The effect upon infant mortality of the mother's employment away from home during the year after the infant's birth may be shown by the following calculation. There were 475 infants who were alive when their mothers commenced or resumed work. If the average infant mortality rate for the city for the remainder of the year had prevailed among them, a total of 29 deaths would have occurred; but actually 43 of these infants died. The ratio of 43 to 29 expresses the extra mortality among these infants of gainfully employed mothers. (See Table XXIII.)

TABLE XXIII.-Infants born in selected year whose mothers resumed work away from home during specified month of infant's life, average number of subsequent deaths per 100 surviving at beginning of month, actual subsequent deaths, and deaths expected at average rates.

An analysis by age of baby at mother's resumption of work indicates that almost all the excessive mortality occurred among the cases in which the mother took up work away from home when the baby was less than 4 months old. For this group, numbering 226, a total of 20 deaths would have been expected at average rates, but 35 deaths occurred. The mortality was, then, one and three-quarters times the average rate. For the remainder, there was practically no difference between the rate for all the infants included in the study and the rate for the infants whose mothers were gainfully employed during the infant's lifetime. If reliance can be placed upon the indications afforded by these figures, it would appear that early resumption of work by the mother is especially harmful to the welfare of her

GAINFUL EMPLOYMENT OF MOTHER AND FEEDING.

One of the common consequences of a mother's having to seek gainful employment after the birth of her baby is that she is unable to nurse him. Table XXIV shows the relation between the type of feeding and the employment of the mother.

TABLE XXIV.-Per cent artificially fed among infants born in selected year to mothers of specified working status, by selected age of infant.

Of the infants of mothers gainfully employed away from home a very large proportion was artifically fed, a proportion about twice as great at 3 and 6 months as for infants whose mothers were not at work. For infants aged 9 months nearly three-fourths of those whose mothers were employed away from home were artifically fed as contrasted with two-fifths for those whose mothers were not at work.

A Portuguese grandmother, who cared for the baby during the day, told of the baby's mother having to go back to the mill when the baby was only 2 weeks old because of the desertion of her husband. For two weeks after returning to work she came home at noon and nursed the baby; after this, however, she decided that when she was tired her milk was not good for the baby and weaned him altogether at the age of 1 month.

The 4-months-old baby of an Italian mother was weaned when his mother returned to her spinning at the mill and was fed a proprietary food and anything else he wished, including ice cream and bananas.

A French-Canadian mother who went back to her work as a weaver three weeks after her baby's birth weaned the baby soon after. The cow's milk which the baby was fed after this time was not suited to him and at 4 months he died of malnutrition.

Another mother (Portuguese) returned to her spinning at the mill three months after the baby's birth. Her milk left her and the baby was weaned. Cow's milk was tried first, then condensed milk, and finally a proprietary food. The baby had convulsions at 4 months, again at 8 months, and at 12 months had convulsions for one month

That not all the infants of mothers employed away from home were artifically fed was due to the fact that in many instances mothers were employed near their homes. It was possible for these mothers to return at certain periods of the day to nurse their infants, or the infants might be brought to the places of employment.

The fact that 46 per cent of the deaths of infants of mothers who worked in the mills were due to gastric and intestinal diseases while only 25 per cent of the deaths of infants of mothers not at work were from these causes would seem to show that the employment of the mother, as a rule entailing artificial feeding of the infant, was an important factor in causing the great number of deaths from this largely preventable cause.

EMPLOYMENT OF MOTHERS IN COTTON MILLS.

Since 540 of the 578 live births to mothers employed outside the home the year after the birth of the scheduled baby were to mothers who were cotton-mill operatives, a special study was made of this group.

The mothers of 96 of these infants were native, and of 444 foreign born, including 194 Portuguese white. The classification of the 444 foreign-born mothers employed as cotton-mill operatives shows them to be of comparatively recent immigration, with 42 per cent illiterate and 58 per cent unable to speak English. The Portuguese white added the greatest number, proportionately, to the illiterate and non-English-speaking groups. Thirty-three per cent of this nationality group had been in this country less than 5 years, and 31 per cent had been here 10 years or more. Sixty-six per cent were illiterate and 78 per cent could not speak English. Among other foreign-born mothers these factors were not so pronounced; mothers of 55 per cent of the births in the groups of other non-English-speaking nationalities were unable to speak English and 23 per cent were illiterate; mothers of 22 per cent had been in the United States less than five years.2

How great was the economic need which caused this employment of mothers in cotton mills is shown in General Table 28. Practically all the working mothers were in families where the father earned under $850, there being only 21 instances in the three income groups of over $850.

In this connection it may be pointed out that in 12 instances of working mothers the mother had been deserted, in 6 cases the father had died, and in 1 case the father was sick the entire year.

LEGISLATION IN REGARD TO EMPLOYMENT OF MOTHER.

Massachusetts is one of four States1 which in 1913 had laws prohibiting the employment of women immediately before or after confinement. The Massachusetts law 2 reads:

Section 1. No woman shall knowingly be employed in laboring in a mercantile, manufacturing, or mechanical establishment within two weeks before or four weeks after childbirth.

Section 2. The foregoing section shall be included in the notice with regard to the employment of women now required to be posted in mercantile, manufacturing, and mechanical establishments, and the provisions thereof shall be enforced by the district police.

Section 3. Violations of section one of this act shall be punished by a fine not exceeding one hundred dollars.

Section 4. This act shall take effect on the first day of January, nineteen hundred and twelve.

No adequate provision was made for the enforcement of the law. Practically it can be carried out only where a matron or other person is appointed to see that its provisions are complied with. It could not be expected that the 34 State inspectors, whose territories were so large that it was impossible for them to make the rounds more than once in two or three years, could supervise the enforcement of this law. Only one New Bedford cotton mill employed a matron to see that the proper rest periods were observed.

CIVIC AND SOCIAL FACTORS.

BIRTH REGISTRATION.

In Massachusetts the city clerks were charged with keeping the records of vital statistics. The State was one of the first admitted into the provisional birth-registration area, established by the United States Bureau of the Census; for inclusion in this area a registration 90 per cent complete is required.3

Physicians and midwives were required under the State law to file with the city clerk a partial report within 48 hours, and a complete report within 15 days, of births which they had attended. The law provided for a fee of 25 cents to be paid the physician or midwife so reporting a birth, and exacted a penalty of a fine not to exceed $25 for failure to report. Parents, householders, keepers of institutions, and masters of vessels were also required by law to report to the city clerk any births occurring within their domain, and for failure to report a penalty of a fine not to exceed $5 was imposed."

1 Connecticut, Massachusetts, New York, and Vermont.

2 Acts of 1911, ch. 229. Approved Mar. 31, 1911.

Massachusetts had been admitted into the similarly constituted census area of adequate death registration in 1880.

4 Laws 1912, ch. 280, secs. 1 and 2.

Various methods of checking and supplementing birth returns were in use in the office of the city clerk at New Bedford. Every year, in January, canvassers were appointed who visited every house in the city to ascertain whether any births had occurred there during the previous year. The canvassers' returns were then compared with the birth records already obtained, and any births which had not been registered were then placed on record. This procedure resulted in making the returns more complete. The only difficulty lay in the fact that frequently canvassers' returns were not identified with records already received on account of slight differences in name, date, or place of birth; many births were thus registered twice. In the course of the investigation, 97 registered births were found to be duplicates and 2 were triplicates. In addition to canvassing, the city clerk made a birth entry whenever a death certificate of an infant who was born in New Bedford and for whom he had no birth record was returned to his office. Members of the clergy had been asked to cooperate with the city clerk in his efforts to secure complete birth registration, by furnishing him with copies of their birth or baptismal records.

That the various methods adopted in New Bedford for securing a complete registration of births have been effective is indicated by the fact that of the 3,542 total births found during the investigation to have occurred in 1913, only 49, or 1.4 per cent, were unregistered. It is evident that registration of births for this city is exceptionally thorough.

THE BOARD OF HEALTH.

The board of health as constituted in 1913 had 26 employees in various capacities and was headed by a full-time health officer.1 Only those of its activities which bear upon infant mortality will be summarized in this report.

It was the duty of one of the two nurses employed by the board of health "to visit the homes of the newly born where midwives have officiated." Many cases of ophthalmia neonatorum in its early stages were discovered and, as already mentioned, specialists were employed to give necessary treatment. During 1913 the nurse made 1,546 visits to homes where births had been reported to the board of health by attending physicians and midwives.2

The mother of every new-born child was mailed a printed circular giving her instructions as to the care of her child during infancy. The pamphlets were printed in English, French, Portuguese, and Polish, and emphasized the advantage of breast feeding, light clothing in summer, frequent bathing, fresh air, and medical attention

1 Municipal Manual, City of New Bedford, Mass., prepared by Charles P. Sawyer, Clerk of Committees, Clerk of Common Council, May 1, 1914; pp. 38 and 39.