children's health centers, and systems of public health nursing adequate to reach every mother and child.

This neglect of maternity and infancy leads not only to thousands of preventable deaths, but to lowered vitality and permanent impairment of health and efficiency for thousands of women and infants who survive. The Children's Bureau studies in rural areas in six different States have revealed:

High maternal mortality rates, above the average for the United States as a whole.

That 80 per cent of the mothers had received no advice or trained care during pregnancy.

Many mothers had no trained attendance of any kind at confine

ment.

Inaccessibility and often entire lack of hospitals, doctors, and

nurses.

Practically no organized effort to meet the need for instruction in prenatal and infant hygiene and for trained care during pregnancy and confinement.

An almost prohibitive cost for providing adequate care at confinement in scattered and isolated rural districts. The very districts where advice and supervision during pregnancy and better help at confinement are most needed are the ones least able to obtain it without financial aid.

In certain cities a beginning in the right direction has been made through the visiting nurses, the prenatal clinic, the hospital receiving maternity cases, and the infant welfare or child health centers. But in no instance has the need for such facilities been fully met. Moreover, the wives of self-respecting men in the lower income groups, who will not accept private charity and who can not afford the cost of adequate care and instruction from physicians and nurses in private practice, are usually unable to secure the protection that modern science might give them and their babies. The neglect of mothers and babies and the resulting losses of life and vigor are matters of grave concern. The Nation can not afford such waste of human resources.

Of more than 22,000 city babies studied by the Children's Bureau and representing every type of home in seven cities, more than threefifths were born into families where the fathers' earnings were below the amount which was at that time the minimum for providing the bare necessities of existence. Only 1 in 10 was in a family where the fathers' earnings reached a fair minimum for comfort.

More recently the Bureau of Labor Statistics of the United States Department of Labor has analyzed the budgets of some 31,000 families. It found the average family income below the amount needed for decent living and well-balanced diet. The expenditure for health care varied from family to family and from group to group. But Commissioner Meeker says:

Despite the great irregularities in the distribution of these expenditures for sickness there is a remarkable increase with the increase in the amount of income. This indicates that those in the lower income groups are not able to pay for adequate medical and hospital service, for no one would contend that those in the higher income groups are squandering money recklessly on physicians, surgeons, dentists, and like.

The problem is not local or sectional, but nationwide. We have noted that the average maternal death rate for the death registration area of the United States is high in comparison with rates in other

countries. According to the mortality statistics for 1918 published by the United States Bureau of Census, the States having Statewide registration of deaths and showing maternal mortality rates even above this high average for the death registration area represent many sections of the country: Colorado, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Montana, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Utah, and Virginia.

Federal action, therefore, is urgently needed, and this bill offers a practicable method of cooperation between the Federal Government and the States. Such a method is already successfully operating in promoting agricultural work, vocational education, and the building of good roads. To extend Federal aid to mothers and babies is of no less importance. To summarize:

Federal aid would stimulate the rapid extension of work which is necessary to prevent further loss of life and health.

It would make possible the coordinating and supervising of local work, which are essential if the lessons of experience are to be generally applied.

It would provide facilities in those areas where the local funds are least able to provide them by making State and Federal appropriations available to supplement local resources.

And, in general, it would further the nation-wide interest in the protection of maternity and infancy which has developed in recent years, and help it to find prompt, effective and permanent expression. At this point, Mr. Chairman, I should like to read a telegram just received. [Reading:]

Dr. ANNA RUDE,

Children's Bureau, Washington, D. C.

NEW YORK CITY, May 11, 1920.

Regret illness prevents coming. General federation favor measures for protecting maternity and infancy.

MARY WOOD, Chairman of Legislation.

(The following telegram was subsequently submitted and directed by the chairman to be inserted in the record:)

Dr. ANNA E. RUDE,

PHILADELPHIA, PA., May 13, 1920.

Director of Hygiene, United States Department of Labor,

Washington, D. C.

Previous important engagement prevents being at hearing. Representing 31 national organizations, including National Congress of Mothers and Parent Teacher Association. On their behalf I urge passage of maternity and infancy bill.

Mrs. FRED K. SCHOFF,

President National Congress of Mothers

and Chairman Child Welfare Department National Council of Women. The CHAIRMAN. Dr. Rude, that is a very clear and comprehensive analysis and statement concerning the bill.

Do any members of the committee wish to ask questions? Congressman Towner, do you wish to ask Dr. Rude any questions?

Representative TOWNER. I might suggest, Dr. Rude, that in the rural districts the problem is almost primarily a nurse problem, is it not?

Dr. RUDE. I think there is no question but that the establishment and maintaining of county nursing units will be one of the most important steps in meeting the problem.

Representative TOWNER. In Iowa and in quite a good many States in the Central West the effort is being made by community centers and other interested associations to try to secure the establishment of hospitals, one in each county, if possible; if not, one in four or five adjacent counties; and then to have one or more nurses assigned to each county, who will go to the remote country districts in maternity cases and in other cases where help is needed and where nurses can not be procured. I do not know how it is in other places, but throughout the Central West the great difficulty now is in obtaining nurses. Dr. RUDE. That is true all over the country, but public health nurses are being trained and educated in many quarters, thus increasing the number just as rapidly as possible.

Representative TOWNER. Do you think there are sufficient nurses in training to supply this increased demand that would come from the stimulation of interests occasioned by, for instance, the passage of this bill and other incentives of that kind?

Dr. RUDE. Perhaps not immediately, but it is hoped that this bill will so stimulate interest as to induce individuals more and more to train for public health nursing. Of course, this bill hopes not only to enlist the services of physicians and public health nurses, but of educators as well. All preventive work is largely educational, and we want to utilize our State universities and agricultural extension

courses.

Representative TOWNER. This work of the community nurses is not only, of course, in these cases, but extends to the examination, survey, and report of the country schools. There is no compulsion about it, but these reports from each county school, from each district school, and each consolidated school is published in the papers. No names are given, but the number of defective teeth, eyesight; and defective conditions generally are reported. That stimulates a great interest in the matter, and conditions are thereby greatly benefited.

The passage of this bill is intended to meet all of these conditions, is it not, Dr. Rude?

Dr. RUDE. Yes. it is important to emphasize, I think, that the provisions of this bill are in no sense compulsory. They are privileges which may be enjoyed by those who wish to take advantage of

them.

Representative TOWNER. To assist the States and stimulate their activities.

Dr. RUDE. There are a number of States which have child hygiene divisions, but such limited appropriations that they feel they can scarcely make a beginning. For instance, Idaho has an appropriation of $3,800 for two years' work. The State Health Officer writes that they can do no work this year, but will have to wait and use their funds next year, in order to be able to pay an $1,800 salary. Manifestly, a State like that very definitely does need Federal funds to supplement the State appropriation.

The CHAIRMAN. That is a very satisfactory exposition, Dr. Rude. The committee will next hear Miss Caroline Fleming, Assistant Chief of the Children's Bureau.

STATEMENT OF MISS JULIA LATHROP, CHIEF OF THE CHILDREN'S BUREAU, DEPARTMENT OF LABOR, WASHINGTON, D. C. (BY MISS CAROLINE FLEMING, ASSISTANT CHIEF).

Miss FLEMING. I am simply reading the statement of Miss Lathrop, who can not be here.

(The statement of Miss Julia Lathrop, read by Miss Fleming, is here printed in full, as follows:)

To the Members of the Senate Committee on Public Health and National Quarantine:

I wish merely to explain why the Children's Bureau especially desires to support Senate bill 3259 for the public protection of maternity and infancy. For seven years the Children's Bureau has devoted much attention to the subject specifically stressed in its organic act, namely infant mortality. Necessarily the study of maternal mortality is involved. None of these studies, it should be stated are medical studies. They consider the economic, industrial, social, civic, and family factors surrounding the child and mother. The bureau finds that many other civilized countries exhibit more favorable records of maternal and infant deaths than does the United States as a whole.

It is also true that the death rates of babies with inthe United States vary from those which are exceedingly favorable, to those which are exceedingly unfavorable according to the care available for mother and child. Rural isolation, civic neglect, low income, ignorance are among the chief accompaniments of high infant mortality in the United States.

Plainly it is for the public interest that young life and maternal life should be conserved. But in order to give an approximately fair chance for life for every child born it is impossible to rely solely upon local funds initiative, otherwise the figures would not show the present extreme variations in localities of varying resources. The figures of family income gathered by the bureau prove irrefutably that a large proportion of babies are born into homes where the income can not cover the expenses of satisfying the reasonable requirements of mother and baby. (See save the youngest.) Hence this bill attempts to safeguard equitably the lives of all babies and mothers, on the plan of joint contribution by the Federal Government and by any States accepting the provisions of the proposed act-a plan of support already tested by the operation of the law for aid to agriculture, the good roads law, and other

measures.

It is the clear purpose of the bill to provide an instrument which shall be flexible and human, but also in the highest degree practical and economical.

It is needless to say that its value will depend upon the scientific wisdom and human understanding with which it may be administered. It is a step toward coordinated responsibility for health and well being, for the bill recognizes that the family is the social unit and that upon its physical, mental, and moral adequacy depends national progress. Family well being involves many services, among them those of teacher, physician, nurse, and social economist. Overlapping must be avoided, and the highest degree of joint service rendered, hence members of the Federal board represent education, health, and social economy. We believe such coordination extremely important.

JULIA C. LATHROP.

Miss FLEMING. Mr. Chairman, I also desire to have submitted for your record, if you please, statement by Sir Arthur Newsholme, of Johns Hopkins School of Hygiene, formerly principal medical officer of the local Government board, central Government health department for England and Wales.

(The statement of Sir Arthur Newsholme, together with appended statement referred to, are here printed in full, as follows:)

STATEMENT BY SIR ARTHUR NEWSHOLME, M. D., K. C. B., JOHNS HOPKINS SCHOOL OF

HYGIENE.

I am asked to make a statement as to the advisability of grants in aid of and to stimulate local work in promotion of the welfare of mothers and their infants.

Such work must depend for its success on the activity and efficiency of local sanitary authorities, which in England are counties, county councils, and smaller authorities.

These authorities vary greatly in efficiency; and there is no law which compels them to attain to a minimum standard of work in these or in most other particulars. The local authority, being representative of local public opinion, is left to form its own standard, though by means of reports of inspectors from the central Government departments, advice and warnings are given and reports are published setting out local defaults.

The principle of giving grants from the treasury of the central Government in aid of local work, when this comes up to a minimum standard, has been found most valuable in raising the level of local work, in respect of police administration, poorlaw work, educational work, and many branches of public health work.

During the last few years it has been developed largely in regard to measures for child welfare and for the prevention and treatment of venereal diseases. In view of the urgency of the last-named problem, a special act of Parliament was passed rendering it obligatory on local authorities to provide means for the diagnosis and treatment

of these diseases.

The rapid growth of work for the promotion of welfare in maternity and infancy may be gathered from the following statement:

It may be added that these grants will hereafter be given by a single department, the ministry of health.

These grants are given on a basis of 50 per cent of total approved expenditure by the local authority or by approved voluntary agencies.

I append a printed statement, on pages 16 and 17 of which is given the multifarious purposes for which these grants are given. It will be seen that they comprise a fairly complete scheme of assistance at home and in hospital, or at a clinic, for mothers and their infants; and that they include not only medical and nursing aid, but also domestic help under certain circumstances.

There can be no doubt that these provisions have already been the means of saving many lives and have relieved and prevented much suffering; and that the promise of the future is even greater.

REGULATIONS UNDER WHICH GRANTS NOT EXCEEDING ONE-HALF OF APPROVED NET EXPENDITURE WILL BE PAYABLE BY THE LOCAL GOVERNMENT BOARD TO LOCAL AUTHORITIES AND TO VOLUNTARY AGENCIES IN RESPECT OF ARRANGEMENTS FOR ATTENDING TO THE HEALTH OF EXPECTANT MOTHERS AND NURSING MOTHERS AND OF CHILDREN UNDER 5 YEARS OF AGE.

1. The local Government board will pay grants during each financial year, commencing on April 1, in respect of the following services:

(1) The salaries and expenses of inspectors of midwives.

(2) The salaries and expenses of health visitors and nurses engaged in maternity and child-welfare work.

(3) The provision of a midwife for necessitous women in confinement and for areas which are insufficiently supplied with this service.

(4) The provision, for necessitous women, of a doctor for illness connected with pregnancy and for aid during the period of confinement for mother and child.

(5) The expenses of a center, i. e., an institution providing any or all of the following activities: Medical supervision and advice for expectant and nursing mothers, and for children under 5 years of age, and medical treatment at the center for cases needing it.

(6) Arrangements for instruction in the general hygiene of maternity and childhood.