The committee met, pursuant to call of the chairman, in the hearing room of the Committee on Finance, Senate Office Building, at 10 o'clock a. m., Hon. Joseph I. France presiding.

The committee thereupon proceeded to the consideration of S. 3259,, which is here printed in full, as follows:

[S. 3259, Sixty-sixth Congress, first session.]

A BILL For the public protection of maternity and infancy and providing a method of cooperation between the Government of the United States and the several States.]

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That there is hereby annually authorized to be appropriated out of any money in the Treasury not otherwise appropriated, the sums authorized in section 2 of this act, to be paid to the several States for the purpose of cooperating with the States in promoting the care of maternity and infancy in the several States; to provide instruction in the hygiene of maternity and infancy, and the sum authorized in section 5 for the use of the Federal Board of Maternal and Infant Hygiene for the administration of this act and for the purpose of making such studies, investigations, and reports as will further the efficient administration of this act.

SEC. 2. That for the purpose of paying the expenses of said cooperative work in providing the services and facilities specified in this act, and the necessary printing and distribution of information in connection with the same, there is permanently authorized to be appropriated, out of any money in the Treasury not otherwise appropriated, the sum of $480,000 for each year, $10,000 of which shall be paid annually to each State, in the manner hereinafter provided: Provided, That there is also authorized to be appropriated for the use of the States, subject to the provisions of this act, for the fiscal year ending June 30, 1921, an additional sum of $2,000,000; for the fiscal year ending June 30, 1922, the sum of $2,400,000; for the fiscal year ending June 30, 1923, the sum of $2,800,000; for the fiscal year ending June 30, 1924, the sum of $3,200,000; for the fiscal year ending June 30, 1925, the sum of $3,600,000; for the fiscal year ending June 30, 1926, the sum of $4,000,000; and annually thereafter the sum of $4,000,000: Provided further, That the additional appropriations herein authorized shall be apportioned among the States in proportion which their population bears to the total population of the United States, not including outlying possessions, according to the last preceding United States census: And provided further, That no payment out of the additional appropriation herein authorized shall be made in any year to any State until an equal sum has been appropriated for that year by the legislature of such State for the maintenance of the services and facilities provided for in this act.

So much of the amount appropriated apportioned to any State for any fiscal year as remains unexpended at the close thereof shall be available for expenditures in that State until the close of the succeeding fiscal year. Any amount apportioned under the provisions of this act unexpended at the end of the period during which it is available for expenditure under the terms of this section shall be reapportioned, within sixty days thereafter, to all the States in the same manner and on the samebasis, and certified to the Secretary of the Treasury and to the State boards described in section 4 in the same way as if it were being apportioned under this act for the first time.

SEC. 3. The Federal Board of Maternal and Infant Hygiene (hereinafter called the Federal Board) shall consist of the Secretary of Labor, who shall be the chairman; the chief of the Children's Bureau, who shall be the executive officer; the Surgeon General of the United States Public Health Service, and the United States Commissioner of Education. The Federal Board shall have charge of all matters concerning the administration of this act, and shall have power to cooperate with the State boards authorized to carry out the provisions of this act. It shall be the duty of said Federal Board to make, or cause to have made, such studies, investigations, and reports as will promote the efficient administration of this act.

SEC. 4. That in order to secure the benefits of the appropriations authorized in section 2 of this act, any State shall, through the legislative authority thereof, accept the provisions of this act and designate or authorize the creation of a State board of maternal and infant hygiene, consisting of not less than three members, which shall have all necessary powers to cooperate as herein provided with the Federal board in the administration of the provisions of this act: Provided, That in any State having a child welfare or child hygiene division in its State board of health, the said State board of health may be directed to administer the provisions of this act through such divisions. The Federal board may require the State boards cooperating under this act to appoint advisory committees, both State and local, to assist in carrying out the purposes of this act; the members of such advisory committees shall be selected by the State boards, and at least half of such members shall be women. In any State, the legislature of which does not meet in 1920, the governor of that State, so far as he is authorized to do so, may accept the provisions of this act and create a State board of maternal and infant hygiene of not less than three members, or designate a division of child welfare or child hygiene in the State board of health, to act in cooperation with the Federal board. The said Federal board shall then recognize such State board for the purposes of this act until the legislature of such State meets in due course and has been in session sixty days.

SEC. 5. That so much, not to exceed 5 per cent, of the amount authorized for any fiscal year under this act, as the Federal board may estimate to be necessary for administering the provisions of this act, shall be deducted for that purpose, to be available until expended. Within 60 days after the close of each fiscal year the said Federal board shall determine what part, if any, of the sums theretofore deducted for administering the provisions of this act will not be needed for that purpose, and apportion such part, if any, for the fiscal year then current in the same manner and on the same basis, and certify it to the Secretary of the Treasury, and to the several State boards described in section 4 above, in the same way as other amounts authorized by this act to be apportioned among the several States for such current fiscal year.

SEC. 6. That out of the amounts authorized under this act the Federal Board is authorized to employ such assistants, clerks, and other persons in the city of Washington and elsewhere, to rent buildings outside of the city of Washington, to purchase such supplies, material, equipment, office fixtures, and apparatus, and to incur such travel and other expense as it may deem necessary for carrying out the purposes of this act.

SEC. 7. That within 60 days after the approval of this act the Federal board shall certify to the Secretary of the Treasury and to each State board described in section 4 the sum which the Federal board has estimated to be deducted for administering the provisions of this act, and the sum which it has apportioned to each State for the fiscal year ending June 30, 1921, and on or before January 20 next preceding the commencement of each succeeding fiscal year it shall make similar certifications for such fiscal

year.

SEC. 8. That any State desiring to avail itself of the benefits of this act shall, by its board described in section 4, submit to the Federal board detailed plans for carrying out the provisions of this act. These plans shall include the provisions to be made in the State for the administration of the act; the provision of instruction in the hygiene of maternity and infancy through public-health nurses, consultation centers, and other suitable methods, and the provision of medical and nursing care for mothers and infants at home or at a hospital when necessary, especially in remote areas. If the Federal board finds these plans to be in conformity with provisions and purposes of this act, due notice of approval shall be sent to the State board.

SEC. 9. That in order to provide popular, nontechnical instruction to the residents of the various States, particularly to those to whom such facilities are not accessible, on the subject of the hygiene of infancy, hygiene of maternity, and related subjects, the State board described in section 4 is authorized to arrange with the State university, land-grant college, or other public educational institution for the provision of extension courses by qualified lecturers: Provided, That not more than 25 per centum of the sums granted by the United States to a State under this act may be used for this purpose.

SEC. 10. That in order to receive the benefits of the appropriations authorized under this act the State shall, through the legislative authority thereof, appoint as custodian for said moneys its State treasurer, who shall receive and provide for the proper custody of such money and its disbursement on requisition of the State board described in section 4.

SEC. 11. That the facilities provided by any State boards cooperating under the provisions of this act shall be available for all residents of the State.

SEC. 12. That the Federal board shall every three months ascertain the amounts expended by the several State boards described in section 4 in the preceding quarter year. On or before the 1st day of January and quarterly thereafter the Federal board shall certify to the Secretary of the Treasury the amount to which each State is entitled under the provisions of this act. Upon such certification the Secretary of the Treasury shall pay to the State treasurer as custodian the amounts so certified. SEC. 13. That each State board cooperating under this act shall make such reports concerning its operation and expenditures as shall be prescribed by the Federal board. The Federal board may withhold the allotment of moneys to any State whenever it shall be determined that such moneys are not being expended for the purposes and under the conditions of this act.

If any allotment is withheld from any State, the State board of such State may appeal to the Congress of the United States, and if the Congress shall not direct such sum to be paid it shall be distributed elsewhere, in the manner described in the last paragraph of section 2.

SEC. 14. That if any portion of the moneys received by the treasurer of any State as custodian under this act shall, by any action or contingency, be diminished or lost, it shall be replaced by such State, and until so replaced no subsequent allotment under this act shall be paid to such State. No portion of any moneys apportioned under this act for the benefit of the States shall be applied, directly or indirectly, to the purchase, erection, preservation, or repair of any building or buildings or equipment, or for the purchase or rental of any buildings or lands.

SEC. 15. That as chairman of the Federal board the Secretary of Labor shall include in his annual report to Congress a full account of the administration of this act and of the expenditures of the moneys herein authorized.

The CHAIRMAN. The committee will first hear Dr. Anna E. Rude, Director of Division of Hygiene, Children's Bureau, Department of Labor.

STATEMENT OF ANNA E. RUDE, DIRECTOR DIVISION OF HYGIENE, CHILDREN'S BUREAU, UNITED STATES DEPARTMENT OF LABOR, WASHINGTON, D. C.

Dr. RUDE. Mr. Chairman, I would like first to give you a brief synopsis of the bill.

Section 1 states that the sums authorized to be appropriated under this act shall be used for the purpose of cooperating with the States in promoting the care of maternity and infancy; for the use of the Federal Board of Maternal and Infant Hygiene in the administration of this act; for the purpose of making studies, investigations, and reports to promote the efficiency of operation.

Section 2 provides for the annual appropriation of $10,000 to each State accepting the conditions of the law, irrespective of State contribution, and an additional appropriation beginning with $2,000,000, which shall be increased annually by $400,000 for five years, so that thereafter the annual additional appropriation shall be $4,000,000. This additional appropriation is to be apportioned among the States in the proportion which their population bears to the total population of the United States according to the last Federal census, provided that each State shall appropriate year by year an amount equal to its allotment from the Federal fund in excess of the initial $10,000. The provision of the initial allotment of $10,000 to each State without requirement of contribution from the States is to the interest of the

smaller and poorer States. Appropriations unexpended at the close of any fiscal year shall be available for use in that State until the close of the succeeding fiscal year, when unexpended funds shall then be reapportioned among all the States in the same manner as previously annortioned.

Section 3 creates a Federal board of maternal and infant hygiene, which is charged with the governmental administration of the measure. The board is to consist of the Surgeon General of the United States Public Health Service, the Commissioner of the United States Bureau of Education, the Chief of the Children's Bureau, and the Secretary of Labor, who shall be chairman of the board. The Federal board is to cooperate with the States in carrying the measure into effect, and it is also empowered to have made such studies, investigations, and reports as will promote efficient administration.

Sections 4 and 10 deal with the creation and operation of the State boards, and provide that in States having a child hygiene or child welfare division in the State board of health that board may be designated the State board. In those States joining in the plan and not having a child hygiene division, the State legislature may create a State board consisting of at least three members, or pending the regular convening of the State legislature the governor may create a State board or designate a division of child hygiene in the State board of health. The State treasurer shall be custodian of the funds. The Federal board is empowered to require State boards cooperating under this act to appoint State and local advisory committees, at least one-half of the members to be women, thus enlisting in its operation the responsible interest of those who will be most immediately affected by the law.

Sections 5, 6, 7, and 12 state the financial provisions for the operation and functioning of the Federal board. The cost of Federal administration shall not exceed 5 per cent of the total amount appropriated during a given year, and within 60 days after the approval of this act the Federal board shall certify to the Secretary of the Treasury and to each State board of maternal and infant hygiene the sum which the Federal board has estimated to be deducted for administration and the sum apportioned to each State for the fiscal year. Similar annual reports of appropriations are required to be certified on or before January 20 of each fiscal year. The Federal board is authorized to employ assistants, etc., in the city of Washington and elsewhere to incur travel and other expenses as are necessary. The Federal board shall report quarterly to the Secretary of the Treasury the sums spent by the State boards during the preceding quarter and shall certify the amount to which each State is entitled for the succeeding quarter.

Section 8 provides that States desiring to avail themselves of the provisions of this act shall submit detailed plans to the Federal board for approval, the plans to include provisions for administration, instruction in the hygiene of maternity and infancy through public health nurses, consultation centers, and medical and nursing care for mothers and infants at home or at a hospital when necessary, especially in remote areas.

Section 9 authorizes State boards to arrange with State universities or other public educational institutions for extension courses on the

hygiene of maternity and infancy and related subjects, provided that not more than 25 per cent of the Federal grant be used for this purpose.

Section 11 makes all facilities provided for States cooperating with the Federal board available to all residents of a State and considered in the light of a public utility.

Section 13 provides that State boards shall be required to report to the Federal board, and if it determines that funds are improperly expended the allotment may be withheld.

Section 14 provides that the States shall be responsible for the money allotted from the Federal funds, and any amount lost shall be replaced by the State before any other apportionment shall be paid. No Federal moneys apportioned to the State shall be used for buildings, repairs, equipment, or rent, the intent being that they shall be applied solely for services.

Section 15 states that the Secretary of Labor shall include in his annual report to Congress a full account of the administration of this act.

The phraseology could be improved in several sections and rearrangement of the order of some of the sections would seem more logical. Obviously lines 23 and 24, section 4, page 4, will require rewording, since there will be no legislature in session after May, 1920. I would therefore suggest that certain amendments of the kind indicated be made.

BRIEF FOR MATERNITY BILL.

The United States is wasting the lives of mothers and babies. In 1918 some 23,000 mothers died in childbirth and nearly a quarter of a million babies died under 1 year of age. Most of these deaths are preventable.

Other countries show markedly lower death rates of babies and mothers in childbirth. It is safer to be a mother in 14 important foreign countries than in the United States, and babies have a better chance in 7 foreign countries than here in our own country.

Maternal mortality and infant mortality from maternal causes are not decreasing in the United States. During the past 20 years the typhoid rate has been cut in half, the tuberculosis rate remarkedly reduced, the diphtheria rate reduced more than one-half, but there has been no decrease in maternal deaths. About one-half of all infant deaths occur within six weeks of birth, and these early deaths are due chiefly to the condition of the mother and the lack of proper care and instruction for the mother during pregnancy and confinement. Maternal deaths and infant deaths from maternal causes are not decreasing, because mothers do not yet have the skilled care and advice that they need.

According to the minimum standards of maternity and infant care outlined as a result of the series of conferences held in May, 1919, under the auspices of the Children's Bureau of the United States Department of Labor, the protection of the child must begin with the protection of the mother. Care during pregnancy and confinement and instruction in the hygiene of maternity, infancy, and childhood must be made available for all mothers through such agencies as prenatal clinics, maternity hospitals, maternity care in the home,