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(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. 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.

SUPPLEMENT TO BRIEF.1

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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 regis

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

1916.

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1890 3 1900 3 1900 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1908. 1909. 1910. 1911. 1912. 1913. 1914. 1915. 1916..

47.0 8.3 45.67.5 5.7 7.6 6.0 7.7

7.3 6.1 7.9 6.9 8.5 6.8 8.1 6.2 8.9 6.8 8.9 7.0

8.7 6.7 8.6 7.2

8.5 7.4 8.6 6.5 8.5 7.2 8.6 7.1 8.9 63

8.9 6.7

9.6

32,699, 843
47,300,947
63, 265, 646

2,586
4,106
5,511

8.7 8.7

4,340

1 Paragraph numbers refer to corresponding numbers in brief.
2 Calendar year unless otherwise specified.
3 Census year ending May 31.

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

TABLE 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 in 1910, 58.3 per cent.

i 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 conditions 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 con

finement 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

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

For a fuller discussion of comparative death rates and of the prever maternal deaths, see the bulletin on Maternal Mortality, prepared by Grad M. D., and published by the Children's Bureau, United States Department of Law, 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 lişt 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.

2 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. J.XXXV.

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

deaths during the first year of life. Moreover, it is generally accepted that the paramount factors causing the deaths during the first month of life are, also, the prenatal condition of the mother and the care she received during pregnancy and confinement. Therefore, the 17,853 deaths occurring within the first month after birth in 1916, but assigned to causes other than prenatal or natal, might also have been largely prevented by making accessible to every mother instruction and supervision in proper prenatal care and skilled assistance during confinement.

The importance of maternal care in the prevention of infant deaths does not stop, however, with these early deaths and deaths from special causes. During the greater part of the first year of life breast feeding is the chief source of protection from all diseases. Scientific observations show that mothers who receive proper care during pregnancy, confinement, and the lying-in period are most apt to nurse their babies.

Gastric and intestinal diseases are obviously related to the care and feeding of the baby; it is also true that in the prevention of respiratory and other communicable diseases the mother's knowledge of how to care for her baby in health is a very important factor. To obtain this knowledge, the mother should be able to consult a physician and to receive from him instruction as to the needs of her child, and should have also in her own home, supervision and instruction by a nurse in the proper care of her infant.

4. In the census of 1910, 60 per cent of all children under 1 year of age were found in rural areas (country districts and places where the population is less than 2,500); less than 1 per cent of all the children under 1 year of age, either in rural or urban areas, were born outside of the United States.

The only infant mortality rates available for the urban and rural districts of the birth registration area are based on a definition of rural as “exclusive of municipalities having a population of 10,000 or more in 1910.” The following urban and rural infant mortality rates are compiled from an unpublished analysis of the 1915 statistics furnished the Children's Bureau by the Bureau of Census.

TABLE VI.-Infant mortality rates for urban and rural areas of the birth registration

area, 1915, by age and cause of death (deaths under 1 year per 1,000 live births).

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