Information kindly furnished by Dr. S. Josephine Baker, Director of the Bureau of Child Hygiene of the New York City Department of Health, substantiates these figures. The data show that midwives' rates vary between $5 and $25. Differences appear in different parts of the city, the rate becoming somewhat higher as we proceed "uptown" in Manhattan. The great bulk of the midwives in Manhattan charge $10. In the Bronx and Richmond, $15 is a more frequent charge than $10, but more than $15 is charged in only a small proportion of cases anywhere.

Of course many immigrant families get along in this country and improve their financial status. When there is not the urgent economic handicap, they want and secure for themselves and their families the best care and attention in time of sickness that is available. Whether this can be secured through the midwife is the question. But since the midwife is not only preferred by a considerable proportion of our population because of tradition and training, but is often the only agency economically possible, she is inevitably influencing the health and future of many young Americans.

STATUS OF THE AMERICAN MIDWIFE

Midwifery in America is at present sadly unstandardized. The best type of midwife is the woman who received her training abroad and who takes up the work as a definite vocation. We also find many examples of the casual midwife, the woman who has had no training except experience with her own and

her neighbors' children. When her family of youngsters have grown old enough for her to leave them she gives part of her time to helping her neighbors, and earns a certain amount of money at the same time.

Although several states, such as New Jersey, Ohio, and Wisconsin, require midwives by law to be trained before obtaining licenses, none of them has any recognized school for teaching midwifery. A large number of commercial schools exist whose advertisements may be found in not a few foreign-language newspapers. Most of these appear to give wholly inadequate training and some are undoubtedly mere diploma mills.

The Bellevue Hospital School of Midwifery, in New York, is the only school in this country under public control, which is in this case municipal. This school is under the direction of the Superintendent of Nurses. No special requirements are necessary for entrance. The applicant must be twenty-one years of age, be able to read and write, and be of good moral character. No fee is charged for the course of eight months, during which the students live in the school. There are nineteen beds for maternity cases, as well as an out-patient department. Each pupil must have attended one hundred cases, and herself conducted twenty confinements, before receiving her certificate. Up to the time of writing (1919) no graduate nurses have taken the course in the Bellevue Hospital training school for midwives. The superintendent says:

We have not yet anything in our course to induce trained nurses to enter the school. The course is too simple.

The number of graduates from this school was only about twenty-eight in 1918-19. Such, at present, is the status of training for midwifery in the United States of America.

The legal and social status of the midwife is very different in this country and abroad. In the United States the midwife has been a declassed person. We have, in general, provided no laws regarding her training, licensing, or regulation. Consequently any woman, whether trained or ignorant, conscientious or unscrupulous, may take up midwifery.

Only recently have we begun to recognize the midwife in an official way. Only twenty-one of our forty-eight states have laws regulating midwifery, but in many of these the laws are almost valueless because no provision for enforcement is made. In Massachusetts and Nebraska the midwife cannot practice legally. In thirteen states there are no laws applying at all, and the midwife may practice for weal or woe. They are Arizona, Arkansas, Florida, Georgia, Idaho, Kentucky, Maine, Mississippi, New Mexico, South Carolina, Tennessee, Vermont, West Virginia. In twelve states the midwife is legally recognized, but there are no general laws regulating her training or practice. They are Alabama, California, Delaware, Michigan, New Hampshire, North Dakota, Oklahoma, Oregon, Rhode Island, South Dakota, Texas, Virginia.

In thirteen of the twenty-one states having midwife regulations, as well as in the District of Colum

1 We owe to the courtesy of Miss Carolyn C. Van Blarcom these data regarding state and municipal legislation on midwifery, revised up through the year 1916.

bia, midwives must pass an examination before receiving a state license, but in seven of these the provision for enforcement is so poor as to make the law of no effect. The thirteen are Connecticut, Illinois, Indiana, Louisiana, Maryland, Minnesota, Missouri, New Jersey, New York, Ohio, Utah, Wisconsin, Wyoming.

Candidates for state licenses are generally examined by the state boards of midwifery, appointed by state boards of health, or by boards of medical supervision. Midwives already practicing usually can continue to do so just by registering.

The Illinois state law has a strong penalty clause covering the midwives who fail in reporting babies with sore eyes. It imposes a fine of $100 for the first case and $200 for the second case, or six months' imprisonment, or both.

In Omaha, Nebraska, we find that 25 per cent of all births registered are midwife cases. Under the laws of Nebraska a midwife may be prosecuted for practicing medicine without a doctor's license, but there is a city ordinance governing the Omaha situation. In a number of cities we find midwives practicing under local ordinances. Buffalo was the first city to enact such a law some forty-three years ago. Los Angeles, in 1910, passed a law by which midwives are examined and licensed by the city Department of Health.

Virginia is one of the twelve states with no general laws, but the city of Norfolk regulates midwives under an ordinance of 1912. In Norfolk a midwife is required to register and be licensed by the Board of Health, and to notify it within ten days of any

change in address, yet there is no penalty clause providing for failure to comply with the law. In Tennessee, another state with no law, Memphis is working under a city ordinance of August 9, 1910, by which midwives are licensed and registered. The license is good for one year and can be renewed annually. Memphis invokes a fine of from $5 to $50 for midwives found practicing without a license.

The system of supervision of midwives in the city of Newark, New Jersey, may be briefly described as one of the excellent examples of the best type of work. New Jersey has a compulsory law, but the following experience indicates how much farther cooperative efforts with midwives will go than mere legal pressure.

When our bureau was organized in 1913 to protect the health and prevent disease and death in mothers and infants we recognized that the active supervision and training of midwives was one of the most effective methods of obtaining this result, since the midwives in Newark attend 50 per cent of the births and in certain groups of nationalities as high as 80 per cent and 90 per cent.

In the beginning we directed our attention to interesting the midwife in the work we were undertaking for the protection of maternal and infant life in the belief that midwives would respond to the appeal as well as other members of the community. The midwives were asked to assist the nurses in their districts: firstly, by reporting promptly all the births; secondly, by establishing the routine of infant care and breast feeding, which would later be taught by the nurse when she visited the mother; thirdly, to advise the mother that the nurse would visit and that she should welcome and accept the instructions that were to be given to her. In this way we capitalize the influence 1 Dr. Julius Levy of Newark, New Jersey, memorandum for this study.