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UNITED STATES DEPARTMENT O F LABQI^
Frances Perkins, Secretary
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Katharine F. Lenroot, Chief

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MATERNITY CARE A T PUBLIC EXPENSE

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IN SIX COUNTIES IN NEW Y O R K STATE

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July 1 1935-June 30, 1936

Bureau Publication No. 267

United States
Government Printing Office
Washington : 1941

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


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Price 15 cents

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Contents
Page
Letter of transmittal------------------------------------------------- --------------------------------------111
Foreword________________________________________________________________________
IV
Plan and procedure of the study---------------------------------------------------------------------1
History of relief and public-health administration in New York S t a te ._ _ _
4
Relief administration--------------------------------------------------------------------------------------^
State and local health administration— ----------------------------------------------6
Temporary Emergency Relief Administration---------------------------------------9
Medical-care program-------------------------------------------------------------------------------19
Brief description of the six counties selected--------------------------------------------------15
County A— First farming county------------------------------------------------------------15
County B — Second farming county---------------------------------------------------------17
County C— Industrial and farming county--------------------------------------------18
County D — First mountainous county---------------------------------------------------19
County E— Second mountainous county----------------------------------------------------20
County F— Suburban county-------------------------------------------------------------------20
General findings-----------------------------------------------------------------------------------------------------22
Number of women studied— results ofpregnancy-------------------------------------22
Place of delivery and attendant--------------------------------------------------Maternal deaths------------------------- ---------------------------------------------------------------24
Proportion of total live births that occurred to women cared for at
public expense______________________________________________________
Expenditures from public funds. _ ----------------------------------------------------------------------Total expenditures----------------------------------------------------------------------------'--------Average expenditure from public funds for maternity care------------------Average cost, including estimated cost of nursing and clinic care-------State and local expenditures------------------------------------------------------------------------Duration and extent of care---------------------------------------------------Prenatal care-------------------------------------- -------------------------------------------------------Postnatal care_____________________________________________________________
Maternity nursing care provided through community agencies-----------Maternity care in individual counties-------------------------------------------------------------County A— First farming county------------------------------------------------------------County B— Second farming county---------------------------------------------------------County C— Industrial and farming county--------------------------------------------County D— First mountainous county-----------------------County E — Second mountainous county-------------------------------* ---------------County F— Suburban county-------------------------------------------------------------------Special considerations in provision of care-----------------------------------------------------Authorization of maternity care by welfare officials-----------------------------Hospital or home care--------------------------------------------------------------------- t ------Meeting hospital costs--------------------------------Maintenance of a high quality of medical service---------------------------------Coordination of medical and social factors---------------------------------------------Recommendations---------------------------------------------------------------------------------------------Appendix____________________________________
Schedule used in the study----------------------------------------------------------Excerpts from Temporary Emergency Relief Administration Manual
of Medical Care-------------------------------------------------------Temporary Emergency Relief Administration Form 2 7 7 ---------------------ii


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Letter of Transmittal
U n it e d S t a t e s D e p a r t m e n t o f L a b o r ,

ind b y T E X A S B O O K B I N D E R Y , D A L L A S , T E X A S

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C h il d r e n ’ s B u r e a u ,

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Washington, October 1, 1940.
M a d a m : I transmit herewith a report of a study of maternity care
at public expense in six counties of New York State. Data are included
on all maternity patients who received medical or nursing care paid
for from public funds during the period July 1, 1935, to June 30, 1936,
in these six counties.
The study brings to light considerations of general significance in
the provision and administration of maternity care, which should
point the way toward constructive developments in the program for
maternal and infant health.
The study was made by the Children’s Bureau in 1937 in coopera­
tion with the New York State Department of Social Welfare and the
State Department of Health. It was planned and supervised by
Beatrice Hall, medical social consultant of the Children’s Bureau.
The report was written by Miss Hall in collaboration with Martha
M . Eliot, M. D ., Assistant Chief of the Bureau, and Edwin F. Daily,
M . D ., Director of the Maternal and Child Health Division, who re­
viewed the findings of the study from the physician’s point of view.
The field work was done by Beatrice Hall, Marguerite Eisenmann,
Stella Perryman, and Edna F. Clark.
Grateful acknowledgment is given to Dr. H. Jackson Davis and
Marion Rickert of the New York State Department of Social Welfare;
Dr. Elizabeth Gardiner and Marion Sheahan of the New York State
Department of Health; and the local welfare and health organiza­
tions and the private nursing agencies that assisted in providing the
data on which the report is based.
Since this report was prepared conferences have been held with
State officials, who have indicated that the recommendations of this
study are applicable to the administration of maternity care under
the present program.
Respectfully submitted.
K a t h a r i n e F . L e n r o o t , Chief.

Hon. F r a n c e s P e r k i n s ,
Secretary oj Labor.
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Foreword
The Children’s Bureau undertook this study with the purpose of
analyzing, for a limited area and period of time, the extent of prenatal,
natal, and postnatal care provided through public funds, and the cost
of this care. No attempt was made to evaluate the adequacy or
quality of the medical service provided. The findings are limited to
the number of patients receiving maternity care at public expense, the
result of pregnancy, the place of delivery and attendant, expenditures
for maternity care, and the content of the care as expressed in terms
of the number of visits and the length of the period during which
patients received medical or nursing care in their own homes or in
hospitals. In order to give added significance to these findings areas
were selected that represent varying community resources and result­
ing differences in medical-care programs.
Recognized gaps in community services and problems arising out of
the administration of medical care were brought to the attention of
the investigators during the course of the study by local relief and
health administrators. The case records also brought to light some
problems of general significance in the provision and administration
of maternity care.
In addition to statistical data the report thus includes a number of
suggestions and conclusions developed in the course of the survey by
those responsible for carrying it out. These conclusions are the
product not only of an intensive study of pertinent records but even
more, perhaps, of numerous conferences with refief administrators,
investigators, welfare officers, county commissioners, public-health
nurses, representatives of private nursing and family agencies, health
officers, and local physicians.
These conferences also revealed significant problems in relation to
the needs and practices of the “ medically needy” families those able
to maintain themselves but unable to pay for necessary medical care.
Consideration has been given to the problem of providing maternity
care for this group in the evaluation of procedures for authorizing care
and in the recommendations appearing in this report.
It is hoped that the report, embodying an analysis of several types
of experience, will help to point the way to constructive developments
in the program for maternal and child health and welfare.


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M aternity Care at Public Expense in
Six Counties in N ew York State
Plan and Procedure of the Study
Plans for the study provided for an analysis of the extent of mater­
nity care through public funds in six counties of New York State during
a 1-year period, from July 1, 1935, to June 30, 1936.
The Children’s Bureau conducted the study in cooperation with the
New York State Department of Social Welfare and the New York
State Department of Health. The field work was done during a 3month period by four medical social workers from the Children’s
Bureau, one of whom supervised the study.
New York State was selected as the locale for the intensive study of
maternity care at public expense because that State’s relief program
had included since 1931 a State-wide plan for medical care in the
home. This plan, the product of prolonged experience of a highly
developed type with problems of relief and public health, was worked
out jointly by the Temporary Emergency Relief Administration (here­
after referred to as TERA) and the State Department of Health, with
the aid of special advisory committees from the State medical, dental,
and nursing organizations. The Manual of Medical Care, issued by
the TERA, which contained the rules and regulations governing medi­
cal care provided in the home to recipients of home relief, included a
statement of minimum standards for maternity service which em­
phasized prenatal care.
The Public Welfare Law of the State of New York, passed in 1929
and since amended, contains adequate provision for the continuance of
the medical-care program administered by the TERA, after its
functions and powers were transferred to the State Department of
Social Welfare on July 1, 1937.
This State, which had had 5 years of operating experience with a
State-wide program, offered what was thought to be a unique oppor­
tunity for study of the extent to which public funds were used to
provide maternity care in rural areas and small cities and for con­
sideration of the number of women in need of such care who had been
reached by the program administered through public-welfare agencies.
It was believed also that the findings of such a study would be helpful
in planning extension of facilities for maternity care in other areas.

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MATERNITY CARE AT PUBLIC EXPENSE

The statistical material was obtained from official records in local
departments of public welfare, from records of hospitals and nursing
organizations, and from local registrars of vital statistics. A list of
patients receiving maternity care at pubbc expense in each of the
counties selected for study was made up by reviewing the receipted
bills of public rebef agencies for medical, nursing, and hospital care
for the period of the study and by checking bsts of visits by city
physicians and bsts of admissions to public hospitals.
A separate schedule was prepared for each patient.1 Local prenatal
and postnatal clinics, hospitals, and nursing organizations were then
visited in order to secure data on clinic, hospital, and home care.
Birth certificates were checked with local registrars to obtain an
accurate count of live births and stillbirths. Additional information
was obtained from the case records of public relief agencies.
Lack of detail in the records caused considerable difficulty in the
collection of statistical material. Relief agencies and nursing organiza­
tions carrying heavy case loads are not always able to keep the type
of record found in many private case-working agencies. In some rural
areas case records were limited to face sheets and relief cards. Nursing
records in one county gave only the total number of prenatal and
postnatal visits paid to each patient; it was impossible to learn the
dates of these visits. In two districts the available records of the
work-relief nurses showed only the total number of visits made,
classified as prenatal, postnatal, tuberculosis, and so forth, with no
record of the patients to whom the visits were made. Although
physicians were requested to include dates of prenatal and postnatal
visits when they submitted their bills2 these dates were often missing,
and no estimate could be obtained of the length of time the patient
was under care.
Furthermore, in small communities the desire to safeguard medical
and social information in many cases affected the type of records
maintained. Where relief workers and clients were often personally
known to each other, detailed information in public-welfare records
might be injurious to the patient, particularly in cases of abortion or
venereal disease. Furthermore, a great many relief investigators
lacked previous training or experience in social work, and few had the
opportunity of consultation with public-health nurses or medical
social workers who could interpret medical information with due
regard for the social needs of patients and consideration of medical
ethics.
Information available in the records was supplemented by personal
conferences with relief administrators, district and local health officers,
1 See appendix for schedule used in the study.
1 See appendix for Temporary Emergency Relief Administration Form 277: Authorization, Invoice,
and Voucher for Professional Services.


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PLAN AND PROCEDURE OF THE STUDY

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nurses, and social workers. These conferences revealed the fact that
in many instances services had been given that were not recorded. A
considerable number of women, for example, had received prenatal
care that was not paid for from public funds from physicians who had
treated them in the past when they were able to pay. It was not
considered practical to attempt to obtain details concerning free serv­
ices furnished by private physicians. Such services made no small
contribution, however, to the adequacy of the medical care obtained
by the relief clients— a contribution not paid for from public funds.


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History of Relief and Public-Health Administration
in New York State
Some knowledge of the history of relief and public-health adminis­
tration in the State of New York to 1936 is essential to an under­
standing of the data presented in succeeding sections of this report.
Changes in administration after 1936 are referred to only incidentally.
Three-fifths of the counties of New York State (exclusive of the five
counties coterminous with the boroughs of New York City) are largely
rural and contain at most one city of 10,000 to 50,000 inhabitants.
Relief Administration.
The 57 counties outside the boundaries of New York City are sub­
divided politically into towns, cities, and villages. Villages have no
functions in the administration of relief. Towns and cities adminis­
tered relief from colonial times under various early poor laws, which
were superseded and revised by the Poor Law of 1909.3 Under all
these poor laws almshouse care was emphasized as the basic form of
relief. Home relief was infrequently given, and it is generally ad­
mitted that it was usually inadequate. In the larger cities private
organizations grew up which spent large sums, not only for relief but
for prevention of sickness and poverty and for rehabilitation of persons
in need. Rural areas, however, for the most part lacked such resources.
The Poor Law made limited provision for medical care for recipients
of public relief. Hospitalization was provided chiefly for emergency
cases and rarely for confinement care, except in counties maintaining
county hospitals. Furthermore, the chief interest of the local official
(overseer of the poor) was to keep relief costs at a minimum. The
provision for medical care was usually interpreted as applying
only to persons already receiving other relief. As a result most of the
burden of providing medical care for the poor in rural areas was borne
by the local physicians, who gave generously of their time and skill.
At the same time a growing volume of legislation increased the relief
responsibilities of the counties and of the State, particularly with
reference to child health and welfare. These developments brought
about increasing cooperation of the town, county, and State, but the
administration of home relief remained a function of the local officials
administering the Poor Law.
The Public Welfare Law, which superseded the Poor Law and
changed the whole concept of public relief and care, was enacted in
* Consolidated Laws 1909, Poor Law.


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RELIEF AND PUBLIC-HEALTH ADMINISTRATION

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1929 and went into effect January 1, 1930.4 The Poor Law had em­
phasized care in almshouses as the basic form of relief; the Public
Welfare Law, as originally enacted, emphasized relief given in the home
as basic and limited institutional care to cases in which home care was
not practicable. The law made it mandatory for every county to
appoint or elect a county commissioner of public welfare, who, in
addition to administering the public relief and care for which the
county public-welfare district was responsible, was given “ general
supervision and care of persons in need in the territory over which he
has jurisdiction.” The law provided that costs of certain types of
relief and care, such as care for children away from their parents,
care for defective or physically handicapped children and children
bom out of wedlock, and hospital care, might be charged back to
the town or city of settlement, although the administrative respon­
sibility was placed with the county commissioner. Responsibility
for the administration of home relief and medical care in the home
was placed with the town welfare officers who replaced the overseers
of the poor.
In the part of this law concerned with administration emphasis was
placed on the preventive and constructive aspects of relief, publicwelfare officials being directed to “ administer such care and treatment
as may restore such persons to a condition of self-support, and further
give such services to those liable to become destitute as may prevent
the necessity of their becoming public charges.” Standards of inves­
tigation, supervision, and cooperation with other public and private
agencies were established.8
Among other provisions the law authorized medical care in their
homes and in hospitals for persons who, while ordinarily self-sustaining,
were unable to provide themselves with needed medical or hospital
care.6 This was a long step forward, but in practical application the
Public Welfare Law did not immediately operate to give a full measure
of medical service to those in need of care, because it was administered
by the local (town) officials, now designated welfare officers. These
officials had replaced the overseers of the poor, but the change in title
had not altered their point of view.
The situation in one rural county is described in a report by Dr. J.
Warren Bell and Dr. Reginald M. Atwater,7 which states that in 1931
there was almost no public provision for prenatal care for women un­
able to pay for this service, despite generous legal provisions for public
medical care under the Public Welfare Law effective January 1, 1930.
Few women knew of the legal provisions, and routine procedure by
4 Laws of 1929, ch. 505.
* Ibid., secs. 77-80.
» Ibid., sec. 83.
7 Providing Prenatal Care for Necessitous Women in Rural New York County. Milbank Memorial Fund,
Quarterly, Vol. 13, No. 2 (April 1935).


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MATERNITY CARE AT PUBLIC EXPENSE

which the county department of health cooperated in bringing cases
to the attention of the county department of welfare functioned satis­
factorily for less than one-fourth of the applicants, despite valid med­
ical reasons why delay was exceedingly undesirable. The defect
appeared to be in the slow response of the welfare officers rather than
in the routine itself.
The town welfare officers continued to be appointed by the town
boards. They were rarely professional persons; the job was a parttime one for which they were paid according to the amount of work
demanded of them. Their compensation varied from $200 or $300 a
year to about $1,800 in some of the larger towns. Their bills for relief
expenditures and for payment of their own services were audited by
the town boards, who were interested in keeping relief costs down
rather than in providing adequate relief or medical care.
Prom November 1931 to July 1, 1937, the administration of relief
in the home was profoundly influenced by the fact that State aid to
local welfare units was available through the Temporary Emergency
Relief Administration, whose functions are considered in detail in a
later section. When the functions and powers of this administration,
pursuant to law,8 were transferred to the State Department of Social
Welfare on July 1, 1937, the duties of the department had been ex­
panded by amendments to the Public Welfare Law to include super­
vision of local welfare departments, reimbursement of local welfare
costs on a participating basis through the fiscal officer of the county,
and establishment of rules, regulations, and policies for local admini­
stration of public relief and assistance throughout the State.9
A certain provision of this law dealt with veterans’ relief, requiring
legislative bodies to make appropriation for the care and relief of
veterans and their families and to determine the method whereby
such funds shall be drawn upon by the veterans’ organizations which
were authorized to dispense relief, and providing that they may pay
employees of the relief committees of such organizations for their
services in administering veterans’ relief.10
State and Local
Health Administration.
In New York State health protection has been a responsibility of
cities and towns and also of villages. Under early laws 11each city and
village and, later, each town was required to appoint annually a board
of health and a physician as health officer.
It was not until after 1900 that every city, town, and village complied
with these laws. Because of the number and small size of these
8 Laws of 1937, ch. 358 (amending Public Welfare Law, sec. 3-i.).
» Laws of 1936, chs. 873, 874, art. 1-A.
10 Laws of 1929, ch. 565, sec. 117.
11 Laws of 1850, ch. 324; Laws of 1885, ch. 270.


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RELIEF AND PUBLIC-HEALTH ADMINISTRATION

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units and the fact that no qualification was required for the position
of health officer except that he be a physician (and frequently there
is only one practicing physician in a village) the problem of providing
adequate health protection has presented even greater difficulties
than the administration of relief. Because the individual town and
village was too small a unit to support necessary health services,
there came about a piecemeal development on a county basis of several
health activities such as prevention of tuberculosis, milk control, and
public-health nursing. These activities were often developed inde­
pendently, with no definite administrative relationship among the
county, town, and village health authorities. Under special enabling
laws, counties might conduct, as uncoordinated and unrelated projects,
almost every activity of a modem health program without organizing
a county board of health which could through central direction coordi­
nate and develop these activities into a unified program.
Since 1915 it has been possible under the Public Health Law for
towns and villages to consolidate into larger health districts.12 In
1921 the law was amended to enable counties to create boards of
health and to conduct health services on a county basis.13 Counties
have been slow to organize health departments, however, and in 1937
there were only five counties maintaining county health departments.
The report of the New York State Health Commission, appointed
in 1931 by Governor Franklin D. Roosevelt to study and report upon
administrative and legislative aspects of public health in the State,
dealt largely with the need for reorganization and improvement of
local health machinery and mentioned the inequality of services in
various sections because of the unevenness of popular sentiment for
health action. This report, published in 1932, states: “ There are now
in up-State New York 1,212 local health jurisdictions consisting of
4 county, 52 city, 309 village, 698 town, and 149 consolidated (village
and town or combination of village and town) boards of health or de­
partments of health * * * Excluding county and city health depart­
ments there is a total of 1,156 local health units, with population rang­
ing from less than a hundred to a few thousand persons, and covering
areas ranging from 0.1 to more than 400 square miles.” 14
Local health agencies are assisted and stimulated by the various
divisions of the State Department of Health through district State
health officers, district State nurses, and special demonstration clinic
services, particularly in orthopedics and maternal care. Other State
departments, such as the departments of education and mental hygiene
and many voluntary health organizations, notably the New York State
Charities Aid Association, county tuberculosis and public-health
12 Laws of 1915, ch. 555.
» Laws of 1921, oh. 509.
» Public Health in New York State, ch. 2. Report of New York State Health Commission, 1932.


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MATERNITY CARE AT PUBLIC EXPENSE

committees, and visiting-nurse associations also assist the local health
authorities.
Within the State Department of Health, a division of child hygiene,
created by statute in 1913, was established in 1914 with responsi­
bility for maternal and child care.15 In 1922 its responsibilities were
extended and its name changed to the Division of Maternity, Infancy,
and Child Hygiene.16 This division undertook to stimulate local
communities in the organization and extension of maternity and childhygiene activities. The Division of Public Health Nursing, also
created by the statute of 1913, assisted in many of the maternal and
child-hygiene activities of the department. The nurses worked under
the direction of the secretary of the department until 1920, when a
director was appointed and placed in charge of the division.
Increased funds available under the Federal Maternity and Infancy
Act (accepted by New York in 1923) made it possible for the Division
of Maternity, Infancy, and Child Hygiene to broaden the scope of its
activities.17 The decade between 1920 and 1930 saw a great increase
in services for mothers and children under the State program. During
this period the decline in the infant mortality rate for New York
State was markedly greater and the decline in the maternal mortality
rate slightly greater than for the United States as a whole.
The maternal mortality rate for 1935 was the lowest that had ever
been achieved in up-State New York. The report of the Division of
Maternity, Infancy, and Child Hygiene for that year attributes the
lowering of the maternal mortality rate in large part to the provision
for medical care dining pregnancy and confinement for women in
families on relief.
At the end of November 1937 joint State and county funds were
maintaining 5 county health departments employing 66 nurses and
were also providing nursing service in 32 other up-State counties
with a personnel of 76 nurses. These nurses worked under local
committees appointed by the county boards of supervisors, and pro­
fessional direction of their activities was provided by the district State
health officers and district State public-health nurses under the general
supervision of the State department. State aid to local communities
has been given on a county basis since 1923.
Since 1932 the State Department of Health has expanded its serv­
ices through the district centers rather than from headquarters.
Pediatricians and obstetricians of the staff of the Division of Maternity,
Infancy, and Child Hygiene have been assigned to certain of the dis­
trict offices and have been given responsibility to promote the expan­
sion of maternal and child-health activities in these districts under the
18Laws of 1913, eh. 659.
18 Laws of 1922, ch. 402.
17 United States, 42 Stat. 224; New York, Laws of 1923, ch. 843.


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immediate supervision of the district State health officers. Increased
attention has been given to the maternal-health work through more
frequent inspection of small maternity hospitals and homes, the
establishment of additional clinical services, the expansion of the
prenatal-letter service, and the provision of increased county nursing
service.
Temporary Emergency
Relief Administration.
The Emergency Relief Act of the State of New York became law on
September 23, 1931.18 It created the Temporary Emergency Relief
Administration in recognition of the peril to public health and safety
occasioned by the emergency during the economic depression.
By the Emergency Relief Act the TERA was given the administra­
tion of State aid to localities for relief given in the home and for work
relief— a new form of relief. The TERA utilized existing local publicwelfare authorities to administer the relief for which the State paid
part of the cost. Home relief was defined in the act as including not
only shelter, fuel, food, clothing, light, and necessary household sup­
plies but also “ medical attendance furnished by a municipal corpora­
tion [or a town, where home relief is a town charge], to persons or their
dependents in their abode or habitation.” 19 In this definition medical
attendance is recognized as a necessity of life, along with food, shelter,
and fuel.
Supervision of the town welfare officers by the county commissioners
is provided for in the section dealing with investigation of home relief :
Investigation of home relief.— In a city public-welfare district the city commis­
sioner shall investigate all cases of home relief. In a county public-welfare district
where home relief is a county charge, the county commissioner shall investigate
such cases. In a county public-welfare district where home relief is a town charge,
the town public-welfare officers shall investigate such cases under the supervision
and general direction of the county commissioner.20

The act as amended authorized State aid to municipalities or to
towns to the extent of 40 percent of expenditures for such home relief
and work relief as were approved by the administration during the
emergency period. The administration could, in addition to the 40percent reimbursement, make direct grants to a municipal corporation
or town on such conditions as it might prescribe.21 The administra­
tion could authorize city and county commissioners to employ addi­
tional personnel whose qualifications were satisfactory to it, determine
the number of such employees, and fix their salaries. Part or all of
is Laws of 1931, ch. 798.
I* Ibid., sec. 2. Bracketed words were added by Laws of 1933, ch. 646.
8° Ibid., sec. 13.
8i Ibid., sec. 16, as amended by Laws of 1932, ch. 667, and Laws of 1934, ch. 66.


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MATERNITY CARE AT PUBLIC EXPENSE

such salaries could be paid from the “ discretionary fund.” 22 In this
way the TERA was able to set standards for personnel and to intro­
duce trained workers into local offices.
Home relief had been the basic form of relief in up-State districts
for 2 years before the Emergency Act was passed, but the social
standards of the Public Welfare Law had not yet been put into general
practice and the traditional concept of poor relief was still a powerful
force. The creation of the TERA gave an unusual opportunity to the
State to put the standards of the Public Welfare Law into operation
through the provision for centralized control and reimbursement de­
pendent upon the maintenance of standards.
The administration from the start determined upon certain princi­
ples, among others that relief must be adequate, with consideration
to the needs of the individual or family, and that investigation to
determine this need was not a desk job. Local administrators were
allowed wide latitude in the determination of “ adequacy,” but the
State insisted that each locality administer relief consistently and
without favoritism. Where additional personnel in local offices were
paid from TERA funds, the final selection of such personnel was made
by law the responsibility of the local official, although the qualifications
of these workers had to be approved by the administration.
Reimbursement by the State of 40 percent of home-relief and workrelief expenditures continued until the autumn of 1933, when the
reimbursement rate for home-relief expenditures was raised to 66%
percent and the Federal Civil Works Administration took over work
relief. After the demobilization of the CWA on April 1, 1934, the
TE R A reimbursed local districts from State and Federal funds to the
extent of 75 percent of approved expenditures for both home and
work relief. Upon the transfer of work relief to the Federal Works
Progress Administration in December 1935 reimbursement returned
to 40 percent, as specified in the original act.23
Medical-Care Program.
The Manual of Medical Care, first issued by the TERA in 1931,
listed the regulations for medical care and the schedule of charges on
which State reimbursement would be given for all kinds of medical
care except costs incident to hospitalization, which remained a local
responsibility. Local welfare districts were free to establish their own
policies and procedures for medical relief but received reimbursement
only for expenditures made according to the rules and regulations of
the manual. In some communities costs met entirely from local funds
were high. In general, these costs represented the difference beMIbid., sec. 19, as amended by Laws of 1936, ch. 822.
m Final Report of T E RA , Nov. 1 ,1931-June 30, 1937, p. 31. Albany, 1937.


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RELIEF AND PUBLIC-HEALTH ADMINISTRATION

11

tween the maximum set by the TER A and the local rates. For
instance, the maximum fee on which reimbursement was calculated
was $2 for a home visit; in some communities because of transportation
difficulties the local welfare officers sometimes had to pay doctors $10
for a home visit.
The maximum for the physician’s services for authorized obstetric
care in the home was $25; this included necessary prenatal care,
delivery in the home, and postnatal care. This charge was subject
to the general restrictions and requirements imposed by the manual
and to the specific requirements of regulation 4, which required that
prenatal care should, whenever possible, begin at or prior to the fifth
month of pregnancy. The maximum rate on which reimbursement
was allowed for delivery in the home and necessary postnatal care was
$15. Payment for prenatal care might be authorized at a rate not to
exceed $1 per visit and a total charge not to exceed $10. The regula­
tions and schedule of charges for obstetric care are given in full in the
appendix to this report.
The program for medical, dental, and nursing care was worked out
jointly by the TE R A and the State Department of Health, with the
aid of special advisory committees from the State medical, dental, and
nursing organizations. The State organization recommended the
appointment of similar professional advisory committees to serve
locally in each public-welfare district. In the communities where the
administration of medical care was most efficiently provided, these
local committees advised commissioners in the administration of the
local program and in individual problems of professional policy and
practice; they assisted (within certain limits) in the determination of
schedules for flat-rate charges; they submitted fists of qualified
physicians and dentists who wished to cooperate under the program
and checked on the professional qualifications of practitioners licensed
to practice in New York State who were not members of the local
professional organizations.
The introduction to the Manual of Medical Care stated: “ The
conservation and maintenance of the public health is a primary func­
tion of Government. In the present economic depression, the ingenu­
ity of Federal, State, and local relief officials is being taxed to conserve
available public funds and, at the same time, to give adequate relief
to those in need.” 24
Medical care in the home, as defined in the manual, includes
“ medicine, medical supplies, and medical attendance furnished by a
municipal corporation or a town, where home relief is a town charge,
to persons or their dependents in their abode or habitation whenever
»* Manual of Medical Care, ch. 1, p. 7.
March 1936 edition.


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Temporary Emergency Relief Administration, New York.

12

MATERNITY CARE AT PUBLIC EXPENSE

possible and does not include hospital or institutional care. It does
not include medical, nursing, or dental services given either ‘ in the
hom e/ in the office, or in a clinic, where such services are already
established in the community and paid for, in whole or in part, from
local and/or State funds in accordance with local statutes or charter
provisions. The scope of ‘ medical care’ . . . includes: Bedside
nursing care, as an adjunct to medical attendance; and emergency
dental care . . . .
‘ Medical care’ . . . shall be construed ordinarily
to include only necessary care for conditions that cause acute suffering,
interfere with earning capacity, endanger life, or threaten some per­
manent new handicap that is preventable when medical care is
sought.” 26
The Public Welfare Law requires public-welfare districts to provide
needed care for sick and disabled persons in hospitals maintained by
municipalities or in any other hospitals visited, inspected, and super­
vised by the State Board of Charities, and authorizes these districts
to contract with other hospitals to pay such sum for the care of sick
persons as might be agreed upon.28 Under the TERA, local com­
munities continued to bear the entire cost of hospitalization. The
Manual of Medical Care emphasized throughout its regulations that
care in the home was not to be authorized for the treatment of con­
ditions for which hospital care was desirable.
Item 4 under Obstetrical Care stated that in cases where it was the
professional opinion of the attending physician that delivery in the
home would be hazardous he should notify the local commissioner of
public welfare immediately in order that hospitalization might be
authorized in accordance with the provisions of the Public Welfare
Law.
The aim of the medical program was stated as “ the provision of good
medical care at a low cost— to the mutual benefit of the indigent
patient, professional attendant, and taxpayer.” 27 The manual listed
the following objectives: Uniform policy, maintenance of professional
standards, more adequate medical care (“ the policy adopted shall be
to augment and render more adequate, facilities already existing in the
community for the provision of medical care by medical, dental, and
nursing professions to indigent persons” ), and uniform procedure.
The administration recognized the need for professional supervision
and advice in administering medical care and received advice and
expert assistance from the State Department of Health, which assigned
a member of its staff as director of medical care. A Division of Medical
Care whose staff included a medical social worker was established to
provide additional supervision over medical and related problems met
25 Ibid., pp. 7-8.
2« Laws of 1929, ch. 565, sec. 85.
11 TE R A Manual of Medical Care, eh. L p. 8.


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RELIEF AND PUBLIC-HEALTH ADMINISTRATION

13

in the administration of both home relief and work relief. The duties
of the staff of this division included making surveys, formulating pro­
cedures, advising in exceptional or difficult cases, particularly in cases
concerned with the treatment of chronic diseases, promoting profes­
sional standards, and suggesting policies for more effective provision
of care. The director of medical care also acted as liaison officer in
medical problems involving the administration, other State and Fed­
eral agencies, State and local professional organizations, and local
departments of public welfare and health.
All municipal corporations (cities and counties) and towns where
home relief was a town charge were eligible for participation in this
medical program to the degree necessary to render more adequate, but
not to supplant, existing local services. In those communities where
medical care was provided primarily on an individual-fee basis the
corporation or town was eligible for reimbursement by the administra­
tion for all types of medical care covered in the manual.
Standards of professional care were safeguarded by a provision that
only professional personnel licensed or registered to practice their
respective professions in the State of New York were authorized to
participate in the provision of care. It was recommended that com­
missioners of public welfare maintain approved lists or files of profes­
sional attendants who had agreed in writing to comply with the rules
and regulations of the manual and authorize care from these lists alpha­
betically in rotation for patients who did not choose their own attend­
ant when requesting care. The traditional relationships existing be­
tween the patient and his professional attendant were recognized in
the regulations, and so far as possible the patient was given his choice
of physician. Licensed midwives were authorized to provide obstetric
care on a reimbursable basis.
Medical care was restricted to persons who were recipients of home
relief or who upon investigation by the welfare officer were found to be
eligible for home relief. Patients not meeting this requirement were
referred to their family physicians or other attendants for care. This
regulation was interpreted in most welfare districts to include the
group unable to pay for medical care, although able to provide them­
selves with the bare essentials of living.
To obtain a comprehensive understanding of this program for
medical care, it is necessary to keep in mind the wide variation in local
resources, the lack of resources in rural areas, and the policy of the
TER A “ to augment and render more adequate facilities already
existing in the community for the provision of medical care by the
medical, dental, and nursing professions to indigent persons.” The
scope of the program was restricted to supplementation of local facil­
ities and implied continuance of the use of hospitals, clinics, and nurs277253°— 41----- 2


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14

MATERNITY CARE AT PUBLIC EXPENSE

ing services already established in the community and paid for, in
whole or in part, from public funds. In view of the lack of such
resources in many rural areas, it is not surprising that more than twofifths of the TERA funds spent for medical care was spent on medical
relief in rural areas, which constituted approximately one-sixth of the
relief load of the State.
During the 5 years preceding July 1, 1937, there was little change in
the scope of the medical-care program but a very definite increase in
the adequacy and uniformity of the medical care provided. Begin­
ning in 1933 a State-wide project of bedside nursing was developed in
cooperation with the State department of health. This service in­
cluded assistance to physicians attending deliveries as well as post­
natal and other types of bedside care, advice in the home on problems
such as diet and prenatal care, interpretation of the physician’s orders,
home calls to determine whether a physician’s services were needed,
and supplementation of the work of local clinics and health demonstra­
tions. The State department of health drafted the general plan for
the service in each community, developed specific programs, and pro­
vided continuous supervision.28
A law of 1937 29 required that, by July 1 of that year, all the func­
tions, powers, and duties of the Temporary Emergency Relief Adminis­
tration relating to home relief be transferred to the State Department
of Social Welfare, and the supervision of such relief then became a
responsibility of that department. The same law terminated also the
local emergency relief bureaus as of such date, or as of July 1, 1938, if
permitted by the State Board of Social Welfare to continue until then;
and provided that thereafter local relief should become the responsi­
bility of the public welfare officials as successors to such bureaus. A
comprehensive system of State aid for home relief was established in
193630 and reimbursement by the State to cities, counties and towns,
where home relief is a town charge, was made subject to approval by
the State Department of Social Welfare.
« Some idea of the scope of the work carried on under this project in the six counties covered in the study
can be gained from table 13 (p. 43).
" Laws of 1937, ch. 358 (amending Public Welfare Law, sec. 3-i, and adding sec. 3-j).
Laws of 1936, ch. 873, sec. 3-e (amending Public Welfare Law).


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Brief Description of the Six Counties Selected
Since limitations on time and funds made a State-wide study by the
Children's Bureau impracticable, it became necessary to select districts
that would yield findings of maximum general significance. The six
counties chosen were decided on after consultation with officials in the
State Departments of Health and Social Welfare. They are located in
the central and eastern part of the State, and each has a considerable
rural population.31 One county includes a city of more than 100,000
population in the midst of a rural area; no other city of as much as
50,000 population is included.
Although a substantial percentage of the population in all six coum
ties is rural, the counties chosen represent a variety of economic
and social backgrounds. Two of them may be classified as farming
counties; one has a considerable industrial as well as a large dairy­
farming population. Two counties are in mountainous sections where
isolation has resulted in a lack of community contacts which has
retarded the development of public-health and other social services.
The sixth is definitely suburban in character. Infant and maternal
mortality rates differed rather widely among the six counties, as did
the amount of economic distress during the year of the study. Data
regarding live births, stillbirths, and infant and maternal mortality
for the State as a whole and for the counties in which the study was
conducted are presented in table l.32
In the selection of the areas for study consideration was given to
the Temporary Emergency Relief Administration policy in its medicalcare program, which was “ to augment and render more adequate,
facilities already existing in the com m unity/’
The six counties, differing in their community resources and health
and welfare programs, were selected to illustrate varying methods of
providing medical services with the help of State funds, developed in
accordance with local programs already in effect. One county oper­
ated almost entirely on a fee system; one county and one city, having
31 In this study the population figures are based on the United States census of 1930. All persons living
in places with less than 10,000 inhabitants are classed as rural.
38 All births and deaths occurring within the State have been allocated to place of residence for counties,
cities, and villages. Births are allocated to the usual place of residencie of the mother and deaths, with a
few exceptions, to the usual place of residence of the decedent. Births outside the State to resident
mothers and deaths of residents recorded in other States have not been included in the figures for counties,
cities, and villages. This omission results in a slight error in the figures for some of these minor subdivisions,
but the error is too small to be significant.

15


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16

MATERNITY CARE AT PUBLIC EXPENSE

county and city hospitals, authorized confinement care largely in these
hospitals and arranged for home deliveries only in emergencies. One
city had a system of salaried city physicians and utilized a private
clinic for prenatal care.
T a b l e 1.— Live births, stillbirths, and infant and maternal mortality in six New

York counties; 1985 -3 6 1
Live births
Area
Number

Infant deaths

Stillbirths

Rate (per
1,000 esti­ Number
mated
population)

Rate (per
1,000 live
births)

Number

Rate (per
1,000 live
births)

Maternal
deaths

New York State__

183,173

13.8

6,821

37.2

8,695

47.5

934

County A ...............

936

14.8

24

25.6

40

42.7

5

Rural_______ __________
Urban...... ........................

452
484

16.1
13.8

13
11

28.8
22.7

20
20

44.2
41.3

1
4

587

18.1

17

29.0

32

54.5

6

Rural__________________
Urban ________________

336
251

19.9
16.1

9
8

26.8
31.9

17
15

50.6
59.8

3
3

County B.......... .

County 0 ...............

2,853

14.4

91

31.9

148

51.9

13

Rural__________________
Urban____________ ____

908
1,945

14.0
14.7

34
57

37.4
29.3

52
96

57.3
49.4

5
8

City I.........................
City n „ ....................

517
1,428

16.6
14.1

17
40

32.9
28.0

22
74

42.6
51.8

2
6

County D .............-

1,082

13.4

41

37.9

55

50.8

8

Rural................................
Urban_________________

696
386

13.3
13.5

25
16

35.9
41.5

30
25

43.1
64.8

5
3

County E ............ —

556

15.9

24

43.2

34

61.2

5

Rural__________________
Urban_________________

283
273

17.9
14.3

14
10

49.5
36.6

19
15

67.1
54.9

2
3

4,769

13.4

143

30.0

187

39.2

25

3,403
1,366

13.4
13.3

98
45

28.8
32.9

131
56

38.5
41.0

19
6

County F _____
Rural....... ..................... .
Urban........... ...................

1 Annual reports of the State Department of Health; numbers averaged for the 2-year period; births
and deaths allocated to place of residence.

Brief descriptions of the six counties follow. Additional informa­
tion regarding the administration of relief, including medical care, and
regarding local resources for medical and nursing care is given in the
section on Maternity Care in Individual Counties.
County A—
First Farming County.
In this county of 65,000 almost half the population is rural. More
than half of the rural family groups live on farms, which comprise
about 80 percent of the land, and are engaged chiefly in dairying.
There is some quarrying and tobacco raising. The population is pre­
dominantly native white, only 13 percent being foreign-bom and less
than 1 percent, Negro.
Some roads are inaccessible in spring and winter because of rain and

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DESCRIPTION OF SIX COUNTIES

17

snow. The relief families who were visited with the county nurse
occupied small houses badly in need of repair and paint; many ob­
tained their water from a pump outside the house. In one section
families were living in huts covered on the outside with tin cans.
Applications for relief were made to the 23 town welfare officers,
most of whom had no professional training in social work. General
supervision of their work was exercised through the county department
of public welfare. The commissioner was assisted by an experienced
case supervisor, who was handicapped, however, by pressure of work
and lack of clerical assistance. Records at the period of this study
were limited to relief cards and face sheets containing identifying
data.
Much of the burden of medical care for the marginal group was
borne by the local doctors. In the rural areas medical care at public
expense was provided on a fee basis in accordance with the provisions
of the TERA Manual of Medical Care.
The county seat has a population of about 37,000. This includes
some 9,000 families, of whom about two-thirds are native white. A
diversified group of industrial enterprises employs a considerable part
of the population. Home relief was administered by the department
of public welfare under the city commissioner. Medical care at public
expense was given by five part-time salaried physicians through care
in the home and through a city clinic.
County B—
Second Farming County.
About 80 percent of the acreage of this county is in farm land, and
more than half of its 30,000 population is rural. Approximately half
of the 16,000 rural residents live on farms. The population of the
county is mainly native white, only 6 percent being foreign-bom.
Dairy farming is the main occupation. Large crops of vegetables
are raised for use in local canning factories. Three large creameries
and several canning factories constitute the main industries; the county
also contains several corset factories, a bakery concern, a wire mill,
bottling and clothing factories, and machine shops. The farms ap­
peared prosperous and well cared for, and the relief load was compara­
tively light, particularly during the summer months. In 1937 a con­
siderable number of families known to the county and city relief offices
received no relief other than medical care and clothing.
The lack of proximity to any large city, the lack of any influx of
summer population, the good farm land, and the presence of varied
industries tends to the development of a stable, self-maintaining
population.
Roads are kept in good condition, and all sections of the county are
readily accessible except during occasional heavy snowfalls.

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18

MATERNITY CARE AT PUBLIC EXPENSE

Responsibility for investigation and administration of relief rested
largely with the town welfare officers, who were assisted by the case
investigators in the comity office. Medical care was provided in
accordance with the regulations of the Manual of Medical Care. This
was the only one of the six counties to maintain a county health depart­
ment under the direction of a full-time physician with training in
public health.
The county seat, with a population of 15,000, had several small
factories. The town had a generally prosperous appearance. The
city commissioner administered relief. A city physician was employed
on a part-time basis, but his services did not include maternity care,
which was provided by local physicians on a fee basis and through the
county prenatal clinic.
County C—
Industrial and Farming County.
This county of 200,000 population contains one city of about
100,000 inhabitants and another of more than 30,000. Approximately
one-third of the population is rural. About two-thirds of the acreage
of the county is in farm land, used chiefly for dairying. The industrial
population is concentrated chiefly in the two cities and in textile
villages surrounding them, where housing conditions were particularly
bad.
At the time of the study reduced employment in the mill towns had
increased the relief needs. Part of the county borders on a mountain
region, where both housing and transportation offer serious problems.
In the more isolated areas some families receiving relief lived in shacks
and summer camps through very severe winters. Applications for
home relief were made to the 26 town welfare officers, who received
general supervision through the county department of public welfare.
Investigators were assigned by the county office to the welfare dis­
tricts. Authorizations for hospital care were granted through the
medical division of the department of public welfare. During the
winter months the investigators were sometimes unable to reach parts
of their territory for several weeks because the roads were blocked with
snow. During these periods the responsibility for administering
relief, including medical care, rested almost entirely with the town
welfare officers. Coordination between the work of the relief office
and that of the county public-health nurses was being worked out,
but the county relief office had not yet succeeded in understanding the
individual medical needs of persons receiving relief. Records showed
a striking lack of understanding of problems related to illness.
City I .— The smaller city is an industrial center with brass and
copper industries predominating. One-sixth of its population is
foreign-bom. The illiteracy rate is relatively high. Home relief was
administered efficiently by the department of public welfare. Medi
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Federal Reserve Bank of St. Louis

DESCRIPTION OF SIX COUNTIES

19

cal care was provided on a fee basis according to the regulations of
the Manual of Medical Care.
City I I .— The larger city is a rapidly growing industrial and ship­
ping center. More than one-fifth of its population is foreign-bom,
Italians and Poles predominating. As in the smaller city, the illiteracy
rate is relatively high. The textile trades constitute the main industry ;
there are also foundries, engine and boiler works, and other metal
factories. The city is a readily accessible shipping center because of
the presence of several railroads.
Home relief in this city was administered by the department of
public welfare. Home medical care had been provided for many
years by city physicians appointed by the mayor and paid on a parttime basis. During the period of the study 12 such physicians were
employed. The salaries of the city physicians were not reimbursable
under the TERA, as this system of paying physicians had been in
operation for several years before the creation of that agency. The
medical division of the department of public welfare authorized all
medical care, including hospitalization, for the relief and marginal
groups.
County D—
First Mountainous County.
This county is in the Catskill region and has a total population of
some 80,000. Its rural population numbers more than 50,000— 65
percent of the total population— and has a relatively high illiteracy
rate. Eleven percent of the population is foreign-bom. Somewhat
less than half the acreage of the county is in farms, devoted chiefly
to fruit growing, dairying, and poultry raising. Cement works, brick­
yards, and small manufacturing concerns are scattered through the
county. There is considerable summer-resort business. Some of the
rural sections are remote and inaccessible. Living conditions there
are very poor, but the people tend to be self-maintaining and do not
readily make their needs known.
The relief investigators in the office of the county commissioner
were, for the most part, local residents with no special training for
their work. Private physicians often gave free service and also took
considerable initiative in bringing needy cases to the attention of relief
officials. Maternity care in the home was provided under the regula­
tions of the Manual of Medical Care.
This county has one city with a population of about 28,000, of whom
about 9 percent are foreign-bom white and 2 percent Negro. Housing
conditions are poor. In this city the relief problem loomed large,
partly because of seasonal employment. Relief administration was
under the department of public welfare. A trained supervisor was
in charge of relief administration, and workers under her direction

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20

MATERNITY CARE AT PUBLIC EXPENSE

also investigated hospital admissions for the group not receiving other
relief. Home medical care (except maternity care) was supplied by
two physicians on part-time salaries; their services to maternity pa­
tients were paid for on a fee basis. During part of the period of the
study persons on relief were allowed to have treatment by private
physicians who were willing to accept the fees provided under the
regulations of the Manual of Medical Care.
County E—
Second Mountainous County.
This county, in the east central part of the State, has a population
of less than 35,000 persons, of whom more than half are in one city.
The population is predominantly native, only 7 percent being foreignbom. Of a rural population of nearly 16,000 about one-fourth are
classified as farm population. The county contains little good farm
land, and living conditions are poor. Transportation difficulties are
great, especially in the winter months. There is some lumbering and
a large summer-tourist business.
Relief administration was supervised by the county commissioner,
applications being made to the town welfare officers. The work of the
two county investigators was hampered by bad roads and severe winter
weather. The commissioner maintained good working relationships
with the welfare officers and the county nurses. The county had
limited medical resources, and isolation added to the difficulty of
educating the people to the use of those available.
This county had no general county hospital and no private clinics or
dispensaries. Medical care was provided on a fee basis according to
the regulations of the Manual of Medical Care.
In the city, located on the edge of a mountain-resort section, relief
was administered in the department of public welfare with a staff
consisting of an experienced case supervisor and three investigators.
Home medical care for relief families, including maternity care, was
provided by a city physician.
County F—
Suburban County.
The sixth county, about 30 minutes by train from a large city, has
a population of more than 300,000. Almost three-fourths of the
population is classified as rural, but only 13 percent of the acreage is in
farm land. The entire area is thickly populated. There are several
urban centers of 10,000 to 15,000 inhabitants, and these and numerous
smaller villages border closely on one another.
The county contains a number of large estates and a great many
homes of prosperous and well-to-do persons. Employment is chiefly in
professional or clerical work in the nearby large city and in the building
and servicing of local homes and estates. The small farming group is

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DESCRIPTION OF SIX COUNTIES

21

engaged mainly in truck farming. Employment in all these lines was
curtailed greatly by the depression; the building trades suffered
particularly, and large numbers of skilled workmen and white-collar
workers swelled the relief load, which at one time constituted onesixth of the population.
Transportation was difficult except by automobile, and the high
bus fares greatly hampered the effectiveness of the available prenatal
and child-health clinics.
An emergency relief bureau administered home and work relief on a
county basis through numerous local offices. The regulations of the
Manual of Medical Care were closely followed, and home medical
care was provided almost entirely on a reimbursable-fee basis. The
staff of the emergency relief bureau included two physicians who
supervised medical care.
Clinic facilities provided by public and private agencies were con­
sidered by local relief and health workers to be inadequate.


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General Findings
Number of Women Studied—
Results of Pregnancy.
The number of women for whom maternity care was provided at
public expense in the six counties during the year of the study was
1,686. The pregnancies of these women resulted in 1,439 live births
(85 percent), 59 stillbirths (4 percent), and 188 abortions (11 percent).
Table 2 shows for each county and for the urban and rural sections
T a b l e 2.— Result of pregnancy, place of delivery, and attendant; women receiving
maternity care at public expense, by county, year ended June SO, 19S6
Live births

Abortions (actual
or threatened)

Stillbirths

In home
Area

Total

In
home
Attend­
In
In
at­
In
At­
At­
ed by
In
Total hos­
tend­ tend­ other Total hos­ tend­ Total hos­ home
pital Total ed
pital
ed
b
y
pital
by ed by person
phyPhy- mid­ or no
sician
sician wife attend­
ant

Total______ 1,686 1,439 3 856

583

573

County A ...

102

98

30

68

67

Rural_______
U rban ......... .

28
74

27
71

3
27

24
44

24
43

County B ...

69

66

31

35

33

2

Rural_______
Urban_______

37
32

37
29

12
19

25
10

24
9

1
1

1

1

2

2

County 0 . . .

371

336

264

72

67

5

15

15

20

20

R u ra l............
Urban_______

93
278

81
255

60
204

21
51

21
46

5

5
10

5
10

7
13

7
13

City I___
City II— .

87
191

78
177

31
173

47
4

44
2

3
2

4
6

4
6

5
8

5
8

County D __

150

127

57

70

70

5

4

i

18

12

6

Rural..............
Urban_______

63
87

53
74

11
46

42
28

42
28

3
2

2
2

1

7
u

1
11

0

1

8

2

59

1

1

i

1

i

248

h

1

188 2126
3

3
3

3
1

1

2

62

2

County E __

65

62

9

53

52

1

2

Rural________
Urban_______

44
21

42
20

5
4

37
16

36
16

1

1
1

1

County F —

929

750

465

285

284

1

35

27

8

144

92

52

Rural________
Urban.............

710
219

584
166

380
85

204
81

203
81

1

24

20
7

4
4

102
42

68
24

18

u

1Includes 9 women delivered at home with postnatal care in hospital.
1 Includes 1 woman delivered at home with postnatal care in hospital.
3 Includes 9 abortions occurring at home with aftercare in hospital.

22


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Federal Reserve Bank of St. Louis

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i

1

i

1

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GENERAL FINDINGS

23

of each county the number of live births, stillbirths, and abortions
that occurred to women receiving maternity care at public expense.
Live births and stillbirths were checked against birth certificates in
offices of local registrars of vital statistics. No certificate is required
in cases where uterogestation has not advanced to the fifth month.
Instructions for registering births in the State of New York follow the
rules of statistical practice adopted in 1908 by the Section on Vital
Statistics of the American Public Health Association.
Among abortions are included all cases of abortion, spontaneous
or induced, in which that diagnosis was recorded either on a hospital
record or by the physician in his report of his visit or on the form
on which he submitted his bill. In the suburban county (County F),
where more than half of the women in the study lived, the percentage
of cases reported in which the pregnancy resulted in abortion was 16.
In the other five counties the corresponding percentage ranged from
12 to less than 2. The number of abortions in the rural areas, except
in County F, was probably understated, because of the desire to safe­
guard this information, in instances where relatives, friends, or
acquaintances of the patients might have access as employees to
the records in the relief office.
Place of Delivery and Attendant.
More than 60 percent (1,030) of the women cared for at public ex­
pense received hospital care (table 2), although in a few cases the
woman was taken to the hospital after the birth or abortion occurred.
Thirty-eight percent (646) of the women were attended by physicians
in their homes.
The negligible number of cases (8) attended by midwives is worthy
of comment in view of the fact that in three of the counties studied a
considerable part of the population was foreign-bom or first-generation
native. Relief workers in these sections reported that they received
very few requests for the services of midwives and that these requests
came from the older women.33
The proportion of deliveries paid for from public funds that took
place in the patient’s home and the proportion that took place in hos­
pitals in each of the six counties reflect local resources and policies.
This is illustrated by the data for the industrial and farming county (County
C ). Physicians in the rural sections and in the larger city were generally unwilling
to perform home deliveries. The rural sections were served by a hospital, sup­
ported entirely by county funds. Care given in this hospital was not charged
back to the town in which the patient resided. As a result the town welfare offi­
cers, who received applications for relief and medical care, made every effort to send
maternity patients to the hospital and authorized home deliveries only in emergen83 A downward trend in the use of midwives’ services in the State of New York, exclusive of New York
City, is indicated by the fact that in 1916,16 percent of the births in the State were reported by midwives,
whereas in 1935 and 1936 only 1 percent of the births were so reported. See New York State Department
of Health report for 1916, vol. 1, p. 291: 1935, vol. 2, p. 22; 1936, vol. 2, p. 22.


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24

MATERNITY CARE AT PUBLIC EXPENSE

cies or in instances where the patient refused hospital care. In the rural sections
there were 65 hospital deliveries (live births and stillbirths) and 21 home deliveries.
The larger city also was served by a public hospital and had facilities in several
private hospitals as well. Physicians were unwilling to perform home deliveries,
and if a patient insisted on being confined at home the local welfare department
accepted no responsibility for providing medical care, leaving the woman to make
her own arrangements. In this city there were 179 hospital and 4 home deliveries.
Of the home deliveries, 2 were emergencies and 2 were paid for by the veterans’
relief organization.
In the smaller city, on the other hand, the maternity service of the city hospital
had a limited bed capacity, physicians were willing to perform deliveries in the
home, and a work-relief nurse was available for delivery and postnatal nursing
care. The director of the home-relief bureau had unusual skill in individualizing
her clients’ needs, and decision as to home or hospital delivery was made upon the
physician’s recommendation after consideration of the home situation. In this
city there were 35 hospital and 47 home deliveries.

Maternal Deaths.
Fourteen deaths occurred among the 1,686 maternity patients
studied (table 3). All these deaths occurred in hospitals: Five fol­
lowed live births, four followed stillbirths, and five followed abortions.
Of the five patients who died after giving birth to live infants, two
refused prenatal care offered by visiting nurses, one received care in a
prenatal clinic for 1 month prior to delivery, and one received medical
care for a period of 7 months; for the fifth woman there was no record
of prenatal care at public expense. One of this group gave birth pre­
maturely to twins, both of whom died within 48 hours. The infants
born to the other four women survived to leave the hospital, one after
12 weeks’ boarding care. One of these four infants (child of a woman
who refused prenatal care and was said by the nurse to have a history
of tuberculosis and syphilis) died during the first month of life. The
death certificate recorded “ malnutrition” as the cause of death.
T a b l e 3.— Number of maternal deaths among women receiving maternity care at
public expense, by county


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GENERAL FINDINGS

25

Among the four patients who died after giving birth to stillborn
infants no records of prenatal care by a physician were found in
three cases; one of these patients had received two home visits
from a nurse. The fourth patient received daily home visits from a
physician for 1 week during the month prior to her admission to the
hospital.
In none of the five cases in which death occurred after an abortion
was there any record of medical care at public expense prior to admis­
sion to the hospital.
Proportion of Total Live Births That Occurred to
Women Cared for at Public Expense.
A comparison between the percentages of family groups receiving
home or work relief 34 in the rural and urban areas of the counties
studied and the percentages of live births to women receiving care at
public expense during the year of study can be made from table 4.
The 14,565 families receiving relief in these six counties constituted
9 percent of the families in the area. The 1,439 live births to women
receiving maternity care at public expense constituted 13 percent of
the total number of five births in the six counties. In each of the six
counties as a whole and in the rural sections and all but one of the
urban sections of the five counties where separate data were avail­
able on urban and rural relief, the percentages of births to women
cared for at public expense were higher than the percentages of family
groups on relief. The one exception to this was the city in the second
mountainous county (County E). As will be pointed out later, the
amount of free maternity care given to the relief group by private
physicians in this city exceeded that provided at public expense.
These figures should not be regarded as necessarily implying a
higher birth rate in the relief group than in the general population.
It was pointed out in the section on the History of Relief and PublicHealth Administration that the regulation restricting medical care to
persons who were eligible for home relief was in most communities
interpreted to include the marginal group of persons unable to pay
for medical care although able to provide themselves with the bare
essentials of living. Hospitalization for maternity care was provided
to a large group of persons who did not receive home or work relief,
particularly in the two counties (the industrial and farming and the
suburban counties) maintaining general county hospitals. In one of
these counties (County C) only 22 of 65 patients delivered in the
county hospital were known to the home-relief division. In the
m The term “ work relief” refers only to projects carried on by T E R A and does not include Works Progress
Administration projects. Although the census definition of a family is somewhat different from that used
by the relief administration, the differences are not so great as to invalidate a comparison of the two groups,
provided 1-person families are omitted from the census count.


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26

MATERNITY CARE AT PUBLIC EXPENSE

other (County F), 331 of 492 patients delivered in the hospital
were known to the home-relief bureau.
T a b l e 4.— Percentage of total families receiving relief and percentage of total live
births to women receiving care at public expense, bp county

Area

Total
families1

Families receiving
relief3

Number

Percent

Total
live
births3

Live births to
women receiving
care at public
expense
Number

Percent

Total___________________________

166,618

14,565

9

10,741

1,439

13

County A ___________________ . . .

15,327

1,090

7

934

98

10

Rural___________ _____________________
Urban________________________________

7,020
8,307

327
763

5
9

440
494

27
71

6
14

County B _______________________

7,822

369

5

593

66

11

R ural... -- ________ ________________
Urban________________________________

4,052
3,770

190
179

5
5

332
261

37
29

11
11

County 0 _______________________

44,335

3,382

8

2,810

336

12

Rural-......... ................ ...............................
Urban________________________ _____

15,158
29,177

759
2,623

5
9

876
1,934

81
255

9
13

City I............. .....................................
C i t y n ..__________________________

6,241
22,936

683
1,940

11
8

506
1,428

78
177

15
12

County D ________ _______ _______

19,418

1,489

8

1,096

127

12

Rural______- _____ - ...............................
Urban________________________ . .

12,566
6,852

788
701

6
10

708
388

53
74

7
19

County E _______________________

8,407

668

8

569

62

11

Rural_________ ____ _________ _________
Urban________________________________

3,849
4,558

237
431

6
9

291
278

42
20

14
7

County F ....... ................... ..............

71,309

7,567

11

4,739

750

16

R u r a l..------- --------- -- -------- ---------------Urban____ _______________ ___ _______

49,793
21,516

3,388
1,351

584
166

17
12

(<)
(*)

«
(*)

1 According to the 1930 census, exclusive of 1-person families.
3 See ftn. 34
3 Actual number of live births registered during the period, allocated to place of residence. Annual reports
of the State Department of Health.
4 Home relief in this area was administered on a county basis, and relief figures are not available for rural
and urban areas separately.

These data indicate a clear need for continuance of the provision
of medical care to the group not on relief. In formulating any pro­
gram for medical care at public expense the needs of this group should
receive consideration. Attention should also be given to the problem
of devising more effective means of locating persons in the marginal
group who need care.


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Expenditures From Public Funds

I«vL

Total Expenditures.
Total public-welfare and relief expenditures for maternity care for
the 1,686 patients studied were slightly more than $64,000 (tables 5
and 6). Of this amount, approximately $14,800 was paid to local
physicians for the treatment of patients on a fee basis. The maxi­
mum upon which reimbursement was calculated for medical care in
the home was $25 for complete maternity care. If prenatal care was
not given, the maximum was $15. In two of the cities studied ma­
ternity care was included in the duties of salaried city physicians; the
cost of this service has been estimated at $665. Mid wives’ fees
amounted to $90. Expenditures for care in public hospitals consti­
tuted the largest item, amounting to $34,200. An item of $14,115
T a b l e 5.— Payment for care in maternity cases, by place of care
Maternity cases
Place of care and payment

In rural areas

Total

In urban areas

Payment
Number Payment
Number Payment
for care Number for care
for care
Cases paid for from public funds only
Total........................... ................ ......

11,686 $64,235.18

1975 $38,461.19

1 711 $25,773.99

Hospital cases. . „ _________________

11,030 $49,984.00

574 $29,454.69

456 $20, 529.40

721 34,206.75
336 14,115.34

402 20,658.45
188 8,152.74

319
148

Payment to—
Public hospital_____ ______________
Private hospital..................... ............ Physicians on fee basis for care during
hospitalization---------- ------ -----------Physicians on fee basis for prenatal
and postnatal care given in home—
Nurses___ ________________________
Home c a s e s ..____ _______________
Payment to—
Physicians on fee basis______________
Midwives—'...........................................
Nurses----------- ---------------------- --------

13,548.30
5,962.60

34

707.00

1

25.00

33

682.00

164
4

918.00
37.00

93
2

601.50
17.00

71
2

316. 50

1401 $9,006.50

1 255

$5,244. 59

415

8,813.00

2
7

27.50
166.00

201
63
5
10

4,351. 75
665.34
62.50
165.00

» 656 $14,251.09
616 13,164.75
665.34
63
90.00
7
331.00
17

20.00

Cases paid for from public and private funds
$6,606.00

$3,238.00

$3,368.00

1,735.00
4,871.00

603.00
2,635.00

1,132.00
2,236.00

1 The total number of cases is less than the sum of the detail as more than one kind of care was given in
some cases.
1 Proportion of salary estimated for maternity care.

27


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28

MATERNITY CARE AT PUBLIC EXPENSE

went for care in private hospitals. These totals include few fees to
private physicians for deliveries in hospitals; such fees were not
reimbursable under TER A regulations.
T a b l e 6.— Expenditures from public funds for maternity care in hospital cases and

home cases, by county 1
Expenditures for maternity care
Area

Hospital cases

Home cases

Total
Amount

Percent

Amount

Percent

Total________________________________

$64,235.18

$49,984.09

78

$14,251.09

22

Rural------------ --------- ---------------------------------Urban_____________________________________

38,461.19
25,773.99

29,454.69
20,529.40

77
80

9,006. 50
5,244.59

23
20

2,942.24

1,634.90

56

1,307.34

44

811.25
2,130.99

140.25
1,494.65

17
70

671.00
636.34

83
30

2,371.39

1,477.89

62

893.50

38

Rural-------- -------- -------------------------------- -----Urban.____________________________________

1,186.19
1,185.20

564.19
913. 70

48
77

622.00
271.50

52
23

County A......... .....................................
Rural...... .........................................................—
Urban...................................... .............. .............
County B ......... .............. ......................

County C ____ ______________ _________

13,528.25

11,856.00

88

1,672.25

12

Rural_____ _____ _______ _____ _ . . . --------Urban.............................. .............. .....................

3,028.80
10,499.45

2,502.80
9,353.20

83
89

526.00
1,146.25

17
11

City I ..............— ........................................
City II________________________________

2,383.70
8,115.75

1,325.45
8,027.75

56
99

1,058.25
88.00

44
1

County D ................. ................................

4,552.30

2,867.30

63

1,685.00

37

Rural--------- -------- -------------------------------------Urban..________ ____________ __________ _

1,563.30
2,989.00

593.30
2,274.00

38
76

970.00
715.00

62
24

County E ......... ............................ ...........

1,663.30

586.30

35

1,077.00

65

Rural___ _______ ______ ____________________
Urban_______ ____________ ____ ________ ___

1,357.80
305.50

380.80
205.50

28
67

977.00
100.00

72
33

County F ___ ________________________

39,177.70

31,561.70

81

7,616.00

19

Rural____ ____________ ____ _____ _________
Urban__________ _______ _______ ___________

30,513.85
8,663.85

25,273.35
6,288.35

83
73

5,240.50
2,375.50

17
27

1 In addition $6,606 was expended from public and private funds for clinic visits and nursing care.

The $368 recorded for nursing care was in large part for nursing
care in the home authorized at the physician’s request and included
only a small part of the total value of nursing care received by the
1,686 patients. This care included in the $368 was usually given by
practical nurses or household helpers. Professional nursing service
was provided largely by public and private nursing agencies already
in the communities and by the work-relief nursing project which
operated in all six counties during the period of the study. It has
been estimated that the amount spent for these services for the 1,686
patients studied totaled $4,871, an amount which is not included in
the total of $64,235.
The proportions of total expenditures used for hospitalization and
for payments to physicians depended to some extent on certain


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Federal Reserve Bank of St. Louis

EXPENDITURES FROM PUBLIC FUNDS

29

aspects of the local situation. When medical care for the relief
group was administered by the town welfare officers, as it was in the
rural districts, costs to the local community were usually a primary
consideration.
This is well illustrated by the situation in the rural section of the
industrial and farming county (County C). There the costs of
hospitalization provided in the county hospital were borne entirely
by the county and were not charged back to the town in which the
patient resided. Hospital-delivery costs during the period studied
averaged $36.02. This included payments for prenatal care in 6
percent of the cases. On the other hand, the patient could be de­
livered at home by a physician for a fee of $25 (a charge which in­
cluded payment for prenatal care presumably from the fifth month
of pregnancy). For a home delivery the town bore the cost but was
reimbursed by the State to an extent varying from 40 to 75 percent
during the period of the study. In such a situation the local welfare
officer, who was often a businessman or farmer with little training or
experience in social work but with a keen appreciation of the value
of a dollar, usually authorized hospital confinements. The taxpayers
in the town escaped any direct costs in such cases, although taxpayers
in the county as a whole were subjected to a heavier cost. The lack
of prenatal care for women delivered in the hospital was a factor that
appeared to receive little consideration.
The difference in the point of view of the welfare officer and of the
physicians, public-health nurses, and social workers, who gave pri­
mary consideration to the needs of the patient, created many difficult
situations in the administration of the medical-care program.
The figures in tables 5 and 6 make no distinction between the
expenditures for which the local unit was reimbursed under TERA
regulations and those which were not reimbursable. It has been
pointed out that hospital care was uniformly a local responsibility.
In addition, some of the physicians’ fees were paid by the local,
administrative unit. In the first farming county, for example,
physicians received payment on a fee basis for hospital deliveries,
and these fees did not constitute a reimbursable item. Local veterans’
relief organizations frequently made special arrangements with local
physicians, involving charges that were not reimbursable.
Average Expenditure From Public Funds
for Maternity Care.
Average expenditures from public funds were computed separately
for home and for hospital deliveries, according to whether they
occurred in the rural, the urban, or the suburban areas. Cases of
abortion were excluded from this computation.
277253°— 41------ 3


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30

MATERNITY CARE AT PUBLIC EXPENSE

The averages are based on amounts actually spent; the figures are
not to be interpreted as representing the full cost of adequate medical
and nursing service for either home or hospital maternity care. Nor
do the expenditures represent the full cost of the services received.
Physicians gave professional service without charge to nearly all the
patients delivered in hospitals; and the costs of the supplementary
clinic and nursing services referred to previously are not included in
the average.
In summary, then, the difference between any two sets of figures
(rural compared with urban cases, or hospital compared with home
cases) may represent either or both of two factors: (1) Differences in
the adequacy of services rendered; and (2) differences in the extent
to which the services provided were chargeable to public funds.
In the computation of the average expenditures from public funds
for maternity care provided to women delivered of live-bom or still­
born infants the following items were included: (1) For hospital
deliveries— payments to physicians for prenatal, delivery, and post­
natal care, to practical nurses or “ home helps” for any home care
incident to the confinement, and to hospitals (public and private)
for delivery and postnatal care and for care in connection with com­
plications of pregnancy; (2) for home deliveries— payments to phy­
sicians and midwives for prenatal, delivery, and postnatal care and to
practical nurses. The average expenditures in the five counties taken
together and in the suburban county (excluding nursing and clinic
care during the prenatal period) were as follows:
Number of

Home delivery:
women
Rural (5 counties). _ ________
___________
152
Urban (5 counties)______________ .
_
________ 149
Suburban county __ ___________ _________________ 293
Hospital delivery:
Rural (5 counties)________________ _________________
98
Urban (5 c ou n ties)____ __ _
_________________ 314
Suburban county_____________ __ ____ ____________ 492

Average
expenditure

$24. 51
19. 24
24. 18

40. 96
43. 17
53. 41

The fact that the average expenditure for home deliveries in all
areas is lower than the $25 fee established for complete maternity care
is due to the large number of cases in which prenatal care was not
paid for directly from public funds. In some instances this care
was given in clinics. Some women did not request a physician’s
services until delivery was imminent, and payment was therefore made
only for delivery and postnatal care ($15). In two of the urban areas
maternity care was not paid for on a fee basis but was included in the
services of salaried physicians.
The average expenditures for home deliveries in the rural areas of
each of the five counties where these figures were available showed


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31

EXPENDITURES FROM PUBLIC FUNDS

little variation. A wider range of average expenditures for home
deliveries was found in the urban areas of these counties, where
maternity services were rendered in some instances by physicians
paid on a part-time salary basis and where there was less demand upon
public-relief funds because of available services already established.
The highest average expenditure for hospital delivery in an urban
area was $55.36; this included payment for the services of the physi­
cian attending the patient in the hospital.
Average Cost, Including Estimated Cost
of Nursing and Clinic Care.
The average costs per maternity patient, including the estimated
cost of nursing and clinic care not paid directly from public funds,
have been computed for each county. These averages were com­
puted on all cases—live births, stillbirths, and abortions. They
show rather wide variations from county to county, reflecting the
proportion of patients receiving hospital care and local resources for
clinic and nursing service.
As a basis for computing these averages the number of nursing and
clinic visits to the maternity patients studied was ascertained. After
consideration of the actual costs of this service in agencies where
figures were available and after consultation with local and State
administrators, the cost of prenatal and postnatal nursing and clinic
visits was estimated at $1 per visit. The cost of a delivery-nursing
visit was similarly estimated at $8. The figure for clinic visits seems
high, but it is thought to be a reasonable estimate in view of the small
number of patients served by many of the clinics visited. The total
cost of nursing and clinic services for the 1,686 patients studied was
estimated at $6,606, of which nursing service accounted for $4,871.
These average costs per case, including estimated costs of nursing
and clinic care received, were estimated as follows:
County

Rural

A. First farming c o u n t y ___
_____
.____ $32. 19
34. 87
B. Second farming county _________ ____
35. 25
C. Industrial and farming county_____ ____
D . First mountainous county__________ ____ 28. 24
34. 15
E. Second mountainous county________ ____

Urban

City I
City II

$39.
39.
31.
49.
36.
24.

73
38
25
93.
22
26

The average cost per case in the suburban county was $45.18.
The lowest average cost in rural areas was found in County D.
Because many families were isolated on out-of-the-way roads, the
amount of public-health and bedside nursing was limited, and women
rarely applied for care early in pregnancy. The highest average cost
was found in the large city in County C, where practically all cases
were hospitalized and the prenatal-clinic and follow-up nursing
services were well organized and adequately staffed.

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32

MATERNITY CARE AT PUBLIC EXPENSE

State and Local Expenditures.
Public expenditures for maternity care were divided between hospi­
talization costs, which were borne entirely by the local unit, and
expenditures for home care, in which the State participated (table 6,
p. 28). These costs form a small fraction of the total public expendi­
tures for medical care in the six counties. For the year of the study
the total expenditure for medical care in which the State participated
was $404,542, of which $14,251 was spent for maternity care. (The
suburban county, County F, expended more than $300,000 for medical
care in the home, of which $7,616 was spent for maternity care.) For
the same period the total cost of hospitalization in the six counties has
been estimated at $573,000, of which $49,984 was for hospital care of
maternity patients.
The amounts spent for hospitalization of maternity patients were
thus greater than amounts spent for medical care in the home. How­
ever, in the rural areas of four of the counties a greater percentage of
the total expenditure for medical care in maternity cases was spent for
home medical care than for hospital care. In each of the urban
sections, however, where hospital care of maternity patients was
more common, greater percentages were spent for hospital than for
home care. If amounts spent are compared, it will be seen from
table 6 that in all but one of the counties as a whole, and in
each of the urban sections, the costs of hospital care exceeded those of
home medical care.
Hospital care for maternity patients was definitely restricted in
two urban and two rural districts to cases in which hospitalization
was recommended by the physician because of complications of
pregnancy. A similar regulation was in force in the urban area of
County D during part of the period of the study. In two other rural
areas the general practice was home delivery, and it appeared that
effort was made by relief administrators to keep hospital costs as low
as possible.
In the more remote rural areas, particularly in Counties D and E,
some women had not had a physician’s services at previous confine­
ments and lacked appreciation of the advantages of medical and
hospital care. Instances were reported of women who declined
hospital care which had been strongly recommended.
Although no instance of refusal to hospitalize a maternity patient
upon a physician’s recommendation came to light during the study,
the question may be raised whether some of the patients delivered
at home might not have been more effectively cared for if hospitaliza­
tion had been provided. In County A, for instance, where hospital­
ization was authorized only on the physician’s recommendation
because of complications of pregnancy, 30 percent of the patients
delivered were hospitalized. In County C, City I, where decision as

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EXPENDITURES FROM PUBLIC FUNDS

33

to home or hospital delivery was based on the medical and social
needs of the patient, 43 percent of the women received hospital care.
It may be assumed that more detailed knowledge of the patients’
needs by relief administrators and increased appreciation by patients
of the advantages of medical care will increase the percentage of
total expenditures used for hospital care.
The cost of hospital care constitutes a staggering burden for some
local administrative units, when borne by them alone, and the findings
of this study indicate a need for financial aid from the State to local
communities in the provision of this type of service.


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Duration and Extent of Care
Prenatal Care.
Tables 7 and 8 and tables 14-19 (pp. 46-64) show for the six
counties studied the extent of prenatal medical care supplied from
public funds for the 1,498 maternity patients delivered of live-bom
or still-bom infants. Included were the care for which payment was
made directly from public funds, either to local physicians on a fee
basis or to salaried physicians paid from public funds, and the care
given through local clinics supported in some instances by public and
private funds and in other cases entirely by private funds.
The tables give the number of months prior to delivery during which
care was reported, not the period of pregnancy at which prenatal care
began. In some counties there was a large proportion of women for
whom the extent of care was not reported. It should not be assumed
that these women received no prenatal care; a number of them were
known to have received care from local physicians who were not paid
from public funds for their services.
Of the 1,054 patients in the six counties for whom data on pre­
natal care were reported, only 38 (less than 4 percent) were known
to have received no medical supervision during the prenatal period;
23 of these were in rural areas and 15 in urban areas. But more than
one-fourth of the 1,054 patients were under care for only 1 month or
less prior to delivery; in this group the percentage was slightly higher
for urban than for rural areas.
The figures in these eight tables give no basis for conclusions as to
the quality of the medical service furnished, as has been stated. The
Manual of Medical Care made specific provision for high quality of
medical service. In none of the communities studied, however, was
there an adequate system of professional review of physicians’ records
to see that these provisions were being carried out.
A well-trained public-health nurse working in one of the small
cities had observed that, after she had prepared patients carefully for
the complete examination which she had been taught was essential,
physicians often did not think a complete examination, including
urinalysis, Wassermann test (not at that time required by State law),
and pelvic measurements, was necessary if the patient felt well.
On the other hand, another public-health nurse in a rural area
reported an increasing number of patients referred by local physicians
for complete prenatal care. One physician in this county had insti­
tuted with his private patients a flat payment for prenatal care and
34


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*

DURATION AND EXTENT OF CARE
T a b l e 7.—Number

35

of months of medical care prior to delivery, by place of delivery
and attendant
Maternity cases
Place of delivery and attendant
Home

Total
of care prior to delivery

Hospital

At­
tended
At.
At­
by
tended tended other
by phy­ by mid­ person
wife
or no
Num­ Percenl Num­ Percent Num­ Percent sician
distri­
distri­
distri­
attend­
ber
ber
ber
bution
bution
bution
ant
Total

Total_______ ______ _ 1 1,498

»904

594

584

8

2

Report on care____________

1,054

100

507

100

547

100

540

5

2

Care received_________

1

1,016

96

488

96

528

97

523

4

5 to 8 months______
2 to 4 months______
1 month or le ss____
Months not reported..... ...........

3 160
440
290

15
42
27

86
211

17
41
32

74
229
128

14
42
23

71
228
128

2
1

126

12

29

6

97

18

96

i

No care received_______

38

4

19

4

19

3

17

i

1

No report on care.................

444

R ural areas____

858

Report on care____________

559

100

217

100

342

100

339

2

1

Care received_________

162

397

47

498

44

360

357

1

536

96

210

97

326

95

325

1

5 to 8 months______
2 to 4 months______
1 month or less____
Months not reported__________

83
244
143

15
44
25

38
92
71

18
42
33

45
152
72

13
44

45
161
72

1

66

12

9

4

57

17

57

No care received_______

23

4

7

3

16

5

14

No report on care_______ _

299

281

21

18

1

1

18

U rban areas_______

640

227

6

Report on care......................

495

100

290

100

205

100

201

3

1.

Care received_________

480

97

278

96

202

99

198

3

1

5 to 8 months .
2 to 4 months
1 month or less
Months not reported___________

3 77
196
147

15
40
30

48
119
91

17
41
31

29
77
56

14
38
27

26
77
56

2

60

12

20

7

40

20

39

i

No care received_______

15

3

12

4

3

1

3

No report on care________

145

406

116 J

234

29

1 Exclusive of 188 cases resulting in abortion.
»Inclusive of 10 cases in which delivery was at home and postnatal care in hospital
3 Inclusive of 1 woman who reported 9 months of care.


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26

36

MATERNITY CARE AT PUBLIC EXPENSE
T a b l e 8. —Number

of months of medical care prior to delivery, by county
Maternity cases
Care prior to delivery

Area
Total
Total

_

Total_______________

.

No care No re­
to port on
Months prior
5 to 8
delivery
care
1 month
2
to
4
not re­
months months or less
ported
or more

U,498

1,016

160

440

290

126

38

99
67
361
132
64
785

85
49
236
99
45
502

17
42
9

2

42
18
95
28

23
15
70
25

2
88

249

3
14
29
37
29
14

3
13
15
3
4

8

6

151

444
14
15
102

18
16
279

i Exclusive of 188 cases resulting in abortion.

delivery in order to encourage them to come to him earlier in preg­
nancy and to report more regularly. His opinion was that this plan
worked successfully.
In one of the cities there was no prenatal clinic. The nurses in
the city health department carried on prenatal instruction without
active cooperation on the part of the city physician. In another
city the relief administrator stated that women were unwilling to
attend the prenatal clinic, and the nurse assigned to follow-up work
reported a discouraging lack of response. This city had a large for­
eign population with a relatively high illiteracy rate.
In the rural areas prenatal work was handicapped by transporta­
tion difficulties, by limited nursing personnel, and by the failure of
women to make their needs known because of a lack of appreciation of
the advantages of medical care. The State-aided county nurses
learned of a large number of patients through local sources of infor­
mation. These nurses carried heavy case loads, however, and dur­
ing the winter months parts of five counties were all but inaccessible
because of weather conditions. Younger women were found to be
taking some initiative in securing care for themselves, but the older
women, who had borne a number of children without medical care
until delivery, saw little need for prenatal care. Public-health work­
ers recognized a need in these areas for further educational work
through agencies such as women’s organizations, newspapers, and
home-nursing classes in the public schools.
Another handicap met in providing prenatal care for women in
families receiving relief was the reluctance felt by many women to
have their pregnancy known until it was obvious. In small com­
munities the welfare officers and investigators were often personally
acquainted with the women in need of medical services. Many of
the relief investigators were young men to whom the women hesitated
to make their needs known.


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Federal Reserve Bank of St. Louis

DURATION AND EXTENT OF CARE

37

Women in the self-maintaining group unable to pay for medical
care often deferred making application in the hope that their financial
situation would improve sufficiently to enable them to pay for their
own care. Welfare departments are frequently handicapped in
providing medical care to the medically needy by the hesitation of
families in that group to apply to an agency associated in their minds
with relief and dependency.
The most important factors in the administration of any program
for prenatal care are the attitude of the welfare officers and the
system through which medical care is authorized. Welfare officers
in some of the areas authorized hospital care at confinement, but took
the view that prenatal care was the responsibility of the family and
that if the family were relieved of all responsibility for medical
care the result would be more children brought into the world at the
expense of the town. Other officers made definite efforts to educate
maternity patients as to the desirability of early care.
Postnatal Care.
Available data on postnatal care are shown in tables 9-11. Among
the 887 hospital patients in the six counties for whom data were
reported, 37 percent remained in the hospital from 6 to 10 days after
delivery, 53 percent remained 11 to 14 days, and 8 percent remained
15 days or more. Less than 3 percent (25 patients) remained less
than 6 days. Twelve of these 25 patients were in one city where the
average length of stay in the maternity service was stated to be 5
days for ward patients and 7 days for private patients. Home care
by local physicians and work-relief nurses was authorized freely in
this city. Both home and hospital care were authorized through the
director of the home-relief bureau, who worked closely with the
superintendent of the city hospital.
Data regarding postnatal care for women delivered at home un­
fortunately are very incomplete. The forms on which the physicians
submitted their bills for payment constituted the chief source of
information; these forms often read “ for prenatal, delivery, and
postnatal care,” with no further information. In the two cities
where salaried physicians were employed these physicians often
made visits to the homes of patients whom they had delivered without
reporting to the welfare office.
Among the 388 cases for which data were available (see table 10)
173 (45 percent) of the patients received from 4 to 6 postnatal visits
each from the physician, 141 (36 percent) received 7 or more visits,
and 74 (19 percent) each received 3 visits or less. About half of
this last group were urban residents, but 17 of the urban patients
were in a city where the data regarding postnatal care are known to
be incomplete.

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38

MATERNITY CARE AT PUBLIC EXPENSE
T a b l e 9.—Number of days of postnatal care in

hospital, by county

Women receiving postnatal care in hospital
Number of days

Area
Total
Ito 5
Total.
Rural..
Urban.
County A .

6 to 10

re­
11 to 14 15 or more Not
ported

i 904

327

466

498
406

211
116

233
233

30

15

69

17

Rural..
Urban.
17

County B_
Rural..
Urban.
County C.
Rural..
Urban.
City I . .
City II.

9
279

14

32

207

65
214

47
160

35
179

5
155
26

30

492

239

206

400
92

192
47

169
37

County D .

20

Rural..
UrbanCounty E .
RuralUrban.
County F.
Rural—
Urban.

10
5
5
36

1Inclusive of 10 women delivered at home with postnatal care in hospital.

Table 11 presents the available information concerning the dura­
tion of postnatal care received by the patients delivered at home.
Among 385 women in the six counties for whom this information
was reported, 58 percent (222 patients) were under a physician’s
care from 6 to 10 days after delivery. About 26 percent (102) re­
ceived medical care for 11 days or more, and the remaining 16 per­
cent (61) had medical care for less than 6 days.
The Manual of Medical Care stated that authorization for obstetric
care should include provision for a final gynecologic examination of
the mother approximately 6 weeks after delivery. A negligible
number of the bills submitted for payment included the date of this
examination. The bills were usually submitted for payment within a
week or 10 days after delivery, however, and it was the opinion of
relief investigators and nurses that examinations were often given
at a later date.
Workers in postnatal clinics expressed discouragement at their
lack of success in getting patients to return for the final examination.

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39

DURATION AND EXTENT OF CARE
T a b l e 10.—Number

of 'postnatal visits by physicians to women delivered at home by
physicians paid from public funds, by county
Women delivered at home by physicians
Postnatal visits by physicians

Area
Total

3 or less
Total.

4 to 6

7 or more

Not re­
ported

1584

74

173

141

196

R u ral...............
Urban...............

357
227

39
35

132
41

86

55

100

County A

68

27

10

8

23

Rural____ ____
Urban________

25
43

10

1

17

5
5

9
14

7

96

County B

33

8

25

Rural..... ...........
Urban...............

24
9

1

7

23

County C

67

14

9

1

Rural_________
Urban............... .

21

7
7

7

1

46

2

37

City I ......... .
City II....... .

44

6
1

2

2

36

County D.

71

13

17

9

32

Rural................
Urban________

43
28

12
1

15

4
5

12
20

2

2

43
6

1

County E

53

1

52

Rural.... ........ .
Urban..............

37
16

1

36
16

County F.

292

11

137

123

21

207
85

8

105
32

80
43

14
7

Rural.
Urban.

3

1Exclusive of 10 women delivered at home with postnatal care in hospital.

These workers thought that the failure of many patients to return
was attributable to their concern with their babies rather than with
themselves and to the increased pressure of home duties after the
addition of the babies to their households. In clinics where a high
percentage of patients returned for the final examination there was
evidence of careful and persistent follow-up on the part of the clinic
nurses. Few clinics were sufficiently staffed for such a follow-up,
however. It appears that this important feature of maternity care
needs greater emphasis and attention.


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Federal Reserve Bank of St. Louis

40

MATERNITY CARE AT PUBLIC EXPENSE

T a b l e 11.—Interval

between delivery and last visit of physician following home
delivery by physicians paid from public funds, by county
Women delivered at home by physicians
Interval between delivery and last visit of
physician following delivery

Area
Total

Less than
6 days

11 days or

6 to 10

more

days

Not reported

1 584

61

222

102

199

Rural................ .
Urban_________

357
227

33
28

160
62

63
39

101

County A.

68

21

15

10

22

Rural................
Urban_________

25
43

7
14

7
8

3
7

14

2

26
23
3

Total.

98

8

County B

33

5

Rural_________
Urban...............

24

1

0

4

2

County C

67

10

8

4

45

Rural_________
Urban_________

21

3
7

7

4

1

7
38
37

46

City I ..........
City II....... .

44

6
1

1

2

16

11

33

14

6

13

5

20

1

County D.

71

11

Rural_________
Urban...............

43
28

10
1

County E

53

1

52

Rural................
Urban________

37
16

1

36
16

County F

292

13

181

77

21

11
2

132
49

50
27

14
7

Rural .
Urban.

207
85

2

1 Exclusive of 10 women delivered at home with postnatal care in hospital.

Maternity Nursing Care Provided
Through Community Agencies.
In an earlier section on State and local health administration
(pages 6 to 9) mention was made of the development of health
services by local units without the central direction necessary for a
coordinated and unified program. Services in local areas were de­
pendent to a great extent on local sentiment and local finances. The
policy of the State health department was to stimulate local communi­
ties to extend their activities through local organizations. Funds
available through the Federal Maternity and Infancy Act from 1922
to 1929 made possible financial assistance to selected communities in
obtaining specialized medical and nursing services for prenatal care
and general instruction in maternity care but not in paying for med­
ical or nursing care at delivery or in the hospital. In some communi­
ties these Federal funds were used to pay part of the salary of nurses,
half of whose time was given to maternity service. State aid to local

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Federal Reserve Bank of St. Louis

DURATION AND EXTENT OF CARE

41

communities has been given on a county basis in New York State
since 1923, and nursing services in many up-State counties have in
recent years been financed jointly by the county and the State.
Knowledge of this background and policy is essential to an under­
standing of the maternity nursing services operating in the six counties
studied. One of the farming counties maintained a county health
department employing three nurses; this department was supported
by State and county funds on a 50-50 basis, and the nurses worked
under the direction of the county health officer. In four other counties
State-aided county nurses worked under local public-health com­
mittees; professional direction of their activities was supplied by the
district State health officers and supervising nurses. During the
period of the study the work-relief project was operating in all six
counties, but in the two farming counties no work-relief nurses were
assigned to the rural areas. Visiting-nurse associations financed by
local public and private funds employed between 35 and 40 nurses
in two counties. In several small cities nurses from boards of health
were actively engaged in maternity work. Private organizations
supported nurses in five counties. Several towns in two counties
made some provision for nursing service through local public funds
supplemented by private contributions.
Two large insurance companies supplied nursing care for their
policyholders, and through this service gave maternity care to large
numbers of the low-income group and to some relief recipients.
These companies maintained nursing services (through local nursing
organizations paid on a fee basis or through their own representatives)
throughout the State, except in the most remote rural areas. State
officials said that the extent to which these services were available
to families on relief could not be estimated accurately, because relief
authorities sometimes failed to clear cases needing nursing care
through the resource division of the relief organization to ascertain
whether such cases were eligible for nursing service from insurance
companies. This procedure would have been difficult and might have
resulted in delay in providing service to patients urgently in need of
attention. The extent to which the services of these nurses were
utilized was also limited by the concealment of insurance resources
by some relief recipients.
The work of most of these nursing organizations included both bed­
side nursing and health supervision. The State-aided county nurses
were engaged primarily in public-health activities and gave bedside
care only in emergencies or for the purpose of teaching families to give
such care. In areas where there was no other agency giving bedside
nursing care or where the provision for bedside care was very limited,
it necessarily followed that such emergencies and demonstrations to
families were frequent and time-consuming. The director of the divi
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Federal Reserve Bank of St. Louis

42

MATERNITY CARE AT PUBLIC EXPENSE

sion of public-health nursing in the State Department of Health es­
timated that 44 percent of the field service of the county nurses was in
maternal and child-health activities.
Duties of work-relief nurses included delivery-nursing service at
the physician’s request. Only one other nursing organization, a
privately maintained agency in a small city, provided nursing care at
delivery.
Some difficulty was experienced in checking the study schedules for
nursing care given by the work-relief nurses. At the beginning of this
project no funds were available for record keeping. In some sections
visits by these nurses were not entered on the permanent record form
used by local agencies. Classified totals of visits paid by the workrelief nurses were available in all areas and are presented in table 12,
T able

12.— Visits by work-relief nurses to all maternity cases and to other cases in

the area included in the study, by county

Area

Number
of
nurses

Type of care given 1

Total
visits

Prenatal Delivery Postnatal

Other

Total__________________________ _

45

56,763

2,823

75

3,485

County A—Urban..____ _______ ____ ___

5

5,644

322

20

655

4,647

County B—Urban___________ __________

3

4,844

430

1

134

4,279

County C ...................................................

9

9,796

629

20

334

8,813

Rural........................... ............ .............

3

3,859

455

10

176

3,218

Urban______________________ ____ _

50,380

6

5,937

174

10

158

5,595

City I ......... ...................................
City I I ____________________

1

5

1,748
4,189

123
51

10

85
73

1,530
4 Ofifi

County D ....................................................

10

14,995

530

28

481

13,956

Rural_____________________________
Urban_____________________________

5
5

7,689
7,306

336
194

26

217
264

7,110
6,846

2

County E—Rural and urban....................

4

5,602

164

6

183

5,250

County F—Rural______ _______ ________

14

15,882

748

1

1,698

13,435

i Inclusive of bedside nursing and health supervision.

Nursing care by the work-relief nurses was not restricted to relief
families but was extended to families who were able to maintain them­
selves but unable to pay for necessary medical care. A large part of
the nurses’ work was concerned with the care of mothers and children,
and their service included attendance at 75 home deliveries.
In table 13 are presented the available data concerning the
contribution of nursing agencies to the care of maternity patients
studied. This represents all visits by nurses paid from public or from
public and private funds and includes visits by work-relief nurses.
It is recognized that the totals for visits fall short of the actual num­
bers, particularly with reference to the activities of work-relief nurses.
The figures therefore fail to represent the actual nursing service

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DURATION AND EXTENT OF CARE

43

rendered, but they indicate the importance of the contribution made
by such community agencies. The cost of the services, as has been
pointed out, was estimated at $4,871.
T able

13.—Number of maternity cases cared for and number of visits by nurses 1

to women receiving care at public expense, by county

Type of care given by nurse
Area

Prenatal

Cases
Total.......... .....................

Postnatal
bedside

Delivery

Postnatal
follow-up

Visits

Cases

Visits

Cases

Visits

Cases

Visits

499

1,940

35

35

266

1,117

199

322

249
250

1,034
906

6

29

6

29

109
157

439
678

77
122

101
221

24

136

20

20

30

279

4

10

7
17

39
97

1

1

3
27

33
246

4

10

26

88

11

17

12

14

51
37

10
1

16

211

705

129

343

103

195

Rural.......................

41

152

20

48

5

7

Urban.......................

170

553

9

9

109

295

98

188

43
127

94
459

9

9

23
86

118
177

98

188

18

136

5

5

25

168

2

3

12
6

77
59

5

5

17

82

8

86

2

3

40

168

1

1

13

22

13

18

26
14

125
43

1

1

1

2

13

18

180

707

58

288

77

151
29

590
117

11

48

11

Rural......... ...................
Urban________ ________
County A ____ ____ _
Rural..........................
Urban..... .......................
County B ....... .................
Rural____ ________ __
Urban________ ______
County C ......................

City I . . . . ...................
City II___________
County D ......................
Rural____________
Urban________
County È ..................
Rural..........................
Urban______________
County F ..................
Rural.............. ........
Urban.......................

niliSfpald f S m Ä Ä d | 1S “ d °ther’


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Federal Reserve Bank of St. Louis

19

9

19

9

1

81
15

fn>mPUbli° m d from public m d private funds- ExcIudes

Maternity Care in Individual Counties
County A—
First Farming County.
In the rural area medical care in the home at public expense was
provided by local physicians on a fee basis. In the urban district care
was given by five salaried physicians to patients in their homes and at
a clinic. These physicians received $100 a month for part-time
services; their salaries were reimbursable under TE R A regulations.
This system was adopted early in 1935 in an effort to reduce the exces­
sive costs of providing medical care entirely on a fee basis. According
to an agreement with the county medical society, physicians received
$15 for delivery and postnatal care of hospital patients; these fees
were not reimbursable items. Prenatal care was given through the
privately financed prenatal clinic of a local private hospital; the
patient was transferred at the seventh month to the salaried physician,
who delivered the patient at home unless complications were present.
Home deliveries were the rule throughout this county, hospitaliza­
tion being authorized only on the physician’s recommendation because
of complications. The prenatal clinic in the city was available to all
county residents who could obtain the necessary transportation, and
hospital care was available in four private hospitals at a daily rate of
$3.50, with extra charges for ambulance, delivery room, and special
drugs. Hospital care at public expense for maternity patients was
usually provided in the two hospitals located in the city. There was
some privately financed free hospital service in one of these hospitals.
One county nurse paid from State and county funds did all types of
health work in the rural area. Local physicians were referring increas­
ing numbers of maternity patients to her for prenatal instruction.
One town employed a nurse who worked under the supervision of the
health officer. No work-relief nurses were assigned to the rural areas,
but the department of public welfare authorized care by practical
nurses at an agreed daily rate to a greater extent than in the other
districts studied. In maternity cases these practical nurses assisted
at delivery and remained in the home between 1 and 2 weeks. Five
work-relief nurses worked in the city under supervision of the city
health department. Some nursing service was provided by insurance
companies for their policyholders.
Welfare officers were sometimes reluctant to meet the special needs
of their clients, such as proper diets for pregnant women. On the


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CARE IN INDIVIDUAL COUNTIES

45

other hand, one welfare officer found difficulty in persuading women
to see the need for medical care during the prenatal period, since they
had had other children with no medical care prior to delivery. A
local physician reported this attitude among many of his patients.
One case m ay be given as illustrating relief policies. The family consisted of
father, mother, and seven children. The man earned $35 a month as a farmer,
and had free rent, a garden, and a car. The mother became pregnant, and the
welfare officer refused to authorize medical care, saying that the man was earning
enough to pay for his wife’s confinement.

Local physicians still carried the burden of medical care for this
group and were often paid “ in kind,” usually receiving the worst of
the bargain. One physician received in payment for a confinement case
several bushels of very large potatoes, all of which were hollow.
In this county 102 maternity patients received assistance from pub­
lic funds during the year of the study. As table 4 (p. 26) shows, the
five births to women receiving care at public expense included 10
percent of the total five births in the county. This percentage was
lower than that in any other county.
Only 30 of the 99 women whose pregnancies resulted in live births
and stillbirths were hospitalized. The high percentage of home de­
liveries (70 percent of the total) and the fact that very little bedside
nursing service was available in the rural sections of the county,
indicated a need for increased service of this type. This need was
met in several cases through the authorization of care by practical
nurses. In many cases where no nursing care was provided through
public funds investigators and the case supervisor stated that rela­
tives or neighbors had given such care. In rural areas the “ good neigh­
bor” contributes to the adequacy of social and health services to a
degree unknown in urban centers, a situation which accounts for some
of the apparent gaps in rural relief programs.
No maternal deaths occurred among the women receiving maternity
care at public expense in this county.
Because it was the general practice in this county to provide
maternity care at public expense through home deliveries, State funds
were used to a greater extent than in any of the other counties studied
with the exception of County E. As table 6 (p. 28) shows, almost
half of the total public expenditure for maternity care was devoted to
care in the home. In the rural section more than four-fifths of the
total was spent for home care.
The estimated average cost per case for medical and nursing care,
including clinic and nursing service furnished by agencies not paid
directly from public funds, was $32.19 in the rural and $39.73 in the
urban sections of the county.
Most of the patients were known to have received some prenatal
277253°— 41------ 4


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MATERNITY CARE AT PUBLIC EXPENSE

care (table 14). In no instance was the physician called to deliver
the patient as an emergency, a fact which indicates the effective
working relationships of the relief agency, the county nurse, and the
physicians. In the rural section, however, one-fourth of the patients
for whom care was reported, and in the urban area a slightly larger
proportion, received care for 1 month or less prior to delivery.
14.—County A: Number of months of medical care prior to delivery, by place
of delivery and attendant; women receiving maternity care at public expense

T able

Maternity cases
Place of delivery and attendant
Area, and number of months of care prior to
delivery

Home
Total
Hospital

Attended Attended
by other
by
person
physician

Total

i 99

30

69

68

i

Care received.._______________________ _________

83

26

59

58

i

5 to 8 months______________________________

17
42
23
3

11

i

12
8
1

30
15
2

2

14

4

10

10

TotaL_______ ______________________

—

5

12

30
15

28

3

25

25

21

2

19

19

9
5
5

1
1

8

2

8

4
5

4
5

2

2

7

1

6

6

Urban areas____________________________

71

27

44

43

i

Care received.______ ___________________________

64

24

40

39

i

8

4

10

10

1

11
8
1

3
26

i

37
18

4
26

7

3

4

4

5 to 8 months__________ ___ _____ ___________

1 Exclusive of 3 cases resulting in abortion.

It seems likely that the figures in tables 10 and 11, showing the
amount of postnatal medical care at home, furnish an understate­
ment of the actual amount of postnatal care given the patients,
particularly in the urban section, where five city physicians were
employed on a monthly basis. Often the physician, having de­
livered the patient, returned on his own initiative (rather than as a
result of a call from the patient, which would as a matter of routine be
recorded in the welfare office) and neglected to report the visit to the
welfare office. This explanation is corroborated by the relatively
large number of cases in which the amount of care was not reported.


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CARE IN INDIVIDUAL COUNTIES

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County B—
Second Farming County.
County B was the only one of the six counties which maintained a
health department under the direction of a full-time physician with
training in public health. Three nurses from this department worked
in the rural area, each nurse taking care of all the services within her
district. The nurses' duties included both public-health instruction
and bedside care. Several clinics were conducted by the county
health department at its headquarters in the city— prenatal clinics
monthly (with a usual attendance of between 10 and 15 patients),
well-baby clinics twice a month, venereal-disease clinics twice a week,
tuberculosis clinics monthly, and immunization clinics several times
a year.
Hospital care at public expense was available to rural maternity
patients in a private hospital at the county seat at an agreed basic
rate of $3 a day. This hospital had a capacity of 114 beds, with 12
ward beds and several private rooms for the maternity patients.
There was some indication that the welfare officers tried to keep
hospital costs at a minimum, and one relief investigator criticized the
eagerness of physicians to hospitalize maternity patients. No in­
stances of refusal by relief officials to hospitalize a patient upon a
physician's recommendation came to the attention of the study
workers, however, and 12 out of 37 rural maternity patients were
hospitalized during the period of the study.
The county nurses visited all pregnant women referred to them by
the relief office or through community contacts; if patients were un­
able to /obtain private care, the nurses referred them to the prenatal
clinic. The nurses assisted mothers in the marginal group in arrang­
ing hospitalization and made an effort to pass on to the hospital
clinical findings in regard to patients for whom hospital care had been
recommended. The nurses assisted at home deliveries only in
emergencies.
In the city, hospital confinements were the rule, with prenatal care
given through the clinic of the county health department. During
most of the year covered by the study two and sometimes three workrelief nurses were assigned to health instruction and bedside care.
The relief commissioner had no previous experience in social work
but showed unusual readiness to avail himself of opportunities for
advice and help from professional workers and was sincerely interested
in his job. The office maintained good relationships with the local
hospital and the county health department.
The needs of the marginal group received unusual attention in this
city, and the health commissioner and the comptroller at the hospital
cooperated in making arrangements for the hospitalization of mater­
nity patients able to pay small amounts toward their care. At the


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MATERNITY CARE AT PUBLIC EXPENSE

time of this study they were admitted to the hospital as “ service”
cases at a rate of $2 a day and later at a flat rate of $25 for a 10-day
maternity stay; this rate was permitted at the discretion of the comp­
troller. The health commissioner notified the comptroller of prospec­
tive admissions, and these patients were requested to come to the
hospital in advance of admission to complete arrangements for care
and for payment of their bills.
In this county 69 maternity patients received maternity care at
public expense during the year of the study (table 2, p. 22). As is
shown in table 4 (p. 26), the five births occurring to women cared for
at public expense included 11 percent of the total live births in the
county during the period covered.
Hospital care was arranged for 32 women whose pregnancies resulted
in live births or stillbirths, 12 in the rural area and 20 in the city.
Nursing care in the home at a daily rate was provided for one patient
in the rural section and two in the city at a total public expenditure
of $65. The data regarding nursing care from the nurses of the
county health department are unfortunately incomplete. It seems
certain that in the rural area particularly these nurses furnished an
important contribution to the adequacy of maternity care.
The average cost per case for medical and nursing care, including
estimated costs for clime and nursing services from community agen­
cies, was $34.87 in the rural section and $39.38 in the city. The
average cost in the rural area was higher than in all but one of the
other counties j the cost in the city was also relatively high.
In the rural section two-thirds of the 37 patients confined at public
expense were known to have received prenatal care (table 15). Three
received no prenatal care, and for 9 women information was not
available. The period of time under care was ascertained for 14 pa­
tients; 2 of these received care for 1 month or less prior to delivery,
11 received care for 2 to 4 months, and 1 patient was under care for at
least 5 months.
In the city four-fifths of the 30 patients confined at public expense
received prenatal care (table 15). The period of time during which
they were under care was ascertained for 21 patients, of whom 14 re­
ceived care through the prenatal clinic. Thirteen women received
prenatal care during 1 month or less prior to delivery, 7 received from
2 to 4 months’ care, and 1 patient was under care for 6 months. It
is possible that some of these patients received free care from local
physicians prior to their attendance at the clinic or before care was
authorized through the department of public welfare. It is probable
that the greater average duration of prenatal care in the rural section
resulted from the concentration in that area of the home visiting of
the county nurses.


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CARE IN INDIVIDUAL COUNTIES

15.— County B : Number of months of medical care prior to delivery, by place
of delivery and attendant; women receiving maternity care at public expense

T able

Matemity cases
Place of delivery and attendant
Area, and number of months of care prior to
delivery

Home
Total
Hospital

Attended Attended
by physi­ by mid­
cian
wife

Total

T o ta l-

167

2 32

35

33

Care received.

49

20

29

29

2

18
16
14

1
10
8
1

1
8

1
8

7
13

7
13

3
15

12

3
3

2
2

1
1

Rural areas.

37

12

25

24

1

Care received--------

25

5

20

20

1
11
2
11

3

1
8
1
10

1
8
1
10

3

2
2

1

2

1

5 to 8 months.......... ...
2 to 4 months_______
1 month or less______
Months not reported.
No care received...---------No report on care received.

5 to 8 months_______

2 to 4 months_______
1 month or less------ —
Months not reported.

1
1

No care received------- ------No report on care received.

3
g

7

U rban areas.

30

20

10

9

Care received---------

24

15

9

9

1

2

1

5 to 8 months....... ........
2 to 4 months..—_____
1 month or less---------Months not reported - .

7
13
3

7
,7

No report on care received.

6

5

6

6

3

3

1

1

i Exclusive of 2 cases resulting in abortion.
' .
>Inclusive of 1 case in which delivery was at home and postnatal care in hospital.

Of the 12 patients from the rural section who were delivered in
hospitals, 1 left the hospital before the sixth day after confinement, 3
received from 6 to 10 days of postnatal care, and 8 received from 11
to 14 days (table 9, p. 38). Of the 20 hospital cases in the city 10
received from 6 to 10 days of postnatal care, 9 received from 11 to 14
days, and 1 patient remained in the hospital for a longer period.
For some deliveries in the rural section it was impossible to ascer­
tain the duration of postnatal care, as dates of the physicians’ visits
were not available. In the city such information was available for
6 of the 9 home deliveries (table 11, p. 40). In 4 cases postnatal care
extended for less than 6 days; 1 patient was under the physician’s care
for 9 days, and 1, for 10 days.
One patient who received care in this county was an Irish woman, 40 years of
age, undergoing her twelfth confinement. Her husband was an expert bricklayer
who had formerly earned as much as $72 a week; he had been hospitalized the


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MATERNITY CARE AT PUBLIC EXPENSE

previous year for chronic appendicitis and double hernia, had had to give up his
regular job, and was dependent on occasional employment.
A t the time the woman applied for medical care her husband had had no work
for 3 weeks. The only income was $15 a month rent from an apartment over a
garage the family owned and the earnings of one of the older boys who had
seasonal employment in the cabbage fields. The family lived in a large, sparsely
furnished house which the father had built. The patient was a very energetic,
capable, happy person, who was an excellent manager and delegated household
tasks to each of the children, so that the family lived in an atmosphere of mutual
cooperation and devotion.
Since the family owed a large hospital bill, the patient could not be admitted
without some guarantee of payment. The department of public welfare author­
ized hospital care and paid $44 for 13 days’ stay. The patient attended the pre­
natal clinic three times and was delivered in the hospital.
The case investigator stated later that this patient was again pregnant. The
family had not received relief in some time, and the mother came to tell the case
supervisor that since two of the girls were working they expected to be able to
take care of the hospital bills themselves. The patient seemed extremely happy
over the prospect of the thirteenth baby.

County C—
Industrial and Farming County.
In line with its relatively large population the industrial and
farming county had a larger number of maternity patients aided by
public funds— 371— than any of the others except the suburban
county. Of these patients, 93 were in the rural section and 278 in
the two cities (table 2, p. 22). Data for the two cities were tabulated
separately because of variations in policies and procedures in granting
care.
In the rural area maternity patients were generally delivered in
the county hospital, a plan favored by the town welfare officers be­
cause hospitalization costs were borne by the county and not charged
back to the towns. The hospital had no regular prenatal or postnatal
clinic, but it was understood that patients wishing this care might
come to the hospital at a specified tune each week. The resident
physician stated, however, that only one or two patients came in
the course of a year; no records were kept of the examinations. A
considerable number of patients received prolonged prenatal care
in the hospital wards, however, some because of complications of preg­
nancy and others because of lack of other resources for boarding care.
One prenatal clinic, opened during the period of the study, gave
care to 30 women; 9 patients reported also for postnatal examinations.
During 1937 the clinic had a usual attendance of 5 or 6 patients; the
records showed 14 new patients during the first 7 months of the year.
The nurses attributed the limited requests for service to transportation
difficulties.
Home deliveries were authorized on a fee basis, according to the
rules and regulations of the TERA, in emergencies and in instances

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CARE IN INDIVIDUAL COUNTIES

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where patients refused hospital care. The patient was permitted to
choose her own physician from the few available physicians, some of
whom were unwilling to perform home deliveries.
Fully three-quarters of the 86 women who gave birth to live or still­
born infants were hospitalized (table 16, p. 53). Little provision was
made for prenatal care aside from the one State-aided prenatal clinic,
and the marginal and relief groups did not appear to be acquainted
with its importance. Nursing service outside the two cities was pro­
vided by four nurses maintained by State and county funds. They
gave both health instruction and bedside care, and the prenatal clinic
mentioned above was under their direction. During the period of the
study two work-relief nurses worked under their supervision.
City I .— In the smaller city (City I) relief policies and procedures
were clearly defined, and the department had availed itself of oppor­
tunities for training staff workers through the training program of the
TEKA. Relief was administered efficiently, the clients’ problems
were individualized, and special needs were recognized and given
consideration.
Eight clinics of various types were conducted under city, county,
or State auspices. The city hospital provided a limited amount of
hospitalization at an agreed rate of $3.50 a day, and the working
relationship between the relief and hospital administrations was
excellent. The organization of available resources here demonstrated
that a public medical-care program could be highly flexible. Pre­
natal care was given in the city clinic or, if reasonable effort to refer
patients there failed, by private physicians on a fee basis. Confine­
ment was either at home or in the city hospital, depending on the
medical and social needs of the individual. The city hospital had only
6 ward beds and 8 private rooms for maternity patients, a fact which
probably influenced to some extent the period of care for the
individual patient. During 1936 the usual stay for ward patients
was said by the hospital administrator to be 5 days and for private
patients 7 days. In this city 35 of the 82 women whose pregnancies
resulted in live births or stillbirths (and all 5 of the women whose
pregnancies resulted in abortion) received hospital care (table 2, p. 22).
One work-relief nurse attached to the relief office gave prenatal
instruction, bedside care, and assistance at delivery at the physician’s
request. Two nurses from the city health department gave clinic
assistance and did follow-up work. A private nursing organization
maintained two nurses who gave care on a fee basis, largely to the
marginal group.
City I I — In the larger city (City II) all maternity cases were
referred to the city hospital for confinement; there was no provision
for home deliveries at public expense; and physicians usually refused
to deliver patients in their homes.

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MATERNITY CARE AT PUBLIC EXPENSE

The lack of any provision for home deliveries at public expense did
not appear to be a serious problem, except in very rare instances.
Patients usually went to the hospital without hesitation, although it
was stated that when the system was first put into operation they
frequently raised objections. Here 179 of the 183 patients were
delivered in the hospital.
Weekly prenatal and postnatal clinics were conducted in two health
centers by a nursing agency. The work of this agency was outstand­
ingly good from the point of view of relationship with the free dis­
pensary and the department of public welfare; the problems of individ­
ual patients received careful consideration; prenatal and postnatal
follow-up were effectively carried out and efficiently recorded.
Services of the 12 city physicians to maternity patients were limited
to treatment of complications of pregnancy in instances in which the
patients were unable to attend prenatal clinics. Medical and dental
treatment was available at the free dispensary maintained entirely
by city funds.
The local nursing organization also supplied nursing care in the
home, and a work-relief project was available for housekeeping service
to maternity patients both before and after confinement. This
organization provided clinics and employed 17 nurses for publichealth instruction and bedside-nursing care. In addition, several
work-relief nurses worked under their supervision.
Relief records in the department of public welfare indicated that
increased food allowances and extra milk were supplied to families in
which women were known to be pregnant. In some active homerelief cases, however, it was noted that no mention of the woman’s
condition was made until the medical investigator had completed
arrangements for hospital care, usually in the ninth month of preg­
nancy. Requests for medical care, including hospitalization, were
handled by a separate division of the department of public welfare,
and there was a recognized need for a closer working relationship
between the home-relief division and the medical division.
The two workers in the medical division were handicapped by pres­
sure of work, and neither worker had had the experience in publichealth or medical social work essential to an understanding of the
interrelation of medical and social factors. The lack of such training
and experience limited the workers’ usefulness in explaining the
medical needs of clients to the relief division.
The average cost per case, in county C as in the other counties
studied, reflected the amount of hospital care given, being higher in
those areas where hospital care was provided freely. In the rural
section the average cost, including estimated costs of clinic and nursing
care obtained through community agencies, was $35.25. In the larger

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CARE EST INDIVIDUAL COUNTIES
T a b l e 16.—County

C: Number of months of medical care -prior to delivery, by place
of delivery and attendant; women receiving maternity care at public expense
Maternity cases
Place of delivery and attendant
Area, and number of months of care
prior to delivery

Home
Total
Hospital

Attended Attended
by
by
physician midwife

Total

T o t a l— ....... .................................. - ........—-

i 351

1279

72

67

5

Care received__________________________________

236

179

57

54

3

5 to 8 months______________________________

35
81
60
3

7
14

5
14

2

10

10

Months not reported......... ................................

42
95
70
29

26

. 25

3

3

No report on care received______________________

102

90

12

10

86

65

21

21

35

16

19

19

2

2

13

2
11
12
10

10

1
2

5
5
7

7
3

5
5
7

50

49

1
1

1
1

U rban areas........ ...........................................

265

214

51

46

5

City I............................................................

82

35

47

44

3

Care received.............................................................

52

18

34

33

1

4
13
16
19

1

3

3

1

6

5

8

8

12

4
19

4
18

1

2

1

No report on care received.................................. —

3
27

16

2
11

9

2

City II...........................................................

183

179

4

2

2

Care received............................................................

149

145

4

2

2

36
71
42

34
70
41

2
1
1

1
1

9
25

9
25

2

i Exclusive of 20 cases resulting in abortions.
* Inclusive of 3 cases in which delivery was at home and postnatal care in hospital.

city it was higher than in any other community studied— $49.93—
and in the smaller city it was $31.25, a relatively low figure.
For this county pertinent data regarding prenatal care in the
351 cases of live births and stillbirths are presented in table 16.
It will be seen that in many cases it was impossible to ascertain the
extent of this care. In the rural section prenatal care was reported
for 35 of the 86 deliveries studied. One welfare officer stated that
during the several years he had been in office no woman had ever asked


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MATERNITY CARE AT PUBLIC EXPENSE

him to authorize prenatal care. Another welfare officer said he had
received such requests but usually refused them, believing that the
man could get odd jobs and pay for his wife’s care. He went on to
say that he did not believe in arranging all this care, because if families
were relieved of all financial responsibility they would continue to
have children year after year at public expense. Further conversation
with relief and health officers gave the impression that the authoriza­
tions for prenatal care were not given readily and that the usual
practice was to authorize confinement care in the county hospital and
assume that the family would be able to obtain prenatal care through
its own resources.
Forty-three of the 65 rural patients delivered in the county hospital
were not receiving other aid from public funds, and it is possible that
some of these patients were able to secure prenatal treatment from
private physicians through their own resources. The superintendent
of the county hospital stated, however, that a high percentage of the
maternity patients entered the hospital as emergency cases, and it
was his belief that an equally high percentage had no prenatal care.
The district State health officer recognized this lack and was working
to meet the need.
In the larger city more than 80 percent of the patients (149 out of
183) were known to have received prenatal care. Of those reporting
the length of care received, the percentages receiving care for rela­
tively long periods prior to delivery were larger than in the 6 counties
as a whole. As table 16 indicates, 24 percent received care for 5
months or more prior to delivery, and 48 percent received care for
periods ranging from 2 to 4 months; on the other hand, 28 percent re­
ceived care for 1 month or less prior to delivery.
Among the hospital cases the length of hospital stay after delivery
varied considerably in the three communities, as is shown in table 9
(p. 38). In the rural section the majority of the patients remained in
the hospital from 11 to 14 days, and most of the other patients re­
mained from 6 to 10 days. In the larger city, also, the great ma­
jority (155 out of 179) of the patients received from 11 to 14 days
of postnatal care in the hospital; 10 percent remained 15 days or longer.
In the smaller city, however, 12 out of 35 patients confined in the
hospital left before the sixth day, and 16 remained 6 to 10 days.
Tables 10 and 11 (pp. 39-40) show data regarding postnatal visits
of physicians to patients delivered at home. In the rural section of
County C data on the number of visits were available for 15 of the 21
patients delivered at home. Of these 15 patients, 7 received 3 visits
or less from a physician following delivery; 7 received from 4 to 6
visits. Of the 14 patients for whom data were secured regarding the
duration of postnatal care 3 received care less than 6 days, 7 received


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CARE IN INDIVIDUAL COUNTIES

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care for 6 to 10 days, and 4 were under a physician’s care for 11 days
or more.
In the large city only 4 of the 191 deliveries studied occurred at
home; 2 of these were arranged for by the veterans’ organization, and
2 were emergency cases. Final gynecologic examinations were received
by 62 of the 191 patients. Careful follow-up for these examinations
was carried out by the staff of the local nursing organization, which
maintained the clinic at which most of the examinations were given.
The fact that only one-third of the patients delivered received this
examination, despite the careful follow-up, indicates that this phase
of maternity care needs greater emphasis.
Data regarding postnatal care of patients delivered at home in the
small city are too incomplete to justify comment.
The physical and mental isolation of some rural families and their
consequent failure to make medical needs known are illustrated by the
following extreme instances taken from the nurses’ reports:
In visiting a handicapped child, the nurse found a woman who had delivered
herself of a baby 3 days before. The welfare officer, who would have provided
help, was not asked to do so. The nurse got bedding and supplies through the
Red Cross. Nursing care was given for 4 days at the request of the health officer.

In the spring, when the roads became passable, the nurse visited a farm off the
main road and up a very steep hill. A woman pregnant 4 months was driving a
team of horses in preparation for spring planting; she said she felt well. Her last
baby had been born at 7 months; her husband delivered her and she did not see
a physician either before or after delivery. The baby was pale and looked illnourished but clean. Another child, 2 years of age, appeared to be well-nourished.
The 6-year-old child seemed to be mentally retarded and was said by the father
to have worms. As the father had been told that tobacco would help to cure this
condition the child was chewing tobacco.

County D—
First Mountainous County.
In the first of the two mountainous counties studied maternity care
was rarely provided from public funds prior to the coming of the
TERA. Some women were delivered without a physician’s services,
attended by a member of the family, a neighbor, or a midwife. When
the TERA medical-care program was first adopted some town boards
were unwilling to give medical relief, and conflict frequently arose
between the board and the town welfare officer concerning authoriza­
tion for care.
During the period of the Study 150 women received help from public
funds in the form of maternity care— 63 in the rural sections and 87 in
the city (table 2, p. 22). In the rural area the problem of providing
medical care was made more serious by the remoteness and isolation
of some of the population and by the unequal distribution of medical
services. In some sections women requested care directly from the

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MATERNITY CARE AT PUBLIC EXPENSE

physicians, who then took the initiative in bringing the needs of the
patients to the attention of the relief officials and in recommending
hospitalization or special nursing care for women needing such
services. ^ The decision as to home or hospital delivery was made on
the physician’s recommendation. Home deliveries were common in
the rural areas; only 13 of the 56 deliveries 36 took place in the hospital
(table 17). Most of the patients living in sections distant from hos­
pitals preferred home deliveries. One physician usually paid a
special visit to these patients before delivery in the company of the
work-relief nurse.

7?' CoufV_P: Number of months of medical care prior to delivery by place
of delivery and attendant; women receiving maternity care at public expense
Maternity cases
Place of delivery and
attendant

Area, and number of months of care prior to delivery
Total

Hospital
TotaL.........

71
99

5 to 8 months__
2 to 4 months.
1 month or less..
Months not reported

n

'

R ural areas .
Care received

No care received
No report on care received

......... *
................................
...................... ..........

7

59
5 to 8 months.
2 to 4 months.
Months not reported
No care received
No report on care received

62

2

7
18
18
19

2

------- --------- ------------...............................

7

8
1

13

43

6

34

i
3

6

14

1

11

6
1

8
1

3

*

Urban areas...

1 month or less.

37

7

No care received.
No report on care received

5 to 8 months..
2 to 4 m onths...
1 month or less...
Months not reported

Home—at­
tended by
physician

48

28

31

28

1

7
33
1

16

6

17

1

4
7
16

1

16

'Exclusive of 18 cases resulting in abortion.
Inclusive of 1 case in which delivery was at home and postnatal care in hospital.

Hospitalization for maternity patients was provided in two private
hospitals located in the city at a flat rate of $35 for 10 days’ stay.
Another private hospital, in an adjoining county, was sometimes used
for maternity care at a rate of $3 a day plus extras. Patients not
" In addltlon there were 7 abortions, of which 1 was a hospital case (table 2, p. 22).


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CARE IN INDIVIDUAL COUNTIES

57

receiving relief who applied for hospitalization were referred to the
investigators, and the county office exercised some supervision over
doubtful cases.
State-aided prenatal clinics were held monthly in three townships,
and patients living outside the towns were eligible to attend these
clinics. Three towns employed nurses to give prenatal and post­
natal care and to assist in deliveries at the physician’s request. Five
work-relief nurses working under the supervision of the district State
health officer gave bedside care including assistance at delivery.
No prenatal care at public expense was received by 14 of the 56
patients in the rural section. Twelve received care for 1 month or less
prior to delivery; 17 for 2 to 4 months; 7 for a longer period. For the
remaining 6 either there was no report or the amount of care was not
known (table 17). Records showed some evidence that food allow­
ances for pregnant women were increased, but it was not usual for
clients to make their pregnancy known before the last 2 months of
the period.
Of the 11 hospital patients for whom data were available, 8 remained
in the hospital from 11 to 14 days after delivery and 3 for 6 to 10
days (table 9, p. 38). Among the 30 women delivered at home for
whom data were available, 10 received medical postnatal care for less
than 6 days, 14 had from 6 to 10 days’ care, and the remaining 6 re­
ceived care for a longer period (table 11, p. 40). Five of these patients
were known to have had nursing care at delivery from the work-relief
nurses; as the records of one nurse were not available data on the
amount of this care were incomplete.
In the city a nurse on the staff of the department of public welfare
authorized hospital and home medical care and allotted calls to
the salaried physicians and the four work-relief nurses working under
her direction. The staff nurse had a good working relationship with
the case supervisor and the relief investigators. They all believed,
however, that clients asked for medical care unnecessarily. The inves­
tigators were aware of the medical problems of their clients and made a
definite effort to meet special diet or clothing needs resulting from
illness. A number of records noted physicians’ recommendations for
extra milk or increased food allowances, with corresponding increases
in the relief allowances. The relief office had enlisted the aid of a
private agency in the city to provide a short period of rest in a con­
valescent home and housekeeping assistance during pregnancy for two
patients for whom the doctor had recommended special consideration.
During part of the period of the study hospital confinements
were freely authorized in the two available private hospitals. In
February 1936, in an effort to reduce relief costs, women were required
to accept the services of one of the salaried physicians, and patients
were delivered at home unless the physician recommended hospital

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care because of complications. Later it was decided to hospitalize all
patients for their first confinements. In addition to the services of
the work-relief nurses some nursing service was also supplied byprivate organizations.
Of the 76 women delivered in this city, 48 were delivered in the hos­
pital.36 Of these patients, 3 remained in the hospital less than 6
days following delivery; 23, from 6 to 10 days; and 22, from 11 to 14
days (table 9, p. 38). The period of postnatal care was reported for
only 8 of the 28 women delivered at home (table 11, p. 40).
For the urban cases it was impossible to separate the data for the
period during which hospital confinements were authorized for all
patients and for the later period when hospital care was authorized
only on the physician’s recommendation. The relief personnel be­
lieved that they were able to consider the problems of patients suffi­
ciently during the latter period to insure adequate care. The records
indicated consideration for individual needs through frequent exchange
of information among the city physicians, the nurse in the medical
division of the welfare department, and the relief investigators. One
physician believed that if hospital care was not authorized freely, there
was urgent need for nursing assistance at home deliveries. A hospital
executive thought that the change in policy had resulted in lastminute admissions to the hospital among women in the marginal group.
His opinion was that these patients realized that if they applied for
care early in pregnancy, arrangements would be made for delivery at
home, and that they preferred to go without prenatal medical care
at public expense and enter the hospital for delivery.
Some of the hospital patients paid small amounts toward their
hospital bills. The average cost per case in the city was estimated
at $36.22. In the rural section the average estimated cost was $28.24,
the lowest figure for the rural areas in any of the six counties.
County E—
Second Mountainous County.
In this county, which was next to the smallest of the six counties
in population, 65 maternity patients received help from public funds.
Of these cases, 44 were in the rural section of the county, 21 in the city
(table 2, p. 22).
Hospitalization for obstetric care was available in four private
hospitals, of which two made a flat rate for obstetric cases. Local
health workers stated that there was no difficulty in obtaining hospi­
talization for patients for whom physicians recommended this care.
Home deliveries were the rule, however, hospitalization being provided
only on the physician’s recommendation. In the rural areas medical
care was provided entirely by private physicians paid on a fee basis.
••In addition there were 11 abortions, all hospital cases (table 2, p. 22).


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CARE m

INDIVIDUAL COUNTIES

59

Physicians’ fees for home visits were often $10, because of the isolation
of many of the homes; since State reimbursement could be obtained
only on a $2 fee, local costs for medical care were high.
The working relationships of the commissioner, the county nurses,
and the local physicians appeared to be based on a sympathetic
understanding of mutual problems and a desire to supplement one
another’s services.
During part of the period covered by the study, there were three
county nurses in the rural area, cooperating with local health officers
and private physicians. Later the number was reduced to two.
During most of the period a work-relief nurse was assigned to assist
them.
The county commissioner stated that women rarely applied for
medical care until a month before delivery was anticipated and that
many of the older women had never had a physician’s services at con­
finement until care became available through the TERA. The county
nurses encountered a great deal of resistance to prenatal care among
the older women who had had several children without medical atten­
tion. They told of one woman whom they had persuaded to see a
physician before the birth of her sixth child. After that confinement
she had six miscarriages, which she attributed to the medical care
she received. Although the mother was 46 years of age, had diabetes,
and did hard farm work, she was very anxious to have another baby.
In the city some hospitalization was provided in one private hos­
pital, but home deliveries were the rule. Medical care was provided
by a salaried physician. Care by private physicians on a reimbursablefee basis was authorized only in emergencies. Relief and health
workers stated that patients expressed great unwillingness to go to
the city physician, and accepted his services only after they had made
every effort to obtain care from local physicians. No prenatal clinic
was available, but relief investigators referred all pregnant women to
the nurses in the city health department for prenatal care. Both
groups were handicapped by lack of a good working relationship with
the physician and a clear understanding of division of responsibility.
The three nurses in this department devoted most of their effort to
health instruction and gave bedside care only in emergencies. A
private agency supported a visiting-nurse service, employing one nurse
for bedside care. It also sent graduate muses to assist at home deliv­
eries at the request of any physician. Patients paid for these serv­
ices if they were able to; otherwise the fee was met from private
funds. Bedside care at a daily rate was rarely authorized by the wel­
fare department.
Of the 43 maternity patients in the rural area, only 5 were delivered
in the hospital (table 18). In the city 5 of the 21 patients had hospital
deliveries, and 2 of these were emergency cases. The data on pre
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MATERNITY CARE AT PUBLIC EXPENSE

natal and postnatal care of both these groups of patients are very
scanty (table 9, p. 38, and table 18). In the city, 16 patients were
delivered at home by the city physician; data concerning postnatal
care for these patients were not available. For most of the home
deliveries in the rural area, also, the extent of postnatal care was
not reported (tables 10 and 11, pp. 39 and 40).
18.—County E: Number of months of medical care prior to delivery, by
place of delivery and attendant; women receiving maternity care at public expense

T able

Maternity cases
Place of delivery and attendant
Area, and number of months of care
prior to delivery

Home
Total
Hospital
Total

T ota l............ .........
Care received__________
5 to 8 months_______
2 to 4 months_______
1 month or less_____
Months not reported.
No care received_________
No report on care received.

i 64
45

Attended Attendant
not
by
physician reported

1

53

>10

64

3

42

42

2
8
6
29

2

1

7
6
29

7
6
29

3
16

1
6

2
10

1
10

R u ral areas_____

43

5

38

37

Care received..................

38

1

37

37

5 to 8 months_______
2 to 4 months....... .....
1 month or less_____
Months not reported.
No care received_______________________________
No report on care received______________________

1

...........

1

4
4
29
1 ---------- -1 ------------—
1
4
4 t ------------------- t------------------------

Urb a n areas.
Care received_____
5 to 8 months...
2 to 4 months...
1 month or less.
No care received_________
No report on care received.

2
12

1
2

1
10

1

10

i Exclusive of 1 case resulting in abortion.
>inclusive of 1 case in which delivery was at home and postnatal care in hospital.

As no list of the city physician’s visits was available, a list of home
deliveries during the period of the study was secured from the records
of the local registrar of vital statistics and checked against the central
index of the relief agency. In the course of this investigation it was
discovered that in addition to the 16 cases delivered by the city
physician 19 relief clients were delivered during this period by local
physicians who received no payment from public funds. It seemed
probable that the relatively large amount of free care given by private
physicians in this city resulted from a general dissatisfaction with the

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CARE IN INDIVIDUAL COUNTIES

61

services of the city physician and that the medical needs of the relief
group were not being adequately met by the local welfare department
under the existing arrangement. This was the only community
covered in the study in which the percentage of live births occurring to
women cared for at public expense was lower than the percentage o f
family groups receiving home and work relief (table 4, p. 26). It is;
also the only community in which information was obtained as to the;
amount of free care given by private physicians to patients receiving’
relief.
In the rural section the average cost per case, including estimated
costs of nursing care from community agencies, was $34.15 (p. 31).
In the urban area the average estimated cost was $24.26, a considerable
percentage of which was the estimated cost of community nursing
service. This figure is much below that for any of the other com­
munities covered, but the extent of free care furnished by private
physicians was probably larger in this than in any of the other com­
munities.
County F—
Suburban County.
The suburban county had the largest population and also the largest
number of maternity cases (929) in which care was received through
public funds. The great majority of the abortions also occurred here
(table 2, p. 22) and represent 16 percent of the total cases with which
the study was concerned in this county. Among these 929 cases,
10 maternal deaths occurred; 2 followed live births, 3 followed still­
births, and 5 followed abortions (table 3, p. 24). The live births to
women receiving care at public expense constituted 16 percent of the
total live births in the county (table 4, p. 26).
More complete statistical data were available in the suburban
county than in any of the others studied, and this fact, together with
the large number of cases upon which the averages are based, makes
the findings of special interest.
For a year previous to this study an emergency relief bureau had
administered home and work relief on a county basis through a large
number of local offices which were grouped in districts under qualified
case supervisors.
,?■/
The bureau had been developed under the direction of a capable
administrator, experienced in social work. Classes and training
courses had been held for investigators, discussion groups had been
organized under the case supervisors, and workers had been encour­
aged to attend classes and extension courses in nearby colleges and
professional schools. A nutrition project was maintained for the
purpose of assisting families receiving relief in buying food and
277253°— 41------5


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MATERNITY CARE AT PUBLIC EXPENSE

preparing properly balanced meals. An effort was made to work
out policies for cooperative case work with social agencies in the
community; some local offices worked out this problem with con­
siderable success; the records in other offices gave little evidence of
joint planning. In general, the records showed a lack of knowledge
o f health problems of individuals or of consultation with physicians
for the purpose of determining social needs related to medical condi­
tions. Few records showed constructive planning to meet problems
o f disease and disability, although some cases showed excellent
teamwork among the home-relief investigators, nutrition workers,
physicians, and visiting nurses.
The generalized program for home medical care was carried out
almost exclusively by local physicians on a reimbursable-fee basis.
The regulations in the Manual of Medical Care were followed closely,
and the amount of nonreimbursable medical relief was negligible.
During the period of the study two physicians were appointed to the
staff of the emergency relief bureau to supervise medical aid. Clinic
services were limited to maternal and child health, venereal disease,
tuberculosis, and a few specialized services. The local medical
society was opposed to any extension of general clinic facilities for
the relief and marginal groups. However, various clinic and nursing
services were available for maternity care. Although these resources
for maternity care were considered by local relief and health workers
to be inadequate to meet the needs of the group unable to pay for
medical care, the chief problem was one of effective utilization of
available resources through community planning and careful working
out of agency relationships. Hospital care was authorized by the
several administrative units of the department of public welfare
(county, town, city, and veterans’ relief), and not by the emergency
relief bureau.
The local public-health committee conducted prenatal, postnatal,
and gynecologic clinics. A free prenatal clinic was supported by
public and private funds, and two private hospitals conducted clinics.
A mothers’ health center was supported by voluntary funds. Hos­
pitalization was supplied by a county hospital and by private hospitals
on a fee basis. The maternity service of the general county hospital
was limited to a few beds, and for this reason welfare officials had
been requested to continue authorizing care in local private hospitals
until additional facilities could be provided. Four private hospi­
tals in the county and two across the county line received maternity
patients upon authorization from departments of public welfare.
Four of these hospitals charged flat maternity rates of $35, $45, $50,
and $58 for welfare patients; one charged $4 a day plus $7 for labora­
tory and delivery-room fee; the other charged $3.50 a day plus $5
for the delivery room.

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CARE IN INDIVIDUAL COUNTIES

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Relief clients could receive prenatal care from one of the local
clinics or from a private physician who was paid on a fee basis. If
the patient wished treatment from a private physician, this was
authorized by the emergency relief bureau according to the rules
and regulations of the Manual of Medical Care.
If a maternity patient wished to be confined in a hospital, she made
application to the welfare officer and received authorization for
hospital care. Decision as to home or hospital confinement rested
largely on the physician’s recommendation or the patient’s preference.
The majority of the records examined gave little evidence of considera­
tion of social factors and consultation by the investigator or case
supervisor with the physicians supervising medical care before a
decision was reached.
A survey of nursing care made in this county in 1936 disclosed 18
agencies supplying nursing care, including private agencies, village
and township boards of health, and the county public-health com­
mittee with 5 staff and 14 work-relief nurses. The nursing facilities
were unevenly distributed, however, leaving some areas inadequately
provided for, and case loads were heavy. The relief bureau paid
practical nurses and household workers at a daily rate for home care
of clients. In one locality a woman trained in home-nursing classes
was often employed, and her work was supervised by the local private
nursing organization.
Of the 785 deliveries resulting in live births and stillbirths, 492
occurred in hospitals and 293 took place at home. In 502 of these
cases prenatal care was reported (table 19). The fact that publichealth work with emphasis on maternity care had been carried on in
this county for more than 10 years previous to this study had un­
doubtedly made the community conscious of the desirability of such
care. Furthermore, local relief and health workers expressed the
opinion that private physicians did not hesitate to request authoriza­
tion for medical care from the relief bureau in case the patient was
unable to pay. This is borne out by the fact that of the 492 women
delivered in hospitals almost one-third (161) received no other aid
from public funds.
Of the 502 patients receiving prenatal care, almost half (249)
received care for 2 to 4 months prior to delivery; somewhat less than
one-third (151), for 1 month or less. Eighty-seven received care
for 5 to 8 months, and 1 woman was reported to have had care for
9 months prior to delivery (table 19).
Of the 486 patients for whom length of postnatal hospital care was
reported (table 9, p. 38), almost half (239) remained in the hospital
from 6 to 10 days after delivery. Another 42 percent received from
11 to 14 days’ care, and 36 (7 percent) remained in the hospital 15


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64

MATERNITY CARE AT PUBLIC EXPENSE

days or longer.
care.

Only 5 patients had as little as 5 days of hospital

T a b l e 19.— County F : Number of months of medical care prior to delivery, by place

of delivery and attendant; women receiving maternity care at public expense
Maternity cases
Place of delivery and attendant
Area, and number of months of care prior to
delivery

Home
Total
Hospital
Total

Attended
by
physician

T o ta l.......................

» 785

Care received____________

502

5 to 8 months or more.
2 to 4 months________
1 month or less_______
Months not reported..

*88
249
151
14

41
97
79
6

No care received_______ _
No report on care received.

4
279

268

608

400

208

207

28
117
46

28
116
46
6

R ural areas______
Care received..............—

293
278
47
152
72

1

47
151
72
8
3
11

377

5 to 8 months____- ___
2 to 4 months________
1 month or less............
Months not reported..

63
196
108
10

35
79
62
4

No care received____ ____
No report on care received

4
227

219

1

3
8
85

Urban areas....... .
Care received___________

Attended
by
midwife

82

82

5 to 8 months________
2 to 4 months________
1 month or less______
Months not reported..
No report on care received
1 Exclusive of 144 cases resulting in abortion.
1 Inclusive of 4 cases in which delivery was at home and postnatal care in hospital.
8 Inclusive of 1 woman who reported 9 months of care.

Of the 292 patients delivered at home by a physician, the extent of
postnatal care was ascertained for 271 (tables 10 and 11, pp. 39-40).
About half of these (137) received 4 to 6 postnatal visits from a
physician; another 45 percent (123) received 7 or more visits. Only 11
of the patients received as few as 3 visits. Two-thirds (181) of this
group of 271 patients were under a physician’s care for 6 to 10 days
following delivery. Another 28 percent (77 patients) received post­
natal care for 11 days or more, and 13 patients received care for less
than 6 days following delivery.
The total public expenditures for maternity care in the suburban
county (table 6, p. 28) show a relatively small amount ($7,616) paid for
home medical care as compared with the amount ($31,562) paid for


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CARE IN INDIVIDUAL COUNTIES

65

hospital care. Since physicians in this county were, in general, willing
to perform home deliveries and the relief bureau did not urge hospital
care, it seems likely that the large percentage of hospital deliveries
is attributable chiefly to the urbanized character of the area and the
long education of the population in public-health work which led the
patients to appreciate the advantages of hospital care.
The average cost per case, including estimated contributory costs
for clinic and nursing care which were not paid directly from public
funds, was $45.18. This figure is a relatively high one when compared
with costs in the other counties studied. But, in view of the fact that
among the women for whom prenatal care was reported 30 percent
had no care until the month before delivery and only 18 percent had
prenatal care for 5 months or more, the cost is probably lower than
that necessary to provide what may be regarded as adequate care.


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Special Considerations in Provision of Care
For six counties of New York State this report has described the
operation, so far as it is related to maternity services, of a State-wide
program for medical care in the home, conducted under the auspices of
local welfare departments with supervision and financial assistance
from the State agency. Procedures for hospitalization of maternity
patients have been described and the extent of such care tabulated
and studied. The scope of the State program was restricted to supple­
mentation of local facilities and services, and the policy adopted in­
volved the continued use of hospitals, clinics, and medical, dental, and
nursing services already established in the communities. The varied
character of these local resources resulted in wide variation in local
practices and in the extent of State participation in the provision and
financing of medical care. Nevertheless the study of 1 year’s opera­
tion in six counties revealed certain common problems demanding
further thoughtful consideration.
The most important of these problems are:
1. The difficulties inherent in the authorization of medical, nursing,
and hospital care of maternity patients by officials or workers with
little or no understanding of medical needs.
2. The method and basis of determining whether delivery should
be in the hospital or the home.
3. The problem of meeting hospital costs.
4. The maintenance of a high quality of medical service.
5. The relation of medical and social factors and provision for
special needs related to illness.

Authorization of Maternity Care
by Welfare Officials,
In the rural areas studied, authorizations for maternity care were
issued by nearly 100 local welfare officers under the general supervision
of the county commissioners. Supervision of township officials by
county officials was in general limited by a regard for traditional town
rights and by the inaccessibility of some of the areas during the winter
months. These local welfare officers usually had no medical knowledge and no formal training in social work and sometimes had only a
limited general education. They worked on a part-time basis and
were usually paid a modest sum according to the amount of work
demanded of them.
66

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SPECIAL CONSIDERATIONS

67

Their attitude toward the welfare work they were doing varied
widely. Some made, a sincere effort to meet the needs of the families
receiving relief; others appeared to grant relief, including medical
care, grudgingly and to think that the more unpleasant it was for a
person to remain on relief the sooner he would cease to be a charge on
public funds. It was natural that the rural welfare officers tended to
emphasize cost of services rather than the applicants’ needs, in view o f
their own background, which had taught them the value of a dollar
but not the principles of good medical care or social work. Further­
more, their expenditures were audited by the town boards who ap­
pointed them, and their appointments depended to some extent on
their ability to keep relief costs at a minimum.
There was evidence that the attitude of some welfare officers tended
to discourage clients from making early application for prenatal care
and that the effectiveness of instruction given by public-health nurses
was limited in some instances by the efforts of the welfare officers to
curtail relief expenditures. The standards set forth in the Manual of
Medical Care were far in advance of the general practice in some com­
munities, and this further complicated the problem.
As the object of public provision for maternity care is to enable
mothers to give birth to healthy children normally, with minimum
risk to life and health, through the employment of modem medical
knowledge and skill, it seems reasonable that authorization for care
should be in the hands of individuals who have an understanding and
appreciation of the principles of good medical care. Knowledge of the
medical need as well as the social situation of patients is essential in
granting such authorization and in making the choice between home
and hospital care.
The authorization involves, therefore, the determination of medical
need, which should be a medical responsibility assumed by a physician,
and the determination of eligibility for care at public expense, a respon­
sibility of the government agency authorizing the expenditure o f
funds. Ideally, final decision regarding authorization of care can
best be made by a well-qualified physician on the staff of the agency
authorizing care, who has been given responsibility for reviewing the
recommendation of the physician attending the patient and of the
social worker who is familiar with the social situation. The review o f
the social worker’s recommendation should be made in the light of the
patient’s medical need.
It is recognized that great difficulties are involved in introducing
such procedures in local administrative units that are not large enough
to permit effective and economical administration of medical-care
programs under the direction of a physician. A practical temporary
solution may be to devise means of giving local health and welfare
workers increased understanding of the basic principles involved in

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MATERNITY CARE AT PUBLIC EXPENSE

the provision of medical care at public expense and of the social and
psychological factors related to health that demand consideration in
the determination of eligibility.
In all the local administrative units studied, a part-time or full­
time health officer who was a qualified physician was available, and
it would appear that the services of these health officers might be
utilized by the welfare department in an advisory capacity. Explana­
tion of medical needs by these officials would insure earlier and more
adequate prenatal care. The welfare official would be able to exercise
his function of authorization more satisfactorily if he had the oppor­
tunity of periodic consultation with a medical social worker for con­
sideration of policies, review of accepted and rejected cases, and dis­
cussion of individual problems. It is possible that eventually a plan
might be worked out providing for authorization of care by the welfare
officer upon certification of medical need by the local health officer
or a medical officer on the staff of the welfare department.37
Hospital or Home Care.
Individual consideration of the needs of each patient is fundamental
in an adequate medical-care program. It is also a fundamental con­
cept of social case work. This principle is not followed in any plan for
maternity care which provides either that all patients are hospitalized
automatically or that all are delivered at home.
In some areas included in this study, hospital care at confinement
was restricted to women for whom physicians recommended hospitali­
zation because of complications of pregnancy. In one city all patients
were hospitalized, and there was no provision for home deliveries for
patients cared for at public expense. Such restricted plans inevitably
result in situations in which patients attempt to circumvent the sys­
tem by not making the fact of pregnancy known until delivery is
imminent. In the county in which authorization for hospital deliver­
ies was the routine practice there were instances of women wishing to
he delivered at home who called the welfare officer to request a physi­
cian’s services after labor was well under way. In areas that had a
rigid policy of home delivery, on the other hand, hospital administra­
tors reported an increase in emergency admissions.
In other communities the choice of home or hospital delivery was
made by the patient; in one county authorization for home care was
given by the county relief agency and authorization for hospital
car6 by the several town welfare officers. In only one area (County C,
City I) was the authorization of home or hospital care at confinement
made by the relief director on the basis of the medical recommendation
and the social situation.
V Provision has since been made in some counties in New York State for the county medical director or
consultant to perform the same functions for town welfare departments as for the county department upon
the request of the town and upon its agreement to conform to the policies and procedures of the county


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The desirability of routine hospitalization for confinement is a mat­
ter on which medical opinion is not unanimous. Physicians are
agreed, however, that the safety of a delivery is dependent on the
quality of the medical and nursing service, including measures taken
to protect the patient from infection and to deal with emergency
situations, rather than on the locale of the confinement. The recent
demand on the part of the public for hospital care at confinement has
made heavy demands on hospitals inadequately equipped to serve
maternity patients. Minimum requirements for obstetric depart­
ments in general hospitals have been formulated by the American
Hospital Association, the American College of Surgeons, and other
organizations, and hospitals are adapting their physical facilities and
the organization of their medical and nursing staffs to comply with the
standards that have been set.
An ideal program, which may ultimately be achieved, would include
a sufficient number of beds in hospitals with adequate obstetric service
to afford safe care for every maternity patient and sufficient funds for
the physician’s fee, the hospital charge, and prenatal and postnatal
nursing service in the home for those unable to obtain medical care for
themselves. But while funds are limited and beds in hospitals with
adequate obstetric service are not available in sufficient numbers,
some choice must be made of the cases to be hospitalized.
This choice should be made on the recommendation of the physician
attending the patient, after consideration of the home situation and
the adequacy and quality of available resources. It is also recognized
that consideration of the total funds available for maternity care will
influence the choice to some extent in instances where social rather than
medical factors indicate that hospitalization is desirable. For
instance, local administrators may be forced, through limitation of
funds, to choose between a more liberal policy regarding hospital care
at confinement and added provision for prenatal care.
In this connection attention may be directed again to the figures
presented in the section on Expenditures From Public Funds (p. 27),
which indicate that the average cost of hospital deliveries was signif­
icantly higher in all the areas studied than was the average cost of
home deliveries, partly, indeed, because complete maternity care was
not provided from public funds for home deliveries. The average cost
of home deliveries in all these areas was based on direct expenditures
from welfare funds, and bedside nursing was provided directly from
welfare funds for only a very small number of cases. Prenatal medical
care and nursing service were provided for many of these patients by
agencies in the community, supported in some instances by appropria­
tions from other public funds and in others by private contributions.
The average cost of these home deliveries would be much higher if
full provision were made for all costs including nursing service at

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MATERNITY CARE AT PUBLIC EXPENSE

• delivery and postnatal nursing care— services which are essential in
any plan for home care of maternity patients.
An estimate of the real cost of complete and adequate home care
should include payment for care by a physician from the time when
pregnancy is suspected throughout the prenatal, delivery, and post­
natal period; and a minimum of three home visits by a nurse during the
prenatal period, nursing care at delivery, and five postnatal nursing
visits. The cost of this complete care is estimated at $41, on the
basis of the maximum medical fee upon which reimbursement was
allowed and the estimated cost of nursing visits used in this study
(p. 31). This estimate is exclusive of costs of travel for physician and
nurse, necessary supplies and equipment, and continuous nursing
care or housekeeping assistance in instances where such care is recom­
mended by the physician.
Meeting Hospital Costs.
During the entire period of operation of the plan providing State
aid for medical care in the home, local communities bore the full cost
of hospitalization. In table 6 (p. 28) it has been shown that in all
but one of the counties as a whole, and in all the urban sections con­
sidered separately, the total expenditures for hospital care of maternity
patients exceeded those for home care. This is to be expected, al­
though the ratio of costs is undoubtedly influenced by the fact that
complete maternity care was not provided directly from public funds
for women delivered at home. Seventy-five percent of the total
expenditure from State and local welfare funds for maternity care
was for hospitalization of maternity patients. These expenditures,
as has been pointed out, were a charge on the local funds and in many
communities were met with great difficulty. It is questionable how
long local welfare districts can continue to carry these charges without
assistance. In 1937 the need for financial aid was repeatedly expressed
by county commissioners, since exhaustion of local funds and of re­
sources for borrowing was making the problem acute.
Despite the fact that hospital costs were borne entirely by the local
unit, no instance was noted of refusal by a welfare official to authorize
hospitalization for a maternity patient for whom a physician had
recommended hospital care.
Some counties had a very high proportion of home deliveries, and
unquestionably a much larger proportion of patients would have
benefited by hospital care if greater consideration had been given to
factors of crowding and lack of proper facilities in the home, distance
from the local doctor, and so forth, in making choice of home or hos­
pital care. It is significant that in the area where decision as to home
or hospital care was based on the medical and social needs of the
individual patient 43 percent of the women delivered were hospital
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71

ized, whereas in another county hospitalizing only patients for whom
the physician recommended hospital care because of complications 30
percent were hospitalized.
It appears, therefore, that the proportion of hospital deliveries will
not be decreased through a more individualized administration.
However, in some cases now requiring a hospital stay longer than
average, the length of stay and cost of care per patient may be de­
creased appreciably without impairment of the quality of service
through better coordination of facilities for home and hospital care,
provision of housekeeping service, and so forth. The average costs
for hospital deliveries in the counties studied ranged from about $40
to $59. A fee for physician’s services for delivery and postnatal care
was included in only a very small number of hospital cases. If such
fees were included for patients receiving care in private hospitals and
provision made for payment for adequate prenatal care by a physician
or at a clinic, and for prenatal nursing care, the cost of a hospital
delivery would be between $65 and $70. On the basis of these con­
siderations it appears, therefore, that State aid in hospitalization as
well as in home care of maternity patients is essential to the growth
and development of a satisfactory program for maternity care.
Maintenance of a High Quality of
Medical Service.
The rules and regulations of the Manual of Medical Care included
a statement of minimum standards for maternity care which provided
for a high quality of service. These standards are given in the
appendix to this report. Only physicians and midwives licensed to
practice in the State could be authorized to participate in the plan.
The manual recommended that local commissioners of public welfare
maintain lists of physicians and other licensed professional attendants
who had agreed in writing to comply with the rules and regulations
in the manual. It was further suggested that when a patient requested
the services of a physician not already on an approved list the written
authorization to the physician be accompanied by a copy of the rules
and regulations and a statement that acceptance of the authoriza­
tion implied compliance with these rules in giving professional care.
In none of the areas studied was there provision for general profes­
sional review of the work of individual physicians. In some com­
munities committees from the local professional organizations gave
consideration to cases referred to them by relief workers. The State
medical director and his assistants were also available for advice and
consultation. In some cases local standards of medical care were
raised in this way. There was, however, no checking of medical
records by a well-qualified physician on the staff of the authorizing
agency as a matter of routine, and standards of care were maintained

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MATERNITY CARE AT PUBLIC EXPENSE

only through the employment of properly qualified physicians and
through the issuance of the regulations of the Manual of Medical
Care.
Payment for services was based on diagnosis and on the number and
dates of visits made. The physician, as a rule, received the $25 fee
authorized for complete maternity care, including delivery in the
home, only if the patient had been under his care since the fifth month
of pregnancy. A check might be made of the period of time under
care, since dates of the physician’s visits were necessary for payment
of the bill. No check could be made, however, as to whether the
physician had actually made the required complete physical examina­
tion of the patient early in pregnancy, including a Wassermann or
comparable test (not at that time required by State law), urinalysis,
determination of blood pressure; also pelvic measurements and
examination at or before the seventh month.
It is recognized that reviewing medical records presents great
difficulties. Many physicians do not keep complete records, and
few of them have clerical assistance. They are often impatient of
such procedures, and insistence on detailed records may result in
their refusal to treat relief patients. The fact remains, however,
that adequate care, particularly during the prenatal period, cannot
be insured without some provision for review of the nature of that
care by a physician.
The use of consultant service is an important factor in maintaining
high standards of care. The Manual of Medical Care made provision
for authorization of the services of consultants at the request of the
physician in attendance, the patient, or her family. Lack of recogni­
tion by local welfare departments of the qualifications which should
be required of consultants and the unavailability of well-qualified
specialists in most rural areas made consultation service a difficult
problem. Furthermore, the maximum charge for a consultation on
which State reimbursement was allowed was $2, the same amount
established for the usual home visit. Such provision may be expected
to encourage consultation between local physicians and to make it
possible for young physicians to secure advice from more experienced
general practitioners, but it will not make the services of qualified
specialists in obstetric care available on a consultation basis. To
accomplish this it is necessary to establish objective standards of
training and experience for physicians serving as consultants and to
make provision for recognition of the quality of this service in cal­
culating reimbursable charges.
In several areas prenatal clinics were held regularly and visits to a
local clinic by arrangements approved by the authorized attending
physician were counted as regular prenatal home and office visits.
If the dates of such visits were entered on the physician’s bill, the

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SPECIAL CONSIDERATIONS

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regular flat obstetric fee was allowed. Physicians generally did not
avail themselves of this opportunity, however, and it is questionable
if this provision was generally understood.
Neither of the two county hospitals providing maternity care
operated prenatal clinics, although in one hospital prenatal care was
available by the resident staff at the patients’ request. Few patients
presented themselves for examination, and no records were available
concerning the care given. One county and one city had no prenatal
clinics. In several areas physicians and hospital administrators
spoke of difficulties in exchange of information between clinics and
hospitals and expressed a strong feeling that prenatal care should be
given by the physician who delivers the patient. Continuity of
care by the physician, while desirable, is not always possible, however,
and where this cannot be provided great effort should be made to
facilitate easy and rapid exchange of information regarding exami­
nation and treatment.
Extension of clinic facilities coordinated or associated with hospital
service and workable provision for use of consultation services of
specialists are important points for consideration in assuring high
standards of professional care.
Coordination of Medical
and Social Factors.
Physicians who are giving freely of their skill and time in the treat­
ment of patients on relief rolls have a right to expect the relief adminis­
tration to provide for the special needs of their patients which are
related to the medical problem. A physician treating maternity pa­
tients should receive cooperation from the relief organization in early
referral of cases; assistance in follow-up unless that responsibility is
assumed by another organization; provision for enabling patients to
receive a liberal diet in all instances, with special needs met upon his
recommendation; help in planning confinement care with the assist­
ance of a nurse, if the delivery is to be in the home; and housekeeping
service and essential household equipment when necessary. Anxiety
and apprehension on the part of the patient often limit the effective­
ness of medical care; it is the responsibility of the social worker and the
public-health nurse to aid the physician in dealing with these factors.
In rural areas, where relief offices are staffed by incompletely trained
social workers with heavy case loads, meeting such needs is a difficult,
problem. It may be greatly lessened, however, if there is a qualified
public-health nurse who serves the area and with whom the relief
worker may cooperate. The relief worker cannot provide intelli­
gently for the patient’s needs unless she has an understanding of her
condition in terms of disability and work capacity, activity limitation,
prescribed treatment, and prognosis. She needs to know whether the


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MATERNITY CARE AT PUBLIC EXPENSE

pregnant woman is able to do all her own housework, whether she
needs special food, and whether the physician has recommended any
other special program. The public-health nurse usually can assist the
relief worker in these circumstances, and a division of responsibility
for various phases of treatment of individual patients can be worked
out in conferences between the social worker and the nurse. Con­
ferences with a medical social worker from time to time are necessary
for local workers in developing policies for cooperative effort and are
helpful in treatment of individual cases, since the medical social worker
is especially equipped to advise on social problems connected with
health and medical care.
In some of the areas studied the medical needs of clients were
effectively explained to relief workers by the county nurses. In one
such county, where there was close cooperation between the publichealth nurse and the relief-work supervisor, no emergency authoriza­
tions for delivery were noted. In another county the nurse and the
county commissioner worked well together, and in instances where the
patient was unwilling to ask authorization for maternity care from
the local welfare officer the nurse took the matter up directly with the
commissioner. In one small city the commissioner and the medical
social worker at the local hospital worked closely together, and in
another city the director of the home-relief bureau and the city hospital
superintendent supplemented each other’s efforts intelligently and
efficiently.
In the areas just mentioned records gave evidence of a recognition
of the interrelationship of medical and social factors; the effectiveness
of medical treatment was enhanced by the consideration given by relief
workers to the special needs of individuals. In the majority of areas,
however, there was little indication that the relief investigators
understood the health needs of their clients.
The relation between medical and social factors has come to be
recognized by most physicians, but medical and social agencies have
often been slow to coordinate their efforts. In the public-welfare
field medical care for those unable to pay for it has been planned and
administered largely by the welfare groups that finance the service.
Health departments in general have considered that public health and
certain aspects of preventive medicine were within their province and
have left to the welfare officials all matters related to curative medi­
cine. At the present time health departments are recognizing that
they have a responsibility in relation to the provision of medical care.
They are administering services for crippled children in half of the
States and are showing willingness to provide consultation services
for other types of medical care.
Recognition of the necessity for cooperative effort in the provision
of medical care at public expense has been expressed through the work

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of a joint committee of the American Hospital Association and the
American Public Welfare Association, which has been giving considera­
tion for several years to the subject of hospital care for the needy.
In 1937 the two associations officially adopted a statement of general
policy concerning the use of tax funds for the care of the needy sick
in nongovernmental hospitals.38 This statement emphasized the
fact that a high standard of care of patients is important and is an
ultimate economy and urged that public officials appreciate the close
relation of hospital service to general medical practice and to public
health. In the following year the joint committee presented detailed
suggestions for carrying out these policies effectively. In the section
concerned with determination of eligibility for care emphasis is
placed throughout on the need for conference and joint effort among
the agencies and individuals concerned in the provision of care.
Recognition is given to the fact that hospital care at public expense
should be provided for the marginal group who are otherwise selfsupporting. The joint committee recommends that decision as to
eligibility for care among this group be reached by qualified persons
after investigation and consideration of the medical and social factors
involved in individual cases. The recommendations of the joint
committee have been approved by both associations.
The American Public Welfare Association has further emphasized
the need for development of cooperative relationships between welfare
and health departments. A physician was appointed to the staff of
the American Public Welfare Association in 1937 to act as consultant
on medical care; a few months later several members of the association
were asked to serve as a committee on medical care. The first report
of this committee,39 presented in June 1938, stresses the fact that
many agencies and groups other than welfare officials are intimately
concerned with problems in the administration of medical services.
The provision of better medical care for those unable to pay for it
themselves is recognized as a common goal of the medical professions
and of many national agencies, official and unofficial, the cooperation
of which is essential in furthering improvement in the organization
and administration of public medical services. The committee recom­
mends that welfare authorities cooperate to the fullest extent with
other government departments concerned with public health and
medical care in order that overlapping, duplication, and gaps in
service may be avoided.
In December 1939 the board of directors of the American Public
Welfare Association approved a tentative statement of principles con38 Hospital Care for the Needy: Relations Between Public Authorities and Hospitals. Hospitals (Journal
of American Hospital Association), Vol. 13, No. 1 (January 1939), pp. 22-29.
38 Report of the Committee on Medical Care, Annual Meeting, Seattle, Wash., June 1938. American
Public Welfare Association, Chicago, June 1938. 48 pp. Mimeographed.


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MATERNITY CARE AT PUBLIC EXPENSE

ceming the administration of tax-supported medical care in which
these points are developed further.40 This statement recommends the
development of a cooperative relationship whereby the welfare or other
department charged by law with providing medical care obtains service
or technical supervision through the department of health and pays
for it accordingly. It further recommends that the department
carrying the major responsibility for tax-supported medical care make
official use of the State or local health officer in an advisory capacity
by ex officio appointment or otherwise.
An outstanding feature of the New York State plan for medical
care was the working out of the program under the direction of a
physician from the Department of Health, assigned to the Temporary
Emergency Relief Administration for this purpose. This procedure
insured close cooperation between the two departments. A medical
social worker assisted the medical officer in the administration of
the plan. This same physician was later appointed chief medical
officer in the State Department of Social Welfare, which assumed
the functions and powers of the TE R A on July 1, 1937. As he has
also been designated consultant in medical care to the State Depart­
ment of Health, it is anticipated that the two departments will con­
tinue their coordinated efforts in the field of medical care for the
group unable to provide such service from their own resources.
A supervisor of medical social work has been appointed in the
Division of Medical Care of the State Department of Social Welfare,
and medical social workers have been placed in the district offices to
aid in the administration of medical care. Such workers have been
added to the staff of the home-relief bureau in the suburban county
covered in the study, and other local offices have made similar ap­
pointments.
Recognition on the part of officials administering the State program
of the interrelation of medical and social factors is a powerful force
which is making itself felt increasingly in the local offices. The for­
mulation of policies and procedures embodying this concept is a
gradual process, conditioned by local public opinion and the develop­
ment of personnel qualified to present this point of view in a manner
intelligible and acceptable to local groups. Relief and home medical
care remain local administrative problems under the present Public
Welfare Law, although the fiscal unit has become the county rather
than the town.
In the past few years more frequent contact with State workers
has stimulated local relief and health officials to a coordination of
their efforts. The findings of this report indicate that in some areas
40 Organization and Administration of Tax-Supported Medical Care: A Tentative Statement of Essen­
tials and Principles. Committee on Medical Care of American Public Welfare Association, Chicago, 1939.
8 pp. Processed.


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SPECIAL CONSIDERATIONS

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À

77

the work of local relief and health agencies was well coordinated. In
the areas where this had not yet been achieved, officials were well
aware of the problem and desired professional advice and help in its
solution.
The number of patients receiving aid from public funds for mater­
nity care during the year of the study was impressive, especially in
view of the fact that most rural relief officers had developed a sense o f
responsibility in the provision of maternity care only in the past few
years. In some communities, however, there was still evident a
general lack of appreciation of the value of prenatal care and post­
natal follow-up. The problem of adequate prenatal care was, o f
course, more difficult of solution in the rural than in the urban com­
munities, because of the isolation of many rural families and their
unfamiliarity with relief and clinic procedures. The solution of this
calls for still closer working relationships between welfare depart­
ments and local health authorities, who should be responsible for
providing adequate facilities for prenatal care through clinics and
public-health-nursing services. In some instances, even though the
value of prenatal care was recognized, women felt great reluctance to
receive aid from public funds, associated in their minds with depend­
ency and “ shiftlessness,” and delayed application in the hope that they
might later be able to provide for their own care. This attitude should
be recognized in planning for the care of the “ medically needy” who
are ordinarily self-sustaining but unable to pay for necessary medical
care.
The close working relationship between the New York State Depart­
ments of Health and Social Welfare offers unusual opportunity for
increasing cooperation in plans for maternity care. The introduction
of medical-social workers into the local offices of the State Department
of Social Welfare provides a means of interpretation of medical
problems to relief workers and social problems to health workers and
so of active coordination of local programs for medical and social
treatment. Constructive planning for more adequate public provision
for maternity care may well be the forerunner of constructive plan­
ning for more adequate provision of medical care in other fields.
The provision of maternity care involves all the administrative tech­
niques and procedures necessary for a program of general medical care.
It is a program of which the extent can be accurately predicted, tho
cost closely estimated, the personnel needs easily budgeted. For
these reasons particular interest will attach to further developments
in the New York State program for maternity care.

277253°— 41-

-6


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Recommendations
The following recommendations are offered after consideration of
the fundamental problems observed in the administration of maternity
care in six counties in New York State. They are presented as sug­
gested means of improving maternity service to individual patients
through changes in the procedure of authorization, coordination of
the work of health and welfare agencies, and the provision of increased
facilities.
1. Authorization of home and hospital care (medical and nursing)
should be placed in a single agency or central medical unit, and the
decision as to whether the delivery will be in home or in hospital
should be based on the medical and social needs of the individual.
2. Authorization for maternity care should be made the responsi­
bility of a physician on the staff of or serving in an advisory capacity
to the department authorizing care. Decision should be made after
a review of recommendations from the physician attending the patient
and from a social worker who is familiar with the social situation.
3. Further consideration should be given to the problems pre­
sented by women not in families receiving relief who postpone
securing prenatal care or curtail the length of hospital stay or the
convalescent period because of inability to meet the costs involved.
4. Emphasis should be placed by the central authorizing agency
on continuity of service to the patient. This agency should insist
upon the exchange of medical, nursing, and social information among
the agencies providing such care. The division authorizing medical
care should have close working relationships with all public-health
services, nursing agencies, and hospitals in the community, and also
with divisions of the welfare department concerned with the meeting
of special needs of patients (dietary, clothing, housekeeping assist­
ance, and so forth) which are related to illness.
5. Consultation service of medical social workers should be made
available to local welfare and health workers to give assistance in
relating the medical and the social aspects of maternity care.
6. State aid should be made available to local government units
in the provision of good hospital care to maternity patients on a
participating basis similar to the plan for State aid in the provision
of home care.
7. Increased provision should be made for prenatal clinics, prefer­
ably in connection with hospitals used for maternity care. Emphasis
78


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should be placed upon the laboratory and consultation services which
such clinics can offer to local physicians, particularly in the treatment
of the medically needy.
8. Increased provision should be made for consultant services by
specialists, pediatricians as well as obstetricians, to be readily available
for patients in home and hospital.
9. Review of the services of individual physicians treating patients
at home and in hospitals should be made by a physician on the staff
of the authorizing agency in order that a high quality of medical
service may be maintained.
10. Increased provision should be made by official health agencies
or under their supervision for maternity nursing services, including
nursing assistance to physicians performing home deliveries.


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Appendix
Schedule Used in the Study
U . S. D e p a r t m e n t of L a b o r
C h il d r e n ’ s Bureau
M A T E R N A L CARE STU D Y OF N E W Y O R K RURAL RELIEF CASES
Serial No.
Case N o.

Agent
D ate _

I d e n t if y in g I n f o r m a t io n :
1. County___________________________ 2. T o w n sh ip _____________________________
3. City or v illa g e _______________________________
4. Client’s nam e______________________________ 5. Date of b ir t h ________________
I I . S o c ia l D a t a :
1. Case opened and closed: a. F r o m _________________ t o ______________________
b. F r o m _______________ t o _________________ c. F r o m ______________________
t o ______________ d. F r o m ____________________t o -------------------------------------2. Number of members in household: a. Under 1 8 ____ b. 18 and over_____
3. Total weekly n ee d s_____________ 4. Total gross income____________________ 5. Budget d e ficit________________ 6. N a tio n a lity ------------------------------------ ----------7. Husband’s usual occupation__________________________________________ ______
8. Number of children of this mother: a. Born alive and now liv in g _______
b. Born alive and now d e a d _________c. Stillborn----------------------------------I I I . M e d ic a l S e r v ic e R e n d e r e d :
A. Prenatal care:
C ost
1. Month of pregnancy and
N o. of v is its _____ ______
1 2
3 4 5 6 7 8 9
2. Complications: Y e s __________________ N o _ .
a. Diagnoses and dates of visits
( 1) --------------------------------------------------------------

!B.

C.
D.
E.
F.
G.

( 2 ) --------------------------------------------------------------( 3 ) --------------------------------------------------------------Delivery: D a t e _________________
1. A t home
a. B y ph ysician____________ b. By midwife-----------------c. By other (sp ecify)___________________________________
2. Hospital
a. P u b lic ______________________ b. Private---------------------3. Maternity home (specify) ------------------ -------------------------4. County infirmary (specify)------------ * — ------------------------5. Other (specify) _________________________ ,*----------------------Postpartum care: Dates of visits
--------------------Final gynecological examination: Y e s . „ _ N o — Date
Final status of p a tie n t_____________ - - - - - ----------- --------------------- - Final status of c h ild ______________________________________________
Total cost of medical service rendered (Total of A - D ) .

80


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Federal Reserve Bank of St. Louis

,
_
XXXX

XXXX
XXXX

T E S A Form 217.
W o r k R e lie f
|—
D isability________ j

AUTHORIZATION, INVOICE ANO VOUCHER FOR PROFESSIONAL SERVICES
E M E R G E N C Y R E L IE F
B U R E A U O F ____________

H om e R e lie f

r

V o u c h e r N o.
C ity

C ounty

DATE.

A U T H O R IZA T IO N ;

R e lie f
O r d e r N o.

193-

H om e R e lie f
Case N o.

TO______________
(N am e o f P hysician, D en tist, N urse o r Institution— In d icate w h ich )

D isability
N o.

AD DR ESS(C ity o r T o w n )

(S tr e e t and N u m b er)
USB FOR
HOME
RELIEF

You are hereby authorized to supply medical, dental and/or nursing service within the restrictions and according to the Regulations given
in the T E R A “Manual of Rules and Regulations Governing Medical Care Provided in the Home to Recipients of Home Relief” to:
The bearer, or the patient whose name and address appears immediately below, is an employee of the Work Bureau on Project

USE FOR
WORK
RELIEF
DISABILITY

and alleges that he met with an injury or disability in the course of his employment, on
Date____________
date hereof to:

193___

You are hereby authorized to give N EC ESSAR Y T R E A T M E N T for a period of_

F A M IL Y
N A M E ___

-days from

HEAD OF
F A M IL Y .__
A U T H O R IZ E D
B Y _______________

ADDRESS-

(S tr e e t A d dress o r R F D . N o . and N am e o f C ity o r T o w n )

In d ica te1)
purpose ) -

(

T IT L E -

Following statement to be prepared, invoice dated and signed, and affidavit executed, by Professional Attendant :

INDICATE
HOME OR
OFFICE
CALL ( * )

P A T IE N T 'S N A M E

(**)

S E R V IC E S R E N D E R E D

D IA G N O S IS

SE X

AGE

ST A T U S

<a>

( * ) U se sym bol “ H ”
f o r hom e visit and
“ O ” f o r office visit

( * * ) C— C U R E D
T— NEEDS FU RTH ER
TREATM ENT

NAM E O F
H O S P IT A L

H — H O S P I T A L I Z E D (n am e and
date as s h o w n )
D— DEAD

TOTAL
D ate

193 ...

D A T E I N V O I C E P R E P A R E D ? N O T E (t o physician, d entist, nu rse o r h osp ital) : E n ter o n the original and duplicate y e llo w
co p y o f this fo r m the in fo rm a tio n called f o r a bov e in colum ns 1 to 9, s p e c ify date
in v o ice is prepared, sign u n d e r " r e c e iv e d p a y m e n t," exe cu te affidavit o n both cop ies,
K e e p the triplicate copy f o r y o u r records.
^ -------------------- ■
.1 9 3 ____ and send t o lo c a l r e lie f headquarters.

193

R E C E IV E D P A Y M E N T :

STA TE OF N E W YORK
-County

^ is.:
-being duly sworn says that he actually resides at
.;

that the services rendered or charged in the

above bill or account were actually rendered to the relief case named herein residing in(C ity o r C ou n ty)

on the order of________________________________________________________________________________
(N a m e and T itle o f A uthorizing O fficer)

at the dates and for the prices herein named, which are just and reasonable for the services rendered; that said bill or account is just and true;
that there are no Federal or New York State Taxes included and that there is due hereon $_______________ .and no part of same has been paid
Subscribed and sworn to before me
this_____________day of___________________ 193___

_____________________________________ ______________________________._____ _
S ignature

N ota ry P u b lic o r C om m ission er o f D e e d s
(L E A V E B L A N K )

{P R O F E S S I O N A L A T T E N D A N T — D O N O T W RITE B E L O W T H IS L IN E )
A c c o u n t in g

(T H IS S P A C E F O R L O C A L A C C O U N T I N G O F F I C E )

C l a s s if ic a t io n

C harge

Account Verified; Correct for—

A m ou n t

( Signature)___________________________ _
I certify that the records of this office show that the services covered by this voucher were rendered, and that the prices charged are in
conformity with the authorized scale.
Certified for $______________________

________________________
A cco u n tin g Officer

Paid by the-

-with Check No~
(T itle o f F isca l O fficer)

TERA
Dated_______

(L o c a l G overnm ental U n it)

_________For________

_of_

-------Drawn on the_
(A m o u n t)

(N a m e o f B an k )

(C it y )

277253o—Í1 (Face p. 80)


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Federal Reserve Bank of St. Louis

APPENDIX
IV . N u r s in g C a r e :
No
A . Prenatal instruction: Y e s ---------------1. Month of pregnancy and
N o. of v i s i t s -------------------------------------------1 2 3 4 5 6 7 8 9
a. Work Relief P ro jec t________________________________________
b. Public Health Nurse------------------------ -------------- --------------------(1) State Department of Health----------------------------------------( 2) County --------------------------------------------------------------------------(3) Visiting Nurse Association__________________________
(a) N o charge to D . P. W . -----------------------------------------(b) D . P. W . p a y s _____________________________________
(4) Other private agency (specify) -----------------------------------B. Bedside nursing care:
1. _____________________________________ ____Delivery Postpartum
a. Work Relief P r o je c t________________
b. Public Health N urse-----------------------(1) State Department of H ealth___
(2) County__________________________
(3) Visiting Nursing Association..
(a) N o charge to D . P. W . ----(b) D . P. W . p a y s _____________
(4) Other private agency (specify).
c. Graduate tra in ed ----------------------------d. P ractical____________________________
C. Total cost of nursing care (Total of A and B )----------V . T o t a l C ost o f M e d ic a l S e r v ic e a n d N u r s in g C a r e ( T o t a l
of I I I - G a n d I V - C ) ____________________________________
V I. C o m m e n t s :


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81

xxxx

xxxx

xxxx

Excerpts From Temporary Emergency Relief Administration
Manual of Medical Care
Rules and Regulations Governing Obstetric Care (Regulation 4) and
(in part) Schedule of Reimbursable Charges (Regulation 9):
Regulation 4. Obstetrical Care. Item 1. Scope. Authorization for obstet­
rical service in the home 11 shall include: prenatal care, delivery in the home, and
postnatal care; and a requirement that, as far as possible, such obstetrical service
shall conform, both in frequency of visits and in quality of care, at least to the
standards of maternity care adopted by the regional consultants in obstetrics
of the New York State Department of Health.
Item 2. Not emergency service. Maternity care should not be considered an
emergency service to be authorized late in pregnancy. Local welfare and health
officials, public-health nurses, social workers, family physicians, and families on
home relief should cooperate to the end that continuous medical supervision
should begin for every expectant mother as soon as pregnancy is suspected.
Item S. Minimum standards. The following standards of maternity care
shall be maintained.
a. Prenatal care shall, wherever possible, conform to the following minimum
requirements: 1. First visit at or prior to the fifth month of pregnancy. This
first visit should include: histories of previous pregnancies and labors: determina­
tion of expected date of confinement; and instruction in the hygiene of pregnancy.
2. A general physical examination as early in pregnancy as possible, with special
attention directed to determination of blood pressure, urinalysis, heart, lungs
and kidneys, general nutrition, and a blood Wassermann or comparable test. 3.
Pelvic measurements and examination at or before the seventh month. 4. Visits
at least monthly until the ninth month and weekly thereafter, with urinalysis,
blood-pressure determination, and abdominal examination made at each visit.
5. Treatment as needed for ordinary disturbances incident to pregnancy. 6.
Social service or visiting-nursing service adequate to insure the patient’s coopera­
tion with the attending physician and prenatal clinic.
b. Delivery in the home shall include, in addition to obstetrical attendance for
the mother, treatment for the infant as needed, including the administration of
prophylaxis, as required by law,12 to prevent blindness.
c. Postnatal or postpartum care shall include care for both mother and infant as
often as may be needed, and bedside visits should be made at least on the first,
third, and fifth days after delivery. Authorization for obstetrical care shall in­
clude provision for a final gynecologic examination of the mother about six weeks
after delivery or before she resumes usual activities.
Item 4- Restrictions and precautions. Due caution shall be exercised that
authorization for delivery in the home does not involve undue risk to a patient
for whom hospital care may be imperative. The judgment of the attending physi­
cian shall be a decisive factor in issuing such an authorization. The physician
authorized to attend the confinement in the home shall be responsible for certify­
ing to the local commissioner of public welfare, that, in his professional judgment,
delivery in the home will be safe. In those cases where it is the professional
opinion of the attending physician that confinement in the home will be hazardous
he should notify the local commissioner of public welfare immediately, in order
that hospitalization may be authorized in accordance with the provisions of Article
X , sections 83 and 85, of the Public Welfare Law. However, expenditures for
such authorized hospitalization and hospital care shall not be eligible for reim­
bursement by the Administration.
Item 5. Complications of pregnancy. Authorization for obstetrical care in the
home shall include the items of maternity care specified in the preceding para­
graphs. Where complications and/or intercurrent illnesses arise in the course of
pregnancy and/or the puerperium and require medical care in addition to that
outlined above, the attending physician may request, giving full reasons, addi-

11Written authorization for obstetrical care shall be requested and issued within 48 hours of the date of
the first prenatal visit.
u See Penal Law, § 482, subd. 3, and the State Sanitary Code, Chapter II, Regulation 12, “ Precautions
to be observed for the prevention of ophthalmia neonatorum.”
82


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APPENDIX

83

tional written authorization for giving supplementary care. Reimbursement may
be granted by the Administration on the basis of regular home and/or office visits
for medical care given under such additional authorization. Some of the compli­
cations of pregnancy which may justify additional authorization and reimburse­
ment are: any acute intercurrent infection; pernicious vomiting of pregnancy;
uterine hemorrhage; eclampsia, pre-eclampsia and/or any toxemia of pregnancy;
and threatened miscarriage.
. . : __ .
,
i,
Item 6. Miscarriage, etc. When pregnancy is terminated prior to the full term,
a pro rata allowance may be reimbursable on the basis of the authorized home
and/or office visits actually made: Provided, that in case of any early miscarriage
(prior to the sixth month of gestation), where a dilatation and curettage is per­
formed or care is given for any miscarriage at or after the sixth month, an extra
allowance may be granted for such service. The total allowance, as a basis for
reimbursement, for all such authorized care where the pregnancy is terminated
prior to the full term, shall not exceed the allowance made for authorized complete
obstetrical care of a normal confinement in the home.
Item 7. Prenatal clinic. Prenatal care given in a local clinic by arrangements
approved by the authorized attending physician shall count for regular prenatal
home and office visits, and, if the dates of visits to the clinic are entered m the
physician’s bill, the regular flat obstetrical fee may be allowed as the basis for
reimbursement.
.
,
, ,.
Item 8. Emergency hospitalization, a. When, in the course of a delivery in
the home, complications arise, during the second stage of labor, which make
transfer to a hospital imperative, and such delivery is subsequently performed
by the authorized attending physician or by another physician, reimbursement
may be allowed for payments to the physician originally authorized to attend
the confinement in the home, on the basis of a sliding scale, up to 80 per cent of
the flat obstetrical fee, depending upon the adequacy of prenatal care given.
h. In certain cases, for whom delivery in the home was originally authorized,
but for whom hospitalization was ordered prior to the onset of labor, allowance
m ay be made for the prenatal and postpartum care actually given, on the basis
of the regular home or office charges for each visit.
Item 9. Major obstetrical operations. T o safeguard the lives of .both mother
and child major obstetrical operations shall not be undertaken in the home,
except where there are no hospital facilities within a reasonable distance.
Wherever possible, hospitalization should be authorized locally,14 for such obstet­
rical operations as mid or high forceps application, internal podalic version with
or without subsequent extraction, Cesarean operation, and the introduction of a
Voorhees bag.
_ , „„
.
,.
, ,
,,
Item 10. Obstetrical nursing. Bedside nursing care, as an adjunct to the
obstetrical service, is provided in many communities through local public-health
nurses employed on work relief. As a supplement to the existing community
services, bedside nursing care for expectant mothers and young infants, m ay be
authorized on an individual basis, at the request of the attending physician.
Item 11. Care by midwife. Whenever an expectant mother eligible for home
relief requests the attendance of a licensed midwife at her confinement, such
service may be authorized, and arrangements should be made for adequate
prenatal and postnatal care through existing community services. If there is
doubt about the normal progress of pregnancy or delivery, the patient should
be transferred immediately to a physician or to a hospital. Authorized obstet­
rical service provided by a licensed midwife m ay be eligible for reimbursement
by the Administration on the basis of not to exceed one-half of the fee paid to
a physician for the same type of service.
*
*
*
*
*
*
*
Regulation 9. Schedule of reimbursable charges. Introduction, a. It is
realized by the Administration that with the funds available, it is impossible to
compensate fully the physician, dentist, or nurse for his or her professional serv­
ices. The following schedule of charges, therefore, should not be considered as
complete compensation for services rendered, but rather as a maximum basis for
reimbursement, with due consideration for the conservation of relief funds to
the mutual benefit of the patient, the professional attendant, and the taxpayer.
The following schedule of reimbursable charges was prepared following a con­
ference, in Albany, N . Y ., on April 16, 1934, between authorized representatives
of the Medical and Dental Societies of the State of New York, the Administration,
and the State Commissioner of Health.
n Under §85 of the Public Welfare Law, see Chapter III, Section C.


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84

MATERNITY CARE AT PUBLIC EXPENSE

6. The charges listed are hereby established by the Administration as the
maximum eligible for reimbursement, under these Rules and Regulations. How­
ever, no statement in these regulations shall be construed to prevent a local
commissioner of public welfare from making additional payments, for specified
services, from local funds;38 or from making payment at less than the maximum
charges stated in these regulations, where the local professional organization has
agreed to the authorization of specified services at a lower rate.
Section A . Medical Care. (Personal Services.) The services of a physician
authorized with a view to reimbursement by the Administration, shall be subject
to the restrictions imposed by these Rules and Regulations, and expenditures
for such services shall be eligible for reimbursement at not to exceed the following
schedule of charges.
Item 1. Home visit. Authorized home visits, subject to the restric­
tions imposed by Section D , page 11, and Regulations 1, 2,39 and 3, above
$2. 00
shall be reimbursable at a rate per visit not to exceed_____________________
Item 2. Office visit. Authorized office visits, subject to the restric­
tions stated for Item 1, above, shall be reimbursable at a rate per visit not
to exceed_______________________________________________________________________
1. 00
Item 8. Obstetrical care. Authorized obstetrical care in the home,
including necessary prenatal care, delivery in the home, and postnatal
care, subject to the general restrictions and requirements imposed by
these Rules and Regulations and the specific requirements of Regulation
4, above, shall be eligible for reimbursement:
a. For the services of a physician, on the basis of an all-inclusive flat
rate which shall not exceed________________________________________ __________ 25. 00
or,
b. For the services of a physician, on the basis of a flat rate for delivery
in the home and necessary postnatal and postpartum care at not to
15. 00
exceed___________________ ;_______________________________________ _______________
and prenatal care at a rate not to exceed $1.00 per visit, with a maximum
for such prenatal care at a rate not to exceed______________________________
10. 00
The total charge, under this plan, for prenatal, delivery, and postpartum
care, not to exceed, as above__________ i_____________________________________
25. 00
c. For the services of a midwife, subject to the requirements of Item 2,
c, Section D and Item 11, of Regulation 4, above, on the basis of a rate
12. 50
not to exceed___________________________________ __________________________ —
d. For authorized obstetrical services not covered above, see Regula­
tion 4, Items 5, 6, and 8.

38Under § 83, of the Public Welfare Law, see Chapter III.
88Note especially Item, 6. Also, mileage is not reimbursable.


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