INFANT MORTALITY: JOHNSTOWN, PA.

INTRODUCTION.

The term infant mortality, used technically, applies to deaths of babies under 1 year of age. An infant mortality rate is a statement of the number of deaths of such infants in a given year per 1,000 births in the same year. Some countries include stillbirths in making the computations, but this method is not generally followed in this country nor has it been followed in this report.

Ordinary procedure is to compare the live births in a single calendar year with the deaths of babies under 12 months of age occurring in that same year, even though those who died may not have been born within the calendar year of their death. The infant mortality rates in this report, however, have not been computed on the usual basis, but for the purpose of securing greater accuracy in measuring the incidence of death this bureau has considered, in making the computation, only so many of the babies born in the year 1911 as could be located by its agents, and has compared with this number the number of deaths within this group of babies who died within one year of birth, even though some of these deaths may have occurred during the calendar year 1912.1

Infant mortality can be accurately measured in no other way than by means of a system of completely registering all births as well as all deaths. In 1911 the United States Bureau of the Census regarded the registration of deaths as being "fairly complete (at least 90 per cent of the total)" in 23 States, but the same degree of completeness in the registration of births was found only in the New England States, Pennsylvania, and Michigan, and in New York City and Washington, D. C. An exact infant mortality rate for the United States as a whole can not be computed owing to this generally incomplete registration. In the 1911 census report on mortality statistics," however, the infant mortality rate is estimated at 124 per 1,000 live births. How this estimated rate compared with the computed rates for other countries is shown in the following summary:

1 For more detailed description of method see Appendix II, pp. 86 to 88.
Bulletin 112, Bureau of the Census, p. 23.

DEATHS OF CHILDREN UNDER 1 YEAR OF AGE PER 1,000 LIVE BIRTHS, BY QUINQUENNIAL PERIODS FROM 1901 To 1910, and also for THE SINGLE CALENDAR YEARS 1909 AND 1910.1

1 From the Seventy-third Annual Report of the Registrar General of Births, Deaths, and Marriages in England and Wales (1910). London, 1912.

Available only for the period from 1896 to 1900, when it was 261.

When it had been decided by the Children's Bureau to make infant mortality the subject of its first field study and to include all babies born in a given calendar year, regardless of whether they lived or died during their first year, advice and cooperation were enlisted of mothers, physicians, nurses, and others experienced in the care of children, and also of trained investigators and statisticians, in the preparation of a schedule which was submitted to them for criticism. With its limited force and funds it was not possible for the Children's Bureau to extend its inquiries throughout the entire United States. It was therefore decided to make intensive studies of babies born in a single calendar year in each of a number of typical areas throughout the country that offered contrasts in climate and in economic and social conditions, the results to be eventually combined and correlated. It was necessary to restrict the choice of the first area to a place of such size as could be covered thoroughly within a reasonable time by the few agents available for the work.

Johnstown, Pa., was the first place selected. It is in a State where birth registration prevails, and hence a record of practically all babies could be secured; it is of such size that the work could be done by a small force within a reasonable period, and it seemed to present conditions that could with interest be contrasted with conditions typical of other communities. Moreover, the State commissioner of health and the State registrar of vital statistics were both

working zealously to enforce birth-registration laws; both were actively interested in reducing infant mortality, and they welcomed a study of the subject in their State. In Johnstown the mayor, the president of the board of health, the health officer, and other local officials all showed the same spirit of hearty cooperation and interest.

Inasmuch as the study was confined to babies born in a single calendar year and work was begun in January, 1913, the latest year in which the babies could have been born and still have attained at least one full year of life was 1911.

Work was begun on January 15, 1913, with the transcription from the original records at Harrisburg of the names and other essential facts entered on the birth certificates of babies born in 1911, and, if the baby had died during its first year of life, items on the death certificate were also copied.

In the meantime the people of Johnstown through the press, and through the clergy in the foreign sections, had been informed of the purpose and plan of the investigation. Without the friendly spirit thus aroused and the interest manifested by the Civic Club and other organizations the work could not have been brought to a successful issue. The investigation was absolutely democratic; every mother of a baby born in 1911, rich or poor, native or foreign, was sought, and it is interesting to note refusals were met with in but two cases. The original plan was to limit the investigation to those babies born in the calendar year selected whose births had been registered, the purpose being to secure facts concerning a definite group and not to measure the completeness of birth registration. Shortly after beginning the work, however, agents of this bureau were told that the Servian women in Johnstown seldom had either a midwife or a physician at childbirth; that they called in a neighbor or depended upon their husbands for help at such times, or that they managed alone for themselves, and that therefore their babies usually escaped registration. The omission of these babies meant the exclusion of a number of mothers in a group that was too important racially to be omitted from an investigation embracing all races and classes. Accordingly a list of babies christened in the Servian Church and born in the year 1911 was secured and an attempt made to locate them. In addition an agent called at each house in the principal Servian quarter to inquire concerning births in 1911. A number of unregistered babies of Servian mothers were thus found and included in the investigation.

The agents were sometimes approached by mothers of babies born in 1911 who resented being omitted from the investigation simply for the reason that their babies' births had not been registered. The agents were therefore instructed to interview mothers thus accidentally encountered and to include their babies in the investigation. But no

additional baptismal records were copied nor was a house-to-house canvass made of the city; in fact, no further means were resorted to to locate unregistered babies for the purpose of including them in the investigation.

There were 1,763 certificates copied at Harrisburg, and 1,383 of the babies named in them were reached by the agents. In addition, 168 babies for whom there were no birth certificates, but who were located in the ways just noted, were included, making a total of 1,551 completed schedules secured.

Of the 380 not included in the investigation there were 149 who could not be located at all; 220 others had moved out of reach-that is, into another city or State; 6 of the mothers had died; 3 could not be found at home after several calls, and 2 refused to be interviewed. From the following summary of data recorded on the certificates of the 380 unlocated babies just referred to it appears that the infant mortality rate (134.3) among them is almost the same as that (134) shown in Table 1 for babies included in the investigation. In reality, however, it is perhaps a little higher, as some of these babies no doubt died outside of Johnstown and their deaths were recorded elsewhere.

The rate of infant mortality is regarded as a most reliable test of the sanitary condition of a district. (Sir Arthur Newsholme, Elements of Vital Statistics, p. 120. London, 1899.)

Johnstown is a hilly, somewhat Y-shaped area of about 5 square miles which spreads itself out into long, narrow, irregularly shaped strips, detached by rivers and runs and steep hills. In some places it is not over a quarter of a mile wide, but its extreme length is

about 4 miles. The city is composed of 21 wards and is an aggregation of what were formerly separate unrelated boroughs or towns. The names of these different sections, together with the numerical designations of the wards included in or comprising them, are shown in the following table. This table gives for each section not only the total population according to the Federal census of 1910, but also the number of live-born babies included in the investigation and the number and proportion of deaths among such babies during their first year.

TABLE 1.-DISTRIBUTION OF POPULATION, LIVE BIRTHS, AND DEATHS DURING FIRST YEAR, AND INFANT MORTALITY RATE ACCORDING TO SECTION OF JOHNSTOWN, FOR ALL CHILDREN INCLUDED IN THIS INVESTIGATION.

2 Total live births less than 50; base therefore considered too small to use in computing an infant mortality rate.

To learn where the babies die is perhaps the first step in solving the infant mortality problem. The modern health officer recognizes this and generally has in his office a wall map upon which are indicated sections, wards, city blocks, and sometimes even houses. As infant deaths are reported, pins are stuck in the map in the proper places, a density of pins on any part of the map indicating, of course, where deaths are most numerous, although the percentage of infant deaths may not be the highest. The next table shows the comparative frequency of infant deaths in each of the several sections of Johnstown as well as the rate of infant mortality, total population, proportion of foreign population, proportion of foreign mothers, and total births in the year 1911 in each.