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Dr. MENDENHALL. I am from Wisconsin and have done public health work in that State. In section 5 of the brief you will find a statement of rural maternity conditions, which I think is as accurate as can be made at the present moment. The reporting of births and deaths from the rural districts is so poor that many of us believe, and I am one of them, that the death rate probably is actually greater than the returns now show. The death rates in rural districts are greater in the United States than we appreciate. The percentage of deaths the first month of life is greater in the country than it is in the cities, but if a child survives birth, and does not die the first month of life, it probably has a better chance for life in the country than in the city.

I was asked to speak on my personal observations regarding the success of extension work in Wisconsin, and also to give you an idea of the survey made in Wisconsin in 1916 by the Children's Bureau.

About six years ago the extension division of the University of Wisconsin put into its curriculum the teaching of the hygiene and care of the child, particularly the infant, because there was a great need and demand for such instruction from mothers in rural districts. The first thing that impressed us when we went out to give these talks on the child was that when the mothers came up to talk with us afterwards, or we had a conference with them on the streets, or in the hotels, as we often did, the questions asked us were almost purely obstetrical. They asked us what caused miscarriage, why the baby died at birth, and why they could not breast-feed the baby.

We went back to the university and reported this interest and asked to be allowed to give talks on maternity. Our request was granted, and this part of our health program has met with great interest and appreciation. Many women have felt that these talks gave them definite knowledge, which they had not previously had, about the proper care of themselves during pregnancy, and the need for medical attention and rest during the lying-in period. The university at this time also put out popular correspondence courses on the care of the prospective mother and the care of the child.

The course for the mother has been taken not only in Wisconsin, but also in many other States all over the United States, especially in the rural districts. Unfortunately, such courses cost $4. The university extension has to be supported, and these correspondence courses furnish one means of support. It seemed to me to be a great pity at the time, and I protested that such a course ought to be free, because many of the women who needed it most could not afford to pay for such instruction.

Three years ago I started on agricultural extension work under the Smith-Lever act. Although it was not fully organized until 1917, the appropriation had already been given the State, and in Wisconsin health talks were featured at the meetings held for women in rural communities and in small towns. We often went to small towns, 25 miles from a railroad. At these meetings, talks on maternity, on infant hygiene, and the care of the older child are given, after which the children are examined and the mothers advised as to their health and the care they should give their children.

I remember one woman drove in an open sleigh for 25 miles to hear our talks on the care of the mother and her child. She brought her five children with her, one a baby, because she said she had never been able to have a physician see them before, and she had a great desire to know if her children were perfectly healthy.

Many, problems were presented to us at these conferences. I remember one particularly interesting case of a harelip, a case where the local physician, who happened to be ignorant, had told the mother that harelip children never survive and the only thing to do was to let her child die. This mother came to us, and we were able to tell her how she could save it, how she could pump her own milk and feed it to the baby, and we also advised her where to go later for the necessary operation. When we went back to that village after a period of two years we found that the child had been operated on and was apparently perfectly healthy and normal. I could cite many such instances. Certainly the work was well worth while, and the women showed the greatest interest and enthusiasm. We made it our business to study the care of maternity in these communities. One of the questions we asked at every meeting was how soon the women got up to do the family washing, for we soon found out there was no use in asking how long they stayed in bed after confinement, for many of these women have to do some part of the domestic work after only a few days' rest. I do not think there was any audience where half a dozen hands did not go up when the question was asked if any of them did the family washing before the second week after delivery. As one woman said, What is the use of waiting until the second week, because then you only have two weeks' washing to do instead of one.

These conferences made us realize how many women have only the help of some member of the family at childbirth, or rely on the help of a neighbor woman at this time. The dearth of domestic help and nursing care are serious obstacles to improving rural conditions.

In Wisconsin, in 1915, an analysis of the birth and death certificates showed a low total death rate, as well as a low infant mortality rate and a high percentage of deaths the first month of life. The rural districts showed a much higher percentage of deaths at birth and the first month of life than was found in the cities. As one of our workers said, "If you can survive the first weeks of life, the country is a good place to be born in.

The findings of the Children's Bureau in the survey made by them in Wisconsin in 1916 explain many things we have found to be true and corroborated our observations. From extension work and from the experience of the State board of health, two counties seemed to present quite typical rural conditions. The Children's Bureau conducted partial surveys in these two counties, one a southern, more prosperous, and earlier settled county, and ane a much larger northern county, where the people are just emerging from pioneer conditions.

In this orthern area the land is being cleared, farming is just beginning, and there is evidence of considerable ignorance and poverty. This county has a high percentage of German and Polish settlers. The Children's Bureau's investigations in certain parts of this northern county covered the details of 486 confinements, occurring during the previous two years. The facts obtained from talking to these mothers show why in Wisconsin the percentage that deaths the first month after birth form of all infant deaths is 10 per cent higher in the rural districts than in our cities.

The reason for this bad showing of rural communities can be found in unavoidable hardships or in ignorance. First, under hardships, we must consider work. In the county in the northern part of the State, in one township, which is typical of this county, nine-tenths of the people are farmers, and one-tenth of them are tenant farmers. One-half of the farms are mortgaged, and often the men work out as day laborers, away from their own farm, to help pay off the mortgage. The women have no domestic help, they have large families, and besides their heavy house duties, they share and share alike with the men in all the farm work.

One story, which could be duplicated many times will give an idea of their life. A Polish woman and her husband moved on a "forty,” and they had only 5 acres.cleared. They had two small children when they took this section, and the man went out as a day laborer in order to help pay for it. The woman did all the farm work, milked two cows, pitched the hay, cut the wood and piled it, and dug the potatoes and stored them for the winter. The fall that they moved on the farm she had her third baby. She stayed in bed two or three days at this time, the man doing the farm work and the housework, and the midwife they employed doing the family washing. At the end of the first week after the third baby was born, she had resumed all of her farm duties. Within the next year she had her fourth child. At this time she stayed in bed a week, because she had a fall just before the child was born, and she felt she needed extra rest, so she did not resume her farm work of hauling the wood, pitching hay, etc., until two weeks after the birth of the child. When the fourth child was 2 months old, the father went to Milwaukee, because he could get higher wages in the city and the mother stayed on the farm alone, with the four children, the oldest under 5, with no one to help her do the work inside or outside of the house.

That was a Polish family, but I am sorry to tell you there are American-born women doing practically the same thing in Wisconsin to-day.

Now you will realize what I mean by hard work being a factor in rural health conditions.

The second hardship is dearth of doctors and inaccessibility to hospitals. In this northern county, 55 miles long by 30 miles wide, there are only two hospitals, other than the county poorhouse. One hospital has 60 beds and the other 16; both are at the county seat. A sick woman would probably have to travel many miles over the worst roads you ever saw, and possibly several hours by train in order to get to a hospital. So inaccessibility to hospitals and bad roads are hardships that rural communities endure.

Badly trained attendants is another factor to be considered in the country. Only 58 per cent of the women in the survey were confined by doctors; 36 per cent were confined by midwives, and 6 per cent by others---the neighbors and members of the family. The midwives investigated were 14 in number. Only two of these had had any training at all, and only two, the two who had had the training, had license to practice in Wisconsin. So the others were really working illegally and without any training.

Another hardship, as I mentioned before, is the lack of any available domestic or nursing service in these places. Of 486 confinements in this county, one-fourth of them had no nursing service whatever during confinement. Including the midwife service, three-fourths of

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