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them were taken care of by "folks," as they put it, that is by the neighbor women or by their own people.

The second factor in rural health problems is the question of ignorance. In regard to maternity, the fathers and mothers are absolutely ignorant of the prenatal care that a wonian needs at this time that she should be under a physician's care throughout pregnancy: As a result, only one-fifth of the 486 pregnancies had had any medical supervision, and only two of the 486 had what we call minimum adequate prenatal care using the standard of Dr. J. Whitridge Williams. Worse than the lack of prenatal care was the absence of skilled attendants at confinement. These families do not realize that it is important to have medical attendants at confinement. One man whose wife was sick during pregnancy sent 25 miles for a doctor in midwinter, in order that she might have a real doctor. He would not take the physician living only 8 miles away, who did not have a very good reputation and probably was not a fully qualified physician. He said, "When you gets somethin' for protection"--protection in this case being the doctor_"you wants the best there is.' When his wife was confined three months later, he had the local unlicensed midwife of the place. He did not realize that confinement required the services of a skilled physician.

As a result of th s investigation, which I have described very briefly to you, we found in this county an infant mortality rate of 115. The average rate for the Un'ted States was under 100 for this same year, 1915. We also found a high maternity death rate. Incidentally, this county has one of the worst reputations for chi d-bed fever of any county in the State; it had one of the highest averages over a seven-year period, that is, more cases compared to the number of confinements. This is a striking demonstration of what follows lack of prenatal and obstetrical care.

The three points I should ike to make in closing are these: In the first place, something should be done to enlighten the ignorant public, the fathers and mothers, in regard to the necessity for prenatal care and skilled assistance at confinement and rest during the lying-in period. Secondly, the relation prenatal care and skilled assistance at confinement and rest during the ly ng-in period bears to the children we lose at birth should be convincingly demonstrated. Half of our infants dying during the first year after birth die during the first six weeks of life. Most of these children are born too weak, to ignorant, or too diseased to live. Besides this huge loss of life the first weeks after birth, many infants die during the first year from premature weaning, because the mothers do not nurse them, not having had the proper care and food during the lying-in and nursing periods. The third point is that, in the rural districts, it is abso

utely impossible, so far as I can see, for women of the class I have described to you, to have prenatal supervision and adequate, skilled assistance at the time of confinement, unless some measures such as this bill affords are taken.

Mr. ZIHLMAN. You have a local organization which could be made available under this appropriation ?

Dr. MENDENHALL. We have the State board of health and the university and agricultural extension services, which work in cooperation with the Children s Bureau, and distribute its publications. The survey of the Children's Bureau in the State was made at our request, so that we might have absolute evidence that these conditions just described were true.

Mr. NOLAN. If we were going to grant Federal aid to the States. why confine it to the rural districts; why not give the cities, like Milwaukee, Racine, Detroit, and other large industrial centers up there, some of the benefits of this Federal aid ?

Is there any particular reason why we should discriminate?

Dr. MENDENHALL. Of course there is this one reason: This is for the rural districts, and “rural districts” includes everything under 10,000; so it is not absolutely the open country you are dealing with. All of the large cities have hospitals, have dispensaries, and have good physicians; they have clinics and centers and settlements under different organizations which are now working for the benefit of maternity and infancy.

Mr. Nolan. Why not leave that to the States? Why not say this money should be used at the State's discretion; why confine it specifically to the rural districts? Why not leave that to the States; give them the aid and leave them to determine where the money shall be spent ?

Dr. MENDENHALL. I think we feel that the rural districts need it most. The rural districts are less able to speak for themselves. I should be a little afraid of some of our big cities with their powerful organizations; if there were any funds to be obtained, they might obtain them and leave very little for the country.

Mr. Nolan. Why could we not safeguard that, as it is in a way safeguarded in here; because it must be spent to some extent under the supervision of the Children's Bureau of the Department of Labor ?

Dr. MENDENHALL. That possibly would safeguard the rural interests. I have not thought of that point. I think we know the greatest need for better care of mothers and children is in the rural districts, and nothing has been started there. There must be Federal aid to stimulate State activity. I do not think many of the States have as yet appreciated the fact of this great need.

Mr. Nolan. But I want somebody to explain to me, if they can, why there is any particular reason for providing a new method for assisting in preventing infant mortality in this country, for confining Federal money to the rural districts.

Dr. MENDENHALL. I suppose the Smith-Lever money is confined to the rural districts.

Mr. NOLAN. But we are raising babies in the cities as well as in the rural districts. I do not have any objections to the SmithLever bill; I voted for it because I believed in agricultural extension work and I believed the publications of the Department of Agriculture could give all the information to home gardeners which they desired, through bulletins. But I do not believe information can be given in that way regarding prenatal care of women, although the Children's Bureau has distributed some very valuable publications, but it is not in intimate touch with mothers and children. I can not see why you want to discriminate, or anybody wants to discriminate between the city and the country.

Dr. MENDENHALL. All we want to do is to see that the work in the country is started.

reason.

Mr. Nolan. I have not any objections to legislation; the question of the smallness of the appropriation does not appeal to me as a

And I want somebody who has had this experience to give this committee the reason for it.

Mr. VAN DYKE. As a matter of fact, this is already started in most cities, is it not?

Dr. MENDENHALL. The very large cities have started such work, and they have the available aid for the mother; she can get instruction and skilled assistance and can go to a hospital and have rest during the lying-in period.

Mr. NOLAN. The fact of the matter is they do not do it; I think you will find in your investigations that they do not go to the Hospitals.

Dr. MENDENHALL. Our hospitals are pretty full.

Mr. NOLAN. A great many women do not want to go to the free hospitals, and the others they can not afford.

Dr. MENDENHALL. That is just a matter of education. France in 1915 showed what education can accomplish. In Paris just 5 per cent of the women confined were delivered outside of hospitals or without medical service sent out from maternity hospitals.

STATEMENT OF DR. ANNA E. RUDE, DIRECTOR, DIVISION OF

HYGIENE, CHILDREN'S BUREAU.

Dr. RUDE. I think most of the points have been pretty well gone over, but I do want to impress upon you how, from the very first, the Children's Bureau has been largely governed by existing conditions.

Back in 1912, when it was known that there was to be a Federal Children's Bureau, before there were even any plans for organization made, letters began pouring in from all over the country. Those letters from mothers regarding the care of themselves or their children were a large deciding factor in the Children's Bureau undertaking as its first work studies in infant mortality.

As most of you no doubt know, the Children's Bureau has made eight urban infant mortality studies and an analysis of the resulting figures. As soon as you begin to analyze those figures you note the large number of children who die from causes relating to conditions of the mother during pregnancy or at confinement. The next logical step after these studies was an investigation of conditions relating to maternal mortality. The bureau did this first by a statistical study, taking the figures from the census (the only available figures). At that time 15,000 mothers died annually in this country from conditions relating to childbirth. The 1916 census figures are even worse; they are 16,000.

Tne number of letters which came in from rural localities, particularly regarding prenatal matters, was the deciding element as to the subject of the bureau's first publication, published in 1913, Prenatal Care. Since that time some 500,000 copies of Prenatal Care have been distributed, and there is still a constant demand for the bulletin from rural districts.

To illustrate, one letter came in from a woman who was 65 miles from a doctor or nurse, telling with what horror and dread she was

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anticipating her confinement, because she had witnessesd for years the tragedies which had taken place on the surrounding farms because mothers had had to depend entirely upon the experience of neighbors for any sort of help during confinement. In response to the many letters from rural mothers and because of the fact that three-fifths of our child population is harbored in rural localities, the bureau felt that it must undetake a study of rural conditions.

The Children's Bureau has made studies and done work in nine different States. I have had the invaluable experience of doing work in rural localities in two of the western grazing States and also in one of the Southern States. The appalling conditions which one finds are really due to ignorance of the dangers that are attendant upon childbirth.

In our rural studies we have held, in connection with the surveys, children's health conferences where the people could bring their children and have them examined by a Government doctor and be told of their physical condition and given advice as to their care. The eagerness with which people respond makes one realize the necessity of the Government's giving assistance. In one of our most primitive homestead States, where the conference center was a hundred miles from the railroad and people had to drive 20 and 30 miles to the conference center, we had a 100 per cent attendance; that is, every family who had young children to be examined brought them to the conference center. I remember one mother who had got up at 4 o'clock in the morning of the day before the conference and had started to drive 25 miles over very rough roads. A blizzard had come up during the day, and several times she was compelled to stop at farm houses along the way to thaw out. She remained in the locality of the conference center over night, and the next morning was the first to arrive, bringing one child 2 years old and another 5 and a 2-months-old baby swaddled in blankets.

I am very glad to tell you that as a result of the work we did in that county the board of supervisors in the following spring purchased a Ford for the use of a public health nurse whom they have since secured.

In another one of the western grazing States, where we made an intensive study, data were gathered regarding 463 births. That was in one-half the county. The conditions found therd there were that one-fourth of the mothers left that area for their confinements, going more than 100 miles to the nearest hospital. That is a very small proportion, for the reason that such great expense is entailed that the average homesteader in such a locality can not afford it. The people make their living on their farms, but they have no ready money. Very recently another case has come to our attention where the father has had to leave his home and take a position with the railroad in order to get cash enough to enable him to take his child 100 miles to the nearest hospital for an operation for a congenital foot deformity. I simply cite these cases to show you that in remote rural areas people have no money with which to pay for expensive care of any kind. Out of this same group of mothers there were 230 who had experienced childbirth without any competent medical care whatever; 46 had been delivered by their husbands and 3 women were entirely alone. I recall very vividly a young 18-year-old mother, who told us of having been alone during the three days following the birth of her first child, because her husband was out hunting cattle at the time, which was in the dead of winter.

In the Southern States we have made many more studies; there we find that prenatal care is quite as lacking as in other localities. There were fewer women, if anything, confined by physicians. Another very startling fact which records of children revealed was the lack of medical attendance. For example, more than half of the children under 5 years of age who had died within the past two years in that county had had no medical attention whatever. The certificate was signed simply "No attendant.” That, of course, has to be attributed absolutely to ignorance. Ignorance in this county did not preclude poverty; not at all. It was a thrifty, prosperous county, with no poor people in it. I wish you to realize that we find ignorance among the well to do as well as among the poor. In cities, however, and in many other localities the well to do usually protect themselves from their own ignorance by their cbility to employ skilled help.

In the South we found that the response from the colored people was quite as great as from the white people. We held conferences in the white school houses in the afternoon and in a colored church in the evening. The darkies would come and sit around a warm fire, very often singing, and I remember one occasion when we examined pickaninnies until 2 a. m., because the parents came to stay until every child had been examined. You do get the response if you have something to offer.

Our studies show very clearly that the cost of work in rural localities is so very much greater than in urban localities, because of a scattered population; that the funds are less; and that where there is the most need for work the people are less able to meet it financially.

We have to take the reports of what is already being done in the cities to show us what can be done; there our studies furnish absolute proof of what we can do in rural districts. When you realize that the last census figures, 1916, show that we are losing annually 16,000 mothers, that in that same year we had an annual death rate of 230,000 children under 1 year of age, and when we definitely know that we can prevent one-half this loss of life, we do know that we need some Federal assistance by which this can be accomplished.

One more point. The Children's Bureau was assigned by Congress in the act establishing it the whole field of child-welfare work, and by its studies in infant-welfare and prenatal work and obstetrical care for mothers, as well as because of the knowledge it has of the actual conditions existing in many types of rural districts in many parts of this country, it has been ably prepared for the task of making plans for the carrying out of this Federal measure for the protection of maternity and infancy.

The question that has arisen regarding the child-hygiene divisions I should like to answer. To begin with, we have at the present time only 11 States which have divisions of child hygiene. Six of these have been organized during 1918, and the Children's Bureau has very generously been given the credit for having stimulated this work through its children's year campaign, which was a war-time drive during this past year. With six new divisions not yet organized for work, that leaves only five States which have had Štate divisions of hygiene for any time appreciable, and several of these continually

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