be the use of these if she goes to the hospital, where she cannot use them, and where her friends cannot come to see her lying in state amid her finery?

Such customs are real parts of life. If American workers for health do not know them or understand them, if they take an indifferent or contemptuous attitude toward them, they can neither get the best from, nor give the best to, the people whom they seek to serve.

These few customs, traditions, and superstitions have been mentioned to illustrate the importance of knowing the people with whom we are dealing, their backgrounds and characteristics. There has been no thought of holding up to laughter or scorn any people, or even any superstition. They are historical products of human development.

The social composition of the immigrant family creates another difficulty for the American health worker. The immigrant mother has not the independence of the average American-born woman. Authority over all the members of a family, including the wife herself, is centered much more in the husband. Now the man of the family is often a difficult person for the health worker to reach. He is not at home during the usual working hours of the social worker or nurse. A medical adviser of a child-welfare undertaking in a large Middle Western city tells us that she found it necessary to put some nurses on at night to visit their immigrant families, because in that particular group the mother would not change the baby's diet, however deleterious it seemed to the American doctor or nurse, without receiving the father's permission.

The necessity of reconciling inherited customs with the conditions found in America has in many respects a far-reaching effect on maternity work for immigrant women. Perhaps the respect in which they differ most sharply from native born is in their extensive use of midwives.

The immigrant mother has rarely been accustomed to a man doctor at the time of confinement. She and her friends have used the midwife, who, in most European countries, is a woman of some standing, trained, and in many countries carefully supervised. The midwife is the most important single element in the general question of the care of immigrant mothers, and as such her capability and the quality of her work is of immense importance.

X

THE MIDWIFE

MIDWIVES in the United States bring into the world more than a million babies every year. Although we have no exact records for the country as a whole, information received from a number of states and many cities show it to be a conservative estimate that 30 per cent of all confinements are attended by midwives. The truth is probably nearer 40 per cent than 30 per cent.

Smaller detailed studies have been made from coast to coast. Boston has no official data, since midwives are not recognized by law in Massachusetts, and theoretically are not allowed to practice. Ninety mothers, selected at random from those attending the general clinic of the Maverick Dispensary in East Boston, two years ago, reported that of their 329 children born in this country, 59 per cent had been delivered by doctors, 25 per cent by midwives, 15 per cent by institutions, and three cases, or 1 per cent, had been unattended.

Of 529 mothers who received prenatal supervision from the Division of Child Hygiene of the Department of Health in Newark, New Jersey, 87.3 per cent were delivered by midwives, 9.6 per cent by doctors, 2.6 per cent in hospitals, and .4 per cent had no attendant. The number who used midwives is notable, since up to the time of delivery nurses of

the Department of Health had been supervising their

pregnancy.

Variation in the per cents reported from the different places intimates that nationality must be taken into consideration. One of the most complete available studies of the factor of race is that for New York State. The following table compares the numbers of native and foreign-born mothers resorting to midwives: 1

TABLE XXVI

BIRTHS ATTENDED BY MIDWIVES IN NEW YORK STATE, ACCORDING TO THE NATIVITY OF THE MOTHERS (NEW YORK CITY ExCLUDED), 1916

The difference in the proportionate use of midwives by native and by foreign-born mothers is the outstanding fact of the table. It is not possible, however, to lump the foreign-born mothers together in the generalization that they all have midwives. The 1 Thirty-seventh Annual Report, New York State Department of Health, 1916, p. 454, Table VII.

197

per cent of those who do varies among the races from 66.1 for the Poles to 1.5 for the English-speaking foreign born, a rate that falls below that of the native born. The high per cent for native-born mothers is probably explained by the fact that women of native birth employing midwives "were of Italian, Russian, or Austro-Hungarian parentage, and . . . the custom of the native country of their parents still held considerable sway."

A study of mothers in New York City found 56.2 per cent using midwives; 87 per cent of those using midwives were foreign born; and 58 per cent of those foreign born were Italian. The use of midwives by Italian mothers is everywhere prevalent. In one study of two hundred and eighty-nine Italian deliveries, 91.7 per cent were attended by midwives.2 A study of three cities in California showed that "the midwifery situation . . . is very largely confined to the foreign-born population, principally Italian and Japanese."3 From Chicago, Detroit, and Pennsylvania studies come similar findings. The foreign

1 Jacob Soble, M.D., "Instruction and Supervision of Expectant Mothers in New York City." Reprint from New York Medical Journal, January 19, 1918, pp. 16, 17.

2 Compiled from material received from the Bureau of Educational Nursing, Association for the Improvement of the Condition of the Poor, New York City, 1918.

3 Mrs. Elwyn Stebbins, "Supplementary Report on the Midwives of Oakland, Alameda, and Berkeley," Sixth Annual Report of the American Association for the Study and Prevention of Infant Mortality, pp. 149-150.

4 Report of the Health Insurance Commission of the State of Illinois, May 1, 1920, p. 60. "How Two Thousand Detroit Mothers Were Cared for in Childbirth," Detroit Home Nursing Association, Detroit, 1917, pp. 1, 3, 6. Emma Duke, "Infant Mortality, Johnstown, Pennsylvania," Children's Bureau, United States Department of Labor, 1915, p. 60, Table IV.