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

The 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 unde take 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 ability 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 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

handicapped by lack of funds. Others are so feebly organized as to be doing very little State-wide work. It seems to me very logical to have a director of the division of child hygiene in each State having such a division under the State department of health, as the person who would be appointed to represent the State board of health on this new maternity and infancy board.

Mr. NOLAN. Have you been connected with the Children's Bureau since its inception?

Dr. RUDE. No, I have not. Last year I did field work for the bureau and have been in my present position since July 1, 1918.

Mr. NOLAN. Were you connected with it when it made an investigation in Johnstown; I believe that was one of the first?

Dr. RUDE. No; I was not.

Mr. NOLAN. Have you ever made any investigation of the large cities since you have been connected with the bureau?

Dr. RUDE. No; not since I have been connected with the bureau. Mr. NOLAN. Do you know whether the result of those investigations has awakened the local authorities or the State authorities so that they themselves put into effect any efficient organization in those particular cities, or States, or localities, to take care of this work along the lines suggested by the Children's Bureau.

Dr. RUDE. Wherever a survey or study has been made, it has been very stimulating. We get letters and reports from those different cities stating what has been accomplished; milk stations have been established or infant welfare centers or other welfare organizations, which date back to our work.

Mr. NOLAN. Have they put in organizations molded along the lines suggested by the Children's Bureau of the Department of Labor specialists who are particularly well qualified to take care of the work in the community? Do you know of anything like that?

Dr. RUDE. I could not answer that. Usually of course they have to avail themselves of local material. I think the important effect is the stimulation.

Mr. NOLAN. Has the Children's Bureau made any second surveys after a period of time to see what results have been accomplished? Dr. RUDE. I think somebody who has been connected with the bureau longer than I have been might be able to answer that.

Miss FLEMING. I think Miss Lundberg can answer that.

Miss LUNDBERG. I can not answer along that line; we have not made any studies that far back.

Mr. NOLAN. You made an investigation pretty nearly six years ago in Johnstown.

Miss LUNDBERG. The bureau has kept in touch with the Johnstown conditions through correspondence and through information from the local people.

Mr. NOLAN. Have they themselves benefited and profited by it? Miss LUNDBERG. We feel they have by the reports we have. It is very difficult to credit any definite thing.

Mr. NOLAN. It seems to me the bureau itself might attack that matter and see whether the result of their investigation in a locality after a period of years, would be beneficial, to see whether the infant mortality in that section might be reduced.

Dr. RUDE. That is one of the unfortunate things about Government work. I know I have felt when leaving a community that I should like to be able to do some follow-up work.

Mr. NOLAN. Of course the expense involved would be so much less in getting the statistics as to the cause of death, and so forth, than the first investigation would be, that I think it would be worth while.

Miss LUNDBERG. I think Mrs. Gaffney can give you the figures and definite facts.

STATEMENT OF MRS. MATTHEW PAGE GAFFNEY, CHIL

DREN'S BUREAU.

Mrs. GAFFNEY. The Johnstown infant mortality rate showed an unusually large reduction as compared with other cities in Pennsylvania in the years immediately succeeding the investigation of the bureau there. An infant mortality committee was appointed by the chamber of commerce, as is recorded in the third annual report of the Children's Bureau. Various reports from Johnstown indicate that great interest in children's welfare was aroused by the study, which was expressed in many permanent forms, such as the securing of infant welfare nurses, a baby welfare station, an improved milk supply, and in renewed effort for a complete sewerage system.

Mr. NOLAN. I was interested in finding out what benefit from the unfavorable publicity given a city of that kind would be.

STATEMENT OF MRS. FLORENCE KELLEY, GENERAL SECRETARY OF THE NATIONAL CONSUMERS' LEAGUE.

Mrs. KELLEY. I speak as the secretary of the National Consumers' League, of which Secretary Baker is the president. In the service of that organization I have had occasion to live in the most congested industrial centers in two great cities-the first four years at Hull House, Chicago, and afterwards at the Nurses' Settlement on the east side of New York City. I have been much impressed by the fact that in the reduction of infant mortality, which I have watched at close quarters, it is the children of the aliens for the most part whose lives are saved. It is the alien mothers, the newly arrived strangers, whose appeal to pity has led to the creation of great nursing associations, so that large numbers of them have more skilled care both at birth and also for illness in their families than the better situated native American working-class families in the same city. And as I travel through the country I find the forgotten children and the forgotten mothers are in large part the Americans, the native women, the old stock people, who are living a rural life. Particularly is this true in the South; it is also true in the Northwest and in New England. All over New England there is admirable visiting nursing and hospital care in the cities for foreigners, but not in the country. For instance, where I have spent my summers for many years, in one of the counties of Maine, we find Uncle Sam caring most solicitously for the young lobsters; our waters have fresh supplies of young lobsters at intervals of three years; but the American mothers there must depend for assistance on their rural neighbors. The number of children born is very small, indeed, and the death rate of the newly born is appalling. It is remarkable that Uncle Sam should care so much for the young lobsters and so little for the American children.