruments required. In London a few of the large centres have opened dental clinics for their patients, which are also used by the London County Council for school children, the Council paying a per capita grant for the use of the clinic.
It is difiicult to overrate the value of dental care, and the increasing number of clinics is a hopeful sign.
The number of school children under school age whose teeth require attention is lamentable. ^ Bad first teeth affect the second teeth, so that the former should be carefully attended to.
The recent work by Mrs. Mellanby ^ shows that the growing teeth are affected by rickets, in which con-
* Loc. cit. ' Of. figures in Appendix II.
■ Lancet, December 1918.
THE CHILD WELFARE CENTRE 67
dition the enamel is not laid down properly, and the underlying dentine is thus deprived of its protecting coat. The condition also adversely affects the de- velopment of the jaw.
Lawson Dick ^ found evidence of rickets in the teeth of 52 per cent, out of 586 rickety children examined by him in the course of school medical inspection.
Mellanby^ has shown that an unsuitable dietary is a primary factor in producing rickets and badly formed teeth in young dogs, and there is every reason to believe that this is applicable to children.
Social and Charitable Work. — Child welfare work is not a form of charity, and this should never be lost sight of. In the work of the centre there must inevitably be cases where various forms of charitable aid will be required. But such aid should not be given by the centre itself. Those who work at the centre should be aware of the various charitable agencies which exist, and should use their efforts to secure assistance from the appropriate agency. The agency concerned will have proper channels of information and of assist- ance, which should be made use of.
Co-operation and co-ordination of effort should be aimed at in all cases. The charitable agencies will have cases they wish to refer to the centres, just as the centre has cases to refer to the charitable agency. If each organisation tries to do the work of other bodies there will be overlapping of effort, waste of time and money, and, which is not less important, the work will probably be less well done, owing to the absence of special knowledge on certain points.
The responsible workers at every centre should regard it as a part of their duty to be acquainted with the work of the various agencies for social and charitable
* Proc. Roy. Soc. Medicine, 1916, vol. ix. pp. 83-9.
* Report on the Accessory Food Factors by the Medical Research CJommittee, 1919.
68 THE CHILD WELFARE MOVEMENT
work of the district : they should go further and make themselves personally acquainted with those who are carrying out the work. Personal acquaintance removes many sources of difficulty and prevents many troubles, A little time devoted to a personal interview with the responsible agent of the society in question about a special case is time well spent.
Doubtless, with the expected passing away of the Poor Law and the presumable increase in the powers of the local authority for material assistance, there will be a greater tendency to dispense such aid at centres for child welfare. It will be a tragedy if centres which have the opportunity for doing such admirable preventive work come to be regarded as organisations for the distribution of material relief.
CHAPTER VIII
The Centre {continued)
The varied activities which have been described in the preceding chapters would, by common consent, be described as falling under the heading of preventive work. That is to say, the measures are all directed towards the maintenance of health and the prevention of disease. There are in addition several branches of work which are being increasingly undertaken at child welfare centres which are less directly preventive in their scope.
Such measures trench closely on curative medicine. The dividing line from the work of some centres and that of certain phases of work at some hospitals is fine and in many instances difficult to draw.
The several branches to which reference is made are :
1. The provision of drugs and beds for children.
2. The provision of treatment for children from two to five years of age.
3. The provision of facilities for treatment of maternity cases.
There is much divergence, both of opinion and practice, in regard to the provision of drugs and of arrangement for treatment generally at child welfare centres. The point is one of great importance and it will be well to consider the position fairly fully.
1. The Provision of Drugs.— There can be little
doubt that the provision of treatment in any form
was not contemplated when the infant welfare move-
69
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ment was first started. It is, however, clear that no movement of such a kind could continue long without meeting the numerous cases of ill-health which are too frequent among children of (apparently) all countries. With the greatest care, illness is unavoidable among a number of infants, and the clientele of the infant consultation soon had sick children for whom they sought advice. It was necessary either to send the child to a hospital or to a private doctor, or conversely, to treat the child at the centre. This last method was recognised as being ordinarily undesirable on many grounds. The local doctors and the hospitals objected strongly as causing overlapping of effort, and also because except in cases of minor ailments better facilities for treatment were available at the hospital than at the centre, and the local doctors very naturally objected on the ground of the treatment at the centre being free. They contended, very justly, that many of those attending the centre could well afiord a doctor's fee, and that the cases should be referred to their doctor, or, if too poor, to the local hospital if there was one.
Another point which does not always receive the weight it deserves is the fact that the centres are only open on certain days and hours, and a sick child may need care within those specified times. The mother must then (unless it should occur on the day she is due at the centre) take the child to another doctor or to the hospital. Objections are raised, not unnaturally, at taking over from another practitioner a case which has become acute. The objection is not mitigated by employing a local practitioner as the medical officer to the centre, who can then see acute cases at either his or their own home. This is open to the serious charge of taking patients away from their own doctor, since many of those who attend the centre will have their family doctor, who may not be the medical ofl&cer of the centre. Cases where the ailment is liable
THE CHILD WELFARE CENTRE 71
to need attention before the next consultation should in no case be treated at a consultation.
On the other hand, the centres feel that it is not satisfactory to send children from the centre to the hospital or doctor for minor ailments. Very often the child requires some treatment, but the mother has not considered it worth while to pay for the doctor or to wait some hours, as she may have to do, at the hospital. Not infrequently, therefore, the child remains untreated and progress is impeded. Clearly, it seems simpler for the centre to undertake the treatment of such cases. Again, it is argued that the local doctor may not pay much attention to slight matters which the centre has detected. Compared with the troubles with which he is dealing among his patients, the little trouble of the infant, not severe in itself but requiring attention, seems hardly worth while to treat. While it is said that the general practitioner is not interested in the minor ailments of children, he or she is not likely to become more interested if these cases are not referred to him or her.
Troubles due to errors of dietary have always been regarded as falling within the work of the centre, since for the most part they can be cured by alterations in the dietary and other points of general advice. It is usually agreed that sodium citrate, dusting powders, single doses of aperients and one or two other similar sub- stances may be regarded as legitimate for child welfare • centres. But general cases of sickness requiring drugs should not be treated at the centre.
There is also another subtler objection but one which is nevertheless real. If drugs are given freely at a centre, there is a strong tendency to give them in cases which do not really need them, and which, if due care were exercised, could be dealt with at an earlier stage by hygienic methods. This last is vastly more educative for the mother and better for the child, but it is greatly
72 THE CHILD WELFARE MOVEMENT
to be feared that, if drugs are allowed, there will be a tendency to turn to them. The centre would thus approximate to the out-patient department of a hospital and have travelled far away from the original cause of its estabUshment. If, after due consideration, treatment is encouraged at the centres, it should be administered on separate days and only in cases of minor ailments.
Then there are rickety children requiring treatment over long periods with expensive material such as cod liver oil. For the most part doctors are not anxious to have many of these cases, as they need a good deal of advice, and the mothers are frequently unable to pay either the fees for the visits or the cost of the drugs and food prescribed. It is common for centres to buy cod liver oil in large quantities and also malt, and to sell these at cost price to those children for whom it is pre- scribed by the doctor at the centre.
A useful practice has developed for the summer at certain centres where there is a garden. Certain cases of dietetic troubles, or other forms of minor ailments which may be considered suitable, are put in the garden during the day. They are brought by their mothers in the morning. The mother can also come to feed if the child is on the breast. Excellent results have been obtained by this method, especially in the case of babies who have developed the habit of screaming or who are suffering from too frequent or unsatisfactory feeding.
The improvement obtained in many of these cases is quite remarkable, and the mother is able to see for herself that only simple measures are being adopted. The nervous, irritable infant calms down under regular feeding and open air and obtains the sleep it needs.
There seems no doubt that a number of troubles arise in infants from nervous conditions, and it is stated that these have been increased since the beginning of the war. Very often there is no organic trouble at all, but the child
THE CHILD WELFARE CENTRE 78
needs quiet and good care in order to establish its health and ensure satisfactory progress. Hospital treatment is not required but the home care is not sufficient.
Then there are cases of more severe nutritional dis- orders. Such ailments should certainly not be treated at centres unless special provision is made. This has been recognised, and a number of centres are now making special arrangements for deaUng with some of the babies who attend the centre but fall sick. Every child welfare centre has cases on its books of children who are not acutely ill but are perhaps suffering from some nutri- tional disturbance which does not yield to the mother's care, requiring more attention than she can give. These cases often need only a short period of adequate care in order to be re-started on a satisfactory basis. To meet this need wards have been opened and a nursing staff provided to look after babies, while the advice is given by the doctor of the centre. These wards are varpngly called " observation wards," " babies' homes " or " baby wards," and it is not intended that they should take cases of illness which require full hospital care.
The beds for the purpose above described, whether in summer in the garden or in a ward, are undoubtedly of great value, but the whole question of beds in connection with child welfare centres needs to be approached with caution. So long as they are kept for cases which do not require and perhaps are not suitable for hospital treatment, no objection on general grounds need be raised, but, on the contrary, the beds are valuable.
If, however, they should be allowed to become merely small hospitals, the effect would be disastrous. Small hospitals are either extravagant, both of skilled service and of money, or they are of inferior quality. If acute cases are admitted there should be a resident medical staff and this is costly for a few beds only.
The centres were estabhshed for preventive work, and while it is no doubt difficult to draw a hard and fast line
74 THE CHILD WELFARE MOVEMENT
of distinction between the different spheres of work, as a whole purely curative work should be discouraged at child welfare centres. At the moment the position is compHcated by the wholly insufficient provision of hospital beds for children all over the country. Such accommodation as exists is already severely taxed to pro- vide for the acute cases of illness even in districts where in-patient care is available at all. The Ministry of Health makes grants towards the maintenance of beds connected with the centres, but not towards the beds in a hospital, unless the beds are reserved by arrangement with the local authority for the use of patients sent in through one or other of the channels of child welfare work recognised by the authority.
The problem is not easy — voluntary funds at present supply the upkeep of practically all hospitals, other than Poor Law infirmaries, and until recently,^ the rates might not be drawn upon for sick children outside the Poor Law. The Maternity and Child Welfare Act of 1918 gives power to build and maintain maternity hospitals, but the expenditure of considerable sums of money on children's hospitals has not so far been very favourably viewed by the Local Government Board. This branch of work is directly curative and should be undertaken in connection with any adequate organisa- tion for medical services generally, rather than as an extension of child welfare work. In the meantime, a few of the larger local authorities are giving grants towards the maintenance of children's beds in connec- tion with centres on the understanding that a number of them are reserved for patients from the municipal centres for child welfare. These beds are usually re- served for cases of alimentary disturbances.
It may be necessary for a little while to allow or even
' Power to spend money on hospital beds for cliildren under Ave waa conferred by the Maternity and Child Welfare Act of 1918. See Appendix III.
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to encourage somewhat the provision of treatment at the centres. But the aim should be to provide proper facilities under the recognised auspices for dealing with sick children, namely, the hospitals and local doctors, and to reserve the centres for preventive work.
Human nature will probably always have a greater attraction towards cure than towards prevention. It is impossible to tell at once what may have been pre- vented, but curative measures show results in a short time. The ideal is that there should be^-no ailments needing cure. At the present time there is a great deal of illness among children, and if treatment were definitely taken on by the centres they would soon be flooded with curative work and the preventive work would be crowded out. In some centres this is already the case. The question is not simple and involves many issues, but no effort should be spared to keep the preventive aspect prominently forward as the main object of the centre.
It is difficult to say how far treatment is undertaken at centres throughout the country, but there is reason to believe that the tendency has been growing of recent years and that care is necessary to prevent an undue de- velopment in this direction. Even if a medical service should be established, under which provision were to be made for the treatment of all persons, it is greatly to be hoped that the preventive aspect of the child welfare centre would be clearly maintained.
The above remarks apply specially to children under two years of age. After the child reaches three years the nature of its ailments approximates more to those of older children and are of a different nature.
2. Provision of Treatment of Children from two to five years of age. — The child welfare movement, when it first began, was directed to the prevention of mortality among children under one year of age. Gradu- ally it was realised that much valuable work was undone
76 THE CHILD WELFARE MOVEMENT
by the absence of provision for the care of the child at later periods. The physical condition of children attend- ing school had been attracting attention about the same time. It was realised that much of the educational opportunities offered could not be utilised adequately by the children on account of their ill-health. In 1908 power was given to the local education authorities to provide for the medical inspection of school children, and several authorities soon got to work. The amount of ill-health among the children which was then revealed was very appalling. The children examined on entering school were found to be suffering from one or more ailments, in nearly two- thirds of all cases. Some of them had prob- ably been subject to the trouble for a considerable time before they entered school, and it was recognised that they should have received treatment at an earlier date. At first treatment was not provided by the local educa- tion authorities, but it was found if the parents were merely advised to take the child to a doctor or hospital even if arrangements were made by the authority, that very frequently no action was taken by them.
Hence, special clinics for treating common ailments have been growing in number under the auspices of the local education authorities. Such clinics usually make provision for dealing with enlarged tonsils and adenoid growths, with defective vision, minor troubles of the eyes, discharging ears, minor skin troubles, and in many cases a dental clinic is arranged.
The truly alarming amount of ill - health among entrants brings out very clearly the urgent need for dealing with these children before they enter school. This should be undertaken as a branch of child welfare work.
After about the age of two years the child's ailments approximate to those of older children and at three years of age there is little distinction between theirs and those of children entering school.
THE CHILD WELFARE CENTRE 77
Medical supervision should be exercised right up to school age, and home visitation is usually necessary as well. When the child attends school it can be reached with ease, but it is more difl&cult with the younger children who are at home. The mothers often will not bring them up to the centre and home visits will be re- quired for the detection of ill- health. These visits will be paid by the visitor, who will urge the mother to attend the centre if the child is not progressing favourably. There should ordinarily be special days, as already men- tioned, for children of this age, unless only the medical inspection is undertaken on that day.
The question of treatment for children of this age assumes a different aspect from that among the younger children. Greater facilities are required which are frequently not available in a doctor's surgery, nor in the homes of the patient. It is no use referring many of these cases to the local doctors on these grounds, and the local hospital often does not undertake work of this type. Again there is the difficulty of fee. The mother may be unable or unwilling to pay the fee for such treatment by the local practitioner, even though the fee be in reality moderate. Further, if all these cases were to attend the surgery, the doctor would be overburdened with them. At present in the majority of instances they are not treated until they enter school.
The need for provision of treatment for these children is now being recognised and in some places provision is made, but the work among children from two to five years of age lags sadly behind in its development as compared with that of children under two and over five.
It will evidently be waste of effort to provide separate climes for children imder school age, and so far as it is at all possible arrangements should be made for the children to be treated at the school clinics. Hitherto some difiiculty has been experienced owing to the fact
78 THE CHILD WELFARE MOVEMENT
that [the child welfare work has been undertaken by the Public Health Department, and the work among school children has been under the local education authority. Further, in some areas, the authority may vary and the two branches of work be under two separate authorities. Now that the Ministry of Health is responsible for the health of school children, these difficulties should be minimised, and it is to be hoped that a great extension of work among children under school age will result.
As the provision of medical service for the whole country improves, the work, both among children of school age and under school age, will no doubt be brought in to form part of the services provided.
While it is not possible here to deal at length with the ailments of these children, it will be of interest to show something of the prevalence of the various troubles. The figures of the ailments found on medical inspection among the children of London in 1917 are given in Appendix H, and further information can be obtained by reference to the very interesting reports pubHshed each year by the Medical Officer of the Board of Educa- tion, Sir George Newman, where the figures are given in greater detail for the whole country.
3. The Provision of Treatment for Maternity Cases. — There is no need at the present time to empha- sise the necessity for the care of the mother both before and after the birth of the child. The early work undertaken in connection with the medical examina- tion of expectant mothers showed that there was a great deal more ill-health among women than had been believed. Ante-natal work, as already described at the centres, does not necessarily imply the treat- ment of ailments. Such treatment, however, must be arranged for somewhere if the best results are to be obtained from the work. The same difficulties arise as in the question of treatment among the children, only
THE CHILD WELFARE CENTRE 79
the case is more urgent. The health of the mother affects that of the unborn infant, and there is only a limited period within which to take action.
The facilities at present available for the treatment of minor ailments is as insufficient as in the case of infants. Some doctors are interested in this branch of work, and do much good among their patients, and also take trouble with cases sent on to them from mid- wives. Often the treatment most needed is merely rest and general care, which may be the most difficult of all for the mother to secure.
In some large towns homes of rest for such cases are now available, but in many instances the absence of the mother from home involves grave difficulties.
Pregnancy should not be regarded as a pathological condition, and the general improvement in the con- ditions of life among the poorer classes which the war has brought about should materially assist in reducing the amount of illness among the poorer mothers. The treatment of the present ill-health among them is, however, of great importance.
The provision of treatment at a centre involves some compUcations. Every woman must be attended at the confinement by either a doctor or a midwife, and ordinarily she will be sent up to the centre by whichever of these she has booked with. There will, of course, be a few cases which attend on their own account, and before they have booked. The centre should, however, induce them at once to book with either a doctor or a midwife, or, it may be, with the out-patient midwifery department of a hospital.
But this, in effect, removes the woman from the care of the centre, unless the doctor or midwife agrees that she shall continue to attend.
It is impossible to say if there is any practice on the question of treatment, as each centre doing ante- natal work will make its own regulations. Also com-
80 THE CHILD WELFARE MOVEMENT
paratively little of this work is carried out as compared with the infant welfare work.
The provision of facilities for confinement is not ordinarily undertaken by the centre. A few employ a midwife to attend the cases, especially if there is a shortage of midwives in the district. Some local authorities are now working small maternity hospitals with great success, but usually separate from the centre.
The question of the provision of maternity beds is discussed in connection with the midwifery service in
Chap. xvin.
Generally the position is that the centres are fully aUve to the need for the treatment of ante-natal cases, but the difficulties are great, both on the grounds above mentioned, and also because it is difficult to get hold of the mothers, many of whom do not realise that they need care, and do not, therefore, make any effort to apply for it. As the women themselves get to appreci- ate the need for improvement in their own health the nearer will the problem be towards its solution.
CHAPTER IX
The Organisation of Child Welfare Work in Urban Areas.
In the preceding chapters the work of the visitor under the Notification of Births Acts, and the activities at or connected with a centre, have been considered, reference being made occasionally to the machinery for carrying out the work. If the full benefit is to be obtained without overlapping and unnecessary expense, a great deal of forethought and watchfulness is required on the part of those who are responsible.
In a few areas, notably in MetropoUtan boroughs, the greater part of the work is carried out by voluntary agencies. In the provinces generally the amount of responsible voluntary work is relatively small as com- pared with that of the local authority.^ There can, however, be no doubt that the responsibility for the work, for its organisation, economical working, and avoidance of overlapping, rests everywhere on the local authority. The refusal to undertake their responsibihties does not remove the duty.
In this chapter the general organisation alone will be dealt with, the part played in it by voluntary agencies being considered afterwards.
* Recent figures obtained by courtesy of the Ministry of Health show that out of a total of 1583 centres througliout England and Wales 675 are worked by voluntary agencies. Of the 675, 153 are in the MetropoUtan area. Oi the 908 centres worked by local authorities, 622 are in the hands of municipalities, and 286 in the se of county councils.
6
82 THE CHILD WELFARE MOVEMENT
The Notification of Births Act of 1907 might, subject to the consent of the Local Government Board, be adopted by any local authority. It was found in practice that individual rural districts could not, other than in rare cases, work the Act without undue expense and difficulty. For the most part, at the present time, the work in rural districts, and in the smaller urban districts, is in the hands of the county councils. In this chapter the work in county boroughs, boroughs and urban districts of populations of not less than 20,000 is considered. In rural districts, the sparseness of the population renders a different organisation necessary.
The history of Local Government in this country forms a most interesting study, but one which is entirely beyond the scope of this work, except in so far as it refers to child welfare work. In order to make the descriptions given in this book intelligible. Chaps. XXII to XXV have been added, which supply, it is believed, sufficient information to make the position com- prehensible to the student of child welfare. Here only a few preliminary remarks are made. The whole coun- try^ is divided up into sanitary areas whose boun- daries are clearly defined. Each of these areas has its own council, consisting of a fixed number of persons who are elected by ballot by those inhabitants who are entitled to votes. In boroughs, the mayor is the chair- man of the council, and other councils elect their " chairman." The councils are divided into sub- committees wliich deal with the detailed work falling upon the council. This differs according to the powers placed in the hands of the council concerned. All sanitary authorities have powers to deal with sanitation, and the detailed work is carried out by a public health committee, subject to the approval of the council.'*
' England and Wales alono are under consideration in this book. * Of. p. 210 for information as to the Maternity and Oliild Welfare
WELFARE WORK IN URBAN AREAS 83
While the town clerk or the clerk to the district council is the officer appointed to carry out the decisions of the council, the medical officer of health carries out certain duties under the direction of the council and of its public health committee.
The staff of visitors are appointed by the public health committee, and work under the direction of the medical officer of health as a part of the staff of his department.
The number of health visitors required will vary with the number of births, and with the amount of other work required to be done by the staff. The medical officer of health divides the area to be worked into districts, and allots a visitor to each district, the size of the district varying with its character. Centres should be arranged so as to be convenient for each district. Whether one centre can serve the districts of two health visitors will depend upon the situation and character of the districts. It is found that only a pro- portion of all the infants visited are brought to the centre. With the development of the work, the pro- portion is showing a well-marked increase. Some few years ago 25 per cent, of all infants visited was a high figure for entries at the centre. The more usual figure was 15-20 per cent. Now, in a fair number of towns, the proportion has risen, and 33 per cent., or about one- third of all infants visited, may be found on the registers of the centres. In a few districts the figures reach 50 per cent, of all cases visited.
It has been proved by experience that, allowing for departures from the district and irregularity of attendance, from 125-150 infants in the year is as large a number as can reasonably be dealt with for one consultation a week. This does not allow of more than an average of ten medical consultations per
Ooramittee, now a Statutory Committee under the Maternity and Child Welfare Act of 1918.
84 THE CHILD WELFARE MOVEMENT
infant, or about thirty consultations per consultation session, throughout the year. For one medical officer, thirty patients per half-day is almost too many for each to receive proper attention. At many centres a con- siderably larger number of children are sent through to the doctor at each session. But there are limits to the endurance of a medical officer, and it is generally ad- m tted that twenty-five is really as many as can be dealt with adequately. There is no point whatever in merely passing infants through the consultation room so rapidly that there is no time for a proper considera- tion of each case. At some centres the children are sent up to the doctor whenever they are brought up, with the result that many of them have simply to be told to go on as before. It is waste of the doctor's time to send children who are progressing favourably to the doctor every week or fortnight. The intervals of the visits should be determined by the medical officer, and adhered to unless some untoward occurrence has supervened.
Supposing that not more than 150 infants be reckoned for each weekly consultation session at the centre, and that an attendance of 33 per cent, of all infants visited is allowed for, then each centre can deal with not more than 450 births, or with about the numbers allotted to a full-time visitor taking infants up to one year only.
It has been already explained that both visiting and attendance at the centre should be carried on up to school age, and that on this basis only about 250 bii ths per annum at the outside can be allotted to each full- time visitor. Also that extra consultations should be arranged for the older children. Roughly, in a district of about 450 births, there should be at least one consulta- tion day per week for infants, and one for young chil- dren under school age. The demarcation line is vary- ingly fixed between one and three years of age. In
WELFARE WORK IN URBAN AREAS 85
such a district, it would be necessary to employ two whole-time visitors to carry out the child welfare work only.^ These two visitors should then both attend the two sessions, and each be in the consultation room when the infants from their districts are being seen by the doctor. Each visitor should be able to spare two half- days a week for work at the centre, and the value of this arrangement has already been dwelt upon, both from the point of view of the mother and the visitor herself.
When work is being started in new districts it would be unnecessary to allow for the attendances of so high a percentage of infants visited. Probably for the first two years it suffices to allow for the attendance of about 15 per cent, of all infants visited. Also, the older children, not having been regularly visited at an earlier age, would not attend in large numbers. If the visitors are doing other branches of work, which occupy about half of their time, then the number of infants and of older children they can visit will be correspondingly reduced. This may render their attendance at the centre more difficult, since the centre may then serve four visitors' districts, without any increase in the num- ber of children under school age. The difficulty can be met in various ways, and, although it may not always be easy, it is of the utmost importance that the visitor should attend the consultation when the infants she visits are being seen, and every effort should be made to secure this.
It is found that it is usually difficult or sometimes impossible for a mother to come to a centre which is more than half a mile away from her home. This in- volves the establishment of centres not more than a mile apart. The population and the number of births in
1 This standard of staff is very rarely reached as yet, and would doubtless be regarded as excessive by many. It is, however, necessary it the best work is to be done.
86 THE CHILD WELFARE MOVEMENT
any area of half a mile radius will differ in different towns, and in different parts of the same town. Hence, evidently, the number of centres required, and the number of visitors' districts each centre can serve, will differ, and no generaUsation as to areas can be made. Where the district is congested, the centre can be open five days in the week, and two medical officers can attend on the same occasion, if necessary. This clearly involves the provision of sufficiently large premises in order to avoid overcrowding and delay at the centre.
The transport facihties available in the district will also affect the position and number of the centres required. Tramways being cheap, accessible, and the service frequent, the mothers may be able to attend from rather greater distances, although the expense and difficulty of carrying by tram several small children who cannot be left alone at home must not be forgotten.
Again, it is not necessary that all the activities de- scribed should be available at each centre. Mothers who are able to attend classes can probably go farther than for the consultations. They will usually attend one course in the winter or they may attend alternate winters, and so on. The medical consultation is the central activity of the centre, and this should be provided at all the centres. Other activities can be distributed in other centres. Thus, in Cleveland, Ohio, the sub-centres are open in the morning for medical consultations. Any case requiring treatment is sent on at once to one of the main centres, where, if neces- sary, it is referred to the children's hospital for in-patient or out-patient care ; the hospital is regarded as part of the general scheme, but a distinct branch of the work.
Each town will need to have its own scheme, adapted to suit its distribution of population, tramways, etc.
Staff of the Centre. — The essential staff of the centre will bo the medical officer and the health visitor. If the centre is very large, it is often found necessary to
WELFARE WORK IN URBAN AREAS 87
appoint a superintendent of the centre. The super- intendent will be responsible, under the medical officer of health and the consultation officer, for all the arrange- ments of the centre ; for the adequate keeping of the record cards, and probably for some home visiting of special cases. The precise duties will differ in different places. When the numbers attending are very great a clerk may also be employed to assist the superin- tendent.
Further, there is a need for other workers, who need not be highly trained, and who will take charge of the " toddlers," talk to the mothers, help with the classes, etc. These duties can well be carried out by con- scientious voluntary workers, although at many centres such help is not available.
At some centres in the largest towns, arrangements are made for consultant physicians for maternity cases. Again, where ante-natal care is undertaken, this may or may not be placed in the hands of the medical officer of the infant consultation. Great latitude must be allowed, and the intention in this book is merely to show the general lines upon which this work is carried out.
CHAPTER X
The Combined Duties of a Visitor in the
DIFFERENT LoCAL AUTHORITIES IN UrbAN ArEAS
Reference has already been made in various places to other forms of work which a visitor may be called upon to undertake. When infant welfare work was commenced, it was usual to place the duties upon the female sanitary staff, who did yeoman's work in a large number of districts. As the work grew it became impossible for the existing staff to carry out both phases of the work, and gradually official visitors were appointed as infant visitors, usually termed health visitors. This latter term at present may or may not include infant visiting, depending entirely upon the nature of the health visiting work allotted to the worker.
It has already been explained that all local sanitary authorities were given power to adopt the Notification of Births Act of 1907, and to undertake work for child welfare at the cost of the rates by the Act of 1915. In order to understand how other duties have fallen to the health visitor some digression is necessary.
The Education Act of 1902 made all counties, county
boroughs,^ and boroughs having populations of 10,000 and
over, and urban districts havmg populations of 20,000
and over, education authorities under the Act. All rural
districts or urban districts, and boroughs of insufficient
population to become education authorities in 1902,
come imder the county for educational purposes. When
' For further iniormation, see Chap. XXII. 08
COMBINED DUTIES OP^ A VISITOR 89
the medical inspection of school children was intro- duced in 1908, power to carry on the work was given to all the education authorities. The development of the inspection led to the following up or home visita- tion of many of the children. It was speedily realised that it would be more economical, and altogether more generally satisfactory, to combine the work of following up with the infant visitation.
The same visitor would visit for children of all ages, and time of travelling, and therefore cost be reduced. Hence many local education authorities place the school work upon the infant visitor. Some districts keep the work and workers quite separate, and there is a growing tendency in this direction in the large towns.
In 1911, with the introduction of the Insurance Act, and the tuberculosis work in connection with it, further home visitation was required. The duty of carrying out this work was placed upon the county boroughs and the counties only, so that the non-county boroughs and urban districts who are education authorities were not directly affected by the Act in this particular. A fair proportion of county boroughs have a special staff for the tuberculosis work, but a considerable number place this work also upon the health visitor. Some of the county councils make arrangements with the boroughs and urban districts, whereby their health visiting staff undertakes the tuberculosis visiting on behalf of the county.
In 1913 the Mental Deficiency Act was passed, but its execution has been delayed owing to the war. The duties are in the hands of county councils and county borough councils. This requires home visiting for many of the cases, and the work has already, in some districts, been placed on the health visitors.
The work which may fall to a health visitor may, therefore, comprise infant visiting, an attendance at the centre, including work among children up to school
90 THE CHILD WELFARE MOVEMENT
age, the following up after school medical inspection, and, in addition, tuberculosis visiting among both sexes and all ages, also possibly, the work among mentally defective persons. School and tuberculosis work usually involve attendances at the inspection and dispensary respectively, so that a good deal of time is taken up by these branches of work. There is great advantage in the combination of duties for a health visitor. A change of work keeps her interest from flagging, and some branches of work are less exacting than others. Infant visiting is, as a whole, the most exacting, because the visitor has no assist- ance at her first visit, or after, unless the children attend the centre. In school and tuberculosis work the diagnosis and lines of action are laid down by the medical ofiicer.
In a district with 500 births a year it may be esti- mated roughly that, allowing for the visitation of infants up to one year of age only, the school work will take about as much time as the infant work, and the tuber- culosis work about one- seventh of the whole time required for the other two services.
The work of a health visitor may, therefore, be very varied. In some districts other special forms of work are undertaken and laid upon the health visitor.
In a few places the health visitors act as inspectors of midwives. This is considered fully in later chapters.
The compulsory notification of measles cases which came into operation in the year 1916, and was recently rescinded, brought into prominence the need for visita- tion of notified cases. This duty is not infrequently laid upon the health visitor, but since it involves other considerations, it will be dealt with in relation to infectious diseases in Chap. XXI.
CHAPTER XI
Child Welfare Work in County Areas
In the preceding chapter the work of a child welfare visitor in an urban area was dealt with : where the population is more sparse the work partakes of other aspects. In towns with proper adjustment of districts there should be no appreciable loss of time in getting about from one home to another. When the popula- tion is so small that the visitor has an area of a number of square miles allotted to her, the loss of time involved in travelling becomes a feature which must be seriously considered.
It will clearly make for economy if the visitor is given as many duties in her district as possible, so as to bring about the greatest concentration of work.
It is uneconomical for rural districts to undertake their own infant \^elfare work because they can ordinarily only give the visitor the one duty. The county council, which is responsible for the school work and the tuberculosis work, must send a visitor into the rural district area for these purposes. Thus two visitors incur loss of time in travelling over the same area for different purposes. Such loss of time means increased expenditure on the work, and at the present time the tendency is for the rural work to be undertaken by the county council.
The county council will appoint the visitors, and in most cases where whole-time visitors are employed the several duties of infants, school, and tuberculosis
92 THE CHILD WELFARE MOVEMENT
work are placed upon the same visitor. It is difficult for those who are not well acquainted with the conditions of rural England and Wales to realise the time required to get about some of the areas. The train services on the small local lines are usually infrequent and inconvenient. The main roads are usually good, but the byroads are often very bad in the winter. Some of the remoter houses have no road near them, and are a mile or more away from other houses.
In each county area ^ there will be small towns forming centres with populations of sufficient size to form centres of work for the visitors. Around these will be the rural areas with populations gathered here and there into villages of varying sizes, but with one or more houses some distance removed from any village. Arrangements have to be made for the visitation of all the individuals falhng under any of the schemes for the health of the population of the county. It is usual, if possible, to place one or more visitors in a town, and allot to them the surrounding areas as districts. The number of dis- tricts will depend upon the population and other con- siderations. BicycUng is almost essential for a visitor in a rural area — the distances are too great for walking, and in a few cases only will the railway afford ade- quate faciUties for transit. It is of great advantage for a visitor to have a nucleus of homes near her dwelling. She can often do visiting near by when, owing to bad weather or other circumstances, she might be unable to visit in distant places.
It will be impossible for her to visit on any definite date after the birth other than occasionally, since she will arrange her work so as to spend a whole or part of a day in the same district, visiting infants, school children and tuberculosis cases in the same day, together with
' The administrative county for purpoHos of the work of the oonnty coiincil, consists of the geographical coxmty minus the oounty lK>roughs ; of. Chap. XXII.
WELFARE WORK IN COUNTY AREAS 93
any other visits connected with such other duties as may be laid upon her.
The county councils are not sanitary authorities, and cannot deal with sanitary defects, such as defective sanitation, insujG&cient water supply, etc., which must be carried out by the local sanitary authority, namely, the urban or rural district councils, and arrangements for co-operation between the two councils on this side of the work are essential. It is of the utmost importance that the visitor employed by the county should be on per- fectly friendly terms with the responsible people of the council or councils of her district, even though such councils may sometimes appear to her to be irritating and slow in their methods. The officials of the smaller councils are hampered by the poverty of the council and by the vested interests with which the councillors may be closely connected.
The number of births which can be visited by a county health visitor will depend upon the position of the pop- ulation, whether aggregated or entirely scattered, and upon the time taken by her other duties. It is not possible to require the same number of visits per annum to each case in the country as in the towns, since the average time taken per visit, allowing for the journey, will be greatly in excess of that in a town. Some visits may take almost the whole morning or afternoon if the house is far removed from neighbours.
In some counties there will be districts where very little rural work will fall to the lot of the visitor who may be located in a town or large village which requires her whole time. Arrangements for centres are clearly more difficult than in urban areas, the mothers have farther to come, and if they can find means of conveyance or can walk, they will hardly be able to attend as frequently as in the towns — also it will be more difficult to obtain the services of a medical officer. A great variety of arrange- ments are made. In some cases, a doctor will attend
94 THE CHILD WELFARE MOVEMENT
monthly, and the visitor fortnightly, to weigh babies, and give advice in the absence of the doctor. Or the county council may employ a medical officer to visit the centres in the county on different days, either weekly or fort- nightly according to the work required.
When the district is so sparsely populated that only some five or six mothers can attend at a session, it is doubtful whether the cost of establishing a centre is justified. A good deal will depend upon what charge is made for the rooms, and on existing local conditions generally.
The arrangements for visiting, record cards, etc., do not difier from those already described for the urban areas.
The above description of work appUes in a fair number of counties. But it is now necessary to consider a wholly different system operating in some of the counties, and which, in order to understand it, requires a clear idea of the work of county and district nursing associations.
It is now many years since certain well-disposed per- sons in different villages or towns inaugurated bodies known as nursing associations. The object of the associations was to provide nursing for the sick poor who were unable either to obtain any nursing aid, or whose relations were not sufficiently skilled to give the aid required. These persons banded themselves together with the object of providing funds to pay for the services of a nurse. The greater part of the nurse's salary was paid by the association, a small part only being provided by the very low fee charged for the services of the nurse.
The nurse was under the control of a committee for all matters other than professional, when she was required to work under the doctor called in by the people concerned.
Many associations also provided midwifery aid for the district, and it then became necessary to employ a uursc who was able to undertake this branch of the work.
WELFARE WORK IN COUNTY AREAS 95
This last item is more usually required in rural areas than in small towns. Here independent midwives are prob- ably available, whereas in rural areas they are unable to obtain a liveUhood with midwifery work alone.
The formation of district nursing associations spread fairly widely, especiallyin some counties, but it is evident that their existence depended entirely upon the financial position and inclination of the better-to-do inhabitants. Hence, the district nursing associations were formed most readily in towns, and less readily in the sparsely populated areas, where, however, the need for them is often greatest.
The area which can be served by a nurse who is pro- vided with a bicycle in a rural district is about 2-2 i miles in radius, so that, in order to cover the whole of a county, a very considerable number of district nursing associations are necessary. In every county there are districts where no provision can be made without an almost prohibitive expenditure of money, and even at the present time, only two or three counties have a service which extends over the whole area.
The district nursing associations soon began to ex- perience difficulties — the first was finding the nurse — some nursing training was required, and a midwifery training if this work was to be undertaken. The cost of training was considerable, and comparatively few women were prepared to defray the cost of their own training, especially in view of the relatively small salary which could ordinarily be offered.
Then, if a nurse was ill or needed a hohday, it was diffi- cult to find some one to replace her. These and other considerations were effective in producing another body — the county nursing association — which, while not itself undertaking any nursing or midwifery work, could act as a more influential central body.
County nursing associations have been formed in nearly all counties, and they have been the means of
96 THE CHILD WELFARE MOVEMENT
providing or obtaining funds for the training of women as nurse-midwives, and of assisting district nursing associations in their other difficulties. They have usually secured help from the education committee of the county council for training, but have generally also raised considerable sums of money privately for this purpose.
Assistance was only provided for those district nursing associations who became affiliated to the county nursing association, and who paid an affiliation fee. In every county there have been and are a certain number of district nursing associations worked mainly by individuals who prefer to retain their private patron- age, in spite of difficulties, rather than fall in with any general scheme. It should be remembered that the existence of a county nursing association does not imply that the whole county is provided with nurse- midwives, but only that a central association exists for such district nursing associations as are in being, but it may be that considerable portions of the county are entirely without provision of this nature.
The gradual rise in standard which has been continu- ally demanded in both nursing and midwifery, since the beginning of the present century, together with the cost of living, which had already risen appreciably before the war, have added very materially to the cost of working the district nursing associations.
Moreover, the increasing tendency towards State or rate-aided schemes has made many people less inclined to subscribe to services such as that of district nursing associations. The financial difficulties of the associa- tions have therefore become progressively more pressing of recent years. Simultaneously with this pressure, the work undertaken by the county councils for child welfare, school work, and tuberculosis work, has been developing, and the district nursing associations, powerfully backed by the county nursing associations,
WELFARE WORK IN COUNTY AREAS 97
have in nearly every case pressed the county councils to employ their nurses for this work, and to subsidise them for this purpose.
Theoretically, this scheme appears to have everything to commend it, but further investigation is necessary to see how far such an arrangement may or may not be desirable. The primary difficulties arise in connec- tion with administration, and the qualifications of the majority of the nurseb.
The nurses in the less populous areas have, for the most part, received a year's training only, which in- cluded approximately six months' district nursing and six months" midwifery training. They have received no training in child hygiene, or in school or tuberculosis work. Many of them, although excellent workers, find the keeping of records difficult, and are unable to organise their work satisfactorily without assistance. Administratively, several difficulties arise — the nurses are in the employ of the local associations, and are expected to carry out instructions received from the associations. If, however, the county council is to pay for the time and work of the nurses for special purposes, evidently the nurse must accept and carry out instructions from the county medical officer of health who is responsible for the carrying out of the county work in those branches.
A^ain, the nurses, if employed by the county for special purposes, must either report to the county medical officer of health, or must be visited by some one deputed by him and authorised by the council to see that the work is being satisfactorily performed. County nursing associations nearly always employ a superintendent, who is a fully-trained nurse, with midwifery training and of experience in both branches. This lady inspects the work of the nurses who are em- ployed by affiliated district nursing associations. If the county councils, who are the authority for super-
7
98 THE CHILD WELFARE MOVEMENT
vising the midwives in the county, appoint separate inspectors of midwives, a dual system of inspection is established, and difficulty is almost certain to arise.^
Many county councils therefore employ the super- intendent of the county nursing association as their inspector of midwives under existing circumstances.
Whenever possible, however, medical women should be employed as inspectors of midwives.
If the county council decide to employ the county nursing association, provision should be made for instruction of the nurses in infant hygiene, and in any other duties which may be laid upon them.
There are undoubted advantages in allowing the village nurse- midwives ^ to undertake the child welfare and other county work. The nurse is known to, and knows, practically every one in the district, and it is held that the mothers prefer being visited by some one who lives in the village. Then, also, there is great economy in travelhng expenses and in the whole cost of the work. Against these advantages it has to be remembered that the whole-time visitor is usually very much better trained and more efficient, and, if the nurses are to be employed, some arrangement for their training in infant hygiene should be made. Also, the visitor soon becomes known in the district where she works. When the nurse's district is large, or the area populous, she will hardly have time to attend properly to the pubUc health work, and there may be periods when illness is prevalent, and a few heavy cases of sickness may render it almost
^ The piisition of the county and the superintendent of the county nursing association is discussed further in connection with the inspection of midwives on pp. 131 et aeq.
* A village nurfle-midwifo is a woman who has been trained as a midwife with some experience in nursing. The Queen Victorin Jubilee Institute for Nurses trains fully-trained nursos in midwifery and in Hcho<d work if the nurse wishcH to undcrtiko district work. She then becomes a " Queen's " Nurse. 0)uiity nursing associa- tions can be affiliated to the Institute, and obtain privileges with corresponding obligations,
WELFARE WORK IN COUNTY AREAS 99
impossible for ter to attend to any other duties than her nursing.
An important point arises on the financial side. Owing to the increasing difl&culty of maintaining the nurse-midwives, it may be impossible to retain their services at all unless the grants for public health work are available. In such cases the county council is faced with the risk of allowing a valuable service to disappear for lack of funds. There is power to subsidise the nurse for her midwifery out of county funds, but such a subsidy might have to be unreasonably large in order to maintain the midwife, as compared with the number of midwifery cases attended by her, whereas, with the grant for the special services, a smaller subsidy would be sufficient.
The training of the village nurse-midwife for nursing is a much-debated question, and one which will no doubt receive attention in the near future. At present, it hardly falls within the range of child welfare work, although it is easy to show that sick-nursing and child welfare work are closely connected. As it involves the whole question of nursing in all its branches, and raises large administrative and economic questions, it will not be considered here.
In counties where there is a county nursing associa- tion, the council may employ the nurses in the villages, and may provide whole-time visitors in the towns and in those districts where, owing to the sparseness of the population, it has not been possible to provide nursing aid. In the now few counties where there is no county nursing association the county will provide its own service of visitors, but not the village nurse- midwife, since there are no powers to provide a nursing service out of the rates, although it seems probable that this power must soon be given.
If, and when these powers are given it is not unlikely that the work of the county nursing associations,
100 THE CHILD WELFARE MOVEMENT
being thereby placed on an altogether different basis, may show a tendency to pass into the hands of the county councils. The county nursing associations have a wide and powerful influence for good, and have deserved well of the country. They took up the work when it was difficult, and often little appreciated even by those who were aided. If the time should come, when, as is common in this country, the per- manent effort passes from the hands of a voluntary agency, into that of the State or of a local authority, it is to be hoped that they will receive at least some of the thanks and praise which is due to them.
CHAPTER XII
The Training of Health Visitors.
So far nothing has been said on the training or qualifica- tions which should be possessed by a health visitor. It seemed better to give first of all an account of her work and then to consider the question of her qualifications. The value of the sanitary training was very early recognised, as is shown by the very general appoint- ment of women sanitary inspectors as health visitors. A little later, trained nurses began to take up the work as a profession, and undoubtedly in many ways they are very suitably trained persons. A nurse's training does not, however, include any knowledge of either infant or child hygiene, and very few nurses have acquired more than a rudimentary knowledge of these matters during the course of their training. Again, it was realised that a midwife's certificate was of great value to those working on child hygiene. No definite ruling as to the qualifications of those employed by child welfare agencies has been laid down except for the Metropolitan area. Regulations were issued by the Local Government Board for the qualifications of health visitors in the Metropolitan area in 1909. These regulations, while not being without their use, were so wide that, in effect, they would not necessarily have achieved much. They required a health visitor to have one or other of the following qualifications :
(a) a medical degree ;
(&) a nurse's training ;
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(c) a midwife's certificate ;
(d) some nursing training and tlie health visitor's
certificate of a society approved by the Board ;
(e) the previous discharge of duties of a similar
character in the service of a local authority.
Fortunately, the good sense of the borough councils, acting on the advice of the medical ofl&cers of health, backed by the fact that the appointments must be approved by the Local Government Board, prevented any misuse of the last words, and so far as can be ascertained, no one without at least one of the above qualifications other than (e) was appointed in the Metropolitan area.
In the provinces there was no rule, although a very large proportion of the women appointed as health visitors were trained women.
Some medical officers of health consider that all health visitors should have had a full nurse's training. Others attach comparatively little importance to this and favour a sanitary inspector's training. Others regard the possession of Central Midwives Board certificate as essential. The course of training required for these special certificates in each case covers more groimd than is necessary for child welfare work, and omits other important aspects.
The nurse receives a prolonged traimng in the technique of surgical and medical nursing for adults, but, under the arrangements prevalent in most training schools, she will rarely see a normal baby, and it is very unlikely that she will be instructed in the hygiene of any stage of life, infant or adult, man or woman. She will have no knowledge of sanitation in the home, since the ventilation, etc., of the hospital wards is arranged without her, and usually follows a fairly fixed routine ; there is no reason why she should be acquainted
TRAINING OF HEALTH VISITORS 103
with any of the difficulties of hygiene in the ordinary small home. She may be without any knowledge of midwifery, especially normal midwifery, and have had no contact with any matter relating to the hygiene of pregnancy. It is not to be expected that she should have, for these matters do not form any part of the essential recognised training as it stands at present, and it is the exceptional person who acquires proficiency in any branch of work without training.
On the other hand, the trained nurse has acquired habits of order and discipline, and of regularity in her work, and these qualitites are of untold value to all workers. For school or tuberculosis work the nurse's training is of more direct value than for child welfare work, although even for this, as has been stated, there are many advantages in the training.
The training of a sanitary inspector covers many mat- ters which are acknowledged to be essential for health visitors. It also involves other aspects which are clearly of httle or no value ; such, for instance, as meat inspec- tion, the details of the laying of drains, etc., and again it provides no instruction in child hygiene.
The Central Midwives Board certificate is even more speciahsed, and the training does not ordinarily include much training in infant hygiene. It should, however, be at once stated that this deficiency is met in some of the training schools, and the need for it for the practising midwife is very generally recognised.
No training gives so close an acquaintance with the difficulties of the working mother as a midwifery training when taken in the " district," that is, midwifery work carried out in the home. The psychological value is great, but the training does not include enough child hygiene and other similar matter, nor can this be included in the available time.^ If the period of training
^ The present length of training for a midwife is six months, or four months for one who is a trained nurse.
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were extended to enable a sufl&ciently large acquaintance to be gained, the length of time would in itself render the midwife's training almost prohibitive for the health visitor who must learn other matters as well.
No one of these trainings can therefore be regarded as adequate without further special training. Many- health visitors are required to hold more than one of these certificates in order that they may have been trained in several aspects of child welfare work. The Medical Officer to the Local Government Board recommended^ that health visitors should possess two out of the three qualifications : Nurse's training ; Sanitary Inspector's certificate ; Central Mid wives Board certificate.
Actually a considerable number of health visitors hold all these qualifications, but it must be admitted that, especially during the war, women have been appointed who do not fall within these requirements.
Moreover, there are certain important matters which a health visitor should know which are, as already pointed out, not included in the training for any of these certificates. Infant hygiene is one of them. It is sometimes supposed that there is no special instruction needed in infant hygiene, and that general knowledge and training will supply all that is necessary. Doubtless some points in child hygiene are similar to those for adults, but there is a great deal which is not suppUed by the instinctive reasoning processes of the average person.
Then, again, none of the above trainings supply any knowledge of general social conditions, and it has been explained in the preceding chapters that this is of great importance.
Efforts have been made by various bodies in London and the provinces to arrange trainings suitable for
' Mtmorandum on Htalth Vititort, ato., 1016, p. 7.
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health visitors, and although certificates have been given fairly widely, the results achieved have, for several reasons, been below what might have been anticipated.^
It is diflBicult to say precisely why the certificates did not meet the situation, and, as the Board of Education has now issued regulations in agreement with the Ministry of Health, there is no object in making further inquiry into the cause.
Of recent years, many women have taken the Central Mid wives Board certificate in order to quahfy them as health visitors. This has caused considerable difficulty in arranging for the training of those who intended to practise as midwives, since the number of places for midwifery students is necessarily limited by the material required to train on.
A midwifery training is no doubt a valuable asset to any one who is working among the poorer classes of the community, be it as public health or social worker. The material for training must in the first instance be available for those who intend to practise midwifery, whether independently or attached to hospitals. More- over, when due provision has been made for the training of midwives, it will clearly be for the midwives to undertake the ante-natal and early post-natal care of the mother and child. The health visitor will come in after the period of the midwife's attendance. (Cf. also the Ministry of Health's circular, Appendix IV.) Just now, and for some few years to come, the position is more difficult. Many of the midwives have neither time nor training to undertake the work as it should be done. It is a wiser policy, however, to look ahead and make provision for better midwifery service, than to require all the health visitors to hold a midwife's certi-
^ It was necessary for these certificates to be recognised by the Local Government Board as tailing within the qualifications laid down by them for health visitors in the Metropolitan area. Outside this area no regulations were in force.
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ficate. Moreover, the mere possession of a midwife's certificate does not cany with it more than a rudi- mentary knowledge of ante-natal hygiene, and practical experience must be added to the midwife's training before good ante-natal care can be given. The health visitor must follow the midwife or doctor, and carry the child up to and through school age, and her training should be directed towards this end.
The Board of Education regulations which have been recently issued provide a curriculum of study and prac- tical work for the health visitor which seems to cover all the requirements, and when in full working order should secure an admirable training for those intending to take up any form of work for maternity and child welfare. The courses of study will be held at insti- tutions connected with universities, which must make due arrangement for practical work.
The training includes :
(1) A general knowledge of elementary physiology,
so that having some understanding of the working of the body, in health, they may appreciate the object of the measures adopted in preventive work.
(2) A short course in artisan cookery, so that the
health visitor may reaUse the limitations and difficulties caused by a small income, and by the necessity of cooking with only a few cookery utenails.
(3) A full course in general hygiene and in infant
and child hygiene work of all forms, with much practical work at a centre, and also instruction and practice in school clinics and in tuberculosis work. Also instruction in infectious diseases and minor ailments of children, together with some acquaintance with maternity work.
(4) Lectures on social work, its methods, objects,
TRAINING OF HEALTH VISITORS 107
etc., and some practical work, in order that the visitor may have at least some know- ledge and realisation of the difficulties, and of the facilities which are available to deal with them. The regulations for training should, if properly carried out and enforced, lead to a great improvement in the quality of the work of the health visitor, and thence to her status and salary. This last has improved latterly, and is likely to improve still further as the value of the work is more appreciated and the general level of training raised.
Some 3200 health visitors, some whole-time and some part-time, are now employed by local authorities in England and Wales.^ Many hundreds more will be required as the work expands and health visitors seem likely to become a permanent part of the staff of every large public health department. Anything approaching a detailed discussion on the future development of health visiting would only be out of place in a work such as this.
In pointing out the defects of the training and the needs of the future, a tribute should be paid to the excellent work of many health visitors, both in the early days when the whole movement was on its trial, and at the present time. It is to their efforts and personalities that the work owes its present position.
Reference has just been made to their personalities, and no account of the training and qualifications of a health visitor would be complete without some remarks upon this vital point. Personality counts so much in all relations with our fellows, but in no type of work is it so important as in any branch of work where home visitation is concerned. There is no one type of per- sonality required for the work — there is room for all types — but if any one quality can be singled out, then * A few hundreds of these are employed by voluntary agencies.
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sympathy were surely that one. Good, even excellent work, is done by women of widely different temperaments, wholly divergent outlooks, sociable or even almost un- friendly manners, if the mothers whom they visit feel that the visitor is there to sympathise and not condemn, to advise and not to lecture. If the visitor remembers that we are all ignorant, and that the difference between her own knowledge and the mother's is almost imper- ceptible compared with the sum of all knowledge, that mistakes are often due to ignorance or carelessness, to despair or hopelessness ; if she will put herself in the mother's place and ask herself what she might have done had she been brought up in a similar manner, had her opportunities been as limited, her cares and anxieties as great, she will not fail to aid the mother and to secure the carrying out of her advice.
The visitor is there to lead and educate and not to drive. There are few who will not finally respond, even though it be after several attempts and after the per- sistent kindly aid and advice have often been many times rejected.
Those who have worked most intimately among the poorer classes of the country are among those who are most appreciative of the working-class mothers of this country. If they have a family, their work may be almost incessant, and their patience sorely taxed. What they achieve is wonderful, and, provided that they have matters explained carefully and in simple language, so that they can see the reason why the advice is being given, they will often carry out directions of a difficult char- acter with astonishing skill. They like having explana- tions as to why things should be done, and every health visitor should be able to give simple reasons for her advice. She must not be impatient if the reasons are not remembered on the first occasion. It all appears simple to the visitor, but it is new to the mother. Those even among the so-called educated classes who remember
TRAINING OF HEALTH VISITORS 109
and grasp what they are told on the first occasion are comparatively few in number, and may safely be re- garded as having more than the ordinary amount of intelligence.
It is hard to estimate the extent of the results already achieved by health visitors, but it can safely be asserted that, as a result of many efforts, the general level of knowledge among all classes on the subject of infant hygiene has risen enormously during the last decade, and a considerable part at least of this result may be attributed to the health visitor.
Movements have cumulative force, and the next decade will almost certainly see advances compared with which the present progress will appear very small, but it is the begirming which is always so difficult.
CHAPTER XIII
The Position of Voluntary Agencies in Child Welfare Work ^
The child welfare movement illustrates very well a characteristic feature of many movements in this country. A beginning is made by a body composed of a few phil- anthropically disposed persons, who feel that some effort must be made to meet an existing need. Although the towns commenced the home visitation of infants many years ago, yet a great part of the early work was due to voluntary agencies, or to the initiative of private persons. Home visitation was attempted in a number of districts, and, in a very few cases, was continued for a good many years. As a whole, however, home visitation proved too exacting a work for the majority of untrained and unpaid workers, and the visiting was either taken over by the local authority, or a salaried worker was employed by the society.
The main sphere of voluntary work has been in the centres. A very large number of these were opened by voluntary bodies, and in many cases worked for a num- ber of years by voluntary effort. In the Metropolitan area, some of the early centres are still under voluntary control. At first, the medical officer received no salary. As the centres increased, both in number and in size, it became evident that a salary must be paid to the medical
* Throughout thin chapter and elHewhere in this book, the term *' voluntary " i» used to denote untrained ns woU as unsalaried work, unless otherwise specified.
POSITION OF VOLUNTARY AGENCIES 111
ofl&cer, and it also became usual for a trained salaried worker to be employed to superintend the work of tlie centre, where this last was of any size. The cost of the centres thus rose gradually and rendered their main- tenance very difficult. In 1914, when Exchequer grants were first given, a great stimulus was given to voluntary agencies by the receipt of 50 per cent, of the expenditure. At the same time, however, local authorities also re- ceived grants and their work was expanding rapidly. The Local Government Board required all centres worked by voluntary agencies who received a grant from them, to co-operate with the local authority in its work for child welfare.
In addition to the ever-increasing cost, the sub- scribers began to realise that the work could be taken over by the local authority, at the cost of the rates, and the collection of money became more arduous.
In the provinces, comparatively few of the older centres are still worked by voluntary agencies, and even where this is the case many of them are receiving substantial subsidies from the rates for some, at least, of the branches of work. A number of fresh centres have sprung up under voluntary auspices, with the definite object of proving to the local authority that there was a need for a centre in a particular district. When this need has been proved,, it was hoped that the local authority would be prepared to take over the centre, and in some cases a more or less definite under- taking to this effect was obtained in the first instance. While a great many voluntary bodies undertaking child welfare work have ceased to exist, many have given up their work most reluctantly, and others are struggling hard to maintain themselves. Some, in all a not inconsiderable number, have rehnquished one form of activity to commence another, generally one for which money from the rates was not at that time available. In this way it has been possible to enlarge
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the work in many directions and to gain valuable ex- perience.
At the present time there are few branches of work connected with a centre for which the money cannot be levied from the rates. Practically, the only phases which still require unaided voluntary effort are