VITAL and HEALTH STATISTICS 

ANALWICALSTUDIES 

Infantloss inthe 

Netherlands 

Trends in infant and perinatal mortality in the Netherlands prior to and after World War Il. Analysis by 

age, sex, causes of death, age and parity of motherl 

place of delivery, season, urban and rural areas, and 

social factors; maternal mortality; description of maternal and child health services; general demographic 

and socioeconomic trends. 

Washington, D. C. Augusf 1968 

(lJ. ~EpARTMENT OF 

HEALTH, EDUCATION, AND WELFARE Public Health Service 

Wilbur J. Cohen William H. Stewart 

Secretary Surgeon Gen.=ral 
Public Health Service Publication No. 1000-Ekries3-No. II 

‘Forsale by the Superintendent of Documents, U.S. Government Printing OffIce 

Washington, D. C., 20402- Price 50cents 
NATIONAL CENTER FOR HEALTH STATISTICS 

THEODORE D.WOOLSEY, Director 

PHILIP S.LAWR E“NcE;SC.D., Associate Director 

OSWALD K. SAGEN, PH.D.,,Assistant Director for Health Statistics Development 

WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development 

ALICE M. WATERHOUSE, M.D.,Medical Consultant 

JAMES E. KELLY, D. D. S., Dental Advisor 

LOUIS R. STOLCIS, M. A., Executive O//icer 

MA RGERY R. CUNNINGHAM, ~n/orrnatzon O//icer 

OFFICE OF HEALTH STATISTICS ANALYSIS 

IVJAOM.MORIYAMA,Ph.D.,Director 

DEAN E.KRUEGER, Deputy Director 

Public Health Service Publication No. 1000-Series 3.)40. 11 

Library of congress Catalog Card Number 68-60073 
FOREWORD


This report is one of a group of analytical studies designed to delineate the perinatal and infant mortality problem inthe United States. 

While the primary concern is with the problem of perinatal and infant 

mortality in this country, it was felt that much could be learned from 

the experience of other developed countries with advanced medical systems. During the period 1950-65, infant m,ortalit y was no lcnger declining 

at its former pace in the United States and in several other countries 

(England and Wales, and Scotland, for example) but in the Netherlands 

and Sweden, the rates appear to have declined to a level which is about 

half of that in the United States. Despite declines in infant mortality 

for the United States in 1966 and 1967, the differential between this 

country and the Scandinavian countries remains evident. 

The National Center for Health Statistics arranged with a number 

of investigators to prepare comprehensive reports on perinatal and infant mortality in their own countries. Contracts were negotiated with 

investigators in Denmark, England and Wales, the Netherlands, Norway, 

Scotland, and the United States. Earlier reports evolving from these 

contracts 

No. 4 

No. 5 

No. 6 

No. $ 

No. 9 

appear in Series 3 of Vital and Health Statistics: 

Infant and Perinatal Mortality in the United States


Infant and Perinatal Mortality in Scotland


International Comparison of Perinatal and Infant Mortality:


the United States and Six West European Countries


Infant Mortality Problems in Norway


Infant and Perinatal Mortality in Denmark


The present report for the Netherlands is the sixth in this group of 

studies on perinatal and infant mortality. The methodology, findings, 

and conclusions are those of the investigators. 

Iwao M. Moriyama, Ph.D.


Director


Office of Health Statistics Analysis


... 111 
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CONTENTS 

Foreword 

1, Nature and Processing of Data --------------------------------------

11, 

III. 

w.


v.


VI. 

Notification and Registration 

Live Birtis 

StiUbirths 

Deaths 

Calculation of Rates 

Classification of Causes of Death -----------------------------------

Historical Trends in Infant Loss 

General Trend


Age Components


Sex Differences


Urban and Rural


hternational Comparisons


Postwar Trends in Infant Loss


Age Components 

Perinatal Mortality 

Postnatal Mortality 

Social Factors-------------&-----

Urban and Rural 

International Comparisons 

Maternal Mortality 

General Trend


Causes of Death ---------------------------------------------------


Age of Mother


Outlook for Infant Loss 

Summary 

Nature and Processing of Data ------------------------------------


Mortality Trends


Maternal and Child Health Services


Future Trends


AcWowledgments 

Page 

... 111


1 

1


2 

2 

3 

3 

4 

5 

5 

6 

8 

9 

9 

10


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12 

22 

24 

25 

25 

26 

26 

26 

27 

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28 

28 

28 

30


30


30 

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CONTENTS—Con.
 .


Page 

Bibliography 31


Detailed Tables 34


Appendix I. General Demographic, Socioeconomic, and Sociohygienic 

Trends 48


Population 48


MortaliW 50


Socioeconomic Development 52


General MeticalCare 55


Preventive Care 55


Appendix II. Maternal and Child Health Services 59


Organization of Services 59


Obstetrical Care 60


Maternity Home Help ---------------------------------------------- 60


Welfare Centers ---.--- - 61


Curative Care 62


Appendix 111. Deftiitions of Terms 63


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SYMBOLS 

Data notavailable 

Category nonapplicable . . . 

Quantity zero -

Quantity more than Obut less than 0.05---- 0.0 

Figure doesnot meet standards of * reliability orprecision 
IN THIS REPORT are summan’zed studies which have been carvied on 

for move than a decade on infant loss in the Netherlands. The trends in 

infant and pevinatal mortality are analyzed in the light of changing pattevns of medical demography, the organization and development ofhealth 

and medical services, and the general standard of living. 

Infant mortality was ~educed by hulf in each of three periods: between 

1900 and 1922, between 1923 and 1939, and between 1948 and 1964. All 

age components of infant loss (fetal and infant mortality) have decreased 

more rapidly in the postwar thun in the prewar years. Perinatal mortality has fallen much move slowly thunpostnatal mortality (1-51 weeks), 

drastically chan~”ng the vatio of these two components j?om 1 to 1 in 

1927 to 3 to 1 in 1950-54 and to 5 to 1 in 1960-64. Currently, perinatal 

mortality accounts for more than 80 percent of infant loss. 

Obstetrical care in the Netherlands has three distinctive chmacteristics. 

Fi%st, domiciliary confinement with the sevvices of a family doctor OY 

midwife is far moye usual than institutional confinement, with only 30 

pevcent of the bivths occuming in a hospital. Second, midwives give 

pvenatul and natal cave as independent practitioners. Third, a special 

voluntwy organization pvovides caye in the home foy mothev and the 

newbovn. 

A veview of infant and perinatal mon?ulity by sex, age, cause of 

death, social class, and other facton indicates that jiwther reductions 

in infant loss in the Netherlands may be expected. I 

... Vlll 
INFANT LOSS IN 

J. H. de Haas-Posthuma, 

In this monograph are summarized the studies 

we have carried on for more than 15 years on 

infant loss in the Netherlands. Such investigations 

are indispensable in evaluating child health and 

maternal care programs and sociohygienic conditions. 

Hollandts2 position with regard to infant loss 

is distinctive in three respects: its rates are low 

compared with those of other countries, the frequency of hospitalized births is low, and infant 

care has a relatively long tradition. Moreover, 

its birth rate is higher than that in neighimring 

countries. 

For reasons to be discussed in the text, the 

analysis is not restricted to infant mortality, but 

deals more broadly with infant loss: the total of 

fetal and infant deaths. In order to make the analysis as meaningful as possible, the historical and 

postwar trends of infant loss have been viewed in 

THE NETHERLANDS 

M.D., and J. H. de Haas, M.D.l 

the light of the changing patterns of medical demography, the organization and development of 

health and medical services, and the general 

standard of living. Social, biological, and medical 

factors are closely interrelated in nearly all 

problems of public health. Infant loss is a classic 

example of this interrelationship. 

Although the rates of infant loss in the Netherlands are relatively low, the irreducible minimum is far from having been reached. Analyses 

by sex and other biological factors, social class, 

causes of death, and seasonal variation point in 

the same direction: infant loss continues to fall 

and will decrease further. The present rates are 

low when compared with the past, but not according to modern social and medical conceptions. In 

the atom age, wastage of infant life is an anachronism. 

1. NATURE AND PROCESSING OF DATA 

In analyzing the trend of infant ioss tii the 

Netherlands, it is essential to know how the basic 

data are collected and processed. This section, 

therefore, describes notification and registration 

procedures, the calculation of mortality rates, 

and the classification of causes of death. 

lAt the time this report was prepared, both authors were 

affiliated with the Department of Health Development, Netherlands Institute for Preventive Medicine, Central Organization 

for Applied Scientific Research in the Netherlands (TNO), 

Loiden, 

2[In this report, Holland and the Netherlands are used interchangeably.-Ed.] 

Notification and Registration 

Often overlooked is the fact that the registration of births and deaths in the Netherlands and in 

other European countries is the second stage in 

vital statistics bookkeeping; the importance of 

the first stage— notification—is underestimated. 

Registration is usually in the hands of a competent statistical office, but notification is done by 

people who are not always aware of the significance of accurately reporting each case and of its 

epidemiological implication. 

From a biological point of view, there is no 

sharp borderline between a fetal death and a live1 
born child that dies soon after birth. Statistically, 

however, a differentiation is made according to 

internationally accepted definitions of fetal death 

(stillbirth)3 and live birth. The greater the number of deliveries that take place in hospitals, 

where trained personnel care for the newborn, the 

sharper is the differentiation that can be made. In 

Holland, where about 70 percent of all deliveries 

are in the home, many doctors and midwives 

working outside of hospitals have not been trained 

to adhere strictly to the international definitions. 

Live Z&ths.-Notification of births within 3 

days after delivery is compulsory and must be 

done by someone who was present at the delivery. 

It is usually the father who reports the birth at 

the town hall. There is no medical notification of 

live births in the Netherlands. The registrar asks 

the father or his representative for the following 

information: date of birth, religion, nationality, 

name of physician or. midwife attending the delivery, name of hospital (if any), whether single or 

multiple birth, parity (both including and excluding 

births in previous marriages), date of present 

marriage, legitimate or illegitimate child, and 

age and occupation of father and mother. In cases 

where there had previously been a fetal death or 

the death of a child before birth notification, 

parity is often understated. If the women had been 

transported to the hospital during labor, the 

questions relating to place of birth (hospital or 

home delivery) and to attendant (doctor or midwife) may be answered incorrectly. Medical data, 

such as birth weight, type of delivery, complications of pregnancy, etc., are not asked for, inasmuch as the person giving the information is most 

often a layman. Information, therefore, is not 

available on the distribution by birth weight of the 

newborn as a group. 

Notification of live births may take place 

under the following circumstances: 

Alive at time of notification: Reporting of 

these “ordinary” births is complete. The 

3 [The World Health Organization recommends use of the 

teiim “fetal death” for all pregnancy ,terminations which show 

no evidence of life after complete expulsion or extraction from 

the mother; in European vital statistics the term “stillbirth” 

is used to denote such terminations at 28 weeks or more of 

gestation. -Ed.] 

local registrar sends each birth certificate 

to the Central Bureau of Statistics. 

Dead before notification (faux mort-n<s): h 

submitting the death certificate signed by the 

doctor, the father indirectly gives notice of 

the birth of the child. Through this certif icate, the cause of death, birth weight, and 

duration of gestation are known, but not the 

complications during pregnancy and labor. 

Some doctors, continuing the practices of 

years past and misinterpreting the interniLtional definitions of live birth and fetal death, 

consider liveborn infants with gestations of 

less than 28 weeks who die soon after birth 

to be “nonviable.” In such cases, these deaths 

are not certified by the physician, and as a 

consequence are not reported as live births 

by the parents. 

%illbivths (vrais mort-ne%).l—The father or 

his representative gmes notice of a stillbirth by 

submitting a death certificate filled out by a doctor. This certificate contains questions on cause 

of death, duration of gestation, and complications 

during pregnancy and labor, but not on birth 

weight. 

Three difficulties arise in the reportilg 

of stillbirths: 

1.	 In borderline cases wm, respect to dur~­

tion of gestation (those of 26 to 28 weeks’ 

duration), doctors tend to consider a sti!.lbirth as an early fetal death in order to 

save parents the trouble and costs of a 

funeral. This leads to a.slight understatement of stillbirth and of pe’rinatal mortality. 

2.	 For religious reasons, a stillbirth occurring during the last period of labor may 

be considered to be a live birth, in order 

that the child may be baptized. This practice leads to a slight underregistration of 

stillbirths but does not affect perina :al 

mortality, inasmuch as these children 

are recorded as having died in the first 

week of life. 

3. If liveborn infants of more than 28 weel:s’ 

gestation die very soon after birth and, 

for some reason or other, are reported 

as stillbirths, overregistration of sti 11-

2 
births. occurs. This does not affect perinatal mortality, but does reduce firstweek mortality. 

The net effect of these three factors very 

likely is a slight undernotification and underregist ration of stillbirths and of perinatal mortality. 

Moreover, since 1950 the official definition of 

stillbirth has changed from 26 to 28 weeks of 

gestation. This change has resulted in a slight 

decrease in the stillbirth rate (0.4 per 1,000 

births) compared with preceding years. 

Deaths. —The doctor is legally obliged to fill 

out the death certificate, which is sent to the 

Central Bureau of Statistics by the local registrar. 

Without a death certificate, the deceased cannot 

be buried. Special data are required if a child dies 

in the first week of life: duration of gestation, and 

weight and length at birth. Children dying in the 

first week are the only ones for whom birth weight 

and period of gestation must be reported, but unfortunately, the number of “unknowns” is high. 

Mortality in first week: This component of 

pcrinatal and of infant mortality must be considered separately, as notification of first-week 

mortality is not complete and registration has 

been incomplete until recently. 

As already mentioned, there is no notification 

of birth and death when the doctor considers as 

“nonviable” a child of 28 weeks or less gestation 

who dies within 3 days (the time allowed for giving 

not ice of the birth of a child). This undernotif ica ­

tion leads to underregistration and to an estimated 

lowering of first-week mortality (and infant mor ­

talit y) by 1 to 1.5 per 1,000 births. 

The notification of a death during the first 

hours of life as a stillbirth (and, conversely, 

notification of a stillbirth as a first-week death) 

results in a net underregistration of first-week 

mortality, estimated to be less than 0.5 per 1,000. 

Prior to 1964, notified cases of first-week 

mcmtalit y for infants with gestations of less than 

28 weeks were not registered by the Central 

Bureau of Statistics. Recently, data for the period 

1950-63 have been revised to include such cases, 

resulting in an increase of 1.5 per 1,000 in firstweek, perinatal, and infant mortality. 

Altogether, the limitations of the data discus sed above reduced first-week and infant mortality by 3 to 3.5 per 1,000 births. Underreporting 

may still be responsible for understating the rate 

by 1.5 to 2 per 1,000. In 1963-64, first-week mortalit y was 10.2 per 1,000 and infant mortality 

15.3 per 1,000, according to official statistics. 

Computed on the basis of countries in which notification and registration are presumed to be complete, the Dutch rates would be 12 and 17 per 

1,000, respectively. 

When international comparisons are made of 

stillbirth, and of first-week, perinatal, and infant 

mortality, it is assumed that detailed information 

on the methods of notification and of registration 

by the municipal, provincial, or central bureaus 

of statistics is available. Each stage of the procedure should be examined at the particular 

locale and evaluated periodically. 

Mortality after first week: The problems 

which arise in the notification and registration of 

first- week mortality do not exist with respect to 

mortality after the first week, when notification is 

compulsory and complete. Subdivisions by sex and 

age, season, and cause of death have been possible 

from 1953 onward because of data put at our disposal by the Central Bureau of Statistics. 

International comparisons of postnatal mortality (1-51 weeks of age) do not present any 

difficulties. However, infant mortality as a whole, 

which includes first -week mortality as its main 

component, is not comparable without qualifica ­

tion. 

Calculation of Rates 

Not only is it necessary to know the methods 

of notification and registration, but also the basis 

on which rates are computed. In Holland the calculation of the various components of perinatal 

and infant mortality is shown on page 4. 

In the tables and charts which give first-day 

mortality, the numerator relates to deaths in the 

first calendar day and not in the first 24 hours of 

life. Inasmuch as a far larger number of children 

die during the first than the second 12-hour period 

of the first day of life, the official data on first 

(calendar) day mortality comprise not half, but 

from 70 to 75 percent of the mortality in the 

first 24 hours. Because of this inappropriate 

registration of first-day mortality, data on firstweek mortality include approximately the first 

6% days of life and not the first 7 days. However, 

3 
Component 

Stillbirth 

First-day mortality 

First-week mortality 

Perinatal mortality 

Postnatal mortality 

Infant mortality 

Infant loss 

Numerator 

Stillbirths of 28 or more weeks of gesta­ tion 

Deaths in first calendar day


Deaths in first 7 calendar days


Stillbirths plus deaths in first week


Deaths i.n 1-51 weeks of Ufe


Deaths under 1 year of age


Stillbirths plus deaths under 1 year


Denominator 

Live births and 

stillbirths of 28 

or more weeks of 

gestation 

Live births 

Live births 

Live births and 

stillbirths of 28 

or more weeks of 

gestation 

Live births 

Live births 

Live births and 

stillbirths of 28 

or more weeks of 

gestation 

the effect of this practice is to diminish firstweek mortality only slightly and first-month 

mortality hardly at all. 

Classification of Causes of Death 

Causes of death in this study are generally 

classified according to the sixth and seventh 

revisions of the International Statistical Classification of Diseases, Injuries and Causes of Death 

(sometimes called the International Lists). Reporting, however, depends largely on the viewpoint of the doctor and on available medical 

facilities. The obstetrician gives primary consideration to the obstetric abnormalities, e.g., toxemia, while the pediatrician stresses the pathological condition of the child. 

In Holland, during the past decade only half 

of the newborn dying in the perinatal period were 

born in a hospital; of the children born athome 

and dying in the first week, only one-quarter 

were admittedto ahospital before death.Thus,in 

a large proportion of perinatal deaths careful 

clinical observation is lacking. In 1952-53, postmortem examinations were performed inonly15 

percent ofperinatal deaths, whichproportion may 

have increased to 25 percent at present. 

Nearly half of the stillbirths and one-fourth 

of the first-week deaths occur amonghomedeli~­

cries attended by a general practitioner oramidwife. Taking into account the difficulties e Icountered even in well-equipped hospitals in 

determining the causes of death in newborns, 

whether matureor immature, dataonthereportsd 

causes ofperinatal mortalityshould beinterpreted 

cautiously. 

From a medical point of view, the Seventh 

Revision of the Classification as it refers to 

causes of stillbirth and first-week mortality is 

far from ideal. Students of perinatal and infs.nt 

mortality are therefore eagerly looking forward 

to the Eighth Revision of the International Lis:s. 

After the first week of life, however, diagnof:is 

becomes less complicated, although often far frc)m 

simple without a well-performed postmortem. 

International comparisons of the causes of 

perinatal mortality must take into account differences in the diagnostic methods and the coding 

procedures used in the various countries. E\en 

in the same country, data on causes of death oter 

several decades can begivenix-dy format igroups, 

but not subdivisions, because successive revisicns 

of the International Lists make comparability 

4 
difficult or impossible for a number of causes. 

Nevertheless, weaknesses in the reporting and 

coding of causes of death should not be overemphasized in analyzing perinatal and postnatal 

mortality. Analysis by sex and age of the child, 

seasonal variation, parity and age of mother, 

type of delivery, obstetrical and maternity care, 

social factors, etc., provides considerable information on the possibility of reducing perinatal 

and postnatal mortality. 

Il. HISTORICAL TRENDS IN INFANT LOSS


Infant mortality rates for Holland since 1865 

are shown in figure 1. Until 1918, the faux movt­

?ds were registered as stillbirths and not as infant deaths. Therefore, the official stillbirth rates 

before 1918 were too high; the change explains 

the sudden fall in the rate from 39 per 1,000 births 

in 1917 to 26 in 1918. Automatically, first-week 

and infant mortality rose about 10 per 1,000. This 

change in registration did not influence the rate 

of infant loss, which is the sum of stillbirth and 

infant mortality. 

10 

8 

6 

4 I 

s~ 

1865 1685 1905 196 

YEAR 

F gure , Infant mortal ity rates: Netherl ar&, 

1865-1965. 

General Trend


When account is taken of the revision of registration procedures in 1918, the stillbirth rate 

showed virtually no change between 1900 and 1940. 

Therefore, the reduction in infant loss until 1940— 

from about 200 per 1,000 births in 1900 to nearly 

110 in 1920 and to about 60 in 1938-39—resulted 

from the fall in infant mortality. Since 1940, however, stillbirths have contributed to the decrease 

in infant loss, as may be seen in figure 2. After 

World War II, infant loss decreased from 60 per 

lJJOO in 1946 to 30 fiL963, and 2%in 1965. 

1920 1930 1940 1950 !960 ’65 

YEAR 

Figure 2. Infant mortal ity rates by age, and


sti 11bi rth rates: Netherlands, 1920-6%


5

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--------------

Infant mortality amounted to more than 200 

per 1,000 live births until 1890 and came dmvn to 

about half that leyel by 1920. The rate dropped to 

50 per 1,000 in 1930, 30 in 1948, and 15 in 1963-

64. Infant mortality was halved in each of three 

periods: between 1900 and 1922, between 1923 

and 1939, and between 1947 and 1963, with the 

first period covering 22 years and the other two 

16 years each. 

The peaks of the curves shown in figures 1 

and 2 are accounted for by epidemics of gastrointestinal or respiratory diseases and by disrupted 

living conditions during World War II, when the infant mortality rate rose from about 35 to nearly 

80 per 1,000. The hot and dry summer of 1911– 

notorious for severe diarrhea—had a greater 

impact on infant mortality than did the shortage 

of food, fuel, and clothing during World War I and 

:he influenza epidemic of 1918. The rise in 1929 

was caused by respiratory infections during an 

unusually cold winter, when heating inmost houses 

was still primitiye. 

When the infant mortality rate was about 50 

per 1,000 and postnatal mortality accounted for 

about two-thirds of infant deaths~ as was the case 

in 1930, the main causes of death after the first 

week were diseases of the respiratory system, 

followed closely by diseases of the digestive system, and the common communicable diseases of 

childhood. The virtual disappearance of these 

three killers of infants—together with the improvement in infant care—has greatly influenced 

the trends of infant mortality. As a result of the 

sharp reduction in these causes of death, congenital malformations rose in relative importance 

from fifth to first place as a cause of postnatal 

mortality. 

Age Components 

Historically, stillbirth and infant mortality 

have been analyzed separately. Moreover, infant 

mortality itself is not a homogeneous category, 

inasmuch as its two major components differ in 

nature, first-week mortality being influenced by 

obstetrical factors and .postnatal mortality by 

pediatric conditions, Because the~aux ?no?’t-ne% 

were registered as stillbirths until 1918, infant 

mortality could not be subdivided into its real 

components until that time. 

Table 1 shows the birth rate, perinatal tmd 

infant mortality, and their components for each 

year from 1920 through 1964, Infant loss--the 

modern concept of wastage of infant life—may be 

defined in two ways: the sum of stillbirth and infant mortality or the total of perinatal and ~stnatal mortality. 

Table A compares the relative decreaae in 

the components of infant loss in the 16-year prewar period 1923 m 1939 with that in the 16 postwar years of 1948 to 1964, In both periods postnatal mortality (1- 51 weeks) decreased much 

more rapidly than perinatal mortality, For each 

of these components, the relative reduction was 

greater in the postwar than in the prewar period, 

Pevinatal mcwtulity. — Between 1920 and 1’>40 

the stillbirth rate remained stable at about 25 

per 1,000. Around the beginning of World War II, 

for some unexplained reason, the rate droped 

rather sharply—as it did in a number of ot!ler 

countries—and remained at the level of 19 or 20 

per 1,000 during the 1940~s, The other component 

of perinatal mortality, first-week mortality, was 

19,0 per 1,000 in 1920, decreased slowly duzing 

the 1920’s and 1930’s, and showed little chaoge 

during World War II—fluctuating between 14 md 

16 per 1,000. Perinatal mortality as a whole fell 

very gradually from its level of 45 per 1,00(1 in 

1920, but did not drop below 32 per 1,000 through 

the 1940ts. 

While both stillbirth and first-week mortality 

decreased about 10 percent between 1923 and 1939, 

Table A. Percent decrease for cotnpone nta 

of infant loss rates: Netherlands, 1323 

to 1939 and 1948 to 1964 

= t I 

Coraponent 

infant 10ss


Perinatal mortality


Stillbirth


Infant morta lit y


Under 1 week ------------ 1-51 weeks 

Percent 

decrease 

6 
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------------------ --------

--------------- ----------------------------------- -----------------------------------

Table B. Perinatal and postnatal mortality rates, and ratios of perinatal to 

postnatal mortality rates: Netherlands, 

selected years, 1900-1964 

* 

Peri- Postnatal na ta 1 

Period mor - mor - Ratio 

ta li~y ::;:;y 

ratel 

1960-64---------- 25 6 4:1


1955”59” 4:1


1950-54---------- :: J 3:1


1935-39---------- 41 21 2:1 

1925-29---------- 42 41 

1910”14-”-”-----” ,0.;:: 

1900-1904-------- % J: 0.5:1 

lRate per 1,000 births. 

9Death rates for ages 1-51 weeks per 1,000 live births. 

in the postwar years 1948-64 the reductions 

mnounted close to30percent. Becausethe relative 

decrease was about thesameforboth components, 

the ratio of stillbirth to first-week mortality—4 

to 3—has remained unchanged for the past 40 

years. The parallel decrease for stillbirth and 

first-week mortality in the two periods strengthens the concept that the perinatal period is an 

entity from the medical point ofview, eventhough 

biological factors, such as maternal age and 

parity, havea strongerinfluence onstillbirth than 

on first-week mortality. 

Perinatal mortality hasbeendecreasing much 

less rapidly than postnatal mortality since the 

turn of the century, or longer, drastically changing the ratio between these two components from 

l/2tolin1900-1904,to ltolin 1925-29, 2tola 

decade later, and 4tolin1960-04(table B). While 

in 1925-29 perinatal mortality accounted for half 

of the infant loss, currently it is responsible for 

more than 80 percent of teetotal. Theproblemof 

the wastage of infant life has become largely the 

problem of perinatal mortality; postnatal mortality is no longer of major importance. 

Postnatal mortality .-The reduction in mortality. among infants beyond the first week of life 

has been spectacular. In 1920, postnatal mortality 

was still over 60 per 1,000 live births, but in 

1932 the rate was down to 30 per 1,000 and by 

1939 to less than 20, a reduction of about twothirds in 40 years. During World War 11postnatal 

mortality increased sharply, however, to almost 

63 per 1,000 in 1945. Since then the rate has 

dropped steadily, reaching about 10 per 1,000 in 

1952 and less than 5 at present. The long-term 

decrease in postnatal mortality, accelerated after 

World War II, has been due to the sharp reduction 

in the death rate for diarrheal, respiratory, and 

other infective diseases. 

In the early 1920’s postnatal mortality was 

three times as high, and in the 1930’s nearly twice 

Table C. Xnfant, first-week, and postnatal mortality rates, and ratios of first-week to 

postnatal mortality rates: Netherlands, selected years, 1920-64 

Infant First-week Postnatal
 Period morta 15.t mortality mortality Rat io


y


Rate per 1,000 live births


1960-64 --..-=-”- 16 2:1


1947-51..---..-.-....”----- :: 1:


1930-34 :; 17 O.H


1920-24 74 18 ;: 0.3:1


‘Death rates for ages 1-51 weeks. 

7 
----------------------------- —.

as high, as first-week mortality. Postnatal mortality continued to record the higher rate until 

shortly before 1950, when the rates were about 

equal; in the early 1960’s first-week mortality 

was twice as high as postnatal mortality (table C). 

Postnatal mortality may be subdivided into 

three age components: 7-27 days, 28 days-5 

months, and 6-11 months. The rates for the first 

component are available since 1920 (table 1) and 

for the other two since 1938 (table 2). For the age 

group 7-27 days, the mortality decreased from 12 

per 1,000 in 1920 to 6 in 1930 and to 4 in 1939. 

After reaching a peak of 14 per 1,000 in 1945, the 

rate returned to the immediate prewar level in 

1947, to 2 in 1956 and to an even lower level in 

recent years. 

The war peak proved, in what may be considered an unintended experiment, that mortality 

at ages 7-27 days is much more influenced by 

external factors than is first-week mortality. 

There is therefore no justification for combining 

stillbirth and first -month mortality. Perinatal 

mortality should be restricted to stillbirth and 

first-week mortality. 

Mortality from 28 days-5 months has generally been about twice as high as in the interval 

7-27 days. The death rate for children 6-11 months 

of age was somewhat nigher than for those 

7-27 days until the mid- 1950’s, but since then the 

rates have been practically the same, although 

they relate to age periods of 26 weeks and 3 

weeks, respectively. I 

Sex Differences 

The stillbirth rate for females averag~s 

about 10 percent below that for males, irrespective of the level of the rate (table 3). Practical) y 

no decrease was recorded until World War II 

either for boys or for girls, when the sudden rt ­

duction in the stillbirth rate between 1940 ar,d 

1941 occurred for Imth sexes. 

It has long been known that infant mortalil y 

is lower among girls than boys, the different e 

amounting to about 20-25 percent. The causes {Jf 

infant mortality for each sex in 1929- 30—midwg y 

between the two World Wars—are shown in tab e 

D. Males had a higher death rate than females fcw 

each of the major groups of causes, particular.,y 

the respiratory and digestive diseases. Althou$;h 

the level of infant mortality has fallen sharp.!y 

since then, males have continued to experience 

higher rates. 

Table D. Infant mortality rates and percentage diatribut ion, by sex and cause of death: 

Netherlands, 1929-30 

Cause of death


(Third Revisi.on—


international Lists, 1920)


= 

Rate per 10,000 

live births 

Total 548.9 614.7 479.1 

Tuberculosis-----------------------3l-37 10.2	 10.9 

infective di.seases------------ l-3 O,38-42 48.4 -150.1 4;:: 

Deficiency diseases -------------53,56,61 

Nervous system and sense organs----86-86 3;:: 4::; 32:; 

Respiratory system----------------97 -lO7 103.9 116.3 90.6 

Digestive system--------- lO8-127,ll4-l27 60.6 72.8 47.6 

C~ngenital mlformtions------------- l5g 42.6 46.2 38.8 

Diseases of early imfancy----l13,1162 l62 165.0 185.3 143.5 

Accidents, poisonings, and violence-165- 203 3,2 3.6 2.8 

Other diseases 

43-52,54,55,57 -60,62-69,87-96,128-158 71.9 79.8 63.5 

E;Percentage 

distribution 

100.0 100.0 100 *o —. 

2.0 

;:; ii:: 

0.7 0.8 H 

J:; J:; 1;:; 

11.0 11.8 

::; 

3::: 3;:: 29.9 

0.6 0.6 0.6 

13.1 13.0 13,3 

—— 

SOURCE: Adapted from Central Bureau of Statistics, Statistiek van de sterfte,Zeist. 

8 
Table E. Perinatal, stillbirth, and infant mortality r~~.~, .y size of municipality: 

Netherlands, 1926-40 and 1946-63 

1961-63 1956-60 1951-55 1946-50 1936-40 1931-35 1926-30 

Perinatal mortality 

100,000+ inhabitants--

20>000-99,999---------

Under 20,000----------

Stillbirth 

1OO,OOO-I-inhabitants--

20,000-99,999---------

Under 20,000----------

Infant mortality 

100,000+ inhabitants--

20,000-99,999---------

Under 20,000----------

Under 1 week 

100,000+ inhabitants--

20,000-99,999---------

Under 20,000----------

1-51 weeks 

100,000+ imhabitants--

20,000-99,999---------

Under 20,000----------

Urban and Rural 

Rate per 1,000 birtha 

24.7 26.6 29.8 31.0 37.2 

25.2 26.3 30.8 32.7 40.7 

26.0 29.2 33,0 35.6 41.8 

13.8 15.4 16.5 17.9 24.1 

14.4 15.3 16.8 18.9 25.4 

15.2 17.2 18.6 20.7 24.9 

Rate per .,000 live births 

39.2 41.0


42.0 43.7


42.6 41.9


24.6 ;:.;


24.4


25.4 25:0


34.4 41.6


43.1 54.2


48.7 62.4


14.6 15.6


17.6 19.2


17.4 16.9


19..8 26.0


25.5 35.0


31.3 45.5


16.2 17.8 

::.: 18.2 

. 19.2 

11.0 11.4


11.0 11.1


10.9 12.2


5.2 6.4


5.9 7.1


5.7 7.0


22.0 27.0 28.8


24.1 30.3 36.6


24.2 32.4 40.9


13.5 13.1 13.1


14.3 13.8 15.3


14.7 14.9 16.9


8.5 13.9 15.7


9.8 16.5 21.3


9.5 17.5 24.0


At the beginning of the industrial revolution, 

infant mortality was higher in the cities thanin 

rural areas. Since the end of”the 19th century, 

however, it has been lower in urban than in rural 

areas. Tbedisaavantages olurDan comparedwith 

village life has been more mancompensated for 

by the development of better hygienic measures 

in the cities. 

Before World War II all components ofinfant 

mortality were higherinrural thaninurban areas, 

the differences amounting to40 percent for postnatal mortality and 10 percent for perinatalmortality (table E). However, after World WarH, as 

infant loss decreased, the differences by size of 

municipality became smaller and smaller until 

they have practically disappeared. 

Notwithstanding the facL that the proportion 

of hospitalized births in cities of 100,000 ormore 

inhabitants currently is twice that in municipalities of less than 20,000 population, first-week 

mortality is not lower in urban than in rural 

areas, and the stillbirth rate is only slightly 

lower in urban areas. Hospitalization in itself 

is no assurance that perinatal mortality willbe 

reduced. 

International Comparisons 

International comparisons of infant mortalit y 

are essential not only because of differences in 

the level of the rates between countries but also 

because of differences in their long-term trends. 

Figure 3 shows the trend of infant mortalityin 

several western European countries since 1922. 

The rates have not been standardized forparlty 

or age of mother, but these biological factors do 

not substantially influence the general trend.Differences in notification andregistration practices 

9 
120 f I I 

..--- Belgium \ 

- ,1,,,1,,,,,, England and Wales 

� -m Netherlands . 

* Norway 

— Sweden “1 

,Q~ [920 1930 1940 1950 1960 196 VFAQ 

Figure 3. Infant mortality rates: selecied European countries, 1922-65, 

Iwve also been left out of consicleration and these 

differences may be important; considerable caution must therefore be exercised inmakinginternational comparisons at least when the differences are small. 

Inthe first half of the 1920’s Norway had the 

lowest infant mortality rate4-somewhat over50 

per 1,000 live births— while in Sweden the rate 

was 60 per 1,000, and in the Netherlands and in 

England and Wales it averaged a little over 70 

per 1,000. The rate in Belgium exceeded 100 per 

1,000, During the second half of the 1920’s, the 

rate for the Netherlands fell below that for Sweden. 

In the decade prior to World War II, the infant 

mortality rates in both the Netherlands and Norway 

came down below 40 per 1,000 for the first time, 

both rates averaging about 5 per 1,000 Mo; 

Sweden’s. 

Infant mortality rates in the Netherlands ancl 

in EngIand and Wales have been diverging since 

the early 1920fs, except for the World War II peak 

in the Netherlands, The rate in England and WaIes 

has not yet gone below 20 per 1,000, while in th( 

Netherlands and in Sweden the rate is approximately 15 per 1,000, with that for Norway bein[; 

in between. A striking disparity is found in tht: 

infant mortality rates of the Netherlands ancl 

neighboring Belgium, which countries at presen: 

do not differ much in social conditions but rathe]’ 

in socioeconomic development and in the level of 

medical care. 

Table 4 gives data on the trend of infant Icm:; 

and its components in a number of countries fo:­

the period 1926 to 1961. The prewar stillbirth 

rate—approximately 25 per 1,000— was about the 

same in the Netherlands, Sweden, Norway, Denmark, and Czechoslovakia. In EngIand and Wale Y 

the stillbirth rate was higher (about 40 per 1,000), 

while Belgiumrs was in between. 

Before 1940, infant mortality was higher i I 

Sweden than in Norway or the Netherlands, Sincj 

World War 11, Swedenfs rates have become th; 

lowest in the world, The prewar rates in Englan.1 

and Wales and the United States were from 5 ty 

10 years behind those for Sweden and the Netherlands, assuming that a comparison of large an ~ 

smalI countries is valid. During the interbellur~ 

period, infant mortality in Belgium was twice as 

high, and in Czechoslovakia three times as higt, 

as in the Netherlands. In nearly all countries, am 

accelerated downward trend occurred after World 

War II, as will be described later, 

Ill. POSTWAR TRENDS IN INFANT LOSS


The downward trend of infant loss during the 

postwar period will be analyzed by age, sex, cause 

of death, social factors, and urbanization and in 

the light of socioeconomic conditions and the 

medical care of mother and child. 

4New Zealand had the best record for infant mortality until the end of World War II, but its population was very small 

(1.5 million ). 

AGE COMPONENTS 

After reaching a peak of nearly 80 per 1,0(10 

live births in 1945, infant mortality in the Nether. 

lands returned to the immediate prewar level ~f 

33 per 1,000 in 1947 and m about 27 in 19.50, E!y 

1950, the stillbirth rate was down to slightly lx:­

low 20 per 1,000 and perinatal mortality to a little 

under 35 per 1,000, 

10 
---

-------

--------------

so . 

26 

g 

-. 

~ 

& 

g 10 ~ 

a 

u - 1-51 weeks 

6 -_ Bcmd bn li”~ bitfhs 

‘iEAR I 

Figure 4, Perinatal and infant mortality rates


by age: Netherlands, 1950-64,


The general trend of the components ofinfam 

loss between 1950 and”1964is shown in figure4. 

During this period, both the stillbirth and the infant mortalityrates contintiedtof’dll, reaching13 

and 15per 1,000, respectively, in 1964. The rate 

of infant loss fell to28 perl,000from46 in 1950, 

The postwar trend of first-week mortality 

has been irregular: rising slightly in 1950 and 

19.51 (probably due m a change in registration 

procedure), decreasing from 1951 m 1957, and 

remaining about the level of 11.5 per 1,000 in the 

years 1957-62. In 1964, the rate was down to 10.1 

per 1,000. 

Postnatal mortality (ages 1-51 weeks) decreased to 4.7 per 1,000 in 1964, with the three 

components—7- 27 days, 28 days-5 months, and 

6-11 months—reaching all-time low levels of 1.5, 

2.1, and 1.2 per 1,000, respectively. 

The relative reduction in mortality foi- the 

various age components was not uniform between 

1950 and 1964, The most rapid decrease—nearly 

65 percent—occurred in the age group 28 days-5 

months; the smallest reduction-- 18 percent-– was 

recorded for ages 1-6 days. The age components 

under 1 calendar day and 7-27 days each recorded 

a reduction of 45 percent, the same as for infant 

mortality as a whole. Infant loss fell 39 percent 

and perinatal mortality, 32 percent. The continued 

decrease of postnatal mortality, infant mortality, 

and infant loss brought these rates down to less 

than 5, 15, and 29 per 1,000, respectively, in 1964. 

Table F shows the decrease in first-week 

mortality between 1950-51 and 1959-61 by indiTable F. 140Ttali.ty in the fiti st week	 of I?f e, by individua 1 day: Netherlands, 1950-51 

and 1959-61 

.-

Age 

Under 1 week” 

Under 1 day-----------

1 day----------------­ ---**--** 

: 2;:--”--”-”-------” 

4 days---------------” 

5 day~-” 

6 dtiys”-----d----- a-d 

1959-61 1950-51 I1959-61 1950-51 

Percentage Number of deaths distribution 

8,4% 7,009 100 100 

4,079 

2,109 25 

982 ‘713 11 10 

565 458 

291 271 ; i 

245 243 3 3 

165 216 2 3 

:, ;;; 48 ;; 

I I 

Rate per 1,000 I Percent live births 

11,6 [ 15.3 -24 

I I 

5.6 8.3 -33 

2.9 2.8 

1.3 -:2 

0.8 M -20 

0.4 0,6 -33 

0.3 0..5 -40 

0.2 0.5 -60 

NOTE: Based on calendar days since birth. 
vidual days of age. The reduction was most marked 

on the first calendar day 5 of life and the last 3 

days of the first week. Each day of age contributed 

to the decrease in first-week mortality, except 

the age 1 day. Although this period deserves 

special attention, the main efforts in reducing the 

death toll should be concentrated on the first hours 

of life, as these claim a major part of first-week 

mortality. According to a special survey, onethird of first-week mortality occurs in the first 

hour of life and two-thirds in the first 24 hours. 

The components of infant loss account for 

varying proportions of the totaL The relative importance of the components has changed because 

they have not decreased at the same rate. In 1964, 

the two components with the lowest mortality— 

7-27 days and 6-11 months—each constituted about 

5 percent of the total infant loss and about 10 percent of infant mortality. The proportions were 

somewhat higher for age 28 days-5 months (8 and 

14 percent, respectively). Considerably greater 

were the proportions at ages under 1 day and 1-51 

weeks, each accounting for about 17 percent of the 

total infant loss and for about 32 percent of infant 

mortality. 

Between 1950 and 1964, the proportion of stillbirths and of mortality at ages 1-6 days increased, 

while the proportion of deaths at 1-51 weeks 

(mainly 28 days-5 months) decreased. The ratio 

of perinatal to postnatal mortality increases as 

infant loss rates decrease. Currently, perinatal 

mortality is responsible for more than 80 percent 

of infant loss. 

Stillbirths account for nearly 60 percent and 

first- week mortality for somewhat over 40 percent of perinatal mortality. About two-thirds of 

the stillbirths occur befove and one-third during 

delivery. Half of the stillbirths take place before 

38 weeks of gestation, the obstetrical borderline 

for prematurity. 

5 [In the vital statistics for the Netherlands, age at death 

in the first week of life is determined from calendar date of 

birth and of death, and not the actual length of time the child 

has lived. To take an extreme example, a child born at 1 a.m. 

on January 1 and dying at 11 p.m. on the same date (having 

lived 22 hours) would be cou;ted as a death under 1 day of 

age, whereas a child born at 11 p.m. on January 1 and dying 

at 1 a.m. on January 2 (having lived only 2 hours) would be 

counted as a death at 1 day of age. - Ed.] 

Table 5 shows the components of infant loss 

by sex for the years 1950-64. Except for one instance, each component records a lower rate for 

girls than boys. For infant mortality the female 

rate is lower by about 20-25 percent, for stillbirths about 5-10 percent, for first-week mortality 25-30 percent, for perinatal mortality 

around 15 percent, and for first-month mortality 

about 25 percent. 

When first-week mortality is subdivided, it 

shows that, roughly, the rate for girls is 20 percent below that for boys under 1 day of age and 

30-35 percent below at ages 1-6 days, Postnatal 

mortality (1- 51 weeks) is approximately 15 percent lower for girls than for boys. 

Generally speaking, of all the age components 

the subgroup 1-6 days presents the greatest sex 

difference, second in order being under 1 day. 

Stillbirths and ages 1-51 weeks show the smallest 

sex difference. 

Girls experience the lower mortality notwithstanding, or perhaps because of, the fact that their 

average birth weight (3,370 grams) is 100-200 

grams lower than that for boys (3,530 grams). The 

average birth weight of girls at present is about 

the same as the average for boys a generation ago. 

The trends for the various age components of 

the mortality for girls and boys during the period 

1950-64 are parallel for the two sexes. The stillbirth rate for boys in any year is about at th~ 

level reached 3 years earlier by the girls; fo~ 

first- week mortality the lag is 10 years, for perinatal mortality 6 or 7 years, for postnatal mortality 3 years, and for infant mortality 6 years, 

It would appear, therefore, that the current rate:: 

for girls foreshadow what the total rat es for tht: 

Netherlands will be in the near future. 

Perinatal Mortality 

Stillbirth and first-week mortality, as alread~ 

noted, present associated medical problems and 

hence are combined as perinatal mortality, whic”l 

is now the dominant component of infant 10S.S. 

Perinatal mortality is closely related to prema -

turity and obstetric conditions and has its characteristic causes of death. 

Pvetmzturity.-Inasmuch as medical birt 1 

certificates do not exist in the Netherlands, ths 

12 
exact distribution of newborn infants by birth 

weight and period of gestation is not available. 

From our studies it appears that, on the basis of 

birth weight, 5.5 percent of the live births are 

immature. According to international definition, 

immaturity relates to births of 2,500 grams (5% 

pounds) or less. In the absence of birth weight, 

those with a gestation period of less than 37 weeks, 

or those termed “premature,” may be considered 

immature. Within the group of immatures, 3 to 4 

percent weigh less than 1,500 grams, 15to 20 percent between 1,500 and 2,000 grams, and 75 to 80 

percent between 2,000 and 2,500 grams. No data 

are available on the distribution by period of gestation for the Netherlands. 

The incidence of low birth weight infants 

(2,500 grams or less) is of paramount significance in perinatal mortality; 40 percent of the 

stillbirths and 55 percent of the deaths in the first 

week are among this group. The risk of death 

during the first week is about 20 times as high for 

low birth weight infants as for those weighing 

over 2$500 grams at birth, the death rates being 

about 50 and 2’ to 3 per 1,000, respectively. In 

general, perinataI mortality increases as weight 

at birth decreases. If international comparisons 

are made of perinatal mortality, it is necessary 

to know the birth weight distribution for the various countries; for example, the incidence of infants weighing 2,500 grams or less at birth is 4.5 

percent in Sweden and 5.5 percent in Holland. 

This difference is, in part, responsible for the 

disparity in perinatal mortality between these two 

countries. 

The distributions of weight at birth directly 

affect the average birth weight. As an approximation, the incidence of infants weighing 2,500 grams 

or less at birth decreases 1 percent with every 

increase of 100 grams in the mean birth weight. 

The average birth weight and the incidence of infants weighing 2,500 grams or less at birth is 

higher among girls than among boys. Although 

this difference would lead one to expect a higher 

perinatal mortality among girls, everywhere the 

contrary is true. This paradox has not been explained, unless the duration of gestation is longer 

for girls than for boys of equal birth weight. 

Our study on birth weight in the Netherlands 

indicates that birth weight increases much more 

with parity than with age of mother. An increase 

in the proportion of young mothers will lower the 

average birth weight very little, but a shift to 

higher parities tends to increase the average 

birth weight and lower the incidence of low birth 

weight infants. It is known from the literature that 

social class and the incidence of low birth weight 

infants are correlated. Such data, however, are 

not available for Holland. 

Age and pa~ity.— In 1950, the birth rate was 

23 per 1,000 population, decreasing slowly to 21 

in 1963. Since 1950, the distribution of live births 

by age of mother and parity has been changing due 

to the lower age at marriage and a modest shift 

to lower parities (table 6). The greatest changes 

are the increase from 19 to 26 percent in live 

births to mothers under 25 years of age and the 

decrease from 50 to 41 percent at 30 years of age 

and over. The proportion in the intermediate group 

remains unchanged (32 percent). The increase in 

the group under 25 years is mainly due to the increase in mothers 20-24 years, and although the 

youngest age group (under 20 years) has nearly 

doubled in 12 years, it remains small (4 percent). 

At the other end of the mother’s age range, the 

percentage of mothers 30 years of age and over 

decreased from 50 to 40 percent, and 35 years 

and over from 25 to 18 percent. 

The proportion of primiparae increased from 

28 to 32 percent in this period, the highest ever 

reached in the Netherlands. The proportion of 

live births of second order increased also, from 

24 to 27 percent, while those of third order remained constant (17 percent). For higher order 

births, the proportions decreased (from 31 to 24 

percent), especially among “grandes multiparae.” 

There has been a shift to younger mothers, both 

in primiparae and in multiparae. 

Maternal age has a greater effect onperinatal 

mortality than parity. To compare rates of stillbirths and perinatal mortality among countries, 

the distribution of total births by age of mother 

should be considered, but as a substitute the live 

births can be used (table G). The most striking 

feature of these data is the difference in the proportions in the youngest age group (under 20 

years) in the United States and Holland. Despite 

the same birth rate, 15 percent of live births in 

the United States and 4 percent in Holland were in 

this group. In the next highest age group (20-24 

years), the difference is still in the same direc13 
-------

------------

-----

---------

------------

--------

------------

------------

------------

------

—.

1 

Table G. Birth ratea and percentage distribution of live births, by age of mother: 

selected countries, 1961 and 1962 

United Den- United England Scot 

Nor- Nether- and Sweden Age of mother States mark Kingdom Wales land 1961 way lands 

1962 1961 1962 1962 1962 1962 1962 

Rate per 1,000 population


Birth rate 22.41 16.6 I 18.31 18.0 I 20.11 13.9 I 17.11 20.9 = 

Percentage distribution 

Total 100 100 ] 100 I 100 100 100 100 —. 100 I i 

Under 25 years 50 45 39 39 38 37 26 

Under 20 years 8 8 7 

20-24 years H :: 3{ 2; 

25-34 years 40 45 :; ;;” 50 :; 56 

25-29 years 25 29 31 31 31 27 32 

30-34 years 15 16 18 18 19 20 24 

35 years and over-- 10 10 12 12 12 16 

35-39 years 8 8 9 9 9 11 H 

40 years and over 2 2 3 3 3 5 ~ 

SOURCE: United Nations, Demographic Yearbook , New York. 

tion: 35 percent inf~ LJnited States and22 percent in Holland. In the United States half of the 

live births are to women-under 25years ofage; 

in Scandinavia and the ‘LI~nedKingdom, about40 

percent; and in Holland, about one-fourth. Conversely, the percentages of live births in the 

remaining older agegroupsarehighesti.nHolland. 

The social and rrredical implications ofthedifferences in percemage’ distributions oflivebirthsby 

age of mother in different countries should notbe 

underestimated. 

Age of mother and parity, aswellassociohygienic conditions, .strongly influence both cornponents of perinatal mortality. The stillbirth rates 

byage ofmother and parity in 1952-53 and1962-

63 are shown in table 7. The rate increases with 

age of mother for all parities. Inalmost all age 

groups, primiparae have by far the highest stillbirth rates. The lowest rates are among second 

and third births to mothers under30years ofage. 

Thus, in 1962-63, the total stillbirth rate was a 

little over 15 per 1,000 births;the rateranged 

from less than 7 per 1,000for second and third 

births to mothers under age 25, tomorethan:;0 

per l,OOOforprimiparae a$ages40 and over. 

Between 1952-53 and 1962-63, thestillbifih 

rates decreased in almo& every age giXMJpal[d 

nearly all parities, The largestrelativereducti(~n 

was among first births, 25 percent; for secorld 

and third births the decreasewas 17 percent; ard 

for fourth and higher parities, about5percent. E:y 

age, the reduction in the stillbirth rate was abol!t 

20 percent for infants born to mothers under 31), 

and approximately 10percentwhere mothers we~e 

30 and over. 

Table 7also shows adjusted stillbirth rate, ~, 

that is, the rates that would have beenrecorded n 

1962-63 had the proportions of mothers by age 

and parity in those years been the same as those 

in 1952-53. The adjusted rate in 1962 -63was 15,7 

per 1,000 compared with thecrude rate of 14..!, 

the difference reflecting the shift during the decac e 

in the distribution of births to mothers of 10WCr 

age groups and of lower parities. In other word~:, 

1.3 per 1,000 of the total decrease of 3.4 per l,(IGO 

in the decade—nearly 40 percent of the total--

14

represented changes in the distribution of births; 

the influence of age of mother was stronger than 

that of parity. 

If Holland had had the same distribution of 

births by age of mother as the United States or 

Sweden, the stillbirth rate in 1962-63 would have 

been 12.8 and 13.7 per 1,000, respectively, instead 

of 14.4 per 1,000. Adjustment for this factor reduces considerably the difference in the stillbirth 

rate for these three countries. 

Table 8 shows the relation of first-week mortalit y to maternal age and parity in 1953-54 and 

1962-63. The lowest rates occur among children 

born to mothers 25-34 years of age having their 

second or third child. In 1962-63, the mortality rate averaged about 11 per 1,000 live births, 

ranging from a little over 8 per 1,000 for second 

and third births to mothers at ages 25-34 to about 

23 per 1,000 for first births at ages 35 and over. 

First-week mortality is more than M times as 

high for parturients at ages 40 and over as for 

those at “25-34 years, and about 1%times as high 

for sixth and higher parities as for second and 

third births. Under age 20, the mortality was 14 

per 1,000, or about one-third above the average 

for all ages combined, and higher than the rate 

for an~; othw group under age 40. 

Wheu the first-week mortality rates for 1962-

63 are adjt-steal for age of mother and parity on 

the basis of the-.1“953-54 experience, they are practically th$ sqme as the crude rates, indicating that 

these factois do not influence first-week mortality. 

Between 1953-54 and 1962-63, the relative 

reduction in first-week mortality was about the 

same in Inearly all age groups and nearly all 

parities. The decrease in the adjusted rates by 

ogc and parity varied only from 19 to 24 percent, 

averaging 22 percent. While the variation in reduction by age of mother and parity for first-week 

mortality was much narrower than that for stillbirths, the relative reduction was much greater 

than that for stillbirths. 

Twin biYths --- A special study on infant loss 

in twin births revealed that the frequency of twin 

deliveries decreased from 1.4 percent to 1.2 percent of all deliveries between 1900 and 1963. About 

2.5 percent of all births are twin births, and their 

incidence increases with parity and more particularly with age, up to age 40. 

. 

The stillbirth rate is 2!4times as high in twin 

births as in single births. The difference in mortality between twin and single births is greatest 

in the first week of life and decreases with age of 

the infants. In the first week the mortality of twins 

is six times that for single births, for perinatal 

mortality the ratio is 4 to 1, for postnatal mortalit y about 2 to 1, and for infant mortality more 

than 4 to 1. 

While twin births account for 2.5 percent of 

all births, they are responsible for 5-6 percent of 

all stillbirths, 12 percent of first-week mortality, 

8 percent of perinatal mortality, and 6 percent of 

postnatal mortality, 9 percent of infant mortality, 

and 8 percent of infant loss. The proportion of 

twins in perinatal mortality and infant loss is three 

times as high as would be expected on the basis 

of the number of twin. births. 

Because of the high first-week mortality in 

twin births, the ratio of stillbirths to first-week 

mortality is 2 to 3 for twin births compared with 

a ratio of 3 to 2 for single births. The high firstweek mortality among twins is associated with 

their high prematurity rate—50 percent, against 

4 percent for single live births. 

Among twins in the weight groups 1,501-2,500 

grams, first- week mortality apparently is lower 

than among single births. The explanation may be 

that a twin of this weight had a longer period of 

gestation—and therefore is more mature—than a 

single birth of the same birth weight. Perinatal 

mortality is very high (10-15 percent) among 

twins born to mothers under age 25 and 40 and 

over, and among the first born. Perinatal mortality for twins in these three groups is, respectively, six, two, and five times as high as for 

single births. 

Since 1953, when the statistics on infant mortality for twins began, first- week and infant mortality in twins decreased at the same rate as in 

single births. In that year, less than one-fourth 

of all single deliveries and one-third of twin deliveries occurred in hospitals, while at present 

the percentages are 30 and 60, respectively. Perinatal mortality among twin births in home delivcries—70 per 1,000—has always been much lower 

than in hospital deliveries, most probably because 

the serious pathological cases go to the hospitals. 

High-risk gVOU@.— Under certain conditions, it can be anticipated during pregnancy that 

15 
I


the risk of death for the newlmrn will be much 

higher than average. If the proportion of mothers 

hospitalized at time of birth is low—as in the 

Netherlands—priority should be given to mothers 

in high-risk groups. Although high-risk groups 

are the product of factors which are biological, 

pathological, and social in origin, it is often impossible to evaluate the effect of each factor 

separately because in many cases several factors 

are interrelated. 

(1) Biological: older age of mother, higher 

parity, multiple births, and prematurity. 

(2) Pathological: abnormal presentations, 

operative intervention, unfavorable obstetrical history, andhemolytic disease. 

(3) Social: lowincome, illegitimacy, andinadequate medical care. 

The increased mortality because of biological 

factors has already been discussed. 

The risk of death in the perinatal period is 

about 10 times as high for abnormal presentation, 

especially breech presentation, as for cephalic 

presentation. Operative intervention—forceps, 

version and extraction, cesarean section, etc. — 

are applied in 4-5 percent of all deliveries, the 

risk of death in such cases being from 5 to 10 

times as high as in spontaneous deliveries with 

cephalic presentation. For the newborn to mothers 

who had had previous abortions, premature babies, 

or perinatal deaths, the risk of death is from two 

to three times as high as for the newborn to 

mothers without abnormalities in previous pregnancies. 

The role of social factors in infant loss will 

be discussed in detail later on. At this point it 

may be said that although the rates of infant loss 

have reached low levels, the classical rule still 

prevails: unfavorable social conditions increase 

perinatal and postnatal mortality. 

It is not possible to differentiate our data 

according to the quality of medico-obstetrical 

care. Perinatal and natal care are given to all 

pregnant women, even though many weaknesses 

exist in the way such care is given. Despite these 

weaknesses and notwithstanding— or possibly because of—the relatively” low rate of hospitalization, no group of newborns has been found to have 

a very high risk of death because of inadequate 

care. 

About one-third of all births may be considered to be in high-risk groups, and special care 

is needed for the welfare of both mother and infant. The mother is in need of concentrated care 

during pregnancy and delivery, and her infant 

should r~ceive similar attention immediately afte r 

birth. Special postpartum care is needed by the 

newborn having anomalies which could not b~ 

predicted during pregnancy, e.g., congenital ma] -

formations and pathological conditions following 

difficulties in labor. 

Causes of stillbirth. —The causes of stillbirth 

and of first-week mortality are shown separate] y 

in the International Lists, and hence are so pre ­

sented here. In addition, the causes of death fc r 

the two components are combined into four broad 

groups to indicate the general cause-of-deal h 

pattern for perinatal mortality. 

Causes of stillbirth are given in a supplemer,­

tary classification in the International Lists, tl e 

so-called Y-list (Y30-Y39). Table 9 shows tl e 

trend of fetal mortality by catise for the peric!d 

1950-63. 

In 1950, the leading causes of stillbirth, ‘n 

order of magnitude, were diseases of the fetLs 

and ill- defined causes, placental and cord cor~­

ditions, difficulties in labor, congenital malformations, and diseases of pregnancy and childbirth, including toxemia. Because of differenct:s 

in the trend by cause, the sequence in 1963 WM 

placental and cord conditions, diseases of the 

fetus and ill-defined causes, diseases of pre~­

nancy and childbirth, congenital malformations, 

diseases in mother, and difficulties in labor. 

The death rate for difficulties in labor decreased 60 percent between 1950 and 1963--from 

28 to 11 per 10,000 births. For diseases of the 

fetus and ill-defined causes, the rate fell from 01 

to 33 per 10,000 births, or nearly 50 percent; for 

congenital malformations the reduction was 25 

percent, and for placental and cord conditions 

about 20 percent. Stillbirths resulting from birch 

injury have become negligible, the rate having 

fallen from 3 to 1 per 10,000 births between 19!;0 

and 1963. In contrast, the death rate for diseases 

of pregnancy and childbirth rose from 19 in 19!$0 

to 25 in 1963, and diseases h mothers from 9 to 

13. The mortality from erythroblastosis remainl :d 

at the level of 6 per 10,000 throughout the period, 

16 
Data on the causes of stillbirth by sex are 

available since 1956 (table 9). Each of the major 

causes except congenital malformations shows a 

higher death rate among boys than girls, particularly for placental and cord conditions, difficulties in labor, and diseases of fetus and ill-defined 

causes. For stillbirths caused by congenital malformations, the rate in 1963 was 18 per 10,000 

births among females and 12 per 10,000 among 

males. The excess female mortality from this 

cause reflects the fact that the death rate from 

congenital malformations of the central nervous 

system is M times as high for girls as for boys. 

The latter condition accounts for 80 percent of 

the total mortality from congenital malformations 

among girls and for 70 percent among boys. 

Cawses of j?rst-week mortality. --Table 10 

presents first-week mortality rates by cause, 

sex, and age in 1953-54 and 1961-62. The figures 

in this table do not include infants who were born 

alive after a gestation period of less than 28 

weeks and who died before registration because 

the causes of death for immatures were not 

reported prior to 1956. 

Recent data reveal that three-fourths of the 

immatures are classified in the subgroup, immaturit y, and one-sixth in birth injuries, Therefore, 

the rates for immaturity in table 10 should be 

raised by about 12 per 10,000 and of birth injuries 

by 3 per 10,000. 

In 1961-62, birth injuries were by a considerable margin the leading cause of death, accounting for about 30 percent of the total first-week 

mortality; the majority of deaths from this cause 

were due to intracranial and spinal injury. Congenital malformations were responsible for about 

one-fifth of the total, immaturity without further 

qualifications for one-sixth, and postnatal asphyxia~ for about one-eighth of the total. 

Each of the three leading causes of mortality 

in the first week of life showed a substantial 

reduction between 1953-54 and 1961-62, reflecting in very large measure the experience on the 

calendar day of birth. Postnatal asphyxia, however, recorded an increase in mortality, both for 

the first day and for the remainder of the first 

week. 

6 [As a cause of death, the ternr, “postnatal asphyxia, ” 

includes deaths in the first week of life. -Ed.] 

Analysis of the trend by sex indicates that in 

the 8-year period under review, the first-week 

death rate for birth injuries fell a little over onethird among both boys and girls; similarly, for 

immaturity without further qualification the reduction in mortality was about the same for both 

sexes—one-fifth. A marked sex difference, however, is evident in the trend of mortality for congenital malformations, the reduction amounting 

to only 9 percent for males and 28 percent for females. As a result of this disparity, males had a 

somewhat higher mortality from this cause than 

females in 1961-62, reversing the situation which 

existed in 1953-54. The sharper reduction among 

females reflected mainly the more rapid downward trend among them for congenital malformations of the central nervous system. Even so, 

first-week mortality from this cause among females is still about 1% times that for males, 

while the death rates for congenital malformations of the circulatory system and the residual 

group “other congenital malformations” record 

higher rates among males than females, as table 

H shows. In contrast to the experience for congenital malformations of the central nervous 

system and the residual group of malformations, 

first-week mortality for congenital malformations of the circulatory system increased somewhat for both sexes. 

It is also apparent from table 10 that the 

death rate for the group of conditions in the rubric “other diseases peculiar to early infancy” 

was reduced by more than half among Imth males 

and fema,les. A substantial decrease was also 

recorded for both sexes for erythroblastosis. 

However, for pneumonia and influenza, including 

pneumonia of the newborn, the mortality increased 

somewhat among both boys and girls. 

Causes o~’ pevinatal mo2-tality.-Figure 

shows the trend for the major causes of perinatal 

mortality-fetal deaths and first-week mortality 

combined-in the period 1950 to 1964. Each of 

these groups of causes recorded a decrease in 

this 14-year period: birth injuries, 36 percenq 

the residual group “other and ill-defined causes ,“ 

31 percent; congenital malformations, 29 percent; and erythroblastosis, 9 percent. Perinatal 

mortality as a whole fell 32 percent in this period. The analysis of perinatal mortality by cause 

suggests that further decreases may be expected. 

17 

5 
Table H. Stillbirth and infant mortality rates for congenital malformations, by system, sex, and age: Netherlands, 1953-54 and 1961-62 

Still- Infant mortality
 System, year, birth
 and sex (Sixth and rate
 Seventh Revisions—


per Under
 International Lists, 10,000 1 Un;= Un:er 1-51 7-27 28 days- 6-11


1948 and 1955) births year weekl dayl weeks days 5 months months


Congenital malformations


(750-759)


Rate per 10,000 live births


1961-62 

Male---- 13.8 44.0 19.8 8.4 24.2 7.2 12.2 4.8 

Female-- 18.3 43.6 17.1 8.3 26.5 7.1 14.0 5.4 

1953-54 

Male---- :14.6 49.6 21.8 10.2 27.7 14.5 5.6 

Female-- ‘23.7 49.3 23.7 14.1 25.6 H 12.7 5.3 

Congenital malformations


of central nervous system


and sense organs(750-75fi


1961-62 

Male---- 10.0 10.3 3*4 5.1 1.5 

Female-- 15.2 15.7 ;:: 5.5 7.8 ;:!/ ::; 1.7 

1953-54 

Male---- 211.3 15.9 5.4 8.7 4.4 

Female-- 220.0 25.3 1::2 11.3 10.8 $: 5.5 ;:: 

Congenital malformations


of circulatory system(754~


1961-62 

Male---- 0.4 21.8 8.5 2.1 13.3 4.0 2.2 

Female-- 0.4 19.3 5.2 1.3 14.1 3.2 u 2.8 

1953-54 

Male---- 20.2 19.6 2.1 12.2 3.2 6.6 2.3 

Female-- ‘20.3 15.5 ::2 1.2 10.7 2.6 5.6 2,6 

Other congenital


malformations (755-759)


1961-62 I 

Male---- 3.4 11.8 6.0 2.9 2.2 2.6 

Female-- 2.8 8.5 3*9 1.4 1.8 1.8 M 

1953-54 

Male---- 23.1 13.9 4.---Y2.3 ;.: Female-- 23,3 d.5 i:: 1.8

—. . ::; 

lBased on calendar days since birth.


2J)ataare for 1956-57.


18

36TNIN 

30 

10 

0 

g Gongenlial moltormot Ions 

_ Birth inJurlas, etc. 

_ Erythroblaalosls 

XIE ther causas and II l-dot ‘Ined 

YEAR 

Figure 5. Perinatal mortality rates by cause: 

Netherlands, 1950-64. 

It should be noted once again that the causes 

of stillbirth and first-week mortality are far from 

being precise. Only by careful and competent 

clinical observation of mother and child andby 

postmortem examination canmorereliable causes 

of death be obtained. 

Place of delivevy. —Compared with other 

industrialized countries, Holland has a low proportion of hospitalized births. In Sweden, Norway, 

and the United States the proportion now is nearly 

100 percent, in England_ and Wales 65 percent, in 

Denmark more than 50 percent, and in the 

Netherlands only 30 percent. 

In Holland, hospitalized deliveries occur in 

the obstetrical departments of university and general hospitals, in midwifery schools, and in maternity homes. The standards and type of service 

differ from one group to another, and the quality 

of care varies within each group. Maternity homes 

take only normal deliveries while obstetrical departments of university and general hospitals accept both normal and pathological cases. 

Deliveries in hospitals are attended mainly 

by obstetricians, but also by general practitioners 

and midwives. In the three midwifery schools, 

pupil midwives work under the supervision of an 

obstetrician. In maternity homes, general practitioners and midwives attend most of the deliveries. All institutional deliveries are registered 

as hospitalized, regardless of the types of institution and of the quality of obstetric and pediatric 

care. 

In home deliveries, two types of maternity 

care must be differentiated: maternity home help 

and less organized forms of maternity care. Table 

J gives the percent distribution of home deliveries, 

both with and without home help, and hospital 

deliveries in the period 1953-64. In 1953, about 

one-fourth of the maternities were home deliveries with maternit y home help, one-half were home 

deliveries without such assistance, and the remaining fourth, hospital deliveries. In 1964, 

each of these categories accounted for approximately one-third of the confinements. During this 

decade, home deliveries with maternity home 

help and hospital deliveries increased about 35 

percent, while home deliveries without maternity 

home help decreased in relative frequency. 

The larger the municipality, the higher the 

hospitalization rate and the lower the frequency 

of maternity home help cases, as table K indicates. 

In 1962, in municipalities of under 5,000 population, more than 40 percent of the mothers received maternity home help; in cities of 500,000 

and over, the proportion was less than 20 percent. 

Hospitalized births show a reverse picture, the 

proportions being nearly 20 and 50 percent, respectively. In each group of municipalities, regardless of size, the sum of maternity home help 

and hospitalized cases was approximately twothirds of the total. 

In 1960-62 the hospitalization rate was about 

twice as high for stillbirths as for live births. 

Table L shows that between 1954-56 and 1960-62 

the proportion of hospitalized births in each cate19 
-- -- -- - - - --- --- - - --- - -- ---- - - -- --- --- - ------ - ----- ----

-----------

Table J. Percentage distribution of births, by place of delivery and use of maternity 

home help: Netherlands, selected years, 1953-64 

Delivery at home


Delivery


Year Total in II With Without 

hospital Total I

maternity maternity 

home help home help 

Percentage distribution


;%:1’ - --- .- 100 31 69 37 32 . - - - --- 100 30 70 

1961----------------------------------

1959----------------------------------

100 

100 

29 

27 

71 

73 

:: 

33 

:; 

40 

1957---------------------------------- 100 26 74 31 43 

1955---------------------------------- 100 24 76 30 46 

1953---------------------------------- 100 23 77 27 50 

lpreliminarydata.


gory increasednearly20 percent.The increase 

was least in municipalitiesof 50,000-99,999 

inhabitants (almost zero for live births and 10 

percent for stillbirths) and greatest in municipalities of 100,000-499,999 (about 30 percent). 

At present, the hospitalization of stillbirths 

is about one-third higher in thelargestcities than 

in villages; for live births the ratio is nearly 3 

to 1. Even so,more thanhalfthe stillbirths
 in


municipalities
 ofunder20,000 populationoccurin 

hospitals. 

Table L does not answer the question asto 

whether the high hospitalization rate ofdeliveries 

in which the risk of stillbirth is serious contributes 

to the prevention of stillbirths. The figuresdo not 

indicate that it does. The difference in stillbirth 

Table K. percentage distribution of births, by size of municipality, place of de­


liverY, and maternity home help: Netherlands, 1962


II I


II I Delivery at home 

Delivery
 ~ Size of municipality Total “


hos~tal T ~al


m
 II 1 II 1 

Percentage distribution


Delivery


at home


with


maternity


h;~d h&p,


hospitals


Total---------------


500,000 or more 

100,000-499,999-----------

50,000-99,999-------------

20,000-49,999-------------

5,000-19,999--------------

Under 5,000---------------

100 30 70 34 36 64 “ 

100 

100 

49 

37 a H 

33 

32 

6;

6L 

100 31 69 36 33 67 

100 30 70 36 64 

100 22 ;; 6:! 

100 19 i: 42 :; 6>. 

20 
-----------------

-----------

-------- -------- -------- --

- -- - - -- - - -- -- -- - - - -- - --- - -- - --

-------- -------- -------- --

Table L. Percent of births occurring in hospitals, and perinatal mortality rates, by 

size of municipality: Netherlands, 1954-56 and 1960-62 

Perinatal All births Live births Stillbirths mortality 

Size of municipality I 

1960- 1954- 1960- 1954- 1960- 1954-

1962 1956 1962 1956 1962 1956 

+ 

I Percent of births in hospitals I Rate Der 

1,000 births 

Total 

L 

29 ==4!===4==60 26.1 30.1 

100,000 or more ------------- 69 25.7 27.9 

100,000-499,999----------- 67 25.6 27.9 

500,000 or more 25.7 27.9 

50,000-99,999--------------- i; 25.2 29.2 

20,000-49,999--------------- 60 25.6 29.1 

5,000-19,999---------------- 56 26.6 31.5 

Under 5,000----------------- 53 27.2 32.2 

rates between rural and urban areas is less than with hospital deliveries (53 per 1,000);partofthis 

10 percent and hardly any difference exists in wide difference, ofcourse,reflectstheconcentrafirst-week mortality (table E). Similarly, differ- tion of pathological cases in hospitals. 

ences in perinatal mortality by size of munici- Deliveries with maternity home help inpalityhave nearly disappeared. To repeat, ahigh creased 30 percent over the7 years, making the 

frequency of hospitalization is not the means, so-called selection less and less probable. Atthe 

certainly not the only means, for reducing peri- same time, perinatal mortality in this group denatal mortality. This conclusion, unorthodox asit creased by30 percent. While perinatal mortality 

is the world over, is supported by the datain has been decreasing among the group without 

table M. Perinatal mortality in home deliveries maternity home help as well as the group with 

is very low(12 per l,000birthsin1963) compared such assistance, the rate for the group with help 

Table M. Perinatal mortality rates, by place of birth and use of maternity home help: 

Netherlands, selected years, 1953-63 

Delivery at home 

Delivery 

Year Total in With Without hospital ~ota~ maternity maternity 

home help home help 

I Rate per 1,000 births 

1963 -------- 25 53 12 11 13 

1960---------------------------------- 27 58 15 13 16 

1958 -- -.-

1955---------------------------------- H % :; H ;; 

1953 -------- 32 65 22 18 24 

21 
--

14


I


12


tiiinii


10 

ye 

i 

g 

2 

o 

- Congenitalmalformations


_ Resplrotory


EZZl Ill-defined


E22x2 Other causes


1950 1955” 1960 1964 

YEAR 

Figure 6. Post.naial mortality rates by cause: 

Motherlands, 1950-6+, 

(Postnatal period: 1-51 weeks) 

remains about 25 percent lower. The difference 

in first-week mortality is somewhat higher than 

in stillbirths. The group without maternity home 

help includes many cases enjoying such helponce 

or twice adayforanhour atatime (instead of the 

whole day) blurring thedividinglinebetweenhome 

deliveries with and without maternity home help. 

The favorable results achieved inhome deliveries in the Netherlands, notwithstanding the 

existing weaknesses in maternity care, have 

encouraging implications for developing countries. Instead of pursuing the chimera of a high 

frequency of hospitalized births without adequate 

hospitals, the organization of home deliveries 

by midwives is a realistic goal in underprivileged 

regions. Without being so intended, a large-scale 

“experiment” on maternity policy of widespread 

importance has been taking place in the Nethe~. 

lands. 

Postnatal Mortality 

Postnatal mortality (1-51 weeks), which in the 

past constituted a major part of infant mortality, 

has become only a minor part of it. 

times of death, — Figure 6 gives a bird’s. 

eye view of the postwar trend of mortality, b? 

cause, at ages 1-51 weeks. As is evident from 

table 10, the five major causes of death in the 

first 7 days—birth injuries, congenital malfor ­

mations, immaturity without further qualification, 

diseases peculiar to early infancy, and erythro. 

blastosis— record a much lower mortality rat,~ 

in the postnatal period; this is particularly trul~ 

of birth injuries and immaturity. 

Congenital malformations are by far thl> 

leading cause of death in each of the three ag: 

components of postnatal mortality-7.27 days, 

28 days-5 months, and 6-11 months —comprisin: 

from one-third to one-half of the deaths in eac”~ 

group. Moreover, the death rate from this grou I 

has shown only a slight reduction between 1%S3. 

54 and 1961-62. The mortality for the residual 

category “ill-defined and other causes’ ‘—seconli 

in rank-was nearly halved in the 8-year period. 

Influenza and pneumonia, third in importance, re. 

corded a sharp decrease in mortality, as did th: 

group of infective and parasitic diseases, Di. 

arrhea and enteritis and the other diseases of th ? 

digestive system, which used to take a heavy toll 

of infant life, have become almost negligible as 

causes of death. The accident death rate (chiefly 

sudden infant deaths) decreased about a thir i 

between 19.53-54 and 1961-62. 

Table 10 shows the rates for the causes cf 

postnatal mortality by sex in the same years 

(1953-54 and 1961-62); table H gives details on 

congenital malformations, the leading cause 

group. The sex ratio of mortality from congenit~ 1 

malformations in infant mortality has not changec, 

being 100 in both periods. During the last decades 

the rates are exactly the same in males and fe. 

males, each decreasing by about 10 percent, Al. 

though there do not appear to be striking sex 

differences in postnatal mortality from congenitx 1 

malformations as a whole, when the data ar: 

examined by system, one can see that interm 1 

shifts have taken place. Mortality from ccmgenita 1 

malformations of the central nervous system is 

22 
-------- ---- ----- -------- -------- ---- -------- --------- -------- ------- ---------- --------- ------------- --------- -------- --------- -------- --------

-------- -------- -------- --------- --------- ------------ --------- -- -------- --- ---------------------------- --

---------------------------- -------- ----

decreasing for both sexes in the three age groups: 

about 40 percent in boys and 30 percent in girls. 

On the other hand, mortality from congenital 

malformations of the circulatory system is increasing for both sexes in the age groups 7-27 

days and 28 days-5 months. The rates for other 

congenital malformations are decreasing slightly 

in boys and increasing somewhat in girls. 

In the three subgroups of congenital malformations (central nervous system, circulatory 

system, and other systems), the ratios are in 

favor of the boys in stillbirths, and in favor of 

the girls in first-week mortality only with regard 

to the central nervous system. Most probably the 

increase in mortality from congenital malformations of the circulatory system is not real, but 

may be due to a transfer from the ill-defined and 

other causes. These shifts may result from medical fashion, better diagnostics, and the growing 

attention which is being given to congenital malformations of the circulatory system. This does 

not, however, explain why the increase for congenital malformations of the circulatory system 

or the accompanying decrease for ill-defined and 

other causes has been greater for girls than boys. 

The perinatal and postnatal mortality from 

congenital malformations may be expected to decrease as the distribution of births shifts to 

younger mothers and lower parities, since the 

incidence of congenital malformations is rather 

high among infants born to mothers 35 years of 

age or older. This factor will be overshadowed 

by the transfer of ill-defined and other causes to 

congenital malformations of the circulatory system. 

This analysis of causes of death in the postnatal period by sex and age components justifies 

the expectation that a decrease in respiratory 

diseases, congenital malformations, and ill-defined and other causes will bring the rates under 

4 per 1,000 in 1970:4 for boys and 3 for girls. 

Seasonal vaviation.—Before World War 

summer peaks were a notorious feature of infant mortality. Gradually these peaks, caused by 

gastroenteritis, colitis, and nutritional disorders, 

have leveled off. However, the winter peak caused 

by respiratory conditions, although diminishing 

since the beginning of the fifties, has not yet 

disappeared and in some years the mortality from 

these diseases still flares up. 

Table N presents the seasonal variation in 

infant loss by age in 1960-62; the average rate for 

each month is expressed as a percent of the 

average rate for the 3-year period as a whole. 

Table N. Index numbers for com~onents of infant loss. by month of death: Netherlands., 1960-62 - -

U196O.62=1OO1


Still- First Peri- Post- Month birth weekl natall nata12’3 Infan@ E&aft 

Index 

January ”--- ..------- 113 103 108 108 

February . ------- 100 100 106 104 

March 104 106 107 

May. . . . . . ..- . . . . . . . . . ------ 97 98 100 

..Tune 100 99 97 99 

July ------.- 100 93 92 

August 

September ”.,----- 1:; 

89 1:: ;: 

95 

October 100 ;2 

November 1:: 103 l% 101 

December . ------- ---,----- 104 104 105 101 

April 10; 1% 103 104 

‘Based on rates.


2J)eaths at 1-51 weeks of age. 

‘Based on number of deaths, adjusted for unequa 1 number of days in month. 

23


I 
Postnatal mortality shows the widest monthly 

variation, with the mortality index ranging from 

79 in July and August to 125 in January. On the 

other hand, first-week mortality records the 

smallest seasonal range, from 97 to 104; this 

reflects the insignificant role of the respiratory 

infections in the first 7 days of life. The seasonal 

range for stillbirths is somewhat broader (89-

113) than it is for first-week mortality. In small 

part, the higher incidence of stillbirths in the 

first than in the second half of the year is attributable to the seasonal trend of mortality from 

congenital malformations of the central nervous 

system (de Groot, 1965). The question arises as 

to whether the seasonal variation in stillbirth 

is caused mainly by infectious diseases in the 

mother. 

Inasmuch as both stillbirths and infant mortality show a winter peak, it is apparent that infant loss would have a peak, although it be a modest one. If preventive pediatrics should succeed 

in eliminating the winter peak, infant mortality 

and infant loss would decrease by 5 percent. 

SOCIAL FACTORS 

In the many years that infant mortality has 

been studied, attention has been paid to the differentials by social class. Infant mortality is the 

classical yardstick of sociohygienic conditions. 

This statement must again be evaluated, since 

the rates continue to fall and first-week mortality 

has become the dominant component of infant mortality. 

Fathe@s occupation. —Table 11 shows firstweek, posmatal, and infant mortality rates by 

occupation of father in 1952-54 and 1961-62. 

Occupations are grouped into five social classes 

(I-V) ranking from high to low. Comparable data 

for stillbirths, and thus for perinatal mortality, 

are available only for 1961. The rates in the table 

are not adjusted for parity and age of mother, but 

Hoogendoorn (1959) has shown that social class 

differences remain practically unchanged when 

adjustment is made for these factors. 

The table shows the classical picture: mortality is lowest in the highest social class and increases more or less progressively with decrease 

in social class. Farm laborers, however—a group 

too small to deserve much attention-do not fit 

into the general pattern. 

In 1961-62, lmth first-week and posmatal 

mortality among children with parents in class I 

were about 20 percent below the averages for the 

country as a whole, whereas in class V the mortality rates were 10 percent above the national 

average. A decade earlier, the difference was 

smaller for first-week mortality and greater for 

postnatal mortality. The relative reduction in 

postnatal mortality in the period did not vary 

appreciably by occupational class. 

The stillbirth rate in 1961 ranged from 10.0 

per 1,000 births in social class I to 17.6 in class 

V, omitting consideration of farm laborers. This 

range is wider than that for any of the components 

of infant mortality. The influence of father’s occupation on stillbirth and infant mortality seems 

unmistakable, although the effect of associated 

factors, such as general health of the mother, 

medico-obstetrical care, hospitalization, postpartum care, biological factors, etc., cannot be 

taken into account. 

Infant mortality in social class V shows a lag 

of about 7 years in reaching the level attained by 

social class 1. The lag would be even greater if 

the highest income group included in social class 

I were compared with the lowest income group in 

class V. The infant mortality rate for the country 

as a whole in 1965 achieved the same level as 

group I in 1961. 

Ille&”timacy. —Illegitimacy has never beeu 

a serious problem in Holland, compared with othe]” 

European countries. The percent of illegitimate: 

births decreased from 2.6 in 1900 to 1.3 just before World War II. In the war years the rate increased to 3.5 in 1945, reached the lowest leve 1 

(1.2) in 1955, and has increased to 1.9 in 1965. 

In the sixties, 3.5 percent of first births and 0.7 

percent of subsequent births are illegitimate. Cf 

the illegitimate births, 70 percent are first and 

30 percent are subsequent births; these percentages have not changed during the postwar periotl. 

Thirteen percent of the live births to mothers 

under age 20 are illegitimate, more than 10 timts 

the proportion among mothers at ages 20 and ove c, 

Two-thirds of all illegitimate births are :0 

mothers under 25 years of age, nearly one-third 

from those under age 20, and 3 percent from 

24 
mothers under 16. Thecorresponding proportions 

for legitimate births are 25 percent, 3 percent, 

and 0. 

According to data collected in 1957-58, the 

stillbirth rate for illegitimate children, after 

adjustment for age of mother and parity, was 

15 percent higher than that for legitimates; in 

primiparae, the excess was 35 percent. Firstweek mortality was 70 percent higher and postnatal mortality 80 percent higher for illegitimate 

than fir legitimate babies (Hoogendoorn, 1961). 

The risk of death for the illegitimate child now 

approximates that for the legitimate child in the 

prewar years. 

Although the mothers of illegitimate children 

often marry afterwards, the unmarried mother 

usually must go to work soon after delivery. 

But it is not easy for her to place the child in a 

cr~che; day nurseries are not well developed in 

HoHand, either quantitatively or qualitatively. 

Illegitimacy is much more frequent in cities 

than in rural areas, but the “bad” influence of the 

city is not as great as would appear from the 

figures. The unmarried pregnant girl who lives in 

a village or small town tends to deliver her child 

in the city, where she is unknown. From a human 

and social point of view, the status of the unmarried mother and her “natural” child is far 

from ideal. 

URBAN AND RURAL 

The historical trend of infant loss by urban 

and rural areas has already been described. The 

postwar situation will be analyzed by size of 

municipality and by province. 

Municipalities. —Table 12 shows stillbirths, 

first-week, and postnatal mortality by size of 

municipality in two postwar periods. In 1950-52, 

as before World War 11, the rates for all components decreased with increase of size ‘of 

municipality. These differences leveled off, 

however, during the 1950’s. In 1960-62, the stillbirth rate still showed a difference of about 10 

percent between municipalities having less than 

20,000 inhabitants and the three largest cities, 

the disparity reflecting mainly differences in age 

and parity of mother and of social class. Firstweek, postnatal, and infant mortality are no longer 

inversely related to size of municipality, although 

postnatal mortality in the largest cities is still 

lower than it is in towns and villages. The leveling 

off of the differences between urban and rural 

rates has occurred by the greater relative reduction in smaller than in larger municipalities. 

Pvovinces. —The division of the Netherlands 

into provinces has a long tradition, although it has 

become somewhat blurred by industrialization, 

urbanization, migration, and improved transpor ­

tation. There appears to be little correlation between the perinatal and infant mortality rates 

and the level of the birth rates by province. 

Differences in perinatal and postnatal mortality 

between provinces are related to social factors, 

the distribution of births by age and parity of the 

mother, quality and adequacy of medical and hospital care, patterns of living, degree of urbanization, etc. It is as difficult to unravel these factors 

in comparing different regions of the same country 

as it is to compare the rates of different countries. 

INTERNATIONAL COMPARISONS 

History has taught again and again that marked 

differences in infant loss between countries and 

between regions or ethnic groups within the same 

country reflect socioeconomic differences, which 

can be compensated for, in part, by maternal and 

child health activities. 

Stillbirth and first-week mortality showed 

practically no decrease in western European 

countries prior to 1940. At the beginning of 

World War H the stillbirth rate, for some unexplained reason, dropped suddenly in these countries, and since 1950 both stillbirths and firstweek mortality have fallen with virtually no 

interruption. In 1960-61, perinatal mortality in 

the Scandinavian countries, Czechoslovakia, and 

the Netherlands reached the level of about 25 per 

1,000, compared with slightly over 30 per 1,000 

in England and Wales and in Belgium (table 4). 

Postnatal mortality during the 1950’s decreased about two-thirds in Czechoslovakia, approximately one-third in the Scandinavian countries, England and Wales, and the Netherlands, 

one-half in Belgium, and one-fifth in the United 

States. In 1960-61 postnatal mortality was lowest 

in Sweden (4.4 per 1,000), followed by Holland 

and Denmark. In Norway, England and Wales, and 

the United States, postnatal mortality was about 

25 
twice as high as in Sweden; in Belgium and approximately 17 per 1,000 and infant loss about 

Czechoslovakia, notwithstanding the sharp reduc- 30 per 1,000; in England and Wales the rates were 

tions in these countries, the rates were about 5 per 1,000 higher, on the average, and in the 

three times Sweden’s, United States 8 per 1,000, In Czechoslovakia inSweden also has the banner record for in- fant mortality and infant loss have been sharply 

fant mortality and infant loss, with Holland rank- reduced during the fifties, accomplishing in one 

ing second and Norway third, according m rates decade what the northwestern European coununadjusted for age and parity. In the early 1960’s tries were able to do in one generation. 

infant mortality in these three countries was 

IV. MATERNAL MORTALITY€

Just as infant mortality reflects the health tions of delivery for 45-50 percent, and compli.. 

of the child and its care, maternal mortality is a cations of the puerperium for nearly 25 percen: 

yardstick of the health of the mother and of the of maternal mortality. 

prenatal and natal care she receives. Inasmuch Toxemia is responsible for no less than 6( I 

as obstetrical care and the mother’s health greatly percent of the deaths from the complicatioml 

influence perinatal mortality, an analysis of infant of pregnant y. Since 1950, the mortality from 

and especially perinatal mortality must include a the complications of pregnancy has been halvetl 

general description of maternal mortality. and that from the complications of delivery hal~ 

been reduced about 60 percent, The reductio]l 

General Trend for these two causes reflects a decreased inci. 

dence of toxemia, contracted pelvis, antepartun~ 

Before 1880, the maternal mortality rate was hemorrhage, etc., and partly accounts for the de. 

as high as 50 per 10,000 births and decreased crease in perinatal mortality. 

to about 25 at the beginning of the 20th century, While progress has been made in reducin; 

There was no reduction during the first quarter the death rate from complications of the puer -

of the century and— still more not eworth y—the perium, nearly one-third of the deaths from thi g 

rate increased from 25 in 1925 to 33 per 10,000 cause— and from abortions-are due to sepsis. 

in 1930. Shortly thereafter, however, the rate Women with serious complications of pregbegan to decrease, returning to the 1920 level nancy, delivery, and the puerperium are usually 

in 1940, During World War II, maternal mortality hospitalized. Inasmuch as 80 percent of materna 1 

did not increase much, in sharp contrast with the deaths occur in hospitals (where only 30 perter t 

high peaks reached by some causes of death. 

Since 1945, maternal mortality has decreased 

steadily and, as inmost other European countries, 

together with a reduction in perinatal mortality, 50 World 

~. ‘\A--~ ‘ ParlnfJdl rmrtollty rat. Currently, the maternal mortality rate is little yx=:+~ 

more than 3 per 10,000 births— a reduction of ~ 30 - .,*.J* *+’’%,, .s *r. .*. 

approximately four-fifths in the past 20 years z \

u% %<.+, ?& 

(fig, 7), = 20 - *.-.

. Birth rate 

l%gw ,,000,0,”10,10” 

J

:;;:J:$E * 10- )4&fw&logo Y “%11,,,,,,,*, 

Causes of Death o 1,,,,1,,,,1,,,, 1,, 1,‘+.I,,U, 

1920 1930 1940 I 950 I V60 k5 

Although maternal mortality decreased YEAR 

markedly, the four broad groups of causes have 

not changed appreciably in relative importance; 

complications of pregnancy account for 20-25 Figure 7. Birth, perinatal, and maternal mortal= 

percent, abortion for 5-10 percent, complica- ity rates: Netherlands, [920-64, 

26

08 

of all deliveries take place), maternal mortality justed for age, maternal mortality is approxiin home deliveries is low. It is extremely low mately the same in the Netherlands, the United 

(less than 1 per 10,000 births) among mothers States, and England and Wales, but lower in 

utilizing maternity home help services, a group Sweden, 

which is also associated with a very low perinatal 

mcmtalit y, 

Age of Mother 

Maternal mortality varies markedly with age, 

as is shown in figure 8. Women at ages 20-29 re- :;0 10 

d 

,/ 0 

...- ‘ 

cord the lowest rates—2 per 10,000 births in ~. - ‘\ 

‘\, 1950-52 *.H *H ....’”’”’”’” 

1%0.62. Thereafter the mortality increases ‘6 

*.----** ...”” 

:4 ...”” 

sharply with age, reaching 14 per 10,000 at ages ....” 

ill . ...” 

40-44. The rates at ages 45 and over have not 5 

1960-62 . . ...”’ 

Z2 - . . ...” . . . . . . . . . . . . . . . ...-”” 

been computed because the annual number of births .. . . . . 

to mothers at these ages is about 1,000 or less. 

Inasmuch as maternal mortality is strongly 

influenced by the distribution of mother’s age at 

time of birth, the rates for different regions 

or countries can be compared only if age-specific Figure 8. Maternal mortal ity rates by age: Ne~herrates are known, Table 13 indicates that, when ad- lands, 1940-W2, 1950-52, and 1960-62. 

V. OUTLOOK FOR INFANT LOSS 

In studying the history of infant mortality 

in industrialized countries, one is impressed 

with the periodically recurring fatalistic statement that the minimal level has been reached and 

further decrease is impossible. At the beginning 

of this century, an infant mortality rate of 100 

per 1,000 live births was considered an unattainable goal, After World War 1, a national rate of 

50 per 1,000 seemed almost Utopian. Yet, during 

World War 11 a rate of 30 per 1,000 was attained 

in Sweden$ and at the end of the 1950’s at least 

three countries recorded an infant mortality of 

less than 20 per 1,000. By 1964, Holland had an 

infant mortality rate of 15 per 1,000 and an infant loss of 28 per 1,000, 

It is understandable that countries with rates 

above 20 per 1,000 and a diminishing downward 

trend take comfort in the idea that the curve is 

beginning to follow an asymptotic course. This 

theory gives way, however, if the trend in more 

privileged countries is studied. The Netherlands 

belongs to this group of countries, even though 

this favorable situation has not resulted from 

evaluation and planning—at least not before 1950— 

but to a long tradition of basic infant care in the 

family, stimulated by district nurses and welfare 

centers and supported by basic social security 

measures and a rising standard of living. 

As already noted in various sections of the 

text, an analysis of infant loss by age, sex, parity, 

cause of death, seasonal variation, and social 

class leads to the conclusion that a hard core or 

irreducible minimum is far from having been 

reached. It appears likely that the rate of the 

highest social class at present will be the national 

average in the near future, resulting from improvement in sociohygienic conditions and in 

medical, obstetric, and pediatric care. Nonspec ­

tacular arrangements, such as maternity home 

help, may not be less important than technical 

innovations. 

Analysis of the factors mentioned above lead 

to the following predictions regarding infant loss 

and its components in the Netherlands. In 1964, 

the stillbirth rate was 13.4 per 1,000, first-week 

mortality 10.1, and postnatal mortality 4.7; hence 

27 
the perinatal rate was 23.4 per l, 000, infant mortality 14.8, and infant loss 28. It maybe expected 

that abut 1970 the stillbirth rate will be reduced 

to 10-11 per 1,000, first-week mortality to 8-9, 

and postnatal mortality to 3-4; accordingly, peri -

natal mortality would be 18-20, infant mortality 

11-13, and infant loss 22-24 per 1,000. Account 

should be taken of the fact that the rate of decrease will be accelerated if the factors tending 

to reduce the mortality have a cumulative effect 

but will be slackened if there are counterbalancing trends. 

During the 1970’s, the rate will prolmbly 

continue to decrease, bringing the infant mortal it y 

rate below 10 and infant loss below 20 per 1,000. 

The prediction that infant mortality and infant 

loss in 1970 will be abut half the rates recordec 

20 years earlier are neither optimistic nor pessimistic, but realistic, 

W. SUMMARY


Nature and Processing of Data 

In Holland, where about 70 percent of confinements occur in the home, large numbers of 

doctors and midwives have not been trained to 

adhere strictly to the international definitions of 

stillbirth and live birth. There is no medical 

notification of live births; notification of births 

within 3 days after delivery is compulsory, and 

is usually done by the father. 

Inaccuracies in notification and registration 

of immature babies, until about 1950, had the effect of lowering first-week and infant mortality 

by 3.0-3.5 per 1,000 live births. Since then, 

undernotification may still be responsible for 

lowering the rates by about 1.0- 1.5 per 1,000. 

Mortality Trends 

Infant mortality was reduced by one-half in 

each of three periods: from 1900 to 1922, from 

1923 to 1939, and from 1948 to 1964, the first 

period covering an interval of 22 years and the 

other two, 16 years each. The infant mortality 

rate was approximately 50 per 1,000 live births 

in 1930, 30 in 1948, 20 in 1956, and 15 per 1,000 

in 1964. Infant loss in 1964 (28 per 1,000 births) 

was about one-fourth that in 1920. 

Both before and after World War II, the decrease in postnatal and infant mortality exceeded 

the reduction in perinatal mortality. Each of the 

age components of infafit loss fell more rapidly 

in the postwar than in the prewar period. In the 

early 1920’s postnatal mortality was three times 

as high as first-week mortality, and in the 1930’s 

nearly twice as high. Shortly before 1950 the rates 

were about equal, and currently first- week mortality is twice as high as postnatal mortality. The 

ratio between stillbirth and first-week mortality 

(4 to 3) has not changed in the past 40 years. In 

contrast, the ratio between perinatal and post-. 

natal mortality has changed drastically, from 1 to 1 

in 1927 to 3 to 1 in 1952 and 5 to 1 in 1962. The 

problem of wastage of infant life has become th~, 

problem of perinatal mortality. 

Perinatal mortality accounts for more than 

80 percent of infant loss. Stillbirth is responsibh: 

for 60 percent and first-week mortality for 4[) 

percent of perinatal deaths, First-week mortalip~ 

comprises about two-thirds of infant mortality an~1 

one-third of infant loss. 

Infant mortality for girls has consistentl!~ 

been much lower than for boys. Before World Wa:. 

II all components of infant mortality were highe c 

in rural than in urban areas, but with the decreas: 

in mortality the differences have nearly dis -

appeared, although hospital deliveries are twit z 

as frequent in cities as in rural areas. 

Prematurity is of paramount significance i o 

perinatal mortality; 40 percent of stillbirths ani 

55 percent of first-week mortality are among 

premature. During the first week of life, tha 

risk of dying is about 20 times as high for pre. 

mature infants as for infants born at term. Ths 

prematurity rate of live births in Sweden is 4.5 

percent, and in Holland 5.5 percent. This difference accounts in part for the difference in peri -

natal mortality between the ,two countries. 

The stillbirth rate increases with age c~f 

mother at all parities. In every age group, pri ­

miparae have by far the highest stillbirth ratx. 

The rate is three times as high among womt n 

28 
over 40 as among those under 25, and about M 

times as high at higher parities as among second 

and third births. Between 1952-53 and 1962-63, 

the stillbirth rate decreased for almost all age 

groups of mothers and nearly all parities, reflecting to a considerable degree the shift in distribution of births toward younger mothers and 

lower parities. The influence of age surpasses by 

far that of parity. Age and parity have a stronger 

influence on stillbirth than on first-week mortality, 

The frequency of twin births increases with 

parity, and even more so with age of mother. Twin 

births comprise about 2.5 percent of all births. 

Stillbirth is 2!4times as high for twin as for single births. The ratio is 6 to 1 for first-week mortality, 4 to 1 for perinatal mortality, 2!4to 1 for 

postnatal mortality, and more than 4 to 1 for infant mortality. The high first-week mortality is 

due to the high prematurity rate—50 percent compared with 4 percent for single live births. Since 

1953, when the statistics for infant mortality for 

twins began, the reduction of first-week and infant 

mortality in twins paralleled that for single births. 

Under certain conditions, which may be of biological, pathological, and social origin, the risk 

of death for the newborn is much higher than 

average, These high-risk groups include children 

of older mothers and higher parity, twin deliveries, and premature; all such confinements 

should be hospitalized. 

The infant’s risk of death in abnormal presentations, especially breech presentation, is 

about 10 times as high as in cephalic presentation. 

Neivborn infants of mothers with a history of 

abortion and prematurity have two to three times 

the mortality of babies born to mothers without 

�abnormalities in previous pregnancies. 

About one-third of all deliveries are in the 

high-risk groups. Including cases in which the 

chances of dying are difficult to determine, a 

hospitalization rate of about 40 percent will meet 

Nl medical and social needs, at least if an adequate selection of the high-risk groups takes 

place, 

The major causes of stillbirth, such as difficulties in labor, placental and cord conditions, 

and congenital malformations, have decreased 

with varying rapidity since 1950. Boys have a 

higher death rate than girls for each cause of 

stillbirth except congenital malformations. 

In first-week mortality, birth injuries, immaturity, and congenital malformations are the 

dominant causes. Sharp decreases have occurred 

in the death rate for birth injuries and immaturity for both sexes, the rates for males remaining higher than for females. The excess 

mortality among females from congenital malformations has changed to an excess mortality 

among males— resulting mainly from the drastic 

reduction in mortality from congenital malformation of the central nervous system in females. 

The causes of perinatal mortality decreased 

between 1950 and 1963: birth injuries by 30 percent, the residual group “other causes” by 25 

percent, congenital malformations by 20 percent, 

and erythroblastosis by 10 percent. Perinatal 

mortality as a whole fell about 30 percent. 

Analysis by cause suggests that a further decrease 

in perinatal mortality may be expected. 

The leading cause of postnatal mortality is 

congenital malformations, followed by the subgroup “other causes” and influenza and pneumonia. The rates for both subgroups have more 

or less halved in 13 years. 

Seventy percent of confinements occur in the 

home–half of which obtain maternity home help 

service—and 30 percent in hospitals. The larger 

the municipality, the higher the hospitalization 

rate and the lower the maternity home help 

services. Approximately 60 percent of stillbirths 

occur in hospitals, or almut twice the proportion 

of live births. 

Perinatal mortality in home deliveries, particularly those with maternity home help, is very 

low, in part because the high-risk cases are 

concentrated in hospitals. Nevertheless, the 

favorable results in home deliveries in the 

Netherlands justify the conclusion that hospitalization on a large scale is not the only means for 

reducing perinatal mortality. This point deserves 

the special attention of developing countries. 

Infant mortality rates still show differences 

by socioeconomic class. In 1961-62, the rates in 

class I were about 15 percent lower, and in class 

V 10 percent higher2 than the national average. 

The influence of social class on stillbirth 

is stronger than that for any of the age compon29 
ents of infant mortality. The present rates forthe 

higher social classes will be the national averages 

in the near future. 

Illegitimacy has never been an important 

proMem in the Netherlands. The risk of death of 

the illegitimate child at present is about what 

it was for legitimate children in the immediate 

prewar period, 

Before 1940, perinatal and postnatal mortality 

were higher in Sweden than in Norway or in the 

Netherlands, Since World War II, the infant mortality rates for Sweden have been the lowest in the 

world. In these three countries the infant mortality rate now approximates 15-20 per 1,000 and 

infant loss about 30 per 1,000. In England and 

Wales and in the United States, the rates are 

higher. The favorable situation in the Netherlands 

reflects a long tradition of basic infant care in 

the family, aided by district nurses and welfare 

centers and supported by social security measures and a rising standard of living. 

Maternal and Child Health Services 

Domiciliary confinement has been far more 

usual than institutional confinement in the Netherlands. Hospitalized births accounted for about 

20 percent of the total in 1950, 25 percent in 

1956, and 30 percent in 1963. If hospitalized, 

mothers and babies stay an average of 10-12 

days. 

Midwives give prenatal and natal care as independent practitioners. About 3S percent of the 

babies are delivered by midwives, 45 percent by 

general practitioners, and 20 percent by obstetricians. The obstetrical approach still is conservative: cesarean section is performed in little 

more than 1 percent of deliveries, and analgesia 

is hardly practiced. 

Prenatal and natal care are the legal right 

of members of the sickfunds, but hospitalization ‘ 

for “normal” delivery is not included. Although 

practically all mothers receive prenatal and natal 

care, only about 60 percent see their doctor or 

midwife six times or more during pregnancy. 

To compensate for the low frequency of hospital births, a special organization (Maternity 

Home Help) has been founded to provide care for 

the mother and newborn child and to help in the 

household. In 1950 this organization covered onefourth and in lg63 one-half of all home deliveries. 

Infant welfare centers have grown in number 

from one in every 450 live births in 1930 to one 

in every 100 in 1960. The main activity of these 

centers is periodic examination of healthy infants, 

who have an average of 10 or 11 examinations 

during the first year of life, About 75 percent of 

the infants enjoy periodic supervision. The primary task of the infant welfare centers has shifted 

from the fight against infant mortality to health 

promotion and child development, 

Future Trends 

Analysis of infant 10SS by age, sex, cause of 

death, and social class indicates that by 1970 the 

stillbirth rate in the Netherlands will be reduced 

to 10-11 per 1,000, first-week mortality to 8-~, 

and postnatal mortality to 3-4 per 1,000, Flence, 

perinatal mortality will be 18-20, infant mortality 

11-13, and infant loss 22-24 per 1,000, It is expected that the rates will continue to decrease 

during the 1970’s, 

Acknowledgments 

The authors gratefully acknowledge the assistance of J. T. P. Bonte, sociologist, in the 

preparation of portions of the manuscript. In 

addition, the following coworkers have given 

valuable assistance: Mrs. A. M. Verhage-den 

Heijer, who typed the manuscript; Mrs. S, van 

der Weele-Verhoekx, who worked on tables and 

figures; Miss A. C. M. van Olst, who compiled 

the bibliography; and Mr. N. H. de Kleijn, who 

prepared the original graphs. 

30 
BIBLIOGRAPHY


Beeck, F, J. op de: VeeIvuldig forcipaal. beeindigen der 

baring en de invlosd hiervan op de kindereterfte (Multiple 

forcipal termination of labor and its effect on child mortality). 

Ned. T. Qeneesk. 9794S6, 1963. 

Beeck, F, J. op de: Enkele obstetrische en medisoh-soci ale as.pecten van de perinatale sterfte (The obstetrical and 

mcdicnf. ~ocitll problem of the perinatal mortality). Tbesie 

I.krocht. 1954. 

Beg~aving zonder verlof Ambtenaar Burgerlijke Stand (Burial without consent of the Registration C)fficer). Ned. T. Genaesk. 104:115?5, 1960. 

Barge, B. S. ten, and Linthorst, G: Een onderzoek naar de 

doodsoorr.aak bij 200 levenloos aangegeven kinderen te Rottnrdnm (An investigation into the causes of death of 200 liveborns, dead before notification-so-called ‘‘faux mort-n&s”­

in Rottordam), Ned. T. Geneesk. 93:553, 1949. 

Bergu, B, S, ten: Obstetrische kindersterfte (Perinatal 

mortality). Ned. T. Geneesk. 95:2851, 1951. 

Berge, B. S. ten, Schutj J. A. F., and Na:s, C. A. G.: Zwangorenvoorzorg en neonatale sterfte (Prenatal care and neo. 

natal mortality). Ned. T. Geneesk. 95:1480, 1951. 

Blankonetein, M. van, Welbergen, U. R., and Haas, J. H. 

de: De ontwikkeling van de zuigeling (Development of the in. 

~. Contact, Amsterdam, 1962. Dutch, Danish, Finnish, 

l%nch, Norwegian, and Swedish editions. 

Brink, T. ~an den: Geboorterezistratie en geboortestatistiek (Birth registration and birth ~~tistics). ~.eoc. Geneesk. 

39:286.1961. 

Bruijne, J, L de: Neonatale sterfte (First-week mortality). 

Ned, T, Ueneesk, 105:109, 1961. 

Bruijrm, J. L de: Prematuritae en dyematuritas (Prematurity and dyematurity). Maandschr,Kindergeneesk. 32:380, 

1964. 

Daamon, C. B. F.: Enkele oorzaken van de perinatale 

sterfte (Some causes of perinatal mortality). Ned. T~Geneesk. 

97:269o, 1953. 

Dnamen, C. B. F.: Het, verband tussen vroeggeboorte en 

rmonatalo sterfte (The reIation between prematurity and necnatal mortality). Ned, T. Geneesk. 99:2695, 1955. 

Dnamen, C. B. F.: Oorzaken van perinatale sterfte; verSIag van do Lilste wetenschappeli jke vergadering van het 

_N_derlarrds Tijdschrift voor Geneeskunde (Causes of perinatal mortality). Ned, T. Geneesk. 107:1203, 1963. 

Qeldaren, H. H. van, Posthuma, J. H., and Haas, J. H. 

de: Geboortegewicht en ~raematuritas in Nederland (Birth 

weight and prematurity in-the Netherlands). T.soc .Geneesk. 

82:443, 1964. 

Gelderen, H. H. van: Pre-school child mortality in the 

Netherlands. Thesie Leiden, 1955. 

Ge~eeskundig ‘Hoofdinspecteur van de Volksgezondheid 

(Cbio~ Medictd Officer of Health): Rapport over de positie van 

d~ vroedvrouw in Nederland (Report on tbe status of the midwifa in the Netherlands). ‘s-Gravenhage, 1963. 

Gorter, E.: Volkenbondsonderzoek naar de oorzaken der 

zuigohngmrstcwfte (Enquiry into the causes of death of infant mortality-League of Nations). Ned. Maandschr.Geneesk. 

8:361, 1t130. 

(loudsmit, C. J, :Over het verlof tot begraven (On the conrwmt for burial of irmnaturely born children). T.soc. Geneeek, . 3H:71. 1060. 

Ch&t,-hi. J. W.de: Epidemiologische aspecten van aangeboren ufwijkingen (Epidemiological aepecte of congenital 

malformtttions) .-Hui~arts en We&nscbap 8:121,176,211; 1965. 

Haas, J. H. de: P.erinatal mortality and maternity home 

help in the Netherlands. Neonatal ‘Studies (Paris) 3:71, 1954. 

Haas, J. H. de: De zuigelingensterfb in Nederland twintig per duizend (Infant mortality in the Netherlands, twenty 

per thousand). Ned. T. Geneesk. “1OO:1742,1956. “ 

Haas, J. H. de: Kinde rsterfte in Nederfand Child mortality 

in the Netherlands; atlas. VRUGorcum, Assen, 1956. 

Haas, J. H. de: Mortalitg de l’enfant aux Pavs-Bas: son .–, — d&,eloppementetses repercussions (Mortality of &e infant in 

the Netherlands; ite developmentand’ conseq~ences). Courrier 

6:247, 1956. 

Haas, J. H. de: The place of the midwife in relation to 

maternity care. Nursing Mirror 105:929,997, 1957. 

Haas, J. H. de: l’Analyse de la mortinatalit6 et de la mortalitg de l’enfant (Analysis of tbe stillbirth and infant mortality). Courrier 8:577, 1958. 

Haas, J. H. de: Differenti31e sterfte bij jongere leeftijdsgroepen (Differential mortality of younger age groups). T.eoc. 

.— Geneesk. 36:519, 1958. 

Haas, J. H. de: Future trends in maternal and child health. 

Acts Paediat. (Uppsala) 47:446, 1958. 

Haas-Posthuma, J. H. de: EnquL?te naar de corzaken van 

de obstetrische sterfte uitgaande van de Gezondheidsorganisatie T.N.O. (Enquiry into the causes of perinatal mortality). 

Med.Contact 7:11, 1952. 

‘– Haas-Posthuma, J. H. de: Landelijk onderzoek naar de 

oorzaken van de obstetrische kindersterfte (Investigation into 

the causes of perinatal mortality in the Netherlands). T.prakt. 

Verloek. 54:136, 1952. 

Haas-Posthuma, J. H. de: PerinataIe sterfte in Nederland 

en andere landen, 1926-1950 (Perinatal mortality in the Netherlands and in other countries, 1926-1950). T.soc.Geneeek. 

31:273, 1953. 

Haas-Posthuma, J. H. de: Daling van de perinatale sterfte 

in Nederland onder landelijke en stedelijke verhoudingen, 

1926-1953 (Decreasing perinatal mortalitv in tbe Netherlands 

~9#aI and urban areas; 1926.1953). T.s&. Geneesk. 33:100, 

Haas-Posthuma, J. H. de: Prenatale zorg en perinatale 

sterfte (Prenatal care and perinatal mortality). T.soc. Geneesk. 

37:314, 1959. 

Haas-Posthuma, J. H. de: Perinatale sterfte in Nederland. 

onderzoeknaar factoren, die de perinatale sterfte beynvloeden 

(PerinataI mortality in the Netherlands; investigation into factort

— s influencing perinatal mortality). v.Gorcum, Assen, 1962.

r,. -– m- ., uaas-rosmuma, ~. “ H, de, and Haas, J. H, de: Over het . . verlof tot bsgrave n (On the consent for burial of immaturely 

born children). T.soc.Geneesk. 39:285,288; 1961, 

Hart, P. G.: Zwangerschap, baring en kraambed bij primiparae, jonger dan 18 jaar (Pregnancy, labor, and childbirth of 

prlmiparae under 18 years of age), Thesis Utrecht, 1961. 

Hartog, C. den, Posthuma, J. H., and Haae, J. H. de: 

Onderzoek naar de voeding van de zwangere op het platte. 

land (Survey on tbe nutrition of pregnant women in rural areas). 

Voeding 14:1, 1953. 

Hemmes, G. D.: Beschouwingen over de sterfte van 

kraamvrouwen en haar kinderen (On maternal and infant mor. 

tality). Ned. T. Geneesk. 91:2331, 1947. 

Hoeven, H. C. van der: Voor elkaar; de ziekenfondsen te 

midden van de sociale veranderingen in de iaren 1900-1960 

(The eickfunds during the social charrpes in the years 1900-

W. Utrecht, 1963. 

31 
Hoge Raad: Arrest van 14 september 1959 (High Courk 

Judgment of September 14, 1959). Ned. Jurieprudentie 119:308, 

1960; T.soc.Geneesk. 38:176, 1960. 

Hoogendoorn, D.: De kans op doodgeboorte voor kinderen 

met een hoog geboorterangnummer, respectievelijk kinderen 

van oudere moeders (The risk of stillbirth of children, late in 

order of birth, or children of mothers advanced in years). Ned. 

T. Geneesk. 9fi2130, 1953. 

Hoopendoorrr. D.: De zuieelim.zensterfte in Nederland in -. verb and met het geboo~terangnummer van het kind, de leeftij d 

van de moeder en de eociale status van het gezin (Infant mortality in tbe Netherlands in relation to the child’s number of 

birtb, the age of the mother, and the social situation of the 

family). Van Gorcum, Assen, 1959. 

Hoogendoorn, D.: Doodgeboorte en zuigelingensterfte van 

de onwettig geborenen (Stillbirth and infant mortality of 

illegitimate children). Ned. T. Geneesk. 105:376, 1961. 

Hoynck van Papendrecht, H. P. C. M., and Hart, P. G.: Mortinataliteit en vroege sterfte bij erythroblastosis foetali e door 

rhesus antagonism (Stillbirth and neonatal mortality in erythroblastmsis fetalis). Ned. T. Geneesk. 105:272, 1961. 

Kerrebijn, K. F.: Kindercardiologie in Nederland (Child 

cardiology in the Netherlands). Thesis Leiden, 1964. 

Ketting, B. W Sterfte en doodsoorzaak van prmaturen 

1949-59, Rijkskweekschool voor vroedvmuwen h. Merdam 

(Mortality and causes of death of premature, 1“949-59).~. 

T. Verlosk. 60:313, 1960. 

Kloosterman, G, J., and Huidekoper, B. L.: Over de betekenis van de placenta voor de “obstetrische sterfte”; een 

onderzoek van 2000 pl acenta’e’ (The placenta and its eigni ficance for “obstetrical mortality ~’; a study of 2,000 plaoentss). Ned. T. Verlosk. 52:318, 1952. 

Klooeterman, G. J., and Huidekoper, B. L.: De obststricus en de perinatale sterfte (The obstetrician and perinatal 

mortality). Ned. T. Geneeek. 104:2029, 1960. 

Kortanoever, M. E.: Langdurende zwangerscbap en overdragen kind (Prolonged duration of pregnancy and postmaturi­

— 

ty). Thesis Leiden, 1948. 

Loo, H. van der: De betekenis van intra-uterine milienfactoren voor de perinatale sterfte (The relation between intrauterine environment and perinatal mortality). Thesis Leiden, 

1956. 

Loo, H. van de~ Prenatale zorg en periinatale sterfte (prenatal care and perinatal mortality). Geneesk.Gids 36:301, 319; 

1958. 

Lookeren Campagne, J. van: Morbi.diteit en mortaliteit van 

pasgeborenen (Morbidity sad mortality of newborns). Ned.T. 

Geneesk. 95:2854, 1951. 

Maesen de Sombreff, P. L. E. van der: De betekenis van 

“Kind” in de artikelen 2, 29 e.v. en 52 B. W., in de Wet OP 

de Iijkbezorging en in de artikelen 290 en 291 van het Wetboek van strafrecht (The legal meaning of the expression 

c~child”). R. M. Themis. 431, 1958. 

Maesen de Sombreff, P. L. E. van der: Kind of vruch~ 

enige opmerkingen naar aanleiding van het arreet van de Hoge 

Raad van 14 september 1959 (Child or fetue; some remarks 

with reference to the Judgment of the High Court of September 14, 1959). Ned. Juristenblad 31:675, 1960. 

Nederlands Huisartsen Genootschap-Studiegroep obstetrie 

en gynaecologi e, Werkgroep verloskunde (Dutch Association 

of General Practitioners: Study Group on Obstetrics and Gynecology): Series of articles published in Huisarts en Wrton­

@QP 4:372, 1961; 5:10, 322, 326-1962; 6:9, 54, 73, 75, 11.1, 

182, 220, 287, 328-1963; 7:371, 1964. 

Nederlandse Bond voorMoederschapezorg en Kinderhygi&re 

(Dutch Association for Maternal and Child Health): Prenatale 

zorg dag 1958 (Prenatal care; conference 1958). T.soc.Ge­

.— neesk. 37:279, 1959. 

Neurdenburg, M. G.: De sterfte in het eerste lcwensjaar 

(Mortality during the first year of life). T.soc.Geneesk. 6:7, 

1928. 

Neurdenburg, M. G.: Daling van de zuigelingensterfte en 

van het geboortecijfer (Decrease of infant mortality and birth 

rate), Maandechr. Kindergeneesk. 4:285, 1935. 

Omers, R. J. J.: Over de behandeling van zwangeren met 

e.en gestoorde bloedsuikercurve en de resultaten ten aanzlen 

van de fetal loss (The treatment of pregnant women with a 

disturbed bloodsugar curve and the implications for fetal loss). 

Thesis Groningen, 1960. 

Omers, R. J. J.: Perinatale sterfte (Perinatal mortality), 

T.soc.Geneesk. 39:646, 1961. 

Oudkerk, P. hi.: De neonatale sterfte van premat.uur gcbu. 

renen (Neonatal mortality of premature infants). Ned. T.Gr.. 

neesk. 100:1280, 1956. 

Pel, J. Z. S., and Pel-Mellink, J.: Een duizendtal bevallingen in een huieartsenpraktijk (A thousand deliveries in a gen. 

eral practitioner’s practice). Huisarts en Wetenschap 5:133, 

1962. 

Polak, M. F.: Frequentie van doodsoorzaken bij doorlge. 

borenen (Frequency of causes of death among stillbirths). 

Ned. T. Geneesk. 97:2597, 1953. 

Polman, A.: Ontwikkeline en huidi~e stand van de sterfto 

in Nederland en Belgi& (Evolution and the present state of the 

mortality of the Netherlan ;ds and BelEium).. Ver. Demoeranhie. -. L. . 

e-Gravenhs.ge, 1951. 

Pompe, W. P. J.: Noot bij het arrest van de Hoge Raacl van 

14 September 1959 (Note on the Judgmentof the High Court of 

September 14, 1959). Ned. Jurisprudentie 119:308, 1960. 

Querido, A., et al.: Nota over de perinatnle sterfto (Report 

on perinatal mor~y). Ned. T. Verlosk. 56:116, 1956. 

Rottinghuis, H., and Beeck, F. op de: Beschouwingen over 

de obstetrische moedersterfte gedurende de jaren 1941-1949 

(Observations on maternal mortality during tbe years 1941-

1949). Ned. T. Geneesk. 95:3823, 1951. 

Sikkel, A.: De perinatale sterfte in de Universiteits.vrou. 

wenkliniek te Amsterdam (Perinatal mortality in the Obs tetri. 

cal Department of the University of Amsterdam). Thesis Am. 

sterdam, 1954. 

32 
Sihkcl-Buffinga, A, J.: Stuitligging (Breech presentation). 

l’hcwis Amsterdam, 1954. 

Sindrnm, I. S.: De sterfte der moeders in de Universiteits-

\ ruuwrnldiniek te Amsterdam in de jaren 1939 tot 1949 (Maf[,rnnl mortulity in the Obstetrical Department of the University of Amsterdam during the years 1939-1949). Ned. T. Gemw,sh. !M:155E, UJ50. 

Sindram, I. S.: De sectio caesarea bij diabetes mellitus 

(~osnreun section and diabetes mellitue). Ned. T. Geneesk. 

!lh:2tiH6, 1951. 

Sindrmn, I. S.: Onnodige verloskundige sterfte (Avoidable 

obstetrical dcwths), Ned. T. Verlosk. 51:128, 1951. 

Sindrmn, I. S.: Zwang~ 

:md dililwtes). Thesis Amsterdam, 1955. 

Spccken, J. L. M. H.: Vroeggeboorte (Premature birth). 

Tlnwis Utrccht, 1964. 

Stroink, J. A.: Moederschapszorg in Nederland (Maternal 

cm-c in thn Netherlands). Ned. T. Geneesk. 103:2330, 1959. 

Tjua Gic TjicmK Iets over de resultaten van de behandeIing vmr vrocggcboorte(Res ults of the treatment of premature). 

‘lXXFLironingon, 1952. 

Verbrugge, H. P.: Interne kraamzorg; organieatie en ,groei 

(Maternity home help; organization and expansion). T.soc~Geneesk. 43:315, 1965. 

Verhagen, H. A. J.: De verloskunde van de huisarts (Obstetrics and the general practitioner). Hui sarts en Wetenschap 

3:221, 1960. 

Waalwijk van Doom: Over het vraagstuk der vroeggeboorte 

(The problem of prematurity). Thesis Amsterdam, 1950. 

Westerbeek van Eerten, B. J.: De onvoldragen vrucht en de 

Wet op de lijkbezorging (The immature fetus and the Burial 

Act). Med. Contact 15:251, 1960. 

Wolff, P. de, and Meerdink, J.: La mortalitd ~ Amsterdam 

selon les quartiers (Mortality of Amsterdam according to 

quarters). Population 7:639, 1952. 

Wolff, P. de, and Meerdink, J.: La mortalit~ infaptile ~ 

Amsterdam selon les groupes eociaux (Infant mortality of 

Amsterdam according to social classes). Population 9:293, 

1!?54. 

000 

33 
-----------------------------

---------------- -------- -------- ---

-------- ------------------------ --------

---------------------------------------

------------------------------------------

DETAILED TABLES 

Page


Table 1. Birth rates and infant loss rates by age: Netherlands,1920-64------------------ 35


2. Infantmortality rates by age: Netherlands,1938.64 36


3,	 Birth rates and stillbirth, perinatal, and infant mortality rates, by sex; Netherlands,1925-64 ~------- ----”---- .“------ 37 

4. Infant loss rates by age: selectedcountries,1926-61--------------------------- 3E. 

5. Infant loss rates, by sex and age: Netherlands,1950-64------------------------- 39 

6.	 Percentagedistributionof live births,byage of mother and parity: Netherlands, 

selectedyears, 1950-63 --.----- .------- - 4(I 

7.	 Stillbirth rates and percent change, by age of mother and birth order: 

Netherlands,1952-53 and l962-63------------------------------------------------4:.


8.	 First-weekmortality rates and percent change, by age of mother and total birth 

order: Netherlands,1953-54 and 1962-63 4:! 

9. Stillbirthrates by cause and sex: Netherlands,1950-63------------------------- 4.) 

10. Infant mortality rates by cause, sex, and age:Netherlands,1953-54and 1961-62-- 41k 

11.	 Perinatal.stillbirth. and infant mortality rates for legitimatebirths, by age 

and fathe;’s occupation:Netherlands,selectedyears, 1952-62------------------- c!+!j 

12,	 Stillbirth, perinatal, ~;oi;~t mortality rates, by size of municipality: 

Netherlands,1950-52and . ..-”.-. 45 

13. Maternal mortality rates by age: selected countries,1959-60-------------------- 47 

34

-----------------------

---------------------

--------

--------

----------------------

---

---

---

---

---

---

---

---

----

----

---

---

---

---

---

---

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---

---

---

---

---

Table l.. Birchrates and infantlossrstea by age: Netherlands,1920-64


I Infantmortality


Infant


still- Perinata1 loss
 Year birth mortal.ityl (;.ee~d


R;t;oer
 Rate per 1,000 Rate per 1,000 live births 

R;t;o~er


births
 popLation births


1964-------------------------


1963-------------------------


1962-M


1.96L------------------------”


1960-------------------------


1959------------------------’-


1958-------------------------


1957-------------------------


1956-------------------------


1955-------------------------


1954-------------------------


1.953-------------------------


1952-------------------------


1951---”


1950-------------------------


1949-------------------------


1948-------------------------


L947-------------------------


1946-------------------------


1945-------------------------


w:------------------------- -.-”.-,.”..- “.--...-..” -.” 

1942-------------------------


~;;;”--..
”---.--.----..---”--


.-,....””””,-
 “---””


1939-------------------------


L938----------------R


1!?37-------------------------


1936-------------------------


1935-------------------------


1934-------------------------


1933-------------------------


1932-------------------------


1931-------------------------


1930-------------------------


1929-------------------------


1928-------------------------


1927-------------------------


1926-------------------------


1925-------------------------


1924-------------------------


L923”-”


L922-------------------------


1921-------------------------


L920-------------------------


20.7 13.4 23.4 14.8 10.1 11.6 4.7 28.0 

20,9 14.3 24.5 15.8 10.4 12.0 5.4 29.9 

20.9 14;6 25.7 17.0 11.3 12.8 5.7 31.3 

21,3 14,8 25.9 17.0 11.3 12.8 31.6 

20.8 14.9 26.6 17.9 11.9 13.5 2:: 32.6 

21.4 15.7 27.1 18.1 11.6 13.3 6.5 

21,2 16.7 28.0 18,5 1.1.4 13.3 35.0 

21.2 16.9 28.1 18.4 11.4 13.1 ::; 21,3 16.9 29.0 20,2 12.3 14.2 36.8 

21.3 17.0 30.2 21.6 13.4 15.6 8:2 

21.5 17.4 31.2 22.6 14.1 16.2 8.5 39.6 

21.7 17.5 31.5 23,7 14.3 16,5 

22.3 18.2 32.4 24,1 14.4 16.6 ;:: 41.8 

22,2 1.8.3 33.4 26.7 15.4 18.4 11.3 

22.7 19.3 34.2 26.7 15.2 17.9 11.5 45.4 

23.7 19.3 33.0 26.6 14.0 16.8 12.6 

25.3 18.9 32.4 28.9 13.8 17.4 15.1 47.6 

27,8 20.1 34.2 33.1 14.4 18.5 18.7 

30.2 20.2 34.8 41.6 14.9 20.9 26.7 58.1 

22.6 19.2 35.0 78.7 16.1 29.8 62.6 97.3 

24.0 18.5 33.6 46.8 15.4 23.0 31,4 63.9 

23.0 18.5 32.4 41.0 14.2 20.4 26.8 

21.0 19$3 33.6 39.9 14.5 21.0 25.4 

20,3 21.3 37,5 43.4 16.6 22.7 26.8 

20.8 25.1 40.7 39.4 16.0 21.4 23.4 63.3 

20.6 24.8 39.9 33.B 15.5 19.8 18.3 57.6 

20,5 24.7 40.1 36;9 15.9 20.5 21.0 60.3 

19,8 25.2 40.5 38:0 15.9 20.9 22,1 

20.2 25.1 40.8 38.9 16.1 21.5 22.8 

20.2 25,1 41.6 39.9 16.9 22.5 23.0 64.1 

20.7 25.1 41.7 42.6 17.0 22.5 25.6 

20.8 25.1 41.5 43.4 16.8 22.4 26.6 

22.0 25.2 41.1 46.4 16.4 22.4 30,0 

22.2 $$: 41.6 49.2 17.1 23.4 32.1 

23.1 . 41.4 51.3 17.3 23.4 34.0 74.2 

22.8 24,7 41.4 59.0 17,2 24.6 ;:.; 23.3 ;;.; 41.1 52.3 16.3 23.6 

2J.: 42.9 58.6 17.4 24.8 41:2 

24;8 41.2 ;;.: 16,7 24.1 44.4 

24;2 25.4 41.1 . 16.1 23.6 42,3 82.3 

25.1 

26.2 

26.0 

27,7 

43,0 

44.6 

60.6 

::.; 17.5 2.5.7 

17.4 26.0 

43.1 

48.8 

.-. 

-“-

26,1 26.9 44.8 18.4 28.7 58.4 

27.7 26,3 43.7 85:3 18.0 30.8 67,3 

2S.6 26.1 44.7 82,5 19.0 31,1 63.5 106.4 

Ed. nate: For the yeara 19.50.64,
 inclUdesliveborninfantswith gestationsof less than 28 weeks who 

dieJbeforeregistration] 

SOURCES;NetherlandsCentralBureauof Statiatics,Zestig jaren statiatiekin tijdreeksex.
 (Historical

seriesof the Netherlands)>Zeiat, 1959.


NethezLanda CentralBureau of Statistics,Jaaroverzichtenbevolking en volkagezondheid 

(Annwlvital and healthreports),The Hague. 

35

--------------------

------------------------ ----

-------------------------------------

------------------------------------

Table 2. Infant mortalityrates by age: Netherlands,1938-64


Under Under 1-6 1-51 7-27 28 days- 6-11
 Year 1 week~ 1 dayl dayaL weeks days 5 months months


Rate per 1,000 live birtha 

1964------------------------------------ 10.1 4.6 5.6 4.7 1.5 2.1 1.2 

1963------------------------------------ 10.4 4.8 5.5 5.4 1.6 2.4 1.4 

1962------------------------------------ 11.3 5.4 5.8 5.7 1.5 2.7 1.5 

1961------------------------------------ 11.3 5.5 5.8 5.8 1.5 2.7 1.5 

1960------------------------------------ 11.9 5.8 6.1 6.0 1.6 2.8 1.6 

1959------------------------------------ 11.6 5.4 6.1 6.5 L.7 3.1 1.7


1958------------------------------------ 11.4 5.6 5.8 7.1 1.9 3.4 1.8


1957------------------------------------ 11.4 5.6 5.8 7.0 1.8 3.3 1.9


1956------------------------------------ 12.3 6.6 5.7 7.9 1.9 4.0 2.0


1955------------------------------------ 13.4 7.4 6.1 8.2 2.1 4.1 2.0


1954------------------------------------ 14.1 7.6 6.5 8.5 2.1 4.2 2.2 

1953------------------------------------ 14.3 8.1 6.2 9.3 2.2 4*7 2.5 

1952------------------------------------ 14.4 7.7 6.7 9*7 2.2 4.8 2.7 

1951------------------------------------ 15.4 8.3 7.1 11.3 3.0 5.4 2.9 

1950------.-----y--- 15.2 8.4 6.8 11.5 2.7 5.9 2.9 

1949------------------------------------ 14.0 7.8 6.2 12.8 2.8 6.7 3.4 

1948------------------------------------ 13.8 7.5 6.3 15.5 3.6 8.0 3.9 

1947------------------------------------ 14.4 7.6 6.8 19.1 4.2 9.8 5.2 

1946------------------------------------ 14.9 8.1 6.8 23.8 6.0 11.8 6.o 

1945------------------------------------ 16.1 8.3 7.8 63.5 13.7 34.8 15.0 

1944------------------------------------ 15.4 8.C 7.4 30.9 7.7 15.8 7.5 

1943------------------------------------ 14.2 7*5 6.3 25.9 6.2 12.8 6.9 

1942 --.----- 14.5 7.i 6.9 25.0 6.4 12.5 6,1 

1941------------------------------------ 16.6 8.6 7.9 27.0 6.> 12.5 8.3 

1940------------------------------------ 16.0 8.C 7.5 23.1 5.: 10.9 6.8 

1939 15.5 8.5 6.5 18.2 4.: 8.9 5.0 

1938 15*9 8.6 7.2 20.7 4.6 9.8 6.3 

lBaaedon calendar daya since birth. For the years 1950-64, includes liveborn infants with


gestationof less than 28 weeks who died before registration.


36

--------------------------------------------

-------------------------------------------

------------------------

-------------------------------------------

------------------------------------------

-------------------------------------------

------------------------------------------

--------------------------------------

-------------------------------------------

-----------------------------------

-------------------------------------------

-------

------------------------------------------

-------------------------------------------

---------- ------------------------

-------------------------------------------

-------------------------------------------

-------------------------------------------

------------------------------------------

---

---

---

---

---

---

---

---

---

----

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

Table 3. Birth ratea and s,tillbirth,perinatal,
 and infant mortality rates, by sex: Netherlands, 1925-64


Birth Stillbirth I Perinatal Infant 

mortality mortality] 

Year 

= ~ 

Rat : per Ratf per 

1: 100 Rate per 1,000 births 1: 100 

popt .ation live births 

1964-------------------------------------------10.6


1963-------------------------------------------10.7


1962 10.7


1961-------------------------------------------10.9


1960-------------------------------------------10.7


1959-------------------------------------------11.0


1958 10.9


1957------------------------------------------”10.9


1956.------------------- 10.9


1955-------------------------------------------10.9


1954-------------------------------------------11.1


1953-------------------------------------------11.2


1952 11.5.


1951 -. 11.5


1950 11.7


1949-------------------------------------------12.2


1948 -. 13.1


1947-------------------------------------------14.3


1946-------------------------------------------15.6


1945 ----. 11.7


1944-------------------------------------------12.4


1943 11.9


1942----”-- . 10.9


1941-------------------------------------------10.5


1940 10,7


1939------------------------------------ 10.6


1938 . 10.6


3.937-------------------------------------------
10.2


1936 10.4


1935-------------------------------------------10.4


1934-------------------------------------------10.6


1933 .---------- 10*7


1932-------------------------------------------11.3


1931-------------------------------------------11.5


1930-------------------------------------------11.9


1929 11.7


1928 12.0


L927-------------------------------------------11.9


1926 12.2


1925 12.5


10.1 13.7 13.0 25.1 21.5 16.7 12.8 

10.1 15.3 13.3 27.3 21.7 17.8 13.6 

10.2 15.4 13.7 27.9 23.3 19.0 14.9 

10.4 15.5 14.2 28.4 23.3 19.4 14.5 

10.1 15.4 I 14.4 28.9 24.2 20.0 15.7 

10.4 16.4 15.1 29.4 24.8 20.4 15.6 

10.3 17.5 15.9 30.1 25.6 20.5 16.4 

10.3 17.4, 36.4 30.2 25.9 20.7 15.9 

10.3 17.4 16.3 31.4 26.4 22.9 17.3 

10.4 17.9 16.0 33.0 27.2 24.4 18.7 

10.4 18.1 16.6 33.7 28.6 25.0 20.0 

10.5 18.0 16.9 34.3 28.6 27.0 20.1 

10.8 19.3 17.2 35.3 29.3 26.6 21.4 

10.8 18.7 17.9 36.0 30.6 30.0 23.2 

11.0 19.7 18.8 36.8 31.4 29.8 23.3 

11.5 19.8 18.8 30.0 23.5 

12.2 19.5 18.2 32.7 25.6 

13.5 21.4 18.7 37.5 29.3 

14.6 21.3 19.0 43.5 33.5 

10;9 20.3 18.0 -.. 88.6 70.0 

11.6 19.2 17.8 -... 51.5 40.8 

11.1 19.7 17.2 44.1 35.8 

10.1 19.9 18.7 44.4 34.2 

9.8 22.2 20.3 49.4 37.3 

10.1 26.6 23.5 44.0 3401 

10.0 26.2 23.3 37.6 29.6 

10.0 26.7 22.6 41.2 31.6 

9.6 26.4 23.8 --,. 43.0 32.9 

9.8 26.4 23.7 -J- 43.2 34.2 

9.8 26.3 23.8 45.2 34.4 

10.0 26.3 23.8 47.5 37.3 

10.1 27.0 23.1 49.5 37.9 

10.7 26.7 23.6 52.3 39.9 

10.7 26.4 23.5 56.1 42.6 

10.2 25.7 23.4 56.6 44.8 

11.1 26.3 23.(J ..- 66.5 51.1 

11.4 26.9 23.3 59.5 44.8 

11.2 27.6 24.2 66.4 50.6 

11.5 26.3 23.3 68.3 53.5 

11.8 27.8 .22.9 66.0 50.3 

l~or the years 1950-64, includes liveborn infants with gestationa of less than 28 weeks who died


before registration.


37

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------------------------------------------- --------------------------- ------

-------------------------------------

------------------------------------ ---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

---

--------------------------------------------

-------------------------------------------

---------------------------------

------------------------------------

--------------------------------------

--------------------------------------------

--------------------------------------------

-------------------------------------------

--------------------------------- ------------------------------------------- ------------------------------------

-------------------------------------

---

---

---

---

---

---

---

---

---

---

---

---

---

-------------------------------------------- ------------------------------------------

---------------------------------

----------------------------------

--------------------------- ---------

-------------------------------------

---------------------------------------

--------------------------------------------

--------- --------------------------- -------- --------- ----------------------------------

---------------------------------

-------------------------------------------

------------------------------------

-------------------------------------

--------------------------------------- -------- --------------------------------------

--------------------------------------------

-------------------------------------------

---------------------------------

-------------------------------------

------------------------------------

-------------------------------------

I 

Table 4. Infant loss rates by age: selected countries, 1926-61


—. —. 

1960- 1957- 1954- 1951- 1946- 1926. Infant loss component and country 1961 T 1959 1956 1953 1950 1930

1 , 

Stillbirth Rate per 1,000 births 

N$;~~lands 14.8 ;;.’$ 17.1 18.0 20 20 25 25 2i 

13.2 16.8 18.5 20 23 28 27 21; 

Noway 

Denmark 13.4 14:0 

15.1 

14.8 15.6 18 20 

16.2 18.3 18 

23 25 -2:;

-2[, 

England and Wales :$; 21.6 23.2 22.7 :; 3: 41 4(I 

Belgium-----;

Czechoslovakia 12:4 

15.8 

13.5 

17.6 

13.8 

20.5 

16.2 

;: 

16 

25 30 

23 :$ 

31. 

2:{ 

United states------------------------------------- 12.h 11.9 12.5 13.8 16 :; 

Perinatal mortality 

Netherlands3-------------------------------------- 26.2 27.7 30.1 32.h 33 34 40 41 :: Weden -------------------------------------------- 24.9 26.3 28.3 31.2 34 39 47 46 Nomay 23.4 24.4 25.1 26.9 31 33 39 41 4i Denmark 26.7 29.1 33.4 34.4 

England and Wales 32.4 35.1 37.4 37.5 40 

Belgim4------------------------------------------ 30.9 32.3 35.6 39.9 46 :’! :! :? $1 

Czechoslovakia 24.3 25.6 28.3 34.6 

United States------------------------------------- 29.0 28.8 29.4 31.1 35 35 

Infant mortality Hate per 1,000 live births


Netherlands3 

&eden 

17.4 

16.2 

18.3 

16.8 

21.5 24.8 

20.1 40 

24 50 

31 3 45 56 

Nomay 18.4 19.7 23.8 39 :; ,,:: Demark 21.6 ;:.: 28.3 :; :: -82 England and Wales 21.7 28.0 36 50 5$ 62 Belgium 29.6 32:5 45.6 64 1%! Czechoslovakia 24.6 31.3 58.5 100 l% 1:: 1% 150 United States 25.6 26.6 28.2 32 40 51 60 68 

Under 1 week 

Netherlands 3'5------------------------------------- 11.6 11.5 14.7 14 16 17 17 

%eden5------------------------------------------- 11.8 11.2 12.9 14 +: 19 19 18 Nomay 10.1 10.6 11.4 13 13 16 16 17 Denmark5 14.2 13.8 16.3 England and Wales 13.3 13.8 15.1 19 22 22 22 Belgium4i-------.- 16.3 16.8 19.8 ;? 19 20 18 18 Czechoslovakia 11.9 12.1 18.4 United States 16.6 16.9 17.3 19 20 24 26 28 

1-51 weeks


Netherlands 6.8 8.2 10.1 16 35 21 28 

.*eden 2:: 5.6 10 23 31 ;; Nerway 8.3 9.1 1::+ 1;:: 18 ;; 23 29 33 Denmark 9.0 10.2 12.0 England and Wales i:: 10.1 12.9 31 33 40 46 Belgim 13.3 1::? 22.4 25.8 :! 69 66 71 84 Czechoslovakia 12.8 19.2 21.7 40.1 

United States 9.0 9.7 9.5 11.0 13 20 27 34 40 

Infant loss Rate per 1,000 births


Ng;~nlands 32 35 39 :; 62 ;? 81 29 32 35 70 Noway 32 34 39 62 70 ,7% Denmark :: 47 s 1:[ 

England and Wales i? :: 48 51 103 Belgim-----T 44 48 58 66 1?: 121 136 Czechoslovakia 37 45 50 133 153 173 United States 36 39 39 i; 

I I 

11931-40.


21921-30.


31ncludes liveborn infants with gestation of less than 28 weeks who died before registration.


4Bef0re 1951-deaths under 5 days; 1951-55—deaths under 7 days estimated from deaths under 5 days and deaths
 under 10 days; 1956-61-deaths under 7 days.


5Based on calendar days since birth.


SOURCES: United Nations, Demographic Yearbook, New York.


World Health Organization, Epidamiological and Vital Statistics Reports, Geneva.


National statistical publications.


38

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Table 5. Infant loss rates, by sex and age: Netherlands,1950-64 

~nclndes Iivebom infants with gestations of less than 28 weeks who died before registration]

sex and year 

Stillbirth 

Under 

1 weekl 

Under 

1 dayl 

1-6 1-51 7-27 28 daysdaysl weeks days 5 months 

6-11 

months 

Infant 

10ss 

~t;o$er Rate per 

Male Rate per 1,000 live births 1,000 

births births 

1964----------------


1963----------------


1962


1961----------------


1960----------------


1959----------------


1958----------------


1957----------------


1956----------------


1955----------------


1954----------------


1953----------------


1952----------------


1951----------------


1950----------------


Female


1964----------------


1963----------------


1962----------------


1961----------------


1960----------------


1959----------------


1958----------------


1!357----------------


1956----------------


1955----------------


1954----------------


1953----------------


1952----------------


1951----------------


1950---------------­


13.7 11.6 5.1 6.5 5.2 1.8 2.2 1.2 30 

15.3 12.2 5.6 6.6 5.6 1.7 2.5 1.4 33 

15.4 12.8 6.0 6.8 6.2 1.7 2.8 108 34 

15.5 13.2 6.1 7.0 6.3 1.7 3.0 1.7 35 

15.4 13.7 6.6 7.2 6.3 1.7 3.0 1.6 35 

16.4 13.2 6.0 7.2 7.2 2.0 3.4 1.8 37 

17.5 12.9 6.2 6.7 7.7 2.1 3.6 1.9 38 

17.4 13.0 6.2 6.8 7.7 2.0 3.6 2.2 38 

17.4 14.2 7.4 6.8 8.8 2.1 4.5 2.2 40 

17.9 15.4 7.9 7,4 9.0 2.5 4.5 2.0 4?. 

18.1 15.9 8.5 7.4 9.1 2.2 4.6 2.3 &3 

18.0 16.6 9.1 7.5 10.4 2.5 5.1 2.7 45 

19.3 16.3 8.5 7.8 10,3 2.4 45 

18.7 17.7 9.3 8.4 12.3 3.1 48 

19.7 17.5 9.4 8.1 12.3 2.9 48 

13.0 8.7 4.1 4.6 4.2 1.1 1.9 1.1 26 

13.3 8.5 4.1 4.4 5.1 1.5 2.2 1.4 27 

13.7 9.7 4.8 4.8 5.2 1.4 2.6 1.3 28 

14.2 9.3 4.9 4.4 5.2 1.4 2.4 1.4 29 

14.4 9.9 5.0 4.9 5.8 1.5 2.6 1.7 30 

15.1 9.8 4.8 5.0 5.8 1.5 2.8 1.6 31 

15.9 9.9 5.0 4.9 6.6 1.7 3.2 1.7 32 

16.4 9.7 5.0 4.6 6.2 1.5 3.0 1.7 32 

16.3 10.3 5.7 4.6 7.0 1.7 3.6 1.7 33 

16.0 11.4 6.8 4.6 7.4 1.8 3.7 2.0 35 

16.6 12.1 6.6 5.5 7.9 1.9 3.9 2.1 36 

16.9 11.9 7.1 4.8 8.1 1.7 4.2 2.3 37 

17.2 12.3 6.8 505 9.1 2.1 39 

17.9 13.0 7.2 5.8 10.2 2.8 41 

18.8 12.8 7.3 5.5 10.5 2.4 42 

l~a~ed on calendar days Since birth. 

39

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--------------------------------

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Table 6. Percentage distributionof live births, by age of mother and parity: Netherlands, 

selectedyears, 1950-63 

II Parity


Year and age of mother 

1962-63


!00.0 

Under 25 years 26.2


Under 20 years 3.9


20-24 years 22.3


25-29 years 32.4


30-34 years 23.6


35-39 years 12.9


40 years and over 4.9


1956-57


100.0


Under 25 years 20.4 

Under 20 years “-------- - 2.5 

20-24 years 17.9 

25-29 years 32.6 

30-34 years --.------. 25.9 

35-39 years 15.0 

40 years and over 6.1 

1950-51


Total 100.0


Under 25 years 18.6


Under 20 years 2.2


20-24 years 16.4


25-29 years 31.4


30-34 years 25.4


35-39 years 17.2


40 years and war------------------------------------ 7.3


Percentagedistribution


32.3 L7.3 L6.9 9.5	 5.4


—


17.3 6.7 1.7 0,4 3.1


3.3 0.5 0.0 0.0 3.0


14.0 6.2 1.6 0.4 3.1


10.8 1.2.2 5.9 2.2 2.8


3.0 6.4 6.2 3.8 2.0


0.9 1.7 2.6 2.4 1.8


0.2 0.3 0.6 0.7 D.7


30.7 25.1 16.1 !0.2 6.5


—


13.4 5.1 1.4 0.4 0.1 

2.2 0.3 0.0 0.0 

11.2 4.8 104 0.4 0.l 

12.2 11.0 5.4 2.4 1.C 

3.9 6.6 6.0 4.0 2.5 

1.0 2.0 2.7 2.6 2.2 

0.2 0.4 0.6 0.8 0.8 

27.8 24.1 16.9 L1.O	7.0


—


11.6 5.0 1.5 0.4 0.1 

109 0.3 0.0 0.0 . 

9.7 4.8 1.5 0.4 0.1 

10.8 10.3 5.9 2.7 1.1 

3.8 6.0 5.8 4.1 2.t 

1.2 2.2 2.9 2.9 2.4 

8*6


0.0


000


0.5


2.2


3.5


2.4


11.4


0.0 

0.0 

0.6


2,9


4.6


3.2


13.2


0.0


0.0


0.6


3.1


5.6


003 0.5 0.8 0.9	 (J*$ 3*9
 —


40

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-----------------------------------------

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--------------------------------------

Table 7. stillbirthrates and percent change, by age of mother and birth order: Netherlands,


1952-53 and 1962-63


I II 

Birth order
 Adjusted All
 for
 Year and age of mother	 or-
 birth ders
 order1
 w 

1962-63 Rate per 1,000 births


All ages (adjustedfor mother’s agel)------------ 15.: 15.4 16.5 11.3 25.7


All ages (total)--------------------------------- 15.1 14.4 1504 10.8 17.0 25.4 

Under 20 years 10.2 10.8 6.3 * 

20-24 years-------------.--------------q--------------- 10.5 12.7 6.7 8.7 * 

25-29 yeaxs 11.5 15.2 8.9 12.7 16.8 

30-34 years -----.---.------ 14.8 24.3 12.4 14.4 16.2 

35-39 years 21.9 38.4 18.1 20.5 24.3 

40 years and over _ 34.2 52.3 29.1 30.0 36.9 

1952-53


All ages 17.8 20.6 13.0 17.6 27.2


Under 20 years 13.4 L3.4 14.0 8.6 * 

20-24 years 12.8 L2.8 14.6 9.8 L2,.2 * 

25-29 years 14.4 L4.4 20.1 10.9 L1.9 13.9 

30-34 years 16.9 L6.9 30.9 13.3 L4.8 18.0 

35-39 years 22.9 22.9 43.4 19.5 L9.5 24.8 I 

40 years and over 38.9 38.9 72.0 29.6 37.1 40.2 

Percent change 

All ages (adjustedformother’s agel)------------ -12 -13 -20 -13 -3 -6
 -


All agea (total)--------------------------------- -15 -19 -25 -17 -3 -7


Under 20 years -24 -23 -27 ... ..� 

-19 

20-24 years -18 -13 -32 -29 ... 

25-29 years -18 -20 -24 -18 +7 -I-21 

30-34 years -lo -12 -21 -7 -3 -lo 

35-39 years -3 -4 -12 -7 -I-5 -2 

40 years and over -11 -12 -27 -2 -19 -8 : f 

lAdjusted by the direct method using the distributionof total births by age of mother and


birth order, Netherlands,1952-53.


41

.

.

.

--------------------------------------------

--------------------------------------------

-------------------------------

--------------------------------------

Table 8. First-week mortality rates and percent change, by age of mother and total birth order:


Netherlands, 1953-54 and 1962-63


[Based.m calendardays since birth] 

Adjusted Birth order


for All


Year and age of mother live or­
 birth ders ~ 2 4 6


order 1 and and and


3 5 over


1962-63 Rate per 1,000 live births


All ages (adjusted formother’a agel)------------ 11.1 10.9 12.2 9.3 10.9 14.:!


All ages (total)--------------------------------- 11.0 LO.8 12.0 9.3 11.0 14.:! 

1 

Under 20 yeara----------------------------------------- 14.4 14.3 14.6 9< . 

20-24 years 11.0 LO.9 10.7 10.7 >’: . 

25-29 years-------------------------------------------- 9.7 9.5 11.2 8.3 10.0 :.. 

30-34 years-------------------------------------------- 10.1 9.9 14.4 8.5 9.5 12.? 

35-39 years-------------------------------------------- 12.7 12.7 23.7 11.5 11.4 12.’) 

40 years and over-------------------------------------- 16.6 16.5 9< 14.9 15.4 17.! 

—. 

1953-54


All ages----------------------------------------- 14.2 14.2 15.5 12.2 14.2 17.6 

—. 

Under 20 years-------------------------------------’--- 18.4 18.4 17.2 * 

20-24 years 13.7 13.7 13.9 13.4 ,!: . 

25-29 years-------------------------------------------- 12.4 12.4 13.6 10.8 14.9 

30-34 yeara-------------------------------------------- 13.1 13.1 18.4 10.9 13.3 15.L 

35-39 years-------------------------------------------- 16.4 16.4 32.0 15.7 13.4 17.) 

40 yeara and over-------------------------------------- 21,8 21.8 * 23.3 18.5 21.2


L%rcent change


All ages (adjusted formother’s agel)------------ -22 -23 -21 -24 -23 -17
 —-


AIL ages (total)--T------------------------------ -23 -24 -23 -24 -23 -13
 —-


Under 20 years----------+------------------------------ -22 -22 -15 ... . . . ... 

20-24 years-------------, -20 -20 -23 -20 . . . ... 

25-29 years-------------------------------------------- -22 -23 -18 -23 -33 ... 

30-34 years-------------------------------------------- -23 -24 -22 -22 -29 -15 

35-39 years-------------------------------------------- -23 -23 -26 -27 -15 -2$ 

40 years apd.,over -24 -24 * -36 -17 -l;
 —­


lAdjusted by the direct method using the distribution of live birthsby age of mother and birtl 

order, Netherlands, 1953-54. 

42


v 
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---

--- --- ---

---

---

---

---

---

---

--- ----

---

---

---------------------------- --- ---

------------------------------ ---

---

---

---

--- ---

---

---

---

---

---

------------------------------

---

---

---

---

---

---

---

---

---

--- ---

---

---

--- ---

------------------------------ ---

---

--- --- ---

---

---

--- ---

------------------------------ ---

---

--- --- ---

---

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--- ---

------------------------------ ---

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Table 9. Stillbirth rates by cause and sex: Netherlands, 1950-63


Cause of stillbirth and sex
 (Sixth Revision- 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950
 International Lists, 1948)


Rate per 10,000 births


All causes 143 146 148 149 157 167 169 169 170 174 174 182 183 193 . = 

Male 153 154 155 154 164 175 174 174 

Female........-.......------------ 133 137 142 144 151 159 164 163 

Diseases and conditions of
 pregnancy and childbirth--Y32 25 22 22 22 21 28 29 22 21 21 16 18 15 — 19


Male------------------------------ 27 23 22 24 21 28 30 24 

Female 24 21 22 20 21 27 27 19 

Difficulties in labor------Y34 11 13 14 14 15 21 22 23 23 24 21 24 25 — 28

Male 13 15 17 15 17 24 24 25


Female---------------------------- 9 11 11 13 12 18 20 20


Other diseases or conditions


in mother-----Y30,Y31,Y33,Y35 13 13 13 14 13 10 12 7 7 8 9 9 9 9
 -

Male 14 13 15 14 13 10 13 8 -%.


Female---------------------------- 12 13 12 14 12 9 10 7


Placental and cord
 condi.
tions-----.----.-----Y36 38 39 37 37 43 39 37 43 40 41 41 42 45 — 47


Male------------------------------ 41 43 38 39 47 43 40 44


Female---------------------------- 34 35 35 36 38 36 34 41


Birth injuries-------------Y37 1 1 2 1 2 3 3 2 3 3 3 3 3 — 3


Male 1 2 2 2 3 3 3 3 

Female---------------------------- 1 <1 2 1 2 2 2 2 -.. 

Congenital malformations of fetus------------------Y38 15 16 16 16 16 21 19 19 21 22 20 21 20 20 

Male 12 14 14 13 13 17 13 16 

Female---------..----------------- 18 18 19 19 20 25 25 23 

Erythroblastosis---------Y39.2 6 6 6 6 6 6 6 6 6 6 6 6 6 — 5

Male 7 6 7 7 7 7 6 7 

Female.........------------------- 5 7 6 5 6 5 6 5 

Other diseases of fetus and ~ ill-defined causes----------- .-----Y39.0,Y39.1,Y39.3-Y39.6 33 35 38 38 41 40 42 47 50 51 57 60 62 61
 —


Male 37 38 41 41 43 43 43 48


Female---------------------------- 30 33 36 36 40 38 41 46 

— 

[Ed, note: Rates by cause do not add to the total because of rounding]


43

-----------

-------------

------

--

Table 10. Infant mortalityratea by cauae, sex, and age: Netherlands,1953-54 and J.961-62


[Excludes Iiwbominfants with gestaticms 1.ss than 28 weeks whodied h.fmensgistzatim]


Cause of death, sex, and years


(Sixth and SeventhRevisions—InternationalLists, 1


Jnder Under Under 1-6 7-27 28 daya- 6-11 

1948 and 1955) year 

1 weekl 1 dayt daysl daya 5 months month3 

All cauaes Rate per 10,000 live birtns


Both sexes--~~%;-~~-- 153.8 96.4 42.8 53.6 15.2 26,9 15.3
 .- 216.9 127.5 66.2 61.3 21.0 44.5 23.6


Male--------l96l-62-- 175.5 1L3.O 47.7 65.3 16.6 28.8 17.1


1953-54-- 243.6 1;$.: 73.7 72.4 23.8 48.5 25.3


Female------626l-62-- 131.0 37.7 :;.; 13.7 24.9 13.4


1953-54-- 188.4 107:8 58.2 18.6 40.2 21.3


Infectiveand parasitic


diseasea 001-020,045-048,053,
 056,057,085 

Both sexes--1961-62-- 0.0 0.0 0.3 0.5 

1953-54-- ::: ::; 0.1 0.0 ;:: 2.2 

Male--------l96l-62-- 0.9 0.0 0.1 0.3 ;:; 1953-54-- 4.1 ::: 0.0 0.; 2.1 

Femele------626l-62-- ().1 ;::
 1953-54-- ::; 0.; 0.; 0.6 0.1 ;:: 1.8


Influensa and pneumonia,includingpneurmn%a.
. _


of newborn ----------------480-493
 ,763


Both sexes--1961-62-- 4.1 0.9 3.2 1.2 2..4 1.9 

1953-54-- 1::: 0.6 2.4 3,1 

Male--------l96l-62-- 11.1 H ::: 1.5 H 2.0 

1953-54-- 17.6 3.7 6:; 3.1 3.0 3.1 

Female------626l-62-- 0.6 2.5 1.0 ;:; 1953-54-- 1$: ::: 0.6 2.3 1.7 7.3 $; 

All other diseases of respiratory


system-----------------------------470-475,500-527


Both sexes--1961-62-- 1.2 0.2 0.1 0.1 0.1 0.4 

1953-54-- 1.8 0.1 ::? 

Male--------l96l-62-- 1.7 0.; 0.; 0.; 0.1 H 0,7 

1953-54-- 0.2 0.9 

Female------626l-62-- ;:: 0.; 0.6 0.; ::: 0,2 

1953-54-- L.7 ::: 1.1 0,5 

Gastritis,duodenitis,enteritis,and colitis,


includingdiarrhea of newborn----------
 543,57l,572


Both sexes~-1961-62-- 1.5 0.0 0.0 0.1 0.4 0.8 

1953-54-- 0.1 0.7 0.5 

Male--------l96l-62-- ;:: 0.; o.i 0.2 0,5 1.2 

1953-54-- 1.8 

Female------626l-62-- 0.9 - ::: ;:: ::: 1953-54-- 1.0 0.0 0.5 0.5 

Other diseaaea of digestive


system---------------------53O-542,544-57O,573-587


Both sexes--1961-62-- 0.9 0.4 0.5 0.4 0.5 0.3


L953-54-- ::; 0.4 0.6 0.5 0.6


Male-- 1961-62-- 2.4 U 0.5 ::; 03


1953-54-- 3.8 ::: ::: 08


Ferns
le------1961-62 ~:!j 0.3 ::2 0.2 ::; 02


1953-54-- ;:: . 0.3 0.5 0.4 0.8 05


I 

Congenitalmalformations--------------------75O-759


Both sexes--1961-62-- 43.8 18.5 8.4 10.1 ;.; 13.1


1953-54-- 49,5 22.7 12.1 10.6 13.6 H
 Male--------1961 

1953-54-- 49.6 21.8 10.2 11.6 ;:; 14.5 56 

Female------626l-62-- 43.6 17.1 8.8 7.1 14,0 54 

1953-54-- 49.3 23.7 1::: 9.7 7.6 12.7 53 

Birth injuriesand aaphyxia-----------------76O-762 

Both sexea--1961-62-- 41.1 39.5 19.3 20.2 . 

1953-54-- 55.5 53.1 30.7 22.4 ;:: ::! 01 

Male--------l96l-62-- 50.0 47.9 21.5 26.4 1.7 0.3 . 

1953-54-- 67.5 65.2 36.4 28.8 0’0 

Female------1961-62-- 31.7 30.6 ;;.; 13.6 U :;; 1953-54-- 42.7 40.2 . 15.6 2.2 0.2 0<7 

I~~azn&l and spinal injury 

---------------------------------------760 

Both sexea--1961-62-- 19.4 18.3 6.4 11.9 

1953-54-- 22.1 20.5 7.3 13.2 ;:: ;:; 0,; 

Male--------l96l-62-- 24.8 23.4 16.0 1.3 

1953-54-- 29.2 27.3 H 18.1 ::; O.i 

13.7 13.0 5.4 7,6 ::; 0.0 

14.6 13.1 5.3 7.8 1.3 0.1 O.i 

-62-- 44.0 19.8 8.4 11.4 12.2 48


44

--

--

--

--

---------------- --

Table 10. Infant mortality rates by cause, sex, and age: Netherlands,1953-54 and 1961-62—Con. 

[Excludes
 livebom infants with gestations less than 28 weeks who died before registratio~ 

I Cause of death, sex, and years 7-27 28 daya - 6-11 (Sixthand SeventhRevisions—InternationalLists, days 5 months months 1948 and 1955) 

Rate per 10,000 live births


Other birth injury------------------------------76l


Both sexes--1961-62-- 6.0 3.1 0.1 0.0 

1953-54-- 2;:2 

Male--------l96l-62-- 11.3 

2%i 

11.1 

16.7 

2:? 

0.2 

0.2 

0.1 

0.1 

1953-54-- 25.9 25.8 1$:: 6.0 0.0 0.1 

Female------626l-62-- 0.0 

1953-54-- 1::: 1::: 1::: ::; 0.4 0.: 

Postnatslasphyxia and atelectaais--------------762 

Both sexes--1961-62-- 12.4 12.0 6.8 0.3 0.1 

1953-54-- 11.0 10.6 6.6 ::: 0.4 0.1 0.; 

Male--------~~%~-~~-- 13.8 13.5 7.2 6.3 0.2 0.1 

12.4 12.1 4.7 0.3 0.0 

Female------626l-62-- 10.9 10.5 ::: 4.0 0.3 0.0 

1953-54-- 9.6 9.0 5.9 3.1 0.5 0.1 0.; 

Other infectionsof newborn-----~----------­
 765-768


Both sexes--1961-62-- 1.6 0.7 0.1 0.6 0.8 0.1 

1953-54-- 1.6 0.5 0.1 0.5 0.7 0.4 

Male--------l96l-62-- 0.8 0.0 0.7 1.0 0.2 

1953-54-- ;:: 0.6 0.6 0.4 

Female------626l-62-- 1.2 0.6 0.1 0.5 ::: 1953-54-- 1.2 0.5 0.1 0.3 0.5 ;:: 

Neonatal disorders arising from certain diseases 

OE mother during pregnancy---------------------769 

Both sexes--1961-62-- 4.1 3.8 1.9 1.8 0.2 0.1 0.0 

1953-54-- 0.1 0.1 0.1 

Male--------l96l-62-- ::: ::: ;:; ;:: 0.1 0.2 

1953-54-- 3.3 3.2 1.9 1.3 0.0 0.0 

Female------:~~l.:~~-- 3.0 1.4 1.5 0,2 0.1 0.; .- ::? 3.3 1.8 1.5 0.1 0.1 0.1 

Hemolytic

(erythroblastosia) ;;;-;;;;;::;;~~:;~7O 

3.6 2.0 1.6 0.2 0.1 

1953-54-- 2:; 2.5 U 0.3 

Male--------l96l-62-- 4.6 ::: 2.1 ;:; ::! 0.0 0.1 

1953-54-- 8.6 6.9 3.0 4.0 0.2 0.3 

Female------~~~~-~~-- ::: 0.1 ::: ::: ;:: ;:: 0.5 0.0 O.i 

diaeaaea	of newborn
 -----------;


Other diseases peculiar to early infancy----7774774 

Both sexes--1961-62-- 8.0 3.5 0.7 0.7 

1953-54-- 17.9 1::: ::: ;:: 0.9 

Male--------l96l-62-- 2.0 U ;:: 0.9 

1953-54-- 2::: 1::: 5.3 8.0 i:: 0.9 

Female------626l-62-- 6.5 4.3 1.4 ::; 0.5 

1953-54-- 14.9 9.8 3.5 ::: 1.6 ;:; 0.8 

Immattirity,
unqualified-------------------------776

Both sexea--1961-62-- 17.5 16.3 9.6 1.1 0.2 

1953-54-- 22.8 20.5 l::i 1.7 0.4 0.: 

Male--------1961-62-- 20.3 19.0 1?:: 0.2 

1953-54-- :$: 23.6 1;:: 10.8 k: 0.3 

Female------
626l-62-- 13.5 5.3 8.2 1.0 0.1

1953-54-- 19:3 17.2 8.7 8.5 1.4 0,5 0.;


Accidents------------------------------.---E8OO-E962


Both sexea--1961-62-- 4.0 0.1 0.0 0.1 :.: 2.0


1953-54-- 0.2 0.1 0.2 2.9 ;:; 

Male--------~~l.~-~~-- 2:: 0.1 0:1 2.3 2.1 

6.4 0.3 0.1 ::; 0.3 3.1 2.7 

Female------1961=62= 0.2 0.0 0.1 0.2 1.7 1.1 

1953-54-- ::; 0.1 0.0 Q..1 0.3 2.6 1.9 

All other causes---------------------------Residusl 

Both sexes--1961-62-- 14.6 3.4 1.4 2.0 ‘1.7 3.8 

1953-54-- 26.6 2.7 2.9 2.8 1;:; 

Male--------~~l.~-~~-- 17.8 ::: 2.7 2.0 ::: 

30.1 6.2 ::: 3.2 3.3 1;:; ;.: 

Female 11.3 1.4 1.4 4.0 

22.9 ::: i:: 2.6 2.2 9.0 6:7 

lBased on calendar days since birth. 

45 
----------------------------

---------

-------- --------------------

-----------------

-----------------

I 

Table 11. Perinatal, sci,llbirth,
and infant mortalityrates for legitimatebirths, by age add


father’aoccupation:Netherlands,selectedyears, 1952-62


[Excludes Iivebom infants with gestations less thtm 28 weeks who died before registration 

ZiilEUnder 1 year I	 Under 

1 weekl 1-51 weeks 

Class and occupaticmof father


1961 

Rate per 1,000 

le;~;~~te Rate per 1,000 legitimate live births 

Total 24.3 14.8 15.2[ 2166 9.6 12,6 5.6 I 9.0 — 

I.	 Professionaland cleri_cal . . . . . ..- 17,9 10’0 12.4 17.7 7.9 11’1 4’5 7,0 

Managers and proprietary 21.8 13,4 14.5 19.9 11.9 5.7 8.1 

1:::	 Farmers and farm managers 26.7 16.9 1.5’7 23.5 1::: 14.5 5.3 8.3


Iv, Farm laborers 30,5 19,9 16.9 22.7 10.9 13,9 6,0


v.	 Other laborers--------------”---- 28.L 17.6 16,9 23.4 T10,5 13.3 6,4 I t 

tBas~d on calendar days since birth, 

Table 12. Stillbirth, perinatal,	 and infant mortality rates$ by size of municipality: Netherlands, 1950-52 and 1960-62 

[Includes Iiveborn infants with gestations less than 28 weeks who died before regktration] 

Infant mortality


Stillbirth Perinatall


Size of municipality Jnder 1 year Under 1 weekt 1-51 weeks 

1960- 1950- 1960- 1950- 1960- 1950- 1960- 1950- 1960- 1950-


1962 1952 1962 1952 1962 1952 1962 1952 1962 1952


Rate per 1,000 births Rate per 1,000 live births 

~o~a~....---.---.-..- I 14.8 18.6 26.11 33,2 17’3 25.7 11.5 15’0 5“8 10,7 

1---

Amsterdam----------------y 14,5 17.6 26,9 31,8 17.7 24.9 12,6 14.5 5.1 10.4 

Rotterdam 14.8 17’5 25.2 31.7 15.9 24.3 g.: 14*5 5,3 9,8 

The Hague 12.8 16.3 24.7 30.3 17.5 22.1 . 14.2 5.4 7.9 

20,000-259,999J=------ 14.5 17.8 25,.5 32.0 17.2 25,1 11’1 14.5 6.1 10.6 

100,000-259,999----------- 14,6 17,6 25,6 32,0 17.1 25.1 11,2 14,6 5,9 10.5 

50,000-99,999-”-------”-”” 13.9 17.0 25.2 31.6 17.4 25.6 11.4 14.8 6.0 10,8 

20,000-49,999------------- 14.8 18,4 2.5.6 32.3 17.1 24.9 10,9 14,2 6.2 10.7 r 

Under 20,000---------- 15,3 19,6 26.8 34.8 17.5 26,6 11,7 15.5 5.8 11.1 

5,000-19,999-------------- 1.5.2 19.5 26,6 34’5 17,4 26.4 11,6 15.3 5.8 11,1 

Under 5,000--------------- 15.5 19.8 27.2 35.3 17’8 27’.0 11.9 15.9 5.9 11.1 

500,000-899,999------- 14.1 17.2 25.7 31,4 17.0 23.9 11,8 14.4 5.2 9.5 

[Ed.

lgaaed

note:

on 

There

calendar

are 

days 

no

tmunicipalities

since birth. 

in

z

the Netherlands with populationbetween 26(Y~OO0and


600,000]


46

----------------------

-------------------------------------------------

-----------------

----------------------------------------------------

---------- --------

----------------------------------------------------

----------------------------

Table 13. Haternalmortality races by age: selectedcountries,1959-60 

-

Age of mother
 EEzE3ERate per 10,000 live births


Total (acljusted~l
 ........--*-.”---- 3.7 4.8 4.6 4.5


Tota~---------------------------------------------------- 3.0 3.7 3.9 4.5 

Under 20 years 2.6 2.5 2.3 0.7


20-24 years--....”---------------------
 .”------ 0.8 2.1 2.1 2.0


25-29 years 2.0 3.0 3.4 2.3


30-34 years-----..-”.----!-------.--!-.. .---------- -
 4*O 5.0 4.5 3.6


35-39 years 6.0 9.0 8.4 8.8


40-44 years........------------- -.----- 19.1 14.6 13.6 21.6


lAdjustedby the direct method using the live-birth distributionby age of mother, Nether­


lands,1959-60,


SOURCE:World Health Organization, Epidemiologicaland Vital StatisticsReports,Vol, 16, No.


11, p, 642, 1963.


47

APPENDIX I 

GENERAL DEMOGRAPHIC, SOCIOECONOMIC, AND SOCIOHYGIENIC TRENDS 

The Netherlands, situated on the lower course of the 

Rhine and Meuse Rivers, has an area of nearly 34,000 

square kilometers (about 13,000 square miles), of which 

one-fourth is below sea level. About 70 percent of the 

country is used for agriculture. A fourth of the area 

consists of built-up sections, uncultivated land, roads, 

railways, etc. Inland waters account for about 7 percent 

of the surface. The present density of the population 

varies from province to province, ranging from 125 to 

1,000 per square kilometer, with an average of 365. 

Population 

Growth. —Figure I gives a bird’s-eye view of a 

century of birth rates and death rates, the major components of population growth. Between 1860 and 1880 

the birth rate was about 35 and the mortality 25 per 

1,000. Since 1880, both the birth and the death rates have 

decreased gradually. The birth rate reached 30 per 

1,000 in 1907, 25 in 1918, and 20 in 1935, the lowest 

ever registered in the Netherlands. After reaching a 

postwar peak of 30 per 1,000, the birthrate fell to nearly 

23 in 1950 and to nearly 21 in 1964, varying by size of 

f municipality, social class. and mWi.gious denomination, 

601


40 -

“.4w\&q~ 20 -

+-&L4 

The birth rate has been decreasing in all groups of 

municipalities, whatever their size. Family plannir[g 

has reached the cities, towns, and villages, but until 

1965 was not promoted—and may be hindered—by tk e 

Government. Since 1965, official policy is in favor ,]f 

family planning. Since 1950, the birth rate in the thr( e 

largest cities decreased from 18 to 16.5 per 1,000 po~(­

r.dation, in the towns of 20,000 to 250,000 inhahitan s 

from 22 to 20.5, and in the municipalities under 20,0[ 10 

from 24.5 to 23 per 1,000, The reductions have n]t 

changed the inverse relation between the birth ra .e 

and size of municipality. 

The birth rate is highest in the Roman Catholic and 

Calvinist segments of the population (23-24 per 1,00C), 

followed by the nonreligious groups (19.5) and t]Ie 

Protestants (18 per 1,000). Catholics comprise 40 percent of the population, Protestanta nearly 40 perce m 

(half of whom are Calvinists), and the nonreligiolls 

groups nearly 20 percent. While the birth rate is in 

general inversely proportional to income level, r(:. 

ligious denomination appears to exert the stronge St 

influence on marital fertility. 

The crude death rate was about 20 per 1,000 poplIlation in 1890, 15 in 1905, and 10 in 1925; it rose to a 

— Bkth rate 

_ Death rate 

f 

10 - ‘“ L\ 

8 -

6 

5 811111111 1111#11 11#111, lltltlll, !t, lllll ,,,11,1, !ll, ,11! {! 11,1,,11,,,11! It, ,ttlllt t,llll, l,, l,, l,, ,1, ,,, 

1860 1870 1880 1890 1900 19[0 1920 1930 1940 1950 1960 196) 

YEAR 

Figure 1. hi rth and death rates: Netherlands, 1~6$-136Y.


48 

1 
--------

--------

--------

-----------

-----------

---------

-----------

-----------

-----------

-----------

-----------

-----------

-----

peak of 15 per 1,000 before the end of World War II, but 

by 1%50 was 7.5, the lowest ever recorded. During the 

fifties the crude death rate remained stable. When adjusted for changes in the age composition of the population, the rate shows a downward trend, dipping to below 6 per 1,000 in recent years. 

The natural increase was 10 per 1,000 population 

before 1880, 15 from 1900 until 1930, but decreased to 

12 per 1,000 during the economic crisis and prewar 

years 1930-40. 

Population growth was about the same as natural increase between 1920 and 1940, In the first years ailer 

World War II, population growth was smaller than 

natursl increase, because of emigration. Since 1955, 

however, population growth has been the greater, as 

immigration (chiefly from Indonesia) has exceeded emigration, 

The fertility rate per 1,000 women at ages 15-44 

decreased ‘from 145 at the turn of the century to less 

than 90 just before World War II, snd more recently 

increased to about 100. Both the fertility rate and the 

birth rate decreased until 1940 but reversed that trend 

in the following decade; in the past 10 years, however, 

both rates have decreased slightly. 

Table 1. Percentage distribution of population 

Since 1910 the population has doubled—from 6 to 

12 million. 

Age and sex. —In 1900, 35 percent of the population 

was under 15 years of age, and from 1930 to the present the proportion has been about 30 percent, with a 

slight decrease since 1960. The age group 15-54 years 

has comprised somewhat over half the population since 

1900. The proportion at ages 55 and over is increasing 

as rapidly as that under 15 is decreasing. This shift is 

due mainly to the long-term reduction in the birth rate, 

from 32 per 1,000 in 1900 to below 20 in 1965 and 1966. 

From a pediatric and educationalpoint of view, it 

is noteworthy that the so-called aging of the population 

results in an increasing number of children having 

grandparents until reaching school-age or later. Two 

generations ago, hardly half of the population could 

expect to reach age 65; according to current mortality, 

75 percent of the males and 85 percent of the females 

live to that age. 

Table I shows the sex and age distribution of the 

population for the census years 1920 and 1960. Around 

1920 the number of males exceeded the females until 

age 20, and in 1960 until age 30. No change, however, 

has occurred in the sex ratio of the population at ages 

by age and sex, and sex ratios: Netherlands, 

1920 and 1960 

Age 

All ages 

Under 15 years 

Under 1 year 

1-4 years 

5-9 years 

10-14 years 

15-19 years 

20-24 years 

25-29 years 

30-34 years 

35-44 years 

45-64 years 

65 years and over 

1960 census 

Both Male Female sexes 

II I


Percentage distribution 

100.0 100.0 100.0 

30.7 31.6 29.8 

2.2 2.3 2.2 

8*6 8.9 8.4 

9.6 9*9 9.3 

10.2 10.5 9.9 

7.9 8.1 7.7 

6.9 7.1 6.8 

6.7 6.8 6.6 

6.6 6.5 6.6 

12.4 12.3 12.6 

20.1 19.5 20.7 

8.7 8.1 9.2 

1920 census


Males Males 

per Both Male Female per 

1,000 sexes 1,000 

Females females 

Percentage distribution 

992 100.0 100.0 100.0 987 

1,050 32.6 33.3 32.0 1,030 

1,049 2.7 2.7 2.6 1,046 

1,049 8.7 8.9 8.4 1,036 

1,054 10.8 11.1 10.6 1,028 

1,049 10.4 10.6 10.3 1,024 

1,043 9.8 10.0 9.6 1,020 

1,034 8.7 8.7 8.7 990 

1,019 7.8 7.7 7.8 969 

987 6.9 6.8 7.0 964 

967 12*1 1200 12.3 965 

931 16.1 15.9 16.3 958 

879 5.9 5,6 6.3 881 

49

--

Table H.. Crude and adjusted death rates, by sex, and index numbers for crude and adjusted rates, 

by sex: Netherlands, selected years, 1938-63 

Ihdex Index Crude rates Adjusted rates~ for crude rates for adjusted rates 

Year 

Both Both Both sexes Etale Female sexes Hale Female ;:::5 Male Female ~exe~ &lale Female

I I 

1963----- 8.0 8.9 5.9 5.0 93 102 ?30 61 

1961-----

1959-----

7.6 

%: 

(x .5.7 ::: 

6.5 

5.0 88 

88 

95 

94 

% 

82 

:: 

70 

76 

77 

to 

t3 

1939----- ::: 8,8 :;; ::: 2:$ 

Rate per 1,000 population 1938-39=100 

1938----- 8,5 8.7 8,4 8*4 %2 8.2 } 100 100 100 100 100 1( o 

— 

lAdju~ted to age distribution of Ehe population in 1936 USi.ng the direct method. 

SOURCE; Adapted from Central Bureau of Statistics, pocket Year Book, 1964. 

65 and over. The deficit inwomen ofmarriageable age 

is not as pronounced as would appear from-tbetabl~, 

inasmuch aa girls generally marry men older than 

themselves, 

Infants constituted slightly over 2,5percent of the 

population in 1920, but a somewhat lower proportionin 

1960, for both bQys and girls, llepercentage ofpreschool children (1.4 years) has remained atnearly9 

percent for boys andabout8.5 for girls. 

Mortality 

Crude andadjwsted mtes.-Since the turn of the 

century, the crude death ratea for males have been 

halved and for female~ more than halved, thuawidening 

the sex difference in mortality, Valid comparisons of 

mortality rates for varioua time periods or between 

countries require that the rates be adjusted for differences in the age distribution of thepopulatione. Table II 

shows crude and adjusted rates since 1938$ as given by 

the Central Bureau of Statistica, Compared withprewar 

rates, mortality for malea has decreased 20 percent 

and for females about 40 percent, The widening sex 

difference in mortality results largely from the increasing death rates from various,causes among men 

at the older ages while those for older women continue 

to fall. 

Sex and age,-Mortality rates for men and women 

in all age groups decreased until 1950, During the past 

half century, aradicalahif[ has mkenplaceint heper. 

cent distribution of deaths by age. In 1911-12, from35 

to 40 percent of thetotal mortality occurred underage 

20, compared with 6-8 percent in recent years. The 

most dramatic change inthemortality pattern has been 

~he reduction in death rates among infanta and preschool children. Infant mortality was responsible for 

20-25 percent oftbetotal mortality 50 years ago, conlpared with less than 5 percent in recent years; mo 

tality among preschool children has fallen from ~~tn 

little more than 1 percent of the total. Inthecens Js 

year 1920, infant deaths were five orsixtimes thepr]­

portion they constituted of the population; in 1960, tle 

ratio was 2 to 1. 

Major cawe.s of death.— The radical change in mo rtality patterns reflects the drastic fall inmortalityfm 

a number of themajor causes attheyounger age groups. 

As causes of death among children, diseases of the 

respiratory system diminished from giants to dwar’s, 

while the common infectious diseases, tuberculosis, 

and diseases of the gastrointestinal system have practically disappeared as causes of mortality. 

Changes in the percent distribution of deaths by 

cause at the ages under 20 are shown in table HI. qhe 

death rates for accidents, congenital malformations,: nd 

neoplasms did not decrease and therefore becane 

rdatively more important. Currently, congenital roilformations are as dominant ininfant mortality asrespiratory and digestive diseases were in the past. 

Violence—almost entirely accidents—has become the” 

major cause of death in this age range. 

Life expectancy. —During thelast half century, the 

decrease in mortality at all age groups, particularl~ in 

childhood, has greatly increased the expectation of ife 

at birth. As table IV shows, the life expectancy for males 

increased from 51.0 years in 1900-1909 to 71.4 ye ~rs 

in 1956-60, a gain of 20.4 years; for females, it r me 

from 53.4 to 74.8 years, or 21.4 years. In the late fiftjes, 

the expectation of life at birth for males increased 

slightly but remained constant at all subsequent a~es. 

In the sixties, expectation of life is decreasing for m: les 

50 
Table 111, Percentagedistribution of deaths among persons under 20 years of age, by age and
 cause: Netherlands,selectedyears, 1921-63


I


Cause of death


(SeventhRwiaiw-International Lists, 1955)


Percentagedistribution


ALI causes”””..-....-.“....-.-.”------..-....---- 100.0 100,0 100.0 100.0 100.0 100.0 

‘Wbercuksis, all fwxna..--­
 ....---.....-..-.---ool-olg 0.0 0.2 2.5 0.2 12.3 

All cwkm infmtive and parasitiadiseasea------O2O-l38 0.9 1;:: 18.8 

Neopla$ms.......................................l4O.239 0.7 ::; ::: 1::; 8,3 0.9 

DiabetesmelMtus....-........-.........--”---------26O 0.0 0.0 0.2 0.0 0.1 

Diaeaaes of the bl~od and blood-formingorgans--29O-299 0.1 0.1 0.2 0.5 0.5 0.3 

IMaea$w ~f che nervous system and sense wgans-330-398 6.2 

Di,aeaaw of the c%rculataryeyatew-------------4OO-468 ;:; n ;:: M ;:; 

lkheaae~ of the reapiratcmysystem--------------47~-527 3,4 22.4 10.2 1;:2 34.7 

Di,aea!3@aof the digestive syste~-........-.--...53O.587 2.2 v! 20,5 5.8 4.1 6.3 

DLseaae~ d the &eniCourinarysystem.-.---------59O-637 0,1 0.1 0.4 0.8 0.8 0.9 

Deliverxeeand aampltqationsof pregnancy, 

childbirth,and the puerperium-------”689------64O-689 ... .,. ... ... .,* ... 

CrxwsniCalrnalformations--------------v---------750-7592;.; 21.4 16.0 9,7 0.8 

S mptoma, senilityaand ill-definedconditions--78O-795 . 6.6 2::; 3.1 5,8 9,4 

Ax1 other 

diseasee..--.-.25O.25&,270.289,300.326,700-749,760-77655.8 ‘ 50.0 19.3 2.0


Acctdents,poison~nga,and violence-----------E8OO-E999 2,6 2.3 0.5 3::: 2%; 7.5


——


— 

5-14 years 15-19 years


Cauge of death I I


(SeventhRevision-InternationalLists, 1955) 1961- 1951- 1921


1963 19531 19231


!!z!!z@


percentagedistribution


~J.1 Cauaea. . . . . . . . . . . . . . ..-..-w-p----q---”=m”--”” 100.0 100.0 100.0 100,0 100.0 

Tube~cUksis, all foams...-....-..-..-..-------”OOl-~l9 0.5 6.9 5;.: 

All other infectiveand parasiticdiseases------O2O-l38 2.; l::? 

Neopla@ma-..------.-.--...---.--.---------------l4O-23917.6 1;.: J:: l!:; 2:4 

Diabetes melkitus-----------------------------------26O0,4 0.4 1.3 

Diaeasea

Meeatiea of the nervous system and sense organs-330-398 9.3 8.0 8,2 

Disieaseaof the circulatorysystem--------------4OO-468 l:+ 3.3 6.4 5:4 

Diwsa$es of the respiratorysystem--------------470-5~7 N 6.0 3.0 6.8 

Diaeaaea ~f Cht?digestive system----------------53O-587 3.6 3,9 2.4 5.8 2:: 

systen------------59O-637 1.7 2,0 2.8 3.3 2.2 

Deliveriesand compkkatians”o~ pregnancy, 

of the blood and blood-formingorgans--29O-299 O*5 0:8 0.6 0:9 ;.; 

Diseases Qf the gerd,tourinsry


childbirth%and the puerperium----...----------64O-689 0.2 0,5 0.4


Congenitalmlforwtiona----------=---e--------=750=75g 9.; ;.; 5.9 ~.; 0.4


S mptoms, senility,and ill-definedcanditiQns--78&795 2.6 . 5.2 . 1.8


A x1 other


diseasee---.--.25O-252897O-289
 ,300-326,700-749,760-776


Accidents,poifloninga,
and violence----------”E8OO-E999 4::: 3::; 4::: 2::: ::$


l~~zl.z~ and 1951.53 deaths adapted to the SeventhRevision-


51

------

------

~ 

Table IV. Expectation of life at specified€ azes. bv ;ex: Netherlands, 1890-1940 and€

Period€

1961 -65----€

1956-60----€

1953-55----€

1950-52----€

1947-49----€

1931-40----€

1921-30----€

1910-20----€

1900-1909--€

1890-99----€

Male Female 

At 1 year At At 1 year€ b~rth of age birth of age€

Average number of years of life remaining 

71.1 71.4 75.9 75.9 

71.4 ;+: 74.8 75.0 

71.0 73.9 74.3 

70.6 71:6 72.9 73.5 

69.4 70.8 71.5 72.4 

65.7 67.8 67.2 68.6 

61.9 65.3 63.5 65.8 

55.1 60.3 57.1 61.1 

51.0 58.2 53.4 59.5 

46.2 54.8 49.0 56.2 

SOURCE: Central Bureau of Statisti.cs, Pocket 

Year Books. 

at all ages, but still increasing for women. Infant mor-€

tality was so high at the beginning of the century that€

the expectation of life at birth was 8 years less than€

that atagel.Since 1950,thisdifferential has diminished€

tolessthanl year.€

Socioeconomic Development 

At the beginning of this century, social security€

hardly existed. Unemployment and sickness created€

poverty. Housing for the working class was cramped€

and primitive. A normal working day was more than€

10 hours. Wages were low old-age pensions had not€

yet been dreamed of. During World War I,food short-€

ages led to rationing. The twenties brought some pros-€

perity, but the economic crisis of the thirties again€

brought widespread unemplo~ent and misery.€

Since World War II, Holland has become one of the€

so-called welfare states-of western Europe: a certain€

level of social security for the great masses, relatively€

little unemployment, moderate wages increasing with€

the standa~d of living, no poverty as asocial evil, no€

serious alcoholism and, @st but not least, an average€

diet of reasonable quality and quantity.€

In 1950 there was one car for every 73 inhabitants;€

in ,1956 one in 27, andin 1964 one in 7. Motor-assisted€

pedal cycles (mopeds) more and more replace traditional€

bicycles. A network of roads andrailroads covers the 

country. “ 

Urbanization.—The rapid population growth in the 

densely inhabited Netherlands goes hand in hand with an 

increase in urbanization, and the Netherlands is one of€

the most urbanized countries in Europe. Although no ~€

city in Holland has as many as 1 million residents, the ~€

cities in the western part of thecoumry,which together€

shelter4 million people, run into each other.€

In 1900, one-thirdof thepopulationlived inmunici-€

palities of less than 5,000 inhabitanta, buttheproportion€

decreased toone-fifth in1939, andtoonly one-eighthin€

1963 (table V). In municipalities of 5,000-19,999, the€

proportion hasremained constant at30percent, andin€

municipalities of 20,000-99,999 it has been steadily in-€

creasing.€

On the other hand, in19001ess than one-fourthof€

the population lived in cities of more than 100,000 in-€

habitants, and this proportion increased to one-third in€

1960. Among municipalities, only the group of munici-€

palities of 20,000-99,999 inhabitants has increased its€

share of the total population since 1950; the shortage€

of housing in the big cities forces people to live in€

neighboring towns.€

In the largest cities, births are somewhat fewer€

than would be expected on the basis of their population,€

but in municipalities of under 20,000 inhabitants, the€

birth rate is somewhat higher than average.€

Not less important than the changing distribution€

of the population by size of municipality has been the€

postwar tendency of villages and small towns to adopt€

an urbanized way of life. Holland is a small country.€

The longest distance from north to south is 300 kilo-€

meters (about 190 miles), and from east to west 150€

kilometers (about 95 miles). It is becoming more and€

more densely populated:€

1900------ 150/sq. km. 390/sq. mi.€

1920 210/sq. km. 540/sq. mi.€

1960 350/sq. km. 910/sq. mi.€

Because of restricted area and increasing density, the€

distinctions between rural and urban areas, and es-€

pecially Mween the rural and urban way of life, di-€

minish year by year.€

Occupation. -Table VI gives the percent distribution of the working population by occupation and sex€

in the census years 1947 and 1960.€

Between these censuses, the proportion of the work-€

ing population which was self-employed decreased as€

employees increased. The biggest shift occurred in€

agriculture; the proportion so engaged dropped from 19€

to 11 percent of the working population, the reduction€

being much more marked for females than for males.€

iVorkers in domestic service decreased while workers€

in industry increased. The relative number working in€

public utilities, trade and finance, transport and other€

services, and in construction rose. Only 1.5 percent of€

the workers are in mining.€

The proportion of women in the working population€

decreased slightly between 1947 and 1960—from 24 to€

52 
------------------ ---------------

------------------ --------------

------------------ --------------

------------------

------------------ --------------

------------------ --------------

------------------ --------------

------------------ --------------

Table V. Percentagedistributionof	births and population,by size of municipality:Netherlands,


selectedyears, 1909-63


Item Total 500,000 

1963


Births


Population


1960


Births 

Population


1955


Births


Population


1950


Births


or more


100 15 

100 18 

100 

100 H 

100 

100 H 

100 17 

250,000- 1oo,ooo- 20,000- 5,000- Under 

499,999 249,999 99,999 19,999 5,000 

Percentagedistribution 

10 13 

11 12 

10 13 

11 12 

10 16 

11 14 

11 16 

Births-----------------Population-------------- 100 21 11 

1939


Births


Population


1930


Births


Population


1920 

Births


Population


1909 

Births 

Population


100 13 4 23 

100 16 5 20 

100 14 2 27 

100 17 5 21 

100 15 2 

100 17 2 % 

100 34 

100 1: i 29 

NOTE: 1909-30 populations are census data; 1939-63 populations are estimated. 

SOURCES:Adapted from Central Bureau of Statistics,IStatistiek van de loop der bevolkingvan Nederland (Vital statisticsand migration statisticsof theNetherlands),1900-1940;and Vitaland 

heal,thstatistics,migration and age distribution,1940-63.


22 percent of the total. In 1947, nearly one-fourth of 

the agricultural workers were wome~ in 1960, only 

10 percent. In industry, the proportion has remained 

constant (16 percent), consisting mainly of girls under 

25 years of age. The numbers of women (including. the 

married) in governmental, educational, and social servicee are increasing considerably, while those in domest ic work and agriculture are diminishing. 

About 7 percent of married women work, and of 

these only about one out of every four hasat Ieast one 

child under age 6. Only a negligible proportion of mar-. 

ried women with infants work. With reference to child 

rearing, it is important to know that married women, 

especially mothers of young children, seldom work— 

even part time—eventhough they can easily get jobs. 

Day nurseries for infants are scarce and are utilized 

mainly by children of unmarried mothers. 

Education.-Primary school education has been 

compulsory since 1900. Education beyondthislevelmay 

be used as an indirect yardstick of social conditionsin 

a country. The proportion attending postprimary schools 

has nearly doubled since 1947. Sitice1960, 80 percent 

53 

14 
-------------------------

-------------------------------

----------

--------------------

-------------------

----------------------

-------------------

Table VI. Percentage distribution of employed population, by occupation and sex: Netherlands, 

1947 and 1960 

Occupation Both sexes Male Female — (International Standard 

Industrial Classification) 1960 1947 1960 1947 1960 19[+7 

Total 100 

Agriculture (including fishing)----- 11


Mining


Ffanufacturing and industry 3$


Constructi,on-----.-----.--.n.q------ 10


~bli,c uti~ities


Trade and finance 1:


Transport, storage, and . . co~xcatlon-----------..-----.-qother services 1; 

Domestic services 3 

Residuall ----.---------------------” 2 

lMostly military. 

SOURCE: Adapted from Central Bureau of Statistics. 

of the boysand thegirlsatage 14 received such schoolin~ at age 16, the proportions are 60 ~d30 percent, 

respectively, and at age 18 they are 30 and 10 percent. 

Male adolescents attend secondary and vocational 

schools, and females mostly schoolsfor home economics. More than 6 percent of the boys andl.5 percent 

of the girls enter a university. Government expenditures on education increased from 1.6 percent of the 

national income in 1900 to 3.7 percent in 1940 and6 

percent in1960. 

Practically all adolescents not attending school 

have jobs in factories, offices, public services,oragriculture. Most of the older girls are trained in household 

work in their own homes and have some experience in 

handling babies. District nurses have for along time 

been giving special courses for expectant mothers, 

preparing them for motherhood and baby care. About 

10 percent of the girls entering the Iabor force choose 

professions like nursing, home help service, nursery 

teaching, etc., thus becoming better prepared to take 

care of children than are their contemporaries. 

Housing. —In our welfare state, housing is a major 

social problem. Less than half of the families enjoy 

decent housing, nearly half have only moderately good 

housing, and 5-10 percent live in bad housing. Onefourth of all families live with other individuals or 

families. Young couples are the hardest hit by the 

housing shortage. 

One-fourth of all families have no children at 

home. Of the families with children, nearly two-thirds 

have one or two children, nearly one-third have three 

percentage distribution 

100 100 —. :1.00 —— 

19 13 18 

2; 3$ 17 

8 12 

1 1 

14 14 

5 

5 I 

Pocket Year Book, 1964. 

to five children, and 7percent,six ormore. A separate 

room for the infant is the exception. 

The greatest part of the population liveainhou:Jes 

where such necessary conveniences as central heating, 

a bathroom, telephone, and elevator are the exception 

rather than the rule. Of modern household appliances, 

only the vacuum cleaner and the washing machine ure 

in general use in working-class families. Nearly all 

families, however, have radio and television. Almost 

every house has electricity and running water, but 

running hot water is still relatively uncommon in both 

homes and schools. The fluoridation of drinking water 

has increased in recent years. Toilets arelackinf in 

some rural areas and satisfactory sewage systetn# i!re 

not yet available everywhere. 

Social le~”skation. —The first social Iegislationvas 

the Child Lalmr Act of 1874, which was followed by a 

law on compulsory primary education in 1900, Pritmry 

education has been completely free of charge siuce 

1956. 

In 1903 a lawprovided that workers injured by an 

accident during the working hours were entitled to benefits. The Sickness Benefit Actof1913guranteed bene~its 

during illness of 80 percent of the wages; the betx:fit 

period was gradually increased to 1 year. The Lal]or 

Act of 1919 provided regulations to protect men imd 

women working in industry. The Health Insurance iict 

of 1941 made health insurance compulsory for those 

with incomes under a certain level. Old-age pensi{ms 

(in 1957) and pensions for widows and orphans (in 1959) 

became legal rights, while allworkers were requi:”ed 

54

to pay premiums until age 65. It should be noted that 

premiums are paid for most of the social benefits. 

Officially, social security, “fromthec radletothe 

graver’ has been achieved, butinpractice there is still 

much to be desired: better housing, higher pensions, 

democratization of the educational system, etc. 

Health insurance. -As early as the second half of 

the 19th century, private (nonprofit) sickfund associations were founded for poor people. These organizations 

increased in number, so that at the outbreak of World 

War II half of the population were members. Indigent 

people received free medical care by doctors appointed 

on a part-time basis for that purpose by the municipalities. 

General regulations concerning health insurance 

came into force in 1940-41, This legislation, requiring 

compulsory medical insurance for wage-earners with 

earnings below the so-called prosperity level, provided 

workers and their families the legal right of medical 

care (family doctor, hospitalization, medicines, etc.). 

The prosperity level has risen with the cost of living 

from 4,500 florins a year in 1950 to 7,000 in 1957 and 

to 10,000 in 1965. The premium is set by the Government as a percentage of salary (at present 5 percent), 

employer and employee each paying half. 

This program differs from the British National 

Health Service in two respects: doctors are not paid 

by the State, but by the sickfun@ and people having a 

salary above the so-called prosperity level (one-fourth 

of the population) are not automatically insured. 

General Medical Care 

For more than a century, doctors have been distributed throughout the country, even in the more remote areas. The family doctor is still the key person 

in the system of general medical care services. The 

basis of this system is compulsory health insurance, 

which includes complete curative and obstetrical care: 

family doctor, midwife, specialist, medicines, hospitalization, sanatorium care, and ambulance services. 

However, nursing care at home is not provided. 

Private, nonprofit sickfund associations are the 

administrative link between doctors and patients. Practically all doctors are attached to the sickfunds, which 

cover about 70 percent of the population. The family 

doctor is paid a per capita fee a year—which increases 

with the cost of living—for all insured people on his 

roll, irrespective of the amount o~ type of care given 

the family, The family may choose its own doctor, but 

there is no financial relation between the doctor and his 

sickfund patient. The members of the siekfund are not 

free to go to a specialist or to a hospital, but must be 

referred by the family doctor. 

The annual cost of health insurance per person was 

increased from 38 florins in 1951 to 100 in 1962 (about 

$28). During that period, hospital care accounted for 

one-third of the total cost, fees to the family doctor 

and the specialist for almut 30 percent of the total, and 

medicines for about 15 percent. Obstetrical care took 

only 1 percent of the costs, maternity benefits being 

low—only 55 florins (about $15) per birth. The more 

well-to-do patients, for the most part, have individual 

health insurance coverage. 

Preventive care is not given by the sickfunds, but 

is provided by voluntary organizations to infants and 

toddlers, by municipal school health services to the 

school population, and by factory health services to 

workers in industry. These services are practically 

free of charge. 

The total cost of health care— whether paid by the 

Government, sickfunds, private organizations, or patient— amounted to 3.6 percent of the national income 

in 1953 and to 4.4 percent of the total in 1959. The entire sum paid for medical care is not much greater 

than the amount spent for smoking. 

In 1950, there was one doctor for every 1,100 inhabitants; in 1962, one for every 900. The number of inhabitants per doctor varies inversely with the size of 

municipality, ranging from one doctor for every 2,000 

population in villages to one for 600 in the larger cities. 

The proportion of general practitioners is decreasing 

while that of specialists is rising. In 1950, 41 percent 

of the physicians were family doctors and 26 percent 

specialists; in 1963, the proportions were 34 and 33 

percent, respectively. This trend will undoubtedly continue in the near future. The number of inhabitants per 

family doctor decreased from approximately 3,000 in 

1950 to 2,600 at present. 

There is currently a shortage of doctors in the 

clinical, preventive, and research fields. Dentists are 

in very short supply, only one for every 5,000 population. 

The ‘shortage of nurses has decreased after revision of 

the salary scale, but the problem is far from solved. 

In 1949, hospital beds numbered slightly more than 

4 per 1,000 inhabitants and since then have increased 

to nearly 5 per 1,000. For children under age 15, there 

are 3.5 beds per 1,000., and for adults 5.3 per 1,000. 

Eleven beds per 1,000 live births are available for infants, apart from bassinets for the newborn. Most hospitals are privately owned by religious groups. The 

total number of hospitals has increased only slightly 

in the past decade, but the number of beds has grown. 

About 40 percent of the hospitals have less than 100 

beds, and nearly 50 percent, between 100 and 375. Nearly 

all the hospitals have a children!s department five 

cities have a childrents hospital. 

Preventive Care 

As already noted, neither the sickfunds before 1940 

nor the compulsory health insurance program inaugurated at the beginning of World War If provided preventive care or nursing at home. To fill this gap, voluntary organizations— so-called cross societies—have 

been founded since the turn of the century. 

55 
.—— 

Cross societies. — The main activity of these societies (which have no relation to the Red Cross) has been 

to provide the services of district nurses, who have a 

double task: to give basic nursing care to seriously ill 

patients at home and to teach the families fundamental 

health practices. Health education thus was given before it became known as such and was concentrated on 

general hygiene, infant care, and aftercare of tuberculosis patients. 

District nurses are of two types: the “general duty” 

nurse of cross societies in rural areas, and special 

nurses for infant care provided by voluntary organizations in larger cities. From the ~ginning, ~th types 

assisted in infant welfare centers. For 60 years, families have gladly accepted district nurses as home 

visitors. For more than two generations they have done 

nonspectacular but important work and, until recently, 

under difficult conditions. 

No exact information is available on the number of 

district nurses before 1940. It appears that in 1920 

there was one district nurse for every 10,000 inhabitants. By 1940 the ratio was one nurse for every 6,000, 

in 1957 one for 4,500, and more recently one for 3,000. 

The number of patients, particularly children, visited 

by the nurses decreased, but the field of activities has 

been widened and has come to include care of the aged 

and aftercare of patients with chronic diseases and 

mental disturbances. 

Before World War II, the local premises of the 

cross societies were extremely simple, and the hundreds of new centers built since 1950 are still far 

from luxurious. Usually, the nurse has her living 

quarters over the center. Years ago, she used to live 

in rented rooms, but always in the community and 

in close contact with her “patients.” The three main 

cross societies have the same policy, but are divided 

according to religion as are hospitals, schools, trade 

unions, etc. 

Cave of the older child. —Before World War II, not 

much special attention was given the preschool child. 

This did not prevent mortality among preschool children 

from decreasing more rapidly than infant mortality. In 

the 1930’s, cross societies organized welfare centers 

for preschool children in the same way that they did 

infant welfare centers, but it was not until after 1950 

that a reasonable numb”er were available. Moreover, the 

activities of the “district nurse have increasingly been 

directed to the preschopl child. 

School health services which were begun at the end 

of the 19th century have grown to cover the entire 

country. Nearly all school health officers are employed 

full time. The pioneer work in school health services, 

which included health education of the family, has probably indirectly influenced infant care. School health 

services are organized by municipalities and are stateendowed, just as welfare centers for infants and preschool are organized by cross societies, which are 

voluntary agencies subsidized by the Government. 

In the past, school health services supervised primary school pupils and, since 1945, also all nursery 

school pupils. In the past decade, an increasing number 

of postprimary school students have been supervised. 

University health services have come into operat [on 

since World War II. Although a continuity of care from 

conception to young adulthood is not yet assured, e:tch 

child receives more or less comprehensive care in 

the various stages of his development. A longitudinal 

followup tracing the development of the child is still 

far from having been reached, but is advocated by lhe 

Department of Health Development of the Netherlands 

Institute for Preventive Medicine. 

i%tn”tion. —The vicious circle of malnutrition let ding to lack of resistance against illness, infectictts 

diseases, and infants succumbing to these diseases 1as 

been broken, at least in industrialized countries. No 

single factor has improved the health of the inf: nt 

more than the adequate nutrition of mother and chi:d, 

Nutrition of the great mass of people was poor in 

the 19th century, and its improvement is one of the ma. or 

achievements of the 20th century. Few scientific diita 

are available. However, local surveys at the beginn ng 

of this century indicated that the average daily intx ke 

per capita was about 2,500 calories, including less ti an 

70 grams of protein and 50 grams of fat. National d,lta 

on the intake of nutrients and calories are availalde 

since 1936 and are shown in table VII. Before Wo-ld 

War II, the average per capita intake daily was 80 grams 

of protein and 100 grams of fat. Soon after the war, fat 

consumption was lower than it had been just prior to 

the war, but the protein intake reached the prewar level, 

almost equally divided between animal and vegeta ~ble 

protein. Since 1948, fat consumption has been increas (.ng 

steadily. The average daily caloric intake per capita has 

risen to almost 3,000 and as in preceding years, 11 percent is supplied by protein. 

The per capita intake of milk was 500 cubic centimeters before World War II, 650 in 1948, and gradually 

decreased to 550 cubic centimeters in 1963, On the 

other hand, the consumption of cheese, meat, poult ‘y, 

and eggs has increased, while fish consumption kas 

remained constant. Hence, the ratio of animal to 

vegetable protein has been increasing and is in the ratio 

of 5 to 3. 

Special surveys show that the nutrition ~f pregmmt 

and nursing mothers is below the daily allowances ~or 

these groups, especially with respect to animal protein, 

calcium, and riboflavin-deficiencies caused mainly by 

inadequate milk intake. 

The diet of pupils aged 13-16 years in a primary 

technical school was carefully studied. The aver~ ge 

daily caloric intake within this group rose with advar ce 

in age from 3,500 to 4,000, of which 12 percent was 

supplied by proteins, 33 percent by fats, and 55 percl mt 

by carbohydrates. The total protein intake of adolescents 

averages more than 100 grams daily, of which less tl an 

half is of animal origin. The nutrition of female aco56 
�

Table VU. Per capita daily intake of nutrients and calories: Netherlands, selected years, 1936-63 

Protein Calories 

Year Fat Source 

Total Number


F Protein Fat Carbohydrate I 

Percentage distribution 

1.963---------------- 135 2,970 

1958---------------- 123 2,900 

1953---------------- 1:: 2,800 

1948---------------- 2,630 

1936-38------------- 102 2,730 

SOURCE:Mulder, T., De voeding in Nederland. Voeding 20:105, 1959; 23:16,1962; 25:604, 1964. 

lescents (mothers-to-be) is poorer than that of males, 

because, among other things, they drink less milk— although mistakenly—to watch their weight. The daily 

caloric intake of the age group 8-10 years averages 

2,200 for girls and nearly 2,500 for boys, the protein 

consumption being 60-75 grams daily, more than half 

consisting of animal protein. 

Because surveys are lacking, it is-not possible to 

describe the trend of nutrition among preschool chil­

~ren over the past half century. Most probably, the 

diet was fa~from adequate at the beginning ofthecentury, but htis gradually improved. The average daily 

intake inthe agegroup l-4 years averages 1,400-1,500 

calories, 40 grams of protein—of which two-thirds isof animal origin—and 55 grams of fat. Milk consumption is half a liter per day, and the supply of vitamins 

and minerals is adequate, 

Cod-1iver oil has been given infants andpre~chool 

children since the turn of the century, but no; regulariy. 

Rickets was far from uncommon in the good old days. 

Since 1920, vitamin D has been given infants more 

regularly and rickets has disappeared. The rachitic 

pelvis has become a rarity. 

The nutrition of infants has never been analyzed. 

Until World War II, breastfeeding was common, at least 

for the first 3montbs; artificial feeding was prepared 

by mothers from fresh cow’s milk. Pasteurization of 

milkhaa been compulsory since 1940, andbovinetuberculosis was eradicated in the 1950’s. A revolution in 

infant feeding has occurred in the past 15years bythe 

sale of commercially prepared liquid infant foods which 

have the right formulas and are hygienically prepared. 

Tuberculosis.—The trend of tuberculosis mortalityin acountry may be looked upon asa yardstickof 

the development of sociohygienic conditions. Until the 

end of World War 1, tuberculosis took a heavy toll of 

life, especially among infants, as figure 11shows. Between the two World Wars, however, mortality from 

this disease fell rapidly, as the result of a systematic 

fight against the disease and of improved sociohygienic 

conditions. Tuberculosis mortalityin infants decreased 

from more than 200 per 100,000 in 1920 to about 35 in 

1940, while a similar reduction occurred among preschool children. During World War II, the rise in mortality from the diseaae was less marked than one would 

have expected under war conditions and severe malnutrition. Since 1946, tuberculosis mortality has dropped 

I 

I 0., 1,2, .1, ,,,1, , <,1,,,,1,,,, l,. ... ,, I,, C, I,, ,,lllI 

1,!0 ,,,, ,,20 ,s2, ,,3, ,,3s ,,,, t,,, ,,,0 ,,,, ,,,!3 

,,.” 

Figure Il. Infant mortal ity rates for tuberculosiss:


Netherlands, 1910-61.


57 
--

I€

—€

40.0 

20.0 

10.0 

8.0 z 

~ 6.0 ~ 

: 4.O . 

: 

g 2.0 -

g 

z 

# 1.0 -, 

Q8 -

: 0.6 -

~ 

0.4 -

0.2 -

0.1, , ,1,,,,1,,, , I 1 0, , Illtllti,,, l,,,,,,,, , - 1922 1930 1940 1950 19’eo 

YEAR 

Figure Ill. Mortal ity rates for diphtheria at al 1 ages:


Netherlands, 1923-6!.


precipitously (without mass BCG vaccination) and has 

been virtually eliminated as a cause of death. Sanitoria 

for tuberculous children have been closed for lack of 

patients. 

Vaccination—s.-Before World War II mass vaccinations were restricted to smallpox. The significance of 

smallpox vaccination in a country like Holland is more 

traditional than real and is not always harmless for 

infants. 

Vaccination against diphtheria was on an individual 

basis prior to the war, and the reduction in morbidity 

and mortality from the disease without a mass vaccination program created a false security. Thousands of 

—000 

children fell victim to diphtheria during World War II, 

After the war, however, vaccination against diphtheria 

and whooping cough became popular. In 1952-53, routine 

vaccination was introduced on a voluntary basis and 

reached about 80 percent of the children, a measure of 

the health consciousness of their parents. Since 1956, 

both diphtheria and whooping cough have practica I ly 

disappeared as causes of death (figs. HI and 11’). 

Inasmuch as a contact by mail is made to remind 

the parents of every infant and preschool child to have 

their children vaccinated or revaccinated, and as most 

vaccinations are given in welfare centers free of charge, 

attendance at welfare centers has been stimulated by 

the vaccination program. 

From a public health viewpoint, the downward trends 

for tuberculosis and the common infectious diseases of 

childhood are” of much greater overall importance than 

would be expected from the control of these diseas~s. 

Their virtual eradication among children has not only 

decreased general mortality and morbidity but has also 

indirectly improved the health status of children and 

parents. 

~.. .€

;€$ ,::€

: c.€

q 40 :€

g ,0:


ii —&aSad m k birth,€

u Based m VW!.MO,€

‘g ,, :€

K 0“ .€

0>€

0., ,*,O ,s,0 ,,*O ,,,0 ,,4. ,,s0 Mm 

, YE,” 

I 

Figure IV. Mortal ity rates for pertussis among children


under 5 years, by age: Netherlands, 1900-1965.


58


1 
APPENDIX II 

MATERNAL AND CHILD HEALTH SERVICES 

Organization of Services Figure V shows the present maternal and child 

health (MCH) organization, which, in principle,, has 

Prenatal care, infant care, and school health serv- not changed appreciably during the past 40 years. The 

ices began about the same time—shortly after the turn left side of the chart shows the government public 

of the century—albeit independently of each other. All health authorities of the state, provincial, and municthese activities were modest in the beginning, but to- ipal levels. The maternal and child health officer in 

gether they brought health consciousness to working- the Office of the Chief Medical Officer of Health superclass families. vises the MCH organization, but through the provincial 

I ORGANIZATION OF MATERNAL AND CHILD HEALTH IN .THE NETHERLANDS


I <


Director genera! Infectious diseases 

of public health : Tuberculosis Mental health 

0 Hospltok Dental services : 

.- Rehabititation Statistics Instlt”te of 

Marital hospitals lPhormacy Chief medical officer .: ~utritio” Maternal and Preventive 

Lo boratorl*s lVeterinOry service of health child hea~th Medicine 

I —— .— I — — — — — — ! — — —. 

I n 

Provincial medicol w 

officer of health =Z 

:~ 

Zm~ln 

;> 

z 

district nurse u 

— — — —— —. 

Municlpa1 hwith service 

Child guidance ___ Maternity home help LOCO1health clinic 

authorities 

District nurse 

M.C. H. oct[vities FAMILY 

Schoo[ hm[th service Heo[th colonies Midwife 

SpeciOL service Family d.xt.m 

o 

IPa, lo,K 177F 

Figure V. flrganization of official and voluntary maternal and chi Id health services in the Netherlands. 

59 
medical officer of health. On the right side are shown 

the major national, provincial, and municipal voluntary 

agencies. 

The family doctor and the midwife are independent, 

practicing a “free” profession, but Zmthreceive by far 

the largest part of their income from sickfunds. The 

district pediatrician is a provincial or district supervisor of all MCH activities except those of the family 

doctor, the midwife, and the hospital. The superintendent 

district nurse supervises the district nurses, insofar 

as their work in infant and toddler welfare centers is 

concerned, and gives courses for expectant and young 

mothers. 

Obstetrical Care 

Obstetrical care in the Netherlands has three 

characteristics, which historically and currently are 

interrelated. 

(1)	 Domiciliary confinement is “much more usual 

than institutional confinement. 

(2) Midwives handle deliveries by themselves. 

(3)	 A special organization provides maternity car~ 

and help in the home. 

Prenatal and natal care are legal rights of members 

of ‘the aickfunds. The doctor or midwife is paid by the 

sickfunds on a per case basis. The midwife is indirectly 

protected by the fact that the sickfunds do not pay the 

doctor for cases of normal pregnancy and delivery if 

a midwife practices in the district where the pregnant 

woman lives. Neither is the cost of hospitalization reimbursed for “normal” deliveries. In determining whether 

hospitalization is medically justified, the policy of the 

sick funds, in accordance with the general obstetrical 

attitude in the past, has given greater priority to the 

condition of the mother than of the child. Until the midfifties, little consideration was given to biological 

factors influencing perinatal mortality, such as age and 

parity of the mother, twin pregnancy, unfavorable obstetrical history, and prematurity. 

Prenatal care. —Prenatal care, which has been developed by both doctors and midwives since 1900, has 

been modernized and expanded since World War II. 

About 60 percent of the pregnant women see their doctor 

or midwife six times or more during pregnancy. The 

number of visits decrease with increase in parity, even 

though mothers of particularly high parity need extra 

attention during pregnancy. 

Half of the pregnant women place themselves under 

the supervision of a doctor or a midwife before 18 

weeks of gestation, the first visit usually being earlier 

when attended by a doctor. Nevertheless, prenatal visits 

show a definite concentration in the last month of pregnancy, Aimost half of perinatal mortality occurs in premature and therefore cannot be influenced by prenatal 

care in the last weeks of pregnancy, however frequent 

this may be. 

Special surveys have shown that prenatal care can 

be improved. This can be accomplished, in part at least, 

by closer cooperation between midwife, family doctor’, 

and obstetrician, 

Natal cave. —Traditionally, confinement has usually 

taken place at home. Between the two World Wars, only 

10-15 percent of all deliveries occurred in hospitals, 

which proportion increased to 20 percent in 1950, to 25 

percent in 1956, and to 30 percent in 1963. The large 

differences in hospitalization between rural and urkan 

areas have remained, however, the proportions in 1!50 

ranging from 12 percent in the villages to about 40 pt rcent in the large cities; in 1963 the range was from 18 

to 55 percent. 

In the three largest cities, half of the deliveries 

take place in hospitals. In small municipalities, the 

limited facilities for institutional confinements contr~bute to underhospitalization. As has already been noted, 

30 to 35 percent of all births are in high-risk groups. 

T&ing into account difficulties in diagnosis, an aver: ge 

hospitalization rate for births of 40 percent seems t.dvjaable for the Netherlands. 

In 35 percent of all births, obstetrical aid is Entrusted to nlidwives, in 45 percent to general practitioners, and in “20 percent to obstetricians. On the 

average, the obstetrician has 100-250 deliveries a 

year, the general practitioners 0-100, and the midw[fe 

50-200. Of all home confinements, more than 40 pt rcent are attended by midwives, more than 50 percf :nt 

by family doctors, and about 5 percent by obstetricians. 

Specialists are in charge of about 60 percent of ~11 

institutional deliveries and general practitioners : nd 

midwives of almut 20 percent each. 

In towns, obstetrical aid in domiciliary confir ements is given mainly by midwives and in rural arwas 

mainly by doctors, the ratio of doctors to midwi~ es 

being 1 to 2 in towns and 2 to 1 in rural areas. 

The obstetrical approach continues to be generally 

conservative. In 1938, cesarean section was per forrr ed 

in 0.5 percent of all deliveries and in 1958 in a little 

more than 1 percent. Analgesia is hardly ever practic ed 

and is not preferred by the mother. Notwithstanding ~.he 

conservative attitude, the general practitioner regula cly 

uses forceps or performs breech extraction if needl:d, 

and the midwife sometimes performs a breech extr: ction. 

Maternity Home Help 

To make up for the relatively low frequency of 

hospitalized confinements, an organization has b~:en 

founded to provide maternity home help. A trained girl 

gives care to mother and child during childbirth t.nd 

takes the place of the mother in the home. This unicpe 

organization has centers all over the country, and :he 

60 
------------

---------------------- ---------------

Table VIII. Percentage distribution of live 

births and stillbirths, by place of delivery 

and uae of maternity hotne help: Netherlands, 

selected years, 1950-63 

Deliveriesat home


Deliv­


cries
 Year Total in With Without


hospital maternity maternity


home help home help


I Percentagedistribution 

1963--- 100 :; 

1959--- 100 :; X 

1955--- 100 24 30 46 

1950--- 100 20 19 61 

nurses in charge supervise thematernityhomehelpers, 

especially the students. 

The girls are trained for 15months onhow to care 

for the mother and child, onhow tocook, wash, anddo 

other household chores (including the care of older 

children at home), and are taught the basic elements of 

obstetrics and pathology of the newborn. The girls stay 

with the family 10 hours a day for 10 days. Family 

doctors like the assistance of maternity home helpers 

very much, but midwives are not so enthusiastic about 

thorn. 

In 1950, this organization covered one-fourth of all 

home deliveries, and by 1963 the proportion had risen 

to one-half. As table VIII shows, the relative frequency 

of births in the home with maternity home help and in 

the hospital have increased, while home confinements 

without home help have been diminishing (Verbrugge, 

1%5). 

In 1950 maternityhome help was given to about 

50,000 families; at present, the annual number is nearly 

100,000. In this group of home deliveries, maternal 

mortality and perinatal mortality remain very low, 

despite a doubling of the number of families served. 

The larger the municipality the lower the percentage of families using maternity home help, contrary to 

the relation of hospital confinement and size ofmunicipality. The combined total of births in hospitals and 

those in the home with help has been practically constant in rural and in urban areas (around 65 percent). 

Welfare Centers 

Infants, —With theawakening ofsocial
consciousness

in western Europe, progressive people were shocked at 

the high infant mortality rate. In Holland, the first infant welfare centers were started at the turn of the 

xmtury, after analysis of infant mortality brought to 

light the great differences between social classes. In 

the largercities voluntary agencies werefounded
toreduce thehighrates.Infant
welfarecenterswere setup


in thepoorestpartsofthecities,
 sometimescombined


witha milkkitchen, inimitation
 oftheFrenchgoutte de 

lait. The nurse was the pivot of the welfare centers; in 

the cities she devoted herself exclusively to infant care. 

Gradually, cross societies organized infant welfare 

centers in villages,. which were conducted by a doctor 

with a district nurse as home visitor. The influence of 

the first centers on infant care was greater than could 

have been expected from their relatively small number. 

Mothers eagerly accepted the advice of the doctor and 

the nurse, passing their newly acquired knowledge to 

family members and neighbors. In time, the number of 

c~nters grew, increasing from 400 in 1930 to 1,100 in 

1940. Infant care developed so rapidly in this prewar 

decade that the severe economic depression and widespread unemployment did not adversely influence infant 

mortality, which, in fact, decreased steadily in this 

period. 

III the past, understandably, the advice given in the 

infant welfare centers concerning feeding, bathing, 

clothing, keeping the baby outdoors, and caring for sick 

infants was somewhat rigid. The use of clocks, scales, 

and exact feeding formulas was a reaction against the 

old-fashioned methods of infant care in the average 

family. Although the rigid approach has not yet disappeared, since 1950 infant care has greatly improved 

and milk-hygiene has reached a satisfactory level. 

The growth in infant welfare centers is also shown 

by the fact that in 1930 there was one center for every 

450 live births, in 1940 one in every 170 births, and in 

1960 one in every 100. A summary of the increased 

attendance at the centers since 1956 is given in table IX. 

In 1956, two-thirds of all liveborn children visited infant welfare centers; in 1962, the proportion was threefourths. No definite information is available on the social 

class of the infants not visiting the centers. Most probably, the majority are of the middle and upper social 

classes, which are cared for by the family doctor or a 

pediatriciatq a small proportion are of the lower social 

class families reluctant to accept periodic supervision, 

although especially in need of it. However, even the 

Table IX. Average attendanceat infant welfare 

centers: Netherlands, 1956, 1959, and 1962 

I I I 

Characteristic I1962I 1959I 1956


Entrantsper 100 livebirths- 74 

Visits per infact 10 !? :: Infantsper session: 

Total 21 22 21 

First visits 2 2 2 

SOURCE: van Wieringen,.3.C., unpublished


data.


61 
poorest segment of the population are sickfund members 

and hence get free curative care for their infants. 

The main activity of infant welfare centers includes 

the periodic examinations of healthy infants, which 

average a little over 10 in number during the first year 

of life. The first examination, preceded by a visit of 

the district nurse to the family, takes place when the 

baby is between 3 and 8 weeks of age, usually earlier in 

cities than in rural areas. Routinely at every visit the 

child is weighed, feeding instructions are given, its 

psychosomatic development is watched, and it is given 

a physical examination. The nurse makes home visits, 

especially if medical and social reasons make it necessary. Infant welfare centers also give vaccinations 

against diphtheria, whooping cough, tetanus (since 1953), 

and polio (since 1957). At the end of the first year of 

life, about 80 percent of the babies-the proportion 

varying from 60 to 100 percent in different areas—are 

vaccinated against these four diseases, by means of 

quadruple vaccines, and against smallpox. Vaccination, 

however, is not compulsory, 

Vitamin D prophylaxis has been practiced systematically since the 19301s, by which time the use of codliver oil had long been common. For a generation, 

rickets has not been a problem in pediatrics. Obstetrics, 

in turn, has reaped the fruits of the prevention of rickets 

in the present generation of childbearing women during 

their childhood and adolescence. 

Breast feeding has always been encouraged by infant welfare centers. In the 1930ts, two-thirds of the 

infants at the age of 3 months had complete or nearly 

complete breastfeeding; in 1950, the proportion was 60 

percent; in 1960, it was 50 percent, and more recently 

is 45 percent or less. The popularity of breastfeeding 

is decreasing for a variety of reasons: mothers are no 

longer willing to continue until the end of the nursing 

period, doctors no longer advocate it with the same 

conviction as before, and prepared infant foods have 

become available in very handy form and are of good 

composition. Increased hospitalization of births may 

be another reason for the decreasing frequency of 

breastfeeding. It has long been known that a smaller 

proportion of the infants born in hospitals than those 

born at home are breast fed—one of the disadvantages 

of hospitalization. 

There is a sharp, and mmewhat artificial, division 

between preventive and curative care of the infant. The 

infant welfare centers are concerned only with’ ‘healthy” 

children and are not allowed to give any treatment. If 

an infant is ill, he has to be referred to the family 

doctor. 

Infant mortality at ages 1-11 months, the period 

of observation in infant welfare centers, has become 

relatively low. The original task of the centers— reduction in infant mortality— is no longer of paramount 

importance, even though postnatal mortality can be reduced further, particularly in working-class families. 

The primary function of the centers has become health 

promotion. While the task’ of the centers has shifted, 

practices and approaches have not always been adapted 

to meet this radical change. 

In the Netherlands, preventive care of mother and 

child has a tradition of two generations. Practically a11 

mothers receive prenatal and natal care, and more thun 

80 percent of the infants have periodic supervision. 

Toddlers. —The first welfare centers for toddlers 

were started in the larger cities almut 1930—a logic. d 

continuation of the care given by infant welfare center:. 

In 1940, there were only 125 centers for toddlers distril,­

uted throughout the country; in 1955, they numberc d 

about 1,000, and at present approximately 2,000. TI e 

proportion of all 1- year-olds attending these centers 

increased from almut 45 percent in 1955 to around 60 

percent in 1962. 

Between 1 and 4 years of’age the child is examined 

an average of four times, always by a doctor. The dis ­

trict nurse makes home visits to toddlers. The revac ­

cination of these older children indirectly protects infants before they are vaccinated. 

The rapid expansion of toddler welfare centers in 

the postwar period goes hand in hand with the increasin J 

interest of mothers, nurses, and doctors in the behavior 

of the preschool child. These centers probably are indirectly improving infant care by rhaking mothers aware 

of the problems of educating young children and by”re - . orientation of the approach of workers in infant welfar? 

centers to the problems of infancy. In the medical cart: 

of infants and toddlers, increasing attention is beini 

given to the biological development of the child. However, 

child development is not yet the basis of child welfan 

work, as it should be in these advanced times. 

Curative Care 

Mothers and children, as members of the family. 

have free medical care if the father belongs to a sickfund. When the child is ill, the family doctor is called 

and in serious cases the child is referred to a pediatrician, and eventually to a hospital, 

In general, there is no shortage of beds for chil= 

dren, as 3.5 beds per 1,000 children under the age of 1: 

are available, and some acute illnesses are disappear 

ing. Beds for infants are usually occupied by thos 

with chronic conditions, such as congenital malforma 

tions. The average hospital stay for children is 18 or 1’ 

days; for mothers and their newborn, it is 10 to 12 day 

Pediatrics is an old specialty in Holland, datin: 

from the end of the 19th century, at least in the large 

cities. The number of pediatricians has gradually bee 

increasing. Just before World War II, Holland had on 

pediatricii% for every 22,000 children under age 15; i 

1950, one in 15,000; and, more recently, one in 11,00 

More than 40 percent are women. Pediatricians ar 

consultants and are not allowed to be the family docto 

62 
I 

for children. Although most ppulamclans are more perienced pediatricians specializing in newborn ba­


interested in curativ~ than preventive care, they render bies.


service to welfare centers, Superspecialization is Cooperation between pediatricians and obstetri­


slowly developing in pediatrics. Child cardiology isad- cians is slowly developing. This is particularly neces­


vancing with cardiac surgery. Themtmber of surgeons sary because pathological cases comprise a relatively


for children is low, and there are only a handful of ex- large proportion of hospital deliveries.


APPENDIX Ill 

DEFINITIONS OF TERMS 

Stillbirth.—The birth of a fetus after the 28th week of 

gestation which does not breathe or show any other evidence of life. 

Births.-The sum of live births and stillbirths. 

Infant death .—The death of a Iiveborn infant under 1 year 

of age. 

Infant loss. —The sum of stillbirths and infant deaths. 

Pem’natal deaths.—The sum of stillbirths and deaths 

among Iiveborn infants during the first 7 calendar days 

of life. 

Neonatal death.—The death of a liveborn infant during 

the first 28 calendar days of life. 

Postneonatal death.— The death of a livelmm infant from 

28 days through 11 months of age. 

Postnatal death.—The death of a liveborn infant from 7 

days through 11 months of age. 

Rates 

Infant loss, stillbirth, and perinatal mortality rates are 

expressed per 1,000 births. 

Infant, neonatal, postneonatal, and posmatal mortality 

rates are expressed per 1,000 live births. 

ooo— 

63 
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS 

Public Health Service publication No. 1000 

SeYies 1.	 ProgYams and collection pYoceduves.— Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding the data. 

SeVies 2. Data evaluation and methods Yesearch. —Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, contributions to statistical theory. 

Series 3.	 Analytical studies. — Reports presenting analytical or interpretive studies based on vital and health 

statistics, carrying the analysis further than the expository types of reports in the other series. 

Sevies 4. Documents and committee reports. — Final reports of major committees concerned with vital and 

health statistics, and documents such as recommended model vital registration laws” and revised birth 

and death certificates. 

SeYies 10.	 Data from the Health Interview SWvey. —Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related toPics, based on data cO1lected 

in a continuing national household interview survey. 

Series 11.	 Data fvom the Health Examination Su?’vey.—Data from direct examination, testing, and measurement of national samples of the population provide the basis for two types of reports: (1) estimates 

of the medically defined prevalence of specific diseases in the United States and the distributions of 

the population with respect to physical, physiological, and psychological characteristics; and (2) 

analysis of relationships among the various measurements without reference to an explicit finite 

universe of persons. 

SeTies 12.	 Data from the Institutional Population Surveys. — Statistics relating to the health characteristics of 

persons in institutions, and on medical, nursing, and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

SeYies 13.	 Data from the Hospital Dischavge .’%’vey. —Statistics relating to discharged patients in short-stay 

hospitals, based on a sample of patient records in a national samP1e of hospitals. 

Series 20.	 Data on mortality. —Various statistics on mortality other than as included in annual or monthly 

reports— special analyses by cause of death, age, and other demographic variables, also geographic 

and time series analyses. 

Series 21.	 Data on natality, rnan%ge, and divoyce. —Various statistics on natality, marriage, and divorce other 

than as included in annual or monthly reports— special analyses by demographic variables, also 

&eographic and time series analyses, studies of fertility. 

Series 22. Data fyom the National Natality and Mortality Swveys. —Statistics on characteristics of births and 

deaths not available from the vital records, based on sample surveys stemming from these records, 

including such topics as mortality by socioeconomic class, medical experience in the last year of 

life, characteristics of pregnancy, etc. 

For a list of titles of reports published in these series, write to: Office of Information 

National Center for Health Statistics 

U.S. Public Health Service 

Washington, D.C. 20201