Fabian Tract No. I49· THE ENDOWMENT OF MOTHERHOOD. By HENRY D. HARBEN. PuBLISHED AND SoLD BY THE FABIAN SOCIETY. PRICE TWOPENCE. (.,, -.... ___ :.-~ '~ . '\ ;, LONDON: THE FABIAN Soci ET Y, 3 C LEMENT's hm, STRAND, W.C. MARCH 19 10. H. K. Lewis's Publications THE PRESERVATION OF INFANT LIFE. A Guide for Health Visitors. Six Lectures to the Voluntary Health Visitors in the Borough of St. Pancras. ByEMILIA KANTHACK (Mrs. De Voss). With a Preface by Dr. ]. F.]. SYKES, Medical Officer of Health, St. Pancras. Crown 8vo, Is. net; post free, Is. 2d. "The lectures ... admirably fulfil the purpose for which they were written."-Public Health. HYGIENE OF THE NURSERY. Including the General Regimenand Feeding of Infants and Children; Massage and the Domestic Management of the OrdinaryEmergencies of Early Life. By Lours STARR, M.D., Physician to the Children's Hospital, Philadelphia, etc. Seventh edition. With !llustrations. Crown 8vo, 3s. 6d. · "A book which should commend itself to all who have the welfare of young children at heart." -The ladr. THE CAUSATION OF SEX. A New Theory of Sex based on Clinical Materials. With Chapters on the Forecasting of the Sex of the Unborn Child, and on the Determination or Production of Sex at Will. By E. R UMLEY DAWSON, L.R.C.P. Lond., M.R.C.S. Eng., etc. With 21 Illustrations. Demy 8vo, 65. net. "A remarkable and striking hypothesis, in support of which he describes a number of interest· ing facts."-The Mendel Journal. "The theory works out with curious exactitude in the cases tested by the present writer." British Health Review. Books not in stock, in all branches of literature, procured at a few hours' notice. London: B. K. LEWIS, 136 Gower St., and 24 Gower Place, W.C. Telegrams: Publicavit, London. Telephone : 10721 Central. THE FX.BIAN SOCIALIST SERIES. VOLUMES NOW READY. I. SOCIALISM AND RELIGION. COil/TENTS: (1) Christian Socialism, by the Rev. Stewart D. Headlam. (2) Socialism and Christianity, by the Rev. Percy Dearmer. (3) Socialism and the Teaching of Christ, by the Rev. John Clifford. (4) A Word of Remembrance and Caution to the Rich, b) Tohn Woolman. II. SOCIALISM AND AGRICULTURE. CONTENTS: (1) The Village and the Landlord, by Edward Carpenter. (2) State Aici to Agriculture, by T. S. Dymord. (3) The Secret of Rural Depopulation, by Lieut.-Col. D . C. Pedcler. (4) The Revival of .Agriculture, by the Fabian Society. III. SOCIALISM AND INDIVIDUALISM. CONTENTS : (1) The Difficulties of Individualism, by Sidney Webb. (2) The Moral Aspects of Socialism, by Sidney Ball. (3) The Impossibilities of Anarchism, by G. Bernard Shaw. (4) Public Service v. Private Expenditure, by Sir Oliver Lodge. IV. TH I!J BASIS AND POLICY OF SOCIALISM. CONTENTS: (1) Facts for Socialists, by the Fabian Society. (2) Capital and Land bythe Fabian Society. (3) Socialism: True and False, by Sidney Webb. (4) Twentieth Century Politics, by Sidney Webb. V. THE COMMONSENSE OF MUNICIPAL TRADING. By Bernard Shaw. With new Preface. " vVhether you agree with it entirely or not, you are bound to admit its intellectual power and pfrsuasive eloquence. VI. SOCIALISM AND N.A.TIONAL MINIMUM. by Mrs. Sidney Webb, Miss .B. L. Hutcnins, and others. VII. WASTAGE OF CHILD LIFE. By J. Jon•~>ton, M.D. " Pa,sing from one count to another, he puts together his huge indictment of national extravagance; showing also how the pracu:e of thrift might enwre to the nation the possession of healthy and efficient citizens."-Daily Neu•s. VIII. SOCIALISM AND SUPERIOR J3RAINS: A Reply to Mr. Mallock. By Bernard Shaw. The first four volumes consist of a I·(.".vised, collected, and cla.sslfled edition of some of the most valuable or the t... mous •· Fabian 'l'racts" in a style more sul!a.ble for the general reading public. Each booklet is printed on good paper with good type, and is supplied in two forms, viz., ln attractive wrappers at 6d. each, net, and in quarter cluth boaras, gUt top, at 1/~ each, net. t'ostage: 1d. and. 2d. eacn, excepG for !rio. 5,1; d . and. :let. THE .tl'ABIAN SOCIETY, 3, CLEMENT'S INN, STRAND. THE ENDOWMENT oF MoTHERHOOD. "It were good that men in their Innovations would follow the example of Time itself, which indeed innovateth greatly, but quietly, and by degrees scarce to be perceived. . . . It is good also not to try experiments in States except the Necessitybe urgent, or the utility evident : and well to beware that it be the reformation that draweth on the change, and not the desire of change that pretendeth the reformation." -BACON, "On Innovations." The Need. IT is one of the paradoxes of our present stage of democracy that public attention is habitually rivetted on the discussion of those questions on which men differ most, instead of on the furtherance of those measures upon which they most agree. Were it not so, the proposals that have been made in certain quarters of late years for the endowment of motherhood, for maternity pensions, or, at least, for some form of insurance against some of the initial expenses of maternity, would surely have been more favorably noticed. To raise the economic status of women by a method which would emphasize and appreciate at its full value their work as mothers of the race is an aim in which Suffragists and Anti-Suffragists, both male and female, find themselves in accord. To focus the collective energy of the State on the task of building the homes of England anew, should reconcile to Socialism those whose opposition is at present most reasoned and most sincere. The proposals contained in the present paper are advanced from the standpoint of our present social conditions, and of the presentattitude of the public towards them. There are those who believe that if we could wipe out the world and begin creation afresh we should make a much better job of it ; but whether this be so or not, in any move towards political progress we have to start from where we are, and deal with the world as it is. Ideals have their value. There is an ideal state in my own mind where all babies would have the best chance of growing up into perfect men made in God's image, where all mothers would have pleasure in the beauty of their motherhood, and receive the meed of care and reward that is their due. Such a state is in my mind, such a state on this earth and in this England I believe one day may come to pass; but I have no intention of describing it. For no ideals are worth much until in our imagination we have succeeded in linking them on to the present state of things, until we have formed an idea of how we are to make for them. And it is this next step which is my humble subject here; humble, because it is small, imperfect, and somewhat uncertain ; and yet not without value if it leads out of the confusion of to-day towards the saner order of a future time. 4 What then is the present condition of things from which, as I have said, we must start, as they affect the mothers and the children during the crisis of maternity ? Millions of our people live in poverty, and it is just at the period of child-bearing that the shoe of poverty pinches most. Not only are its effects most disastrous, but actually there are a greater proportion of our families in poverty at that time than at any other. Men or women while single can keep themselves with comparative ease. After fifteen years of marriage the elder children begin to bring money into the home to supplement the parents' earnings. Later on the children marry and are offthe parents' hands altogether; and even for the helplessness of old age there is now a pension in store. But in the early years of marriage the earnings are smallest, the expenses highest, and the proportion of poverty is greater then than at any other time.* Such are the circumstances of motherhood and child-bearing in the present conditions. The result can be measured in the figures of infant mortality, but they only tell half the tale. The holocaust of little children mayhave its problems for the next world, but once they are dead we have no more to do with them ; it is the survivors that matter most, and though they may come out of the fire alive, they are in most cases not unscathed : they carry in one form or another through all their remaining years the heavy handicap of the conditions which environed them even before they were born, and made their coming more than half a tragedy. It is because of the survivors more than for its intrinsic importance, that it is worth while to draw attention to infant mortality-the danger signal of modern family life. Infant Mortality. The death rate among infants during the first years of life is still excessive, although at last it shows signs of diminishing. Owing to the advance of medical knowledge and the improvement in hygiene, the general death rate has declined during the past so years, but the infant death rate shows no equivalent change. The mortality of children between the ages of 5 and 10 has been reduced from 7·8 per thousand in 1857 to 3'4 per thousand in 1907, but the mortality among children under 5 has been reduced during the same period only from 67·8 to 40·9. And the mortality of infants under one year actually increased from 145 in the decade 1843-1 854, to 154 in the decade r89I-I900. It has however declined to 131l for the 5 years I901-I905, and still further to I r8 for 1907.+ Half the deaths of infants under one year occur in the first three months. Three times as many babies die in the first month as in any subsequent month. Of the deaths in the first month, the greatest number occur in the first week. If babies went on dying at the same rate as they die in the first week, none would live to be a * See this brought out with impressive effect in "Pon rty: a Study of Town Life," by Seebohm Rowntree. t Local Government Board Report on Social Conditions, rgog. 5 year old. Of these deaths in the first week, the majority occur on the first day.':' The chances of infant life may be thus expressed: The highestdeath rate is on the first day. It declines gradually during the rest of that week, falls enormously the second week, remains about stationary the third week, falls again considerably the fourth week, falls enormously in the second month, after which it continues to fall slowly during the rest of the year. The figures vary according to locality, but, speaking generally, they are highest in mining and industrial districts, and especially where women are employed in industry. The worst county for I907 was Lancashire with a mortality of I 6 I per I ,ooo. Nine rural counties had a mortality of under 90. The rate of infant deaths in the three worst towns is double that of the three worst counties. In I907, Stalybridge had a mortality of 219.+ But these oft-quoted figures do not tell the whole tale, for high as the rate of infant mortality is for the whole population, the rate for the unskilled working class is far higher still. When the generalinfant mortality rate at York was 1 76, Mr. Rowntree calculated that for the poorest section of the working class it was 24 7. If any person in the prosperous middle or upper class will take the trouble to compute how many babies have died in their first yearof life in his own family and in those closely connected with him, he will find that this mortality does not amount to more than two or three out of a hundred births, or at the rate of 20 or 30 per thousand. In families in which adequate food and attention can be given, the infantile death rate, even in towns, is already kept down to such a figure. Here are some official statistics. INFANT MoRTALITY PER I,ooo BIRTHS t England and Wales: I 873-1877 148 (average) I892-I902 152 , I907 ... JI8 " London and ten urban counties for the same period : 1873-1 877 I6I (average) I892-1 902 I6S " I907 ... 128 " In sixteen rural counties :I873- 1877 I 892-1902 I27 (average) I25 " I907 ... 99 " * "Infant Mortality," Dr. Geo. Newman. t The figures for illegitimate children are of course higher than for legitimate children. In Manchester, with an infant death rate of 169 for legitimate children, the figure for illegitimate children was 362. t Local Government Board Report on Social Conditions, 1909. 6 The nine counties with infant mortality rate under 90 in 1907 were: Dorset, Wiltshire, Hertfordshire, Berkshire, Buckingham- shire, Herefordshire, Cambridgeshire, Surrey, and Sussex. Infant mortality in Europe 1896-1905 per r,ooo :Russia 268 Italy 168 Austria 223 Belgium 153 Hungary 2 I 5 France 149 Prussia 196 England 147 Spain I 78 Holland 144 Causes of Infant Mortality. The principal causes of death are (a) In the first three months-diseases of immaturity. (b) In the second three months-diseases of digestion, e.g., diarrhcea. (c) In the third three months-diseases of respiration, e.g., pneumonia. The deaths from these three causes are steadily increasing in proportion, in spite of the advance of medicine, which saves the lives of thousands of children in other diseases. The causes of these three groups of disease are roughly as follows: (a) Immaturity is mainly due to over-fatigue of mothers when pregnant, coupled with under-feeding, and the sort of bread-tea-andpickles diet in which so ma:-~y women indulgt:, in some cases perhapsthrough vitiated taste, but more often the direct result of their low economic conditions. (b) Gastric trottble.-Diarrhcea, which carries off so many victims in the second three months of life, is mainly the result of neglect and mismanagement ; in fact, of bad mothering, due to poverty, drink, or ignorance ; dirt, dirty bottles, improper food, and above all, irregular feeding, contribute principally to this group of diseases. Epidemic diarrhcea is most prevalent in the third quarter of the year. The worst month is August. Here are the figures : Mortality from epidemic diarrhcea : Rural districts generally 5 per I ,ooo Wigan and Liverpool 20-30 , Manchester 30-40 , For the whole country (average) I 89 I-1900... 27 , " " 1901-1906... 25 " (c) Respiratory Diseases are principally due to exposure. Leavingbabies to lie in wet clothing, exposing them to sudden changes of temperature in the air they breathe, from the hot stuffy upper room to the door-step, from the warm, crowded mothers' meeting to the frosty night air outside-these things affect the bronchial tubes and lungs of a baby however well wrapped up, and claim their victims bythe mass. 7 Present Provision for Maternity. I have said enough to call attention to the havoc of human life and health which is being wrought under present conditions in English homes, and yet in our haphazard way there is a greal deal that we do already, both individually and collectively, to meet the needs of maternity at the present time, and in order to be in a position to grapple with the problem, it is necessary to realize just what is now being done by the State, by charity, and by individual thrift. (a) The State aid has been so fully dealt with in Chapter III. of the Minority Report of the Poor Law Commission that it need not be explained in detail here. In the first place there are some I s,ooo babies born in Poor Law Institutions. Then there is the large number of mothers who receive medical (including midwifery) orders, sometimes with, sometimes without, outdoor relief. The number of infants under one year maintained on outdoor relief is about s,ooo. The policy that governs the provision of relief and medical aid varies with the locality, and the relief when given is as a rule inadequate and wholly unconditioned, the welfare of the child not being taken into consideration. Side by side with the Poor Law there is the intervention of the local health authorities with their provision of midwives and medical advice, in some cases even of milk. Their activities are less universal than those of the Poor Law, but the principles that guidethem are more rational, aiming as they do at education rather than mere relief, dealing with the future welfare of the child rather than with the present destitution of the mother. By the establishment of health visitors alone, quite extraordinary results have been already obtained in some districts. Now that midwives are under the statutory obligation by the Midwives Act of I902 to call in a doctor when certain difficulties occur, local authorities often, though not always, pay the doctor's fees in such cases, and this practice will become more general. The Minority Report lays stress on the need for a unified service for birth and infancy, and also for the co-ordination and amplificationof what has already been done by the community as such. (b) Turning to charities, there are:r. The Maternz"ty Hospdals.-These are fewer than mightbe expected. There are seven in London, which in the year I905 dealt with about I z,ooo patients, or under ten per cent. of the births of London. In the rest of the United Kingdom there appear to be at least nineteen, of which six are in Ireland. 2. The General Hospzials, £ncludz1zg Hospzlals for liVomen.The bulk of the indoor cases treated in the generalhospitals are cases that have serious complications, but there are a large number of outdoor cases treated by students for the purpose of education. 8 3· Nurses and Midwives whose ;ees are partly paid bycharitable boaies.-There are at least twenty such charities in London. (c) There are a few friendly societits which give maternitybenefits ; for example, the Hearts of Oak pays thirty shillings to the husband, and the Royal Oak Society two pounds, but most of the other friendly societies make no special provision for maternity at all. In women's friendly societies confinements would be reckoned with other illnesses. There are of course in existence numerous medical clubs which provide a doctor on payment of a weekly sum of money, and manyslate clubs pay for doctor and midwife during confinement.* Cli--o~ It will be seen from the foregoing that an immense amount of care and expense is already being devoted to maternity and infancyin this country, and yet the result is as I have described above ; inadequacy, diversity, overlapping, want of system, mark all that is being done. The money spent, welcome as it is in individual cases, is largely wasted in so far as the community is concerned; for the problem, as a whole, has not yet been faced, the enemy is still at the gates. Immaturity, digestive disease and respiratory disease-the three main causes of infant mortality-are still sapping the fitness of the surviving population. If we are to safeguard and strengthen our race, we must roll back the attacking armies as they approach alongthese three main lines of advance. The critical period is the first three years of life ; the battlefield is the home. The Community must Step In. People must soon realize, however anti-social their prejudices may be, that home life in its old sense has been half destroyed by our modern industrial system. lt is no use prating of its sacredness, and of the value of parental responsibility. Such homes as unfortunatelyexist by thousands in our industrial centres are not sacred; they are blighted; a healthy nation has no use for them; they must be either ended or mended. In one form or another the community must interfere. Two principles should guide our interference. The first is the simple proverbial one that "prevention is better than cure." If we are to assume, as we do assume, and have assumed for centuries back, the responsibility for the motley wreckage of human society in the form of old people, sick people, paupers, wastrels, criminals, lunatics and the rest, it is plain common sense not to let our State activitybegin there, but to assert also the right to interfere with the conditions out of which this wreckage is produced. The second principle is a financial one. Money spent on the beginning of life is more economical than money spent on the end of life. Money spent on a child is returned to the community in two ways. First, in saving of expenditure at the other end of the scale; secondly, in the actual production of future wealth. It should • "The Endowment of Motherhood," Dr. Eder. 9 be regarded as an insurance against the expense of wreckage in the future. It may also be regarded as an investment bearing interest in the shape of health, energy, intelligence and labor power in the coming generation. It is financially well worth our while to develop our children, or at least to safeguard them sufficiently to enable them to accomplish the work that lies before them in life,-whether mental or physical, whether as citizens or as rulers, whether as wage-earners or as captains of industry. Granting the need of State intervention, what form is it to take? Are we to replace the home by State institutions, or shall we set ourselves to build the home anew ? There is much to be said for either alternative. State Maintenance. On the one hand, the State maintenance of children would probably enable the physical welfare of the growing race to be most efficiently safeguarded. Plato advocated State nurseries more than two thousand years ago, and various modifications of his plan have attracted advanced thinkers of all ages since his time. In some respects modern practice in England is tending in that direction. Compulsory State schools on the one hand, and the participation of women in industrial occupations on the other, tend more and more to divest the parents of their old responsibilities and force the community to take them up. It is only a few steps in one direction from the present state of things to the complete State maintenance of children, and the practical abolition of the family as a social unit. We might have State or municipal hospitals with maternity wards to which every woman could have access, where babies could be launched into life under ideal sanitary conditions, be fed well, nursed properly, and gi,·en the best possible start. Then we might have public endowment for the encouragement of nursing mothers, side by side with public creches into which the children would be drafted, and remain under perfect conditions of food~ air and nursing until old enough to go into the public nurseries or kindergartens which would replace our present infant schools, and where physical and mental development would be carried out on a progressive systemuntil the children were of age to enter the public elementary schools. In the schools, too, meals and games would be arranged for as at present in the upper and middle class schools. Perhaps the buildings, instead of being dotted about, would be grouped in open spaces, with playgrounds in accessible suburban spots to and from which free trams could convey the thousands of children whose homes mightstill be in crowded districts. And perhaps, too, dormitories could be provided for the children of those, who, like the parents of the middle and upper classes, might prefer the boarding school to the day school as affording better discipline and training of character. By some such means as these, the budding citizens could be rescued from the evils that beset them now, and home-life, already more than half destroyed by modern industry, could be supplemented and replaced out of the wealth that industry produces. IO Such an ideal is well worth notice. It could easily be linked on to our present conditions; it would strike at the root of the deterior· ation over which the public shed their unanimous but futile tears. Objections to State Maintenance. But it has two great disadvantages. The first is on the merits. The death rate of infants, not only in workhouses, but also in well managed private institutions, compares most unfavorably with that in the homes, even of the worst districts. The Minority Report of the Poor Law Commission (pages 100 and following) shows that the infant mortality in Poor Law Institutions is between two and three times as great as in the general population ; and that this is not entirely due to mismanagement is shown by the fact given in the same report that "3,ooo infants attended to in their homes-poor and wretched as were those homes -by the competent nurses of the Plaistow Maternity Charity, had a death rate during the first fortnight after birth considerably less than that in the most successful voluntary hospitals." "' The following are the rates of infant mortality for first fortnight per I ,ooo births. t In four large maternity hospitals of London 30 For whole population ... 3I.I In poor law institutions of London- Legitimate children Illegitimate children In poor law institutions outside London- Legitimate children 5r2 Illegitimate children 53·6 These statistics must be taken with some reserve, and are not by any means conclusive ; but they point to the peculiar danger of institutions for infants which, although it is at present unexplained, we cannot aff0rd to ignore, and they certainly justify the conclusion arrived at by the signatories to that report : ·'It may well be that human infants, like chickens, cannot long be aggregated together even in the most carefully devised surroundings without being injuriously affected." On the other hand, Dr. McVale in his report to the Poor Law Commission is impressed by the admirable work done in the maternity wards in the large city infirmaries. "There could be no comparison between the comfort and safety of midwifery practisedin such surroundings and that conducted in the homes of the labor classes.... I see no reason not to give institutional treatment.'' Apart from these facts altogether the institutional solution savors too much of what a great philosopher calls "regimentation." It might tend to cut the race all to one pattern, to turn out citizens after the fashion of machine-made arLicles. It might tend to stifle true * Of 3,005 infants attended at birth by the nurses of the Plaistow MaternityCharity in the mother's own home in one of the most poverty-stricken districts of West Ham, 47 died in the first fortnight, or 15'33 per r,ooo births. t Minority Report, Part r, Chapter III. II individualism, which it should be the aim of Socialism to enfranchise and uplift. The second objection is one of expediency. Every step towards such an ideal as this would meet with the bitter opposition of that powerful class of opinion which wages perpetual warfare against anyinterference with the sanctity of home life. The ignorance of facts, terrible every-day twentieth century facts, shown by such peoplewhen they talk loosely about home life is pitiful enough, but their motive is genuine and sincere, and if this problem can be dealt with within the family instead of outside of it, by rebuilding the home instead of replacing it, the task of popularizing it will be far easier and, other things being equal, the method is preferable. There are signs that the desire to supply brand-new State institutions on hard and fast lines is giving way to the more elastic theory of State improvement and encouragement of existing conditions. The latest instance in point is old age pensions. We might have had communal almshouses on modern lines provided out of public money and not out of charity, enjoyed as a right and not as a favor, but instead of that we are pensioning the old people in their homes, and it is probably the extension and development of this policy that the future will bring. So too will it be with the problem of the children. We have gone almost as far as English public opinion will ever go in the direction of State interference outside the home. Free and compulsory education, free and compulsory medical examination in the school, free and compulsory vaccination, free meals at the expense of the rates supplemented by voluntary hospitals, voluntary creches, nursing systems, etc.-all these things have developed during the past generation. And yet it is not enough. The problems of health are not seriously grappled with even now. A step must be taken bythe community, and taken soon, to safeguard the future race from the effects of the wide-spread disease of poverty which attacks our children by millions, spreading physical and moral devastation in each new generation ; and if I believe that the response of the community to this call will be to build the home afresh instead of replacing it, it is not that, in the abstract, one theory is necessarilysuperior to the other, but because the English people ha.ve always chosen to transform rather than to abolish, and because the endowment of motherhood, while it will, like all forward steps, be first urged upon the community by Socialists, will command the supportof those whose opposition to Socialism is based on the extraordinary error that its aim is to destroy the home. The Scheme. The need of State action has now been sufficiently emphasized, so too has the economic wisdom of it. Reasons have been adduced to show why such an action should be brought to bear w£th£n the home and not outside of it. Starting with these premises and bearing always in mind present conditions and the present state of public opinion, we have now to consider what scheme is possible. 12 The first step must be the establishment of a system of complete public provision for all the extra expenses incident on maternity. Medical Attendance. First and foremost comes the need for qualified medical and nursing attendance on the mother and the newly born infant. At present many mothers go almost unattended in their hour of need ; many tens of thousands more have attendance that comes too late, or is quite inadequately qualified ; hundreds of thousands of others fail to get the nursing and home assistance that is required to prevent long-continued suffering and ill health to mothers and children alike. This lack of qualified midwifery attendance and nursing will become even more apparent within a year or two, when the provisions of the Midwives Act come fully into force, and none but certificated midwives are allowed to practise. The local health authority ought to be required to provide within its area qualified medical attendance, including all necessary nursing, for all cases of childbirth of which it has received due notice. There is no reason why this should not be done as a measure of public health, free of charge to the patient, in the same way as vaccination is provided for all who do not object to that operation ; and on the same principle that led to the gratuitous opening of the hospitals of the Metropolitan Asylums Board to any person suffering from particular diseases quite irrespective of his means.':' What is, however, important is that the necessary medical attendance and nursing shall always be provided. If the community prefers to recover the cost from such patients as can clearly afforJ to pay-say, for instance, those having incomes above a prescribed amount-instead of from everybody in the form of rates and taxes, this (as with the payment for admission to an isolation hospital) may be an intermediate stage. In one way or another, there must be no childbirth without adequate attendance and help to the mother. Pure Milk. We have next to consider the need of sustenance, both of the mother and of the newly born citizen. At present many tens of thousands of these infants perish simply from inanition in the first few days or weeks after birth. In town and country alike manyhundreds of thousands of families find the greatest difficulty, even when they can pay for it, in buying milk of reasonable purity and freshness, or in getting it just when they require it, or often indeed in getting it at all. The arguments in favor of the municipalization of the milk supply are overwhelming in strength.+ But an even stronger case can be made out for the systematic provision by the Local Health Authority, to every household in which a birth has taken place, of the necessary quantity of pure, fresh milk, in sealed bottles, delivered every day. ~'hatever else is left undone, the * Diseases Prevention (London) Act, r883 ; Public Health (London) Act, 1891. t See Fabian Tract No. 122, "Municipal Milk and Public Health." I3 necessary modicum of pure milk, whether taken by the mother or prepared for the child, might at any rate be supplied as the birthright of every new-born citizen. These two measures-the universal provision of medical attendance and nursing and the universal provision of milk-would go very far to meet by the co-operative State organization represented by the local health authority, the actual extra expense which a birth causes to the average household. But the provision cannot be deemed complete unless an independent provision is made for the maintenance of the mother during the period for which she ought, in the public interest, to abstain from work. Maternity Pensions. The next step therefore must be the establishment of a system of maternity pensions on somewhat similar lines to the old agepensions, which, after much promising, have at last arrived. These maternity pensions must be free, universal, and noncontributory, for reasons which are familiar to all who have followed the controversy over old age pensions. If they be not universal, they will come as of favor, and be open to the objections rightly urged against all doles, public or private. A contributory scheme could only exist as part of a universal sick fund, and State insurance would be a new principle in this country.'-' If the contributions were optional, the poorest mothers would get no pension at all. If they were compulsory on a fixed scale, the scheme would still further impoverish those it is intended to benefit. If the contributions were on a sliding scale, the pension would be smallest just where it is most necessary. Four questions immediately arise : How much is the pension to be? How long is it to last? How is it to be administered? What would it cost the community ? The amount of the pension will of course depend upon the view taken by the community of the purpose it is intended to serve. To work out a pension scheme, for instance, on the basis of compensation for loss of the mother's earnings would at once involve a sliding scale such as is in force in Germany and Austria, which would be unfair in the working, and benefit the poorest least. Moreover, the theory is fallacious, inasmuch as it views the woman as a worker and not as a mother. Let the pension be regarded rather as the recompense due to the woman for a social service, second to none that can be rendered. The time will come when the communitywill set a far higher value on that service than it does at present, and will extend the moderate pension scheme here proposed into the full endowment of motherhood. But at present the main point is to tide the mother over a time of crisis as best we may. *Should the State, as seems likely, inaugurate a scheme of sick or unemployment insurance in the near future, such change in the premises from which the argument starts would, of course, carry with it the necessary modification of the argument itself. On the one hand then it can be argued that any sum, however small, would be a relief in many cases to the pressure of want. On the other hand, it could fairly be urged that at such a time no reasonable sum, however large, would be wasted, so many are the extra needs of the mother and the new-born child, so all-important to the future is their full satisfaction. For the purposes of this paper, I suggest that a middle course be adopted, not because it is a middle course-for the golden mean is often the worst course of all-but for the following reasons. T oo small a pension is uneconomic; unless it secure to some extent the object in view, the expense would not be worth while. Five shillings per week for a month would be money thrown away_ On the other hand, a large pension extending over a long period, say, one pound per week for nine months, would cost so much that public opinion would not seriously consider it, and given the present standard of life, it is quite likely that much of it would be wasted. Let us begin with a sum far less than will be provided eventually by a far-seeing and progressive community. I suggest, therefore, ten shillings per week as being ample to cover the proper maintenance and feeding of an ordinary working- class maternity case_ The cost of a maternity case in Queen Charlotte's Lying-in Hospital for provisions alone works out at 7s. 7d. per week. But food can of course be bought by a hospital in large quantities, and therefore at a much lower price than would be possible to a private family. How LoNG SHOlTLD THE PENSION LAsT ? The average durati on of a maternity case inside a hospital appears to be a fortnight. The statutory minimum of nursing under the Midwives Act is ten days. The normal period during which upper class mothers keep their beds is three weeks, but for some time after leaving bed, the mother is incapable of any active work without harm to herself. Many internal diseases and nervous complaints, as well as a good deal of the drinking among women, have their originin getting about too soon. For some weeks at least, whether the mother nurses her baby or not, she requires much more than ordinary rest and nourishment. These considerations apply also, thoughin a less degree, to the period preceding confinement. Under the law of Great Britain, the period of enforced cessation from factory work is four weeks. The same period is prescribed in Holland and Belgium. In Switzerland the period is eight weeks. These laws, though of great value, are often cruel in the working, as they deprive the woman of wages without compensation just at the time she needs money most. The result is they are often evaded. Germany and Austria have recognized this. In Germany women are forbidden to work for six weeks after r.onfinement.* But the insurance law of Germany provides women with free medical attendance, midwife and medicine, and in addition with an allowance not exceeding seventy-five per cent. of her customary wage for the * The period may be reduced to four weeks on production of a medical certificate. 1~ six weeks. There is further a proviSIOn that pregnant women unable to work should be allowed the same amount for not more than six weeks previous to confinement. A similar insurance system exists in Austria and Hungary. In some parts of Germany, the municipality goes still further. In Cologne, the working mother is given a daily grant to stay at home and suckle her child, and visitors see that this condition is fulfilled. The Cologne system has been adopted by some municipalities in France. In Leipsic, every illegitimate child becomes a ward of the municipality, which puts it out to nurse with certified persons who must produce it for inspection on demand. These provisions enable the government of Germany to enforce the law against the employment of women in the last period of pregnancy without hardship to them, and only when some such measures are adopted in England will our law cease to be evaded, and become a real safeguard instead of a dead letter. The compensation given to German mothers, though far in advance of anything we have in England, is already felt to be insufficient, but there is a difficulty in making it more generous arisingfrom the fact that the system is a scheme of insurance; the benefits cannot be increased without a rise in the contribution. In a free pension scheme, this difficulty will not occur. A small beginning might be made by way of experiment to familiarize the public with the advantages of caring for maternity, with a knowledge that its scope could be extended indefinitely without dislocation of the scheme. But the period like the amount must be substantial even at first. If the pension is to have any permanent value it should extend, I suggest, over a period of at least eight weeks : about two weeks before and six weeks after the date on which the birth is expected to take place. I attach no importance to the particularperiod of eight weeks, which must be regarded as a rough minimum chosen to afford a basis for preliminary calculation of the cost of the scheme to the community. The Scheme in Working. The pensions might be administered on the following lines, to the details of which no particular importance need be attached. The first payment should be made a fortnight before the anticipated date of confinement, on condition that the recipient was not at this time engaged in any occupation likely to prove injurious to her health or to her offspring. Most women would willingly complywith this condition could they afford to do so. Application should be made at least a month before the first payment. lf, as I suggest, the scheme were accompanied by free nursingand supervision, the case would at once be placed in the hands of the nurse in whose district it fell, who would pay a preliminary visit to the applicant's home, arrange with her as to the best place in the house for the lying-in, and give her good advice as to care and diet. r6 If any symptoms were unsatisfactory, the applicant would be advised to see the medical officer. Special cases could then be scheduled and watched. Difficult and abnormal cases could be removed to the infirmary in good time where they could be treated more conveniently than in the home, and where recovery would be more rapid. In such a case, the pension, or part of it, would presumably pay for the patient's treatment in hospital. In serious cases it might be possible, on the report of the medical officer, to make grants for extra nourishment, even before the pension became due, and in the same way to keep cases of slow recovery furnished with money longer than the prescribed eight weeks. There would be no need to tie a patient down to a particulardoctor and nurse, provided the persons chosen by the patient were approved of by the pension authority. Women would be encouraged to make their application as long before the statutory month as possible. At first they would not wish to do so ; but in a few years, and especially in first pregnancies, many young mothers would come to feel that they had somewhere to go for advice, and would seek out the pension authority early. Much folly would thus be avoided. The mere handing of a one-sheet pamphlet of elementary rules of health to each applicant would not be without its effect in removing some of the ignorance that at present prevails. The women would talk it over on their door steps and in their courts, and gradually the old wives' tales and remedies would give way to a few tags of sound hygiene. The pension authority would, as tactfully as possible, use the pension as a lever to promote a higher standard of health in the applicant's home. For instance, as regards overcrowding, if it transpired at the preliminary visit that the only room available for the confinement was one in which not only the woman and her husband but also several children slept, temporary arrangements could be insisted on for the reduction of this number during the receipt of the pension. For a small sum per week, which the pension moneywould far more than provide, accommodation could be obtained for most of the family elsewhere in the same house, or at least in the same street. Both the mother and baby would thus get a national minimum of air for the time being, and in the course of time, a higher standard of opinion would be set up in the matter of house room, and the way be paved for future reform. There are numerous other ways in which the local authoritymight, through the medium of the pension, increase the standard of health. If it be true, as the experts tell us, that breast feeding is all important to national health, then special advantages might be offered to nursing mothers under the scheme. Supposing a fee for the requisite nursing and medical attendance were charged and deducted from the pension, mothers would still be better off than at present, but if the nursing were free, as suggestedabove, the cost that would be added to the pension scheme would be compensated for by a considerable saving in our present voluntarymachinery. 17 Each case, as I have said, would be in the hands of a certificated nurse, but much of the routine work could be performed under the direction of the nurse by less skilled women who would play the part of mother substitute as well, for the medical aspect of the case is by no means the most important. When the mother of a family is laid by, few workmen can afford to pay for extra help, and so the children are neglected, go to school unwashed, with dirty clothing, and unbrushed hair, and without properly cooked meals at home. Under the pension scheme, as is the case even now in many country districts under private nursing institutions, a mother substitute, or a pupil nurse, could be provided to be manageress to the family during the first three weeks. What would the Scheme cost ? First, as regards the provision of nursmg and medical attendance, with the necessary supply of milk. The cost of nurses varies according to density of population, cost of living, etc., in the various localities. Moreover, in some districts, the average duration of labor is three or four times as long as in others; the cases in such districts require far greater attention during recovery, occupying more of the nurse's time, and therefore costing more. In some town institutions, medical and nursing expenseswork out at only Ios. a case, while in some unions and hospitals the out-door cases are reckoned at 1c:s. a case. We are told that the State does things expensively, and certainly its standard should be as high as that of the best poor law or charitable administration in a matter of this kind; so we will take this last figure as our estimate, and adding thereto the cost of milk for eight weeks, at perhapsanother I)S. per case, we shall arrive at an outside figure of £I 10s. per case for nursing, medical expenses, and milk. Now, as regards the cost of pensions. The total number of births in the United Kingdom for the year 1907 was l,J48,S73· Some of these of course were twins, or even triplets. In such cases I do not suppose a full lOS. would be given for each child. More probably it would be decided to augment the pension by a small sum, say only 2s. 6d. per week extra, for each additional child ; but this is a mere matter of detail, and need hardly enter into our rough calculation. Without making any allowance for this, the pension of 10s. per week f0r eight weeks on the basis of the 1907 figures would involve a cost to the community of£4,6oo,ooo per annum. If ten per cent. be added for the extra cost of special cases, we get £s,ooo,ooo as the outside cost of pensions. With the addition of £1,75o,ooo for the cost of provision of nursing, medical attendance, and milk, the total is £6,7so,ooo. If the pension were paid through the existing old age pension authority, the cost of administration would be almost negligible. But this is only the gross cost. From it must be deducted a sum for non-claimants, the number of whom would depend on how far the scheme were accompanied by inspection and other requirementswhich would keep off those who did not really need it. Speaking 18 roughly, we may take it that the servant-keeping class would not be likely to apply for the pension. This class was estimated by, Mr. Booth at II"3 per cent. in London, and by Mr. Rowntree at 28 per cent. in York. It is reasonable to suppose that at least 20 per cent. of the mothers would not apply for pensions under the scheme suggested, in which case the amount to be written off under this heading would be £I,3So,ooo, leaving a total of £s,4oo,ooo. This expense, which in round figures may be described as five and a half millions of money, would be accompanied, of course, by a considerable saving in three directions : i. the rates ; ii. charity ; iii. friendly societies, etc. i. If the estimate I have quoted above be correct, namely, that fifteen thousand children are born every year in poor law institu· tions, and five thousand infants under one year subsist on outdoor relief, it is evident that from the cost of the scheme there must be subtracted the expenses under this head. In England and Wales, the proportion of illegitimate births in workhouses is estimated at seventy per cent., but there is a growingtendency among respectable married women to use the workhouse as a maternity hospital. This tendency would undoubtedly be arrested by the pension scheme now proposed, but the great bulk of the maternity work under the poor law would probably continue because it deals with those without homes, casuals, illegitimate cases, etc. These persons would be relieved as at present, but the expense, instead of falling on the rates, would be defrayed out of the pensions to which they, in common with the rest of the community, would be entitled. ii. There would also be an enormous saving in the expenses of hospitals, nursing institutions, and other charitable agencies. The general hospitals take in cases with serious complications and treat outdoor cases for the purpose of educating their students. This would continue as at present and work in with the scheme, the hospitals being paid for the work done out of the money voted for the maternity law. Thus their sphere of usefulness would probablybe enlarged and their finances at the same time relieved. The lying-in hospitals would find that some who at present used them would, under the pension scheme, prefer to remain in their own homes ; but the more complicated cases, which now remain ill- attended at home, would be removed under doctor's recommendation to the lying-in hospitals, which would thus find their activity in· creased and their work paid for. Over nine per cent. of the births of London are treated by lying-in hospitals at a cost of about£2s,ooo a year. Under this head alone then this sum would be saved to the charitable public of London every year and be liberated for use in other ways. Similar amounts would be saved in other centres. As for the nursing institutions, their great work would at last be nationalized, or, if the institutions remained under private management, the nurses they provide would be paid for by the communityfor the cases they attended. It is impossible to estimate what the saving to charities would be without far fuller details as to the expense of hospitals and other charitable agencies than I have found it worth while to obtain ; but if the saving under this head is less than might be supposed, that is only another way of saying how inadequately maternity is providedfor under our haphazard charity system, which does not, indeed cannot, attempt to cover the whole ground. iii. Lastly, there would be a small saving in the benefits given for confinements by thrift societies and clubs. The money would be thus liberated for fuller benefits in other directions. Objections to the Scheme. A host of objections present themselves to the mind against the scheme I have outlined. They may be divided into two heads- practical and theoretical. The first practical objection will come from enthusiasts who will say that los. per week is not enough : it will not replace the wagesin many cases, much less afford the extra comfort and nourishment required at such a time. But the fact is that the better-class working woman who is earning more than 10s. per week is not likely to be so near the poverty line as her poorer sister, and the pension, though acceptable, is not so absolutely vital in her case. The IOS. will be all to the good for her, while for the very poor it will more than replace anythingthey could earn, and will go some way at least towards securing that national minimum of comfort at a time of crisis in the life of the individual and of the community which is the main purpose it is intended to serve. Another objection is that in many households the 10s. may not be spent on the mother and the baby: the husband would drink the money. My belief is that these cases will be far fewer than is often supposed. Even rich people, if they found themselves in such a position that they could not rely on a future more than a few days ahead, if they lived in a world of destroyed illusions, where memoryis all and hope has little place, would probably do much as the very poor do; they would drop calculation and let things slide. But give the poorest even eight weeks during which they can see thc::ir way clear, and they will feel less helpless, they will derive a stimulus from the new sensation, they will behave more sensibly. Still the objection has force none the less, and be the cases few or many, they must be guarded against. The nurse will see at once how the land lies, and acting on her report, the local authority should schedule the case, and pay the pension in kind through the nurse, or throughinspectors or health visitors, whose business it should be to look after such cases. The difficulty is there as in the case of out relief. It has to be met, but it is not insuperable. It would be ridiculous to deprive the whole nation of a beneficial scheme just because there are rogues about. Another difficulty I clearly foresee is that of arranging the staff of nurses, doctors, etc., so long as the hospitals and medical schools 20 remain in private hands. As things are at present arranged, there would inevitably be overlapping and jealousy and undue expenditure. Indeed, if overlapping is not now apparent, it is merely because there is no attempt by voluntary agency to cover nearly the whole ground, which is strong evidence of the need of the scheme. But the time is not far distant when the health services will be socialized, and the first beginnings of a far humbler scheme than that mentioned in the present paper would tend to hasten the event. Finally, there is a powerful theoretical objection to any scheme which lessens the burden of maternity, namely, that it will tend unduly to increase the number of births amongst the poorest classes. Three considerations must be urged in answer to this : (a) The poorest classes already breed almost as fast as they · can, faster than any other part of the community. (b) The tendency of parents is to become more prudent in proportion as they have more chances in life and a better position to lose. The more comfortable working classes, as represented bymembers of friendly societies and trade unions, for instance, have not, on the average, so many children as the unskilled laborer.':' (c) In Germany, where compensation, fifty to seventy-five per cent. of the wages lost, is paid to the mother, this payment for confinement, so far from increasing, is a diminishing proportion of the total sick pay. But it is possible that, apart from increase of births, there might, or indeed there probably would be, an increase of population due to the reduction of infant mortality. This is not necessarily an evil. Whether it is so in fact or not depends wholly on the character and quality of the increased population. Surely an increase due to causes that make for a higher level of health all round cannot be said to be an evil except by those who are haunted by the ancient bogey of over-population. Our object is not to increase the population, but to obtain a national minimum of health for the race. What though this incidentally increase the population, too? If the future race is onlysufficiently healthy and efficient, over-population will be no danger to it. It will not allow the few to displace it, to monopolize the land, to pin it into slums, and to live upon it ; but it will claim its heritage, it will survive in the struggle for existence, it will be fruitful and multiply and replenish the earth, replacing, if need be, more effete and less healthy peoples. The modern topsy turvey view of a child as an expense, instead of a source of wealth, will not survive the economic disorganization from which it springs. Advantages of the Scheme. Over against all such objections there stand out clearly the advantages to the whole nation of such a scheme as I have outlined. *See Fabian Tract No. I3I. 21 To the individual these advantages are obvious. They may be summed up as follows: 1. Money at a time of crisis in the home. As Bernard Shaw has truly said, " What is the matter with the poor is poverty." 2. H ealth to the mother and the child consequent upon the increased care and attention at that time. Moreover, the mother would be saved many of the future consequences of bad recoveries. Thousands of women take to drink at first purely to gain temporary relief from ailments consequent upon unhealthy conditions of motherhood. 3· The husbands would be saved much worry and expense due to the incomplete recoveries and ill-health of their wives. 4· Above all, there would be increased affection between the mother and child springing up in the golden days of rest that will replace the present nightmare of worry, affection that will bear priceless fruit in the home life and conditions of the future. Great as the boon would be in individual cases, the advantages to the community would be greater still. In the first place, the rate of infant mortality would be reduced, and at the same time would disappear the degeneration of the children that survive. It is impossible to over-rate the value of the health lessons that would be received in the home during the regular visits of the nurses. Little by little, closed windows, dirty bottles, " comforters," ignorance of management and feeding, wanton exposure of children, and the hundred- and-one details that go to pile up our figures of mortality and disease and leave their legacy of trouble and expense to the survivors, would disappear before the method and common sense of a more enlightenedgeneration. Once establish your national minimum in so important a sphere of life as child-bearing, and the seed is bound to grow. It will develop into full endowment of motherhood, and bear fruit in the ever-increasing freedom and health of the coming race. "Superfluous Women." In the second place, there seems every reason to believe that with healthier conditions the present disparity of number between the sexes would also disappear. In I907 there were living in this country I 6,879,509 males and 18,o66,o9 I females. This excess of females is not due to an excess at birth, for there are always more boys than girls born, the mean proportion for the decade 1897-1906 being I ,037 boys born for every 1 ,ooo girls. It is due simply to the fact that male children succumb more readily to the dangers that await them in infancy. The proportion of deaths to 1 ,ooo births in I907 was as follows :Under I day I 2'90 males and 9·7I females , I week 14·78 , 11 I I ·26 11 , I month -46·17 , " " 34'98 , I year -130·26 , )) 104'49 II The death-rate under 5 years per I ,ooo.l iving was 44'77 males to 37"02 females.':' * See Registrar-General's Reports for England and Wales. 22 Now, as these infant deaths arise largely from causes that are preventible, and are more active in urban than in rural districts, it follows that the present ratio between the sexes is abnormal, and would be modified by legislation of the kind proposed. Although this scheme was drawn up before the appearance of the Minority Report of the Poor Law Commission, and although Maternity Pensions are not suggested there, yet I venture to think there is nothing in the scheme inconsistent with the principles underlying that report, or with the facts and figures contained therein. Indeed, it would seem to fulfil completely two conditions upon which the Commissioners lay great stress; first, that the service of birth and infancy should be unified, and secondly, that the normal place for the mother and the child is the home. It has often been urged that the endowment of motherhood would tend to facilitate early marriages, and in this way prevent much misery, immorality and disease consequent upon the economic impossibility of recognized relations between the sexes at a time when the passions are strongest. I do not think the present scheme would achieve this. It would hardly touch the middle classes, and among the poorer classes of the community, which it would un doubtedly benefit, marriage is already embarked upon at a sufficiently early age. Conclusion. One word in conclusion. Twice, and twice only, in modern history, according to Dr. Newman, has the mortality of the little children of the working classes been sensibly reduced. Once was during the cotton famine in Lancashire, the other was during the siege of Paris. In both cases, poverty and privation sent up the general death rate whilst reducing infant mortality, in Paris by as much as forty per cent.':' Tl/(: pamlysis ofindustry spelt life for the 1'ace. Why? Because the oarents were at home and the children had their meed of care and i