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Although the total infant mortality rate in rural areas is somewhat lower than the rate in cities, there is no such difference between city and country when the rates from causes directly related to the care and condition of the mother are considered separately.

TABLE VII.-Infant mortality rates for urban and rural areas in the birth registration area, 1915, by age and cause of death. (Deaths under 1 year per 1,000 live births.)

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The following analysis of the infant mortality rates in New Zealand offers an interesting comparison with the infant mortality rates of the rural parts of the birth registration area of the United States.

TABLE VIII.-Infant mortality rates in the rural parts of the birth registration area, United States, 1915, and in New Zealand, 1916, by cause of death. (Deaths under 1 year per 1,000 live births.)

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TABLE IX.—Infant mortality rates in the rural parts of the birth registration area, United States, 1915, and in New Zealand, 1916, by age at death. (Deaths under 1 year per per 1,000 live births.)

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5. The findings in the Children's Bureau studies of maternity and infant care in rural counties in Kansas, Montana, North Carolina, and Wisconsin have been analyzed. The conditions vary greatly. The maternal mortality rate in the United States birth registration area for 1915 was 6.1; for 1916, 6.2 per 1,000 live births. In Kansas, in the area investigated, a rate of 8.6 per 1,000 live births was found, while in the Montana survey, the maternal mortality was 12.7, or over double the average rate for continental United States.

In the Kansas county studied, 95 per cent of the births about which facts were secured were attended by a physician. In one-third (119) of the pregnancies, the mother had some prenatal care.

In the Montana county, 463 mothers were visited. Over one-fifth of these left the area for their confinement. Of the 359 who remained, 230 met the experience of childbirth without skilled assistance three of these were entirely alone and delivered themselves, 46 were delivered by their husbands, and over one-half were attended by untrained women.

Smaller still was the proportion of mothers delivered by a physician in a rural county in North Carolina.

Even in the two rural districts in Wisconsin, where facts about 614 mothers were secured, over one-third were not attended by a physician at confinement.

Scarcely a mother in any of the rural areas studied had prenatal care measuring up to an accepted standard of adequacy, and more than three-fourths had no advice, on account of the inaccessibility and expense of medical care. In only one of the areas studied (Kansas) were hospital care and trained nursing care available. In none of the areas was a public-health nurse at work.

New Zealand, as is well known, has been successful in securing and maintaining for a considerable term of years lower infant mortality rates than those recorded for any other country. A progressive reduction of the infant death rate has followed the development of work similar to that contemplated by the present bill by the New Zealand Society for the Health of Women and Children and by the Government. These activities are described in one of the early bulletins of the Children's Bureau, a copy of which is submitted herewith.

The chief aims of this society are (1) to uphold the sacredness of the body and the duty of health; (2) to acquire and disseminate accurate information and knowledge on matters affecting the health of women and children; (3) to train specially and to employ qualified nurses whose duty it will be to give gratis to any member of the community desiring such services, sound, reliable instruction, advice, and assistance on matters affecting the health and well-being of women and their children.

The society has more than 80 branches scattered over the country, according to the 1916 report. It issues a book on the care of mother and baby, secures constant and generous cooperation from the press, conducting a baby column in most of the newspapers throughout the country, holds many meetings, has a special hospital in Dunedin where infants who are sick or not flourishing can be cared for and watched until a proper regimen is established for the individual case and the mother fully instructed. Traveling or visiting nurses furnish instruction and actual care. The Government also employs visiting nurses for the remote "back blocks." In some instances these nurses are also responsible for small cottage emergency hospitals at their stations. The Government maintains four maternity hospitals, which are intended to be selfsupporting. It also publishes and distributes free of cost books dealing in a practical manner with the hygiene of maternity and infancy. It cooperates effectively with the Society for the Health of Women and Children. Thus throughout this comparatively new pioneer State a fairly complete plan is in operation making available to a preponderating number of the mothers of New Zealand, in country and town alike, health instruction, nursing care, and medical and hospital service.

A comparison of the infant mortality rates for New Zealand with those of the Australian Commonwealth shows the former to have been consistently lower than the latter for each of the five years, 1911 to 1915.

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Though full details as to the care provided for maternity and infancy in the two countries are not available, certain outstanding facts would appear to indicate that the methods employed in New Zealand have a share in causing the differences shown in the table. The Commonwealth of Australia makes an allowance of £5 when a child is born. Notwithstanding the general acceptance of this allowance, it is com puted that 36.4 per cent of the births in the last year for which information is avail

able were not attended by a physician. The report on infant mortality submitted to the Australian parliament in June, 1917, by the committee concerning causes of death and invalidity in the Commonwealth strongly urges the adoption of a general scheme of practical measures, such as are in force in New Zealand and elsewhere, as a means of lessening the infant mortality rate. In August, 1917, the same committee submitted a report on material mortality in childbirth. Figures are given to show that, although there was a decrease in the death rate after the introduction of the maternity bonuses, this decrease was not so great as it had been during the preceding years. The report concluded with the following paragraphs:

"Speaking generally, your committee is of the opinion that much greater benefit could be obtained from the large sum of money spent annually than is being obtained under the present system, and that as the wastage of life and damage to health now occurring in connection with childbearing is due to the ignorance of the mother and lack of skilled care such improvement should be sought in two directions:

"(1) The provision of every facility for pregnant women to obtain skilled advice before the confinement occurs.

"(2) The provision of trained attention by a properly qualified and properly supervised midwife or nurse during the lying-in period.

The exact method by which the latter of these highly necessary measures is to be accomplished should be a matter for further earnest consideration.

"Information is necessary concerning the causes of illness as well as the causes of death among women during confinement. With the economic aspects of the direct payment to womer of cash bonus, your committee is concerned only in so far as the health and lives of the women are affected.

"In the opinion of your committee, however, there is imperative need for the immediate extension of existing facilities for pregnant women to obtain skilled anvice concerning their health before their confinement, and the Commonwealth Government might well provide financial assistance to enable women's hospitals and similar institutions to inaugurate or extend such branches of their activity, and might even undertake the provision of such facilities in places where they are as yet nonexistent. The return to the community would almost certainly more than compensate for the expenditure involved."

6. In Canada, the Victorian Order of Nurses, which gives bedside care to the sick and to maternity patients, and which receives a grant from the Dominion Government was founde 1 originally in response to the demand for nursing care made by the farm women of western Canada. This order has established a number of cottage hospitals in small communities, and is developing a plan for rural nursing. Two nurses, living in a nursing home which has accommodations for two or three emergency hospital cases, work in a rural area of about 100 square miles, giving nursing care to the sick and to naternity patients.

The western provinces of Canada-Manitoba, Saskatchewan, and Alberta-are developing plans for rural nursing and hospital work, subsidized by the provincial governments.

The Province of Manitoba has developed a system of rural public-health nurses which is financed jointly by the provincial government, the rural municipality, and the local school system. These nurses work in the rural schools and visit every home in their district. Their work is to bring to the rural mothers knowledge of how to keep themselves and their children well. In addition, a system of public-health nursing is being planned, this system to provide bedside care.

The war gave new emphasis to the fact that the protection of maternity and infancy is a public responsibility that can not with safety be evaded by any government. Details concerning the steps taken by the various governments in the early stages of the war are given in a paper on "Infant Welfare Work in War Time," by Dr. Grace L. Meigs, of the Children's Bureau, submitted herewith.

According to that pamphlet:

"In England, practically from the first day of the war extraordinary measures were taken to maintain and increase all means looking to the protection of mothers and babies. The part played by the National Government is perhaps the most salient point in this work.

"It happened that just before the war Parliament was considering a grant to aid local sanitary authorities and voluntary agencies in carrying out such plans for maternal and child welfare as were approved by the local government board. The grants made yearly to such work might amount to one-half of its total expense. In a memorandum bearing the interesting date of July 30, 1914, the local government board gave the details of what such schemes should include, divided into measures for antenatal, natal, and postnatal care. The systematic home visiting of infants and young children was dwelt on, as well as the carrying on of centers for infant and maternal welfare.

Especially emphasized also were the need of coordinating public and private work; the importance of providing proper prenatal and obstetrical care; and the desirability of giving greater attention to the care of the child between infancy and school age." The report of the local government board for 1917 emphasizes the necessity for increasing the protection of mothers and babies and describes the program now in operation, which is justified by the improved infant mortality figures for the many separate sanitary districts of England and Wales, where with marked uniformity decreases appear for the second year of the war as against the first. The average figures for England and Wales indeed showed an infant mortality rate for 1916 of 91, as against an average yearly rate of 110 for the period from 1911 to 1914. The chief features of the program of the local government board are:

1. The extension of money grants by the local government board to local sanitary districts under carefully specified conditions.

2. The notification of births to the local medical officer of health within 36 hours. (Registration may be made within six weeks.)

3. The establishment of centers for hygiene and medical advice for mother and babies.

4. Provision for proper care at childbirth.

5. Sufficient arrangements for hospital care when necessary.

6. Home visiting by health visitors.

The duties of health visitors are educational as well as practical. Many of the visitors are nurses. It is plain that their work is closely analogous to that of the public health nurses in the United States.

It is of special interest to this country that the program of the local government board covers rural as well as urban areas. As a result of the stimulus supplied by government funds, the local government board could report in March, 1917, that "all the metropolitan boroughs except Camberwell, all the 82 county boroughs except Gateshead, 51 of the 61 county councils outside London, and 360 county districts had some provision for health visiting." Only one important county district remained in which no health visiting had been provided for.

During the months from March, 1914, to February 1917, in spite of the fact that a war-time shortage of doctors and nurses made the work incr asingly difficult, the number of health visitors in Great Britain was increased from 600 to 1,024, an average of one health visitor to 800 babics. The number of health centers, which had increased to 842 in February, 1917, reached 1,278 by July, 1918, and the number of mothers and children attending the centers increased in much greater proportion.

The maternity and child welfare act, passed August 1, 1918, widened the power of local authorities in England and Wales by enabling them to make such arrangements as might be sanctioned by the Great Britain Local Government Board for attending to the health of expectant and nursing mothers and of childr n under 5 years of age. It made available for these new services the Government grant for maternal and infant welfare work (of not exceeding one-half of approved net exp nditure) which was first provided in 1914. The act provided for the appointment by the county councils of maternity and child welfare committees, the membership of such committees to include, at least, two women. In its circular the Local Government Board states that it is important that working women should be represented on this committees. The circular gives a list of the services for which the Government grant will be paid to local authorities and to voluntary agencies, and makes sugg stions for developing the new services, which cover hospital treatment for children up to 5 years of age, lying-in homes, home helps, provision of food for exp ctant and nursing mothers and for children under 5 years of age, creches and day nurs ris, homes for childr n of widowed and deserted mothers and for illegitimate children, and experimental work for the health of mothers and children.

7. The aim of infant welfare work is to make available to all mothers opportunity for physical examination, instruction in their diet and general hygiene during pregnancy, and expert advice on the care of their babies in health. From the work that has been developed in many cities in the United States and abroad, a standard method may be broadly stated as follows:

For effective infant welfare work it is necessary to have an adequate staff of well-paid visiting nurses, working under competent medical direction. These nurses must be trained in the principles of public health nursing and qualified to instruct mothers in the hygiene of pregnancy and in the daily care of well babies. Their duties include, also, a systematic effort to make individual mothers realize the importance of physical examinations, the value of trained advice during pregnancy, and the importance of nursing their babies throughout the earlier months of the first year.

Another essential in infant welfare work is one or more consultation centers where mothers may go for advice and for examination by a physician during pregnancy, and to which they may bring well babies to be placed under medical supervision.

Such centers do not give medical or surgical treatment, but refer cases requiring such treatment to the patient's private physician, or to a clinic or hospital. The importance of breast feeding is stressed here, as well as by the nurses who visit the mothers at home. When breast feeding is impossible, or when a baby is old enough to be weaned, the physician at the health center advises the mother about her baby's food, but the actual preparation of food is done at home, where the visiting nurse demonstrates the necessary care and precautions to be observed.

In connection with infant welfare work, it is usually possible and always desirable to carry on educational publicity dealing with the facts of prenatal and infant hygiene and the importance and availability of expert advice and examination. This is done through such channels as a local situation may suggest, but newspaper articles and popular leaflets prepared by experts are universally valuable.

In rural districts, where as yet infant welfare work has scarcely been attempted in spite of the great need, a well-rounded plan would include:

1. Public health nurses who shall be available for instruction and service, as are the public-school teachers and other public officers. These nurses should be especially equipped to recognize the danger signs of pregnancy. The nursing service should center at the county seat or some other accessible point.

2. An accessible conference center for maternal and infant welfare, which will afford opportunity for the medical examination of mothers and of well children, and for medical supervision and advice on matters of health.

3. Hospital facilities for mothers and children.-There should be a county maternity hospital or beds in an easily accessible general hospital for the proper care of abnormal cases and of normal cases, when it is convenient for the women to leave their homes for confinement.

4. Skilled attendance at confinement obtainable by every woman in the country. 5. Instruction in the hygiene of maternity, infancy, and childhood, to be made available for all girls and women through different forms of extension teaching.

STATEMENT OF MR. R. S. SEXTON, LEGISLATIVE REPRESENTATIVE, AMERICAN FEDERATION OF LABOR.

Mr. SEXTON. Mr. Chairman, I do not know whether I can add very much to the enlightenment of this committee and, in the presence of the array of what I presume to be expert testimony that will be adduced on this subject later on, whether my statements will be of much value or not, I do not know. But I submit them very gladly in support of this measure.

The American Federation of Labor takes the position that child life is the greatest asset to the Nation and all protection and assistance should be rendered that is possible to protect that life and to assist maternity. This bill provides for that assistance which has been overlooked or ignored or passed up with a degree of indifference heretofore in our country. The American Federation realizes the great importance of assistance of this kind; it realizes that those who are in greatest need of such medical and professional assistance and support, in the hours of child birth and through the years of immaturity of children and during the travail of mothers, that proper safeguards have been greatly neglected. This will provide in a sensible, intelligent, and beneficial way that assistance and insure the lives of mother and child. If we are going to have a great Government, supported by healthy, intelligent people, we must provide for the protection of infant life. This bill, I apprehend, does all of the things that are necessary to carry out that principle, and therefore it is one of the most meritorious bills that has been introduced along those lines. I believe that the committee will be able to see the necessity of it, and recommend its passage, and I express the hope that it will be enacted into law.

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