whether they discourage breast-feeding, is still being discussed. The shortage of milk during the World War and its high price made the question acute.
The maternal and infant centre is in some cases provided with a garden where the mothers can sit with their little ones, or where infants may be left to sleep under guardianship while the mother is indoors. Occasionally a play centre for young children is com- bined with an infant centre. These play centres are instituted in crowded districts for the use of young children. Though they may be acquired and supported by the local authority they are some- times given by private donors and occasionally equipped by them or by bodies like the Carnegie U. K. Trust. The movement was naturally retarded by the World War and its after effects. In play centres provision is usually made for toddlers, children below five years of age and also separately for older children who can play organized games. A portion of the ground is often covered with asphalt for use in bad weather and a pavilion is provided for storing apparatus and for shelter. There must of course be adequate super- vision and possibly an expert instructor. The nature of these devel- opments depends on the size of the ground available and the amount of money that can be spent on it.
The limitation of the legitimate activities of the infant centre has never been defined. Thus, not only does the relationship of the pre-natal work with that of the ordinary midwife come to be a somewhat difficult one, but there arises the further question of what amount of treatment and drugs should be given. In any case it seems clear that it would be wholly unsuitable to convert an infant centre into anything of the nature of a small and expensively run hospital. 1 At the same time there is fre- quently difficulty in obtaining the hospital treatment suitable for infants and very young children, and certainly no opportunity is given for teaching the mother how to carry on that treatment at home. It has been matter of complaint that the health of children between two and five (school age) has not been cared for sufficiently owing to the dual authority (Public Health Department and Education Authority) which respectively con- trolled infant welfare and school-children. But under the Minis- try of Health the case may be different.
Health Visiting. The number of visits paid to a mother by a health visitor naturally varies, but about 400 cases are allowed to one visitor, though of course it may be that the visitor is called upon to visit children up to school age, when not nearly so many could be allowed. The visitor is called on to visit all homes where still- births are reported, and it is necessary to report all births taking place after the twenty-eighth week of pregnancy. A certain amount of ante-natal visiting may also be done if the visitor has midwifery qualifications, but this might be regarded as interfering with the work of the midwife or doctor engaged by the mother.
Organization of Child Welfare Work. The movement has made rapid progress. It was estimated that in 1921 there were in England and Wales 1,754 infant centres, mostly in the hands of municipalities or county councils, though 693 were worked by voluntary agencies. 2 The municipal centres are carried on by the Public Health Committee under the local authority. The county, city or borough council elects its Committee for Public Health, and in 1918, under the Maternity and Child Welfare Act, a statutory committee was made necessary for the purpose of carrying out its requirements, the majority of whose members must be members of the council. Before the 1918 Act these duties fell on the Public Health Committee, though sometimes it devolved them on a sub-committee which might become the statutory Welfare Committee. At least two mem- bers of this committee must be women and it has to report to the Public Health Committee. In counties this Welfare Committee is usually a separate one, and is granted considerable power. The staff of visitors work as part of the staff of the department of the Medical Officer of Health. In the towns the visitors endeavour to get the mothers to bring their infants to the centres and in some places half of those visited do so. Of course, not all these children necessarily go before the doctor on each occasion. There are many variations in the manner of working the centre, depending on the nature of the area. In the country the visitors usually undertake the threefold duties of infant, school and tuberculosis visiting. The visitors are usually stationed in small towns or villages within the area and visit around these. " Centres " may or may not beestab- lished in these towns or villages. In most counties there are nursing associations for the supply of parish nurse and medicines, and the Education Committee often helps in the training of the nurse. These nurses are sometimes employed as visitors for infant welfare work as well as for school work and occasionally for tuberculosis and
1 During 1920 fifty new maternity homes with over 500 beds were provided by local authorities and voluntary agencies in England and Wales.
2 On June I 1921 there were 1,789 infant welfare centres in Eng- land alone, 710 of which were voluntary.
are subsidized for such visiting through the association. Of course they must be under the Medical Officer of Health in respect of such work. The superintendent of the county nursing association may also be appointed inspector of midwives for the county. Usually wholetime visitors are employed in the larger towns. It is thought by some that the whole nursing service should be placed under the councils and the voluntary element done away with; others are strongly opposed to such a policy as tending to bureaucracy.
Work of Education Authorities. It is difficult to consider infant welfare work in Great Britain without taking into consideration also the work of Education Authorities to whom power was granted to carry on the work of medical inspection in 1908. As with infant consultations it was soon found that following up the cases in their own homes was essential if good was to be done, and very often the infant visitor carries out the visiting for both infants and school- children. The Mental Deficiency Act of 1913 also requires county and borough councils to do work which requires visitation. Unless care is taken there is serious danger of overlapping.
Training of Visitors. The training of infant visitors cannot as yet be said to be standardized. The training of a nurse is useful, but hospital experience alone is not sufficient, any more than is that of midwifery or the sanitary diploma. The Board of Education has now issued a regulation for the training of health visitors which is fairly complete, and includes theoretic training in physiology, hy- giene, and social work, as well as practical training in cookery and housewifery, and much work of various kinds at health centres. Voluntary workers with social knowledge and wide experience arc of great use. There were in 1920 3,359 health centres in England and Wales, and probably many more will be required.
Day Nurseries and Creches. In addition to the recognized infant welfare work, there are numerous day nurseries and creches which are eligible to receive Government aid. The mothers contribute a proportion of the cost. Nursery schools receive grants from the Board of Education under the Act of 1918 and creches come under the Ministry of Health. Children up to school age are taken by the former and infants by the latter. During the World War, when married women were working, these institutions were invaluable and, if well conducted, day nurseries form an excellent training ground for young women and girls. An endeavour has been made to obtain a service of " home helps " of a domestic sort to provide assistance for the mother before and after childbirth, but it has been found difficult to obtain candidates for training.
Infant Mortality. It appears that the association of a high birth- rate with a high infant mortality is a rule to which exceptions are rare. Thus it is the high birth-rate, despite its accompanying waste, rather than the low birth-rate and the greater saving of life that accompanies it, that dominates the increase of population. There is no doubt that the efforts made to preserve infant life have been a very effectual method of preserving the population, but this has not made up for the reduced number of babies born. The chief cause of the deaths of infants are (l) developmental, wasting diseases and convulsions; (2) diarrhoea and enteritis; (3) measles and whooping-cough, bronchitis and pneumonia. One-third of the deaths during the first year occur during the first months of life. What is called the " infant mortality-rate " is the number of infants dying under one year of age per 1,000 infants born. The follow- ing table shows the infant mortality-rate for England and Wales and the birth-rate for the corresponding year.
Infant Mortality-rate Birth-rate
(per 1,000 births). (per 1,000 of pop.).
1901-5 138 28-2
1906-10 117 26-3
1913 1 08 ,28-0
1916 91 20-9
1917 96 17-8
1918 97 17.7
1919 89 18-5
1920 80 25-4
This shows that the birth-rate has tended to fall as well as the infant mortality-rate, but the fall of the latter is remarkable and may be ascribed partly to the improved social conditions during and since the war, and partly to the definite work for child welfare, as well as to the decrease in the number of births. Where there is overcrowding and bad sanitary conditions child welfare work seems to do little to prevent infant mortality. The rate of mortality amongst illegitimate children is approximately twice as great as that amongst legitimate infants. The Ministry of Health has approved a number of Homes for single women before and after confinement as well as hostels where the mothers and children can live when the mother is able to take up daily work. The highest mortality amongst infants in England and Wales is found in the northern county boroughs which include the great industrial centres, and the least in the southern rural areas. It is to be hoped that with good midwifery and ante-natal service and better social conditions, the large infant mortality that now exists may be de- creased, for it is clear that the health of the mother and child is the first step towards the health of the community. The Midwives Act of 1902 and the provisions for maternity benefit in the Insurance
