Full text of "Maternal and child-health services under the Social security act, title V, Part 1; development of program, 1936-39 .."

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UNITED STATES
DEPARTMENT
OF LABOR

FRANCES PERKINS

Secretary

CHILDREN'S
BUREAU

KATHARINE F.LENROOT
Chief

Bureau
Publication
No. 259

UNITED STATES
GOVERNMENT

PRINTING OFFICE
WASHINGTON i 1941

X-

^513 -f

Maternal and
Child-Health Services

Under the Social Security Act

Development of Program, 1936-39

UNITED STATES DEPARTMENT OF LABOR
FRANCES PERKINS, Secretary

CHILDREN'S BUREAU
KATHARINE F. LENROOT, Chief

Maternal and Child -Health Services
Under the Social Security Act

Title V, Part 1

Development of Program, 1936-39

Bureau Publication

No. 259

For sale by the Superintendent of Documents, Washington, D. C. Price 15 cents

U. S. SUPERINTENDENT OF DO:

MAR 12 1942

CONTENTS

Page

Letter of transmittal v

A national advance 1

How the program came into being 1

The social-security program for maternal and child-health services 4

Federal participation 5

State programs 11

Local programs 13

Health services for mothers 17

Prenatal service 17

Clinical consultation service 20

Midwife supervision 21

Need for delivery care 23

Complete delivery care 26

Maternity homes and hospitals 28

Maternal-mortality studies 29

Maternal mortality and stillbirths 31

New standard birth and death certificates 36

Child-health services 37

Infant and child mortality 38

Protecting the lives of the newborn 44

The child-health conference 46

The physician at the child-health conference 47

The public-health nurse in the child-health program 49

Continuous health supervision 50

Health services for children of school age 50

Nutrition in the child-health program 51

Dental-hygiene service 55

Prevention of children's diseases 56

The need for medical care 58

Mental health of the child 59

Health education 60

The professional workers and the postgraduate-training program 62

The physician 65

The public-health nurse 68

The dentist and dental hygienist 71

The nutritionist 72

The health educator 73

Studies and investigations 73

State maternal and child-health studies 76

State initiative at work 77

Special projects in urban areas 84

The status of the program at the close of 1939 87

Appendix 1. — Text of the sections of the Social Security Act relating to
grants to States for maternal and child-health services, as amended by the

Social Security Act Amendments of 1939 89

Appendix 2. — Tables summarizing State progress for the year ended
June 30, 1939:

I. Maternity and child-health-conference centers supervised by

State health agencies, by States 93

II. Number of counties with specified type of service, by States 94

ill

IV Con ten ts

Appendix 2 — Continued. Page

III. Specified types of activities, by States 96

IV. Services for which practicing physicians, dentists, and nurses

received payment, by States 98

V. Postgraduate education received by practicing physicians, den-
tists, and nurses, by States 100

VI. Postgraduate education received by staff members, by States 102

Appendix 3. — State health agencies administering maternal and child-
health services under title V, part 1, of the Social Security Act, Decem-
ber 1939 104

Appendix 4. — Advisory Committee on Maternal and Child Health Services
and Special Advisory Committees on Public Health Nursing and on
Dental Health, 1939 107

TABLES

1. Federal payments to States for maternal and child-health services under

the Social Security Act, title V, part 1, for the fiscal years ended

June 30, 1936, 1937, 1938, and 1939 6

2. Services for which practicing physicians, dentists, and nurses received

payments, year ended June 30, 1939 14

3. Services provided under State health agencies in rural and urban

counties, year ended June 30, 1939 15

4. Maternal and child-health services, calendar years 1938 and 1939 16

5. Maternal mortality rates by States, 1939, 1938, 1937, and 1936 33

6. Infant mortality rates by States, 1939, 1938, 1937, and 1936 39

7. The 15 leading causes of death among persons under 20 years of age;

United States, 1939 43

8. Postgraduate education received by State and local staff members, year

ended June 30, 1939 64

CHARTS

1. Percentages of annual Federal allotments of maternal and child-

health funds matched by States in the fiscal years 1937 and 1939,
Social Security Act, section 502 (a) 8

2. Attendant at birth, live births that occurred in cities of specified size

and in rural areas; United States, 1939 25

3. Maternal mortality rates; United States expanding birth-registration

area, 1915 1939 -- 32

4. Maternal mortality rate in each State; United States, 1939 32

5. Maternal mortality rates among white and Negro women; United

States, 1931-1939 34

6. Causes of maternal death, percentage distribution; United States,

1939 35

7. Infant mortality rate in each State; United States, 1939_ 38

8. Infant mortality rates, by age; United States expanding birth-registra-

tion area, 1915-1939 40

9. Infant deaths, by age in months; United States, 1939 41

10. Causes of infant death, percentage distribution; United States, 1939. . 41

11. Causes of neonatal death, percentage distribution; United States, 1939 42

12. Population per public-health nurse in urban and rural areas in each

State; Continental United States, Alaska, and Hawaii, January 1,

1940 69

LETTER OF TRANSMITTAL

United States Department of Labor,

Children's Bureau,
Washington, D. C, September 15, 1941.

Madam: There is transmitted herewith Publication No. 259, Maternal
and Child-Health Services Under the Social Security Act: development
of program, 1936-39. This bulletin covers the first 4 years of Federal
and State cooperation under title V, part 1, of the Social Security Act,
providing for grants to the States for maternal and child-health services.

During this period maternal mortality in the United States was reduced
by almost one-third and infant mortality by one-sixth. The encouraging
progress that has been made gives assurance that with the expanded
resources recommended by the Children's Bureau Advisory Committee
on Maternal and Child Health Services and by other bodies it will be
possible to provide really adequate care for mothers and children through-
out the Nation. The fact that physical examination of registrants
under the Selective Training and Service Act of 1940 resulted in the
rejection of almost half of our young men as physically or mentally unfit
for general military service emphasizes the importance of an adequate
maternal and child-health program as an essential guarantee for the
future of our democracy.

Dr. Martha M. Eliot, Associate Chief of the Children's Bureau, has
been responsible for general supervision of the initiation and development
of the program for grants to the States for maternal and child-health
services and crippled children's services. In 1941 the Division of Health
Services was established in the Children's Bureau, combining the two
former divisions, the Maternal and Child Health Division and the
Crippled Children's Division, that had been directly responsible for
administering these programs.

The staff of the Maternal and Child Health Division in 1939 included
the following: Edwin F. Daily, M. D., Director, Jessie M. Bierman,
M. D., Assistant Director, Clara E. Hayes, M. D., Consultant in Maternal
and Child Health, Maud M. Gerdes, M. D., Specialist in Maternal and
Child Health, Walter H. Maddux, M. D., Consultant in Pediatrics,
Marjorie M. Heseltine, Consultant in Nutrition, and Naomi Deutsch,
R. N., Director of the Public Health Nursing Unit. The audit's work
was the responsibility of the State Audits Unit, William J. Maguire,
Director.

VI Letter of Transmittal

The regional staff of the Division that performed the important
function of giving field consultation service to the State health agencies
in the development of their maternal and child-health programs included
the following medical consultants, Sarah S. Deitrick, M. D., Thomas A.
Morgan, M. D., Doris A. Murray, M. D., Frances C. Rothert, M. D.,
Edith P. Sappington, M. D., and John M. Saunders, M. D.; and the follow-
ing public-health-nursing consultants, Alice F. Brackett, R. N., Ruth
Cushman, R. N., Ruth A. Heintzelman, R. N., Hortense Hilbert, R. N.,
Jane D. Nicholson, R. N., and Ruth G. Taylor, R. N.

Respectfully submitted.

Katharine F. Lenroot, Chief.
Hon. Frances Perkins,

Secretary of Labor.

Maternal and Child-Health Services Under
the Social Security Act, 1936-39

A National Advance

In 1939 the maternal mortality rate in the United States showed
a drop of 30 percent, and the infant mortality rate showed a drop of
16 percent, as compared -with 1936. Both rates were the lowest on
record for the United States. The maternal mortality rate was 40
deaths from conditions due to pregnancy and childbirth per 10,000
live births, and the infant mortality rate was 48 deaths under 1 year
of age per 1,000 live births. These gains were achieved through the
effort of professional and community groups extending back 30 years
or more to bring increasing medical knowledge and better health
practices to bear upon the initial period of life and to extend the
benefits of advancing knowledge to the full period of children's growth
and development.

The Social Security Act, approved August 14, 1935, ' provided for
the extension and improvement of maternal and child-health services in
the States through Federal grants administered by the Children's
Bureau of the United States Department of Labor and, in the States,
by the State health agencies. This publication presents a picture of
Federal and State cooperation in providing maternal and child-health
services during the 4-year period following the passage of the Social
Security Act.

How the Program Came Into Being

A Nation-wide program to protect the health of mothers and
children is not a new movement but is rather a midway goal in a
movement that started with the opening of the first milk station in
1893 in New York City, for the purpose of providing babies with safe
milk during summer heat. Similar stations were opened in other
cities and led, on the one hand, to city and State regulation of the
milk supply and, on the other hand, to the organization of infant -

1 The text of the sections of the Social Security Act relating to grants to States
for maternal and child-health services, as amended by the Social Security Act
Amendments of 1939, is given in appendix 1, p. 89.

Maternal and Child-Health Services

welfare societies to bring medical knowledge and nursing service to
bear on the saving of the lives of babies in the poorer areas of cities.

Community effort to provide prenatal care for mothers began in
New York City in 1908 with service offered by the Association for
Improving the Condition of the Poor and the pediatric department of
the New York Outdoor Clinic. In 1912 the Women's Municipal
League of Boston began a 5 -year experiment in providing prenatal
care, given by nurses, to women in their homes.

In 1908 the city of New York established a bureau of child hygiene
in its health department, and in 1912 Louisiana established the first
child-hygiene division in a State department of health.

During 1909 two conferences were held which were of far-reaching
importance in their effect on child health and child welfare. The
Conference on the Care of Dependent Children, called by President
Theodore Roosevelt, which met in January at the White House,
endorsed the proposal for the establishment of a Children's Bureau in
the Federal Government to collect and disseminate information
affecting the welfare of children. The conference on the prevention
of infant mortality, held in New Haven in November 1909 under the
auspices of the American Academy of Medicine and including in its
membership leaders in social welfare as well as in medicine, led to the
establishment of the American Association for the Study and Preven-
tion of Infant Mortality.

The Federal Children's Bureau, created in 1912 by act of Congress
and placed in the United States Department of Commerce and Labor
(transferred to the new United States Department of Labor in 1913),
started at once on its studies of infant mortality and on the preparation
of popular publications on the care of the expectant mother and the
young child.

The second publication issued by the Children's Bureau was "Birth
Registration; an aid in protecting the lives and rights of children"
(1914). Many groups cooperated in promoting a more complete
registration of births in the States. In 1915 the United States Bureau
of the Census established the birth-registration area, including at the
start 10 States and the District of Columbia and expanding each year
as State after State improved its registration of births until in 1933 all
the States were included in the area.

The American Association for the Study and Prevention of Infant
Mortality, composed of pediatricians, infant -welfare nurses (fore-
runners of the public-health nurse), social workers, public-health
officials, and others, provided the leadership in the ever-widening
movement to protect the life and health of human beings during the

Development of Program, 1936-39

first days and months of life. In 1919 the name of the organization
was changed to the American Child Hygiene Association, to reflect
the growing emphasis on the protection of the health of children of
all ages. In 1923 this association combined with the Child Health
Organization (started in 1918) to form the American Child Health
Association, which continued its leadership in promoting child-health
programs throughout the country until it was disbanded in 1935.

In 1918 the Maternity Center Association was organized to improve
maternity care by teaching the public what adequate maternity care is,
why it is necessary, and how it can be given.

In 1919 a resolution of the American Child Health Association led to
the formation of the Joint Committee on Maternal Welfare, which by
1921 included committees of the American Child Health Association,
the American Gynecological Society, the American Association of
Obstetricians, Gynecologists, and Abdominal Surgeons, and the Ameri-
can Pediatric Society. Representatives of other organizations were
added later and in 1934 the committee was incorporated as the
American Committee on Maternal Welfare. In pursuance of its ob-
jective of safeguarding the lives and health of mothers and infants,
the committee, among other activities, encouraged the organization,
through State medical societies, of State and county committees on
maternal welfare.

Widespread study was given to the health needs of children during
Children's Year, 1918-19, initiated to insure protection for children in
the United States during the war period. The conclusions developed
by national and regional conferences on child-welfare standards called
by the Children's Bureau with the approval of President Wilson in
1919 led among other results to the passage by Congress of the
Sheppard-Towner Act, authorizing $1,240,000 a year for Federal grants
to the States for the promotion of the hygiene of maternity and
infancy. From 1922 to 1929, under administration of the act by the
Children's Bureau, the State health agencies in all but 3 States, with
the aid of Federal funds, developed State and local maternal and
child-health programs.

The rapid development of medical science and the increased at-
tention devoted to the problems of maternal and child health were
brought to a focus in the reports of the section on medical service of
the White House Conference on Child Health and Protection, called
by President Hoover in 1930. The medical leaders of the country
pointed out the unnecessary waste of maternal and infant life and the
means at hand for avoiding that waste and for promoting the growth
and development of children.

Maternal and Child-Health Services

The Social Security Program for Maternal and Child-
Health Services

The inclusion of Federal aid for the promotion of maternal and
child-health services in the bill that became the Social Security Act,
approved August 14, 1935, was a recognition of the desirability of a
Nation-wide maternal and child-health program and of the necessity
of Federal participation as being vital to its success.

The social-security funds opened the door to a national program to
protect maternal and child health. In the objective — "the extension
and improvement of maternal and child-health services"- — the act
recognized the need for continuing expansion if the program is to be-
come active in all communities in the United States and if it is to be
developed to meet fully the health needs of mothers and children.

Within 10 months after the appropriations under the Social Se-
curity Act first became available (February 1, 1936) all the 48 States,
the District of Columbia, Alaska, and Hawaii had submitted plans
for maternal and child-health services to the Children's Bureau and
had qualified to receive Federal grants for this purpose.2

The combined Federal, State, and local funds included in the State
plans for maternal and child-health services for the fiscal year ending
June 30, 1939, exceeding $7,000,000, provided for the following main
types of expenditure:

Professional services including travel: Percent

Medical 19

Nursing 54

Dental 5

Nutrition 2

Health education 1

Postgraduate education for professional workers 3

Other expenditures — clerical service, scientific supplies, equipment,

and other expenses T 16

These items reveal the character of the services designed for pro-
moting the health of mothers and children "especially in rural areas
and in areas suffering from severe economic distress." The largest
part of the program is the provision of physicians and public-health
nurses, who bring scientific knowledge to the protection of the lives of
mothers and children before, during, and after birth, and to the
promotion of the growth and development of children. The State
programs increasingly are taking advantage of the recent scientific
research that has unfolded a new and important chapter on the
nutrition of the mother as a factor in the birth of a healthy child and

2 For an account of the administration of the Federal-State program during its
initial period, see Federal and State Cooperation in Maternal and Child- Welfare
Services Under the Social Security Act (Children's Bureau Publication No. 254,
Washington, 1938).

Development of Program, 1936-39

on the significance of nutrition in the growth and development of the
child. Attention has been given to the care of the teeth of the ex-
pectant mother, of the child's first set of teeth, and of the permanent
teeth that come during school years. Safeguarding children against
disease necessitates vaccination against smallpox, immunization
against diphtheria, and supervision of health throughout infancy and
the preschool and school years. The item "other expenditures"
included, therefore, expenditures for vaccines, toxoid, and equipment
for child-health conferences and prenatal clinics. Although the
tabulation indicates that only 1 percent of the total expenditure was
specifically for "health education" it is obvious that a large proportion
of the medical, nursing, dental, and nutrition services are educational
also. The term "health education" is used here in a restricted sense
and includes only salaries and travel of health educators.

Although it has the advantage of Federal and State consultation
service, the maternal and child-health program is essentially a com-
munity program — bringing to parents knowledge and professional
skill to aid them in learning the day-by-day practices that are essential
to individual health, to family health, and to community health.

Many of the individuals and many organizations that have shared in
this movement for more than a quarter of a century are continuing to
share in its current development through service or representation on
the advisory committees of the Children's Bureau and the State health
agencies, and through leadership in the many voluntary organizations,
local, State, and National, that participate in some way in the move-
ment to safeguard the lives and promote the health of mothers and
children.

Recent evidence of the continuing interest of many groups in the
health of mothers and children was the organization in 1938 of a
National Council for Mothers and Babies, including in its membership
more than 50 national organizations joined together for the exchange
of information, for study, and for cooperative effort in increasing
public interest in better care for mothers and babies.

Federal Participation

For the purpose of enabling each State to extend and improve as
far as is practicable under the conditions in such State, services for
promoting the health of mothers and children, especially in rural
areas and in areas suffering from severe economic distress, the Social
Security Act of 1935 authorized the annual appropriation of $3,800,000
for grants to the States, including the District of Columbia, Alaska,
and Hawaii.3 The first appropriation under this authorization was

3 An increased annual appropriation was authorized by the Social Security Act
Amendments of 1939, and Puerto Rico was added to the number of States and
Territories eligible for grants. (See text of the act, as amended, p. 89.)

Maternal and Child-Health Services

made available for the 5-month period, February 1 to June 30, 1936.
Table 1 shows Federal payments made to the States for the fiscal years,
1936 to 1939.

TABLE 1. — Federal payments to States for maternal and child-health
services under the Social Security Act, title V, part 1, for the fiscal
years ended June 30, 1936, 1937, 1938, and 1939

Federal payments under approved State plans

State i

Fiscal year

1936 (Feb. 1-

June 30)

Fiscal year
1937

Fiscal year
1938

Fiscal year
1939

United States .

$1,252,436.22

$2,990,261.88

$3,722,477.50

$3,724,362.29

45,100.68

6,364.06
18,261.58
30,768.94
39,689.32

7,421. 71
20,139.85

7, 747.00
14,522.80
26,324. 17
59,638.63

8,343,33
15,752.38

102,446. 14
16,411.95
51,735.02
70,071.78
51,599.79
60,788.70
41,654.86
32,059.65
32,557.64
65,978.07

132,076.81
42,630.93
39,518.90
70, 144.50
47,845.42
42, 728.06
28,702. 16
87, 170.59
88,924.43
36,999.27
53,239.74
79, 175.21
84,440.68
67,506. 15

104,696.25
43,467.27
42,599.52
1.997.05
28,557.03
27,022.79
75,481.94
61,003.47
78,655.04

116,362.25
28,974.34
83,456.11
64,333.76
27,441.25
50.813.96
31,409.34
98,994.68
27,021.32
92,295.27

129,543.93
43,045.03
23,312.53
77,174. 17
47,895.91
68,616.78
64,974.41
24,710.03

107,837.00
31,378.79
50,320.05
56,851.53

126.728. 18
56,239.63
36,849.44
28,854.66
41,246.41
75,215.00

126,726.37
37,273.56
42,845.83

124,756.90
75.850.59
50,353.67
49,548.40
97, 113.88
91,844. 19
54,853.47
59,988. 17
82,452.80

107,363.66
72,052.99
90,737.49
66,001. 75
50,077.82
27.760. 15
39.289.41
27,290.47
79,283.94
64,662.60

166,977.07

133.887. 53
53.611.52

141.639.00
79, 241.41
59.249.93

147.847.85
35,945.48

104,061.53
43,895.43
96,404.51

183,123.39
40,607.92
36,376.97
95,156. 10
47.888.07
56,415.68
62,499.81
7,999.50

105,854.92

Alaska _ __ _ _

40,831.62

58,176.24

74,158.69

California __ - _ - _

97.415.08

Colorado - __ .

58,399.68

52,073.83

Delaware. _ .

30,764.33

District of Columbia.

54.014.08

Florida ______

76,333.29

126,365.74

Hawaii

34,765.16

Idaho

44,683.65

Illinois. ___

133,630.24

20,573.19
26,224.43
25,260.83
28,898.30
31,485.36
19,496.95
19,788.52
28,444.22
37,995.54
21,732.00
51.000.44
20.875.00
15,338.09

9,400.00
16,428.95
11,975.67
13,566.67
28,873.41
78,579.19
50,121.32

9,724.27
22,010. 00
18,176.45

78, 162.67

51,836.81

79,371.65

Kentucky ._ .

Louisiana -

Maine _ _ _ -

Maryland _

Massachusetts _ _ _ ._

Michigan . -

100,226.71
98,548.01
51, 126.36
62,165.51
78,913.48
84.576.82

68,828.47

93,663.03

112,492.42

43,314.84

25,487.90

32.747.00

New Hampshire - __ __ _

36,937.80

75,473.70

72,351.10

181,027. 29

North Carolina . _ .

111,673.30

North Dakota

Ohio

48, 132. 76
100,934.60

84.654.49

56,666.27

63,371.66
8,396.67
34, 128.66
16,833.50
35,448.49
42,001.66
10,610.50
14,250.34
34,627.34
23,794. 12
27,763.34
25,982.91
9,183.78

133,002.49

30,264.85

South Carolina

97,628.28

South Dakota

44,654.25

79,831.92

Texas - .

162,534.39

Utah

54,514.96

38,981.03

94,599. 73

50.605.94

West Virginia

44,340.38

Wisconsin

64,845.30

11,779.23

' The term "State" includes the District of Columbia, Alaska, and Hawaii.

The Secretary of Labor was made responsible for the allotment of
the Federal funds to the States. The sum of $2,820,000 (fund A)
was to be allotted on the basis of $20,000 to each State and a share of
the remaining $1,800,000 in the proportion that the number of live
births in the State bore to the total number of live births in the United

Development of Program, 1936-39

States for the latest calendar year for which such figures were available.
The allotment to each State was made available for payment of half
the sum expended under the State plan for maternal and child-health
services. In other words, the matching of Federal funds with State
or local funds for this purpose was required. Any balance in an
allotment from this fund unpaid to a State at the end of the fiscal
year remained available for payment to that State until the end of
the second succeeding fiscal year. An additional sum of $980,000
(fund B) was to be allotted on the basis of the financial need of the
State for assistance in carrying out its State plan after the number
of live births had been taken into consideration, and these funds were
payable to the States only during the fiscal year for which the annual
appropriation was made. Matching with State or local funds was not
required for fund B.4 The percentages of annual Federal allotments
of maternal and child-health funds that were matched by the States
in the fiscal years 1937 and 1939 are shown in chart 1.

The Children's Bureau of the United States Department of Labor
was made responsible for giving consultation service to the State
health agencies to aid them in the development of State plans for
maternal and child-health services. When the annual plan submitted
by each State health agency is found to be in conformity with the
requirements of the Social Security Act it is approved by the Chief
of the Children's Bureau and becomes the basis for quarterly pay-
ments to the States.

The Maternal and Child Health Division of the Children's Bureau,
which is immediately responsible for the maternal and child-health
program, had as its director in 1939 an obstetrician and as its assistant
director a pediatrician. The staff included also an obstetric consul-
tant, a specialist in maternal and child hygiene, and a nutrition con-
sultant. A Negro pediatrician on the staff was available for assign-
ment to States having a large Negro population. The Director of the
Public Health Nursing Unit serves as consultant on the nursing phases
of the program. The field staff included for each of five regions a
medical consultant and a public-health-nursing consultant. The
medical-social consultant serving on the staff of the Crippled Chil-
dren's Division and the regional staff of medical-social consultants have
advised on many aspects of the program, particularly in connection
with the medical-care aspects of the maternity program. The State

4 For the terms under which these funds were allotted see sees. 502 and 504
of the Social Security Act (appendix 1, pp. 89, 90).

The procedure for making allotments and providing for payments to the States
is described in Children's Bureau Publications No. 253, Grants to States for
Maternal and Child Welfare Under the Social Security Act of 1935 and the Social
Security Act Amendments of 1939 (Washington, 1940), and No. 254, Federal
and State Cooperation in Maternal and Child- Welfare Services Under the
Social Security Act (Washington, 1938).

8 Maternal and Child-Health Services

Chart 1. — Percentages of annual Federal allotments of maternal and child-health funds
matched by States in the fiscal years 1937 and 1939, Social Security Act, Section
502 (a) >

I937 I939

PERCENT PERCENT

0 gO 40 60 60 ICO 0 20 40 60 60 100

1 I I I I I I I I I I l

ALABAMA

ARIZONA

ARKANSAS

CALIFORNIA

COLORADO

CONNECTICUT — — — ■■■■— ■ + — ■ ■■■■■■■■— +

DELAWARE ■■^^■■■^■■■M * ■■^BHDEBnHBaHni

DISTRICT OF COLUMBIA IMHMMH^HH^MMWHHai BaBHBnOBDBHHDaBV

FLORIDA — — — — —— — + ^ — — I +

GEORGIA t^nBHBHI^^Hi« ^ — +

HAWAII MBBOB!B3^nBBHHH* nraHHBHHHBOSBSHnBM

■in !■■■ i m in i«— gag— b - mmmammam^mBumamKmmm

Indiana mmBsm^o^mmMmmm^^i^m+ wm^^mmmmm^^i^mmmm ■*■

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■Bars extending to 100 percent on scale indicate that States represented supplied matching funds
in the amount of 100 percent or more of annual Federal allotments.

Audits Unit, with a field staff of five auditors, was responsible for
seeing that the expenditures of Federal and State funds for maternal
and child-health services (and the two other programs administered
by the Children's Bureau under the Social Security Act) were in
agreement with the State plans as approved.

The effectiveness of the consultation service is enhanced by the
recommendations of advisory committees to the Children's Bureau,
appointed by the Secretary of Labor and composed of leaders from
the medical, dental, and nursing professions, from national health and
social agencies, and from national organizations concerned with ma-
ternal and child health. The committees in 1939 included a General

Development of Program, 1936-39 9

Advisory Committee on Child Welfare Services, which advises the
Children's Bureau on its three social-security programs, and, as
technical committees, the Advisory Committee on Maternal and
Child Health Services (including subcommittees on maternal health
and on child health) and special advisory committees on dental health
and on public-health nursing.5 (See appendix 4, p. 107.) The State
and Territorial health officers meet at least once a year in conference
with the Children's Bureau to consider how advances can be made
in the maternal and child-health program.

In 1936, as part of its administrative responsibility for the social-
security program for maternal and child health, the Children's Bureau
called upon the State health agencies for quarterly reports of health
services rendered to mothers and children, under the supervision of
the State health department, in connection with title V, part 1, of
the Social Security Act. These reports are based on the plan for the
tabulation of health-department services approved by the State and
Territorial health officers in 1936 (revised in 1940). The Division of
Statistical Research of the Children's Bureau, which is responsible
for the collection of these statistics, gives consultation service to the
State health agencies for the development of methods of reporting
that will yield data comparable between States and reliable as a
national measure of maternal and child-health services. A tabula-
tion of these services for the calendar years 1938 and 1939 is given in
table 4, p. 16. In accordance with the requirement in the Social
Security Act that the State agencies send in such reports as the
Secretary of Labor may require, the State health agencies are sending
to the Children's Bureau progress reports on the development of the
program of maternal and child-health services within the States.
These reports are the basis for annual summaries of progress referred
to throughout this report.

From time to time the Bureau calls conferences of the directors
and other staff members of the bureaus of maternal and child
health of the State departments of health. A national con-
ference of State directors of maternal and child health was held
in Washington on September 30 and October 1, 1937. The first
regional conference of maternal and child-health directors was
held in San Francisco in February 1938. Regional conferences of
State maternal and child-health directors and public-health-nursing
supervisors were held in Providence, R. I., and in Chicago in Decem-
ber 1938. Regional conferences of public-health nurses were also

5 When the Secretary of Labor reappointed these advisory committees in
April 1940, the committee on dental health was made a subcommittee of the
Advisory Committee on Maternal and Child Health Services and the committee
on public-health nursing was made a subcommittee of both the Advisory Com-
mittee on Maternal and Child Health Services and the Advisory Committee on
Services for Crippled Children.

10 Maternal and Child-Health Services

held in Boston in February 1937, in Richmond, Va., in May 1938,
and in Portland, Oreg., in June 1938.

At the beginning the State health agencies were not able to recruit
their forces fast enough to take full advantage of the Federal aid
offered, and in some cases State and local appropriations were not
sufficient to match in full the Federal funds allotted from fund A.
Payments to the States for the fiscal year 1938 showed that the pro-
gram had attained a development substantially equivalent from a
financial standpoint to the annual appropriation authorized in the
Social Security Act.

At the hearings on the National Health Bill held by a subcommittee
of the Senate Committee on Education and Labor during the spring
of 1939 evidence submitted showed that there were still extensive
areas where, because of limited funds, the State health agencies had
been unable to develop maternal and child-health services, that in
other areas the program was not sufficiently developed to meet fully
the needs of mothers and children, and that the funds so far made
available permitted the development of remedial medical-care service
for individual mothers and children only in a few local areas and on
an experimental basis.

On recommendation of the Senate committee the bill for amending
the Social Security Act, then under consideration, was amended to
authorize an increase in the appropriation for grants to the States
for maternal and child-health services. Fund A, for which matching
is required, was increased to $3,840,000, and fund B, allotted on the
basis of the financial need of each State, for which matching is not re-
quired, was increased to $1,980,000. These increased authorizations,
bringing the total to $5,820,000 for grants to the States for maternal
and child-health services, were included in the Social Security Act
Amendments of 1939, approved August 10, 1939, and appropriations
under these increased authorizations were made available. For the
year ending June 30, 1940, the appropriation was increased to $4,800,-
000, which included approximately one-half of the increased amount
authorized.6 Increased payments to the States, for the most part,
began after January 1, 1940. The Social Security Act Amendments
of 1939 also made Puerto Rico eligible to receive grants for maternal
and child-health services, beginning January 1, 1940." Another
amendment required that State plans should provide for the estab-
lishment and maintenance of a merit system for the selection and
retention of employees included in the plan.

6 The appropriation for the fiscal year ending June 30, 1941, was $5,820,000,
the full amount authorized in the Social Security Act Amendments of 1939.

7 The text of title V, part 1, of the Social Security Act as amended and of
related sections of the act are given in appendix 1, p. 89.

Development of Program, 1936-39 11

The period covered by this report is the initial period, when State
programs were being developed and expenditures were within the
amounts authorized by the original act. By the close of 1939 plans
for somewhat extended programs made possible by increased funds
were under consideration.

State Programs

Promoting the health of mothers and children in the States under
professional leadership is a planned program and is concentrated at
points of special need. Under the Social Security Act the responsi-
bility for developing and submitting a plan, and for administering
its provisions after it has been approved, is that of the State health
agency. As the needs of the States vary widely because of geo-
graphic, racial, agricultural, or industrial conditions, the plans for
extending and improving maternal and child-health services are
different for each State.

In order to participate effectively in the social-security maternal
and child-health program, each State health agency established, or
expanded within its departmental organization, a maternal and child-
health division under the direction of a physician. Of the 51 State
maternal and child-health directors serving on June 30, 1939, 21 had
been trained in pediatrics or obstetrics, and of this 21,9 had received
at least 1 year's additional training in a school of public-health
administration. Of the remaining 30, 11 had received training in
public-health administration for at least 1 year and 13 had had from
8 to 28 years' experience in public-health administration. Because
of the many clinical features of the maternal and child-health pro-
gram, previous clinical experience was considered by most of the State
health authorities a requisite qualification for a maternal and child-
health director.

A well-qualified public-health nurse serving as the chief State
advisory nurse and at least one specialized consultant in maternal
and child-health nursing in the division of public-health nursing, in
States where such a division exists, are believed to be essential for
the conduct of a maternal and child-health program.

The State budgets for the year ended June 30, 1939, provided for
71 physicians to serve full time on State staffs as assistant maternal
and child-health directors or clinical consultants, for 8 physicians to
serve part time for consultation service, for 541 public-health nurses
to serve in an administrative, consultant, or supervisory capacity,
for 43 nutritionists (in 24 States), for 34 health educators (in 20
States), for 67 dentists (in 29 States), and for 52 dental hygienists
(in 13 States).

328109°— 42 2

12 Maternal and Child-Health Services

The maternal and child-health division works with other divisions
of the State health department, such as the divisions of county health
work, public-health nursing, communicable-disease control, vital sta-
tistics, and sanitation. Cooperative working relationships are also
maintained with the State department of education, the State depart-
ment of welfare, the State crippled children's agency, the home-
economics extension service of the State university, and other State
agencies providing services for children or affecting children. The
maternal and child-health divisions also cooperate actively with
private agencies serving children.

The functions of the State division of maternal and child health,
as shown by the State maternal and child-health plans, are (1) to
develop maternal and child-health services in district or county
public-health units and in areas without full-time public-health
services; (2) to develop high standards of service in the maternal and
child-health field; (3) to enlist the cooperation of members of the
medical and allied professions and of community groups in extending
State- wide facilities for continuous medical and nursing care and
health supervision through maternity, infancy, and childhood, and
in maintaining high standards of care; and (4) through health-educa-
tion programs conducted by physicians, dentists, nurses, and nutri-
tionists to inform parents and children of the practices essential for
health.

The State plan submitted to the Children's Bureau each year as a
basis for Federal payments serves also as the working plan for the
year's program for the State health officer and the maternal and
child-health director. The plan shows State and local staff organiza-
tion to be maintained with the combined Federal, State, and local
funds, and the activities to be carried on. It explains how the State
proposes to meet the seven prerequisites for receiving the Federal
grant, which are outlined in the Social Security Act, including (1)
financial participation by the State, (2) administration or supervision
of administration by the State health agency, (3) efficient administra-
tion (including, after January 1, 1940, provision for a merit system
of personnel administration), (4) regular reporting, (5) extension and
improvement of local maternal and child-health services, (6) coopera-
tion with professional and citizens' groups and organizations, and
(7) development of demonstration services in needy areas and among
groups in special need. In requesting Federal funds available under
section 502 (b), which are allotted on the basis of the financial need
of the State for assistance in carrying out its State plan and for which
matching by State and local funds is not required, the State plan
describes the unmet needs of the State in the field of maternal and
child health and the extension of service that will meet such needs
at least in part.

Development of Program, 1936-39 13

The majority of the State health agencies have taken advantage
of the active interest of many groups in their States by organizing
advisory committees on maternal and child-health services to aid the
division of maternal and child health in planning and developing its
program. On these committees serve representatives of the State
medical and nursing associations, specialists in obstetrics and pedi-
atrics, dentists, representatives of parent-teacher associations, of farm
groups, and of other State organizations whose members are con-
cerned with the extension of maternal and child-health services.

These committees have aided the State health officers and the
maternal and child-health directors in developing standards for the
selection of State and local personnel and in planning postgraduate
education for professional workers in the field of maternal and child
care, and have advised on the extension of service in local areas and
on special projects. The members of such committees have played
an important part in promoting understanding of the program within
their own organizations and in their communities. Several hundred
private citizens each year thus share in promoting State maternal
and child-health programs.

Thirty State health agencies reported for the year ended June 30,
1939, that from one to four meetings of the advisory committee had
been held during the year in each of these States.

The demonstration services included in the State plans have proved
to be spearheads in the attack on many of the difficult aspects of the
health problems of mothers and children. A maternal and child-
health demonstration is defined as a project established in an area in
special need of certain types of maternal and child-health services,
staffed by especially well-qualified personnel, and providing more
and better services than are available in any comparable area in the
State. The project should demonstrate the value of such services to
the people of the area and of other areas. In such demonstrations
provision is made for technical supervision and consultation by
persons who meet the standards of personnel qualifications recom-
mended by the State and Territorial health officers.

Many of the illustrations in the succeeding pages are taken from
programs initiated as "demonstration services."

Local Programs

Part of the Federal-State funds is used by the State health agencies
to build up maternal and child-health services in local areas, especially
rural areas. The health officer in the county or local political sub-
division having an organized public-health unit is responsible for the
development of the maternal and child-health program as a major
feature of the local public-health program.

Maternal and Child-Health Services

Medical service at prenatal clinics and child-health conferences
and in the health supervision of school children is sometimes given
by the local health officer, but more commonly it is given by local
practicing physicians engaged to give service periodically at clinics,
conferences, and examinations of school children. Local dentists
participate similarly in the program. One or more public-health
nurses on the staff carry on the nursing phases of the maternal and
child-health program as part of a generalized program covering all
nursing phases of the local public-health program. The nurse
arranges for and assists the physician at prenatal and postnatal clinics,
child-health conferences, and health examinations of school children,
conducts classes for mothers and fathers, visits mothers and children
at home, and carries on other supplementary activities.

The services for which practicing physicians, dentists, and nurses
received payments under the maternal and child-health program for
the fiscal year ended June 30, 1939, are shown in table 2.

TABLE 2. — Services for which practicing physicians, dentists, and nurses
received payment, year ended June 30, 1939

Persons receiving payment

Physicians

Dentists

Nurses

Type of service

Number

States

which

service

was

given

Number

States

which

service

was

given

Number

States

which

service

was

given

1,178

2,634

634

113

22
291

453

4
16
11

Infant and pre-school conferences . .

322

In local areas that are not served by organized public-health units
a public-health nurse is frequently employed to give community
nursing service, with the aid of a citizens' advisory committee, under
the direction of the district health officer or directly under State
supervision until a local health unit is organized.

In a few of the larger counties having a well-developed health
program a consultant obstetrician and a consultant pediatrician
advise on the development of the maternal and child-health program,
and additional physicians are placed on the health-department staff
to carry on the program. When additional public-health nurses can
be employed the area is usually divided into districts so that each
nurse will be able to give more adequate service to the families in her
district. Table 3 shows the number of urban and rural counties in
which specified services are provided.

Development of Program, 1936-39

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Maternal and Child-Health Services

As the program develops, dentists, nutritionists, and other health
workers are added to the local staff on a full-time or a part-time basis.
In the counties selected by the State health agency for demonstrations
specially qualified staff is provided to render the services planned for
the project.

The number of mothers and children served in this Nation-wide
program and the extent of services given reach impressive totals, as
is shown in table 4. Additional tables showing progress made in the
States in the various phases of the maternal and child-health program
for the fiscal year ended June 30, 1939, are included in appendix 2.

TABLE 4. — Maternal and child-health services, for the calendar years

1938 and 1939 ]

Type of service

Medical services:

Maternity service:

Cases admitted to antepartum medical service

Visits by antepartum cases to medical conferences
Cases given postpartum medical examinations

Infant hygiene:

Individuals admitted to medical service

Visits to medical conferences

Preschool hygiene:

Individuals admitted to medical service

Visits to medical conferences

School hygiene: Examinations by physicians

Public-health-nursing services:

Maternity service:

Cases admitted to antepartum nursing service

Field and office visits to and by antepartum cases

Cases given nursing service at delivery

Cases admitted to postpartum nursing service

Nursing visits to postpartum cases

Infant hygiene:

Individuals admitted to nursing service

Field and office nursing visits

Preschool hygiene:

Individuals admitted to nursing service

Field and office nursing visits

School hygiene:

Field and office nursing visits

Immunizations:

Smallpox

Diphtheria _--7

Dental inspections (by dentists or dental hygienists):

Preschool children

School children

Visits for midwife supervision

1 Reported by State health agencies administering State plans under the Social Security Act, title V,
part 1.

Reports were received from 48 States, Alaska, Hawaii, and the District of Columbia.

Note, — The figures in this table are known to be somewhat incomplete. Differences shown between
the 2 years may be due to a real change in the amount of service provided, to a change in the number
of health jurisdictions included, to more accurate or complete reporting, to statistical errors due to
variations in interpretation of terms, or to other factors. The figures on admissions and visits are
fairly dependable as an indication of services provided, but on account of inconsistences in the methods
used by the States in reporting, these figures should not be used for computing average visits per
admission. Reports for 1938 include some services (by public agencies) not administered or supervised
by the State health agency, but reports for 1939 do not; this factor is believed to account for the
apparent decrease in several services in 1939.

Number reported '

1939

1938

124,924

119,623

333,651

344, 174

27,452

22,710

137,567

156,749

402,479

534,882

276,425

266.466

472,462

492,431

1,385,078

1,836, 124

213,267

215,957

602,917

604.568

16,823

16,987

151,676

140,250

406,728

408,609

381,054

395,966

251,467

1,295,478

441, 103

435,243

1,065,950

1,090,151

1,439,890

3,327,746

1,465, 136

1,686,632

1,059,478

1, 176,815

69,050

140.628

1,415,576

1.654,929

39,424

38.933

Development of Program, 1936-39 17

Health Services for Mothers

By 1936 the various types of activities that now characterize a
State health program for mothers were being carried on in various
areas, mostly urban, and a limited number of women were receiving
the benefit of educational and clinical services thus made available.
A great contribution of the Federal-State maternal and child-health
program has been to make known the need for community provision
for the care of mothers and the techniques for giving the services
required for such care and to enlist the cooperative efforts of health
agencies, the medical profession, and community groups to make these
services available in a steadily increasing number of communities.
Out of this growing body of experience are coming new methods of
promoting the health of mothers and protecting the lives of the
newborn.

Prenatal service.

By 1936 it was recognized that adequate medical and public-
health-nursing supervision started early in pregnancy would increase
the probability of safe delivery for the mother and of health for the
baby. The prenatal clinic or conference conducted by a physician,
supplemented by the educational services of the public-health nurse
in the conference, in home visits, and in group instruction, is the type
of service recognized as necessary for women unable to obtain such
prenatal care otherwise. The figures in table 4 (p. 16) reflect gains
made in providing this service, but tabie 3 (p. 15) shows that on
June 30, 1939, prenatal-clinic service under State health-department
supervision was available in only 17 percent of the rural counties
and in only 26 percent of the urban counties in the United States.
Prenatal clinics under municipal or voluntary auspices are being held
in many cities, and figures for these clinics are not included in the
tabulations given here. The urban counties under supervision of
State health agencies are as a rule the counties with smaller cities.

In States where the prenatal conference has not been developed the
objective has been to encourage mothers to go to the offices of private
physicians for prenatal service. Although effort is made to correlate
this service in the physician's office with field public-health-nursing
service, the trend in the States seems to be toward the development of
prenatal clinics to be held once a month or oftener at centers accessible
to the women in each county or other local area.

Prenatal supervision by physicians aided by public-health nurses
assures the health of most women in their approach to a normal
delivery. It also enables the physician to discover complications
that indicate the probability of a difficult delivery and the need for
hospital care at that time.

18 Maternal and Child-Health Services

An adequate diet during pregnancy and lactation helps to protect
the mother against certain complications of pregnancy and increases
her chances of producing and rearing a healthy baby with a minimum
drain on her own body. Instruction in the choice of foods and other
factors related to good nutrition is therefore an integral part of pre-
natal service. In a growing number of States the physicians and
nurses who instruct mothers in diet rely upon a nutrition consultant
for simply written leaflets and other teaching devices that take into
consideration racial or regional food customs and the foods and
equipment available in the homes of the community. It is often
possible for the consultant to attend prenatal clinics and mothers'
classes to demonstrate effective methods of teaching nutrition to
groups and individual mothers. In the District of Columbia, through
a cooperative arrangement between the health department and the
local chapter of the American Red Cross, home-economics instructors
paid by the chapter teach groups of women at prenatal clinics how to
select and prepare the foods they need.

The experience of Virginia illustrates the development of a prenatal
service. The Bureau of Maternal and Child Health of the State
Department of Health, with the approval of the State medical society,
started in October 1936 the development of prenatal clinics in counties
with full-time health departments. The county health officer and
the public-health nurse administer the program. The clinics, held
preferably in health centers or in especially prepared clinic rooms, are
conducted by local practicing physicians. Physicians who have not
previously conducted clinics are given professional assistance from
the Bureau of Maternal and Child Health in starting and establishing
the routine of the clinics. A standardized routine based on experience
is recommended for their use. Patients referred by physicians, nurses,
midwives, or social agencies are admitted to the clinic by appointment
only. The public-health nurse is responsible for the management of
the clinic. She arranges for patients to come to the clinic on their
initial and return visits. She gives group instruction at the clinic
prior to the arrival of the clinic physician and makes home visits to
aid the prospective mother in following the instruction of the physician
and in making necessary preparations for the birth of the baby. The
clinics were held once a month at first; if conditions warrant they
are held once a week. The obstetrician on the staff of the Bureau
of Maternal and Child Health visits the clinics regularly to give
assistance and consultation service through the clinic to the physician
in charge and to invited physicians in each area. By June 30, 1939,
physicians were conducting prenatal clinics in 210 centers which had
been established under the supervision of the State Department of
Health and local health agencies.

Development of Program, 1936-39 19

The problem of providing for continuity of care — an important part
of the maternity-care program — has been found difficult by the State
health agencies. Many prenatal clinics have been established without
a working relationship with a nearby hospital. No prenatal clinic can
function satisfactorily without a cooperative arrangement with a local
hospital or hospitals where complicated cases can be referred for care
during pregnancy or at the time of delivery. Much of the value of
prenatal care is lost unless good hospital care can be provided when
necessary. In every prenatal clinic a system should be developed
whereby a copy of the patient's prenatal record is always available
to her attending physician at time of delivery, whether the delivery
is in the hospital or in the home. Continuous medical and nursing
supervision of the maternity patient during pregnancy, at the time
of delivery, and during the postpartum period should be the objective.

The extent of the services to mothers being rendered with the aid of
Federal maternal and child-health funds under the supervision of
State health agencies is shown by the activities reported by the
State health agencies for the calendar years 1938 and 1939 (table
4, p. 16). Prenatal medical service was given to 124,924 expectant
mothers, who made 333,651 visits to prenatal conferences for medical
supervision; and 27,452 mothers were given postnatal examinations.
Prenatal nursing service was given to 213,267 expectant mothers,
involving 602,917 visits with mothers at home or in the office; and
151,676 mothers received postnatal nursing service, involving 406,728
visits for postnatal care.

Reports from the States showed that on June 30, 1939, 1,229
maternity centers 8 were in operation in 34 States, the District of
Columbia, Alaska, and Hawaii, where monthly conferences were
being held, at which physicians gave prenatal and postnatal service
to mothers as part of the maternal and child-health program super-
vised by the State health department. Nineteen percent (573) of
the 3,076 counties in the United States and Hawaii reported having
these centers. South Carolina reported such centers in each of its
46 counties, and Hawaii, in each of its 4 counties; Arizona, in 9 of its
14 counties; Kentucky, in 82 of 120 counties; Maryland, in 20 of 23
counties; and North Carolina, in 50 of 100 counties. In some States
such medical conferences for mothers are not held, as the State plan
contemplates that mothers will go to private physicians for medical
supervision throughout the maternity cycle.

As of June 30, 1939, the States reported that prenatal and postnatal
services to mothers were being given by public-health nurses through

8 See appendix table 1. The count does not include centers where conferences
are held less frequently than once a month, nor maternity centers held in cities
or under private auspices which were not operating under a State maternal and
child-health plan supervised by a State health department.

20 Maternal and Child-Health Services

home visits in 1,918 (62 percent) of the counties. These services were
reported in every county in 12 States and Hawaii, and in the District
of Columbia. In 14 more States these services were reported in two-
thirds or more of the counties — in 8 of these States, 90 percent or
more of the counties. Group instruction of mothers by nurses was
reported in 849 counties in 47 States and Hawaii, and in the District
of Columbia.

The services so reported as part of the State maternal and child-
health plans are rendered for the most part in the smaller towns and
rural areas. In the larger cities the local health departments provide
extensive prenatal and postnatal services for mothers. However,
since there are 3,076 counties in the United States and Hawaii, of
which 2,453 are rated as rural counties (counties having no city of
10,000 population or more), it is evident that in a large number of
rural counties in the United States the State health agencies had not
been able by June 30, 1939, to assist in establishing maternity centers
or public-health-nursing service for mothers (table 3, p. 15).

Clinical consultation service.

Case consultation service to practicing physicians by obstetricians
is being developed as a means of improving maternal care. As an
outgrowth of the program for postgraduate education (pp. 65-68), 11
States in their 1939 maternal and child-health plans provided for the
employment of obstetric consultants for this service on a full-time or a
part-time basis.

In Maryland two highly trained obstetricians of Baltimore are
employed on a part-time basis by the State Department of Health to
visit the prenatal clinics throughout the State, to advise the local
physicians conducting the clinics, and to render clinical consultation
when necessary. One of the leading obstetricians in Birmingham,
Ala., is employed on a part-time basis to assist in establishing prenatal
clinics conducted by local physicians at regular intervals and to consult
with them concerning patients presenting unusual complications.

In Michigan a full-time obstetrician on the State staff visits various
sections of the State for more or less extended periods and places
himself at the disposal of the local practicing physicians, to discuss
individual cases with them and to assist them on surgical cases.
Some of the physicians ask the consultant to go with them to visit
their patients or they ask patients to come to their offices for examina-
tion by the consultant. Occasionally patients learning of the presence
of the specialist in the neighborhood ask their physicians to arrange
for an examination and consultation. Through discussion among
physicians in groups the value of the service given individual patients
reaches a larger number of physicians. By such means obstetric

Development of Program, 1936-39 21

consultation service is made available in parts of States where no
specialist in obstetrics is practicing.

In New Jersey the Bureau of Maternal and Child Health of the
State Department of Health offers to private physicians consultation
service for abnormal conditions in patients of the low-wage group.
The family physician may select any consultant from an approved
list and the State Department of Health pays the prescribed fee for
the consultation service.

In Connecticut a similar plan is in operation for physicians and
patients living in cities of 50,000 population or less and in rural areas.
In these areas all practicing physicians are given a list of obstetricians
who have signified their willingness to serve and who are certified by
the American Board of Obstetrics and Gynecology or of physicians
who have had special training or long experience in obstetrics. These
physicians are appointed as consulting obstetricians by the State
Department of Health and are paid by the State department for each
consultation reported.

Midwife supervision.

The untrained midwife is a significant factor in relation to health
services for mothers in many States. In some counties these midwives
attend as many as 80 or 90 percent of the births, and in one State as
many as 50 percent. Ignorance of proper techniques and of clean
procedures makes her a serious danger to the health of mothers and
newborn babies. She is a symbol of the low economic level of many
thousands of families that cannot pay for a doctor's care for the
mother when the baby is born. In some areas where there are no
physicians the untrained midwife is the only person who can be called
on to assist at the birth.

The degree of control over the midwife exercised by the State health
department varies from the State where the department issues an
annual license or permit to midwives and maintains some supervision
over them throughout the year to the State where no licenses are
required and the State department is able to offer only a meager
amount of class instruction. Decided progress has been made recently
in the supervision of midwives by State and local health officers and
public-health nurses. Many of those least qualified to practice
midwifery are being eliminated each year. However, a count as of
June 30, 1938, showed that about 35,000 midwives were practicing in
34 States and about 22,900 of them were under some degree of
supervision by health agencies.

Improved supervision procedures have been developed during the
past few years. Formerly, class instruction by public-health nurses,
aided by physicians, and nurses' visits to the homes of midwives for

22 Maternal and Child-Health Services

inspection of their equipment and for some instruction, was the extent
of training or guidance. The strengthening of the maternal and child-
health service in the State health departments has provided medical
and nursing leadership capable of planning and assisting local personnel
in carrying on a more thoroughgoing program of midwife supervision.
With the increased numbers of county health officers and public-health
nurses, more maternity clinics have been developed in local areas
where midwives' patients can be given prenatal supervision by phy-
sicians. Several States have added public-health nurses with midwife
training — nurse-midwives — to the State supervisory staff to give to
local public-health nurses consultation service on midwife supervision.
In a few counties in Alabama, Florida, Kentucky, and Maryland
public-health nurse-midwives employed locally to supervise untrained
midwives give supervision at the bedside when the midwife is con-
ducting a delivery. To some extent in other areas midwives are
being given supervision at delivery in addition to class instruction.
In the county demonstration areas in Georgia, North Carolina, and
Virginia the public-health nurse who instructs midwives is present
when the midwives conduct deliveries to see that the prescribed pro-
cedures are carried out. Several States have sent public-health
nurses to the Lobenstine Clinic in New York for midwifery training,
including three Negro nurses sent by Alabama and Florida.

Two precautions are prescribed in the States with sufficient super-
visory service and enough prenatal clinics to make the regulations
reasonable. First, a midwife is not permitted to attend a birth unless
the patient has been in regular attendance at a prenatal clinic, so
that her condition is known to be probably normal. Second, if a
midwife attending a birth finds that complications are likely to arise,
she is required to call a physician to handle the delivery.

Midwife manuals have been issued by the departments of health of
Alabama, Kentucky, Maryland, and Mississippi, and several States
have issued guides for the teaching of midwives. The Children's
Bureau is preparing such a manual.9

The Maryland State Department of Health has developed a
carefully worked out midwife program. Women who apply for licenses
to practice midwifery must be recommended as to character by respon-
sible citizens. They are given a short course of instruction and a
written examination outlined by the Bureau of Child Hygiene.
The examination papers are graded by two physicians in each county
appointed by the State Department of Health to serve as midwife
examiners. If the applicant is approved by the two physicians and
the chief of the Bureau of Child Hygiene, she is recommended for a

9 A Manual for Teaching Midwives (mimeographed) was issued by the Chil-
dren's Bureau in February 1940; it is now being printed.

Development of Program, 1936-39 23

license. It is the policy to recommend for license only such women
as will raise the standard of midwifery practice, after certification by
the local health officer that a midwife is needed in the territory where
the applicant proposes to practice. The supervision of the work of
midwives in the counties is carried on by the public-health nurses and
nurse-midwives under the direction of the county health officers.

Soon after the Federal maternal and child-health funds became
available the Maryland Bureau of Child Hygiene placed nurse-mid-
wives in 2 counties where 50 percent of the births were attended by
midwives. In each county the services of the nurse-midwife were
placed at the disposal of the local physicians. On request she assists
the physician in deliveries of patients who are paying no delivery fee
or only a small fee. She calls the physician at the appropriate time
and renders skilled aid during delivery. In a few instances the nurse-
midwife conducts normal deliveries. After the delivery she gives the
nursing care needed. The nurse-midwives in these counties also give
instruction to the untrained midwives and attend deliveries in the
effort to improve the standard of care given. These midwives must
see that their patients attend the prenatal clinic. After the birth
the nurse-midwife instructs the mother in the care of her newborn
infant.

The Frontier Nursing Service in the Cumberland Mountains of
Kentucky for many years has had nurse-midwives who practice
midwifery. Health departments are beginning to employ nurse-
midwives to take the responsibility for home deliveries in areas where
physicians are not available for this service. In Macon County, Ala.,
two Negro nurse-midwives in September 1939 were placed on the
local health-department staff for this service. Almost immediately
their services were so much in demand that they were attending
almost half the number of births formerly attended by midwives.

Need for delivery care.

As the prenatal program developed, the need for providing better
care for mothers at delivery became increasingly apparent. The fact
that more than a million births in a year occur in families with incomes
of less than $1,000 a year 10 explains in national totals a situation
faced daily by health officials in every county of the United States.
Many families cannot afford to pay for a physician's service at the
time of the mother's delivery or, if something can be paid for the
doctor, there are no funds to pay for a nurse to aid him or for hos-
pital care when it is needed in an emergency. Public funds have
not been available to pay for such care except in limited amounts,

10 A National Health Program: Report of the Technical Committee on Medical
Care, 1938. p. 11. Interdepartmental Committee To Coordinate Health and
Welfare Activities, Washington, 1939.

24 Maternal and Child-Health Services

mostly from welfare funds in urban areas. In a few rural areas private
agencies are guaranteeing home-delivery nursing service whenever
called upon. Among these are the Frontier Nursing Service in eastern
Kentucky, the Kellogg Foundation in several counties in southern
Michigan, and the Commonwealth Fund in Tennessee and Mississippi.

Many of the State health agencies, with the aid of maternal and
child-health funds, have undertaken demonstration projects in pro-
viding various types of care at the time of delivery for mothers unable
to obtain such care otherwise.

Slightly more than half the live births in the United States in 1939
(51 percent) occurred in hospitals, with physicians in attendance.
For the 1,107,060 live births that occurred at home physicians were in
attendance for 80 percent; midwives attended 19 percent; and the
attendant was not reported for the remaining number. The figures
become increasingly significant when the urban and rural births are
considered separately. The great majority of the births at home oc-
curred in rural areas — 889,749, comprising 78 percent of all rural
births. Although nearly four-fifths of these births were attended by
a physician, it is probable that in relatively few cases was there a
nurse to assist the physician, and that frequently the physician was
called for the first time shortly before the time of delivery — too late
to give adequate prenatal care. In 185,671 cases these rural mothers
were attended by midwives, a type of care that now occurs infre-
quently in cities. In two States more than half the rural births were
attended by midwives. The lack of a physician's care at delivery,
the lack of nurses to assist at delivery, and the smaller proportion of
mothers hospitalized in the rural areas are due to the unavailability
of doctors, nurses, and hospitals, because of distance or because the
families cannot afford to pay for such care. Chart 2 shows how much
greater is the proportion of births at home and births unattended by
a physician for the smaller towns and rural areas than for the medium -
sized and larger cities.

Up to June 30, 1939, home-delivery nursing service had been estab-
lished in connection with the local health department in one or more
counties in each of 35 States, making a total of 102 counties. A total
of 16,823 mothers were given nursing service at delivery during the
calendar year 1939 as part of the maternal and child-health program.

Where home-delivery nursing service is in operation the county or
local health agency offers nursing assistance to physicians at home
deliveries. The nurse, under standing orders developed in consul-
tation with local physicians, aids the mother in making advance
preparations for the birth, brings sterile equipment to the home when
the birth is about to occur, makes the final preparations for the
delivery, assists the physician during the delivery, gives the immediate

Development of Program, 1936-39

Chart 2. — Attendant at birth, live births that occurred in cities of specified size and in

rural areas; United States, 1939 '

Cities of 50,000 to 100,000

Cities of 100,000 or more

No medical
attendant, I %

No medical
attendant,2%

Cities of 10,000 to 50,000

No medical
attendant,4%

Rural areas

Based on data from U. S. Bureau of the Census.

nursing care needed, demonstrates to members of the family the daily
care needed for mother and child, and returns at least four times
within the first 10 days after the birth to give care and instruction
during the postpartum period.

The public-health nurse responsible for organizing a maternity-
nursing program needs to be thoroughly familiar with public-health-
nursing administration and with the requirements of a program of
maternal care. She arranges for certain members of the nursing staff
to have advanced preparation for maternity nursing, plans for the
provision of sterile equipment, arranges for the rotation of staff so
that the nursing service will be available 24 hours a day every day in
the year, provides for keeping adequate records and reports, establishes
working relationships with private physicians, and supervises the
program in operation.

Methods of providing home-delivery nursing service vary in
different localities. In Pike County, Miss., for example, every nurse

26 Maternal and Child-Health Services

on the staff of the county health department gives maternity care as
part of the general family nursing service. To be able to follow such
a plan a county health agency must have enough nurses on its staff
so that the nurses in varying periods of rotation may be held available
on first call and on second call day and night to attend maternity
cases, without interference with other routine activities and with
provision for time off after prolonged service.

According to another plan, the Washington County health depart-
ment in Iowa has two maternal and child-health nurses who are
responsible for prenatal, delivery, and postnatal nursing service.

Under a third plan, followed in Northampton County, N. C, special
public-health nurses are employed in addition to the regular staff to
give service at the time of delivery only.

The specialized type of service given in North Carolina is being
used most frequently during the present experimental stage of develop-
ing home-delivery nursing service. It is frequently advisable to have
this service given by specialized personnel until the time when it can
be given competently by the entire staff. The desirability of having
the general public-health nurse, because of her continuing acquaint-
ance with the family, retain the responsibility for nursing supervision
during the prenatal and postnatal periods is receiving careful
consideration.

According to a fourth plan, used throughout New Jersey, nursing
care at delivery is not part of the service of the public-health-nursing
staff, but private-duty nurses are employed for this service. Under
this plan the public-health agency must assume responsibility for
selecting and supervising local graduate nurses who have had good
basic preparation in maternity nursing. A period of intensive prepa-
ration for such nurses is also needed in order that they may understand
the health agency's policies and procedures and their responsibility for
rendering a high quality of service in accordance with the agency's
policies.

Home-delivery nursing service, where available, has enabled the
attending physician to render a higher quality of service at deliveries
because of the nurse's assistance and because of the sterile equipment
and supplies that the nurse brings with her from the health department
or has taught the family to provide. In local areas where this nursing
service is available it is much appreciated by the families and by
the practicing physicians, and the physicians in adjoining areas are
eager to have it extended.

Complete delivery care.

Few States and local communities have been able, with the limited
maternal and child-health funds so far available, even to experiment
with providing medical service at the time of delivery for mothers who

Development of Program, 1936-39 27

cannot obtain this care unaided. Sporadically such care is provided
in small communities and rural areas on a medical-relief basis from
public or private welfare funds. A beginning has been made under the
maternal and child-health program in developing programs of complete
maternal care on a public-health basis in recognition of its place in
oreventing the death of the mother or newborn infant and in preventing
injury or illness that may endanger the health of the mother and child
who survive.

In Oklahoma, Cherokee County was chosen for a program of com-
plete maternity care. It is part of the program of a five-county
district health unit in the northeastern section of the State. The staff
includes among its members a pediatrician, an obstetrician, two public-
health nurses for each of the five counties, and three additional nurses
for the maternity program in Cherokee County.

A survey had shown that 99 percent of the deliveries in Cherokee
County in 1937 occurred in the home, 33 percent were attended by
persons other than physicians, the maternal mortality rate for the
period 1933-37 was 54 per 10,000 live births, and the infant mortality
rate was 41 per 1,000 live births. In this county from 50 to 75 percent
of the people could not pay for medical, nursing, or hospital care.

The maternity program, started in April 1938, is carried on by the
staff obstetrician with the aid of three maternity nurses. The nurses
urge expectant mothers to visit the nearest maternity clinic conducted
by the staff obstetrician with the assistance of a local practicing
physician. The patient is given a complete examination, including
laboratory tests. If her condition calls for medical treatment, the
patient is so informed and, if she has a private physician, a copy of all
findings is sent to him. If she has no physician, a social-welfare
worker plans a budget with the patient and, if the patient can pay an
appreciable part of the doctor's fee, a doctor is engaged. If she cannot
pay, she chooses her physician and is given a letter at the prenatal
clinic authorizing payment of the doctor's fee from maternal and
child-health funds. For prenatal care beginning at or before the
fifth month, delivery care, and postpartum care, the doctor receives
$25. The fee is $20 if the patient receives care after the fifth month
and before the seventh month, $17.50 if care starts during the last
3 months, and $15 for delivery and postpartum care only. An
additional payment of $5 is made to the doctor for travel of 10 miles
or more at the time of the delivery.

When such a case has been accepted by a physician he instructs
the patient to visit him regularly, and the public-health nurse visits
the patient at home once a month. When labor begins, the patient
calls her physician, who requests the attendance of the nurse, and
they attend the patient together. The nurse works under the direc-

328 1'.»<. i VI 3

28 Maternal and Child-Health Services

tion of the physician, but she follows a set technique in regard to the
preparation of the patient, the materials used, and the use of solutions.

After the delivery the nurse visits the patient on the third, sixth,
and ninth days, and, unless the patient lives in an isolated section,
the physician also visits her. If the nurse reports any abnormality,
the physician visits the patient regardless of where she lives. The
nurse visits the patient during the fifth postpartum week and urges
her to visit her physician. The physician makes the postpartum
examination, treats any abnormality, and when the patient is dis-
charged, is eligible for the payment of his fee. In case hospitalization
is necessary because of serious complication, the expense is met
from county funds.

Similar demonstrations of maternity care, including payment for
complete medical and nursing care and hospital care if not otherwise
provided, are being developed by health departments in limited areas
in Alabama, Louisiana, Maryland, Michigan, Nebraska, New Mexico,
and North Carolina. Most of these demonstrations were started
after the close of the year 1939, with the increased funds made avail-
able under the 1939 amendments to the Social Security Act.

Maternity homes and hospitals.

The regulation and, generally, the licensing of maternity homes
and hospitals are the responsibility of the State health agency in
16 States and of the State welfare agency in 19 States. Few, if any,
of these State agencies have sufficient qualified personnel on their
staffs to inspect annually every maternity home and hospital in
the State.

It is recognized that one of the greatest problems in improving the
care of maternity patients and newborn infants is the improvement
of the standards of care and equipment in the hospitals caring for
these patients. The cities of Chicago and New York have coura-
geously faced the inadequacies of many of the hospitals and have issued
stringent regulations for their conduct in the care of maternity
patients. The need for such regulations is indicated by a report of
15 small Negro hospitals in 2 adjoining States in which the maternal
mortality rate was more than 300 per 10,000 live births and by a
report from another State that the maternal mortality rate in hos-
pitals approved for the training of interns (larger hospitals) was
approximately one-third the rate in small hospitals with less than 150
births a year.

Frequently small hospitals do not have adequate space or beds for
the proper isolation of maternity patients and newborn infants to
protect them from patients suffering from infectious conditions. On
the other hand, many small maternity hospitals and maternity
wards in general hospitals are conducted with great care and make a

Development of Program, 1936-39 29

direct contribution to the reduction of maternal and neonatal mor-
tality and morbidity.

At the request of State bureaus of maternal and child health re-
sponsible for the licensing or regulation of maternity homes and
hospitals, the Children's Bureau has been giving advisory service on
standards that should be met by hospitals receiving maternity
patients.

At a meeting in December 1938 the Children's Bureau Advisory
Committee on Maternal and Child Health Services recommended
that the Bureau take steps to secure the cooperation of various pro-
fessional and administrative groups and of the State health depart-
ments in formulating standards for hospitals and maternity homes
caring for mothers, infants, and children, and that attempts be made,
by obtaining effective State licensure of hospitals and maternity
homes and by other means, to establish and maintain hospitals that
conform to acceptable standards of care for mothers, infants, and
children. The first action taken by the Children's Bureau pursuant
to this recommendation was the drafting of suggestions for legislation
placing in the State health agency responsibility for the licensing and
supervision of maternity hospitals and homes.

Maternal-mortality studies.

In 1915 the Children's Bureau began an analysis of the statistics
on maternal mortality available in the United States Bureau of the
Census and from various foreign countries.' This led to the inclusion
on the schedules for infant-mortality studies of questions relating to
the care mothers had received before and during childbirth in order
to discover the preventable causes for the loss of maternal and infant
life. A series of reports followed on infant and maternal mortality
in urban and rural areas.

In 1921 a questionnaire study was undertaken to determine the
adequacy of facilities for maternity and infant care in communities of
less than 200,000 in the United States.

In 1927 the Children's Bureau, on the recommendation of its
Obstetric Advisory Committee, began a study of the causes of ma-
ternal mortality in which the departments of health and the medical
societies of 15 States participated. Physicians on the staff of the
health department in these States, or on the Children's Bureau staff,
undertook to interview the doctor, midwife, or other attendant at
delivery and to obtain the hospital record of those who had had
hospital care for every woman whose death had been assigned to
puerperal causes in 13 States in 1927, and in these States and 2 other
States in 1928. This study, published by the Children's Bureau in
1934 (Publication No. 223, Maternal Mortality in 15 States), pro-

30 Maternal and Child-Health Services

vides the most comprehensive data so far made available on the
causes of maternal mortality and the means of prevention.

The growing discussion of maternal mortality rates and the un-
favorable comparisons that were made between the rates of the
United States and those in other countries led in 1929 to the formation
of the subcommittee on comparability of maternal mortality rates of
the Committee on Prenatal and Maternal Care of the White House
Conference on Child Health and Protection (1930). The subcom-
mittee, on which the Children's Bureau was represented, analyzed
foreign laws and registration practices in relation to births and ma-
ternal deaths and the procedures used in classifying cause of death
when pregnancy and childbirth had been mentioned. The committee
concluded that the maternal mortality rate for the United States,
even when estimated in accordance with the assignment procedures of
16 other countries, was exceedingly high as compared with the rates
of other countries.11 The study gave further impetus to the move-
ment to reduce maternal mortality in the United States and to the
initiation of a series of maternal-mortality studies.

Continuing studies have been undertaken in many States by the
State health department and the maternal-welfare committee of the
State medical society, which are based on inquiry into the circumstances
surrounding each maternal death in a given area or in the entire
State. Consideration of the facts is then given by a panel of physi-
cians and a conclusion is reached as to whether the death might have
been prevented and by what means. The number of such studies
increased rapidly after 1936, when the Federal funds for maternal
and child-health services made it possible for the State health agencies
to provide staff assistance for the preliminary inquiry on each maternal
death.

A well-developed program for study in this field is being carried on
in Philadelphia. In 1934 the committee on maternal welfare of the
Philadelphia County Medical Society made a report on a study of
maternal mortality, which was the beginning of a continuing examina-
tion of the cause of every maternal death in the Philadelphia area.
Later this committee was joined in the study by a committee to study
fetal deaths, appointed by the Obstetric Society of Philadelphia, and
a subcommittee on neonatal mortality appointed by the advisory
committee on maternal and child welfare of the Philadelphia health
department. Since 90 percent of the births occur in hospitals, the
hospital staff usually submits an analysis of each maternal, fetal, or
neonatal death, and staff opinion regarding it, which is presented to

11 Comparability of Maternal Mortality Rates in the United States and Certain
Foreign Countries, p. 20. Children's Bureau Publication No. 229. Washington,
1935.

Development of Program, 1936-39 31

the appropriate committee for review. Each committee selects cases
in which the diagnosis seems questionable or cases appropriate for
demonstrating special handling for presentation to the joint com-
mittee that meets on the fourth Friday of each month. In attend-
ance at the joint meeting are the obstetricians and pediatricians who
are members of the committee and also health officials, general prac-
titioners, expert pathologists, young men just beginning medical
practice, and hospital interns. The discussion includes consideration
of all circumstances surrounding the death and an explanation of tech-
niques that were used or might have been used. The study serves
not only to aid practicing physicians in improving their techniques
but also to provide data for further scientific study in obstetrics.

Similar studies are being carried on increasingly by medical groups
in many parts of the country.

The vital-statistics section of the American Public Health Associa-
tion in 1938 recommended that the Children's Bureau make available
schedules for special studies of maternal and neonatal mortality.
Such schedules were issued by the Children's Bureau in the spring of
1939, together with a plan of procedure to be followed in making the
study. The use of the same procedure and schedules for such studies
in the various States will result in obtaining comparable data that will
be increasingly valuable in the effort to prevent maternal and neonatal
deaths.

By the end of June 1939, 4,300 schedule forms for maternal deaths
and 4,100 forms for neonatal deaths had been distributed. Six
State health agencies — Georgia, Nebraska, New Jersey, New Mexico,
Rhode Island, and Utah — had initiated studies using the form for
maternal deaths, and five State agencies — Nebraska, New Jersey,
New Mexico, Rhode Island, and Utah — had initiated studies using
the form for neonatal deaths. Other State agencies beginning such
studies or having them already under way have reported that they
also plan to use the forms.

Maternal mortality and stillbirths.

In 1939, 9,151 mothers died from conditions due to pregnancy and
childbirth, a rate of 40 maternal deaths per 10,000 live births. This
represented a drop of 35 percent from 62, the maternal mortality rate
of 1933, the first year when all the States were included in the birth-
registration area. A 14-percent drop in the maternal mortality rate
of 1937 (49), as compared with the 1936 rate (57), was the first indica-
tion that substantial gains were being made as a result of increasing
knowledge of how to care for mothers during pregnancy and at the
time of childbirth. The 1938 rate (44) again showed a substantial
decrease and the trend continued in 1939. (See chart 3.)

Maternal and Child-Health Services

Chart 3. — Maternal mortality rates; United States expanding birth-registration area

1915-39 >

100

o
o
o
o"

1 ' '

10 STATES

■ 1 • ■

23 STATES

■ ' | ■ ■

33 STATES

46 STATES

48 STATES

ANO

A AND

ANO

AND

1 c

/ \ Q

1 1 '

. . . 1

1915 1920 1925

1 Based on data from TJ. S. Bureau of the Census.

1930

1935

1939

The urban maternal mortality rate of 1939 (45) continued to be
higher than the rural rate (36). This is ascribed to the fact that the
hospitals are located mainly in cities and that when complications
threaten many rural mothers are brought to the hospital in the city
and, if a death occurs, it is recorded in the city. The maternal mor-
tality rate for mothers who lived in cities (39) was lower than that for
mothers who lived in rural districts (41).

Chart 4. — Maternal mortality rate in each State; United States, 1939 ■

1 Based on data from U. S. Bureau of the Census.

Development of Program, 1936—39

The low maternal mortality rates attained by some of the States,
as well as the recent decreases, supports the estimate of physicians
that many more maternal lives can be saved. Seven States (Con-
necticut, Idaho, Minnesota, North Dakota, Oregon, South Dakota,
and Wisconsin) had a maternal mortality rate of less than 30 in 1939,
and one of these, Idaho, attained a rate of 22. Eleven States and the
District of Columbia had rates of 50 or more.

TABLE 5. — Maternal mortality rates, by States; United States 1939, 1938,

1937, and 1936

State (number of deaths in 1939)

Maternal mortality rate '

1939

1938

1937

1936

United States (9,151)

Alabama (361)

Arizona (48)

Arkansas (202)

California (321)

Colorado (111)

Connecticut (60)

Delaware (18)

District of Columbia (73)_.

Florida (211)

Georgia (362 )_.

Idaho(24)

Illinois (370)

Indiana (210)

Iowa (131)

Kansas (108)

Kentucky (262)

Louisiana (302)

Maine (59)

Maryland (105)

Massachusetts (224)

Michigan (289)

Minnesota (148)

Mississippi (307)

Missouri (243)

Montana (35)

Nebraska (78)

Nevada (8).

New Hampshire (27)

New Jersey (182)

New Mexico (71)

New York (603)

North Carolina (374)

North Dakota (32)

Ohio (424)

Oklahoma (176)

Oregon (40)

Pennsylvania (613)

Rhode Island (35) _
South Carolina (253)
South Dakota (34)

Tennessee (297)

Texas (590)_

Utah (40)

Vermont (23)

Virginia (268)

Washington (95)

West Virginia (136)

Wisconsin (151)

Wyoming (17)

59
44
57
31
54
26
41
52
65
56

22
31
36
30
37
43
62
39
37
35

31
29
59
41
32
35
41
34
32
50

47
24
39
40
24
38
34
59
29

56
49
31
36
51
36
33
28
35

68
48
55
33
45
26
56
56
75
67

41
34
37
33
41
42
59
46
38
39

37
28
59
39
33
35
32
38
37
57

38
53
24
38
42
35
39
28
79
36

56
56
30
37
53
33
39
29
32

63
54
68
41
54
25
39
58
68
74

45
39
35
45
43
47
72
66
42
46

36
31
71
51
37
41
92
45
38
50

40
54
47
46
52
40
48
38
77
40

57
33
57
54
46
50
36
38

74
91
76
47
71
41
71
69
81
82

44
45
48
46
57
56
87
51
47
49

52
42
69
61
55
50
56
48
40
74

49
66
43
50
62
54
52
40
90
46

70
69
44
50
58
52
53
42
50

1 Maternal deaths per 10,000 live births.

Maternal and Child-Health Services

The mortality rate for Negro mothers in 1939 (77) was more than
twice as high as that for white mothers (35). The trend of mortality
rates for white and Negro mothers for 1931-39 is shown below.

Chart 5. — Maternal mortality rates among white and Negro women; United States,

1931-39 1

I20

100

o
o
o
o

1 ■

"v.^ Negro

■

«-. — White

1931 1932 1933 1934 1935

1 Based on data from U. S. Bureau of the Census.

1936

1937

1938

1939

Maternal mortality, stillbirths, and neonatal mortality should be
considered together because, for the most part, all three are due to
prenatal and natal conditions. These deaths in 1939 included 9,151
deaths of mothers, 72,598 stillbirths, and 66,383 deaths of infants
in the first month of life — a total of 148,132 deaths.

In the light of maternal-mortality studies made by physicians it
has been estimated that at least one-half of the maternal deaths are
preventable. It is well recognized that major reductions in deaths
from toxemias of pregnancy and from sepsis associated with delivery
can be made when facilities for proper prenatal and delivery care
become more widely available. (See chart 6.)

Development of Program, 1936-39

Chart 6. — Causes of maternal death, percentage distribution; United States, 1939

1 Based on data from U. S. Bureau of the Census.

Stillbirth statistics have not been reliable because State require-
ments for reporting stillbirths have varied widely, reporting has been
incomplete, and there has been no accepted classification of causes of
stillbirth. The magnitude of the stillbirth problem led the Children's
Bureau in 1936 to undertake a study of the causes of stillbirth,
with the cooperation of the subcommittee on stillbirths of the Ameri-
can Public Health Association. (See summary of findings, p. 73.)
A direct purpose of the stillbirth study was the collection of informa-
tion which could be used in formulating a classification of the fetal
and maternal causes of stillbirth and rules for the selection of the
primary cause of stillbirth to be used whenever two or more causes are
mentioned on a stillbirth certificate. The need for this information
to formulate a classification system acceptable to both clinicians
and research workers and to constitute a fundamental step toward
the development of international comparability of statistics on causes
of stillbirth was pointed out by the subcommittee on stillbirths in 1935.
Using the information collected in the study, the Children's Bureau

36 Maternal and Child-Health Services

prepared a list of causes of stillbirth which was presented to the
International Commission for Revision of the International List of
Causes of Death. At its meeting in Paris in 1938 the Commission,
in order to promote a basis for uniform experiment, adopted an
International List of Causes of Stillbirth, which was found to be not
fully satisfactory for use in the United States.

Subsequently, to meet the need expressed by physicians and
research workers in this country, the Children's Bureau developed a
classification of the causes of stillbirth that includes a list of causes of
stillbirth, a tabular list of terms included under each title of the list,
and rules of procedure for selecting the primary cause when two or
more causes are reported on the same certificate. This classification
was approved by the subcommittee on stillbirths and was submitted
to the committee on research and standards of the American Public
Health Association. It was approved by that committee for publica-
tion and trial in the United States on October 11, 1940.

Comparable statistics on the causes of stillbirth for the States,
together with clinical studies, will pave the way for an active and
widespread effort to reduce the number of stillbirths.

New standard birth and death certificates.

The stillbirth study and studies made by many groups have demon-
strated the need for additional information regarding certain conditions
of pregnancy and labor that are related not only to stillbirth but to
live birth, and the practicability of collecting the needed information
in the ordinary process of birth registration. The Children's Bureau
cooperated with the American Committee on Maternal Welfare in
preparing recommendations regarding the basic data that should be
obtained in connection with such registration.12 The Bureau there-
after worked with the vital-statistics section of the American Public
Health Association and the United States Bureau of the Census in
developing the medical items of the standard certificate of stillbirth,
the optional section of the standard certificate of live birth, which
covers conditions during pregnancy and labor, and the instruction
in the medical certification of the standard certificate of death which
reads: "Include pregnancy within 3 months of death." The revised
standard certificates, which incorporate the new medical items, were
recommended to the States on January 12, 1939, for adoption as of
1940. By the end of 1939 several States had adopted the new forms,
including the optional medical items, and many other States were
considering their adoption.

12 Revision of Birth, Death, and Stillbirth Certificates; a brief report by the
subcommittee on causes of maternal, fetal, and neonatal death of the American
Committee on Maternal Welfare. American Journal of Obstetrics and Gyne-
cology, Vol. 35, No. 2 (February 1938), pp. 332-337.

Development of Program, 1936-39 37

The States which adopt the new forms will be able to secure through
them new information greatly needed for the effective planning and
conduct of the maternal and child-health program. The State health
agencies which make use of instructions worked out by the Children's
Bureau for editing, coding, and tabulating the medical items on the
certificates will obtain comparable information regarding the condi-
tions that surround the fetus during pregnancy and labor. The
information will show the significance of these conditions in relation
to whether the pregnancy terminated in live birth or stillbirth, whether
the live-born infant survived the first month of life, and whether the
mother lived through the 3 months following the delivery.

Child-Health Services

The child-hygiene movement started with attempts to reduce
infant mortality, to prevent certain children's diseases, and to correct
certain defects in children. It has become a comprehensive program
to protect, promote, and conserve the health of children from the
prenatal period through adolescence. It is no longer an experimental
movement but is an integral part of the public-health program.
Preventive pediatrics and the science of nutrition are constantly
strengthening the scientific basis of child-health work and providing
new tools with which to work.

The infant mortality rate is no longer considered the only index
of child-health progress; yet it cannot be said that the infant-mor-
tality problem has been solved. Improved sanitation, scientific feed-
ing, pasteurization of milk, and immunization procedures have proved
their worth in reducing the number of deaths of infants more than 1
month of age, but they are not yet applied widely enough. Diarrhea
and enteritis and respiratory infections (pneumonia, influenza, and
whooping cough) still remain serious problems for infants 2 to 11
months of age. Expert medical and nursing care for all mothers during
the prenatal period and at delivery, and of the newborn infants, as
carried out in certain limited areas, has proved its value in reducing
mortality among newborn infants as well as among mothers. The
provision of prenatal care as part of the public-health program is
increasing, and plans for providing expert medical and nursing care
at time of delivery and for newborn infants are being worked out in
small areas by health departments in various parts of the country.
Modern obstetrics is contributing to the saving of the lives of babies as
well as of mothers.

The prevention of premature births is a problem requiring further
study, but wider application of methods already well known regarding
the care of premature infants will reduce the large number of deaths

Maternal and Child-Health Services

due to this cause. Several States have instituted plans for dealing
with this problem in a practical manner.

The infant mortality problem is not solved, but steady progress in
that direction is being made. The 1939 infant mortality rate of 48
represents an all-time low for the United States and was 6 percent lower
than the rate for 1938. The decrease is evident in both urban and
rural areas and for both white and Negro infants.

But it is not enough that more babies shall survive their first year
of life. Health supervision throughout infancy and childhood pays
big dividends in terms of mental and physical health, not only in
preventing handicaps and defects but in making positive gains.
Through child-health conferences and related activities, health depart-
ments are increasing the facilities for health supervision of infants and
preschool children. In addition, there is a growing appreciation of
the health department's responsibility for the health of children of
school age.

Infant and child mortality.

The State maternal and child-health directors are constantly
watching the infant mortality rates, as they are one index of the
success of the programs. The directors are especially interested in
the rates for counties and communities because these local rates
indicate where maternal and child-health activities should be developed
and strengthened.

In 1939 there were 108,846 deaths in the first year of life — a rate of
48 per 1,000 live births. In other words, 1 baby out of every 21 babies

Chart 7. — Infant mortality rate in each State,- United States, 1939 1

Oeoths in the first year of life
per 1,000 live births

ESU Less than 40

pj?il 40 - 54

|K8g| 70 or more

1 Based on data from U. S. Bureau of the Census.

Development of Program, 1936-39

born alive died before his first birthday. Oregon established a new low
record for State infant mortality — 35 per 1,000 live births. Connec-
ticut and Minnesota had rates of 36. Thirteen States had rates of
less than 40.

TABLE 6. — Infant mortality rates by States; United States 1939, 1938,

1937, and 1936

Infant mortality rate '

State (number of deaths in 1939)

United States (108,846).

Alabama (3,675) .

Arizona (1,031)

Arkansas (1,637)

California (4,385)

Colorado (1,134)

Connecticut (842)

Delaware (193)

District of Columbia (669)

Florida (1,822)

Georgia (3,780)

Idaho (508)

Illinois (4,474)

Indiana (2,302)

Iowa (1,697)

Kansas (1,146)

Kentucky (3,187)

Louisiana (3,077)

Maine (785)

Maryland (1,422)

Massachusetts (2,358)

Michigan (3,955)

Minnesota (1,798)

Mississippi (2,907)

Missouri (2,655)

Montana (534)

Nebraska (816)

Nevada (87)

New Hampshire (363)
New Jersey (2,184)...
New Mexico (i,549)_.
New York (7,370)

North Carolina (4,683).
North Dakota (645)...

Ohio (4,691)

Oklahoma (2,162)

Oregon (593)

Pennsylvania (7,343). ..

Rhode Island (412)

South Carolina (2,834).

South Dakota (481)

Tennessee (2,874)

Texas (8,110)

Utah (514)

Vermont (291)

Virginia (3,221)

Washington (976)

West Virginia (2,272).

Wisconsin (2,179)

Wyoming (223)

1939

60
94
46
42
55
36
44
48

56
58
46
38
39
39
39
53

63
52
50
37
42
36
56
45

49
37
45
46
39
109
39

59
49
43
50
35
46
39
66

41
54
67
40
46
61
37
55
40
46

1938

61
99
51
44
60
36
53
48

68
45
41
43
41
43
61

67
56
56
40
45
39
57
52

46
36
48
48
40
109
41

69
50
43
49
39
46
44
80

44
63
65
47
48
66
39
62
42
52

1937

62
121
54
54
73
40
64
61

60
62
44
43
50
44
44
59

66
65
61
44
48
41
59
57

51
42
40
48
39
124
45

66
52
50

57
42
50
48
76

51
61
74
41
49
70
40
62
43
56

1936

67
120
51
53
74
42
65
72

59
70
51
47
51
48
52
67

72
64
69
47
51
44
58
58

57
44
70
46
44
122
47

69
50
51
60
44
51
48
81

48
68
71
53
58
74
45
71
48
58

1 Deaths in the first year of life per 1,000 live births.

Although the 1939 mortality rate for Negro infants (73) was an
all-time low record for the race in the United States, this rate was still
far above the rate for white infants (44). Low family income of
Negro parents especially limits the medical and nursing service that
they can provide for their babies, and the great majority of Negro
births occur in sections of the country where community nursing,
medical, and hospital facilities are inadequate.

Maternal and Child-Health Services

More than half the infant deaths in 1939 occurred in rural areas;
the infant mortality rate for rural areas was 51 as compared with 45
for cities of 10,000 or more population. Twenty-four cities of 100,000
or more attained a rate of less than 35 per 1,000 live births; in this
group Somerville, Mass., achieved a rate of 27. Some of the cities of
this size and many rural counties had exceedingly high infant mortality
rates, which emphasizes the necessity of providing more adequate
maternal and child-health services in such areas.

A decline in mortality from the second to the twelfth month of life
accounts for most of the reduction in the infant mortality rate in
the United States so far. In 1939 only 19 of every 1,000 babies who
survived the first month of life died before reaching 1 year of age, as
compared with 58 in 1915. This represents a decline of 67 percent
during the period 1915 to 1939.

Chart 8. — Infant mortality rates by age; United States expanding birth-registration area

1915-39 ,

I9I5 1920 1925

• Based on data from U. S. Bureau of the Census.

1930

1939

The 1939 mortality rate in the first month of life (the neonatal
period) was 29 per 1,000 live births in the United States as compared
with 44 in 1915 — a decline of 34 percent. The mortality rate for the
first day of life was 14 in 1939 as compared with 15 in 1915. In 1939,
66,383 infants died in the first month of life as compared with 42,463
deaths during the 11 later months of the first year (chart 9).

The causes of the infant deaths in 1939 are shown in chart 10.

Development of Program, 1936-39

70.000

60,000

40,000

20,000

10,000

Chart 9. — Infant deaths, by ase in months; United States, 1939 '

Under I month
35

I30
J 25

0 20
2 I5
° 10

1 5

z
0

i 1

Under I To 6 I 2 3

I Ooy Days Week Weeks Weeks

1 I — r

i". ' i i

Under I 23456789 10 II

I Month Month Months Months Months Months Months Months Months Months Months Months

Age at death
1 Based on data from U. S. Bureau of the Census.

Chart 10. — Causes of infant death, percenta3e distribution,- United States, 1939

1 Based on data from U. S. Bureau of the Census.

Maternal and Child-Health Services

In 1939 the major causes of neonatal deaths were premature birth (47
percent); injury at birth (15 percent); and congenital malformations
(11 percent). The fact that 84 percent of the deaths of infants in the
first month of life were due to prenatal and natal causes emphasizes
again the importance of skilled care for the mother during pregnancy
and labor. Special studies have shown that the neonatal mortality
rate can probably be reduced one-half.

Chart 11. — Causes of neonatal death, percentase distribution; United States 19391

• Based on data from U. S. Bureau of the Census.

That marked advance has been made during the 4 years, 1936-39,
when the Federal Government and the States have cooperated in a
maternal and child-health program, is demonstrated by the fact that
if the 1935 infant mortality rate (56) had prevailed in 1939 there
would have been 18,341 more infant deaths during the year.

Mortality rates for children rapidly decrease after the first year
until the lowest rate is reached at 10 or 11 years among both boys
and girls. From then on the rates increase with each year of age.
Study of the causes of death among children and young persons
throws light on the relative importance of various diseases as causes

Development of Program, 1936-39

of both mortality and morbidity. Some of these diseases cause per-
manent injury to the health of children who contract them but survive.
The means of preventing death from most of the diseases especially
prevalent among children are known. Yet in 1939, 182,825 deaths
occurred among persons under 20 years of age. A large majority of
these deaths were due to conditions for which medical science has
shown the means of prevention or of cure.14 The 15 leading causes
of death among persons under 20 years of age, listed according to
order of incidence, are shown below.

TABLE 7. — The 15 leading causes of death among persons under 20 years

of age; United States, 1939 1

Cause of death

Total

Number

All causes.

The 15 leading causes.

Premature birth

Pneumonia (all forms)

Accidents

Gastrointestinal diseases. _
Congenital malformations

Injury at birth

Tuberculosis (all forms)..

Influenza

Diseases of the heart

Appendicitis

Whooping cough

Congenital debility

Diphtheria

Syphilis

Measles

182,825

139,514

All other causes.

32,251

21,604

19,394

14,128

11,907

10,164

6.596

4,759

4,301

3,980

3,010

2,808

1.831

1,749

1,032

43,311

Per-
cent

Under
1 year

100.0 108,846

76.3 88,945

17.6

11.8

10.6

7.7

6.5

5.6

3.6

2.6

2.4

2.2

1.6

1.5

1.0

23.7

32,251

13,786

2,379

10, 129

10,390

10, 164

540

2,311

370

2,013

2,808

167

1,300

297

19.901

1 to 4

years

26,887

19,574

4,682

4,426

3,536

893

1, 149

1,256

373

638

907

1, 130
140
444

7,313

5 to 9
years

12,338

7,864

1.053

3, 158

193

258

514
377
719
884
74

422

174

4,474

10 to 14
years

15 to 19

years

12,614 22,140

8,191

867

3,350

109

188

861

305

1. 181

1. 102

14.940

1,216

6,081

161

178

73
70
75

4,423

3.532

510

1,658

1,316

201
42

7,200

1 Based on data from U. S. Bureau of the Census.

In the age group, 1 to 4 years, pneumonia, accidents, and gastro-
intestinal diseases caused 47 percent of the 26,887 deaths. Accidents
took first place in the age group, 5 to 9 years, and pneumonia and
appendicitis were the next most important causes of death. Acci-
dents, diseases of the heart, appendicitis, and pneumonia were the
leading causes of death in the age group, 10 to 14 years. Accidents
continued to be the leading cause in the age group, 15 to 20 years,
and tuberculosis was second, followed by diseases of the heart, appendi-
citis, and pneumonia.

Nearly three-fifths of the deaths (108,846) of persons under 20
years of age occurred in the first year of life, and more than two-fifths
of these were due to premature birth, injury at birth, and congenital
debility conditions that cause death mainly in early infancy. Also,
three-fourths of the deaths from syphilis in this age group occurred
during the first year of life.

" For discussion of the means of prevention of children's diseases, see p. 56.
328100° rj I

44 Ma ternal and Child-Health Services

To the public-health administrator these figures are important
signposts, which indicate the need for preventive and educational
health services in the communities under his supervision. However,
health-supervision services, valuable as they are in the prevention of
illness and death, are of even greater value in the promotion of healthy
growth and development for children and young people as they
approach maturity.

Protecting the lives of the newborn.

Progress is being made in the reduction of neonatal mortality, as
is shown by the rates during the years in which the social-security
activities have been under way. These rates were 33 in 1936, 31
in 1937, 30 in 1938, and 29 in 1939.

Under the maternal and child-health program the State health
agencies and the medical and nursing professions are enlisted in an
intensive effort to reduce neonatal mortality. Saving the life and
health of the baby is the co-objective in the program for better maternal
care. Better prenatal care, better medical care at delivery, nurses'
visits to the home before and after delivery, instruction given the
mother and the members of the family on the care of the newborn
child, and continuous medical supervision of the baby are integral
parts of the local maternal and child-health program.

Special efforts are being made in the States to provide better care
for the infant born prematurely, as prematurity is the cause of almost
half of the neonatal deaths. Several States have developed State-
wide educational programs in the care of premature infants for the
benefit of both professional and lay groups, and nurses have been
given postgraduate courses in their care. Through these efforts the
people have learned that many of these infants can be saved. Com-
munity groups have equipped some health departments with special
cribs for premature infants cared for at home and for use in transporting
premature infants to a hosptial.

Massachusetts is carrying on an especially complete program to
reduce mortality and morbidity from premature birth, under the
direction of a pediatrician in the State Department of Public Health.
A law passed in 1937 provides for the reporting of premature births to
local boards of health, for transportation of the baby by the depart-
ment of health to a hospital especially equipped for his care, and for
hospitalization at the expense of the local board of public welfare, if
the parents are unable to pay. Special baskets for the transportation
of premature infants are provided to insure keeping the baby warm
during the trip to the hospital.

After a hospital has been equipped to serve as a premature center,
its nursery supervisor is given a graduate course in the care of prema-
ture infants at the Boston Lying-in Hospital. These nursery super-

Development of Program, 1936-39

visors are thereafter better equipped to teach student nurses the care
of the premature infant. By June 1939, 48 hospitals had been recog-
nized by the State Department of Public Health as meeting standards
set forth as necessary for the care of premature infants.

When a hospital has been designated as a premature center the
physicians in the community are notified and are sent a pamphlet on
the care of the premature infant. In the program of postgraduate
medical education provided through the Massachusetts Medical
Society, one of the lectures in the pediatric section includes the care
of infants born before term.

A public-health nurse with special preparation in care of the new-
born and the prematurely born infant was engaged by the Massachu-
setts State Department of Public Health to hold conferences with
groups of public-health and hospital nurses and to instruct them by
means of lectures and demonstrations. Smaller local groups were
organized throughout the State as a result of these larger conferences,
in which the subject was further discussed under the leadership of the
district public-health-nursing consultants of the division of maternal
and child health. Talks are given to groups of women on care of the
premature baby, and a leaflet has been issued for their use.

In Cattaraugus County, N. Y., the county health department has
undertaken a program of providing care for premature infants in their
own homes. The county, with a population of about 73,000 scattered
over 1,343 square miles, has 4 general hospitals, of which none had in
1939 a separate nursery for premature infants. Forty percent of the
1,400 births each year occur at home. The health-department
program consists of (1) the instruction of the health-department staff
as to the needs of premature infants and the methods of meeting their
requirements; (2) the provision of portable incubators or heated beds
which are distributed throughout the county in the district health
stations where they are quickly available on the request of local
physicians; (3) the provision of information to the medical profession
of the county regarding the care of premature infants and the equip-
ment available; and (4) general publicity for the education of the
public.

The staff-education program is conducted by the department's
consultant in maternal and child hygiene, who is informed on the
special techniques used at the Sarah Morris Station in Chicago, and by
the supervising nurse who has had special training in this field of
nursing. All the physicians of the county have attended an institute
on the care of premature infants. Various types of incubators have
been tested for the selection of the most efficient types for use in homes
with and without electricity.

46 Maternal and Child -Health Services

The child-health conference.

In the expanding program of maternal and child-health services the
State health agencies are making increasing use of the child-health
conference as a means of providing health supervision for large num-
bers of infants and preschool children. In 38 States, the District of
Columbia, Alaska, and Hawaii, such child-health-conference facilities
were provided under State and local health-department auspices,
according to 1939 reports. These facilities vary in the States from a
single conference center in some counties to more than one center in
many counties. Conferences were held in every county in Connecti-
cut, Delaware, Rhode Island, and Hawaii. Fourteen other States
reported child-health conferences in half or more of their counties.

During the year ended June 30, 1939, the State health agencies of
36 States reported the establishment of 522 child-health centers at
which conferences were held at least once a month, making a total of
2,394 centers in which monthly conferences were held (appendix table
1). This increase of 22 percent in the number of operating centers in
1 year indicates that the State health departments are encouraging
the use of the child-health conference as one of the best means of
giving parents the educational services of the physician and the
public-health nurse.

There is great need for the expansion of preschool health supervision.
Although most of the largest cities have long had facilities for the health
supervision of infants and preschool children in child-health centers,
such centers where child-health conferences are held monthly are
provided in only about one-fifth of the rural counties in the United
States. In certain States the scattered population makes it imprac-
ticable to provide enough conferences so that they are sufficiently
accessible for monthly sessions during the winter months. In the
counties without a public-health nurse to serve in rural areas (780
counties on January 1, 1939), no one was responsible for the organiza-
tion of child-health conferences and the related health services.

In some States the policy has been followed of providing health-
supervision service for infants and preschool children through the
public-health nurse, with emphasis on the parents' taking their children
to their private physicians for medical supervision. Under this plan
the community fails to obtain the full benefits of medical participation
in child-health supervision, as many families take their children to
physicians only in case of active illness. The influence of the child-
health conference in the community is not limited to the children who
can attend the conference. It has been found that a good child-health
conference stimulates the community to demand and the practicing
physicians and dentists to give increased health supervision to children
cared for through private practice.

Development of Program, 1936-39 47

When a conference becomes well established and good service is
being rendered, frequently the greatest problem is that more children
come than can be cared for properly. Recognition of this fact leads
to the development of more conference sessions in the same or in
other locations. The appointment system is being used successfully
even in rural areas.

During 1939 the Children's Bureau sent out to several hundred
pediatricians, physicians, and public-health nurses participating in
the maternal and child-health program a draft of a publication on
the child-health conference with a request for suggestions. Many of
the suggestions and comments made were incorporated in the final
draft before its publication. This publication is, therefore, the product
of experience in conducting child-health conferences in all parts of
the country.15

The physician at the child-health conference.

During the year ended June 30, 1939, the health agencies in 33
States employed practicing physicians to conduct child-health con-
ferences, and in 16 States practicing dentists received payment for
services rendered in connection with child-health conferences. The
increasing utilization of practicing physicians and dentists for this
work appears to be a very significant development.

The development of an effective child-health conference requires
careful planning. The physician who conducts the conference must
know the fundamentals of pediatrics. He must have some idea of
what "normal" physical and mental development is from early
infancy through childhood. He must know the "points" of a "good"
child just as a judge in a stock show knows the points of a good
animal. With a standard of excellence in mind and a knowledge of
the fundamentals of nutrition and of mental hygiene, the physician
is able to give health supervision that helps each child to realize his
own potentialities in mental and physical health.

Of equal importance is the physician's interest in teaching mothers
how better to understand their children and to provide for their
needs, for the chief function of the health conference is education.
It offers a golden opportunity to teach parents the things about
raising children that they have never had a chance to learn. Most
of them, having grown up before the new science of nutrition was
sufficiently developed for practical application in daily life, are often
unaware of the possibilities it offers for the greater health, happiness,
and efficiency of their children. The same can be said of the new
concepts of mental hygiene. This new knowledge will have no effect

15 The Child-Health Conference; suggestions for organization and procedure.
Children's Bureau Publication No. 261. Washington, 1940.

48 Maternal and Child-Health Services

on the coming generation unless it is taught to the parents of today's
children and to the young people who will be parents tomorrow.

Desirable as it may be, it is not necessary to have all child-health
conferences conducted by pediatricians, but it is necessary that the
physicians who conduct them know preventive pediatrics and receive
assistance and consultation service from pediatricians. More and
more, general practitioners of medicine are taking on the new role of
supervising the health as well as taking care of the illnesses of their
patients. This is the result not only of increased medical emphasis
on preventive medicine but also of increased public demand for this
type of service.

The 1938 list of physicians certified by the American Board of
Pediatrics showed that less than 3 percent of its diplomates were
practicing in communities of less than 10,000 population. Yet as
many babies are born in rural areas and small cities as in urban areas.
The responsibility for caring for rural children intelligently rests with
the general practitioners serving these areas. The presence of a
well-run child-health conference in a community exerts a good influ-
ence not only on the children and their parents but also on the type of
medical practice in the community.

The State reports of activities under maternal and child-health
plans recorded for the year 1939, show that 137,567 infants and
276,425 preschool children were admitted to medical service, and
402,479 visits of infants and 472,462 visits of preschool children were
made to medical child-health conferences. Dentists and dental
hygienists made 69,050 inspections of preschool children, most of
which were probably made at child-health conferences (table 4, p. 16).

In the expanding program of maternal and child-health services
under the Social Security Act, the State and local health agencies
have been confronted with the problem of supervising properly the
professional services in the large number of child-health conferences
being established. A number of methods have been developed in the
States for setting and maintaining high standards in these conferences.
Several States employ pediatricians on the State staff to work with
the local practicing physicians or health officers who have not had
experience in child-health supervision. In some States practicing
pediatricians serve the conferences in the areas in which they live,
and are paid on a part-time basis by the State. Other States have
developed training centers where physicians who are to conduct
conferences may go for a short period of training.

In Connecticut more than 100 well-child conferences in rural areas
are conducted by local physicians under the supervision of the State
Bureau of Child Hygiene. Physicians who wish to participate in
these conferences and who are considered qualified by the State
Department of Health, are required to attend six sessions of model

Development of Program, 1936-39 49

child-health conferences conducted by pediatricians. At the sixth
session the local physician conducts the conference under the super-
vision of the pediatrician in charge. These local physicians are usually
appointed to serve for 1 year, and when the appointments are made,
preference is given to physicians who are interested in or who are
devoting a major portion of their time to medical practice for children.
The local conferences are visited periodically by full-time pediatricians
on the State staff who can advise on the proper administration of the
conference and on the kind of services to be rendered.

The public-health nurse in the child-health program.

An alert, well-trained public-health nurse is as indispensable in the
child-health conference as she is in all phases of the child-health
program. One of her chief functions in the conference is interpreting
the findings and advice of the physician to the individual mothers and
making sure they understand how to follow instructions given. The
nurse's conference with the mother is not a mere repetition of the
physician's conference. It serves to enhance the total educational
value of the visit. Aside from this function and that of taking
responsibility for the smooth running of the conference, the nurse
performs an invaluable function in direct teaching in the home. She
makes the lessons of the health conference more effective by explaining
and demonstrating ways in which they may be carried out under the
conditions existing in the child's own home. Organized classes for
mothers are proving invaluable adjuncts to the teaching in the
conference, and they enable the nurse to reach larger numbers of
mothers than she is able to reach in individual visits. Her knowledge
of and use of community resources helps to implement the work of
the conference.

All the States, the District of Columbia, Alaska, and Hawaii
reported home visiting by public-health nurses for infant and preschool
hygiene in one or more counties or local areas during the year ended
June 30, 1939. However, only 11 States and Hawaii reported such
service in every county. Seven other States reported nurses' home
visits in all but one or two counties, which may have been similarly
served by city health departments. Twenty additional States reported
the service in one-half or more of their counties. With a total of
more than 5,600 public-health nurses in local communities rendering
service under the administration or supervision of the State public-
health agency, this was the most extensive type of activity provided
under the State maternal and child-health plans. The volume of
service rendered by the public-health nurses under the State plans
for maternal and child-health services has increased greatly since
1936.

50 Maternal and Child-Health Services

Continuous health supervision.

Great emphasis is being placed on the desirability of providing
continuous health supervision from infancy throughout childhood.
Formerly infant -welfare centers were established to provide health
service during the first year or two of life, and conferences for preschool
children were established separately later. Such a separation has been
recognized to be entirely artificial, as growth and development are a
continuous process. Great skill and knowledge of child development
and behavior are required of the health-conference staff to manage
the manifold problems of the preschool period. Only in recent years
has instruction on these subjects been given in medical schools, whereas
the feeding and care of infants has been part of the curriculum for
three or four decades.

The growing practice of transferring the conference record to the
school tends further to emphasize the desirability of continuing
regular health supervision throughout childhood.

An educational program that begins with the child of school age
loses its greatest opportunity for preventive service. Undoubtedly
one reason for dental programs in the past having been almost exclu-
sively concerned with the child of school age is that no comparable
opportunity of reaching large numbers of preschool children existed.
The infant and preschool child-health conferences are providing this
opportunity.

Health services for children of school age.

As the objective of child-health work is to protect, promote, and
conserve the health of children from the prenatal period through
adolescence, it is obvious that an important phase of the work is
concerned with the health of the child of school age. With school
health work conceived to be a part of community health activities
serving the child of all ages it should not be necessary to continue
indefinitely devoting major effort to detecting and correcting the
preventable defects of school children. The numbers of physical and
mental defects among school children indicate lost opportunities for
prevention during infancy and preschool years.

Most State departments of health are responsible for school health
service, especially in rural areas, as part of the maternal and child-
health program and are cooperating with State departments of educa-
tion in developing programs of school health education. School
health service includes providing a health-permitting school environ-
ment, controlling communicable disease, making the health resources
of the community available to school children, encouraging periodic
health supervision of children and teachers by physicians and dentists,
and making available the services of public-health nurses in explaining
the health needs of the pupil to teachers and parents. Of primary

Development of Program, 1936-39 51

importance are efforts to render these services so that they will
have real educational value to the child, to his parents, and to the
school personnel.

The State health agencies reported that during the calendar year
1939, 1,385,078 examinations of school children were made by physi-
cians, and 1,439,890 visits on behalf of school children were made
by public-health nurses as part of the activities under the State plan
for maternal and child-health services. During the years 1936 to
1939 the expansion of this service has not been emphasized as much
as the expansion of service for infants and preschool children, partly
because this phase of child-health service had previously been better
developed, and partly because it was increasingly recognized that
health supervision during the earlier years is the first essential to the
protection of the health of the school child.

The Division of Maternity, Infancy, and Child Hygiene of the New
York State Department of Health undertook a school health study in
the Astoria-Long Island City health district. In this project the
faults and shortcomings of the "routine" school medical examina-
tion were explored from the standpoint of the adequacy of the
examination itself, the educational value which theoretically the
examination is supposed to hold for child, parent, and teacher, the
kinds of records kept, and the types of nurse and doctor contacts
made subsequent to the examination. The results of the study and
the standards being developed will doubtless be of great value to those
responsible for school health programs in all parts of the country.

Nutrition in the child-health program.

In no other phase of maternal and child-health work is the act
of "taking thought" day by day more effective than in the field of
nutrition, for mothers of even very small means have some freedom of
choice in the foods they give their families. The nutrition program
under the maternal and child-health plans is primarily an educational
program. Problems of malnutrition arise from ignorance, inertia,
and poverty. The nutritionist can cope with two of these — ignorance
and inertia- and she can make some headway against poverty by
convincing those responsible for appropriating funds for assistance
to the needy that it is a good investment to spend funds to conserve
health.

To translate science into everyday use is the task of the nutritionist
at work in the States. She has studied the needs of individuals for
the essential food elements, including the ever-lengthening list of
vitamins; and she teaches the family to use green vegetables, milk, and
whole-grain cereals. She works in terms of foods that the family can
grow at home or can afford to buy, of recipes that can be followed easily
with a minimum of time and equipment. Her aids are leaflets, posters,

52 Maternal and Child-Health Services

and exhibits, and above all the word-of-mouth advice that the public-
health nurse gives during her home visits. The nutritionist on the
State staff helps her coworkers, State and local, to keep up to date on
the subject of nutrition and to teach nutrition effectively in the home,
the health center, and the school. Forty-one State health agencies
and Hawaii reported that during the year ended June 30, 1939, in-
struction in nutrition had been included as part of in-service edu-
cation given to physicians, dentists, dental hygienists, and nurses.

From Minnesota comes a typical series of four nutrition fliers —
"Stretch the Food Dollar, Make It Buy Health," "Protective Foods,"
"A Day's Meal for Your Family," and "The School Lunch." Maine
has printed a French edition of its nutrition folders for French-
Canadian families; Kansas has made a Spanish translation of its folders
for its Mexican families. The Minnesota housewife who lives in rural
areas is urged to plan the family's food supply a year ahead, to plant
a garden, and to can and store surplus fruits and vegetables for the
long winter. She is given homely advice such as: "Use the wild
Minnesota greens — lambs quarter, watercress, dandelion, dock, and
others, in the months before the garden produces. Gather wild fruits
when they are available. Fish caught in Minnesota in season — pike,
fresh herring, and white fish — are much cheaper than many other
kinds."

Mothers are told that the noonday lunch, especially when it is
eaten at school, requires careful thought and planning to meet the
child's needs. They learn that children learn — as an army advances —
"on the stomach," and that the hot lunch pays high dividends.
Hot lunches at school have been widely encouraged by maternal and
child-health nutritionists.

Other fields in which the nutritionists have been active include:
Giving dietary advice to child-caring institutions; conferring with
managers of school lunchrooms; organizing an educational program for
migratory workers; helping rural teachers to make possible good
nutrition practices at school ; planning for nutrition work in maternal
and child-health demonstrations; and consulting with welfare workers
on family budgets and food allowances.

Since 1936 the Georgia State Department of Public Health, through
the health unit in Hancock County, has carried on a demonstration of
maternal and child-health services with special emphasis on nu-
trition. This demonstration has been made possible through the
active cooperation of several other agencies concerned with the re-
lation of the food supply of rural people to their health. Among these
agencies are the College of Agriculture and the extension service of
the University of Georgia, the State Agricultural Experiment Station,
and the State Department of Education. Studies of the nutritional
status of children, together with surveys of their dietary habits, have

Development of Program, 1936 39 53

revealed need for increased consumption of protective foods. Studies
of the soil and of farming practices have shown that more protective
foods can be raised in the county. Educational programs to that end
have been undertaken and have resulted in increased production in
both home and school gardens. To supplement the foods provided at
home, hot lunches are served to a large proportion of children attend-
ing school. Under the leadership of farm agents, home-demonstration
agents, and Jeanes teachers, both adult and youth groups are carrying
on projects directed toward provision of better food for all age groups,
especially for infants and young children. Through an active program
of prenatal clinics, instruction of midwives, child-health conferences,
and medical examinations of school children the county health unit is
working for better health of mothers and children.

In Maine the food service in a State normal school was reorganized
after a study by the State nutritionist. The Illinois nutritionist was
lent for 4 weeks to flooded areas in the southern part of the State
where she organized and supervised food service in refugee camps,
made out special diets for hospital patients, and set up infant-feeding
stations. The Ohio nutritionist made a 3/2-month survey of the need
for nutrition programs in representative counties of the State.

How even a single nutritionist strengthens the nutrition content of
the maternal and child-health program throughout a State is illus-
trated by reports from Maryland, where this work was started in
1937. County health officers and their staffs of public-health nurses
have been quick to take advantage of the consultative services of the
State nutritionist. As soon as she has had an opportunity to learn
the most pressing nutrition problems of a county, through conferences
with the health workers and visits to typical homes in the company
of the field nurse, she looks into the local resources that may be mobil-
ized for meeting these problems. With the support of the State
departments concerned she works out a plan for coordinated service
among local teachers, welfare workers, extension agents, and public-
health workers. There has been general agreement that group instruc-
tion may well reinforce and supplement the individual teaching
done by the public-health nurse in homes and at the health con-
ference. In several counties the home-demonstration agents of
the extension service of the State university now attend prenatal
clinics to teach mothers the essentials of a good diet for themselves
and their families and to show them how simple, low-cost foods can
be made so palatable that their families will enjoy them. In two
counties arrangements have been made whereby home-economics
teachers, paid by the county department of education with funds
for adult education, give a series of 10 lessons on foods and nutrition
to groups organized by county health workers. Soon after this work

54 Maternal and Child-Health Services

was in progress there was evidence that the health and welfare workers
had a better understanding of how to meet the food and nutrition
problems of low-income families, and that the public-education
agencies were making more of a contribution to public health and
social welfare.

In a southern city, with a population of some 60,000, the
health department and the school system have worked out a coopera-
tive project built around the school lunch. The board of education
found it difficult to maintain school lunchrooms because of competition
from commercial enterprises that sold unsuitable food under insanitary
conditions on the edge of the school grounds. The school adminis-
trators appealed to the health department for help. By joint effort
it was possible to enlist public support for the passage and enforcement
of an ordinance forbidding "dog wagons" to operate in the neighbor-
hood of the schools. The field was thus left clear to build up
patronage for the school lunchrooms. Both the health department
and the board of education sought help from the head of the home-
economics department of the State college located in the city.
Through her good offices a home economist who had majored in
education and in lunchroom administration was employed to organize
the lunchrooms as part of the educational program of the schools.
Obviously the first step was to serve nutritious and appetizing food
at low cost and then to devise means whereby needy children could
be fed without being set aside from the group. Funds have been
obtained from local agencies for the lunches of younger children
whose families are unable to pay for them. Nearly all older children
who need to do so are given an opportunity to earn their lunches by
working in the lunchroom. All children who work in the lunchroom
are given the regular health examination for food handlers and
instructions in the sanitary handling of foodstuffs. The health officer
and the superintendent of schools in this southern city have not been
content with merely providing good lunches at low cost but have
built the health-education program around the school lunch. The
lunchroom manager, the school nurse, and the teachers of physical
education and home economics have been leaders in setting up a
health-education project in which every teacher and pupil has
participated.

The nutrition services of State departments of health have worked
with the departments of public instruction to develop special summer
training programs for lunchroom managers of schools in communities
that are too small to employ trained dietitians. Nutritionists from
the State department of health take part in a course, lasting from 3
days to 2 weeks, which is given at a State teachers' college. These
courses have been popular with both the managers and their employers,
who in some cases pay the expenses of the workers. As a follow-up

Development of Program, 1936-39 55

measure, a nutritionist is available throughout the school year for
consultation with school administrators and with managers of school
lunchrooms.

Many State health departments are prepared to assist school ad-
ministrators, especially those working in rural areas, to plan units in
health education and nutrition and programs of related activities.
It is not uncommon for the health department to serve as a source of
bulletins, exhibits, and illustrative materials for use in connection
with school health projects. Several nutritionists on the staffs of
State and local departments of health maintain a lending library of
posters, food charts, and food models. In some States arrangements
have been made to supply litters of white rats to schools that are
equipped to conduct feeding experiments.

Dental-hygiene service.

The dental programs of the States vary considerably. Educational
programs for teachers, pupils, and lay groups are widespread. Pro-
grams of prophylaxis involving the cleaning and inspection of the
teeth are carried on in many State maternal and child-health programs.
As yet these programs for the most part have reached school children,
and little emphasis has been given to the care of the teeth of the
preschool child. It is frequently necessary for the public-health
nurse to explain to mothers the importance of dental hygiene in
relation to general health and nutrition and the importance of early
discovery and treatment of defects.

In Oregon the oral-health program was begun July 1, 1937, under
a full-time dental director as a function of the Division of Maternal
and Child Health of the State Board of Health, with the active co-
operation of the Oregon State Dental Association. The program was
planned to include prenatal, postnatal, and preschool activities, but
the school program was given the greatest emphasis in order to famil-
iarize the teachers and the general public with the value of dental
health. The plan includes provision for education in the home, the
community, and the school, and for professional groups. Remedial
service through private dentists is encouraged. For children whose
families are unable to provide necessary care, the attempt is made
to finance this service through community groups or relief agencies.
In the first year of the program in a county special emphasis is given
to providing dental care for every first-grade child, and each year
another grade is added, up to the fourth grade. The service includes
prophylaxis and repair of carious teeth. The education program for
the home, the community, and the school advocates for the expectant
mother, the preschool child, and the younger school child more
complete information on matters of nutrition, oral hygiene, and early
dental attention.

56 Maternal and Child-Health Services

The usual procedure in school dental inspection is to send the
child home with a slip saying (in 9 cases out of 10) that his teeth need
the attention of a dentist. Few communities have made provision
for the follow-up of these children to see whether the recommenda-
tions are carried out. Even fewer communities have made provision
for giving the corrective care needed when the families are unable to
pay for such care from their own resources. The inspection of the
teeth of tens of thousands of children without provision for the cor-
rection of defects cannot be considered a satisfactory type of service.
The problem of providing corrective care for all dental defects of
children has raised serious questions in the minds of everyone involved
in the administration of public-health programs, including leaders in
the dental profession. The number of children with dental defects is
so great that even limited programs for selected age groups cannot be
developed on a Nation-wide basis unless present resources for care
are greatly expanded and many more dentists are trained in children's
dentistry.

The technical procedures of dentistry have made great advances,
but many dentists realize that they are not now in possession of
sufficient facts to formulate an effective preventive program. The
greatest need in dentistry today is for a united effort by medical and
dental educators and research workers to enlist all available resources
for a fundamental dental-research program. The present Federal
grants-in-aid for maternal and child-health services are not available
for extensive research. Many health authorities and their dental
advisers incline to the opinion that, pending better knowledge of how
caries may be prevented, the limited maternal and child-health funds
now available for dental hygiene can best be spent in strengthening
the nutrition program. They fully recognize the great importance
of carrying out corrective procedures, especially among young children,
but point out that funds are not yet available in sufficient amount to
make an appreciable attack on the problem.

Prevention of children's diseases.

The whole health-supervision program is directed toward the
development of optimal health in children through building sound
foundations of mental and physical health, through instruction of
parents and others on how to protect children against infection,
through immunization against certain communicable diseases, and
through the early recognition of abnormalities and incipient disease
at the stage when remedial treatment offers the best chance to pre-
vent the development of serious illness.

For a number of the communicable diseases there are specific
preventive measures that increasingly are being used in the maternal
and child-health program.

Development of Program, 1936-39 57

Congenital syphilis, which causes the death of many children and
injury to the physical and mental development of many more children,
can be prevented. Routine testing of the mother early in pregnancy
followed by adequate treatment in case the tests are positive has been
made standard procedure from the start in the prenatal clinics con-
ducted under State health-department supervision. This recom-
mended procedure by the end of 1939 had been reinforced by the
passage of laws in 17 States requiring physicians or midwives in
attendance upon pregnant women promptly to send specimens of the
patient's blood to approved laboratories for syphilis testing.16

In New Jersey, where this procedure has been widely adopted
through medical initiative and as a result of a law passed in 1938, it
was estimated that tests were made on the mothers of at least two-
thirds of the babies born in 1939. A study of information obtained
from 1 month's birth certificates showed that only 30 percent of the
women whose infants were stillborn had been tested, compared with
84 percent of the women who gave birth to living children.17 In the
supervision of prenatal clinics, in the postgraduate courses in ob-
stetrics, and by every available educational means the State health
agencies are emphasizing the importance of these tests. The pro-
vision of laboratory facilities for making tests as a part of the State
health agency's venereal-disease control program is also an important
factor in increasing the effort to prevent congenital syphilis.

Immunization against diphtheria in the first year of life has long
been standard medical practice. The State and local health agencies,
through the child-health conferences, provide the opportunity for
early immunization for infants brought under health supervision and
for the immunization of preschool children not previously protected.
Extending beyond the doctor's office and the areas where such con-
ferences are held, the health-education programs of State and local
health agencies, especially through the public-health nurse and the
summer round-up for medical examination of children entering school,
encouraged by parent-teacher associations, are steadily increasing the
proportion of children who have been immunized against diphtheria.
The State health agencies reported for the calendar year 1939 a total
of 1,059,478 immunizations against diphtheria as part of the maternal
and child-health program. The number of persons under 20 years
of age who died from diphtheria dropped from 4,586 in 1933 to 2,401
in 1937 and to 1,831 in 1939. The figures indicate that substantial

16 These 17 States are California, Colorado, Delaware, Illinois, Indiana, Iowa,
Maine, Massachusetts, Michigan, New Jersey, New York, North Carolina,
Oklahoma, Pennsylvania, Rhode Island, South Dakota, and Washington.

17 Prenatal Blood Tests for Syphilis; operation of the New Jersey law, by
John Hall. The Child (published by the Children's Bureau, U. S. Department
of Labor, Washington), Vol. 4, No. 8 (February 1940), pp. 201-204.

58 Maternal and Child-Health Services

gains have been made but that large numbers of children are not yet
reached by preventive measures. It is essential that protection
against diphtheria be extended into all communities and that the
immunization measures be maintained as routine procedures in all
physician's offices and all child-health programs.

Similarly vaccination against smallpox during the first year is pos-
sible for an increasing proportion of children as a result of the exten-
sion of maternal and child-health services. The State health agencies
for the year 1939 reported 1,465,136 vaccinations against smallpox
as a part of maternal and child-health activities.

It is advisable that each child attending the child-health con-
ference be given a tuberculin test. In case the test is positive the
child is referred to a physician for further examination and recom-
mendation of care, and a careful search for the source of infection
is made.

The need for medical care.

A serious block in the provision of health service for children comes
at the point where medical care must be provided for the treatment
of disease or for the correction of defects. It is the customary practice
in child-health conferences and health examinations at school to advise
parents to take their children to a private physician for the treatment
of such conditions. In cities free medical and hospital services and
out-patient clinics are frequently available for children in families
with low incomes. Each of the cities of more than 250,000 popula-
tion has one or more out-patient clinics. But only 2 percent of the
cities with less than 10,000 population have such resources 18; and
in the smaller towns and rural areas often the only resource is the
service given without charge by practicing physicians. In many
sparsely settled and mountainous areas doctors and hospitals are not
readily available.

In some States medical care is provided to some extent for com-
municable diseases, especially for tuberculosis, hookworm disease,
and, recently, for syphilis. All the States, with the aid of Federal
grants under title V, part 2, of the Social Security Act, are providing
medical care for crippled children, and additional funds made avail-
able by the 1939 amendments of the act will make possible the starting
of medical-care programs for children suffering from rheumatic heart
disease.19

18 Proceedings of the National Health Conference, July 18-20, 1938, p. 46.
Interdepartmental Committee To Coordinate Health and Welfare Activities,
Washington, 1938.

19 See Services for Crippled Children under the Social Security Act; develop-
ment of program, 1936-39 (Children's Bureau Publication No. 258, Washington
1941).

Development of Program, 1936-39 59

The county public-health nurses are ingenious in aiding families
to use whatever medical-care facilities are available for children in
their communities. However, the assumption by communities of
responsibility for providing facilities for the care of sick children
whose families are unable to provide the care needed is sporadic and
incomplete, even in many progressive communities. This need be-
came apparent during the first years of the Federal-State maternal
and child-health program, but with the funds available little could be
done to deal with the problem.20

Mental health of the child.

The maternal and child-health program which deals with the mother
during her pregnancy and with the child during the first months and
years of life affords the earliest opportunity for assisting in building the
foundation for the mental health of the child. The doctor and nurse
who explain to husband and wife what is involved in parenthood can
contribute immeasurably to the mother's assurance and peace of mind
during pregnancy and the first weeks of motherhood. The early
training and care of the baby and of the young child affect his health,
happiness, and mental attitude throughout life. The doctor in his
office and at the prenatal and child-health conference and the public-
health nurse in all her contacts with parents can aid parents in pro-
moting the mental health as well as the physical health of children.

The pattern for the mental health, as well as the physical health, of
the child is laid during infancy and the early years. Intelligent care
during these years will aid in preventing the development of behavior
problems that later may require treatment at a child-guidance clinic.

Most of the State health agencies have recognized that instruction
in how to promote mental health in the child-health program should
be part of the postgraduate educational training given to doctors and
nurses as public-health workers and as private practitioners. In a
few States the promotion of mental health has been given greater
emphasis. In New Jersey courses in child care and training have been
given for nurses.

The Division of Child Hygiene of the Massachusetts State Depart-
ment of Public Health carries on a research project in selected local
areas to study and eliminate the preventable causes of early school
failure in rural and village areas. Three factors are recognized as inter-
fering with success in the first grade — physical handicaps, psychological
factors such as emotional tension due to feelings of inadequacy and to
repeated failure and criticism, and educational causes. The program

20 See recommendations included under Expansion of Maternal and Child-
Health Services in a National Health Program (Report of the Technical Com-
mittee on Medical Care, 1938, issued by the Interdepartmental Committee To
Coordinate Health and Welfare Activities, Washington, 1938).
32S199"— 12 5

60 Maternal and Child-Health Services

in each local area includes testing and examination of children; lectures
to teachers, school physicians, and nurses; and consultation service on
the institution of preventive measures. The Massachusetts Division
of Child Hygiene also has a coordinator of parent education, who co-
ordinates all the parent-education activities of members of the staff
and gives group instruction to teachers, nurses, and social workers.
She meets with groups of parents for instruction in habit training in
fields indicated by the findings of well-child conferences. Lay leaders
are given a 3-year course on parent education as it relates to the infant
and to the child of preschool age, school age, and the adolescent group.
These leaders under supervision carry on community projects in
parent education.

A division of child psychiatry was operated in the Bureau of
Maternal and Child Health of the Indiana State Board of Health
from August 1937 to March 1939. The demonstration under the
State maternal and child-health plan was started to initiate a mental-
hygiene program for the children of Indiana through the cooperative
efforts of the State Board of Health, the State Department of Public
Welfare, the Indiana University School of Medicine, the State De-
partment of Public Instruction, and the Indiana Medical Association.
A unit including a psychiatrist, a psychologist, and two social workers
provided a clinical psychiatric and child-guidance service for the
children in three counties, in a State orphanage, and at the James
Whitcomb Riley Hospital (affiliated with the Indiana University
School of Medicine), which receives child patients from all parts of the
State. The psychiatrist in charge gave each year a series of 10 lectures
to the senior class of the Indiana University School of Medicine.
Consultation service was also given to practicing physicians, to
matrons and officials of State correctional institutions, and to teachers'
colleges. Many talks on child training were given to teacher groups
and parent-teacher groups. In March 1939 the division of child
psychiatry was transferred to the new division of medical care in the
Department of Public Welfare, to form the nucleus of an enlarged
mental-hygiene program for both children and adults.

Health education.

As health education is a major objective of health departments in
rendering their many services, increasing consideration is being given
to ways and means of making these educational efforts more effective.
In addition to the need for informing the public of the functions of
the health department and of means whereby community health may
be improved, there is the need for teaching individuals how they
can achieve better health for themselves and the members of their
families. Many kinds of educational techniques are required. An
increasing number of health departments are employing health-

Development of Program, 1936-39 61

education specialists to take charge of general educational activities,
to help all health-department staff members do more effective teach-
ing in the performance of their jobs, and to help coordinate the
health-education activities of other agencies, such as the schools,
with those of the health department. During the fiscal year 1939,
20 State health departments employed specialists in the field of
health education.

According to reports from the States, 47 State health departments
during 1939 assisted public schools in the improvement of their
programs of health instruction, and 33 State health departments
aided teacher-training schools in the improvement of their teaching
of health. In 25 States classes in maternal and infant care were
offered in high schools, with the assistance of the State health depart-
ments; the enrollment for these classes in 1939 was 66,245. Effective
health education is increasingly recognized to be the result of the com-
bined efforts of the home, the physician, and the dentist, the health
department, and the schools. This cooperative approach to the
problem characterizes the health-education programs being developed
under the stimulus of the State health departments.

Many interesting methods of attacking health-education problems
are being worked out in the States. The basic idea of the Kentucky
health-education plan is that public health is concerned not only with
saving human lives but also with guiding individuals to live health-
fully and effectively in their daily environment. 2u Since the first
step toward the application of this principle is an efficient corps of
public-health workers who render all health services in an educative
way, committees on "continued learning in service" of State staff,
local staff, and allied groups map out annual plans for weekly staff
conferences in which all staff members participate. Through district
public-health study groups and weekly conferences staff member
are kept informed of progress in all phases of the public-health pro-
gram and of the most effective ways in which they can render service
that will have educational value. The plan is under the direction
of a committee made up of bureau directors of the State Department
of Health, with the assistance of a health-education consultant.

The health-education consultant of the Montana State Board of
Health spent her first year in teaching classes in health education in
the teacher-training colleges upon the invitation of their presidents.
She thus was afforded an opportunity to become acquainted with the
teachers as they were being equipped for health-education work in
the schools of the State. This formed a basis for planning an in-

-" Kentucky's Plan for Public Health Education, by A. T. McCormack, M. D.,
and Reba F. Harris, M. A. Public Health Reports, Vol. 52, No. 44 (October 29,
1937). U. S. Public Health Service, Washington.

62 Maternal and Child-Health Services

service program for teachers in cooperation with the education
authorities of the State.

The health-education consultant spent the second year in the
field, visiting schools in all sections of the State, which gave her an
acquaintance with actual school situations. An advisory com-
mittee on problems of health in the schools was appointed by the
State superintendent of public instruction at the suggestion of the
health-education consultant. The committee prepares material for
use in the schools and acts in an advisory capacity on programs of
health in the schools. Two "laboratory" situations were developed,
one in a typical urban school system, which affords an opportunity
for actual coordination of the school and community health program,
and the other in the schools of a rural county. It is hoped that in
these situations health-education methods can be worked out and
measurable results obtained.

In Oregon, under the direction of the health-education consultant
on the staff of the State Board of Health, great progress has been
made in organizing State and community groups interested in child-
health education. As it was recognized that no one professional or
social group has a monopoly of interest in and responsibility for
child health, groups of parents, teachers, physicians, dentists, public-
health workers, community welfare and social agencies, and civic
groups are represented on a State joint committee. Work has begun
in several local communities in developing a coordinated program of
health education, involving all community groups interested in or
concerned with child health.

The Professional Workers and the Postgraduate-
Training Program

The entire value of a service program depends upon the knowledge
and skill of those who render the service. It is fortunate for the
maternal and child-health program that the personnel for the State
and local programs has been drawn from the medical and allied pro-
fessions, which have a steadily growing volume of scientific knowledge
and standards for training and measuring the attainments of their
members. The growing acceptance of the procedures advised in the
care of the mother and child is evidence of the confidence that the
public feels in doctors, nurses, and other public-health workers.

During the period 1936 to 1939 the State health agencies selected
State personnel and gave advisory service in the selection of local
personnel for the maternal and child -health program in accordance
with qualifications recommended by the Children's Bureau Advisory

Development of Program, 1936-39 63

Committee on Maternal and Child Health Services and by the State
and Territorial health officers meeting in annual conference with the
Children's Bureau.

The careful selection of personnel was supplemented by providing
incoming appointees with the opportunity to observe and to practice
procedures in county health units where, for purposes of demonstra-
tion, the best available personnel in the State was assigned to conduct
maternal and child-health centers. Tennessee and West Virginia
are among the States that maintain such training centers to which
incoming appointees are sent for periods of weeks or months for their
initiation into the service.

It was also found advisable by the State health agencies to provide
stipends from maternal and child-health funds to enable State mater-
nal and child-health directors, others on the State staff, and local
public-health nurses to go to centers for professional education in
order to supplement their basic training with training for public-
health administration or for special phases of the maternal and child-
health program. Forty-four State health agencies reported that
during the year ended June 30, 1939, 794 staff members were given
stipends for postgraduate education, including 115 physicians,
34 dentists, 5 nutritionists, and 640 public-health nurses (table 8).
The same practice, which had been followed to a lesser extent in the
preceding 3 years, has been an important factor in improving the
quality of maternal and child-health services, one of the objectives
named in the Social Security Act.

Hundreds of local practicing physicians participate in the conduct
of maternal and child-health conferences, and doctors, dentists, and
nurses in private practice are responsible for the care of mothers and
children among all groups. To reach the practitioners in each of
these professions, the State health agencies, in cooperation with the
State and county medical societies and the societies of other profes-
sional groups, have undertaken extensive programs of postgraduate
education. The response in attendance at courses offered is indicative
of the active desire of members of these professions to keep abreast
of advancing knowledge and techniques in their fields.

Growing recognition of the value of the selection of personnel on a
merit basis and of the retention of qualified personnel led the Congress
in 1939 to amend title V, part 1, of the Social Security Act, so as to
require that State plans for maternal and child-health services should
provide after January 1, 1940, for the establishment and maintenance
of personnel standards on a merit basis.21

21 See the text of section 503 (a) of the Social Security Act, as amended, p. 90.

Maternal and Child-Health Services

TABLE 8. — Postgraduate education received by State and local staff

members, year ended June 30, 1939

Type of course and staff members receiving-

All types of courses

Physicians

Dentists

Nutritionists

Public-health nurses.

Supervisory

Nonsupervisory .

General public-health courses.

Physicians

Dentists

Nutritionists

Public-health nurses.

Supervisory

Nonsupervisory .

Other types of courses
Physicians

Obstetrics

Pediatrics

Venereal disease

Type not reported.

Dentists: Public-health dentistry.

Nutritionists: Nutrition

Public-health nurses

Maternity nursing

Pediatrics

Orthopedic nursing

Venereal disease

Physiotherapy

Public-health-nursing supervision
Type not reported

Number of

States in
which given

21
9
5

3
3
3
1

3
3

11
3
2
5
1
1
5

Number of
staff mem-
bers receiv-
ing

794

115

' 640

565

554

1 452

421

246

7
10

i 194

103

1 Of these 640 nurses, 6 received both general public-health and other types of training.

Seventeen States, the District of Columbia, Hawaii, and Puerto
Rico already had civil-service laws covering their State health agencies.
In the other States the selection and retention of qualified personnel
was dependent upon the administrative policy of the State health
officers and of the Governors. To assist the State health agencies in
developing personnel systems under which they will be in position to
comply with this new requirement in the Social Security Act, the
Children's Bureau presented a draft of recommended standards for
the establishment and maintenance of a merit system of personnel
administration, and for qualifications of certain classes of professiona1
employees in State and local agencies administering maternal and
child-health services, at a special conference of State and Territorial
health officers on October 23, 1939. After suggestions of the con-
ference were incorporated these recommended standards were issued
to the States on November 1, 1939. At the same time a statement
of policies adopted by the Children's Bureau as a basis of review of

Development of Program, 1936—39 65

provisions for a merit system of personnel administration was issued
to the States. The State health agencies were asked to submit by-
January 1, 1940, supplements to their maternal and child-health
plans signifying their intention of establishing a merit system of
personnel administration.

On the advice of the State health officers the Surgeon General of
the United States Public Health Service issued regulations under
title VI (Public-Health Work) of the Social Security Act, directing
that in a State where a merit system of personnel administration is
established for one part of the public-health agency it should be made
applicable to all State and local personnel who are rendering services
in accordance with budgets submitted to the United States Public
Health Service.

By these means the efforts made by the State health officers to
select and retain qualified personnel for maternal and child-health
services and for other public-health work were reinforced.

The physician.

The maternal and child-health director in each State is a physician.
Each State program is carried on in cooperation with medical groups
in the State; each local program in cooperation with the physicians
of the community.

The budgets in the State plans for the year ended June 30, 1939,
provided for 118 full-time and 8 part-time physicians on State staffs;
on local staffs, for 49 full-time physicians, 1 part-time physician, and
65 part-time consultants. Thirty-three States reported the employ-
ment of more than 2,600 local practicing physicians on a fee basis
for consultation service, conduct of clinics and conferences, and
home-delivery medical service. Organizing and directing the pro-
gram were the State and county health officers, who are also physicians.
Hundreds of other physicians contribute advisory and volunteer serv-
ice each year. Thousands take advantage of the opportunities offered
for postgraduate education in obstetrics and pediatrics.

A characteristic of all the State maternal and child-health programs
has been the selection of medical personnel on the basis of qualifica-
tions recommended for this type of service by the Children's Bureau
Advisory Committee on Maternal and Child Health Services and the
conference of State and Territorial health officers. State advisory
committees for the most part have concurred in these recommenda-
tions, and the State health officers have written them into civil-
service examinations or have used them as a guide in the selection of
appointees for maternal and child-health positions. Similarly the
recommendations have been used as a guide by the county health
officers for local appointments and in the selection of physicians to
conduct prenatal clinics, child-health conferences, and examinations

66 Maternal and-Child Health Services

of school children. At the April 1939 conference of State and Terri-
torial health officers with the Children's Bureau the health officers
recommended that after June 30, 1939, newly appointed State and
local maternal and child-health personnel should meet the minimum
qualifications recommended for each position.

Summaries of State reports show that each year a larger proportion
of the physicians on State staffs in both administrative and clinical
positions have had special training in the fields of pediatrics or obstet-
rics; and others have devoted a major portion of their practice to
these specialties; most of the maternal and child-health administra-
tors have had special training or long experience in public-health
administration.

Since many of the medical staff at work on maternal and child-
health programs in 1936 and many of the incoming appointees had
not had an opportunity to obtain the desirable combination of train-
ing in obstetrics, pediatrics, and public-health administration, the
State health agencies in many cases have granted leave for supple-
mentary training. Most of these physicians took courses at univer-
sity schools of public-health administration and returned to their
States to serve as directors or assistant directors of maternal and
child-health divisions.

States have established county training centers including well-
rounded maternal and child-health programs conducted by the best
personnel in the State, to which local health officers and other physi-
cians on local staffs have come for periods of training — frequently for
an initial period of training before entering service in another county
of the State.

Programs for continued in-service training for all public-health per-
sonnel in the State are being developed slowly. The details of organ-
ization and conduct of this type of staff education have been unusu-
ally well outlined by the Kentucky State Department of Health.
(See p. 61.)

One of the most widely welcomed phases of the maternal and child-
health program has been postgraduate education in pediatrics and
obstetrics for practicing physicians. During the year ended June 30,
1939, more than 14,700 physicians in 43 States and Hawaii attended
courses of one or both types, financed with maternal and child-health
funds and organized by State health agencies in cooperation with
State and county medical societies. At the beginning these courses
were given occasionally at various centers in the State, but a tendency
to develop them as a permanent educational service in the States has
appeared. Examples of three types of postgraduate education are:

Under one plan, full-time instructors give lectures and hold clinics
for physicians in the various regions throughout the State. In Ten-
nessee this plan has been admirably carried out at first by a staff

Development of Program, 1936-39 67

obstetrician and later by a pediatric lecturer. The Tennessee courses
are planned and financed jointly by the State Department of Public
Health, the Commonwealth Fund, the State medical society, and the
medical school of the State university. Similar courses were con-
ducted in Oklahoma and several other States during the year 1938-39.

Another type is the course given by the part-time instructor. Most
of the States have at one time or another employed specialists in pedia-
trics or obstetrics, to give "refresher" courses in local centers. The
success of these courses depends first on painstaking preparation made
long in advance to insure the attendance of physicians busy in their
daily practice and, second, on the ability of the lecturers to deal with
the problems that confront practitioners in various communities.

The extent of this type of postgraduate education is shown by the
following figures for the year ended June 30, 1939:

Lecture courses for practic- Number of com- Number of Number of

r mumties in which lectures physicians

ing physicians: given given attending

Pediatrics 499 (in 37 States) 1,284 14,760

Obstetrics 617 (in 37 States) 2,152 14,606

A third type of postgraduate education has developed in response
to requests on the part of local physicians for short clinical courses in
medical centers. The State health departments in Illinois, Minne-
sota, Michigan, and Indiana, in cooperation with the State university
medical schools, have arranged for short courses at the medical teach-
ing centers where local physicians can observe and study the more
recent advances in the fields of obstetrics and pediatrics. This type
of postgraduate education must be separate from undergraduate edu-
cation and requires the undivided time of full-time instructors.

The supervisory services provided for local physicians conducting
prenatal clinics and child-health conferences, and the clinical consul-
tation service offered physicians in some States are also important
types of postgraduate medical education.

As part of this program a Negro pediatrician on the medical con-
sultant staff of the Children's Bureau has given postgraduate lectures
to Negro physicians in Alabama, Mississippi, and Georgia under the
auspices of the State departments of health. In Mississippi, in 1937-
38, in order to reach all Negro physicians the State was divided into
9 districts, a central meeting place was designated in each district
and a 10-lecture course was completed during a 2 -week period. In
addition, conference and clinic visits with individual doctors were
made at their request. The lectures were directed to maternal and
child care but, because no other lecturer was giving courses to Negro
physicians, related subjects in general health were included in the
courses — periodic health examinations, immunizations, tuberculosis,
malaria, and the diagnosis and treatment of venereal diseases. Of

58 Maternal and Child-Health Services

the 58 Negro physicians in Mississippi, 55 attended the course. Com-
petition with midwives, inaccessibility of patients, and uncertainty
of pay have made the practice of obstetrics unattractive to most
Negro physicians in the State. For very practical reasons their
major interest is in general medical practice. All the physicians
were interested and eager to adopt suggestions made concerning their
opportunities to help educate their patients in health matters and
concerning improvement of their practice, including immunization
of children and periodic health examinations.22

The medical profession recognizes its responsibility for providing
better care for mothers at childbirth. In 1937 the Council on Medical
Education and Hospitals of the American Medical Association re-
ported that:

* * * the teaching of obstetrics is at a lower level than that of the
other major clinical departments. Comparatively few schools offer to their
students an adequate practical experience under competent supervision.

During 1938 the Children's Bureau analyzed 2,538 replies to
questionnaires on clinical training of the medical graduates of 1936
and found that during their medical training 59 percent had attended
a total of 20 or fewer deliveries; 19 percent had delivered no women
in hospitals; 27 percent had delivered no women at home. Of
interns who had attended hospital deliveries, 22 percent reported the
deliveries attended by them had not been supervised by an ob-
stetrician. Yet 72 percent of these graduate physicians planned to
practice obstetrics; 15 percent planned to specialize in this field.
The lack of opportunity for training in obstetrics has made practicing
physicians eager to take advantage of the opportunities offered for
postgraduate education in obstetrics; and their realization of the
importance of such training will bring better provision for obstetric
training in undergraduate courses in the medical schools.

The public-health nurse.

The number of public-health nurses is increasing in the United
States in response to a growing demand. A survey made in January
1939 showed an 8-year increase of 45 percent for the whole country;
a 42 -percent increase in urban areas and a 50-percent increase in rural
areas. From 1937 to 1939 the number employed by public agencies
showed an increase of 19 percent. The great need for nursing service
for mothers and children was probably the most powerful force in
building up the Nation's staff of 23,029 public-health nurses. Of
these, 5,322 were employed on January 1, 1939, by public agencies
for service in rural areas, but there were still 780 counties (25 percent
of the total number) that had no rural public-health-nursing service.

22 See Postgraduate Courses for Negro Physicians in Mississippi, by Walter
H. Maddux, M. D. The Child, Vol. 3, No. 8 (February 1939) pp. 181-182.

Development of Program, 1936-39

At least three times this number of public-health nurses is necessary
to make such service available in all areas, urban and rural, in the
United States. The population per public-health nurse in each State
and in Alaska and Hawaii as of January 1, 1940 is shown in chart 12.

Chart 12. — Population per public-health nurse in urban and rural areas in each State;
Continental United States, Alaska, and Hawaii, January 1, 1940 '

Population per pub
health nurse

[E~2] 2,000 - 4,

[HI 5,000 - 9,000
10,000 -14,000
15,000 or more

1 Based on data supplied to the U. S. Public Health Service by State and Territorial health departments.

More than half of the Federal, State, and local funds budgeted in
State maternal and child-health plans for the fiscal year 1939 were
designated for public-health-nursing service. On June 30, 1939,

70 Maternal and Child-Health Services

the State health officers reported that under these plans public-
health nurses in 1,950 counties were rendering service under the
supervision of the State health department or in local health depart-
ments receiving financial or supervisory aid from the State health
department.

Especially notable has been the increase in the number of public-
health nurses who serve in State health departments in an advisory
or supervisory capacity. Reports from the States for the year ended
June 30, 1939, show 418 nurses so employed. The State nursing
personnel is usually composed of a director, district advisory nurses,
and consultants in special phases of public-health nursing. The
number of States that have appointed public-health-nursing consul-
tants in maternal and child health since 1936 has increased steadily.
The service of the consultants makes possible a closer integration of
the work of the maternal and child-health divisions with the public-
health-nursing units, which enables the nursing aspects of the maternal
and child-health program to be put into action more effectively.
Such consultants also assist the general supervisor with staff nursing
education in which an intensive effort is made to improve the quality
of performance of staff nurses, State and local, and to give the needed
emphasis to the maternal and child-health phases of the work of the
public-health nurse carrying on a generalized family health program.

During the year ended June 30, 1939, more than 5,600 public-health
staff nurses were employed in local communities, under the adminis-
tration or supervision of the State health agencies. During 1939
more than 1,000,000 nursing visits were made for prenatal and post-
natal care to mothers, and more than 2,750,000 visits were made for
services to infants, preschool children, and school children.

The count of visits indicates the volume of nursing activity in the
maternal and child-health field, but it does not reveal the significance
in the community of the continuing services of the public-health nurse.
Day by day she makes parents acquainted with the health resources
of the community- — the prenatal clinic, child-health conference,
crippled children's clinic, tuberculosis and venereal-disease clinics,
hospital out-patient service — and with social resources such as welfare
services and recreational facilities. After the baby's birth the nurse
encourages the mother to return to the physician for the postpartum
examination that may in later years mean health instead of invalidism
due to neglect. Her intelligent observation of the baby and the
child may lead to early recognition and treatment of potentially
serious conditions.

Qualifications for public-health nurses serving in the maternal and
child-health program, which follow closely the standards set by the
National Organization for Public Health Nursing, have been recom-
mended by the conference of State and Territorial health officers and

Development of Program, 1936-39 71

by the Children's Bureau advisory committees on public-health nurs-
ing and on maternal and child-health services. For the most part
these recommendations have been observed by State and local agencies
in making new appointments, and the State health officers have
recommended that, after July 1, 1939, no appointments be made of
public-health nurses who fail to qualify under these standards.

In the expanding maternal and child-health program it has been
found to be desirable to provide supplementary training for public-
health nurses. During the first 3 years, 1936-38, of the social-security
program more than 2,700 nurses received stipends from public-health
and maternal and child-health funds to enable them to take additional
training for periods extending from 6 weeks to a school year. The
stipends of 800 of these nurses were paid in whole or in part from
maternal and child-health funds. To meet the demand for training,
6 additional public-health nursing courses were offered by universities
in various parts of the country, making a total of 26 public-health-
nursing courses approved by the National Organization for Public
Health Nursing. A number of the nurses receiving stipends from
maternal and child-health funds have completed programs of study
in advanced maternity nursing. Those responsible for such courses
have been stimulated to enlarge the program in their institutions to
meet an ever increasing demand by the public-health-nursing group
for further preparation.

Staff-education programs for nurses have been carried on in all the
States to enable the nurses to keep abreast of current scientific develop-
ments. In many States institutes have been held on maternal and
child-health nursing and related subjects. Regular conferences of
nurses and other professional workers have been organized, as well
as separate study programs for the public-health-nursing staff. In
counties designated as teaching centers, to which well-qualified per-
sonnel has been assigned to assist with the instruction, planned pro-
grams have been organized for the introduction of new staff nurses
to the work.

Many of the States have prepared general manuals outlining
public-health-nursing policies and procedures, and uniform record
systems have been developed.

The dentist and dental hygienist.

Only 17 State departments of health had any well-developed dental
program as part of their public-health service in 1936. For the fiscal
year 1939, 40 States budgeted a portion of their maternal and child-
health funds for dental-education programs. More than $381,000
was budgeted for dental services in the State plans. Federal grants
through the United States Public Health Service increased this amount
to approximately $460,000. Maternal and child-health funds were

72 Maternal and Child-Health Services

to be used for the employment of 66 full-time dentists and 49 dental
hygienists on the staffs of State health departments, and approximately
$80,000 was budgeted for payments to local practicing dentists for
their services.

State health departments reported for the calendar year 1939, that
more than 1,480,000 dental inspections of children were made by
dentists or dental hygienists employed or supervised by the health
departments. Only one-twentieth of these inspections were of children
of preschool age. Service by dentists at prenatal clinics is increasing,
but information as to the extent of this type of service is not available
as yet.

The difficulties of treating children and the time consumed in rela-
tion to the financial reward have tended to limit the number of dentists
who have given special attention to the care of children's teeth. The
problem of what qualifications should be required of dental hygien-
ists and what should be the sphere of their services requires the most
careful consideration.

Recently several of the State health agencies have initiated post-
graduate-education programs in children's dentistry for practicing
dentists, and it is likely that many States will expand graduate educa-
tion in this field.

For the year ended June 30, 1939, 18 State health agencies reported
lecture courses for practicing dentists under the maternal and child-
health program as follows:

Communities in which lecture courses for dentists were given 158

Lectures given 282

Number of dentists attending 4, 945

The nutritionist.

Before the social-security program for maternal and child-health
services was started in 1936, only 2 State health agencies employed
nutritionists in their maternal and child-health divisions. In one
additional State a nutritionist was in charge of a bureau of public-
health education and nutrition. By June 30, 1939, 22 State health
agencies and the District of Columbia were employing nutritionists,
and the plans for 28 States, the District of Columbia, Hawaii, and
Puerto Rico for the fiscal year 1940 provided for 62 nutritionists.
Other State health agencies have improved their nutrition services to
mothers and children through enlisting the cooperation of other State
agencies, notably the home-demonstration divisions of the agricultural
extension service.

To meet the increased demand for nutritionists trained for public-
health work, six colleges and universities have expressed willingness to
offer supplementary courses to nutritionists in the employ of State

Development of Program, 1936-39 73

and local health departments. Up to June 30, 1939, six State agen-
cies had taken advantage of this offer.

A committee of State health officers on the basis of an inquiry made
in January 1939 reported that five times as many nutritionists were
needed in the public-health program as were then employed.

Qualifications for such nutritionists recommended by the State
health officers are based on standards set by the American Home
Economics Association and the American Dietetic Association.

The health educator.

Twenty State health agencies in their maternal and child-health
plans for the fiscal year 1939 provided for 34 employees in the health-
education field. Of the total of 20 States, 3 States provided personnel
for both public-health education and school health education, 8
States provided personnel for school health education only, 6 for
public-health education only, and 3 for health education without
specifying the type of program.

That the health-education aspects of the public-health program
benefit greatly by the presence on the staff of specially trained per-
sonnel is a fact being recognized increasingly by the State health
agencies.

Studies and Investigations

Medical research and study of administrative procedures are im-
portant to continuing improvement in the program for maternal and
child-health services.

The Division of Research in Child Development of the Children's
Bureau currently makes studies of the growth and development of
children that are intended, on the one hand, to provide basic research
data for the development of methods of medical diagnosis and treat-
ment of conditions affecting children and, on the other hand, to serve
with other medical research as the basic information for Children's
Bureau publications for physicians and for parents on the care of
children. An important part of the Children's Bureau research has
been centered on stillbirths, maternal care and maternal mortality,
premature infants, neonatal mortality and morbidity, and indices
of physical fitness of children.

As one phase of its series of studies on infant and maternal mortality
the Children's Bureau in 1936 undertook a study of stillbirths in
cooperation with the subcommittee on stillbirths of the American
Public Health Association. The study was based on 6,750 stillbirths
occurring in 223 hospitals located in 49 cities in 26 States.

The findings of the study suggest that there is a special risk both for
the first child and for later-born children of mothers of relatively late
childbearing ages and that such mothers are aware of this risk and are

74 Maternal and Child-Health Services

seeking hospital care in considerable proportions. The findings
demonstrate that adequate care during pregnancy is the most funda-
mental approach to the stillbirth problem, but improvement in
delivery technique is also important. Fifty-seven percent of the
white and 68 percent of the Negro fetuses died during the prenatal
period. The prenatal care received by the great majority of the
mothers of these still born infants was inadequate.23

The data of the study have been used in formulating a classification
of the causes of stillbirth that has been proposed for national adoption
(see p. 35). Interest aroused among physicians and health officers
has resulted in the effort to obtain more accurate knowledge as to the
causes of stillbirth and methods of prevention. Studies in which the
Children's Bureau stillbirth schedule is used have been undertaken in
several cities. Medical committees are determining the causes of
individual stillbirths and are fixing responsibility, a method similar to
that used in maternal-mortality studies.

The Children's Bureau frequently cooperates with medical groups
or hospitals on research projects. A study of maternal mortality in
the District of Columbia, a study of birth weights of 2,000 newborn
infants in Union Memorial Hospital in Baltimore, and studies of
premature infants at Johns Hopkins Hospital, Baltimore, and New
York Hospital, New York City, were under way in 1939, or the
reports were in preparation.

At the request of the Bureau of Health of the Maine State Depart-
ment of Health and Welfare the Children's Bureau in 1938-39 made
a study in northern Maine of the diets and the vitamin-C content of
the blood of a group of school children.

A study of the effect of rickets on the pelves of adolescent children
was started in 1938. The children included in the study are those who
were studied in early infancy in connection with the New Haven
rickets-control demonstration study made by the Children's Bureau
in 1923-25.

The report of a study of the physical fitness of 713 school children
made for the purpose of comparing methods of assessing the nutritional
status of children has recently been published by the Children's
Bureau. This is based on anthropometric, clinical, and socioeconomic

23 Analysis of the findings of the study may be found in the following prelimi-
nary reports: The Causes of Stillbirths (based on the first 2,000 stillbirths stud-
ied; Southern Medical Journal, Vol. 30, No. 6, June 1937); Problem of the
Causes of Stillbirths (based on 6,750 cases; American Journal of Public Health,
Vol. 28, No. 4, April 1938); The Problem of Stillbirths (276 cases in the District
of Columbia Medical Annals of the District of Columbia, Vol. 7, No. 8, August
1938).

Development of Program, 1936-39 75

observations made of 713 7-year-old white boys and girls in New
Haven, Conn.24

The Social Security Act authorizes the Children's Bureau to make
studies and investigations to promote the efficient administration of
the maternal and child-health program and the other two programs
that are administered by the Children's Bureau under the provisions
of the act. Limitation of funds as yet has prevented the Bureau
from undertaking such studies, except to a minor extent. Four
studies directed at special problems in State maternal and child-health
programs were made by the Maternal and Child Health Division
during the fiscal year 1938. These were:

Maternity care in New York State. — In cooperation with
the New York State Departments of Health and Social Welfare,
the Children's Bureau made a study of maternity care in six counties
in New York State, to determine the number of women receiving
prenatal, delivery, and postpartum care at public expense and the
cost of such care. 25

Obstetric education. — A survey, by questionnaire, was made
of clinical obstetric education of physicians in undergraduate and
graduate years, based on the obstetric education of 2,538 medi-
cal-school graduates of the year 1936.

Hospital maternity -care survey. — A survey, by questionnaire,
was made of hospital maternity care in towns or cities of less than
50,000 population, based on replies from 1,449 of the 2,816 hospitals
addressed.

Resources and facilities for maternal care and care of new-
born infants. — This summary was based on questionnaires sent to
each State and Territorial health officer. Forty-one State health
officers, including those of the District of Columbia, Alaska, and
Hawaii, were of the opinion that facilities and resources for maternal
care did not meet the needs of their regions. Replies from the other
State health officers indicate that their needs also were not fully
met. In 17 States the number of general practitioners including
obstetrics in their practice was reported to be insufficient. In 40
States the number of specialists in obstetrics was reported to be in-
sufficient. In only 1 State was nursing service on a State-wide basis
provided for bedside care for mothers at time of delivery for families
who were unable to provide such care themselves. Fifteen of the
eighteen States in which more than 5 percent of the live births were
attended by midwives reported that training for midwives was

24 Methods of Assessing the Physical Fitness of Children. Children's Bureau
Publication No. 263, Washington, 1940.

25 Maternity Care at Public Expense in Six Counties in New York State.
Children's Bureau Publication No. 267, Washington, 1941.

328199°— 42 6

76 Maternal and Child-Health Services

unsatisfactory. Fourteen States reported that no funds were avail-
able for medical or nursing care in the home. To the question of
whether the geographic distribution of hospitals having obstetric
service was satisfactory, 33 State health officers replied that such
distribution was not satisfactory, and added such comments as the
following: "Twenty-seven out of ninety-nine counties do not have
an approved hospital," "Seventy-two out of one hundred and twenty
counties have no hospital," "Many persons in mountainous districts
are 100 to 200 miles from any hospital facilities," and "No hospital
obstetric service available to rural colored population of 14,000."
In 28 States the number of beds for obstetric cases was not considered
sufficient. Eleven States reported that in none of the hospitals in
rural areas and small cities were obstetric consultants available.
Twenty-nine States reported no funds available for free or part-pay
care in hospitals for maternity cases, other than the funds provided
by local county welfare or relief boards.

State maternal and child-health studies.

The State health agencies, in addition to their studies of maternal
and infant mortality, are undertaking studies of factors affecting the
health of mothers and children, of the effectiveness of procedures
and equipment used in promoting their health, and of diseases espe-
cially prevalent among mothers and children.

Special studies by the State divisions of maternal and child health
were reported in all the States but 6 during the year 1938-39. Studies
relating to the health of mothers made by the State health agencies
during 1938 were the following: In Maryland, study of diets of
50 pregnant women; in Massachusetts and Wisconsin, studies of
delivery by Cesarean section; in Flint, Mich., a study of maternal
deaths, hospital standards, and obstetric procedures; in Minnesota,
a study of the results of obstetric practice; in San Miguel County,
N. Mex., a study of maternity records; in Utah, a survey of economic
need in a two-county demonstration area preliminary to initiation of
a medical delivery service.

Several State health agencies directed their attention to the prob-
lems related to stillbirths and neonatal mortality, for example, the
following studies: In Kansas, a survey of incubators for premature
infants; in Maryland, a screened-crib survey; in Maine, a study of
hospital facilities for care of premature infants; in New York, studies
of the factors of age and order of birth in maternal mortality, and of
fetal and infant loss in up-State hospitals; an analysis of the births in
the Buffalo City Hospital; on familial susceptibility to stillbirths and
neonatal deaths; on the age of the father and survival of offspring; in
Tennessee, the incidence of premature birth and the frequency of

Development of Program, 1936-39 77

hospital births; in Wisconsin, the analysis of causes of infant deaths
by hospitals.

Another group of studies were directed toward the problems of
child health. For example, in Colorado, a survey of eye conditions in
4 counties ; in Georgia, a study of the calcium and phosphorus metabo-
lism of 18 families, and a study of vitamin- A deficiency in 400 children
examined annually; in Maryland, a study of tuberculosis patch test-
ing; in Maine, a study of vitamin-C nutrition, a study of hereditary
hypoplasia in conjunction with the National Institute of Health, and
a study of a week's dietary at each State institution; school-lunch
surveys in Massachusetts, Ohio, Oklahoma, and Maine; in Massa-
chusetts, a study of audiometer testing and tuberculosis surveys; in
Nevada, a survey of fluorine stain and its distribution throughout the
State among preschool and school children; in Ohio, a study of the
food habits of school children in 2 counties; in Oregon, the registra-
tion of handicapped children and a 2 -year study of the hearing of
children; in Tennessee, continuation of a school health study based on
the records of 58,921 children. In Wisconsin, a study of the deaths
of children under 12 years of age from appendicitis.

A group of studies relating to the adequacy of maternal and child-
health services included, among others: In Indiana, a survey of child-
health conferences and prenatal clinics, and a survey to determine
the number of dental reparative programs being financed by lay
groups; in Maine, reports on town dental-health-education projects;
in Massachusetts, school hygiene surveys and 11 dental surveys; in
Mississippi, the report on the Pike County maternity service; in
Montana, a study of dental care and dental-health education; in
New Hampshire, a study of the conduct of child-health conferences;
in New Jersey, a survey of resources for maternal and child-health
services in each county; in Ohio, a study of health education in the
public schools; in South Dakota, a survey of the distribution of cod-
liver oil; in Tennessee, an analysis of Gibson County delivery-nursing
service; in Texas, studies of immunization, of school health-education
facilities, and an analysis of nurses' activities in 1938; in Virginia, a
survey of maternal and child-health activities in each full-time county
health department; and in Washington, a diphtheria-immunization
survey.

State Initiative at Work

The following selections from narrative accounts of progress for
the year ended June 30, 1939, sent in by State maternal and child-
health directors, show the variety of activities that are carried on in
the States in extending and improving their maternal and child-health
services. Many other States are carrying on similar activities, more

78 Maternal and Child-Health Services

extensively developed, in some cases, than the activities here described.
Other accounts might have been selected to show additional examples
of ingenuity and persistence in seeking to make the maternal and
child-health programs of the greatest possible value to mothers and
children who could be reached with the funds available during the
first 4 years of the Federal-State program.

Alaska.

Up to June 30, 1939, public-health-nursing service had been estab-
lished in 12 local areas. In January 1939 the Office of Indian Affairs
made a contract with the Territorial Department of Health to provide
nursing service to the Indians in two towns, thus eliminating duplica-
tion of service. In the Cook Inlet area the nurse employed by the
Office of Indian Affairs serves the northern end of the area and Kenai
Peninsula, and the nurse employed by the health department serves
the southern end.

In the Matanuska Valley project, established in the fall of 1938, a
health center has been established where prenatal nursing conferences
and medical and nursing child-health conferences are held. Medical
and hospital care are provided for mothers and children. Prenatal
care is given by the physician in his office by appointment.

California.

To achieve continuous health education from birth throughout the
years to maturity, a committee made up of members of the staffs of
the State departments of health and of education was formed to
work out a health-education course of study for the elementary and
secondary schools of the State.

The 3 series of institutes for nurses (1938-39) were attended by
1,857 public-health and school nurses, private-duty nurses and
hospital-staff nurses, physicians, dentists, and educators. In addition
to 25 pediatricians who gave talks and participated in discussion, 11
persons trained in child guidance participated in the panel discussion.
The institutes are of great value in the school health program and
bring to the attention of the public the role of the public-health nurse
in community life.

Colorado.

To meet the problems of high maternal and infant mortality rates
among its Spanish-American population and in sparsely settled regions
with limited facilities for rural maternity-hospital service Colorado
established demonstration units in Otero and Las Animas Counties.
The activity of these units has contributed to the drop in the State
infant mortality rate from 73 in 1937 to 60 in 1938 and to 55 in 1939.

During the year ended June 30, 1939, eye clinics were held in 4 rural

Development of Program, 1936-39 79

sections as part of the maternal and child-health program. About
1,000 elementary-school children were examined and about one-third
of these were given refraction service without charge. It was planned
for the following year to encourage these eye clinics where the county
and State can share the expense equally.

Hawaii.

Thirty maternal-health centers and eighty-nine child-health centers
were in operation in the Territory of Hawaii on June 30, 1939. The
effort to bring all hospitals accepting maternity cases up to a minimum
standard each year has brought higher standards of service, especially
in rural hospitals. Hospitals are being graded in three classes, and
the hospitals in the lowest class are urged to discontinue service, as
their equipment and personnel do not enable them to give good service
to mothers. Other hospitals have plans for reconstruction that will
bring them up to a higher rating. Mass school health examinations
carried on in the rural areas have proved unsatisfactory. In Honolulu
it has been found practicable to have 95 percent of the children exam-
ined in a private physician's office, and the program called for extend-
ing this plan to rural areas. Effort is being concentrated on the
incoming first-grade children.

Kansas.

After a study had shown that 32 percent of the deaths of infants in
Kansas during 1934-37 were due to prematurity, a survey was made
of facilities for the care of premature infants in the State. Many
areas were found to be without such facilities. Eighteen electrically
operated and twenty-five hot-water incubators were purchased and
placed in the areas of greatest need, in the belief that better facilities
for care will result in a reduction in infant deaths due to this cause.

Maine.

Twice as many child-health conferences, providing for the examina-
tion of preschool children and infants of families in the low-income
group, were held in 1938-39 as in the preceding year. The services
of local practicing dentists, a new service, were available at 15 of the
conferences.

Nutrition studies and surveys during 1938-39 included a vitamin-
C study in Aroostook County, conducted by the State Bureau of
Health and the Children's Bureau of the United States Department
of Labor, with the assistance of the Maine Agricultural Experiment
Station, studies at Fort Kent and Newport, and related studies and
surveys of food served in high schools, academies, and State institu-
tions. A study of vitamin-deficiency diseases among children in

80 Maternal and Child-Health Services

relation to dental health was made, and educational projects in dental
health were conducted in the schools of a number of towns, which
served both as research studies and demonstrations of service.

Michigan.

In May 1939 a 5-week "refresher" course in pediatrics, with an
attendance of 306 physicians, was given in 5 centers in the Upper
Peninsula by pediatricians selected by the advisory committee of
the Michigan branch of the American Academy of Pediatrics. In
April 1938 the University of Michigan, in cooperation with the Bureau
of Maternal and Child Health of the State Department of Health,
began a series of 2 -week courses for intensive training in obstetrics
to which, at first, 2 physicians and later 4 physicians were admitted
for each course, with a total of 54 physicians attending during the
year 1938-39. A field consultant in obstetrics was appointed on
July 1, 1938, to give consultant service to rural practitioners where
no such service was already available. During the year 1938-39
the consultant visited 41 counties; gave 275 consultations in hospitals
doctors' offices, and patients' homes; and delivered 33 talks to local
medical groups. A pediatric consultant was appointed in August
1939 to cooperate with maternal-health committees of local medical
societies in developing studies of maternal deaths, hospital standards,
obstetric procedures, and other methods of improving obstetric care.

Missouri.

The increase in the number of county nursing services has done more
to stimulate interest in maternal and child health than any other
factor. Local advisory committees, home-hygiene classes, and the
distribution of literature are described by nurses as the most successful
means of disseminating information. Forty infant and preschool
centers were established during the year ended June 30, 1939, and are
making notable progress. With the steady increase in county
nursing services more such centers will be established.

Montana.

Counties throughout the State are realizing the importance of
continuity of public-health-nursing service and are giving increased
financial support to these programs; 23 of the 56 counties in the State
now have 12-month service. Well-child conferences held once a
month had been developed in 5 counties by June 1939, as compared
with 1 county prior to that year. Plans for conferences are under way
in 3 more counties.

Development of Program, 1936-39 81

Nevada.

Classes in home nursing, infant and child care, personal hygiene,
prenatal and postnatal care, communicable-disease control, and
first aid have been held by public-health nurses in all districts for
mothers and high-school girls. Prenatal cases are being found earlier
than in former years, and expectant mothers are urged to seek early
regular medical supervision. Well-baby conferences are a growing
success; during 1938-39, 72 such conferences were held.

New Hampshire.

A full-time well-qualified public-health nurse serves the Belknap
County demonstration area. Excellent health committees are active
in each town, with local physicians and nurses serving as ex officio
members. The great majority of expectant mothers are reached
fairly early in pregnancy and are cared for by private physicians.
Formerly the great majority of mothers were confined at home,
but now an increasing number are going to hospitals as a result of
the new evaluation of care needed and because more physicians are
refusing to attend home deliveries. All babies are visited soon after
birth and, if accepted for public-health-nursing service, they are
visited once a month during the first year. Preschool children are
visited at least four times a year. All children are immunized for
diphtheria after the age of 6 months.

New Jersey.

The maternal-welfare committee of the State medical society, in
cooperation with the Bureau of Maternal and Child Health, has
arranged a program of prenatal care for mothers who cannot pay for
such care from their own resources. All public-health nurses working
in the State have been informed that any such mother will be taken
care of by a designated physician in the county in which she lives.
These physicians are giving voluntary service. The mother is
referred to the designated physician by the field physician associated
with the Bureau of Maternal and Child Health.

Parent-child relationships were the subject of several courses for
public-health nurses held during 1938-39. Twenty-five discussion
groups were held by district supervisors. A New York University
extramural course of 15 lectures on "An Educational Program for the
Care of Mothers and Infants" was given to 37 nurses in central and
south New Jersey. The University of Newark gave a course of 13
lectures on "The Understanding, Care, and Guidance of Children"
to 29 nurses. A course of 6 lectures was given to the supervisory
nursing staff by the Child Study Association of America.

82 Maternal and Child-Health Services

New Mexico.

The school health consultant appointed in July 1938 accepted
during the first year invitations from 21 county and 6 town schools to
study problems of healthful living in school, home, and community
and to guide them in the solution of these problems. School adminis-
trators submitted 2,500 questions and problems in writing, and 1,000
high-school boys and girls expressed interest in some special phase of
healthful living, which formed the basis for planning service to
schools. Two publications were issued with the approval of the
State superintendent of education entitled "Indoor and Outdoor
Play Activities" and "Healthful Living Through the School Day and
in Home and Community." Progress has been made in analyzing
needs and in beginning to meet these needs through improvement of
school environment, better use of school facilities, safer playgrounds,
organized play with pupil leadership and teacher guidance, better
home-school relationships, and appreciation of healthful living as part
of all the activities of the school day and in the home and community.

Ohio.

Under the nutrition program many rural people have been taught
wiser purchase and planting of food articles. School lunchrooms
have been inspected, and suggestions for improvement have been
made. Summer camps have been studied and constructive criticism
given. Talks by the State nutritionist at teachers' institutes and
farm institutes have directed the teaching of nutrition into construc-
tive channels. Civic and other groups have had the benefit of
nutrition service. Experiments with rats have had a dramatic appeal
which has provoked the interest of large groups of school children,
teachers, and parents. Local health commissioners and physicians
have learned a great deal from the nutrition program. Assistance has
been given rural physicians in devising diets for diabetic, nephritic, or
anemic patients. Exhibits at institutes and fairs have been studied
by large numbers of rural people.

Rhode Island.

During the year 1938-39 the number of visits of mothers and babies
to well-child conferences increased, and more mothers attended the
conferences regularly. The whooping-cough immunization program
was continued satisfactorily. Diphtheria immunization also was
continued, and a large number of preschool children were protected
against the disease. There was only one death in the State from diph-
theria in 1939. The tuberculin skin-testing program in the high
schools was continued, and more parents and physicians became
interested in it. The public-health nurses expanded their educational

Development of Program, 1936 39 83

work by conducting home-hygiene courses, sponsored by the American
Red Cross, and by conducting an educational program among girls
employed on National Youth Administration projects, a group found
to be badly in need of education in health and personal hygiene.

Texas.

Progress has been made in coordinating the activities of the agencies
interested in public health. Coordinating committees have been
organized. The State medical association has assigned members of
the staff of the State Department of Health to all its outstanding
committees. The director of maternal and child health is a member
of the association's committee on maternal and child health. Effort
has been directed toward avoidance of competition among specialized
services within a community, a policy that has been accepted by the
State Department of Education, the State Tuberculosis Association,
and other groups. To avoid duplication the school and the local
tuberculosis associations have begun to participate financially in the
establishment of community-wide services. Counties which had some
type of full-time health service included approximately 50 percent of
the population of the State by June 30, 1939, as compared with 20
percent the year before. The service has been strengthened by uniting
the local nursing services with the full-time health units.

Vermont.

In spite of the hurricane which necessitated expending large sums
for reconstruction, the State legislature in 1939 appropriated $15,000
for the Maternal and Child Health Division of the State Department
of Public Health, an increase of $10,000 over previous years. Local
appropriations amounted to more than $8,000, a substantial increase
over the $6,000 of the previous year. The increased local appropria-
tions and the many requests for establishment of maternal and child-
health services in additional towns indicate the interest of the people
in the service.

Washington.

The Snohomish County maternal-health center, the central unit
of a proposed group of maternal-health centers for the county, was
opened in May 1939. Medical examinations are held every 2 weeks.
The examining physician is on a 9 -month rotating service. An
obstetrician has been employed as a consultant to the health center.

On January 1, 1939, a maternal-mortality survey was begun. Up
to June 30, 1939, 48 maternal-death certificates had been received
from the Division of Vital Statistics. Questionnaires had been sent
to the physicians who signed the certificates, and 40 had been filled
out and returned. The certificates are reviewed by the "committee

84 Maternal and Child-Health Services

of eight," the State maternal and child-health medical advisory com-
mittee. The survey will be continued indefinitely.

Wisconsin.

Visual-educational materials have been extensively used throughout
the State. The films "By Experience I Learn" (child development
from 9 to 18 months) and the photographic work on "Now I Am Two"
(the third of the child-development series) were completed. Books
placed on the shelves of the State traveling library reached many
rural mothers. The trailer classroom continued to carry the message
of "Safer Motherhood" to parents in remote areas.

Special Projects in Urban Areas

The Social Security Act as passed in 1935 called for the extension
and improvement of maternal and child-health services especially in
rural areas. Although this provision did not preclude the use of part
of the Federal maternal and child-health funds in urban areas, the
State health agencies found it necessary to use most of the funds in
rural areas because maternal and child-health services were limited
or lacking in the larger part of the rural areas of the United States.

In many counties having small or medium-sized cities the county
health service covers the urban as well as the rural section of the
county, and in such cases the maternal and child-health program
serves the mother and the child in the town as well as in the country.
The postgraduate-education program for physicians, nurses, and
dentists in most of the States is made available to members of these
professions in all parts of the State. Other State-wide phases of the
maternal and child-health program also benefit the cities as well as
the rural areas.

Under several State plans for maternal and child-health services
special projects in the larger cities have been provided to meet special
needs, for example:

Jefferson County, Ala.— In Alabama the Jefferson County demon-
stration, serving the city of Birmingham and the rest of the county,
includes public-health-nursing services and prenatal, postnatal, and
child-health clinics at 11 centers, with consultant obstetric and
pediatric services, conducted by physicians; and the Jefferson County
health department participates in a maternal and child-health service
for Negroes at the Slossfield health center in Birmingham.

Kansas City, Kans. — Beginning in 1937 the Kansas State Board
of Health provided funds for a demonstration maternal and infant -
health program in Kansas City, Kans., conducted in cooperation with
the health department of Kansas City and the University of Kansas
Medical School.

Development of Program, 1936-39 85

St. Louis, Mo. — From June 1936 to December 1938 a special
demonstration study of the Millcreek and downtown districts of St.
Louis was made in cooperation with the Missouri State Board of
Health, to discover the factors contributing to the excessively high
maternal and infant mortality and to reduce the mortality.

Memphis and Nashville, Tenn. — In Memphis, Tenn.,the State
Department of Public Health provides part of the funds for maternal
and child-health activities of the city health department because of
the high maternal and infant mortality rates. The State Department
of Public Health also provides part of the funds for a demonstration
of adequate school health service in the city of Nashville.

District of Columbia. — The District of Columbia, which was
included with the States as eligible for grants for maternal and child-
health services under the Social Security Act, is an urban area with a
population of approximately 660,000 within an area of 62 square
miles. It is, therefore, the outstanding example of the development
of maternal and child-health services in an urban area, financed with
the aid of Federal funds.

The number of expectant mothers receiving prenatal care at health-
department clinics in 1938 (3,868) was 60 percent of the number of
patients registered for prenatal care in all clinics of the city ; in hospital
clinics 2,610 expectant mothers registered for prenatal care. The
fact that the number of expectant mothers registered at prenatal
clinics (6,478) is equivalent to nearly 50 percent of the 13,401 births
(including stillbirths) occurring in 1938 is concrete evidence of the
proportion of families in the District of Columbia who are in need of
assistance for health and medical services attendant on childbearing.

In health supervision of the infant and preschool child the Health
Department provides an even greater percentage of the services
rendered in the city, as there is only one other child-hygiene service —
that offered by the Child Welfare Society at Children's Hospital. The
number of infants registered for health supervision at all clinics in
1938 was equivalent to 59 percent of the 12,950 live births in the city.
The infant and preschool children registered for health supervision
come from three economic groups in the community: (1) Those totally
dependent upon public services for both preventive service and medical
care (this group is comparable to the group of expectant mothers
receiving prenatal care at Health Department clinics); (2) those
dependent on public services for preventive care and partly dependent
for medical care (comparable to expectant mothers registered in
hospital clinics for prenatal care); and (3) those who have private
general family medical care for ordinary illnesses, but not regular
preventive health service. Experience has shown that as the economic
status of a family improves, the appreciation of the value of health

86 Maternal and Child-Health Services

supervision gained through clinic services results in the family's
having private preventive care to the extent of its resources.

With the birth certificate a leaflet is sent to the parents of each
newborn child, giving the addresses of the health-department clinics
and the Children's Hospital clinic, where health supervision and
instruction in the care of babies are available to those unable to pay
for private preventive care. The 1938 response to this information
service is indicated by the fact that 70 percent of the new babies
registered for preventive services at the clinics were registered before
the third month of life.

Marked increases were reported in the immunization of babies
against diphtheria in the first year of life, in the number of protective
vaccinations of children in advance of the compulsory vaccination
for school entrance, and in tuberculin testing at the child-health
clinics.

The increase in 1938, as compared with 1937, of 63 percent in the
number of preschool children given service at the Health Department
child-hygiene clinics reflects progress in bringing preschool children
under supervision. More significant is the evidence of improvement
in the continuity of health supervision for young children; 54 percent
of the preschool children registered in 1938 had been registered at the
child-health centers during a previous year, whereas in 1937 this was
true of only 48 percent.

The marked increase in the number of home visits during the
prenatal and postnatal periods made by Health Department public-
health nurses to maternity patients registered at the Health Depart-
ment clinics represents noteworthy progress. Some increase in
nurses' home visits to infants and preschool children occurred in 1938,
but, because the staff was limited, far too few of the children registered
at the clinics received home-nursing visits.

Other developments included (1) a plan for the assignment of
maternity patients for home or hospital delivery service which would
use to best advantage the hospital facilities, the medical -school home-
delivery service, visiting-nurse service, so far as it is available, and
W. P. A. housekeeping-aide service; (2) coordination and integration
of preventive services and services for the care of sick children, to
obtain medical care and hospitalization for them and to direct children
who have been sick to health-supervision services; (3) nutrition serv-
ice, including individual teaching conferences at maternal and child-
health centers, consultation service on nutrition to medical, nursing,
and social-service staffs, the provision of surplus-food orders to families
certified by nurses, and a special case study of diets consumed in
relation to income and expenditures of patients attending maternal
and child-health centers, as a basis for educational activities; (4) the
introduction of medical-social service for both maternal and child-

Development of Program, 1936-39 87

health and crippled children's programs; (5) a case study of every
maternal death in cooperation with the medical society of the District
of Columbia and the United States Children's Bureau; (6) formula-
tion of minimum standards of care and rules and regulations for
obstetric wards and nurseries for newborn infants; (7) assistance to
child-placing agencies in connection with social aspects of issuance
of permits for boarding homes, institutions for children, and day
nurseries; and (8) detailed analysis of statistics of mortality and
clinic attendance to evaluate adequacy of services in relation to needs,
and analysis of special problems of various sections of the city as a
basis for better planning to meet concrete needs.

The Status of the Program at the Close of 1939

Reports sent in by the State health agencies each year show signifi-
cant progress in extending and improving maternal and child-health
services, especially in rural areas. The stronger consultation service
from the staff of the State health agencies, the increasing numbers of
counties and communities with full-time public-health service, the
growing number of public-health nurses giving family nursing service,
the increasing numbers of prenatal and child-health centers where the
health of mothers and children is supervised by physicians and den-
tists, the advances made in the early immunization of children against
diphtheria and smallpox, the substitution of health supervision of
school children for the hurried physical examination, the tremendous
advances in health-education programs for all members of the family—
these gains have been pronounced during the past 4 years. The
eager acceptance by the medical, dental, and nursing professions of
the opportunities offered for postgraduate education affords a promise
of continuing improvement in maternal and child-health services.
The recent reductions in maternal, neonatal, and infant mortality
bear striking witness to the improved care that is being given to
mothers and children.

However, the operation of a Nation-wide program brings to light
not only the advances made but also the areas and the individuals
that are not reached by the program offered. The evidence presented
in the foregoing pages of the extent to which maternal and child-
health services are available emphasizes the gains made recently, but
it also makes abundantly clear the necessity for greatly expanding
the program, if maternal and child-health services are to reach mothers
and children in every community in every State. Better health
organization in more local areas, more public-health nurses, more
prenatal clinics, more child-health conferences, more and better super-
vision of the health of the school child, more health education are
immediate objectives to be sought in every State. The accomplish-

88 Maternal and Child-Health Services

ment of these ends requires the continuance of the training program
for the personnel in State and local health departments in order to
provide the leadership that an advancing maternal and child-health
program needs.

The active participation of the members of the medical, dental, and
nursing professions in the development of the maternal and child-
health program shows their recognition of the opportunity for and the
significance of preventive service in promoting family health and the
health of the community. Further assistance from these professional
groups will be needed as the program spreads into new communities
and reaches more mothers and children in each community where it
is established.

Even with the additional funds made available under the Social
Security Act Amendments of 1939, the maternal and child-health
program still faces the inability of many families and communities to
provide treatment facilities and service for the mother when the baby
is born and for the child when he is ill.

The 4 years, 1936 to 1939, have forged an alliance among the parents,
the medical and allied professions, and the public-health agencies
of the United States that promises to raise to a new level the family
health experience in this country.

Appendix 1. — Text of the Sections of the Social
Security Act Relating to Grants to States for
Maternal and Child-Health Services, as Amended
by the Social Security Act Amendments of 1939 '

[Original law printed in roman; new law printed in italics.]

Title V.— GRANTS TO STATES FOR MATERNAL AND CHILD

WELFARE

Part 1.— MATERNAL AND CHILD-HEALTH SERVICES

APPROPRIATION

Section 501. For the purpose of enabling each State to extend and improve,
as far as practicable under the conditions in such State, services for promoting
the health of mothers and children, especially in rural areas and in areas suffer-
ing from severe economic distress, there is hereby authorized to be appropriated
for each fiscal year, beginning with the fiscal year ending June 30, 1936, the sum
of $5,820,000.2 The sums made available under this section shall be used for
making payments to States which have submitted, and had approved by the
Chief of the Children's Bureau, State plans for such services.

ALLOTMENTS TO STATES

Sec. 502. (a) Out of the sums appropriated pursuant to section 501 for each
fiscal year the Secretary of Labor shall allot to each State $20,000, and such part
of $2,800,000 3 as he finds that the number of live births in such State bore to the
total number of live births in the United States, in the latest calendar year for
which the Bureau of the Census has available statistics.

(b) Out of the sums appropriated pursuant to section 501 for each fiscal year
the Secretary of Labor shall allot to the States $1,980,000 4 (in addition to the
allotments made under subsection (a)) according to the financial need of each
State for assistance in carrying out its State plan, as determined by him after
taking into consideration the number of live births in such State.

(c) The amount of any allotment to a State under subsection (a) for any fiscal
year remaining unpaid to such State at the end of such fiscal year shall be avail-
able for payment to such State under section 504 until the end of the second
succeeding fiscal year. No payment to a State under section 504 shall be made
out of its allotment for any fiscal year until its allotment for the preceding fiscal
year has been exhausted or has ceased to be available.

' 49 Stat. 629; 53 Stat. 1360.
3 $3,800,000 in the law as enacted in 1935.
3 $1,800,000 in the law as enacted in 1935.
* $980,000 in the law as enacted in 1935.

90 Maternal and Child-Health Services

APPROVAL OF STATE PLANS

Sec. 503. (a) A State plan for maternal and child-health services must (1)
provide for financial participation by the State; (2) provide for the administration
of the plan by the State health agency or the supervision of the administration
of the plan by the State health agency; (3) provide such methods of administra-
tion (including after January 1, 1940, methods relating to the establish-
ment and maintenance of personnel standards on a merit basis, except
that the Board 5 shall exercise no authority with respect to the selection,
tenure of office, and compensation of any individual employed in accord-
ance with such methods)6 as are necessary for the proper and 7 efficient
operation of the plan; (4) provide that the State health agency will make such
reports, in such form and containing such information, as the Secretary of Labor
may from time to time require, and comply with such provisions as he may from
time to time find necessary to assure the correctness and verification of such
reports; (5) provide for the extension and improvement of local maternal and
child-health services administered by local child-health units; (6) provide for
cooperation with medical, nursing, and welfare groups and organizations; and (7)
provide for the development of demonstration services in needy areas and among
groups in special need.

(fo) The Chief of the Children's Bureau shall approve any plan which fulfills
the conditions specified in subsection (a) and shall thereupon notify the Secretary
of Labor and the State health agency of his approval.

PAYMENT TO STATES

Sec. 504. (a) From the sums appropriated therefor and the allotments available
under section 502 (a), the Secretary of the Treasury shall pay to each State which
has an approved plan for maternal and child-health services, for each quarter,
beginning with the quarter commencing July 1, 1935, an amount, which shall be
used exclusively for carrying out the State plan, equal to one-half of the total
sum expended during such quarter for carrying out such plan.

(b) The method of computing and paying such amounts shall be as follows:
(2) The Secretary of Labor shall, prior to the beginning of each quarter,
estimate the amount to be paid to the State for such quarter under the
provisions of subsection (a), such estimate to be based on (A) a report filed
by the State containing its estimate of the total sum to be expended in such
quarter in accordance with the provisions of such subsection and stating the
amount appropriated or made available by the State and its political sub-
divisions for such expenditures in such quarter, and if such amount is less
than one-half of the total sum of such estimated expenditures, the source or
sources from which the difference is expected to be derived, and (B) such
investigation as he may find necessary.

(2) The Secretary of Labor shall then certify the amount so estimated by
him to the Secretary of the Treasury, reduced or increased, as the case may
be, by any sum by which the Secretary of Labor finds that his estimate for
any prior quarter was greater or less than the amount which should have
been paid to the State for such quarter, except to the extent that such sum

5 This reference to "the Board" appears to have been made inadvertently as uniform amendments
to several titles of the act were being considered by the Conference Committee of the two Houses of
Congress. It should be construed as if it read, "the Chiefof the Children's Bureau."

6 "Other than those relating to selection, tenure of office, and compensation of personnel" in the
law as enacted in 1935.

7 Added by the amendments of 1939.

Development cf Program, 1936-39 91

has been applied to make the amount certified for any prior quarter greater
or less than the amount estimated by the Secretary of Labor for such prior
quarter.

(3) The Secretary of the Treasury shall thereupon, through the Division
of Disbursement of the Treasury Department and prior to audit or settlement
by the General Accounting Office, pay to the State, at the time or times fixed
by the Secretary of Labor, the amount so certified,
(c) The Secretary of Labor shall from time to time certify to the Secretary of
the Treasury the amounts to be paid to the States from the allotments available
under section 502 (&), and the Secretary of the Treasury shall, through the Divi-
sion of Disbursement of the Treasury Department and prior to audit or settlement
by the General Accounting Office, make payments of such amounts from such
allotments at the time or times specified by the Secretary of Labor.

OPERATION OF STATE PLANS

Sec. 505. In the case of any State plan for maternal and child-health services
which has been approved by the Chief of the Children's Bureau, if the Secretary
of Labor, after reasonable notice and opportunity for hearing to the State agency
administering or supervising the administration of such plan, finds that in the
administration of the plan there is a failure to comply substantially with any
provision required by section 503 to be included in the plan, he shall notify such
State agency that further payments will not be made to the State until he is
satisfied that there is no longer any such failure to comply. Until he is so satisfied
he shall make no further certification to the Secretary of the Treasury with respect

to such State.

* * * * * * *

Part 5.— ADMINISTRATION

Sec. 541. (a) There is hereby authorized to be appropriated for the fiscal year
ending June 30, 1936, the sum of $425,000," for all necessary expenses of the Chil-
dren's Bureau in administering the provisions of this title, except section 531. •

(fo) The Children's Bureau shall make such studies and investigations as will
promote the efficient administration of this title, except section 531.

(c) The Secretary of Labor shall include in his annual report to Congress a full
account of the administration of this title, except section 531.

V •T- J(S JJS 9fC 3|f S|C

Title XL— GENERAL PROVISIONS

DEFINITIONS

Section 1101. (a) When used in this act —

(1) The term "State" (except when used in sec. 531) includes Alaska, Hawaii,
and the District of Columbia, and when used in titles V and VI of such act
(including sec. 531) includes Puerto Rico.10

(2) The term "United States" when used in a geographical sense means the
States, Alaska, Hawaii, and the District of Columbia.

*******

(d) Nothing in this act shall be construed as authorizing any Federal official,
agent, or representative, in carrying out any of the provisions of this act, to take
charge of any child over the objection of either of the parents of such child, or of
the person standing in loco parentis to such child.

• The amount for each fiscal year is determined by Federal appropriation acts.
' Sec. 531 deals with vocational rehabilitation.

10 Added by the amendments of 1939. The amendment (shown in italics) became effective
January 1, 1940.

328199 42 -7

92 Maternal and Child-Health Services

RULES AND REGULATIONS

Sec. 1102. The Secretary of the Treasury, the Secretary of Labor, and the Social
Security Board, respectively, shall make and publish such rules and regulations,
not inconsistent with this act, as may be necessary to the efficient administration
of the functions with which each is charged under this act.

SEPARABILITY

Sec. 1103. If any provision of this act, or the application thereof to any person
or circumstance, is held invalid, the remainder of the act, and the application of
such provision to other persons or circumstances shall not be affected thereby.

RESERVATION OF POWER

Sec. 1104. The right to alter, amend, or repeal any provision of this act is hereby
reserved to the Congress.

SHORT TITLE

Sec. 1105. This act may be cited as the " Social Security Act."

Appendix 2. Tables Summarizing State Progress in
Maternal and Child-Health Services Administered
or Supervised by State Health Agencies for the
Fiscal Year Ended June 30, 1939

APPENDIX TABLE I. — Maternity and child-health-conference centers
supervised by State health agencies, by States, year ended June 30, 1939

Maternity centers
(prenatal and post-
partum)

Child-health-confer-
ence centers (infant
and preschool)

State

Total,

June 30,

1939

Number
established

during

year ended

June

30, 1939

Total,

June 30,

1939

Number
established

during

year ended

June

30, 1939

United States

1.229

347

2,394

522

Alabama _ __ _

55
1

27
7
6
7

1
5
4

1
4

2
37

6
299

7
58
20
14
30
204
89

Colorado __- _ _ _-

Delaware __ _

1
8

43
181

30
4

Florida

Hawaii. _ - _-

Idaho- . -_ _

Indiana.

4
225

1
2

Kentucky ._ .

12
5

17
122

234 76

41 40

Montana _ .

171

New Hampshire

Ohio

Oklahoma

4
5

61
16
180
20
65
3
73
36
66
11
26

Oregon

Pennsylvania

Rhode Island

South Carolina

117

1
1
7

South Dakota

Tennessee

Utah ._

6
2

Virginia

West Virginia

Wyoming

Maternal and Child-Health Services

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Arizona ..

Arkansas . . .

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Delaware _

District of Columbia

Florida .. ... ... _

Georgia . . _.

Hawaii . . . . ._ _

Idaho .. _

Illinois .._... ._____.
Indiana _______ - _....

Iowa . _ _

Kansas . .

Kentucky .

Louisiana

Maine . .-

Maryland __ _

Massachusetts

Michigan

Minnesota .

Mississippi

Missouri

Montana

Development of Program, 1936-39

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Appendix 3. — State Health Agencies Administering
Maternal and Child-Health Services Under Title V,
Part 1, of the Social Security Act, December 1939

ALABAMA State Department of Public Health, James N. Baker, M. D..

State Health Officer.
Bureau of Hygiene and Nursing, B. F. Austin, M. D., Director.

ALASKA Territorial Department of Health, W. W. Council, M. D..

Commissioner.
Division for Maternal and Child Health and Crippled Children,
Marcia Hays, M. D., Director.

ARIZONA State Board of Health. Coit I.Hughes, M. D., Superintendent.

Division of Maternal and Child Health, Jack B. Eason, M. D.,
Director.

ARKANSAS State Board of Health, W. B. Grayson, M. D., State Health

Officer.
Maternal and Child-Health Division, VV. Myers Smith, M. D.,
Director.

CALIFORNIA State Department of Public Health, W. W. Dickie, M. D.

Director.
Bureau of Child Hygiene, Ellen S. Stadtmuller, M. D., Chief.

COLORADO State Division of Public Health, R. L. Cleere, M. D., Secretary

and Executive Officer.
Division of Maternal and Child Health, Burris Perrin, M. D.,
Director.
CONNECTICUT State Department of Health, Stanley H. Osborn, M. D., Com-
missioner of Health.
Bureau of Child Hygiene, Martha L. Clifford, M. D., Director.

DELAWARE State Board of Health, E. F. Smith, M. D., Acting Executive

Secretary.
Division of Maternal and Child Health, Floyd I. Hudson, M. D.
Director.
DISTRICT OF COLUMBIA Health Department of the District of Columbia. George C.

Ruhland, M. D., Health Officer.
Bureau of Maternal and Child Welfare, Ella Oppenheimer.
M. D., Director.

FLORIDA State Board of Health, A. B. McCreary, M. D., State Health

Officer.
Bureau of Maternal and Child Health, W. H. Ball, M. D., Director.

GEORGIA State Department of Public Health. T. F. Abercrombie,

M. D., Director.
Division of Child Hygiene, Joe P. Bowdoin, M. D., Chief.

HAWAII Territorial Board of Health, Richard K. C. Lee, M. D.,

Acting Territorial Commissioner of Public Health.
Bureau of Maternal and Infant Hygiene. Charles Wilbar, M. D..
Director.
IDAHO State Department of Public Welfare. Emory Afton, Com-

missioner.
Division of Public Health, H. L. McMartin, M. D., Director.
Bureau of Maternal and Child Health and Crippled Children.
G. H. Bischoff, M. D., Director.

ILLINOIS State Department of Public Health, A. C. Baxter, M. D..

Director.
Division of Child Hygiene and Public Health Nursing, Grace S.
Wightman, M. D., Chief.
INDIANA State Board of Health, Verne K. Harvey, M. D., Director.

Bureau of Maternal and Child Health. Howard B. Mettel, M. D.,
Director.
104

Development of Program, 1936 39 105

IOWA State Department of Health, Walter L. Bierring, M. D.,

Commissioner of Health.
Division of Maternal and Child Health, J. M. Hayek, M. D.,
Director.

KANSAS State Board of Health, F. P. Helm, M. D., Secretary and

Executive Officer.
Division of Child Hygiene, H. R. Ross, M. D., Director.

KENTUCKY State Department of Health, A. T. McCormack, M. D., State

Health Commissioner.
Bureau of Maternal and Child Health, C. B. Crittenden, M. D.(
Director.

LOUISIANA State Board of Health, J. A. O'Hara, M. D., President.

Division of Maternal and Child Health, Virginia Webb, M. D.,
Acting Director.
MAINE State Department of Health and Welfare, George W. Lead-
better, Commissioner.
Bureau of Health, Roscoe L. Mitchell, M. D.. Director.
Division of Maternal and Child Health, Robert E. Jewett, M. D.,
Acting Director.

MARYLAND Stare Department of Health, R. H. Riley, M. D., Director.

Bureau of Child Hygiene, J. H. Mason Knox, M. D., Chief.

MASSACHUSETTS State Department of Public Health. Paul J. Jakmauh. M. D.,

Commissioner of Public Health.
Division of Child Hygiene, M. Luise Diez, M. D., Director.
MICHIGAN State Department of Health, H. Allen Moyer, M. D., Com-
missioner of Health.
Bureau of Child Hygiene and Public Health Nursing, Lillian R.
Smith, M. D., Director.

MINNESOTA State Department of Health, A. J. Chesley, M. D., Secretary

and Executive Officer.
Division of Child Hygiene, Viktor O. Wilson, M. D., Director.
MISSISSIPPI State Board of Health. Felix J. Underwood. M. D.. Executive

Officer.
Maternal and Child Health Division, J. A. Milne, M. D., Acting
Director.

MISSOURI Stare Board of Health, H. F. Parker, M. D.t State Health

Commissioner.
Division of Child Hygiene, James Chapman, M. D., Director of
Child Hygiene.

MONTANA State Board of Health. W. F. Cogswell, M. D., Secretary.

Maternal and Child Health Division, Edythe P. Hershey, M. D.
Director.

NEBRASKA State Department of Health. P. H. Bartholomew, M. D.,

Acting Director of Health.
Division of Maternal and Child Health. Roland H. Loder. M. D.,
Director.
NEVADA State Department of Health, Edward E. Hamer. M. D.. State

Health Officer.
Maternal and Child Health Division, H. Earl Belnap. M. D.,
Director.

NEW HAMPSHIRE State Board of Health, Travis P. Burroughs, M. D., Secretary.

Division of Maternal and Child Health and Crippled Children's
Services, Mary M. Atchison, M. D., Director.

NEW JERSEY State Department of Health. J. Lynn Mahaffey. M. D.,

Director of Health.
Bureau of Child Hygiene, Julius M. Levy, M. D.. Consultant.
NEW MEXICO State Department of Public Health. E. B. Godfrey, M. D.,

Director.
Division of Maternal and Child Health. Hester Curtis. M. D.,
Director.
NEW YORK State Department of Health. Edward S. Godfrey. M. D.,

State Commissioner of Health.
Division of Maternity. Infancy, and Child Hygiene. Elizabeth
M. Gardiner, M. D., Director.

NORTH CAROLINA State Board of Health. Carl V. Reynolds. M. D.. State Health

Officer.
Maternal and Child Health Services. G. M. Cooper, M. D.,
Director.

106 Maternal and Child-Health Services

NORTH DAKOTA State Department of Public Health, Maysil M. Williams,

M. D., State Health Officer.
Maternal and Child Health Division, (Director to be appointed).

OHIO State Department of Health, R. H. Markwith, M. D., Director

of Health.
Bureau of Child Hygiene. A. W. Thomas, M. D., Chief.

OKLAHOMA State Department of Public Health, Grady F. Mathews,

M. D., State Health Commissioner.
Division of Maternal and Child Health, Paul J. Collopy, M. D.,
Director.

OREGON Stare Board of Health, Frederick D. Strieker, M. D., State

Health Officer.
Division of Maternal and Child Health, G. D. Carlyle Thompson,
M. D., Director.

PENNSYLVANIA State Department of Health, John J. Shaw, M. D.. Secretary

of Health.
Bureau of Maternal and Child Health, Paul Dodds, M. D.,
Director.

RHODE ISLAND State Department of Health, Lester A. Round, Ph. D.,

Director.
Bureau of Child Hygiene, Francis V. Corrigan, M. D., Chief.

SOUTH CAROLINA State Board of Health, James A. Hayne, M. D., State Health

Officer.
Division of Maternal and Child Health, R. W. Ball, M. D..
Director.

SOUTH DAKOTA State Board of Health, J. F. D. Cook, M. D., Superintendent

of Health.
Division of Maternal and Child Health, Viola Russell, M. D.,
Director.

TENNESSEE State Department of Public Health, W. C. Williams, M. D.,

Commissioner of Public Health.
Division of Maternal and Child Health, John M. Saunders, M. D.,
Director.

TEXAS Stare Department of Health, George W. Cox, M. D., State

Health Officer.
Division of Maternal and Child Health, J. M. Coleman, M. D.,
Director.

UTAH State Board of Health. William M. McKay, M. D., Acting

State Health Commissioner.
Bureau of Maternal and Child Health, Lela J. Beebe, M. D.,
Director.

VERMONT State Department of Public Health, Charles F. Dalton, M. D.,

Secretary and Executive Officer.
Maternal and Child Health Division, Paul D. Clark, M. D.,
Director.

VIRGINIA State Department of Health. I. C. Riggin, M. D., State Health

Commissioner.
Bureau of Maternal and Child Health. B. B. Bagby. M. D..
Director.

WASHINGTON State Department of Health, Donald Evans, M. D., Director

of Health.
Division of Maternal and Child Hygiene, Percy F. Guy, M. D..
Chief.

WEST VIRGINIA State Department of Health, Arthur E. McClue, M. D.. State

Health Commissioner.
Division of Child Hygiene, Thomas W. Nale, M. D., Director.

WISCONSIN State Board of Health, C. A. Harper, M. D., State Health

Officer.
Bureau of Maternal and Child Health, Amy Louise Hunter.
M. D., Chief.

WYOMING State Board of Health. M. C. Keith, M. D., State Health

Officer.
Division of Maternal and Child Health, Margaret H. Jones,
M. D., Director.

Appendix 4. — Advisory Committee on Maternal and
Child Health Services, and Special Advisory Com-
mittees on Public Health Nursing and on Dental
Health, 1939

ADVISORY COMMITTEE ON MATERNAL AND CHILD-
HEALTH SERVICES '

Chairman, Fred L. Adair, M. D., Professor of Obstetrics and Gynecology,
University of Chicago School of Medicine, Chicago, 111.; Chairman, American
Committee on Maternal Welfare.

S. Josephine Baker, M. D., Princeton, N. J.

Horton Casparis, M. D., Professor of Pediatrics, Vanderbilt University School of
Medicine, Nashville, Tenn.

Hazel Corbin, R. N., General Director, Maternity Center Association, New York,
N. Y.

M. Edward Davis, M. D., Associate Professor of Obstetrics and Gynecology,
University of Chicago School of Medicine, Chicago, 111.

Robert L. DeNormandie, M. D., Boston, Mass.

Amelia H. Grant, R. N., Director, Bureau of Nursing, City of New York De-
partment of Health, New York, N. Y.

Clifford G. Grulee, M. D., Secretary and Treasurer, American Academy of
Pediatrics; Editor, American Journal of Diseases of Children; Clinical Professor
of Pediatrics, Rush Medical College, University of Chicago, Chicago, 111.

Henry F. Helmholz, M. D., Professor of Pediatrics, Mayo Foundation, University
of Minnesota Medical School, Rochester, Minn.

George W. Kosmak, M. D., Editor, American Journal of Obstetrics and Gyne-
cology, New York, N. Y.

George M. Lyon, M. D., Chairman, Committee on Postgraduate Education,
American Academy of Pediatrics, Huntington, W. Va.

Alice F. Maxwell, M. D., University of California Medical Center; Assistant
Professor of Obstetrics and Gynecology, University of California Medical
School, San Francisco, Calif.

Lyle G. McNeile, M. D., Professor of Obstetrics and Gynecology, University of
Southern California School of Medicine, Los Angeles, Calif.

Guy Millberry, D. D. S., Dean, University of California College of Dentistry,
San Francisco, Calif.

Norman F. Miller, M. D., Professor of Obstetrics and Gynecology, University of
Michigan School of Medicine, Ann Arbor, Mich.

Mary E. Murphy, Director, Elizabeth McCormick Memorial Fund, Chicago, 111.

Harry S. Mustard, M. D., Professor of Preventive Medicine, New York University
College of Medicine, New York, N. Y.

Alice N. Pickett, M. D., Assistant Professor of Obstetrics, University of Louis-
ville School of Medicine, Louisville, Ky.

Appointed for a 2-year term by the Secretary of Labor in December 1937.

107
328199° — 12 8

108 Maternal and Child-Health Services

E. D. Plass, M. D., Professor of Obstetrics and Gynecology, College of Medicine,
State University of Iowa, Iowa City, Iowa.

Grover F. Powers, M. D., Professor of Pediatrics, Yale University School of
Medicine, New Haven, Conn.

Lydia J. Roberts, Chairman, Department of Home Economics, University of
Chicago, Chicago, 111.

M. Hines Roberts, M. D., Professor of Pediatrics, Emory University School cf
Medicine, Atlanta, Ga.; Chairman, Committee on Child Health Relations,
American Academy of Pediatrics.

Viola Russell, M. D., Director, Division of Maternal and Child Health, State
Board of Health, Pierre, South Dakota.

Marion W. Sheahan, R. N., Director, Division of Public Health Nursing, State
Department of Health, Albany, N. Y.

Clifford Sweet, M. D., California State Chairman, American Academy of Pedi-
atrics, Oakland, Calif.

Howard C. Taylor, Jr., M. D., Associate Editor, American Journal of Obstetrics
and Gynecology, New York, N. Y.

Douglas A. Thorn, M. D., Director, Division of Mental Hygiene, State Depart-
ment of Mental Diseases; Professor of Psychiatry, Tufts College Medical
School, Boston, Mass.

Felix J. Underwood, M. D., Executive Officer, Mississippi State Board of Health,
Jackson, Miss.; President, Conference of State and Provincial Health Authori-
ties of North America.

Philip F. Williams. M. D., Assistant Professor of Obstetrics, University of Pennsyl-
vania School of Medicine, Philadelphia, Pa.

SUBCOMMITTEE: ADVISORY COMMITTEE ON CHILD HEALTH

Chairman, Henry F. Helmholz, M. D.

S. Josephine Baker, M. D. Grover F. Powers, M. D.

Horton Casparis, M. D. M. Hines Roberts, M. D.

Clifford G. Grulee, M. D. Clifford Sweet, M. D.

George M. Lyon, M. D. Felix J. Underwood, M. D.

SUBCOMMITTEE: ADVISORY COMMITTEE ON MATERNAL HEALTH

Chairman, Fred L. Adair, M. D.

Hazel Corbin, R. N. Lyle G. McNeile, M. D.

M. Edward Davis, M. D. Norman F. Miller, M. D.

Robert L. DeNormandie, M. D. Alice N. Pickett, M. D.

George W. Kosmak, M. D. E. D. Plass, M. D.

Alice F. Maxwell, M. D. Howard C. Taylor, Jr., M. D.

James R. McCord, M. D. Philip F. Williams, M. D.

SPECIAL ADVISORY COMMITTEE ON PUBLIC-HEALTH

NURSING 2

Chairman, Katharine Tucker, R. N., Director, Department of Nursing Educa
tion, The School of Education, University of Pennsylvania, Philadelphia, Pa.

Hazel Corbin, R. N., General Director, Maternity Center Association, New
York, N. Y.

Elizabeth G. Fox, R. N., Executive Director, Visiting Nurse Association, New
Haven, Conn.

2 Members appointed in July 1937 for a 2-year term.

Development of Program, 1936-39 109

Amelia H. Grant, R. N., Director, Bureau of Nursing, City of New York Health
Department, New York, N. Y.

Florence L. Phenix, R. N., Assistant Director, Crippled Children's Division,
State Department of Public Instruction, Madison, Wis.

Winifred Rand, R. N., Staff Member, Merrill-Palmer School, Detroit, Mich.

Marion W. Sheahan, R. N., Director, Division of Public Health Nursing, New
York State Department of Health, Albany, N. Y.

Jessie L. Stevenson, R. N., Supervisor, Orthopedic Division, Visiting Nurse Asso-
ciation of Chicago, Chicago, 111.

Shirley C. Titus, Dean and Professor of Nursing Education, School of Nursing,
Vanderbilt University, Nashville, Tenn.

Mrs. Abbie R. Weaver, Director, Public Health Nursing Service, Georgia State
Department of Public Health, Atlanta, Ga.

SPECIAL ADVISORY COMMITTEE ON DENTAL HEALTH 3

Chairman, Guy S. Millberry, D. D. S., Dean, University of California College
of Dentistry, San Francisco, Calif.

Bert G. Anderson, D. D. S., Assistant Professor of Surgery, Yale University
School of Medicine, New Haven, Conn.

Harvey J. Burkhart, D. D. S., Director, Rochester Dental Dispensary, Rochester,
N. Y.

C. Willard Camalier, D. D. S., President, American Dental Association, Washing-
ton, D. C.

William N. Hodgkin, D. D. S., Vice President, National Association of Dental
Examiners, Warrenton, Va.

A. LeRoy Johnson, D. M. D., 444 Madison Avenue, New York, N. Y.

Leroy M. S. Miner, M. D., D. M. D., Professor of Clinical Oral Surgery and Dean,
Harvard School of Dentistry, Boston, Mass.

Lon W. Morrey, D. D. S., Supervisor, Bureau of Public Relations, American
Dental Association, Chicago, 111.

Gerald D. Timmons, D. D. S., Indiana University School of Dentistry, Indian-
apolis, Ind.; Secretary-Treasurer, American Association of Dental Schools.

3 Members appointed in July 1937 for a 2-year term.

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