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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.



Miss FLEMING (reading):



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 distriots 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 cther 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 cire 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.

(6) 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

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. Štandard 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.


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 1.Population, deaths, and death rates per 100,000 population in the death regis

tration area, from diseases caused by pregnancy and confinement: 1890, and 1900 to 1916.

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i Paragraph numbers refer to corresponding numbers in brief.
2 Calendar year unless otherwise specified.
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.

PABLE II.-Average death rates per 100,000 population in certain countries from diseases

caused by pregnancy and confinement, 1900 to 1910.

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1 Rates based on figures for 1901 to 1910 2 Rates based on figures for 1906 to 1910. 3 Rates based on figures for 1903 to 1910. 4 Rates based on figures for 1902 to 1910. 5 Rates based on figures for 1907 to 1910. 6 Rates based on figures for death-registration area which increased from year to year; in 1900 it comprised 40.5 per cent of the total population of the United States and m 1910, 58.3 per cent.

7 Figures not available. It will be noted that the maternal death rate in the death registration area of the United States has not decreased since 1900. During the same period the death rates from other preventable diseases have been markedly reduced. The death rate from typhoid fever has been cut in half; and that from diphtheria and croup has dropped to less than one-third; those from tuberculosis and pneumonia have both shown a decided fall.

Only 2 of the 15 foreign countries show rates from cond ons caused by childbirth higher than the rate in the death registration area of the United States. The rates of three countries, Sweden, Norway, and Italy, which are notably low, show that better rates from maternal mortality than those prevailing in the United States are attainable.

A more accurate measure of maternal mortality is found in comparing the number of maternal deaths with the number of life births. Such data are available only for the birth registration area of the United States for the three years, 1910, 1915, and 1916. On this basis, also, the rate in the United States is higher than the rate in foreign countries. TABLE III.-Death rate

per 1,000 live births from all causes related to pregnancy and confinement in the birth registration area of the United States for specified years.

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1 The birth registration area included 24.1 per cent of the population of continental United States in 1910, 31.0 per cent in 1915, and 32.4 per cent in 1916.

Puerperal septicemia (childbed fever), to which nearly 7,000 deaths are assigned annually in the United States, is an infection which can usually be prevented by the same measures of cleanliness and asepsis which are used universally in modern surgery. Although puerperal infection may usually be attributed to the hands of the attendant, women may occasionally infect themselves through improper hygiene during pregnancy or confinement. Therefore, prenatal instruction and supervision is an essential part of the work for the prevention of this infection.

The second group of deaths related to childbirth, of which there are about 9,000 annually in the United States, includes deaths from many different conditions. A large number of these complications can be prevented through proper hygiene and supervision during pregnancy and through skilled care at labor. Certain other

complications which as yet can not be prevented can be detected before serious harm is done, and treatment can be given which will save the mother's life.

For á fuller discussion of comparative death rates and of the preventability of maternal deaths, see the bulletin on Maternal Mortality, prepared by Grace L. Meigs, M. D., and published by the Children's Bureau, United States Department of Labor, in 1917, submitted herewith.

3. In the birth registration area of the United States, the infant mortality rate was 99.9 per 1,000 live births in 1915, and 101.0 per 1,000 live births in 1916. The following list shows the latest available infant mortality rates in the birth registration area of the United States and in 10 foreign countries.

TABLE IV.-Infant mortality rates in different countries for specified year. (Deaths under

1 year per 1,000 live births.)

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1 All rates with the exception of those for New Zealand and England and Wales were obtained from Birth Statistics, 1916, Bureau of the Census, p. 19.

The New Zealand Official Year Book, 1917, p. 104. 3 Seventy-ninth Annual Report of the Registrar General of Births, Deaths, and Marriages in England and Wales, 1916, p. LXXXV.

The 164,660 deaths under 1 year of age, in 1916, in the death registration area, which included in 1916, 70.2 per cent of the population, may be distributed among the main groups of causes as follows:

TABLE V.- Infant deaths during 1916, in the death registration area of the United States,

by age and cause of death.

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1 During the first year of life, deaths from prenatal and natal conditions form 41.6 per cent of infant deaths from all causes.

Compiled from Mortality Statistics, U. S. Bureau of the Census, 1916.

The infant deaths from prematurity, congenital debility, and injuries at birth, which are often assembled under the heading “diseases of early infancy," and the infant deaths from syphilis are due to conditions which can be directly influenced by the care the mother receives during pregnancy and confinement. These deaths, with those from malformation, the cause of which is as yet undetermined, form a group dependent upon prenatal and natal causes, which total 41.6 per cent of all the

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