facilities in rural districts are still more limited, and women must depend upon attendants privately engaged.

Yet even in large cities cases unattended by physician, midwife, or nurse, or even by a neighbor, are far from unknown. In a study of maternity care made in Detroit in 1917 appears the following story: 1

Mrs. K., Hungarian, has four children. Husband acted as interpreter. When asked if a doctor or midwife was employed he replied: "Oh, she had her baby while I was at work-only the children here. She sat up in bed and cared for herself. Was out of bed on the second day after birth."

In this same survey of 2,000 maternity cases in Detroit, it was found that

in the great majority of instances the time the patient remained in bed was determined, not by her physical condition, but by the assistance she was able to secure. The presence of boarders or roomers in the house at such times very materially shortens the time a mother is cared for in bed. Nationality also plays some part. It was found that daughters of foreign-born mothers remained in bed much longer than their mothers had been accustomed to. Foreign-born women who came to the United States at an early age and received their education in this country followed the customs of American women, rather than their relatives or fellow countrywomen. They remained, as a rule, longer in bed and had a distinctly higher standard of care.

In a study made in New York by the Association for the Improvement of the Condition of the Poor, 1"How Two Thousand Detroit Mothers Were Cared for in Childbirth," Detroit Home Nursing Association, Detroit, 1917, p. 11.

in two hundred and sixty-five maternity cases cared for by midwives, data showing the rest period after childbirth are of interest.

TABLE XXV

DAYS IN BED AFTER DELIVERY OF CASES CARED FOR BY MIDWIVES, NEW YORK CITY, 1912-19

Over 60 per cent of the women delivered by midwives stayed in bed only six days or less, while four women were in bed less than two days. What the effects of these short periods of rest after childbirth may be on mortality rates is a matter for conjecture. Conditions that existed a few years ago in a city of middle size and that are still characteristic of many similar cities which we have studied, are depicted in the survey of Johnstown, Pennsylvania, by the Federal Children's Bureau, published in 1915.1

Two thirds of those having no attendant (at birth) were Serbo-Croatians. It was a Polish woman, however, who gave the following account of the birth of her last child:

At five o'clock Monday evening went to sister's to return washboard, having just finished day's washing. Baby born while there; sister too young to assist in any way; woman not accustomed to midwife, anyway, so she cut cord herself; washed baby at sister's house; walked home, cooked supper for boarders, and was in bed by eight o'clock. Got up and ironed next day and day following; it tired her, so she then stayed in bed two days. She milked cows and sold milk 1 Emma Duke, "Infant Mortality, Johnstown, Pennsylvania," Children's Bureau, United States Department of Labor, 1915, pp. 32-34.

day after baby's birth, but, being tired, hired some one to do it later in week.

This woman keeps cows, chickens, and lodgers; also earns money doing laundry and char work. Husband deserts her at times; he makes $1.70 a day. A fifteen-year-old son makes $1.10 a day in coal mine. Mother thin and wiry; looks tired and worn. Frequent fights in home.

Frequently the Serbo-Croatian women dispense altogether with any assistance at childbirth; sometimes not even the husband or a neighbor assists. More than 30 per cent of the births among the women of this race took place without a qualified attendant. More than one half of those delivered by midwives, less than one fifteenth of those delivered by physicians, and about one fifth of those delivered without a qualified attendant had babies who died in their first year of life.

Fifteen of the nineteen Serbo-Croatian women whose babies died under one year of age kept lodgers.

The native mother usually had a physician at childbirth; the foreign born, a midwife. The more prosperous of the foreign mothers, however, departed from their traditions or customs and had physicians, while the American-born mothers, when very poor, resorted to midwives. The midwives usually charged $5, and sometimes only $3; they waited for payment or accepted it in installments, and they performed many little household services that no physician would think of rendering.

One or two of the intelligent graduate midwives in Johnstown have been an educational force among the foreign mothers for some years past. On the other hand, there were others who were so dirty and so ignorant that they were a menace to the public health.

BACKGROUNDS FOR MOTHERHOOD

If neglect in confinement is more frequent for immigrant than for native women, the explanation may be found in various circumstances peculiar to the immigrant's situation in America.

Earlier chapters of this volume have described the typical social and economic conditions under which immigrant families live in American communities. Poverty and crowding, unsanitary houses and neighborhoods, are so frequent as to be almost characteristic, whether it is the immigrant's own fault or the fault of the American community, or some of each. Maternity care under these economic and social conditions presents difficult problems at best, but it is further complicated by barriers of language and differences in customs and points of view between the American medical and health worker and the immigrant.

No events of life are more interwoven with tradition and superstition than are pregnancy and birth. It is impossible to understand the situation which must be dealt with among immigrant women in this country unless we know something of their backgrounds and customs. Some of these are of interest merely to the curious; some have practical value for the health worker. It must be borne in mind that in different parts of a single country, such as Italy or Poland, these customs and traditions may vary widely, and that what is told one by a certain Italian mother as a long-rooted custom of her country may really be only a local one of her community or district.

Numberless traditions cluster about the care of the mother. A nurse who had had much experience working in Polish sections says:

As soon as a Polish woman is pregnant she gets a scrubbing job. No matter what her work may have been before, she now wishes to scrub.

If there is a theory behind this it is probably that the exercise is good for the prospective mother. This woman was told that in Poland a countess will scrub when she knows that a baby is coming."

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Many Italian women are found to have a "superstition" against taking a bath during pregnancy. They tell nurses that this will cause an abortion or miscarriage. A wise nurse, who had lived in southern Italy, observed that their bathing there had been in the streams, lakes, or sea; the shock of cold-water bathing possibly brought trouble to the pregnant woman and may have been the source of a tradition against any bathing during pregnancy. This nurse is accustomed to explain carefully to her patients that while it was not well to bathe in Italy in cold water, out of doors, here in America the custom is to take a warm bath indoors, and that the bath will be a comfort to the mother and help to keep her well. A frequent Jewish superstition seems to be that a pan of water set under the bed of a woman in confinement will keep away poisons and bedsores." A Russian-Jewish superstition told by some midwives is that a pregnant woman must not look on the face of a dead person, or the baby will be born white. Another, that after the baby is born, if the mother will blow into a bottle, the placenta will come and all will be well. Workers among the Poles tell of the same bottle-blowing superstition. It has been suggested by some doctors and nurses that the muscular exertion of hard blowing may be of assistance in labor. Russians and Greek Catholics appear to have a tradition that the mother should be churched between four and six weeks after delivery.