j:8xasasasososfxxosixososci^^ 
 
 CERTAIN ASPECTS 
 
 OF 
 
 PUBLIC MATERNITY AND 
 INFANT CARE 
 
 IN 
 
 BERLIN AND STOCKHOLM 
 
 
 BY 
 
 ELIZABETH PINNEY HUNT 
 
CERTAIN ASPECTS 
 
 OF 
 
 Public Maternity and Infant Care 
 
 IN 
 
 BERLIN AND STOCKHOLM 
 
 ic ^^ 
 
 By 
 
 ELIZABETH PINNEY HUNT, A. B., M. A. 
 
 Bryn Mawr College 
 
 FelloNA/, American Scandinavian Foundation, 
 University of Stockholm, 1920^2 1 
 

 ^^ 
 
 
CONTENTS 
 
 Introduction. 
 General Organization. 
 
 PART I. 
 
 MATERNITY CARE. 
 
 Department of Public Guardianship. 
 Maternity Hospitals. 
 
 PART II. 
 
 INFANT CARE. 
 
 Municipal Clearing House for Foster Children. 
 
 Departments of Public Guardianship. 
 
 Clinics and Milk Stations. 
 
 Children's Hospitals. 
 
Kft 
 
Deaths from Diseases due to Pregnancy and 
 Confinement, 1910 
 
 Rate per 1000 Live Births Rate from puerperal septicemia 
 
 „ , . _ ^ per 1,000 live births 
 
 Pennsylvania 7.1 Pennsylvania 3-2 
 
 France 4.6 France 2 2 
 
 New Zealand 4.5 ^^^ Zealand L3 
 
 England 3.6 England 1.4 
 
 Germany 3.2 Germany 1.4 
 
 Sweden 25 Sweden .9 
 
 Maternal Mortality, 1910 
 
 Rate of deaths per 1000 live 
 births 
 
 Rate of deaths from puerperal 
 septicemia per 1,000 live births 
 
 
 
 
 
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 p^ 
 
 Source: Compiled from. Official Sources. 
 
Introduction 
 
 The problem of how best to care for mothers and infants 
 has been before the American public during the past few years. 
 The work along these lines done by the Federal Children's 
 Bureau and the recent enactment of the Sheppard-Towner bill 
 providing for Federal and State Maternity Care, have done, 
 perhaps, most to arouse discussion of the scope of public respon- 
 sibility. Many charts have been drawn showing how far behind 
 America stands in comparison with other countries in respect 
 to maternity and infant mortality. The trend seems to be, defi- 
 nitely, to arouse a sense of responsibility for these unnecessary 
 deaths on the part of those who are professionally engaged in 
 maternity and infant care, as well as on the part of the general 
 lay public. 
 
 A study of the characteristic public work carried on in two 
 large cities of two of the countries showing low maternity and 
 infant death rates, may, therefore, prove timely. As it has been 
 possible to observe personally various aspects of the public work 
 for maternity and infant care in Berlin and Stockholm, a de- 
 scription of such work in these two cities will be, perhaps, valua- 
 ble. 
 
 Where gaps occur in facts and statistics, allowance must be 
 made, in the case of Germany, for a natural reticence due to in- 
 ternational conditions since the war. Furthermbre, the German 
 institutions have not had sufficient funds in many cases to tabu- 
 late and print their more recent data. In Stockholm this lat- 
 ter difficulty did not exist. 
 
 It must be remembered that both foreign studies are de- 
 scriptive only of the conditions found at the time the surveys 
 were made. In Berlin the survey took place in January, 1921, 
 in Stockholm, in November, 1920. 
 
 The writer has confined the study to institutions personally 
 visited, and has made no attempt to pass judgment on the med- 
 ical aspect of the problems involved. The purpose of the short 
 study is to present a fair picture of the outstanding public re- 
 sources for maternity and infant welfare in Berlin and Stock- 
 holm, and of the organization of the administration of these re- 
 sources. It is the social, not the medical problem that is de- 
 scribed. 
 
PUBLIC MATERNITY AND INFANT CARE 
 IN BERLIN AND STOCKHOLM 
 
 The statistics relating to maternity mortality in the United 
 States and several of the larger countries in Europe reveal a 
 marked difference in favor of Europe, It is possible that this 
 difference, while due to many causes of race, adaptation to en- 
 vironment, and different modes of living, may be due in part, 
 to a superior organization of the factors involved in the social 
 supervision of maternity and infant care. 
 
 Maternal {Mortality Rates in the United States and Certain Foreign 
 Countries per 1.000 Live Births 
 
 Uruguay (1919) 2.3 
 
 Italy (1916) 2.7 
 
 Sweden (1916) 2.7 
 
 Norway (1917) 3.0 
 
 The Netherlands (1919) ' 3.4 
 
 Japan (1918) 3.8 
 
 Hungary (1915) 4.0 
 
 England and Wales (1919) 4.4 
 
 Finland (1918) ,, 4.4 
 
 Ontario (1919) ' 4.5 
 
 Ireland (1919) , 4.7 
 
 German Empire (1918) 4.9 
 
 Australia (1920) 5.0 
 
 Spain (1915) 5.2 
 
 Switzerland (1915) 5.5 
 
 France (1914) 5.7 
 
 Scotland (1919) 6.2 
 
 New Zealand (1920) 6.5 
 
 U. S. Birth Registration Area, 1919) 7'.4 
 
 Chile (1919) 8.8 
 
 Source: Compiled from official sources or from Annuaire 
 International de Statistique, by the Federal Children's Bureau 
 Latest figures available, January 1, 1922. 
 
Public Maternity and Infant Care 
 
 Before discussing, separately, types of the public institu- 
 tions in Berlin and Stockholm which deal most prominently 
 with maternity care and infant care, it will ibe necessary in each 
 city to give a brief outline of the general organization covering 
 the two closely allied divisions of work. 
 
 The public work in Greater Berlin for the protection of 
 needy mothers and infants is covered by State, Provincial and 
 Municipal institutions, and by those that are private, with 
 grants-in-aid from Republic, Province, State, or Municipality. 
 With two exceptions the work described in Berlin will be con- 
 fined to municipal institutions. 
 
 The municipal work in Greater Berlin falls under the super- 
 vision of two city departments, (1) The Department for Chil- 
 dren, and (2) The Municipal Board of Health. The municipal 
 department of greatest interest is the Department for Children, 
 which was founded only as long ago as 1919, and is, at present, 
 undergoing a process of change. It represents an effort to cen- 
 tralize the work done for mothers and children and, in its new 
 plan, which has passed the Municipal Deputation for the Wel- 
 fare of Youth, and is about to be passed by the Municipal Coun- 
 cil, it advances far in the direction of satisfactory centralization. 
 
 The general scope of the work of the Department for Chil- 
 dren, as now planned, may be summarized briefly. 
 
 The Central Department for Children of Berlin, is com- 
 prised of three departments : — 
 
 I. General Division, which deals with Organization and In- 
 formation and is located at 33 Altejacobstrasse. 
 
 II. Child Care and 'Guardianship, which is divided into: — 
 
 1. Division for Child Welfare, with headquarters at 
 33 Altejacobstrasse, and consists of four divisions: — 
 
 (a) Preventive Care for Children, which deals with 
 the Stations for the Care of Small Children, Day Nurseries, 
 Children's Houses, Foster Children, and Crippled Children; 
 
 (b) Welfare Work which arises in Connection with 
 the Police, such as cases of homeless juveniles, and girls in 
 moral danger; 
 
 (c) Care of Children Educated Outside of the Family 
 Group ; 
 
 (d) Care for Delinquent Children. 
 
 2. Division of Public Guardianship, with headquarters 
 at 43 Landsbergerstrasse. The Division of Public Guardianship, 
 
 8 
 
Public Maternity and Infant Care 
 
 founded in 1912, and enlarging its field in 1921, has, in general, 
 for its scope : 
 
 (a) The supervision of all needy children, whose par- 
 ents are either inadequate or deceased; 
 
 (b) Pre-natal and maternity care; 
 
 (c) Professional care for illegitimate children'; 
 
 (d) "Work connected with the adoption of children; 
 
 (e) Legal work arising in connection with its afore- 
 mentioned duties. 
 
 III. Department for Child Kecreation, with an office oii 
 Neuefriedrichstrasse, covers the work done by the city for chil- 
 dren's playground, gymnastics, theatres, music, etc. 
 
 The Central Department for Children is reproduced in each 
 of the twenty districts of Greater Berlin. In each district is the 
 District Station, which acts as a bureau of information for the 
 inhabitants of the district, and from which investigators work. 
 The central office has final jurisdiction over all cases. 
 
 The Municipal Health Department touches the work for 
 mothers and infants in two of its departments : — 
 
 1. The Department of Hospitals. 
 
 2. The Department of Social Hygiene. 
 
 These two departments exist for Greater Berlin. Each of 
 the twenty districts of Greater Berlin has for itself a Health 
 Division, whose function is to fulfill the orders of the central 
 Health Department. 
 
 The Department of Hospitals, has, as the name indicates, 
 the entire supervision of Municipal Hospitals, including those 
 for women and infants. The department of Social Hygiene is 
 engaged in so far as it touches our subject, in the supervision of 
 medical work in the various homes and institutions for mothers 
 and babies — as the medical work in the Public Orphan Home 
 and in the Stations for the Care of Infants. 
 
 Under the first department, the Department of Hospitals 
 are the three large municipal houses for maternity and infant 
 care: — The City Maternity Hospital, The Municipal Home for 
 Children and Mothers, and Kaiser and Kaiserin Friedrich'a 
 Childrens' Hospital. 
 
 Turning now to the general plan of the public work for 
 mothers and infants in Stockholm, a contrast at once is obvious 
 in com^parison to Berlin. The organization in Stockholm tends 
 more to decentralization. In several features, however, the in- 
 
 9 
 
Public Maternity and Infant Care 
 
 stitutions are much alike, though operated under different auth- 
 orities. The public work carried on may be classified into that 
 falling under (1) The State Health Department; (2) The Muni- 
 cipal Board of Health; (3) The State Social Department, which 
 covers the work of the Board for Child Welfare similar to 
 the Berlin Department of Public Guardianship and the work of 
 the Poor Law Authority, which is not now of importance in Ber- 
 lin. Grants-in-aid, as in Berlin are given by the State to var- 
 ious private institutions. The institutions in Stockholm^ may be 
 grouped, for clearness, as below. • It is obvious that work cov- 
 ered by municipal organization in Berlin, is under State auth- 
 ority in Stockholm. 
 
 I. State Department of Health 
 1. General Maternity Hospital. 
 
 II. Mknicipal Board of Health 
 
 1. South Municipal Maternity Hospital. 
 
 2. Sachs Baby Hospital. 
 
 3. Bureau for the Care of Foster Children. 
 
 III. State Social Department 
 
 1. Bureau for Child Care. 
 
 2, Poor Daw Board. 
 
 (a) Municipal Infant Home. 
 
 (b) The Municipal Home for Children at Asogaten. 
 The above outline of the organization of the most important 
 
 public work for maternity and infant care in Berlin and Stock- 
 holm, leads to a closer examination of particular institutions re- 
 lating first to maternity care and secondly to infant care. 
 
 10 
 
PART I.— MATEPvNITY CARE 
 Department of Public Guardianship 
 
 The Department for Public Guardianship, already men- 
 tioned, as a division of the ]\Iunicipal Department for Children, 
 is the outstanding feature of the public work in Berlin for 
 mothers. It touches the work of maternity care in its division 
 for pregnancy and confinement. The course of action oc- 
 curs somewhat as follows: Women who are pregnant and find 
 need of assistance that their families are unable to provide, may 
 apply for aid to the Department of Public Guardianship. All 
 cases must go through t)his central office. The story of the 
 woman is heard, and she is then advised. Usually she is sent 
 to a hospital for advice or prenatal care, or if the confinement 
 is due to occur within eight weeks, she may enter a hospital as 
 a working patient. After childbirth s^he may remain in the 
 ward ten days, after which period she must, in most cases, find 
 other accommodation. If the mother is to be confined at her 
 home, the Division for Public Guardianship provides her with 
 all the necessary articles for her illness, and in all cases gives 
 the infant's layette. All needy pregnant women may re- 
 ceive from the Division for Public Guardianship for three 
 months before confinement, a certain amount of free milk daily. 
 Leaflets describing proper care during pregnancy, as well as 
 proper care for the infants, are circulated among the applicants 
 for help. A list of hospitals which the Division for Public 
 Guardianship may call upon for beds is kept on hand. In each 
 hospital there are from twenty to one hundred beds. 
 
 The Division for Public Guardianship gives money in cases 
 of stress and money also goes to confined women from two other 
 sources, (1) The Public Sick Fund, to which all persons whose 
 family income is no more than 10,000 marks a year may be- 
 long.* Each member pays a small sum per month, and the State 
 
 *Forei^ Exchange Rates — New York on Berlin and New York on 
 Stockholm for a 7-year period. Nominal Exchange quotations for 
 checks furnished by Brown Bros. & Co., Phila. 
 NEW YORK ON BERLIN: 
 
 1915 1916 1917 1918 1919 1920 1921 
 
 .2225 .1918 .1766 0895 -0225 .0140 
 
 1 Mark i iMark 1 Mark 1 JVIark 1 Mark 1 Mark 
 
 NEW YORK ON STOCKHOLM: 
 
 .2537 .2787 .2962 .335 .2925 .2175 .2037 
 
 1 Crown 1 Crown 1 Crown 1 CroA\m 1 Crown 1 Crown 1 Crown 
 
 "All of the above quotations are for a date in January in each 
 
 year with the exception of the New York on Berlin for 1917 and 1913 
 
 which records for January are not available." (Brown Bros- & Co.) 
 
 11 
 
Public Maternity and Infant Care 
 
 pays a definite lump sum. Confined women who are 
 members are entitled to 18 marks a day for ten days after child- 
 birth. Most of the hospitals charge a small sum per day, which 
 may, then, come out of the Public Sick Fund. (2) The second 
 source of income to confined women appears through the Moth- 
 ers' Confinement Pension Bill which appeared in Germany dur- 
 ing the war, (September, 1919). The main features of the bill 
 are necessary to an understanding of its provisions. 
 
 National Confinement Pensions 
 
 Main Features — As Issued by the Department of Public Guardianship. 
 
 A — Help in Child Bed 
 
 1. It exists for the woman in child bed, who, for at least 
 six months prior to her confinement, has been insured by the 
 National Pension, as well as by a legal Sick Fund Benefit, or by 
 a Sick Fund of a Friendly Society against illness. 
 
 2. It exists for her in the following ways : — 
 
 (A) As a contribution toward the cost of confine- 
 ment to be paid in a lump sum, at one time^ from 50 marks 
 up; 
 
 (B) As money for child bed above the Sick Fund 
 IMoney — and, at least 1 1-2 marks daily including Sundays 
 and Holidays for ten weeks; of which four shall fall in the 
 time before and six in the time after confinement. The 
 money for child 'bed for the first four weeks is due on the 
 day of confinement; 
 
 (C) As a money grant of 25 marks for the services 
 of midwife and doctor, in case such should be needed for 
 the delivery; 
 
 (D) As a nursing premium, as long as the woman 
 nurses her new-born infant, to the amount of half of her 
 Sick Fund Benefit money or more^ — but at least 75 pfennig 
 daily, inclusive of Sundays and Holidays, as long as twelve 
 weeks after confinement. If a woman should die in con- 
 finement, or during the period of her convalescence, the 
 payments of the National Mothers' Pensions shall still be 
 due, and shall be paid to whomsoever is in charge of the 
 child. 
 
 12 
 
Public Maternity and Infant Care 
 
 3. The person will be paid through, the Sick Fund Bene- 
 fit, to which the woman belongs. 
 
 Help in Child Bed for Uninsured Women 
 1, It will protect the uninsured wives, daughters, step- 
 daughters, and foster daughters of insured men, who live in the 
 same household. 
 
 1st. If their residence is in Germany. 
 2nd. If they have no claim on the assistance for child 
 bed, (for example, according to A. I.) 
 
 3rd. And if the insured men have been insured 
 against sickness, not less than six months prior to the 
 woman's confinement. 
 
 The conditions on which said woman shall receive the pen- 
 sion are practically the same as in A-2. It shall be taken care 
 of by the Sick Fund Benefit to which the male relative belongs. 
 
 Care in Child Be3d 
 
 1. It exists for German women of small means in child 
 bed who have their residence in Germany, and who deserve 
 Help in Child Bed, neither as insured women or as uninsured 
 women related to insured men. By small means is meant: — 
 
 (A) A married woman in child bed, whose total in- 
 come, combined with her husband's during the year or the 
 tax year prior to the confinement, has not exceeded the sum 
 of 4,000 marks. This sum may be increased for each exist- 
 ing child under fifteen years by 500 marks. 
 
 (B) An unmarried, or lone woman in child bed, if her 
 total income in the year or tax year prior to confinement 
 has not exceeded the sum of 4,000 marks. This sum may 
 be increased for each existing child under fifteen years by 
 500 marks. 
 
 2. The conditions of payment are practically the same as 
 in A-2. 
 
 This carefully classified bill for help in confinement and 
 nursing is designed to bring relief of a constructive nature (1) 
 to women of limited income who have taken the precaution to 
 insure themselves; (2) to women of a limited income whose male 
 relatives have insured themselves; (3) to women of small income 
 who have no claim on insurance either through themselves or 
 their male relatives. It does not omit, therefore, destitute 
 cases, and it stimulates women of small income to insure them- 
 selves. It relieves men of limited income who look ahead far 
 
 13 
 
Public Maternity and Infant Care 
 
 enough to insure themselves, by assisting their dependents 
 through confinement. 
 
 (Stockholm possesses no such pension system. Furthermore, 
 the Board for Child Welfare in Stockholm has no division 
 which takes care of pregnancy and confinement as does the 
 Berlin Department for Public Guardianship. The similarity of 
 these two Boards lies in their work for illegitimate infants, 
 which will be discussed later. 
 
 Maternity Hospitals 
 
 There are two maternity hospitals in Greater Berlin that 
 demonstrate clearly the nature of the work of the public hos- 
 pital for cases of pregnancy and confinement. One is the City 
 Maternity Hospital. This Maternity Hospital at Charlotten- 
 berg is the only maternity hospital in Berlin supported and run 
 by the City. It is a decidedly well equipped institution, housed 
 in a large grey cement building, three stories high, constructed 
 aJbout an open garden or court. The interior is colored in white 
 and tan — plaster walls, and tiled floors. The equipment is quite 
 modern in all details, as the place was finished only in 1913. 
 The organization, however, is not new, and its maternity division 
 existed formerly in a less fine home in another part of the city. 
 
 Seven resident doctors and forty trained nurses are in care 
 of the 200 women patients and perhaps 100 infants. The cases 
 are cases for confinement or for gynecological treatment. There 
 is a special operating room for gynecological cases as well as 
 two rooms for delivery cases. (It may be noted here that both 
 in Sweden and Germany, deliveries are executed on the bed, not 
 on operating tables, as is the case in the more modern American 
 hospitals). 
 
 The patients are required to pay 12 marks a day. If the 
 individual is too poor to afford this amount the Public Sick 
 Fund, or the Social Welfare Deputation meets the fee* No cer- 
 tificate or recommendation from any authority is necessary for 
 admission to the hospital. Both married and unmarried women 
 are taken and the rooms are arranged to accommodate from two 
 to ten persons. The infants are not kept in separate nurseries, 
 as is done in the Kaiserin Auguste Victoria Haus. One finds 
 in Sweden too that the infants and mothers remain in the same 
 ward or room together. 
 
 The Social Welfare Deputation is the converted Poor Law Board. 
 
 14 
 
Public Maternity and Infant Care 
 
 After the mothers leave the hospital they may proceed, if 
 destitute, to the various private homes for women and their 
 babies, or to the Westend Home for Children and Mothers, which 
 belongs to the City. 
 
 Unlike the City or State Maternity Hospitals in Stockholm, 
 the Berlin Maternity Hospital provides for pre-natal care. A 
 clinic is held twice a week, to which pregnant women may come 
 for examination, advice, and minor treatments. 
 
 (It was not possible to secure the cost of the hospital to the 
 city). 
 
 The amount of work that this hospital does is clear from the 
 following statistics taken from the hospital books. In 1919, 
 1440 women were admitted. The living born numbered 1043, 
 the dead born 44. Deaths of infants after birth were 50. 
 There were 66 gynecological cases in 1919 and 413 abortions. 
 
 The most famous maternity hospital in Germany is the 
 Kaiserin Auguste Victoria Haus, also at Charlottenberg. This 
 Hospital, Home, and Training School for the care of mothers 
 and infants exists for the purpose of providing the most scien- 
 tific treatment for four types of cases. It treats diseases of 
 pregnancy, normal confinement cases, healthy children whose 
 mothers are at work, and ill children. In addition it serves as 
 a training school for 100 women, who, after a year's course in 
 the hospital, try a State examination, and if successful may hire 
 themselves out as professional infant nurses. 
 
 The Hospital divides its patients into 1st, 2nd, and 31x1 
 classes, according to the bed occupied by the patient. Unmar- 
 ried women about to become mothers, may enter the Hospital 
 three or four months previous to confinement, working in the 
 meantime to pay for their board. After childbirth such cases 
 may remain so long as a year, provided they perform adequate 
 work. 
 
 The Hospital is in the medical charge of five resident and 
 ten visiting doctors, two midwives, and forty trained nurses. 
 No operations are performed in the Hospital, and complicated 
 confinement cases are not taken. A pre-natal clinic, supported 
 by the City, is maintained in connection with the Kaiserin Au- 
 guste Victoria Haus, open twice each week, where women may 
 go for examination and advice. 
 
 The physical environment of the place is beautiful. The 
 
 15 
 
Public Maternity and Infant Care 
 
 large, finely designed building of gray cement is set in attrac- 
 tive grounds, and all details are maintained with taste. 
 
 The Foundation which supported this center of science for 
 maternity and infant care is private, and until 1914, received no 
 aid from the public. ISince that date, however, the Republic 
 pays 250,000 marks a year; a small sum, when one considers 
 that the annual cost for maintenance is 3 1-2 million marks a 
 year. 
 
 The Kaiserin Auguste Victoria Haus performs an import- 
 ant function in Germany, as a leader in propaganda work for 
 general education in hygienic maternity and infant care. 
 Pamphlets and leaflets are issued on these subjects and it is 
 seen that such information reaches the hands of those who 
 should have it, by the use of the Birth Registration offices, as 
 distributing agents. A magazine for doctors and nurses is is- 
 sued monthly, called, "Sauglinge-und-Kleinkinderschutz," 
 which treats the problem from a scientific standpoint. 
 
 The statistics published by the Hospital which are of inter- 
 est follow. The report is dated from April, 1918 to 31st March, 
 1919. 
 
 A— 
 
 1. Women. (Not including confinement cases) 
 
 Married Unmarried 
 
 At the beginning of the [Report Year 6 28 
 
 New cases 216 100 
 
 222 128 
 
 Total 350 
 2. Confinement Division. 
 
 At the beginning of the Report Year 7 11 
 
 New cases 201 70 
 
 208 81 
 
 Total 289 
 B— 
 
 Children. Legitimate Illegitimate 
 
 At the beginning of the Report Year 65 72 
 
 New cases 803 193 
 
 868 265 
 
 Total 1133 
 
 16 
 
Public Maternity and Infant Care 
 
 (Deaths for women are not given in the Hospital Report. 
 Of the sick children numbering 768 of the total 1133, 148 died.) 
 
 In Stockholm public hospital care for maternity cases is 
 covered by the two large institutions operated by the State and 
 Municipal Health Departments respectively. They correspond 
 in general characteristics to the City Maternity Hospital in Ber- 
 lin. Their main differences lie in the fact that they do not pay 
 as much attention to the pre-natal clinic. The General Mater- 
 nity Hospital, existing under the State Health Department, may 
 be used by women from any part of Sweden and is supported by 
 the State. The income from a capital fund which has been ac- 
 cumulated gradually through gifts makes up part of the total 
 budget. The hospital was founded in 1775, and the new build- 
 ing which is located on high ground not far from the Stadium, 
 on Planterhagsvagen, was erected in 1913. This new hospital 
 is a large white cement building of rectangular proportions, con- 
 structed about an open courtyard, thus affording light to all 
 rooms and corridors. It accommodates about 100 patients who 
 in the main are drawn from the poorer groups in Stockholm, 
 whose treatment in the hospital is free, and whose only requisite 
 for admission is a birth certificate from their respective parish 
 registrars. For the care of the women there are seven graduate 
 nurses and four doctors. Besides these superior persons are ten 
 nurses in training and twenty-five medical students who live on 
 the upper floor of the hospital, and work in the hospital for four 
 months between the third and fourth years of their medical 
 course, as a part of their obstretical and gynecological training. 
 
 The interior arrangements and equipment of this modern 
 maternity hospital are excellent in all details. Unlike the Ber- 
 lin City Hospital each maternity patient has a separate delivery 
 room. After the delivery the mother and infant are removed 
 to the convalescent ward, which holds from one to six patients. 
 The operating rooms are large, light, and perfect in their access- 
 ories. One ward of the hospital is given over to gynecological 
 cases. Among the hospital's patients are many cases of crimi- 
 nal abortion which are frequent in Stockholm. The number of 
 abortion cases in the hospital in 1919 were 630 with eight deaths, 
 
 17 
 
Public Maternity and Infant Care 
 
 Statistics for the hospital for 1919, as given in the year book of 
 Stockholm's Municipal Board of Health, are as follows: — 
 
 Total entered 2638 
 
 For delivery 2429 
 
 Under 20 years 126 
 
 Under 2030 years 1449 
 
 Under 30-40 years 7'33 
 
 Over 40 years 121 
 
 Other cases 209 
 
 Children bom — 
 
 Living at full term 1710 
 
 Living before term 62 
 
 Dead born full term 35 
 
 Dead born before term 15 
 
 Miscarriages 630 
 
 Total Cases — 
 
 Deliveries without .abortions 1799 
 
 Abortions 630 
 
 Other cases 209 
 
 2638 
 In 1919 the hospital reports: 
 
 Total expenditures 339,061.04 Cr. 
 
 ■ Paid by State 316,694. Cr. 
 
 The hospital makes no specialty of pre-natal work. Women 
 may go there for advice and examination during pregnancy, but 
 no emiphasis is laid on this phase of care. 
 
 Adjoining the hospital is a private home for the care of 
 mothers and babies who, after their eight or nine days in the 
 hospital, have no place to go. There are places for fifty such 
 mothers and they may remain in this shelter for six weeks, after 
 which time they must seek other accommodations. In general 
 such women find a position for work at the end of the six weeks, 
 while the infant, usually illegitimate, is boarded out by the Poor 
 Law Authorities. 
 
 18 
 
Public Maternity and Infant Care 
 
 The work done by the General Maternity Hospital from 
 the social standpoint, needs no comment. It supplies scientifi- 
 cally and effectively a constant demand in the city. There are 
 but two criticisms that are in point — that no pre-natal maternity 
 clinic is maintained; and that the patients are kept in the hos- 
 pital too short a time after childbirth. As the Swedish women 
 are exceedingly strong, these two defects in the hospital work 
 apparently do not have far-reaching effects. 
 
 The other large public maternity hospital in Stockholm 
 under the City Board of Health, the South Maternity Hospital, 
 is distinctly a city institution. It derives its support largely 
 from the city and from the income of the small charge on pati- 
 ents and a small amount of capital owned. 
 
 The hospital is ,a spacious yellow cement construction, well 
 adapted to its needs, though it is not as modern as the State 
 Maternity Hospital. Each woman has a separate delivery room, 
 being moved afterwards to the general wards. The patients re- 
 main in the hospital ten days. The charge for Stockholm 
 women ranges between 3 and 12 crowns a day, according to 
 the desirability of the bed. Most of the women are from the 
 City of Stockholm, but they are permitted to enter from other 
 parishes, in which cases the rate ranges between 7 and 8 crowns 
 a day. 
 
 In charge of the hospital work is one supervising doctor 
 and his assistant, beside four midwives. In addition there are 
 sixty women in training for midwifery who remain in the hos- 
 pital one year, after which time, provided they pass the state 
 examination and are licensed under the State Board of Health, 
 they are sent out by said State Board to various communes in 
 Sweden. A trained midwife is appointed for each district.^ The 
 district, a classification made and used by the State Department 
 of Health on the basis of population, is a division of a county 
 and represents about 3000 persons. The state pays each mid- 
 wife the small annual sum of 800 crowns. From her patients 
 she receives from 15 to 25 crowns for each delivery — an ex- 
 tremely small amount for the responsibility involved. In the 
 cities a midwife may charge as high as 150 crowns, and in 
 Stockholm the City Health Board pays in addition to the state 
 wage 10 croviTQS for each confinement case. In cases that are not 
 normal the midwife is required by law to call in a doctor. In 
 order that the elder group of midwives may not suffer by the 
 progress in obstretical science, repetition courses for their bene- 
 
 19 
 
Public I\Iaternity and Infant Care 
 
 fit are held every ten years at Goteborg and Stockholm, for a 
 period of fourteen days. Since in the country almost all of the 
 women are delivered by midwives, and there is only one other 
 such training school, namely ^t Goteborg, the work done by this 
 hospital is, in this respect, particularly, of importance. 
 
 (Statistics of interest as given by Stockholm's Municipal 
 Board of Health for 1919 show :— 
 
 Children born — 
 
 Living bom full term 2182 
 
 Living born before term 150 
 
 Dead born full term 33 
 
 Miscarriages 528 
 
 Total cases — 
 
 Deliveries without abortions 2350 
 
 Abortions 528 
 
 Other cases 343 
 
 3221 
 
 Total cost 441,860.18 Cr. 
 
 Cost to City 327,061. Cr. 
 
 20 
 
Public Maternity and Infant Care 
 
 o o 
 
 Cost to Public 
 
 CJ to 
 «D O 
 
 
 CO CQ 
 
 
 
 
 Tj< 00 
 O rH 
 
 Total Cost 
 
 tA O 
 
 CD iO 
 O 00 
 
 
 of tH 
 
 CO Tif 
 
 CO ^ 
 
 % to Deliveries °9 ^S 
 
 still Born 
 
 Total Deaths 
 
 O <M 
 
 % to Deliveries '=^. ^ 
 
 CO ^ 
 
 1^ Premature Births S ^ 
 
 ^ % to Deliveries g g 
 
 O 
 
 Live Births 
 
 t- CO 
 
 t- CO 
 
 s 
 
 g % to Total ^ 2 
 
 § Cases =^ ^ 
 
 O 00 
 
 ^ Abortions Ǥ S 
 
 g % to Total ^ S- 
 
 g Cases «o t~ 
 
 S Oi o 
 
 o Deliveries ?^ co 
 
 O "^ ^ 
 
 w % of Deaths 53 g 
 
 to Total o o 
 
 
 Total Cases 
 
 CO cq 
 
 «0 CO 
 
 
 (M CO 
 1 1 
 
 
 ii 
 
 Hosp. 
 
 
 
 02 u 
 
 21 
 
PART II —INFANT CARE 
 
 The institutions in Berlin and Stockholm pertaining more 
 definitely to the care of babies, while of necessity a part of the 
 care for maternity, may be dealt with as organizations designed 
 for the protection of infants and young children, since the em- 
 phasis is placed on that aspect of the dual problem. As in re- 
 gard to maternity mortality, the statistics for Sweden and Ger- 
 many for infant mortality exhibit results that might indicate 
 the superiority of the social machinery th^at operates for the 
 care of infants. Hence it may not be useless to survey briefly 
 the typical organizations in Berlin and Stockholm confined to 
 this phase of the work. 
 
 Infant mortality rates for certain foreign countries and United States 
 per 1,000 live birtihs 
 
 Chile (1919) 
 
 306 
 
 Hungary (1915) 
 
 264 
 
 Bavaria (1918) 
 
 203 
 
 Japan (1918) 
 
 189 
 
 Spain (1918) 
 
 183 
 
 Italy (1916) 
 
 166 
 
 Germany (1920) 
 
 135 
 
 Prussia (1919) 
 
 121 
 
 France (77 Depts., 1919) 
 
 119 
 
 Finland (1918) 
 
 115 
 
 Scotland (1919) 
 
 102 
 
 Uruguay (1919) 
 
 101 
 
 Ontario (1919) 
 
 96 
 
 Denmark (1919) 
 
 92 
 
 Ireland (1919) 
 
 88 
 
 U. S. (Birth Registration Area, 1920) 
 
 86 
 
 Netherlands (1919) 
 
 84 
 
 Switzerland (1919) 
 
 82 
 
 England and Wales (1920) 
 
 80 
 
 Sweden (1916) 
 
 70 
 
 Australia (1920) 
 
 69 
 
 Norway (1917) 
 
 64 
 
 New Zealand (1920) 
 
 51 
 
 Source: Comipiled from official sources or from Annuaire 
 International de Statistique by the Federal Children's Bureau. 
 Latest figures available, January 1, 1922. 
 
 22 
 
Public Maternity and Infant Care 
 
 Departments of Public Guardianship 
 
 As mentioned before, the prominent administrative organ 
 dealing with children, and existing in both Berlin and Stock- 
 holm, is that for the protection of the illegitimate child. In 
 Berlin it is the second section of the Division of Public Guard- 
 ianship, and in Stockholm, the Board for Child Welfare. A 
 short description of each organization will reveal the points of 
 similarity and dissimilarity. 
 
 In Berlin, when an illegitimate infant is born the local City 
 Registrars are required to report the birth to the Division of 
 Public Guardianship, which thereupon, immediately appoints a 
 Public Guardian for the child. This guardian supervises the 
 development of the child until it is twenty-one years of age. 
 There are twenty-four Public Guardians in Berlin, each of 
 whom has in his or her care about one thousand children. It is 
 furthermore, the duty of the Public Guardian to see that the 
 father makes the payment to the mother of the child, that is re- 
 quired by law. In 1920 eight million marks were taken in by 
 the Division of Public Guardianship and paid over to unmar- 
 ried mothers. This amount of money was paid by the unmar- 
 ried fathers according to legal regulation. 
 
 If, after the period of confinement, the mother and infant 
 are destitute, there are several homes partially supported by the 
 City, to which the pair may be sent to remain for varying per- 
 iods of time. There is one notable municipal home for Chil- 
 dren and mothers, The West End Municipal Home for Moth- 
 ers and Children at Charlottenberg, which costs the city a con- 
 siderable sum to run, since it has place for ninety mothers and 
 one hundred and sixty children, with one resident doctor, twen- 
 ty-eight trained nurses, and eight teachers. 
 
 If the mother is to be separated from her baby, through 
 force of circumstance, the infant is sent to the Municipal Or- 
 phan Home or to a partially private home until a place in a 
 family is found for the child. In 1920 the Division of Public 
 Guardianship in Berlin handled 19,176 eases. (It was not pos- 
 sible to secure figures of cost to the city) . 
 
 In Sweden the administrative agent for the purpose of 
 guarding the illegitimate child is the local Board for Child Wel- 
 fare, an authority which was created by law in 1902, and came 
 mto existence in 1903. A Board for Child Welfare exists in 
 
 23 
 
Public Maternity and Infant Care 
 
 each parish in Sweden. These Boards are under the super- 
 vision of the State Social Department. The province of the 
 Board for Child Welfare is to supervise and care for (1) mor- 
 ally defective children and (2) children born out of wedlock. 
 The second division has been in operation in Stockholm since 
 1918. 
 
 In Stockholm the division of the Board for Child Welfare, 
 which deals with illegitimacy, has its headquarters in an office 
 at Hamngatan 36. About one third of the budget is carried by 
 the state and two thirds by the city. This central office deals 
 with illegitimate ehildren for the entire city. The important 
 members of the staff are a head inspector, who acts as super- 
 visor, thirty salaried and eighty-five volunteer Public Guard- 
 ians, or persons who are directly in charge of the individual 
 children. The birth of an illegitimate child is reported to the 
 central Board by the pastor, who is official birth registrar of 
 the parish in which the child is born. If the child has been 
 born in a hospital, both the hospital authority and the parish 
 pastor must send word of the birth. Midwives and doctors are 
 legally liable to notify the pastor when they have delivered an 
 unmarried mother. As soon as a case is reported a Public 
 Guardian is sent to take the situation in charge permanently. 
 
 The first duty of the Public Guardian is to have the father 
 of the child identified. The mother's word, regardless of the 
 type of person she may be, or what her reputation is, is accepted 
 at first as a guide to action. If the man denies parentage, the 
 matter is brought to court under the law. If the father ac- 
 knowledges paternity a standardized printed form is filled in 
 and signed by him in the presence of the Public Guardian as 
 acknowledgment that he is the father, and as a pledge to sup- 
 port the child according to the provisions of the law. One man 
 is held responsible for fatherhood even though there have been 
 several men involved. If the man selected by the mother as the 
 father of her child is in another city or country, he is subject, 
 nevertheless, to the law and may be traced by police or consuls. 
 If he is in an occupation that carries him out of Stockholm, and 
 one the wage of which is paid from Stockholm, the amount for 
 the support of the child may be subtracted from the wage be- 
 fore payment. 
 
 The duty of the Public Guardian, once the father has been 
 apprehended, is to watch the education of the child and to fol- 
 low up the payments of the father. The Public Guardian is 
 
 24 
 
Public Maternity and Infant Care 
 
 supported in all his duties by legral right. That the system as 
 outlined has been fruitful in results is evidenced by the follow- 
 ing statistics. 
 Number of cases supervised 1919. 
 
 Carried over from previous year 1507 
 
 New cases during the year 1697 
 
 Total cases handled in 1919 3204 
 
 Cases closed during the year : 
 
 Because of the marriage of parents. . . . 163 
 
 By the death of the child 199 
 
 Transfer of child to another source of 
 
 protection 112 
 
 For other causes 17 491 
 
 2713 
 Number of cases in which paternity was 
 
 established 2076 
 
 Number of cases regarding paternity 
 
 which were dropped as incapable of 
 
 being settled 237 
 
 Number of cases in which paternity was 
 
 not settled at the end of the year 400 2713 
 
 (Derived from the Statistical Yearbook of the City of Stock- 
 holm, 1920) 
 
 A certain decentralization of delegated authority in the care 
 of the illegitimate child exists in Stockholm through the over- 
 lapping provinces of the Poor Law and Municipal Health au- 
 thorities. When a child is boarded out in Stockholm it comes 
 under the supervision of the Bureau for the Inspection of Foster 
 Children, of the Municipal Health Department, as well as under 
 the supervision of the Public Guardian, unless it be boarded out 
 by the Poor Law Board, whereupon it is in charge of the Poor 
 Law Board as well as the Public Guardian. 
 
 Destitute cases are maintained usually in the Poor Law or 
 semi-private institutions at a nominal, or, if necessary, no 
 charge, for a limited period until permanent arrangements can 
 be made. Usually the period of respite for the destitute mother, 
 during which time she is restored to health and efficiency, lasts 
 
 25 
 
Public Maternity and Infant Care 
 
 for about a year after the birth of the child. At the end of this 
 time either a position is found for the mother where she may 
 keep her baby with her, or the child is boarded out in a care- 
 fully selected family and the mother finds work alone. In gen- 
 eral it seems to be true that the great majority of illegitimate 
 children are boarded out and the mother goes to work. The 
 Board for Child Welfare maintains five institutional homes for 
 children where they may receive temporary shelter for varying 
 periods of time. (See note * and **). 
 
 In Berlin the decentralization apparent in Stockholm does 
 not exist. The Division for Public Guardianship is a part of 
 the central Department for the Welfare of Children and is re- 
 sponsible alone to that authority. The inspection of foster chil- 
 dren is carried on by a division also of the Department for the 
 Welfare of Children, whereas in Stockholm, the Municipal 
 Health Board asserts control. 
 
 Municipal Clearing House for Foster Children 
 
 The Municipal Orphan Home at 33 Altejacobsstrasse, in 
 Berlin, is typical of work done both in Berlin and Stockholm, 
 as a clearing house for children who are to be placed out. 
 
 This Orphanage, supported entirely by the Municipality, 
 and supervised by the Department for the Welfare of Children, 
 is a home and clearing house for about fifteen thousand chil- 
 dren, who are, or are to become, temporarily or permanently, 
 foster children. These children are by no means all orphans in 
 the strict sense of the term, but are situated so that it is necess- 
 ary for them to be boarded out with a family, or to be cared for 
 in the Orphan Home. The children come to the Home through 
 the Department for Social Welfare, or from the Division of 
 Public Guardianship, and remain in the Home not longer than 
 
 * Guinchard — Sweden, Land and People, Vol. 1, p. 163- In the 
 years 1901-10, 33.6% of the children born alive in Stockholm were 
 born out of wedlock. 
 
 ** Statistical Yearbook for City of Stockholm, 1920 Table 29, 
 Births in Stockholm. 
 
 Year 
 
 Living Born 
 
 Legitimate 
 
 Illegitimate 
 
 1902 
 
 7426 
 
 4993 
 
 2433 
 
 1907 
 
 8153 
 
 5342 
 
 2811 
 
 1912 
 
 7436 
 
 4717 
 
 2719 
 
 1917 
 
 6634 
 
 4618 
 
 2016 
 
 1919 
 
 5887 
 
 4287 
 
 1600 
 
 26 
 
Public Maternity and Infant Care 
 
 the two or three months they are waiting to be boarded out with 
 foster parents, who will be paid for their care. 
 
 The Orphan Home and its adjoining house, the Asylum for 
 Children, have room for three hundred children, of whom per- 
 haps forty are ill children, receiving medical attention, one 
 hundred and seventy are infants under a year old, and the re- 
 mainder are healthy older children awaiting their new homes. 
 No infants are turned over to foster parents from the Orphan 
 Home before reaching three months of age. In immediate 
 charge of this group of children are six doctors, four graduate 
 nurses, and sixty-one women helpers for the Orphan Home; 
 for the Aslyum for Children are the same doctors and forty 
 women helpers. 
 
 The building of the institution was erected in 1907. (The 
 organization dates back to 1850). The house is of gray 
 cement, five stories high, and constructed about a court yard, 
 The interior walls are painted dark green, and in comparison 
 to the bright Swedish coloring of similar places, the atmosphere 
 within the home is somlbre. The general condition of plaster, 
 woodwork, floors, etc., is poor, due, of course, to the scarcity of 
 money since the war. The enforced economies have affected 
 more important items than physical environment, however, as 
 one saw by a glance at the meal of yellow potato soup that the 
 children were eating for dinner. 
 
 The Orphan Home maintains a clothes room, where out- 
 fits of new clothing for children of all sizes from infancy to 
 fourteen years are stored. The clothing is purchased by the 
 Orphanage, — a contrast to a similar institution in Stockholm, 
 where clothing is made in the sewing room, and affords work 
 to poor women who are known to the Poor Law authorities. 
 The clothes were of as good quality as could be expected, under 
 the severe economic conditions in Germany. 
 
 The Orphan Home maintains three teachers for boys and 
 two for girls, so that all waiting children of school age have 
 their proper lessons in well fitted school rooms. 
 
 The Asylum for Children, already mentioned as under the 
 same supervision as the Orphanage, and for all practical pur- 
 poses existing as a part of that institution, is an institution 
 which in addition to municipal support, receives an income 
 from the Schmidt-Gallisch Foundation, left for the purpose. 
 The asylum, housing infants only, with beds for one hundred 
 and twenty, is of the finest modem equipment and construction, 
 
 27 
 
Public IMaternity and Infant Care 
 
 built in 1915, attractively decorated and in rather marked con- 
 trast to the Orphan House. The infants are separated in 
 groups of two or three by glass compartments, so that less dan- 
 ger of infection exists. The children are in charge of the same 
 doctors as work in the adjoining Home and are destined to be 
 foster children. 
 
 The general statistics for the two above institutions, dated 
 April 1st, 1917, and covering the preceding year, published by 
 the Municipal Council of Berlin, are given below. 
 
 General Statistics 
 
 From April 1, 1916 to April 1, 1917 
 
 iContrasted to April 1, 1916 
 iMale Female Together + more 
 
 (a) Parentless 5368 4481 9849 — 452 
 
 (lb) Taken out of evil surroundings— 3226 1820 5046 + 819 
 
 (c) Children of the unemployed 12 10 22 -t- 10 
 
 (d) Children of the S. G. Found- 29 29 58 — 23 
 
 Total 8635 6340 14975 
 
 On April 1, 1916 8263 6368 14621 + 354 
 
 It will be observed by the Table that three hundred 
 and fifty-four children were added in 1917 to the total 
 already in the care of the Orphanage and the Department for 
 the Welfare of Children. That is, in the year ending April 
 1st, 1917, 14,975 children were destitute children of the Depart- 
 ment of Child Welfare of the City of Berlin or were children 
 cared for in the Orphanage by foster parents. 
 
 Clinics and Milk Stations 
 
 The Stations for the Care of Babies in Greater Berlin are 
 institutions unlike any in Stockholm. There are ten in the city 
 and each serves the purpose of hospital clinic, milk station and 
 family physician. 
 
 The particular station under discussion is located at 10 
 Badstrasse. It is a new building, having been finished during 
 the war, of gray cement, three stories high, and of comfortable 
 size. It is maintained by the City under the direction of the 
 Department for the Welfare of Children. On the ground floor 
 are the doctors' private offices, the large entry hall, and the sep- 
 arate entry and room for contagious cases. This latter room is 
 
 28 
 
Public Maternity and Infant Care 
 
 divided by glass partitions for protection against infection. On 
 the second floor are dressing room, weighing room, two examin- 
 ing rooms, operation room, and business office. On the third 
 floor are the bedrooms of the nurses and the milk kitchen which 
 is equipped with the most modern contrivances. 
 
 Three doctors spend two hours each a day at the Station, 
 and seven nurses and helpers do the general work. These indi- 
 viduals examine during a year as many as 2500 infants, and 
 1500 children between one and six years. 
 
 The function of the Infant Station is to examine, advise, 
 and treat children between birth and six years of age, who are 
 too poor to obtain other medical help. Mothers may come here 
 with their children without recommendation or certificate from 
 a public authority, and all treatment is free. For the milk that 
 is dispensed the recipients pay a low price. 
 
 One of the important functions of the work is to act as a 
 propaganda center for the encouragement of breast feeding. 
 The Stations are the centers from which the nursing premiums 
 granted by the State are distributed. This money is paid every 
 three months. 
 
 The system of Stations for Infant Care is not new in Ber- 
 lin, dating back at least fifty years. 
 
 Statistics of the cost of the nine stations existing in 1915 
 as given by the Statistics of the Council of Berlin are : 
 
 Nursing War 
 
 Stations Premium Milk Officials Tax Rent Uiakeep Total 
 
 1 17,189 17,680 12,999 908 6,600 5,296 59,672 
 
 2 13,010 9,046 12,165 881 1,792 5,873 42,767 
 
 3 13,709 12,241 12 828 917 980 3,255 43,930 
 
 4 15,241 24,134 10',869 768 3,200 3,355 57,567 
 
 5 10,887 25A31 11,782 896 5,000 4,919 58,615 
 
 6 12,259 13,940 11,783 768 2,100 3,999 44,849 
 
 7 17,859 23,218 11959 840 1,815 4,022 69,713 
 
 8 16,135 20,883 13",252 1,058 2,628 4,081 58,037 
 
 9 11,251 19^671 11746 1,004 2,310 3,181 49,163 
 
 Marks 127,540 166,944 109,383 8,040 25,425 37,981 474,313 
 
 Stockholm has an Association of Milk Stations, which, as a 
 partly public organization, supplies the demand for which milk 
 depots exist. There are six milk stations for infants, Katar- 
 ina's Milk Depot, Skanagatan 72, Adolf Fredrik's, Vidargatan4, 
 Kungsholmen's, Drottningholmsvagen 12-A, Ostermalm's, Frej- 
 
 29 
 
Public Maternity and Infant Care 
 
 gatan 3, Jakob's and Johannes', Dobelnsgatan 38-B and Brann- 
 kyrka's, Skoldgatan 3. These milk depots are for the purpose of 
 overseeing the first year's development of babies, of providing 
 proper milk and milk formulas for them, and of giving the 
 mothers general valuable advice. The cost of the stations is 
 borne in part by the city, through the Poor Law Board and the 
 Health Department. It may be of interest in this connection 
 to present the income figures for 1919 of one representative sta- 
 tion : — 
 
 Jakob's and Johannes' Milk Depot Income for 1919: 
 
 From the Poor Law Board Cr. 3,417 
 
 From Johannes' Parish 1,200 
 
 From Jakob's Parish 1,200 
 
 From the Association of Milk Stations. . 4,500 
 
 Gifts 120 
 
 Annual Fees 507 
 
 Interest 297.59 
 
 Payment for milk 1,134.39 
 
 Payment for bottles 65.60 
 
 Rents 120 
 
 Board of Health 3,549.25 
 
 Total 16,109.83 
 
 The central association which contributes Item four in the 
 account just given is a private organization composed of mem- 
 bers who through a board consisting of representatives from 
 each of the stations, plus a doctor who is president, act as mana- 
 gers and organizers of the stations. 
 
 Statistics for the year 1919 as given in the brief annual 
 pamphlet issued by the association are : — 
 
 Per cent. 
 Stations ^^f^l Deaths of Deaths 
 
 Infants to Total 
 
 Katarina's 180 4 1.7 
 
 Adolf Fredrik's 102 .0 
 
 Kungsholmen 's 183 1 , .5 
 
 Ostermalm's 118 1 .9 
 
 Jakob's and Johannes' ..95 2 2.1 
 
 Brannkyrka's 258 3 1.2 
 
 Total 936 10 1.1 
 
 SO 
 
Public Maternity and Infant Care 
 
 The stations are used by the wives of working men and 
 usually these women can afford to pay 1 crown for a visit, which 
 includes milk. Of the sixty-three women who were attending the 
 Ostermalns Milk Station in November, 1920, but four were un- 
 able to pay. If the infants are breast fed no charge is made 
 for care given at the station. To encourage mothers to give 
 their babies breast milk only, the city, through the milk stations, 
 pays 45 crowns a month to women who nurse their infants. One 
 trained nurse and an assistant presided at Ostermalms Station, 
 and the doctor made two visits a week. The attending doctor is 
 paid 1000 crowns a month for his work in a local station. 
 
 Children's Hospitals 
 In Stockholm the Sach's Baby Hospital is a typical exam- 
 ple of a first-class public children's hospital. It is supported by 
 the City Board of Health. It was built in 1911 at Arstalunden, 
 Stockholm, beautifully located on the side of a hill overlooking 
 the Hammarbyleden River, and Lake Malaren. The hospital 
 was erected with private money and then presented to the city 
 of Stockholm. It is a modem building of modern equipment. 
 It contains fifty-four beds for sick children under two years of 
 age, in charge of whom are two doctors, three trained nurses, 
 twelve women in training, and eight wet nurses. There is also 
 room for six mothers in cases in which infants are taking 
 breast milk. Children with contagious diseases are not ad- 
 mitted. 
 
 Babies are brought to the hospital by no particular author- 
 ity. Poor families may keep their infants in the hospital with- 
 out charge, provided they demonstrate their inability to pay by 
 presenting a parish certificate from the local Poor Law Authori- 
 ties to this effect. Children of more well-to-do parents pay 
 3 crowns a day, and if the mother remains with the child 
 1.50 crowns a day in addition. Wet nurses remain in the hos- 
 pital one year, receiving 30 crowns per month, and board. Af- 
 ter children leave the hospital their parents are encouraged to 
 bring them back for examination and advice, in order that ade- 
 quate follow-up work may be done. 
 
 In 1919 the support of this institution was divided as fol- 
 lows : — 
 
 From patients 17,588 Cr. 
 
 From the City 172,585.95 Cr. 
 
 Interest on gifts 6,318.67 Cr. 
 
 Other receipts 539.33 Cr. 
 
 197,031.95 Cr. 
 31 
 
Public Maternity and Infant Care 
 
 Further statistics from the 1919 Report of the Municipal 
 Board of Health are: 
 
 PATIENTS 
 
 Left from Preceding Remaining at 
 
 Year Entered Departed Deaths end of year 
 
 42 337 289 49 41 
 
 Deaths in % of Days in Average Days Average Number 
 
 admissions hospital for patients of patients 
 
 14.54 17,700 52.5 54 
 
 Kaiser and Kaiserin Friedrich's Children's Hospital, en- 
 tirely supported by the City, is the foremost children's hospital 
 in Berlin. The hospital was founded and built by an association 
 of citizens, but was adopted by the City, at least a decade ago. 
 The cost to the City for the maintenance of the place, which pro- 
 vides four hundred fifty beds for ill children up to fourteen 
 years of age for all general and contagious diseases, as well as a 
 bacteriological division, and an equipment for Roentgen Rays, 
 was in 1920 about 5 1-2 million marks. 
 
 The hospital consists of a group of red brick houses, built 
 on a small campus. The system provides a separate pavilion 
 for each disease of a contagious character, and a pavilion for 
 general illness. 
 
 The patients are cared for by two doctors who act as direc- 
 tors, and by twenty-seven internes, of whom ten live on the prem- 
 ises. The nursing is done by one hundred trained nurses and 
 there are seventy domestics for general work. The patients come 
 in as individuals, not necessarily recommended by any authority. 
 The patients who are residents of Greater Berlin must pay 6 
 marks a day, and 12 marks a day if they are not residents of 
 the City. The cost to the City per patient is 50 marks a day. 
 
 In 1920 the hospital cared for 3300 patients, of whom 770 
 died. The Director, Dr. Finkelstein, informed the writer that 
 there existed in the hospital in 1920, twice as many cases of tub- 
 erculosis as before the war, and four times as many cases of 
 ricketts. The smaller income group are at present unable to 
 provide nutritious food for their children and the result may be 
 seen in the too many small patients suffering from malnutri- 
 tion. 
 
 32 
 
Public Maternity and Infant Care 
 Year 53 S3 
 
 O 
 
 Cost to Public 
 
 K 
 
 33 
 
 ^ 
 
 
 Total Cost W S 
 
 o 
 o 
 o 
 
 s ^ 
 
 Deaths in % of ^ sv? 
 Admisisons ;2J jo 
 
 Deaths 
 Admissions 
 
 w p 
 
 a 
 
 - 
 
 ■a 
 
 • r-4 
 
 S3 
 
 a* 
 
 O 
 
 w 
 
 a 
 
 o 
 
 >> 
 
 
 ^ 
 
 OT 
 
 
 ^ 
 
 
 • t-4 
 
 
 (U 
 
 W 
 
 fa 
 
Public IVEaternity and Infant Care 
 
 The following table is derived from "Infant Mortality in 
 Berlin During the War and Later, ' ' by Prof. Dr. H. Silbergleit, 
 Director of the Statistical Bureau of the City of Berlin. (Pub. 
 1920). 
 
 The Development of Infantile Mortality in Berlin 
 From 1870^1919 
 
 Deaths, exclusive of Deaths Children Under 
 
 
 Living iBorn 
 
 
 Dead Born 
 
 
 1 yr in 
 
 % Living Bom 
 
 Year 
 
 M. 
 
 F. 
 
 Total 
 
 M. 
 
 F. 
 
 Total 
 
 M. 
 
 F. 
 
 Total 
 
 1870 
 
 15629 
 
 14749 
 
 80378 
 
 5648 
 
 4526 
 
 10074 
 
 35.50 
 
 30.69 
 
 33.16 
 
 1880 
 
 22391 
 
 21742 
 
 44133 
 
 7548 
 
 6290 
 
 13838 
 
 33.71 
 
 28.93 
 
 31.36 
 
 1890 
 
 25362 
 
 24084 
 
 49446 
 
 6951 
 
 6672 
 
 12623 
 
 27.41 
 
 23.55 
 
 25.63 
 
 1900 
 
 25568 
 
 24268 
 
 49836 
 
 6505 
 
 5257 
 
 11762 
 
 25.44 
 
 21.66 
 
 23.60 
 
 1910 
 
 22704 
 
 21487 
 
 44191 
 
 3862 
 
 3074 
 
 6936 
 
 17.01 
 
 14.31 
 
 15.70 
 
 1915 
 
 16023 
 
 14977 
 
 31000 
 
 2324 
 
 1939 
 
 4362 
 
 15.12 
 
 12.95 
 
 14.07 
 
 1919 
 
 14596 
 
 13233 
 
 27829 
 
 2081 
 
 1682 
 
 3663 
 
 
 
 
 The 'German institutions described above cover in the main, 
 types of Municipal work and of work aided by the Municipality 
 for needy mothers and infants of Greater Berlin. An example 
 of an institution providing care for mothers and babies that is 
 under other than City control, but still not wholly private, may 
 be of interest. For work supported by the State of Prussia, the 
 great Charity Hospital on Schumannstrasse stands foermost. 
 This hospital, under the direction of the University of Berlin, 
 and serving as a school for medical students, as well as a pub- 
 lic benefit and scientific center, cared for 1652 patients in its 
 Maternity Division in 1920. The patients pay small sums. A 
 clinic is held weekly for pre-natal advice. The hospital is old, 
 and the equipment not of the best; for instance^ the delivery 
 room is for eight women but "Die "Wissenshaft" is unexcelled. 
 The Children 's Ward of the Charity provides one hundred beds 
 for infants under one year. 
 
 As an example of work supported and supervised by one of 
 Prussia's twelve provinces, is the School for Midwives at Neue 
 Koln in Greater Berlin. 
 
 There are two private institutions in Stockholm, and one 
 semi-private institution, which are doing excellent work and may 
 be studied as valuable models even though they are not public 
 property at present. 
 
 34 
 
Public Maternity and Infant Care 
 
 The Engelbrekt Day Nursery and Housekeeping School, 
 founded in 1910, and governed by a Board of Women Trustees, 
 has its home in a modest wooden house at 102 Valhallavagen, a 
 point within easy walking distance of the inhabitants of Engel- 
 brekt parish, which contributes generously to the support of the 
 home, paying about 5000 crowns a year. The city contributes 
 10,000 crowns a year, 2,000 more crowns are received annually 
 in gifts, and the remainder of the total annual running cost of 
 about 4,000 crowns, is met by the fees charged the students in 
 the school, and fees charged for the care of the children, along 
 with other funds raised by various committees. 
 
 The house accommodates twenty infants, thirty-five chil- 
 dren between two and seven, thirty-six students and six teach- 
 ers. The children are kept from seven a. m. to six p. m. and are 
 charged 50 ore a day per child from the Engelbrekt parish. 
 Children coming from outside of the parish must pay a little 
 more. The children are under the medical supervision of a vis- 
 iting doctor who in addition to the general care of the children 
 prescribes all milk formulas for infants. The bottles are made 
 up at the nursery and taken home at night by the mother. No 
 iH children are received, and the students are submitted to a 
 thorough medical examination before they are permitted to take 
 the course which necessitates the handling of the infants. 
 
 Children are ordinarily sent to the nursery either by the 
 Parish Poor Law Board, the Parish Pastor, the Parish Sister, or 
 the Public Guardian. All mothers, to enter their children, must 
 show a certificate that they are in need of the kind of care the 
 nursery offers, signed by the Parish Clerk. 
 
 The girls who work at the Engelbrekt School learn the es- 
 sentials of housekeeping and baby care, and for the course pay 
 70 crowns a month. The courses are from five to ten months in 
 duration, after the completion of which positions are found 
 readily for the graduates. 
 
 The advantage of this combination Training School and Day 
 Nursery, over the day nursery as it is known commonly in the 
 American community, is that the children supply the material 
 for the schooling of girls in the proper methods of how to care 
 for the young child. This plan has worked out very satisfac- 
 torily in Stockholm, and the nurses trained in such institution?^ 
 are in demand as trained child nurses. The teachers are experi« 
 enced in domestic science, and the principles of hygienic child 
 care, and the attending doctor gives instruction as he examines 
 
Public Maternity and Infant Caee 
 
 the children and prescribes formulas and diets. In this way the 
 students become proficient in general housework, including sim- 
 ple cooking, and primarily in nursing well children. 
 
 A somewhat similar plan has been developed by the private 
 Society for Child Welfare. This Society has laid emphasis on 
 the need of a more widespread understanding, on the part of 
 mothers and nurses, of the proper care of the well child. It con- 
 sists of about six hundred interested members, who pay dues and 
 contribute gifts of money. The Society was founded in 1897 
 and is managed by a Board of Trustees. Dr. Fiirstenberg, a 
 children's specialist, is the leading spirit of the organization. 
 
 The home for babies, maintained by the Society, well situ- 
 ated at Kungsholmen in an open section of the city, was built in 
 1916, and is up to date in every respect as to scientific equip- 
 ment. It has room for forty-three babies, five or six mothers 
 who are nursing their infants, and twenty-four young women 
 who remain in the house four months for a course in baby care. 
 The unique feature of this Home is that only healthy infants are 
 taken. The object of the society is in the main, to train young 
 women as nurses for normal babies, or as capable prospective 
 mothers. It is quite usual indeed, for young women who are 
 engaged to be married, or who expect some day to be engaged to 
 be married, to take this four months training in the Home. The 
 girls pay 125 crowns a month for the course, and the infants, 
 many of whom are sent in and paid for by the Poor Law Auth- 
 orities, are charged at the rate of 3.50 crowns a day. The cost 
 to run the house is 300 crowns a day. Dr. Furstenberg acts as 
 non-resident supervisor of the home, and teacher of the young 
 women. A head nurse is in charge of the household arrange- 
 ments and oversees this part of the students' training. 
 
 The social significance of this exemplary little private in- 
 stitution is its independent position as a criterion for the most 
 scinetific methods of care for the well baby. It is essentially 
 practical. 
 
 "An institution remarkable of its kind is the "Little Ones 
 Home," opened in 1900. At present thirty-seven children are 
 received into this refuge burdened with sj^philis, and by the 
 anxious attention bestowed upon them, it is hoped that they may 
 be saved future suffering, prevented from propagating the com- 
 plaint, and rescued for useful work in society. Thanks to Pro- 
 fessor Edward Wellander, Sweden is here doing pioneer work 
 
 36 
 
Public IVIaternity and Infant Care 
 
 in this regard.*" Profesor Wellander founded this Home and 
 provided a capital fund from the interest of which it is today- 
 supported. The home located in Kungsholmen near the Home 
 of the Society for Child Welfare, can accommodate fifty chil- 
 dren who enter at four months of age, if a Wasserman test has 
 proven positive, and remain until four years of age. During 
 this period intensive treatment is given. All the children who 
 have in the past left the home have been, temporarily at least, 
 freed from the disease. One trained nurse and ten assistants 
 do the work in the house. 
 
 The children are usually illegitimate, and at the end of 
 their stay in the Home are, if not wanted by their mothers, taken 
 over by the Poor Law Authorities. Children may enter the 
 Home from any source whatsoever. They may be members of 
 families of any degree of wealth, but usually are the offspring 
 of Stockholm's less fortunate social element. Statistics for the 
 Home as given in Stockholm 's Report of the City Health Board 
 for 1919 are :— 
 
 PATIENTS 
 
 Number of beds occupied at the beginning of year 46 
 
 Entered 16 
 
 Deaths 5 
 
 Days kept 13,047' 
 
 Total cost in crowns 38,065.25 
 
 ******* 
 
 The Swedish institutions that have been described above 
 have been selected as types of the work in maternity and infant 
 care done by and for Stockholm's public. They have proven 
 themselves, without exception, impressive in their character of 
 individual efficiency and economy. There is one obvious criti- 
 cism which the preceding study brings forth, namely, the de- 
 centralization of work done for children and infants. As sug- 
 gested before, a foster-infant may be supervised by the Board 
 for Child Welfare, inspected by the Board of Health, and in re- 
 ceipt of relief from the Poor Law Board, in which case it is ob- 
 viously possible that much overlapping of effort, and conflict 
 of authority could occur. The responsibility rests in three de- 
 partments with the consequent danger of waste and missed 
 cases that is difficult to avoid in such a system. That such has 
 not been more conspicuously the case is due to the honesty and 
 
 * By M. Blumental in Guinchard's, "Sweden, Land, and People." 
 
 37 
 
Public Maternity and Infant Care 
 
 care of the officials in charge of Stockholm's puMic work. The 
 lack, moreover of centralized authority and responsibility, is 
 recognized by those prominent in public social office in Sweden. 
 To remedy the condition a Royal Commission has been at work 
 and their report, which was due to appear in the spring of 1921, 
 will recommend important changes, the crux of which will rest 
 in making the Board for Child Welfare the central and supreme 
 authority for the public care of needy children. The work done 
 by the Department of Education for the relief of public school 
 children will run parallel to this converted Board of Child Wel- 
 fare. The change cannot be wrought before 1923, but at that 
 time those interested may find the condition worthy of study. 
 
 The problem in Berlin is its vastness, and with the present 
 complications of limited public and private funds, plus extreme 
 hardship for those of insufficient income, the problem is even 
 more difficult than ordinarily. 
 
 One of the most encouraging signs in Berlin is that the Poor 
 Law Board exists no more, and in action its successor, as far as 
 concerns the work for mothers and infants, is concerned in a co- 
 operative capacity. This condition eliminates the factor that 
 tends most to divide and decentralize the present work in Swed- 
 en. Furthermore, the supervision of the Board of Health is so 
 designed as not to overlap the province of the Department for 
 the Welfare of Children. 
 
 A marked characteristic of the work in Berlin is that it is 
 distinctly of an educational or constructive nature. Pre-natal 
 clinics, propaganda for proper care during pregnancy, confine- 
 ment, and through the nursing period, the concentrated respon- 
 sibility for foster children, and the National Mothers' Pensions, 
 indicate the fact that Berlin has long since distinguished be- 
 tween "Relief," and that which is decidedly "Treatment and 
 Cure." 
 
 The concept of one central agency dealing with all needy 
 children has been planned admirably in the Berlin Department 
 for the Welfare of Children. 
 
 The successful carrying out of a policy of extensive public 
 service depends in large measure upon the efficient and eco- 
 nomical utilization of the resources at hand, by State and Muni- 
 cipal governments. And as one travels between institution, and 
 supervising authority, one is impressed in Germany and Swe- 
 den with the honest use of public funds; workmanlike offices 
 
 38 
 
Public Maternity and Infant Care 
 
 for the fewest possible officials. Everywhere there is evidence 
 of a strict economy in overhead with a corresponding benefit to 
 the institutions. The public money is invested obviously in ex- 
 penditures of real, not doubtful value. 
 
 NOTE 
 
 For a satisfactory and comiprehensive ibilbliograjphy on the sub- 
 ject of Maternity and Infant Care, see "Bibliography on the Care and 
 Feeding of Infants and Children," issued by the Bureau of Child Hy- 
 giene of the New Jersey State Department of Health. 
 
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