Metropolitan maternity: maternal and infant welfare services in early-twentieth-century London

The history of the welfare state has, in the past twenty or so years, moved away from a simple teleological account of a shift from the cruelty of the new Poor Law to the new Jerusalem of Beveridge. There is now a much more sophisticated understanding of the risk pools of various forms of welfare provision, of the interplay of interests in the shaping of policy, of the impact of Idealism and patriarchy, and of the place of the British welfare state in comparative perspective. But one area has been relatively neglected: the local development of welfare provision. There has, it is true, been a concern with the distinctive patterns of provision within the old Poor Law, largely as a result of the work of the Cambridge Group for the History of Population and Social Structure. There has been excellent work on local variation in patterns of philanthropy, not least in the provision of voluntary hospitals of which the best examples have been Hilary Marland on Wakefield and Huddersfield, and John Pickstone on Manchester and its region. It has also been suggested that employers' attitudes to national legislation varied, so that industrialists in Birmingham supported the national insurance schemes of 1911, whereas their counterparts in the north-east of England were hostile. Despite these suggestive hints of the importance of regional or local divergences, the approach is relatively undeveloped. Lara Marks' excellent study of the provision of maternal and infant welfare services in four London boroughs is therefore particularly welcome. The lack of such studies is surprising, for it is clear that in the nineteenth century the role of local authorities was considerable, and the central state passed many responsibilities to the localities. The growth of local government expenditure was much more rapid than central government expenditure, and there was a very active and dynamic municipal culture from about 1860, with towns vying with each other in the provision of art galleries or museums, town halls and water works. Recent work by Bob Millward has indicated that there were divergences between towns in the municipalization of public utilities, and he has made some attempt to explain the lags and leads in terms of the need of revenue from trading activities, and the extent to which the municipal boundaries coincided with the area supplied by the utilities. There is, however, little systematic analysis of the extent to which different authorities were able to provide welfare services and-a vital point-how much real difference it made. Could it be that local authorities spent more or less on welfare, but made little difference to life chances because their efforts were overwhelmed by the level of poverty or overcrowding in the town? What Metropolitan maternity shows is that the efforts of local authorities did matter. Marks focuses on the provision of infant and maternal welfare services in four metropolitan boroughs from about 1900 to 1939: Stepney, a poor East End district dominated by casual labour and high levels of overcrowding; Woolwich, with its skilled artisans and relatively good housing stock; Hampstead, a prosperous suburban area; and Kensington, an area with a large number of wealthy residents but also with considerable numbers of poor and swathes of notorious slums. Surprisingly, the poorest district-Stepney-had the lowest level of maternal mortality, in large part because of the standards of maternal care provided by the voluntary teaching hospitals in the area. By contrast, the wealthy mothers of Hampstead who were able to purchase the services of a general practitioner or midwife were more likely to die as a result of childbirth. Medical care was more significant than economic conditions in the case of maternal mortality, but not infant mortality, which was highest in Stepney and Kensington. Nevertheless, the pattern of local provision did matter: the poorer district of Woolwich had a much better record than Kensington, and the