the subject of the hygiene of infancy, hygiene of maternity, and related subjects, the State board of maternity aid and infant hygiene is authorized to arrange with the State university, land-grant college, or other educational institution for the provision of extension courses by qualified lectures: Provided, That not more than twenty-five 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 provided 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 rquisition of the State board of maternity aid and infant hygiene.

SEC. 11. That the facilities provided by the State board of maternity aid and infant hygiene under the provisions of this act shall be available for all residents of the State, but the State board may require persons receiving specified services to pay a fee for the same under regulations approved by the Secretary of Labor: Provided, That moneys collected under this section shall be turned over to the State treasurer and deposited in the fund used for the purposes and expenses of carrying this act into effect.

SEC. 12. That the Chief of the Children's Bureau, Department of Labor, shall every three months ascertain the amounts expended by the several State boards of maternity aid and infant hygiene in the preceding quarter year. On or before the first day of January and quarterly thereafter the Secretary of Labor 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 the State board of maternity aid and infant hygiene shall make such reports concerning its operations and its expenditures of funds as shall be prescribed by the Chief of the Children's Bureau, with the approval or under the direction of the Secretary of Labor. If the Secretary of Labor determines that any moneys provided under this act are not being expended for the purposes and under the conditions of this act, he may decline to approve any further allotments to such State.

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 appropriated under this act for the benefits 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 building or lands.

SEC. 15. That the receipt by any person of aid under this act shall not be construed as the receipt of charitable relief, and shall not in any way affect unfavorably the legal status of such person.

SEC. 16. That 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 provided.

STATEMENT OF MISS JEANNETTE RANKIN, REPRESENTATIVE IN CONGRESS FROM THE STATE OF MONTANA.

Miss RANKIN. I have prepared a little synopsis of the bill. Section 1 of the bill provides for an appropriation of money to be paid to the States for the purposes of cooperating with the States in promoting the care of maternity and infancy in rural districts; and to provide instruction in the hygiene of maternity and infancy.

Section 2 calls for the sum of $480,000 to be permanently appropriated each year, $10,000 of which shall be paid annually to each State; also an added sum of $1,000,000 for the first year, this sum to be increased $200,000 each year until it reaches the sum of $2,000,000. These supplementary allowances must be equaled by State appropriation. The allotments to States are to be made on the basis of relation of the rural population of State to total rural population of United States by last preceding Federal census. Any unexpended State apportionment at the close of the fiscal year shall be available for the State until the close of succeeding fiscal year. If still unexpended, it

shall be reapportioned within 60 days to all the States as if it were being apportioned for the first time.

Section 3 provides that to secure the benefits of the act the State legislature must accept its provisions and authorize the creation of a State board of maternity aid and infant hygiene, with power to cooperate with the Chief of the Children's Bureau, Department of Labor, in its administration. The State board is to be appointed by the governor, of which he is to be ex-officio chairman, composed of a physician from the State board of health, a registered nurse, a teacher from the university or agricultural college. I want to offer an amendment later providing for three women on that board. The board is to elect its vice chairman and secretary, and notify the Chief of the Children's Bureau of the assent of the State. Where the legislature does not meet within a year of the passage of the act, the governor shall accept the provisions and create a board to cooperate with the Chief of the Children's Bureau. The Chief of the Children's Bureau shall recognize such board until the first legislature has been in session 60 days.

Section 4 provides that the Chief of the Children's Bureau shall have the administration of the act and shall cooperate with the State boards; shall also make studies, investigations, and reports that will further its effective administration.

Section 5: The cost of Federal administration is not to exceed 5 per cent of the total amount appropriated during a given year. The allotments to the State shall be made on the basis of the relation that the rural population of each State bears to total population of the United States by the last preceding Federal census.

Section 6: The Secretary of Labor is authorized to employ assistants, and so forth, in the city of Washington and elsewhere, to rent buldings, purchase supplies, and so forth, and to incur other necessary expenses.

Section 7 provides that within 60 days of the approval of the act the Secretary of Labor shall certify to the Secretary of the Treasury and to each State board of maternity aid and infant hygiene the sum he estimated to be apportioned to each State.

Section 8: States desiring to avail themselves of the act shall submit to the Secretary of Labor detailed plans for work. These plans shall include the provisions for administration, for instruction in the hygiene of maternity and infancy, for medical and nursing care for mothers and infants, especially in remote areas.

In section 9, that extension courses may be arranged for in educational institutions, but not more than 25 per cent of sum granted to State to be so expended.

Section 10: That the State, through legislative authority, shall appoint the State treasurer custodian of the funds.

Section 11: That a fee may be required for the facilities provided, but it must be turned into the fund.

Section 12: That the Chief of the Children's Bureau shall report money spent in each State every three months.

Section 13: That the State board shall report, and if the Secretary of Labor determines money is not properly expended he may decline to approve further allotments.

Section 14: That the States shall be held responsible for the money given them, and no money is to be used for buildings, equipment,

or rent.

Section 15: That the act is not a charity.

Section 16: That the Secretary of Labor shall include in his annual report to Congress a full account of the administration of the act. Miss Fleming, the assistant chief of the bureau, is here and has prepared a brief which she desires to read to the committee.

The maternity and infancy bill would place with the Secretary of Labor and the Chief of the Children's Bureau the responsibility for its administration, so far as the Federal Government is concerned. The Department of Labor is a department to promote human welfare, one of whose duties it is to ascertain adequate standards of life. The Children's Bureau, in the bill establishing it in 1912, was assigned by Congress the whole field of child welfare, and no other branch of the Government is concerned with child welfare as a whole. During the six years of its existence it has been making a careful study of infant and maternal mortality, of the most successful methods of carrying on infant welfare work, of obtaining for mothers proper prenatal supervision and instruction, and the possibility of adequate obstetrical care. As a result of these studies it has published many bulletins and leaflets, which have increased the general interest in these vital matters and widened the realization of the importance of maternal and child welfare to the Nation.

Many communities throughout the United States have been led by these studies to consult the Children's Bureau as to the best way of starting and developing infant and prenatal work.

Special surveys made by the Children's Bureau in rural communities have furnished knowledge of the actual conditions existing in many types of rural districts in different parts of the country, and through these investigations the bureau has awakened the public to the urgent need of rural work for mothers and children. Information obtained from these careful studies of rural conditions has prepared the Childrens' Bureau for the task of making plans for the administration of the proposed measure. A summary of the important points which prove the need for this Federal measure for protection of maternity and infancy follows:

1. At least 16,000 women die every year in the United States from childbirth, and uncounted thousands suffer impairment of health from causes related to maternity. Approximately one-quarter of a million babies die every year within 12 months of birth. At least one-half of these deaths occur within the first six weeks after birth. 2. From the last available figures maternal death rates are apparently higher in the United States than in 13 other principal countries and show no decrease from year to year.

Of the maternal deaths in the United States about 7,000 are assigned to childbed fever, a disease almost entirely preventable, and about 9,000 are assigned to other conditions which may frequently be prevented or cured.

3. Infant mortality rates are higher in the United States than in 10 other principal countries. Within the first year after birth we lose 1 in 10 of all babies born; New Zealand loses 1 in 20.

While almost one-fourth of the infant deaths in the United States are ascribed to gastric and intestinal diseases, which result from improper care and feeding of the baby, over two-fifths are due to prenatal and natal conditions.

4. Considerably more than one-half of the babies in the United States are born in rural areas, and these show the same high infant mortality that is found in cities from causes related to the care and condition of the mother.

The infant mortality rate from other causes is slightly less in rural areas than in cities, but in the rural areas of the United States it is far greater than the corresponding rate for New Zealand as a whole.

5. The Children's Bureau studies in rural areas in different States have revealed(a) High maternal mortality rates, above the average for the United States as a whole. (b) That a majority of mothers have received no advice or trained care during pregnancy, and may have had no trained attendance of any kind at confinement.

(c) Inaccessibility and often entire lack of hospitals, doctors, and nurses. (d) Practically no organized effort to meet the need for instruction in prenatal and infant hygiene and for trained care during pregnancy and confinement.

(e) A many times larger cost for providing adequate care at confinement in scattered and isolated rural districts compared with cities. 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.

6. The neglect of mothers and babies in rural areas, and the resulting losses of life and vigor are matters of grave concern. The Nation can not afford such waste of human

resources.

New Zealand has reduced her infant mortality rate to the lowest point achieved by any country by a system of instructive nursing and Government maternity hospitals which make instruction and care accessible to all mothers. The work is largely subsidized by Government funds.

Canada, with vast, sparsely settled districts, similar to those in certain of our States, has realized that one of its greatest needs is provision for nursing and hospital care for maternity cases and for the sick, and of preventive nursing work in these rural districts. The western Provinces have already developed plans for rural nursing and hospital work, subsidized by the provincial governments.

England and Whales achieved in 1916, in spite of war-time conditions, the lowest infant mortality rate in their history. Health visitors and consultation centers have been encouraged since 1914 and greatly extended through grants in aid from the national treasury to local authorities and recognized agencies. The maternity and child welfare act was passed in August, 1918, during the crisis of the war.

Before the war France led the way in all infant welfare work, and recognized the duty of the state to protect maternity. As early as 1910, a law was passed providing that women should be cared for in institutions at public expense for one month before and one month after confinement. Measures for safeguarding pregnant and nursing mothers and their babies were considerably aided by State subsidies to private agencies. Such work has not been relaxed since the war.

During the first month of the war, the military government of Paris organized a central office of maternity aid "to assure to every woman who is pregnant, or who has a baby less than 3 years old, the social, legal, and medical protection to which she has a right in a civilized society-to be sure that no woman is ignored and that no child is forgotten."

7. Standard methods of infant welfare work and maternity care have been developed in recent years in this country and are being extended in many cities.

8. Abundant precedent for Federal aid to State work in rural areas is found in existing legislation for promoting scientific farming, teaching home economics, protecting the health of domestic animals, and building good roads.

9. The present bill would stimulate the development in rural ares of visiting nursing, consultation centers for mothers and babies, hospital care for mothers in remote districts, and courses of instruction in maternal and infant hygiene.

10. Like the Smith-Lever Act, this bill is primarily for the purpose of educational extension. The former brings the most medern knowledge of scientific farming and home economics to the farmer and his wife in their home, recognizing that actual demonstration is the best way to teach. In the same way, this measure would bring to the woman on the farm modern knowledge about the care of children and her own care during pregnancy and confinement.

11. Like the Smith-Lever Act, each State adopting its provisions is granted a sum of $10,000, with which work can be immediately organized in selected counties. The additional appropriation, rising from a total of $1,000,000 the first year, to a total of $2,000,000 after five years, is apportioned to the States on the basis of their rural population; a State receives its share of the additional sum only after an equal amount has been appropriated by the State legislature.

12. A high standard of State work would be required. All State plans must be approved by the Secretary of Labor and the Chief of the Children's Bureau, and the amount which may be deducted for Federal administration (a sum not greater than 5 per cent of the total appropriation) is intended to permit a first-hand knowledge by the Children's Bureau of the work that is carried on in the States.

13. Administration in each State is placed with a board consisting of the governor of the State and three other persons representing the three professions whose cooperation is indispensable, a physician, a nurse, and a teacher; and in order that the work may be efficiently developed in cooperation with existing agencies, the physician must represent the State board of health, and the teacher must represent the State university, or the State college of agriculture.

SUPPLEMENT TO BRIEF.1

1. Sixteen thousand deaths annually from causes related to childbirth is a conservative estimate for the United States, based on the 1916 figures for the death registration area.

More women between the ages of 15 and 44 die from causes related to childbirth than from any other one cause except tuberculosis.

The number of infant deaths in the United States must also be estimated from the number reported in the death registration area. In 1916, 164,660 infants wunder one year died in the death registration area, which included 70.2 per cent of the estimated population of continental United States. If the death registration area included the same percentage (70.2) of all the infant deaths in the United States, the total number would be at least 235,229. Over 117,000 of this number may be estimated to have died during the first six weeks after birth.

2. The following tables show, first, maternal death rates per 100,000 population in the death registration area of the United States 1890, and year by year from 1900 to 1916, and second, average maternal death rates per 100,000 population in the death registration area of the United States and in 15 foreign countries for a series of years from 1900 to 1910.

TABLE I.-Population, deaths, and death rates per 100,000 population in the death registration area, from diseases caused by pregnancy and confinement: 1890, and 1900 to

3 Census year ending May 31.

4 Figures for puerperal septicemia for the census years 1890 and 1900 not comparable with those for later

years.