The Politics of Motherhood: Child and Maternal Welfare in England, 1900-1939 9780773593251

Table of contents :
Cover
Title
Copyright
CONTENTS
List of Tables and Figures
A Note on References
Preface
Introduction
PART I: THE PROBLEM OF CHILD AND MATERNAL WELFARE
1. The Perceptions of Care-givers and Clients
PART II: SAVING THE INFANTS
2. 'The Ignorance and Fecklessness of Mothers'
3. Educating the Mothers
PART III: SAVING THE MOTHERS
4. The Medicalisation of Childbirth: Hospitalisation
5. The Medicalisation of Childbirth: Domiciliary Practice
PART IV: WOMEN'S DEMANDS
6. Economic Assistance
7. Birth Control
Conclusion
Appendix
Index

Citation preview

THE POLITICS OF MOTHERHOOD

THE POLITICS OF MOTHERHOOD CHILD AND MATERNAL WELFARE IN ENGLAND, 1900-1939

JANE LEWIS

ip CROOM HELM LONDON McGILL-QUEEN'S UNIVERSITY PRESS MONTREAL

© 1980 Jane Lewis Croom Helm Limited, 2-10 St John's Road, London SW11 ISBN 0-7099-0259-X British Library Cataloguing in Publication Data Lewis, Jane The politics of motherhood. 1.Maternal health services — England — History — 20th century 2. Medical policy — England — History — 20th century 3. Child health services — England — History — 20th century I. Title 362.1'9'8200942 RG964.G7 ISBN 0-7099-0259-X McGill-Queen's University Press 1020 Pine Avenue West, Montreal H3A 1A2 ISBN 0-7735-0521-0 Legal deposit 4th quarter 1980 Bibliotheque Nationale du Quebec

Printed and bound in Great Britain by Redwood Burn Limited Trowbridge & Esher

CONTENTS

List of Tables and Figures A Note on References Preface Introduction

13

PART I: THE PROBLEM OF CHILD AND MATERNAL WELFARE 1. The Perceptions of Care-givers and Clients

27

PART II: SAVING THE INFANTS 2. `The Ignorance and Fecklessness of Mothers'

61

3. Educating the Mothers

89

PART III: SAVING THE MOTHERS 4. The Medicalisation of Childbirth: Hospitalisation

117

5. The Medicalisation of Childbirth: Domiciliary Practice

140

PART IV: WOMEN'S DEMANDS 6. Economic Assistance

165

7. Birth Control

196

Conclusion

219

Appendix

227

Index

230

TABLES AND FIGURES

Tables 1.1 Age Specific Death Rates, 1921 and 1931 1.2 Estimated Average Size of Completed Family, Manual and Non-manual Workers According to Period of Marriage 2.1 The Three Main Causes of Infant Mortality (Per 1,000 Live Births), 1911, 1921, 1931 3.1 Number of Rooms Occupied by Families Attending the Islington Welfare Centre and School for Mothers, 1916, 1922 and 1930 4.1 Primary Avoidable Factors in Maternal Deaths, 1930-2 4.2 Place of Birth of Babies Born to Interviewees, 1905-39 4.3 Causes of Maternal Mortality, 1911-38 4.4 In-patients as a Percentage of All Maternity Patients at Three London Hospitals, 1911-38 5.1 Percentage of Births Attended by Midwives in Urban and Rural Areas, 1918-27 5.2 Percentage of Trained Midwives in Three Cities, 1911-35 5.3 Percentage of Midwives' Cases Resulting in Calls for Medical Aid, 1911-35 6.1 Infant Mortality Variation by Class (Mean for All Classes = 100) 6.2 Infant Mortality Variation by Class (Class II = 100) 6.3 Maternal Mortality in Selected Areas in 1924-8 and 1929-33 7.1 Crude Birth Rate, 1870-1932 7.2 Percentage Proportion of Deaths From Abortion to Those From All Puerperal Causes in England and Wales During the Years 1926-37 8.1 Percentage Married Females in the Workforce by Age Group, 1911, 1921 and 1931

45 48 62

99 118 120 122 133 142 143 149 178 179 180 199

210 222

Figures 1.1 Infant Mortality Rate and its Components, England and Wales, 1905-38 1.2 Maternal Mortality and Puerperal Sepsis Rates, England and

32

Wales, 1911-39 2.1 Diarrhoea Rate, Five-year Moving Averages, England and Wales; 1897-1912

37 63

A NOTE ON REFERENCES

All places of publication are London unless otherwise stated. Abbreviations used are as follows: BMA British Medical Association BM! British Medical Journal LGB Local Government Board MOH Medical Officer of Health PP

British Parliamentary Papers

PRO

Public Record Office

WCG Women's Cooperative Guild WLL Women's Labour League

PREFACE

I started the research for this book with a view to writing about women's and children's health during the early twentieth century. I began, therefore, with an interest in both women's history and the social history of medicine. Efforts to improve various aspects of maternal and child welfare began shortly after the Boer War and continued throughout the period, but what was particularly striking was the way in which policy-makers and the providers of health care equated improvements in maternal and child welfare with the development of a closely defined set of social services which by no means met the needs women themselves expressed. What required explanation was why particular social policies were developed, what their underlying assumptions were, and why other policy options were ignored. The development of social policy is usually described `from above', whether from the point of view of politicians, civil servants or the professionals involved. My early interest in women's history determined that I also keep the clients' point of view firmly in mind, both in regard to their reactions to the policies implemented and to their own demands for change. It is, then, the interaction between policy makers, the providers of health care and the female clients that I have in mind when I refer to the `politics' of motherhood. This approach brings to the forefront a number of important themes relating to women and social policy, namely, the relation between health and the family economy, the control of health care and control of reproduction. Many of these treat subjects of present day interest, for example, the medicalisation of childbirth, which has involved a loss of control by women over its management. It is important that we stop to examine the pedigree of our social policies and ask whether a policy developed under a specific set of social, economic and political conditions can continue to be relevant in a markedly different situation. It is as necessary to ask this of the policy to hospitalise births as it is of Keynesian theory. If many of the subjects treated in this book are topical, it follows that they were and are often controversial. As will become clear, the politics of motherhood are extremely complicated. I can only hope that the material presented here will contribute to an understanding of the issues involved. Many people have helped and encouraged me. I would like to extend

special thanks to Dr David Alexander, Sue Bruley, Karen Clark, Leonore Davidoff, Dr Ruth Pierson, Sue Richter, Dr K.B. Roberts, Mark Shrimpton, Dr J.N. Thompson and Jeff Weeks. I would also like to thank the Family Planning Association, the Medical Women's Federation, the National Association of Child and Maternal Welfare, the Royal College of Midwives, and the Women's Cooperative Guild for providing me with access to archival material; Miss E. Rhys-Williams, who generously allowed me to use her mother's papers; and the 83 women who consented to share with me their memories of maternity between the wars.

INTRODUCTION

During the early twentieth century the bete noire of those who sought to improve maternal and child welfare was the mother who claimed to know all about childbearing and childrearing because she had `born 12 and buried 8'. The cover of Mother and Child, a magazine serving the maternal and child welfare societies during much of the period, showed a Madonna-like mother watching over a healthy, contented baby-in-arms with a well-cared-for older child standing in the protective shadow of its mother. The campaign to `glorify, dignify and purify' motherhood and to transform this image into reality began in earnest soon after the Boer War, and by 1939 ante-natal care, skilled attendance in childbirth, infant welfare clinics, health visitors and hospital facilities for parturient women and infants were among the maternal and child welfare services available.' Child and maternal welfare services were developed earlier than most other health services. They were not connected with the poor law and were thus free of its stigma. Moreover, they were continually expanded despite the financial stringencies of the inter-war period. Campaigns mounted during `National Baby Week' or to `Save the Mothers' were full of emotional appeals for the protection of motherhood. The child and maternal welfare movement was endorsed by politicians from all parties and the early voluntary infant welfare organisations received impressive support from members of the medical profession working as medical officers of health, general practitioners and consultants. Women's groups also welcomed the new importance that attached to maternity as a result of the movement. The Women's Cooperative Guild, an organisation of married working-class women, campaigned before World War I for greater attention to the needs of mothers, and after the War and the granting of the vote, the organised feminist movement also began to stress the need for greater recognition of the mother's services. However, the aims and concerns of the groups involved in policy-making and of the women who used the services differed widely. The scope of the services offered was in fact very limited and by no means met the demands of women's groups campaigning for improvements in child and maternal welfare. Infant welfare services were strictly educational; health visitors and infant welfare clinics were not 13

14

Introduction

permitted to offer medical treatment and confined themselves to instructing mothers in infant hygiene. In the case of maternal welfare, attention was devoted principally to providing better medical care at parturition. But from the women's point of view help during pregnancy and at parturition was of little use if pregnancies were too frequent, or the mother overtired and undernourished, and advice on rearing children was ineffectual if the mother did not have the means to put it into practice. In brief, women's groups found it impossible to separate the need for personal health care services from the broader social and economic issues raised by maternal and child welfare. Thus they demanded both an extension of the services provided, to include for example simple medical treatment as well as advice on care at infant welfare clinics, and additional measures, such as direct economic assistance for mothers in the form of cash, milk and meals, and free access to birth control information at government clinics. Family allowances were eventually introduced in 1945, but there was little relaxation of government policy regarding access to birth control information. Moreover, government officials never considered family allowances and birth control as part of maternal and child welfare policy, which continued to be narrowly defined in terms of personal social services. When, for example, family allowances were eventually granted, they were more a part of the government's wider economic strategy than a conscious attempt to broaden maternal and child welfare policy. The gap between official policy regarding maternal and child welfare services and women's demands provides the structural framework for this book. It also begs the main questions addressed: why were some of the major needs articulated by women ignored and why did the services provided take the particular form they did? An examination of the aims of the groups making and implementing maternal and child welfare policy is central to both these questions. Politicians, members of the medical professions, civil servants (who in many cases were also trained doctors) and voluntary workers were all involved in child and maternal welfare work. In defining the scope of child and maternal welfare policy, these groups operated within the bounds of an implicitly accepted framework of ideas and values.' The belief that the family should be subject to minimal outside interference, attitudes towards broader issues such as poverty, which impinged on the whole problem of child and maternal welfare, and ideas as to the appropriate nature and extent of state intervention all played a part in limiting the scope of child and maternal welfare services. The specific form the services took can only

Introduction

15

be understood in relation to these broadly held beliefs and the assumptions of the predominantly male, middle-class policy-makers as to the proper role of the female clients they envisioned using the child and maternal welfare services. Also, at the administrative level, the interests of the various groups involved in child and maternal welfare work often came into conflict. Intra-professional rivalries between members of the medical profession, divisions between branches of government and suspicion between voluntary workers and state authorities all played a part in determining the nature of the services offered. Interest in child and maternal welfare began with the recognition that infant mortality was a problem of national importance. Medical officers of health had begun to record the number of infant deaths and to investigate their cause during the late nineteenth century. They had also been interested in the infant welfare work being done in France, where Gouttes de Lait promoted breastfeeding, providing pure modified cow's milk when this was impossible., weighed babies and gave advice on their care. With the aid of voluntary workers, who often came from the Ladies Sanitary Associations,3 a few similar programmes had been started in Britain, but infant welfare did not become a national issue until after the Boer War, when it became part of the drive to improve the quality and quantity of population and was included in the campaign to improve physical efficiency. Concern over physical efficiency first arose when attention was drawn to the poor quality of army recruits. The large amount of publicity that was generated led to the appointment of an Inter-departmental Committee on Physical Deterioration. The committee's report, published in 1904, devoted much attention to the welfare of infants and school children, recognising that it was in the national interest to safeguard the next generation and thereby improve the quality of the race.' The Education (Provision of Meals) Act of 1906, which provided for meals to be given to school children who needed them and the Education (Administrative Provisions) Act of 1907, which established medical inspection in schools, demonstrated clearly that the welfare of the young had become a matter of national concern rather than an object for private charity,' and it was primarily on these grounds that further government intervention in this aspect of family life was justified. In France, where state intervention to secure the physical welfare of school children and voluntary effort on behalf of infants had a much longer history, conscious pronatalism and a concern with the quality of the race had also provided much of the impetus to reform. Between 1910 and 1916, the Local Government Board issued

16

Introduction

regular reports on infant, and later maternal, mortality and the scale of local efforts to improve infant welfare during these years increased dramatically. The loss of population during World War I further increased awareness of the importance of infant life, and child and maternal welfare work was extended to include the ante-natal period. Again, state intervention was justified in terms of the national good and racial improvement. When the Ministry of Health was created in 1919, one of its six departments was devoted to maternal and child welfare. During the inter-war period increased emphasis was put on maternal welfare, for while infant mortality declined, maternal mortality actually increased slightly. Because government concern centred on the need to improve the quantity and quality of population, maternal and child welfare was measured exclusively in terms of mortality statistics. The range of maternal and child welfare services reflected the way in which the problem was approached. Maternal and child welfare was viewed in terms of a series of discrete medical problems, to be solved by the provision of health visitors, infant welfare centres and better maternity services. Issues associated with mortality, such as morbidity rates amongst married women, were pushed to the background, and the social, environmental and biological issues underlying the mortality figures tended to be ignored. Women were unable to separate their health problems from the wider fabric of their daily lives, but policy-makers neatly compartmentalised maternal and child welfare as a specific range of services. Responsibility for the care of women and children was assumed to rest in the hands of a male provider. There was, therefore, great reluctance to intervene directly in the private world of the family and its economy. Late nineteenth-century legislation on behalf of women and children had touched them only at the workplace or in the school, not in the home, for while it was recognised that any failure on the part of the male breadwinner to provide for his dependants left them helpless victims, it was also believed that family responsibilities provided the greatest incentive for men to work. This belief continued to exert a powerful influence and very few steps were taken to ease the burden of dependency during the early twentieth century. Thus, while the major innovation in health policy during the period, national health insurance (1911), provided a maternity benefit, dependent women and children were excluded from its main provisions and continued to pay for medical care. It was also feared that provision of school meals would threaten parental responsibility, though in this case the concern

Introduction

17

for the quality of the next generation overcame objections. It was more difficult to justify intervention on behalf of wives. Free dinners for pregnant women were therefore never made widely available and fierce objections were encountered to more far-reaching proposals for economic assistance for mothers in the form of family allowances. Attitudes and policies concerning poverty also ran counter to the demands of women's groups for direct economic assistance. The dominant nineteenth-century doctrine of `less eligibility', which set out to make state assistance less attractive than any form of work or self-help, gave way slowly and unevenly to the idea that the state had a responsibility to ensure first a `social minimum' for its population and later, during World War II, to provide an optimum standard of welfare for all. The main aim behind national health insurance, for example, was to keep the insured man out of the workhouse and to prevent pauperism caused by ill-health, rather than to build good health.6 During the 1930s in particular, any attempt to provide more direct economic assistance for women and children was likely to have severe political repercussions. Evidence that family poverty had a detrimental effect on health and well-being appeared in many of the social surveys and nutrition reports of the 1930s, but it was impossible to make direct provision for women and children without admitting that the wages of male breadwinners, especially those drawing unemployment benefit, were insufficient. And this was something no government dared do. It is true that some government officials, especially the Commissioner for the Special Areas, began to look favourably on the distribution of birth control information via government clinics to the unemployed. The aim here was purely a reduction in numbers and bore no relation to women's desire to control their own fertility. However, the spectacular decline in the birth rate provoked an outcry that made such a policy impossible. The demands of women's groups for policies to deal with low levels of nutrition, the inability of women and children to afford medical treatment and the poor health of the multiparous woman also came into conflict with the perceived responsibilities of the state. All child and maternal welfare policies involved an increase in government activity and expenditure. A line was drawn both in theory and in practice between what the state would and would not do, although on what criteria is much debated.' In practice, it appears that the state generally chose to meet need by limited indirect means or by direct conditional assistance. Both methods could be used to support individuals deemed worthy of help and ideally encouraged them to become self-supporting.

18

Introduction

Social policy based on universalist principles or involving intervention consciously to direct the course of the economy was rejected. Thus in dealing with unemployment, government countenanced labour exchanges, labour colonies and public works but drew the line at the sort of contra-cyclical spending advocated by the Minority Report on the Poor Laws in 1909 and the Liberal Yellow Book of 1928.8 Direct economic assistance in the form of unemployment insurance based on shared responsibilities was acceptable and the dole, made heavily conditional, was tolerated, but the socialist `right to work' policy which eschewed all conditions and required change in the organisation of industry and society was not. Similarly in the case of maternal and child welfare, services which concentrated above all on educating the mother in personal hygiene were preferred to direct economic assistance in cash or kind, such as family allowances, which were desired by women's groups for every mother and by the Independent Labour Party (ILP) as part of their programme for a living wage, which was designed to restructure industry and society. All governments struggled to maintain economic orthodoxy in the matter of balanced budgets during peacetime and any policy which threatened to increase financial burdens was feared. Government expenditure on social services had increased dramatically from under 4% of the gross national product up to World War Ito at least 8% of the GNP for every year between the wars. Moreover, during the inter-war years, the proportion of the social services budget devoted to social insurance and assistance alone never fell below 46%.9 Direct economic assistance for mothers was no more favourably regarded than that for men. For example, in 1932 married women's national health insurance benefits were cut despite the fact that any reduction in them was likely to affect nutrition and hence health standards. A shared awareness and acceptance of these philosophical, political and economic limitations affected the way in which maternal and child welfare policy was defined and was also reflected in the aims and assumptions behind the actual implementation of child and maternal welfare services.10 The principle aim of the majority of the child and maternal welfare services was to promote a greater sense of moral responsibility on the part of the mother. Child and maternal welfare services were personal and individual, health visitors advised mothers in their own homes and education on personal health care and nutrition was also given to girls at school and to mothers at infant welfare centres and at ante-natal clinics. Nineteenth-century social policy had been based on the belief that need was attributable to individual moral failure

Introduction

19

and the early infant welfare service reflected the close connection that existed between social and moral reform in Edwardian England." Health visitors and infant welfare centres set out to reform the character of the working-class mother and to inculcate the requisite sense of moral responsibility. Women's groups and social surveys claimed that poverty was a major factor causing infant mortality and ill-health amongst married women, but government officials went to considerable lengths to avoid treating poverty directly. Instead, mothers were to be encouraged to realise the value of self-help and to be taught how to make the best use of whatever resources they had. The emphasis placed on the importance of parental and especially maternal responsibility was underpinned by the commonly held assumptions as to women's proper role.12 Most health officials shared the contemporary belief that women's duties as mothers were allimportant. Infant mortality in particular was seen as a failure of motherhood. When child and maternal welfare workers spoke of the importance of women's responsibility as mothers, they referred to all social classes, though there was little doubt that they thought working-class women to be in greatest need of instruction. Nevertheless, even advice manuals aimed at the middle class emphasised the `scientific' aspect of motherhood and the instructions contained in them became more and more elaborate. While child and maternal welfare workers shared a common approach to the problem, at the administrative level the self-interests of, and tensions between, the groups involved served to further restrict the services offered. Because maternal and child welfare and particularly the problem of maternal mortality was treated primarily as a medical problem, the influence of the medical profession in formulating maternal and child welfare policy was particularly great. General Practitioners demanded that state clinics and infant welfare societies give nothing but preventive care so as not to threaten their private practice.13 In general, preventive medicine was kept separate from curative medicine and this was clearly the case in the field of infant welfare.14 With regard to childbirth, obstetricians used the interest in child and maternal welfare and the desire to reduce maternal mortality to advance their own neglected speciality. Maternal mortality was regarded as a problem requiring expert attention, even though contemporary advances in medical knowledge had little effect on the services that were offered. It was the application rather than the discoveries of medical science that was crucial. For example, the use of antiseptics and the need for scrupulous cleanliness in the delivery room had been discovered

20

Introduction

in the late nineteenth century but had not been rigorously applied. Nevertheless, more medicalised childbirth was promoted as the best way of reducing mortality and the best possible care was equated with that provided by an obstetrician in a teaching hospital. This view was not supported by the GP who relied heavily on domiciliary deliveries to build up his practice. GPs, midwives and consultants each sought to assert the importance of their role in the development of child and maternal welfare services. Conflicts also arose between the Local Government Board and the Board of Education and between the central government and local authorities over responsibility for the implementation of policy. These struggles were paralleled by antagonism between voluntary workers, who ran the early infant welfare organisations and clinics, and government officials. For in spite of the government's public acknowledgement and encouragement of voluntary effort and the desire of many volunteers to continue their work, much of it was taken over by the state during World War I. Despite the gulf between the demands of women's groups and the official definition of what constituted a child and maternal welfare service, women did welcome the services that were offered. Working women's groups and middle-class women's organisations approved the new emphasis on motherhood, hoping that the status of women who stayed in the home would rise. Few of them were conscious of the full implications of their additional demands for free access to birth control information, to reduce the amount of disability resulting from or exacerbated by frequent pregnancies, and direct economic assistance for mothers in the form of free milk, meals and family allowances. These demands seemed obvious to women with first-hand knowledge of the problems faced by women with large families, small incomes and poor health. But child and maternal welfare policy was intended to save lives and promote an increase in population, not to limit it by making birth control advice widely available. Similarly, healthier motherhood was meant to strengthen the family, not threaten it by giving economic assistance to mothers and undermining the responsibility of fatherhood. It was ironic that in prescribing middle-class ideas of responsible motherhood, child and maternal welfare policies often discouraged already existing patterns of mutual aid between women. For example, the health visitor competed with the grandmother and neighbours for the role of adviser, and the local authority-approved home help and the trained midwife with the `handywoman', who was proscribed by law but highly valued by working-class women, because she both delivered the baby and looked after the family. The leaders of working women's

Introduction

21

organisations also had occasion to deplore the patronising attitudes which child and maternal welfare workers often exhibited towards their clients. It is also worth considering how far those involved in making child and maternal welfare policy actually created the needs they set out to meet. For example, the specialists consulted on the question of maternal mortality advocated hospitalisation as the best way of lowering mortality. It was natural that articulate women's groups should then demand what they were told was the best form of care, although how representative their views were of the whole female population is difficult to assess. A final balance sheet of gains and losses cannot be drawn up. It would be impossible to decide whether the decrease in infant mortality could or should be weighed against a subtle strengthening of the ideology of motherhood, or better medical care in childbirth against the loss of control by women over its management. But it is important to be aware that all this happened and that neither changes in medical practice nor in social policy, both of which were so important in determining the shape of maternal and child welfare services, can be assumed to have been benevolent. A similar realisation recently caused women's groups in Britain and North America to question the routine intervention in childbirth which characterises hospital practice, and to promote breast- rather than bottlefeeding.ls These demands have been accompanied by the perception that female experience has been dominated by male practitioners, which has also informed recent historical inquiry into the relationship between women and medicine." In this study, the main goal is to attempt to understand and explain the mechanisms at work in structuring and controlling a social welfare movement of material and ideological importance to women.

Notes 1. Infant life protection laws, provision for the child between one and five years and provision for the unmarried mother may also be legitimately defined as maternal and child welfare services, but these are not included within the scope of this study. 2. I found Alan Ryan's article, `Utilitarianism and Bureaucracy : the views of John Stuart Mill' in Studies in the Growth of Government, edited by Gillian Sutherland (NJ : Rowan and Littlefield, 1972), pp. 33-62, helpful on this point. 3. For the work of the Ladies Sanitary Associations, see W.C. Dowling, 'The Ladies Sanitary Association and the Origins of the Health Visiting Services', MA dissertation, LSE, 1963.

22

Introduction

4. PP, 'Report of the Inter-Departmental Committee on Physical Deterioration, Vol. I', 1904, Cd. 2175, XXXII, 1. For more general information on the campaign for physical efficiency, see G.R. Searle, The Quest for National Efficiency (Oxford UP, 1971), pp. 59-67. Bernard Semmel, Imperialism and Social Reform (Allen and Unwin, 1960), and Michael Freeden, The New Liberalism (Oxford: Clarendon Press, 1978) also deal with aspects of the efficiency movement. 5. B.B. Gilbert, The Evolution of National Health Insurance in Great Britain. The Origins of the Welfare State (Michael Joseph, 1966), pp. 102-58, deals with these measures in detail. 6. This is also the view of B.B. Gilbert, British Social Policy, 1914-1939 (Batsford, 1970), pp. 260-1. Frank Honigsbaum, The Struggle for The Ministry of Health, 1914-1919, Occasional Papers on Social Adminisation no. 37 (G. Bell and Sons, 1970), p. 12, disagrees and argues that Lloyd George did favour the extension of national health insurance into a more comprehensive health service from the very start. It is of course possible that national health insurance was designed to meet both these ends, but if Honigsbaum is right, then the neglect of women and children's health at a time when infant mortality was such an important issue needs comment. 7. H.V. Emy, Liberals, Radicals and Social Politics, 1892-1914 (Cambridge: Cambridge UP, 1973); Freeden, The New Liberalism; Jose Harris, Unemployment and Politics, 1886-1914 (Oxford UP, 1972); and Donald Winch, Economics and Policy. A Historical Study (NY: Walker and Co., 1969) all have different views on this issue. 8. PP, 'Report of the Royal Commission on the Poor Laws and Relief of Distress', 1909, Cd. 4499, XXXVII, 1, p. 2216, and Britain's Industrial Future. Report of the Liberal Enquiry (Liberal Publications Department, 1928). 9. Alan T. Peacock and Jack Wiseman, The Growth of Public Expenditure in the UK (Princeton: Princeton UP, 1961), p. 91. 10. John Goldthorpe, 'The Development of Social Policy in England, 1800-1914', Transactions of the 5th World Congress of Sociology, 4 (1962), pp. 41-56, and Phoebe Hall et.al., Change Choice and Conflict in Social Policy (Heinemann, 1975) both stress the importance of considering the `ends' of social policy as well as the 'needs' of society. 11. This point is elaborated for an earlier period by Brian Harrison, `State Intervention and Moral Reform in Nineteenth Century England', in Pressure from without in Early Victorian England, edited by P. Hollis (Arnold, 1974), pp. 289-322. 12. Hilary Land, 'Women : Supporters or Supported?' in Sexual Divisions and Social Process and Change, edited by Diana Leonard Barker and Sheila Allen (Tavistock, 1976), pp. 108-32, and Robert Pinker, `Social Policy and Social Justice', Jrnl. of Social Policy, 3 (Jan. 1974), pp. 1-19, have both pointed out the traditional assumptions as to women's place in the Beveridge Report. Elizabeth Wilson, Women and the Welfare State (Tavistock, 1977) also shows how the ideology accompanying social policy has had important effects on women. 13. During the 1930s similar fears also led the BMA to question the function of municipal hospital outpatient clinics (Brian Abel-Smith, The Hospitals, 18001948 (Cambridge, Mass.: Harvard UP, 1964), pp. 379-80. 14. Many others have commented on this phenomenon. See for example: John Gordon Freymann, `Medicine's Great Schism: Prevention vs. Cure: An Historical Interpretation', Medical Care, 13 (July 1975), pp. 525-36; George Rosen, 'Historical Trends and Future Prospects in Public Health' in Medical History and Medical Care, edited by Gordon McLachlan and Thomas McKeown (Oxford UP, 1971), pp. 59-81; Asa Briggs, `Making Health Every Citizen's Birthright: The Road to 1946', New Society, 46 (16 Nov. 1978), p. 383. On the

Introduction

23

separation between preventive and curative practice in infant care especially, see Cicely D. Williams and Derrick B. Jeliffe, Mother and Child Health: Delivering the Services (Oxford UP, 1977), p. 19. 15. Danae Brook, Naturebirth (Penguin, 1976), Appendix III, pp. 275-7, lists some of these groups. 16. See for example, Carol Smith-Rosenberg, 'The Hysterical Woman: Sex Roles and Conflict in Nineteenth Century America', Social Research, 39 (1972), pp. 652-78; Ann Douglas Wood, The Fashionable Diseases: Women's Complaints and their Treatment in Nineteenth Century America', and Regina Morant, 'The Lady and her Physician', both in Clio's Consciousness Raised, edited by Lois Banner and Mary Hartman (NY: Harper, 1974), pp. 1-22 and 38-53.

PART I THE PROBLEM OF CHILD AND MATERNAL WELFARE

1

THE PERCEPTIONS OF CARE-GIVERS AND CLIENTS

Concern over the quality and quantity of population legitimised both infant and maternal welfare work and caused it to concentrate on securing a reduction in mortality rates. The major clinical causes of infant and maternal mortality were established and the services directed towards preventing them. Infant and maternal mortality rates and general health standards were also adversely affected by frequent pregnancies, poor living conditions, poor nutrition and overwork, but these broader aspects of child and maternal welfare were not tackled. The 1904 report of the Inter-departmental Committee set up to inquire into physical deterioration contained a long section on the high infant mortality rate, which was considered as symptomatic of poor general health standards as the physical deficiencies of army recruits, although some witnesses voiced the opinion that a high infant mortality rate weeded out the unfit and thus improved the quality of population.' In 1904, the Registrar-General also included an extensive analysis of infant mortality in his Annual Report. Other government reports followed, all of which described the incidence of infant mortality and attempted to determine the cause. During World War I, it was also realised that maternal welfare and maternal death were related to foetal and neonatal death.' Care of the mother thus became part of the campaign against infant mortality. Maternal mortality became an important issue in its own right during the inter-war period because, whereas the infant mortality rate declined dramatically, the maternal mortality rate rose, making it very difficult to justify the encouragement being given to women to have more children. Mortality rates were the chief measures of infant and maternal welfare used. Certainly, both the infant mortality rate and the maternal mortality rate were, and generally are, sensitive indices of social and economic development. However, having defined the problem of infant and maternal welfare in terms of two rates, policies were increasingly aimed at improving the rates as such, rather than solving the problems which they attempted to quantify. Because of this, the attempt to prevent the clinical causes of first infant and later maternal deaths was made without due attention to the underlying social, environmental and biological causes common to both. The extent to which the official solutions were responsible for causing the eventual decline in infant and 27

28

The Perceptions of Care-givers and Clients

maternal mortality is beyond the scope of this study.3 What is at issue here is the way in which the government's purpose in dealing with child and maternal welfare largely determined the way in which the problem was approached and the policies which evolved. The fust part of this chapter examines the concerns of health officials involved in maternal and child welfare work and shows how these both modified the extent to which they believed infant and maternal mortality rates could be reduced and determined the lines along which solutions were developed. The second part looks at the problem of maternal and child welfare from the mother's point of view, showing the gap between the needs of childbearing women and the official perception of their problems. Social surveys of the period and recent work on the distribution of income within the family indicate that women as a group had the poorest standard of living. What evidence there is also suggests that the general level of women's health during the period 1906-39 was low. Women's groups recognised that the circumstances under which women bore and raised children were central to child and maternal welfare.

I Official Perceptions In their reports, health officials involved in infant welfare work emphasised above all the number of infant lives saved. The Local Government Board (LGB) and, after 1919, the Ministry of Health, issued five reports on infant mortality between 1910 and 1916 and six major reports on maternal mortality between 1916 and 1937. In 1910, Arthur Newsholme, Chief Medical Officer at the LGB and author of the reports of infant mortality, spoke of `the widespread awakening to the national importance of child mortality' that had taken place between 1906 and 1910, and which had culminated in John Burns, the President of the LGB, requesting a report on the subject. In 1913, his second report stressed that when the infant mortality rate for the years 1906-12 was compared to the rate between 1899 and 1905, it could be calculated that 185,722 lives had been saved. John Burns himself made a point of announcing in 1909 that 15,000 lives had been preserved between 1908 and 1909 due to the fall in infant mortality.4 The concern to stop the wastage of infant life became even more explicit during World War I. An article in the British Medical Journal entitled `War Wastage and the Birth Rate' urged greater attention to the problem of infant mortality in view of the double threat to population.s

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29

In its report for 1915-16, the LGB argued that `at a time like the present there is urgent need for taking all possible steps to secure the health of all mothers and children and to diminish ante-natal and postnatal mortality'.6 The National League for Physical Education and Improvement put out a book in 1916 called Life-Saving in War Time: A Campaign Handbook, in which it was argued that if infant mortality was reduced it was probable that more males would be saved than females because the male infant mortality rate was higher.' This was a popular wartime argument. A similar point was made in the Carnegie Trust Report on Maternal and Child Welfare in 1917: The value of population has never been appreciated as it is today, and regrets at the unheeded wastage of infant life in bygone years are as sincere as they are useless, a simple calculation shows that had the annual wastage of male infant life during the last 50 years been no greater than it is at present, at least 500,000 more men would have been available for the defence of the country today.' Obviously, these health officials believed that in large part infant mortality could and should be prevented. But while it was agreed that a larger population was essential, eugenists anxious to breed a better race feared that intervention to save infant life would interfere with natural selection and thus work against rather than towards improving the quality or physical efficiency of the race. The Inter-departmental Committee appointed to investigate physical deterioration had found no clear evidence of inherited physical degeneracy, but many eugenists nonetheless believed this to be the true nature of the problem, in which case the only solution was to eliminate the `unfit'. A high infant mortality rate was regarded as one of the most efficient ways of doing this. Many health officials believed national deterioration to be a serious threat and they took eugenics seriously. While they could not accept the extreme eugenist view that environment played no part in infant mortality, they nonetheless accepted racial efficiency as an important goal and did their best to show that infant welfare work contributed to it? George Newman, Chief Medical Officer to the Ministry of Health, put the need to consider `eugenics and the principles of sound breeding' first in a policy of preventive medicine.10 Nevertheless, Newman believed that nurture as well as nature played an important role and stated in his major work on infant mortality that `a high infant mortality rate almost necessarily denotes a prevalence of those causes and

30

The Perceptions of Caregivers and Clients

conditions which in the long run determine a degeneration of the race'." Thus infant welfare work would improve rather than impede racial progress. As another author put it: `In searching for the cause of a polluted stream one naturally traces it backwards and towards its source .. .'12 The unfit army recruits who sparked the inquiry into national deterioration had once been infants. In his first report on infant mortality made in 1910, Newsholme felt obliged to stress that a high infant mortality rate was associated with a high mortality rate of children aged 1-5 years because many of the environmental causes at work were similar: This comparison [between the two mortality rates] is important, because attempts to reduce infant mortality are regarded by many as an interference with natural selection, which must be inimical to the average health of those surviving ... The statistics ... do not support this view.13 Karl Pearson, Galton Professor of Eugenics at University College, criticised Newsholme's report in the Cavendish Lecture of 1912 and the Chadwick Lecture of 1913, maintaining that `a low infantile death rate does mean a high delicacy rate and it is far from demonstrated that a physically and mentally efficient population will be created by preserving more infant lives'.14 No fewer than six pages of Newsholme's second report in 1913 were devoted to answering Pearson's criticisms. Not all eugenists went as far as Pearson. C.W. Saleeby, for example, rejected the ideas of what he called `the better-dead school', believing that `racial poisons', such as syphilis and alcohol were responsible for a large percentage of infant deaths and that these could be prevented." However the `better-dead' school was given additional impetus when the Registrar General's Annual Report for 1911 showed clearly that middle-class fertility was declining faster than working-class fertility due to the increasing use of contraceptives. For it was working-class infants who tended to die in the greatest numbers and eugenists argued that further intervention to save them would increase further the class differential. This possibility was viewed with alarm because `fitness' tended to be equated with socio-economic status.' During World War I, the powerful desire to increase population tended to overshadow concerns as to quality and infant welfare work was extended. The continuing decrease in the birth rate during the inter-war period had a similar effect. However, Pearson continued to insist that heredity was a more important factor than environment in causing infant deaths and the Eugenics

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31

Review reflected his ideas: `From every point of view, we can best afford to lose the lives of infants', for by their very deaths they `offered the strongest possible presumption of inherent worthlessness'." The commitment of health officials to seek the greatest possible decrease in the infant mortality rate was clearly shown by the large attendance of medical officers of health at the National Conferences on Infant Mortality held in 1906 and 1908. Yet eugenist arguments were not without effect. A few physicians were tempted to agree with the eugenists. For example, as late as 1940, Sir Robert Hutchinson, President of the Royal College of Physicians, reflected: `One cannot help wondering, indeed, whether the stinting production and careful saving of infant lives today is really, biologically speaking, as wholesome as the mass production and lavish scrapping of the last century'.'$ Others compromised by attempting to justify infant welfare work on eugenic grounds. The most dramatic decline in the infant death rate took place amongst infants aged 1-12 months, the period referred to as postneonatal (see Figure 1.1). Common infectious diseases, especially bronchitis and pneumonia, TB diseases, diarrhoea and enteritis were the most common causes of death during this period. It was generally recognised that these causes of death had little to do with heredity, although many still believed TB to be inherited. Certification of the cause of deaths taking place during the first month of life (neonatal deaths) was vague. The most common cause was described as `developmental and wasting diseases,' which included atrophy, marasmus and debility, prematurity and congenital malformations. By World War I certification practices were beginning to change and the number of deaths recorded under the category atrophy, marasmus and debility declined and the number under prematurity increased.19 Most of these were widely believed to be due to hereditary weakness. Many doctors were therefore anxious to point out that the great decline in infant mortality was due to the decline in the post-neonatal rather than the neonatal death rate and, moreover, believed that the number of neonatal deaths neither could nor should be decreased. In 1904, S.G. Moore, an authority on infant mortality and Medical Officer of Health for Huddersfield, divided the causes of infant mortality into three categories: preventable, unpreventable and doubtfully preventable. All causes of death during the first month were listed as unpreventable.20 Dr Charles Porter referred to the mortality of the first month as `a rapid weeding out of weaklings',21 and Newman described these infants in 1906 as `not so much diseased as merely unfit and either not ready or not equipped for a separate existence'.22

RATE PER 1000

Figure 1.1: Infant Mortality Rate and its Components, England and Wales, 1905-38

IMR

/..^. \•/ '_ i '.. I 1 J 1

IMR = Infant mortality rate; NMR = Neonatal mortality rate; PMR = Post-neonatal mortality rate.

--.` NMR PMR

T

YEAR

1910

1920

1930

N

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33

During World War I, it was realised that foetal and neonatal deaths were associated with the mother's welfare, and the overwhelming desire to increase population caused infant welfare work to be extended to the ante-natal period. However the old fears regarding natural selection did persist. In 1923, the Medical Officer of Health for Sheffield argued that infant welfare schemes in Sheffield did not save many neonates and none dying from congenital defects, which he believed accounted for most of the deaths amongst infants of unemployed (and therefore hereditarily inferior) parents 23 In his 1936 report as Chief Medical Officer at the Ministry of Health, Newman again rejected the idea that improvement in the environmental conditions of infancy allowed the unfit to survive. He pointed out that because most of the life saving was done between 1 and 12 months, it was the fitter infants who were helped to survive.24 Thus most early infant welfare work aimed to prevent the infectious and diarrhoeal diseases common during the last 11 months of infancy. Infant welfare work on a national scale was started by the National Conference on Infant Mortality, which met in 1906 at Leeds, with 20 medical officers of health and councillors from Newcastle, Leeds, Edinburgh, Greenock, Wakefield and Huddersfield present. An executive of 13 medical officers of health, including Newsholme, at that time MOH for Brighton, and Newman, then MOH for Finsbury, and 5 councillors was elected. The committee approached no fewer than 73 eminent people to become vice-presidents and John Burns became President of the Conference. His impassioned speech at the 1906 National Conference showed how active government concern was. Many medical officers of health and physicians were involved in the infant welfare departments of the numerous local health societies that sprung up after the Inter-departmental Committee on Physical Deterioration made its report in 1904. For example, Eric Pritchard, a specialist in infant care and founder of the Society for Infant Consultations in 1911, was closely associated with the work of the St Marylebone Health Society, founded in 1906. Before World War I the majority of infant welfare work was done by voluntary societies and organisations which ran centres where infants could be weighed and advice given on their care. There were two main societies involved in this work. The National Conference on Infant Mortality, which was founded in 1906, became the National Association for the Prevention of Infant Mortality and the Promotion of the Welfare of Children under School Age in 1912, and in 1911 the Association of Infant Consultations and Schools for Mothers was set up as a department

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The Perceptions of Care-givers and Clients

of the National League for Physical Education and Improvement. This became the Association of Infant Welfare and Maternity Centres in 1930. By 1916, there were 160 branches of voluntary organisations and 35 local authorities running infant welfare centres. After the outbreak of war government activity intensified. The LGB issued circulars urging local authorities to set up more infant welfare centres and to extend infant welfare work to deal with the ante-natal period and the child between 1 and 5 years. An outline of a complete welfare scheme was issued to local authorities and a 50% grant was made available to defray the expenses incurred by appointing health visitors and running centres.25 After 1915 parents and medical attendants were also obliged to notify the authorities of all births, so that arrangements could be made for the infant to be visited by a health visitor and the mother encouraged to attend the infant welfare centre, something the National Conference on Infant Mortality had pressed for. Some areas, for example Bradford, had implemented a scheme of voluntary notification as early as 1908. Finally, in 1918, a Maternal and Child Welfare Act was passed, which required each local maternal and child welfare authority to set up a maternal and child welfare committee and enabled, though it did not compel, these local authorities to provide a full maternal and child welfare service, including salaried midwives, health visitors, infant welfare centres, day nurseries and milk and food for necessitous mothers and infants. The Act was strongly opposed on the grounds that it would prove an inadequate measure and because it posed a danger to negotiations with the insurance societies over the formation of a Ministry of Health. (The insurance societies feared losing control over the administration of the maternity benefit, which had been included in the National Health Insurance Act of 1911.2') The amount of voluntary infant welfare work also increased during World War I, although not as dramatically as that of the government. A National BabyWeek Committee organised a week-long publicity campaign on the subject of infant mortality in 1917, which became an annual event, and a group of well-to-do women started a Children's Jewel Fund, the idea being that each one gave `a jewel for a Baby's life'. When the fund closed in 1920, £700,000 had been collected. In the course of infant welfare work during World War I, attention was also directed towards the welfare of mothers. Newsholme's fourth report on infant mortality, issued in 1915, also addressed the problem of maternal mortality because: The great reduction in national fertility, especially when considered

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35

in connection with the great loss of fathers and potential fathers now occurring in war, emphasizes the importance of considering the causes of infant and child mortality with a view to their reduction and of thus maintaining effective fertility to the utmost practical extent. This is considered in the present report chiefly from the stand point of the mother ... To a very large extent the same causes operate in producing extensive maternal mortality and excessive infant mortality the first few weeks after birth and still more in the ante-natal period.27 When Newsholme declared his intention of considering the problem of infant mortality from `the standpoint of the mother', what he meant was that the welfare of the child depended in large part on the welfare of the mother and thus prevention of maternal mortality was `as much in the interest of the child as the mother'.28 Child life, not maternal welfare, was still the focus of attention. In St Pancras, where some of the earliest infant welfare work was done, the medical officer of health provided an early expression of the view that the mother's welfare was crucial in determining that of her child. The mother was advised `to take care of her health so as to make her infant strong at birth, prepare herself to suckle her baby and pay special attention to the nipples'.29 In 1918, Dr Charles Porter admitted that maternal welfare schemes were intended to further reduce infant mortality as more lives could be saved if attention was paid to the antenatal period.30 Ante-natal care of the mother began with the idea of protecting the foetus. Ballantyne's classic text on the subject, published in 1904, made no mention of safeguarding the mother31 and in 1914 both Amand Routh, an eminent physician, and A.K. Chalmers, Medical Officer of Health for Glasgow and a founder of the National Conference on Infant Mortality, advocated ante-natal care as a means of bringing down the infant mortality rate.32 Similarly, during World War I, the term 'postnatal care' was synonymous with infant rather than maternal care. No routine post-natal check-ups were given to mothers. If treatment was received it was given in the gynaecology wards of hospitals rather than in maternity and child welfare centres. Women's groups such as the Women's Cooperative Guild, which took an active part in the maternal and child welfare campaign, were concerned to emphasise the needs of the mother. In 1917, the Women's Cooperative Guild's memorandum on maternity insisted that `the care of the mother should have equal consideration with that of the infant'.33

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The Perceptions of Care-givers and Clients

At a 1921 conference on infant welfare, a guild representative asked infant welfare workers to put the welfare of the mother before that of the child.34 The guild did not support the maternal and child welfare campaign as a means of increasing population. As early as 1911, the Woman's Corner in the Cooperative News welcomed the declining birth rate because infant mortality was so high and because it was felt that women could not cope with the huge burden of frequent childbearing and childrearing.35 However, the guild justified its views by appealing to eugenic sentiment. It advertised its national maternity scheme as a programme to protect the `mothers of the race' and as a means to create `an Al motherhood'.36 Dr Porter insisted that by 1918 it was generally acknowledged that healthy mothers were an asset to the nation in their own right as well as on account of the healthier children they might raise.37 Certainly by 1924 much more attention was paid to mothers but this was chiefly because of the rising maternal mortality rate. The first government report on maternal mortality appeared in 1924. During 1918-19 the maternal mortality rate rose sharply (due to the influenza epidemic and an outbreak of sepsis) falling back to pre-war levels in 1921. But from 1923 onwards, it rose again, remaining at over 5 per 1,000 until 193638 (see Figure 1.2). The absolute numbers of women who died in childbirth were small and puerperal mortality was by no means the main cause of death in married women aged 15-44. During the periods 1911 to 1920 and 1921 to 1930, TB was by far the greatest killer, accounting for 24% of deaths in the first period and 26% in the second. Maternal mortality was the second largest cause of death, accounting for 17% of all deaths in both periods. However, it was the only major cause of death to show an increase during the inter-war period. Politically the question of maternal deaths was very difficult to deal with. The maternal and child welfare movement had stressed the importance of women's role as mothers, and this view was reflected during a debate in the House of Commons in 1927 on a bill to remove the prohibition on married women's work which operated in many of the professions. Many MPs objected to a bill that would encourage women to neglect their all-important `natural duties' and it was rejected 39 Yet, when childbirth was so dangerous, it was difficult for MPs to openly encourage women to have more children. The problem became more urgent during the 1930s when the birth rate reached its lowest point. Moreover, the decline was greater amongst the middle class than amongst the working class. Eugenists and MPs were especially concerned to increase the middle-class birth rate,40 but, unlike infant mortality,

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Figure 1.2: Maternal Mortality and Puerperal Sepsis Rates, England and Wales, 1911-39 8

RATE PER 1000

Maternal mortality rate

0 1911

1820

1830

1939

38

The Perceptions of Care-givers and Clients

maternal deaths appeared to be as common amongst the middle as the working class. For example, the maternal mortality rate in 1931 in Chelsea was 5.4 while in Hackney it was 3.2 per 1000. During the inter-war period, most academic opinion agreed that underpopulation rather than overpopulation was the main threat. The existence of both theories is confusing. The child and maternal welfare literature is preoccupied with the idea of underpopulation and of raising a better imperial race. But, as Ian Drummond has pointed out, Leopold Amery (Colonial Secretary between 1924 and 1929) used the idea of overpopulation, especially in regard to `surplus women', in his campaign for Empire settlement.41 By the 1930s, though, Amery was an equally determined underpopulationist. Keynes also believed that Britain was overpopulated during the 1920s, but, by the 1930s, he too had been converted to the underpopulationist point of view and warned of the effect a declining birth rate would have on levels of consumption and hence on unemployment. (According to William Petersen, this was a crucial development in the formulation of his General Theory)42 A few demographers and physicians believed physiological causes to be responsible for the decline in the birth rate and used the apparent inability of many women to breastfeed as proof that the reproductive organs were atrophying.43 However, most recognised that the decline was caused by increased use of contraceptives. Fear of pain in labour and death in childbirth, together with economic motives, were thought to be the main reasons for their use. This was part of the reason why MPs of all parties pressed for better maternity services and the introduction of family allowances during the late 1930s. Many attempts were made to predict the rapidity and extent of population decline. Demographers used the net reproduction rate, a fertility measure derived by Robert Kuczynski, to measure the degree to which the present population was replacing itself.44 However it was impossible to produce sophisticated population projections because the age of the woman at marriage and at the birth of her children was not recorded. No marriage cohort analysis was therefore possible. In 1933, the net reproduction rate fell to .75, while demographers insisted that it had to be raised to two to ensure the survival of the race.45 The population projections made on the basis of the low net reproduction rates of the 1930s made sensational reading. The best known was Enid Charles's The Twilight of Parenthood, which gave three forecasts using different base years. The most gloomy prediction assumed that fertility and mortality rates would follow the trend set during the decade 1924-34, in which case, population would begin to decline in 1939 and by the year

The Perceptions of Care-givers and Clients

39

2033 the total population of England and Wales would be no larger than that of the county of London in 1934. Other predictions made under the auspices of the influential Population Investigation Committee, set up in 1935 by A.M. Carr Saunders, were equally pessimistic 46 These forecasts attracted much publicity. Carr Saunders wrote two long articles on the population question for the Daily Telegraph in 1937, and the BBC broadcast a series of talks on the subject.47 Several popular books also appeared on the market. Two were written by G.F. McCleary, former MOH for Battersea, who was also actively involved in the child and maternal welfare movement and who wrote two accounts of its early history.48 Parliament debated the population issue several times and in 1938 passed the Population (Statistics) Act, which required such information as the mother's age at the birth of each child to be recorded. The publicity accorded the high maternal mortality rate was disturbing because of the possible effect on the birth rate, and it was also politically embarrassing. The government itself had been responsible for drawing public attention to the issue when maternal mortality was made the subject of an official report, issued in 1924. Having helped create public concern, it was placed in a difficult position when the maternal mortality rate failed to decline. In 1927, an influential unofficial Maternal Mortality Committee was formed by May Tennant and Gertrude Tuckwell to lobby Parliament on the issue. May Tennant was one of the few women to have been involved in the early infant welfare societies and had been a superintending Inspector of Factories before her marriage to H.G. Tennant, the Liberal MP, in 1896. On at least one occasion there is a record of her entertaining the Minister of Health socially and at the same time pressing the views of her committee.49 The majority of the committee's members were titled and similarly wellconnected.50 Gertrude Tuckwell was a prominent trade-unionist and represented the interests of Labour women on the committee. The Labour Party was also committed to providing a national maternity service and raised the issue continuously throughout the 1930s.51 The government was well aware of the political advantages presented by the issue of maternal mortality. During the course of a debate on population in 1937, Duncan Sandys, a Conservative MP, tersely reminded a Labour MP that his party did not have a monopoly of concern over mothers.52 While the government was obliged to go on seeking a solution to the problem it tried to play down its significance. In 1932, Newman suggested in a departmental memorandum that the birth rate had already been adversely affected by the publicity accorded

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maternal deaths and that it would therefore be inadvisable to draw more attention to the issue.53 Unfortunately, the final report of a departmental committee appointed to investigate maternal mortality was published in the same year and stated that in 45.9% of the deaths investigated a `primary avoidable factor' could be isolated and that these deaths could therefore have been prevented.54 The unofficial Committee on Maternal Mortality set up by Tennant and Tuckwell made much of the fact that as many as half of all maternal deaths were preventable.55 A 1937 government report on the subject expressed the irritation felt by the Ministry of Health at the way in which the findings of one of its own committees kept on being used against it. The report commented that no branch of public health had been subjected to such stringent criticism as that of maternal and child welfare. It noted that the absolute number of maternal deaths was very small and suggested that the public had been led by the 1932 findings to think that the causes of maternal mortality were simple when in fact the reverse was true.56 The Ministry of Health's attitude towards the unofficial Maternal Mortality Committee also became defensive. The department had supported the appearance of the Minister of Health, Neville Chamberlain, at the annual conferences of the committee held in 1928 and 1929, because the committee `gingered up LAs' and `on the whole ... kept an even keel', confining itself to `suitable' propaganda.S7 But in 1934, it was decided that the minister should not attend the committee's annual conference (now regarded as an unwelcome event), chiefly because he had nothing to say. When the committee expressed its disappointment at the lack of any new initiatives in the 1937 report, the Ministry of Health dismissed its criticism as `amateurish' and deplored its `lack of discretion'.58 A 1937 government circular sought to reassure women on the subject of death in childbirth: `The young married woman can be told with confidence that if she is in normal health and will take ordinary and sensible precautions ... the risk she will run in childbirth need be no matter of anxiety.i59 The medical profession was also perturbed by the adverse publicity the maternal mortality issue gave the doctors and supported the government's view that the nature of the problem was administrative and scientific, demanding specialist study rather than public debate.60 In addition, the women's press sought to reassure its readers. Woman's Own devoted nine articles to the question of safer motherhood in 1936, and told its readers confidently that while `every now and again ... a calamity occurred',61 the figures were misleading, for frequently the woman had been in poor health or had not sought medical

The Perceptions of Care-givers and Clients

41

aid. Home Notes sought to reassure by avoiding the subject: Even the wives who flatter themselves that they are too sensible to believe such rubbish, have their little weaknesses. Probably they read the papers and get all hot and bothered by statistics about maternal — no, I won't even let the word creep into this article.62 Interest in maternal welfare had begun as an adjunct to the main goal of the child and maternal welfare movement: the saving of infant life. However the intractability of the maternal mortality rate complicated the issue. In one sense the 1937 government report on maternal mortality was right; the causes of maternal death were complicated and not easily reducible to a `primary avoidable factor'. However, the report still concentrated on the most common clinical causes of death — sepsis, toxaemia and haemorrhage — and their proper treatment. The underlying biological, environmental and social causes common to maternal and infant mortality were not considered important. Because the major official concern was with population, the problem of maternal and child welfare was defined in terms of mortality rates, which led to an emphasis on measures to counter particular clinical causes of death. But many women's groups felt that the welfare of mothers and infants depended more on the conditions under which reproduction took place, and that these were unsatisfactory for large numbers of workingclass women. Successful childbirth meant more than the physical survival of both mother and child.

II Women's Perceptions On the basis of replies to a questionnaire on maternity issued to its members in 1914, the Women's Cooperative Guild summed up the conditions under which working-class women bore and raised children: ... during the months of pregnancy, the woman must learn by experience and ignorance, usually being told that all her troubles are `natural'. In order to scrape together a few shillings she often goes out to char or sits at her sewing machine or takes in washing; she puts by pence in money boxes, she saves little stores of tea, soup, oatmeal and other dry goods; when times are bad she goes without, providing for her husband and children before herself. If not working long hours in a factory, her home work may be more injurious,

42

The Perceptions of Care-givers and Clients when ill or well, she washes, mangles, lifts heavy weights and may still be carrying an infant in arms. She may at the same time, have to nurse a sick husband or child. Up to the last minute before childbirth she has to wash and dress the children, cook the meals she's sometimes too tired to eat, and do all her own housework. At her confinement often only an untrained midwife is available, who sometimes has to make use of a child's help . In the areas where bad housing causes the family in hundreds of thousands of cases to live in two or three rooms ... privacy and quiet are impossible.63

Pregnancies were often too frequent and accompanied by insufficient food and rest. As Eleanor Rathbone, a feminist and Independent MP, pointed out in 1924, when children arrived family poverty became most extreme and yet this was the time when women needed extra money most.64 Studies of infant mortality undertaken since World War II have emphasised the role played by biological (age and parity), environmental and social factors in infant and maternal mortality. Official investigations of infant and maternal mortality made between 1910 and 1937 recognised the existence of these. For example, Newsholme showed in his reports that infant mortality was higher amongst the poor and where sanitary conditions were bad. But these studies concentrated on pinpointing the medical failure responsible for death. Investigators were anxious to find one main cause of death and neglected the cumulative effect of biological, environmental and social variables. In 1949, Ian Sutherland was one of the first to consider that it was `reasonable' to assess the social and economic environment of the pregnant woman when seeking the reasons for the decline in the stillbirth rate.65 He assessed the relationships between the stillbirth rate and age and parity, social class, and the general health of the mother separately, but never considered their cumulative effects. A more extensive study of 1.5 million stillbirths published in 1955 made the influence and interlinkage between these underlying causes clearer 66 While the study was confined to stillbirths, a more recent work has pointed out that `it seems reasonable to assume that many of the same forces, economic, social and medical that influence the level of infant and perinatal mortality affect the rate of maternal mortality'.67 The 1955 study showed increased age to have a detrimental effect on the stillbirth, neonatal and maternal death rates, but not on the post-neonatal death rate. First and later parities were associated with higher stillbirth and maternal death rates, and the post-neonatal death rate rose steadily with increasing

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43

parity. The study also showed that social class and region acted as independent variables, that is, one could not be explained through the other. For example, the high stillbirth rate in the North could not be explained by the fact that a higher proportion of the population was working class. Similarly, age and parity acted independently within each social class. In the case of post-neonatal deaths, the effect of age and parity was probably indirect: the more children and the older the mother, the more likely the family was to be poor, the mother to be unable to cope and the child to be exposed to infection. This cumulative effect has been clearly illustrated by Raymond Illsley.68 For example, working-class women are likely to live in poorer regions, to marry young and to have more children. Recent work has shown the most likely predictor of obstetric performance to be height, because it is the best indicator of this cumulative effect 69 Working-class women are more likely to be short and within each social class northerners are shorter than southeners. Thus during the late 1950s, the scale of obstetrical performance was found to run from the tall wife of a professional worker living in the South having her second or third child, to the short wife of a semi-skilled worker living in the North having her fourth or subsequent child. While these studies were investigating only specific mortalities, they nonetheless showed the social, environmental and biological circumstances of the mother to be crucial to the wellbeing of both mother and child. The Women's Cooperative Guild recognised this intuitively when it urged that more attention be paid to the welfare of the mother. The letters collected by the guild showed the heavy toll taken by the repeated cycle of poverty, sickness and pregnancy. Out of the 386 women who replied to the guild's questionnaire on maternity, 348 had borne between them 1,396 live children, 83 stillbirths and 218 miscarriages.70 Even more clearly the book showed how each pregnancy further exacerbated poverty and sickness. The numbers of maternal deaths and even infant deaths was small compared to the number of women whose reproductive experience was accompanied by ill-health. In the view of the guild, women's health standards were a better guide to the nature of the reproductive experience than mortality statistics. Data on female sickness and morbidity rate are very scarce. The main source is the National Health Insurance statistics, which make no special reference to conditions of pregnancy and which refer only to women working outside the home. Married women thus occupied accounted for only 10% of all married women at the time of the 1911, 1921 and 1931 censuses. There is reason to suppose that the general health standards of

44

The Perceptions of Care-givers and Clients

married working women would be exceptionally low. They were, after all, doing two jobs. On the other hand the WCG's collection of letters had shown that many poor women who did no work outside the home were too ill to do so. The Women's Industrial Council maintained that it was the healthier and stronger women who went out to work." And it should also be remembered that many women did part-time work, often under very poor conditions (laundries were probably the most notorious examples), and were not covered by the National Health Insurance Act.'Z They, like married women who stayed at home, were thus obliged to pay for medical attention. From the start of the national health insurance scheme, the sickness rate of married women in particular was much higher than expected. In 1918, a special Women's Equalisation Fund had to be established to help meet the women's claims. The insurance societies argued that in absolute terms the amount of sickness among women relative to that among men was actually higher than the figures showed, because the rates were based on the Manchester Unity Experience of 1893-7 with a 35s. addition made for married women, rather than on the basis of the actual experience of women's insurance societies. By 1931-2, unmarried women were experiencing 25% more sickness and 65% more 'disablement' (after six weeks sickness benefits were cut and the claimant referred to as `disabled') than expected, and married women 140% more sickness and 60% more disablement. Men's rates, on the other hand, were less than had been expected. The sickness rate of young married women was especially heavy. 73 A similar pattern is revealed by the death rates for single and married women of childbearing years. The age specific rates of married women were consistently higher than those for single women below the age of 37 in 1921 and below the age of 25 in 1931, indicating the toll taken by pregnancy and childbirth (see Table 1.1). In her unpublished autobiography, Gertrude Tuckwell explains that her interest in the question of maternal mortality developed when she was a member of the Royal Commission on National Health Insurance during the 1920s and noticed the prevalence of sickness amongst married women. She became convinced that a committee to watch over women's health was necessary and in 1927, a year after the Royal Commission published its report, she helped found the unofficial Maternal Mortality Committee.74 No other large data source on the amount of sickness amongst married women is available. On the whole hospital records do not give enough detail, noting only severe complications. One case book kept by

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The Perceptions of Care-givers and Clients

a midwife working for the General Lying-In Hospital during 1924 recorded the general state of health of 20. pregnant women.75 None was considered to be very ill except one suffering from oedema. What is noticeable, and lends support to the impression given by the Women's Cooperative Guild's letters on maternity, is the large number of minor, but discomfiting, ailments. Twelve suffered from constipation, which they relieved by taking copious quantities of senna; six from bad varicose veins; six from very bad teeth, and three from internal lacerations due to previous childbirths. Bad teeth were especially common and indicated a poor diet and lack of dental treatment, which was expensive. During the inter-war period many lying-in hospital charities gave out false teeth to pregnant women. Table 1.1: Age Specific Death Rates, 1921 and 1931

Age

Single

1921 Married

20 23 25 28 31 34 37 40 43 45

.00297 .00317 .00333 .00360 .00393 .00431 .00478 .00548 .00650 .00732

.00365 .00365 .00368 .00381 .00405 .00439 .00477 .00523 .00578 .00637

Married/ Single 1.23 1.15 1.11 1.06 1.03 1.02 1.00 .95 .89 .87

Single

1931 Married

.00262 .00284 .00301 .00326 .00353 .00377 .00411 .00484 .00584 .00663

.00315 .00295 .00294 .00300 .00313 .00341 .00384 .00426 .0 049 2 .00554

Married/ Single 1.20 1.04 .98 .92 .89 .90 .93 .88 .84 .84

Source: General Registry Office, The Registrar General's Decennial Supplement for 1931, Pt 1.2 (HMSO, 1931), p. 13, Table J. In 1939, a major investigation into the health of married women was carried out by the Women's Health Inquiry Committee, which included amongst its members, Gertrude Tuckwell and Mrs Barton of the Women's Cooperative Guild. The investigation was undertaken because of the lack of data on women's health. The information presented is not as useful as it might have been because no control group was used. However, the picture that emerges has much in common with those drawn by other researchers during the period. Women on the lists of health visitors, settlement workers and factory welfare organisers were sent questionnaires and 1,250 replies were received, all from working-class women. On this point the committee concluded that middle-class women had less to complain about and therefore did not reply. Of the 1,250, 558

46

The Perceptions of Care-givers and Clients

said they were anaemic, although from the diet sheets submitted the committee felt certain that this was an underestimate; 291 suffered from headaches; 273 from constipation; 258 from rheumatism; 191 from untreated gynaecological problems and in a further 203 cases there was evidence of these, although no medical diagnosis had been made; 165 from bad teeth; and 101 from ulcerated varicose veins. Again, the outstanding feature was the large amount of minor illness. In total, the committee believed 31% of its respondents to be in good health, 22% to be in `indifferent' health, 15% in poor health and 31% in very bad health. Many of the women themselves did not consider their condition to be morbid as long as they were `able to cope'. A woman in Cardiff, aged 35, suffered from decayed teeth, bronchitis every winter and a prolapsed uterus dating from her second pregnancy, yet she did not consider herself `ill'. The majority of women replying had a very low expectation of health.76 Other specific studies and qualitative evidence add to the impression of low standards of general health amongst married women. In particular, social surveys of the period and medical inquiries frequently reported a disproportionate number of women suffering from anaemia and debility, due to poor diet, frequent childbearing and hard household work. In her study of Middlesborough, Lady Bell reported that girls began to `ail' as soon as they began to menstruate." In 1916, the Liverpool Maternity Hospital listed 129 of the 569 patients attending its ante-natal clinics as `suffering from anaemia and debility, frequently the result of lack of nourishment, lactation, rapidly repeated pregnancies, illness or lack of the wage earner, etc'.78 In 1931, Helen Mackay's research on anaemia showed both its prevalence and how anaemia in the mother predisposed towards anaemia in the child. By 1933, Mackay was convinced that women in the East End of London were more anaemic than in 1931.79 An investigation by two women doctors in the special areas of Durham and Tyneside showed that 44% of 181 women married to employed men and 50% of those married to unemployed men had low haemoglobin counts.80 The Peckham Health Centre, opened in 1935, found 25% of the 1,660 women examined during the first eighteen months of its operation to be anaemic. These women were of a slightly higher socio-economic group than those examined in Durham and Tyneside.81 In her recent analysis of the general welfare of labouring families, Linda Oren has pointed out that wives served as a buffer for their husbands `through the medium of the family's economy'.82 As housekeepers, women were responsible for solving the food/rent equation.

The Perceptions of Care-givers and Clients

47

Surveys showed that many wives did not know what their husbands earned and that few husbands increased housekeeping monies when they received a wage increase or when children arrived.83 In a study of 42 Lambeth families, Mrs Pember Reeves, a member of the Fabian Women's Group, pointed out that the measure of a good husband was whether he paid sufficient housekeeping money. Many women were faced with the decision of whether to spend more money on rent and a better house, or on food. Mrs Reeves considered food to be the better choice,84 but G.C.M. McGonigle, the MOH for Stockton, studied a group of families who were moved from slum houses to a new housing estate and showed that health levels deteriorated after the move because a greater proportion of income was absorbed by rent.85 On the other hand, the Women's Health Inquiry felt that a good house was the better option because women ate poorly anyway and a house with running cold and even hot water, a gas stove rather than a range and a bathroom would at least ease the workload. The nature of housework varied significantly between regions. In mining areas it was exceptionally heavy and it is interesting that the maternal mortality rates were also high in mining districts. In 1931, maternal mortality among miners' wives was 62% above the national average.86 The women interviewed for this study revealed that while gas stoves were common in Birmingham and London by the early 1930s, many women in Liverpool, Hull and Frome cooked on ranges or even the open grate. Two of these women also mentioned the lack of a bath as the particular reason for moving during the inter-war period.8? Finally, if the money left over for food was insufficient, it was usually women who went short, for the breadwinner had to be kept in good health. Mrs Reeves calculated that the man's food in Lambeth families cost an average of 6d a day and food for the rest of the family 2'd. a day. In a study of employed families during the 1930s, two investigators found a similar phenomenon. One woman `appeared to live almost entirely on cakes, biscuits, puddings and fruit ... On this she maintained apparently good health and strength.' These investigators interpreted this as an indication that women needed a lot less food than dieticians were wont to recommend.ß8 The Pilgrim Trust survey of a sample of unemployed men included some 170,000 wives. It was calculated that if women had eaten 83% of the number of calories consumed by men — as dieticians recommended — they would have received 2,366 calories per day, but in fact they ate only 2,010 or 70% of the amount eaten by men.89 Poor nutrition, poor living conditions and low levels of health were

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The Perceptions of Care-givers and Clients

exacerbated by childbearing. Throughout the period working-class women had larger families than middle-class women (although the gap was closing during the inter-war years) and probably a greater number of pregnancies (see Table 1.2). The women whose letters were published by the Women's Cooperative Guild in 1915 had experienced a large number of miscarriages and investigations carried out at the Jessop Hospital in Sheffield revealed that 21% of pregnancies between 1925 and 1929 ended in spontaneous or criminal abortion.90 Between 1928 and 1931, several articles appeared in medical journals stressing the problem of morbidity resulting from childbirth. Dr James Young commented: `It is probably not an overstatement to say that about 60% of hospital gynaecology is a legacy from vitiated childbearing.' He estimated that 40,000 women a year passed on `to recruit this army of ill health'.91 W. Blair Bell reported an investigation of 2,275 consecutive parous women examined in the gynaecology outpatients department of the Liverpool Royal Infirmary. Thirty-four per cent had local or constitutional lesions relating directly to pregnancy and parturition. Blair Bell estimated that while about 3,000 mothers died in childbirth, 5,000 died from the `late results' of childbearing and 60,000 (10%) of all pregnant women were disabled.° Table 1.2: Estimated Average Size of Completed Family, Manual and Non-manual Workers According to Period of Marriage Date of marriage 1900-9 1910-14 1915-19 1920-4 1925-9

Non-manual workers 2.79 2.34 2.05 1.89 1.73

Manual workers 3.94 3.35 2.91 2.73 2.49

Source: PP, `Report of the Royal Commission on Population', 1948-9, Cmd. 7695, XIX, 635, p. 29, Table xxi. Women's groups realised that the problem of sickness and morbidity was central to maternal and child welfare. In 1932, the Women's Cooperative Guild, whose maternity campaign had started in 1911, sent a memo to the Medical Women's Federation asking for more attention to be paid to the question of morbidity. They claimed that health officials had approached maternal and child welfare `wholly from the pathological point of view', ignoring home conditions and general standards.93 The Medical Women's Federation was more moderate in its

The Perceptions of Care-givers and Clients

49

criticism, but it too felt that the general health of women was a crucial determinant of obstetric performance. In its evidence to the Ministry of Health's Departmental Committee on Maternal Mortality in 1929, the Maternal Mortality Committee of the Federation stated that it was 'of the opinion that insufficient attention is often given to the investigation of the general health of the patient'.94 The committee formed by Gertrude Tuckwell and May Tennant made mortality its first concern. This was partly because many middleclass mothers died in childbirth and the composition of the committee was predominantly middle class, and partly because maternal mortality was a controversial political issue and therefore a good rallying point. However, Tuckwell's original interest had been in the problem of married women's sickness rates and, as a trade-unionist, she was supported by the Labour women's groups. In 1932, Tuckwell and Tennant approached the Ministry of Health to ask for an inquiry into sickness and disability amongst women. A month later Dame Janet Campbell, the Medical Officer in charge of maternal and child welfare at the Ministry of Health, explained to Newman that the committee believed that much unnecessary sickness was the result of women's inability to afford adequate medical treatment. She made some general suggestions for plans to examine women at maternal and child welfare centres and to conduct follow-up examinations after a period of six months. Newman recognised the problem of morbidity resulting from childbirth and quoted the findings of Young on the subject. However an official inquiry would cost £2,000 a year and he did not believe it ' "advisable" in the sense of being desirable from our point of view'. The findings could only prove `embarrassing' and `could have but one ending, namely, the demonstration of a great mass of sickness and impairment attributable to childbirth, which would create a demand for organized treatment by the state'. Newman went on to add: Childbirth has always been woman's travail and always will be .. . the broad fact remains, first that childbirth is a heavy strain on the physique of any woman and the bodies of many must therefore be impaired, secondly, that there is in modern civilized nations an insufficient number of organized facilities for effective treatment.9s The problem was thus admitted to be too large to tackle. Unaware of Newman's feelings, the committee wrote again to the Ministry of Health to say that what they really had in mind was `an inquiry into the generally extensive sickness prevalent amongst married women',

50

The Perceptions of Care-givers and aients

rather than just post-natal complications. This was dismissed as `impossible'.96 The government showed a similar attitude in its treatment of the problem posed by the sickness experience of insured women. During the course of 1914 an investigation by a government committee into sickness claims registered under the National Health Insurance Act, Margaret Böndfield gave a lengthy explanation of the excessive sickness amongst married women, referring to the Women's Cooperative Guild inquiry into maternity. However the committee's report made no reference to her evidence and concluded that women's claims were excessive chiefly because of women's ignorance of the principles of insurance and because of `malingering' 97 The report took care to point out that the amount women received in benefits approximated closely to their average earnings. In his reports the Government Actuary also implied that women were malingering when he noted that the `recovery' rate amongst married women receiving disablement benefit was much higher at 75% than that for men at 61% or unmarried women at 55%.98 The Actuary wanted women's insurance put on an actuarily sound basis and in 1932 Parliament agreed to do this by cutting women's benefit rates. Eleanor Rathbone spoke out against the cuts both in the House of Commons and at the conference of the unofficial Committee on Maternal Mortality in 1932. During the parliamentary debate on the cuts she was the only member to use the `unpleasant' word malingering openly, yet as she said, it `permeated the whole Debate and the Actuary's report'.99 There was no other reason why women should have been singled out for, as Miss Pritchard pointed out in her speech, the claims of miners were as excessive as those of married women)0° Rathbone and Labour women's groups felt it impossible to reconcile the cuts with the government's stated interest in improving maternal welfare. The infant and maternal mortality statistics which were used to measure child and maternal welfare are sensitive indicators. However, the approach of health officials was such that they ignored strong evidence which indicated that the problem of child and maternal welfare extended beyond the issue of mortality and they treated the concerns of women's groups as a separate problem. This in turn limited their analysis of the causes of mortality. The concern about the quality and quantity of population provided infant and maternal welfare workers with ample justification for their work, but it also acted as a brake on their activities. Eugenist objections that saving infant lives would impair rather than improve the quality of the race were particularly strong before World War I, and while health

The Perceptions of Care-givers and Clients

51

officials refuted these they were nevertheless careful to concentrate on preventing causes of infant death which were not associated in any way with hereditary weakness. Thus, even though Ballantyne's text on antenatal pathology had appeared in 1904, the importance of the connection between ante-natal conditions and foetal and neonatal death was not investigated until World War I. Maternal welfare work became more common during the war and increasing attention was paid to it when the maternal mortality rate began to rise. Yet, here again, anxiety over the falling birth rate, together with the political implications of drawing public attention to a mortality the government appeared incapable of reducing, had a pronounced effect on the way in which the problem was approached. Emphasis was placed on the clinical causes of mortality rather than welfare in the broader sense of well-being. The cumulative effect of social, environmental and biological variables on mortality rates were ignored. Yet, in so far as these were reflected in the general health and living standards of married women, there was every indication that their contribution was significant. The narrowness of the official analysis of the problem was partially due to political considerations. Women's groups demanded measures to improve conditions for mothers and children which included economic assistance for mothers and free access to birth control information, neither of which was politically acceptable. As the next part of this study shows, the main purpose of infant and maternal welfare work was to counter the major clinical causes of mortality and the role assigned the mother by child and maternal welfare workers reflected the lack of consideration accorded the conditions under which women raised their children.

Notes 1. PP, `Report of the Inter-Departmental Committee on Physical Deterioration, Vol. II. Minutes of Evidence', 1904, Cd. 2210, XXXII, 145, p. 107. 2. The connection between war and social reform is well documented. See for example, Arthur Marwick, Britain in the Century of Total War (Penguin, 1970). 3. But see the work of M.W. Beaver, `Population, Infant Mortality and Milk', Population Studies, 27 (July 1973), pp. 243-54; and J.M. Winter, `The Impact of the First World War on Civilian Health in Britain', Econ. Hist. Rev., 30 (Aug. 1977), pp. 478-507. 4. PP, `42nd Annual Report of the Local Government Board, 1912-13. Supplement Containing a Second Report on Infant and Child Welfare', 1913, Cd. 6909, XXXII, 1, p. 2; and National Health, 1 (April 1909), p. 99. 5. BMJ, 15 April 1916, pp. 555-7. 6. PP, `45th Annual Report of the Local Government Board, 1915-16.

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The Perceptions of Care-givers and Clients

Supplementary Report of the Medical Officer,' 1916, Cmd. 8423, XIII, 79, p. xxxiv. 7. Mabel Palmer, Life-Saving in War Time, A Campaign Handbook. Compiled for the Infant Welfare Propaganda Committee of the National League for Physical Education and Improvement (Arthur Pearson, 1916), p. 19. 8. Carnegie UK Trust, Report on the Physical Welfare of Mothers and Children, vol. I (The Trust, 1917), p. 1. 9. Physicians showed great interest in the Report of the Inter-departmental Committee on Physical Deterioration and played a leading part in the formation of a National League for Physical Education and Improvement, which aimed to promote physical efficiency. Sir Lauder Brunton and Thomas Barlow (both consultants) served on its Executive Council. Bentley B. Gilbert, 'Health and Politics: The British Physical Deterioration Report of 1904', Bulletin of the History of Medicine, 39 (1965), pp. 143-53, argues that physicians and socialists only used eugenic arguments without being committed to them, but the line is difficult to draw. 10. PP, 'An Outline of the Practice of Preventive Medicine', 1919, Cmd. 363, XXXIX, 677, pp. 46 and 99. 11. George Newman, Infant Mortality: A Social Problem (Methuen, 1906), p. v. 12. J. Johnson, The Wastage of Child Life (Manchester: John Heywood, 1908), p. 6. 13. Cd. 5263, p. 9. 14. Karl Pearson, The Chadwick Lecture, 1913, MS, Pearson Papers, Item 73, University College, and Karl Pearson, Darwinism, Progress and Eugenics (The Cavendish Lecture, 1912). 15. C.W. Saleeby, The Nurture of the Race' in Report of the Proceedings of the National Conference on Infant Mortality at St. George's Hotel, Liverpool, 1914 (National Association for Prevention of Infant Mortality and for the Promotion of the Welfare of Infancy, 1914), pp. 140-6, and National Health, 8 (March 1916), pp. 220-2. 16. Karl Pearson, Problems of Practical Eugenics (Dulau, 1912). 17. 'Notes of the Quarter', Eugenics Review, 21 (1929-30), p. 163. 18. Robert Hutchinson, `Paediatrics; Past, Present and Prospective', Lancet, 28 Dec. 1940, p. 802. 19. PP, '77th Registrar General's Report for 1914', 1916, Cd. 8206, V, 53, p. xxxiii, comments on this. 20. S.G. Moore, Report of the Medical Officer of Health on Infantile Mortality, Ordered by the County Borough of Huddersfield, 1904 (Huddersfield: Public Health Committee, 1904), p. 14. 21. BMJ, 7 July 1900, p. 38. 22. Newman, Infant Mortality: A Social Problem, p. 47. 23. F.E. Wynne, 'Should Infant Mortality be Reduced?' Lancet, 4 Aug. 1923, pp. 211-13. 24. Ministry of Health, Annual Report of the Chief Medical Officer, 1936 (HMSO, 1937), p. 15. 25. PRO, MH 10/78, `Maternal and Child Welfare', Circular, 30 July 1914, and Memo, July 1914; and LGB, Regulations under which Grants will be paid by the LGB in Aid of Maternity and Child Welfare Work, 1916 (HMSO, 1916). 26. For details of this dispute see: PRO, CAB 24/30 GT 2458, Addison's Memo on Infant Welfare, 31 Oct. 1917; CAB 24/39 GT 3332, Hayes Fisher's Memo, 12 Jan. 1918; CAB 24/39 GT 3350, Addison's Memo; CAB 24/44 GT 3884, Addison's Memo on the Maternal and Child Welfare Bill, 11 March 1918. For a complete picture of the debate over the establishment of a Ministry of Health, see Bentley B. Gilbert, British Social Policy 1914-39 (Batsford, 1970),

The Perceptions of Care-givers and Clients

53

pp. 101-32; and F. Honigsbaum, The Struggle for the Ministry of Health 1914-19, Occasional Papers in Social Administration, no. 37 (G. Bell and Sons, 1970). 27. PP, `44th Annual Report of the LGB, 1914-15. Supplement Containing a Report on Maternal Mortality in Connection with Childbearing and Its Relation to Infant Mortality', 1914-16, Cd. 8085, XXV, 157, p.16. 28. Ibid., p. 3. 29. Annual Report of the Medical Officer of Health for St. Pancras, 1909, p. 3. 30. Charles Porter, The Future Citizen and His Mother (Constable, 1918), p. 11. 31. J.W. Ballantyne, Manual of Ante-Natal Pathology and Hygiene (Edinburgh: Wm Green, 1904). 32. Amand Routh, 'Ante Natal Hygiene', BMJ, 14 Feb. 1914, pp. 355-63, and A.K. Chalmers, 'Ante-Natal Hygiene and Its Relation to Still and Premature Births and Mortality in the First Months of Life' in the Proceedings of the National Conference on Infant Mortality Held at St. George's Hall Liverpool, 1914, pp. 27-35. 33. Women's Cooperative Guild, Memo on the National Care of Maternity (Guild, 1917), p. 1. 34. Lancet, 16 July 1921, p. 152. 35. 'The Declining Birth Rate', Cooperative News, 18th March 1911, pp. 335-6. 36. 32nd Annual Report of the Women's Cooperative Guild, 1914-15, p. 11; and the 45th Annual Report of the Women's Cooperative Guild, 1927-1928, p. 5. 37. Porter, Future Citizen and His Mother, p. 9. 38. Here the maternal mortality rate includes deaths from and associated with pregnancy and childbirth. Before 1911 any death within a month of childbirth, regardless of whether it was directly connected with parturition, was considered a puerperal death. This definition missed out any deaths due to puerperal causes occurring after the 31 days as it included deaths unassociated with pregnancy and parturition. In 1927 the form of certification was again changed and, in 1935, the Registrar-General estimated that one-fifth of the deaths classified as associated with childbearing after 1927 would not have been included prior to that date: General Registry Office, Registrar General's Statistical Review for England and Wales for 1935 (HMSO, 1938), p. 118. Maternal mortality rates should have been based on the total number of pregnancies, but this was impossible because the number of abortions and multiple births were unknown. Thus the number of live births was used as the base until 1928, when the number of stillbirths began to be recorded. After 1928, the number of live and stillbirths were used as the denominator. The population used was the number of women aged 15-45 years. 39. Debates, House of Commons, 204, 1927, col. 1224. 40. See for example, Debates, House of Commons, 329, 1937-38, col. 1767; Eleanor Rathbone, 'Family Endowment in Its Bearing on the Question of Population' (1924), Beveridge Papers, Coll. Misc. 9. Beveridge made his own views most explicit in his review of Louis I. Dublin's Population Problems (New York: Houghton Mifflin, 1926), Beveridge Papers, VII, LSE. For examples of eugenist views see, David Heron, On the Relation of Fertility in Man to Social Status and on the Changes in this Relation that have Taken Place During the Last 50 Years, Drapers Co. Research Memoirs, studies in National Deterioration (Dulau, 1906); and Karl Pearson, The Problem of Practical Eugenics (Dulau, 1909). 41. Ian M. Drummond, Imperial Economic Policy, 1917-1939 (Allen and Unwin, 1974), pp. 43-144. 42. J.M. Keynes, 'Some Economic Consequences of a Declining Population', Eugenics Review, XXIX (1937), pp. 1-5. See also E.C. Snow, 'The Limits of Industrial Employment: The Influence of the Growth of Population on the Development of Industry', Jr. of the Royal Statistical Society, 98 (1935), pp. 239-73. William Petersen, Problems of Population (Gloucester, Mass.: P. Smith,

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1970), pp. 46-71, gives a good account of the debate between Keynes and Beveridge on population. Jose Harris, William Beveridge. A Biography (Oxford: Clarendon Press, 1977), p. 342, feels that there was little real difference of opinion between them. But letters during this period, while friendly, would seem to indicate otherwise. Beveridge Papers, VII, Beveridge to Keynes, 27 Sept. 1923 and 18 Jan. 1924. 43. A.K. Chalmers, The Declining Birth Rate: Its Causes and Effects', Eugenics Review, 8 (1916-17), pp. 322-8, and Professor Corrado Gini, 'The Decline in the Birth Rate and the "Fecundability" of Women', Eugenics Review, 17 (1925-6), pp. 258-74. 44. Robert Kuczynski, The Balance of Births and Deaths (Allen and Unwin, 1928), pp. 40-54. 45. D.V. Glass, 'The Fall of the Birth Rate', Medical Press and Circular, LXCV (21 July 1937), pp. 46-8. 46. Enid Charles, The Twilight of Parenthood (Watts and Co., 1934); 1st Annual Report of the Population Investigation Committee, 1937, p. 1. Members of the Committee were: Sir Walter Langton, Eardley Holland (British College of Obstetricians and Gynaecologists), L.S. Penrose (Medical Research Council), H.D. Henderson (Royal Economic Society), Dr Stella Churchill (Society of Medical Officers of Health), Sir Charles Close (British Population Society), Miss E. Frederick (Royal College of Nursing), Mrs Eva Hubback (Principal of Morley College), Julian Huxley, Cohn Clark, Lancelot Hogben, Robert Kuczynski, E.M.H. Lloyd, D.H. McLachlan, T.H. Marshall, Lady Rhys-Williams, and Professor James Young. See also: PEP, The Coming Fall in Population, broadsheet no. 73 (PEP, 1936), and Population Facts and Trends, broadsheet no. 165 (PEP, 1940). 47. A.M. Can Saunders, 'Britain's Dwindling Population' and 'Europe's Falling Birth Rate', Daily Telegraph, 14 Sept. 1937 and 15 Sept. 1937, Rhys-Williams Papers; T.H. Marshall, The Population Problem (Allen and Unwin, 1937). The BBC series was called 'One Generation to Another'. 48. G.F. McCleary, Population: Today's Question (Allen and Unwin, 1938), and The Menace of British Depopulation (Allen and Unwin, 1937). 49. PRO, MH 55/679, Hearder to Montmorency, 27 June 1938. 50. The Committee members were: Mrs H.J. Tennant, Gertrude Tuckwell, Countess of Iveagh, Lady Barrett, Mrs Barton, Mrs Bramwell Booth, Lady Margaret Boscawen, Lady Cynthia Colville, Lady Crozier, Viscountess Erleigh, Viscountess Fitzalan, Miss Alice Gregory, Miss Haldane, Dowager Viscountess Harcourt, Mrs Hubback, F. Kershaw, Dr Marion Phillips, Mrs Piercy, Miss Constance Smith, and Miss Usher. 51. PRO, CAB 24/213 225 (30), Arthur Greenwood's Memo on Maternity Services, pointed out that cuts in this area were difficult to make because of the opposition's policy. In 1934 the minister asked for a brief on maternity in expectation of another Labour attack on the subject: MH 55/265, minister to Sir Arthur Robinson, 14 Nov. 1934. 52. Debates, House of Commons, 320, 1936-7, col. 525. 53. PRO, MH 55/262, Newman to Secretary, 26 Oct. 1932. 54. Ministry of Health, Final Report of the Committee on Maternal Mortality (HMSO, 1932), p. 13. 55. Maternal Mortality, Report of a Meeting Held at the Friends House, Euston Road, 1932, p. 13. 56. PP, 'Report on an Investigation into Maternal Mortality', 1936-7, Cmd. 5422, XIII, p. 16. 57. PRO, MH 55/262, Newman to Secretary, 27 June 1929. 58. PRO, MH 55/679, Cameron to MacLachlan, 8 Sept. 1937. 59. PRO, MH 55/679, Circular 1622, 7 May 1937.

The Perceptions of Care-givers and Clients

55

60. The Maternity Services', Lancet, 28 March 1936, pp. 736-7. 61. Woman's Own, 7 (11 July 1936), p. 517. 62. Home Notes, CLXXI (4 July 1936), pp. 8-9. 63. Women's Cooperative Guild, Memo on the National Care of Maternity, (WCG, 1917), p. 1. 64. Eleanor Rathbone, The Disinherited Family (Edward Arnold, 1924). 65. Ian Sutherland, Stillbirths, their Epidemiology and Social Significance (Oxford UP, 1949), p. 43. 66. The study appeared as a series of articles in the Lancet of 1955: J.N. Morris and J.A. Heady, 'Social and Biological Factors in Infant Mortality, I: Objects and Methods', 12 Feb., pp. 343-8; J.N. Morris, J.A. Heady and C. Daly, 'II: Variation of Mortality with Mothers Age and Parity', 19 Feb., pp. 395-7; 'III: The Effect of Mothers Age and Parity on Social Gass Differences in Infant Mortality', 26 Feb., pp. 445-8; J.N. Morris, J.A. Heady, C Daly and C.F. Stevens, 'IV: The Independent Effects of Social Class, Region and Mothers Age and Parity', 5 March, pp. 499-502; J.N. Morris and J.A. Heady, 'V: Mortality in Relation to Father's Occupation', 12 March, pp. 554-9. 67. Sam Shapiro, Edward R. Schlesinger, and Robert E.L. Nesbitt Jr, Infant, Perinatal, Maternal and Childhood Mortality in the US (Cambridge, Mass.: Harvard UP, 1968), p. 156. 68. Raymond Risley, The Sociological Study of Reproduction and Its Outcome', in Childbearing — Its Social and Psychological Aspects, edited by Stephen A. Richardson and Allen F. Guttmacher (Williams and Williams Co., 1967), pp. 105-6. 69. N.R. Butler and Denis G. Bonham, Perinatal Mortality. The 1st Report of the 1958 British Perinatal Mortality Survey (Edinburgh: E. & S. Livingstone, 1963), pp. 278-80. 70. Margaret Llewellyn Davies, Maternity: Letters from Working Women (G. Bell, 1915), p. 9. 71. Clementina Black (ed.), Married Women's Work (G. Bell, 1915), pp. 224-5. 72. Sally Alexander, 'Women's Work in Nineteenth Century London: A Study of the Years 1830-50' in The Rights and Wrongs of Women, edited by Juliet Mitchell and Ann Oakley (Penguin, 1976), p. 64, makes the point that this work is inadequately recorded by the census. 73. PP, 'Report of the Government Actuary on the 2nd Valuation of the Assets and Liabilities of Approved Societies', 1926, Cmd. 2785, XIV, 717, pp. 28-30; PP, 'Report by the Government Actuary on the 3rd Valuation of the Assets and Liabilities of Approved Societies', 1931-2, Cmd. 3978, XIV, 879, p. 32; and PP, 'Report by the Government Actuary on an Examination of the Sickness and Disability Experience of a Group of Approved Societies in the Period 192127', 1929-30, Cmd. 3548, XXV, 825, p. 10, Table C. 74. TUC Archives, Tuckwell Papers, unpublished autobiography of Gertrude Tuckwell, TS, Chapter 28. 75. General Lying-In Hospital, midwives notebook for 1924, Royal College of Midwives. 76. Margery Spring Rice (ed.), Working Class Wives. Their Health and Conditions (Penguin, 1939), with an Introduction by Dame Janet Campbell, pp. 35, 37, 85, 213. Spring Rice was a founder of the Kensington Women's Welfare Centre (a birth control centre) and Dame Janet Campbell retired in 1934 as the Medical Officer in charge of child and maternal welfare at the Ministry of Health. 77. Lady Florence E.E. Bell, At The Works (Edward Arnold, 1907), p. 221. 78. Annual Report of the Registrar General of the Liverpool Maternity Hospital, 1916, pp. 6-7. 79. Helen Mackay, Nutritional Anaemia in Infancy with Special Reference to

56

The Perceptions of Care-givers and Clients

Iron Deficiency, Medical Research Council Special Report Series no. 157 (HMSO, 1931); and Lancet, 3 June 1933, p. 1205, letter from Helen Mackay. 80. Margaret I. Balfour and Joan C. Drury, Motherhood in the Special Areas of Durham and Tyneside (Council of Action, 1935), pp. 24-6. 81. Innes H. Pearse and Lucy H. Crocker, The Peckham Experiment (Allen and Unwin, 1943), p. 141. 82. Linda Oren, The Welfare of Women in Labouring Families: England, 1860-1950' in Clio's Consciousness Raised, edited by Lois Banner and Mary Hartman (Harper, 1974), p. 240. 83. See for example: D. Noel Paton, Crawford Dunlop and E. Inglis, A Study of the Diet of the Labouring Classes in Edinburgh (Edinburgh: Otto Schulze and Co., 1904), p. 17; Bell, At the Works, p. 79; D. Caradog Jones (ed.), A Social Survey of Merseyside, voL L (Liverpool: University of Liverpool Press, 1934), p. 147; M.S. Soutar, E.H. Wilkins and P. Sargant Florence, Nutrition and Size of Family. Report on a New Housing Estate, prepared for the Birmingham Social Survey Committee (Allen and Unwin, 1942), p. 32; Charles H. Madge, War Time Patterns of Saving and Spending (Cambridge UP, 1943), pp. 54-60; Michael Young, The Distribution of Income within the Family', British Jrnl. of Soc., 3 (1952), pp. 305-13 summarises and discusses some of this material. 84. Magdalen Stuart Pember Reeves, Round About a Pound a Week (G. Bell, 1913), pp. 17 and 156. 85. G.C.M. McGonigle and J. Kirby, Poverty and Public Health (Gollancz, 1936), pp. 108-27. 86. The nature of housework in mining areas was vividly described during the course of the inquiry into the coal industry in 1919: PP, `Report of the Inquiry into the Coal Industry', 1919, Cmd. 360, XII, 305, evidence of Mrs May Hart, pp. 1016-18, Mrs Elizabeth Andrews, pp. 1019-20, and Mrs Agnes Brown, pp. 1023-4. 87. Information on the socio-economic background of these women and the questions they were asked may be found in the Appendix. 88. E.M. Widdowson and R.A. McCance, `A Study of English Diets by the Individual Method, Pt. II', Jrni. of Hygiene (July 1936), p. 305. 89. Pilgrim Trust, Men Without Work (Cambridge UP 1938), p. 140. 90. PRO, MH 71/28, Doris Pindar, `Investigation into Abortions, their Incidence Causative Factors and Sequelae', n.d. 91. James Young 'An Address on Maternal Morbidity from Puerperal Sepsis', BMJ, 9 June 1928, p. 967, and The Woman Damaged by Childbearing', BMJ, 18 May 1929, pp. 891-5. 92. W. Blair Bell, 'Maternal Disablement', Lancet, 30 May 1931, pp. 1171-7. 93. Archives of the Medical Women's Federation, minutes of the Meetings of the Council, voL III, 5 May 1932, reply to the memo of the Women's Cooperative Guild by the Maternal Mortality Committee of the MWF. 94. Minutes of the Meeting of the Council, vol. II, i and 2 Nov. 1929, text of the evidence presented to the Maternal Mortality Committee of the Ministry of Health. See also, Lady Barrett, 'The General Health of Childbearing Women', paper given in 1924 to the Medical Women's International Association, MWF Archives. 95. PRO, MH 55/262, Campbell to Newman, 15 Aug. 1932; and Newman to Secretary, 26 Oct. 1932. 96. Ibid., Tuckwell to Robinson, 14 Dec. 1932 and Robinson to Tuckwell, 6 Jan. 1933. 97. PP, `Minutes of Evidence Taken by the Committee on Sickness Benefit Claims under the National Health Insurance Act', 1914-16, Cd. 7698, XXX, 551, pp. 361-372; and PP, `Report of the Departmental Committee on Sickness Benefit Claims under the National Health Insurance Act', 1914-16, Cd. 7687, XXX, 1, p. 47. 98. Cmd. 3548, p. 15.

The Perceptions of Care-givers and Clients 99. Debates, House of Commons, 267, 1931-2, col. 288. Also, Maternal Mortality, Report of a Meeting Held at the Friends House, 1932, pp. 17-18. 100. Debates, House of Commons, 267, 1931-2, col. 255.

57

PART II SAVING THE INFANTS

2

'THE IGNORANCE AND FECKLESSNESS OF MOTHERS'

Both the causes of infant death and the reasons for the decline in the infant mortality rate are extremely complicated. Yet while the participants in the National Conference on Infant Mortality and the members of other new associations interested in preventing infant mortality acknowledged many possible causes of infant death, for the purposes of active study and intervention they managed to reduce them all to one `fundamental' cause: maternal ignorance. This had but one solution: maternal education. Concentration on the mother arose in the first place from a belief that diarrhoea, which was the main cause of infant mortality in the late nineteenth and early twentieth century, was due to contamination in the home from dirty feeding bottles, dummies and the like. Each mother, then, had to be made aware of her responsibility for personal hygiene and the control of domestic dirt. If, out of ignorance, mothers exposed their infants to infection by bottle- rather than breastfeeding, education would correct the situation. All mothers could be ignorant, but some working-class mothers were also considered to be careless and neglectful of their children. Working mothers were put in this category because their children were consigned to the vicissitudes of both the feeding bottle and the childminder. Institutions set up to educate women in infant care were designed for the working class, combining middle-class philanthropy with the state's desire to save lives by the cheapest method. But while the solutions implemented were thus class specific, the accompanying ideology of the new, improved motherhood, that would raise a better race, was not. Women from all classes wanted advice in raising their children, but working-class women approached their instructors with more needs than were met. Problems arising from poverty and insanitary living conditions were as pressing as any individual inadequacies. The infant mortality rate declined sharply after 1911 and maternal and child welfare workers proclaimed the success of their methods: women were now educated in proper methods of infant care. Because the reasons for the decline in infant mortality are so complex, it is not possible to assess exactly how far ignorance was the main problem and education its solution. What is important is to show how and why health 61

62

The Ignorance and Fecklessness of Mothers'

officials reduced the problem to a single cause and what the implications of this were for women. During the early twentieth century the post-neonatal mortality rate was much greater than the neonatal mortality rate (see Figure 1.1) and causes of infant death during the post-neonatal period attracted correspondingly greater attention. Of these, diarrhoea was the biggest killer, followed by bronchitis and pneumonia (see Table 2.1). The large number of neonatal deaths recorded as being due to development and wasting diseases took place chiefly in the neonatal period and were largely ignored. It was commonly believed that deaths in the fust month were due more to inherited weakness than anything else and that the mortality of the first month thus represented a genuine measure of natural selection. It was not until World War I that neonatal deaths were realised to have ante-natal causes closely linked to preventable deficiencies in the mother's health.' Table 2.1: The Three Main Causes of Infant Mortality (Per 1,000 Live Births), 1911, 1921, 1931

Neonatal Developmental and wasting Post-neonatal Bronchitis and pneumonia Diarrhoea

1911

1921

1931

41.37

33.00

29.34

18.26 36.20

14.78 13.79

15.20 5.20

Source: PP, `74th Annual Report of the Registrar General for 1911', 1912-13, Cd. 6578, XIII, 493, p. xxxix; General Registry Office, Registrar General's Statistical Review for 1921 (HMSO, 1923), p. 21 and for 1931 (HMSO, 1923), p. 21.

The diarrhoea death rate peaked at the turn of the century (Figure 2.1). In 1911, 28% of infant deaths were still attributable to this one cause. The number of deaths due to diarrhoea declined during the early part of the century and fell rapidly after 1911. But it is important to remember that early interest in infant mortality concentrated on preventing infantile diarrhoea, and that the solutions which evolved to cope with this specific problem set the pattern for child and maternal welfare work during the early part of the twentieth century. The aetiology of diarrhoea was unclear to contemporary observers. By 1900, all were agreed that it was an urban disease, contracted by exposure to contagion, but were uncertain as to the precise source.2 Observation revealed that outbreaks of diarrhoea were more common in hot summers, where sanitation was poor and where the bacteria count

Figure 2.1: Diarrhoea Rate, Five-year Moving Averages, England and Wales, 1897-1912 35- RATE PER 1000

30

25

20

15

YEAR

T 1890

1900

1910

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The Ignorance and Fecklessness of Mothers'

in milk was high. Pollution or `dirt' of some kind was commonly held responsible. In 1903, the Medical Officer of Health for Croydon mentioned dirty soil, dirty milk and dirty homes as the three main sources3 and this was reiterated in the journal Public Health as late as 1915.4 Controversy arose over the main locus of the pollution, whether it was in the soil due to improper sanitation and refuse disposal, in milk due to uncleanliness at the farm or in the home, or solely in the home itself. In 1900, Arthur Newsholme, Chief Medical Officer to the Local Government Board from 1908 to 1918, came down firmly on the side of poor sanitary arrangements as the main cause of diarrhoea. Accumulation of waste matter on the surface was the main evil. Towns with high rainfall, impervious soils that would not soak up this matter and efficient refuse and night soil collection, were therefore likely to have a low death rate from infantile diarrhoea. Newsholme rejected the idea that milk contamination was the main problem, contending that milk was merely the vehicle of contagion while accumulated dirt was the cause. He noted that Hull's soils, rainfall and sanitary arrangements made it particularly susceptible to diarrhoea' and it is interesting to note that during the inter-war period Hull had the highest rate of death from infantile diarrhoea, with 79% of deaths occurring in houses where privies or pail closets were still used.' Midden and ash privies were common in most urban areas until after World War I. For example, in 1914 in Hull as many as 54% of households had ash privies or middens; in Liverpool the figure was 15%. Scavenging and sanitation seem to have been particularly poor in the northern textile towns.' Middens were very large, uncovered receptacles, sunk below ground level. They were by no means watertight and often served two, four or more houses. Ash privies were an improvement. They were built above ground level and cemented at the bottom. Ash was thrown in at the front and the contents withdrawn through a door at the back.8 The lower mortality rates of towns using water closets over towns using privies was carefully recorded and commented on in all Newsholme's reports on infant mortality. But as one medical officer of health pointed out in 1902, sanitation had improved greatly during the previous 25 years and yet the mortality from diarrhoea had increased.9 Studies concentrating on the way in which the disease was actually communicated to the infant showed that breastfed infants were less prone to diarrhoea than bottlefed ones, although no distinction was ever made between those bottlefed for a few months and those bottlefed from birth. However, more recent research has shown that when infants are raised under less than optimal

The Ignorance and Fecklessness of Mothers'

65

conditions, those breastfed are less at risk.10 Newman found that between 1902 and 1903 in Finsbury, 30 breastfed infants died, 55 who had been bottlefed and 61 who had experienced mixed feeding. Newman felt these figures indicated the greater safety in breastfeeding but this is difficult to justify given a lack of incidence rates." In 1905 the Medical Officer of Health for Derby calculated the death rate of breastfed infants to be 69 per 1,000 and of bottlefed infants 197.5 per 1,000.12 Similar evidence emerged for Croydon and Salford during 1907-8.13 These figures seemed to suggest that infant mortality was most easily diminished by breastfeeding and, if this were impossible, by a careful mother who would ensure a clean environment for her child; difficult though this might be in the face of unpaved yards, poor sanitation and the mass of houseflies that was bred on the horse manure in cities. It was on the basis of this evidence that Newman, in his influential infant mortality study of 1906, argued that diarrhoea was `mainly due to domestic infection'.14 Domestic dirt and the dangers it represented to the infant were real enough.15 The environmental pollution stressed by Newsholme directly affected conditions within the home and Labour women showed their awareness of this in their campaigns for pit-head baths for coalminers, efficient night soil collection, better road paving, sanitary bins with lids, pure milk and cheap gas to supply the necessary hot water for cleaning.16 The questionable jump in the argument of medical officers concerned with the problem of infant mortality was from the existence of dirt to women's responsibility for it. For as labour women's demands showed, the control of domestic dirt was not fully within the housewife's grasp. In fact, women frequently argued that given both poor sanitation and the lack of hot water, little more in the way of domestic cleanliness could be expected. Health officials focused their attention on the mother because with great effort she could often manage to preserve infant life despite her insanitary surroundings. In 1913, Newman wrote that the problem of infant mortality was `mainly a question of motherhood and ignorance of infant care and management'. By 1916 it was considered a `truism' that infant mortality was due more to people themselves than to their external surroundings." Faulty maternal hygiene was thus invoked as the primary cause of infant mortality. According to S.G. Moore, it was `not climate, not topography, nor municipal sanitation, but the lives and habits of the mothers in the homes' that made all the difference between life and death.18 Newsholme continued to stress the many possible causes of diarrhoea and while he refused to reduce these to the

66

The Ignorance and Fecklessness of Mothers'

one issue of maternal hygiene, he too came to regard `the ignorance and fecklessness of mother' as the most important factor causing infant mortality.19 When William Brend published a study under the auspices of the Medical Research Council stressing the role of environmental factors in explaining excessive infant mortality in urban areas, he was immediately criticised on the grounds that his expertise lay in medical jurisprudence and that he therefore paid insufficient attention to the clinical causes of infant death and their solution.20 The concept of maternal efficiency was popularised further by Karl Pearson, Professor of Eugenics at University College. In the Chadwick Lecture of 1913, Pearson argued that the health and habits of parents were fifteen times as influential as any other factor causing infant deaths.21 He developed this idea further in two papers published during the 1920s. A series of correlations purported to show that good maternal habits, defined as a `matter of intelligence and temperament', were more important than any other variable (such as housing, employment of the mother, wages, etc.).22 The possession of good or bad habits was linked primarily to the health of the mother and these were, like health, hereditary characteristics. Pearson's views were very influential. In a 1926 study which sought reasons for the poor physique of working-class children in Scotland, the authors concluded that maternal efficiency and heredity rather than poverty were the crucial variables in determining the height and weight of the children. Repeated reference was made to Pearson's work and the authors expressed the feeling that in the past they had too readily accepted the view that small size was due to deficient diet.23 Most medical officers of health believed maternal habits to be the key explanatory variable as firmly as did Pearson, differing only in their contention that these were susceptible to change. It was this conviction that made concentration on maternal efficiency so attractive to child and maternal welfare workers. As Newman commented in 1913, because of the developments in the study of heredity and habits, health workers were finding their `way back to origins'.24 Eugenics and the infant hygiene movement combined to move the focus of preventive medicine away from the purely environmental concerns of older public health officials towards the individual, from whom more immediate changes could be expected.25 Pearson's statistical grasp was beyond reproach; his mistakes arose from assuming that a statistical association could be interpreted as a causal relationship. This was a problem he recognised in the abstract but ignored in practice because of his belief that hereditary factors were

The Ignorance and Fecklessness of Mothers'

67

more important than environmental factors. The assumption of medical officers of health that maternal efficiency was the key to the problem of infant deaths was similar in that they interpreted the relationship between infant mortality and all other variables such as sanitation and poverty, as an indirect one. In 1910, Newsholme admitted that infant mortality was highest amongst the urban working class, where sanitation was worst, medical attention infrequent and milk the most contaminated.26 The RegistrarGeneral's report for 1911 showed clearly that the mortality rate of working-class infants was greater than that of middle-class infants. The excess mortality of Social Class V over Class I was 41% in the first month, 92% at one to three months, 142% at three to six months, 165% at six to nine months and 183% at nine to twelve months. A report on infant mortality in two poor wards of Birmingham between 1908 and 1911 emphasised that regardless of the great value of breastfeeding, it was outweighed in importance by poverty.27 Yet in a report made to the Local Government Board in 1913, the Medical Officer of Health for Birmingham reiterated that dirt alone was responsible for infantile diarrhoea, and admitted the influence of poverty only in so far as drink and poverty combined with dirt made mothers positively dangerous.28 A similar comment to the effect that poorer districts were noted for their improper care of children was made by the Medical Officer of Health for Liverpool 29 Newsholme's second investigation of infant mortality concentrated on urban areas and showed that the death rate was particularly high in the poorest wards of big cities. Yet in all his reports Newsholme went to extreme lengths to point out that there was no direct connection between the two. According to his analysis, infant mortality did not result from poverty per se, but rather from the `removable evils' associated with it. Thus to speak of abolishing poverty `by the direct application of money' as the best way of reducing infant mortality was `unscientific'. For example, intemperance caused poverty and money would only make this worse. Newsholme quoted other medical officers of health to show that not all poor mothers lost their children and the crucial factor had therefore to be maternal efficiency, even when on the same page he admitted that poverty could lead to malnutrition in the care-giver,30 which would presumably impair efficiency. This is not to say that some mothers did not make errors in caring for their infants, particularly in the matter of feeding. Indeed, many women welcomed advice on infant care and management. Moreover, instruction was relatively cheap to provide and likely to give more

68

`The Ignorance and Fecklessness of Mothers'

immediate results than efforts to improve the sanitation of whole districts or the standard of living of the poor. But women were not wholly responsible for infant deaths, and medical officers of health and LGB officials adopted an untenable position when they argued that education alone would solve the problem and that neither poverty nor environmental factors played an important part in causing infant mortality. As late as 1928, Newsholme (by then retired) repeated his assertion that `good mothering' was the all-important factor.31 By the 1930s, more attention was paid to poverty because of the increased emphasis on optimum standards of nutrition and the effect of low incomes on diet. For example, a study by the Medical Officer of Health for Kensington showed that North Kensington, a poor area, had an infant mortality rate that was two and half times greater than that of the richer South Kensington,32 and the widely-read studies of Richard Titmuss showed that while the national infant mortality rate continued to decline, the differential between classes was widening during the 1930s.33 During this later period it was more difficult to ignore poverty as a cause of infant mortality and poor health, although as will be shown later, policy-makers still felt that the mother, if instructed, could manage adequately. The emphasis put on the question of maternal efficiency by those involved in child and maternal welfare work cannot be adequately explained by either their belief that domestic dirt caused excessive infant mortality or the increasing tendency of preventive medicine to concentrate its efforts on the individual. The emphasis on maternal responsibility gained its legitimacy from an ideology of motherhood rooted in the nineteenth-century doctrine of spheres, which made women's proper place the home. Now that the welfare of the next generation was recognised to depend on the mother, the rhetoric of motherhood at once insisted on and elevated her maternal duties and status. The child was `the epitome of the race', and child nurture within the family was all-important.34 Labour women and social workers, as well as medical officers, shared the philosophy that the greatness of the nation was only equal to the sum of its families, and within the family the mother was `the pivot'.35 Few disputed Newman's call in 1906 for a high standard of motherhood with more attention to `the health, the intelligence, the devotion and the maternal instinct of the mother',36 although opinions as to how this was to be achieved differed. Inefficient motherhood was attributed either to ignorance or carelessness, although no hard and fast line was drawn between the two. Carelessness tended to be a woiking-class phenomenon and, according

The Ignorance and Fecklessness of Mothers'

69

to evidence given to the Inter-departmental Committee on Physical Deterioration in 1904, was increasing." Most commonly included under this heading were the `overlaying' of infants (when infants sleeping with their parents were accidentally smothered) and the employment of mothers outside the home. On the other hand, it was possible for any mother to be ignorant, especially in the matter of infant feeding, and proper feeding was crucial if diarrhoea was to be prevented. In so far as wasting and debility were believed to be preventable, it was thought that these too hinged on suitable, cleanly feeding.38 Because investigations had shown the mortality to be highest amongst the hand-fed, breastfeeding was advocated as the panacea.39 It is impossible to determine how far the infant hygienists were correct in their condemnation of mothers' ignorance. What does emerge is a lack of research into ways of establishing and maintaining breastfeeding, and even a certain implicit ambivalence towards it, despite the public encouragement given to mothers to feed their babies naturally; an absence of any consensus on the best method of handfeeding; confusion as to who stood in need of advice; and a lack of understanding of the many factors that might have played a part in the decision to bottlefeed. Working-class children died in greater numbers, but working-class mothers were much more likely to breastfeed. Because the problem was not a simple one of maternal efficiency, the advice given by infant hygienists was often inappropriate and failed to address the reality of the feeding problems of middle- and working-class women. Breastfeeding was considered to be the natural, normal function of women. One infant feeding manual-writer asserted that the woman who did not breastfeed was not worthy of the name of mother. Mary Scharlieb, an influential Catholic doctor, urged women to breastfeed in order to ensure the regeneration of the race and C.W. Saleeby, a leading eugenicist, asserted that women who did not feed their children naturally should be `ashamed to look a tabby cat in the face'.40 Middleclass women, who often left feeding to a nurse, were especially condemned for their `selfishness' and `unwillingness' to breastfeed.41 Yet there was little research into the difficulties women experienced in breastfeeding and certainly very little training of medical students in its management. Harold Scurfield, the Medical Officer of Health for Sheffield, complained that `Medical Officers of Health and Special Committees on infant mortality frequently report that excessive infant mortality rates are due to the ignorance of mother, but the fact is that there is nobody to teach the mothers. The doctors are not taught and the midwives are not taught.'42 At a meeting held at the Local

70

The Ignorance and Fecklessness of Mothers'

Government Board in 1919, it was resolved that medical education should include paediatrics as a compulsory rather than a voluntary subject for doctors and midwives. In 1923, Newman again commented on the lack of education medical students received in paediatrics, which apparently persisted despite the revised curriculum laid down by the General Medical Council earlier that year; the subject was compulsory in only three of the London teaching hospitals. In 1932, the General Medical Council's Inspector of Medicine urged that more attention be paid to diseases of children and the Inspector of Midwifery regarded the attention given the subject of infant hygiene as `farcical'.43 One of the few pieces of research on breastfeeding was done by Lucy Naish, Assistant Physician at the municipal infant consultations in Sheffield, in l913.44 She dealt with the common problems of sore and cracked nipples and engorged breasts. One woman interviewed, who breastfed for three months with cracked nipples, described her experience as `sheer hell'. In an essay on cultural aspects of childrearing, John and Elizabeth Newson quoted a letter they received from a middleclass woman who, during the 1930s, was persuaded to breastfeed by the popular manuals of Frederick Truby King: `As for breastfeeding, I feel so strongly about this that I can hardly express myself: For the mother who finds breast feeding terribly difficult — and there are so many of these — the solemn pronouncements she will hear ... can lead to real emotional and mental suffering.i45 The Lancet published Naish's paper and commended it in an editorial on breastfeeding, but added that women lacked `the strength of will to endure the minor discomforts'46 of natural feeding, thus showing little sympathy for women experiencing the kinds of problems described. Advice given in many of the manuals of the day would have exacerbated the problems of the breastfeeding mother. Authors often advised treating the nipples with cologne or some other alcohol-based substance before parturition in order to `harden' them. This would only have caused cracks and soreness. Advice of this nature continued to be given well after it was known that oil rather than alcohol was the better treatment 4' Such practices apparently persist in some areas today 48 In one manual devoted to breastfeeding, written by a nurse trained at Sir Frederick Truby King's Mothercraft Training Centre, the mother was warned that the process was inevitably accompanied by pain for the first few weeks.49 Before the 1920s and the discovery of vitamins, the diet recommended in the manual literature for the nursing mother consisted of gruel, eggs, milk and water, which would have impeded the middle-class woman wishing to breastfeed, much as poverty handicapped

`The Ignorance and Fecklessness of Mothers'

71

the working-class woman. In fact, working-class women who could afford it seem to have often been treated to one special meal after the birth, the favourite being a lamb chop. It might have been this particular custom that Ada Bailin, the editor of Baby, was attacking when she condemned any deviation from the recommended diet for nursing mothers in her manual of infant care. Lucy Naish stressed the importance of regular feeding, in common with the established practice of the day, because she believed the breast secreted milk at regular intervals. Most infant hygienists recommended feeding by the clock for a certain number of minutes to ensure the most efficient stimulation of the gland. In 1911, Eric Pritchard, whose infantcare books were some of the most widely read, recommended 20 minutes at two-hourly intervals for the first two months and thereafter three hourly, but by 1922 he was recommending 10 minutes at each breast.S° During the 1930s feeds every four hours with 15-20 minutes at the breast were considered ideals' However, Marie Stopes, who advised on the care of babies as well as on birth control, bade mothers give their babies all the milk they wanted `in the interests of the race'.52 Not until Harold Waller's research during the late 1930s was the importance of the reflex mechanism in milk secretion discovered, which caused Waller to condemn `this absurd guidance by the clock, which ... takes no account of the psychology of lactation or of the emotional side of motherhood'.53 Waller had great influence amongst the midwives and doctors who trained and worked at the British Hospital for Mothers and Babies where he was a consultant, but like many other specialists in infant care, his impact outside his own hospital was limited. In as confused an area as infant feeding each consultant had his own ideas and each doctor, midwife and health visitor his or her own interpretations.54 Despite the difficulties associated with breastfeeding, it was estimated that four-fifths of working-class women breastfed in 1910, and in Warwickshire in 1915, the estimate was still as high as six-sevenths.ss Some of these babies were probably also given a taste of food from the table, a practice often recommended today for infants aged 6-12 months, but one that was severely frowned upon in 1910 for fear that unsuitable food would be given.S6 One reason for the large numbers of workingclass women breastfeeding was the low cost involved, but towards the end of the period, working-class women were undoubtedly using more patent foods or fresh milk out of choice. A sample of 500 families surveyed in Hull in 1924 showed that whereas 73% had breastfed their children prior to the war, only 44% were doing so afterwards.57 Working-class women were instructed to breastfeed by midwives and

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The Ignorance and Fecklessness of Mothers'

health visitors. Dr Sykes, Medical Officer of Health for St Pancras, stopped health visitors giving out leaflets with advice on artificial methods of feeding for fear of encouraging hand-feeding. Pressure from the National Association for the Prevention of Infant Mortality was exerted on the Central Midwives Board to include a clause in the rules governing midwifery practice to oblige midwives to notify the cause of any cessation in breastfeeding during their statutory ten-day period of attendance on the mother. After a further approach made to Newsholme at the Local Government Board, the regulation was included in the CMB's rules of 1919.58 When working-class women did not breastfeed it was often due to inability to do so. The common complaint was that on getting up after the usual ten days in bed following the delivery the milk left them. One woman interviewed was warned not to breastfeed because of weakness, but she persevered for reasons of economy. Another recalled going `two days without anything to eat .. , if only anyone had given me a hard crust of bread I wouldn't half of enjoyed it'. She got out of bed on the fifth day after childbirth and was unable to breastfeed. Dr Ethel Bentham, a leading member of the Woman's Labour League (WLL), felt that better feeding of mothers was the key to successful breastfeeding.S9 This conclusion was reiterated in the reports of the Baby Clinic set up by the WLL in 1911. Dr Amand Routh, a member of the National Association for the Prevention of Infant Mortality, admitted that the poor nutrition of mothers was a factor determining choice of feeding practice, though he still maintained that ignorance was more important.60 In 1914, the MOH for St Pancras stated that it was `illogical' to give medical advice to mothers when food was needed.61 In the same year, the MOH for Birmingham reported that three voluntary societies were giving Id. dinners to poor, pregnant and nursing mothers and, after wrestling with the possible threat this posed to the responsibilities of the father as provider, came down in favour of the experiment ea A menu for the ld. dinners provided in Hull during World War I and the early 1920s showed the diet to be adequate but plain — Monday: meat and potato pies, milk pudding; Tuesday: Irish stew and steamed fruit; Wednesday: haricot mutton, mashed potato and milk; Thursday: roast meat, mashed potato, vegetable and milk; Friday: stewed meat, potatoes, suet pudding and treacle; and Saturday: stew and milk pudding. Yet one respondent who ate these dinners, remembered them vividly as `lovely dinners' and a great treat. The dinners were very much a wartime concession on the part of local authorities, instigated when child and maternal welfare work reached its peak, although some

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voluntary societies had provided them for some years before World War I. The dinner schemes went beyond the usual bounds of local authority activity, for by assuming one of the primary responsibilities of fatherhood, local authorities implicitly acknowledged the effects of poverty. While a precedent for their action existed in the many forms of state intervention on behalf of children (in whose future health the nation had a direct interest), this is one of the very few examples of direct assistance being extended to mothers. Another common cause of artifical feeding in working-class homes was sickness on the part of the mother. Karl Pearson's studies revealed this, although Pearson himself attributed the mother's illness to hereditary weakness.63 Working-class women could rarely afford to call in a doctor either for themselves or to advise on feeding methods, and bottlefeeding would swiftly ensue. Women interviewed recalled relying on the services of a dispensary or the `cheap' doctor, who charged only 6d. for a visit, probably because he seemed to specialise in `his own medicine'. Middle-class women were more likely to consult a doctor with their infants and, unlike medical officers of health, few general practitioners took much interest in infant hygiene and were not so likely to encourage mothers to breastfeed. There was even a certain implicit ambivalence on the question of feeding in the advice of some infant specialists. Sir Frederick Truby King, the most popular author of infant-care manuals during the inter-war period, stressed the importance of breastfeeding, maintaining that `almost every mother can certainly fit herself to nurse one baby properly for nine months',6a although he allowed that twins presented greater, if not insuperable, problems. Yet he also marketed his own patent infant foods, Karilac and Kariol, which the doctor of one woman interviewed sent away for on her behalf as soon as she experienced difficulty in breastfeeding. Eric Pritchard, who had made infant feeding his specialty after his second child died when it had been fed exactly the same food as the first, was perhaps the most equivocal on the subject. He maintained that breast milk was only perfect if it was secreted under perfect conditions, which included rigorous aseptic procedure. Frequent test weighings were necessary to ensure the baby was getting enough food, and in Pritchard's experience these often established the need for supplementary feeds. True scientific feeding meant the adaption of the food `to the digestive and nutritional requirements of each infant'.65 In addition, patent food manufacturers began to put out baby books, aimed primarily at middle-class women. For example, Cow and Gate

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issued their first edition of Motherhood in 1920 and this, naturally enough, advised complementary feeds of Cow and Gate. Before World War I, well-known brands of patent foods were usually very unsuitable for infants because of the high proportion of farinaceous material and low amounts of fat and protein they contained.66 Hand-fed infants were likely to suffer no matter what food was used. In the Derby investigation of 1905, the most lethal food was found to be condensed milk, worse even than 'crusts and sago'. Newman attributed this to over-dilution of the milk, but as Janet Blackman has recently pointed out,67 before World War I can-openers were not generally available and the can would often have been opened at the store. After being carried home and kept for some days in a warm room (storage cupboards were often located next to the chimney or the copper boiler in working-class homes6ß ), the milk quickly became contaminated. Working-class women bought condensed milk in everincreasing quantities before World War I because it was cheaper than cow's milk or patent foods (evidence given to the Inter-departmental Committee on Physical Deterioration in 1904 revealed that condensed milk was cheaper at 2/d. a tin than cow's milk at 4d a quart). Separated and machine-skimmed varieties of condensed milk were the cheapest of all, but the most unsuitable, because they lacked fat (and therefore Vitamins A and D) and contained too much carbohydrate.69 Infant hygienists recommended scientific feeding by 'humanizing milk' and manuals provided complex charts for mixing cow's milk, water, cream and sugar, and later, barley or lime water and codliver oil as well, as first one and then the other was discovered to contain nutrients vital for the prevention of deficiency diseases.70 The major deficiency disease was rickets and articles in Home Notes revealed that this was feared as much by middle- as by working-class mothers." Scientific feeding was so complicated that one writer recommended that infant food 'be prescribed' like medicine. Even if the food was mixed correctly, the results were not always satisfactory, as one article in a woman's magazine made clear: On paper it is a very easy matter to feed one's baby: just h ounce of this mixed carefully with a tablespoon of that and a tiny pinch of something else, and behold the young person will thrive wonderfully ... My experience was to the contrary.'Z Scientific feeding was also expensive, despite the fact that many infantfeeding specialists made their own substitutes for cream which clinics

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sold to the poor. Dr E.A. Barton, who ran the clinic at University College Hospital, distributed `UCH cream', and Eric Pritchard made up `Marylebone cream' using linseed oil (later research revealed this to lack the Vitamin D, which was present in cream and which prevented rickets). Even in his leaflet designed for distribution amongst the poor in Marylebone, Pritchard recommended that fresh milk be bought twice a day and sterilised using what was undoubtedly a simple apparatus, but one which nonetheless cost 2s. 6d. 73 Even if milk was bought, it was unlikely to be either pure or clean. Milk was sold as `Grade A (certified)' or `Grade A' before 1922 and afterwards as `Certified', `Grade A (TB tested)', `Grade A' and `pasteurised'. Anything below this was cheaper and untreated in any way. Dried milk was not used in any great quantity until World War I,74 although its use was advocated by medical officers of health at the 1906 National Conference on Infant Mortality, and the MOH for Leicester, Killick Millard, distributed it from his municipal milk depot as early as 1910. The early investigations of Professor Delepine showed high levels of bacteria to be present in milk awaiting distribution in Manchester.7S Milk was contaminated by insanitary conditions on farms and in milk shops. Not until the 1920s was most milk sold in bottles. Newman's investigation of milk in Finsbury in 1903 revealed 21% of his samples to have been adulterated. Despite this evidence and the protests made by Labour women against the quality of the milk supply,76 medical officers of health blamed dirty homes rather than the farms or milk shops for the contamination. This helps to explain the fate of the milk depots which sold humanised milk and were amongst the earliest efforts made by municipalities to combat infant mortality. The first one was set up in St Helen's in 1899, modelled on the lines of one established in Fecamp, Normandy. The dep8ts also offered educational classes for mothers and soon only these remained, chiefly because the dep8ts were so expensive to run (in Liverpool, in 1903, the deficit incurred in running them was £2,028),77 but also because it was believed that ignorance not milk was the fundamental problem. Sykes, for example, contended that `the milk supply was only a small part of the whole matter'.78 Dr Robertson, MOH for Birmingham, stated even more categorically that babies died from ignorance and not from bad milk.79 Yet it was hard to see how mothers could either buy good milk or keep it fresh. Infant hygienists were not even united on the wisdom of boiling milk because this was considered by many to destroy the `enzymes' that made it a `living' food.80 Not until 1917 were research findings published that destroyed this myth.81 In view of the confusion, it is hardly surprising

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that women did whatever was economically feasible or whatever was recommended locally, by health officials, doctors, neighbours or relatives. Twenty-nine women of the eighty-three interviewed bottlefed their babies and all tried two or more different kinds of food until the baby seemed satisfied. When infant hygienists blamed unsuitable feeding on mothers' ignorance, they worked on the basis of their own preconceptions rather than analysis. A similarly distorted picture resulted when they attributed the infant deaths certified as being due to overlaying to carelessness on the part of the mother. The number of deaths from overlaying was very small — the rate in 1911 was only 1.4 per 1,000 — but they have attracted a disproportionate amount of attention, both from contemporary observers and from historians.82 This is probably because such deaths appeared to represent the most uncaring neglect; it was claimed that the women were usually drunk at the time. Alcohol was often referred to as a `racial poison', and one writer in the British Medical Journal of 1903 saw overlaying as a sign of racial degeneration.83 In common with many political leaders of the day, Newsholme felt particularly strongly about the effects of alcohol and in his fifth report on infant mortality, he suggested that if the pubs were to close for six months a great improvement in health and efficiency would result. John Burns, the President of the Local Government Board, believed that alcohol caused both overlaying and the birth of physically poor specimens of humanity.84 It was claimed that the high number of deaths from overlaying on Saturday and Sunday nights proved the connection with drunkenness. In 1916, the Registrar-General published a table showing that deaths due to overlaying had dropped significantly on these two nights during 1915 and 1916, when the Defence of the Realm Act had limited opening hours."S However, statistics published by the MOH for Birmingham in 1917, showed a decline in the number of arrests for drunkenness and an increase in the number of deaths due to overlaying.86 It was possible that death certificates were as misleading in the case of overlaying as in other causes of infant death. The Registrar-General suggested that `crib death' seemed to be increasing and might account for some of the deaths attributed to overlaying, and William Brend suggested in his report that respiratory disorders might be the true cause of death. A midwife, writing in 1908, pointed out that Saturday was a very heavy day for housework for the working-class mother and that fatigue more than drunkenness would explain the high number of deaths on Saturday night.8' Fear of overlaying led to a demand by infant welfare workers for parents to provide a separate cot for

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their children. Yet in 1943, Margaret Ribble, one of the first authors to show a concern for the psychological well-being of the infant, referred to overlaying as `an ancient belief, still current, that babies who sleep with the mother are in danger of suffocation'.88 The widespread contention that working-class mothers did not care about their children also inspired the campaign by medical officers of health against infant life-insurance. It was common for the poor to insure each infant at Id. or 2d. a week against death until well into the 1920s, for an infant's funeral could easily cost as much as 30s. 89 Medical officers and infant welfare workers believed that poor parents allowed their children to die in order to claim the insurance money, although at the 1906 Conference on Infant Mortality, an insurance representative pointed out that not only was a legal limit of £6 placed on infant insurance, but that insurance was a universal working-class practice which was neither understood nor appreciated by the middle class 90 The 1906 conference resolved that companies should provide for funeral expenses directly through the undertaker and not through the parents. But burial insurance was a sign of both love for the deceased and self-respect for the aggrieved. Adults were insured against funeral expenses as well as infants, for whereas great shame attached to a pauper burial, pride accrued from a `good send off'. In her study of Middlesborough, Lady Bell recorded the satisfaction of a woman who buried her husband `with ham'; in other words she was able to afford a high-tea for the mourners.91 Many recent works on the history of childhood have suggested that women in the past did not love their children. Edward Shorter argues this to have been the case in the working-class family as late as the nineteenth and early twentieth centuries. Moreover, it was not a case of working-class mothers withholding love because the infant was likely to die, but rather lack of love causing death.92 But love is not a definable or measurable variable over long periods of time and it is unreasonable to expect expressions of love in the late nineteenth or early twentieth centuries to take a mid-twentieth-century form. What can be assessed is the degree to which parents strove to protect and nurture their children within the bounds of the possibilities available to them. Women lacked control over many of the potential causes of infant death and even if sometimes they contributed to the death of their infants (for example, by improper feeding), there is no evidence to show that they did not also fight to save their children. In a biography of a South Shields woman, bom in 1889, the following comment is made following the death of an infant: Johnny [the woman's husband] did not know what to

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say, although he tried. Death was one of those things that happened and there was nothin' anybody could do about it ... but ... No matter how many ye get, ye always want them all. Everyone.' One respondent referred to her second baby, who died of bronchitis in 1909, as a `November baby'; a phrase that evinces a degree of fatalism. But she also recalled nursing him night and day and doing her best to follow the instructions of the doctor she called in. By insuring infant lives, or even by working for wages that would perhaps provide better food or medical care during sickness, women were not neglecting their children. Yet it was commonly held that the mother who worked could not possibly look after her child properly.94 At the 1906 Conference on Infant Mortality, John Burns, who became President of the conference, called for legal restrictions on married women's work and the conference resolved that women should be compelled to stay at home for three months after the birth of a child rather than the one month prescribed under Section 61 of the 1901 Factory Act. The controversy over the effect of married women's work on the infant mortality rate began in earnest during the 1890s, and the evidence presented by participants who believed in the harmful influence of women's work was accepted by Margaret Hewitt in her work Wives and Mothers in Victorian Industry, published in 1956.95 Medical officers of health, in particular, contended that going out to work stopped women breastfeeding, and that carrying the baby to nurse in the early morning also exposed it to the danger of bronchitis. George Newman was alone in also considering the effect of work upon the pregnant rather than the nursing woman.96 Newsholme recognised the increasing numbers of deaths registered under the heading of prematurity, but maintained that this was a matter of changing practices of certification.97 Death due to prematurity was in fact as high in mining districts — where few women worked, but where housework was extremely heavy — as in textile areas where as many as 63% of women worked.98 The argument against women's employment outside the home stemmed more from the belief that women's place was in the home than from the evidence produced to connect it with infant mortality. Manuals of the period agreed that the person looking after the child should be the mother.99 George Reid, MOH for Staffordshire, supported his attack on women's work using data from the pottery districts. He divided the pottery towns of Staffordshire into three categories: those where `many women' worked, those where `fewer women' worked and those where `practically no' women worked. The infant mortality rate was lowest in the areas where `practically no' women worked. Reid felt

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that his statistics `spoke for themselves',10° yet he considered no variables other than women's employment and provided no data showing how soon women returned to work after parturition. Most married women had no desire to return to work immediately after childbirth if they could avoid it. Between 1905 and 1913 an average of fourteen complaints per year were made to factory inspectors under Section 61 of the 1901 Act, and a very high number of the cases concerned unmarried and deserted women.'°' When Reid broke down his figures by town, it transpired that one town where a large number of women worked had a low infant mortality rate, which Reid was forced to explain by its superior sanitary arrangements.'°2 A 1912 report on two poor wards of Birmingham, undertaken in response to a Home Office circular asking for more information on the effect of women's work on infant mortality, reached the opposite conclusion to Reid's: It would appear from these figures that in this district at any rate, factory work has not such an injurious effect on the child as one would imagine. This probably means that there are many other factors at work besides the industrial employment of the mother. From my own observations amongst these women, I have come to the conclusion that it is not the child of the working mother who has the worst chance. The woman who is thrifty and energetic ... goes to work, and the additional money has an important influence on the prevention of poverty.'03 Two reports on women's work during World War I also made the point that women's employment might well be a lesser evil than poverty.104 Newsholme admitted that the data on women's work were inconclusive, but he could not bring himself to admit that women's employment had no effect on the infant mortality rate: It would be folly to infer from this that the industrial occupation of mothers is not a most injurious element in our social life ... the most that can be inferred ... is that the industrial employment of married and widowed women cannot be regarded as in itself the chief cause of excessive infant mortality. 'os The attack on women's work was founded on the assumption that women's proper place was in the home. Women trade-unionists defended their right to work, especially in the face of the threat legally to restrict the employment of married women. One wrote in Reynolds Newspaper:

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`If the Rt. Hon. John Burns will show me a way out of the difficulty [poverty] I shall be delighted, but it seems to me that until then I must work.'106 However working women had no sympathy with the Freedom of Labour Defence League, who also opposed Burns, but from the other end of the political spectrum, maintaining that women's work should be freed of all restrictions. Working women supported the idea of compulsory leave from work as long as it was paid leave; hence they supported the terms of the International Labour Organization's Washington Convention, which provided for six weeks paid maternity leave before and after childbirth for women in `industrial and commercial undertakings', and later the movement for family allowances.107 Britain never adopted the Washington Convention. The government Actuary maintained that it was wrong to usurp the father's responsibility and, more decisively, adoption of the convention would have meant increasing male and female national health insurance contributions by 4d per week.108 Working women were very conscious of the burden imposed by doing two jobs, one at home and one at work. Some members of the Women's Labour League felt that outside activities for working women should consist of recreational pursuits, such as sewing parties, church groups and Women's Cooperative Guild or League meetings, not waged work.109 Day nurseries were never promoted by working-class women. Mary MacArthur, the most prominent woman trade-unionist, declared that women had no desire to go on working in factories while trying to nurse their children in crèches that might be provided by the factory owner and that `every encouragement' should be given to mothers to stay at home.10 Working women and medical officers of health were agreed that creches were a last resort. Thus, when the day nurseries opened during the war were closed rapidly after it was over, little opposition ensued. Labour women gave their support instead to nursery schools.11' These were designed to promote the health and education of workingclass children rather than to help working mothers by providing child care. Thus they elicited greater support from health officials, government and middle-class women.112 Many participants in the debate over women's employment believed that regardless of the direct effect of married women's employment on the welfare of infants, the ignorance of all women, and perhaps especially of the `factory mother', was the real problem. In a paper on the connection between married women's employment and infant mortality, Mrs Florence Greenwood, a Sanitary Inspector in Sheffield, commented that `only those who visit the homes of the working classes

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day by day and see how they live can estimate the dense ignorance that prevails'; she did not make it clear whether working women or nonworking women were the most ignorant.113 The Medical Officer of Health for Birmingham implied that working women were more ignorant of domestic duties than women who stayed at home when he said that if women's work continued on such a large scale girls between fourteen and twenty years of age should be compelled to take extra education courses in infant care.114 Mrs May Tennant, a Superintendent of Factory Inspectors, denounced the ignorance of the factory mother as `a danger to the race'.15 However, Clementina Black, the President of the Women's Industrial Council, argued, like the Birmingham Report of 1912, that women who worked were likely to be of a more energetic and intelligent character, and that it was thus amongst the women who stayed at home that the highest level of ignorance was likely to be found.116 This was endorsed by Karl Pearson's findings, which concluded that maternal efficiency had nothing to do with women's employment or environmental variables, but rather depended on heredity. After the investigation into the health and efficiency of married women workers conducted during World War I, fewer references were made to women's work as a primary cause of infant mortality, but the emphasis on women's ignorance of home duties remained. When health officials focused their attention on preventing infantile diarrhoea, they consciously chose to concentrate on improving the quality of maternal care to the virtual exclusion of any other factors. Certainly, maternal care was more susceptible to immediate improvement. But this does not either explain or excuse the way in which medical officers of health, physicians and Local Government Board officials skirted, and even denied, the influence of factors such as low incomes, poor housing conditions and sanitation, and contaminated milk. Those involved in the child and maternal welfare movement held women responsible for all infant deaths that were due to preventable causes. In their view, women's chief duty was to their infants and anything that detracted from this, such as work outside the home, was to be discouraged. Mistakes made in infant rearing due to ignorance, especially in the area of feeding, were to be remedied by education. All women were considered to need training in infant care and management, but the ignorance of working-class women was perceived to be greater. Their education involved the double aim of imparting actual information and imbuing them with a proper sense of middleclass values. Margaret Loane, a health visitor, observed in 1902 that the existence of a working-class culture went unrecognised by the middle-

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class official,"' whose attitude was neatly summed up in a comment by a consultant at Great Ormond Street Hospital for Sick Children, when he reported in 1915: `Already there are signs that the haphazard method, or rather lack of method, which has prevailed in the rearing of children, especially amongst the poor, is giving place to something better."18 All girls could be trained in school and middle-class women were educated chiefly via infant-care manuals, but working-class women did not read these19 and, hence, other ways had to be found of passing on the skills that were perceived to be necessary. Women found it impossible to abstract the problem of ignorance from those of poverty and environment. They welcomed advice in raising their children, but as will be seen in the next chapter, resented the patronising way in which it was often given and also pressed for an expansion of the services offered in a direction that proved unacceptable to the authorities.

Notes 1. PP, '44th Annual Report of the Local Government Board, 1914-15. Supplement in Continuation of the Report of the Medical Officer, containing a Report on Maternal Mortality in Connection with Childbearing and its Relation to Infant Mortality', 1914-16, Cd. 8085, XXV, 157; and E.W. Hope, 'Infant and Maternal Welfare Scheme. Report of the Medical Officer of Health, 1916' in Proceedings of the Council, 1916, p. 589, Liverpool Reference Library, were two of the first reports to acknowledge this. 2. George Rosen, A History of Public Health (New York: MD Pubs Inc., 1958), p. 288, describes such confusion as 'common'. See also, Peter W.G. Wright, 'The Birth of Child Rearing as a Technical Field and Its Importance as a Form of Social Control', paper given to the British Sociological Association Annual Conference, Manchester, 1976, pp. 11-12, for the late-nineteenth-century background to this and the slowness with which germ theory was applied to the problem of diarrhoea. 3. H.M. Richards, 'The Factors which Determine the Local Incidence of Fatal Infantile Diarrhoea',fm!. of Hygiene, 3 (1903), pp. 325-46. 4. 'Summer Diarrhoea' (editorial), Public Health, 28 (July 1915), pp. 222-3. 5. Arthur Newsholme, A Contribution to the Study of Epidemic Diarrhoea (D. Rebman Ltd, 1900), pp. 28 and 63. 6. Annual Report of the Medical Officer of Health for Hull, 1922, p. 26 and Annual Report of the MOH for Hull, 1924, p. 30, Hull Public Archives. 7. Local Government Board, Return as to Scavenging in Urban Districts (HMSO, 1914), p. iv. 8. PP, '39th Annual Report of the Local Government Board, 1900-10. Supplement to the Report of the Board's Medical Officer, containing a Report by the Medical Officer on Infant and Child Mortality', 1910, Cd. 5263, XXXIX, 973, p. 64. 9. J. Spottiswoode Cameron, 'Sanitary Progress in the last Twenty-Five Years and in the Next', Public Health, 15 (Nov. 1902), pp. 65-93. 10. See for example, Olof Mellander, Bo Vahlquist and Tore Mellbin, 'Breast Feeding and Artificial Feeding', Acta. Paed. Scand., 48 (1959), pp. 55-70.

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11. George Newman, Report on the Milk Supply of Finsbury (Thomas Beam, 1903), p. 49. 12. William J. Howarth, `The Influence of Feeding on the Mortality of Infants', Lancet, 22 July 1905, pp. 210-11. 13. Helen M. Blagg, A Statistical Analysis of Infant Mortality and Its Causes in the UK (P.S. King, 1910), Table IX, n.p. 14. George Newman, Infant Mortality: A Social Problem (Methuen, 1906), p. 173. 15. Ann Oakley, Wisewoman and Medicine Man: Changes in the Management of Childbirth' in The Rights and Wrongs of Women, edited by Ann Oakley and Juliet Mitchell (Penguin, 1976), pp. 38-42, fairly condemns the 'anti-dirt' campaign for placing the burden of responsibility on women, but passes over the significance of this point. 16. 8th Annual Report of the Women's Labour League, 1913, n.p.; and Katherine Bruce Glasier, 'Wanted: A New Order of Knighthood! To Battle with Dirt and Darkness', Labour Woman, 1 (Oct. 1913), p. 85. 17. PP, `Report of the Chief Medical Officer of the Board of Education for 1913', 1914-16, Cd. 7730, XVIII, 277, p. 19; and Board of Education, `Education and Infant Welfare', Circular 940 (HMSO, 1916), p. 2. 18. S.G. Moore, 'Infant Mortality and the Relative Practical Value of Measures Directed to Its Prevention', Lancet, 22 April 1916, p. 852. 19. Cd. 5263, p. 70, Newsholme quoted Newman's similar views on p. 72. 20. William A. Brend, `The Relative Importance of Pre-Natal and Post-Natal Conditions as Causes of Infant Mortality in The Mortality of Birth, Infancy and Childhood, Medical Research Council Special Report Series no. 10 (HMSO, 1917), pp. 1-36. The criticism of Brend appeared in National Health, 9 (Dec. 1917), p. 168. 21. Karl Pearson, The Chadwick Lecture, 1913, MS, Pearson Papers, Item 73, D.B. Watson Library, University College. 22. Mary Noel Kam and Karl Pearson, Study of the Data Provided by a BabyClinic in a Large Manufacturing Town, Drapers Co. Research Memoires, Studies in National Deterioration X (Cambridge UP, 1922); and 'On the Relative Value of the Factors which Influence Infant Welfare. An Inquiry by Ethel M. Elderton based on data provided by Dr. A.G. Anderson, MOH Rochdale; Dr. William Arnold Evans, MOH Bradford; Dr. Alfred Greenwood, MOH Blackburn; Dr. H.O. Pilkington, MOH Preston; and Dr. C.H. Tattersall, MOH Salford, Pt. I.' Annals of Eugenics, I (1925-6), p. 175. 23. D. Noel Paton and Leonard Findlay, Poverty, Nutrition and Growth. Studies of Child Life in Cities and Rural Districts of Scotland, Medical Research Council Special Report Series no. 101 (HMSO, 1926), pp. 190, 197, 209, 227, 250. 24. Cd. 7730, p. 16. 25. A similar point is made by Karl Figlio, `Chlorosis and Chronic Disease in Nineteenth Century Britain: The Social Construction of Somatic Illness in a Capitalist Society', Social History, 3 (May 1978), p. 176. (On the relation of eugenics to social policy see, Charles E. Rosenberg, 'The Bitter Fruit: Hereditary Disease and Social Thought in Nineteenth Century America', Perspectives in American History, 8 (1974), pp. 181-235.) 26. Cd. 5263, pp. 8-24 and 54. 27. Dr Jessie Duncan, Reports on Infant Mortality in St. George's and St. Stephen's Wards (Birmingham City Council, 1912), pp. 12-13, Birmingham Reference Library. 28. PRO, MH 48/183, John Robertson, 'Report of the Medical Officer of Health on Child Welfare' (City of Birmingham), 1913.

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29. Annual Report of the MOH for Liverpool for 1912, p. 13, Liverpool Reference Library. 30. Cd. 5263, p. 55; PP, '45th Annual Report of the Local Government Board. Supplement in Continuance of the Report of the Medical Officer of the Board for 1915-16, containing a Report on Child Mortality at Ages 0-5', 1917-18, Cd. 8496, XVI, 1, p. 67; and PP, '42nd Annual Report of the Local Government Board for 1912-13. Supplement in Continuance of the Report of the Medical Officer of the Board, containing a 2nd Report on Infant and Child Mortality', 1913, Cd. 6909, XXXII, 1, p. 76. 31. Carnegie Infant Welfare Institute Quarterly Magazine, March 1928, p. 1, Birmingham Reference Library. 32. Medical Officer of Health for Kensington, Report of Infant Mortality in Kensington (Kensington Borough Council, 1932), p. 3. 33. R. Titmuss, Birth Poverty and Wealth (Hamish Hamilton, 1943), p. 26. 34. Frederick Davis, Childhood Its Nurture, Nature, Psychology and Education in Relation to Social Life (Bale and Danielsson, 1912), p. 5. Davis was a trained pharmacist, but does not appear to have had any training in psychology. 35. Lady Florence E.E. Bell, At the Works (Edward Arnold, 1907), p. 171; see also, Mrs J.R. MacDonald, Mrs Player, Dr Ethel Bentham, Dr Olive Claydon, Mrs F.L. Donaldson and Mrs G.H. Wood, Wage Earning Mothers (Women's Labour League, n.d.), p. 24; and Helen Bosanquet, The Family (MacMillan, 1906), p. 259. 36. Newman, Infant Mortality: A Social Problem, p. 257. 37. PP, 'Report of the Inter-Departmental Committee on Physical Deterioration, Minutes of Evidence, Vol. II', 1904, Cd. 2210, XXXII, 145, pp. 115 and 290. 38. Enid Campbell Dauncey, 'Ignorant Mothers', Contemporary Review, 97 (May 1910), pp. 603-7; Sir Arthur Newsholme, The Enemies of Child Life', Nineteenth Century, 83 (January 1918), p. 93; and Ministry of Health, Annual Report of the Chief Medical Officer, 1919-20 (HMSO, 1920), p. 123. 39. Nancy Pottishman Weiss has traced a similar movement in the USA: 'The Mother-Child Dyad Revisited: Perceptions of Mothers and Children in Twentieth Century Child-Rearing Manuals', Jr. of Social Issues, 34 (Spring 1978), pp. 36-8. 40. Selina F. Fox, Mother and Baby (J. & A. Churchill, 1912), p. 99; Mary Scharlieb, Womanhood and Race Regeneration (Cassell and Co., 1912), p. 26; and C.W. Saleeby, Woman and Womanhood (New York: Mitchell Kennedy, 1911), p. 177. Saleeby trained under J.W. Ballantyne at Edinburgh and was a popular public speaker. 41. PP, 'Report of the Inter-Departmental Committee on Physical Deterioration, Vol. I', 1904, Cd. 2175, XXXII, 1, p. 50; and H. Llewellyn Heath, The Infant, the Parent and the State (P.S. King, 1907), p. 24. 42. Harold Scurfield, 'The Need for Infant Management Being Given a More Important Place in the Medical Curriculum', Public Health, 26 (Jan. 1913), pp. 111-13. 43. LGB, Minutes of the Discussion of Paediatrics, 6 March 1919 (HMSO, 1919); Ministry of Health, Recent Advances in Medical Education in England, Memo to the Minister of Health by Sir George Newman (HMSO, 1923), p. 134; and General Council of Medical Education, Addendum to the Minutes of the General Medical Council for 1932. Reports of the Inspector of Qualifying Examinations, 1930.1932 (General Medical Council, 1932), p. 21. 44. Lucy Naish, 'Breast-feeding: Its Management and Mismanagement', Lancet, 14 Jan. 1913, pp. 1657-9. 45. John and Elizabeth Newson, 'Cultural Aspects of Childrearing in the English Speaking World' in The Integration of a Child into a Social World, edited

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by Martin P.M. Richards (Cambridge UP, 1974), p. 62. 46. Lancet, 14 Jan. 1913, p. 1677 (editorial). 47. See for example, J.W. Ballantyne, Expectant Motherhood (Cassell, 1914), p. 198; Ada Bailin, The Expectant Mother (n.p., n.d.), p. 17 (Ada Bailin was the editor of Baby); and Woman's Own, 26 Nov. 1932, p. 258. 48. Susan Lipshitz, 'The Mother and the Hospital' in Tearing the Veil, edited by Susan Lipshitz (Routledge, 1978), p. 34. 49. Hester Viney, The Book of Breast-Feeding (Routledge, 1924), p. 2. 50. Eric Pritchard, Infant Education (Henry Kimpton, 1911), pp. 172-3 and The Physiological Feeding of Infants, 4th edn. (Henry Kimpton, 1922), p. 125. 51. Sir Frederick Truby King, The Expectant Mother and Baby's First Month (Wellington, New Zealand: Dept of Public Health, 1935), pp. 47-8 and 78. 52. Marie Stopes, Baby's First Year (Putnams, 1939), p. 79. 53. Harold Waller, Clinical Studies in Lactation (Heinemann, 1938), p. 140. 54. In a recent interview in New Scientist, Martin Richards commented: 'there is no relation between who gets what except which midwife is doing the delivery' (New Scientist, 2 Sept. 1978, p. 847). 55. 'The Ignorance and Fecklessness of Mothers', National Health, 2 (Sept. 1910), p. 174; and 'Infant Welfare in Warwickshire', National Health, 6 (June 1915), P. 215. 56. Anna Davin, 'Imperialism and Motherhood', History Workshop Jr. (Spring 1978), pp. 9-65. 57. Katherine M.L. Gamgee, 'Breast Feeding: Some of Its Aspects from the Public Health Point of View', Jr. Roy. San. Instil., XLV (Oct. 1924), p. 203. See also, John and Elizabeth Newson, Infant Care in an Urban Community (New York: International University Press, 1963), p. 164 et seq. where this trend is documented for the post-World War II period. 58. PRO, MH 55/550, James Wheatley to Newman, 27 Jan. 1916; and Note on the Central Midwives Board Rules, 25 March 1919. 59. Ethel Bentham, Wage-Earning Mothers', League Leaflets, April 1916, Labour Party Archives. 60. Amand Routh, 'How the Health of the Urban Babe can be Safeguarded' in Mothercraft, edited by the National Association for the Prevention of Infant Mortality (National League for Physical Education and Improvement, 191S), p. 20. 61. Annual Report of the MOH for St. Pancras, 1914, p. 42. 62. Annual Report of the MOH for Birmingham, 1914, p. 20, Birmingham Reference Library. 63. Kam and Pearson, Study of the Data Provided by a Baby Clinic, pp. 20-5. 64. Frederick Truby King, Natural Feeding of Infants (Whitcombe and Tombs, n.d.), p. 9. 65. Pritchard, Physiological Feeding, p. xvi; see also pp. 1-3, 20 and 29. 66. T. Hutchison, 'Patent Foods', Lancet, 5 July 1902, p. 1; and F.J.H. Coutts, On the Use of Proprietory Foods for Infant Feeding, Report to the Local Government Board on Public Health and Medical Subjects, no. 80 (HMSO, 1914). 67. Janet Blackman, 'Baby Scales and Tin Openers', Mother and Child, 45 (Dec. 1973), pp. 15-16. 68. Magdalen Stuart Pember Reeves, Round about a Pound a Week (G. Bell, 1915), p. 54; and C.E. McNally, Public Ill-Health (Gollancz, 1935), pp. 181-91. 69. F.J.H. Coutts, Report to the Local Government Board on an Inquiry as to Condensed Milks, with Special Reference to their Use as Infant Foods (HMSO, 1911), pp. 31-5. 70. See, for example, the extensive charts in Mabel Liddiard, The Mothercraft Manual (LA. Churchill, 1924), pp. 80-95; and Eric Pritchard, Physiological

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Feeding. 3rd edn (Henry Kimpton, 1909), pp. 65-81. Liddiard was the Matron of the Mothercraft Training Centre founded by Truby King. 71. Home Notes, CXXXVIII, 30 June 1928, p. 935 and XXIV, 13 June 1912, p. 464. 72. Ibid., LX, 15 Oct. 1908, p. 141. 73. Pritchard, Infant Education, p. 174, Appendix. 74. PRO, MH 56/62, 'Report of the Inter-Departmental Committee on Condensed Milk, 1920', shows the decline in the use of condensed milk to have been greatest between 1919 and 1920. 75. The Disease-Producing Milk Supply of the Great City', Lancet, 31 Oct. 1908, pp. 1310-11 (editorial); and 'The Manchester Milk Supply', Lancet, 18 June 1910, p. 1702 (editorial). 76. For example, Woman's Dreadnought, 3 (17 June 1916), p. 494; and Women's Cooperative Guild, The Milk We Want (WCG, 1925). 77. G.F. McCleary, Infantile Mortality and Infants Milk Depots (P.S. King, 1905), p. 132. 78. Discussion following A.K. Chalmer's paper, 'Infant Mortality', Public Health, 18 (April 1906), p. 436. 79. Lancet, 25 Feb. 1911, p. 543. 80. Pritchard, Physiological Feeding, 3rd edn (1909), p. 51. 81. Janet Lane-Claypon, Milk and Its Hygienic Relations (Longmans, 1916), pp. 63-75. 82. For example, J.M. Winter, The Impact of the First World War on Civilian Health in Britain', Econ. Hist. Rev., 30 (Aug. 1977), pp. 478-507; and Lloyd Demause's explanation of overlaying in terms of the reluctance of the mother to let her child sleep by him or herself, 'The Evolution of Childhood', in The History of Childhood, edited by Lloyd Demause (New York: Psychohistory Press, 1974), p. 21. 83. See Newman, Infant Mortality: A Social Problem, pp. 205-10; C.W. Saleeby, The Progress of Eugenics (Cassell and Co., 1914), pp. 230-44; and 'Physical Degeneration, Pt. III', BMJ, 5 Dec. 1903, p. 1471; see also, Hugh Tuke Ashby, Infant Mortality (Cambridge UP, 1915), p. 6. 84. John Burns, 'On the Primary Importance of Better Conditions of Life' in National Physical Training, edited by J.B. Atkins (Ibister and Co., 1904), p. 63. 85. PP, '79th Annual Report of the Registrar General for 1916', 1917-18, Cd. 8869, VI, 1, p. xi. 86. Annual Report of the MOH for Birmingham, 1917, p. 5. 87. Mrs Greenwood, 'Note on the Midwives Act', Public Health, 21 (July 1908), p. 205. 88. Margaret Ribble, The Rights of Infants (New York: Columbia UP, 1943), pp. 18-19. 89. Reeves, Round About a Pound, pp. 66-7 and 80-2. 90. See the opposing views of: Councillor W. Fleming Anderson, 'Infant Life Insurance' and Frederick Schooling, 'Infant Mortality and Life Insurance', Report ... of the National Conference on Infant Mortality, 1906, pp. 199-211 and 211-17. 91. Bell, At the Works, p. 77. 92. Edward Shorter, The Making of the Modern Family (New York: Basic Books, 1975), pp. 168-204. 93. Joe Robinson, The Life and Times of Francie Nichol of South Shields (Allen and Unwin, 1975), p. 64. 94. Carol Dyhouse, `Working Class Mothers and Infant Mortality in England, 1895-1914', Jr. of Social History, 12 (Winter 1978), pp. 248-67, sketches in the early parts of this debate. Dyhouse concludes that work did not affect the infant

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mortality rate. Anthony Wohl, Working Wives or Healthy Homes?', a paper given at the Annual Conference for the Social History of Medicine, Cambridge, 1977, while sympathising with the lot of working women, disagrees, believing that anything which resulted in bottlefeeding must have been detrimental. 95. Margaret Hewitt, Wives and Mothers in Victorian Industry (Rockcliffe, 1958; reprint edn, Westport: Greenwood Press, 1975), pp. 106-20. 96. Newman, Infant Mortality: A Social Problem, p. 80. 97. Cd. 5263. p. 25. 98. PP, '74th Annual Report of the Registrar General for 1911', 1912-13, Cd. 6578, XIII, 493, p. 89, Table 28B. 99. For example: W.B. Drummond, An Introduction to Child Study (Arnold, 1907), p. 157; Liddiard, Mothercraft, pp. 108-9; and Harold Scurfield, Infant and Young Child Welfare (Cassell, 1919), p. 54. Drummond was Assistant Physician to the Royal Hospital for Sick Children in Edinburgh. 100. Annual Report of the MOH for Staffordshire for 1901, p. 22, LSE, Papers of the British Association for the Advancement of Science, Committee on the Effect of Legislation Regulating Women's Labour, Coll. Misc. 486, Box 1/8. 101. PP, 'Report of the Women's Employment Committee', 1918, Cd. 9239, XIV, 783, Appendix VII, pp. 107-10. 102. George Reid, 'Infant Mortality and the Employment of Married Women in Factories', LSE, Coll. Misc. 486, Box 1/9. 103. Jessie Duncan, Report on Infant Mortality in St. George's and St. Stephen's Wards, p. 9. 104. PP, 'Report of the War Cabinet Committee on Women in Industry', 1919, Cmd. 135, XXXI, 241, pp. 234 and 244; 'Final Report of the Health of Munition Workers Committee', 1918, Cd. 9065, XIII, 195, p. 23. 105. PP, '43rd Annual Report of the LGB. Supplement in Continuation of the Report of the Medical Officer of the Board for 1913-14, containing a Third Report on Infant Mortality dealing with Infant Mortality in Lancashire by the Medical Officer and Drs. Copeman, Manby, Farrar and Lane-Claypon', 1914, Cd. 7511, XXXIX, 371, p. 18; and Cd. 5263, pp. 57-8. 106. Reynold's News, 25 April 1909, Tuckwell Papers, file 23, TUC Archives. 107. Woman Worker, May 1921, p. 8, editorial, TUC Archives. 108. PP, 'Memo by the Government Actuary on the Washington Draft Convention Concerning the Employment of Women before and after Childbirth', 1921, Cmd. 1293, XXXI, 583. 109. MacDonald, et. al., Wage Earning Mothers, p. 116. 110. Mary MacArthur, 'The Woman Trade Unionist's Point of View' in Women and the Labour Party, edited by Marion Phillips (Headley Bros, 1918), pp. 18-19; and Woman Worker, Feb. 1920, p. 6. 111. Labour Woman, 17 (Sept. 1929), p. 137; and 19 (Dec. 1932), p. 185. 112. PRO, ED 24/1466, Circular 1054 (MH) and 1405 (Board of Education), 'Children under School Age', 5 Dec. 1929; E. Stevenson, 'The Future of Nursery Schools', Mother and Child, 1 (May 1930), pp. 46-50; and 'Why Wait until They're Five?' Woman's Own, 29 Oct. 1932, pp. 102-3. 113. Mrs Florence J. Greenwood, Is the High Infantile Death Rate Due to the Occupation of Married Women? (Bale and Danielsson, 1901), p. 4, LSE Coll. Misc. 486, Box 1/9. 114. Annual Report of the MOH for Birmingham, 1914, p. 14. 115. May Tennant, 'Infant Mortality and Factory Labour, Pt. I' in Dangerous Trades, edited by Thomas Oliver (John Murray, 1902), p. 73. 116. Clementina Black (ed.), Married Women's Work (G. Bell, 1915), pp. 1-2; and 'Report on the Industry and Motherhood Inquiry, Pt. II', Women's Industrial News, 21 (April 1918), pp. 13-14. The Women's Industrial Council was founded in

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1894 and worked to improve women's job skills, investigated conditions of women's work and operated committees on girls' clubs and physical drill. 117. Margaret Loane, The Next Street But One (Arnold, 1902), p. 43. 118.0. Hildescheim, The Health of the Child (Methuen, 1915), p. ix. 119. None of the 83 working-class women interviewed had read an infant care manual.

3

EDUCATING THE MOTHERS

In his 1913 report as Chief Medical Officer to the Board of Education, Newman stressed the following: `The principal operating influence [in causing infant mortality] is the ignorance of the mother and the remedy is the education of the mother.' Infant hygienists stressed that childrearing in modern society was not the `natural' process it was for mothers in `primitive' cultures. For the very reason that the modern mother was more intelligent she could not rely on instinct, but had to be instructed in scientific methods of child care. S.G. Moore, for example, felt that it was `monstrous that the fate of a new generation should be left to the chances of unreasoning custom, impulse and fancy — joined with the suggestions of ignorant nurses and the prejudiced counsel of grandmothers'.2 The Lancet agreed that working-class mothers especially knew nothing about the proper conditions of health for infants and were guided by `traditions handed down from bygone ages'.3 Whilst there was widespread support for the idea of educating mothers, the purposes of the various groups involved differed. Policymakers and health officials were convinced that education was the only solution to the problem of infant mortality. The questions posed to the witnesses who appeared before the Inter-departmental Committee on Physical Deterioration in 1904 provide a good example of their bias. All witnesses were asked whether they felt that educating girls and mothers in infant management was a good idea, yet when a witness indicated that poverty rather than ignorance might be the reason for the use of canned milk, for example, the point was never pursued.4 Voluntary societies could play a part in educating mothers but could do very little to alleviate poverty and the Women's Health Association of Great Britain, a predominantly middle-class organisation, gave this as its reason for concentrating its efforts on education, even though it recognised that it was probably not the only cause of infant mortality.s The Women's Cooperative Guild (WCG), whose members were working men's wives, did not believe that educating mothers would have any effect on the infant mortality rate, because women did not have the material means of practising what they were taught. However, they were in favour of educating mothers because once women knew what was best for their babies, they might then demand the means with which 89

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to do a good job.6 Education in infant management could be channelled through either the mother or the daughter. `Schools for Mothers', `Babies Welcomes' (which were the names given the early infant welfare clinics run by voluntary societies) and health visitors were designed to reach the mothers, but they could not hope to reach as many mothers as compulsory education could daughters. The school medical service set a precedent for the Board of Education's involvement in health matters and the poor health of social entrants made the board particularly anxious to stress the importance of teaching mothercraft to girls. In 1904, the Committee on Physical Deterioration recommended `some great scheme of social education' with more concentration on homecraft and infant management in the schools. The committee considered the possibility of girls claiming partial exemption from school before the age of 14 (the school-leaving age) on the condition that they continued part-time education in homecraft and mothercraft after 14, the hope being that they would remember more when they became mothers.' The first steps towards a comprehensive education for girls in these subjects was taken in 1905, when the Board of Education required that all syllabuses in laundry, cookery and household management be submitted to the board rather than to the inspectors for approval, so that they might be checked for practical content.' After 1905, the number of classes offered in these subjects increased. J.W. Ballantyne, the pioneer of ante-natal care, called attention to the `doll instinct in girl children, so little appreciated or utilized', believing that these instincts should be channelled by the education system, so that girls might be better trained for the roles of wife and mother that a majority of them would grow up to fill.9 This view found widespread support and pressure was put on the Board of Education to restructure the schoolgirls' curriculum. A special report to the board, made in 1906, stated that most thoughtful women were `coming to share' the opinion that girls should be educated differently from boys and that `the reaction against excessively domestic and feminine types of training has already gone too far'.1° Only a minority of girls would work for their living outside the home and to organise the curriculum around their needs was to encourage `learned spinsterhood and depopulation'." In her book on infant mortality, Helen Blagg, a settlement worker, asked: `Of what use is it to teach girls to read and write and calculate if they cannot perform the ordinary duties of wife and mother?'12 Eugenists stressed that an academic education would stand in the way of marriage and maternity, because most men preferred less educated women; a serious

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consideration in view of the falling birth rate. Dr Murray Leslie, Chairman of the Women's Imperial Health Association, felt that femininity was an important eugenic quality that should be encouraged in the schools. Together with Dr Ballantyne and Dr Mary Scharlieb, he believed that boyish games such as field-hockey could result in difficulties in childbirth or an inability to nurse. This led him to suggest a `Law of Consonance' by which `a woman should only develop intellectually along lines that are consonant with the natural development of her capacity for race creativeness'. Dr Leslie's views of women's education were not far removed from those of many nineteenth-century doctors, who believed that during adolescence, a girl should rest mentally and physically in order to allow all her energies to go into developing her reproductive system.13 The initiative in promoting the teaching of infant care in the schools was taken by the medical officers of health. In Stockport, for example, the Sanitary Committee gave a prize to each school willing to teach elementary hygiene and care of infants to girls and distributed books on infant feeding in the schools. The National League for Physical Education and Improvement also sent a deputation to the Board of Education in support of many of the recommendations of the 1904 Committee on Physical Deterioration, including that of teaching infant management to girls, and in 1909 the National Conference on Infant Mortality also asked the board to act.14 The board responded in 1910 by issuing a `Memo on the Teaching of Infant Care and Management in the Public Elementary Schools' (one year after Newman became the Chief Medical Officer). The memorandum was rewritten in 1925, when a more didactic tone was adopted, and it remained in use until World War II.15 The suggested course was designed to be taken by girls during the last two years before leaving school at 14 and combined lessons in personal hygiene, temperance, home nursing, housekeeping and infant care. The latter emphasised proper methods of feeding and the dangers of domestic dirt, because these were believed to be the major causes of infant mortality. The importance of cleanliness had also been stressed in a curriculum drawn up by James Niven, MOH for Manchester, and presented to the National Conference on Infant Mortality in 1906.16 It was also the main theme of a Board of Education Committee report on housecraft, which recommended that `a course on housecraft should take as its starting point the necessity of unremitting warfare with dust, dirt and decay'." A report on the teaching of mothercraft to schoolgirls in York revealed that this emphasis was taken seriously. The course began with a lesson on the nature of dust and dirt.1ß

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The 1910 memorandum also suggested that every effort should be made to appeal to the motherly instincts of the girls. The use of a live baby rather than a doll for demonstrations was considered particularly crucial in this regard: `A doll is not likely to appeal to the deeper feelings and instincts of girls of this age ... The frailty and helplessness of a baby appeals to these girls as perhaps nothing else can.i19 With this point in mind, the National League for Health and Maternal Welfare urged that day nurseries would be good places to train schoolgirls in the art of infant management, and the 1925 edition of the memorandum listed examples of day nurseries where this had been done successfully.2° Above all, the teaching was to be simple and practical. Classes in mothercraft given to schoolgirls in Malvern during the 1920s aimed to teach `the craft, art and profession of a good mother', in order that the girls might do their duty to both family and nation and emphasised the value of cleanliness, fresh air and sleep (with a separate cot for the baby). A series of rhymes helped drive the points home: Baby thrives at Mother's breast That's the food he likes the best Give when his meal hour strikes Not at any time he likes And at night no meals are due Sleep is best for him and you If healthy children you would raise Open windows nights and days Boil the milk and cover it too This wise Mothers will surely do Mix the above with common sense Discipline kind and save the pence This should make the children thrive Bright and Gay like bees in the hive 21 An infant-care manual that was popular amongst the middle classes was recommended for use in the elementary schools and provided the means of transferring middle-class ideals of infant care to workingclass schoolgirls.22 Infant welfare workers continued to work for more education of this sort in schools. While the 1925 revisions to the 1910 Board of Education Memorandum were welcomed, Miss Halford, the Honorary Secretary of both the National Association for the Prevention of Infant Mortality and the Association of Child and Maternal Welfare

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Centres, had wanted the government to make such education compulsory.23 The teaching of mothercraft to schoolgirls received more attention than any other subject in National Health (the organ of the leading maternal and child welfare societies) during the inter-war period. Infant management lessons were often taught as a part of housecraft or some other domestic subject and despite the government's warning that such courses should not be used as vocational training for domestic service, for fear of making them unpopular, this was nonetheless how they were often seen. In 1918, Rebecca West attacked domestic education for girls because of its connection with service.24 It appears that there were grounds for suspicion. On at least one occasion, the Board of Education linked the need for more domestic education to the servant shortage.25 This dubious association with a working-class occupation made it even harder to introduce courses in infant care and domestic subjects into the more academic curriculum of the middle-class girls' secondary school. One way around this problem was to invest domestic subjects with scientific pretensions. Infant hygienists and writers of housecraft manuals, both stressed the importance of `scientific management', whether of infant feeding or housework. Manual-writers argued that science was a matter of `organized common sense' and that there was nothing to stop time-and-motion principles being applied in the home.26 Rigid feeding schedules, for example, reflected these principles. The term domestic science, which was applied to the domestic education of girls in secondary schools, represented an attempt to merge science and housecraft. If domestic subjects were to be accorded the importance it was felt they deserved, they had to be made scientific. As early as 1902, a book co-authored by Arthur Newsholme recommended a scientific approach to the details of domestic economy in order that it might appeal to all classes of girls 27 Alice Ravenhill, a lecturer in hygiene for the West Riding County Council, also believed that a scientific attitude of mind would improve the attitude of middle-class girls towards housework.28 The problem was to decide how far domestic science should replace pure science. There was a danger that neither would be covered properly and, in particular, that the practical aspects of domestic subjects would be neglected. One physician felt that there was no point in girls knowing the chemical composition of various foods and yet `having no idea that potato soup is unwholesome for young babies'.29 This was in fact a possibility if the pupils read only the new domestic-science textbooks.30 Different schools varied in their approach. At Haberdashers' Aske's

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in London, domestic subjects and sciences were completely integrated, the girls doing `experiments' on eggs and meat before learning how to cook them. Clapham High School, on the other hand, was very much against any such programme.' The Association of Headmistresses (an organisation representing the public schools) accepted `the importance to the community' of training in domestic subjects, but decided that scientific training should precede lessons in the `domestic arts', and that these in turn should supplement and not replace `liberal education subjects'.32 In 1913, a Consultative Committee on Practical Work in Secondary Schools agreed that two years pure science should precede education in domestic subjects.33 Thus while the two subjects were on the whole kept separate, it was intended that girls should finish their education with domestic rather than pure science. Girls over fifteen years of age were permitted to drop science and mathematics in favour of domestic subjects. Further education in domestic science was given in the women's department at King's College (subsequently King's College for Women), which opened in 1909, and which trained women as Home Science and Economics teachers. Feminist writers in the radical Freewoman deplored the idea of turning housecraft into a science and having `young women going to the university to learn how to clean'.34 But most middle-class women accepted the importance of efficient wife- and motherhood, although it is hard to discern how far their endorsement of domestic education extended to girls and women of their own class. The Women's Health Association of Great Britain stated: As far as the rearing and training of children, housework, cooking and domestic hygiene generally are concerned, it is almost entirely to women that we must look for their actual performance. And yet, how few mothers are taught how to rear their children properly, what points to look into in choosing a house, and how to carry on the home with economy and success. There is, indeed, an appalling ignorance of the most elementary principles of domestic hygiene and economy amongst young women of the middle and lower classes.35 Yet their lectures on health and hygiene were conducted along the lines of a mothers' meeting, with a clergyman invariably taking the chair, and were undoubtedly designed more for working- than middle-class women. Nevertheless, the National Council of Women felt that a year's course in domestic science should be a part of every girl's education.36 The Board of Education encouraged domestic science throughout the

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period 1906-39 and more time was devoted to it in school. In 1931, Mother and Child (which replaced National Health) sent a questionnaire to the 316 local education authorities asking how many included mothercraft in their syllabuses. Of the 157 which replied, 133 gave full courses. In the same year domestic science was recognised as an examination subject in all secondary schools. During the 1930s the Ministry of Health approached the Board of Education to ask for extra emphasis to be put on the teaching of cookery. In the course of the debate over nutrition standards in the 1930s, the Ministry of Health eagerly supported the position of a majority of medical officers of health who argued that `bad feeding is due not so much to poverty as to ignorance'. The Board of Education responded in 1937 with the appointment of a departmental committee on cookery and teachers of cookery were told to make their lessons `practical, definite, systematic, progressive and simple'.37 Certainly, there had been nothing `progressive' about the cookery classes Dorothy Scannell received during the two years before leaving school in 1925. In her autobiography she recalls: As we entered facing us was a large blackboard on which was permanently written, `A nourishing meal for a poor family of six, Three fresh herrings, 2 lb. of potatoes', underneath were the words, `If a pudding is needed and able to be provided, then a suet pudding with black treacle.'38 The Board of Education supported domestic education as the best means of equipping girls for marriage and motherhood. The board never supported complete differentiation of the curriculum, although as late as 1948 a report by John Newsom recommended it on the grounds that education was ultimately concerned with values and especially those relating to home and family. This, together with, in his opinion, the psychological and physical differences between the sexes made it advisable for secondary schoolgirls to concentrate on domestic science and biology during the last two years of school.39 Mothers were less easy to contact than daughters and a plethora of voluntary and, later, state agencies emerged to try and reach them. Newman insisted that `this practical and continuous training of the mother goes to the root of the whole matter'4° The earliest form of advice given to mothers was contained in the leaflets written and distributed by either health societies, as in Marylebone, or by medical officers of health, as in St Pancras. Possibly the first effort in this direction was made by the Medical Officer of Health for the Rhondda, who

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between 1902 and 1909 distributed leaflets on the prevention of summer diarrhoea in the part of his district where the infant mortality rate was highest. In a notice on diarrhoea issued by the MOH for Liverpool in 1912, mothers were told that diarrhoea was caused by dirt, insufficiency of fresh air, improper food and neglect. To prevent it, they should keep their children and homes clean, empty slop pails regularly, open windows, breastfeed (with no resort to titbits from the table), protect food from flies and make sure their infants were left with a responsible person if they had to go out to work.41 Often a short advice card accompanied the longer sheet. Dr Sykes, MOH for St Pancras, stopped referring to artificial feeding in 1903 for fear of encouraging it, noting that `the only way to humanize cow's milk is to pass it through the mother and not through a machine'.42 Those who, like Sykes, were firmly against the idea of giving any advice on artificial feeding were also hostile to the idea of milk dep8ts, favouring instead some sort of `School for Mothers'. This was the most popular name for the institutions run by voluntary agencies (usually with the support of the MOH) to educate mothers. Most Schools for Mothers, Babies Welcomes and Infant Consultations featured a combination of classes and health talks for mothers, and individual consultations with the mother about her infant, during which the baby was weighed and advice on feeding and management given by the medical officer. The smaller institutions offered a more limited range of activities. The first School for Mothers was started in St Pancras in 1907 by Mrs Alys Russell and Miss Dora Bunting in cooperation with Dr Sykes. Their example was rapidly followed by others, for example the Marylebone Health Society set up a baby clinic, with Eric Pritchard as its Medical Officer. By 1917, there were 321 voluntary societies known to the Local Government Board to be operating a total of 446 infant welfare centres (as they were more commonly called by World War I), while a further 396 centres were operated by local authorities. The major expansion of child and maternal welfare work and the institutionalisation of infant welfare centres came during World War I after 50% grants were made available to local authorities for the support of centres in 1915. Birmingham Council established a centre of its own in 1910 to serve two poor wards in the city and voluntary organisations provided three additional infant welfare centres. By 1917, Birmingham had eight municipal and eight voluntary centres. Liverpool operated six milk depots in 1912, where sterilised milk was sold by the municipality and infant consultations were offered by a voluntary society. The `milk depots' became `infant welfare centres' in 1915, and by 1917 there were

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five municipal and eleven voluntary centres. Prior to 1914, Hull had only one School for Mothers, but by 1917 it had two and by 1918, four a3 The main purpose of all these institutions was to pass onto the mother information about, a sense of responsibility towards, and pride in, home and family. The range of activities involved included infant weighings, baby shows, sewing meetings, cookery demonstrations and provident clubs. A school always had more babies come for consultations than mothers for classes; in 1910 St Pancras had 130 women attend its classes each week and 300 coming for consultations. The organisers valued the opportunity for personal instruction provided by the infant consultations as highly as they did the class sessions. It was impressed upon the mother that if her child was doing well it would gain in weight, and that regular attendance was necessary to check this .44 Each mother attending the North Islington School for Mothers paid 'd. to join, whereupon a case paper on the family was started. While the baby was being undressed and weighed the mother was given a card on which the weight of the baby was recorded each week. Advice on the clothing of infants was given while it was being undressed and advice on feeding after the weighing. Mothers were warned against using a stiff binder (thought to help the baby sit up) and the layers of alternately front and back fastening, tight garments that were common.as Centres also campaigned against the use of flannelette, which was inflammable, but they had little success, because flannelette was the cheapest, warm, soft clothing available. Strangely, the reports of these schools make no reference to giving advice on the management of breastfeeding, although women were advised on the correct method of mixing dried milk. In 1909, the questions asked at the St Marylebone Health Society's consultations concerned the manner of feeding, use of a dummy, sleeping arrangements for the child and the frequency of outings and baths." These seem to have been fairly standard preoccupations and the advice given to mothers focused on personal hygiene and the control of dirt, which were believed to be the main causes of infant mortality. The North Islington School reported in 1916 that `without claiming to work miracles, our workers can tell you of homes where the windows are now always open, where the babies take regular rests in the tiny garden, where the mother's appearance and outlook on life has changed'!" Dummies were discouraged because of the dirt they accumulated when dropped and also because they were believed to distort the shape of infants' mouths. A writer in National Health offering advice to

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examiners on mothercraft commented: `Remember that a baby that has had a dummy is like a tiger that tasted blood.i48 The Wandsworth Centre, in common with many others, started an Anti-Dummy League; mothers could join if their children had not used a dummy for six months or more.49 It took an average of six or seven visits by the mother to the Marylebone Centre before she gave satisfactory answers to the questions on dummies and separate cots. The St Pancras School sold banana crates as cots for ls. each and the Lancet believed that any `industrious and sober' parent could afford one with a little `self-denial'.50 But, as Mrs Pember Reeves pointed out in her study of working-class families in Lambeth, the material for a mattress cost 2d. and blankets ls. 6d., making a total cost of ls. 8d.5' It was far cheaper to allow the infant to sleep with its parents. Three of the women interviewed reported using a drawer rather than a cot or crate for their babies. The social background of mothers attending the schools is not absolutely clear. In a report for the National League of Physical Education and Improvement, I.G. Gibbon maintained that the schools should be trying to educate the upper working class, those classified by Booth as belonging to Classes C (poor with irregular earnings) and D (poor with small regular earnings), not the very poor and destitute of his Classes A and B, whose ways were too idle and vicious to be reformed.52 Gibbon feared that the schools were concentrating their efforts amongst the poorest; however this is not immediately apparent from the records available. Many centres recorded the occupations of the husbands of the mothers attending, but the categories used are rarely consistent over time and the data that follow are approximate. In fifteen (24%) of the cases at the Marylebone Centre in 1909, the occupation of the husband was recorded as labourer, and in 59% of cases the occupation recorded would probably have put the family in Booth's Class C or D or even above. No information was recorded in eleven (17%) of cases and it is quite possible that these families might have qualified for inclusion in Class A or B. At Islington in 1916, 20% of the 590 mothers did not record their husbands' occupations, 11% were married to labourers, 11% to white-collar workers and the rest would probably have fallen into Booth's Classes C or D. By 1922, the percentage of labourers had dropped to six, but 7% were listed as unemployed and as many as 15% were definitely white-collar workers. There was little change in the figures provided for 1930. This suggests that during the inter-war period the school was receiving mothers from a slightly wider range of occupational groups. The housing statistics that were given also support this idea (see Table 3.1).

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Table 3.1: Number of Rooms Occupied by Families Attending the Islington Welfare Centre and School for Mothers, 1916, 1922 and 1930 No. of rooms 1 2 3 >3

1916 10 47 35 8

% of families 1922 17 39 32 12

1930 14 39 31 16

Source: Annual Reports of the North Islington Maternity Centre and School for Mothers, 1916-1930.

Wage data, which would be the most reliable indicator of social class, were given only for the year 1916 and were collected directly from the mothers, who might well have been misinformed as to their husbands' true wage. Of the 65% of husbands whose earnings were known, 18% earned more than 30s.; 43% earned exactly 30s.; 25% 25s. ; and 12% between 15s. and 25s.53 Even if we place all those for whom the earnings were unknown and those earning between 15s. and 25s, in Classes A and B, 57% still qualify for inclusion in a higher social class. Attendance at the centres was voluntary and news of the opening of a centre would have travelled largely by word-of-mouth from those who attended first. In St Pancras, the School for Mothers was started by visitors going from house to house and distributing a leaflet saying `Bring your baby to be weighed'. Only four mothers attended the first session. The poor turn-out was due in part to the popular superstition which held baby-weighing to be bad luck.54 Thus, the initial members would probably have been a little more adventurous and possibly better educated than their neighbours; this was likely to have been true of many members of the early Schools for Mothers and infant welfare centres. Considerations such as these may help to explain why, possibly in spite of their efforts, centres did not reach the poorest mothers. Some articulate working-class women wanted information on infant care. It was, after all, members of the Women's Cooperative Guild who visited Ghent and brought back from there the idea of a School for Mothers. Many local branches of the guild worked with Schools for Mothers and petitioned local authorities to open municipal centres. Leonora Eyles, who later wrote for Woman's Own, gave regular advice in Lansbury's Labour Weekly to Labour women on baby clothes and feeding. In 1911, the Women's Labour League founded their own baby clinic in North Kensington and named it in honour of Margaret McMillan

100 Educating the Mothers and Margaret McDonald, both strong supporters of child welfare work and of nursery schools in particular. Labour women deplored the patronising attitude of many voluntary workers in the early centres. The comment of one of the workers at the St Pancras School for Mothers, congratulating the efforts of the mothers attending the school is typical: `for she is only a rather "low" working girl, married just in time for her child to be born in wedlock. Not a high type — no, but capable of "growing-up" nevertheless, because of her love for her child.'ss The desire for more congenial direction of the centres was one of the reasons behind the Women's Cooperative Guild petitions for municipal centres (where the staff would be paid workers), the Women's Labour League's own experimental clinic and Sylvia Pankhurst's centre, which served Bow during World War I. The idea of educating working-class mothers appealed to voluntary workers, whose attitudes were similar to those who had joined the Ladies Sanitary Association in the late nineteenth century and volunteered to teach the poor cleanliness, or organised a Mother's Meeting to teach sewing. The stress on provident clubs and the effort made to redeem at least ld. towards the cost of the mothers' dinners, where these were provided, also reflected the middle-class ideals of thrift and self-help. However, voluntary workers also often gave the centres a distinctive character and, while condescending, could also be more flexible in the services they offered. At North Islington, the founder chose to initiate a scheme of holidays for tired mothers, which provided funds for a week or a fortnight's holiday for 37 mothers in 1915. When the local authorities decided that `expert' knowledge in the form of paid staff was necessary, something was undoubtedly lost.% Writing on the Baby Week Exhibition at Central Hall in 1917, Sylvia Pankhurst summed up the feelings of many working-class mothers: `In spite of all the purse-proud patronage and snobbery which has been displayed in connection with them, maternal and infant welfare centres are proving a great boon to numbers of women.'" Regardless of the purpose of centres and whether education was the best way of preventing infant mortality, there is no doubt but that the centres provided information, much needed nourishment, companionship and a measure of reassurance for many women. Most centres offered the women tea and biscuits, North Islington sometimes provided sausages and chocolate biscuits as an added inducement. The women were able to talk over their problems with each other and in groups with a nurse or health visitor, as well as individually with a doctor. In her

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autobiography, Hannah Mitchell, a member of the WCG, commented that she wished an infant welfare centre had existed to help her when her baby was born 58 Despite the often bare surroundings and considerable overcrowding in later years, a visit to the centre gave the opportunity for an outing. It is interesting that middle-class women looked on the centres for working-class women with a degree of envy. All the manuals of the day stressed that childrearing should be scientifically managed, yet the middle-class women, who were the most assiduous readers of infantcare manuals, received no support in their endeavours to follow instructions which often proved difficult to carry out. The manuals stressed that cleanliness and regularity were necessary not only for physical health, but also to build the character of an imperial race. Self-control, obedience, unselfishness, purity and truthfulness were ideals to be inculcated by regular feeding, early toilet training and leaving the baby alone as much as possible.59 Manuals and magazine articles were the main source of information on childrearing practices for middle-class women, and doctors, when consulted, would have been likely to agree with the tenor of advice they offered. Some midwives viewed the rigid doctrines with a degree of scepticism, especially the prohibition on cuddling and soothing babies,60 but their greatest contact was with the working class. Many writers have documented this rigid approach to childrearing, both in Britain and the United States61, and Jay Mechling has warned that it cannot be assumed that manual literature reflects actual behaviour.62 However, the written manuals were but one manifestation of a pervasive ideology of motherhood and there is evidence from middleclass women themselves that they took the new approach to childrearing seriously and found the recommended methods of infant management to be a source of worry. John and Elizabeth Newson quoted two letters they received from women who reared their children according to the instructions of the most popular manual-writer of the inter-war period, Sir Frederick Truby King: `My daughter was born during the Truby King period and it took a month of untold agony for my daughter and me before I threw every book I had out of the house,' and: 'I was caught up in the Truby King Mothercraft doctrine ... The Health Visitors prated and bullied; one's baby screamed and tears splashed down one's cheeks while milk gushed through one's jersey. But one must never pick the baby up — it was practically incestuous to enjoy one's baby.i63 A book published in 1930 bewailed the complications of childrearing and demanded an expert `Childrearing Service' to help middle-class women.64 More interesting still, was the move to organise middle-class baby clubs.

102 Educating the Mothers In 1924, National Health commented that there was nowhere for the middle-class mother to seek advice except at Truby King's Mothercraft Training Centre. In 1928, the Chelsea Baby Club was founded by two feminists, the author Vera Brittain and Eva Hubback, Principal of Morley College. Women paid 2/ guineas to join and the babies were made the official members. Eva Hubback started a second club in Hampstead and a third began in Bayswater. By 1938 there were enough to form a federation and Harold Waller became its adviser. At a 1935 conference, one of the organisers explained the start of the babies' club movement in terms of the greater sympathy of the inter-war women's movement with the problems of motherhood and of the evidence that working women's children were benefiting from attendance at centres. Vera Brittain felt that most of her generation had been but `poor specimens' and that welfare centres were one way of building a better race. The gulf between the kind of health care services provided for the middle and working class made it impossible for middle-class women to attend the centres established for working-class women, besides, as Brittain commented, `the middle class mother was less humble and teachable than the poorer mothers and always on the defensive'.65 Moreover, the attitude of the medical profession would undoubtedly have prevented such a move. The reaction to the founding of the Chelsea Club was very strong. In an editorial called `The Menace of the Clinic', the Lancet condemned the club as a threat to the general practitioner because it was impossible to know where hygiene ended and treatment began.66 Because GPs feared that clinics would impinge on their practice, no medical treatment was offered at either middle- or working-class centres; mothers were referred to a doctor if more than advice was required. Yet treatment was a major need for working-class women in particular, because they could not afford doctors' fees. Sylvia Pankhurst believed `that if professional interests were put on one side it would be found best for the present maternal and infant welfare centres to treat the bulk of the ailments they now refer to private practitioners'.67 When the Women's Labour League's clinic opened in 1911, it gave medical treatment as well as advice. The WLL announced: `the hope of the clinic is to show in this poor district that a higher standard of health might be reached if medical aid were to be freely at the command of parents for the many and mysterious ailments of childhood'.6B As a WLL leaflet of 1912 pointed out, mothers were not able to syringe ears and put in drops themselves and they were unlikely to take their children to the doctor for such minor treatment. The clinic reported that

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nearly all the ailments it treated resulted from malnutrition: rickets, defective teeth, enlarged tonsils and adenoids (which are not in fact closely associated with malnutrition) and `the usual eye and ear troubles and the skin eruptions that are so frequent among illnourished children'.69 The baby clinic operated a system whereby the Babies Welcomes and Schools for Mothers in the area sent them babies for treatment and in return they sent women for the ld dinners. Labour women stressed not only that treatment should be free, but also that it should be made available at the welfare centre. St Pancras opened a small dispensary for sick infants in 1915, but it was not located in the same building as the School for Mothers and only treated about 350 patients a year. Voluntary organisations and local authorities were insistent that the function of schools and welfare centres was to educate and not to give medical treatment. Only a very few centres helped sick babies. The biggest in London was E.A. Barton's baby clinic at University College Hospital, where the need for medical treatment naturally came first. Gibbon stated clearly that `the treatment of sick infants is beyond the scope of a School for Mothers ... If a "School" undertakes the treatment of sickness it will very probably ultimately be drawn away from its main purpose.'7 " Local authority welfare centres were no more oriented towards giving treatment than the voluntary ones. The take-over of voluntary centres by municipal public health committees was made possible by the Local Government Board grants of 1915. This meant that many voluntary workers were replaced by trained staff, but neither the directors nor the philosophy behind the centres' work changed. The voluntary centres had all been affiliated to the Association of Schools for Mothers and Infant Consultations (founded in 1911), which was chaired by Eric Pritchard, and whose work was intimately connected in turn to both that of the National Conference on Infant Mortality and the National League for Physical Education and Improvement. The membership of these organisations largely consisted of the medical officers of health and doctors who also directed the work of local public health committees and maternal and child welfare committees. Thus, the same medical officers of health had played a major part in organising local child and maternal welfare work before the central government stepped in.71 The most famous examples were those of Huddersfield, where S.G. Moore and Alderman Broadbent pioneered the notification of births in 1907, and St Pancras, where F.J. Sykes helped to organise the School for Mothers.

104 Educating the Mothers Requests by the Independent Labour Party, trade unions, the Women's Cooperative Guild and the Women's Labour League that the LGB do more to provide infant welfare centres" were ignored, because of a departmental disagreement between the LGB and the Board of Education over who should control the rapidly expanding number of centres. The argument, which was never publicly acknowledged, continued throughout the war years and at one point threatened to delay the establishment of the Ministry of Health. The dispute is important for what it reveals about Newman's philosophy of infant welfare work. Newman saw all infant welfare work as primarily educational: I know as a matter of experience that they [Schools for Mothers] are profoundly educational in fact. Nothing impressed me more in my Wednesday clinics for infants in Finsbury than the direct, prompt and profound effect that the Schools for Mothers had on the education of the Mother in what may be called `child craft'.73 His views were shared by Janet Campbell, who worked with him first at the Board of Education and later at the Ministry of Health, where she was appointed Senior Medical Officer in charge of child and maternal welfare. When the question of grants for the work done by voluntary infant welfare centres came under consideration in 1914, the problem of jurisdiction became more urgent. The Lord Chancellor, Lord Haldane, was called in to rule on the matter and he decided that all purely educational work, namely the class instruction given at the Schools for Mothers and like institutions, should be supervised by the Board of Education and all other work by the Local Government Board.74 This was hardly practical, as one institution usually combined both kinds of work and the St Pancras School, for example, proceeded to apply to both departments for money. Gradually, pressure from medical officers of health, suspicious of control by an alien administration at the Board of Education, and the LGB's involvement in both implementing the Notification of Births Act of 1915 and in creating a Ministry of Health, caused Newman to back down.75 The Maternal and Child Welfare Act of 1918 was thus piloted through Parliament by the LGB. However, Newman brought his strong ideas as to the educational component of infant welfare work with him to the new Ministry of Health when he became its Chief Medical Officer. Thus, during the inter-war years, infant welfare centres were still discouraged from any activity that went beyond inspection and education.

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In Hull, however, the MOH admitted that it was `uphill work' to get mothers to see the welfare centres as educational institutions; they tended to bring their ailing babies or came to buy supplies of dried milk, which was sold at cost.76 Interviews confirmed this. Of the eleven women who attended the welfare centres with their children, two mentioned milk as the main reason for going and the others went in order to have their infants immunised. The emphasis placed on the centres as educational institutions stemmed from the diagnosis of the problem of infant mortality as one of maternal ignorance and was reinforced by the fear of the medical profession that if anything more than instruction were given, the practice of the GP would be threatened. The centres met women's need to share their problems and to a certain extent women were able to use only the programmes they felt to be important, but the help offered was limited. In fact, the bedrock of infant welfare work was not so much the centre as the health visiting system. Lady visitors were attached to all the Schools for Mothers, for example they did the publicity work for the St Pancras School. They taught mothers elementary hygiene, methods of infant care and management and one also taught cookery in the homes of the mothers rather than at the School. Centres were a novelty and attracted a lot of attention and comment, but more money was spent on health visiting by LAs than on any other form of maternal and child welfare work. During 1919-20, 31% of the grant made by the new Ministry of Health to local authorities for maternal and child welfare work was spent on visiting, and during the period 1918-29, 16%.77 Health visiting was peculiarly English. In France, where so many of the early experiments like milk depots and infant consultations were started, instruction was carried out entirely in institutions. The work of health visitors evolved from the efforts of the late nineteenth century `lady health missioners' who had combined poor visiting and the distribution of religious tracts with sanitary visits and the distribution of soap and disinfectants.78 Despite state intervention to notify births and undertake maternal and child welfare work, it was still believed that infant care should remain the province of individual mothers and the preferred method of voluntary and state intervention — health visiting — reflected the older Charity Organization Society belief that the habits of the poor could best be reformed by direct contact with their betters. In fact the Charity Organization Society took an active interest in health visiting.79 While health visitors were supposed to encourage women to visit the infant welfare clinics (the LGB reported that of those visited one quarter

106 Educating the Mothers were so persuaded in 1915), many saw equal value in a system of instruction that permitted women to remain close to their domestic duties. Dr Elizabeth Sloan Chesser felt that the `final solution' to infant mortality was to educate the mother in her own home.BO In Huddersfield, S.G. Moore advised: `The mot d'ordre is: "keep the mother and her infant together in the home. Do not entice them away, take help to them there." i81 The visitor was supposed to counter the influences of hostile, old fashioned grandmothers and interfering neighbours who might favour the use of unhygienic long-tubed feeding bottles or dummies. Homes were divided into four categories: the poor but `good' ones, where the mother was `reliable' or efficient, which needed to be visited once every three months; the `bad', which needed visiting more than once a month for the first year; the ordinary home once or twice a year and for `the better class houses', no card need be filled up. The middleclass woman was thus exempted from visiting. In most places, however, the number of visitors employed was not sufficient to do such a thorough job, despite the importance attached to visiting. In 1918 the LGB had advised that one visitor be appointed per 400 births and by 1934 this was increased to one per 250-80 births. Liverpool and Hull were chronically short of visitors. Liverpool had fewer than one per 500 births in 1916 and in 1935, when Manchester and Birmingham had one per 140 births, liverpool still only managed one per 310. Many of Hull's eleven visitors struggled to visit between 500 and 1,000 infants.82 One reason for the shortage was the poor pay and status of health visiting. The work of the health visitor was considered pre-eminently women's work. Michael Carpenter has described how nursing duties in general straddled the scientific and non-scientific worlds because of the emphasis placed on hygiene and cleanliness.83 Thus the nature of the work, together with its long association with voluntary service, served to retard the growth of professional status amongst health visitors.84 The health visitors employed by the Ladies Sanitary Association in the 1860s and 1870s were initially working-class women, but these were rapidly replaced by middle-class, educated women during the late nineteenth and early twentieth centuries. One speaker at the 1906 Conference on Infant Mortality declared that a `Girton girl' would undoubtedly do the best job. Middle-class visitors were urged to be tactful,8S but friction between mother and visitor was inevitable and it is certain that health visitors were not as well-thought-of as the welfare centres. The mother who attended the centre did so voluntarily, the health visitor imposed upon the mothers. One former health visitor described how she was resented as an authority figure and referred to by

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many of the women she visited in the East End of London as `the Town `All'. Another respondent described a disagreement she witnessed between her own mother and a health visitor. Her mother had decided to call her second child by an `unusual' name: Ronald. When the visitor heard what the baby was going to be called, she commented: `You've been reading too many novelettes.' The mother, deeply offended that it was thought that she had time for such reading, asked the health visitor to leave. One of the workers who had helped run the North Islington Clinic during the inter-war years also had a poor opinion of health visitors. Not only did she find them pompous and officious, but they were usually unmarried and this, not unnaturally, made mothers suspicious of the advice they offered. Certainly, few of the women interviewed even remembered calls by the health visitor, yet some mentioned the school attendance officer coming round. Moreover, many reported relying on the advice of relatives and neighbours, which the health visitor was supposed to supersede. It is hard to assess what part the education of mothers and daughters played in the rapid decline of infant mortality after 1911. The increasing number of girls educated in infant management after 1910 came too late to have played a major part and the proportion of women visiting the Schools for Mothers and centres was relatively small. In St Pancras, in 1910, 300 mothers attended per week and, presuming that these were all regular attenders, this accounted for only 5% of all the births registered in the borough that year. Besides, it is reasonable to suppose that these mothers were better educated in the first place. Attendance at the centres improved greatly during the inter-war period. Government statistics showed that 56% of infants attended the welfare centres during 1931 and 62% in 1937. However, the reasons for the decline in the infant mortality rate were as complex as the causes of infant death. Pure milk, a better standard of living, better sanitation and better medical attention for premature infants must all have played their part. But when child and maternal welfare workers reflected on the rapid decrease in mortality, they had no hesitation in attributing it to the education of mothers. The Ministry of Health and the Board of Education agreed that `the reduction in infant mortality is no doubt due to the combined action of various factors, but there can be no question that one of the weapons which has been most effective in this campaign is the education of the mother'. ß6 Amand Routh and Eric Pritchard believed that the decline in infant mortality could `definitely' be ascribed to education. Improvements in environmental conditions and the standard of living were dismissed as

108 Educating the Mothers `minor factors'.87 A 1928 study arbitrarily assigned the causes of infant death to one of three categories: (i) capable of direct medical control: syphilis, injuries at birth and diphtheria; (ii) capable of indirect control by the mother: TB, diarrhoea, atrophy, debility, marasmus, overlaying and convulsions; and (iii) uncontrollable: infectious diseases, premature birth and malformations. The categories are reminiscent of Moore's in 1904,88 although the number of ailments susceptible of control by the mother has been changed. Infectious diseases have been removed and TB and convulsions added. TB was commonly thought to be hereditary and convulsions were included because it was believed that they were commonly caused by faulty feeding. The study argued that only the number of deaths due to causes in the second category had shown marked decrease, and that therefore maternal efficiency must have been the key factor in bringing down the infant mortality rate.89 Regardless of the effect on infant mortality, the maternal and child welfare services were helpful to women, who as consumers had some power to select whatever aspect of the services they found most useful. This was particularly true of the infant welfare centres, where attendance was voluntary. For example, infant consultations were always much more popular than mothercraft classes, because even if infant welfare workers were unnecessarily rigid in their ruling against dummies and babies sleeping with their mothers, the opportunity to seek advice on specific problems was highly valued. A sympathetic health visitor could well have played a similar role, but generally the mother had no control over the timing of her visits. The services offered were nonetheless extremely limited. Particularly distressing to women was the infant welfare centres' offer of diagnosis and advice, but no treatment. This was due in part to the attitude of doctors who feared that clinics (particularly when they were state-run) would intrude into the province of the GP. It was also because the philosophy of the infant welfare movement stressed above all individual responsibility and self-help. The instruction of mothers in ways of controlling domestic dirt, which was believed to be the major cause of infantile diarrhoea, in proper feeding methods and sleeping habits, were all designed to enable mothers to take greater responsibility for their infants and, by extension, for their families' health. It was felt that any offer of curative medicine, or dried milk at cost or free, conflicted with the role of centres as educational institutions; women would attend only in order to obtain medical treatment and milk. Mothercraft education carried with it a powerful ideology of motherhood, which stressed the duties and responsibilities of mothers and

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which affected both adult women and schoolgirls. The need for mothercraft education was stressed continuously throughout the period 1906 to 1939 and the importance attached to making mothers more efficient extended beyond the part it was thought they could play in bringing down the infant mortality rate. This is perhaps most clearly seen in regard to the schoolgirls' curriculum, where more domestic education was seen as the answer to evidence of poor nutrition among low-income families during the 1930s, as well as to the problem of infant mortality. There is no evidence to show that women objected to the new emphasis placed on the importance of motherhood, rather, they seem to have used it to demand an expansion of maternal and child welfare services. It was in part because it stood in contradiction to the emphasis being placed on the importance of motherhood that the high maternal mortality rate became such an important issue during the inter-war years. However it was not as easy to arrive at a single solution as it was in the case of infant mortality; education alone would obviously not provide the remedy.

Notes 1. PP, 'Report of the Chief Medical Officer of the Board of Education for 1913', 1914-16, Cd. 7730, XVIII, 277, p. 21. 2. S.G. Moore, Report of the MOH on Infantile Mortality Ordered by the Health Committee of the City Borough of Huddersfield, 1904 (Huddersfield: Public Health Committee, 1904), p. 14. 3. Lancet, 18 Aug. 1906, p. 446 (editorial). 4. PP, 'Report of the Inter-Departmental Committee on Physical Deterioration, Vol. II', 1904, Cd. 2210, XXXII, 145, p. 293, Miss Eves mentions the price differential between condensed and fresh milk; pp. 363-5, Dr Robert Hutchinson states that ignorance not poverty is the reason for the use of condensed milk and this passes unquestioned. 5. Flora Murray, 'Infant Mortality', National Health, 1 (Jan. 1909), pp. 27-9. 6. 'Nurse Polly and I and the Babies', Cooperative News, 16 Aug. 1913, p. 1039, WCG Archives. It is interesting to compare this to a similar attitude on the part of Francis Place towards birth control; see Angus McLaren, Birth Control in Nineteenth Century England (Croom Helm, 1978), pp. 53-4. 7. PP, 'Report of the Inter-Departmental Committee on Physical Deterioration, Vol. I', 1904, Cd. 2175, XXXII, 1, pp. 57 and 62-3. 8. PRO, ED 11/60, memo dated 8 Aug. 1905. 9. J.W. Ballantyne, Expectant Motherhood (Cassell, 1914), p. 72. 10. PP, 'Special Report on Educational Subjects, Vol. 16, School Training for the Home Duties of Women, Pt. III', 1906, Cd. 2963, XXVIII, 437, p. iii. 11. PRO, ED 12/41, minute, 3 Nov. 1907. 12. Helen Blagg, A Statistical Analysis of Infant Mortality (P.S. King, 1910), p. 15.

110 Educating the Mothers 13. Dr Murray Leslie, Woman's Progress in Relation to Eugenics', Eugenics Review, 2 (1910-11), pp. 282-98; see also Meyrick Booth, `The Myth of the Modern Woman', English Review, 45 (Dec. 1927), pp. 705-9. Carol Dyhouse, `Social Darwinistic Ideas and the Development of Women's Education, 18801920', History of Education, 5 (Feb. 1976), pp. 41-58, analyses these attitudes more fully. For more general information on doctors' attitudes towards women's education see: John S. Haller and Robin M. Haller, The Physician and Sexuality in Victorian America (NY: Norton, 1974), pp. 38-9 and 60-1; and Carroll SmithRosenberg, `Puberty to Menopause: The Cycle of Femininity in Nineteenth Century America' in Clio's Consciousness Raised, edited by Lois Banner and Mary Hartman (Harper, 1974), pp. 23-7. 14. PRO, ED 24/279, Note of a Deputation, 27 Feb. 1906; and National Health, 1 (April 1909), p. 99. 15. PRO, ED 11/51, Circular 758, `Memo on the Teaching of Infant Care and Management in the Public Elementary Schools', 1910; and Board of Education, The Teaching of Infant Care and Management to School Girls', Circular 1353 (HMSO, 1925). National Health, 17 (May 1925), p. 365, praised the more didactic tone of the new memo in an editorial. 16. James Niven, `The Teaching in Schools of Elementary Hygiene in Reference to the Rearing of Infants' in Report of the Proceedings of the National Conference on Infant Mortality, 1906 (P.S. King, 1906), p. 31. 17. PRO, ED 12/43, The Teaching of Housecraft in Secondary Schools. Report of the Committee Appointed by the Board', 30 May 1910, p. 22. 18. Miss Dobson, `Mothercraft as Taught to School Girls in York', National Council of Women, Occasional Paper no. 83, June 1919, pp. 27-29. 19. Circ. 758, p. 8. 20. PRO, ED 11/150, Minute on Deputation, 12 May 1923; and Circ. 1353, pp. 9-11. 21. PRO, ED 11/150, `Lessons on Mothercraft to Schoolgirls', 21 July 1923; see also Nina Marion, `Mothercraft for School Girls', National Health, 11 (July 1918), pp. 9-10. 22. Minutes of the National Association for the Prevention of Infant Mortality and Promotion of the Welfare of Children under School Age, 19 March 1923. The recommended book was written by Mrs Langton Hewer, but the note does not say which of her works was chosen; all were popular. 23. `The Teaching of Mothercraft to Schoolgirls', National Health, 16 (Feb. 1924), pp. 250-2. 24. Rebecca West, 'Women as Brainworkers' in Women and the Labour Party, edited by Marion Phillips (Headley, 1918), p. 63. 25. PRO, ED 11/278, minute dated 18 June 1937, blamed the shortage of domestic servants on the education given to girls. 26. Ruth Binnie and Julia E. Boxall, Housecraft Principles and Practice (Pitman, 1926), Foreword and pp. 198-203; Ruth Whittaker, Modern Developments, in Domestic Science Training (J.M. Dent, 1937), pp. 42-3. 27. Arthur Newsholme and Margaret Eleanor Scott, Domestic Economy (Swann and Sonneschein, 1902), p. 202. 28. PRO, ED 12/41, clipping from Education, 21 Feb. 1908, p. 119. Alice Ravenhill was also the author of a special report for Board of Education in 1905: PP, `Special Reports on Educational Subjects, Vol. 15. School Training for the Home Duties of Women, Pt. I', 1905, Cd. 2498, XXVI, 783. 29. W.B. Drummond, Introduction to Child Study (Arnold, 1907), p. 158. 30. Charles Hale, Domestic Science (Cambridge UP, 1916), is a good example. 31. PRO, ED 12/43, 'The Teaching of Housecraft in Secondary Schools. Report of the Committee Appointed by the Board', 30 May 1910.

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32. PRO, ED 12/43, 'Annual Conference of Headmistresses, Resolutions', 9 and 10 June 1911. 33. PP, 'Report of the Consultative Committee on Practical Work in the Secondary Schools', 1913, Cd. 6849, XX, 291 pp. 45-52. 34. Rona Robinson, 'King's College for Women', Freewoman, 15 Feb. 1912, pp. 255-7. 35. National Health, 1 (Dec. 1908), pp. 18 and 22. 36. Mrs Etty Potter, 'Woman's Place in the Home', Women in Council, 13 (Nov. 1935), p. 143. 37. PRO, ED 11/249, MH to Board of Education, 21 Feb. 1938 and 'General Hints to Teachers of Cookery', 29 Dec. 1937. 38. Dorothy Scannell, Mother Knew Best. An East End Childhood (MacMillan, 1978), p. 136. 39. John Newson, The Education of Girls (Faber and Faber, 1948), pp. 18-19, 45, 115 and 131. 40. Ministry of Health, Annual Report of the Chief Medical Officer for 1920 (HMSO, 1921), p. 25. 41. Annual Report of the MOH for Liverpool, 1912, p. 47. 42. Annual Report of the MOH for St. Pancras, 1909, p. 31; and Annual Report of the MOH for St. Pancras, 1910, p. 24. 43. Annual Report of the MOH for Birmingham, 1910, p. 19; LGB, Maternal and Child Welfare. Report on the Provision made by Public Health Authorities and Voluntary Agencies in England and Wales (HMSO, 1917), pp. 27-8; and Minutes of the Proceedings of the Sanitary Committee, XXVII, 8 May 1914, Hull Public Archives. 44. Evelyn M. Bunting, et. al., A School for Mothers (Horace Marshall, 1907), p. 9. 45. 1st Annual Report of the North Islington School for Mothers, 1914, p. 3, North Islington Welfare Centre Archives. 46. '66 Records of Newborn Babies from the St. Marylebone Health Society, sent by Dr. Flora Murray and Dr. Christine Murrell, 1909', Pearson Papers, Item 297. 47. 2nd Annual Report of the North Islington Maternity Centre and School for Mothers, 1916, p. 4. 48. 'Elementary Mothercraft Examinations', National Health, 6 (Oct. 1915), p. 283. 49. 4th Annual Report of the Mothers Welcome, Metropolitan Borough of Wandsworth, 1918-19, p. 5, GLC Archives. 50. The Mortality of Children from Overlaying or Accidental Burning', Lancet, 15 Sept. 1906, p. 749. 51. Magdalen Stuart Pember Reeves, Round About a Pound a Week, (G. Bell, 1915), p. 51. 52. LG. Gibbon, Infant Welfare Centres. The Work of Infant Consultations, Schools for Mothers and Similar Institutions (National League for Physical Education and Improvement, 1913), pp. 30-1. Booth's eight social classes were: A. lowest class of occasional labourers, loafers and semi-criminals; B. casual earnings, very poor; C. intermittent earnings, poor; D. small regular earnings, poor; E. regular standard earnings, above the poverty line; F. higher-class labour; G. lower-middle class; H. upper-middle class (Charles Booth, Life and Labour of the People, vol. I (Williams and Norgate, 1889), pp. 33-61). For a commentary on this division of the poor into the deserving and undeserving during the late nineteenth and early twentieth century, see Gareth Stedman Jones, Outcast London (Penguin, 1976), pp. 303-14. 53. Pearson Papers, Item 297; 2nd Report of the North Islington Maternity

112

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Centre and School for Mothers, 1916, pp. 21-2; 8th Report of the North Islington Maternity Centre and School for Mothers, 1922, pp. 19-20; and 16th Annual Report of the North Islington Maternity Centre and School for Mothers, 1929-30, pp. 28-9. 54. Alys Russell, `The First School for Mothers Comes of Age', National Health, 21 (July 1927), pp. 8-14. 55. Bunting, et. al., A School for Mothers, p. 39. 56. The ill-feeling this caused is reflected in Russell's `The First School for Mothers Comes of Age', p. 13; and Mrs. H.B. Irving, `State and Voluntary Work for Promoting Welfare in Maternity and Infancy', National Council of Women, Special Occasional Papers, no. 67, April 1915, pp. 23-30. 57. `The Baby Week Exhibition at Central Hall', Woman's Dreadnought, 4 (7 July 1917), p. 793. 58. Geoffrey Mitchell (ed.), The Hard Way Up (Faber and Faber, 1968), p. 102. 59. H. Scurfield, Infant and Child Welfare (Cassell, 1919), pp. 126-7; Mrs. J. Langton Hewer, The Baby of Today (Bristol: John Wright and Sons, 1921), pp. 20-1; W.B. Drummond, The Child his Nature and Nurture (J.M. Dent, 1915), p. 146; Mabel Liddiard, The Mothercraft Manual (J. & A. Churchill, 1924), pp. 103-9. 60. Florence Daniel, The Expectant Mother (C.W. Daniel and Co., 1925), p. 65. In Nursing Notes, XXXVII (Nov. 1924), p. 154, an equal degree of scepticism was also accorded the demands for a separate cot, referred to as: `The Great Cradle Controversy'. 61. There is a vast collection of literature on this subject. Some of the most useful pieces are: Nancy Pottisham Weiss, `Mother the Invention of Necessity: Dr. Benjamin Spock's "Baby and Child Care" ', American Quarterly, XXIX (Winter 1977), pp. 519-46; Martha Wolfenstein, `Fun Morality' in Childhood in Contemporary Cultures, edited by Martha Wolfenstein and Margaret Mead (University of Chicago Press, 1955), pp. 168-78, traces the differences in editions of the Infant Care Bulletin of the USA Children's Bureau; John and Elizabeth Newson, `Cultural Aspects of Childrearing' in The Integration of a Child into a Social World, edited by Martin P.M. Richards (Cambridge UP, 1974), pp. 53-82, did the same for Liddiard's Mothercraft Manual; Catherine Storr, `Freud and the Concept of Parental Guilt' in Intimacy, Family and Society, edited by A. Skolnick and Jerome H. Skolnick (Boston: Little Brown and Co., 1974), pp. 377-89, treats the English manual-writers, especially Truby King and Dr Winnicott; Celia B. Stendler, `Sixty Years of Child Training Practices', Jr of Peed., 36 (Jan. 1950), pp. 122-34, examines these changes as reflected in women's magazines. 62. Jay Mechling, `Advice to Historians on Advice to Mothers', Jr. of Soc. Hist., 9 (Fall 1975), pp. 44-63. 63. Newsons, `Cultural Aspects of Childrearing', p. 62. 64. Jean Ayling, The Retreat from Parenthood (Kegan Paul, Trench and Trubner, 1930). 65. Manchester Guardian, S May 1938, see also: 3 Dec. 1931 on the issue of babies' clubs, Fawcett Library Clippings. 66. Lancet, 28 July 1928, pp. 174-5. 67. Sylvia Pankhurst, The Home Front (Hutchinson, 1932), p. 213. 68. WLL, The Baby Clinic, pamphlet, n.d., p. 1, Labour Party Archives. 69. WLL, The Baby Clinic, p. 2. 70. Gibbon, Report on Existing Schools, p. 4. 71. R.J. Dingwall, `Collectivism, Regionalism and Feminism: Health Visiting and British Social Policy, 1850-1975', Jr. of Soc. Pol., 6 (July 1977), pp. 291-315, relates this to the economic strength of the regions prior to World War L

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72. PRO, ED 24/1377, 'List of Organizations Addressing Resolutions to the Board of Education Requesting Financial Aid for Schools for Mothers, 1914'. 73. PRO, ED 24/1375, Newman to Secretary, 4 March 1914. 74. PRO, ED 24/1377. The whole file is devoted to the subject of Haldane's award, see especially, J.A. Pearse to Haldane, 23 June 1914. 75. PRO, ED 24/1363, Newman to the Secretary, 15 Nov. 1916. 76. Annual Report of the MOH for Hull, 1923, p. 25. 77. Ministry of Health, Annual Report on the Chief Medical Officer for 191920 (HMSO, 1920), p. 108; and Annual Report of the Chief Medical Officer for 1929 (HMSO, 1930), p. 26. After 1929 LAs received block grants and no further breakdown of monies is available after that date. 78. W.C. Dowling, 'The Ladies Sanitary Association and the Origin of the Health Visiting Service', MA Dissertation, LSE, 1963. 79. Jones, Outcast London, pp. 256-7, describes the founding and aims of the COS. The COS attempted to organise charitable relief and to ensure that only the deserving poor were helped. See also Charity Organization Society, Health Visiting (COS, n.d.). 80. D. Elizabeth Sloan Chesser, Woman, Marriage and Motherhood (Cassell, 1913), p. 168. 81. S.G. Moore, 'Infant Mortality in Huddersfield', National Health, X (Jan. 1918), pp. 16-17. 82. PRO, MH 48/252, LGB to Liverpool Corporation on the subject of a report by Janet Lane-Claypon after a visit to Liverpool, 20 March 1916; and Proceedings of the Council, 1934-5, p. 1107, 'Report of the MOH on the Reorganization of Maternal and Child Welfare Services, 1935', p. 31, Liverpool Reference Library; Annual Report of the MOH for Hull, 1920, p. 22. 83. Michael Carpenter, 'The New Managerialism and Professionalism in Nursing' in Health and the Division of Labour, edited by Margaret Stacey and Margaret Reid (Croom Helm, 1977), p. 167. 84. Jr. Roy. San. Instit., XLIX (March 1929), pp. 533-8, address by Mrs Wintringham. There were no regulations for the training of health visitors until 1919: PP, 'Regulations for the Training of Health Visitors', 1919, Cmd. 354, XXXIX, 159. For the low status of health visitors in comparison with sanitary inspectors, see The Annual Report of the Health Visitors Association, 1907-8, p. 11; 1908-9, pp. 11-12; 1909-11, pp. 10-11 and 1912-13 p. 11; and Florence J. Greenwood, 'The Evolution of the Health Visitor', Jr. Roy. San. Instit., XXXIV (1913), pp. 174-82. 85. Emelia Kanthack, The Preservation of Infant Life (H.K. Lewis, 1907), p. 2, advised visitors: 'I always approached my East End patients with my very best manners and extended the same little courteous considerations to them that I would have served towards a lady.' 86. Circ. 1353, p. 6; see also, Ministry of Health, Annual Report of the Chief Medical Officer for 1920 (HMSO, 1921), p. 21 (his italics). 87. Amand Routh, 'The Influence of Ante-Natal Hygiene on Infant Mortality', National Health, 14 (Dec. 1921), p. 85; Eric Pritchard, 'Infant Mortality and the Welfare Movement', Contemporary Review, 120 (July 1921), pp. 76-82; and James Wheatley, 'Discussion on the Factors Contributing to the Recent Decrease in Infantile Mortality'. BMJ, 27 Oct. 1923, pp. 754-9. 88. See above, p. 31. 89. Peter L. McK inlay, 'The Decline in Infant Mortality', Jr. of Hygiene, 27 (June 1928), pp. 424-38.

PART III SAVING THE MOTHERS

4

THE MEDICALISATION OF CHILDBIRTH: HOSPITALISATION

The health of the pregnant woman had become subject to investigation during World War I, when it was realised that ante-natal factors had a serious bearing on the incidence of infant mortality. But as the maternal mortality rate rose between 1923 and 1936, a correspondingly greater amount of attention was devoted to the mother. A high maternal mortality rate appeared particularly reprehensible when the importance of the duties and responsibilities of motherhood were being stressed, and the government was acutely aware of this. It had been the government's own reports, issued during the 1920s, that had drawn attention to the problem and the lack of any improvement in the situation made it appear that no action was being taken to correct it. Public outcry on the issue came from all classes of women, for it appeared that as many middle-class as working-class women were dying. For example at the 1932 meeting of the unofficial Maternal Mortality Committee (whose members included women from all social classes), a Mrs A.L. Smith commented: `I am speaking of mothers of my own class, because according to Sir George Newman, the death rate is higher for instance in well-to-do neighbourhoods like Hampstead, than in the slums of London." In his speeches to the Maternal Mortality Committee in 1929 and 1930, Arthur Greenwood, the Minister of Health, referred to maternal mortality as a `stubborn problem'.2 Certainly the causes of death in childbirth were difficult to pin down, but the approach of investigators to the problem had much in common with earlier investigations into infant mortality. Official reports considered only the immediate clinical cause of death and ignored broader social and medical factors such as nutrition and the general health of the mother. Even so, childbirth involved three stages, the ante-natal, labour itself and the post-natal, and death could be due to complications arising in any one or more stages. Also, if the mother received attention at each stage, it was possible for three different attendants to be involved. Specialists in hospitals, general practitioners, independent and institutional midwives and local authority clinics all provided maternity services. The official government reports often bemoaned the fact that maternal mortality had no one `obvious' cause, like infant mortality, 117

118 Hospitalisation and was thus `less easily influenced by educational methods'.3 Health officials tried to cut through the complex causes of maternal deaths by isolating `the primary avoidable factor' involved in each case. The reports of the Departmental Committee on Maternal Mortality and Morbidity, set up in 1929, recorded the clinical cause of each death and the point at which it was believed that the maternity services had fallen down, this being the `primary avoidable factor' (Table 4.1). Because it was possible for women to have passed through so many hands during pregnancy and parturition, this amounted to an effort to apportion blame between the medical attendants involved (in the case of failure of ante-natal care and error of judgment in labour), administrators (in the case of lack of ante-natal care or facilities) and the mother herself. It was not so easy to blame women for maternal mortality as it was for infant mortality, but in regard to ante-natal care women could be held responsible for not actively seeking it. Table 4.1: Primary Avoidable Factors in Maternal Deaths, 1930-2 Lack or failure of ante-natal care Lack of facilities Negligence of patient Error of judgement (during labour) No evidence of departure from established procedure

526 123 266 658 1856

(15%) (3%) (7%) (19%) (54%)

Source: Ministry of Health, Final Report of the Departmental Committee on Maternal Mortality and Morbidity (HMSO, 1932), p. 23.

Investigators emphasised the clinical aspect of the maternal mortality question and considered it å problem for the medical profession alone. As one member of the unofficial Maternal Mortality Committee pointed out, the views of married women were not represented on the committees appointed to look into the question by the Ministry of Health. Usually, the only female representative on these was Dame Janet Campbell, the Senior Medical Officer in charge of maternal and child welfare at the Ministry. Mrs Barton, General Secretary of the Women's Cooperative Guild, had served on the Advisory Committee on Nutrition with no particular expertise, but the guild's views on maternity were not represented despite the publication of their papers on maternal welfare. When the Committee on Maternal Mortality and Morbidity was appointed in 1929, it was weighted in favour of consultant obstetricians. Four male obstetricians sat on the committee, together with three Ministry of Health officials, one bacteriologist and one general

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practitioner. The number of obstetricians would probably have been greater, had not twenty-three of them embarrassed the ministry by taking advantage of the public concern over maternal mortality to write to The Times publicly to demand more research monies for their work. Only two of these found a place on the committee.4 Other departmental committees, like the one of 1937, also co-opted obstetricians because these men were the most familiar with difficult maternity cases. The emphasis placed on the investigation of the immediate causes of maternal deaths meant that attention was focused almost exclusively on abnormal pregnancy and parturition. In the light of the problem posed by the maternal mortality rate, specialists began to review their definitions of pregnancy. J.W. Ballantyne, the pioneer of ante-natal care, came to the conclusion that Professor Bar's description of pregnancy as `harmonious symbiosis' would not do. On the other hand a physiological process could not easily be considered pathological. Thus he felt that pregnancy must be acknowledged as a state of `health under conditions of strain ... physiology working under high pressure'. Increasingly, though, pregnancy was classified as an illness and its management became ever more medicalised.5 Janet Campbell felt this was justified because she believed that the definition of pregnancy as a natural physiological process had resulted in abnormalities being considered inevitable.6 Research into the clinical causes of maternal deaths led to a call for the medicalisation of childbirth. Obstetricians and departmental committees advocated, first, techniques for the management of labour developed for use in hospitals rather than in the home (despite the fact that government reports revealed only 3% of deaths to have resulted from inadequate facilities), and, second, for more scientific care by better trained doctors, midwives and medical officers working in local authority clinics. The first of these recommendations encouraged the hospitalisation of childbirth, which resulted in a rise in the status of midwifery and this in turn reinforced medicalisation. Midwifery had long been the `Cinderella' of medicine. In the nineteenth century, the Royal Colleges of Physicians and Surgeons considered midwifery to be `manual labour' and thus unworthy of the attention of a `gentleman'.' Any research finding, such as Semmelweiss's discovery of the cause of puerperal fever in 1847, was slow to be applied. Few chairs of obstetrics existed before the interwar period and most of the midwifery training of doctors and midwives was obtained on the district.' For example, University College Hospital (UCH) had only eight maternity beds before a new 30 bed

120 Hospitalisation unit was opened in 1926, and with this new unit came a professorship in obstetrics. With the new importance attached to preventing maternal deaths and the recognition accorded specialised knowledge in the area, obstetricians could demand an improved status for their specialty,9 and in 1929 a British College of Obstetricians and Gynaecologists was founded. This became the Royal College of Obstetricians and Gynaecologists in 1938. The primary object of the College was to standardise the training and examination of post-graduates specialising in obstetrics and gynaecology, so that the standard of medical attendance available to women might be improved. It also effectively established the boundaries of the specialty. Women tended to accept the recommendations of the Ministry of Health's committees on the medicalisation of childbirth and demanded what the reports told them was best, whether it was more hospital beds, or the attention of a doctor as well as a midwife. Four of the five resolutions passed by the unofficial Maternal Mortality Committee in 1930 (just after the publication of the Interim Report of the Government Committee on Maternal Mortality and Morbidity) reflected a preoccupation with the provision of medical services. The fifth, however, asked for ancilliary services such as home-helps, which the committee, and more particularly Labour women, pressed for strongly. Only if these were provided could a woman either go to hospital and leave her family, or get adequate rest if the delivery took place at home. like Labour women's demands for the expansion of infant welfare work, this request went beyond the official delineation of the problem and its solution. Table 4.2: Place of Birth of Babies Born to interviewees, 1905-39

Home Hospital Hospital (%)

1905-9 2 0 0

1910-14 1915-19 1920-4 11 19 31 1 1 2 8 5 6

1925-9 30 4 11

1930-4 27 9 25

1935-9 24 17 41

The increase in the percentage of births taking place in hospital provides the clearest indication of the trend toward medicalised childbirth. In 1927, 15% of births took place in hospital; in 1933, 24%; in 1937, 25%; and in 1946, 54%.10 A similar trend was reflected in the experiences of the women interviewed (Table 4.2). There were, however, considerable regional differences in the number of hospital births. In Liverpool, Birmingham and Hull, less than 3% of all deliveries took

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place in hospital in 1915, but already in St Pancras 12.5% were hospital births, because of the proximity of the teaching hospitals and the greater number of lying-in charities. These provided free maternity care until the introduction of maternity benefits in 1911, after which patients were usually expected to contribute financially towards their care. By 1935, 56% of births in St Pancras took place in hospital, in Liverpool 41%, in Birmingham 33%, and in Hull only 22%." Yet the records of institutions employing midwives in domiciliary practice seemed to indicate that home deliveries could be as safe as those conducted in hospital and were certainly cheaper from the local authorities' point of view. Janet Campbell's early reports on maternal mortality emphasised the particularly fine record of the Queen Victoria Jubilee Institute (QVJI) midwives, who served all of England and Wales with the exception of Wiltshire, Essex and Northumberland, attending 80,147 cases (10%) in 1924. Where they worked alone the maternal mortality rate was half the national rate.'Z In a Local Government Board report, published in 1917, Janet Lane-Claypon stated that hospital births merely saved the midwife or doctor time and trouble and were unnecessary even in the case of a primiparous woman.13 By 1935, Janet Campbell admitted the advisability of hospital care for first and abnormal births, but felt that the rest could take place at home.14 Lady Rhys-Williams of the National Birthday Trust, agreed that hospital births were `fantastically expensive'. Moreover she felt that they were unnecessary when midwives were properly trained, and undesirable, because a home birth enriched the family experience and helped to lay sound foundations for family life.'s However obstetricians disputed the safety of home deliveries. W. Blair Bell, a consultant at the Royal Infirmary in Liverpool, claimed that the QVJI statistics ignored the 25% of midwives who called in doctors to assist them in difficult cases, and he left no place at all for domiciliary midwifery in his ideal scheme for maternity care.16 It is impossible to determine the relative safety of doctors versus midwives and home versus hospital during the period. In its analyses of the confidential reports on maternal deaths, the Ministry of Health showed that the place of delivery and the place of death (and thus the medical attendant) were often different. Cases that developed complications at home (most commonly as a result of the misapplication of forceps) and emergencies would often be transferred to hospital. It was thus impossible to draw firm conclusions as to the responsibility for death." After the importance of Lister's work on antisepsis in surgery had been recognised, childbirth in hospital was potentially as safe as in the

122 Hospitalisation home and in many hospitals the precautions taken were undoubtedly superior to those of midwives or doctors in domiciliary practice.18 But, as will be shown, even as late as the inter-war period there were great differences between standards of practice in the London lying-in or teaching hospitals, for example, and the institutions run by the poor law guardians and municipalities. This tended to be forgotten by obstetricians when they recommended the hospitalisation of childbirth. In fact obstetricians only referred indirectly to the question of safety when arguing in favour of hospital births. The move towards hospitalisation was prompted by research into the clinical causes of maternal deaths, which recommended the adoption of certain techniques developed for use in hospital. Consultants then argued that because these techniques could not be used properly in the home, hospital was the proper place for childbirth, a judgment that was based on consideration of abnormal labour alone. The Registrar General's annual reports showed there to be three main causes of maternal mortality: sepsis, haemorrage, albuminuria and toxaemia (Table 4.3). Table 4.3: Causes of Maternal Mortality, 1911-38

sepsis haemorrhage albuminuria & toxaemia other

1911 1,262 (37%) 557 (16%) 632 (19%)

1921 1,171 (35%) 242 (16%) 604 (19%)

1931 1,050 (40%) 386 (15%) 637 (24%)

1938 555 (29%) 328 (17%) 451 (24%)

962 (28%)

1,005 (30%)

528 (20%)

583 (30%)

Source: PP, '74th Registrar General's Annual Report for 1911', 1912-13, Cd. 6578, XIII, 493, pp. xc-xci; General Registry Office, Registrar General's Statistical Review for England and Wales for 1921 (HMSO, 1923), pp. 80-1; Statistical Review for England and Wales for 1938-39 (HMSO, 1947), pp. 114-17.

The Ministry of Health's detailed inquiries into maternal deaths, begun in 1932, found similar results to those of the Registrar General. Thus research into the clinical cause of maternal deaths focused on these three. Puerperal sepsis could follow either an abnormal birth where instruments had been used, or where haemorrhage had occurred, or a completely normal labour, in which case the haemolytic streptococcus virus present in the mouth, nose or throat of the medical attendant was to blame. The reports of the Departmental Committee on Maternal Mortality and Morbidity showed how common the latter form of

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infection was. Of the 616 deaths due to sepsis that were investigated by the committee between 1929 and 1930, 294 followed normal labour, 47 followed delivery by low forceps, but where the labour was otherwise normal, and 275 followed complicated labour.19 In 1847, Semmelweiss had observed that the death rate of mothers in hospital wards attended by medical students was three times that in wards attended by midwives. He attributed this to the contagion brought by the students from the post-mortem room and to inadequate hygienic precautions in the use of instruments. Doctors were outraged at the suggestion that they were the carriers of infection, and antiseptic and aseptic routines remained slack until well into the twentieth century.20 In the Milroy lectures of 1904, W. Williams considered puerperal sepsis to be preventable, but stressed sanitary reform as the chief means of prevention. The antiseptics that were in common use were often ineffective. Sulphur and carbolic acid were usual at the beginning of the century and these were replaced by lysol during World War I, which was often too heavily diluted to be useful. Not until the 1930s did research show dettol to be the most effective. All the Ministry of Health reports stressed the importance of proper anti- and asepsis, and advised the use of masks and gloves on the part of medical attendants. The 1928 Scottish Report on Maternal Mortality stressed that antisepsis was dangerous without asepsis and the Interim Report of the Committee on Maternal Mortality and Morbidity of 1930 stressed the reverse. The dangers of droplet infection were known as early as 1900, but until Leonard and Dora Colebrook's work during the 1930s on the typing of the bacteria causing infection and the identification of carriers, little attention was paid to the need for masks and gloves either in textbooks or in practice. In fact masks were very easy to infect if touched, and when used carelessly became more dangerous than no mask at all. Some of the more successful nursing institutions, like the QVJI, never used them. Miles Phillips nevertheless described the delay in the adoption of the face mask as `astonishing'.21 Sepsis was in fact more prevalent than even the heavy death rate indicates. Notification of `puerperal fever', as it was called before 1926, was lax, but as Campbell pointed out, while some local authorities reported a case mortality of 100% (in other words only cases where death ensued were reported), others fell below 50%.22 In 1926, puerperal fever was reclassified as puerperal pyrexia and defined as a fever occurring within 21 days of birth or miscarriage, where a reading of 100.4F or more was sustained over a period of 24 hours. Notification increased after this, possibly because of the increased recognition

124 Hospitalisation accorded the problem, although deaths from sepsis also increased between 1927 and 1934, with rural mothers becoming as susceptible as urban mothers 23 It is possible that during these years the haemolytic streptococcus was particularly virulent. The mortality from sepsis did not fall significantly until 1936 (see Figure 1.2), when antibiotics in the form of sulphonamides were introduced, but there is some evidence that at the Jessop Hospital in Sheffield, for example, the number of cases was beginning to fall before drugs were used 24 little could be done to prevent death from haemorrhage until blood transfusions became widely available during World War II, although, in its report of 1932, the Committee on Maternal Mortality and Morbidity vaguely recommended more hospital beds as a means of reducing mortality due to this cause. Haemorrhage was known to be more likely to occur in weak and exhausted multiparous women, or to follow interference in labour. This should logically have led to more emphasis on the traditional midwifery techniques used by the midwife in the home, but other movements associated with the attempt to prevent deaths due to toxaemic conditions of pregnancy favoured more rather than less intervention. Even in 1938, it was not known exactly what caused toxaemia, but it was realised in the early twentieth century that if albuminuria was detected early enough by means of efficient antenatal care, it could be controlled.25 Ballantyne constantly pleaded for `prematernity beds', but with a view to protecting the foetus rather than the mother. Very few hospitals paid sufficient attention to the need for ante-natal beds where women with toxaemic conditions could obtain complete rest before delivery. In fact, most hospitals required that a woman actually be in labour before they would admit her. (The British Hospital for Mothers and Babies was an exception in this regard, insisting that women be admitted some time before the expected date of birth.) Some specialists believed that the quality of care received at parturition was far more important than ante-natal work.26 In 1916, a writer in the BMJ did not feel that it was necessary for all women to receive ante-natal care, and midwifery texts did not include full sections on the subject until well into the 1920s.27 The first full text on ante-natal care did not appear until 1935. When toxaemia, pelvic deformity or a difficult presentation were revealed in the course of ante-natal examinations, induction or caesarian section often followed. Both these practices increased dramatically in the late 1920s and 1930s as ante-natal care became more widespread. University College Hospital did few inductions for toxaemia before 1930, although

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inductions for pelvic deformity were common prior to World War I and throughout the 1920s. At the Liverpool Maternity Hospital the number of inductions increased from 29 cases in 1916, to 67 in 1919, 100 in 1925 and 171 in 1930 before levelling off. A similar pattern emerges from the published reports of the General Lying-In Hospital. An article in the Lancet complained that ante-natal care might well have increased the amount of `meddlesome midwifery' and F.J. Browne, the author of the first textbook on ante-natal care, concluded that many induced labours were unnecessary and that in some cases antenatal care had `simply transferred mortality from one column to another'.28 Research on other aspects of maternal health and welfare tended to be ignored. Very little attention was paid to the question of post-natal care for women, for example. As late as 1937, only 10% of women were attending post-natal clinics, whereas 54% received ante-natal care.29 The 1937 report of the Ministry of Health Committee on Maternal Mortality also commented on the rarity of any post-natal examination. Such post-natal care as was given concentrated on the position of the uterus and the establishment of breastfeeding, ignoring blood and urine tests, blood pressure, the condition of muscles and pelvis, and birth control.30 Because of their connection with infant welfare work, antenatal clinics started earlier than post-natal clinics and expanded their work as the importance of detecting albuminuria and high blood pressure was realised. Post-natal care had no such direct bearing on preventing maternal death. Its main function was to alleviate lesser gynaecological problems, such as prolapse, which, while they caused suffering and undermined health, did not endanger life. The unofficial Maternal Mortality Committee changed its resolutions to include a demand for post-natal care at its 1932 conference on the grounds that it gave `1000 percent interest in happiness',31 but medical journals devoted very little space to it. The BMJ included only one major article on the subject during the whole period. Similarly, research into normal rather than abnormal pregnancy and labour was ignored. Kathleen Vaughan published several articles on the value of exercises for pregnant women and the best position for natural labour, but her application for a Medical Research Council grant was refused and the Ministry of Health could not see any particular relevance in her work.32 During the early part of the century, specialists looked with disfavour on any form of activity foi pregnant women. In 1906, Comyns Berkeley, author of some of the most influential textbooks on midwifery, advised that pregnant women should not even use the sewing

126 Hospitalisation machine. Later editions of the same textbook ignored the question of exercise completely, recommending only that the pregnant woman avoid `excitement' of any kind.33 Despite the knowledge that poor muscle tone seriously affected the labours of many multiparous women,34 little notice was taken of the idea of exercises until J.S. Fairbairn adopted Vaughan's ideas and started ante- and post-natal exercise classes at St Thomas's Hospital in the late 1930s. Concentration on the abnormalities of labour and the necessity of rigorous aseptic and antiseptic procedures for all labour (whether operative or routine) caused more and more specialists to insist that every labour was a `major surgical procedure'.35 Victor Bonney, a leading obstetrician, viewed childbirth thus: Pregnancy is a state induced by the growth of a neoplasm; labour is a process accompanied by self-inflicted wounds and the puerperium is the period of healing ... Midwifery concerns itself with the treatment of these three and is a pure surgical art.36 Bonney insisted that he wanted to see `midwifery not necessarily more "operative" but more "surgical.i37 Part of the emphasis on surgical procedure was designed to protect the patient from sepsis, but other innovations were, despite Bonney's proviso, surgical in the sense of more operative. For example, not only did the number of inductions increase, but also the number of episiotomies, a technique designed to prevent severe perineal tears. In many cases, however, these could be avoided by slow delivery of the head, but with the hospitalisation of childbirth, physical intervention became the acceptable form of innovation in obstetric practice.38 Episiotomy became more common during the 1930s. For example at the General Lying-In Hospital, episiotomies were first recorded in 1933. New editions of the midwifery textbooks also reflected the change. Thomas Watts Eden's manual did not mention episiotomy until the 1920s. In Comyns Berkeley's textbook of 1917, the technique was reserved for use in `exceptional cases', where severe tears of the perineum were inevitable. More space was devoted to it in the 1938 edition which now advised its use `in certain cases'.39 Medical textbooks also reflected the change in attitude towards surgical aseptic routine for childbirth. In 1906, Watts Eden felt that it would be advantageous to shave and disinfect the vulva as for a surgical operation, but warned his readers that this would be misunderstood and resented in private practice. In 1927, Aleck Bourne recommended

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clipping the pubic hair if the patient refused shaving, but in 1930 Henry Jellett, Master of the Rotunda Hospital, assumed there would be no difficulty in preparing the patient in this manner.40 The maternal and child welfare committee of the Medical Women's Federation (MFW) urged that `there should be a tightening up of the technique of the preparation of the patient for labour, e.g. the giving of an enema, shaving the patient, etc'.41 The recommended delivery position also changed to reflect the greater emphasis on surgical technique. The normal position in England during the early part of the twentieth century was to have the woman lie on her left side. In his midwifery text published in 1898, Playfair explained that this prevented `unnecessary exposure of the person',42 undoubtedly a powerful reason for using it in Victorian and Edwardian England. But in this position it was also easier to effect the slow delivery of the head and to prevent perineal laceration.43 Victor Bonney, however, insisted that women should lie on their backs with their feet in rests (the lithotomy position still in use today), which could then be secured when the woman was anaethetised. This procedure made obstetric surgery easier. Many members of the medical profession felt that birth should be a `medical event' and that to give birth at home was in some way degrading. This view contrasted sharply with that of Lady Rhys-Williams and the National Birthday Trust. Campbell commented in her 1924 report that many home deliveries were unsatisfactory, `partly because it is not easy to secure effective asepsis in a small dwelling, but largely because a confinement is an event made common and trite by familiarity'.44 Thomas Watts Eden expressed a similar view when he congratulated the 1926 Conference of the National Association for Maternal and Child Welfare on having `travelled today very far from the old view that a confinement is an interesting domestic occurrence which should be celebrated in the family like Christmas or a birthday party'.45 Most specialists assumed that sterile conditions were impossible to achieve in the home. Mary Scharlieb felt that poor homes where a family shared one or two rooms were particularly inappropriate settings for childbirth, and Edith Summerskill, a future Minister of National Insurance in the Labour Government of 1950-1, agreed that deliveries in overcrowded homes were undesirable.96 Certainly, the aseptic procedure outlined by Henry Jellett was impossible to follow in the home. In addition to the preparation of the patient, the delivery room had to be disinfected, the clothes of the attendants boiled for 20 minutes and their hands scrubbed with biniodide or mercury soap, and copious hot

128 Hospitalisation water and sterile dressings had to be provided. Jellett supported the traditional methods of non-interventionist midwifery commonly used by midwives in domiciliary practice, but nonetheless felt that midwives were not good at aseptic procedure.47 There were, of course, still many untrained midwives who had been in practice when the Midwifery Act of 1902 was passed and who continued to practice as `bona fides'. Until 1914, these outnumbered trained midwives, but by 1920, 80% of those practising were trained, and by 1934, 97%.48 Midwives used the same texts (which stressed the importance of asepsis) as medical students, the most popular being Comyns Berkley's Midwifery by Ten Teachers. In addition, every effort was made to ensure that midwives knew the importance of aseptic procedure. In 1911, Section E of the midwives' rules, laid down by the Central Midwives Board, was amended to force the midwife who had been in contact with a case of puerperal sepsis to stop practice for 24 hours while her clothing and person were disinfected. At the front of the books in which midwives from the General Lying-In Hospital recorded their district case notes, was written the `Antiseptic Rule', which bade the midwife disinfect her hands, wash the vulva of her patient, clip the public hair and swab the vulva again with soap and water.49 Alice Gregory, Honorary Secretary of the British Hospital for Mothers and Babies, where midwives were trained to meet the conditions they would confront in a poor, domiciliary practice, drove home the message with a rhyme which began: `Clean hands our weapon, Clean hands our sisters' safeguard.'5° Conditions in poor homes were certainly far from optimal. The Motherhood Book of 1934 printed a list of `necessities' for a confinement which would obviously have been beyond the reach of workingclass women; the total cost was £4 Is. 11 lid. 5 ' This list was similar to the ones given by consultants. Alice Gregory knew the reality of the situation faced by poor women and suggested some cheaper alternatives. Attendants could use brown paper and newspaper instead of mackintosh sheets and more newspaper to catch the swabs rather than bowls.52 One woman interviewed revealed that the women who lived on the same street as she did in Birmingham during the late 1920s and 1930s had only one bowl and jug between them, known as `the midwife's bowl and jug', which was passed up and down the street as and when required. Only five women interviewed had running hot water in their houses or flats during this period. Nevertheless, recent work has shown the simple aseptic and antiseptic precautions advocated by Gregory to be adequate. Shaving and enemas, for example, are not necessary.53 However, articulate women's groups supported the hospitalisation of

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childbirth. The Women's Cooperative Guild complained that many poor women could afford only an untrained midwife and relied on a neighbour to come in and help with the washing and other household tasks.54 In 1914, the guild started its `National Care of Maternity' campaign and produced several schemes for a national maternity service. Each successive proposal concentrated more on the need to provide poor women with the best skilled medical assistance available. In 1914, the demand was for trained midwives; in 1917 for a trained midwife and easy access to a doctor, with specialist care and hospital accommodation where necessary; and by 1918, a doctor to supervise every case and enough hospital beds to accommodate all those living in poor home conditions." Mrs Hood, a member of the guild, stressed the importance of adequate hospital accommodation many times. In small working-class homes the rooms were too small to allow the bed to be pulled away from the wall and children were often present at the birth because there was nowhere else for them to go. More serious still in Mrs Hood's view was the question of rest. Unlike the writer in National Health, who felt that it was impossible to remove the `Chancellor of the Exchequer' from her home, the guild believed that women should go to the hospital so that they would be away from the everyday worries of managing a household. Mrs Hood went so far as to state that if women got proper rest after childbirth they would not need post-natal care.56 Leonora Eyles discussed the relative advantages of home and hospital births in Lansbury's Labour Weekly and she also stressed the possibility of more rest in hospital. In Vera Brittain's novel, Honourable Estate, Ruth Alleyndene, the heroine, reflected on this problem after experiencing a difficult birth: ' suppose I'd been a working man's wife, and no private income to meet the expense of staying in this nursing home till the twins were safely over their first weeks and I've had all the rest I need?'S7 Middle-class women supported the hospitalisation of childbirth because they desired specialist care and because anaesthesia was more readily available in hospital,58 although it was by no means routine. In 1932, at the Royal Free Hospital, 60% of patients received some form of pain relief. Only a doctor could give analgaesics in the home and of course no full anaesthetic was possible there. Lady Baldwin, a member of the National Birthday Trust, started an anaesthetics fund in 1930 and the Trust bought and donated to hospitals apparatus for the administration of gas and air. The plea for anaesthesia was sympathetically received. As early as 1918, the Chief Medical Officer at the Local Government Board perceived that a new drug called `twilight

130 Hospitalisation sleep' (a mixture of scopolamine and morphine) could prove of valuable assistance in the effort to persuade women to have more children. 59 Women themselves used this argument to press for readier access to pain killers. A Mrs Hardy of Doncaster wrote to the Minister of Health: `the chief cause of the low birth rate is the fear of bearing children, which is a ghastly experience'.60 It is by no means clear that the views of middleclass women, which received so much publicity, were shared by workingclass women. The Annual Report of the General Lying-In Hospital for 1932 reported that: `In the locality (Westminster and Lambeth) a definite stigma is attached to any mother who had an abnormal confinement, that is to say an anaesthetic.'61 One of the women interviewed expressed the same view. A similar difference of opinion occurred over the question of maternity bags. These bags contained the necessities for a confinement and were provided by some LAs for poor women. The WCG and the Women's Labour League demanded that LAs provide more of these, but in 1935 the Medical Officer of Health for St Pancras reported that the bags had not been used.62 This was probably because of the stigma attached to their use. As one woman interviewed in Birmingham put it: `Well, my dear, I'm sorry to say I had to have a bag.' Many working-class women preferred to be at home for births after the first because of the difficulty in caring for other children. Women's groups realised this and pointed out the need to include provision for home-helps in any maternity scheme. The Hull Public Health Committee recorded the case of a woman who was found to have albuminuria while pregnant, but who could not go into the maternity hospital even when a bed was found for her because of her other children.b3 The importance of home-helps was stressed in the Women's Cooperative Guild scheme of 1917: `In the opinion of working women themselves one of their most pressing wants is for reliable help in the home ... during confinements.i64 This need was also mentioned in the national maternity schemes drafted by specialists, departmental committees of the Ministry of Health and the BMA, but only under the subsidiary heading of ancillary domiciliary services. To specialists, the trained home-help with carefully defined duties was primarily a means of professionalising this aspect of maternity work and of superseding the undignified `crude arrangements' mothers made with `gossiping neighbours' to help them during the after childbirth.65 The Women's Employment Committee of the Ministry of Reconstruction devoted a lot of attention to the question of home-helps, both as a necessary part of health care services and as a means of employment for women.66 Money for training home-helps was supplied

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by the Central Committee on Women's Employment during World War I. Six of these finished their training at the North Islington Maternity Centre and School for Mothers. A voluntary home-helps society was also set up with money from the Children's Jewel Fund. But homehelps proved hard to find because of the poor wages they were paid. During World War I, North Islington helps received 12s. 6d per week and 6d a day for meals, where these were not taken with the family. In Birmingham, helps working for the city health authorities as part of its `nine day nursing' scheme, received only 2s. a day for ten hours work.67 This compared with the 24s. per week paid to cotton workers in 1918 and the 30s.-40s. to munitions workers. Local authorities were reluctant to spend money on this service and expenditure on homehelps never exceeded 2% of the yearly maternal and child welfare budgets allocated to LAs by the ministry between 1919 and 1928.68 A survey of seventy-five LAs and eight voluntary home-helps societies conducted by Mother and Child in 1931, revealed only 422 homehelps to be available. Even with the low wages the helps received, the mothers could not easily afford them. At Islington, it cost £300 a year to train each help and administer the service and only £100 of this was recouped from the women using the service.69 Mothers hiring a home-help from a voluntary society or from an LA, paid according to means. At Hull in 1926, the home-helps were paid 5s. 6d. a day but the family paid this much only if its income came to over 17s. per head. The sliding-scale of payments reached as low as is if the family income amounted to less than 9s. per head.70 Nor were home-helps as popular as more traditional arrangements made with neighbours, not least because their duties were so closely defined. One woman interviewed, who had had a child in Birmingham in 1933, recalled paying 2s. 6d a day for a help and being disappointed because she `wouldn't do certain things'. In this instance, the help did the washing but no mending or darning, a necessary part of the weekly routine. In view of this, it is perhaps not surprising that in her 1946 study of Middlesborough, Griselda Rowntree found that applications for home-helps came mainly from the middle class.'' Government reports and specialists recommended the hospitalisation of childbirth, and women accepted their opinion while making additional demands for domiciliary services that would make it easier for women to go to hospital. It is thus difficult to assess how far the increase in the number of hospital births reflected genuine demand and how far it was the direct result of the policies of hospitals and local

132 Hospitalisation authorities. Official and medical estimates of the number of maternity beds needed rose constantly throughout the inter-war period. In 1920, Janet Lane-Claypon estimated that 5% of births needed hospitalisation. Ethel Cassie, Assistant Medical Officer in Birmingham, estimated the demand for beds to be between 20% and 25% in 1934 and, in 1937, the Medical Officer of Health for Dewsbury raised this to 50% when commenting on the Ministry of Health's 1937 report on maternal mortality. By 1944 the Royal College of Obstetricians and Gynaecologists felt that plans should be made to hospitalise 70% of all births.'Z It is probable that these estimates more closely reflect the ideals of administrators and consultants than the actual demand. In 1921, Janet Campbell favoured the establishment of small ten-to twenty-bed maternity homes,73 but maternity schemes favoured by specialists were based on large hospitals. W. Blair Bell's scheme relied on what he termed `base, field and casuality clearing hospitals' (essentially a rationalised system of teaching, general and cottage hospitals) to provide the main links in the service, and Munro Kerr developed a similar system depending on `primary and secondary' hospitals.74 In both cases it was felt that maternity units in teaching and general hospitals should have between 60 and 70 beds, which was large enough to command the services of a consultant. Similarly, in 1932, the specialist-dominated Departmental Committee on Maternal Mortality recommended that maternity beds be located in large institutions where it was believed that women would get the best care.75 The big teaching hospitals were in fact the first to expand their maternity facilities. University College Hospital claimed that patient demand forced it to increase the number of maternity beds. F.J. Browne, the Professor of Obstetrics at the hospital, defended the enlargement of the obstetrical unit by arguing that if women wanted to have their babies in hospital and could not get a bed in a voluntary hospital, it was possible that they `might even prefer' the poor law infirmary to staying at home.76 Thus, if the hospital was to maintain its quota of maternity patients, it had to increase the number of in-patients. But UCH also made corresponding cuts in the number of district midwifery patients, so that some women had no choice but to give birth in hospital. Medical students at UCH felt that the decline in the number of district cases prevented them from getting adequate training in dealing with emergency cases in the home. In reply, Browne stressed that the new midwifery was built on hospital techniques which were the crucial part of any student's training." The trend towards increasing the

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number of in-patient births at the expense of district practice was followed by all the major voluntary hospitals. Statistics from Elizabeth Garrett Anderson Hospital (EGA), the General Lying-In Hospital and UCH illustrate this (see Table 4.4). Table 4.4: In-patients as a Percentage of All Maternity Patients at Three London Hospitals, 1911-38

Elizabeth Garrett Anderson Hospital University College Hospital General Lying-In Hospital

1911 nd* nd 26

1916 nd nd 54

1921 nd nd 33

1927 18 40 44

1938 66 65 64

* nd — no data Source: The Obstetrical Reports of UCH; the Annual Medical Reports of the General Lying-In Hospital, GLC Archives, HI GLI A32; and the Annual Reports of the Elizabeth Garrett Anderson Hospital, PRO.

In 1929, the number of maternity beds available increased dramatically when local authorities took control of the poor law institutions. For example, the London County Council (LCC) took charge of 478 beds in 21 hospitals.78 These had been used occasionally for non-poor law cases before 1929, but, as Browne's comment implied, a certain stigma had attached to anyone using them. The facilities available in many of the non-teaching hospitals hardly matched the specialists' ideals of modern, efficient obstetric care. The minutes of the maternity committee of the EGA show that before the new building was opened in 1929, there was no separate labour ward and it was felt that a death from sepsis which occurred in 1925 was probably due to the crowded and unsuitable accommodation.79 The conditions in the hospitals taken over by the LCC in 1929 were much worse. The Lambeth maternity ward was reported to be very dirty with `obsolete' bathroom facilities, and at St Pancras, as late as 1936, there were no proper sterilisers, no isolation ward for sepsis cases and the labour ward shared a kitchen with a ward taking septic cases.' After 1929, the LCC permitted any mother to go into hospital for the birth of her child and this caused further problems of overbooking and overcrowding. In 1935, three cases of sepsis at St Olave's were thought to be due to overcrowding.Ø1 These problems were common in other hospitals too. One patient at the EGA was moved four times after admission because of overbooking, and in a celebrated Manchester case a woman died after being moved four miles to another hospital one hour after the birth of her child.82 An article in Labour Woman

134 Hospitalisation criticised the General Lying-In Hospital for similar administrative practices.83 Hospitals had only limited means of countering the main causes of maternal mortality. One of their main advantages was supposed to lie in their rigorous observance of aseptic and antiseptic procedures. But it was alleged that these often lapsed when junior staff were put in charge of difficult cases." Also, in overcrowded conditions sepsis cases could not be isolated. Without quoting specific examples, the 1932 report of the Committee on Maternal Mortality and Morbidity drew attention to the wide variation in mortality rates between hospitals. In the private nursing homes favoured by many middle-class mothers, conditions were probably the most dangerous of all. A case of sepsis would force the temporary closure of these institutions if reported, thus it was likely that either temperatures were not taken routinely, or that cases of sepsis were not reported and not isolated.85 On the other hand, some institutions, such as the East End Lying-In Hospital, had an excellent record and the LCC attributed the exceptionally low rate of mortality among East End mothers to the quality of care at this maternity hospital." Diagnosis of toxaemia depended on good ante-natal care, which was more often the responsibility of local authority clinics, midwives and doctors than hospitals. If caught in its early stages, rest was known to be essential, but for most working-class women this was impossible to obtain at home, yet ante-natal beds were few. The medical intervention that followed the diagnosis of a severe case was inevitably accompanied by its own dangers. One of these was haemorrhage, the likelihood of which was increased by intervention in labour. No satisfactory treatment was available for this until blood transfusions became common after World War II. The tendency among some present-day sociologists and feminists is to stress that pregnancy is a natural physiological function and to dismiss all aspects of hospitalised childbirth as bad.87 Looking at the interwar period, when the trend towards hospitalisation accelerated so rapidly, it is not so easy to reach such a clear-cut conclusion. Doctors who had shown their commitment to midwifery in the days when it had been considered a poor option for any medical student to specialise in, came into their own when maternal mortality became a political issue. They saw the chance to make the changes they honestly believed necessary and, also, to increase the prestige of their specialty by insisting that childbirth become a medical event and take place, if possible, in hospital. Besides, the clinical causes of maternal death did need investigation and sepsis in particular did require more stringent aseptic and

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antiseptic procedures. Women themselves recognised this and supported more medicalised management of childbirth. However, specialists viewed all childbirth as potentially abnormal and concentrated all their attention on labour. The limited technology available to parturient women in most hospitals made it doubtful that hospitalisation would result in a fall in maternal mortality. After all, adequate aseptic and antiseptic precautions, which were the most highly regarded part of hospital practice, were also possible in the home during the course of a normal birth. During the period 1900-39, a careful attendant gave the best chance of a safe childbirth and such a person could be found in the home as easily as in the hospital. The home remained the usual place of delivery throughout the period. The emphasis put on the need to medicalise childbirth in the reports issued by the Ministry of Health was extended to domiciliary practice and called into question the competence of the general practitioners and midwives who did home deliveries. But GPs had little and midwives no representation on the departmental committees. Thus, while hospitalisation was promoted by those it affected most, efforts to upgrade medical practice in the home put both GPs and midwives on the defensive. The resulting inter-professional rivalries and tensions did nothing to improve the quality of care.

Notes 1. Maternal Mortality. Report of a Meeting Held at the Friends' House, Euston Road (The Maternal Mortality Committee, 1932), p. 26. See also, Maternal Mortality. Report of a Meeting Held at the Central Hall, Westminster (The Maternal Mortality Committee, 1929), p. 13, for a similar comment by Mrs Eva Hubback. 2. Maternal Mortality ... Central Hall, p. 5; and Maternal Mortality. Report of a Meeting Held at the Friends' House, Euston Road (The Maternal Mortality Committee, 1930), p. 7. 3. Janet Campbell, The Protection of Motherhood. Reports on Public Health and Medical Subjects, no. 48 (HMSO, 1927), p. 3; and PP, `Report on an Investigation into Maternal Mortality', 1936-7, Cmd. 5422, XI, 1, p. 11. 4. PRO, MH 55/266, Newman to Maclachlan, 7 May 1928; and The Times, 3 April 1928, p. 17. The two who both signed the letter and sat on the Committee were William Fletcher Shaw and F.J. Browne. 5. J.W. Ballantyne, 'The Nature of Pregnancy and Its Practical Bearings', BMJ, 14 Feb. 1914, p. 351; Margaret Mead and Niles Newton, 'Cultural Patterning of Behaviour', in Childbearing — Its Social and Psychological Aspects, edited by Stephen A. Richardson and Alan F. Guttmacher (Williams and Wilkins Co., 1967), p. 170, have stressed the importance of the way in which a culture classifies pregnancy. The debate over whether pregnancy should be treated as an illness continues today: see, John B. McKinlay, 'The Sick Role — Illness and Pregnancy', Soc. Sci. and Med, 6 (Oct. 1970), pp. 561-72; and Warren M. Herrn, 'The Illness

136 Hospitalisation Parameters of Pregnancy', Soc. Sci. and Med., 9 (July 1975), pp. 365-72. 6. Carnegie UK Trust, Report on the Physical Welfare of Mothers and Young Children, vol. II (Carnegie UK Trust, 1917), p. 1. 7. William Fletcher Shaw, The Story of the Royal College of Obstetrics and Gynaecology (J. & A. Churchill, 1954), p. 5. See also, Ivan Waddington, `General Practitioners and Consultants in Nineteenth Century England' in Health Care and Popular Medicine in Nineteenth Century England, edited by John Woodward and David Richards (NY: Holmes and Meier, 1977), p. 177. 8. I have used midwifery and obstetrics interchangeably. Unlike the USA, it was quite usual in Britain to speak of midwifery training in regard to the medical student as well as to the midwife during the period 1900-39. 9. Terence J. Johnson, Professions and Power (MacMillan, 1972), p. 57, makes the point that specialised knowledge is essential to the ideology of professionalism. 10. The Royal College of Obstetricians and Gynaecologists, Report on a National Maternity Service (Royal College, 1944), p. 25; and Jt Committee of the Royal College of Obstetricians and Gynaecologists and the Population Investigation Committee, Maternity in Great Britain (Oxford UP, 1948), p. 48. 11. Annual Report of the MOH for St. Pancras, 1935, p. 128; Annual Report of the MOH for Birmingham 1935, p. 146 ;Annual Report of the MOH for Hull 1935, p. 135; and Proceedings of the Council, 1934-5, 1107, 'Report of the MOH on the Reorganization of the Maternal and Child Welfare Services', p. 5, Liverpool Public Archives. 12. Nursing Notes, XXXVII (Aug. 1924), p. 107; John S. Fairbairn, 'Observations on the Maternal Mortality Rate in the Midwifery Service of the QVJI', BMJ, 8 June 1927, pp. 47-50; and Campbell, Protection of Motherhood, p. 47. 13. Janet Lane-Qaypon, Report on the Provision of Midwifery Service in the City of London, Reports to the LGB on Public Health and Medical Subjects, no. 111 (HMSO, 1917), p. 12. Janet Lane-Qaypon was an Assistant Medical Inspector at the LGB between 1912 and 1916 before becoming Dean of the Household and Social Science Department at Kings College for Women. 14. Janet Campbell, Maternity Services (Faber and Faber, 1935), p. 24. 15. 'A Head Quarters for the Midwifery Services', July 1933, Rhys-Williams Papers. 16. 'A National Maternity Service', Lancet, 13 June 1931, pp. 1279-86 and 15 Aug. 1931, p. 368. 17. Moreover, few hospitals indicated how their figures were complied. Some listed deaths occurring in cases transferred from homes under the heading 'domiciliary practice' and some under 'in-patients'. Additionally, larger maternity hospitals accepted more emergencies and more abnormal cases than small hospitals and this adversely affected their maternal mortality rate. 18. A dramatic improvement in the maternal mortality rate occurred at the General Lying-In Hospital during the 1880s. But this was to be expected as Lister himself was appointed Consulting Surgeon there in 1879. (Philip Rhodes, Doctor Leake's Hospital (Davis Poynter, 1977), p. 205. 19. Ministry of Health, Interim Report of the Departmental Committee on Maternal Mortality and Morbidity (HMSO, 1930), p. 14. 20. Ann Oakley, 'Wise Woman and Medicine Man' in The Rights and Wrongs of Woman, edited by Ann Oakley and Juliet Mitchell (Penguin, 1976), pp. 34-5; and Patricia Branca, Silent Sisterhood (Croom Helm, 1975), p. 87. Antisepsis involves the use of antiseptics; asepsis means the observation of scrupulous cleanliness in all procedures and may include the use of antiseptics. 21. Miles H. Phillips, 'The History of the Prevention of Puerperal Fever', BMJ, 1 Jan. 1938, pp. 1-7.

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137

22. Janet Campbell, Maternal Mortality, Reports on Public Health and Medical Subjects, no. 25 (HMSO, 1924), p. 59. 23. General Registry Office, Registrar General's Statistical Review for England and Wales for 1927 (HMSO, 1929), p. 80. 24. J.M. Munro Kerr, R.W. Johnstone and Miles H. Phillips, Historical Review of British Obstetrics and Gynaecology (Edinburgh: E. & S. Livingstone, 1954), p. 20. See also the statement to this effect by A.J. Wrigley, `Observations on Maternal Mortality' in Modern Trends in Obstetrics, vol. III, edited by R.J. Kellar (Butterworths, 1963), p. 214. 25. J.M. Munro Kerr, 'Toxaemias of Pregnancy and their Effect on Maternal and Infant Mortality' in Report of the International Conference on Infant Mortality, 1913 (n.p., n.d.). The aetiology of toxaemia is still unknown; it is recognised by the presence of albumin in the urine, high blood pressure and swelling. Untreated cases develop into eclampsia which is accompanied by convulsions. 26. Aleck W. Bourne, 'The Limits of Ante-Natal Care', Tr. of State Medicine, XLIII (Aug. 1935), pp. 435-44. 27. For example, Thomas Watts Eden, A Manual of Midwifery 5th edn (J. & A. Churchill, 1915), pp. 98-100, were devoted to ante-natal hygiene, but in the 6th edn, published in 1925, pp. 682-5 covered the necessity for full ante-natal care, including blood pressure checks and urine analysis. A similar difference is found between the 9th and 10th edns of Henry Jellett, A Short Practice of Midwifery (J. & A. Churchill, 1924), pp. 94-6, and 1930, pp. 114-26; and between the 1st and 2nd edns of Comyns Berkley (ed.), Midwifery by Ten Teachers (Edward Arnold, 1917), pp. 81-3, and 1920, pp. 85-7. 28. G.W. Theobald, `For Drastic Reform in the Teaching and Practice of Midwifery: A Plea', Lancet, 25 Sept. 1926, pp. 633-7; and F.J. Browne, `Ante Natal Care and Maternal Mortality', Lancet, 2 July 1932, p. 1. 29. Ministry of Health, 19th Annual Report of the Ministry of Health 1937-8 (HMSO, 1938), p. 241. 30. Aleck Bourne, `Influences which Undermine the Health of Women', Jr. of the Royal Instit. of Pub. Health, 1 (Sept. 1938), pp. 705-11. 31. Maternal Mortality ... Friends' House (1932), p. 23. See also Countess of Limerick, `Post Natal Care', Jr. of Royal Instit. of Pub. Health, 2 (June 1939), pp. 358-67. 32. PRO, MH 55/687, Vaughan to Minister of Health, 1 Feb. 1930. See also, Ibid., 20 Oct. 1934, memo on Vaughan's work. 33. Comyns Berkley, A Handbook of Midwifery for Obstetric Dressers, Pupil Midwives and Midwives, 1st edn (Cassell, 1906), pp. 37-42; and (ed.), Midwifery by Ten Teachers (1917), p. 87. 34. For example, A. Leyland Robinson, `The Old Multi-para: The Influence of Age and Parity on Maternal Mortality', BMJ, 12 July 1930, pp. 47-50. 35. J.M. Munro Kerr, James Hay Ferguson, James Young and James Hendry, A Combined Textbook of Obstetrics and Gynaecology (Edinburgh: E. & S. Livingstone, 1923), p. 320. 36. Victor Bonney, `The Continuing High Maternal Mortality of Childbearing: The Reason and the Remedy', Proc. of the Roy. Soc. of Med, 12 (1919), Pt III, pp. 83-4. 37. Ibid., p. 97. 38. M.P.M. Richards, `Innovation in Medical Practice: Obstetrics and the Induction of Labour in Britain', Soc. Sci. and Med., 9 (Nov.-Dec. 1975), pp. 595-602, makes a similar point. He suggests that induced labour is an `irrational practice' fraught with iatrogenic complications and yet is claimed to be `scientific', because in hospital any intervention is defined as such. His argument becomes

138 Hospitalisation more powerful when applied to a technique like episiotomy. 39. Thomas Watts Eden, Manual of Midwifery, 6th edn (1925), p. 297: Berkley, Midwifery by Ten Teachers, 6th edn (1917), p. 297 and Midwifery by Ten Teachers, 6th edn (1938), p. 263. 40. Eden, Manual of Midwifery, 1st edn (1906), p. 208; Aleck W. Bourne, et. al., The Queen Charlotte's Practice of Obstetrics (J. & A. Churchill, 1927), pp. 250-1; and Henry Jellett, A Short Practice of Midwifery, 10th edn (1930), pp. 6-8. Berkley, Midwifery by Ten Teachers (1938), p. 259, also assumes this. 41. Minutes of the Meetings of the Council of the Medical Women's Federation, vol. II. 26 Oct. 1928, MWF Archives. 42. W.S. Playfair, A Treatise on the Science and Practice of Midwifery, 9th edn (Smith Elder and Co., 1898), p. 367. 43. Munro Kerr, et. al., Combined Textbook of Obstetrics and Gynaecology, p.321. 44. Campbell, Maternal Mortality, p. 49. 45. Thomas Watts Eden, 'Midwifery in the Home from the Consultants Point of View', Annual Report of the National Association of Maternal and Child Welfare 1926, Archives of the NAMCW. 46. Mary Scharlieb, The Welfare of the Expectant Mother (Cassell, 1919), p. 82; and Maternal Mortality ... Friends' House (1932), p. 27. 47. Henry Jellett, 77ie Causes and Prevention of Maternal Mortality (J. & A. Churchill, 1929), pp. 12 and 106-7. 48. Annual Reports of the Work of Central Midwives Board for 1911 (PP, 1912-13, Cd. 6061, XL, 891, p. 2); for 1914 (PP, 1914-16, Cd. 7784, 561, p. 2); for 1920 ((HMSO, 1921), p. 21); for 1934 ((HMSO, 1935), p. 2). 49. Notes of Labour, 1924 (General Lying-In Hospital), Royal College of Midwives Library. 50. Alice Gregory (ed.), The Midwife: Her Book (Henry Fowke and Hodder and Stoughton, 1923), p. 189. 51. The Motherhood Book (Amalgamated Press Ltd, 1934), p. 104. 52. Gregory, The Midwife, p. 28. See also G.T. Wrench, Rotunda Midwifery for Nurses and Midwives (Hodder and Stoughton, 1908), p. 108. 53. For example, see Danae Brook, Nature birth (Penguin, 1977). 54. Cooperative News, 29 April 1911, p. 539, letter. 55. 32nd Annual Report of the Women's Cooperative Guild, 1914-15, p. 23; WCG, Memo on the National Care of Maternity (WCG, 1917), p. 3; Eleanor Barton, 77te National Care of Motherhood (WCG, 1928), pp. 3 and 6. 56. Maternal Mortality ... Central Hall, p. 20; Lancet, 16 July 1921, p. 152, report of a conference on infant welfare; and Mrs Hood, `Maternal Mortality from the Working Woman's Point of View', Annual Report of the National Conference on Maternal and Infant Welfare for 1928, NAMCW Archives. 57. Vera Brittain, Honourable Estate (Macmillan, 1936), p. 513. 58. Maternal Mortality ... Friends' House (1930), p. 30; and PRO, MH 55/262, 28 Nov. 1935, notes on the policy of the Maternal Mortality Committee. 59. PP, '48th Annual Report of the LGB for 1918-19. Supplement Containing the Report of the Medical Department', 1919, Cmd. 462, XXIV, 599, p. 119. 60. PRO, MH 55/625, Mrs M. Hardy to the Minister of Health, 4 July 1938. 61. Annual Report of the General Lying-In Hospital for 1932, p. 35, GLC Archives, HI GLI A30. 62. 9th Annual Report of the Women's Labour League, 1928, p. 54; Hood, 'Maternal Mortality', Annual Report of the Nat. Conf on Maternal and Infant Welfare, 1928, p. 77; and Annual Report of the MOH for St. Pancras for 1935, p. 128. 63. Minutes of the Proceedings of the Health Committee, XXXII, 26th Sept. 1919, Hull Public Archives.

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139

64. WCG, Memo on the National Care of Maternity, p. 4. See also PRO, MH 55/518, memo of the WCG on home-helps addressed to the Committee on Subsidiary Health and Kindred Services of the Women's Employment Committee of the Ministry of Reconstruction. 65. PRO, MH 55/230, Campbell to A. Stutchbury, 11 June 1920 and Annual Conference Report of the NAMCW, 1929, pp. 58-60, NAMCW Archives. 66. PRO, MH 55/517, memo by Miss A.M. Anderson on Subsidiary Health and Kindred Services for Women, pp. 5-6. 67. Ibid., p. 6. 68. PRO, MH 55/260, notes on home-helps, 17 Jan. 1930. 69. PRO, MH 55/230, memo by Miss Puxley, 28 Oct. 1921. 70. Minutes of the Proceedings of the Health Committee XXXIX, 11 Oct. 1926, Hull Public Archives. 71. Griselda Rowntree, Maternity Services in Middlesborough (Association for Planning and Reconstruction 1946), p. 7. 72. Janet Lane-Claypon, The Child Welfare Movement (G. Bell, 1920), p. 159; Ethel Cassie 'Has Ante-Natal Work Reduced Maternal Mortality?' Mother and Child, 5 (Dec. 1934), p. 354; J.F. Galloway, 'The Maternity Services', Jr. Royal Sanitary Institute, LVIII (May 1938), pp. 706-12; and Royal College of Obstetricians and Gynaecologists, Report on a Nat. Mat. Service, p. 27. 73. Janet Campbell, 'Maternity Homes', Lancet, 16 July 1921, pp. 162-4. 74. 'A National Maternity Service', Lancet, 15 Aug. 1931, p. 368. 75. Ministry of Health, Final Report of the Departmental Committee on Maternal Mortality and Morbidity, 1932 (HMSO, 1932), pp. 39 and 41. 76. UCH Magazine, 15 (Aug. 1930), p. 166. 77. UCH Magazine, 15 (April 1930), pp. 57-9 and 15; (Aug. 1930), p. 163. 78. 'Maternity Wards in LCC Hospitals and Institutions 1929', Papers of Letitia Fairfield, GLC Archives, PH GEN 3/6. By 1936, local authorities provided 62% of maternity beds; see PEP, The Hospital System, Broadsheet no. 84,, (1936). 79. PRO, EGA Maternity Committee Minutes, Box 122, 11 July 1923 and 30 Jan. 1925. 80. 'Requirements of Maternity Wards', 14 July 1932, Papers of Letitia Fairfield, PH GEN 3/6 and April 1936, PH GEN 3/7. 81. Fairfield to Brander, 7 March 1935, Fairfield Papers, PH GEN 3/7. 82. PRO, MH 55/262, Deputation of the Maternal Mortality Committee to the Ministry of Health, 11 Dec. 1934. 83. 'Lying-In-Hospitals, St. Thomas's and Others', Labour Woman, X (Dec. 1922), pp. 186-7. 84. Dugald Baird, 'Maternal Mortality in Hospital', Lancet, 3 Feb. 1936, pp. 295-8; and Cmd. 5422, p. 285. 85. Jellett, The Cause and Prevention of Mat. Mort. p. 124. 86. LCC, Maternity Services of London (P.S. King, 1936), p. 17. 87. See for example, Alice S. Rossi, 'Broad Perspectives on Parenting', Daedelus, 106 (Spring 1977), pp. 1-31; Ann Oakley, The Medicalized Trap of Motherhood', New Society, 34 (18 Dec. 1975), pp. 639-41; S. Arms, Immaculate Deception: A New Look at Women and Chrldbirth (NY: Bantam, 1977).

5

THE MEDICALISATION OF CHILDBIRTH: DOMICILIARY PRACTICE

The great increase in the number of hospital births was not without effect on the members of the medical profession concerned with the care of the pregnant and parturient woman in the home. In particular, general practitioners feared losing patients to hospitals. Midwifery practice was not overly remunerative, but it was believed to lay the foundation of family practice.' The BMA's own scheme for a national maternity service, published in 1929, stressed that the GP `should always be the bedrock on which the medical services of the country, including midwifery, must be built up'. It also minimised both the need for maternity beds (suggesting that only 3% of women needed hospital deliveries) and the role of the midwife.' Thus the GP's ideal maternity service differed greatly from that of the consultant. GPs feared the hospitalisation of childbirth because very few of them had a chance to follow their cases to hospital. One in five GPs had access to beds in cottage hospitals during the 1930s, but the new maternity units were being located in the larger general and teaching hospitals. One specialist's scheme for the maternity services proposed that obstetrics become a specialty, practiced only in hospital which would thus have excluded the GP altogether. F.J. Browne stated quite categorically that midwifery was incompatible with general practice because of the postgraduate training that he felt was necessary 'and the irregular hours demanded. Ministry of Health reports were readier to recognise the work done by the GP, but they too sounded a warning note: the GP must be well-trained and ready to pass on complicated cases to hospitals.' Early reports of the ministry stressed the need to upgrade the standard of midwifery practice by improving the education of medical students and midwives.4 The low status of midwifery within the medical profession had been accompanied by a low level of training in obstetrics and gynaecology. As a result, not only was childbirth itself often poorly managed, but care of the pregnant woman was also neglected. With the new emphasis on the maternal mortality rate and the quality of maternity services during the inter-war years, more attention was directed towards the poor training received by doctors and midwives. The trend towards making childbirth a medical event 140

Domiciliary Practice

141

tended to favour the doctor as a birth attendant in the home, despite the failings in his obstetrical education. Tensions developed between doctors, midwives and local authorities, who competed both for control of the existing services and for a stake in any new national maternity service that might be set up. In this regard, ante-natal care, which was recognised to be necessary if toxaemic conditions of pregnancy were to be controlled, was a particularly critical new service. Thus, while the attention of a trained, professional attendant became more common, there was little cooperation among, or coordination of, the various agencies involved in providing maternity care. Women's groups deplored the way in which this adversely affected the quality of the services offered and, in 1928, the unofficial Maternal Mortality Committee called on local authorities to organise as complete a service as possible under the provisions of the 1918 Maternal and Child Welfare Act, but both doctors and midwives were suspicious of state intervention. While removal to hospital might either be sought or be decreed during pregnancy or labour itself, most women during the inter-war years made provision for a home birth and this usually involved choosing between the services of a doctor and a midwife. In large part it was a choice dictated by financial considerations. Before World War I, midwives' fees averaged 10s.; Elizabeth Garrett Anderson Hospital midwives still charged this as late as 1928.5 However, fees varied considerably between the regions. In 1917, London midwives would usually charge either 12s. 6d. for first births and IQs. for all subsequent ones, or 15s. for first births, in which case 12s. 6d. was the normal fee thereafter. A very few midwives with midde- and upperclass practices were able to charge as much as two guineas.6 By the 1930s, the usual charge in London was between 25s. and 50s. for first births and 21s. and 40s. for subsequent ones. Fees in London were higher than those charged in the North, where in the 1930s the upper limits of midwives' fees were 35s. for a first birth and between 27s. 6d. and 30s. for subsequent ones. A doctor practising in London in 1917 would normally have charged between 11 and 2 guineas, although this could fall as low as one guinea in the case of the poor. By 1936, this had risen to £3 for first births and £2 for multiparous women, and would usually include the cost of one ante-natal examination.' The position of the midwife had been legally defined in 1902 by the Midwives Act, which set up the Central Midwives Board (CMB). to keep the roll of certified midwives and to oversee practice. A bitter struggle with the doctors had ensued before a place in the maternity services was assured for the midwife by the 1902 Act.6 The attempt of

142 Domiciliary Practice the Ministry of Health's committees to find the `primary avoidable factor' in maternal deaths questioned the standard of practice of both doctors and midwives. This, together with suspicions aroused by plans to reorganise the maternity services, caused old rivalries to surface again. One GP made his views on the responsibility for maternal mortality quite clear in the BMJ: This increased maternal mortality, if it is real — I have no statistical information on the matter — is due to the shortsightedness and stupidity of a body of medical men, who advised the Government of the day when the Midwives Bill was introduced, that it was desirable to establish a licensed body of midwives, a trained body to take the place of untrained and ignorant women who acted in the capacity of nurses but who did nothing — did not attempt to do anything — except wait by the bedside of the labouring woman ...9 Another, writing in the Practitioner a year later, in 1929, felt that the Ministry of Health was biased against doctors and had `an obsession' with midwives, when in fact their practice only deprived the patient of proper medical care `on a par with the best surgical work of the day'.'° Table 5.1: Percentage of Births Attended by Midwives in Urban and Rural Areas, 1918-27

1918 1921-2 1924-5 1927

London 49 47 47 51

County Boroughs 65 67 55 70

Counties n.d. 47 53 61

Source: The annual reports of the Ministry of Health.

The percentage of births attended by midwives had risen during World War I due to the shortage of doctors and continued to show a general pattern of increase between 1918 and 1927, particularly in rural districts (see Table 5.1). In Wales, over 90% of births were attended by midwives throughout the 1920s and 1930s. The record of the QVJI nurses showed that the work of midwives could be excellent. In Wales, however, maternal mortality was 35% in excess of that for England between 1924 and 1933." While intervening variables, such as low nutrition levels and lack of any maternity services in many rural areas,

143

Domiciliary Practice

would have explained a large part of this difference, midwives were still open to criticism because so many `bona fides' (untrained women) were practising, and because the training period for certified midwives was so short. Before World War I, the number of trained midwives varied widely from area to area and was generally small, especially in rural areas and smaller county boroughs. However by the 1930s almost all practising urban midwives were trained (see Table 5.2). In 1908, the Medical Officer of Health for Hull reported that 73% of midwives practised without antiseptics and 12% conformed to the 'Sail)/ Gamp' image of practising while drunk. In 1911, the rules laid down by the CMB made the taking of temperatures and pulses compulsory and the same MOH reported that it was `laborious' work to instruct the untrained midwives how to use a thermometer.'Z However, the example of Mrs Layton, a Women's Cooperative Guild member who played an active part in the guild's maternity campaign, serves to show that not all bona fides were illiterate.L3 Many were undoubtedly skilled practitioners, lacking only the formal knowledge necessary to pass the certificate examination. Mrs Layton failed the examination despite her long practical experience and undoubted skill. In a textbook written for bona fides wishing to become certified midwives, Margery Loane concentrated on explaining medical terms and on providing their Greek derivations, which gives, perhaps, an indication of the degree and nature of the theoretical knowledge demanded by the examiners.1° Table 5.2: Percentage of Trained Midwives in Three Cities, 1911-35

Birmingham* Hull Liverpool

1911 nd 30 88

1915 31.5 43 86

1920 53.3 38.9 100

1925 76.4 83 100

1930 90 91 100

1935 97.6 96 100

*St Pancras is not included here because the local supervising authority for midwives in London was the LCC. Source: The annual reports of the Medical Officers of Health for Birmingham, Liverpool and Hull.

Protection against the more dubious practices of the untrained midwife was in any case largely guaranteed by the rules governing midwifery practice laid down by the CMB. These were almost humiliatingly strict from the point-of-view of the educated, trained midwife and, in 1918, the Midwives Institute complained about the `over-legislation' of

144 Domiciliary Practice midwifery by the board.15 Section E of the rules specified the clothing and equipment required of the midwife and laid down strict rules on disinfecting procedures after contact with cases of sepsis. Some local supervising authorities even required that disinfection take place at a public disinfecting station. All midwives were also subject to inspection at any time. The Midwives Committee of the LCC, which supervised all London midwives, kept a careful check on midwifery practice. It reported every month on the cases of opthalmia neonatorum occurring in babies delivered by midwives, the number of cases of sepsis amongst mothers and the nature of charges brought against midwives.16 The CMB ruled in cases where charges were brought against midwives under the rules. These could be petty as for example when in 1911 a midwife was cautioned at a penal session of the CMB for sending a note to a doctor rather than the appropriate form." However the number of penal cases tried by the CMB declined sharply from 103 in 1910, to 65 in 1920 and 37 in 1930, reflecting the improvement in midwives' standards of practice. In 1902, the training period for midwives was set at only three months for fear of creating a shortage. The length of training was extended three times between 1902 and 1937: to six months for the untrained and three months for trained nurses in 1916, to twelve months for the untrained and six months for nurses in 1924, and to twenty-four months and twelve months respectively in 1937. Training could be given by a recognised practising midwife, a district nursing association, an approved nursing home, a poor law institution, or hospital and the standard of instruction varied widely.l8 Most members of the medical profession, the Maternal Mortality Committee and trained midwives themselves felt a longer period of training to be advisable. Only GPs raised some objection, because they feared that midwives would take up too much valuable teaching material in the teaching hospitals.19 Trained midwives felt that a longer period of training would increase their professional standing. Alice Gregory began pressing for an extension of the training given midwives in 1913, believing that it would be possible to popularise the work among `a superior class of women' if the training was longer and inspection more rigorous.20 The Midwives Institute agreed with this view and also felt that only with more training could the midwife be more self-reliant and undertake work in the rapidly expanding field of ante-natal care, where many medical officers of health complained that their work was inadequate.21 Certainly, the extension of midwifery training did attract a new type

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of woman to the profession. In 1911,83% of all midwives were either married or widowed and 70% were aged over 45 years. The comparable figures for all occupied females were 23% and 17%. By 1931, this picture had changed considerably, 52% were married or widowed and 48% over 45, when the comparable percentages for all females in the work force had remained almost the same at 21% and 18%.22 The midwife was ceasing to be an older local resident and was becoming a younger, probably middle-class professional. The Women's Cooperative Guild had recognised the possibility that a longer period of training might close the occupation to working-class women when it campaigned for grants for midwifery training, and Janet Campbell at the Ministry of Health had also feared a dearth in applications for training from the `homely' woman, popular amongst mothers.23 The Local Government Board did provide grants for pupil midwives in 1919 (despite objections from the BMA, who felt this was unfair to medical students),24 but this did not stop midwifery from becoming, like nursing, a middle-class preserve. The crucial question with regard to midwifery training was what the midwives were to be taught. Should they be given access to the latest knowledge, for example, in the field of ante-natal care? Here the decisive factor was the way in which the roles of midwife and doctor were to be defined. Midwives were well-placed to play a central role in the maternity service and to introduce the new practice of ante-natal care to women. Compared to other health officials, the midwife was trusted and respected, especially by working-class women.25 However, the maternity scheme favoured by the BMA threatened to relegate the midwife to the status of maternity nurse, because, while she was given the right to conduct normal confinements, the BMA felt that the GP should give all ante-natal care and make the decision as to whether the case would be handled by the midwife.26 Midwives also feared that the Ministry of Health reports did not make the midwife's role clear enough, and that this lent support to the doctor's position.27 In the case of ante-natal care, on the one hand, complaints were made that the form provided by the CMB for the midwife to record the results of antenatal examinations was too complicated for them to use because of their inadequate training, and, on the other, the Maternal and Child Welfare Committee of the BMA feared that any further training of midwives in ante-natal care would take away the interest of GPs in midwifery.28 Another much-debated question was whether midwives should be allowed to administer analgaesia and anathaesia in the home. Public demand for these was strong, but there were dangers attached to many

146 Domiciliary Practice of the methods used. Twilight sleep was a good example. This was approved for use in hospitals in 191929 and Marie Stopes was among the first to use the drug after receiving assurance from the Twilight Sleep Nursing Home Ltd that there was no danger to the child. But, for whatever reason, her baby died.30 Midwives were particularly anxious to be allowed to use chloroform capsules as an analgaesic in domiciliary practice. The National Birthday Trust gave them enthusiastic support, but in 1936, a report by the British College of Obstetricians and Gynaecologists recommended that the capsules were unsuitable for use in the home. The evidence adduced by the College was not very satisfactory. Out of a total of 2,380 cases where the capsules were tried, only one death occurred and that in the practice of a medical student.31 The College did allow that midwives could use gas and air as an analgaesic if they had received special training and if one other trained person were present. But the cost of the apparatus required to administer gas and air made it impossible for most independent midwives to purchase it. The Midwives Institute described the report as `deeply disappointing'.32 As late as 1939, only 1,029 women (approximately 0.5%) giving birth at home with midwives in attendance received analgaesia. Even then the BMA objected to the right of midwives to give gas and air. During the course of a discussion at the 1939 Annual Conference of the BMA, Louise Mcllroy, an obstetrician, spoke in favour of the midwives in this regard, giving the justification that not all women could have doctors to attend them. According to a report by Lady Rhys-Williams, this was greeted by shouts from the floor of `why not?'.33 The dangers of either chloroform or gas and air were subsidiary to the basic issue of who was to control midwifery practice. The BMA insisted that each and every doctor had the right to practise midwifery if he so desired. It was therefore also forced to insist that all doctors were competent. Yet in 1928 the BMA opposed an investigation of maternal deaths on the grounds that such action was `precipitate', presumably because it feared that the results of the investigations would reflect badly on the practice of many GPs.34 However, the Midwives Institute welcomed the move. The BMA also opposed the ministry's plans to set up a pool of specially qualified doctors in each area who would volunteer to answer midwives' calls, insisting that all doctors had the right to volunteer to serve, regardless of qualifications.3s Yet the poverty of the ordinary GP's education in midwifery was one of the earliest points to be taken up by both specialists and government committees. Jellett believed that: `it is in part the want of proper

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obstetrical education that is leading to the belief that women in normal confinements are safer under the care of midwives'.36 Comyns Berkley pointed out that midwifery had always been considered a specialty (albeit a lowly one) and hence standards of training for GPs had tended to be ignored,37 despite the fact that midwifery had been a compulsory part of the qualifying exams since 1886. Moreover, very few obstetricians had ever been members of the General Medical Council, which laid down the examination rules for medical students. In a discussion at the Obstetrics and Gynaecology Section of the Royal Society of Medicine, it was admitted that midwifery was frequently taught by junior registrars and recently qualified house surgeons with little attention given to practical work, the reason given being that there were few maternity beds available to provide teaching materia1.38 In 1896, the General Medical Council laid down that a student had to spend three months in attendance on the wards of a lying-in hospital or conduct twenty labours on the district, five of which were to be supervised, in order to complete his midwifery training. This was amended in 1906 to ensure that a student received adequate practical instruction in the management of labour before actually delivering any of his twenty cases. This was a necessary precaution if Eardley Holland's description of his early experience as a medical student in Glasgow, delivering babies armed with `a few tips' from the Resident House Accoucheur and a small obstetrics textbook, was at all common.39 The BMJ, however, felt these amendments to be impractical, especially in London where maternity beds in teaching hospitals were in short-supply and where it was feared that such a requirement might drive students to other schools where teaching material was more readily available.40 In 1923, the General Medical Council further stipulated that two full terms had to be devoted to midwifery instruction and that the student was to be supervised in five deliveries before proceeding to the remaining fifteen. But when Campbell investigated the education of medical students in midwifery in 1923, she found that the student was rarely supervised before going out onto the district for in many cases he did not actually deliver the hospital cases but merely watched:" Sir Dugald Baird recalled that in the Glasgow Hospital between 1925 and 1929, few medical students were ever seen on the wards or in the ante-natal clinics.42 (The General Medical Council did not specify that students should receive instruction in ante-natal care until 1930.) The recollections of the Obstetric Assistant at University College Hospital during the 1920s are also revealing:

148 Domiciliary Practice In the twenties there was NO teaching in labour apart from a routine medical school lecture. The plan was for the new List [of obstetrics students] to go out with someone of the previous month's list to see a baby born; they were then supposed to know all about it ... Fortunately perhaps the baby was a BBA [born before arrival] . I tied the cord and gave the baby to the 'handywoman'. Then I tried to express the placenta, but was so ignorant I did not know that I had to turn the patient on her back, delivery having been on the side ... That was in June 1922.43 Many hospitals, UCH included, refused to allow a medical student to be accompanied on the district by a trained midwife for fear that she would diminish his sense of responsibility.44 Neither the work nor the equipment of medical students attending cases on the district was subject to supervision. A retired health visitor who had been attached to the Infant Welfare Department of UCH, recalled that the maternity bags of the students were kept by the door in the Casualty Department, were rarely checked and hence usually dirty. Not until F.J. Browne became Professor of Obstetrics in 1926 did the training at UCH begin to conform with the minimum regulations laid down in 1923. The attitudes towards obstetrics revealed by this evidence make it difficult to believe the assertion of Munro Kerr, an obstetrician, that the battle to implement the General Medical Council's regulations was merely a question of increasing the number of maternity beds to provide teaching material.4S Despite the failings of the GP's training in obstetrics, it was still generally felt that because of his greater medical knowledge he, rather than the midwife, was the better attendant in childbirth. The 1930 report of the Committee on Maternal Mortality and Morbidity accepted the central role assigned the GP by the BMA in its plans for the maternity services and this, in turn, became part of the government's abortive scheme for a national maternity service.' The emphasis placed on the need for medical attendance in childbirth led to a more closely defined hierarchical relationship between doctor and midwife. One of the main measures of a good midwife became the number of times she proved herself capable of recognising the gravity of a situation by calling in a doctor. Reports of the Ministry of Health and medical officers of health both made the increase in calls for assistance a cause for congratulation. Thus the more highly-trained midwife tended to be more dependent than self-reliant. In Hull, Birmingham, Liverpool and London the rise in the percentage of midwives cases requiring medical aid

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Domiciliary Practice showed remarkable consistency (see Table 5.3).

Table 5.3: Percentage of Midwives' Cases Resulting in Calls for Medical Aid, 1911-35

Birmingham Liverpool Hull London

1911 nd 6.2 8.5 11.5

1920 10.5 13.7 12.4 12.6

1925 19.0 17.7 22.7 17.1

1930 35.7 29.7 28.4 22.5

1935 34.7 30.1 33.6 28.4

Source: The annual reports of the Medical Officers of Health for Birmingham, Liverpool, Hull and St Pancras. The 1918 Midwives Act defined more closely the circumstances by which the midwife was obliged to call in a doctor and provided for his payment by the local authority concerned; the reason being that women who had booked with a midwife were usually unable to afford a doctor's fee as well. Before 1918, midwives often had considerable difficulty in persuading doctors to attend, even in emergencies, because they were reluctant to be connected with a possible case of puerperal sepsis, especially when a fee could not be guaranteed.47 In many cities, midwives formed themselves into an association whereby each paid Is, to cover the cost of a fee should a doctor have to be called. Where no such scheme operated, it was not uncommon for three or four doctors to be contacted before one could be persuaded to attend.4s When the local authorities started to pay doctor's fees, they often paid more if either instruments had to be used or an anaesthetic be given. It is possible that this encouraged intervention in labour. Cases of extensive perineal laceration or haemorrhage required a doctor's attention, but certain ironies attached to the precedence accorded the GP in midwifery because of his superior medical training. For example, the GP was much more likely to use forceps both in emergencies and in the course of his regular practice. A speaker at the National Conference on Infant Welfare of 1919 pointed out that midwives working in the home had more patience with the physiological process of birth and tended to interfere less frequently than doctors. (The rules laid down by the Central Midwives Board prevented the midwife from using instruments.)49 In 1933, the Chief Medical Officer of the Ministry of Health estimated that GPs used forceps in 60% of all their cases.S° The error most commonly attributed to the midwifery practice of doctors was that of `failed forceps'. In these cases, forceps

150 Domiciliary Practice were applied before the cervix was fully dilated, resulting in gross lacerations of the cervix, vagina or perineum, which were often followed by sepsis. When, in 1916, there was an unexpected fall in infant mortality within twenty-four hours of birth, the annual report of the Registrar General speculated that it was probably due to the small numbers of doctors available for general practice and the consequent fall in the number of forceps deliveries.s' Because doctors did not have the time to sit with a midwifery case for long periods of time, they tended, in their regular practice, to work with untrained `handywomen', who watched the patient and called the doctor at the moment they considered appropriate. Thus doctors' midwifery practice often combined the most sophisticated medical attendance with the attentions of the untrained 'gamp', which the Midwives Act of 1902 had been designed to eradicate. The 1902 Act had made it illegal for an uncertified midwife to practice `habitually and for gain', but it was found difficult to prove that known `handywomen' did this and few prosecutions succeeded before the phrase was removed from the Act in 1926.52 In 1916, the General Medical Council warned GPs by letter that to work with a handywoman was to be in contravention of the 1902 Act. Public pressure to stop the GP encouraging the work of handywomen also came from the unofficial Maternal Mortality Committee and the National Union of Societies for Equal Citizenship, a feminist organisation. Yet, as late as 1929, the report on the Training and Employment of Midwives admitted that `the attempts which have been made by law to put an end to this abuse have largely failed in their object'.53 These women also acted as layers-out of the dead, which proved one of their main sources of danger to the parturient woman. From the working woman's point-of-view, though, the handywoman was, above all, inexpensive. When, in 1921, a Mrs Robinson was charged in Hull with practising midwifery illegally, the woman who had hired her pleaded that she had done so only `for cheapness'; Mrs Robinson's services cost 10s.54 In London, as late as 1934, a handywoman could still be hired for as little as 15s., and the cheaper the nurse, the more she did. Handywomen nursed the mother and washed the baby as well as doing more domestic chores than did the trained home-helps.55 Because of their lack of training, most GPs were no better prepared to give ante-natal care than midwives. One GP wrote to the Lancet recalling how in 1921 he began practising in the East End `brimfull of ante-natalism', but in the face of his colleagues' apathy his enthusiasm evaporated. By 1929, practice in the East End had improved, but he then moved to Worcester where attitudes were on a par with those of

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the East End doctors in 1921.56 This vital gap in the maternity services was filled by the local authorities. An LGB circular issued in 1914, provided details of a complete maternal and child welfare scheme, including provision for ante-natal care to be given at the centres set up to do infant welfare work. The circular took many LAs by surprise. In Hull, the medical officer of health wrote a memorandum for the health committee on the circular in which he was obliged to explain the term ante-natal care.57 Nevertheless, many LAs took steps to start ante-natal clinics and this trend was accelerated by the passing of the Maternal and Child Welfare Act of 1918. The direct involvement of LAs in the maternity services evoked the antagonism of all private practitioners. That the patient should be allowed free choice of a medical attendant was as important to independent midwives as to GPs.58 Both feared the competition emanating from clinics, especially in the field of ante-natal care, and any attempt by the LAs to organise the midwifery services. Midwives were suspicious of clinics because they feared losing their patients if they referred them there for ante-natal care. Two examples illustrating this were given by a sympathetic consultant speaking at the National Conference on Infant Welfare in 1919. In one instance a midwife had sent her patient to a clinic for a dental examination, and the woman was surprised and shocked when she received a full medical examination. Blaming the midwife, she told her that her services would no longer be required. In the second case, the clinic referred the patient to a hospital without consulting the midwife who lost her patient and her fee.59 In 1918, Nursing Notes advised midwives that they were not obliged to cooperate with LA clinics if they disliked their practices. Suspicions were not laid to rest until, in 1936, under the pressure of a declining birth rate, increasing competition from hospitals, low fees and bad debts, independent midwives acceded to a salaried midwifery service controlled by the LAs.6° GPs also opposed state-run, ante-natal clinics on the grounds that they would threaten their fees, just as they had opposed middle-class babies' clubs. Comyns Berkley felt that clinics would alter the status of the profession and the relationship between doctor and patient to the detriment of both.61 The BMA and the Socialist Medical Association considered that all ante-natal care should be put in the hands of the GP. The BMA statement read: `The Association is firmly of the opinion that the usual routine work done at these centres can be done quite as well at the consulting room of the doctor or in the home of the patient.'62 The BMA would have made the LA clinics into centres for consultations with specialists and education in mothercraft. Yet, as

152 Domiciliary Practice Arthur Newsholme pointed out, GPs had no real grounds on which to object to LA intervention, which had only begun because of the reluctance of the doctor to do such routine, time-consuming and poorly-paid work.' The unofficial Maternal Mortality Committee and Labour women demanded that LAs make their services as extensive as the 1918 Act permitted, in the hope not only that maternity services would then become available to more women but also that their coordination would improve." Labour women, in particular, favoured the establishment of clinics. The Women's Cooperative Guild worked hard during the 1920s to gain representation on the maternal and child welfare committees of LAs and in Willesden, for example, guild members gave strong support to the authority when its maternity scheme encountered opposition from local GPs, backed by the BMA.bs When the Trades Union Congress (TUC) and the BMA launched a joint scheme for a `General Medical Service for the Nation' (in which maternity care was included), it favoured the BMA's preference for making the GP central to the maternity services and found no place for the work of the LA clinics. No women trade-unionists were represented on the committee and the seven TUC members included three GPs. When the scheme was presented to the Annual Conference of the TUC in 1938, women attacked it strongly, seeking reassurance on the future of the clinics.66 The government accepted the BMA's idea of the doctor's role in antenatal care and it was only when its scheme for a national maternity service was abandoned in 1931, in favour of a less costly expansion of LA clinics, that the place of these was secured. The number of LA antenatal clinics rose from 995 in 1931 to 1,307 in 1937 and the percentage of women attending from 33% to 54%. Only in rural areas, where clinics were few and far between, did LAs often make arrangements with local GPs to give ante-natal examinations for a fee paid by the LA.67 After 1930, the government concentrated its attention on LAs and circularised them regularly to ascertain what improvements they intended to make in their services. But, because the maternal and child welfare service provided by the LAs under the Act of 1918 was permissive, much depended on the personality of the medical officer of health, who had to be both interested in the subject and willing to approach the public health committee with his ideas. The efforts of Dr Andrew Topping at Rochdale are a good example. When Topping arrived in Rochdale in 1930, the town had had the highest maternal mortality rate in England for seven consecutive years. By going through the case records of all the maternal deaths he discovered that the

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majority of women had received no ante-natal care and that there had been a lot of unnecessary interference in labour by doctors. Armed with this information, he approached the BMA, the health authority and women's organisations and secured their cooperation first to publicise the problem and then to rectify errors in maternity practice and fill gaps in the services. As a result, maternal mortality in Rochdale dropped from 9 per 1,000 between 1928 and 1931, to 1.76 per 1,000 in 1932. Topping stressed: `There is actually nothing in the Rochdale scheme except a good cooperation between the doctor, the midwife, the health department and the local authority.'68 The cost of the scheme was minimal. Many LAs however feared that good maternal and child welfare services would prove costly and were reluctant to increase their efforts in this regard. Local authorities seem to have believed that a better service meant a more professional, more medicalised service, an impression easily obtained from the kind of services advocated by consultants. It is interesting, too, that the Royal Commission on National Health Insurance, which reported in 1926, put the need for consultant specialist services ahead of insurance coverage for dependants in its recommendations on maternity.69 Thus when the ministry wanted to set up panels of qualified GPs to do midwifery in the late 1930s, county councils in particular were unwilling to cooperate, because they feared that this would be followed by a demand for other `more elaborate' services.70 Similar fears might have deterred LAs from replying to the ministry's circulars requesting information on the steps they intended to take to improve their maternal and child welfare services. Only one quarter of maternal and child welfare authorities replied with positive proposals, most of which involved providing more hospital beds, more consultants and more maternity centres; all of which were too expensive for smaller and poorer LAs. None stated any intention of trying to ensure the kind of cooperation won in Rochdale.'( Indeed the retrenchment of the early 1930s made it difficult for LAs even to maintain the level of services. While the government publicly urged them to do more, in private it recognised their problems. The Prime Minister minuted the Minister of Health's memo on the abandonment of a national maternity service thus: Could we go on laying the foundations [of a national maternity scheme] at a much smaller cost to the Exchquer? I know that feeling amongst women of all classes and parties is very strong. It is a natural

154 Domiciliary Practice instinct which will be hard to come up against. If we have to face the worst I am willing, but note that what we propose is to add to local charges without bearing any (however slight) national obligation.72 In public the Ministry of Health sounded optimistic about the progress of LAs in providing more comprehensive maternity services, but, in 1932, Newman admitted to the minister that in many areas there had been `retrogression'.73 In view of the lack of training doctors received, the shortage of money and minimal coordination of services in many areas, it is not surprising that the quality of ante-natal care was often poor. The reports of medical officers of health and the Ministry of Health recorded only the number of ante-natal sessions given and the percentage of women attending. It is quite possible that some women only attended once or twice. In fact many LAs interpreted the Ministry of Health's advice that each woman should attend an ante-natal clinic at least twice as the maximum. One member of the Medical Women's Federation complained that it was impossible for her to give proper ante-natal supervision to women when the LA would only pay for two visits.?4 In a study of Birmingham's antenatal statistics for 1932, Ethel Cassie, the Assistant MOH, deduced the average number of attendances per mother to be three, but that, in fact, many attended only once and some between five and eight times. In 1933, the Chief Medical Officer of the Ministry of Health recommended that women attend an ante-natal clinic seven times and condemned much of the care offered by LAs as `perfunctory, unskilled or incomplete'.75 Many ante-natal examinations merely ascertained the expected date of the birth and the position of the foetus, while blood pressure and urine tests, both vital if toxaemic conditions were to be recognised and treated, were often ignored and dental work not insisted upon. Some doctors and medical officers saw ante-natal work only as an extension of infant welfare work and a means of educating the mother in mothercraft, a point severely criticised by the unofficial Maternal Mortality Committee '6 The whole idea of ante-natal care was very new and it is easy to be misled by the large amount of material in medical journals and in London local government records for the 1930s, because research findings emanating from teaching hospitals circulated rapidly in the capital. Harold Scurfield, MOH for Sheffield, reported in the Lancet that there was virtually no ante-natal care given outside London in 1924.77 The The MOH in Hull admitted that there was none given there in 1922, and in 1929 it was still described by the outgoing MOH as totally

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inadequate.78 Only recently trained doctors could be expected to have grasped the importance and nature of ante-natal procedures. In both Florence Daniel's down-to-earth manual for pregnant women and Aleck Bourne's text for medical students, it was intimated that only the most modern doctors would give ante-natal examinations.79 None of the women interviewed received any ante-natal care. The typical response was: `They didn't do things like that then.' Even women who took their babies to the clinics never went on their own account. The death rate due to toxaemic conditions of pregnancy increased slightly during the 1930s. Many recognised that this was probably due to the inadequate ante-natal care received by most women, but others responded by either questioning the value of ante-natal services or by blaming women themselves for not attending clinics. Some specialists felt that too much was claimed for ante-natal work and doubted that eclampsia was preventable.ß0 Putting the blame on women for not taking full advantage of the services offered, was a more defensive reaction on the part of LAs and obstetricians. Comyns Berkley felt that the lack of improvement in the toxaemia death rate.could only be explained by women's carelessness.81 In 1932, the Medical Officer of Health for Liverpool claimed that of the women not receiving ante-natal care, 62% had only themselves to blame.82 No explanation as to how this figure was reached was offered. Some LAs wanted to make pregnancy notifiable (a procedure followed in cases of highly infectious disease) so that ante-natal care could automatically follow. S.G. Moore advocated this, and Huddersfield instituted a voluntary scheme of notification. By 1936, 80% of pregnant women in Huddersfield notified the fact. Both women's groups and midwives reacted strongly against notification of pregnancy, which they regarded as `snooping' on the part of the health authorities.83 They gave more support to the argument that mothers must be educated to use ante-natal care facilities. In his address to the Maternal Mortality Committee in 1930, Arthur Greenwood emphasised this and the succeeding Minister of Health, Hilton Young, did likewise in his address to the committee in 1932.84 Ministry of Health reports also stressed the need to educate women as to the value of ante-natal care. Henry Jellett commented in his text on maternal mortality: `The ignorance of the average woman regarding the ordinary essentials of pregnancy is marvellous.'85 This was probably true because secretiveness regarding pregnancy had long been encouraged as part of the modest behaviour expected of women. In 1922, an article in the Lancet noted the need to overcome women's `natural repugnance' to internal medical examinations

156 Domiciliary Practice and, in 1928, Nursing Notes spoke of the need for the sympathetic treatment of women when such examinations were given by male doctors.' Labour women complained about the lack of women doctors available for ante-natal work and also about the long waits women had to endure, often with their other small children, at clinics.$' Women's groups were exhorted by health officials and consultants to do `missionary work' in spreading the ante-natal gospel, but there was little attention paid to those aspects of the service which might have deterred women from attending ante-natal clinics. When a disregard for women's sensibilities occurs today it is referred to as a neglect of the psychological aspects of pregnancy and childbirth. In the course of a recent debate as to why women in England are still not attending ante-natal clinics as often as health officials would like, one woman wrote: `Attending an ante-natal clinic is the most inhuman process I have ever been through.'" Since the 1930s, women's complaints about the deleterious psychological effect of medicalised childbirth have increased and complaints about the neglect of other physical causes of difficulty during pregnancy and childbirth, such as poor housing, have decreased with improving living standards. However, both are aspects of the same problem: the failure to see the reproductive process as an integral part of women's lives and the tendency to define it as a series of medical problems. The departmental committees that concentrated on investigating the clinical causes of maternal deaths embraced the medicalisation of childbirth as the best way of reducing the maternal mortality rate. Ideally, they felt that a much larger number of births should take place in hospital. The care provided for women giving birth at home would be improved by raising the standard of obstetrical education for doctors and midwives. This was sorely needed and the changes made in the curricula of pupil midwives and medical students during the period undoubtedly benefited parturient women. However, doctors and midwives felt that medicalisation questioned their competence and threatened eventually to put an end to their practice. The inter-war period saw a rapid advance in the number of hospital births, which led to competition between midwives and doctors, who felt both the need to defend their work and to secure their respective professional interests in the midwifery services. This, together with the conflict between private and state medicine, affected the quality of the services offered. The desire to make parturition a purely medical event created a preference for the doctor as a childbirth attendant, despite his often limited obstetrical education. In so far as the doctor, like the hospital,

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was more likely to intervene in labour than the midwife, this did not help to ensure safe childbirth. Medicalised childbirth was understood by obstetricians, doctors, midwives and local authorities to mean more technical and expensive, rather than more careful, management of parturient women. The tendency was to make childbirth the province of highly trained professionals. But this did not always meet the needs of the pregnant woman, especially if she was working class and experiencing a normal birth. The social distance between the doctor or middle-class professional midwife and the working-class mother was great, and many working-class women missed the more homely attentions of the handywoman. Women's groups, such as the unofficial Maternal Mortality Committee and the Women's Cooperative Guild, pressed hard for more maternity beds and more doctors to attend women at home, because they understood these to be the best forms of care. But they also attached great importance to the provision of non-medical services, such as home-helps, who would compensate for the prohibition put on the handywoman's services. This indicated their realisation that pregnancy and parturition could not be separated from the fabric of women's lives, which in a majority of cases involved caring for home and family, and that a perfect medical service alone would not necessarily result in perfect reproductive efficiency.

Notes 1.See, for example, James A. Longworth, The New Maternity Services from the Point of View of the GP', Jr. Roy. Instit. Pub. Health, 2 (April 1939), pp. 245-9. 2. 'A National Maternity Service', BMJ, Supplement, 29 June 1929, p. 259. 3. R.W. Johnstone, 'The Preventive Frame of Mind in Midwifery', BMJ, 7 Jan. 1928, pp. 6-9; F.J. Browne, 'Team Work and Post-Natal Care', Mother and Child, 5 (Dec. 1934), p. 343; and Ministry of Health, Final Report of the Dept. Cttee. on Maternal Mortality and Morbidity (HMSO, 1932), p. 37. 4. Janet Campbell, Maternal Mortality, Reports on Public Health and Medical Subjects, no. 25 (HMSO, 1924), p. 69; and Janet Campbell, The Protection of Motherhood, Reports on Public Health and Medical Subjects, no. 48 (HMSO, 1927), pp. 38 and 45. 5. Nursing Notes, 26 (April 1913), p. 100; and PRO, EGA Maternity Cttee Minutes, Box 122, 1 June 1928. 6. Janet Lane-Claypon, Report on the Provision of Midwifery Service in the City of London, Reports to the LGB on Public Health and Medical Subjects, no. 111 (HMSO, 1917), p. 31. 7. LCC, Maternity Services in London (P.S. King, 1936), pp. 4-5; Midwives Institute, The Midwife in Independent Practice Today (The Institute, 1936), p. 21; and Lane-Claypon, Rep. on the Provision of Midwifery Service in London, p. 27. 8. See, Jean Donnison, Midwives and Medical Men (Heinemann, 1977).

158 Domiciliary Practice 9. BMJ, 30 June 1928, pp. 1126-7, letter from David Roxburgh. 10. A.Z.C. Cressy, The Practice of Midwifery: An Expression of Opinion after 40 years of General Practice', Practitioner, 122 (Feb. 1929), pp. 126-9. 11. PP, 'Report on Maternal Mortality in Wales', 1936-7, Cmd. 5423, XI, 367, p. 114. 12. Annual Report of the MOH for Hull, 1908, p. 49; and Annual Report of the MOH for Hull, 1912, p. 72. Sairy Gamp was a character in Charles Dickens' novel, Martin Chuzzlewit (Thomas Nelson, 1913). 13. Mrs Layton, 'Memories of Seventy Years' in Life as We Have Known It, edited by Margaret Llewellyn Davies (Hogarth Press, 1931; reprint edn, Virago, 1977), pp. 1-55. 14. M. Loane, Simple Introductory Lessons in Midwifery (Scientific Press, 1906). 15. Nursing Notes, XXXI (April 1918), p. 49. 16. Papers Presented to the Midwives Act Committee, 1918-34, GLC Archives. 17. Nursing Notes, XXIV (Dec. 1911), p. 294. 18. M. Olive Haydon, The Teaching of Practical Midwifery', National Health, 10 (May 1918), pp. 319-21, and Janet Campbell, The Training of Midwives, Reports on Public Health and Medical Subjects, no. 21 (HMSO, 1923), p. 27. 19. The Teaching of Midwifery', BMJ, 8 June 1906, p. 1378, leader; and Report of the Departmental Cttee. on the Training and Empl. of Midwives, p. 24. 20. Alice Gregory, The Necessity of Improving the Training of Midwives and Its Bearing upon Infant Life', Report of the International Conference on Infant Mortality, 1913. See also, PRO, MH 55/518, Alice Gregory's midwifery scheme submitted in 1917 to the Subsidiary Committee on Health and Kindred Services for Women. 21. Nursing Notes, XXXVII (July 1924), p. 96, and (Nov. 1924), p. 150. 22. Census of England and Wales for 1911, Occupation Tables, Table 4, p. 101 and Census of England and Wales for 1931, Occupation Tables, Table 5, p. 39. 23. Margaret Bondfield, The National Care of Maternity (WCG, 1914), p. 122; WCG, The National Care of Maternity (WCG, 1917), p. 3; and Campbell, The Training of Midwives, pp. 4 and 18. 24. The Midwives Act Amendment Bill and the Incorporation of the Midwives Institute', Lancet, 18 June 1910, p. 1699, leader. 25. Sheila Kitzinger, 'Women's Experiences of Birth at Home' in The Place of Birth, edited by Sheila Kitzinger and John A. Davis (Oxford UP, 1978), pp. 146-8, shows that these feelings about midwives still prevail today. 26. 'A National Maternity Service', BMJ, Supplement, 29 June 1929, p. 259 and Nursing Notes, XLII (Nov. 1929), p. 153. 27. Nursing Notes, XLIII (Oct. 1930), p. 137 and (Nov. 1930), p. 153; and XLIV (April 1931), p. 18. 28. Minutes of the Meetings of the Council of Medical Women's Federation vol. II, 11 and 12 May 1928, and 26 Oct. 1928, Archives of the MWF; and BMJ, 17 March 1928, pp. 466-7, letter from Louise Mcllroy. 29. PP, '48th Annual Report of the LGB for 1918-19. Supplement Containing the Report of the Medical Officer', 1919, Cmd. 462, XXIV, 572, p. 119. 30. British Museum, Stopes Papers, Add. MS. 58568, E. Barlow Brown to Stopes, 15 April 1919. 31. PRO, MH 55/625, British College of Obstetricians and Gynaecologists Investigation into the Use of Analgaesics Suitable for Administration by Midwives, 1936. 32. Nursing Notes, XLIX (March 1934), p. 33. 33. Report on 1939 BMA Conference, TS, Rhys-Williams Papers.

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34. PRO, MH 55/266, A. Robinson to the minister on the subject of his correspondence with Alfred Cox, of the BMA, 2 April 1928. 35. PRO, MH 55/682, G.C. Anderson (of the BMA) to A.B. Maclachlan, 3 May 1937. 36. Henry Jellett, The Causes and Prevention of Maternal Mortality (J. & A. Churchill, 1929), p. 85. 37. Comyns Berkley, The Teaching of Midwifery (Manchester: Sheratt and Hughes, 1930), GLC Archives, PH/PHS/2/10. See also, Comyns Berkley, 'Save the Mothers and Children', BMJ, 2 Jan. 1926, pp. 4-8. 38. Proc. of the Roy. Soc. of Med., 12 (1919), Pt III, pp. 56-9. 39. Quoted by Sir Dugald Baird, 'The Evolution of Modern Obstetrics', Lancet, 10 Sept. 1960, pp. 557-64. 40. 'The Teaching of Midwifery', BMJ, 8 June 1906, pp. 1378-9, leader. 41. Janet Campbell, Notes on the Arrangements for Teaching Obstetrics and Gynaecology in the Medical Schools, Reports on Public Health and Medical Subjects, no. 15 (HMSO, 1923), p. 46. 42. Baird, 'Evolution of Modern Obstetrics', p. 557. 43. The experiences of Norman White quoted in W.R. Merrington, UCH and Its Medical School: A History (Heinemann, 1976), pp. 148-9. 44. LCC, Maternity Service of London, p. 7. 45. J.M. Munro Kerr, et. el., A Combined Textbook of Obstetrics and Gynaecology (Edinburgh: E. & S. Livingstone, 1923), p. 302. 46. PRO, CAB 24/214 CP 300 (30), memo on Maternal Mortality by the Minister of Health (Arthur Greenwood), 10 Sept. 1930. 47. Nursing Notes, XXIV (Nov. 1911), p. 267, quoted the case of GPs in Enfield who demanded that the midwives guarantee a fee of 11/2 guineas before they would come. See also, Carnegie UK Trust, The Physical Welfare of Mothers and Young Children, vol. II (The Trust, 1917), p. 60. Annual Report of the MOH for Birmingham, 1916, Appendix on Maternal and Child Welfare, p. 5, stated the reluctance of doctors to attend emergency cases for fear of puerperal fever. 48. Nursing Notes, XXIV (Dec. 1911), p. 299, reported a Leicester case of haemorrhage where the first doctor called refused to attend; XXV (Nov. 1912), p. 298, reported a case where a midwife waited 18 hours before a doctor arrived; XXVI (Dec. 1913), p. 337, reported a Cheshunt case where three doctors refused to attend. 49. Olive Haydon, 'The Work of the Midwife in relation to Ante- and NeoNatal Mortality', National Conference on Infant Welfare Report, 1919 (National League for Health, Maternity and Child Welfare, 1919), p. 68. 50. Ministry of Health, Report of the Chief Medical Officer for 1933 (HMSO, 1934), p. 261. 51. PP, '79th Annual Report of the Registrar General for 1916', 1917-18, VI, 1, p. xxxiv. 52. PP, 'Annual Report of the Work of the Central Midwives Board for 1914', 1914-16, Cd. 7784, XXVII, 561, p. 8, complained about the difficulty of securing a conviction under the Act. 53. Ministry of Health, Report of the Dept. Cttee. on the Training and Employment of Midwives (HMSO, 1929), p. 65. The retired health visitor who had worked in the Infant Welfare Dept at UCH had in her possession a photograph of some 18 handywomen who lived on or near the Caledonian Road, taken by a midwife sometime between 1920 and 1925. 54. Minutes of the Proceedings of the Health Committee, XXXIV, 21 July 1921, Hull Public Archives. 55. Florence Daniel, The Expectant Mother (C.W. Daniel and Co., 1925), p. 13. 56. Lancet, 1 Aug. 1931, p. 268; letter from 'A Worcestershire GP'.

160 Domiciliary Practice 57. Minutes of the Health Committee XXVII, 23 Oct. 1914, Hull Public Archives. 58. Nursing Notes, XXIV (Sept. 1911), p. 219, and XLIV (July 1931), p. 38. The number of independent midwives is very difficult to estimate. Local supervising authorities did not distinguish between independent and institutional midwives in their returns. The Midwives Institute attempted to assess the number of independents for the purposes of a survey they conducted in 1936 and came up with the figure of 7,565, or 46% of all practising midwives (The Midwife in Independent Practice Today, p. 8). 59. Report of the National Conference on Infant Welfare, 1919, p. 85, remarks of J.S. Fairbairn. 60. PRO, MH 55/652, Report of the Jt. Council of Midwifery, 1935, which recommended a salaried service. Midwives Institute, Midwife in Independent Practice Today, pp. 8-18, lists the reasons for the decline in the practice of independent midwives. 61. BMJ, 11 Nov. 1916, pp. 651. 62. 'A National Maternity Service', BMJ, Supplement, 29 June 1929, p. 260. 63. Arthur Newsholme, International Studies in the Relation between the Private and Official Practice of Medicine, vol. 3 (Allen and Unwin, 1931), p. 42. 64. Maternal Mortality. Report of a Meeting held at the Friends' House, Euston Road (the Maternal Mortality Committee, 1932), p. 34. 65. 39th Annual Report of the WCG, 1921-2, p. 13. 66. 70th Annual Report of the TUC, 1938, p. 326, Miss D.M. Elliot (Gen. and Mun. Workers); p. 327, Miss F.E. Lillywhite (Women Public Health Workers); p. 328, Mrs B.M. Draper (Nat. Union of County Officers); p. 330, Miss B.A. Godwin (Women Clerks and Secs.); p. 331, Mr F. Marshall (Gen. and Mun. Workers). 67. For example in Cheshire: Maternal Mortality Committee, Schemes Considered at Conference, 1935 (Maternal Mortality Committee, 1935), pp. 9-14; and in Cumberland: Kenneth Fraser, 'A County Campaign against Maternal Mortality', Mother and Child, 5 (April 1934), pp. 3-4. 68. Maternal Mortality Committee. Schemes Considered at Conference, 1935, p. 5. See also, Andrew Topping, 'Maternal Mortality and Public Opinion', Public Health, 49 (July 1936), pp. 342-9. 69. PP, 'Report of the Royal Commission on National Health Insurance', 1926, Cmd. 2596, XIV, 311, p. 152. 70. PRO, MH 55/682, County Council Association to the Ministry of Health, 6 July 1937 and a minute on this, 11 Aug. 1937. 71. Ministry of Health, Annual Report of the Chief Medical Officer for 1930 (HMSO, 1931), p. 20. 72. PRO, CAB 23/70 16 (32) 7. 73. PRO, MH 55/273, Newman to Robinson, 6 May 1932. 74. Minutes of the Executive Committee of the Medical Women's Federation, 4 Dec, 1937, letter from Mary Scharlieb. 75. Ministry of Health, Annual Report of the Chief Medical Officer, 1933 (HMSO, 1934), p. 260. 76. Maternal Mortality. Report of a Meeting Held at the Central Hall, Westminster (The Maternal Mortality Committee, 1929), p. 28, speech of Councillor Mrs Moore (WCG). 77. Lancet, 11 Oct. 1924, p. 779, report on a Maternal Mortality Conference at the Royal Society of Arts. 78. Minutes of the Proceedings of the Health Committee, XXXV, 22 June 1922, and 18 Sept. 1929, Hull Public Archives. 79. Daniel, The Expectant Mother, p. 76; and Aleck W. Bourne, et. al., Queen Charlotte's Practice of Obstetrics (J. & A. Churchill, 1927), p. 73.

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80. A.J. Wrigley, 'A Criticism of Ante-Natal Work', BMJ, 19 May 1934, pp. 891-4; Aleck W. Bourne, `The Limits of Ante-Natal Care', Jr. State Med., XLIII (Aug. 1935), pp. 435-44. 81. The Times, 31 Dec. 1934, letter from Berkley. J.M. Winter, 'Infant Mortality, Maternal Mortality and Public Health in Britain in the 1930's', Jrnl. Eur. Econ. Hist. 8 (Autumn, 1979), pp. 453-60 accepts this view, but believes that women's attitudes changed during the 1930s. 82. Annual Report of the MOH for Liverpool for 1932, p. 116. 83. See for example, `The Birth Rate', Woman's Dreadnought, 3 (8 July 1916), p. 506, editorial. 84. Maternal Mortality ... Central Hall (1929), pp. 8-9, and Maternal Mortality ... Friends' House (1932), pp. 6-9. 235. Dellett, Causes and Prevention of Maternal Mortality, p. 130. 86. Frances Ivens, The Organization of the Care of Maternity', Lancet, 17 June 1922, pp. 1227-8 — Hester Viney also spoke of women's 'shyness': 'Propositions in Favour of Ante-Natal Care', National Health, 17 (Dec. 1924), pp. 184-5; and Nursing Notes, LXI (Feb. 1928), p. 19. 87. Protect the Nation's Mothers, Report by the Standing Joint Committee on Industrial Women's Organizations to the National Conference of Labour Women (Labour Party, 1935), p. 15. 88. Guardian, 9 Sept. 1978, p. 6, letter from Kathryn Gray.

PART IV WOMEN'S DEMANDS

6

ECONOMIC ASSISTANCE

The unofficial Maternal Mortality Committee, the Women's Cooperative Guild and the Women's.Labour League had always insisted that family income was as crucial a factor as the maternal and infant welfare services in providing the conditions for healthy childbearing and childrearing. These women defined the problem of child and maternal welfare in terms of women's economic dependency within the family. Direct economic assistance or endowment was necessary if motherhood was to be invested with a new status and if women were to guard their own health and that of their families effectively. This analysis provided the impetus for the early struggle of the WCG to secure a maternity benefit as part of the 1911 National Health Insurance scheme, and for the interwar campaign for family allowances. Assistance could be provided in kind (for example in the form of free milk, meals and vitamin supplements for expectant and nursing mothers and infants) as well as in cash. Both forms of state intervention were sought by women's groups, although Labour women favoured payments-in-kind, because of their fear of the effect of family allowances on wages, and because payments-in-kind were less subject to erosion by inflation.' During the early 1930s, however, substantial cash payments paid directly to the mother, in the form of allowances, seemed only a remote possibility. The debate over the effect of unemployment on nutrition levels, on the other hand, made free milk and a rise in Unemployment Assistance Board (UAB) benefits more realistic goals. Women's groups were the first to seek economic aid for mothers. Their policies were pragmatic and subject to influence from other interested bodies. Any programme which, directly or indirectly, redistributed wealth generated political debate and many supporters of family allowances, increased UAB benefits for children, and free or cheap milk did not think the principle of paying the mother for her services important. Many of those who advocated family allowances felt that the welfare of the child was more important than anything else and supported allowances as a means of ending child poverty. In 1934, many of the women who had started the campaign for allowances formed the Children's Minimum Council (CMC) and turned their attention to the more easily attainable goals of free milk and increased UAB benefits. In 165

166 Economic Assistance order to attract parliamentary support for such measures, it was necessary to emphasise the link between the welfare of the child and the future of the race. Intervention by the state on the part of children had a longer tradition and raised fewer fears of subverting the male breadwinner's responsibility than intervention on behalf of wives. Thus legislation was demanded primarily in the interests of children, although evidence concerning the poor health of mothers was often adduced in support of the demands. The government could not admit to there being a need for direct economic assistance to the family when the main arguments for such assistance were based on evidence of poverty and malnutrition, particularly amongst the unemployed. As in the case of infant welfare, the government was determined to deny that poverty played any part in determining standards of health or mortality rates. To have done so would have implied acknowledgement that unemployment benefit rates were too low, an impossible admission at the best of times, but particularly during the 1930s, when the debate over the effects of mass unemployment on health was so intense. Thus the first response of health officials was to concentrate on educating mothers to better use the income at their disposal, a solution reminiscent of the official response to the problem of infant mortality. When more material assistance was granted in the form of free milk and, subsequently, family allowances, it was not in order to pay the mother for her services, or even to secure the well-being of the child, but rather as a method of disposing of a milk surplus in the first instance and as a means of keeping wages down in the second. Prior to World War I, discussion of the economic position of married women was widespread in women's groups. Labour women's journals were particularly concerned about the issue, but in most feminist organisations it came a poor second to the vote. The Fabian Women's Group (FWG) was founded with the main object of discussing women's economic independence. In the Women's Corner of the Cooperative News, the debate over the economic position of married women opened with a consideration of whether married women should, or could, be independent. It was argued that childbearing was a social function which demanded a woman's whole attention and which should therefore be financially rewarded. One correspondent asked: `Because a man sells his labour while the mother applies hers directly in the home, why should he claim to be the bread winner?i2 Anna Martin, who wrote in the Cooperative News and suffragette journals, contended that the authorities were expecting mothers to `make bricks without straw' when they

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demanded that they improve the welfare of their infants without providing any additional income.' Various solutions to this problem were offered. Anna Martin believed that a wife should be legally entitled to a portion of her husband's income, but, in a debate organised by the Women's Labour League, she was opposed by Mrs Pember Reeves, a member of the FWG, who believed family allowances to offer the best solution.4 Another early and less controversial suggestion was to give pensions to widows with dependent children, popularly referred to as `mothers' pensions' or `mothers' endowment'. During a discussion held to mark National Baby Week in 1918, one participant felt these to be worthy of support, whereas a policy of allowances was considered to be too expensive to implement.' Mothers' pensions started in the USA with the idea that the mother was the best person to look after her child and that it was thus better to pay her to do this than to take the child into care. The Local Government Board recognised the force of this argument in a report it prepared on the subject in 1918. Mothers' pensions were also endorsed in principle during World War I by the Women's Employment Committee of the Ministry of Reconstruction and the War Cabinet Committee on Women's Employment.6 The Labour Party made the pensions part of its programme in 1918; members who had qualms about supporting family allowances did not hesitate to support the cause of widows.' Legislation providing for widows' pensions was enacted in 1925. One of the first major efforts to secure a measure of economic assistance for all married women was the WCG's campaign for maternity benefits. In 1910, the guild asked its members how they provided for childbirth and the replies showed: That the provision made is usually at the cost of the woman, who either saves out of the household money, thus going without just at the time she needs more nourishment, or takes extra work, thus overdoing herself when she needs to have less work and more care.8 On the strength of this evidence, the guild sent deputations to the Attorney-General and Lloyd George, asking that provision for a maternity benefit be included in the National Health Insurance Act of 1911. The Act did include a benefit of 30s. payable to the wives of insured men and women insured in their own right. While the guild welcomed this, it deplored the fact that the benefit was paid to the husband and not the wife, and when an amending bill to the 1911 Act was proposed, the guild again campaigned for the benefit to become

168 Economic Assistance the mother's property. This was secured in 1913, and the guild described the victory as: `the first public recognition of the mother's place in the home and a new step towards some economic independence for wives'.9 A similar struggle to have family allowances paid to the mother was to take place in 1945. In both cases it was feared that payment to the mother would lessen the responsibility of the father, while male Labour MPs and trade-unionists also regarded the move as a slight on the integrity of the working-class husband.10 To pay all mothers an allowance was a large and a more controversial step. An early experiment, combining the idea of a maternity benefit and a family allowance, was conducted by the FWG. They used a donation of £500 to pay what they called maternity allowances to 42 women whose husbands earned between 18s. and 26s. per week. (Anything below 18s. was considered a hopeless case and above 26s. did not need help.) A list of suitable candidates was obtained from the outpatients department of a lying-in-hospital (probably the General Lying-In Hospital on York Road, as the experiment was conducted in the London Borough of Lambeth), and an unspecified amount of money was paid to the mother before and after the birth of her child. The FWG described this as 'an experiment in maternity allowances under conditions conducive to economic independence'. The book that was issued describing the experiment showed how desperately the money was needed." Mrs Pember Reeves, who took charge of the Lambeth experiment, felt: `The woman who shrinks from the feeling that her wifehood is a means of livelihood will proudly acknowledge that her motherhood is a service to the state.'12 The feeling that motherhood had been undervalued, and required not just the support of better maternity services but some more material recognition, grew stronger among women's groups during and after World War I. In a collection of essays on feminism published in 1917, Maude Royden, a feminist lay-preacher, claimed that in order to prove their common humanity feminists had been forced to `ape' men. A woman who bore children and ran a household was still only `an arrested man and a perpetual minor', but a woman who could clip tickets on a tramcar was recognised `as a super-woman — in other words a man'.13 This observation was prompted by the lavish praises of women's work during World War I; as Ellen Askwith commented, the surfeit of praise was insulting, it proved how undervalued and unrecognised women's work in the home had been in the past.14 With the granting of the suffrage imminent, it was also realised that the vote would prove of little practical use to women in a society structured by male values.

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In 1917, the National Union of Women's Suffrage Societies (NUWSS), the largest constitutional suffrage society, began to redefine its goals.15 Traditionally feminists had demanded political, social and economic equality with men; `a fair field and no favour' for those who worked outside the home. This led to their opposition to protective legislation for women workers which incurred the anger of trade-union women, who had fought hard for such protection. Eleanor Rathbone, who became President of the NUWSS in 1919 (in the same year it changed its name to the National Union of Societies for Equal Citizenship), believed that what was really needed was a programme to secure `a real equality' for women. The time was ripe `to demand what we want for women, not because it is what men have got, but because it is what women need to fulfill the potentialities of their own natures and to adjust themselves to the circumstances of their own lives'.16 If women's special contribution as mothers, for example, was recognised to be of equal value to any male occupation it would be to the benefit not only of women but to all human society. (It was a similar belief in the dignity of motherhood that had caused Vera Brittain and Eva Hubback, both feminists, to set up middle-class baby clubs.) While they did not wish to confine women to the home, most feminists did not question women's role in rearing children. Rathbone commented: `Women are the natural custodians of childhood. That at least is part of the traditional role assigned to us by men and one that we have never repudiated.'"To further the goal of a real equality, the National Union of Societies for Equal Citizenship (NUSEC) adopted as part of its programme demands for family allowances and free access to birth control information, which together would permit women economic independence and control over reproduction. It was also hoped that such a programme would appeal to trade-union women, who felt strongly that working-class women should not be driven to work by economic necessity and thus bear the strain of two jobs. Rathbone had first proposed a scheme of allowances in 1917 subsequent to her first-hand knowledge of the working of separation allowances during the war.18 Despite difficulties in its administration, this programme had resulted in an improvement in the health of school children and although no record was kept of the physical well-being of the mothers, there were grounds to suppose that better food and freedom from pecuniary worry had beneficial effects on body and mind. In 1915, the Birmingham Infant Health Society reported that: `It is the unanimous opinion of our lady workers that on the whole the mothers have been much more prosperous during the last six months

170 Economic Assistance [after the introduction of separation allowances in July 19151.'19 Rathbone felt that the study of the family as an economic unit had escaped the attention of economists and that the welfare of women and children was entirely dependent on the generosity of wage-earning fathers. The economic dependence of women and children on men reduced them to the status of `male luxuries', to be ranked in the view of one Liverpool schoolmaster with the costs of running a car.20 From the feminist point of view, family allowances involved: `The conscious allocation to the mothers qua mother of resources adequate for the proper performance of their function.'21 Ideally, the mother would be paid an allowance which equalled the difference between the cost of a man and wife living together and that for a single man living away from home, plus allowances for saving and for children. In practice, the Family Endowment Council, set up by Rathone in 1917, asked for a weekly allowance of 12s. 6d. for the mother, 5s. for the first and 3s. 6d. for subsequent children.22 It was felt that this would put an end to the economic subjection of the wife, which many feminists believed to be the root cause of the degradation of all women.23 In addition, wages could then be paid on a bachelor/spinster basis and, thus, the main impediment to equal pay — that a man had to support a family — would be removed.24 In any case, it was a fiction that wages provided adequately for dependents and Beatrice Webb made an emotional appeal for allowances as the 'bairns's part'.2S Rathbone also made this point central to her case for allowances. Her major work on family allowances showed that the average family of five, on which all previous calculations as to family poverty had been based, was atypical. Only 8.8% of families had three children. Unmarried workers accounted for 27% of families, 24.7% consisted of a married couple with no children under 14 years, 16.6% had one child, 13% two children and 9.9% more than three children. Moreover, 40.4% of the child population was to be found in the 9.9% of families with more than three children.26 Because there was a high correlation between large families and low wages, this meant that the percentage of children living in poverty was greater than the percentage of adults. Children were both the cause and victims of poverty and the issue of child poverty quickly became the major rallying point for the family allowances movement. All subsequent social surveys of the 1930s made a point of showing not only the percentage of families falling below the poverty line, but also the percentage of children, which was always greater.27 In 1925, the Family Endowment Society (FES)28 presented evidence

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to the Royal Commission on the Coal Industry, pointing out that 47% of miners had more than three children and that the 32.9% falling below the subsistence level established by Rowntree in 1918 were fathers of no less than 66.5% of all miners' children. The society's memorandum also used evidence from Janet Campbell's 1924 report on maternal mortality, which showed that the health of miners' wives was particularly poor relative to other occupational groups. The society argued that implementation of a scheme of allowances would be relatively easy in a specialised industry, where the danger of workers with dependents flooding in and single men leaving would be minimised.29 The commissioners accepted the logic of the society's argument that a living wage for miners with large families was impossible without a scheme of allowances, and justified their view on the grounds that allowances could be used as part of, or as a substitute for, wages: We regard the introduction of a system of children's allowances — to be paid for out of a single pool, whether for the whole industry or for each district that adopts it — as one of the most favourable measures that can be adopted for adding to the well-being and contentment of the mining population. If the total sum available for workers' remuneration can be kept at the present level, the allocation of a small part of this to children's allowances will raise materially the general level of comfort, if the full remuneration cannot be maintained the harmful effects of any reasonable reduction can largely be mitigated.30 Recognition by the commission took the question of family allowances out of the theoretical stage. The FES publicised the commission's adoption of allowances as a solution to the problems of the coal industry by distributing 30,000 pamphlets on the subject. The Times also paid close attention to the commission's recommendations and began to report the activities of the FES on a regular basis. After 1926 the original purpose of allowances as payment to the mother for her services and as a means to equal pay faded from view. The concept of family allowances appealed to a variety of groups: the original FES was composed of four feminists and three socialists, but by 1927 only five of the fifteen executive members of the FES were feminists; the rest included socialists, imperialists, eugenists and humanitarians. Socialist support was based on the belief that family allowances would further the vertical redistribution of wealth. H.N. Brailsford envisaged a family allowance programme which applied

172 Economic Assistance only to workers and which would be funded by taxes levied on the rich.31 Liberals also joined the FES, and Beveridge, an early supporter of allowances, became President of the society in 1925. His involvement was motivated more by humanitarian concern for child poverty than by any other factor.32 Socialists and most feminists wanted allowances to be paid out of taxation at a flat rate. Rathbone and members of the Eugenics Society, including Beveridge, favoured a graduated system of allowances paid in direct proportion to family income, via an insurance or a `pool' system, and based on a particular occupational group like the miners or teachers. They felt that this would ensure that encouragement to have more children was given to the higher socio-economic groups, for as Rathbone commented, many supporters of allowances feared giving incentive to increase `population of the wrong kind'.33 Rathbone intended the FES to be an umbrella organisation for all those with an interest in promoting `the principle of direct provision for the family', whatever their motivation. Rathbone herself sympathised with both eugenist and feminist reasons for supporting allowances, but her main concern was to secure some sort of immediate relief for the children. Mary Stocks, her biographer, reported that when Rathbone moved a resolution in favour of allowances at the Annual Conference of NUSEC in 1925, her `voice broke on the children'.34 Allowances became a means to alleviate child poverty rather than a means to social change. Labour women also believed that the welfare of the child was more important than that of the mother.35 Together with the Independent Labour Party, they supported the idea of allowances, but the TUC and the Labour Party were suspicious of their effect on wages — especially after the Royal Commission on the Coal Industry's recommendations — fearing that allowances would prove to be another form of poor relief akin to the nineteenth-century Speenhamland system, whereby relief given in cases of destitution had effectively held down wages.36 The TUC and the Labour Party referred the question of allowances to their Joint Committee on the Living Wage, which sent out a questionnaire on the subject to trade unions in 1929. A majority of unions replying were in favour `of further financial provision being made for the children', but in the form of kind rather than cash. While the committee felt that it could nonetheless recommend the adoption of allowances, the Labour Party did not feel that it could move on the issue without support from trade-unionists.37 Labour women had always been concerned to press for more direct provision for the family in kind. As a part of the increased concern for

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infant welfare expressed during World War I, the LGB issued a free milk order under which the board paid 50% of the cost of milk distributed by LAs to mothers and infants. The 1918-19 report of the board's Chief Medical Officer stated: `At any rate, there can be no doubt that the ordinary diet of many mothers in industrial districts is so poor in quality, that it is surprising that they can maintain life on it, much less sustain the unborn infant.i38 The national importance of maternal and child welfare always outweighed political considerations in wartime. In 1921, the milk order was revoked in an effort to economise, although Labour women's groups exerted enough pressure to force a deferral of the cuts until 1922. All sections of the WLL and 212 WCG branches made their opposition to the cuts known.39 Under the 1922 regulations, each LA had to set an income scale, according to which free and cheap milk would be distributed from welfare centres, and have it approved by the Ministry of Health. Hull, for example, was forced to reduce the minimum income below which a family of five became eligible for subsidised milk from 38s. 2d to 37s. 6d 4° Infants were eligible to receive one pint of milk per day and supplies were provided to women only in the last three months of pregnancy. Between 1919 and 1920 the milk and food bills of LAs amounted to 17.3% of their maternal and child welfare budgets, by 1929-30 this had dropped to 13.4%. Many Labour women preferred that pregnant women be given dinners rather than milk, because these could not be shared amongst the whole family.41 However, LAs tended to phase out dinner programmes for pregnant and nursing women during the 1920s, preferring in many cases to give `sunshine treatment' in cases of poor nutrition. In 1922, the MOH for Hull expressed doubts about the value of dinners: It is difficult to estimate the physiological value of these meals. Undoubtedly many mothers benefit greatly. A considerable number attend somewhat irregularly, and a still larger number fail, from habits of faulty hygiene and bad housing conditions, to derive the benefit they should from these meals. Although there is much unemployment in Hull, comparatively few cases of actual underfeeding come under notice.42 In 1924, the council opened a `sunshine clinic' for the treatment of rickety children and poorly fed mothers, claiming that codliver oil and milk were less effective than treatment with sunlamps.43 The clinic was extremely popular, possibly because it was new, and the few women

174 Economic Assistance and children who attended were considered privileged in some way. The same respondent who had received the dinners for mothers given in Hull during the war, said that she later received sunshine treatment, whereupon her friend commented: `Oh, you were privileged if you had the sunshine treatment.' A respondent who had been involved in running the North Islington Clinic believed that it was impossible to overestimate the feeling of well-being experienced by women and children after being thoroughly warmed under the sunlamps during the winter months. The emphasis Labour women placed on the need to assist mothers with payments-in-kind was reinforced by the 1930 decision of the Labour Party not to support family allowances and the rapidly accumulating research into the importance of nutrition and diet. During the 1930s, nutrition became a political question. After such research as Corry Mann's study of how the physique of school children could be improved by the addition of milk to their diets, the properties of milk became invested with an almost medicinal quality.44 This, together with the fact that a considerable milk surplus was being produced, gave support to the argument for making milk available at a cheaper price. Labour Woman advised its readers: `Corry Mann is a name for all mothers to remember.i45 The women's institutes were also active in demanding a reduction in milk prices. They sent deputations to the Ministry of Health each year from 1936 to 1938. Research also showed the need for a special diet during pregnancy. F.J. Browne insisted that ante-natal care began at birth with a good diet.46 In 1928, Mellanby demonstrated that Vitamin A could increase resistance to infection and that this could prove important in the prevention of sepsis.47 He recommended a daily diet for pregnant women which included two pints of milk, one or two servings of green vegetables, one or two eggs, an apple or orange and codliver oil, plus fish twice a week and liver once a week. This same diet was also recommended by Louise McElroy, a leading obstetrician, as a means of lessening the chance of toxaemia.48 While a 1932 report by Janet Campbell on areas experiencing high maternal mortality rates acknowledged that `it is likely that nutrition plays a more important part in maternal morbidity than was realized', the 1932 report of the Departmental Committee on Maternal Mortality and Morbidity recognised Mellanby's findings, but made no recommendations with regard to diet, and a 1937 report concluded that whilst diets were often ill-balanced, no important elements were missing. The only government report on maternal mortality to argue that there was a definite association

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between poor diet and maternal mortality was an investigation in Wales published in 1937.49 In 1931, a Nutrition Advisory Committee was set up by the Ministry of Health. In 1932, the committee issued a report on the general principles of nutrition, advising that the average male needed 3,000 calories and 37 grams of first class protein daily.50 Shortly afterwards, the BMA published a report on nutrition stating that the Ministry of Health's minimum was insufficient to maintain `working capacity' and that the average male required 3,400 calories and 50 grams of first class protein daily.51 This difference of opinion was more apparent than real because the two committees had been given different terms of reference. The Advisory Committee had worked on preparing general guidelines and the BMA on a diet specifically intended to ensure the maintenance of `working capacity', which they interpreted as work involving some muscular exertion. In fact, three men, G.F. Buchan, V.H. Mottram and S.J. Cowell, were members of both committees and actually signed both reports. In 1934, the two committees managed to overcome their differences and to reach agreement on a sliding-scale of calories and grams appropriate for both sexes, according to various types of work. In the meantime, a vitriolic correspondence over the issue within the Ministry of Health and in the press ensued, showing how sensitive an issue nutrition was. As the Parliamentary Secretary to the Minister of Health remarked, it was publicly alleged that the ministry was obviously wrong in its contention that unemployment had not led to malnutrition, because it had set its dietary minimum too low.52 The Ministry stuck firmly by its report and early in 1934 it issued a circular to LAs recommending a basic diet of 3,000 calories and 37 grams of protein.S3 Moreover, Newman sought to stiffen the committee's line by removing those who had also signed the BMA report as well as Frederick Gowland Hopkins and Mellanby, whose interest in promoting the consumption of milk and codliver oil he regarded as `sentimental'. He preferred the uncompromising views of Arthur Greenwood and E.P. Cathcart, whose judgement he praised as `objective', while the BMA's report was dismissed as: `an essay written by Dr. McGonigle of Stockton, who (having come to grief on universal rickets among children and the grave disadvantages of moving slum people to better houses) is now embarking on a publicity campaign in regard to nutrition'. McGonigle, the Medical Officer of Health for Stockton-on-Tees, was viewed with suspicion by the ministry as `a promising labour politician'.54

176 Economic Assistance Despite the lack of connection between the argument over calories and grams and the actual diet of the working class, the debate continued because calories and grams could be easily computed and priced. Measurement of levels of nutrition amongst the poor became a crucial part of the social surveys of the 1930s, which used the BMA's diet as the minimum acceptable standard. Interpretation of the relationship between unemployment and poor nutrition largely followed political lines. For example, in commenting on the same Ministry of Health report for 1933, which stressed that while malnutrition existed, the situation still compared favourably to that of the pre-World War I years, The Times ran the headline: `The National Health — Well Maintained' and the Daily Herald: `The Toll of Unemployment — Malnutrition in the Depressed Areas.' With the publication of the BMA report, the Labour Party immediately prepared notes for its speakers which began: `Independent medical testimony [the BMA report] is now available proving that the present scales of unemployment pay are inadequate to meet the bare minimum food requirements of the average unemployed family.'ss When the new UAB scale came into force in 1934, reaction from working men's organisations was immediate. Particular emphasis was placed on the effect of unemployment and poor nutrition among women and children. The Daily Herald commented that even the report on children in poor law homes allowed 4s. 6'fd. per child per week, whereas the UAB scale permitted only 2s. 56 Neither the Ministry of Health's Nutrition Advisory Committee report nor the BMA's report had laid any great stress on ideal diets for women and children. Mellanby's view that the `feeding of the pregnant woman [was] at the base of the whole problem's' was ignored in the advisory committee's report. Similarly, while the BMA report made some allowance for milk for children when composing its diet sheets, none was made for the special diet doctors agreed was desirable for pregnant women, even though the cost of Mellanby's diet for pregnant women added Ss. to the weekly food bill budgeted for by the BMA. However in the political battle over nutrition, reference to the effect of poor diet on maternal mortality and on the welfare of infants and young children — the future race — were frequent. After the parliamentary vote on UAB scales, Rathbone formed the Children's Minimum Council (CMC), described by Eva Hubback as `a temporary meeting ground for the many organizations whose concern is largely or mainly with child welfare'." The programme of the CMC included raising the UAB scales to provide a large enough income to purchase the BMA's minimum diet, free milk for

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all school children, cheap milk for nursing and expectant mothers and their infants, free milk where expenditure for food was insufficient and free meals for children where family income was insufficient to provide the minimum diet. The council also supported family allowances and the principle of rent rebates for large, poor families.59 The decision to focus on the child was pragmatic. The council stressed the need to secure `a minimum which makes for physical fitness';6° the idea of a national minimum was to be the main concept behind the Beveridge Report. In public, the council justified the concentration on the welfare of the child, and measures to benefit the pregnant mother that would also benefit the child, as being in the best interests of the nation. In private, they acknowledged that this was the strategy they felt was most likely to bring success in terms of parliamentary legislation. In 1934, the Family Endowment Chronicle commented that: `During the last few months there have been few opportunities of pressing forward schemes of direct family allowances and a good deal of the activity of the Family Endowment Society has been thrown into the campaign for "a children's minimum".'61 Marjorie Green, Secretary to the CMC as well as to the FES and NUSEC, recalled that when the TUC turned down cash allowances, and when the cuts of the early 1930s began, `hope ran out' for allowances, which was why the FES switched its attentions to the question of a children's minimum.62 The CMC was an even more influential body than the FES. MPs who voted against the new UAB scales, the Women's Cooperative Guild, the Standing Joint Committee of Industrial Women's Organisations and NUSEC, as well as the FES, were all affiliated to it.63 The first actions of the CMC were to oppose the new UAB scales, arguing that they made purchase of the minimum diet laid down by the BMA impossible, and to press for free and cheap milk for mothers and infants. The council quoted the results of Margaret Balfour's and Joan Drury's study of women's health in the `special areas' of Durham and Tyneside in its 1935 report to the Ministry of Health: `It is evident that a large proportion of the expectant mothers do not attend the centres and we are of the opinion that it is the feebler and less energetic mothers who stay away and so are not eligible for the nutriment they so greatly need.' The council also used the fact that milk surpluses totalled 20% of the winter production, and 40% in spring and summer, in its deputations to the Milk Marketing Board and in its evidence given to the Milk Reorganization Committee." In 1937, the council's twentyone-page brief on the question of milk attracted the attention of 48 newspapers.

178 Economic Assistance The government could not accept that UAB rates were too low to provide an adequate diet. The Board of Education had the following to say about the CMC's demand for free school meals: In fact this demand, like that for the larger children's allowances, is largely based on the assumption that the financial assistance to be given to the unemployed under the Government's Unemployment Bill is insufficient to enable them to feed their children adequately. This is an assumption the Government cannot accept.6s Similarly, the government could justify giving free or cheap milk to children `not on the grounds of the particular needs of malnourished children, but on the grounds that all children, healthy or unhealthy, rich or poor are alike the better for a daily glass of milk'.66 Politically, the government could not afford to recognise the existence of malnutrition due to poverty. Evidence of malnutrition, and how far it could be held responsible for any observed medical shortcomings, therefore became the key issue in the debate. Mortality statistics provided one of the main grounds for argument. The Ministry of Health insisted that a falling infant mortality rate proved that there had been no fall in living standards. The report of the Chief Medical Officer had used this argument as early as 1926 with regard to Durham, where many were out of work due to the miners' strike.67 The Ministry of Health also accused the CMC of picking out the `most lurid paragraphs' in the local reports of medical officers of health to support their contention that infant mortality was rising in the special areas. Table 6.1: Infant Mortality Variation by Class (Mean for All Classes = 100)

I II III IV V All

1911 61 85 90 92 122 100

1921-3 48 70 97 113 123 100

1930-2 53 73 94 108 125 100

1939 57 72 94 109 128 100

Source: Richard Titmuss, Birth Poverty and Wealth (Hamish Hamilton, 1943), p. 26; and (for the 1939 figures), General Registry Office, Registrar General's Decennial Supplement for 1931, Pt. III (HMSO, 1952), p. 86, Table Q1.

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While the infant mortality rate for all classes declined during the inter-war period, in general the gap between classes closed more slowly during the 1930s than during the 1920s, and in 1939 remained greater than in 1911 (Table 6.1). For example, compared with the Registrar General's Class II, Classes III, IV and V all showed an increase in infant mortality between 1911 and 1939. During the 1920s, the differential decreased, but actually showed a slight increase during the 1930s (Table 6.2).68 Table 6.2: Infant Mortality Variation by Class (Class II = 100)

I II III IV V

1911 72 100 107 115 144

1921-3 69 100 140 162 176

1930-2 73 100 129 149 171

1939 79 100 129 150 176

Source: Richard Titmuss, Birth Poverty and Wealth (Hamish Hamilton, 1943), p. 26; and (for the 1939 figures), General Registry Office, Registrar General's Decennial Supplement for 1931, Pt. III (HMSO, 1952), p. 86, Table Q1.

Harry Roberts, a well-known East End GP, went to some lengths in both the New Statesman and the News Chronicle to show that maternal deaths were as numerous in the West End of London as in the East End, and to claim that poverty could not therefore be the major factor.69 The maternal mortality rate in the East End was low because the sepsis rate was low, due mainly to care taken in the lying-in hospitals; however the death rate from haemorrhage, which depended less on services (because no really effective treatment was available) and more on the general health level of the women, was relatively high. The Ministry of Health was always anxious to dodge the class issue, claiming that the middle-class way-of-life was as unconducive to healthy childbearing as that of the working class. The richness of the middle-class diet was more likely to produce toxaemia, and the sedentary way-of-life, poor muscle tone.70 It was also true that the care the middle-class woman received at the hands of doctors and in nursing homes was often poor. However, this does not in any way eliminate the possibility that poor nutrition also adversely affected the mortality rates of mother and infant. The inter-war reports on maternal mortality all denied this possibility except the Welsh report of 1937, which felt that the `excessive' maternal mortality rate was due in part to poor nutrition." However, both the special areas of South Wales and of Sunderland and Durham were shown

180 Economic Assistance to experience a rise in maternal mortality between 1924-8 and 1929-33: (see Table 6.3): Table 6.3: Maternal Mortality in Selected Areas in 1924-8 and 1929-33

Glamorgan admin. cty Monmouth admin. cty Merthyr CB* Cardiff, Newport & Swansea* Wales Sunderland CB* Durham admin. cty

Special areas 1924-8 1929-33 5.40 6.54 4.41 6.51 6.18 5.32 5.16 4.22 4.53

6.50 4.80 4.95

Other 1924-8 1929-33 5.95 5.32 4.02 3.96 5.06

4.65

5.48

5.41

nd

nd

Note: *The boundaries of the special areas did not divide these districts. Source: PRO, MH 55/629, 'Maternal Mortality in the Special Areas, report by Nancy Howell and A.T. Jones', 9 Oct. 1936; and PP, 'Report of and Inquiry into the Effects of Existing Economic Circumstances on the Health of the Community in the Cty. Boro. of Sunderland and certain districts of Cty. Durham, by James Pearse, J.A. Cison and K.W. Grant', 1934-5, Cmd. 4886, IX, 627, p. 26.

Official inquiries often showed how poor women's health was, but nonetheless denied either that there had been any deterioration or that the low health levels were due to malnutrition. The Sunderland and Durham investigation was prompted by a letter to The Times from Dr Walker, a physician in the area, who charged that health standards had deteriorated. The government investigators found that 27% of 103 women seen at ante-natal centres in Sunderland were in 'poor' or 'subnormal' health, and likewise 23% of 56 seen in Durham. Similarly, 20% of 1,303 schoolchildren seen were 'subnormally nourished'. However, the investigators were 'unable to accept Dr. Walker's statement that there has been in this area a substantial and progressive deterioration in public health'.72 In response to a report by the Newcastle Dispensary in 1931, which made similar charges to those levied by Dr Walker, the Chief Medical Officer commented that only pregnant and nursing women had been examined by the dispensary and that the high incidence of anaemia among such women was related not to unemployment or to malnutrition, 'but to sickness, pregnancy, post confinement, lactation, etc.'.73 What many groups saw fit to question was the cause of these anaemic conditions during and after pregnancy, which they suspected were due to poor feeding. Many members of the unofficial Maternal Mortality Committee were

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convinced that few women were getting the diet suggested by Mellanby and that poor nutrition was a serious factor in maternal mortality. At the 1932 Conference of the Maternal Mortality Committee, Miss Sutherland, the Chief Woman Officer of the Labour Party, commented: `Now it does seem to me — and I want just to stress this point a little — it does seem to me that this problem of nutrition gets us to the very root of the whole problem of maternal mortality.'74 Mrs J. Clarke, a member of the WCG, reiterated this concern. At the Labour Party Conference of 1934, Lady Noel-Buxton proposed the resolution: `In view of the recent rise in the maternal mortality rate, and the unchallengable evidence [what this was was not made clear] that one of the contributing causes is the under-nourishment of mothers, this conference calls on HM Government to arrange for the immediate provision of free milk to nursing and expectant mothers in necessitous circumstances.'7S The Committee Against Malnutrition, founded in 1934 by a group of socialist doctors, insisted that it was only because the health of women was so poor that good maternity services were so important.76 The belief that poverty caused widespread, poor nutrition and ill-health received additional support when John Boyd Orr published his book, Food Health and Income, in 1936. He showed that 10% of the population could not possibly afford the recommended BMA minimum diet and that a further 20% were on the borderline. Whilst the government started a programme to provide cheap milk for school children in 1934, no official steps were taken to provide extra nutrition for mothers. However, two large-scale independent experiments in feeding mothers were undertaken by the National Birthday Trust and the People's League of Health. Lady Rhys-Williams began the National Birthday Trust's campaign in the special areas of South Wales in 1933, by providing salaried midwives' refresher courses in midwifery, free disinfectants and extra antenatal sessions. However, these improvements in the maternity services had no effect on the maternal mortality rate. At the suggestion of the midwives themselves and with the cooperation of the local authorities, the trust began to distribute free foodstuffs during Christmas of 1934 in the Special Areas. In 1935, funds were found to continue the experiment in the Rhondda. Necessitous pregnant women received Brandox, Ovaltine and Marmite for an average period of three months at antenatal clinics. The effects on the death rate appeared to be very significant. Between 1928 and 1933, the death rate in the special areas of South Wales had averaged 7.20 per 1,000 and in 1934 rose to 11.29. In 1935, it dropped to 4.77 per 1,000 and the improvement was main-

182 Economic Assistance tained during 1936. After some delay, a grant of £3,000 (less than half the amount requested by the trust) was made by the Commissioner of the Special Areas to extend the work to South Shields, Sunderland and Gateshead. From 1937 onwards the scheme was administered by the Joint Council of Midwifery under the chairmanship of Lord Athlone." By 1939, antibiotics had become a more important means of reducing the maternal mortality rate than feeding could ever be, but Lady RhysWilliams maintained that the neonatal death rate and the stillbirth rate were both much improved by feeding the mothers. The local medical officers of health were well-pleased with the scheme; W.R. Nash, MOH for Caerphilly wrote to Lady Rhys-Williams: As you are aware the food stuffs sent to us by the Joint Council of Midwifery have done a tremendous amount of good work in my area. The women attending my ante-natal clinics are in the main so poor that it is necessary to supplement and adjust the diet in almost every case. It is an illuminating fact that all puerperal pyrexia and a lot of other obstetrical troubles seem to occur in those women who have not attended the ante-natal clinics." The experiment received wide press coverage. For example, the Daily Express ran the headline: `Women Will Tell Doctors how to Cut Mothers' Death Rate by Half' and there was public outcry when, in 1939, the continuation of the experiment was threatened by a shortage of funds." Health officials however remained sceptical. When Lady RhysWilliams approached Letitia Fairfield, a medical officer with the London County Council about extending the experiment to London, Fairfield remarked that the results the trust had obtained were `almost too good to be true'.80 In 1939, the Ministry of Health insisted that the experiment include a proper control group of equivalent income, age and parity and that this group should also receive a placebo, before the ministry would consider funding it. But, as Rhys-Williams explained to members of the National Council of Women, it had been hard to get the required cooperation from medical officers of health to conduct the experiment on a scientific basis until they had some evidence that extra feeding could make a substantial difference to the mortality rate.S1 A similarly sceptical attitude was displayed by the ministry towards the People's League of Health. The league was founded by Olga Nethersole at the end of World War I and had originally been intended by Lord Rhondda to serve as the propaganda arm of the Ministry of

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Health. The League's Committee on the Nutrition of Mothers was chaired by Professor James Young, of the University of London Medical School, and included some distinguished names, for example, Louise Mcllroy, J.S. Fairbairn, Eric Pritchard, F. J. Browne, Comyns Berkley, Victor Bonney and John Boyd Orr. Between 1938 and 1939, the League distributed supplementary calcium, iron and first class protein in pill form (to prevent the supplements being shared amongst the whole family) to 5,022 women in ten London hospitals. The death rate of primigravidae due to toxaemia showed a very signficant improvement which the committee felt `hardly possible to overestimate'.82 However, the Ministry of Health regarded the League as a `meddling' body and viewed its periodic deputations to the ministry as extremely tiresome. In 1927, it was reluctantly suggested that perhaps a minister should be present `to take part in the sacrifice annually offered by the Ministry of Health on the shrine of Miss Olga Nethersole'.83 The ministry's own Advisory Committee on Nutrition had considered the question of nutrition and childbearing, in 1934, in response to a paper on the subject, and the opinion was expressed that an investigation into the whole question would be desirable. Yet little assistance was provided by the Ministry of Health to either the National Birthday Trust or the People's League of Health. Suspicion also marked the ministry's attitude towards Balfour's and Drury's investigation into maternal health in Durham and Tyneside in 1935. Their findings were ignored because `apparently neither the qualifications of the investigators nor the scale of the investigations were such to hold out expectations that the investigations would have any value on the general question of maternal mortality'.84 However the excellent credentials of the People's League's Committee on the Nutrition of Mothers and the CMC did not help them in their approaches to the ministry. The CMC was characterised by Lord Balniel in a report sent to the ministry as: `a number of disappointed spinsters, representing "many millions of mothers" [who] advocated all the old demands for free milk, etc. for nursing mothers, etc., etc.'.85 While the Ministry of Health criticised the efforts of independent investigators to measure the effects of poor nutrition, its own criteria were notoriously unscientific. Local medical officers relied mainly on visual assessment and, as the CMC pointed out, the result was a collection of personal observations. Marjorie Green quoted the case of two medical officers who made successive examinations of the same group of children at an interval of seven days. The doctors' assessment differed at the first examination and both changed their opinions at the second

184 Economic Assistance examination.86 Few medical officers used methods such as haemoglobin counts, which Balfour and Drury employed in Durham and on Tyneside. Because of the difficulty in making an accurate clinical assessment of nutrition standards, the National Birthday Trust had distributed foodstuffs using a purely economic criterion. Similarly, the CMC and the Committee Against Malnutrition believed that economic rather than clinical criteria should be used to assess malnutrition. However, all local authorities required a medical certificate, often from the registered medical officer rather than a GP, before they would grant cheap or free milk. This situation did not change until 1939. The government skirted the question of whether the main cause of malnutrition was poverty, by blaming the ignorance of housewives for poorly balanced diets. As early as 1924, a report on the nutrition of miners and their families concluded that `the most encouraging result' of the investigation was that the standard of nutrition was best in households where the wife had been a domestic servant. This suggested to the investigators: `that by better education and organization more adequate physiological results can be obtained, even at the admittedly low level of income found in most of the districts'.81 In 1933, a Dr Simpson of the LCC was seconded to the Ministry of Health to investigate the nutritional standards of Leeds schoolchildren. He found many instances of malnutrition, even where the poor relief rate was high (6s. a head). This led him to believe that: `Ergo, malnutrition is perhaps as much a question of ignorance as L.s.d.'88 When the debate over nutrition reached its height in 1934, the staff of the Ministry of Health were directed to concentrate their `attack on the ignorance of the populace'.Ø9 The Nutrition Advisory Committee agreed that `every thing turns on the woman', and that in many cases she received insufficient instruction to do a good job. Mellanby felt that laziness and apathy on the part of the housewife were largely to blame for poor nutrition. The committee seized eagerly on the suggestion that Dr Elwin Nash be hired to give cookery demonstrations to housewives in low-income areas. Dr Nash promoted deep-fat frying and haybox cookery (a slow cooking method), and specialised in recipes for windfall apples and broken biscuits.90 The BMA also gave a public exhibition of recipes made from the diet sheets published in its 1933 report on nutrition; however the quantities of food used were so remote from the realities of the weekly working-class budget that the demonstration was a fiasco. With the publication of Boyd Orr's work showing that income was insufficient to purchase a minimum diet in so great a percentage of cases, the Ministry of Health redoubled its efforts to make education the

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focus of the debate and urged the Board of Education to make sure all school girls were educated in cookery.91 Groups whose views on maternal and child welfare were otherwise disparate agreed that women were in large part to blame for poor nutrition. In 1932, Birmingham's MOH believed that education had to be the `first line of defence' against malnutrition, as did the British College of Obstetricians and Gynaecologists, who believed that antenatal clinics should teach more cookery. Many women associated with the maternal mortality campaign also supported cookery lessons as a solution. Lady Baldwin, for example, volunteered her services to give cookery demonstrations. In 1938, it was proposed to appoint a woman officer to instruct women how to spend their UAB money more efficiently." Yet the studies which maintained that ignorance not poverty was responsible for poor diets, also admitted there to be little or no wastage of food. Imbalance often occurred in diets when a slightly more expensive, tasty `relish' was purchased — usually for the husband's tea — to relieve the monotony.93 G.C.M. McGonigle, the Labour women's sections, the CMC and the Committee Against Malnutrition all objected to blame being placed on the mother. McGonigle maintained that his investigations showed that housewives tended instinctively to buy the right kinds of foods: `The rule of thumb methods used by these women work well, and it is doubtful if education in the principles of nutrition would enable them materially to improve the nutritional condition of their families.'" Moreover, as the Committee Against Malnutrition pointed out, many of the BMA's recommended recipes required the use of an oven, which was extremely expensive, and the spices chosen to enliven bland foods were on the whole uncommon. The eager cookery instructors tended to ignore the traditions and psychology of workingclass cookery as well as the material realities of the working-class kitchen. While the government denied that UAB benefits were inadequate and ignored the results of independent studies showing the possible consequences of poverty on nutrition, it did go some way towards meeting the demands for cheap or free milk for mothers, infants and children of school age. There were two reasons for this: first, under the block-grant system begun in 1929, local authorities were responsible for allocating part of their budget to milk schemes for mothers and infants, and the Ministry of Health was as ready to apply pressure on authorities who were slow to spend their money in this way as they were to chide those who lagged behind in providing maternity services. Second, the

186 Economic Assistance problem of the surplus production of milk made it easier for the Ministry to confront the Milk Marketing Board and the Ministry of Agriculture with the nutritional needs of women and children. In 1936, a Ministry official commented on the deputation of the CMC to Lord Eustace Percy the previous year: `Their views on milk were not so unreasonable ... and it looks as if their immediate object was to press for improvement of the practice of the less generous authorities, a road on which we can travel with them some way.i95 Responses to the Ministry of Health's survey of 1936 showed that 65% of 410 authorities replying gave milk to children under five. Only 36% gave milk to expectant mothers throughout pregnancy while an additional 13%, including many Welsh authorities, provided free or costprice milk only during the last three months of pregnancy.% Apparently, many LAs believed that the 1921 budgetary cuts imposed on the provision of milk still held good, whereas in fact, after 1929, the central government had no authority to control their spending in any one area and, owing to the political controversy over nutrition, the Ministry of Health actively encouraged more extensive milk programmes. In some places, the qualifying income for free milk was such that families drawing UAB benefits still had to pay for it. Many of the LAs that imposed these income qualifications were located in areas where unemployment was worst and the authorities therefore poor because of low revenues from the rates. Of the sixteen maternal and child welfare authorities serving areas where unemployment was over 25%, six gave no free milk.97 In addition, some medical officers of health did not like giving out milk at clinics. The MOH of Wallsend opposed it because he objected to pasteurised milk.98 Other maternal and child welfare workers were reluctant to see so much of the time of clinic staff devoted to the distribution of milk. The main aim of the CMC was to have cheap milk delivered to the home, which involved large-scale subsidies for milk producers and went beyond the mandate of local authorities. Under the Milk Act of 1934, the government took the initiative in giving a £500,000 grant (called the Milk Publicity Fund) to the Milk Marketing Board to make milk available to children in schools at VZd. for one-third of a pint. The scheme was only partially successful with 45% of children participating. In 1936, the Ministry of Health anxiously anticipated `another storm about nutrition' in the wake of the publication of Boyd Orr's book and cast about for `a scheme to meet what is seen as a "dietetic and social wrong"'." The milk-in-schools scheme had been essentially a publicity scheme designed to stop milk going into manufacture at low prices.

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(Labour Woman had labelled the choice as `Children vs. Cheese'.) Increasingly, however, the provision of milk for mothers and children was seen as a necessary social service. This was the basis of the argument used by the CMC and the Committee Against Malnutrition, and both the Ministry of Health and the Treasury recognised its implications. Not unnaturally, the Milk Marketing Board felt that producers could not be expected to support the cost of a social service. Thus the question that the Ministry of Health was left with was: would the Treasury bear the cost? In seeking a means to extend the provision of cheap and free milk to mothers and infants, the Ministry of Health had to face the additional complications posed by the controversy over pasteurisation. If milk was to improve the standard of health it had to be safe; however the Milk Marketing Board saw this as an additional obstacle to any milk scheme and the Milk Reorganization Committee of 1936 ignored the question."* The issue continued to plague negotiations until compulsory pasteurisation was introduced after World War II. In 1936, the Ministry of Agriculture approved a limited scheme to provide mothers and infants with milk in the Rhondda. Milk was delivered at a charge of 2d. per pint without a means test being imposed. The losses to producers were met by the Commissioner for the Special Areas. In 1937, the scheme was extended to Jarrow. Those who had taken no milk before the scheme began took much more, but moderate consumers did not increase their consumption and thus little incentive was provided to producers not to process their milk. In Jarrow the scheme did better than in the Rhondda because so few had taken any milk at all before 1937. Consumption actually increased by 114%.101 Because of the difficulty in subsidising the programme, the Chancellor of the Exchequer refused to extend it. It was not until 1939 that a scheme was worked out, although it was never put into operation because of the outbreak of war. During World War II, the health of children and the question of nutrition became questions of national rather than political importance. From June 1940, a National Milk Scheme provided every pregnant or nursing mother and every child under five with a daily pint of milk, as well as vitamin supplements in the form of fruit juice, codliver oil, `national rose hip syrup' and pills. The Lancet urged: `The Children must be Fed!' During World War II, as during World War I, fears about not only the welfare but also the numbers of people increased. For this latter reason attention again reverted to the idea of family allowances as a means of increasing the birth rate. Leopold Amery, who was a

188 Economic Assistance leading member of the Eugenics Society and who as Colonial Secretary between 1924 and 1929 had campaigned for Empire Settlement, supported family allowances on these grounds; and Churchill, who opposed other measures of welfare legislation, was eager to provide both milk for mothers and children and allowances, because: `We must encourage by every means the number of births.'102 During wartime, when great sacrifices were being demanded of rich and poor alike, it was also considered crucial to stem possible discontent arising from the unequal distribution of wealth. The Times spoke of `an enlightened national conscience' and the need for `certain minimum standards'.103 However, increased wages forced up prices. Again allowances were seen as a means of breaking this `vicious spiral' and of mitigating hardships, without conceding any general advance in wages. The idea of family allowances as a supplement to wages had first been broached by the Royal Commission on the Coal Industry and was reinforced in 1937 when the report of the Unemployment Assistance Board showed 6% of male wage earners to be better off drawing unemployment benefits than working. Generally these were cases where `the applicant has a low wage rate and a large family'. This report particularly shocked more conservative elements of opinion. Violet Markham declared that she had never realised how `deplorably low' wages were and Lady Rhys-Williams felt that because of the findings of the report she could now support allowances because: `It is so much better to uphold the dignity of the home by putting the necessary money into the hands of the mother, than by teaching the children to look outside the home for all the good things of life.'10' One of the strongest arguments against allowances had been that workers would lose all incentive to work if they no longer had the responsibility of supporting their wives and children. After 1937, it was the turn of proponents of allowances to talk of incentive. During 1938 and 1939, conservative opinion led the call for allowances as the solution to the problem of low wages and large families. In the House of Commons the Bishop of Winchester called for the appointment of a committee on family allowances, and Leopold Amery wrote a major article for The Times drawing attention to the report of the UAB and to allowances as a solution to the needs of the employed worker.105 He received strong support from Graham White and Harold Macmillan. Some private firms introduced schemes of family allowances; amongst the most important were Pilkingtons, Tootals and Cadbury's. Management reported that the cost of the schemes rarely exceeded 1.5% of the total wage bill and L.J. Cadbury stated categorically that family

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allowances were a method of wage payment.106 In his important memorandum to the Treasury on wages and the cost of living in 1939, Lord Stamp accepted these views when he recommended allowances as the best means of `limiting the expansion of the wages bill with the minimum of personal hardship'.107 The TUC, however, continued to oppose allowances in the face of mounting opposition. Unions were accused of `making the children suffer' because of groundless fears about their own wages, and Rathbone accused trade-union men of liking the economic power they exercised over their wives. The TUC was also accused of fearing to loose power over its members if it permitted the state to implement a scheme of allowances.108 TUC support for allowances was eventually given in 1942 in virtual recognition of a fait accompli, for a few days before, Kingsley Wood, the Chancellor of the Exchequer, had issued a lengthy memorandum on the subject.109 The memorandum provided for allowances to be paid to all children under 15 at the rate of Ss. per week. Only a flat rate was considered workable, for if allowances were graded according to income, then assessment might be made on the basis of need and allowances paid to bring wages up to subsistence levels, as in the case of the Speenhamland system so feared by trade-unionists. There were immediate complaints that the flat rate on which the calculations were based was insufficient.» Suggestions were made that the allowances be supplemented by further grants in kind, particularly by increased school meal services. But the original desire of the FES for cash paid to the mother was strongly supported. Many felt it was an insult to suggest that mothers would not spend wisely in the interests of their children, and that cash would prove a more efficient form of giving assistance than kind as well as providing direct encouragement to parenthood." When the Beveridge Report on Social Insurance and Allied Services was published in 1942, it recommended an 8s. per week cash allowance for all children but the first; ls. per week was already being given in the form of school milk and meals. In so far as the allowances did not rely on the insurance principle they represented a radical departure from previous social policy. However, the 1945 Family Allowances Act gave only 5s. per week to all children but the first, the same amount that had been suggested by the FES in 1918, with no provision for paying the mother. The government made it clear that allowances were designed only to ease the financial burden children imposed on parents and to provide a measure of encouragement to have more children. l12 Because the motives of the government in introducing both the milk

190 Economic Assistance schemes and family allowances were so different from those which had originally prompted action from women's groups, it was inevitable that the measures enacted would be partial, and bring ameliorative rather than radical change. The only remnant of the original principles behind the request for family allowances was that the House of Commons agreed to pay allowances to the mother rather than the father. All women's groups recognised the importance of economic assistance to mothers in the form of cash or kind if they were to be able to improve their own health and that of their families. Feminists were also anxious to increase the status of motherhood by securing a financial reward for mothers' services. While this concern inspired the early campaign for family allowances, it became submerged in the political debate over the effect of poverty on health, and economic assistance as a means to better health became the only consideration. The suggestion that poverty was a cause of malnutrition, poor health and even death amongst mothers and infants caused great political controversy. The government responded by denying that economic assistance was necessary and by dismissing the investigations of groups such as the Children's Minimum Council, the People's League of Health and the National Birthday Trust as unscientific, as well as making derisive reference to the members of these organisations in private. Advocating the same solution as they had in response to the problem of infant mortality, health officials insisted that the education of mothers was the answer to poor nutrition. The same desire to avoid the issue of poverty and its effects on health also helps to explain why the government kept its attention so firmly fixed on an improved maternity service as the answer to the problem of maternal mortality. When women further demanded free access to birth control information through the maternal and child welfare clinics, political controversy again resulted, this time because of the concern over the birth rate.

Notes 1. Labour Party, Report of the 23rd Conference, 1923, p. 247. 2. 'Shall Married Women be Dependants?' Cooperative News, 2 Nov. 1912, pp. 1375-6 and 16 Nov. 1912, p. 1436, letter from 'Wife and Mother'. 3. Anna Martin, The Mother and Social Reform (NUWSS, 1913). 4. 'Should Wives be Paid?', Cooperative News, 13 Dec. 1913, p. 1654. 5. National Health, 11 (Oct. 1918), p. 90. 6. LGB, Mothers Pensions in the USA. Report Prepared by the Intelligence Department of the LGB (HMSO, 1918), p. 1; and I'P, 'Report of the War Cabinet Committee on Women in Industry', 1919, Cmd. 135, XXXI, 241, p. 179; 'Report of the Women's Employment Committee', 1918, Cd. 9239, XIV, 783, p. 55.

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7. Labour Party, Report of the 18th Conference, 1918, p. 138. 8. 28th Annual Report of the Women's Cooperative Guild, 1910.11, p. 17. 9. 31st Annual Report of the Women's Cooperative Guild, 1913-14, p. 24. Jean Gaffin, `Women and Cooperation' in Women and the Labour Party, edited by Lucy Middleton (Croom Helm, 1977), pp. 113-42, gives a fuller account of WCG activities during the period. 10. See 31st Annual Report of the Women's Cooperative Guild, 1913-14, pp. 22-3; Labour Party, Report of the 30th Conference, 1930, p. 176 (views of Mr Rhys J. Davies of the Distrib. and Allied Workers Union); and PRO, T161/1116, E. Hale to F.N. Tribe, 29 April 1940. 11. Minutes of the Fabian Women's Group, 24 May 1910, and 9 June 1910; and Magdalen Stuart Pember Reeves, Round About a Pound a Week (G. Bell, 1915). 12. Mrs Bernard Shaw (ed.), Summary of Eight Papers and Discussions upon the Disabilities of Mothers and Workers (FWG, 1910), p. 5. 13. Victor Gollancz (ed.), The Making of Women: Oxford Essays in Feminism (Gollancz, 1917), p. 29. 14. The Times, 26 April 1921, p. 13. 15. For further information on the feminist movement during the inter-war years see my article, 'Beyond Suffrage: English Feminism in the 1920's,' Maryland Historian, 7 (Spring 1975), pp. 1-17. 16. Eleanor F. Rathbone, Milestones: Presidential Addresses at the Annual Council Meetings of the NUSEC (NUSEC, 1929), p. 28. 17. Rathbone, Milestones, p. 4. 18. Eleanor F. Rathbone, 'The Remuneration of Women's Services', The Economic Journal, 27 (March 1917), pp. 55-68. 19. PRO, MH 48/183, Annual Report of the Birmingham Infant Health Society and School for Mothers, 1915, p. 2. 20. Eleanor F. Rathbone, The Ethics and Economics of Family Endowment (The Beckley Lecture, 1927), p. 52. 21. Mary Stocks, Case for Family Endowment (Labour Publishing Co., 1927), p. 10. 22. K.D. Courtney, H.N. Brailsford, Eleanor F. Rathbone, Mary Stocks, Elinor Burns and Emile Burns, Equal Pay and the Family (Headley, 1918), p. 40. 23. Alice Heale, 'Payment of the Mother', unpublished address, March,1925, Fawcett Library, gives the strongest statement to this effect. 24. Rathbone, 'Remuneration of Women's Services', and Eleanor F. Rathbone, Disinherited Family (Edward Arnold, 1924), p. 48. Mrs Sydney Webb argued the case for allowances on these grounds in her 'Minority Report to the War Cabinet Committee on Women in Industry', Cmd. 135, pp. 305-7. 25. Cmd. 135, p. 307. 26. Rathbone, Disinherited Family, p. 16. Eleanor F. Rathbone, The Case for Family Allowances (Penguin, 1940), p. 42, gives revised statistics based on the 1921 census. The percentage of families with more than three children had dropped to 6.7%. 27. See, for example, A.D.K. Owen, A Survey of the Standard of Living in Sheffield (Sheffield Social Survey Committee Pamphlet no. 9, 1933), pp. 21-9; P. Ford, Work and Wealth in a Modern Port (Allen and Unwin, 1934), pp. 98-9 and 108; Herbert Tout, The Standard of Living in Bristol (Bristol: Arrowsmith, 1938), pp. 38-9; and B.S. Rowntree, Poverty and Progress, 2nd Social Survey of York (Longmans, 1941), p. 52. 28. The Family Endowment Committee changed its name to the Family Endowment Council in 1918 and again to the Family Endowment Society in 1925.

192 Economic Assistance 29. Eleanor F. Rathbone, Memo of Evidence on Behalf of the Family Endowment Society to the Royal Commission on the Coal Industry (FES, 1925), pp. 4-5. 30. PP, 'Report of the Royal Commission on the Coal Industry', 1926, Cmd. 2600, XIV, 1, p. 164. 31. H.N. Brailsford, Families and Income (ILP, 1926), p. 9. 32. 'Family Endowment in Britain', n.d., LSE, Beveridge Papers, IX B, no. 14. 33. Eleanor Rathbone, 'Family Endowment in Its Bearing on the Question of Population', Beveridge Papers, Coll. Misc. 9, folio 96; and Rathbone, Disinherited Family, p. 289. This view was first expressed by W. McDougall, 'A Practical Eugenic Suggestion' in Sociological Papers (Macmillan, 1904), pp. 53-80. 34. Mary Stocks, Eleanor Rathbone (Gollancz, 1949), p. 118. 35. Problems of Population and Parenthood Being the 2nd Report and the Chief Evidence Taken by the National Birth Rate Commission, 1919-1920 (Chapman Hall, 1920), p. 301, evidence of Mrs Pember Reeves; and Labour Party, Report of the 29th Conference, 1929, p. 23, resolution from the Women's Conference. 36. Labour Party, Report of the 26th Conference, 1926, p. 274. 37. Files of the Jt Cttee, on the Living Wage, TUC Archives, T 189 File 117.4; and Labour Party, Report of the 30th Conference, 1930, p. 213. 38. PP, '48th Annual Report of the LGB for 1918-1919. Supplement containing the Report of the Medical Department', 1919, Cmd. 462, XXIV, 577, p. 14. 39. 'Milk: Infant Mortality and Government Economy', Labour Woman, 9 (Oct. 1921), p. 155; 'Milk and a Victory for Labour Women', Labour Woman, 9 (Nov. 1921), p. 171; and 39th Annual Report of the Women's Cooperative Guild, 1921-22, p. 13. 40. Minutes of the Proceedings of the Health Committee XXXIV, 8 April 1921, and 24 May 1921, Hull Public Archives. 41. Labour Women, 10 (Feb. 1922), p. 19. 42. Annual Report of the Medical Officer of Health for Hull, 1922, p. 23. 43. Minutes of the Proceedings of the Health Committee XXXVIII, 12 June 1925, Hull Public Archives. 44. H.C. Corry Mann, Diets for Boys during the School Age, Medical Research Council Special Report Series no. 105 (HMSO, 1926). Two more influential studies were published in the Lancet: John Boyd Orr, 'Milk Consumption and the Growth of School Children', Lancet, 28 Jan. 1928, pp. 202-3; and Gerald Leighton and Mabel L. Clark, 'Milk Consumption and the Growth of School Children', Lancet, 5 Jan. 1929, pp. 40-3. 45. Labour Woman, 18 (June 1930), p. 87. 46. F.J. Browne, 'The Health of the Woman Citizen as Potential and Actual Mother', Jr. of State Med., XXXIX (Dec. 1931), pp. 688-702. 47. Edward Mellanby, 'Vitamin A as an Anti-Infective Agent', BMJ, 20 Oct. 1928, pp. 691-8. See also, Edward Mellanby, 'The Relation of Diet to Health and Disease', BMJ, 12 April 1930, pp. 677-81; and Nutrition and Disease (Edinburgh: Oliver and Boyd, 1934), pp. 85-6; and 'Nutrition and Childbearing', Lancet, 18 Nov. 1933, pp. 1131-7. The most up-to-date work on this subject is that of Nevin S. Scrimshaw, Carl E. Taylor and John E. Gordon, Interactions of Nutrition and Infection (Geneva: WHO, 1968). 48. Louise Mcllroy, The Toxaemias of Pregnancy', Lancet, 18 Aug. 1934, pp. 345-50. 49. Janet Campbell, High Maternal Mortality in Certain Areas. Reports on Public Health and Medical Subjects, no. 68 (HMSO, 1932), p. 8; Ministry of Health, Final Report of the Departmental Committee on Maternal Mortality and Morbidity (HMSO, 1932), p. 117; PP, 'Report of an Investigation into Maternal

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Mortality', 1936-7, Cmd. 5422, XI, 1, p. 278; and PP, `Report on Maternal Mortality in Wales', 1936-7, Cmd. 5423, XI, 367, pp. 93-4. 50. Ministry of Health, Memo to the Minister of Health on the Criticism and Improvement of Diets, by the Adv. Cttee. on Nutrition (HMSO, 1932), p. 7. 51. BMA, Report of the Committee on Nutrition (BMA, 1933), pp. 7-8. 52. PRO, MH 56/55, Geoffrey Shakespeare to the Minister, 24 Nov. 1933. 53. PRO, MH 56/47, Ore. 1370, 4 Jan. 1934. 54. PRO, MH 56/55, memo by Newman to Shakespeare, 4 Dec. 1933, and MH 56/56, Sir Arthur Robinson to the minister, 11 Jan. 1934. The reference is to McGonigle's study of a new housing development in Stockton; see, G.C.M. McGonigle and J. Kirby, Poverty and Public Health (Gollancz, 1936), pp. 108-26. 55. Ministry of Health, Report of the Chief Medical Officer for 1933 (HMSO, 1934), pp. 208-21; and PRO, MH 55/275, enclosures, 27 Nov. 1934; and PRO, MH 56/55 Labour notes for speakers, 1 Dec. 1933. 56. PRO, MH 56/56, clipping, 11 Jan. 1934. The report referred to was: Ministry of Health, Report on Diets in Poor Law Children's Homes by the Adv. Cttee. on Nutrition (HMSO, 1932), p. 10. Bentley B. Gilbert, British Social Policy 1914-39 (Batsford, 1970), pp. 183-4, describes the uproar that followed the implementation of the new UAB scales. 57. PRO, MH 56/46, meeting of the Nutrition Advisory Committee, 15 Dec. 1933. 58. PRO, PREM 1/165, deputation of the CMC to the PM, 12 March 1934. 59. Children's Minimum Council leaflet, 1938. See also, Geoffrey Wilson, Rent Rebates, Fabian Pamphlet no. 28 (Gollancz, 1936), gives details of rent rebate schemes. 60. PRO, PREM 1/165, deputation of the CMC to the PM, 12 March 1934. 61. Family Endowment Chronicle, 3 (Aug. 1934), p. 9. 62. Interview with Marjorie Soper (nee Green), 6 April 1977, interviewer Sue Bruley. I am grateful to Sue Bruley for the transcripts of this interview. 63. PRO, MH 55/275, CMC deputation to Ramsay McDonald, 27 Feb. 1934. In 1938 the list of Vice-presidents of the CMC included: Sir Edward Grigg, Dame Janet Campbell, Lord Noel Buxton, Dr Eric Pritchard, Lady Denman (of the National Birth Control Association and the Federation of Women's Institutes), Mr Julian Huxley, Sir John Boyd Orr, Sir George Schusted, Rev. S.M. Berry, Sir Daniel Hull, Sir Robert McGarrison, Mr C.S. Orwin, and the Lord Bishop of Winchester. The executive included: Mr R. Acland, Dr Margaret Balfour, Mr Edward Fuller, Mr Harold Nicholson, Miss Symons, Mrs E. Barton, Mrs E. Hubback, Miss E. Rathbone, Miss Gertrude Tuckwell, Lady Rhys-Williams, Mrs Ayrton Gould, Mrs Barbara Drake, Miss Susan Lawrence, and Mr Duncan Sandys (CMC Report for the Year Ending 1938, Rhys-Williams Papers). 64. CMC, Memo on the Scale of Needs Suitable for Adoption by the UAB in Assessing Assistance to Applicants under Pt. II of the Unemployment Act, 1934 (CMC, 1934); PRO, MH 55/275, CMC deputation to Lord Eustace Percy, 1935; and PRO, PREM 1/165, Milk Policy statement by the Ministry of Agriculture and Fisheries, 22 Feb. 1934. 65. PRO, PREM 1/165, Board of Education to the Prime Minister, 10 March 1934. 66. PRO, ED 24/1367, 'Provision of Milk in Schools', 19 Feb. 1934. 67. Ministry of Health, Annual Report of the Chief Medical Officer, 1926 (HMSO, 1927), p. 148. 68. J.M. Winter has given vupport to the Ministry of Health view expressed during the 1930s. He points to the closing of the gap between the infant mortality rates of the Registrar-General's Classes I and V during the 1930s and notes that the high summer diarrhoea mortality during 1911 makes it a poor year on which

194 Economic Assistance to base comparisons (Infant Mortality, Maternal Mortality and Public Health in Britain in the 1930s', Jrnl. Eur. Econ. Hist., 8 (Autumn 1979), p. 451). I chose to base my comparison on Class II because Class I is relatively small. The 1921 Decennial Supplement of the Registrar-General shows that Class I accounted for 2% of all occupied married males and Class II for 27% (General Registry Office, Registrar General's Decennial Supplement for 1921, Pt I (HMSO, 1927), p. ciii, Table A). 69. 'Can Health be Bought?', New Statesman, 10 (28 Dec. 1935), p. 1008; and 'The Price of Motherhood', News Chronicle, 14 May 1934, p. 10. 70. PLH deputation to Kingsley Wood, 21 July 1936, GLC Archives, PH Hosp. 2/27. 71. Cmd. 5423, pp. 93-4. 72. Cmd. 4886, p. 43. 73. Ministry of Health, Annual Report of the Chief Medical Officer, 1932 (HMSO, 1933), p. 38. 74. Maternal Mortality, Report of a Meeting Held at the Friends' House, Euston, 1932, p. 14. 75. Labour Party, Report of the 34th Conference, 1934, p. 182. 76. Bulletin of the Committee Against Malnutrition, no. 7 (March 1935), p. 8. See also C.E. McNally, Public Ill-Health (Gollancz, 1935), pp. 118-20. McNally was the Hon. Treasurer of the Committee Against Malnutrition. Derek Llewellyn-Jones, Human Reproduction and Society (Faber and Faber, 1974), p. 430, states that services also become more significant when the health level of the mother is low. 77. For an account of this experiment see, 'Malnutrition; Maternal Mortality', TS, Rhys-Williams papers; Judith Jackson, Maternal Welfare (National Birthday Trust, 1936), pp. 38-41; and Lady Rhys-Williams, 'Malnutrition as a Cause of Maternal Mortality', Public Health, 50 (Oct. 1936), pp. 11-19. 78. W.R. Nash to Rhys-Williams, 11 Sept. 1938, Rhys-Williams Papers. 79. Daily Express, 3 Sept. 1938 and Manchester Guardian, 14 June 1939, clippings in Rhys-Williams Papers. 80. Memo of interview, 10 March 1938, GLC Archives, PH Hosp. 2/27. 81. National Council of Women News, 16 (Oct. 1930), p. 108. 82. 'Interim Report of the People's League of Health, 1939', GLC Archives, PH Gen. 3/7. 83. PRO, MH 58/154, A. Robinson to H.J. Wilson, 20 April 1927. 84. PRO, MH 55/688, Note, n.d. 85. PRO, MH 55/275, Lord Balniel to A.N. Rucker, 15 Feb. 1934. 86. Marjorie Green, Malnutrition among School Children (CMC, 1938), p. 7. 87. Committee upon Quantitative Problems in Human Nutrition, Report on the Nutrition of Miners and their Families, Medical Research Council Special Report Series no. 87 (HMSO, 1924), p. 29. 88. PRO, MH 56/48, Simpson to T. Carnwath, 28 Nov. 1938. 89. Ibid., H.E. Magee's report on Simpson's work, 16 Jan. 1934. 90. PRO, MH 56/46, meeting of the Nutrition Advisory Committee, 23 Sept. 1933; meeting of the Nutrition Advisory Committee, 23 April 1934; and Nash's Report, 18 Aug. 1934. The BMA put out its own cookery book in 1935: Family Meals and Catering (BMA, 1935). 91. PRO, ED 12/210, memo MH to Board of Education, 1 Oct. 1935. See above p. 95. 92. Annual Report of the MOH for Birmingham, 1932, p. 111; PRO, MH 55/642, British College of Obstetrics and Gynaecology to Sir Julian Cahn (of the National Birthday Trust), 29 May 1936 and Baldwin to Kingsley Wood, 11 June 1936; PRO, AST 7/315, report on a parliamentary debate, 22 July 1938.

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93. Reeves, Round About a Pound, p. 131. 94. McGonigle and Kirby, Poverty and Public Health, p. 256. See also Bulletin of the Committee Against Malnutrition, no. 16 (Sept. 1936), p. 35; and PRO, MH 55/275, Marjorie Green to the minister, 27 Nov. 1934. 95. PRO, MH 55/68, G.E. Yates to A.B. MacLachlan, 19 Nov. 1936. 96. PRO, MH 55/629, comments on the Welsh Board of Health Report, 1 Dec. 1936; and PRO, MH 79/350, 'Supply of Milk under MCW Arrangements', 17 Oct. 1936. 97. CMC, Special Areas Bill. Memo on Proposed Provision for Additional Food, etc. for Mothers and Children in the Distressed Areas (CMC, 1937), pp. 10-11. 98. PRO, MH 79/347, report of an investigation of Milk-in-Schools, 21 March 1936. 99. PRO, MH 79/347, Treasury and MH Conference, 16 March 1936. 100. 'Safe Milk', Mother and Child, 6 (May 1935), pp. 45-6. 101. PRO, MH 79/350, Ministry of Agriculture to MH, 1 March 1937; and MH 55/643, Borough of Jarrow Report on Milk Scheme, 26 June 1937. 102. The Times, 25 June 1938, p. 8; and Robert Rhodes-James (ed.), Winston S. Churchill. His Complete Speeches, 1897-1963, vol. VII (Bowker, 1974), p. 7186. 103. The Times, 9 Sept. 1941, p. 5. 104. PP, 'Report of the Unemployment Assistance Board for the Year Ending, 31 Dec. 1937', 2937-8, Cmd. 5752, XIII, 77, p. 82; PRO, AST 7/390, Markham to Cadbury, 11 July 1939; speech at the Lloyds Debating Society, 16 Dec. 1938; and Rhys-Williams to Miss M. Gillie of the Sunday Express, 5 May 1939, Rhys-Williams Papers. 105. Parliamentary debates (Lords), 110, 1938, col. 629; and The Times, 14 June 1938, p. 17. 106. Rathbone, Case for Family Allowances, pp. 115-18, and The Times, 5 Jan. 1940, p. 4, letter from L.J. Cadbury. 107. PRO, T 161/116, Lord Stamp's memo on Wages and the Cost of Living, 30 Nov. 1939. 108. The Times, 13 July, 1939, p. 7; Rathbone, Case for Family Allowances, pp. 1024; and Eleanor Rathbone 'Five Shillings a Child', New Statesman, 21 (31 May 1941), p. 550. 109. PP, 'Family Allowances, Memo by the Chancellor of the Exchequer', 1941-2, Cmd. 6354, IX, 51, p. 8. 110. The Times, 15 May 1942, p. 5, letter, J.A. Cecil Wright. 111. The Times, 26 May 1942, p. 2; and Eleanor Rathbone, 'Cash or Kind?', New Statesman, 23 (13 June 1942), p. 380. 112. Parliamentary debates (Commons), 408, 1944-5, col. 2260.

BIRTH CONTROL

With the advantage of hindsight, Richard Titmuss described the widespread acceptance of birth control as the most important factor contributing to both the improvement in women's health and female emancipation.1 During the period 1911-39, national health insurance statistics, social surveys and reports of physicians all showed the extent of morbidity due to, and exacerbated by, childbirth. The personal records of the women who wrote to the Women's Cooperative Guild at the beginning of World War I also revealed the misery attending frequent pregnancy and childbirth. Taken together, this evidence supports Titmuss's conclusion. Fertility control was as important as economic assistance in improving maternal welfare. Women's groups did not make any formal demand for birth control until the 1920s. This was because the birth control movement had been dominated by the Malthusian League up to World War I, and the league's philosophy did not inspire public support. Founded in 1877, the league believed that overpopulation was the cause of misery and want, and that birth control was the only means by which the worker might avoid poverty and actually improve his lot. The league's academic tone and dismal philosophy were unattractive. Moreover, it was also associated both with radical ideas about sexuality, which G.R. Drysdale had promoted in his book the Elements of Social Science, published in 1871, and with atheism, because the Drysdale family (who were the leading members of the League) had played a major part in the defence of Charles Bradlaugh and Annie Besant at their trial in 1870. Bradlaugh and Besant were both freethinkers and were prosecuted for republishing the Fruits of Philosophy, a birth control text first published in 1832. The falling birth rate and the high abortion rate alone show that women were anxious to control their own fertility, but they did not openly support the birth control cause until Marie Stopes provided a more respectable justification for the use of contraceptives during the 1920s. Policy-makers, eugenists and even the Anglican Church, all of whom had remained unmoved by the Malthusian League, were also impressed by Stopes's arguments. However, women's groups were concerned with birth control chiefly as a means to better health and greater freedom for the individual mother, while policy-makers and eugenists welcomed birth control as a means to racial improvement and greater 196

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social control.' Stopes herself and many members of women's groups perceived no tension between these two aims. The initiative in promoting birth control during the inter-war period rested first with Stopes and from 1930 onwards with the National Birth Control Association (NBCA).3 Women's groups passed resolutions of support during the 1920s and certain individuals worked with the birth control societies, but, apart from some members of the Labour Party's women's sections, they did not form their own birth control groups. The main demand of birth controllers during the inter-war years was for birth control information to be made available at the child and maternal welfare centres. In 1930, very limited gains were made in this direction when the government agreed to make such information available to sick women, for whom pregnancy was deemed detrimental to health. This decision could be justified in terms of improving the quality of population. No further liberalisation of the regulations permitting the distribution of birth control information occurred. Most MPs and Ministry of Health officials considered birth control antithetical to maternal and child welfare. A childbearing women could not, in their view, also be in need of contraceptive advice. The main motive behind the child and maternal welfare movement was to maintain and increase the population. Any liberalisation of attitudes towards birth prevention therefore seemed an illogical step. In addition, frequent pregnancies affected maternal welfare in the broadest sense, but could not be proved to have a significant effect on either the infant or maternal mortality rates, which were the main concern of health officials. Just as family allowances were eventually granted on purely pragmatic grounds, so birth control gained a measure of official acceptance only when the concern over the numbers of population had passed and when it was deemed economically expedient for women to be given incentives to enter the labour force. During the 1920s, many major women's groups came out in support of birth control as a necessary part of any maternal and child welfare policy and as the natural complement of economic assistance for mothers. The WCG was the first to do so in 1923. In 1924, Labour Party women passed a resolution at their annual conference demanding that birth control information be made available at governmentsponsored maternal and child welfare clinics to women who asked for it and at the doctors' discretion when it was felt to be medically desirable. After the conference, the Workers' Birth Control Group was formed to promote this aim. It used no justification other than the claim of all women as mothers to knowledge of matters concerning their health:

198 Birth Control `It is time the claims of the working woman in her capacity as a mother were more fully recognized.i4 The Workers' Birth Control Group had hoped that the Labour Government of 1924 would support their goals. Unfortunately, the Minister of Health, James Wheatley, was a Roman Catholic. The annual conference of the Labour Party women's sections passed resolutions in favour of birth control in 1925, 1926 and 1927. But in 1927, the National Executive of the Labour Party decided that `the subject of birth control was in its nature not one which should be made a political party issue's Many socialists rejected the idea of birth control because of its association with malthusianism (which argued essentially that the poor were responsible for their own misery), and believed that what was needed was a more equal distribution of wealth rather than fewer children. But as Dora Russell, a founder of the Worker's Birth Control Group, recalled in her autobiography: `We labour women fully agreed with the money argument, but asserted that even if we lived in Buckingham Palace, we would not want a baby every year.'6 The National Union of Societies for Equal Citizenship (NUSEC) also came out in support of birth control in 1925, the same year that it declared its support for family allowances. The Women's Liberal Association passed a resolution in favour of birth control in 1927 and the National Council of Women did likewise in 1929. Mary Stocks, an executive member of the NUSEC, believed both family allowances and birth control to be essential if women were fully to control their own lives by maintaining their economic independence and controlling their own fertility. The Women's Leader, a feminist journal, put the case for birth control in terms of a woman deciding for herself her conditions of work, her output and thereby the quality of her product.' But the NUSEC did little to actively promote contraception. Its members worked either through societies designed to campaign specifically for birth control or individually in their own localities. Mary Stocks, for example, set up her own birth control clinic in Manchester. Women's groups were late in giving formal support to the idea of birth control. The WCG welcomed the decline in the birth rate as early as 1911 and an article in Labour Woman in 1913 pleaded for understanding as to why working-class women should want to use birth control.8 However, neither called for more information to be given on the subject. Sylvia Pankhurst was very concerned with the question of maternal welfare and advocated a longer gap between pregnancies, yet, in 1916, she appeared to be antagonistic to any general use of birth control.' These views were similar to those described by Joseph and

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Olive Banks in Feminism and Family Planning: in the 1890s and early twentieth century, some women complained about the exhaustion of women bearing many children, but stopped short at advocating birth control. Some, like Vera Laughton Matthew, felt that if a woman could not `refuse her husband' then her subjection was complete. The Banks's believed that these views indicated that feminists did not support birth control, but as Angus McLaren has pointed out, this was not necessarily the case. Women advocating abstention or even `purity for men', like Christabel Pankhurst, were all united in demanding that motherhood be voluntary, even if they did not support mechanical methods of birth control.10 Moreover, the decrease in the birth rate showed that in practice more and more couples were limiting their families, although whether at the initiative of husband or wife is impossible to say." The birth rate declined steadily and with it family size (see Table 7.1). Table 7.1: Crude Birth Rate, 1870-1932 1870-2 1900-2 1910-12

34.1 22.8 24.5

1920-2 1930-2

24.5 15.8

Source: D.V. Glass, Population Policies and Movements in Europe (Oxford: Clarendon, 1940), p. 5. There is also evidence to suggest that the number of abortions was great. Many working-class women did not believe self-abortion to be illegal or immoral if it were done before `quickening'.12 Two of the women interviewed for this study confused birth control and abortion, answering a question on birth control with references to hot mustard baths and taking large quantities of epsom salts, which were commonly believed to induce abortion. Lead plaster, ergot, pennyroyal, quinine, castor oil and Reckitt's blue were also popular abortifacients. Attempted abortion by drug-taking was obliquely referred to in seven of the letters published by the WCG in 1915. Marie Stopes published letters she received asking for birth control advice and many of these also requested abortion advice." In 1929, Stopes reported that her travelling birth control clinic had received 20,000 requests for abortion information in just over a year and a half. The BMA estimated that between 16% and 20% of all pregnancies ended in abortion; what percentage of these was criminal is unknown. Certainly, large numbers of women resorted to abortion. Angus McLaren records the case of some 10,000 requests for `female pills' from one

200 Birth Control small company alone during a two-year period. Such pills could cost as much as 7s. 6d each, and a bottle of liquid that was probably a mixture of washing soda and stout, as much as 10s..14 Formal demands for birth control by women were delayed chiefly because the only established group advocating contraception in England before World War I was the neo-malthusians. The league appealed to feminists for support, but when its arguments were so widely distrusted it stood little hope of success. C.V. Drysdale never understood why women campaigning for the vote would not also make birth control their cause.15 Alice Vickery Drysdale, the first woman to be admitted to the Pharmaceutical Society and wife of C.R. Drysdale (the leader of the league until his death in 1907), tried to encourage the formation of a women's Malthusian League on the grounds that birth control would promote morality and end prostitution through early marriage.16 The consequent elevation of sexual relationships would, she thought, soon get women the vote. Two feminists, Eva Hubback and Edith How-Martyn did join the league in 1910, but were never very active because they disliked the classical economic doctrines it espoused. Edith How-Martyn paid tribute to Alice Vickery's `spade work for the woman's side' in 1929.17 but women did not begin openly to discuss birth control until World War I. The league's argument for birth control was rigidly repressive and its strict adherence to malthusian economics was hopelessly outdated even by the 1880s. More important still, the attempt to spread the knowledge and practice of contraception was widely condemned on the practical grounds that it was both dysgenic and that Britain needed a larger, not a smaller, population. The league wanted to increase the use of birth control amongst the poor, yet despite its efforts, it was the middle and upper classes rather than the working class who were limiting their families. Three separate studies had pointed out the differential decline in the birth rate. One by the Galton Laboratory reiterated David Heron's earlier conclusions, `proving' that there was an inverse relationship between the birth rate and the `socially most valuable members of the community' (determined by wage rates). Sidney Webb showed that both intellectuals and members of friendly societies were limiting their families, although unlike the Galton Laboratory study, Webb concluded that this indicated the thrifty of all classes to be using contraception. Finally, the report of the Registrar-General for 1911, showed conclusively that, regardless of the behaviour of responsible artisans in friendly societies, the birth rate was indeed declining more rapidly amongst the middle and upper classes than amongst the working

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class.18 C.V. Drysdale was quite ready to recognise the eugenic fear that the wrong people were using birth control, and the league increased its propaganda efforts among the poor. Between 1913 and 1917, 12,000 birth control leaflets were distributed in poor areas of London. This did not change the fact that in practice birth control was proving dysgenic. In 1908, a meeting of Anglican clergy expressed their dismay that the able and `fit' members of society were neglecting their duty to parenthood, and Dean Inge of St Paul's (a member of the Eugenics Society) made the more explicitly eugenist complaint that `the birth rate of the professional classes is only half that of the unskilled labourers'.19 Conservatives and imperialists also deplored the reluctance of the middle class to be parents; A.J. Balfour, PM between 1902 and 1905 and Unionist leader until 1911, and Leopold Amery, Conservative MP, were both members of the Eugenics Society. Women's groups also felt the problem to be important. An article in Labour Woman, which was intended as a reply to a previous piece asking for a measure of understanding for women who were using birth control, called contraception `an evil' and cited the studies of the Galton Laboratory and Karl Pearson as proof.20 Eleanor Rathbone, President of the NUSEC, also showed herself to be aware of the danger of increasing `population of the wrong kind' when she talked of family allowances, and both the NUSEC and the WCG supported the campaign to legalise sterilisation for certain groups of `unfit' persons.21 The Malthusian League was also attacked by those who sought an increase in the overall birth rate, regardless of class differentials. Sir James Marchant, Secretary to the influential National Birth Rate Commission, concluded: `In the difference between the number of cradles and the number of coffins lies the existence and persistence of our Empire.i22 The Malthusian noted wryly that its new campaign among the poor would be dismissed as `race suicide', showing that the league realised how influential the birth rate propagandists were.23 C.V. Drysdale insisted that there was a close association between a high birth rate and a high infant mortality rate, and that it would be more humane to decrease the number of births. The few socialists who supported birth control also believed that there was little point in worrying about the decrease in the birth rate when so many infants born alive subsequently died. One male socialist commented, `12 million starving! And the cry is "more babies"!'24 However, eugenists believed that a high birth rate and a high infant mortality rate were necessary if poor specimens were to be weeded out and survival of the fittest ensured.

202 Birth Control Health officials did not often take the extreme eugenist view. Many accepted that there was an association between a high birth rate and a high infant mortality rate, but nevertheless argued for increasing rather than decreasing the birth rate because this was the most effective way of increasing population. The Medical Officer of Health for Liverpool commented in 1917: `It is the high birth rate, not withstanding the waste of infant life usually accompanying it, which dominates the increase in population.'25 Newsholme denied the association between a high birth rate and a high infant mortality rate altogether, pointing out that in Ireland the birth rate was high and the infant mortality rate low.26 This was a valid part of Newsholme's defence of infant welfare work, but it also argued against the need to reduce fertility in order to reduce infant mortality. Recent work on the reasons for the decline of infant mortality have lent support to Newsholme's view. There are parallel trends in fertility and infant mortality over short intervals, but because there is no appreciable time lag between the two, it is difficult to see how the relationship could be causal. It has been suggested that the lack of any correlation between the fall in fertility and the fall in infant mortality may be explained by the fact that the proportion of high birth order infants was too small to be a statistically significant factor.27 In order to test conclusively for any association, it would be necessary to select a sample of high parity mothers. While high fertility was not directly linked to high infant mortality, it is possible that there was an indirect link with post-neonatal mortality: the mother was more likely to be fatigued and less able to cope, and poverty to increase. It is also certain that the health and welfare of mothers suffered, which very few health officials paused to consider. At the end of World War I, George Newman commented: `In the legitimate desire to encourage a high birth rate we are sometimes apt to forget or ignore the heavy burden which a family of children near together in age places upon the working class mother,i28 but he never advocated the use of contraceptives. The wartime experience did make discussion of birth control easier among doctors who came to accept the use of the condom, chiefly because of its use as a prophylatic in the fight against VD. But while the war did much to change moral values, it did not render either the league's case for birth control or the practice of contraception any more respectable. It needed the new approach provided by Marie Stopes, who published her first book containing birth control information (Married Love) in 1918, to make the idea of contraception acceptable to women, doctors, health officials and MPs, whose motives for

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supporting contraception, and the extent to which they were prepared to see it used, differed widely. Stopes divorced herself completely from the malthusians. She was a Christian rather than a freethinker and set out to provide a strong scientific justification for birth control, rather than an economic one. She was also determined to come to terms with eugenic and underpopulationist opposition to birth control. The name of the society she founded in 1921 reflected this; she called it the Society for Constructive Birth Control and Racial Progress (CBC). Stopes was determined to make the study of birth control scientific. Married Love, published in 1918, contained only one chapter on birth control; the rest was a scientific treatise on the rhythms of women's sexual needs. This approach won her the approval of many members of the medical profession. Like the Malthusian League, Stopes constantly canvassed medical opinion, knowing how important their support was. The medical profession effectively controlled access to birth control information and reliable appliances.29 Contraceptives could be purchased by mail-order or in rubber shops, but when the main method for women in the early 1920s was the cervical cap, medical assistance in fitting it was essential, especially when as Stopes's own birth control clinic soon discovered, so many women had internal injuries as a result of childbirth. The medical profession had always shown either antagonism towards, or ignored, the issue of birth control. Angus McLaren has suggested that this was because the birth control movement was from the first a form of self-help and, as such, was regarded with suspicion by doctors.3o Physicians often called attention to Stopes's lack of medical qualifications, but her work on sexuality was taken seriously. Francis Champneys and Amand Routh, physicians who had opposed birth control when giving evidence to the National Birth Rate Commission in 1917, both corresponded with Stopes. Champneys provided detailed commentary on medical points for Married Love and Routh declared the same work to be `perfect in every way', although he still had reservations about the chapter on birth control. Eardley Holland, another prominent physician, was very interested in Stopes's analysis of the first five thousand patients to attend her birth control clinic and asked her to give a paper at the Obstetrics and Gynaecology Section of the Royal Society of Medicine.31 Opposition did, of course, continue, especially from Catholic doctors such as Mary Scharlieb. And some doctors changed their views without admitting it. Professor Louise Mcllroy was the most famous case. Stopes, disguised as a poor woman, presented herself at the out-patients department of the Royal Free Hospital and was fitted with a cap by Mcllroy in

204 Birth Control order to prove it.32 Many ordinary GPs also wrote to Stopes, won over in the words of one by her `clear and scientific explanations' and, in this particular case, by her `beautiful spiritual thoughts'.33 (Stopes's writing style was extremely flowery.) Some also sought her advice on the vast number of sex-related emotional problems that arose in the wake of World War I. Stopes's main argument for birth control was medical. From her sex research, she concluded that women in fear could not enjoy sex, and she also stressed that the health of mothers and babies could best be secured by controlling conception. Early books on birth control had advocated the use of contraceptives as a means of improving the health of the mother. For instance The Wife's Handbook, first published about 1884, devoted a large amount of attention to this aspect of `family limitation', as did the popular pamphlet True Morality, or the Theory and Practice of Neo-Malthusianism by J.R. Holmes, published at the turn of the century. The Malthusian League had also considered the problem of `maternal martyrdom', although more from the strictly feminist desire to achieve control over reproduction than from the health point of view.39 Stopes joined the debate over the association between a high birth rate and a high infant mortality rate, quoting evidence which showed that the mortality rates of high birth order infants were particularly high. At first she used Ploetz's very early findings of 1912, showing the mortality rates of the seventh and succeeding infants to be high, and later the work of the MOH for Bradford published in 1921, which drew the line at the fifth, and finally the statistics of her own birth control clinic, which drew the line at the third.3s Stopes stressed the word control and defined three types. First there was negative control or contraception, designed for those who, on medical grounds, should not on any account have children: women with organic or congenital disease, women whose previous pregnancies had been severely complicated (for example by eclampsia), mental defectives and the physically handicapped. Ideally many of these would be sterilised, although the CBC did not actively promote this until 1928, because Stopes felt that public opinion was not ready for birth control and sterilisation in 1921.36 Equally in the racial interest was positive control, the second type. This was the giving of advice to people who had tried unsuccessfully to have children. And finally there was something Stopes called optimum control or geroception: the use of birth control to spacetchildren, which ensured the birth of healthy babies to healthy mothers. Stopes argued that all three methods were both eugenic and in the interests of a larger population. She even tried to

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demonstrate statistically that people who spaced their children ended up with larger families.37 The CBC insisted that it was pro-baby: only wasteful, inefficient propagation of the species would be eliminated. Stopes summed up this philosophy for the National Birth Rate Commission in 1916: The part of the birth rate which I would encourage to decline is the part which leads at present to uselessness, intolerable waste, the part which leads at present to endless coffins of children under two years, the part which leads at present to feeble mindedness, the part which leads to the agonizing torture of the mother. All those births ought to be blotted out, so that the woman gets a rest in between healthy births. The only births I would suggest stopping are those which lead to nothing but misery, ill-health, and moral and mental and physical deterioration.38 The reaction to Stopes's emphasis on the positive aspects of birth control was favourable. She held a large meeting at the Queen's Hall in 1921 to promote the CBC. After the meeting, J.R. Clynes commented: `I had entirely failed to see the real meaning of the word constructive.'39 Edward Carpenter, who had despaired of the `matter-of-factness' of the Malthusian League, became a Vice-president of the CBC, along with H.G. Wells. Edith How-Martyn and Eva Hubback left the league to work with the CBC, and Maude Royden, a leading member of the NUSEC, who had rejected the idea of birth control in 1917, also gave her support to the CBC, because she felt that it would make a positive contribution to the maternal and child welfare campaign.40 In fact, Stopes was the first English birth controller to make the connection between birth control as a way of safeguarding the health of the individual and as a means of promoting racial improvement central to the argument in favour of contraception. Birth control was, as she put it: `the advocacy of untrammelled physiological control in the interests of the race'.41 Those who needed to space their families and achieve optimum control were still the working class, as a questionnaire sent out to MPs before the 1924 election makes clear. Candidates were asked to answer yes or no to the following: I agree that the present position of breeding chiefly from the C3 population and burdening and discouraging the Al is nationally deplorable, and if I'm elected to Parliament I will press the Ministry of Health to give such scientific information through the ante-natal

206 Birth Control clinics, welfare centres and other institutions in its control as will curtail the C3 and increase the A1.42 Stopes was more successful than the Malthusian League in gaining public acceptance for her work because she approached population control by way of the health of the individual. The working classes were no longer urged to use birth control because they were considered to be economically and eugenically undesirable, but rather in order to spare them individual hardship and personal suffering. This `positive' and `constructive' approach to birth control made it more acceptable to women's groups who were most concerned about the welfare of mothers, and, because it was more likely to succeed, eugenists supported it. Sir James Barr, a leading member of the Eugenics Society and former President of the BMA greeted the CBC as `a great movement, which I hope will get rid of our C3 population' 43 By 1926, the Eugenics Society was organising seminars on birth control for medical officers of health. The Medical Women's Federation had rejected birth control in 1922, because it had proved dysgenic in practice, but in 1927, the federation drew attention to the lack of birth control instruction in medical schools and followed this with a resolution passed in 1931, calling on all medical schools to provide for such instruction.94 In 1927, a Birth Control Investigation Committee was formed and included as members such prominent doctors, demographers and eugenists as Sir Humphrey Rolleston, A.M. Carr Saunders and Dr C.P. Blacker. The BMA acknowledged the influence of this committee when it declared the subject of birth control to be worthy of close attention in 1930.45 The argument that birth control should be offered to the poor as a solution to individual suffering but also with the aim of controlling their birth rate, became more entrenched during the late 1920s and 1930s. In a 1926 House of Lords debate, Lord Buckmaster defended his motion to make birth control information available to married women at maternal and child welfare clinics, by pointing out that the high working-class birth rate was threatening the quality of the race. By making birth control information more readily available, he hoped that the working class would be encouraged to limit their families.` In 1929, the Wood Report on mental deficiency identified the existence of a `social problem' group, defined in greater detail in 1937 by C.P. Blacker as having the following characteristics: `insanity, epilepsy, occupational instability, inebriety and social dependency'.47 In 1932, a NUSEC deputation to the government asked for an extension of birth control

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and sterilisation on behalf of the social problem group. In this case it was clear that the unemployed were the group in question.4$ A long and interesting correspondence took place during the 1930s between the government's Commissioner for Special Areas, Malcolm Stewart, and Lady Maureen Stanley for the NBCA. Lady Stanley wanted Stewart to make a grant to the National Council of Social Services for birth control and have it passed on to a Mother's Centre Sub-committee of the NBCA. Birth control information would be given on medical grounds, which would include evidence of malnutrition. Stewart was in full sympathy with this, commenting in a report to the Ministry of Labour: `The figures given in page 5 of my report show that the birth rate in these areas is considerably above average, whereas it ought in my opinion to be below average.' Stewart's desire to give money directly to the NBCA was not approved, but it was arranged that when Merthyr Tydfil applied for a grant for a gynaecology clinic — where birth control information could be given under the 1930 directive — it would be approved.49 The CBC also used `the bitter distress' of motherhood in the depressed colliery districts to appeal for money in a leaflet signed in 1929 by Sir James Barr, Sir Arbuthnot Lane and Sir S. Archdall Reid (all notable physicians). Stopes was sincere in arguing for birth control as a means of improving women's health and she perceived no tension between her demand for birth control in the interests of the individual and in the interests of racial control. In her leaflet on birth control designed for working-class mothers, she promised them `new hope' and, in simple language, offered a way to escape the misery of frequent pregnancies.50 Her own collection of letters from women seeking birth control advice told a similar story to that of the WCG collection of letters on maternity, published fifteen years before. The early birth control clinics played a major role in revealing the morbidity due to childbirth. A sympathetic medical officer of health, speaking at a birth control conference in 1930, admitted that `the birth control centres have, in fact, discovered a gap in our arrangements for the medical care of women'.S1 Of Stopes's first 10,000 patients, 1,321 had slit cervixes, 335 serious prolapses and 1,508 internal deformations. Stopes herself felt that mortality statistics were `misleading as indices of the toll of motherhood' and that the evidence of morbidity provided ample justification for greater freedom of access to birth control information.52 The North Kensington Women's Welfare Centre, set up by the NBCA, started gynaecology sessions, to which patients were referred by doctors, maternal welfare centres, health visitors and some-

208 Birth Control times even hospitals. Of 250 patients seen in 1934, 10% were found to be in generally poor health, 31% had pelvic infections, 13% misplacements and growths, and 21% general uterine problems.53 In correspondence with the Ministry of Health, the NBCA stressed the role birth control clinics played in providing post-natal care, which so few women otherwise received, and used this as an argument for including birth control clinics in maternal and child welfare centres. The NBCA wanted to call these `Mother's Clinics'.54 With the debate over the issue of maternal mortality, the health of the individual mother became the main focus for birth controllers. In 1928, birth control ceased to be debated as a separate issue at the Labour Women's conference; instead it was slipped into a resolution on maternal mortality, which called for the investigation of all maternal deaths and, as a preventive measure, methods of family limitation.ss The Workers' Birth Control Group's campaign for open access to birth control information was taken up by an all-party group of women, who passed out leaflets calling for a `community of knowledge' before the 1929 election. A major deputation to the Ministry of Health in February of 1937 by the NBCA, the Women's National Liberal Federation, NUSEC, the National Council of Women, the British Association and the National Union of Conservatives again pressed for free access to information and more gynaecology clinics, on the grounds that they would `diminish ill-health and disablement due to pregnancy and childbirth'.56 But government officials concentrated their attention on maternal mortality, not morbidity or the general health levels of women. Moreover, there was a reluctance to promote birth control as the solution to maternal mortality because of the threat it posed to the birth rate. Only if it could be proved that high parities endangered the mother's life would the government be forced to take notice of the demands of women's groups for birth control. Campbell's 1924 study of maternal mortality showed that 37% of the 380 deaths investigated were among women giving birth to their fourth or subsequent child. However, Campbell only acknowledged there to be some risk to the mother after the eighth child.57 The 1937 report on maternal mortality quoted a 1933 investigation by the London County Council into the association between maternal mortality and parity, where it had been found that women having first children had a death rate of 5.2%, after which the mortality rate dropped, rising again for the fourth child and doubling to 12.7% for those having their fifth and sixth children. But arguments in favour of birth control, based on the risk that mothers at a high

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parity were exposed to, tended to be dismissed because, with the falling birth rate, there were proportionately more first births amongst all classes, and it was argued that collectively these represented a greater risk than the dwindling number of high parity women.S8 The idea that middle-class women appeared to be as susceptible to death in childbirth as working-class women could be used to support this argument, as a high proportion of first births took place amongst the middle class. Government officials were more concerned about the question of abortion. It was feared that the mortality rate due to abortion was increasing and thus inflating the maternal mortality rate (abortion often resulted in septic infection). As early as 1906, an article in the British Medical Journal traced the spread of cases of poisoning amongst women attempting to abort by swallowing pellets of lead and scrapings from lead plaster in northern industrial towns. The National Birth Rate Commission, which sat during World War I, recommended that lead plaster be scheduled as a poison, which was done in 1917. The War Cabinet Committee on Women in Industry also drew attention to the problem of abortion, which was seen as a threat to both the quality and quantity of population.59 It was only when the high maternal mortality rate became an additional problem that the government took more interest in the issue of abortion. After 1926, deaths due to abortion were separated from the other maternal deaths, which made it possible to trace the rise in the abortion rate (see Table 7.2). Medical officers of health, in particular, were upset that the increasing number of deaths due to abortion continued to be included in the maternal mortality rate. In his 1935 report, the Medical Officer of Health for St Pancras openly expressed his dissatisfaction that physicians should be held in any way responsible for the outcome of abortion cases. In 1929, a study by Professor Beckwith Whitehouse at the University of Birmingham, showed that among 3,000 patients experiencing 11,430 pregnancies there was a 17% abortion rate. The interim report of the Ministry of Health's Maternal Mortality Committee stated categorically that the practice `of intentional abortion is greatly on the increase' and that the high maternal mortality rate could well be partially due to this factor, even though it adduced no statistical evidence. In the same year the Registrar General also stressed the problem of sepsis following abortion.60 The National Council of Women demanded a government inquiry into abortion in 1936, and Lady RhysWilliams organised a special committee of the Joint Midwifery Committee to investigate the subject. The activities of this committee, together with the considerable attention devoted to the subject by the

1927

1928

1929

1930 1931

1932

1933

1934

1935 1936

1937

-

-

-

-

10.53*

-

13.401- 19.29 20.71 18.26 16.63 16.81

14.79 15.20 13.60 14.80 16.80 15.30 16.87 17.13 17.35 17.52 16.13 14.82

13.27 13.71 11.92 12.76 14.85 13.34 14.65 14.44 14.34 14.37 13.47 11.22

1926

* Interim report of Departmental Committee. t Final report of Departmental Committee. Source: Ministry of Health and Home Office, Report of the Inter-Departmental Committee on Abortion (HMSO, 1939), p. 18.

(1) Returns of the Registrar-General (i) Percentage proportion of deaths due to abortion to those from all puerperal causes, excluding criminal abortion. (ii) Percentage proportion of deaths due to abortion to those from all puerperal causes including criminal abortion. (2) Analysis of confidential reports submitted to the Ministry of Health. Percentage proportion of deaths from abortion to those directly due to pregnancy and childbirth.

Table 7.2: Percentage Proportion of Deaths From Abortion to Those From All Puerperal Causes in England and Wales During the Years 1926-37

touuo3 r/l.agOlt

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1937 Ministry of Health Committee on Maternal Mortality, and the mounting concern over the falling birth rate, prompted the government to set up its own Inter-departmental Committee on Abortion in 1938. Women's groups also demanded that the government take some action on the question of abortion. In 1924, the WCG resolved: 'In view of the persistently high maternal death rate and the evils arising from the illegal practice of abortion, this Congress calls upon the government to revise the laws of 1861 ... thereby making of abortion a legal operation?' NUSEC also asked for abortion to be legalised in 1936. Frida Laski wrote a letter to the Manchester Guardian saying: `Many of us are convinced that reform of the abortion laws is central to the problem of maternal mortality.'62 Above all, women's groups and birth controllers took the opportunity to advocate birth control as an alternative to abortion. In 1932, the Society for the Provision of Birth Control Clinics stressed: It cannot be too often repeated that the effective alternative in G. B. at the present time is not between birth control on the one hand and uncontrolled reproduction on the other, but between birth control on the one hand and abortion on the other.63 In their evidence to the inter-departmental committee the NUSEC and the NBCA stressed the value of birth control in preventing abortion, especially amongst the estimated 100,000 women whose abortion attempts were never proved, but who nonetheless caused damage to themselves and their unborn children. However, the inter-departmental committee concluded that birth control would only act as an alternative to abortion if a perfectly reliable contraceptive were available. As it was, the committee felt that birth control would only encourage a decline in the birth rate and thus rejected the idea of making birth control information more readily available: A proposal that public money should be spent on a measure which is likely to aggravate this position [the low birth rate] by making contraception universally available on request and thereby to affect adversely the continuity of the state, is one which we feel we cannot endorse." Anxiety about the numbers of population seems to have been the main reason why government officials resisted the demands for making birth control information generally available in maternal and child welfare

212 Birth Control centres. When the government took a step towards granting access to birth control information in 1930, it stipulated that only sick women whose reproductive experience was likely to prove `wasteful' were to be assisted. This measure could be justified on eugenic grounds. Information could be given only to nursing and expectant mothers attending maternal and child welfare centres and special gynaecology clinics. The special gynaecology clinics could not be held at maternal and child welfare centres for fear of `disrupting' the educational work being done amongst mothers and infants.65 This meant that many voluntary birth control societies which were prepared to run such clinics were left without the necessary premises in which to hold them, for to have provided their own would have been too costly. Nor could mothers not attending maternal and child welfare centres or gynaecology clinics get information unless they were referred to the private care of a GP, or a hospital. This often meant travelling a long distance to an alien environment. It also involved expense, if indeed the information was made available at all. In a 1932 report on certain areas with exceptionally high maternal mortality rates, Janet Campbell declared: `there appears to be much less public demand for contraceptive instruction than some suppose'. The CBC's Birth Control News was quick to point out that this flew in the face of all the resolutions passed by women's groups.66 A further government circular of 1934 did extend the original 1930 provisions to include women suffering from illnesses that would not necessarily be treated at either maternal and child welfare or gynaecology clinics. Four types of organic disease were specified — TB, heart disease, diabetes and chronic nephritis — which complied with the recommendations of the 1932 Departmental Committee Report on Maternal Mortality.67 But no further liberalisation of the regulations took place, and the argument that all women had the right of access to birth control information in order to space and limit the number of births was ignored. By the mid-1930s, the case for birth control as both a means to further the welfare of the individual woman and as a racial measure was outweighed by the population scare. By 1937, only 95 local authorities out of 423 maternal and child welfare authorities had established birth control clinics; a deputation by the NBCA to the government in the same year complained that `a conspiracy of silence' surrounded the decision permitting even this limited level of activity by local authorities. Quantity had become more important than quality. Across the top of Stewart's correspondence with the Minister

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213

of Labour was scrawled: `but Chancellor of Exchequer appealing for more babies'. This was a reference to Chamberlain's budget speech of 1935, in which he had commented on the implications of a declining birth rate for an imperial power.68 The attention attracted by the gloomy population forecasts of the 1930s increased the feeling against birth control. Many underpopulationists tended to advocate family allowances as an alternative to birth control, especially as it was felt that allowances would relieve economic pressure on the middle classes whose small birth rate was believed to be so eugenically damaging. Beveridge regarded birth control with suspicion, but was a strong proponent of allowances, as were several Labour Party members, for example Ethel Bentham, who signed the majority report of the Joint Committee of the TUC and the Labour Party on the Living Wage which recommended allowances, and G.K. Chesterton, who welcomed allowances `as the true contrary of birth control' in Lansbury's Labour Weekly. Dora Russell replied angrily to Chesterton in the next issue of the paper: Mr. Chesterton has written quite a long article on birth control, it mentions Malthus, Godwin, capitalists and working men, it just refers to children, but nowhere in the whole article do I find the word mother or the word woman ... Mr. C's attitude is to me as much a class war against the mother as the mine owner's attitude is a class war against the miner.69 Policy-makers feared that if they allowed open access to birth control and thus legitimised it, they would lose all control over population growth. Influential evidence submitted by Alexander Gray to the Living Wage Committee and to the Royal Commission on National Insurance in 1926, expressed these fears neatly: `There cannot at the same time be acknowledged communal responsibility for the maintenance of children and unlimited private enterprise in the procreation of children.'70 If state assistance were to be given in cash and kind to families, the state must also control who was going to receive these benefits, in other words, who was going to be born. Many countries did develop formal population policies in the 1930s. Outside the fascist states, the best example was Sweden, which allowed access to birth control but which also gave greater incentive to parenthood in the form of family allowances, tax deductions, and children's education allowances.71 Britain did not develop a formal population or family policy, although undoubtedly an informal one existed, for example in

214 Birth Control housing and taxation allowances, as Hilary Land and Roy Parker have pointed out," and the denial of birth control information must be seen as part of this informal policy. It would appear that changes in informal family and population policy closely reflect the manner in which reproduction is tied to changes in the relationship between women and the economic system. Family allowances were granted first to keep wage rates down and secondly to increase population. Similarly, birth control only received public sanction in 1949, when the Royal Commission on Population welcomed the idea of women doing two jobs, inside and outside the home, and agreed `that there is nothing inherently wrong in the use of mechanical means of contraception'.' The commissioners anticipated that market demand would cause an expansion of the workforce and thus were anxious to encourage married women's work. It made a special plea for part-time work for married women. Marriage bars, which had operated against women, especially in the professions, were also removed after World War II.74 Once public sanction had been given to married women's work, birth control information could also be given. The grounds on which the commission recommended birth control were, first, health (the risks of abortion were particularly emphasised) and, secondly, the need to avoid measures that might `restrict the freedom of women'.75 An adequate population should be secured by creating social conditions conducive to voluntary parenthood, that is by balancing free access to birth control information against financial assistance to families and social services for the benefit of children and relief of mothers (as in Sweden). By the time the Royal Commission reported in 1949, the birth rate was climbing again and its recommendations were never discussed in full by parliament. Thus birth control achieved recognition for the first time only when a full population policy had been articulated and only when it was perceived that a change in women's participation rate in the workforce might be desirable. It is interesting, however, that access to birth control information was still by no means considered an integral part of the child and maternal welfare service. Not until 1967, under the National Health Service (Family Planning) Act, were permissive powers conferred on local health authorities to give birth control advice without regard to marital status and on social as well as medical grounds.

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Notes 1. Richard Titmuss, Essays on the Welfare State (Allen and Unwin, 1976),

pp. 88-94. 2. Angus McLaren, Birth Control in Nineteenth-Century England (Croom Helm, 1978), pp. 254-5, has stressed this point. 3. In 1930, the executive, vice-presidents and governing body of the NBCA included: Lady Denman (also President of the Federation of Women's Institutes), Margaret Llewellyn Davies (former General Secretary of the WCG), Eva Hubback (executive member of NUSEC), Mary Stocks (executive member of NUSEC), Margery Spring Rice, and Mrs Sydney Frankenburg (author of successful childrearing manuals). 4. Workers' Birth Control Group, Memo on Birth Control presented to the Minister of Health by a Deputation, May 9th 1924 (Workers' Birth Control Group, 1924), pp. 2-3. Members of the Group included: Dorothy Jewson, MP; Mrs L'Estrange Malone; Mrs Adamson; Dora Russell; Mrs K.F. Robertson; William Adamson, MP; Major Church, MP; Ernest Thurtle, MP; F.A. Broad, MP; H.G. Romeril, MP; and S.P. Viant, MP. 5. Labour Party, Report of 27th Conference, 1927, p. 54. 6. Dora Russell, The Tamarisk Tree (Virago, 1977), p. 170. Only the Fabians fully recognized that rising real incomes were associated with falling family size. See McLaren, Birth Control in Nineteenth-Century England, pp. 187 and 221. 7. Mary Stocks, The Case for Family Endowment (Labour Publishing Co., 1927), pp. 9 and 83; and Women's Leader, 2 Oct. 1925, p. 283. 8. 'The Declining Birth Rate', Cooperative News, 18 March 1911, pp. 335-6; and F.N. Harrison Bell, 'Wanted! Understanding — A Word to the Archbishop of York', Labour Women, 1 (July 1913), p. 43. 9. Sylvia Pankhurst, The Birth Rate: Notes and Views on the National Birth Rate Commission (Workers Suffrage Federation, 1916). 10. J.A. and Olive Banks, Feminism and Family Planning in Victorian England (Liverpool: Liverpool University Press, 1964), pp. 102-3 (one example was Mona Caird, 'The Morality of Marriage', Fortnightly Review, XLVII (March 1890), pp. 310-30); Vera Laughton Matthew, The Women's Movement and Birth Control (St Joan's Social and Political Alliance, n.d.), p. 2 (the society was a Catholic feminist group, but the viewpoint was not uncommon outside Catholic circles.); and McLaren, Birth Control in Nineteenth-Century England, p. 198. 11. J.A. Banks, Prosperity and Parenthood (Routledge, 1954), argues implicitly that men had the greater say for economic reasons, but Patricia Branca and Daniel Scott Smith argue the case for a 'domestic feminism' and an active decision-making role for women within the home. See Patricia Branca, Silent Sisterhood (Croom Helm, 1975); and Daniel Scott Smith, 'Family Limitation, Sexual Control, and Domestic Feminism in Victorian America' in Clio's Consciousness Raised, edited by Mary Hartman and Lois Banner (Harper Torchbooks, 1974), pp. 119-36. 12. PRO, MH 71/22, memo of evidence by the Midwives Institute to the Interdepartmental Committee on Abortion, p. 23. 13. Margaret Llewelyn Davies, Maternity: Letters from Working Women (G. Bell, 1915), pp. 38, 40, 42, 45, 65, 94-5; and Marie Stopes, Mother England (Bale and Danielsson, 1929), pp. 12, 25, 34, 50, 75, 103, 123, 141, 158 and 161. 14. McLaren, Birth Control in Nineteenth-Century England, pp. 231-8; and PRO, MH 71/18, evidence to the Ministry of Health. 15. C.V. Drysdale, 'Freewomen and the Birth Rate, Pts. I-III', Free woman, I (30 Nov. 1911), p. 36; (21 Dec. 1911), p. 89; (4 Jan. 1912), p. 130.

216 Birth Control 16. Alice Vickery Drysdale, A Woman's Malthusian League (Malthusian League, 1900), p. 1. 17. David Owen Centre, Family Planning Association Archives (hereafter FPA), A23/58, enclosure in the Stopes/Aldred Correspondence of 1929. 18. David Heron, On the Relation of Fertility in Man to Social Status and on the Changes in this Relation that have taken Place during the Last 50 Years, Drapers' Co. Research Memoirs, studies in National Deterioration (Dulau, 1906); Ethel M. Elderton, Amy Barrington, H. Gertrude Jones, Edith M.M. de . G. Lamotte, H.J. Laski and Karl Pearson, On the Correlation of Fertility with Social Value (Dulau, 1913); Webb's finding as quoted in C.D. and W.C. Dampier Whetham, The Family and the Nation (Longman, 1909), pp. 137-8; and PP, '74th Report of the Registrar General, 1911', 1912-13, Cd. 6578, XIII, 493, pp. 137-8. 19. The Times, 5 Sept. 1905, p. 10, and 1 June 1918, p. 8. 20. Emily C. Fortez, 'The Limitation of the Family', Labour Woman, I (Sept. 1913), p. 69. 21. Eleanor Rathbone, 'Family Endowment in Its Bearing on the Question of Population', LSE, Beveridge Papers, Coll. Misc. 9, folio 96; and FPA, A8/19, deputation by NUSEC to the Ministry of Health, 27 Jan. 1932; the guild advocated compulsory sterilisation at its annual conference in 1930: 48th Annual Report of the Women's Cooperative Guild, 1930-31, p. 22. 22. Sir James Marchant, Cradles or Coffins? (C. Arthur Pearson, 1916), p. 17. 23. The Malthusian, 23 Dec. 1917, p. 2. 24. George Simpson, Infantile Mortality and the Birth Rate (Salford: Duggan Press, 1911). Lady Florence E.E. Bell made a similar comment in her study of Middlesborough published in 1907 (At the Works (Arnold, 1907), p. 195). 25. 'Report of the Medical Officer of Health on Maternal and Infant Welfare', May 1917, p. 10; Proceedings of the Council, 1916-17, p. 667, Liverpool Public Archives. 26. PP, '39th Annual Report of the LGB, 1909-1910. Supplement Containing the Report by the Medical Officer on Infant and Child Mortality', 1910, Cd. 5263, XXXIX, 973, pp. 48-9. 27. W. Brass, 'Regional Variations in Fertility and Child Mortality during the Demographic Transition in England and Wales', paper presented at the 1BC/BSPS Conference, 1977, p. 16. I am indebted to Ian Buchanan and to Dr John Simons for help on this point. 28. Ministry of Health, Annual Report of the Chief Medical Officer for 1919-20 (HMSO, 1920), p. 110. 29. Stopes Coll., Add. MS. 58539, Enid Eve to Stopes, 23 March 1921. Eve was a health visitor in Holborn and gave birth control information 'sub rosa'. Jane Lorimer Hawthorn's letters to Stopes make it clear that her willingness to see patients referred to her Harley Street office was important (Add. MS. 58566) and Maude Kerslake commented that 'any instruction given tin government clinics] rests on the personality of the MOH' (Add. MS. 58567, Kerslake to Stopes, 2 March 1923). 30. McLaren, Birth Control in Nineteenth-Century England, pp. 78-89 and 116-40. 31. Stopes Coll., Add. MS. 58568, Sir Francis Champneys to Stopes, 13 Aug. 1918; Add. MS. 58565, Sir Amand Routh to Stopes, 2 Jan. 1919; Add. MS. 58569, Eardley Holland to Stopes, 10 Nov. 1924. 32. Marie Stopes, Preliminary Notes on Various Technical Aspects of the Control of Conception Based on the Analysed Data from Ten Thousand Cases (Mother's Clinic for Constructive Birth Control, 1930), pp. 37-44. 33. Stopes Coll., Add. MS. 58568, C. Blaikie to Stopes, 24 Nov. 1918.

Birth Control

217

34. Annie Besant, The Social Aspects of Malthusianism (Malthusian Tract no. 10, 1880), p. 4. 35. Dr A. Ploetz, 'Neo-Malthusianism and Race Hygiene' in Problems of Eugenics. The Report of the First International Eugenics Congress, Vol. II (Eugenics Society, 1913), pp. 183-9; Stopes Papers, Add. MS. 58568, Dr John J. Buchan to Stopes, 12 April 1921; Marie Stopes, The First 5000 (Bale Danielsson, 1925), p. 24. 36. Stopes Papers, Add. MS. 58589, CBC memo, 22 Nov. 1928. 37. Birth Control News, 1 (Sept. 1922), p. 1. 38. Problems of Population and Parenthood, being the 2nd Report of and the Chief Evidence taken by the National Birth Rate Commission, 1918-20 (Chapman and Hall, 1920), evidence of Stopes, p. 249. 39. Queen's Hall Meeting on Constructive Birth Control, April, 1923, Report (Putnams, 1921). 40. A. Maude Royden, `Modern Love' in The Making of Women: Oxford Essays on Feminism (Gollancz, 1917), p. 53; and Queen's Hall Meeting, p. 5. 41. Marie Scopes, Early Days of Birth Control (Putnams, 1922), p. 6. 42. Stopes Papers, Add. MS. 58560. 43. Queen's Hall Meeting, p. 8. 44. Medical Women's Federation, minutes of the meetings of the Council, May 8 and 9, 1922; Nov. 4, 1927; and May 8, 1931. 45. British Medical Journal, 5 April 1930, p. 658. 46. Debates, House of Lords, 63, 1926, cols. 997-1003. 47. Board of Education and Board of Control, Report of the Mental Deficiency Committee (HMSO, 1927), pp. 78-89; and C.P. Blacker, A Social Problem Group? (Oxford UP, 1937), p. 4. 48. FPA, A8/19, NUSEC deputation, 27 Jan. 1932. 49. PRO, MH 61/10, Stewart to Brown, 15 July 1935 and Stewart to Stanley, 20 May 1935. 50. Marie Stopes, A Letter to Working Mothers on How to Have Healthy Children and Avoid Weakening Pregnancies (CBC Mother's Clinic, 1919). 51. Society for the Provision of Birth Control Clinics, Conference on the Giving of Birth Control Information by Public Health Authorities (Birth Control international Information Centre, 1930), p. 22. 52. Marie Stopes, Preliminary Notes on Various Technical Aspects of the Control of Conception, p. 11. 53. FPA, NK 90, Case Report from the North Kensington Clinic, Jan. 1934 — Nov. 1934. 54. FPA, A8/12, Denman to Shakespeare, June 1935. 55. 9th Annual Conference Report of the Women's Labour League, 1928, p. 60. 56. FPA, A8/21, deputation, Feb. 1937. 57. Janet Campbell, Maternal Mortality, Special Reports on Public Health and Medical Subjects, no. 25 (HMSO, 1924), Appendix B, pp. 6 and 109-12. 58. PP, `Report on an Investigation into Maternal Mortality', 1936-7, Cmd. 5422, XI, I, pp. 101 and 109-10. 59. Arthur Hall and W.B. Ransom, 'Plumbism from the Ingestion of Diachlyon as an Abortifacient', BMJ, 24 (Feb. 1906), pp. 428-30; The Declining Birth Rate ... Being the Report ... of the National Birth Rate Commission, p. 58; and PP, 'Report of the War Cabinet Committee on Women in Industry', 1919, Cmd. 135, XXXI, 241, p. 231. 60. Annual Report of the Medical Officer of Health for St. Pancras for 1935, p. 33; Beckwith Whitehouse, 'Abortion: Its Frequency and Importance', BMJ, 14 Dec. 1929, pp. 1095-9; Ministry of Health, Interim Report of the Departmental

218 Birth Control Committee on Maternal Mortality and Morbidity (HMSO, 1930), p. 40; and General Registry Office, Registrar General's Statistical Review for England and Wales for 1930 (HMSO, 1931), pp. 77-8. 61. Janet Chance, The Case for Reform of the Abortion Laws (Abortion Law

Reform Association, 1936), p. 15, gives all the resolutions passed by women's organisations. 62. PRO, MH 71/30, clipping from Manchester Guardian, 27 May 1937. 63. Society for the Provision of Birth Clinics, Birth Control and the Public Health (The Society, 1932), p. 5. 64. Ministry of Health and Home Office, Report of the Inter-Departmental Committee on Abortion (HMSO, 1939), p. 66. 65. PRO, MH 55/289, Circular 1208, 14 July 1931. See also, Debates, House of Lords, 63, 1926, coL 1010. 66. Janet Campbell, High Maternal Mortality in Certain Areas, Reports on Public Health and Medical Subjects, no. 68, (HMSO, 1932), p. 21; and Birth Control News, 11 (Oct. 1932), p. 93. 67. Circular 1408, 31 May 1934, published in the Birth Control News, 13 (July 1934), pp. 33-4; and Ministry of Health, Final Report of the Departmental Committee on Maternal Mortality and Morbidity (HMSO, 1932), pp. 130-1. 68. PRO, MH 61/10, Addendum to Mr F. Tribe's memo of 16 April 1935; and Debates, House of Commons, 300, 1934-5, col. 1634. 69. Lansbury's Labour Weekly, 2 (1 Jan. 1927), p. 11. 70. Files of the Joint Committee on the Living Wage, TUC Archives, TI90, evidence of Alexander Gray, 23 March 1928; and PP, 'Report of the Royal Commission on National Health Insurance', 1926, Cmd. 2596, XIV, 311, pp. 292-8. 71. Alva Myrdal, Nation and Family, the Swedish Experiment in Democratic Family and Population Policy (Kegan, Paul, Trench and Trubner, 1941). 72. Hilary Land and Roy Parker, 'Family Policies in Britain: The Hidden Dimensions' in A.J. Kahn and S.B. Kammerman (eds.), Family Policy (NY: Columbia UP, 1978). 73. PP, 'Report of the Royal Commission on Population', 1948-9, Cmd. 7695, XIX, 635, pp. 159-60. 74. Treasury, Report of the Civil Service National Whitley Council Committee on the Marriage Bar (HMSO, 1946), gives a full account of the lifting of marriage bars in the professions and in private industry. 75. Cmd.7695, p. 159.

CONCLUSION

It is by no means clear that child and maternal welfare policies were primarily responsible for the fall in infant and maternal mortality. Moreover, professional rivalries and political considerations placed considerable constraints on the range of services provided and limited the benefits women gained from them. Women's groups fought hard to establish a more complete maternal and child welfare service, but tended to accept the traditional role of wife and mother that was assigned them. There is no doubt, moreover, that child and maternal welfare policies carried with them a strong ideology of motherhood. The most welcome services to women were the infant welfare clinics — despite the often patronising attitudes of those running them — and the ante-natal clinics. Clinics were especially important because most married women were not covered by the National Health Insurance Act, but their usefulness was tempered by the fact that they did not offer treatment. The controversy during the inter-war years over the establishment and function of state clinics, and the way in which this relates to the emergence of a national health service, has been largely ignored. The allied struggle to make birth control information available at maternal and child welfare clinics has also been neglected, even though the early birth control movement has attracted much attention from historians. The defensiveness of GPs in the face of the threat from clinics was reflected throughout the medical profession in the responses to the idea of a national maternity service and, in particular, to efforts to upgrade the level of skill amongst childbirth attendants. Despite statements to the contrary, maternal and child welfare was treated as a political issue. Official concern about population and mortality rates was couched in an unimpeachable rhetoric, which talked of the need to save lives and improve the quality of motherhood. But the real needs of mothers and infants were never addressed directly. In the light of the realities of the childbearing and childrearing experience, government policy often appeared contradictory: having professed a desire to improve maternal and child welfare, married women's national health insurance benefits were cut in 1932 and the need for both birth control and economic assistance denied. Unlike women's groups, the government never asked what it was like to bear and rear a child. To have done so would have meant confronting 219

220 Conclusion the problem of welfare in its widest sense and the demands of women both for financial assistance in rearing children and control over their own fertility. These controversial areas were ignored until it was shown that they impinged on more legitimate government concerns, such as the economy. Health officials also carefully separated the problem of mortality from the closely-related one of sickness, because most of the studies addressing the problem of the high incidence of sickness amongst married women also dealt with unemployment and poverty as possible causes. Even when a causal connection was rejected, it was hard to convince all sectors of opinion that there was no association between the two. In the case of maternal mortality, it was easier to avoid arguments relating to poverty and class because large numbers of middleclass women died in childbirth. This made it possible for officials to argue that better maternity services alone were the answer and to ignore evidence that better nutrition, for example, also seemed to improve mortality figures. Part of the reason for the contemporary focus on infant and maternal mortality was the ready indictment of existing government health provisions provided by the mortality statistics. When possible, the national government pointed out that local authorities were responsible, and hence to blame, for poor maternity services. At the same time, government officials promoted the education of mothers and potential mothers as the best way of reducing mortality rates. While the help given women in mothercraft classes was often useful, the philosophy behind them was as close to the self-help ideals of earlier charitable endeavours as to those of a welfare state. But such education pro,. grammes were attractive because they were cheap and could be implemented quickly with some hope that immediate improvement would result. They also had the advantage of avoiding the political controversy that was bound to be raised by any offer of economic assistance. Women's groups agreed that mothercraft and cookery education was a good idea and thus provided valuable community support for the programmes. The hospitalisation of childbirth also commanded the support of articulate women and a powerful group of obstetricians. The campaign to make motherhood safer and, in the words of John Burns in 1906, `purer' and more `dignified', was also designed to make mothers more efficient. The primary concern of health officials was the welfare of the infant rather than the mother — not for nothing did Cow and Gate make `King Baby' the centre of its advertising campaigns — and it was in the interests of the race that women received better care during pregnancy and parturition and were taught mothercraft.

Conclusion

221

It was impressed on women that they were responsible for the welfare of their infants and in part for their own health, especially during pregnancy. Yet the intervention of trained midwives, doctors and hospital staff at childbirth, and health visitors or infant welfare clinic staff to direct the process of infant feeding, often actually distanced the mother from childbirth and childrearing. As the intervention of experts became more common, so the management of childbirth and childrearing became more technical. At the same time, the basic everyday needs of the mother in regard to household chores were neglected. For while the aim was to replace the untrained handywoman or neighbour with trained staff, the latter concentrated only on helping the mother at birth and with matters immediately related to her infant. The mother's other family responsibilities were ignored. The demand of women's groups for home-helps showed their awareness of this side of the problem, but because maternal mortality was considered to be a purely medical question, women's views on the issue were poorly represented. The failure to consult and inform women as to the changes taking place in the management of childbirth quickly led to difficulties, especially in implementing ante-natal care. Here, lack of appreciation of women's aversion to physical examination by male doctors contributed to the slow spread of ante-natal programmes. Despite the belief in the need for expert advice, child and maternal welfare workers still held women responsible for raising good, healthy citizens. An address in Mother and Child entitled `Mother — the Keeper of the Nation's Health' summed up this attitude. Manual-writers and women's magazines stressed the importance of women's role as guardians of the family's health, described by one paper as `mothering in its widest sense'.2 Women did not question this aspect of the child and maternal welfare movement, but rather used the new emphasis on motherhood to demand additional measures, such as family allowances, which would enable them to perform their duties as mothers better. It is hard to determine how genuine women's acceptance of the ideology of motherhood was. Many of those involved in the maternal and child welfare movement accused women (especially feminists) of neglecting motherhood. The connection between the selfishness of the women's movement in this regard and the falling birth rate was also a favourite theme with eugenists.3 Few women would have dared to speak against motherhood when the quality and quantity of population was considered to be of such great national importance. in any case, it is doubtful that any conscious opposition to it existed. The

222 Conclusion organised feminist movement of the period 1906-39 never questioned women's role in the home, which involved total responsibility for childrearing. Regulations which forced women to resign from work upon marriage were never subjected to concerted feminist opposition. After World War I and the granting of the vote, organised, predominantly middle-class, feminists joined organised working women's groups, such as the Women's Cooperative Guild and the National Council of Women, in stressing the racial importance of motherhood and work done in the home. They used this, as well as the feminist argument of paying the mother for her services, to demand remuneration. Working women expressed their desire to devote themselves to home and family much earlier. A Women's Cooperative Guild member commented: `The nurture of children is a race matter... the working class mother may and I believe will, make better use of the science of health than her richer sister has done, because her life is simpler and her love of home more real.'4 Trade-union women also spoke against the strain that a second job outside the home imposed on many women. The emphasis placed by the child and maternal welfare movement on better child care and the importance of motherhood reinforced women's traditional role in the home. It is striking that the percentage of married women in the labour force remained constant at the low figure of 10% throughout the period; there is no doubt that a higher percentage of married women had been employed outside the home between 1850 and 1890.5 The 10% figures does obscure wide variations and, at the aggregate level, a large percentage increase in married women aged between 18 and 24 entering the workforce between 1911 and 1931, and a smaller increase among those aged 25 to 34. But since only about 6% of married women were younger than 24 throughout the period, the increase in numbers of young married women working was relatively insignificant (see Table 8.1). Table 8.1: Percentage Married Females in the Workforce by Age Group, 1911, 1921 and 1931

1911 1921 1931

18-20 21-4 25-34 35-44 45-54 55-64 65-74 75+ 13.7 12.9 10.6 10.6 10.5 8.8 5.7 2.3 15.0 13.2 9.9 9.3 7.6 4.9 2.0 8.8 19.6 19.3 13.8 10.5 3.3 1.2 8.8 6.6

Total 10.3 9.1 10.4

Source: Census of England and Wales for 1911, General Report (HMSO, 1917), p. 161, Table LIX; for 1921, Occupations (HMSO, 1924), p. 54, Table 4; for 1931, Occupational Tables (HMSO, 1934), p. 39, Table 5.

Conclusion

223

Indeed, it is likely that most women worked only until the birth of their first child; the average age of a woman at the birth of her first child was 27 in 1910 and 26 in 1930.6 Yet during the period 1906-39, changes in family size and household technology reduced the burden of work for women within the home, which meant that women were freer to go out to work. The shift towards smaller families was the more important factor. Between 1911 and 1946, the proportion of completed families with two or less children increased from 20% to 67%.' In addition, the period between births diminished and the average age both at marriage and at the birth of the first child fell slightly, so that a woman's childbearing years were less in absolute terms and were over earlier in her life cycle. During the 1930s, the trend towards smaller houses and the rapid proliferation of domestic appliances also made it possible for middleclass women to reduce the burden of household tasks. During the inter-war period, the cost of appliances fell dramatically, making them a cheaper proposition that servant labour. By 1938, nine million houses were wired for electricity and 68% of these had electric or gas cookers, and 10% vacuum cleaners. However, it is important to remember that with the introduction of domestic science, standards of housework were raised, with the result that more time was spent on household tasks. In practice, housework would always expand to fill the time if the woman did not go out to work.' In regard to the working-class family, it would be more correct to speak of the increase in the provision of basic amenities than of the acquisition of appliances, although amongst some sections of the employed working class the latter was becoming a possibility during the 1930s. Wilmott and Young believe that a large number of married women would have welcomed part-time work during the 1930s had it been available.9 It is possible that many married women decided to postpone the decision to look for work until the employment situation improved. Conversely, it is possible that many women did seek some kind of work, especially if their husbands were unemployed. Neither response would necessarily have been revealed by aggregate labour-market statistics such as employment or unemployment figures. Women postponing their entry into the workforce or seeking work for the first time and failing would not have been recorded as economically active. Many married women especially would have sought part-time work which would not necessarily be included in the census returns or labourmarket statistics. Of the women interviewed, eighteen (22%) had

224 Conclusion worked, a figure well above the average. But eight of these had done odd charring jobs, hawked goods or worked for friends. The balance between the number of jobs opening to women in those areas of the economy which were expanding during the inter-war years and the number closed-off by the decline of the old industries has not been studied. Neither is there any detailed information on the balance between the number of middle-class and working-class jobs that were opening and closing, nor any analysis of how the marriage bar affected the work patterns of married women. Most important of all, we have no idea as to how women responded to the economic crisis of the 1930s: whether they behaved as 'discouraged workers' and did not try to enter the labour force, or whether they behaved as 'added workers', seeking full- or part-time work in greater numbers.10 However, it is clear that the ideology of motherhood persuaded married women that their role in the home was of national importance and that motherhood was their primary duty. If it was the case that young married women did work in greater numbers during the period in order to supplement the family income, but ceased to work with their first pregnancy, it is likely that standards of acceptable behaviour played some part in their decision. As Ann Oakley has remarked: The doctrine that women belong in the home never carries more conviction than when it is allied with 'proof' that women's activities outside the home are detrimental to the health and welfare of themselves, their families, and the community as a whole." The most acceptable role for women was undoubtedly that of housewife and mother. Peter Stearns has stressed the new strength of the Edwardian working man's preference for a wife who did not work outside the home.l2 The working-class man's belief that a woman's place was in the home represented not so much a filtering down of middleclass ideals as a change both in the internal relations and in the function of the working-class family. Men gained self-respect and real privileges when wives were full-time housewives, and for husband and wife personal fulfilment was realised through the private interactions of the family and increasingly through conspicuous consumption.13 Married women who stayed at home whether through personal preference, or because of societal or economic pressure, found that the emphasis on more 'scientific' and more time-consuming methods of child care and housework filled any possible void created by having smaller families.14 A certain scarcity value attached to children in small

Conclusion

225

families and this naturally increased the efforts expended in raising them, a trend that was powerfully reinforced by the maternal and child welfare movement. Thus childrearing was even more closely attached to childbearing, despite the decline in the frequency of the latter. Throughout the period 1900-39 the emphasis placed on the duty of motherhood by the child and maternal welfare movement played a part in determining the behaviour of married women. The maternal and child welfare policies adopted also showed remarkable consistency; whether the problem was infant welfare prior to World War I or nutrition in the 1930s, the answer was believed to lie in the education of mothers. Perhaps not surprisingly the reality of women's health needs remained constant as well. Social surveys published during the 1930s echoed the findings of the Women's Cooperative Guild fifteen years before. During and after World War II, child and maternal welfare policy underwent radical change, especially in regard to attitudes towards birth control and economic assistance for mothers. But some trends, such as hospitalisation of childbirth, accelerated and mortality rates continued to be used as the index of welfare. The ideology of motherhood also survived. By the 1950s, emphasis had shifted from the physical to the psychological needs of the child and according to John Bowlby's influential theory of `maternal deprivation', full-time motherhood was now crucial for the healthy mental development of the child.1$

Notes 1. Mother and Child, 8 (Oct. 1937), pp. 267-8. 2. Truth, 5 Oct. 1910, TUC Archives, Tuckwell Papers, file 23. Babyland urged women to awaken to the `new possibilities' of motherhood: Babyland, 2 (15 Feb. 1910), p. 31; in an editorial, National Health reminded its readers of the important role played by the new `women's pages' in the daily papers: `Mainly Mothercraft', National Health, 18 (May 1926), p. 407; even the organ of the Communist Party, the Daily Worker, started a woman's page in the 1930s with mothercraft information being given by Madge Brown (I am indebted to Sue Bruley for this information). 3. See, for example, Lt Col. F.E. Fremantle's Presidential address to the Hygiene of Maternity and Child Welfare Conference, Jr. of the Royal Sanitary Institute, XLI (Jan. 1921), p. 192; and Alice Ravenhill, `Eugenic Ideals for Womanhood', Eugenics Review 1(1910), pp. 265-74; and Meyrick Booth, `Woman and Maternity', English Review, 52 (Jan. 1931), pp. 81-9. 4. `The National Care of Maternity', Cooperative News, 21 March 1914, pp. 377-8, clippings files, Women's Cooperative Guild Archives, Walthamstow. 5. Margaret Hewitt, Wives and Mothers in Victorian Industry (Rockcliffe, 1959), pp. 9-20.

226 Conclusion 6. Michael Young and Peter Wilmott, The Symmetrical Family (NY: Pantheon Books, 1973), p. 103. 7. PP, 'Report of the Royal Commission on Population', 1948-9, Cmd. 7695, XIX, 635, p. 26, Table XVII. 8. Betty Friedan, The Feminine Mystique (NY: Norton, 1963), comments at length on this. 9. Young and Wilmott, Symmetrical Family, p. 104. 10. Diane Werneke, 'The Economic Slowdown and Women's Employment Opportunities', International Labour Review, 117 (Jan.-Feb. 1978), pp. 37-52, gives a detailed explanation of these two theories of women's behaviour during an economic slowdown. 11. Ann Oakley, Housewife (Allen Lane, 1974), p. 47. 12. Peter Stearns, 'Working Class Women in Britain, 1890.1914' in Suffer and Be Still, edited by Martin Vicinus (Bloomington: Indiana UP, 1973), pp. 100-20. 13. See Eli Zaretsky, Capitalism, the Family and Personal Life (Pluto Press, 1976). 14. Barbara Ehrenreich and Deirdre English, For Her Own Good (NY: Anchor Press, 1978), pp. 127-89, have reached a similar conclusion with regard to the American experience. 15. John Bowlby, Forty Four Juvenile Thieves: Their Characters and Home Life (Bailliere, Tindall and Cox, 1946), and Maternal Care and Mental Health (Geneva: WHO, 1951).

APPENDIX: A NOTE ON SOURCE MATERIALS

Printed government documents and departmental files have been supplemented by medical reports and journals; the reports of medical officers of health serving in Liverpool, Birmingham, Hull and the old St Pancras borough of London (to provide a context for 83 interviews conducted in the same areas and a sense of the way in which central policy decisions were carried out); the archives of infant welfare associations and centres, women's groups and birth control societies; and the papers of individuals engaged in maternal and child welfare work. The interviews provided a range of regional, albeit predominantly urban, views, but the material has been used for illustration rather than as an integral part of the analysis because of the small sample and the special problems associated with interpreting the data.

Interviews A total of 83 interviews were conducted, 9 in Frome, 23 in London, 20 in Hull, 19 in Liverpool and 12 in Birmingham. Contact was made with women who had had one or more children prior to 1939 and who were willing and able to be interviewed through the day centres organised by Age Concern, and the `sheltered' housing and old people's homes run by the local authorities. Such a sample is biased in many ways, not least (in view of the subject of the study) by the fact that all the women interviewed had survived. All the respondents were asked the following questions: 1. When were you born? 2. When did you have your first child/second child, etc? 3. Where did you have your first child/second child, etc? 4. (If at home) Did you have a midwife/doctor? 5. Did you have any ante-natal care at a clinic? From your midwife/ doctor? 6. Were you given any pain-killers during labour? 7. Did you have `a bad time?' Were there any complications? 8. What did you have to provide for the midwife? 9. When did you get on your feet again at home/hospital? 227

228 Appendix 10. Did you get any post-natal care? 11. Did you get any advice on bringing up your children from the clinic/midwife/doctor/your mother? 12. Did you get any advice on feeding? 13. Did you have a cradle for your baby? 14. Where did you live when your first/second, etc. children were born? 15. What kind of a house was it? Did it have running water/indoor toilet/gas stove/range/open fire? 16. What did your husband do? 17. Was he lucky in the 1930s or was he unemployed? 18. Who managed the budget? Did you get housekeeping money? 19. Did you get anything special to eat during pregnancy or while nursing? 20. Where did you go when you were sick? Not all answered all questions and in some cases the answers were unclear or too vague to be useful. The circumstances under which most of the interviews were carried out were often far from ideal.' Many women were reluctant to talk alone, so two or three were often interviewed at the same time. A return visit to check the responses was impossible. Naturally enough most of the women refused to `go over it all again'. Fifty-eight women replied to the question asking their husband's occupation. Of the remaining 25, four refused to answer and the replies of the rest were too vague to permit a precise description of the husband's job. The vast majority of the 58 women would appear to have been married to working-class men.2 Many of these belonged to the more prosperous sections of the working class and only one husband was unemployed for the majority of his wife's childbearing years, although many others suffered shorter periods of unemployment during the inter-war years. Husbands' Occupations army (3) artist brass worker (2) builder cafe owner cargo superintendent clergyman clerk (2) cooper

coppersmith cowkeeper docker driver for the Corporation factory worker (2) fisherman florist foreman (2) fruiterer

Appendix gas-company employee hawker hospital orderly (4) insurance salesman ironmoulder joiner labourer (8) lorry driver mechanic navy (3)

229 painter and decorator (3) plumber policeman postman printer railway worker (3) rat catcher removal man stable worker

Notes 1. The best guide to collecting oral testimony is Paul Thompson's The Voice of the Past (Oxford UP, 1978). 2. I am aware of the difficulties inherent in deriving the wife's social class from that of her husband (see, Hilda Smith, `Feminism and the Methodology of Women's History' in Liberating Women's History, edited by Berenice A. Carroll (Chicago: University of Illinois Press, 1976), pp. 369-84), but in this instance it seemed desirable to attempt to provide at least some guide as to the class composition of the sample.

INDEX

birth rate, decline in 17, 30, 36, 38, 51, 196, 199, 213 births, notification of 34, 104 Black, Clementina 81 Blacker, Dr C.P. 206 Blackman, Janet 74 Blagg, Helen 90 blood transfusions 124, 134 BMA 140, 145, 146, 148, 151, 152, 175, 176, 181, 185, 199, 206 Boer War 13, 15 Bondfield, Margaret 50 Bonney, Victor 126, 127 bottlefeeding 21, 61, 64, 65, 69, 73-6 Bourne, Aleck 126-7, 155 Bowlby, John 225 Bradlaugh, Charles 196 Brailsford, H.N. 171 breastfeeding 15, 21, 61, 64, 65, 67,69-73,78,97 Brend, William 66, 76 British Asociation 208 British College of Obstetricians and Gynaecologists 120, 146, 185 British Hospital for Mothers and Babies 124 British Medical Journal 28, 76, 124, 125, 142, 147, 209 Brittain, Vera 102, 129, 169 Broadbent, Alderman 103 bronchitis 31, 62, 78 Browne, F.J. 125, 132, 133, 140, 148, 174 Buchan, G.F. 175 Buckmaster, Lord 206 Bunting, Dora 96 Burns, John 28, 33, 76, 78, 80, 220

abortions 196, 199, 209-11 albuminuria 122, 125, 130 Amery, Leopold 38, 187-8, 201 anaemia 46 anaesthesia and anaesthetics 129-30, 131, 145-6 analgaesia 145-6 ante-natal care 13, 33, 34, 35, 119, 124, 125, 134, 145, 151, 154, 155, 221 ante-natal clinics 18, 125, 151-2, 185, 219 antibiotics 124 antiseptics 19, 121-2, 123, 134 Askwith, Ellen 168 Association of Child and Maternal Welfare Centres 92-3 Association of Headmistresses 74 Association of Infant Welfare and Maternity Centres 34 Association of Schools for Mothers and Infant Consultations 103 Babies Welcomes 96, 103 Baby 71

Baby Week Exhibition 100 Baird, Sir Dugald 147 Baldwin, Lady 129, 185 Balfour, A.J. 201 Balfour, Margaret 177, 183, 184 Ballantyne, J.W. 35, 51, 90, 91, 119, 124 Bailin, Ada 71 Balniel, Lord 183 Banks, Joseph and Olive 198-9 Bar, Professor 119 Barr, Sir James 206, 207 Barton, Dr E.A. 75, 103 Barton, Mrs 45, 118 Bell, Lady 46, 77 Bell, W. Blair 48, 121, 132 Bentham, Dr Ethel 72, 213 Berkley, Comyns 125-6, 128, 147, 151, 155 Besant, Annie 196 Beveridge, William H. 172, 213 Beveridge Report 177, 189 birth control 14, 17, 20, 38, 169, 196-214; clinics 207, 208, 212 Birth Control News 212

Cadbury, L.J. 188-9 caesarian section 124 Campbell, Dame Janet 49, 104, 118, 121, 123, 127, 145, 147, 171, 174, 208, 212 Carnegie Trust Report 29 Carpenter, Edward 205 Carpenter, Michael 106 Cassie, Ethel 132, 154 Cathcart, E.P. 175

230

Index CBC see Society for Constructive Birth Control and Racial Progress Central Midwives Board (CMB) 72, 128, 141, 143, 145, 149 cervical caps 203 Chalmers, A.K. 35 Chamberlain, Neville 40, 213 Champneys, Francis 203 Charity Organization Society 105 Charles, Enid 38 Chelsea Baby Club 102 Chesser, Dr Elizabeth Sloan 106 Chesterton, G.K. 213 childbirth: delivery positions 127; forceps used in 149-50; medicalisation of 20, 21, 117-35; see also home, childbirth in Children's Jewel Fund 34, 131 Children's Minimum Council (CMC) 165,176,177,178,183,184, 186, 187 chloroform 146 Clarke, Mrs J. 181 Clynes, J.R. 205 Colebrook, Dora and Leonard 123 condoms 202 cookery, teaching of 95, 185 Cooperative News 36, 166 cots 98 Cow and Gate 73, 220 Cowell. S.J. 175 creches 80 'crib death' 76 Daniel, Florence 155 Defence of the Realm Act 76 Delepine, Professor 75 dettol 123 diarrhoea 31, 61, 62-5, 69, 96, 108 disablement benefit 50 domestic science 93-5, 223 Drury, Joan 177,183,184 Drysdale, Alice Vickery 200 Drysdale, C.V. 201 Drysdale, G.R. 196, 200 dummies 97-8 eclampsia 155, 204 Eden, Thomas Watts 126, 127 Education, Board of 89, 90, 91, 92, 93, 94, 104, 178 Education (Administrative Provisions) Act 15 Education (Provision of Meals)

231 Act 15 Elizabeth Garrett Anderson Hospital 133 enteritis 31 episiotomies 126 eugenics 29, 30, 50-1, 66, 91 Eugenics Review 30-1 Eugenics Society 172, 188, 201, 206 eugenists 29, 30, 36, 90-1 Eyles, Leonora 99, 129 Fabian Womens Group 47, 166, 167, 168 Factory Act 78 Fairbairn, J.S. 126 Fairfield, Letitia 182 family allowances 14, 18, 20, 38, 80,166,167,168,169,170, 171, 172, 174, 187, 188, 190, 213, 214 Family Allowances Act 189 Family Endowment Chronicle 177 Family Endowment Council 170 Family Endowment Society (FES) 170, 171, 172, 177, 189 Freedom of Labour Defence League 80 Freewoman 94 Galton Laboratory 200, 201 General Medical Council 70, 147, 148, 150 Gibbon, I.G. 98 GPs 19, 20, 73, 102, 108, 117, 140-9 passim, 150, 151-2, 204 Gray, Alexander 213 Green, Marjorie 177, 183 Greenwood, Arthur 117, 155, 175 Greenwood, Florence 80-1 Gregory, Alice 128, 144 haemorrhage 41, 122, 124, 134 Haldane, Lord, 104 Halford, Miss 92-3 hand-feeding 69, 73, 74, 96 see also bottlefeeding 'handywomen' 20, 150 Health, Ministry of 105: creation of 16, 34, 104; mortality rates and 28, 40, 107 health visitors 13, 16, 18, 19, 20, 34, 105-7 Heron, David 200

232 Index Hewitt, Margaret 78 Holland, Eardley 147, 203 Holmes, J.R. 204 home, childbirth in 121, 127, 128, 130, 135, 140-57 home helps 20, 120, 130-1, 150, 221 Hood, Mrs 129 Hopkins, Frederick Gowland 175 How-Martyn, Edith 200, 205 Hubback, Eva 102, 169, 176, 200, 205 Hutchinson, Sir Robert 31 Risley, Raymond 43 Independent Labour Party 18, 104, 172 induction 124, 126 Infant Consultations 96 infant life-insurance 77, 78 infant mortality 15, 19; decline in 61, 202; diseases causing 31, 62-5; environmental factors 27, 30, 33, 42, 66, 67, 81, 82, 107-8, 117; hereditary factors 66-7; overlaying 76-7; poverty and 19, 67, 68, 73, 81, 82; rates of 27, 32, 178-9; et passim infant welfare centres 16, 18, 19, 34, 96, 97, 99, 100, 103, 104, 108, 197, 212, 219 infant welfare clinics 13, 14, 90 Inge, Dean 210 Insurance Societies 44 International Labour Organization 80 Jellett, Henry 127-8, 146-7, 155 Jessop Hospital 124 Karilac 73 Kariol 73 Kerr, Munro 148 Keynes, John Maynard 38 King, Frederick Truby 70, 73, 101, 102 Labour Party 39, 167, 172, 174, 176,181,197,198,213 Labour Women 133-4, 174, 198, 201 Ladies Sanitary Associations 15, 100, 106 Lancet 70, 89, 98, 102, 125, 150, 154,155,187

Land, Hilary 214 Lane, Sir Arbuthnot 207 Lane-Claypon, Janet 121, 132 Lansbury's Labour Weekly 99, 129, 213 Laski, Frida 211 Layton, Mrs 143 Leslie, Dr Murray 91 Liberal Yellow Book 18 Lister, Joseph 121 Liverpool Maternity Hospital 125 Lloyd George, David 167 Loane, Margery 81, 143 Local Government Board 15, 16, 28, 29, 34, 96, 103, 106, 151, 167, 173; et passim London County Council 133, 134, 208 Lysol 123 MacArthur, Mary 80 McCleary, G.F. 39 McDonald, Margaret 100 McGonigle, G.C.M. 47, 175, 185 Mcilroy, Louise 146, 174, 203-4 Mackay, Helen 46 McLaren, Angus 199, 203 Macmillan, Harold 188 McMillan, Margaret 99-100 malnutrition 103, 178, 180 see also nutrition Malnutrition, Committee Against 181, 184, 185, 187 Malthusian, The 201 Malthusian League 196, 201, 204, 205, 206 Mann, Corry 174 Marchant, James 201 Markham, Violet 188 Married Love 202, 203 Martin, Anna 116-17 `Marylebone cream' 75 Maternal and Child Welfare Act 104,141,151 maternal mortality 16, 19, 27, 34-5, 36-8, 118, 142; clinical causes of 41, 122; environmental causes of 27, 41, 174-5; mothers' attitudes to 27-8, 36-41; official attitudes to 28-35; rates of 45, 179-80; et passim Maternal Mortality and Morbidity Committee 49, 117-19, 120, 123-5,134,148,209,211

Index Maternal Mortality Committee, unofficial 39, 40, 44, 50, 117, 118, 120, 125, 141, 150, 152, 180 maternal welfare 16, 35, 43, 153 maternity: manuals on 70, 92, 101, 155; research into 125; textbooks on 35, 124, 125, 155 Maternity and Child Welfare Act 34 maternity benefit 16, 34, 165, 167, 168 maternity leave 80 Matthew, Vera Laughton 199 Mechling, Jay 101 medical education 70, 140 Medical Research Council 66, 125 Medical Women's Federation 48, 127,154,206 Mellanby, Edward 174, 175, 176, 181,184 midwifery 119-20, 125, 126, 127, 128; rules governing 143-4 Midwifery Act 128 midwives 20, 34, 72, 121, 123,124, 128, 140, 141, 142, 143, 144-5, 148, 151;'bona fides' 143 Midwives Act 141, 142, 149, 150 Midwives Institute 144, 146 milk 15, 64, 74,107, 186, 189; free and cheap 20, 105, 165, 166, 173, 176-7,178, 181, 184, 185,186,187 Milk Act 186 milk depots 96 Millard, Killick 75 Mitchell, Hannah 101 Moore, S.G. 31, 89, 103, 106, 155 morphine 130 Mother and Child 13, 95, 131, 221 Motherhood 74 motherhood, ideology of 21, 68, 108-9, 221-2, 224, 225 Motherhood Book, The 128 mothers: economic assistance to 165-90; education of 89-91, 95-109; free meals for 20; ignorance of 61-82; working 78-81 Mottram, V.H. 175 Naish, Lucy 70, 71 Nash, Dr Elwin 184 Nash, W.R. 182 National Association for Maternal and Child Welfare 127

233 National Association for Physical Education and Improvement 34 National Association for the Prevention of Infant Mortality 33, 72 'National Baby Week' 13, 34 National Birth Control Association 197, 207,208,211, 212 National Birth Rate Commission 201,203,205,209 National Birthday Trust 121, 127, 146, 181, 183, 184 National Conference on Infant Welfare 149, 151 National Conferences on Infant Mortality 31, 33, 34, 61, 75, 77, 78, 91, 103, 106 National Council of Women 94, 198,208,209 National Health 93, 95, 97-8, 102, 129 National health insurance 16, 17, 18,165 National Health Insurance, Royal Commission on 44, 153 National Health Insurance Act 34, 44, 50, 167, 219 National Health Service (Family Planning) Act 214 National League for Health and Maternal Welfare 92 National League for Physical Education and Improvement 29, 91, 98, 103 National Milk Scheme 187 National Union of Societies for Equal Citizenship (NUSEC) 105, 169, 172, 177, 198, 201, 205, 206-7, 208, 211 National Union of Women's Suffrage Societies 169 Nethersole, Olga 182, 183 Newman, George 29-30, 31, 33, 39-40, 49, 65, 70, 74, 78, 89, 91, 95, 104, 154, 175, 202 Newsholme, Arthur 28, 30, 33, 34, 35, 42, 64, 65-6, 67, 72, 76, 78, 93, 152, 202 Newson, Elizabeth 70, 101 Newson, John 70, 95, 101 Niven, James 91 Noel-Buxton, Lady 181 Notification of Births Act 104 nurseries 80, 92

234 Index

151, 156 nutrition 17, 18, 47, 68, 174-5, 176,179,181,183,184,187 Nutrition, Advisory Committee on 118, 184

Nursing Notes

obstetricians 19, 20, 118-19, 121, 122 oedema 45 Oren, Linda 46 Orr, John Boyd 181, 184, 186 paediatricians 70 Pankhurst, Christabel 199 Pankhurst, Sylvia 100, 102, 198 Parker, Roy 214 Pearson, Karl 30, 66, 73, 81, 201 People's League of Health 181, 182-3 Percy, Lord Eustace 186 Phillips, Miles 123 Physical Deterioration, Committee on 15, 27, 29, 33,69, 74, 89, 91 Pilgrim Trust 47 Playfair, W.S. 127 pneumonia 31, 62 Population (Statistics) Act 39 Porter, Dr Charles 31, 35, 36 post-natal clinics 125 Practitioner 142 pregnancy: definitions of 119, 126; exercises during 125-6 pregnant women, dinners for 17, 72-3, 173 Pritchard, Eric 33, 71, 73, 75, 96,103,107 Pritchard, Miss 50 Public Health 64 puerperal fever 119 see also sepsis puerperal pyrexia 123 see also sepsis Queen Victoria Jubilee Institute 121,123,142 Rathbone, Eleanor 42, 50, 169, 170, 172, 176, 189,201 Ravenhill, Alice 93 Reeves, Mrs Pember 47, 98, 167, 168 Reid, George 78-9 Reid, Sir S. Archibald 207 Rhondda, Lord 182

Rhys-Williams, Lady 121, 127, 146, 181, 182, 188, 209 Ribble, Margaret 77 rickets 74, 103 Roberts, Harry 179 Robertson, Dr 75 Rolleston, Sir Humphrey 206 Routh, Amand 35, 72,107, 203 Rowntree, Griselda 131 Royal Free Hospital 129, 203 Royal Society of Medicine 147, 203 Royden, Maude 168, 205 Russell, Alys 96 Russell, Dora 198, 213 St Olave's hospital 133 St Thomas's Hospital 126 Saleeby, C.W. 30, 69 Sandys, Duncan 39 sanitation 62, 64, 67, 107 Saunders, A.M. Carr 39, 206 'Save the Mothers' 13 Scannel, Dorothy 95 Scharlieb, Dr Mary 69, 91, 127, 203 school meals 15, 16-17, 178, 189 schools: medical services in 15, 90; mothercraft teaching in 90, 91-3, 95 'Schools for Mothers' 96, 97, 99, 103, 107 scopolamine 130 Scurfield, Harold 69, 154 Semmelweiss, Ignaz Philipp 119, 123 separation allowances 169-70 sepsis 37, 41, 122-4, 134, 149, 150, 174, 179, 209 Shorter, Edward 77 Simpson, Dr 184 Smith, Mrs A.L. 117 Socialist Medical Association 151 Society for Constructive Birth Control and Racial Progress (CBC) 203, 204, 205, 206, 212 Society for Infant Consultations 33 Society for the Provision of Birth Control Clinics 211 Stamp, Lord 189 Stanley, Lady Maureen 207 sterilisation 204 Stewart, Malcolm 207, 212

Index stillbirths 42 Stocks, Mary 172, 198 Stopes, Marie 71, 146, 196, 197, 199, 202, 203, 204, 205, 206, 207 sulphonamides 124 Summerskill, Edith 127 'Sunshine clinics' 173-4 Sutherland, lan 42 Sykes, Dr 72, 75, 96, 103 TB 31, 108, 212 Tennant, May 39, 40, 49, 81 Titmuss, Richard 68, 196 Topping, Dr Andrew 152-3 toxaemia 41, 122, 124, 134, 154, 155, 174, 179, 183 True Morality 204 TUC 152, 172, 177, 189 Tuckwell, Gertrude 39, 40, 44, 45, 49 'twilight sleep' 129, 146 underpopulation, theories about 38-9 Unemployment Assistance Board 188; benefits 165, 176, 178, 185 University College Hospital 119-20, 124-5, 132, 133,147-8 Vaughan, Kathleen 125, 126 voluntary workers and agencies 14, 15, 20, 33, 89, 96, 100, 103, 104 Walker, Dr 180 Waller, Harold 71, 102 Washington Convention of International Labour Organization 80 Webb, Beatrice 170 Webb, Sydney 200

235 Wells, H.G. 205 West, Rebecca 93 Wheatley, James 198 White, Graham 188 Whitehouse, Professor Beckwith 209 Wife's Handbook, The 204 Williams, W. 123 Winchester, Bishop of 188 Woman's Labour League 72, 80, 99, 102-3,130,167,173 women: health of 19, 28, 43-5, 48, 49, 50; role of 19 Women's Cooperative Guild 35-6, 41,43,44,45,48,50,87,99, 100, 118, 129, 130, 143, 145, 152,167-8,196,197,201, 211 Women's Equalisation Fund 44 women's groups 13, 19, 35, 41 128-9, 141, 166, 196, 197, 206, 208; see also under names of groups Women's Health Association of Great Britain 89, 94 Women's Health Inquiry Committee, 45, 47 Women's Imperial Health Association 91 Women's Industrial Council 44, 81 Women's Leader 198 Women's Liberal Association 198 Women's National Liberal Federation 208 Wood, Kingsley 189 Wood Report 206 Workers Birth Control Group 197-8 World War 116, 28, 30 Young, Dr James 48, 49, 183 Young, Hilton 155