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U. S. DEPARTMENT OF LABOR
JAMES J. D AVIS, Secretary
CH ILD R E N ’S BUREAU
GRACE ABBOTT, Chief
PROCEEDINGS OF THE
FOURTH ANNUAL CONFERENCE OF
STATE DIRECTORS IN CHARGE OF THE LOCAL
ADMINISTRATION OF THE MATERNITY
AND INFANCY ACT
(ACT OF CONGRESS OF NOVEMBER 23, 1921)
HELD IN WASHINGTON, D. C.
JANUARY 11-13, 1927
BUREAU PUBLICATION No. 181
UNITED STATES
GOVERNMENT PRINTING OFFICE
WASHINGTON
1927
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S I N G L E C O P IE S
OF THIS PUBLICATION MAY BE OBTAINED FREE UPON
APPLICATION TO THE CHILDREN’ S BUREAU
A D D I T I O N A L C O P IE S
OF THIS PUBLICATION M AY B E PROCURED FROM
THE SUPERINTENDENT OF DOCUMENTS
U. S. GOVERNMENT PRINTING OFFICE
WASHINGTON, D . C.
AT
25 C E N T S P E R C O P Y
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Ul 5 S : c_
* IS I
CONTENTS
Letter of transmittal__________________________________________________________
Page
v
TUESDAY, JANUARY 11— MORNING SESSION
Maternal-mortality studies, by Robert L. De Normandie, M. D., instructor
in obstetrics, Harvard Medical School____________________________________
Discussion, by Rudolph W . Holmes, M. D., associate professor of
obstetrics and gynecology, Rush Medical College, University of
Chicago, and others__________ _________________________________________
Obstetrical and pediatric postgraduate courses in Kentucky, by Annie
S. Veech, M. D., director, bureau of maternal and child health, State
board of health, Kentucky_____ ____________________________________________
Discussion, by Alice W eld Tallant, M. D., consultant, Children’s
Bureau, United States Department of Labor_______________________
The Tioga County demonstration in prenatal care, by Ralph W . Lobenstine, M. D., chairman, medical advisory board, Maternity Center
Association of the City of New York______________________________________
Discussion, by M. Luise Diez, M. D., associate director, division of
maternity, infancy, and child hygiene, State department of health,
New York, and others______________________________________ ;___________
2
4
12
14
19
21
TUESDAY, JANUARY 11— AFTERNOON SESSION
The problem of compulsory notification of puerperal septicemia, by George
Clark Mosher, M. D., committee on maternal welfare, American Asso
ciation of Obstetricians and Gynecologists_________________________________
Discussion, by Elizabeth M. Gardiner, M. D., director, division of
maternity, infancy, and child hygiene, State department of health,
New 'York, and others__________________________________________________
Training the obstetrical nurse, by Carrie M. Hall, R . N., president,
National League of Nursing Education_____________________________________
Discussion, by Elizabeth F. Miller, R . N., State department o f public
welfare, Pennsylvania, and others_______________ _____________________
30
42
45
49
WEDNESDAY, JANUARY 12— MORNING SESSION
The county health organization in relation to maternity and infancy work
and its permanency, by John A . Ferrell, M. D., Dr. P. H., associate
director, international-health division, Rockefeller Foundation, New
York City-------------------------------------------------------------------------Discussion, by John E . Monger, M. D., director o f health, State
department of health, Ohio____________________________________________
Evaluation of maternity and infancy work in a generalized program, by
Jessie L. Marriner, R. N., director, bureau of child hygiene and publichealth nursing, State board of health, Alabam a_________________________
Discussion, by Florence M. Patterson, R. N., general director, Com
munity Health Association, Boston, and others______________________
55
66
69
72
WEDNESDAY, JANUARY 12— ,A FTERNOON SESSION
Breast-feeding demonstrations, by Frank Howard Richardson, M. D.,
regional consultant, division of maternity, infancy, and child hygiene,
State department of health, New York____________________________________
Discussion____________________________ ______________________________________
A breast-feeding survey in 11 counties in Michigan, by Lillian~R.~ Smith,
M. D., director, bureau of child hygiene and public-health nursing,
State department of health, Michigan____________ ._______________________
Discussion, by Ruth E. Boynton, M. D., director, division of child
hygiene, State department of health, Minnesota_____________________
hi
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IV
CONTENTS
Page
Analyses of child-care teaching in mothers’ classes and little mothers’
classes, by Agnes K. Hanna, director, social-service division, Children’s
Bureau, United States Department of Labor_______________________________
Discussion, by Miriam Birdseye, extension agent, Office of Coopera
tive Extension W ork and Bureau of Home Economics cooperating,
United States Department of Agriculture____________________________
97
102
THURSDAY, JANUARY 18— MORNING SESSION
A possible cost-accounting system on separate items of work carried on
under the maternity and infancy act, by S. Josephine Baker, M. D.,
consultant, Children’s Bureau, United States Department of Labor____
Discussion, by Irl Brown Krause, M. D., director, division of child
hygiene, State board of health, Missouri, and others________________
Itinerant conferences as an advance agent in developing permanent cen
ters, by Cora S. Allen, M. D., director, bureau of child welfare and
public-health nursing, State board of health, Wisconsin________________
Discussion, by Mrs. Helen de Spelder Moore, R . N., assistant director,
bureau of child hygiene and public-health nursing, State depart
ment of health, Michigan________________________ M ___________________
Developing permanent health centers, by Mary E. Brydon, M. D., director,
bureau of child welfare, State board of health, Virginia________________
Discussion, by Mrs. Jean T. Dillon, director, division o f child hygiene
and public-health nursing, State department of health, W est
Virginia---------------------------------------------------------------Foundation for permanent child-hygiene program in New Hampshire, by
Elena M. Crough, R. N., director, division of maternity, infancy, and
child hygiene, State board of health, New Hampshire____________________
Discussion, by A. Elizabeth Ingraham, M. D., director, bureau of child
hygiene, State department of health, Connecticut____________________
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113
119
122
128
128
132
135
THURSDAY, JANUARY 13— AFTERNOON SESSION
Supervision of field nurses, by Jane C. Allen, R. N., general director, Na
tional Organization for Public Health Nursing________________________
Discussion, by Mary D. Osborne, R. N., supervisor, public-health
nursing, bureau o f child hygiene and public-health nursing, State
board o f health, Mississippi, and others___________________________
Standards for training of public-health nurses, by Elizabeth Fox, national
director of public-health nursing, American National Red Cross_______
Discussion, by Ada Taylor Graham, R. N., director, bureau of child
hygiene and public-health nursing, State board of health, South
Carolina, and others______________
Methods of training staff nurses in prenatal and infant care, by Mathilde
S. Kuhlman, R. N., director, division of public-health nursing, State
department of health, New York_____ ._________________________________ _
Discussion_______________________ M________________________________________
Appendix.— List of persons attending the conference_______________________
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LETTER OF TRANSMITTAL
U nited S tates D epartment of L abor,
C hildren ’s B ureau,
Washington, September 1, 1927.
S ir : There is transmitted herewith a report o f the fourth confer
ence o f State directors in immediate charge o f the local administra
tion o f the maternity and infancy act, held at the Children’s Bureau,
January 11 to 13, 1927.
Respectfully submitted.
G race A bbott, Chief.
Hon. J ames J. D avis,
Secretary o f Labor.
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PROCEEDINGS OF THE FOURTH ANNUAL CONFERENCE OF STATE DIREC
TORS IN CHARGE OF LOCAL ADMINISTRATION OF THE MATERNITY AND
INFANCY ACT (ACT OF CONGRESS OF NOVEMBER 23, 1921), HELD IN
WASHINGTON, D. C„ JANUARY 11-13, 19271
TU E S D A Y, J A N U A R Y 11—MORNING SESSION
GRACE ABBOTT, CHIEF, CHILDREN’ S BUREAU, UNITED STATES DEPARTMENT OF LABOR,
PRESIDING
The C hairm an . It is certainly a great pleasure to have so many
o f you here to-day. I am going to say just a word or two about the
status o f the bill extending the maternity and infancy act, because
1 know it is a subject in which you are all interested. The bill is at
present “ unfinished business ” in the Senate and has been for a week,
which means that every afternoon at 2 o’clock the Vice President
calls up the bill and lays it before the Senate. It has had four or
five test votes, on which there was a favorable majority o f about
2 to l.2
I am going to turn the meeting of this morning over to Dr. Robert
L. De Normandie, whom you all know. He was here last year,
and I am especially glad we have him here for this particular pro
gram. It is a great pleasure to introduce Doctor De Normandie.
[D r . R obert L . D e N orm and ie took the ch air]
The C h airm an . First, before we proceed with the reading o f the
papers, I want to tell you how glad we o f the consulting obstetrical
committee are to be able to do anything we can for you, either as a
group or individually. .
The first paper Doctor Haines has put on the schedule is a rather
short one that I am going to read on maternal-mortality studies.
1 T h e view s expressed in the fo llo w in g papers and discu ssions are th o se o f th e in d ivid u al
speakers, fo r w hich th e C hild ren’ s B ureau d isclaim s resp on sibility.
2 T h e resolu tion exten din g the m atern ity and in fa n c y act fo r tw o years w as passed by
th e Senate on J a n u a ry 1 3 , w ith an am en dm ent pro vid in g th a t a ft e r Ju ne SO, 1 9 2 9 , the
m a tern ity an d in fa n c y a ct should be o f no fu rth e r force and e ff e c t ; i t w a s sign ed b y the
P resid en t on Jan. 2 2 , 1 9 2 7 ,
1
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MATERNAL-MORTALITY STUDIES
B y R obert L. D e N ormandie, M. D., I nstructor
in
O bstetrics,
H arvard M edical S chool
You will remember that last year I read a paper before you on
“ How to make a study o f maternal mortality,” and went over certain
points which I felt were important to have record o f if the study
o f maternal deaths was to amount to anything. As the result o f this
paper the Children’s Bureau has had made up the schedule which
you now have. Let me go over it with you.
The first page, as you readily see, is taken up with the information
that is derived from the death certificate and the birth certificate.
These two certificates are a matter of record and are obtained from
the boards o f health. The second page tabulates the care that the
patient had during her pregnancy, her past obstetrical history,
whether it was a hospital case, and the method of delivery. The
third and fourth pages are taken up with the analysis o f the cause
o f death as found in the death certificate. These various headings,
which are numbered according to the International Classification o f
the Causes o f Death, need no elaboration. They are points that
seemed necessary for a careful and complete analysis o f the causes
o f death.
After this schedule was drafted, it was sent to each member o f the
consulting obstetrical committee o f the Children’s Bureau for his
criticism. The question was raised whether the schedule was too
detailed; and one physician remarked that he doubted if he could
tell all the things that were asked for, even though his records were
unusually complete. My feeling is that all the points which are
suggested for investigation can be readily found out if the investi
gator sees the physician who signed the death certificate, within
a short time o f the death. Unquestionably, if it is a year or more
after the death the facts sought for may not be obtained. None
o f us have so many deaths in obstetrics that we do not remember
all too vividly the ones that we do have, and the facts, if sought
early, can readily be obtained. The schedule has the unanimous
approval of the committee.
The obvious advantage of having available such a schedule as this
is that maternal-mortality studies can now be made in various parts
o f the country with this standard schedule. The statistics thus
obtained will be more nearly comparable than any we have ever had
before and will be unassailable.
Now that the schedule has been prepared the question arises, how
and where shall we make the studies? You will remember that last
year it was stated that similar studies had been suggested, but the
medical profession in certain communities would not cooperate.
There may be opposition to such a study. My feeling is that it
should be done through the State boards of health and the State
2
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MATERNAL-MORTALITY
s t u d ie s
a
medical societies by physicians well trained in investigative work
and having a full knowledge o f obstetrics. I feel strongly that the
State boards can do a study of this sort much better if they have
the cooperation o f the State medical societies. I can see no reason
why such cooperation will not be given if it is first explained to a
small group o f the outstanding men in the State exactly what the
study means, how it is to be made, and by whom. Such a study is
not a criticism. It must be made clear that it is educational. The
physicians first called in consultation should not necessarily be
obstetrical men, but men o f the community interested in the broad
subject o f public welfare. This movement has grown rapidly in
the last few years, and has the support not only o f the best physicians
but o f many o f the most intelligent laymen throughout the country.
Get the support o f this group, and I believe there will be no opposi
tion to these studies.
Because some o f the directors felt that this study could not be
made, I have shown the schedule to many physicians—general prac
titioners, specialists, and men who are interested in the improvement
o f the obstetrical situation purely as a public-health movement— and
they all agreed that it could be done.
We must make it clear that such a study is not a criticism of the
medical profession, but is an investigation to find out how we can
better our results. It is possible that from an intensive study such as
this we can show that some o f the deaths which are charged to
obstetrical conditions are not in any way due to obstetrics, for the
registrars o f vital statistics, who many times are not medical men,
classify them according to the best information they have, as ma
ternal deaths, although they should not be regarded as puerperal.
I am confident that an intensive study carried out over a period o f
years in various States, or better, in all the States, with this same
schedule, will yield most interesting results, and will show us where
we must attack this problem to improve the results.
The first studies, I believe, should be done in the States that ask
for them, and then I should hope that the value o f these studies will
be so apparent to the other States that they too will plan for them.
You all know how the statistics that the Census Bureau publishes
have been questioned, and how easy it is to draw unfair conclusions
from any set o f statistics. But if these deaths are intensively studied
the facts will be there and will be unassailable, and until we have un
assailable facts we shall not be able to show whether the obstetrical
situation is good, bad, or indifferent, or whether it is in any way im
proving. Such a study as this will show at once whether the funda
mental difficulty is with the prenatal care or with the natal care.
We have had in the last few years an intensive campaign on prenatal
care, but prenatal care alone will not save women and babies. Good
prenatal care is thrown to the winds unless we have good natal care;
and if this study shows that the prenatal care is satisfactory but that
the natal care is bad, then we can see at once where we must try to
improve our work. It will show, I think, whether the medical
schools are turning out men who are satisfactorily trained. It will
show whether the deaths are due to the physicians’ lack o f care or
to the patients’ environment, or whether they are due to the midwife
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
situation, which is so great a problem in many parts o f the country.
Certain groups believe that the midwife is the only economic solu
tion o f the obstetric situation and that we must have her. These
groups feel strongly that if we have the midwife she must be well
trained and well supervised.
It is only within the last few years that we have been getting any
real statistics on the subject, so that we can talk intelligently and put
our finger on the various weak links o f the chain in the care and
delivery o f the pregnant woman. We have all had our ideas, and
many o f them have been at great variance. Now, however, we are
getting on a firm foundation, and by studies such as this schedule
will bring out, the facts will be more firmly established and we can
speak with authority, showing wherein improvement must come.
Each one o f you directors knows the situation in your State. You
know your physicians and you know how best to gain their confidence
in order to make a study such as this schedule calls for. Such studies
are worth while, I am sure, and o f the greatest value if carried over
a series o f years in many States. I ask that your discussion be free
and frank so that it will bring out the difficulties in making these
studies.
D IS C U S S IO N
The C h a i r m a n . Doctor Haines has an outline o f the instructions
which will go with these schedules to the physicians that make the
studies. Doctor Haines, will you read them ?
Doctor H a i n e s . Doctor De Normandie has covered part o f the in
structions. I will just bring out one or two additional points. Some
o f you have had the “ Scope and purpose o f the study,” and Doctor De
Normandie has outlined it; I will not take that up. These are in
structions to investigators in the use of the schedule. The standard
death certificate should be copied just as it is found in the statisti
cian’s office, and also the birth certificate that we find on the first page
o f the schedule. I f the heart has been examined, the word heart will
be checked, so that if heart is checked, it means “ Yes.” I f the heart
has not been examined “ N ” should be checked. I will read the section
o f the instructions pertaining to prenatal care.
Inquiries 23-26 refer to prenatal care given by a physician. When the inter
viewer is receiving information from a physician who was attendant at death
but who gave no previous supervision during pregnancy, caution must be taken
as to whether the answer to this inquiry will be “ None ” or “ Not reported.”
Do not answer “ None ” merely because the attendant at death states that he
gave no prenatal ca.re. Before answering “ None,” ascertain whether prenatal
care was given by some other physician, and if this can not be found out enter
“ N. R .” for inquiry 23, covering the entire section on prenatal care. To deter
mine the proper answer for “ Summary ” of prenatal care (inquiry 24) the
interviewer should read the following excerpts from Standards o f Prenatal
Care (Children’s Bureau Publication No. 153) :
“ Patient should be examined by a physician at least once a month during the
first six months, then every two weeks or oftener as indicated, preferably every
week in the last four weeks. A t each visit to the physician the patient’s general
condition must be investigated, blood pressure taken and recorded, urinalysis
done, pulse and temperature recorded, and the weight of the patient taken if
possible. Abdominal examination should be made at each visit and the height
of the fundus determined at this examination. Abdominal palpation in the
eighth and ninth months will show whether or not there is any obvious dispro
portion between the head and the pelvis.
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MATEEN"AL-MOETALIT Y STUDIES
5
“ In a primigrávida, if the presenting part two weeks before the estimated
date o f delivery is not well in the pelvis, the physician in charge should deter
mine, so far as is possible, whether any disproportion between the pelvis and the
baby exists. I f a disproportion is diagnosed in any case special care should
be taken to avoid vaginal examinations immediately prior to or after the onset
of labor. This precaution is wise because of the danger o f serious infection
should operative procedures later become necessary.”
I f these standards have been followed, check prenatal care as “Adequate.”
I f some prenatal care was given, but it was not up to the above standards,
check inquiry 24 as “ Inadequate.” When “ None ” is checked, there will be no
further entries under inquiries 28 to 26 (<Z).
Inquiry 25 (a). — I f the heart has been examined, check “ heart,” and also
check “ normal ” or “ abnormal ” to show results of examination; i f abnormal,
specify the abnormality. ( 6 ) I f the lungs have been examined follow the same
procedure in checking.
Inquiry 25 (c ).— I f “ measurements” is checked, check also “ external,” or
“ internal,” or both. I f any abnormality was discovered, check “ abnormal,” and
specify the abnormality; otherwise check “ normal.”
Inquiry 25 ( d ) .— I f a Wassermann test was made, check “ W asserm ann” and
then denote the results by putting a check on “ neg.” for negative or on “ pos.”
for positive. I f there has been no Wassermann, check “ N .”
Inquiry 26 refers to prenatal visits and does not include the attendant’s visit
at time of delivery. Under inquiry 26 (a), if the physician had not seen the
patient for the purpose o f giving prenatal care prior to visit at which birth
occurred, check “ N.” I f he did see the patient, put a check under each month
o f visit. For instance, if he saw the patient for the first time in the fifth
month and for each month thereafter, checks will be placed in columns 5, 6, 7,
and 8. For the ninth month information should be obtained as to weekly v isits;
and i f the physician saw the patient during each week o f the ninth month,
checks will be placed under column 9— in columns 1, 2, 3, and 4. Similarly,
for 26 ( 6 ) and 26 (c) check the months in which the urine and abdomen were
examined and for 26 (d) the months in which the bipod pressure was taken.
The C h a i r m a n . When any one of you gets up to discuss any o f the
questions, will you kindly give your name? Now I ask you to bring
up any points which are not entirely clear to you.
Doctor H a i n e s . An important question in my mind is what should
be considered the standards in the hospital.
Doctor B r y d o n . May we accept the standing o f hospitals accord
ing to our State’s rating? We have State inspection o f hospitals. I
also want to ask if this information should not be gotten at the hos
pital itself. We could not get it anywhere else, I imagine.
The C h a i r m a n . I should imagine that it would be gotten at the
hospital. O f course if the State has hospital ratings I think it would
work out satisfactorily to accept them. We do not have hospital
ratings in Massachusetts. Certain hospitals are given the right to
do obstetrics, but they are not rated as good and bad; the good and
the bad have the same kind o f license. Have you a different system
in your State?
Doctor B r y d o n . Yes. The nurses’ examining board of the medical
society has an inspector o f hospitals, and the rating is very carefully
looked after, I understand.
The C h a i r m a n . That would be especially for training schools?
Doctor B r y d o n . Yes.
Doctor L e v y . I would like to suggest that you indicate whether
the patient is delivered by the interne or by the attending physician.
W e often send a patient from a general practitioner to a youngster
in a hospital, and we think we are sending her to expert hospital care.
I think the person who actually delivers the patient should be
entered.
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
The C h a i r m a n . Doctor Levy, will that not come out in a hospital
case when an investigator goes to look up the records? He can see
there who delivered her.
Doctor L e v y . Possibly; not always. It depends upon how the
records are kept.
The C h a i r m a n . I f the records are accurate, they will show it.
Doctor L e v y . Yes. But I think that is one o f the important things
to get.
Dr. G . M. A n d e r s o n . Are not many women delivered by internes,
and yet the signature on the birth certificate is always that o f the
doctor in charge of the department, or attending on the staff ? In the
West I know that is the case; probably hundreds of women are
delivered by internes, yet the signature on the birth certificate will be
that of the doctor.
The C h a i r m a n . I should like to ask the group here whether that
is generally so? I think in Massachusetts the doctor makes out all
the birth certificates.
Dr. G. M. A n d e r s o n . Whoever makes it out, that has nothing to
do with who attended the woman. The clerk at the office can make
them out. Our State requires every hospital report to be made by the
vital statistician. In that way we get two checks; someone in the
office will make out birth certificates for the cases o f that month, and
as she catches the doctors coming and going she gets them to sign
them.
Doctor L e v y . That is not our practice.
The C h a i r m a n . I am informed that in the West and Middle West
that is the practice. The chief’s signature goes on the certificate, and
not the interne’s.
Dr. G. M. A n d e r s o n . Yes; but y o u wish to investigate the kind of
service that the woman gets, which depends on who delivered her—
whether it is an interne or an obstetrician.
The C h a i r m a n . Yes; we shall have to make a point o f that, Doctor
Haines.
Doctor B a k e r . I think it is true in New England hospitals that
the superintendent signs all the certificates.
The C h a i r m a n . I am perfectly sure in our hospitals we do- not
sign them; the individuals who actually deliver the patients are
students at Harvard, who sign their own birth certificates. How is
it in Illinois, Doctor Holmes ?
Doctor H o l m e s . In Illinois the law now requires that the prospec
tive graduate in medicine shall have a fifth year as an interne in an
accredited hospital before his diploma is issued. He is given, on
certification o f the dean o f the college, a temporary, limited license
to practice medicine in the hospital during this fifth year. A t the
completion o f his interneship he is eligible to take the State board
examination for full licensure. During this year o f interneship he
is not permitted to sign birth or death certificates.
It has been aptly stated, I believe by Doctor Cabot, of Boston, that
people rarely die from the disease with which they are afflicted.
That is, the diseases which afflict individuals lower the vitality so
that there is a bacterial invasion— and the concurrent infection ter
minates the life. For example, tuberculosis in its pure form is a
sputumless malady; bodily vitality is lowered, and immunity against
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MATERNAL-MORTALITY STUDIES
7
bacteria is reduced to the lowest point; the lungs become infected
with many other types of bacteria, which are highly destructive to
pulmonary tissue and cause secretions that are expectorated. Per
haps it is more correct to state that the symptom complex o f tuber
culosis comprises the first stage o f tubercle formation in the lungs
or elsewhere; and the second stage, the breaking down o f these
tubercles from a development o f a “ mixed ” infection; and third, a
gradual disintegration o f all bodily functions. Yet, after all is said
and done, i f the first stage may be arrested, death need rarely be due
to tuberculosis; the mixed infection is the ultimate cause o f death.
In Illinois, largely owing to the activities o f the Institute of
Medicine, there is a strong movement to further a high percentage
o f post-mortem examination in hospitals. Often a true diagnosis
as to cause o f death may be made only by such post-mortem examina
tion, through which the primary as well as secondary causes are
ascertained.
I have always believed there is a strong difference between a death
“ o f ” pregnancy, labor, and the puerperium, and a death “ in ” those
obstetric periods. In the former the death is due to an obstetric
complication o f the prospective or new-made mother; the latter is an
accidental, extraneous malady. In the former, an obstetric cause
o f death would be such as a toxemia, placenta previa, or puerperal
infection. Typhoid, pneumonia, influenza, etc., would be causes o f
death “ in ” relation to prospective motherhood. It would be emi
nently desirable to have vital statistics tabulated under the two
headings.
From about 1899 to 1905 I was chairman o f a committee to investi
gate the problem o f criminal abortion in Chicago. When we began
our investigation about 10 or 12 deaths due to criminal abortion came
to the attention of the coroner annually. The activity of the com
mittee aroused public interest so that in the next year the incidence
o f deaths which became public was double to treble the figures that
we first found. The committee felt that not 1 per cent o f all the
deaths due to criminal abortion ever came to the attention o f the
coroner. In other words, the midwives, with the connivance o f
corrupt physicians, or the corrupt physicians themselves buried their
victims under false certificates o f death. Further, we felt that per
haps only 1 or 2 per cent of criminal abortions resulted in death.
In other words, probably there were as many criminally interrupted
pregnancies in our large communities as there were full-time infants
born."
You may recall the notorious “ dress-suit case ” o f Boston where
the dismembered body of a young woman, dying as the result of a
criminal abortion, was placed in suit cases and thrown into Boston
Bay—but the authorities recovered the body. I have been credibly
informed that the coterie o f physicians responsible for the crime had
boasted that they performed 2,000 operations annually. A physician
in Chicago whom we had had apprehended for an illegal operation
told me confidentially that he had performed 20,000 operations in
his medical career, covering a period o f about 55 years. Constantly
deaths from criminal operations are certified as due to pneumonia or
typhoid— in fact, any cause which will pass muster. W ho can ascer
tain the toll ? The only way would be for every child-bearing woman
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PROCEEDINGS, MATERNITY AND IN FA N C Y CONFERENCE
(from 12 or 14 to 45 years) who dies to have a post-mortem examina
tion performed by an expert pathologist. A law for this purpose
would be so abhorrent that it could be neither passed, nor if passed,
enforced—public sentiment would be against it. And yet, should
not all these deaths be recorded as accidents o f the puerperal state?
And certainly the matter should be viewed with concern as a cause
o f infant mortality.
I would like to make a statement which has no specific relationship
to any paper that will be presented during the conference; but my
remarks are germane to the whole subject o f maternal and infant
welfare as conducted by the bureau under whose auspices the confer
ence is functioning.
During the year or more that the Sheppard-Towner bill was dis
cussed I was strongly opposed to i t ; on a number o f occasions I was
permitted to express my views publicly, as I was known to be antago
nistic to the bill and the manner o f its operation if it became law.
Unfortunately, on one occasion—a meeting of a medical society—I
had strongly arraigned the bill, when Miss Abbott arose to defend
its purpose. Later, when the bill became law I was surprised to
receive an invitation from Miss Abbott to serve on the consulting ob
stetric committee of the Children’s Bureau— and this at a time when
I still was bitterly antagonistic to the law’s operation. I had one
reason for accepting this invitation. So long as the bill had become
law I felt that the best possible use o f the appropriation should be
made and that I, in my small way, might contribute something
through my obstetric training toward improving the lamentable ob
stetric conditions in this country. And has this much defamed
maternity and infancy act accomplished anything ? I believe the act
has advanced obstetric practice and knowledge in rural and small
communities 25 years ahead o f the time it would normally have come.
In times past I have lent my voice publicly in opposition to the Shep
pard-Towner Act. I now wish to announce publicly that I have had
a change of heart and opinion. And I wish Miss Abbott to know
that my appointment to the obstetrical committee has been one o f the
great honors o f my life.
Whatever good is being done by educating the women of this coun
try in prenatal care will be nothing in comparison to what will
accrue when the rank and file o f general practitioners have been made
to realize the need of better obstetrics, and will give what the
women—the patients—have been taught to demand. The fact that
committees have been organized in every State o f this country, with
four exceptions, which will bring home to the dwellers in small com
munities and rural districts that prenatal care is an. essential part
o f bearing children, is going to be one of the greatest educational
factors in this country and to spell conservation o f maternal and
infant life to an extent now hardly appreciated.
The Commissioner o f Health of Chicago, Dr. Bundeson, has just
issued a most excellent brochure on the subject o f prenatal care—
500,000 copies in the first edition. A colossal good will come from
the dissemination of the information contained therein. A t the
present time more than 50 per cent of the labors in Chicago are con
ducted in hospitals, while hardly 10 years ago— at least before the
"World War—not far from 60 per cent Of women in labor were
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M A TER IAL-M O R TALITY STUDIES
9
attended by midwives. Education has accomplished this, and educa
tion will increase this proportion until the midwife is entirely elimnated— and the mortality rate will diminish with her going.
The C h airm an . I am sure that many physcians who feel just as
Doctor Holmes felt against the Sheppard-Towner bill will come
over to it too, as they learn more about the work.
Doctor H aines . W ill you ask Miss Rood to speak on the hospital
standards ?
Miss R ood. I made. a statement to Dr. Viola Anderson that I
believe the American Hospital Association has a committee working
to develop hospital standards. I can not tell you anything more
about it.
The C h airm an . Does anybody know about that?
Miss M orris. I do not know of the work of the American Hospital
Association, but in the spring the American College of Surgeons,
with the assistance o f the State board o f health, made a survey ox
the hospitals of Louisiana. The records were informational and
interesting. The President of the Louisiana State Board o f Health,
Doctor Dowling, expects us to use that—provided the hospitals are
advised of their grades.
The C h airm an . May I ask whether all the hospitals were graded
or just those having 35 beds or more?
Miss M orris. I think the grading was done for all.
Doctor G ardiner. I think you did bring out the point that the
investigations into maternal deaths should be made as soon after the
birth as possible. In some o f the work we tried to do, where a period
of a year had elapsed, the interne had left the hospital, the attending
physician did not remember the case, and it was almost impossible
to get accurate information.
The C h airm an . That is the most important part—to investigate
as soon as possible after the death of the individual is reported.
Doctor P ickett. In the Louisville City Hospital all death certifi
cates and birth certificates, too, are signed by the medical superin
tendent of the hospital; but in any hospital where they have an
interne to deliver the woman there is also a record, and the interne
who delivers the woman signs that— “ delivered by so and so.”
There never was an obstetrical record that did not have on it
“ delivered by,” and the man who delivers the case signs it. In
standardized hospitals I think it would be an easy matter to find
out who made deliveries, because you have not only birth and death
certificates but hospital records; and if there is anything on that
delivery record, certainly there would be the name of the man who
made the delivery.
Miss A bbott. W e have not allowed in the schedule for the name
o f the person who made the delivery, but I think we can provide
for it.
Doctor L evy . May I ask a question in regard to who should make
the investigation? I am not suggesting that it should be made
by the State medical society; I should like to have someone discuss
whether it should be made by the State society or by the State
department in cooperation with the State society. I believe if you
can get the medical society whole-heartedly to make the investiga
tion, then they will use the facts they have learned in dealing with
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
the doctors themselves. The State department will not be able to
use the findings very actively if it is done the other way around.
Doctor N oble. I feel the same way about Pennsylvania.
The C h airm an . Would it not be better to do it in one way in some
States and in the other way in other States ? But the stimulus must
come from the State board o f health.
Doctor L evy . It is all right for the State board o f health to supply
the stimulus as long as the medical society is willing to assume the
responsibility.
The C h airm an . Doctor Haines, will you read what the outline
says on this subject?
Doctor H aines (reading):
The schedule and plan for such a study have been worked out by the con
sulting obstetrical committee for the Children’s Bureau, of which Doctor De
Normandie is chairman. The printed schedules that have been returned from
the Government Printing Office are available to any State undertaking the
study in sufficient quantities for the study without cost to the State.
The method of procedure agreed upon by the consulting obstetrical commit
tee is to make the study in States in which the State medical society under
takes to sponsor the study. The plan is to secure the information asked for on
the schedule for every maternal death. The information would be sought from
the physician or midwife attending the woman, the investigator to be a com
petent and tactful physician. The investigation will be limited to maternal
deaths. The facts secured will indicate the deviation from generally accepted
standards in the cases in which death occurred but will not give any informa
tion about those who do not die but suffer unnecessary invalidism. The study
should be carried over a period o f two or three years. The information should
be collected on the schedules soon after the death of the mother, while the
details are still fresh in the memories of attendants.
The Children’s Bureau will give assistance in the preparation o f the material
for publication.
Doctor L evy . I should like to ask too whether you are insisting
that a doctor should make the investigation?
The C h airm an . I do not think we are insisting, but many of us
feel we should get more if a doctor questioned a doctor than if a
nurse or a public-health worker questioned a doctor.
Doctor L evy . I think that is true.
Dr. G. M. A nderson. In the three mountain States—the only ones
I know— I am wondering how the State medical societies can carry
on such an investigation because I am sure they have no available
funds.
Miss A bbott. W e have some money that could be used in that way.
W e hope to get someone who is a member o f the State medical society
and who is interested in a study o f this sort to bring it up. Someone
should sponsor it in the State society, other than those in the State
health department. I think Doctor Yeech could tell us how the State
department in Kentucky is going about it.
Doctor V e e c h . Our State board of health o f Kentucky is simply
part o f the medical profession; the members o f the State board of
health are recommended to the Governor by the State medical society.
The C hairm an . I believe with Doctor Levy that it would be well
to have the State medical societies sponsor this investigation.
Doctor U nderwood. I am of the opinion that the directors here
should go back to their States and if it is not already sold, sell this
proposition to the State health officer. Then let him get in touch
with a few o f the leaders o f the State medical association, who will
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m a te r ia l - mortality studies
11
readily understand the need for this work and who will bring it up
at the next State medical association meeting, when the association
can go on record as approving and requesting the State department
to make the study in cooperation with the Children’s Bureau.
Doctor C rumbine . On behalf of the American Child Health Asso
ciation I would like to say that within the limits of our personnel and
budget we should be very happy to assist any State in the study of
maternal mortality upon the request o f the State or o f the Children’s
Bureau.
Doctor B reeding. I think the suggestions made by Doctor Under
wood are excellent. I believe this investigation, if undertaken, should
be brought about, if possible, through the State medical organiza
tions. An excellent move, after it is initiated in this way, would be
to follow it up in the county organizations. In Tennessee we have a
policy o f meeting county medical associations, or local societies, from
time to time to discuss with them our problems. The reason for some
opposition from the medical profession to activities of health depart
ments is a lack of understanding between the health departments and
the local medical societies. It is our observation that where we meet
these societies, discuss our problems with them, and bring about an
understanding o f what we are trying to do we have little trouble in
securing cooperation. Now whatever program we undertake through
the State medical societies must be taken home and executed through
the physicians in the county societies.
The C h airm an . Doctor Veech, of Kentucky, has done a most
interesting piece o f work, and she is going to tell us about graduate
courses in pediatrics and obstetrics for physicians.
66982°— 27----- 2
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OBSTETRICAL AND PEDIATRIC POSTGRADUATE COURSES
IN KENTUCKY
B r A n n ie S. V eech, M. D ., D irector, B ureau
C hild H ealth , S tate B oard
of
of M aternal
H ealth , K entucky
and
Kentucky’s bureau o f maternal and child health from its beginning
has recognized that the activities carried on under the Federal ma
ternity and infancy act, for the promotion o f maternal and infant
health, should be educational. Several groups interested in the
necessary program presented themselves, the most important one
being the medical profession. The part which they were to play
in the program had to do almost entirely with pediatrics and ob
stetrics, somewhat in their therapeutic but more in their hygienic
and public-health aspects. W e realized that some members o f the
profession had not had in their medical training the opportunity
for modern teaching along these lines and that the burden o f urgent
care o f the acutely sick had kept them tied to their local respon
sibilities. Others, like our surgeons and other specialists, were com
pelled by the press o f work to confine their study to the types of
work-in which they were actually engaged. Therefore, for the past
four and a half years we have made an unceasing effort to bring to
the profession in our State in every possible way the best information
available concerning modern obstetrics and pediatrics and the newer
knowledge o f mother and child care. The specialists in the pro
fession in our State have given most generous assistance to us in
carrying out this program.
The Kentucky Medical Journal, the organ o f the State medical
association, carried for two years an obstetrical article each month,
written by Dr. Alice Pickett, director o f the prenatal clinic at the
Louisville City Hospital. In these articles the need and the results
o f prenatal care were stressed in relation to eclampsia, miscarriage,
and the general hygiene o f pregnancy, and the reports and results
o f the management o f all difficult cases o f delivery in the obstetrical
department of the Louisville City Hospital were briefly given.. To
idealize maternity and also to draw especial attention to this obstet
rical column, the medical journal permitted us to head the column
each month with a reprint o f the Sistine Madonna and the Christ
Child. Without doubt this series o f obstetrical articles running over
so long a period o f time did much to focus the attention o f the
profession throughout the State on prenatal care. W e have co
operated from the_ beginning with the medical department o f the
University o f Louisville in its obstetrical department and its pre
natal clinic in the Louisville City Hospital by paying the salary
o f a trained nurse, who is the registrar for the clinic and the ob
stetrical department. This clinic is a teaching center not only for
the medical students but for doctors and nurses from all over the
12
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13
State. The director o f one o f our successful prenatal clinics in a
full-time county health unit o f the International Health Board in
Kentucky, which also is partly financed by Sheppard-Towner funds,
was trained in this clinic.
The State medical association has for the past four years made it
possible for our bureau to have a large part in its annual program.
A t such times we have had speakers on the program on prenatal care
and obstetrics, on infant care and all phases o f pediatrics, especially
in its preventive aspect, or we have had part in the discussion o f these
subjects. One o f our best-received essays before them was by our
nutritionist. The county medical societies o f the State are always
eager to have our speakers on maternal and child health, and much
educational work has been done in this way by physicians from our
department. For four years we have had not only local but national
speakers, such as Dr. Richard Bolt, o f California, Dr. Mary Riggs
Noble, o f Pennsylvania, and others as lecturers on maternal and child
health for the annual health officers’ school.
We have always considered our demonstration health centers
throughout the State educational centers for parents. They also
furnish additional training for the local doctors who help us. In
these health clinics the local doctors have the opportunity to make
physical examinations o f 20 to 60 or more children, and are then put
in touch with the simplest and most up-to-date literature on maternal
and child health. We also put into their hands the latest and best
reprints on immunization, infant feeding, and all phases o f maternal
and child care from authorities on these subjects. We have had the
voluntary help o f more than 1,200 doctors in our work, many o f
them cooperating year after year. Without them we could not accom
plish so much. A ll o f them are general practitioners, having great
responsibilities and a large area to cover in their work. They wel
come cooperation with us, give generously o f their time and services,
and some write into our office for advice in some o f their infant and
maternal problems. We find the sincere confidence and generous co
operation o f the laity and the medical profession in Kentucky most
heartening and a great stimulus to us for greater service.
The latest and most intensive piece o f educational work accom
plished through our department was a course given by Dr. Alice Weld
Tallant. Doctor Tallant spent six weeks in Kentucky, during which
period she gave a series o f lectures before 12 county medical societies
and two district medical societies. Postgraduate work for the rural
doctors, presented through local medical societies, affords an excel
lent opportunity for review and the presentation o f modern phases
o f both child-health and obstetrical work. Four lectures were ar
ranged with a luncheon or dinner meeting between. This was done
for the convenience o f physicians living at a distance, in order that
they might be able to hear the entire series. The lectures covered
prenatal care, the complications o f pregnancy, and the management
o f difficult deliveries. In the second lecture prenatal care was re
viewed, so that any doctor missing one lecture would still get an
understanding o f the value o f prenatal care.
Doctor Tallant was accompanied by a physician and a nurse from
our department. The nurse was in charge o f local arrangements and
the set-up o f the equipment, which Consisted o f manikin, fetal doll,
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
bony pelvis, stethoscope, blood-pressure apparatus, Wassermann out
fit, and everything necessary in linens and sterilization for setting up
a clinic.
The social meeting between the lectures gave Doctor Tallant an
opportunity to discuss private cases brought to her by the doctors.
The total attendance was 500. Before going out in the field Doctor
Tallant was the dinner guest o f the Louisville Obstetrical Society, at
which meeting she discussed her proposed work and had the sug
gestions and approval o f the group. Her work in Kentucky was
sponsored not only by the State board o f health but by the State
medical association. She was invited to discuss several obstetrical
papers at the annual meeting o f the association, and there was a de
mand for her lectures and demonstration by many more medical
societies than she was able to meet in the time allotted to her1.
D IS C U S S IO N
The C h a i r m a n . It is a most interesting experiment that Kentucky
has tried. Dr. Alice Weld Tallant, consultant for the Children’s
Bureau, will tell us about her point o f view.
Doctor T a l l a n t . After hearing Doctor Veech’s paper on the work
she has carried out in Kentucky, you will easily understand how the
way had been prepared for me so that my sojourn in the State was
begun under favorable auspices. I was also fortunate in starting my
work in the same month that the State medical society meetings weTe
being held. Through the courtesy o f Doctor McCormack, secretary
o f the State board o f health, I was allotted a place on the program
in the discussion o f the obstetrical papers, and thus had an oppor
tunity to meet a number o f physicians from different parts o f the
State, so that I did not feel like an entire stranger in my later travels.
The kindness of Dr. Alice Pickett still further smoothed my path
way; Through her invitation I was privileged to attend a meeting
o f the Louisville Obstetrical Society, at which I received the benefit
o f free discussion of my plan o f procedure and many helpful sug
gestions as to obstetrical conditions and needs. It may interest you to
know the points which the Louisville obstetricians all urged me to
stress particularly— asepsis, o f course, and also the dangers o f the
improper use of pituitary extract.
The object o f the Children’s Bureau in sending me out into the
field was to arouse interest in prenatal care, to spread information as
to the details of prenatal examinations, and to urge the importance o f
prenatal clinics. The idea o f my holding clinics had been considered,
but the difficulties in the wav of gathering together the patients were
too great, and it was therefore judged wiser for me simply to give
talks and demonstrations before county medical societies. As these
societies in Kentucky are for the most part rather small groups, it
was possible to keep the discussions informal, and I believe that this
served to make the meetings more helpful.
Everything was planned beforehand for me in a wonderful way,
and no detail was omitted which could make my trip easier. My
itinerary was made out for me, and I was piloted through my
journeymgs by Doctor Jennings, the assistant director under Doctor
Veech, whose knowledge o f the devious ways o f travel in Kentucky
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15
never failed, even when it was a question o f discovering a bus at 4
a. m. or a train connection in Virginia, when Kentucky railroads left
us in the lurch. One o f Doctor Veech’s nurses also accompanied us,
to get the room and equipment in readiness for my talks, or sometimes
went in advance of us, to herald abroad my coming. Another com
panion o f our travels really deserves a chapter to herself, if time
allowed. After we decided that a demonstration would be a valuable
part o f the meetings, Doctor Veech secured a manikin for us through
the courtesy o f the medical department o f the University o f
Louisville. When I tell you that this member o f the party never
failed to arrive in time for my use, I think you will share my respect
for the abilities o f the directors o f my tour, for the intricacies o f
traveling with an obstetrical manikin are better imagined than de
scribed before this assembly. T ry doing it yourselves some day, if
you do not believe me.
With everything so carefully and completely arranged for me,
nothing remained for me to do but wait until I had been escorted to
the meeting place and then begin to talk. Since it is self-evident that
no one, however well-equipped with knowledge and eloquence, could
be expected to cover the whole subject o f obstetrics in an hour
and a half, the question naturally arises, What points did I take up
in my talks ?
Our first idea was to hold two meetings, one on prenatal care and
the other on obstetrical complications, but in many places we had
only one, into which both subjects were compressed. Moreover, we
discovered almost at the outset that a discussion o f prenatal care
alone did not create much interest. This did not surprise me, for as I
noted in the paper which I read before this conference last year, my
impression was that most doctors are pretty well “ fed up ” on this
topic, whether or not they put into practice all its teachings. More
than this, I had seen enough o f the experiences o f general practi
tioners to understand that with the best will in the world they could
not carry out the principles o f prenatal care, even in a large city like
Philadelphia, if their patients did not see the importance o f frequent
consultations and did not present themselves for examination. It
did not take long to find out that this condition o f things was even
more marked in the rural districts o f Kentucky (and doubtless in
other States as well). As soon as I asked the physicians at the meet
ings the result o f their observations, the almost unanimous reply was
that their patients rarely consulted them during the prenatal period
and often did not even engage a doctor in advance but sent in a call
after labor had begun. Some noted that there had been an improve
ment in the last few years and thus bore testimony to the campaign
o f education which Doctor Veech’s bureau o f maternal and child
health has been carrying on.
Although a detailed exposition o f prenatal care by itself was
proved unpractical I managed to introduce one phase or another at
every turn. The pelvimeters on the table o f equipment which the
nurse had set up gave me a chance, while showing them to the
audience, to lay stress on the value of pelvimetry. The blood-pres
sure apparatus served its purpose in like manner. I then attacked
the matter from another angle by making “ obstetrical complications ”
the topic under discussion and bringing in prenatal care indirectly
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
but emphatically as the preventive side o f their treatment. As far
as time allowed I touched on the complications o f pregnancy and
their treatment by prenatal care as well as by other measures, in
cluding the so-called “ accidental ” complications, such as tuberculosis,
heart lesions, and venereal disease, besides those directly connected
with pregnancy, such as pernicious vomiting, pyelitis, and abortion.
In the same way I went over the complications o f labor, indicating
how far they could have been prevented by prenatal care. I took
the stand that these matters were familiar to physicians but that we
must look to the physicians to help in the education o f patients by
pointing a moral whenever possible.
In this connection I always made it clear that the State bureau of
maternal and child health stood ready to aid the doctors by sending
out leaflets o f instruction to the patients of those who wished them
and by arranging for the examination of urine and blood specimens.
I tried in every to bring out the fact that the bureau wished to co
operate with the physicians and not to work against them, and often
referred to the recommendation in the prenatal leaflet that the patient
should begin early to save money for the confinement fee, in order
to pay her bill promptly.
I always took pains to explain that the Children’s Bureau had
arranged for my work as a part of its program for combatting
maternal and infant mortality. But I was equally careful to empha
size the fact that the States are pretty much alike in maternalmortality statistics, and that Kentucky had been chosen first not
because of its bad record but because I)octor Veech was an old friend
o f mine who had been kind enough to want me first.
Statistical tables I avoided, simply stating the proved fact that
there are three main causes o f maternal mortality: Toxemia and
eclampsia, puerperal infection, and hemorrhage, and that the first
two groups are responsible for one-half to two-thirds or even a larger
proportion o f all maternal deaths. Here came another opportunity
to discuss prenatal care and how far it was effective in preventing
these conditions. I also went over the subject o f postpartum hemor
rhage from the point o f view of prevention and tried to show how
important a part was played by the proper management o f the third
stage of labor.
As to puerperal infection, I repeated at every meeting that it
was preventable and could be almost wiped out by careful asepsis; but
I also did my best to explain that I fully understood how difficult and
even impossible it is to carry out the details o f perfect technique
in many homes. I recalled cases o f my own in which I had had to
work unaided, such as a home where I had used one hand to stir
the fire and put on the water to boil, while keeping the other sterile
for the necessary obstetrical manipulations. Still I maintained that
clean obstetrics could be done in the most unfavorable surroundings
and instanced the low mortality and morbidity of many outpatient
clinics in large cities, quoting the figures from my own service when
I was at the Woman’s Medical College— 11 deaths from infection in
10,000 confinements, including Cesarean sections and many other
emergency cases. Again the State bureau was introduced as a pos
sible help to the doctor through its pamphlet of directions to the
patient how to prepare sheet's* tbwels, and cither supplies so that there
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would be material for at least a clean obstetrical field, even if not for
an absolutely aseptic one.
The next thing was to outline the treatment o f these three con
ditions. Here the point was to choose methods that could be used in
homes where equipment and trained assistance are at a minimum.
It is fortunate that the trend o f obstetrical treatment at the present
time is toward simple and conservative measures, for one can confi
dently assert that they can be carried out by almost anyone in almost
any home and that they are in the long run as successful as more
elaborate procedures.
The manikin demonstration I held in readiness to put in when
interest seemed to wane, knowing full well that any gathering o f
busy people is bound to tire of too much talking and that it is always
easier to watch than to listen. After showing as best I could how
the perineum could be protected, even though the doctor was alone,
I went on to the delivery o f breech presentations, forceps and version,
using a leather-doll fetus. The question o f anesthesia for these
operations often came up, as the physicians described cases which
they had to carry through without assistance; but I claimed that it
was possible to start the anesthetic and' let some member o f the
family continue it during the operation, as I had had such experience
myself.
Time was always allowed for free and informal discussion, which
was to me the most interesting part o f the meetings. I never tired
o f hearing about the emergencies which had to be met in remote
spots and isolated homes, and the unusual complications which tried
judgment and initiative. These doctors had faced operations with
no hospital to fall back on, like one man who had performed a suc
cessful Cesarean section in his office. Some o f them had come many
miles to hear me, because they were eager to find something new and
helpful, and I felt continually on my mettle to give them my best.
One point I wish to make very clear in closing. My talks were
not undertaken in any spirit of preaching at the so-called “ country
doctor,” or blaming him for obstetrical conditions in this country.
I have the greatest respect for the general practitioner in his dealings
with problems that would tax the most highly trained specialist.
He works under the handicaps of long distances, poor roads, unco
operative patients, lack o f equipment, assistance, and hospital facili
ties, and it is a wonder that he can carry on as he does. I welcomed
the opportunity to hear the experiences o f the Kentucky physicians
and discuss their cases with them, as a benefit to myself.
What I tried to do was to give in a simple and practical form the
most important points in the principles and practice o f modern
obstetrics and to encourage these doctors to continue to work for high
standards. I also made it my endeavor to assure them o f the desire
o f the State and Federal bureaus to stand behind them, to work with
them, and to help them in their needs. Although I shall be abidingly
grateful for all that Doctor Yeech and the members o f her bureau
did for me in Kentucky, I can not say enough in appreciation o f the
reception accorded me everywhere by the physicians o f the State.
Doctor H a i n e s . I think you all understand that Doctor Tallant is
a consultant o f the Children’s Bureau and may be available for such
work again, if it could be arranged at her convenience.
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
Doctor V eech. I should like to say again in connection with Doc
tor Tallant’s work that she worked under great difficulties, making
trains, as she said, at 4 o’clock in the morning and traveling in busses
over bad roads. We tried really to get into the most isolated areas.
We felt that in our larger and more prosperous towns the physicians
have a better chance. They are the ones who go to State medical
meetings, and it was at the State medical meeting that Doctor Tallant
had an opportunity to meet them. But most o f her work was done
with the physicians who had the least chance to get away from the
places where they live.
The C h airm an . It is a wonderful piece o f work, and I should
think some of the other States would want to have it carried on.
I f there is no further discussion o f these very interesting talks we
shall go on to the next paper. As I said earlier, Doctor Lobenstine
is detained in New York. He has asked Dr. M. Luise Diez, associate
director o f the New York division o f maternity, infancy, and child
hygiene to read his paper on “ The Tioga County demonstration in
prenatal care.”
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THE TIOGA COUNTY DEMONSTRATION IN PRENATAL
CARE
B
y
B
Y
R
alph
o ar d ,
M
W .
L
M . D., C h a i r m a n , M e d ic a l A d v is o r y
C e n t e r A s s o c ia t io n o f t h e C i t y of N e w
o b e n s t in e ,
a t e r n it y
ork
[Read by Dr. M. Luise Diez]
The problem o f providing expectant mothers in small towns and
in rural communities with reasonable safeguards during pregnancy
and labor is one that is surrounded, on the whole, with more diffi
culties than are met with in the average urban community. This is
due, I think, to the varying conditions to be found in the different
sections o f this large country; to the fact that ignorance and ultra
conservatism in country life are rather harder to cope with than in
the city ; to the fact that distances are great, that good medical and
nursing care are much harder to secure; and finally, to the scarcity of
good hospital facilities.
The general problem o f how to meet the great need in the cities has
been faced with intelligence, zeal, and in at least a few cities with
definite success. Perhaps the most useful of city demonstrations has
been the work and education o f the Maternity Center Association of
New York. This organization has endeavored to face the many
questions that arise in the development o f a maternal-welfare pro
gram amidst city life. There has been definite standardization and
progressive education as well, of doctors, nurses, and mothers.
About two years ago a number o f conferences were held regarding
the possibility of adapting some of the methods of this organization
to rural communities. When the Sheppard-Towner funds made it pos
sible for the New York State Health Department to undertake in the
State o f New York an increased amount o f maternity-welfare work,
State Health Commissioner Dr. Matthias Nicoll, jr., and Dr. Florence
L. McKay, then director o f the division o f maternity, infancy, and
child hygiene, decided to undertake a demonstration in Tioga County
in conjunction with the Maternity Center Association. The State
health department agreed to furnish the funds necessary to make
available to Tioga County a maternity nursing service, such service
to be carried on by nurses chosen from the maternity-center staff
and to be under the immediate direction o f this association. The
undertaking was approached with great enthusiasm and with earnest
ness; the nurses were chosen because of their ability as well as for
their tact. The plan was followed in this study, which should cer
tainly be followed in any similar enterprise elsewhere; namely, an
attempt was made before the actual beginning o f the work to enlist
the sympathy and interest of the county medical profession.
In December, 1924, the Tioga County Medical Society was called
together to discuss the proposed demonstration. O f the 24 physicians
belonging to this society 13 were present at the meeting, and these
voted unanimously to give the demonstration their full cooperation.
19
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
An advisory committee was formed consisting o f Dr. Eugene Bauer
o f Owego, Dr. W. M. Hilton of Waverly, and Dr. Max Fisher o f
Spenser. Two o f these gentlemen were sent to New York City to
observe for several days the methods o f the Maternity Center Asso
ciation as well as those o f several of the more progressive obstetric
clinics.
During the last week of January, 1925, the first prenatal clinics
were begun in Tioga County. The work was started by two nurses,
and a third nurse was added to the staff by the following June.
Office hours were held by these nurses three afternoons a week in
Waverly and three in Owego. In February, 1926, in accordance with
the request o f the district State health officer, a fourth nurse was
added. In addition to these nurses’ consultations, demonstrations
o f the work and numerous talks! were given at the county fair, to
the home bureaus, to the women’s clubs, and to other groups through
out the county. Furthermore, every physician was notified that
these nurses were both ready and glad to give their services to each
and every case o f confinement in which their help might be desired.
I can imagine nothing that could bring more cheer and helpfulness
than a thoroughly qualified nurse to help the physician at the time
o f delivery.
Each clinic is thoroughly equipped with a teaching exhibit of the
Maternity Center Association. The patients are instructed both in
the care o f themselves and in that o f their young babies. They are
carefully taught the danger signals o f pregnancy; the essentials in
the hygiene o f this period; the signs o f approaching or o f actual
labor. Each patient is further advised regarding the necessary
equipment for labor as well as the layette for the baby. From the
outset the mothers have appreciated this service, and the doctors
have more and more realized the value o f both the prenatal follow-up
work o f the nurses and the marked assistance at the time o f labor.
Even during the first year o f the experiment patients came under
the care o f the nurses from every community in the county except
Smithboro. In the group seeking education and assistance there
were a number o f college graduates.
Tioga County was chosen in part because its population is on the
whole intelligent; in part because its size is not too great to allow*
easy access to the centers except during the worst weeks o f the year;
and in a considerable part because o f the open-mindedness o f the
physicians. The population is around 25,000. The births reported
range between 375 .and 485 a year.
B y the end o f the first year more than half the pregnant women o f
the county had been under the care of the nurses; that is, 247 patients,
o f whom 63 per cent were referred by physicians. Among the 151
deliveries there were 2 sets o f twins, 4 stillbirths, 4 miscarriages, and
7 deaths o f babies (these deaths occurring before the mother was
dismissed). The nurses made 3,020 visits to patients in their homes
and the patients made 226 visits to the centers. Some of these pa
tients traveled more than 24 miles for a prenatal visit to the center.
The nurses were actually in attendance on 58 deliveries during the
first complete year o f 1925.
In 1926 the number o f patients carried by the nurses was 356.
The number o f new patients was 253, O f this number, 133 were
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iiO(jrA CO tlK TY PEMONSTRATtON IK PRENATAL, CARE
21
reported by physicians, 116 by laymen, and 4 by social workers.
There were 238 mothers delivered and 225 babies born alive. In the
total number there were 5 stillbirths, 8 miscarriages, 2 sets o f twins,
and 4 deaths o f babies after delivery. During the year 263 mothers
were dismissed— 19 during the antepartum period and 244 in the
postpartum period. There were no maternal deaths in either 1925
or 1926.
In this last year there was a definite gain in the number o f deliv
eries attended by the nurses, which increased from 58 in 1925 to 111
in 1926. Home visits were made in every town in the county. The
total home visits made by the nurses numbered 3,293, while the visits
made by the patients to the centers amounted to 902.
This shows, then, briefly, the salient features accomplished by
three to four nurses in a widespread, rural community in which the
physicians have almost uniformly offered their full cooperation. No
marked results from a statistical standpoint perhaps can rightly be
deduced from the small numbers with which we are dealing. It is
o f interest, however, to note the lack o f deaths in either year o f those
mothers who had been under the care o f these public-health nurses
during pregnancy.
We can not but believe that this movement has aroused widespread
interest in the county, that it has educated the women to the needs
o f expectant mothers and the desirabiliy o f good medical attendance
at delivery; and that the mere presence o f these enthusiastic, highly
trained nurses has stimulated even the physicians to render the very
best possible service to those under their charge.
This Undertaking has been a small one, but the methods followed
should, if more or less widely adopted, produce in the long run very
tangible results in lowering maternal mortality and morbidity as
well as in lessening a very considerable and ofttimes unnecessary loss
in infant life.
D IS C U S S IO N
The C h airm an . Doctor Diez, will you give us the benefit o f your
own views on the work?
Doctor D i e z . At this time it might be interesting to speak o f the
background o f the Tioga County demonstration.
In January, 1924, a nursing demonstration with Sheppard-Towner
funds was asked for Tioga County by the home demonstration agent
o f the home bureau. She was advised that the matter should be taken
before the board o f supervisors so that they might vote the necessary
matching funds.
In March a meeting was held with the tuberculosis and publichealth committee of the State charities aid association to enlist
cooperation in this demonstration. The board o f supervisors did not
feel that they could accept the proposition at this time. Then the
services o f a child-hygiene nurse for a four to six months demonstra
tion was offered. A joint committee o f local people was formed to
raise the funds necessary to finance a car for the nurse. This demon
stration was to be carried on with Sheppard-Towner funds and the
Christmas-seal money o f the tuberculosis committee of the State
charities aid association. Then at the end o f the demonstration it
was to be taken over by the board o f supervisors; and as SheppardTowner funds could not be matched by private funds, the State chari
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
ties aid association was asked to put its funds into the public treasury.
In addition they could have State-aid-to-counties funds, meaning
that one-half o f all money paid by the county for public-health work
could be reimbursed by the State. It was ruled by the State charities
aid association that Christmas-seal money could not be paid into the
county treasury.
In September o f this year Dr. Florence L. McKay had a meeting
with the directors o f the Maternity Center Association asking their
cooperation for a rural maternity demonstration in some county in
the State. A t this meeting it was decided that the center would
furnish three or four nurses who had been trained by the Maternity
Center Association and that their salaries be paid by SheppardTowner funds. There were to be three maternity-center nurses to
be used for group work and a fourth nurse, a floating nurse, to do the
follow-up work wherever the press o f work demanded. Tioga Coun
ty, a rural county with no large cities and with a population of
24,000, an area of 520 square miles, and ail average o f 400 births per
year, was selected.
In December Doctor McKay met with the Tioga County Medical
Society, which consisted o f 24 members, 13 being present at this
meeting. This project was presented to them, and they unanimously
voted to indorse the work and give their cooperation. The advisory
committee was formed of which Doctor Lobenstine speaks. It was
proposed that there would be three nurses appointed the first of the
year. They were to be members o f the staff of the division o f
maternity, infancy, and child hygiene and directed by it with assist
ance from the Maternity Center Association. The promise was made
at this time that this demonstration would not interfere with the gen
eral public health nursing service which the tuberculosis and publichealth committee of the State charities aid association was desirous
of obtaining for this county. Miss Corbin and Miss Zabriskie (nurses
from the Maternity Center Association) went to Tioga County and
were taken over the county by the district State supervising nurse.
After the survey they agreed as to the county’s suitability. The
program was to be under the joint direction o f the State department
o f health and the Maternity Center Association, both having equal
credit in any publication concerning the work which may be forth
coming from time to time. There were to be three nurses specially
trained at the Maternity Center Association and employed by the
State department o f health on its nursing staff and paid by SheppardTowner funds for their work; there was to be no change in the
nursing personnel for at least a year i f it could be avoided. The
State department o f health would pay such traveling expenses of
the directors of the Maternity Center Association as might be neces
sary for the supervision of the work. The State department o f health
would assist in the working out o f general policies, such as mapping
out districts, introducing nurses to physicians, interesting the local
people and appropriate groups, helping to arrange group meetings
in the interest and organization o f mothers’ health clubs. The dis
trict State supervising nurse for that district was to be general
advisory nurse for the general public-health nursing problems.
A medical advisory committee was formed consisting of Dr. Ralph
W . Lobenstine and Dr. Harold C. Bailey, regional consultants to the
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TIOGA COUNTY DEMONSTRATION IN PRENATAL CARE
23
division o f maternity, infancy, and child hygiene and members o f
the Maternity Center Association, Dr. John A. Conway, district
State health officer, and the three local physicians previously
mentioned.
The demonstration was begun January 26 with two nurses avail
able. The nurses were to report on the daily time sheets to the
Maternity Center Association, as was done in New York City, and
the monthly report was to be sent to the State department o f health.
Beginning January 26 the child-health consultations of the division
o f maternity, infancy, and child hygiene were held in Tioga County
for one week, and the maternity-center nurses were present. It was
thought that this might prove of value to the nurses in becoming
acquainted with people interested in public-health work and might
be a means o f contact for home visiting. Demonstrations at county
fairs, hpme-bureau meetings, and women’s clubs were planned. Head
quarters was established in Owego, and a second room was secured
in Waverly for the occasional use o f the nurses when they had to
remain overnight. A t this time it was decided that the center would
not be used for observation purposes for some time, and no prenatal
clinics were to be held unless there proved to be a special need. By
March, 22 patients were under observation, and 38 babies visited.
The physicians were very enthusiastic, referring practically all the
cases. It was now decided that no cases outside the county could
be taken under care, and the people who could afford to pay could
provide their own nursing service. In September jthe second station
was opened in Waverly. Office hours are held in each station three
times a week.
In the fall o f this year there was a change in the reporting system.
Each nurse was to send in weekly reports to the division o f maternity,
infancy, and child hygiene as other staff nurses do, Miss Zabriskie
to send for use in the annual report of the division o f maternity, in
fancy, and child hygiene a copy o f the narrative report which she
submits to the board of the Maternity Center Association.
At the end of 1925 there had been patients under care from every
community in the county except Smithboro. A t the end of the year
there were under care 64 antepartum cases, 39 postpartum cases, and
35 babies. The cost of the first six months of this demonstration
was approximately $6,000.
On the 1st o f February, 1926, a fourth nurse was assigned to duty,
so that two were working out o f Owego and two out o f Waverly,
full time at both stations. During May tuberculosis clinics and
child-health consultations were held in the county, and a general
public-health nursing service was asked for so that the patients
attending these consultations might have adequate follow-up care.
In order that the maternity demonstration should not be lost sight
of when the board o f supervisors was asked for an appropriation for
this nursing service, a conference was held with the members of
the local tuberculosis and public-health committee o f the State
charities aid association, with the county medical society committee,
Doctor Conway, Doctor Gardiner, Miss Kuhlman, and Miss Thomp
son. The services of a public-health nurse for the remainder of the
year were offered by the division o f maternity, infancy, and child
hygiene, the local tuberculosis committee to provide a car and the
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24
PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
maintenance thereof, then at the end o f the demonstration the local
tuberculosis committee to approach the board o f supervisors to secure
an appropriation of county funds plus State-aid-to-counties funds
for the support o f a county public-health nurse. During this dem
onstration the nurse’s salary was, to be paid by the department of
health, the nurse to be under the direction of Doctor Conway, Doctor
Gardiner, and Miss Kuhlman. She was to render reports both to
the local tuberculosis committee and the division of maternity, in
fancy, and child hygiene over Doctor Conway’s desk. She was to
give half time to infant and preschool work, and do the follow-up
work for the tuberculosis clinics and any other general public-health
work needed in the countyIt was decided that after September 1 there would be only two
maternity nurses with the one public-health nurse as a permanent
staff, the demonstration nurse to enter upon her duties November 9.
The lessening of the maternity staff was done in order to prevent the
board o f supervisors from feeling the burden o f a large nursing staff.
In October Doctor Bauer reported that two nurses were not enough
to cover the county and take care o f the number o f cases referred.
Therefore the services o f a nurse were made available for part time
whenever stress o f work demanded.
The following statistics for the county cover the two years pre
vious to the demonstration and the two years of the demonstration:
Year
1926 (January-November) 1......... ....................... ......... ...........................
Births
400
389
381
291
Still
births
18
12
9
5
Deaths
under
1 year
46
27
27
17
Maternal
deaths
1
1
1
i Provisional figures.
Mrs. D i l l o n . D o the nurses have any other duties? Do they do
anything besides this work ?
Doctor D i e z . They do nothing but this maternity work. They
have office hours in the afternoon, but devote the morning to the rou
tine calls. O f course one substitutes for another; if the people in the
one center are away on emergency work, then the people from the
other center take care of any emergency work in the county.
Mrs. D i l l o n . H o w have they been able to maintain their hours?
As I understand it, you have certain hours at which your centers are
open, when the people in that territory know that they will find the
nurses at the centers. How are they able to do that and still take care
of the delivery service ?
Doctor D i e z . They are able to do that because we do not have a
complete delivery service. They have two or three hours in the cen
ter three afternoons a week, and with the full personnel o f four nurses
they were able to take care of this service without any interruption.
With two, o f course, there may be some difficulty in covering the
work.
.
„
Doctor G a r d in e r . I might add that the local society has an office in
the city hall, and they take any emergency calls and see to it that the
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TIOGA COUNTY DEMONSTRATION IN PRENATAL CARE
nurses get them as soon as they come in.
maternity and early-infancy cases.
D o c to r D
ie z
25
This service is limited to
. I f th e n u r se s h a v e b e e n o n d e liv e r y w o r k , th e y h a v e
o f f ic e h o u r s o n t h e n e x t d a y , a n d t h e o u t s i d e w o r k i s t a k e n c a r e o f b y
som e o th e r n u rse.
The C hairm an . They go alone?
Doctor D iez. The two go together ; they go only if the doctor calls
them.
The C h airm an . H ow early in the labor do they go ?
Doctor D iez . I think that depends on when the doctor calls and
when he wants them to go. I do not believe they ever go in before
that ; they are there just long enough to give all possible assistance.
The C h airm an . I s that as it is in other maternity service—that the
nurse does not go until after the doctor goes ?
Doctor G ardiner. They are not -supposed to be there except when
thé doctor is present.
The C h airm an . I understood you to say there were no hospitals in
that county?
Doctor D iez. N o ; there are no hospitals.
The C h a ir m an . What do you do in case o f emergency ? Where do
you send your patients?
Doctor D iez. We are very near Binghamton, so that a hospital is
accessible, though it is not in Tioga County. Binghamton is within
20 or 30 miles, I think.
Doctor N oble. I should like to ask Doctor Diez how she gets her
prenatal cases. Is it always by reference from a doctor?
Doctor D iez . O f course the large majority o f them were referred
by physicians, because the physicians were anxious to cooperate and
have the demonstration prove successful. Some were referred by
social workers, and some through the home bureau. I can tell you
of one case that came to us direct. The traffic officer stopped one o f
the nurses in her car ; she thought he wanted to tell her o f some viola
tion o f the traffic rules, but he said, “ You go to my house; my wife
is going to have a baby.”
Doctor N oble. Are there any midwives in that county?
Doctor D iez. N o .
The C h airm an . Doctor Diez, what happens if the patients come to
the nurses without having any medical supervision ?
Doctor D iez. They are asked to engage a physician.
Miss De L ask y . I s the nursing care given just at the time of
delivery or afterwards?
Doctor D iez. For six weeks afterwards.
Doctor L evy . I think you said the doctors give adequate and com
petent prenatal care. Then what is left for the nurses at the
centers? I take it that the patient’s doctor examines her. You have
no doctor at the center?
D octor D iez . N o.
Doctor L evy . Then the doctor examines, and I would take it he
also advises in the necessary personal hygiene. I should like to have
it made clear just what the nurses do.
Doctor D iez . The doctors are very willing to leave some o f the
prenatal care to the nurses, The nurses at the centers give instruc-
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
tions as to hygiene, especially if the first contact was made with the
nurse. They minister to'the patient, arrange the layette, and assist
the mother in the preparation for labor and the care o f the baby.
Also if the patient has urinalysis done at the center she is instructed
how to do urinalysis herself, in case it should not be possible for her
to go to her physician or to the center for it. Such cases report to
the nurses over the telephone. The nurse also gets in touch with the
physician and carries out any instructions that he may give her to
pass on to the patient.
The C h a irm an - D o I understand that the patients are instructed
in urinalysis?
Doctor D iez. They are taught how to boil the urine for possible
albumin. A t certain periods o f the year it is not possible for the
patients to get to the center nor for the nurses to go to the homes.
Or the patient may be too far along to come into the center. Those
are the only times that they attend to this themselves.
The
C h a irm an .
D
o
th e y
in te r p r e t f a i r l y
s a tis fa c to r ily ?
Doctor D iez. Yes. Sometimes, if the patient can not come to the
center, the husband comes and reports as to his wife’s condition.
Doctor N oble. I should like to ask whether the entire service is free
and whether two nurses attend one delivery.
Doctor D iez. There is no charge to the family. When the nurses
feel a family can afford to pay for service they are instructed and
are asked to provide their own nursing service. You see, under the
State administration no money can be accepted.
Doctor B reeding. In the extremely rural counties is there an ade
quate supply o f physicians?
Doctor D iez. There are rural districts in New York State that
have no physicians for a radius of 10 to 25 miles, and the people just
suffer from lack o f medical care.
The C h airm an . Y ou have no trained public-health nurses or
women trained in the school of midwives in New York that carry
out that work?
Doctor D iez . One o f our supervising nurses has taken training as
a midwife, and she does the work in connection with licensing of
midwives.
The
C h airm an .
I
s
s h e lic e n s e d h e r s e lf ?
Doctor D iez. She is licensed to practice midwifery,' but we have
never tried to have her practice in the State of New York.
Doctor K nox . I think we have had this year two demonstrations
in the obstetrical side of our work that are exceedingly important for
all o f us—the one concerning which we have just heard, in which I am
extremely interested, and the other in Kentucky, where the nurses
with obstetrical training are doing midwifery in places where there
are no doctors. Many o f us from the South are acquainted with this
problem; we have not a sufficient number o f doctors to do this work,
and a large part o f it is done by midwives. I think certain phases
o f this work in Tioga County would be applicable to the South.
Many doctors would welcome the services o f nurses in extending their
prenatal care, because during certain times o f the year the transpor
tation facilities are inadequate to enable them to carry out prenatal
work satisfactorily. Many o f the women prefer midwives, or even
their neighbors, In Maryland we are just beginning now to eliini
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TIOGA COUNTY DEMONSTRATION IN PRENATAL CARE
27
nate the unlicensed midwife ; thpt is the group o f cases in which we
have our high mortality. That is not the group o f cases which have
been accessible to doctors. I am anxious to know how to help the
ignorant mothers, the really indigent cases who can not pay the doctor
- anything. I f we could employ some obstetrically trained nurses I
believe we could help this group o f cases tremendously and do still
more toward eliminating the ignorant, untrained midwives.
Doctor D ie z . I should like to leave with you the impression that
there is a very close relationship and cooperation between the nurses
and the doctors. A report is given by the patient to the nurse,
and the nurse passes it on to the doctor with her report o f her visit
to the patient, so that the nurse never does anything on her own re
sponsibility; she always reports to the attending physician.
The C h a ir m a n . Miss Patterson, will you tell us something about
the public-health work in Massachusetts?
Miss P atterson . We did have some difficulty in getting the doctors
to cooperate with us, but they are now cooperating in the work for
the expectant mother. Just this last year we have come to realize
that if a doctor did not want the nurse’s help it was because the nurse
had not made him understand how she could help. W e have there
fore spent more time calling on the local doctors, and we have had
much better cooperation.
Doctor L e v y . I should like to know the total cost in a year o f a
demonstration of this kind.
Doctor D ie z . I can give it to you for six months: Approximately
$6,000.
J
Dr. G . M. A nderson . I should like to ask Doctor Holmes a
question; he has been training doctors for 25 or 30 years. I wonder
why more doctors are not prepared to deal with the obstetrical
problem.
Doctor H olmes . I have been a teacher o f obstetrics for 30 years;
in all this time I have tried to impress upon students, physicians, and
others the fundamentally important subject o f the proper care o f
women during their child bearing. Many others have lent their
earnest powers toward the same purpose. Yet only lately (the last
1 0 years or so) have the public and the profession been brought to
the near realization o f the vital necessity of “ good obstetrics.”
Many factors come into the question o f what proper teaching is.
First, obstetricians believe that obstetrics and gynecology comprise
one teaching chair; in the hospital the two subjects should be con
joined in practice. A physician may be a good gynecologist with a
rudimentary knowledge o f obstetrics, but he is a poor obstetrician who
is not also a gynecologist. In most colleges and good hospitals the
two are united; in a few there is a divorcement. Johns Hopkins
Hospital represents one modern institution with the two separated,
and if this becomes ijiore prevalent it will be a distinctly retrogressive
movement. They must be taught and practiced together.
Secondly, with extremely few exceptions the trustees and faculties
o f our medical schools have not been brought to realize the funda
mental importance o f obstetrics. As a result the medical and sur
gical departments have a disproportionately large number o f hours
allotted to them for didactic and clinic instruction. Obstetrics, on
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PROCEEDINGS, M ATERNITY AND IN PAN C Y CONFERENCE
the other hand, has a limited number of hours for two years, only too
often at the closing period of the day when teachers and students
are tired. There is hardly a malady affecting adults with which
obstetrics may not be related; yet all the maladies taught in medicine
and surgery may not encroach upon obstetrics. I trust you may
grasp the significance o f the great difference. Many hours a week
for two years are spent by students in the clinic courses o f general
medicine, yet in obstetrics the clinic course comprises the seeing and
attending o f 10 or 12 cases. Possibly the students may see 1 0 or more
additional cases conducted by internes or assistants. But 1 0 , 2 0 ,
1 0 0 , even 1 ,0 0 0 cases o f normal labor do not give a physician an
obstetric experience; his true experience comes from contact with
all the complications and accidents o f obstetrics. The great trouble
is that the physician who may have had numerous normal labors
believes he is skilled, but this experience will not teach him how to
cope with serious complications. I would say that our hours in
medical schools should be increased 50, if not 100, per cent for the
teaching o f didactic and clinical obstetrics. I know that Harvard
gives one o f the best obstetric courses in the United States, yet I am
certain it does not give the students more than 50 cases. In my
college we do not in the remotest degree approximate this.
The C h a ir m a n . Twelve cases are required, but they get about 50.
Doctor H olmes . A s a result of all this the physician is graduated
with a rudimentary knowledge o f normal labor, and with very rudi
mentary information on prenatal care. The training which most
students get is in routine, elementary instruction; they are not trained
to the care o f complicated cases—in surgical obstetrics. W e must
have postgraduate instruction to equip young men to be efficient
obstetricians.
One o f the things the advisory committee to the Commissioner of'
Health o f Chicago, Doctor Bundeson, recommended was that trustees
and faculties should be urged to appropriate more money and allot
more time to the obstetric departments o f their medical schools;
further, to emphasize to the physicians the importance o f matters
obstetric by having an obstetrical paper at least every three months
in each o f the 13 branches o f the Chicago Medical Society; and
further, to undertake a campaign o f education of the public. What
does this educational campaign mean? Every young woman who
applies to the county clerk for a marriage license is going to receive
the next day a pamphlet on prenatal care. This surely will bring
results.
This maternal-welfare work, combined with some infant-welfare
work, which now is before you is of transcendant importance in that
you are educating the women and the general public to demand
better things. And this educational campaign is going to accomplish
far-reaching results because it is being carried on through the county
units throughout the United States under Federal auspices.
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COMPULSORY NOTIFICATION OF PUERPERAL SEPTICEMIA
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TU E SD A Y, J A N U A R Y 11—AFTER N O O N S E S S IO N '
DE. ROBERT L. DE NORMANDIE, INSTRUCTOR IN OBSTETRICS, HARVARD MEDICAL SCHOOL,
PRESIDING
The C h a i r m a n . Miss Hanna has an announcement to make before
we begin this afternoon’s program.
Miss H a n n a . I wish to take a moment of your time to explain
the mimeographed sheets in your chairs. We are very anxious to
have you think over a few o f the questions on these sheets before
you come to the meeting to-morrow. This is a questionnaire to stim
ulate discussion.
The C h a i r m a n . W e have to finish this meeting this afternoon at
about 3.50 p. m., so that we can go over to the Interior Building
auditorium to see the new Children’s Bureau film. Doctor Mosher
is sick and could not come to the conference; but Doctor Holmes
is going to read his paper for him.
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THE PROBLEM OF COMPULSORY NOTIFICATION OF
PUERPERAL SEPTICEMIA
B y G eorge -C lark M osher, M . D., C om m ittee
fare ,
on M aternal W el
A m erican A ssociation of O bstetricians a n d G ynecologists
[Read by Dr. Rudolph W. Holmes]
When Doctor De Normandie telegraphed his request for a dis
cussion o f the subject o f the compulsory notification of puerperal
septicemia, such notification at first glance seemed a self-evident
proposition for maternal welfare. But when, after careful con
sultation, the current American medical literature was found prac
tically blank in its expressions on the subject, it was decided that
the only alternative was an original investigation to discover the
attitude o f the profession and the public concerning this method pro
posed as one means o f solving a problem so tragic as the loss of
women in childbirth in the United States.
A letter was immediately formulated and sent to the national or
ganizations which, it was hoped, could aid in furnishing informa
tion; also, to a number o f State boards o f health in those States
where compulsory notification is the law, as to the observance o f the
law and its results. A questionnaire asking the views o f a number
o f leading obstetricians, teachers in the medical schools, followed.
While the responses from the obstetricians have been prompt and are
incisive in their opinions, it is a great disappointment that no more
nearly conclusive report has been received from officials and govern
ing bodies as to the actual working o f the law where it is on the
statute books. The subject is still sub judice, and your earnest
attention is called to these opinions as they have come to me. It is
hoped that by a discussion we can thresh out the essentials and con
clude a program to be presented to the profession in the various
States as the views o f the directors meeting in this conference.
The information sought was upon the following points:
1. Does any system o f education promise to aid in re
duction o f puerperal septicemia in the United
States ?
2. Have you noticed any difference in frequency in puer
peral sepsis —
{a) In rural and urban communities?
(b) In home and hospital confinements?
3. Is the attitude of the profession as to compulsory
notification of contagious diseases in general an in
dication o f what would result if puerperal sep
ticemia became reportable?
4. Would a penalty attached to the requirement for
compulsory notification of puerperal septicemia add
to the efficacy o f such a law ?
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O f course we take it for granted that any condition which is
responsible for 40 per cent o f the deaths of women in childbirth
and which by general consensus is largely preventable is a tangible
object o f attack in public-health work. A ll those who are included
in the discussion being o f one mind as to these two facts, there
remains only the expression o f individual views as to whether the
greatest benefit is to be derived from compulsory notification and
we should therefore undertake a campaign for its adoption in the
States, or whether other remedies will avail.
A letter from Surg. Gen. Hugh Cumming, o f the United States
Public Health Service, dated December 15, 1926, says:
Education as a means o f preventing puerperal sepsis would be a part o f a
general health-education program. This bureau believes it is better to combine
all phases of health work in one program, rather than to have special effort
devoted by groups o f specialists to a separate phase o f public-health work.
He pointed out that the death rate from puerperal sepsis per 1 ,0 0 0
live births averaged, for 1920 to 1923, inclusive, 3.1 for urban and
2.025 for rural births.
The replies to the question with regard to the attitude of the
medical profession toward compulsory notification o f infectious
diseases in general showed that it is variable throughout the United
States. In communities where the local health authorities take an
interest in the matter very satisfactory cooperation is secured. There
are other areas, however, where the reporting o f communicable
diseases has not been given careful consideration. It would therefore
be impossible to formulate a brief statement setting forth the attitude
of the medical profession.
It is difficult to get complete reports of puerperal sepsis, and so far
as is known no special measures are being taken to secure reporting in
the 16 States where it is a law or a State regulation.
Dr. W. C. Woodward, secretary o f the bureau of legal medicine of
the American Medical Association, writes under date o f December
21,1926:
The wisdom of compulsory notification of puerperal fever seems to me ques
tionable. Probably no disease should be made reportable unless the reports are
made the basis of a thorough investigation of the disease with a view of
preventive or curative measures. Unless we can write into the law requiring
cases to be 'reported adequate provision for investigation or preventive or
curative measures, we are not ready for the law.
Might it not be well to test our readiness for compulsory notification of
puerperal septicemia, to try to state just what the health department is to do on
receipt o f notice o f such a case? How is the health department to learn i f such
a case is not reported? It is difficult to get information necessary to enforce
the law against smallpox and scarlet fe v e r; but when it comes to finding evi
dence that a given woman has had puerperal septicemia, that her physician
knew the fact, and that he failed to report it, the difficulty increases greatly.
A physician can not be compelled to testify against himself. Is the patient or
nurse to be brought in as witness?
“ One fact complicates the whole question and makes it impossible to say that
the disease is in all ca&es absolutely preventable; namely, that a very small
number o f cases develops * * * when every method for avoiding infection
has been used. * * * In general obstetricians of the greatest experience
believe that a small number of cases of infection after childbirth may develop
from bacteria which were already in the body of the patient before confine
ment ; but that in the main such cases are of mild severity and that only a few
fatal cases are due to this cause. Another point which must be borne in mind
is that, in a certain number of cases, women may infect themselves through
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
improper hygiene during pregnancy or just before or at confinement. There
fore, the teaching of proper hygiene is an essential part of the work of
prevention of infection.” 1
It is held that this teaching of hygiene to be effective must reach the entire
female population, and possibly also the male population, before a reporting
law would be of any use in a particular case.
Our chairman this morning, Doctor De Normandie, made some
very pertinent statements on this subject at the directors’ conference
a year a g o:
When a death is recorded as occurring from septicemia there is no question
that this is the true cause of death, for no man will sign a certificate “ puerperal
septicemia ” if there is any possible opportunity for him to assign the death to
any other cause. * * *
There are, I am glad to say, no such terrible epidemics o f puerperal fever
now as there were years ago, but the fact remains that hundreds o f women
die each year from sepsis. Therefore when a patient is found to have died
from sepsis it devolves upon the physician in charge of the case to prove
conclusively that he delivered the patient according to good surgical tech
nique. * * * The burden of proving that he carried out a proper tech
nique rests upon the physician. * * * Any physician practicing obstetrics
who has a death from sepsis every once in a while is a danger to the com
munity, and I feel that we have a full right to question minutely his technique
and his methods of procedure. * * * It is true that any one o f us may
at any time have a case of sepsis. Occasionally we may lose a patient from
sepsis, but only very rarely. The kind of man to whom I refer is the physician
who is having more or less sepsis all the time, who is losing one or two or more
patients a year from sepsis. * * * I would not give you the impression
that for every death from sepsis the physician is to be blamed, for that is
not so ; but I do say that in the large majority o f cases of sepsis the fault
is with the physician. It is in regard to these cases that we must study the
cause carefully, investigating the attendant most thoroughly, whether a phy
sician or a midwife was present. A step in improving this condition unques
tionably is making sepsis reportable.2
The Rockefeller Institute for Medical Research, according to a
letter from Mr. T. Stanley Howe, dated December 14, 1926, has never
done any maternity work, and accordingly it would be impossible to
give any opinions on the points raised by the questionnaire.
Dr. Samuel J. Crumbine, general secretary o f the American Child
Health Association, on December 14, 1926, in a very general reply to
the questions asked, stated that his impression is that in the States
where compulsory notification is the law “ the reporting is poorly
done and thus far it probably has not registered any reduction in the
incidence o f the disease. Any law that does not have a penalty at
tached for violation is a dead letter before it becomes operative. In
Kansas our rule was to keep a list o f physicians who failed to send
in their reportable cases, not invoking the penalty at once. After the
third offense physicians were certified to the county attorney for
prosec'ution.”
The States which make puerperal septicemia reportable, Recording
to replies received to a questionnaire sent out by the Children’s
Bureau in 1923 to the State boards of health, are: Pennsylvania,
Vermont, Ohio, Nevada, South Dakota, Illinois, Colorado, Delaware,
1 M a tern a l M o r ta lity fr o m A l l C onditions C onnected w ith C hildbirth, hy G race L . M eig s,
M . D ., p. 11.
U . S. C hild ren’ s B u reau P u blicatio n N o. 1 9 .
W a s h in g to n , 1 9 1 7 .
D e N orm and ie, R obert L ., M . D . : “ H o w to m ake a stu d y o f m atern al m o rta lity .”’
P roceedings o f the T h ird A n n u a l C onference o f S ta te D irectors in Charge o f L o cal A d m in
istra tio n o f th e M a te rn ity and In fa n c y A c t (a c t o f C ongress o f N ov. 2 3 , 1 9 2 1 ) held in
W a sh in g to n , D . C ., Jan. 11—1 3 , 1 9 2 6 , pp. 4 7 - 4 8 .
U . S, C hild ren’s B u reau P u blication N o .
157.
W a sh in g to n , 1 9 2 6 .
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New York, Kentucky, New Mexico, Oregon, Wyoming, Washington,
Mississippi, and Oklahoma. In only one State, Mississippi, did the
number o f cases reported to the department o f health of the State
exceed the number o f deaths.3
The responses to my questionnaire to the State boards o f health
were not general.
The director o f the division o f maternity, infancy, and child
hygiene in the New York State Department o f Health, Dr. Eliza
beth Gardiner, writing under date o f December 17, 1926, expresses a
doubt whether education will actually help to lessen puerperal sep
ticemia. The greatest good in any community, she says, is effected by
a group o f physicians interested in the problem o f reducing maternal
mortality. She raises the question as to the general attitude o f the
profession toward compulsory notification, and brings out the point
that even with 1 0 0 per cent reporting, the action o f the State health
department could hardly save life. She is not in favor o f penalizing
the physician, suggesting that he is pretty well penalized when he
loses a case from puerperal sepsis.
The director o f the bureau o f child hygiene and public-health
nursing o f the Michigan Department o f Health, Dr. Lillian Smith,
indorses the plan to emphasize the gravity o f puerperal sepsis by
studies in maternal mortality. She is in favor o f reporting puerperal
sepsis and believes no law could be enforced without a penalty for
its violation.
The director o f the Detroit Department o f Health, Dr. Walter E.
Welz, recommends education o f the public as to adequate prenatal
care, the advantage o f hospitalization, and the danger o f delivery at
the hands o f doctor or midwife fresh from contact with sepsis. The
medical profession in Detroit in general is opposed to notification o f
puerperal septicemia, but Doctor Welz is o f the opinion that report
ing would be beneficial on account o f the publicity. He is not in
favor o f a penalty.
The director o f the bureau o f maternal and child health o f the
Kentucky State Board of Health, Dr. Annie S. Yeech, writes that
there is great reluctance on the part o f physicians to report puerperal
septicemia as such. The State law says that the physician who treats
or examines a sick person or makes a diagnosis o f puerperal septi
cemia or has reasonable grounds for suspecting the existence o f the
disease, shall report the same to the county or' city health official
within whose jurisdiction the case occurs. Where a physician is not
called the head o f the family shall make such report, and any
physician or head o f a family who shall fail or refuse to make such
report shall be fined not less than $ 1 0 nor more than $ 1 0 0 for each
day he neglects or refuses to report. Repeated failure to report shall
be sufficient cause for revocation o f a physician’s license to practice
medicine in the commonwealth. Doctor Yeech states that the records
are inadequate. It is evident that the wording o f the law must be
altered if it is to have any effect as a health measure.
3 M a tern a l M o rta lity ; th e risk o f death in ch ildbirth an d fro m a ll d iseases caused by
pregnan cy and confinem ent, by R obert M o r s e W ood bu ry , P h . D ., p. 7 8 .
U . S. C hild ren’ s
B u reau P u blication N o. 1 5 8 .
W a s h in g to n , 1 9 2 6 .
R eplies to a sim ila r q u estionnaire sent
ou t by the C hild ren’s B ureau in A p ril, 1 9 2 7 , in d ica te th a t G eorgia, M issou ri, and T e n n es
see should he added to th ose m ention ed above an d th a t O klahom a should he om itted,
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
The secretary of the Kansas State Board o f Health, Dr. Earle G.
Brown, writes under date o f December 29, 1926, that he believes that
the greater education of the expectant mother would assist, to a cer
tain extent, in decreasing the number o f cases o f perperal sepsis. He
does not believe that compulsory notification o f septic infection would
make any appreciable difference in the number of cases, but it would
be valuable for study. Numerous provisions are made for violation
o f contagious-disease laws, yet prosecution is rare. He does not
believe the enactment o f a penalty clause would make any difference.
From the Colorado State Board o f Health, the secretary, Dr. S. R.
McKelvey, writes under date o f December 2 1 , 1926:
Replying to your letter, I will say we have a statute here worded as follow s:
“ Whenever it shall appear that in the practice of a physician or midwife
there occur an unusual number of cases o f puerperal fever the board o f health
may require such physician or midwife to suspend his or her vocation for such
a time as may seem necessary.”
This is an old act of 1893. W e have no recent publication containing laws
and regulations in health matters in Colorado. W e are hoping in the near
future to promulgate a revised publication bringing everything up to date
as nearly as possible.
I notice in our last publication covering these matters puerperal fever was
placed in the list of diseases declared communicable and reportable, but I
observe that no regulation was printed separately covering puerperal septicemia
or puerperal fever.
W e have no law or regulation defining just what the disease is.
A brief synopsis o f the replies o f the obstetricians interrogated will
be o f sufficient breadth to give a cross section o f the opinion o f the
profession in this country.
Dr. J. Whitridge Williams, o f Johns Hopkins, says that in his es
timation the only means o f lessening the mortality from puerperal
septicemia is proper training of doctors and teaching o f medical stu
dents that infection is in great part preventable. In Baltimore they
see more infection relatively in the hospital than among other pa
tients, and he is inclined to believe that the reason is that the latter
are composed exclusively of patients who promise to have normal
delivery. In his hospital the incidence o f infection varies with the
status o f the patient, being least in private cases, more common in
white-ward patients, and most common in black-ward patients. He
does not explain this except by the suggestion that it is associated
with the relative intelligence o f the patient and her habits o f per
sonal hygiene. He opposes compulsory notification for two reasons:
First, because he believes we have too much governmental interfer
ence in all our actions; second, because in his experience, where noti
fication is required it has been woefully ineffective, as the tendency is
to report only the serious cases. Finally, he opposes any penalty, as
he thinks cooperation o f physicians can be obtained better by educa
tion than by punishment.
Dr. John Osborn Polak, Brooklyn, president o f the American As
sociation o f Obstetricians and Gynecologists, says that in New York
every case o f sepsis occurring after an abortion or a delivery at term
must be reported. I f it is not so reported and a certificate is made out
for infection, the physician is fined. A ll hospitals are scrupulous
about this law. Doctor Polak finds much less mortality in rural than
in urban communities, and a lower death rate in supervised cases in
the homes than in hospital cases.
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Dr. Rudolph Holmes, of Chicago, a member of the consulting
obstetric committee of the Children’s Bureau, writing December 27,
1926, says:
First, we must put an obstetric conscience into the souls of men doin?
obstetrics. I am convinced that heterogeneous infection has been essentially
eliminated from the causes of puerperal sepsis in good obstetric practice. I
firmly believe we have much further to go before we eliminate the danger from
autogenous infection. When immunity is placed on a sound clinical basis,
then autogenous infection likewise will be entirely preventable.
I am convinced that rural practice has a fa r lessened incidence of infection
than urban work.
Indirectly I believe that compulsory notification of sepsis will bring a
diminution of incidence. I f a man who has an undue proportion of septic cases
were denied the right to practice— this may be Utopian— it might reduce the
morbidity and mortality. I suppose a penalty attached to a violation, espe
cially a repeated violation, would have a salutary effect. However, a physician
has just about enough gratuitous burdens imposed by the State. I f more are
imposed they should not be onerous.
Dr. Joseph B. De Lee, o f Northwestern University Medical
School, says that the question o f compulsory notification has been
on trial in England for a great many years without success. He is
opposed to the reporting o f puerperal sepsis because o f the difficulty
o f making a diagnosis. A mild fever or a serious fever can so
easily be ascribed to other causes; and since the public is still under
the impression that the doctor is to blame when a woman sickens
after delivery, the inclination to hide cases is very strong; in most
communities it is irresistible. Doctor De Lee’s observation is that, of
women confined in maternity wards o f general hospitals a much
larger percentage develop sepsis than of mothers who do not leave
home. The general consensus is, however, favorable to hospital de
liveries. He can see no direct way to improve conditions affecting
maternal mortality in the United States. The indirect method,
through the education o f oncoming doctors, will ultimately bring
relief.
Dr. Hugo Ehrenfest, associate editor o f the American Journal o f
Obstetrics, admits that the inquiry raises an interesting problem.
He says the essential basic question is, “ What is puerperal fever ? ”
A law must state exactly what is reportable, and it must contain a
punitive clause to be worth the paper on which it is printed. He
feels that no more laws should be passed that can not be enforced.
He thinks that we can not possibly define in terms which are unmis
takable what conditions should be made reportable. Fever and other
symptoms may have subsided before a diagnosis has been made, so
that the law would have to set a definite limit within which a report
must be made.
Dr. Arthur H. Bill, o f Western Reserve Medical School, Cleve
land, believes in education rather than legislation as a means of im
proving conditions in puerperal sepsis. He brings up the question
of distinguishing between slight pyrexia and a definite infection. In
Ohio all discharge from the eyes o f the newborn must be reported.
One hundred cases o f secretion are reported to one o f gonorrheal
infection. He says there is in his mind no question but that com
pulsory notification of cases of secreting eyes makes physicians more
careful about prophylaxis. It is just as likely that compulsory
notification o f puerperal infection would make physicians more
careful about their aseptic technique in maternity cases. He
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
adds that unless a penalty were exacted for violation of the law, he
does not believe it would be obeyed.
Dr. Arthur H. Curtis, president of the American Gynecological
Society, says it strikes him that postabortal and puerperal infections
are decreasing very rapidly. He feels that compulsory notification
and pen!alty attached thereto are scarcely necessary. W e have
already so many laws that it is difficult to comply with them under
present conditions.
Dr. Edward Speidel, professor o f obstetrics, University of Louis
ville, observes that there is a great difference in the mortality of
hospital and home deliveries. In those institutions to which a great
many cases are transferred after trouble is encountered outside, the
reports are misleading because the mortality is loaded. Their own
hospital has practically no sepsis, except in emergency cases brought
in after labor has begun. He believes that making septic infection
reportable would undoubtedly lead to greater care in the conduct of
labor by physicians; and he suggests that a law without teeth is inef
fective, that there should be a penalty for failure to report sepsis just
as there is for failure to report birth.
Dean Rowland, of the University o f Maryland School o f Medicine,
calls attention to the fact that notification in puerperal infection
raises quite a different question from compulsory notification of
contagious diseases and o f gonorrhea, both o f which are compulsory
in Maryland. In puerperal infection the question of culpability and
liability o f the attending physician comes up. While we know that
the majority o f puerperal infections are due to introduction o f organ
isms at the time of labor, there are certainly cases in which it does
not seem possible to place the blame on the attending obstetrician.
In Maryland a wave of damage suits against physicians has rolled
up recently. Doctor Rowland says he should hesitate to open another
door to introduction of the damage suits which compulsory notifica
tion o f puerperal sepsis, by accentuating its seriousness, would cer
tainly do. Purely from a medical standpoint the matter is not in
the category with acute infectious diseases and gonorrhea, as but one
person is usually involved. He feels he has become a little conserva
tive in the matter of State regulation.
Dr. G. Van Amber Brown, Detroit, assistant secretary o f the
American Association of Obstetricians and Gynecologists, believes
that compulsory notification would put physicians on their mettle.
However, he says, we have too many laws now. He does not believe
that a law requiring notification could be made effective without a
penalty.
Dr. Arthur J. Skeel, of the faculty of Western Reserve Medical
School, Cleveland, says puerperal septicemia is reportable according
to the law of the State o f Ohio and according to ordinance in Cleve
land, but very little effort has ever been made to put the requirement
into effect.
Dr. John T. Altman, Nashville, Tenn., feels that general practi
tioners and midwives, in whose hands the great majority o f all deliv
eries will remain for years to come, should be aroused to their
responsibility in handling cases o f labor. A law requiring that all
cases of sepsis be reported would, in his opinion, go far to arouse
them. He believes that recent graduates are well taught and are
far more careful to avoid infection than the older practitioners. He
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thinks that the instruction o f mothers to demand better obstetric
care by prenatal work and by social service will be o f great aid,
because, when the laity learn that sepsis is preventable, they are
aware when infection occurs that somebody is to blame. The pub
licity o f notification would help the people to realize the great danger
o f the fever. He is not ready to say that a fine should be imposed,
for like most such provisions it would be difficult to enforce. Only
serious cases would be reported, since, because of the stigma, the
milder type would bq styled influenza, typhoid, or malarial fever.
Dr. William Gordon Dice, obstetrician o f the Toledo Hospital,
Toledo, writes that in Ohio puerperal sepsis is a reportable disease,
with a penalty attached for failure to comply with the law ; but the
bureau o f vital statistics says puerperal sepsis has never been re
ported, and he questions whether a penalty can ever be imposed. He
does not believe that making sepsis reportable, even if a penalty could
be enforced, would diminish puerperal sepsis. It seems to him that
education o f the doctors doing obstetrics, together with instruction o f
the laity on the importance o f proper advice and proper care, offers
the greatest hope o f reduction of septicemia in childbirth.
Dr. Carl Henry Davis, Milwaukee, secretary o f the American
Gynecological Society, writes under date of December 18, 1926:
a There has always been a tendency on the part of physicians to
attribute puerperal sepsis, whenever possible, to some other cause than
the real one. Whether compulsory notification will help to reduce
the number o f cases is problematical, and I question i f one can get
very far with trying to put through such a measure, unless all cases
o f infection are made reportable.” Doctor Davis’s conviction is be
coming stronger that a demand for better service on the part o f the
laity and a changed attitude on the part o f both the medical profes
sion and the medical college are essential. The present methods o f
teaching obstetrics, he says, are for the most part inadequate, and no
improvement in morbidity and mortality is probable until students
are taught that an obstetrical case must be handled with the same
precautions as an abdominal operation.
Dr. Adam P. Leighton, of Portland, Me., sees but little good
resulting from compulsory notification. He believes it would react
tremendously upon the medical profession if every obstetrician re
ported generally every case he thought was a true sepsis, postpartum.
The average practitioner can not differentiate sapremia from septi
cemia. From a medico-legal standpoint few men will care to admit
the possibility o f puerperal sepsis.
Dr. N. Sproat Heaney, Rush Medical College, Chicago, writes that
while in Scandinavia last summer, he learned that the maternal
mortality is 9 per 10,000 births, while during the similar period in the
birth-registration area in the United States the maternal mortality
rate was 70 per 1 0 ,0 0 0 births. This he believes is directly attributable
to the insufficient education o f our medical students in practical
obstetrics. Most o f their training is contained in attendance op 6 , 8 ,
or 1 2 deliveries in the out-patient department under tutelage o f an
inexperienced interne; whereas residence for a considerable time is
demanded o f all medical students in Scandinavia. Most o f the de
liveries in Norway and Sweden are performed by midwives, and
their training requires two years’ residence in an obstetrical hospital
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
.
o ï a high degree o f excellence. Doctor Heaney feels that we shall
never lower our maternal mortality until we are able to produce
properly trained, sufficiently educated physicians in America. All
other means will fail, including legislation. He doubts the efficiency
o f compulsory notification, as he feels that the fault is not careless
ness or neglect, but pure ignorance on the part o f the physician. A
study o f puerperal-mortality statistics in different countries shows
that the death rate runs parallel with the amount o f practical educa
tion o f the candidates in well-established institutions before gradua
tion. He believes that the abolition o f puerperal sepsis is an eco
nomic problem. So long as the general practitioner has a score o f
visits a day and 2 0 0 maternity cases a year, the solution o f the problem
o f keeping clear o f puerperal sepsis while constantly attending septic
surgical cases is impossible. When the Utopian age arrives the
specialization of obstetric practice must be absolute. Until then we
must maintain eternal vigilance to avoid contamination o f our
clean maternity cases.
Reporting of infectious diseases has been developed in varying
degrees in the different States, as the laws requiring such reporting
have come to be more or less faithfully observed. Every abridg
ment o f the personal privilege o f the individual, even though its
purpose is to serve the general good, tends to arouse opposition,
which may extend to all forms o f legislative restriction. In none
is it more apparent than in the ordinance or statute which asks us
to do something for nothing.
It is doubtful whether one-half of the cases o f diphtheria and
scarlet fever, pneumonia and typhoid, or chicken pox and measles
are reported to the local board o f health in any municipality in the
United States. Children from certain infected homes go to school
during the desquamative stage of eruptive disease, and pressure is
brought to bear on physicians by neighbors who feel that there is
discrimination against them if their children also are not given the
privilege of disseminating disease. Consequently the spread o f
infection is left unchecked, although we might in time be free from
such scourges if we were all intelligent and conscientious in protecting
our families from the menace o f the immediate mortality, or the
sequelae which mark those whose lives happen to be spared after
the attack.
In his invaluable report on Maternal Mortality, issued by the
Children’s Bureau in 1926, Dr. Robert Morse Woodbury says :
For the prevention of puerperal septicemia the importance o f making it a
reportable disease is clear, since the health authorities are able to enforce
necessary precautions only if they have prompt information that such cases
have occurred.4
The certification required since 1911 by the United States Bureau o f
the Census o f the cause o f death where an obscure or unsatisfactory
report has been received is as follows :
A letter is mailed to the physician in regard to the true cause o f death.
This resulted in 50,000 inquiries in 1916, 43,876 in 1917, and 35,145 in 1921.
Sad to relate, 37.9 per cent of those letters in 1921 were ignored. Still, though
it has not been possible to secure 100 per cent accuracy, the continued mailing
o f pamphlets to those who fail to respond has had the remarkable result of
reducing the proportion of ill-defined and unknown causes from 3.8 per cent
i TJ. S. Children’s Bureau Publication No. 158, p. 78.
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COM PULSORY
N O T IF IC A T IO N
OF
PUERPERAL
S E P T IC E M IA
39
in 1900 to 0.2 per cent in the same States in 1920. The list of causes of
death which were especially confused included convulsions, peritonitis, septi
cemia, hemorrhage, Bright’s disease, uremia, and salpingitis.6
The wide discrepancy in point of view makes it seem only fair to
consider all the elements that must enter into the consideration of a
proposal to make compulsory the notification o f puerperal sepsis.
Before we can expect such an enactment to be o f any value in the
lowering o f mortality we must decide ( 1 ) what is to be a fairly
comprehensive definition of the condition; ( 2 ) how it is to be deter
mined that the case under consideration comes within the bounds of
the classification; (3) who is to determine the diagnosis; and (4)
what penalty is to be exacted for violation of the law. We do not
want to injure the conscientious practitioner who is so unfortunate
as to have a woman in his care develop chills, fever, and pyemia
resulting in death. But it should be our aim to invoke the law before
such a tragedy leads to further grief and economic loss to the
community.
The Royal Society o f Medicine o f England defines puerperal sepsis
as follow s: “ An infection arising within 2 1 days following delivery,
from laceration o f the genital canal or from absorption at the pla
cental site. * * * Blood infection should be indicated by (1)
isolation o f the organism by blood culture, ( 2 ) prolonged pyrexia,
(3) repeated rigors, (4) pyemia, including septic pneumonia, (5)
death from puerperal fever irrespective o f the antemortem
symptoms.”
Since no two States or nations have uniform standards for reports
o f puerperal causes o f death it is essential in considering the accu
racy o f such reports, as Doctor Woodbury points out,6 to consider the
questions o f ( 1 ) accuracy o f rates, ( 2 ) completeness o f death regis
tration, (3) accuracy o f certification; (4) rules for classification o f
causes o f death, and (5) completeness o f birth registration.
An essential element in the data upon which is to be based the
differentiation o f puerperal mortality is the time between the birth
o f the child and the death o f the mother. In Saxony, one o f the
countries which have accumulated such figures, one-fourth o f the
puerperal deaths occur within the first 24 hours, and one-half within
the first week. Death from puerperal septicemia occurred after the
end o f the second week in one-third o f the cases. O f other deaths
consequent on childbirth three-fourths were within one week follow
ing confinement.7
The Minister o f Health o f England and Wales issued amended
regulations to come into force October 1, 1926, relating to the notifi
cation o f puerperal fever and puerperal pyrexia. In a circular to
the local authorities the minister states that experience (since the
public health act o f 1891) has shown the incompleteness o f notifica
tion o f puerperal septicemia and this has resulted not only in inaccu
rate and misleading statistics but also in the hampering o f effective
prevention and treatment. The term puerperal fever is not precisely
defined, frequently a genuine doubt exists as to correct diagnosis, and,
o f course, some slur on the attendant or the patient may act to deter
reporting in doubtful cases.
8Ibid., p. 12.
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«Ibid., p. 118.
7Ibid., p. 31.
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PROCEEDINGS, M ATERNITY AND IN F A N C Y CONFERENCE
According to this circular, it is intended ultimately to replace the
term puerperal fever with the term puerperal pyrexia, but this can
not be done in England without new legislation. Consequently two
forms must be used, one for puerperal fever, the other for puerperal
pyrexia. The latter is defined as “ any febrile condition (other than
one which is required to be notified as puerperal fever) occurring in
a woman within 2 1 days after childbirth or miscarriage, in which
a temperature o f 100.4° or over has been sustained during a period
o f 24 hours or has recurred during that period.”
It is_ admitted that this will lead to a great increase in the number
of notifications and that many cases will be comparatively trivial,
since all pyrexia during puerperium must be reported, but it is held
that the importance o f securing adequate treatment in the early stage
o f infection outweighs these objections.
The Minister o f Health believes on the basis o f reports from many
maternity institutions that pyrexia during the puerperium is fre
quently looked upon as a comparatively unimportant incident and
that proper precautions to prevent spread of infection are at times
neglected with disastrous results. The new report form states the
opinion o f the notifier that the patient has puerperal pyrexia or
puerperal fever and includes a number o f suggestions as to aid ob
tainable for diagnosis and treatment. Practitioners requesting such
aid may be required to supply information as to any conditions prior
to labor that might have been conducive to the fever, the names o f
all persons who made internal examinations, the history o f delivery
and the postpartum period and any cases of specific fever, erysipelas,
or puerperal pyrexia visited recently by the doctor or attendant
who reports the case.8
Commenting in the British Medical Journal on the new notifica
tion regulation, two physicians say that while in the past many
cases o f uterine sepsis have not been reported, i f pyrexia only is to
be reported a large number o f patients with uterine sepsis will be
overlooked and not reported. They hold that after long experience
they find the cases o f raised temperature in sepsis are in the minority,
and maintain that a long persistence o f red lochia is often a more
important sign o f sepsis.9
It may be of interest to mention in passing that the Royal Society
o f Great Britain offers the second Nichols prize o f £250, to be
awarded October 8 , 1927, and again every three years, for the most
valuable contribution by a British subject to the subject of the dis
covery o f causes and prevention o f death in childbirth from septi
cemia. A special discussion o f this subject took place at the meeting
o f the British Medical Association in 1924, and the valedictory ad
dress o f the president o f the Edinburgh Obstetrical Society was also
concerned with this problem.
Gibbon Fitz-Gibbon and Joseph Bigger, in an elaborate investi
gation in Rotunda Hospital, Dublin, in 1923, found streptococci in
the vaginas o f 54 per cent o f 50 patients serially examined and in
only 28 per cent o f a series of controls. These were usually non
hemolytic; only 2 cases out o f 108 swabs showed hemolytic strepto8 B ritish M ed ica l Jou rn al, A u g . 2 1 , 1 9 2 6 , p. 3 5 6 .
t,
R em in gton, a n d M a ry R . ¿ ¡e v a c k : “ N otification o f puerperal fever o r p y rex ia .’
B r itish M edical J ou rn al, Sept. 1 1 , 1 9 2 6 j p. 5 0 6 .
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COMPULSORY NOTIFICATION OF PUERPERAL SEPTICEMIA
41
cocci; nonhemolytic streptococci occurred in 2 0 per cent o f the cases
that were examined postpartum. The investigators concluded that
since in 6 8 per cent o f all cases streptococci were found in the vagina
before and after delivery, they are an element o f the natural flora
of the part. However, since the common form of puerperal sepsis
is caused by hemolytic streptococcus and this was found in only 2
cases of their series, they; argue that these were doubtless due to
exogenous infection. While nonhemolytic streptococci do occasion
ally cause puerperal fever, this is because they, being normal body
saprophytes, are to be considered as opportunists as regards patho
genicity. They are present in the vaginas o f the majority o f par
turient women and occur fairly frequently postpartum. The investi
gators infer that puerperal sepsis may occasionally be due to non
hemolytic streptococci, an endogenous infection; but some unknown
factor, such as a lowering, local or general, o f the patient’s resistance,
or a rapidly enhanced virulence o f the organism, must also be
considered as involved in the process.10
It has been thought expedient to go into the difficulties which have
beset our English friends in their endeavor to frame a law which will
be found satisfactory, because of* the varied conditions which may
cause pyrexia. I f the States are to put upon the statute books com
pulsory notification, we should learn the lesson which evidently has
been forced upon the attention o f the authorities in England, as set
forth by the Minister o f Health.
A t present we have two main weapons effective in the battle against
mortality due to puerperal sepsis. The one more readily available is
the instillation into the minds o f the coming generation of obstetri
cians who are now in the schools and hospitals, o f the fundamental
truths o f asepsis. On this education and that o f the mothers to
demand good care, we must depend for the better statistics which we
demand for the future. When women realize, as through education
they are now beginning to realize, that childbearing can be made a
safe procedure, a powerful public sentiment will be aroused which
will be utilized in reducing puerperal mortality.
_ The other factor which must be brought into the struggle is pub
licity. This affects the generation o f general practitioners now en
gaged in obstetric work along with the treatment o f all sorts o f
suppurating wounds, erysipelas, and other virulent infections; rush
ing in the day’s work from the case with temperature to the clean
maternity patient. Usually they take no time to change clothing, nor
do they protect her by the use o f sterile gloves in the delivery. Pub
licity is the only means o f impressing upon such a physician the fact
that a woman dying o f puerperal septicemia after such needless
exposure is doubtless a victim o f his carelessness or ignorance.
It is not to be argued that compulsory notification will in itself
produce any marvelous achievement. W e are not so sure as to the
value o f a punitive clause in producing results. But it is certain,
with due respect for the views o f those who have no faith in the
benefit o f notification, that the publicity coming from notification
must rouse the physician who now scorns the extra precautions
10 Fitz-G ibb on, G ibbon, and J. W . B ig g e r : “ C linical and b acteriological in v estig a tio n o f
puerperal fever in R otu n d a H o sp ita l, D u b lin .”
Jou rn al o f O bstetrics an d G ynecology o f
the B ritish E m p ire, vol. 3 2 ( 1 9 2 5 ) , pp. 2 9 8 —3 1 7 ,
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
urged in behalf of the lying-in patient, to a realization o f the fact
that he must change his tactics to continue in his work in his com
munity, even if no legal penalty follow.
It is hoped that each delegate and visitor will go home resolved to'
use every available means to reduce puerperal sepsis, whether or not
we resolve to make it an object of compulsory notification. We must
urge upon the medical schools the importance o f giving to prenatal
care, to management of normal labor, and especially to asepsis, the
place they are entitled to have in the curriculum. Now, in the average
course, 4 hours a week in the third and fourth years, are given
for all obstetric teaching, as against 18 hours for surgery, the greater
part o f which will be the least element in the average general prac
titioner’s work. We should further institute a campaign o f educa
tion through the State boards o f health, the State and county medical
societies, the health centers, and other lay organizations having for
their aim better maternity conditions. These will add great impetus
to our efforts.
I f it seems that the profession is not yet ready for universal com
pulsory notification, the educational feature surely must be the one
to which we pin our faith and upon which we unite—not in 1930, as
we hope to do with the birth registration—but in 1927 and every year
until the final goal is reached.
D IS C U S S IO N
The C h a ir m a n . I will call on Dr. Elizabeth M. Gardiner,
director o f the division of maternity, infancy, and child hygiene o f
New York State, to open the discussion.
Doctor G ardiner . On this blackboard I have put some figures
showing how the cases of puerperal sepsis have been reported from
the time when such reporting was required under the sanitary code.
Puerperal sepsis was made reportable in 1913. I looked up the min
utes to see if there were any especial reasons which brought forth that
provision, and the only thing I could find in the records were remarks
by Doctor Biggs which seemed to indicate that the sanitary code was
being reorganized and that he wanted puerperal sepsis included be
cause of the large number o f midwives in New York City at that time.
You will find from those figures that there is only one year (1921)
between 1914 and 1926 in which the cases o f sepsis have exceeded the
number of deaths.
O f course, we could make great use o f the information if there was
perfect reporting o f puerperal-sepsis cases. We do not know any
thing about the prevalence o f puerperal sepsis or the degree o f fatal
ity from it. I f we did know I think that would help us a great deal
in developing a campaign. On the other hand, I think, as was pointed
out in Doctor Mosher’s paper, we need a short definition of puerperal
sepsis so that the doctor would know when he should report a given
case.
I do not think that penalizing for failure to report has ever done
much good. I f we are to accomplish anything it rests with us, as
educators, to put forth a good educational campaign; and I believe
we could eventually interest the organized medical groups themselves
to undertake a campaign to reduce the incidence o f puerperal sepsis.
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COMPULSORY NOTIFICATION OF PUERPERAL SEPTICEMIA
43
The C h a ir m a n . I hope some other directors will tell us their
experiences in reporting sepsis.
Doctor B aker . I quite agree with Doctor Gardiner as to the diffi
culty in getting these cases reported. In New York City there have
been sporadic drives which traced back each death from puerperal
sepsis to determine whether or not a midwife ever had the case at
any time, and in that way we managed to form a certain body o f
public opinion among the medical profession who themselves were
taking an interest in it, but I believe that there has never been any
where in the country any determined effort to enforce a report o f
puerperal septicemia as one o f the definite parts o f any sanitary
code. There might be, o f course, but I do not know o f it.
I have been particularly impressed in the last 2 0 years o f publichealth work by the fact that the impossible always becomes the pos
sible if we keep at it long enough. It has not been so long ago that
we considered it absolutely impossible to maintain prenatal clinics,
even in a city like New Y ork; it was felt that no pregnant woman
would ever come to a prenatal clinic. In many parts o f the United
States to-day our prenatal clinics are far below the demand for
them. I feel the same way about the reporting o f puerperal septi
cemia. I do not have any figures before me, but I am willing to
challenge Doctor Mosher’s statement that not more than half o f any
communicable disease is reported. I am quite convinced from in
tensive studies made on this subject that in our larger cities as high
as 80 or 90 per cent of most communicable diseases are reported.
Some years ago Doctor Biggs first brought out the idea of report
ing tuberculosis; he was faced with the most tremendous opposition,
and it seemed as if it would be impossible to have tuberculosis made
reportable. In general, to-day, tuberculosis is reported as commonly
as other communicable diseases. I do not believe we should be.
pessimistic. We certainly are agreed, I think, that the death rate
from puerperal septicemia is one part o f the problem that concerns
us as public-health officials. Some o f the highly differentiated ob
stetrical problems that lie within the scope o f the other classifications
as causes o f death are distinctly up to the obstetricians or the general
medical group, but the question of puerperal septicemia is a publichealth problem to a great extent; and I think that, first, by follow
ing Doctor Mosher’s idea o f first creating a considerable body o f
public opinion; second, by making the mothers demand better obstet
rical care ; and, third, by hammering at the idea of more compre
hensive and better teaching in our medical schools, we can finally
establish the idea that puerperal septicemia should be reported in
the same way as diphtheria or typhoid. I do not believe it is impos
sible, and I should hate to leave with the idea that the difficulties
are so great that we are not going to do anything more about it.
We are not doing a single thing to-day in child hygiene that has not
been accomplished against strenuous opposition. Yet when the ac
ceptance comes it comes so promptly, freely, and completely that we
forget there has been any struggle. I believe puerperal septicemia
can be made a reportable disease, I believe that the law making it
reportable can be enforced, and I believe those who are in this room
to-day will see that very thing come to pass.
66982°—27-----4
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
The C h airm an . In the list of States in which puerperal septi
cemia is made reportable Pennsylvania was the first. W ill you tell
us about it, Doctor Noble?
Doctor N oble. I had a talk with Doctor Hillsboro the other day.
Septicemia is not being reported; and with the number o f deaths
always exceeding the number o f cases reported, I should like also
to say I could not quite agree with Doctor Mosher about the per
centage of cases of communicable diseases that are reported. I am
sure we have communities in Pennsylvania where public-health work
has been done and where there are nurses on the ground, and com
municable diseases are reported to a very high percentage.
Doctor L evy . I believe with Doctor Baker that it is perfectly pos
sible to make this thing reportable; I only raise the question whether
it is worth while. I think Doctor Mosher’s attitude is an important
one; we should be very careful about passing laws and regulations
that are not necessary in the sense o f serving a very definite and
particular purpose. A great responsibility rests on public-health o f
ficials not to ask medical men to do anything that they can not say is
absolutely necessary for a definite and practical purpose. When a
particular city or a particular State is ready to study puerperal sep
sis, perhaps to aid the doctor in the handling of puerperal sepsis,
I think it is desirable to get those cases reported. There are, how
ever, some questions which should be straightened out before we
take that step. One is a proper definition; unless you carefully define
sepsis you may be making a regulation that will not gain the confi
dence of the doctor.
Doctor G ardiner. Suppose puerperal sepsis is reported to us; as
public-health officials, what action can we take ?
The C h airm an . In England when a case is reported does not the
official go to see about it?
Doctor G ardiner. Does he know o f it at once ?
The C h airm an . In England I think it is reported more quickly
than here. They call anything sepsis where the bidaily reading is
1 0 0 .4 on two occasions. It is a pretty definite ruling, more definite
than some of our rulings. As I see it, sepsis is a very difficult thing
to report. There are no two physicians who will agree what sepsis
is until it has reached a final stage. I have seen cases again and
again that I diagnosed as sepsis, but I could not prove it. Have
you not had the same experience, Doctor Holmes?
Doctor H olmes. Yes; and you do not see the type to-day you saw
20 or 30 years ago.
The C h a irm an - The next paper is “ Training the obstetrical
nurse,” by Miss Carrie M. Hall. Miss Hall and I were at the Massa
chusetts General Hospital together and had our training together.
We had not seen each other for some years until we came down on
the train yesterday. It is a great pleasure to greet Miss Hall and to
hear her read a paper on the training of the obstetrical nurse.
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TRAINING THE OBSTETRICAL NURSE
B y Carrie M. H aul , R. N ., P resident , N a tio n al L eague
of
N ursing E ducation
[Abstract]
For 20 years obstetrical nursing has been one of the required sub
jects for examination for State registration in States that had nursepractice acts. Every State now has such a law, many also having
set a minimum standard of instruction and practice. The minimum
required in New York, which State is fairly typical, consists o f eight
hours o f instruction by a physician and eight by a nurse; three
months o f segregated service (including observation o f at least 12
labor and delivery casés and active assistance in at least 1 0 ) ; four
weeks of postpartum care; and two weeks in a nursery having an
average o f eight babies. Attendance under supervision at prenatal
clinics is recommended.
Obstetrical nursing can not be taught as a thing apart but should
rest upon a knowledge o f general nursing. Surgical and medical
technique and skilled obstetrical care are not all that the prenatal
case, the puerperal case, and the newborn infant require. General
nursing is equally requisite. The nurse o f course must prepare for
and assist the physician at delivery, operation, dressing, and examina
tion; carry out his orders accurately and understandingly; and re
port intelligently to him results of treatment and any signs or symp
toms. She also must possess a volume o f knowledge o f nursing care
and procedure with which the physician does not concern himself,
such as bed-making, bathing, care o f body, hair, mouth, hands, and
feet, changing the patient’s position, and many others. Hence it
is difficult to draw a clear line o f demarcation between the physician’s
responsibilities and the nurse’s duties.
A committee on the grading o f nursing schools consisting o f nurses
representing nursing organizations, o f physicians representing medi
cal associations, of educators, and of a lay woman has issued a pre
liminary study entitled w Plans and budget for a five-year program,”
in which the statement is made that grading the schools implies the
adoption o f certain minimum standards for their graduates; that the
standards to be set depend upon what graduates will be required to
do; and that this can be ascertained only through careful inquiry
into the underlying facts of nursing employment. Consequently the
committee has adopted as one o f its projects an analysis o f nursing
and nurse teaching.
Many nursing schools give more instruction in regard to delivery
and the puerperium than the minimum amount of teaching in ob
stetrics required by State boards of registration o f nurses. Not in
frequently the schedule consists o f about 50 hours (exclusive of
examination) as follows: Instruction by physician, 12 hours; by
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
nurse, 1 2 hours; by social workers, 2 hours; bedside clinic by resident
staff, 2 to 4 hours; demonstrations by nurse supervisors in wards,
nurseries, and delivery rooms, 16 hours. The physician’s lectures
deal with the anatomy and physiology o f the reproductive system,
accessory and associate organs and their functions, pregnancy and
prenatal care, complications and accidents o f pregnancy, preparation
for labor, stages o f labor, mechanism of delivery, complications o f
labor and obstetrical operations, involution and care during puerperium, the normal and the premature child. The nurse instructor dis
cusses the nurse’s duties and responsibilities and nursing procedure.
The student nurse is presupposed to have some foundation in anatomy
and physiology, a year’s ward experience in medical and surgical nurs
ing, and a good understanding of technique in medical and surgical
asepsis. As theory and practice generally are better correlated in
obstetrics than in other branches o f nursing the student nurses as a
rule comprehend the material taught and make high averages in their
examinations.
Obstetrical nursing practice for student nurses is easily obtain
able in hospitals, especially in towns and small cities, where the hos
pitals having 50 to 100 beds) usually have more surgical and obstet
rical than medical and pediatric work. In large cities many general
hospitals have no maternity service; and affiliation then must be
arranged with the nearest lying-in hospital, if this is possible. These
institutions are becoming more willing to accept the general-hospital
nurse for a short period—usually three months. Such hospitals
have abundant clinical material and a high grade o f teaching; how
ever, as the work o f the hospital necessarily devolves upon the student
nurses each student must sacrifice some of her time and strength to
the exigencies of the hospital instead o f devoting the three months
solely to an intensive course in obstetrical nursing.
I believe that we have gone as far as we can under the present
system o f nursing education. Many hospitals provide generously for
the teaching of nurses. My own, for instance, during 10 months in
the year has only half o f its enrolled nurses actually caring for the
sick in the hospital. The others are receiving instruction in the
preliminary course, rounding out their basic training, and having
experience in such elective subjects as nursing in mental diseases,
public-health nursing, and eye and ear work. Yet the curriculum
and experience o f the student nurses are limited by what the indi
vidual hospital offers, not by any predetermined content o f a course
in nursing.
Under this three-month system the student nurses receive fairly
satisfactory teaching and experience in regard to labor and puerperium, but their experience in regard to prenatal care is inadequate.
Most o f the maternity cases in small general hospitals and private or
semiprivate hospitals maintaining training schools are private
patients. They have received in their own homes or in the physician’s
office whatever prenatal instruction was imparted. Consequently the
student nurse seldom sees a case until the woman arrives at the hos
pital, usually after the onset o f labor.
Most hospitals in large cities have prenatal clinics, and for years
student nurses have been assigned to assist the physicians at these.
But the nurse’s part seems to consist o f helping the patient to undress
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TRAINING THE OBSTETRICAL NURSE
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and draping her1 for examination by the physician, taking her tem
perature and pulse, recording on a blank form the findings as re
ported by the interne, and taking the specimens of urine. She re
ceives no instruction as to what it is all about and seldom hears the
physician tell the patient anything more than the date at which she
should return for further examination. This would suggest that not
only the general practitioner but even the obstetrician with demon
stration material at hand is failing to give instruction in prenatal
care to expectant mothers and also overlooking the opportunity to
teach nurses to give that assistance. In other words, the nurseinstructor’s work on prenatal care is not followed by anything done
for student nurses at prenatal clinics; and even though the clinic
provides teaching in all stages of pregnancy no case is followed
through by the nurse from the earliest period o f pregnancy to the
puerperium. I f the physician does not teach this subject, shall the
nurse instructor assume full responsibility for it?
To have the student nurse spend one month in prenatal work and
two in care o f mothers and infants and in the delivery room, as has
been suggested, seems impossible. With the three-month affiliation
the hospital now changes half its student staff approximately every
six weeks and can not be expected to repeat its course oftener than
once in six weeks. Too many administrative adjustments would be
necessary to give to each student a fair amount o f each kind o f ex
perience required and at the same time staff the various wards and
departments o f the hospital properly both day and night. The
students can not all follow exactly the same path. One group will
begin with the mothers’ ward, another in the day or night nursery,
another in the clinic, and so on, for the work o f the hospital must be
covered. Therefore the entire staff will be reassigned among its five
or six services (including mothers’ ward, toxemia ward, nurseries,
delivery rooms, clinics) about every two weeks. In a three-month—
that is, a 13-week— affiliated course the periods vary from two to
two and one-half weeks, or even a longer time, and those few days
more than the 1 2 weeks may just give to the student nurse the mini
mum number of deliveries or service in the nursery or other required
item on her program.
The plan of affiliation just meets the common interpretation o f
obstetrical nursing— ability to assist the physician during delivery
and to give nursing care thereafter to the mother and infant. I f
this is true, the preparation for teaching prenatal care must be
secured after graduation from the nursing schools as they are or
ganized at present.
Maternity centers and the maternity services in visiting-nurse asso
ciations offer excellent fields for this experience. Many such organ
izations have formulated outlines o f material for such instruction
and have shouldered the responsibility for teaching nurses. Such
teaching and conferences, plus the making o f visits with staff nurses
and supervisors, might give to young graduate nurses working for
small salaries enough practice to enable them to do prenatal work
satisfactorily; and only through visiting-nurse services in the field
can 'the nurse have the valuable experience o f following up a casefrom the earliest period o f pregnancy to the puerperium.
Some nurses have found it possible to get a fair insight into the
teaching o f prenatal cate during a four-mOnth course in public
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PROCEEDINGS, MATERNITY AND IN FA N C Y CONFERENCE
health nursing, the lectures in the obstetrical hospital furnishing a
good background.
Not only in rural districts and sparsely settled sections o f the
country but even in cities—especially those having many inhabitants
that are foreign born and accustomed to the services o f midwives—
the nurses frequently are called to attend deliveries. Even in a hos
pital the head nurse or some graduate nurse might have to deliver a
patient because the hospital was too small to afford a resident physi
cian and the patient’s physician had not arrived in time. Such
experiences lead nurses to believe that some means o f preparation for
the delivery o f at least normal cases would be very desirable.
In England where nurses get their certificates from the Central
Midwives Board and must have them for institutional positions,
public-health nursing, and military service, the subjects o f obstetrical
nursing and midwifery are regarded as one and treated as a graduate
course, the obstetrical nursing not being made merely a part o f basic
training. Although the American nurse understands signs and
symptoms o f antepartum and postpartum hemorrhage, stages of
pregnancy, the mechanism o f labor, the various presentations, and
much else that the English nurses are taught, the American nurse is
not taught actual delivery 5 but the English nurse during her prepa
ration has 25 to 30 deliveries under supervision in hospitals or out
m the districts. Under these circumstances such American nurses
as have qualified for mid wives have gone to England for their prepa
ration. The course in most o f the schools there has been increased.
I am told, to nine months or a year.
For two years the National Organization for Public-Health Nurs
ing and the National League o f Nursing Education have had a joint
committee studying the problem o f the need for advanced prepara
tion in obstetrics for at least some members o f the nursing profession *
and the attendance o f several hundred nurses at the committee’s
round-table discussion o f the subject at the Atlantic City convention
m the spring o f 1926 indicates the interest o f the nurses. The inter
est o f hospitals, institutions, and physicians dealing with the mater
nity problem has not been aroused for this type o f instruction
Although it happens that nurses have been led to take the initiative
in outlining courses and securing instructors for some branches o f
nursing education, it is obvious that obstetrical instruction for
nurses should be given by members o f the medical profession. Part
o f .this-instruction might be given simultaneously with the teaching
0 1 medical students.
Certain preliminary requirements should be
outlined, as satisfactory early education, graduation from an ac
credited nursing school, and registration in a State.
The fundamental problem after all is the economic one. Endow
ments for nursing schools and endowments for graduate courses are
sorely needed. The hospitals to-day can not begin to supply the matenals nor the funds required for this work. I f financial means and
educational opportunities could be secured to give to nurses such
obstetrical instruction as has been outlined as desirable for aid to
mothers and infants during the prenatal and natal periods, a new
group o f persons would become interested and the whole cause of
nursing education would be advanced.
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D IS C U S S IO N
The C h a ir m a n . That was a most interesting and admirable paper.
It is a pleasure to hear Miss Hall speak so clearly about the subject,
and I know you appreciate it. I will ask Miss Elizabeth F. Miller,
from the Pennsylvania Department o f Welfare, to open the
discussion.
Miss M iller . In the paper that Miss Hall has just presented there
are some interesting points to which she invites your attention. In
regard to the basic elements o f training for nurses who are aspiring
to State registration for general nursing—so far as this group is
concerned we begin with the preparation o f nurses for several types
of public-health nursing, and that with which you are concerned
chiefly is infant welfare and also the problems of rural nursing. The
relationship between your particular workers and the assistance that
a public-health nurse can give you is of such vital consequence that
it should invite a great deal o f discussion to-day.
Miss Hall has brought out the matter o f the preparation of nurses
in prenatal care. I should like to add a word to that in connection
with the training o f nurses to meet rural needs. In my particular
work in Pennsylvania I am concerned with the hospitals in the re
mote sections, and I have often been impressed with the problem o f
the proper teaching o f prenatal care there. W e realize fully that
in many o f our hospitals, though the State has established a curricu
lum and though it has outlined a course o f 30 hours, very often the
extent of the training and experience that the nurses have o f ma
ternal care consists only of the case that may be hurried in at the last
moment, or some complication that gives a thrill to the medical
student or interne. When I have gone into hospitals I have seen
rows o f empty beds; and there are still communities, especially the
mountain communities in Pennsylvania and elsewhere, in which the
maternity patient will not go to a hospital and in which prenatal
clinics have not been established. That patient or that group of
patients is at a distinct disadvantage when it comes to proper pre
natal care. This accounts for the emergency cases with which we
are concerned and which give a nurse a decidedly wrong perspective
in the matter o f maternity care.
There are also various adaptations o f the curriculum in our schools
o f nursing. These may vary from the 30 hours to desultory teaching
when the instruction is given by the busy practitioner, who may be
delayed because o f inadequate transportation facilities and other
causes. Therefore for the nurse who is to be of the greatest assist
ance to you some training in addition to the basic elements given
in the schools of nursing is necessary.
Miss Hall frankly states the difficulty that many hospitals have m
securing prenatal instruction for the nurses. In this connection
I would like to emphasize the value o f visiting nurses’ societies,
infant-welfare centers, and maternity centers as supplements to the
hospital teaching in obstetrics. Whether you find it true in your
own States or not, we find in Pennsylvania that these facilities are
not used to the extent they might be in providing this instruction
or giving the proper point o f view to the nurses.
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
The last point that Miss Hall has emphasized is the subject o f
special obstetrical training for nurses, to which she has invited your
earnest attention. As a member o f the committee that is working on
this problem and therefore vitally interested in it I would be glad
to hear a frank discussion from your group, representing as it does
all parts o f the United States and many phases o f public-health
activities. As Miss Hall told you, the committee is concerned with
the obstetrical nurse for just one reason—to supply better care for
the rural mother in isolated parts of the country. W e have no inter
est in developing nurses into midwives who would practice for com
mercial purposes. We would like to make that clear at the outset
in order to prevent any possible misunderstanding.
We believe all are agreed that this is distinctly a public-health
movement and therefore should interest every group o f public-health
workers, whether they are doctors or lay directors o f public-health
bodies. We believe that the obstetrical nurse for our rural communi
ties should be one who has had the obstetric training o f a general
nurse plus a special course. The question has come up several times
whether this special 00111*86 could not be included in the regular
nurses’ training course. The committee is o f the opinion that this,
work should be carried on by mature women; that no nurse under 25
years old, for instance, should be accepted for such a course. W e
believe furthermore that these courses should be outlined and spon
sored under medical supervision, such as schools o f public health
and universities offering public-health nursing courses. This will at
once put high value upon the training and arouse the proper appre
ciation and mental attitude on the part o f the applicant.
Questions that arise in considering these courses are: Where they
shall be established, how they shall be financed, and who will be the
instructors. We may recall the statement made by Miss Van Blarcom that any maternal-welfare program must be guided and directed
by the medical profession and must emanate from it; so naturally
the medical profession will be our advisors from the medical stand
point. We believe that the nurse who presents herself as a candidate
should have had public-health training, whatever the length o f the
proposed course may be.
I am sure that you understood from Miss Hall’s paper the surprise
expressed by English nurses that American nurses are familiar with
puerperal hemorrhage and other complications. We believe that with
the background which our nursing students get we can reduce the
obstetrical course from nine months to possibly six months or four
months. However, we are seeking the advice o f the best medical
authorities in various parts o f the country, and we shall be guided
by their judgment.
We should like to convey again to this audience the idea that we
have no thought or desire in any way to usurp the physicians’ prerog
atives. But we do aim and hope to establish better maternal care
for our rural sections. Pennsylvania is fairly densely populated, and
yet m our State, with its many physicians and public-health activi
ties, there are still farmers who are delivering their wives; there are
still 12-year-old sons o f miners who are delivering their mothers;
and there are still neighbors who are called in to practice midwifery,
even though we do have the licensed midwives. Because it is aware
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that this need exists all over the country and that the rural needs are
not met, this committee is launching its program; and the committee
would be glad indeed to have the reaction o f some of the members
o f this audience. It will prove very helpful for our next committee
meeting, which we hope to hold in March.
Doctor S c h w e i t z e r . I want to give just a little experience o f one
o f the nurses in the Indiana division o f infant and child hygiene.
She was a college graduate, a graduate o f a recognized nursing
school. She had had an experience of seven years with a maternity
hospital in Chicago in out-patient obstetric work, and at one time
she served in an Army nursing division. She went overseas, and it
was necessary for her to secure a midwife license in order to instruct
nurses there. When she came to me she remarked she had a license
as a midwife. She taught in a fine way what the riiral people
needed to know concerning hygiene, prenatal care, and so on. Now
she has gone to Columbia University to take advanced work. I give
this as an example o f the type of training that may be available.
She never infringed in any way on the prerogatives of a physician.
She was qualified to do the things she did, and she did them as well
as anyone possibly could; I have only the highest commendation for
her work.
Doctor K n o x . I should like to express my great appreciation
o f these two papers, because they give me a little light on the problem
I spoke of this morning, which is a real problem. It seems to me we
have three possibilities—physicians, midwives, nurses— for helping the
women in some out-of-the-way places. W e have in Maryland, and
I suppose it is equally true in other States, a diminishing number
o f rural practitioners. W e have large areas from which the physi
cians have drifted into the larger towns, leaving the rural areas
almost entirely without medical care. W e have also necks o f land
running into Chesapeake Bay, which are almost inaccessible in the
winter season. We have a large negro population, which is a very
important factor all through the South. Under these conditions
midwives seem to be absolutely necessary; somebody is required be
sides the few doctors for these people. I think the members of my
profession work harder for very little or nothing than any other
profession and very rarely refuse a case even if they are positive they
will get nothing for it. The negro midwives have little or no train
ing; they may have seen a case with a doctor, yet many o f them are
most ignorant. You would be amazed to see the letters we get from
them; I suppose some o f you have received them, too. I had a letter
last week that I could not read at all. There was some effort at
phonetic spelling, but it was practically impossible to read and under
stand it. What we have been doing—I know Virginia has been doing
it also— is to give a course that will make better midwives out o f the
ones we have; to try to get the worst ones out o f business; and to
try to place those who have some training in the localities where
they are most needed, so as to have at least one good midwife in every
area out o f reach o f a doctor.
Can we do anything more with the doctors ? Can we have obstetric
consultants in a town or in a county, or two o f them on salary, who
will do nothing but obstetrics ? That does not seem practical.
The plan that would interest me particularly is to have some nurses
with obstetrical training. I believe some o f the negro registered
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P R O C E E D IN G S ,
M A T E R N IT Y
AND
IN F A N C Y
CONFERENCE
nurses could be persuaded to take these courses. Then if we could
have one or two in each o f our counties where there are negroes we
should save more lives than by any other means I know of. I regard
this as the most important single problem o f our whole program, and
I am glad to have had this opportunity to discuss it.
The C h a ir m a n . Doctor Knox brings up the question of an obstet
rical consultant; the only State that I know has a regional consultant
is New York.
Doctor G ardiner . W e have a number o f regional consultants
drafted from the specialists in pediatrics and obstetrics, but they do
not do anything o f this kind; they have acted as consultants in only a
few cases around Albany. I imagine it is a question of distance and
perhaps the ability o f the doctor to take a particular case at a par
ticular time. I do not believe the obstetrical-consultant idea would
work out in a big area; it might in a small community.
Mrs. R eid. I f this effort were made to have the nurse trained, how
would you get her to stay in a given community? My point is, if
you make the same effort to get doctors into communities that you
make to get nurses into the counties, do you not think it might work
out better in the end?
Doctor G ardiner . They will not go because they can not make a
living in these remote places. I f they were assured three meals a day
they might remain.
Mrs. D illo n . We are just conducting a survey of typical areas in
West Virginia to find out whether or not it will be an economical
measure to attempt to teach the midwives we now have. From infor
mation available from one-third o f the counties, which are typical of
the State, we have decided after careful consideration that it is abso-^
lutely impossible to teach the present type o f midwife, with a few ex
ceptions. We think it would be money thrown away and time wasted.
We have a few intelligent midwives who are doing good work, but
the majority are an uneducated, self-confident group that it is abso
lutely impossible to consider in connection with safeguarding the
lives of mothers and babies. So far as medical service is concerned
we have counties that have only four physicians and counties in
which they are located only in the county seat; and as there are
women 20 or 30 or 40 miles from a physician and roads that, in the
winter, no doctor can get through, the problem will not be adequately
met by medical men, no matter how great and unselfish their interest
may be.
(The meeting adjourned to attend the showing of the film, “ Sun
Babies,” produced by the United States Children’s Bureau.)
W E D N E S D A Y , J A N U A R Y 12—MORNING SESSION
DE. BLANCHE M .
H AIN ES, DIRECTOR, MATERNITY AND INFANT-H YGIENE DIVISION,
CHILDREN’ S BUREAU, PRESIDING
The C h a ir m a n . I should like to talk to you a little about the pro
gram this morning. W e have had a great many requests for the
consideration of the work in the county health units, and we have
with us this morning, as you know, Doctor Ferrell, o f the Rockefeller
Foundation, to speak to us on this topic.
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Last year we had a committee appointed to consider the evaluation
o f maternity and infancy work in the county units, and it seems very
important that the report o f that committee should follow Doctor
Ferrell’s address. Therefore, we shall have Miss Marriner give us
the report o f that committee work on this morning’s program, post
poning the other topics until to-morrow morning.
I feel very apologetic about the number o f report blanks and ques
tionnaires that have been sent to you to fill in this past year, but you
know this has been a crucial year, and we needed the material
requested. One question that we asked you last year was how many
mothers and babies you were reaching with the work. W e all felt
assured that you underestimated the number because you did not
know just how many babies and mothers you reached. Y ou did
know how many you reached in conferences, but there were many
other ways o f reaching mothers and babies. W e hope that you will
include these in your next reports.
Doctor Crumbine has an announcement to make.
Doctor C r u m b in e . I thank Doctor Haines and Miss Abbott for the
opportunity o f inviting everybody to attend the fourth annual meet
ing o f the American Child Health Association, to be held in this
city May 9 to May 11. I wish you would please understand that
this is not a perfunctory invitation, but that it is the desire to have
all the child-health workers in America attend this conference, in
cluding both official and nonofficial agencies. It has been the desire
o f our president, Mr. Herbert Hoover, that this be a unique meeting,
in that it is an attempt to evaluate and appraise the importance of
child-health work thus far, and to formulate the next step; and,
if possible, to make that step with a united front, advancing the cause
o f child health in America. I suspect it is going to be rather a
significant meeting, and'we feel confident that the chief workers in
child health will be present. I know it is difficult for you to attend
so many meetings, but this one is to be held just before the meetings
o f the American Medical Association and the American Pediatric
Society, and therefore it may be convenient for many o f you to
attend it. I sincerely hope that many, if not all, o f you may be
present.
The C h a ir m a n . We appreciate very much having so many super
vising nurses from the States attending this meeting, especially as we
know that many o f you have had to pay your own transportation
expenses.
The subject this morning is maternity and infancy work in the
county unit. Not all the States are doing maternity and infancy
work in these units, but many o f them are, and it will be interesting
to know how many: We shall all be especially interested in the talk
and discussion this morning and in the committee report. It is very
gratifying to have with us the man who has made the county units
popular and who represents the agency that is making the county
unit possible in many States. I introduce Doctor Ferrell, o f the
Rockefeller Foundation.
Doctor F errell. Doctor Haines and ladies and gentlemen, I wel
come this opportunity to be with you. The majority of you here,
engaging in child-health work, are employees o f official health agen
cies. The program of the International Health Board, with which
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
I am connected, operates in this country only through and in the
name of the official health agencies. Therefore whatever may be the
program of the official health agencies is the program o f the Inter
national Health Board. Accordingly we are intensely interested in
whatever you may formulate as your program of activities and your
program looking to permanent work.
I accepted without hesitation the invitation to be present at this
meeting, and I supposed that I would have only four or five pages to
present. As I began to unfold my views, however, the paper began to
gain somewhat in length, but I hope that most o f it may be interest
ing to you. At any rate I will go through with it as fast as I can;
and if it gets too long, do not hesitate to do as they used to do in the
South—just “ sing the speaker dow n! ” [Laughter.]
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THE COUNTY HEALTH ORGANIZATION IN RELATION TO
MATERNITY AND INFANCY WORK AND ITS PERMA
NENCY
B
J o h n A . F errell, M. D ., D r. P. H ., A ssociate D irector, I nter
H ealth D ivisio n , R ockefeller F o undation , N e w
Y ork C it y
y
n a tio n a l
Local health service in every State is essential. In area or in
population-, usually in both, the State is too large to permit the con
duct o f adequate health service unless it is based on small territorial
units. The service to be satisfactory must be continuous and must
serve, at least ultimately, all communities o f the State simultaneously.
Public opinion in the United States is averse to centralization o f
government, and the problem o f administration is simplied— cer
tainly in the field of public health—if the work is conducted .through
and in the name of a suitable local organization. I f the central and
local organizations work in cooperation the sources from which to
obtain funds are increased in number, the-amounts obtainable are
usually larger, and the results are more impressive. Administrative
and financial participation stimulates county pride. Moreover, an
intimate acquaintance and understanding is established between
health worker and the individuals, and the conditions which will
influence the character o f the work are markedly improved. Even
if all the necessary funds were obtainable from the legislature the
State organization would find it exceedingly difficult to employ and
direct a sufficient number of workers to provide adequate health
service throughout the State. It is feasible, however, for the State
to employ a small group of experts in each o f the more important
branches o f health service to give leadership, counsel, and aid to the
local workers. When necessary, experts can share—temporarily, at
least— in training local personnel, in conducting field studies and
demonstrations, and in other important activities. That is to say,
it is practicable for the experts o f the State organization to have
advisory duties in connection with the personnel of the local organi
zation, and thus to contribute substantially to the value o f the work.
In the United States generally the county is the governmental
unit which best serves as a basis for local organization. The average
county in size, population, and wealth is suited to the requirements
o f a small health organization composed of full-time trained staff
members. A town or city having resources in population and wealth
equal to or greater than the average county, and a much smaller
area, is exceedingly well suited to the requirements o f a local organi
zation. Unfortunately the city can not be utilized in the development
of a state-wide service. Both city and county units are employed in
many States, but there has been a marked trend in these States to
ward a consolidation o f city and county health work, except, o f
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proceedings, maternity and infancy conference
course, in the larger cities. In Alabama, for example, there is pro
vision for county health organizations, but none for city health
organizations. The health services o f Mobile, Montgomery, and
Birmingham are conducted under a cooperative arrangement between
city and county authorities as county organizations.
In a number o f States, mainly those in New England, the county
is not a strong administrative unit o f government. Next to the
State, the town or township serves as the local governmental unit.
(Cities, for the purpose o f the present discussion, are not considered.)
The average town or township in such States is generally too weak
in wealth and too small in population to support a creditable full
time health service. The problem o f developing a local health
service capable o f state-wide extension is engaging the attention o f
the public-health authorities in these States. A suitable basis doubt
less will be evolved and ultimately given wide adoption.
The health service in every community should be continuous. A
periodic service for the detection and correction o f physical defects
and for immunization against such diseases as smallpox, diphtheria,
and typhoid fever might prove reasonably satisfactory if the field
o f public health were limited to problems o f this type. We know
that many o f the important problems are o f an emergency character.
No one would be so foolish as to expect that an itinerant health unit
available for one week in April and another week in October would
be able to prevent the spread o f diphtheria or smallpox in a county.
This would be no more reasonable than to propose that a town make
an arrangement to have for two weeks each year the protection of
police or a fire brigade. The emergency character of many publichealth activities renders it necessary to have full-time workers sta
tioned permanently within easy call o f all parts o f the community.
Moreover, as a general rule results are obtained ,gradually through
continuous and persistent effort by workers, who know the people,
the roads, the conditions, and can deal with each problem at the most
opportune time and in the most tactful manner. The itinerant
worker may be capable, earnest, industrious, and exceptionally well
trained, and yet he or she can not meet the needs o f the community
by making brief, irregular visits to the community. An official serv
ice that is adequate, continuous, and permanent— supported by taxes
and conducted by full-time workers—should be our goal.
The merits of specialized versus general activities for the local
health organization or for members o f its staff have been discussed in
recent yeays with animation. In large towns or cities where a great
number o f workers can be employed to serve small areas, specializa
tion in activities by members of the staff may yield excellent results.
When, however, the service is planned for small towns and rural com
munities where few workers are available to cover vast areas, only
limited specialization is feasible. The health worker, whether phy
sician, nurse, or sanitary officer, will find it necessary, as a rule, to
function much after the fashion of a general practitioner o f medi
cine. The field is so broad, the population so large, the funds and
personnel so limited that the the intensive effort advocated by many
authorities is impracticable.
The taxpayers o f the county are reasonably well informed as to the
cost o f the health service, the size o f the organization, and the activi
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ties customarily expected of the health department. They will be
dissatisfied i f the service is limited indefinitely to one or two special
groups o f citizens or to one or two special diseases or health problems.
Furthermore, they would not tolerate— even for a temporary period—
a failure to combat vigorously any threatened epidemic or to deal
promptly with other emergencies, even though the personnel might
be busily engaged in routine measures in connection with some prob
lem which could be continued from month to month and year to
year. They will usually acquiesce in the featuring o f an important
activity for a reasonable period o f time, especially i f extra financial
aid is available for the activity. It is usually unwise, however, to
confine effort to a single phase of health work for too long a period.
The people become tired o f being educated too persistently on one
subject. They relish an occasional change o f topic. The person who
hasn’t hookworm disease or malaria may have or be threatened with
another preventable disease. As a taxpayer he feels that he should
not be neglected indefinitely.
Infant-welfare work offers many advantages as a feature for a
local health organization. This is also true of measures for the
protection o f women during the puerperal period. These problems
are universally important and will be supported by the public as
readily and for as long periods as will any o f the routine procedures
o f a health department, but even in featuring these subjects the best
interest o f the cause o f public health will not be served unless—per
haps at the same time— other activities generally expected o f the
health department receive attention.
The Rockefeller Foundation, with which I am connected, has made
appropriations in this country for aiding in the development o f
county health organizations with the expectation that hookworm
disease, rural sanitation, or malaria control would be featured more
or less continuously for two or three years. In a number o f instances
other activities seemingly engaged the attention o f the health workers
almost to the exclusion o f these problems. I can, therefore, readily
understand and perhaps sympathize with the officers o f the Children’s
Bureau if they become disturbed when their funds in the support
o f full-time county health organizations may not produce promptly
the expected results in the field o f maternity and infancy welfare
work. Various factors may perhaps interfere with the systematic
conduct o f this highly specialized work. These can be overcome,
I believe, and a program o f procedure evolved that will be equally
acceptable to Federal, State, local, and private contributors.
The featuring o f an important health problem by a county organi
zation has been demonstrated to be practicable and oftentimes very
advantageous. This, o f course, presupposes that effective, clear-cut
procedures will be employed and tangible results demonstrated with
reasonable promptness. An impressive result thus obtained will
create public confidence which, in turn, will enable the workers to
stress other important problems in an orderly manner. Gradually
the necessity for maintaining the health service on a creditable basis
will come to be recognized, and then appropriations from State,
county, and county towns can be obtained to meet the cost o f reason
able expansion o f the program. The majority o f the county health
organizations now in existence have been aided— at least in the
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initial stages— with funds intended for the support o f special phases
o f health work. From 1915 to 1920 the United States Public Health
Service and the Rockefeller Foundation assisted in the establishment
o f such organizations because o f an interest in measures for com
bating the filth-borne diseases. Since that time the Public Health
Service and the foundation have supported new county organizations
without committing them to feature any special problem. Their
objective was a full-time, trained staff and a well-rounded program
financed, as early as practicable, entirely with public funds.
The foundation since 1922 has given aid to the establishment o f a
number o f county organizations on condition that malaria would be
emphasized for two or three years as an outstanding problem. O f
the 331 county organizations operating at the close o f 1926, 226 have
received contributions from the foundation, and o f these 37 have
featured malaria control. The American Child Health Association
and the Commonwealth Fund for more than five years have con
tributed to the establishment o f county organizations on condition
that child-welfare activities would be featured. The Milbank
Foundation likewise has aided in the organization o f county health
work with a view to emphasizing tuberculosis control. The principle
seems to have been pretty well established as a sound procedure by
official and voluntary health agencies because the number of county
organizations has increased from year to year in a spectacular man
ner. The contributors in behalf o f special problems, even though
disturbed at times because o f limited activities in their special fields,
have found consolation in knowing that the personnel supported has
learned something o f the importance of the special problems, and
that the activities probably will be continued from year to year and
the results in the special field will be cumulative. Regardless o f any
special interest in the field o f public health it should be a source o f
keen satisfaction to any agency to have played a part in bringing into
existence a county health organization devoted permanently to the
health interests erf the county.
There is no question as to the need o f better care for women in the
puerperal period. The high maternal mortality rate in the United
States is notorious. Practically every community needs better facili
ties for protecting women in the child-bearing period. The task,
like infant-welfare work, provides duties for the health staff every
week in the year. Its nature and importance appeal to everyone.
There is some difference o f opinion with regard to whether the work
to be done should be left to the field o f clinical medicine or to the
field o f preventive medicine and public health. The sincere health
worker should not be interested so much in who does the work as in
the result. I f the medical profession will proceed to reduce our
excessively high maternal mortality the health worker should, when
requested, cooperate as far as practicable. I f reasonable progress is
being made by the physicians or is in prospect, the worker should
devote attention to other important duties. I f the medical profes
sion—in spite o f cooperation offered by the health department—can
not or will not do the work necessary to s’ave the lives and health o f
women in the child-bearing stage, then the problem becomes a charge
upon the health department.
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None o f the special problems mentioned would seem more attractive
as a feature for newly created county organizations than the ma
ternity and infancy welfare work in which the Children’s Bureau is
particularly interested. Since 1922 this organization has cooperated
with State and local boards o f health in the support o f county health,
work, and through aid from the Sheppard-Towner fund many units
have been established which otherwise could not have been put into
operation for years to come. Infant-welfare work is a universal
problem. It makes its appeal in every community and in almost
every home. The methods to be employed have been evolved as an
outgrowth o f successful experience, and it has been demonstrated
that they can be employed successfully by county organizations.
Results o f thorough work will be reflected in the mortality statistics
as promptly as in most other activities or perhaps more promptly.
Unfortunately all the people can not be thoroughly educated over
night with regard to any public-health procedure. Moreover, even
after they are convinced o f the wisdom of changing customs and
habits, much time is consumed before the improved practices become
general and the results are registered in the mortality tables. Not
withstanding these difficulties infant-welfare work offers many ad
vantages as the first step in the development of a sound program for
a county health organization.
Personally, if I were a health worker in a county unit I should not
undertake any activity which could be considered as belonging to the
field o f clinical medicine. The practice of medicine should be en
tirely the province o f the practicing physician, and he should con
sider it a part o f his duties to practice preventive medicine among
his own clientele. I should do everything practicable to get physi
cians to make periodic examinations o f the apparently healthy, to
urge them to immunize the population to the fullest possible extent,
to administer venereal-disease treatments, to correct physical defects
of school children, and to give adequate care to infants and mothers.
In cooperating with them and in attending to general public-health
duties which can not be expected o f the practitioners o f medicine, the
health worker will be fully occupied. When efforts in this direction
fail repeatedly at any point I should feel justified in following the
next logical step. It seems to me unnecessary and unwise for the
health worker apd thé physician to engage in controversy. There is
work enough for all. A fair and reasonable basis for getting the
work done should be established, common ground should be found,
and cooperation and good will should prevail. Any other course
will prove costly to all interested parties, as the cause of public
health will suffer. I f the public-health officials and the practicing
physicians do not agree upon a feasible working plan, the laity then
may assume leadership in the field o f public health and determine—
wisely or otherwise—who shall conduct health work and what shall
be its character and scope.
Perhaps the introduction of a controversial question in this discus
sion is not in order. I mention it because this session of the confer
ence is devoted to a discussion o f permanency of maternity and
infancy welfare work in local health organizations. I f the organiza
tion is not established along sound lines and if the program and pro669820— 27----- 5
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L ? 6 noti S01un^’ t^ie work will not be permanent. More than
^2 ,0 0 0 ,0 0 0 yearly have been appropriated for the past three or four
years by Federal, State, and local governments for the support o f
maternity and infancy welfare measures. The authorities responsible
i ° r the spending o f this money have been experimenting with various
methods o f procedure, and now—quite properly—they desire to make
an appraisal of each method.
At least three methods o f procedure in maternity and infancy
welfare work have been widely adopted in rural areas. In some
instances special workers have been sent out by the State health
departments to cover wide areas and to devote themselves to these
special phases o f health work. In other instances nurses—not a part
o f the county organization—have devoted themselves to county-wide
measures, and in some cases a nurse has had to cover two or more
counties. Moreover, a large percentage o f the 331 county health units
have engaged to some extent in maternity and infancy welfare work
and either in personnel or in money they have derived some support
from the Sheppard-Towner. funds.
A correct appraisal of the advantages and disadvantages, from the
standpoint o f the Children’s Bureau, o f the various methods o f
attacking the problem will be difficult. It is feasible, o f course, to
obtain records o f the activities o f staff members o f each county unit,
and doubtiess these reports will give a very good idea as to the value
o f the work. However, we should remember that certain activities
may be of little value, whereas others may be productive o f striking
results in protecting health and preventing premature death. A
satisfactory method for translating health activities promptly into
tangible evidence o f health conservation has not been developed'. The
morbidity statistics at present are too incomplete to have great value.
The mortality records are reasonably complete, and although they
probably contain many errors they afford about the only available
universal basis for the measurement o f results in health work. They
are far from satisfactory. They will not reflect promptly and defi
nitely many activities that we know to be valuable. No one doubts,
tor example, the value o f removing diseased tonsils or adenoids, or o f
correcting dental defects; and yet it may be one, two, or more decades
before correction of^ these defects will be reflected in mortality sta
tistics. However, since the mortality statistics are the best index
we have for testing results, it would seem desirable to’utilize them in
K? ? i°r^ aP P ra-ise, as far as practicable, the various types o f work
that have been conducted in the field o f maternity and'infancy well a r e work. Even though effective work in this field theoretically
should be reflected quite promptly in the mortality records we know
that considerable time will be consumed in educating the masses with
regard to any health problem to a degree that will lead them to
improve their ideas, habits, and customs. Even if laws could be
enacted calling for procedures recognized by the authorities as most
effective they could not be enforced 'until sanctioned by at least a
majority o f the people.
We have seen evidences, certainly in the field o f infancy welfare,
that effective health work over a period o f years will influence the
infant death rate in a striking manner. The record o f Richmond,
Va., while Doctor Levy was commissioner of health, is an impressive
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example o f this type. During the first year or two, starting in 1907,
the health department devoted itself to inspection. Then the instruc
tion of mothers was started, the milk supply o f the city was im
proved, and privies for homes without sewerage connection were
given attention. In five years they got a striking reduction in the
death rate.
O f the 331 county health organizations, 207 (62.5 per cent) have
been established since 1920. It has been difficult to secure competent
personnel, and a multitude of problems have claimed attention. A c
cordingly it is not reasonable to expect so soon a striking reduction
in death rates from special causes. As the maternity and infancy
welfare work did not get under way until 1922 or 1923, even less
should be expected at this time in the way o f reduction in death rates
in this field.
Although, we have no right at this time to expect marked evidences
o f improvement we should begin at once making such tests as to the
efficacy o f the measures as can be applied by having the figures for
the various types o f work that have been undertaken prepared to
cover recent years, and for succeeding years as soon as the figures are
available. It will be practicable then to get graphs started that, if
continued from year to year, ultimately will reveal any trend that
may occur.
In 19241 I collected the mortality figures for typhoid fever for
several States that had made considerable progress in the establish
ment o f county health organizations. A group o f counties was se
lected that had been operating on a full-time basis for periods of
three to five years, and their records were consolidated in order to
include as large a population group as practicable when computing
the mortality rates. In each State a similar group of counties having
no full-time county health organizations was selected and similar
computations made. The tables, then, for a series of years gave the
mortality record for the entire State, the group o f full-time counties,
and the group o f nonfull-time counties, and these records were
graphically presented.
Assuming the rates in both groups o f counties and for the State
were about the same in the beginning, we should expect theoretically
that the greatest reduction in the rate would be shown by the full
time group and the least reduction by the nonfull-time group, and
an intermediate reduction by the State. I f there was a marked
difference in the three rates in the beginning, as occurred in a num
ber o f instances, we should expect that at least the percentage o f
reduction on an average in the full-time counties would be greater
than in the nonfull-time counties or in the State as a whole. A l
though there were exceptions, the general trend o f the various graphs
was according to expectations. The graphs have now been extended
through the years 1924 and 1925. Samples o f graphs showing infant
mortality are here presented (see pages 62-64) as an illustration of
a method which might be tried for testing the merits o f different
procedures in dealing with maternity and infancy welfare. We have
undertaken the test relative to county organizations in a few instances,
employing the same States (Alabama, North Carolina, Ohio, and
1 See paper read before Conference o f S ta te and P ro v in cia l H e a lth A u th o rities, at
L a n sin g , M ich ., June 1 4 ,1 9 2 4 .
R ep rin ts in lim ited num bers m ay be obtained upon request
to au th or, 6 1 B road w ay , N ew Y o rk C ity.
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
Virginia) and the same groups of counties that were used in the
typhoid studies in order to see what the present situation is and to
chart from year to year the changes that occur. Approximately 50
per cent o f the population in these States is now served by full-timè
county health organizations.
AVERAGE ANNUAL INFANT MORTALITY RATES. ALABAMA, 1920-1925
[N u m ber o f d e a th s under 1 yea r per 1 ,0 0 0 liv e b irth s ; 8 fu ll-tim e cou nty h ealth
orga n ization s ; 8 n on fu ll-tim e counties, 1 9 2 0 -1 9 2 4 , an d 7 n o n fu ll-tim e counties,
1 9 2 5 .]
1920
1921
1922
1923
1924
1 92 5
It would seem important for each State and county organization
to chart the various causes o f death during recent years, and from
time to time to bring the records up to date in order to know what
changes are taking place. Such records should be of inestimable
value as a guide in formulating health programs. Although the in
formation on mortality may be defective, we must do everything we
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can to utilize what is available. Some one may devise a better method
of using the mortality statistics, but I do not see now just what it
will be.
My personal view is that the county health unit affords one of the
most effective means o f dealing with general and special health probAVERAGE ANNUAL INFANT MORTALITY RATES, NORTH CAROLINA, 1914-1925
[N u m ber o f d eaths under 1 yea r per 1 ,0 0 0 liv e b i r t h s ; 6 fu ll-tim e cou nty h ealth
o r g a n iz a tio n s; 6 n o n fu ll-tim e counties, 1 9 1 4 —1 9 2 4 , and 5 n o n fu ll-tim e counties,
1 9 2 5 .]
no
s
s%
>
105
%•
>
loo
N
•
* •
V•
95
•
N
90
‘s •
< V
%•
1»
V
**
85
*4
80
75
70
65
___ rr Fui l - t i m e c o u nt i e s
N o n - fui 1- t î me counties
60
1
1914 1915
1_ j ____1____ 1
1916
1917 1918
1919
1
1
1920
1921
1922
1 9 2 3 1 9 2 4 1925
lems in towns, villages, and rural communities. I should be slow
to change this opinion, even if it should not be emphatically sup
ported by the statistical record suggested above. The county organi
zation is probably permanent, it is expected to have a trained full
time personnel, and the workers should become intimately acquainted
with the people to be served and win their confidence and coopera
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P R O C E E D IN G S ,
M A T E R N IT Y
AND
IN F A N C Y
CONFERENCE
tion. Each succeeding year should bring increased results. These
are fundamental considerations which make for adequacy and per
manency. No other method of procedure, it would seem, could be
expected in the long run to yield as satisfactory results. Even
though results in some instances may fall short o f those hoped for,
AVERAGE ANNUAL INFANT MORTALITY RATES, VIR G IN IA , 1917-1925
[N u m ber o f d eaths under 1 yea r per 1 ,0 0 0 liv e b i r t h s ; 6 fu ll-tim e cou nty h ealth
o r g a n iz a tio n s ; 6 n o n fu ll-tim e counties, 1 9 1 7 —1 9 2 3 , an d 5 n o n fu ll-tim e counties,
1 9 2 4 -1 9 2 5 .]
110
105
IOO
N•
\ •
95
.
N
*> •
\
s^V
90
85
•
80
-I, _
>#
•^
^
V
75
n
\
*
\ •
>*
s
---- m. —
70
65
mm
s
. - 5t :a te
___F i 111- t l it cou nties
N o n -fu ll--tim e counties
66
1917 1918
I
1919
i
1920
i
i
1921
1922
1923
1924
1924
the advantages are so great under the full-time county plan as to
justify patience.
In discussing maternity and infancy welfare work in the county
units I have avoided purposely an attempt to discuss details as to
program or procedure. Many o f those attending this conference are
experts in this special field and have had extensive and successful ex
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65
perience in it. They are qualified to speak with authority and
doubtless will present their views.
Likewise I have avoided a detailed discussion as to the adminis
trative relationship that should exist between staff members of the
central organization and those of the local organizations. Each
team o f workers, whether central or local, must have an administra
tive head through whom all negotiations between the State and local
personnel should be conducted. In a number of States the responsi
bilities o f the State health officer are so heavy that it is necessary for
him to designate a deputy to represent him in matters relating to
local organizations. The experts in each special field o f the central
organization should clear their negotiations through this adminis
trative channel. It would not be feasible, for example, in a county
unit that is composed of a health officer, a nurse, and a sanitary
officer to have the health officer supervised by the State epidemi
ologist, the sanitary officer by the State sanitary engineer, and the
nurse by the director o f maternity and infancy welfare. Neverthe
less, though responsibility should be centralized, the administrative
structure would be unsound if it should prevent staff members in the
local organization from obtaining all necessary instruction, counsel,
and aid from the State experts.
Thoroughness and persistence should be required o f the county
staff in dealing with maternity and infancy welfare measures.
These problems are important and should not be slighted. Lack of
proper training by the personnel is, perhaps, more frequently re
sponsible than any other cause for limited results. Even the physi
cians engaged in private practice are frequently in need of special
training. Certainly the health officer and the nurse o f the county
unit should have thorough training in this field o f service.
The possibilities o f providing facilities for better training of the
practicing physician can best be discussed by others. Something can
be done, I believe, for better training of the health personnel. It is
desirable, o f course, that the health officers attend schools of public
health and there receive complete courses of instruction, and that
nurses complete prescribed courses of first-class schools o f publichealth nursing. Both health officer and nurse should then have
opportunity for practical field training under capable and experi
enced workers. It is not yet feasible, o f course, to have the rank and
file o f the health personnel take full courses in these schools. Un
doubtedly as time goes on the number o f workers to have such train
ing will increase. In the meantime everything possible should be
done to equip the health officers and nurses for their immediate
duties.
In Alabama the State board o f health, with the cooperation of the
International Health Board, has been conducting, since 1922, a field
training station for health officers, and there have been usually from
four to eight young physicians there at all times receiving practical
field training. Forty-six such physicians have been sent by State
boards o f health, with the board’s aid, and 35 at State expense, to
receive from 4 to 12 weeks’ training, and 46 have been appointed by
the board for temporary training. Practically all these 127 men are
now occupying positions in State or county work. The experience
has been very satisfactory and has added a number of valuable
recruits to the ranks of health officers, and in each case the health
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
officer has been able to gain a considerable amount of knowledge and
practical experience that aided him substantially in meeting his
duties.
.
,
.
It has occurred to me that an extension o f the idea might be prac
ticable in giving special training to county health personnel in duties
relating to maternity and infancy welfare work. I f one, two, or
three counties, carefully selected, should have exceptionally able
personnel featuring these branches o f service, present and prospec
tive personnel for county organizations might be sent to these coun
ties and in a few weeks receive the training necessary to enable them,
wherever employed, to carry out similar work. I f such training can
be obtained by the newly selected personnel o f county organizations,
I am sure that maternity and infancy welfare work will not be
neglected and that the results will show marked improvement.
On the whole, it is my opinion that our public-health work is grow
ing rapidly along sound lines and that we are obtaining results which
will win the support o f taxpayers to an increasing degree and attract
to the field young men and young women who with training and
experience will steadily raise our public-health standards.
The C h a i r m a n . I am sure we are all delighted with this talk by
Doctor Ferrell. W e will have the discussion opened by Doctor Mon
ger, director of health in Ohio, who has more county units than any
other health officer in the United States.
D IS C U S S IO N
Doctor M o n g e r . A s I believe that Doctor Ferrell knows more about
county health unit administration than any other person in this
country, whatever I may add to what he has said will simply empha
size points he has made. Any opinion I may express is only my per
sonal opinion on problems as we see them in our own State, and these
may be essentially different in other States. Six years of full-time
health administration in Ohio have at least taught us humility.
But we are sure o f this: That county health-unit administration
is the logical thing, and some things do seem to stand out. W e have
nearly 50 full-time county health administrative units and 31 full
time city administrative units. The increase in budgets in more than
80 per cent of the local units o f the entire State during the past six
years indicates that at least the taxpayers appreciate full-time service
and are willing to pay for its extension. It seems clear that the full
time system does meet a real need.
The success o f any public-health organization depends first upon
efficient administration. To mention only one item, proper direction
requires both natural and acquired equipment; that is, the adminis
trative head must be adequately paid. Furthermore, if public-health
administration is to succeed it must deliver concrete service that the
taxpayer can evaluate personally in return for the money expended.
Just as in business the overhead expense must not be out o f pro
portion to the production, the public-health work must be adminis
tered by units large enough to carry the full cost o f good adminis
tration. County, city, or combined districts must contain enough
people to permit the per capita cost o f administration to be distrib-
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uted to a nonprohibitive point. An administrative cost of more than
15 or 20 per cent is unwise at the outset.
I wish to emphasize a point Doctor Ferrell made by quoting it ex
actly : “ I f I were a health worker in a county unit I should not
undertake any activity that could be considered to belong to the field
o f clinical medicine.” We must remember that in this sort o f work
we» can not go faster than the medical profession can or will go with
us. Let us stick to education and demonstration; if we do not accom
plish all the good the idealist thinks we could, we at least shall not do
the harm we otherwise might do. Continuous service is very valuable,
as Doctor Ferrell has pointed out; but- it is important also that the
health administrator be not a competitor.
DISTRIBUTION OF VISITS BY NURSES; OHIO DEPARTMENT
OF HEALTH, 1926
Public-health administration is a distinct specialty. Perhaps it
may be defined as the application of the principles o f preventive
medicine. This involves many things. The successful public-health
administrator must be first o f all a good doctor, with all the virtues
that term implies ; he must be a good educator and a good publicist ;
he must know the technical details o f his work and see its possibil
ities ; he must possess a human understanding and patience that will
enable him to conquer the many obstacles that beset his way; and lie
must be a good organizer, able to marshal the technical, professional,
semiprofessional, political, volunteer, and lay factors and resources
necessary for success. In short, he must be a scientific statesman (if
there is such a term) able to show the taxpayer that he receives a fair
measure o f service—for the public does not discriminate, it evaluates
results.
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Doctor Ferrell effectively points out the very great value of mater
nity and infancy work to those in administrative positions. We have
never dissociated our department completely into divisions and bu
reaus, and I have been astonished to see the importance of maternity
and infancy work in a big State program. T o ascertain two jea rs
ago the extent of our prenatal, natal, infancy, and preschool woj?k I
had a survey made of two counties carrying out an ordinary general
ized program and found that these activities constituted more than 50
per cent o f the work. I may sum it up by saying that after all the
tap o f the public-health nurse on the taxpayer’s door is foremost in
the whole picture of public-health accomplishments.
I wish to show you a chart (see p. 67) reflecting the consensus of
opinion o f 175 health administrators with large State, county, and
city experience—40 per cent being full-time administrators serving
more than 4,000,000 people— who met three years ago to discuss some
scheme o f evaluation o f public-health activities. This chart will
serve to give you an idea of what maternity and infancy work repre
sented in the nurses’ visits in the city and county units o f Ohio in
1926. The percentage o f visits to prenatal cases was 5.4; to mater
nity cases, 8.9; to infants, 2 2 .2 ; to preschool children, 15.6. You see
how big the maternity and infancy phase of the work is. Though I
am not arguing for a specialized field of endeavor I suggest that this
element o f public-health work makes a surprisingly great contribu
tion in proportion to the required expenditure o f money and effort.
It has had also a secondary beneficial effect in promoting interest in
public-health work in general.
The C h a i r m a n . We will delay the rest o f the discussion until after
Miss Marriner gives us the report of the committee on the evaluation
o f infancy and maternity work in the county units.
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EVALUATION OF MATERNITY AND INFANCY WORK IN A
GENERALIZED PROGRAM
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The report of your committee1 on evaluation of maternal and
infant hygiene work in a generalized program is as follow s:
The committee met in Atlantic City in May, those present being
Miss Marie Phelan, Dr. Blanche M. Haines, Miss Elizabeth Fox, Miss
Ruth Houlton, Miss Florence Patterson, and Miss Marriner. Type
written material prepared by the Children’s Bureau and setting forth
a list o f activities which may be accounted as maternity and infancy
work was distributed to members o f the committee and discussed. It
was agreed before adjournment that the work o f the committee would
have to be continued by correspondence.
During the summer the chairman wrote to each member o f the
committee sending a copy o f the material that had been distributed
in May and asking for its further consideration. Replies came bear
ing evidence o f careful thinking and offering valuable suggestions,
among them that a survey be taken o f the situation in the several
States where Sheppard-Towner funds are being used to subsidize a
general public-health nursing service and that certain amendments
be made in the list o f activities accounted as maternity and infancy
work as submitted at the Atlantic City meeting. Doctor Haines
furnished a list o f the States in which the maternity and infancy
program involves subsidizing local public-health nursing service, and
the following questionnaire was sent to these 26 States:
INFORMATION
FOR
THE COMMITTEE ON EVALUATION OF MATERNAL
HYGIENE WORK IN A GENERALIZED PROGRAM
AND
IN FAN T
1. A re Sheppard-Tow ner fu n d s used i n _______________ to subsidize or m aintain
(Y o u r S ta te)
local or county activities in the public-health nursing f i e l d ? ___________________
2. I f fund s are so used please state briefly your plan o f cooperation.
3. I s a definite signed contract executed by the State and county health organi
zations defining the obligations o f each in the cooperative undertak
in g? -------------------------- : --------4. I f no signed contract is made, how is the obligation to expend these funds
fo r the w e lfare o f m others and babies safeguarded?
5. P lease send copies o f all record and report form s.
6. I f studies have been m ade showing tim e distribution o f nursing activities
please include sam ples o f these.
1 T h e m em bers o f the com m ittee were : Jessie L . M arrin er, ch airm an ; D r. B lan ch e M .
H ain es, ex officio ; M arie T . Ph elan, U . S. C hild ren’ s B u reau ; F lorence M . P a tterson ,
C om m unity H e a lth A sso cia tio n , B oston ; E lizab eth F o x, A m e rican R ed C ross ; R u th H o u l
ton . director, V isitin g N urse A sso cia tio n , M inneapolis, M in n . ; and K ath erin e M . K reizenbeck, bureau o f child hygiene and pu blic-h ealth nu rsing, d ep artm en t o f h ealth , M ichigan .
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Twenty-two States returned the questionnaire with replies. The
answer to the first question was Yes in every instance, merely serv
ing to confirm the list o f States using maternity and infancy funds
to match county funds.
W ith three exceptions the replies to the second question varied
only in financial details o f the plan of cooperation and in adminis
trative procedure; all the larger groups (19) required the nurses to
give generalized service, but expected maternity and infancy work
to occupy from one-sixth to one-half o f the full time, according to
the proportion o f such funds used. Three States were committed
to a specialized maternity and infancy service in which these funds
were used, one having discontinued participation in a county organi
zation after, one year’s trial.
The third question was answered by only 2 1 States. O f these, 11
did not execute signed contracts with the county health organizations;
10 States considered that they.had contracts ( 6 sent copies o f the
form used; 4 stated that letters submitting and accepting the propo
sition and the published program subscribed to by the State and
the county organization constituted a contract). O f the six contract
forms submitted, only three stipulated that a definite proportion o f
the nurse’s time should be devoted to maternity and infancy work;
one required one-fourth and one one-half o f the nurse’s time, and
one required her full time. The other three contract forms deal
almost entirely with financial matters and details o f administration,
making no mention of definite requirements in the interest o f ma
ternal and infant hygiene. One states specifically that “ the nurse
is to devote her entire time to general public health nursing
activities.”
The answers to question 4 from 11 States that do not require signed
contracts varied from such expressions as “ It is not safeguarded,”
“ Safeguarded by honor o f employees,” “ Cooperation g ood ” to de
tailed accounts of supervisory systems which included daily records
o f activities, periodical reports to the State bureau, and periodical
visits and check by the State staff. In one instance the payment o f
the salary o f the nurse is contingent upon her record o f maternity
and infancy work, which must have reached a specified minimum.
Copies o f record and report forms in use were furnished by all
States replying to the questionnaire. Not all o f these provide for
record o f time spent in maternity and infancy work, and none
requires a time record on all phases o f work, though one states that
this will be required next year.
One State has made graphic studies o f the time distribution o f its
nursing personnel, and samples of these studies are included in the
material at the disposal of this committee. A ll material assembled
for the use o f the committee has been brought to Washington for
study at a committee meeting at the Children’s Bureau January 1 0 ,
1927. Any recommendations which may follow this report will be
an outgrowth o f the deliberations of the full committee.
The committee in session on January 1 0 , 1927, at the Children’s
Bureau decided that it would be well to suggest that States have a
clearly defined program for cooperative maternity and infancy work
in counties and make sure that these plans are thoroughly under
stood by those participating. It further suggested that systems of
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recording and reporting activities be perfected in the several States
looking toward a more thoroughly balanced nursing program and
that methods, o f supervision suited to the local situations be adopted,
continued, and improved.
It was quite evident from a study o f the records that it would be
difficult to make up a report o f the work done in the county units of
the different States; and because I am, o f course, more familiar with
our own system than any o f the others, Doctor Haines has asked me
to discuss it and also to bring out the attitude that we try to put into
our supervisory work, which is involved in the study o f time
distribution.
I will give you just the rough items that we had to decide upon
before we could work out a system o f time distribution. Two ques
tions arose: Whether our nurses were carrying on a generalized
nursing program; and whether there was a fair distribution of time
among the various activities. In an attempt to answer these ques
tions the following estimate o f the average time required for the
various activities was adopted as a working basis:
H om e v isits for—
Prenatal care and instruction, 3 0 minutes.
P ostpartum care and instruction, 3 0 minutes.
In fa n t hygiene and instruction, 30 minutes.
Preschool care and instruction, 3 0 minutes.
School follow -u p and instruction, 3 0 minutes.
Com m unicable-disease control and instruction, 3 0 m inutes.
T uberculosis control and instruction, 3 0 minutes.
County institution (alm shouse, e t c .), 2 0 m inutes.
A d u lts (oth er than tuberculosis c a s e s ), 2 0 minutes.
M id w ife, 20 m inutes.
Group m eeting, 1 % hours.
T a lk (school children, e t c .), 15 minutes.
T yphoid vaccination, 100 per hour.
Sm allpox vaccination, 2 5 per hour.
T ravel, 15 m iles per hour.
A ssistan ce w ith school exam inations, 20 per hour.
School visits, 3 0 minutes.
P rofession al visits (to p h y sicia n s), 15 m inutes.
Cooperating agencies, 15 minutes.
Social service, 15 m inutes.
B irth registration (v ita l sta tis tic s ), 15 minutes.
Individual office conference, 10 m inutes.
The time required for the different types of activities was estimated
first by conferences with heads of departments, health officers, and
the more experienced nurses. Exact records were later kept for one
month as a check. These showed that the approximations made were
relatively accurate. No satisfactory estimate o f time spent in travel
has yet been made because in view of differences in cars, in roads,
in individual drivers, and in methods o f computing mileage it seems
practically impossible to strike an average rate per hour.
A supervising nurse from the State department visits each organ
ized county every month. On this visit she studies the record of
daily visit cards o f each county nurse for the preceding month, tabu
lating the types o f activities and the number o f visits under each.
From this she makes an estimate o f the number of hours spent during
the month in each activity. This number compared with the total
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number of working hours for the month gives the percentage of
time devoted to any one activity. For greater uniformity a 44-hour
week is taken as a basis. From the figures a circular, or pie-shaped,
graph (see below) is made for each month so that the nurse may see
her own work as a whole and as part of the activities o f the county
unit.
When our supervisor makes her visit it is in the spirit o f a re
search worker coming to study what the health department is doing
and what it did last month, and not in the spirit of a critic coming to
find fault with what it did not do.
The present system o f supervision has been on trial for only four
months. A marked effect is already seen in more complete, more
accurate, and more intelligible daily records o f the nursing work.
TIME DISTRIBUTION FOR ONE MONTH OF WORK OF EXPERIENCED COUNTY NURSE
What we hope to see is a group of nurses with a keener appreciation
of a well-planned, generalized nursing program and o f its develop
ment in the individual counties as a part o f a state-wide program o f
public health.
D IS C U S S IO N
The C h a i r m a n . W e will now hear from Miss Patterson, general
director o f the Community Health Association o f Boston, who is to
open this discussion.
Miss P a t t e r s o n . I think you must all know that, as shown in Miss
Marriner’s report of the committee, there has been great difficulty in
arriving at the method of evaluating the nurses’ part in maternity
and infancy work. It has always seemed to me that the program of
the maternity and infancy work o f the Children’s Bureau is one o f
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the most potent factors in its success. I think all o f us in publichealth nursing, no matter what we are doing, realize we must have a
strict accounting o f our time. We must show that our work is worth
while and that we have been spending money only as it should be
spent. However, I think very simple records can show this, as Miss
Marriner pointed out. First of all, I agree with Miss Marriner as to
her daily record. I would go a little further and include transporta
tion time on the daily report sheet which the nurse carries into the
home. The report can show an itemized or an arranged statement
that would take not more than one minute to make at the end o f a
visit. The time can be identified by the next visit, which naturally
goes into the transportation. I f it is a daily report it can be sum
marized, taking certainly not more than two minutes at the end of
NOVEMBER TIME DISTRIBUTION OF WORK OF INEXPERIENCED COUNTY NURSE
ON STAFF SINCE JULY
the day, and going through the nurse’s daily report sheets will give
us, wherever she has worked, an absolutely accurate report o f what
she has been doing.
One other thing Miss Marriner did not bring out in those records.
It seems to me that if any public-health nurse is to carry on her work
intelligently and to secure the best results she can do it only by keep
ing an actual account o f her work on each visit, not so much from a
statistical point o f view but as a measure o f what she really accom
plishes. I think all o f us will agree that probably the poorest work
which we have had in public-health nursing is our prenatal work.
The reasons were brought out in Miss Hall’s paper yesterday on
nursing education, which conclusively pointed out that nurses are
not receiving much or any instruction in prenatal care. Further
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more, she showed very clearly that at present nursing education is
limited definitely by hospital necessities which will not permit the
training school to offer public health nursing education on prenatal
care. Miss Hall has suggested that that might be secured from the
public health nursing associations.
We can not improve the maternity and infancy work or safeguard
it— safeguard the funds of the Children’s Bureau, for instance—by
any quantity measurement; the only way in which we can enlarge this
work with this money is to lay more emphasis on quality. This is not
easily done, but there are several practical methods which can be
used. Miss Hall’s students happen to have their field experience with
our association. I might say, by way of explanation, that the Com
munity Health Association has a general nurses’ organization. I
think we bear out Doctor Monger’s theory that any general nursing
service can safely be trusted to carry a heavy proportion of the
maternity and infancy work. We had the general nursing service,
not the child-hygiene work. Last year between 40 and 50 per cent
o f our total was maternity work, and maternity work included
prenatal and delivery care. While o'ur staff is made up mostly o f
nurses who have had four months or more of nursing work, these
students get their field work with our association and get their
prenatal experience with us. This means they get two months o f field
work, and during that time they get the prenatal and maternity
work. However, in only two months’ experience a nurse can get only
a limited view o f what can be accomplished in prenatal education,
especially when only part time is given to this subject. I therefore
believe that so far as possible all public-health nurses who work in
rural communities should have one year’s experience and be under
very careful supervision.
I am not sure that I entirely agree with Miss Marriner in her new
method o f supervision. O f course, one aim o f every supervisor in
general nursing service is to maintain a well-organized plan. That I
think is Miss Marriner’s method. But even more important than
that, it seems to me, is the acquisition o f training by the nurse in her
teaching methods. The supervisor can impart this only by going into
the home with the nurse and watching her methods and suggesting
how she might improve them. Much of the work which Miss Mar
riner described as done by supervising nurses might be done by the
nurses. It is excellent teaching material for the supervisor, but I
should hate to think that the supervising nurse has a teaching duty
only.
The nurse should realize that the success o f her work depends very
largely upon how successfully she works with the doctor. I f we
nurses make more effort to work with the physician it seems to me
that we can do a great deal by discussing with him our routine pre
natal questions, and thus we can educate the women in the com
munity to know what they have a right to expect in pregnancy super
vision. The good doctors always welcome our cooperation, provided
we make it clear how we can help them.
I should like to believe that we could look forward to securing the
results in Boston which our friends have secured in Tioga County
by public-health nursing. But we have found repeatedly that no
matter how carefully we do our educational work with our prenatal
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cases—you can make your urinalysis and blood-pressure tests every
week or every two days, for instance—when we have an abnormal
case we shall not have safeguarded the mother unless the services
o f a skilled obstetrician are available for delivery.
There are certain methods, I think, that can be used to help m
educating nurses in prenatal care. W e are not all as well educated
as we ought to be. Many nurses in the field now, who have been
doing public-health nursing for a number o f years, have not had the
advantages o f instruction in prenatal supervision. Miss Kuhlman,
I think, has done much to help her nurses in prenatal education by
issuing to them outlines of talks which might be given to groups
o f expectant mothers.
I think that our greatest hope lies in attempting to improve the
quality o f our prenatal visits and having a larger degree o f con
fidence in one another.
n
The C h a i r m a n . I am sure we are very glad to find that Miss
Patterson has stressed the point not only o f the amount o f time
spent but of the quality o f the work in the county.
Doctor S c h w e i t z e r . I quite agree with everything Doctor Ferrell
said, and I have been very much pleased with Miss Marriner’s dis
cussion and report. But I think certain points o f view have not
been fully given. W e have grown accustomed in the last few years
to hear two distinct points o f view, that o f the health official as to
what the medical profession should do, and that of the practicing
part o f the medical profession as to what the public-health officials
should d o ; and I believe it is high time that we doctors who are
doing public-health work and the doctors who are engaged in the
general practice of medicine get together and arrive at some agree
ment with regard to what each thinks the other ought to do.
Doctor Ferrell spoke o f the permanent county units that were
being conducted and mentioned the agreement that a certain amount
of time should be given to the control of hookworm and malaria.
I f we were developing county units in Indiana we should not give
two years to the control of hookworm and malaria obviously, be
cause we have practically no hookworm districts in Indiana and very
little malaria. In 10 years in the laboratories o f Indiana I think we
had about 21 positive malaria specimens each year. We could
very well give time, however, to the prevention o f diphtheria and
typhoid. So whatever' we decide depends partly upon geography
and partly upon local needs; and in developing county health units
we must keep those in mind.
I wish to speak briefly with regard to the relation o f the maternity
and infancy work to other parts of the public-health program, and I
believe you will forgive me if I talk of my own State. In several
instances in the last year we have tried to adapt our maternity and
infancy program to State needs and to make it a coordinate part o f
the State work. W e give a maternity and infancy course in a, series
o f five lessons. These lessons are given in 8 to 14 places in each
county, usually with the township as the unit. They are given in two
counties alternately by doctors and nurses who are on the staff of
the division o f infant and child hygiene. The entire course occupies
a period o f six weeks.
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
In one county the child-health conferences were held by means of
the healthmobile two or three years ago. The people since then have
been working with county nurses in an endeavor to carry out some
o f the things that were suggested. They have done some excellent
work o f their own in having some child-health conferences during the
summer and doing the school health work during the winter. This
winter we are giving our maternity and infancy course in that county.
A t first when we talked to the county nurse about it she thought per
haps it might interfere with some things she had planned, but after
she understood the course more thoroughly she found that she could
coordinate it with her work and that its results would be very help
ful for her “ school-nursing ” program. She had been making inspec
tions o f children, doing the routine work in the school, and has just
about completed them. She felt that if the Sheppard-Towner nurse
organized the county, having committees with chairmen in each town
ship to help develop the maternity and infancy program, it would be
an excellent background for the home-nursing work that the county
nurse wished to put on later. So she is going with the nurse from the
division o f infant and child hygiene, organizing in each township
groups who will be given our maternity and infancy course, which
she will follow 'up with her hygiene and home-nursing work. This
again will be followed up by the health examinations o f children by
our own physician and by whatever local physicians wish to help ;
and by the time we get our maternity and infancy course through,
more local physicians are going to be interested in the nursing part
of this program. The child-hygiene workers are making a demonstra
tion in the county in which children who are going to start to school
next fall for the fiTst time will be examined, as well as other children
who are under school age. That is just an example o f how the State
work can be coordinated with the local work.
So far as the State board o f health is concerned, our State health
commissioner has been emphasizing the protection against diphtheria
this year. In the maternity and infancy classes we feel that that is a
very good thing to do, because part o f our work is the study o f the
prevention o f infectious diseases, and therefore part of one o f the
lectures is devoted to this subject, together with motion pictures
showing how to prevent diphtheria.
#I n one or two co'unties we have had the epidemiologist give a spe
cial talk on the prevention o f diphtheria, and always we show this
film and have a talk by our own physician. His work has been
delayed by epidemics in the State, which have demanded his personal
attention, but our instruction in diphtheria prevention has gone on.
We are trying to have the county child-health board continued in
each county as a local organization after we leave. This board is
composed o f medical and municipal officials and lay people. One
man who was approached on this subject said, “ I f you are going
to have a child-health board, don’t have all doctors on it.” He
meant that the other people in the community also are interested in
health protection from the economic and other points o f view, and
they all wanted to have a part in it. So we felt that our childhealth board should be composed of all kinds of people in the com
munity. Wherever we can get child-health boards organized they
will be a nucleus for the development o f county units, which the State
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health commissioner is t r y i n g C j f j Q T : ^ y v ^ h ill bpfore the
present legislature authorizing the expenditure o f -local. funds .for |
that purpose. That is the big project before the State legislature
this year.
One of these boards is trying to get a county nurse. Another is
promoting a program for the prevention of diphtheria. As many
children as possible are immunized in that particular county. The
boards take up whatever project seems to be the best for them to work
out at a given time, but all of them are keeping in mind maternity
and infancy work.
We need to have ideals toward which we are working, but we
must keep in mind all the time that we sometimes have to reach the
ideal indirectly. We have not developed in Indiana county health
units; our work has been almost entirely educational, and it has been
done through physicians and nurses who are employed by the staff.
Wherever we have made examinations of children or done work o f
that type it has been demonstrational.
Wherever we meet the individual doctors in the county work we
find a very large proportion o f them heartily in favor o f the ma
ternity and infancy work; and while some o f them say they do not
want it done indefinitely with Federal money, they are quite willing
to cooperate with us in promoting the work. They almost uni
versally say it is the finest thing that has been done. Two or three
very prominent physicians in the State medical society have said
that they think the work has promoted standards of maternal and
infant care further in the last five years than had been possible in 1 0
or 15 years previous to this time.
Doctor B r y d o n . I have observed in the past few years in these
conferences, and in other national conferences along public-health
lines, that we have been concerned largely with what to do and how
to do it. I suggest for our next conference that we more definitely
discuss results. I believe the time has come when we should say
how many babies are under medical supervision, how many mothers
in the State have had courses in child care, how many little mothers’
leagues have been established, how many young girls have had in
struction in child care, how many children o f preschool age are
physically fit, free o f defects, or representing a minimum standard.
I should like to see that note stressed more than ever as we go on.
The C h a i r m a n . Thank you, Doctor Brydon. We shall be very
glad to consider the suggestion.
Miss M a r r i n e r . I just wish to say that of course we do have case
records in our plan, but since they do not affect this time study in any
way they were disregarded so far as it was concerned. The records
are in the offices o f the county boards o f health, and this study o f the
time distribution, which has extended over four months, was made
partly for the sake o f the contribution it might make to the question
which was asked last year and for which this committee was formed
to find an answer. It is not at all certain that this particular ar
rangement for supervision will be continued indefinitely. I should
be inclined to thing that a combination of the time-distribution study
and the usual type o f supervisory visits in which we go out with the
nurse and get an impression o f her work and make personal sugges
tions to her would be the type o f supervisory visits that would con
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tinue. But we have found the time-distribution study very interest
ing and valuable for ourselves, and we hope that the directors will
be able to get something out of it.
The C h a i r m a n . I am going to ask Doctor Ferrell to close the dis
cussion now.
Doctor F e r r e l l . I think there is little for me to add to the subject.
It has been thoroughly discussed, and I find that I have no conflict o f
view with those w h o‘ have discussed the paper. I am in hearty
accord with the speaker from Indiana, that it would be foolish to
propose the conduct o f activities relating to malaria or hookworm
disease in Indiana. The point that I should like to have emphasized
is that an outstanding activity in a particular . State should be
featured. It is not enough that it be a problem that must be dealt
with; it should be a problem that we know how to deal with.
Maternity and infancy welfare work constitutes a universal problem;
it does not have to be confined to the South, where malaria and hook
worm are present; it prevails in the northern States and in the
Provinces o f Canada and in the distant Tropics. It is an inter
national problem, and it affords an ideal point o f contact between
the health services in this country and those o f other countries.
I am in hearty accord with the speaker from Virginia. It is not
enough in the field o f public health that we be active and industrious
and enthusiastic and earnest. We must be intelligent; we must be
wise ; we must select those activities which will yield tangible results
and watch our results and our procedure, from year to year, and be
sure just as the stockholders and the board o f directors of any large
industrial corporation that is spending money are going to be con
cerned about the dividends—that as trustees o f the public health and
the spending o f public funds we likewise shall be able to give an
account o f our stewardship and show to the stockholders, who are
the taxpayers, a satisfactory dividend on the investment and the work
left to our discretion. [Applause.]
Mrs. H o w e . I should like to ask whether copies o f the committee’s
time-distribution charts will be available for the use o f the directors—
that we might use them in evaluating our own State work?
The C h a i r m a n . I think we shall have to take action on the com
mittee’s report, and then we will decide. W e could easily mimeo
graph it. What will you do with the report o f the committee ?
Doctor S t a d t m u l l e r . I move that we accept the committee’s re
port and ask for copies o f it.
(The motion was seconded, put, and carried.)
The C h a i r m a n . Shall we discharge the committee with a great
deal o f thanks? It has certainly given us a great deal o f informa
tion. We wish to express our appreciation to Doctor Ferrell for
giving us the very fine address that he has this morning, and also to
the others who have taken part in the morning’s p r o g r a m .
(Meeting adjourned.)
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W E D N E S D A Y , J A N U A R Y 12—AFTER N O O N SESSION
DB. BLANCHE M . HAIN ES, DIRECTOR, MATERNITY AND IN FAN T-H YGIEN E DIVISION,
CHILDREN’ S BUREAU, PRESIDING
The C h a i r m a n . Y ou may think it strange that we have put on the
program this afternoon a breast-feeding demonstration as part of a
method o f developing a permanent program of prenatal and natal
eare, but I do not know o f anything that would be so permanent as
to develop breast feeding among all the mothers o f the United States.
We know that the bottle-fed baby dies in greater numbers than the
breast-fed baby, and I believe that we could lower the death rate
from diarrhea and enteritis if, we would stress breast feeding and
educate the mothers not only in the intent to do it but in the actual
doing of it. Consequently it gives me great pleasure to introduce to
you Dr. Frank Howard Richardson, regional consultant in pediatrics
for the division o f maternity, infancy, and child hygiene o f New
York State.
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By
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I am not going to try to teach you trained executives anything
about demonstrations. I may say, however, that a breast-feeding
demonstration, if it is to be permanent, must sell the idea o f breast
feeding as a private practitioner’s method of feeding the babies in
his care, not as a public-health measure. Before speaking further
on breast feeding, however, I want to talk to you about infant feeding
as a whole.
It is a rather interesting fact that every physician has a different
plan for feeding the babies in his practice, varying with the date of
his graduation from medical school. There is no standard method,
such as there is for the treatment o f typhoid or other disease. Unfor
tunately this does not mean that we have been making progress
through the years. Back in 1860 Peters and Meigs had the idea o f
imitating breast milk chemically, but it was not a success. Then
came the percentage idea o f Rotch, of Boston, which left much to
be desired. After that we had the caloric-feeding method; then
letter combinations such as “ B. B.” and “ B. A.,” the use of malt
soup and dry milks; and to-day we have lactic-acid milk.
Along with all this change without real progress two significant
things are to be noted. One was the establishment, back in the
eighties, of the first milk commission by Doctor Coit, in cooperation
with Mr. Francisco, in Essex County, N. J. The idea was simply
to get clean, fresh milk for babies. The other was the work o f Dr.
J. P. Sedgwick, of Minneapolis, Minn., who made the important
assertion—truism though it seems—that breast milk is better than
any other food for babies. This was emphasized by H olt’s observa
tion that many babies in his Fifth Avenue practice, who were fed
carefully and scientifically on the bottle, died; whereas very few of
the clinic babies in the slums, who were mostly breast fed, died
during their first year. Sedgwick did not stop with this pronounce
ment, however. He went further, and asserted that every mother
who desires to do so, and whose doctor is sufficiently interested, can
nurse her baby as long as she desires.
By a doctor who is sufficiently interested is meant the physician
who will take the trouble to learn breast-feeding technique, teach it
to the mothers, and have them practice it. This gives me my theme
for to-day, for I believe that any physician who cares to can have
pretty close to 10 0 per cent breast feeding in his practice.
I wish now to show some pictures. [Lantern slides, “ Simplifying
Motherhood ” and “ How to feed the baby,” were shown.]
This is the only fact that you need impress upon the mother in
order to secure her cooperation; the breast-fed baby has five chances
80
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for life as compared to the bottle-fed-baby’s one. This is the main
point, though incidentally you may mention how much easier for
her the breast feeding will be.
There are two essentials! in breast feeding. One is, complete emp
tying of the breasts. The other is, making up for any deficiency
o f breast milk by giving an artificial or complementary feeding. I f
the nursing baby does not empty the breast the mother must do it
herself. She should use the ball o f the thumb and the ball of the
finger on opposite sides of the breast, at the edge of the pigmented
area, bringing these together toward the nipple, and at the same time
making a slight pull forward and outward. The mother must go
through with this compression, or milking motion, after every feed
ing; and she should express not merely a few drops o f milk but
a stream 3 or 4 feet long. This may be done while the baby is still
nursing. It is an effective way to wake up a lazy baby, who goes
to sleep while he is nursing; sending a throatful o f milk into his
mouth will wake him up, and he will begin sucking immediately.
This emptying of the breast by the mother is not needed, in a ma
jority of instances, where sufficient milk is being secreted. It is use
ful whenever the supply becomes diminished; and also as a test to
ascertain whether the baby has emptied the breast or not.
Two sets o f causes lead to premature or unnecessary weaning— and
in my opinion every premature weaning is unnecessary. One set
o f causes relates to the mother, the other to the baby. The first of
the maternal causes is caking o f the breasts. The oversupply o f
milk when it first comes in makes the breasts very heavy and painful.
It has been the custom in obstetrical hospitals during the first two or
three days after the birth to bind the breast tightly and to give doses
o f castor oil. The flow naturally diminishes in consequence, and
then everyone is surprised when the next day there is no m ilk!
When the patient is lying down instead o f sitting the breasts are
elevated with respect to the chest, and venous congestion is removed,
exactly as elevating the arm diminishes the pain and swelling in a
bruised or infected finger or hand. This position is one which a
properly fitted brassiere should imitate. Such brassieres can not, how
ever, be bought in the stores. Those on sale crowd the breasts against
the chest, flatten the nipples, and do everything else they should not
do, in an effort to produce the so-called boyish figure. Now here
[showing picture] is a simple little contrivance a salesman in one
company made for his wife. The belt anchors a pair o f suspenders
that cross in the back, and end in front in two webbing bags to hold
the breasts. This can be adjusted and tightened and is: very satis
factory. The booklet of the New York Maternity Center Association
gives a very good way to improvise such a sling, as does also that o f the
division of maternity, infancy, and child hygiene o f the New York
State Department o f Health. It is unfortunate that these things can
not be bought and that each mother must improvise her own
Another maternal condition that causes many premature weaningS
is cracked or fissured nipples, an exquisitely painful condition. The
tenderness in normal nipples that is experienced at the beginning of
each nursing by certain high-strung mothers is frequently as pain
ful, or even more so, and nothing apparently can be done to alleviate
it; but at least the mother can be assured that it will grow less as time
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goes on. A fissured nipple, on the other hand, can become very seri
ous. The best care o f Assuring is its prevention! Squares o f ordi
nary waxed paper smeared with a mixture o f bismuth and castor
oil will prevent or cure this condition. Simply pasting these squares
on after the nursing will protect the delicate tissues from contact
with the clothing and keep the two drugs in constant apposition
with the surface o f the nipple.
A third maternal condition frequently offered as a reason for
premature weaning, is “ nervousness.” But if the mother has enough
sleep and rest, there is no strain nor drain; and “ nervousness ” need
never interfere with nursing a baby. I doubt whether any nursing
mother gets anywhere near enough sleep, unless her doctor insists
upon it. Remember that the 10 o’clock nursing usually keeps her
up until 11 o’clock or half past 11; she must awaken for the 6 a. m.
feeding; and i f she is subconsciously listening during the interim
to hear the baby if he wakes and cries, she will not have an adequate
night’s sleep. She is far more likely to have too little sleep than
to have too little food.
I want to say a word about this 1 0 p. m. feeding. I like to have
babies fed at (1) 6 and (2) 10 a. m. and (3) 2 and (4) 6 p. m., then
not again until (5) 11 or 12 p. m. Ten p. m. is the worst possible
nursing time for the mother. It interferes with her going out any
where for an evening’s enjoyment and interferes with her going to
sleep, if she wishes to stay at home and go to bed early. But if the
baby has been fed adequately at 6 p. m. he soon becomes accustomed
to a 6 -hour interval before the next feeding, especially if he has
become accustomed to a 4-hour interval by day. She can pick h i m
up at midnight, or at whatever time she comes in, or she may let h im
sleep until he awakens, and then feed him. He will get used to this
in a very short time. A t two months, or even as early as six weeks,
he may begin to sleep until 2, 3, or 4 in the morning; and shortly
thereafter may be expected to sleep clear through the night. This
o f course presupposes a completely satisfying feeding at 6 p. m.
Some mothers who have already had one or two children suffer
very violent afterpains when the baby begins to nurse. This is due
to the intimate nerve-system connection between the stimulation of
the nipple and the contraction of the uterus. It is not impossible that
the stimulation given by the nursing baby promotes the involution of
the uterus not only for the first few days but for a number o f months.
In regard to food, i f the nursing mother is allowed to eat as she
pleases, but will in addition to her regular diet take a quart o f milk
a day, she need take no further thought as to her diet, except that
she should have enough green vegetables. It will be a good thing
if she will use brown bread, not white, and fresh milk, not Pasteur
ized market milk that may have been on the wagon two or three or
four days. I f she knows some one who has a good cow and further
knows that the milker washes his hands, this will be fine; otherwise
she had better take certified milk.
Now as to some causes for premature weaning on the part o f
the baby. A bubble o f imprisoned air—not gas from indigestion,
nor wind, nor colic—may give to the baby a deceptive sensation of
fullness, and so stop him from nursing. This air, which occupies
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the stomach between feedings, becomes compressed when milk is
taken in. While the baby lies in the usual nursing position, the
fluid coming in from the esophagus prevents this air bubble from
escaping [showing drawings]. But i f the mother lifts the baby up
over her shoulder and gently pats his back, the air bubble will move
about and come out, thus leaving room for more milk. This has
been substantiated by these X -ray photographs made by Dr. Charles
Henry Smith, o f Bellevue Hospital. The X-ray pictures o f this
4-months-old baby at the beginning o f feeding [indicating on picture]
show a small amount o f milk in the stomach, with a bubble o f air in
front o f it. With a large amount o f milk in the stomach and a
large bubble o f air in front o f it [indicating] the baby now is crying
and seems in pain. This is taken a few minutes later. The baby
then is held in the erect position, the milk drops down into the
lower part o f the stomach, and the air is forced into the upper
part and thence into the esophagus. An eructation o f air follows;
then the baby stops crying and goes to sleep. The next picture
shows the stomach contracted on the food and the baby put back in
a horizontal position. There is no reason for the entrance o f more
air, as the whole stomach is occupied by milk, until the food goes
through into the small intestine.
The second set o f pictures [indicating] shows the same thing with
a 6 -months-old baby fed in a horizontal position. Babies should
not be fed in this position, because it puts the esophagus below the
liquid level, like a plumber’s trap, and o f course the air can not
escape. This baby was uncomfortable, and o f course he cried. Put
ting the baby erect and patting him on the back drove out the
air bubble, as in the previous case; and the baby stopped crying and
went to sleep. He remained all right when put in a horizontal
position.
What else can give this deceptive sensation of fullness ? Pressure
from outside the stomach, as from a stool in the rectum or urine in
the bladder, will produce this same effect. These can be overcome
by use o f a lap chamber and a suppository whittled out o f a piece
o f plain white soap. (T o prevent its chipping, the soap for this
suppository must be put in water for a while before it is whittled.)
This process may have to be repeated several times in one nursing.
Placing the lap chamber in position the mother inserts the sup
pository, then with the free hand puts the chamber against the baby—
not setting the baby on the chamber, as this might tire him and
the straining might possibly cause prolapsus ani or hemorrhoids.
The reflex connection is soon established; after this the suppository
is no longer necessary, as placing the chamber in position is enough
to start the movement. A mother reported to me the other day that
i f she used the chamber cold, the baby responded much more quickly.
So-called overfeeding is not to be feared. A ll of us used to think
it a terrible thing to overfeed a nursing baby—though no one could
state exactly what would happen to him if we d id ! I do not believe
it possible for the stomach o f either a breast-fed baby or a bottle-fed
baby to be unduly distended by food which he takes o f himself; in
other words, you can not overfeed a nursing baby. The babies who
give trouble because of “ indigestion,” “ gas,” “ wind,” or other causes,
are generally those who have not had enough food.
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Colic in a nursing baby usually means hunger. He can not be fed
too much at a time though he can be fed too often. I think an interval
o f four hours between feedings better than one o f three hours; but at
these four-hour feedings he must be fed full. A baby who has had
enough food looks satisfied and acts satisfied. A baby not getting
enough will cry or suck his thumb, and eventually become under
weight and emaciated.
“ Green stools ” or “ curdled stools ” should be written on the death
certificate o f many a baby, for many a baby has been unnecessarily
weaned because his stools were green or curdled. I have come to
the conclusion that almost every normal baby sometimes has green
stools. In my experience also curdled stools are about as common as
homogeneous stools. Certainly the appearance o f a stool is negligible,
if there are no other symptoms. Odor means a great deal more. A
number o f mothers have told me they could identify by their baby’s
stools what foods they had had the previous day; but that is quite
different from the stool interpretation we used to make. Even Fritz
Talbott, who has written as much as any one on this subject, is
not now putting nearly so much stress on stool interpretation as he
used to do.
(A demonstration o f breast feeding and manual expression of breast
milk was given with two patients.)
Remember that with manual expression o f milk there is no danger
o f infection, because the fingers do not touch the ostia, or mouths,
on the nipple surface; whereas infection by a breast pump is fairly
easily caused. Furthermore, the breast pump is not successful if the
milk is at all scanty; and the hot stupe is no better. The process in
manual expression is exactly the same as that used in milking a cow.
Pressure at a distance from the nipple, as in breast massage, will
expel some milk, but only from an overdistended breast; and this
will give the woman considerable pain. But a direct pressure prop
erly exerted just back o f the nipple [indicating] causes no pain. The
mother can do this herself. I f she hurts herself she will know that
she is doing it wrong. O f course one should wash his hands before
doing this; but rather for the sake o f the baby than for that o f
the mother.
Now let us get some idea about these two mothers. How old is
this baby ?
First P a t i e n t . Seven months.
Doctor R i c h a r d s o n . Have you plenty o f milk ?
F i r s t P a t i e n t . I had plenty at first but not so much later.
Doctor R i c h a r d s o n . H o w often do you nurse the baby and how
long at a time?
F i r s t P a t i e n t . A t first every three hours, then every four hours.
The nursing lasts 2 0 minutes.
Doctor R i c h a r d s o n . N o w watch what I am doing. The ball o f the
thumb and the ball o f the finger on opposite sides o f the breast, start
ing at the border of the areola [illustrating]. How many o f you can
see this ? [Expressing milk from the patient’s breast.] I find it best
to keep my thumb and forefinger dry; but one mother told me she
could do it better when hers were wet.
Doctor H a i n e s . W ill some one who is conservative estimate the
length o f that stream o f milk? Doctor Holmes, will you?
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85
Doctor H olmes. Six feet.
Doctor R i c h a r d s o n . When d id you nurse the baby before this
time?
F irst P atient . A t 6 o’clock this morning.
Doctor R ichardson. It is now about 4 p. m. I f she has been in
the habit o f going as long as this, she is lucky to have this much'.
Now let us try the other breast. You see that stream; and I have
just begun! I f I keep on, it will flow much more freely. Very
frequently expressing milk from one breast stimulates the flow from
the other. Notice that I use the ball o f the thumb and the ball o f
the index finger.
Now the second patient. How old is your baby ?
S econd P atient . One month.
Doctor R ichardson. And you are going to take him off the breast ?
What is the trouble ?
S econd P atient . He is not satisfied with my milk.
Doctor R ichardson. He is not satisfied with the aumounb o f milk.
I find that most nursing babies are not satisfied a good part o f the
time; hence, colic, crying, and the diagnosis that something is the
matter with the milk. Here complementary feeding saves the day.
I can divide mothers into three classes: One class consists o f those
who have plenty o f milk, e. g., Italians and colored mothers. The
difficulty with these often is to get them to stop nursing after 2 0
months or 2 years.
The second class consists o f those who nearly lose their milk at one
time or another, thanks often to the obstetrician and the rest o f us
doctors, or because of some shock, or because o f overfatigue. That
is a temporary loss, never a complete permanent disappearance. I f
we offer them some assistance and give complementary food to the
baby for a while, the milk always comes back. The beginning o f
menstruation frequently is such a critical time. These mothers can
be tided over very easily by allowing the baby to take as much o f the
complementary food as he will.
Remember the amount o f complementary feeding is never to be
prescribed. This is to be decided solely by the baby. I f only one
makes sure that the breast is completely emptied, then there is no
danger in allowing the baby to take as much of the complementary
food as he will. In fact, he should be urged to take all he will, and
the feeding should not terminate until he has done so. Underfeeding
causes colic; overfeeding never does. In fact, overfeeding is prac
tically impossible, because in the vast majority o f instances, a baby
will not take too great a quantity o f food.
The third class gives difficulty all the time, but the number in it
is comparatively small. Now, this mother [indicating the second
patient] did not give the baby a square deal. You see, in the first
place, that she has a depressed nipple. A t about the sixth month
she should have begun using the thumb and finger three times a day
with the same grip I have shown you, bringing the nipple gently
forward and outward, but without pressure [indicating]. Then she
would have had no trouble with inverted nipples. You see the milk
coming out. Probably she is producing as much milk as the first
patient is. Now I want you to do it yourself, like that [indicating
to the patient]. D o this 5 or 1 0 minutes or as long as there is any
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milk there, every time the baby gets through nursing, and you will
have plenty o f milk for him. The other nipple is in about the same
condition. O f course, the baby himself is going to be the best correc
tive for this inverted nipple. This mother, who was about to give
up nursing because she had no milk, has an abundance o f it, as you
have yourselves seen. - I f she will get all the milk out o f the breast
after the baby has finished each time she will have plenty for him.
Meanwhile she must let him take as much o f any good comple
mentary feeding as he will. When you are teaching the patient to
do this, stand behind her so as to have your hand in the same position
as hers is to be— left hand for right breast, and vice versa [illus
trating] . Ask whether you are hurting her. That will show whether
you are doing it too vigorously. Soon you will be using a gentle
milking motion, as you see, which can be kept up for a long time
without fatigue after you become familiar with the motion.
Get over the idea that it pays to analyze milk. An analysis is o f
no value unless it is made from at least three specimens from every
nursing o f a whole 24-hour period. The content of the fore milk,
the middle milk, and the stripping at the end of a nursing or milking
varies greatly; and there are further variations due to the condition
o f the mother, her diet, her state o f fatigue, and all sorts o f other
things. Hence no analysis is likely to show an average content; and
as the milk is likely to be found, to be too high or too low in one or
another constituent, the nursing is stopped and the baby suffers.
The only serious thing ever likely to be wrong with breast milk is
the quantity o f it.
You may say that this does not fit in with all we have heard about
rickets. Granted; but complementary feeding can take care o f that
possible deficiency. Use cod-liver oil, sunlight, quartz light, one
or all three of them; but do not discard breast milk entirely because
it is not perfect, nor ignore what there is o f it because there is not
enough to use as the baby’s sole food.
As to complementary ieeding, I am so convinced that breast feed
ing is more than good enough that I think it will make good the
defects o f almost any milk mixture that may be used with it. O f
course, certified milk should be used for making the complementary
food. In most cases 1, 2, or 3 ounces o f cream should be discarded
from the top of the bottle, because the law requires certified milk
to have at least 4 per cent fat, and that is too rich for most babies.
What is left may be diluted with two-thirds water at first, then half,
then one-third, until at six months the milk is used undiluted. I f
you boil this milk, boil it to cook it and make a smaller curd when
digested, not to sterilize it. In Europe they have not worried about
curds, because they had to boil the milk as a protective measure; and
boiled milk has a very small curd when digested. I f we do not boil
even clean milk we may have the problem o f the big curd.
As a matter o f fact, I have given up the one-third milk and twothirds water; The complementary feeding on which I start a baby is
half milk and half water, boiled, as much as he wants. I hesitated
about advocating this in public until T found that I rarely addressed
a group of doctors when at least one o f them did not inform me that
he had been doing the same thing, but had not dared to admit that he
had been feeding his babies as much as they wanted.
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This is the simplest and best way I know to prepare complemen
tary feedings: Take a pint o f water. Bring it to the boiling point in
an open saucepan. Pour in a pint o f cold milk, which, o f course,
stops the boiling. Bring it again to the boiling point and let it
.actually boil for three minutes by the clock, though not vigorously.
Stir meanwhile so that it does not stick to the pan nor form a skin or
pellicle1
. Then take it off and add whatever sugar you wish to use.
I start with two level tablespoonfuls of malt sugar for a quart mix
ture. (A quart o f milk a day is enough for any baby, by the way.
When he begins to want more than that he is ready for some addi
tional food.) I f on this amount o f malt sugar the baby has loose
stools, reduce the amount. I f he is constipated, increase to three or
even more tablespoonfuls to the quart mixture. When the baby is
6 or 7 months old I like to stop using both the sugar and the diluent.
Some babies o f this age will take as much as 16 ounces when they are
very hungry, though they do not hold it all in the stomach at one
time. The increased peristalsis pushes it through very rapidly into
the duodenum. I constantly tell my mothers to fill their babies up.
I f they vomit, fill them up again. That sounds rather extreme, but
the vomiting o f a nursing baby is not due as a rule to indigestion but
to an air bubble, as I showed you; or to tightness o f diapers or band;
or even to quick moving about, or crying. It is a simple mechanical
emptying o f the stomach, not at all like the disagreeable and painful
vomiting o f a seasick adult, nor the vomiting o f acute gastroenteritis.
I f the baby does not get any more food after such an emptying o f the
stomach, he naturally cries and “ pulls his little legs up on his
stomach,” and then people think he has .colic and propose to dose him
with peppermint waters, camomile, catnip tea, or castor oil, instead
o f giving him the food he is hungry for and is surely entitled to.
D IS C U S S IO N
Miss G r a h a m . In South Carolina, where many of the people that
we work with have no means of taking care o f the milk, would you
recommend dried milk?
Doctor R i c h a r d s o n . Personally I would much prefer a dried milk
to a doubtful liquid milk. A ll the dried-milk companies make a
straight dried milk and a partly skimmed dried milk. The only
trouble I ever have with milk is the butterfat. I don’t think there is
anything that will take the place o f butterfat; but I don’t think you
want the overfat m ilk; and certified milk, or any special-herd milk is,
as a rule, 4% per cent fat, which is too high. I f you use one o f these
dry milks partly skimmed you will be perfectly safe. And remember
if you are where you are not sure o f your milk, always boil it. But
don’t let anybody tell you that Pasteurization, boiling, or anything
else will take filth out o f milk, because it won’t. Personally I would
not think o f drinking anything but certified milk, though I am not
excessively wealthy. I have found that patients who would be furi
ous if you asked them whether they got second-class butter or coldstorage eggs, do not seem to see that certified milk is just first-class
milk. The commonest question among mothers that I have not con
verted is, “ Well, Doctor, how soon can I take the baby off certified
milk ? ” I always say, “ Just as soon as you start buying second-class
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butter and third-class eggs and cheap meat. I can tell you where
there is a cheap butcher store. Occasionally the butcher drops the
meat on the floor, but you are going to cook it anyway, so it doesn’t
make any difference.” The mother gets insulted, of course, and says,
“ I can pay for anything I need.” Then I tell her, “ Well, pay for
certified milk.” There is only one reason that certified milk costs
more than other milk—because it is better.
Doctor S c h w e i t z e r . Are the films that have been shown for sale?
Doctor R i c h a r d s o n . Y o u will have to ask Doctor Gardiner
whether those films can be bought. They were made by the New
York State Department of Health.
The C h a i r m a n . We have two other topics in connection with the
breast-feeding demonstration. I shall ask Doctor Smith, director o f
the Michigan bureau o f child hygiene and public-health nursing, to
tell us about the breast-feeding demonstration in that State.
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A BREAST-FEEDING SURVEY IN 11 COUNTIES IN
MICHIGAN
B y L illian R. S m it h , M. D ., D irector, B ureau of C hild H ygiene
and P ublic-H ealth N ursing, S tate D epartment of H ealth
M ichigan
T here is no question that the character o f feeding during the first year o f
life is the m ain factor in the health destiny o f the baby. A lthough prenatal and
natal conditions m ay largely account fo r neonatal deaths w e m ust look to
difficulties in feeding as the underlying cause o f the disorders which result in so
m any deaths during the later m onths. T h e early establishm ent o f breast
feeding is o f param ount im portance * * *. T h e r e is no real substitute fo r
m other’s m ilk.
Realizing the need o f education o f mothers as to the importance o f
breast feeding and its effect on infant mortality and morbidity, the
Michigan Department o f Health has conducted a series of breast
feeding campaigns in 11 counties in Michigan, which have included
a total o f 2,082 babies.
The deaths in Michigan in W25 o f 1,742 children under 2 years
o f age from diarrhea and enteritis alone is sufficient incentive for
such an educational campaign, since the incidence o f diarrhea and
enteritis is much higher in artificially-fed than in breast-fed babies.
The bureau o f child hygiene of the New York City Department of
Health several years ago made a study o f deaths from diarrhea and
enteritis and found that “ 17 per cent were exclusively breast fed and
83 per cent artificially fed in whole or in part,” 2 proving the much
greater resistance to this disease on the part o f breast-fed babies.
Increased resistance to disease o f every kind among breast-fed babies
is a well-recognized fact.
The survey in Michigan was conducted by nurses in the employ of
the Michigan Department o f Health. Nurses assigned to this type of
duty had a preliminary course in manual expression o f breast milk
at the clinic for infant feeding in Grand Rapids. They visited
nursing mothers with nurses connected with the clinic and observed
the manual expression o f breast milk by the nurses and by the
mothers, and they themselves learned to express the milk so that they
might instruct the mothers whom they later visited in other counties.
This course proved very valuable, as during the survey not a few
mothers o f premature babies or babies too weak to nurse were found
and the mothers shown how to express the milk and thus give these
babies the benefit o f breast milk which they otherwise would not
have had.
The nurse assigned to a certain county would first visit the physi
cians in the county and secure their approval o f the survey, and next
would visit the county and township clerks and get the names of the
o f o lt V.itAcll a i d^ 4 rti H ’„ M - D - : “ T h e m o rta lities o f in fa n c y .”
A b t ’ s P e d iatrics, vol. 2,
36.
P h ilad elphia, 1 9 2 3 .
2 B aker, S : Josephine, M . D . : C hild H ygien e, p. 2 1 1 .
N ew Y o rk, 1 9 2 5 .
89
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90
PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
parents o f all infants born in the county within the past year. Names
were also obtained from priests, ministers, cradle rolls, and many
were referred by neighbors before they had been reported to the
clerks. In this way the nurse was able to get in touch with the
mothers o f very young babies, and it was on these mothers that she
first called, so as to get to them early the information about the value
of breast feeding and to instruct the mothers as to their own diet and
the care of the baby. Particularly she stressed the great importance
o f regularity o f feeding and of having the baby sleep alone at night
so that it would not want or get night feedings. When the supply of
milk was insufficient, she spent considerable time with the mother
going over her diet and urged the generous use o f milk (at least a
quart daily) and o f corn meal as a cereal. Mothers who were unre
sponsive at the first call were not urged too much at that time, but
literature was left. When the nurse called again she was usually
given a much more cordial reception. In many instances she would
be questioned about the diet and hygiene o f older children in the
family. The nurse was supplied with literature, including diet lists
for expectant and nursing mothers,' breast-feeding schedules, diet
lists for older children, recipe books, and dodgers on the care o f
children. This literature was particularly acceptable in rural dis
tricts where health education is not so readily available as in urban
districts. The following form was used in obtaining information:
B R E A S T -F E E D I N G
SU R VEY
N am e_________________________________ _________________ — ----------- ------------------D ate o f birth---------------------------------------------------- --------- -------------- —
A d d r e s s -------------------------------- ---------------- i - --------- •---------- v— --------------- ,
N ation ality o f m other------------------ ------------------- -------------~ -------- — .-----------Occupation o f fa th e r-------------------—
---------------------- — - —
-------H ow long breast fe d ------------------------------------ ---------------------- -— ----------------—
W h y w e a n e d ---------------------------------- ------------------------- ------------- — ------W h a t is being fe d ----------------------------,—
------------ --------- -------------:--------i—
H om e con d ition s-— -----------------------— - — — --------------------------------•-----------R em ark s------------------------------------------------------------- ----------------- .•— - —^---------------
In later campaigns information has also been obtained as to the
age o f the mother, diet o f the mother during pregnancy and lactation
(whether good, fair, or poor, and what it lacks), the physical condi
tion of the mother, and whether she was attended by a physician or
a midwife, as these factors all have a direct bearing on the ability
o f the mother to nurse her baby.
In many instances an interpreter was needed; often an older child
who had attended school acted in this capacity, or a neighbor was
called in.
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91
BREAST-FEEDING SURVEY IN MICHIGAN
The following table shows the result of this survey by age groups:
T
able
1 .— Duration of breast feeding, by age of babies
Num ber of babies of specified ages
Duration of breast feeding
1 month, 3 months, 6 months, 9 months,
under 3
under 6
under 9 under 12
Over
1 year
Total
Under
1 month
Total number of babies............
2,082
159
543
612
292
211
265
Breast fed:
At time of survey_______________
Previous to su rv e y .. ...................
1,397
517
144
6
450
55
442
120
188
76
101
91
72
169
166
132
67
52
69
31
6
43
12
58
48
14
23
17
19
17
24
24
13
13
17
12
31
21
22
52
31
168
9
38
50
28
19
24
Less than 1 month
_______
3 months, less than 6 . ______
Never breast fed ............................ .......
O f the 2,082 babies surveyed, 1,314 (63 per cent) were under 6
months o f age. The mothers of this group had the advantage o f
being instructed in the benefits o f breast feeding and in infant care
while the babies were still very young. O f these babies under 6
months of age 1,036 were still breast fed, 181 had been weaned,
and 97 had never been breast fed at the time of the survey.
O f the 2,082 surveyed, 168 had never been breast fed, 1,39T
were still breast fed, and the remainder were weaned or on arti
ficial feeding. A group of 103 had been breast fed more than
one year, and 31 of these had been weaned at the time o f the sur
vey. O f the breast-fed babies, 81 per cent were wholly breast fed
and 19 per cent were partially breast fed, an encouraging proportion
of wholly breast-fed babies. O f those who were weaned or partially
breast fed, 331 were receiving cow’s milk and 129 were on patented
baby foods. This shows that mothers are awakening to the value
o f cow’s milk where breast milk is not available, but much educa
tion along these lines is still needed, as the simplicity o f the prepara
tion o f some of the patented foods as compared with modified cow’s
milk and the fact that the patented foods keep better in hot weather
than cow’s milk are strong arguments among mothers in favor of
their use.
The following list shows the reasons reported for the babies not
being breast fed:
R eason s fo r n o t
nu rsin g babies
N um ber o f
m others
T o ta l_____________________ _ _ _______________ __________ ___________ 512
Insufficient am ount o f m ilk________ ,v,________________ ______________ 191
M other ill_____________________ ___ —
— _____________----------- — ______ 100
N o breast m ilk _______ ______________________________________ —
___ A
57
M ilk did not agree with baby_______ _____________________________ r___
43
M ilk not o f good q u ality___________ ______ '_______ _______________ ______ 26
B aby ill-------------------------— 1_______ ,________ _______________||_________ . 20
D efective breasts________ __ ____________ ________________ ______ _______
19
M other pregnant_____________________________________ f-------------------------16
66982°— 27 --------7
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
R eason s fo r n o t
n u rsin g babies
N um ber o f
m oth ers
B ab y w ould not take breast-------------------------------------------------------------M other dead--------------------- --------- ----------------------------------------------------------M other w ould not nurse baby_,-------------------------------------------------------M other had to w ork o u t---------------------------------------- ----------------------------Adopted b aby------------------------------ ---------------------------------------------------------M other did n ot have tim e— --------------------------------------------- — - —
10
8
7
6
5
4
The reason most frequently given for the mothers not nursing the
baby was an insufficient amount of milk, 191 mothers making this
statement. When we consider that many o f these 191 mothers could
have nursed their babies had they been instructed during the pre
natal period as to the effect o f diet on lactation during both the
prenatal and nursing periods, this group has an added significance.
Also, in cases where even proper diet for the mothers did not result
in sufficient milk for the baby, if the mothers had been instructed as
to the value of breast milk many would have continued breast feed
ing supplemented by the feeding of modified cow’s milk. Adequate
prenatal care with proper instruction as to diet would have reduced
this group materially.
The reason next in frequency was that the mother was ill. While
the question o f illness of the mother was not always followed up
in detail, overwork o f the mother and frequent pregnancies were
mentioned as having a possible bearing on many o f the cases. Lack
of proper prenatal, natal, or postnatal care was also mentioned as
a factor in some cases.
That the mother had no breast milk at all was the reason third in
frequency, but since this reason was given by the mother and not by
the attending physician, it can not be relied upon. Many o f these
women doubtless had a scanty secretion o f breast milk, and the
mother either was glad of an excuse not to nurse the baby or was not
encouraged to keep on trying and put the baby immediately on arti
ficial feeding. This group, like the first in which insufficient quantity
o f milk was given as a reason for not nursing, could doubtless have
been considerably reduced by proper measures.
That the breast milk did not agree with the baby was the fourth
reason given, and we know that the actual number of cases in which
breast milk does not agree with a baby is small indeed. Faulty diet
of the mother, causing digestive disturbance in the baby, or deficient
diet resulting in insufficient amount o f breast milk and fretfulness
and failure of the baby to gain in weight, were probably the real
reasons why this gro\ip did not receive breast milk—conditions which
could easily be improved with the cooperation of the mother. In
the groups for which other reasons were given, as in those already
discussed, breast feeding could have been carried on had the mothers
been properly instructed.
The accompanying table shows the nationality o f the mothers
interviewed. American mothers predominated ; next in order came
French, Finnish, Polish, German, and English. The Finnish
mothers nursed their babies longest, 14 per cent o f the entire number
being breast fed for a year or more. Among the babies of American
mothers, the largest group were breast fed between one and three
months; most o f the American mothers weaned their babies by the
end o f the eighth month. The proportion o f mothers who did not
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BREAST-FEEDING SURVEY IN MICHIGAN
93
nurse their babies at all was larger among those of German birth
than in any other nationality group, consisting o f at least 50 mothers.
T
able
2 .—
Nationality of mothers, by duration of breast feeding of babies
Num ber of babies breast fed for specified periods
Nationality of mothers
Total
A m e rican ..........._________
French ___________________
Finnish___________________
Polish____________________
German ........................ .
English___________________
Swedish__________________
Irish__________ _____ ______
Italian.....................................
Slavic_______________ _____
Austrian_____________ ____
Miscellaneous.......................
1,132
172
147
125
109
79
50
43
23
18
15
206
Never
breast
fed
91
21
11
14
15
6
3
7
1
2
3
24
Less
than 1
month
171
21
16
12
15
11
7
6
1
3
20
1 month, 3 months, 6 months, 9 months,
less
less
less
less
than 9
than 3
than 6
than 12
342
48
32
26
27
20
14
9
7
7
5
62
285
38
25
33
28
18
11
9
5
3
2
46
149
17
18
21
11
8
6
4
2
1
18
62
17
26
8
8
13
9
8
3
1
3
18
1 year
or
more
32
10
20
11
5
3
4
4
1
16
As to home conditions, 14 per cent were poor, 25 per cent fair, and
45 per cent good; in 16 per cent the home conditions were not given.
In the course o f the survey many interesting cases were discovered,
and the nurses were able to correct some very erroneous ideas and
to have valuable contacts with mothers at a time when they were
most needed. One history obtained was that of a baby given away
by the mother to a middle-aged couple with no idea as to infant care.
The baby, which was in the 3 to 6 month period, was being given
bananas to control “ chin drop.” The baby was kept clean, and the
adopted mother was apparently grateful for suggestions from the
nurse. Another case was that of a baby 1 to 3 months old, breast
fed. The baby was fussy, and the mother, who was on a deficient
diet, nursed him constantly. After talking with the nurse she prom
ised to put the baby on schedule feeding and to improve her own diet.
A premature baby, weighing 2 pounds, was unable to nurse because
o f weakness. The mother was taught breast expression and given
a demonstration of feeding the baby with a medicine dropper; she
was also instructed as to the general care o f premature babies. The
parents were living in an isolated district where medical advice was
not available, and they were most grateful for help.
We had a number of cases o f babies who were premature or too
weak to nurse at all, or too weak to empty the breast. In these cases
manual expression was demonstrated, and in this way thé mother was
able to give the baby breast milk.
O f course, not all cases were responsive. Many mothers were selfsufficient and did not wish any suggestions. Especially was this true
o f the mothers o f a number o f illegitimate children, most o f whom
were neglected and in poor condition, and not breast fed. The gen
eral response was very good, however, and mothers appeared eager
for definite information as to the effect o f their own diet on their
ability to nurse their babies and seemed to appreciate the advantages
o f breast feeding when these were pointed out. The nurse stayed
long enough in a county so that it was generally known why she was
there, and she did not stop with one call on each mother but returned,
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
in some cases many times, to be sure her recommendations were being
carried out.
Particularly encouraging has been the cooperation o f physicians.
In some cases certain physicians were, if not antagonistic, at least
indifferent at first. A physician in a northern county laughed at the
idea o f a breast-feeding survey, but before the nurse left the county
he was referring his newborn babies to her and urging her to see the
mothers at once, and in some cases where breast feeding could not be
carried out he instructed the nurse to demonstrate to the mother how
to prepare artificial feeding.
Encouraged by the results o f this survey, the Michigan Department
o f Health plans to do more work o f this type in an effort to educate
the mothers o f the State as to the far-reaching effects o f breast feed
ing on the present and future health of the baby.
I might add that we were able to check up very nicely on our birth
registration with the mothers. The young mothers were asked
whether or not they had received a certificate o f birth registration. I f
they had not received it within about six weeks or two months, that
meant either that the birth had not been reported at all or that it had
not been reported properly, and the mothers were instructed to write
to the health department inquiring whether or not the birth had been
reported,, or to take it up with the attending physician. We found
that this improved our birth registration in those counties.
The C hairm an . Doctor Boynton, director o f the Minnesota division
o f child hygiene, will tell us o f the pioneer work in Minnesota.
D IS C U S S IO N
Doctor B oynton . The breast-feeding demonstration in Minne
apolis in 1919 and 1920 was conceived, planned, and supervised by
the late Dr. J. P. Sedgwick, then head o f the department o f pediatrics
o f the University o f Minnesota Medical School. In a paper presented
in 1912 at the third annual meeting of the American Association for
the Study and Prevention o f Infant Mortality he had stated that
“ Maternal feeding should be the keystone o f the propaganda for the
prevention o f infant mortality,” and had presented the results o f an
investigation made by questionnaires sent to the physicians o f Min
nesota and to all physicians registered for the section on diseases of
children at the American Medical Association meeting. His purpose
was to ascertain how many o f their own children had been breast
fed, and how long. He found that 82 per cent o f the children o f the
first group mentioned and 78 per cent o f those o f the second had been
nursed more than three months, and he concluded that the percentage
o f wives o f American physicians nursing their children three months
or longer was greater than that o f wives of laymen. Doctor Sedgwick
pointed out further that the fundamental requirement for the stimu
lation and the continuation o f the milk flow is the complete and
regularly repeated evacuation o f the breasts. Though the idea and
technique o f manual expression were comparatively new at that time,
this method of evacuation of the breasts was soon advocated.
Several years before the Minneapolis demonstration it had been
shown at the clinic for newborn at the University o f Minnesota that
the amount o f breast milk could be increased through regular nursing
and breast expression. Doctor Sedgwick cites cases in which regular
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BREAST-FEEDING SURVEY IN MICHIGAN
95
stimulation o f the breasts by the baby and manual expression rees
tablished lactation for mothers who had ceased nursing their babies
for a period o f four to even nine weeks.
The first step in the breast-feeding demonstration was the formation
o f a so-called “ breast-feeding investigation bureau,” in the department
o f pediatrics o f the university. I may summarize the description of its
organization and methods presented by Doctor Sedgwick at the 1912
meeting o f the American Public Health Association:
Every physician in the city was written to and invited to visit the
university, where the purpose of the bureau was carefully explained.
Representatives were sent to lay details o f the problem before physi
cians with whom communication at the bureau was not possible. It
was emphasized that no physician in private practice would be em
ployed in this work, and the special desire expressed by any physician
was recorded in a card-index file. Some physicians preferred to carry
out the bureau’s directions through their own offices instead o f having
their patients seen by representatives o f the bureau. A fter several
months a representative called on all the physicians to ask whether
the bureau was embarrassing them in any way and to request sug
gestions for preventing any such embarrassment. The municipal
health department and the Infant Welfare Society cooperated, and
the press gave hearty support. The expense for the year’s study
(about $7,000) was met by the graduate school of the university,
the war chest, and individuals. The method o f work was as follow s:
1. The health department reported daily the names and addresses
o f newborn infants and the names of the attending physicians or mid
wives. These were recorded immediately on cards.
2. A social worker called on each mother (usually within three
weeks after the birth) to obtain a brief history o f the baby and the
other children, including the duration o f breast feeding and the
reason for discontinuance if it occurred before the ninth month.
I f difficulty in nursing the baby was reported the bureau at once
communicated with the attending physician; if he gave permission
a nurse visited the patient and an attempt was made to correct the
difficulty.
3. When the baby was 6 weeks old and nine times thereafter at
monthly intervals a card bearing the following questions was mailed
to the mother:
I s you r baby s till breast fe d ?
H o w often do you feed h im ?
D oes he receive the breast only?
A r e you having difficulty nursing th e baby? I f so, w h a t?
I f he is n ot breast fed, when and w h y did you stop ?
H o w long w a s the baby breast fe d ?
4. The visiting nurse made a second call on the mother when the
baby was 2 months old, as it was at this time that mothers were most
discouraged and inclined to wean their babies. After they appreci
ated the desirability o f continuing the breast feeding it was seldom
necessary to do more than urge that regular demands upon the breast
be continued and to stress the necessity of complete emptying at each
nursing. The failure to use the mammary gland regularly and com
pletely is unquestionably the most common and most potent cause for
its failure to function.
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
O f the babies born in the first five months o f 1919, 72 per cent were
on the breast at the end o f the ninth month, 80 per cent at the end
o f the seventh month, 86 per cent at the end o f the fifth month, 93
per cent at the end of the third month, and 96 per cent at the end of
the second month. The infant mortality rate in the city, which had
never been lower than 72, fell to 65 in 1919; and the figures for 1920
were still more encouraging.
After the demonstration was concluded the Infant Welfare Society
was able to continue the work to the extent o f sending a nurse to visit
every baby born in the city until January 1, 1925. The percentage
o f babies breast fed two to nine months or more among the 807
studied in 1919, the 867 studied in 1920, and the 859 visited by the
society in 1924, as compiled by the society’s executive secretary, are
shown in the accompanying table. The table also gives figures for
1926, furnished by the Infant Welfare Society, applying to 865
babies.
This demonstration has shown that education o f the mothers will
increase the proportion o f breast-fed babies and that such education
can be accomplished in a large community.
T
able
3 . — Percentage
of breast-fed babies among groups of babies in Minne
apolis, Minn., by duration of the breast-feeding period
Percentage of babies breast fed in—
Duration of breast feeding
1919
2 m o n th s..........................................................................................
4 months.............................................................................................
6 months_________ ______________________________ ________ —
8 months...................................................... ..................................—
9 months or more.......................................................................
1924
1920
98
91
86
80
78
98
93
89
84
81
1926
97
86
78
69
63
91
82
75
68
64
The C h a i r m a n . In my judgment there is absolutely nothing more
important than educating the people and the physicians, the mothers,
everyone concerned, as to the importance of breast feeding. That is
my belief, and I hope you will go away with that feeling also. We
hope the little breast-feeding folder, on which Doctor Anderson has
worked very hard and which Doctor Richardson has approved, will
prove useful to you.
Miss Agnes K. Hanna, director o f the social-service division o f the
Children’s Bureau, will present the next topic, teaching child care to
groups o f girls and women. It is not the usual method of teaching
child care that she is going to present. I think you will be very glad
to hear her report also on a field trip that she made last summer to
some o f the States in New England and in the Middle West to
observe your work, when she was detailed to the maternity and
infant-hygiene division of the Children’s Bureau.
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ANALYSES OF CHILD-CARE TEACHING IN MOTHERS’
CLASSES AND LITTLE MOTHERS’ CLASSES
B y A gnes K. H a n n a , D irector, S ocial-S ervice D ivision , C h il
dren’ s
B ureau , U nited S tates D epartment
of
L abor
There is general agreement among public-health workers that
teaching is one o f the major activities o f every public-health agency.
Important as is research in health matters to the development o f an
adequate health service, it is o f almost equal importance that the
findings o f research be presented to the layman in the most effective
way.
Although this teaching function of public-health agents is granted,
we are not agreed as to how the actual teaching should be done.
There are many o f you who feel that aside from a certain amount
o f general information presented in lectures or in the literature you
produce, most o f the teaching o f the physician and nurse should be
individual teaching, consisting of instruction given to the mother
when she is with either the physician or the nurse. On .the other
hand, many o f you feel that in addition to this individual contact
you really need group contacts. By teaching groups of mothers it
is possible to reach a larger number o f persons and also to bring
about a realization o f common problems and common interests in the
group which should lead to greater community activity.
As several o f the State departments have undertaken some type
o f group teaching for mothers and for girls o f school age, the Chil
dren’s Bureau sent me last spring to make a preliminary study of
the types o f instruction in child care that was being given in mothers’
classes and little mothers’ classes, and also to study the agencies
giving such instruction. In each State visited contacts were made
with State agencies that might be providing such work—the bureau
o f child hygiene, vocational-education board, and extension service
of the college o f agriculture. In the cities as many private and
public agencies as could be found were also visited. It was evident
in every State that interest in teaching child care to girls and women
was increasing and that many different agencies were attempting such
work. These agencies might be classified into three groups: Schools,
agencies interested in forming club groups for women, and health
agencies.
It seems to me that the responsibility o f State departments o f
child hygiene toward the development o f child-care teaching is
tw ofold: First, to provide the study materials and expert advice to
school officials or to leaders of groups studying child care either in
the schools or in women’s clubs; second, to provide actual instruc
tion to groups o f women who may be interested in coming together
for this purpose.
Schools.
Teaching child care to girls o f school age was originally an extra
school activity. It was taught by public-health nurses either m
97
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
settlements or in the school after school hours, its purpose being to
give help to the little girls who were actually caring for their
younger brothers and sisters. The first piece of work of this type
was initiated about 20 years ago by Dr. S. Josephine Baker, who
called these classes little mothers’ leagues. There has been a marked
change, however, in the point of view toward this type of work.
Health agencies are no longer thinking o f little mothers’ classes as
a means o f giving better care to younger brothers and sisters. This
is being accomplished more effectively by contacts with the mothers
o f these children. It is the education of the girl herself, a potential
mother, with which they are concerned.
The schools also are realizing that child-care topics provide a new
approach to the study of personal hygiene or of home problems. As
a result of such thinking there is a steadily growing tendency for
the schools to include child-care topics as part of the regular
curriculum.
There are two different types of courses in child care that may be
found in the schools. The junior courses are a direct outgrowth of
the little mothers’ league work and cover usually 10 to 20 lessons
concerned primarily with the physical care of the infant and the pre
school child. This course is given either to girls of the seventh,
eighth, and ninth grades or in a continuation school. The senior
courses are offered to the more mature students in the eleventh and
twelfth grades. Such courses include the study of child psychology
and child management as well as the physical care o f children and
may include a study o f reproduction and care of the expectantmother.
In the localities visited in this preliminary survey there was much
variation in the extent to which the schools were providing child
care courses and in the persons teaching these' courses. In some
cities courses in child care have been given in a few schools as the
result of the interest and initiative of individual teachers, whereas
in others the study of child care is a required topic. Junior courses
were being taught by grade teachers, by home-economics teachers, or
by nurses. Senior courses were invariably taught by home-economics
teachers. Most of the State departments visited knew o f individual
pieces of work that had been done by teachers, nurses, or home dem
onstration agents under their supervision or direction, but only one
State (Wisconsin) had attempted a complete state-wide plan for in
corporating child care as a recognized part o f the school curriculum.
The teaching o f child care to girls o f school age should be a school
activity. One of the important activities o f State departments o f
child hygiene should be to interest school authorities in child-care
teaching and to help in the development o f adequate teaching by pro
viding authoritative teaching material and training classes for teach
ers in the normal schools and in service. In each o f the States visited
the department had given some work in the normal schools, and in
most States study materials had been prepared or were being pre
pared. In several States, however, the State nurses, not the teachers,
were actually teaching the children. The use o f the State nurse as
a teacher in the school is o f value only as a demonstration.
An analysis o f the outlines for junior courses in child care (little
mothers’ classes) prepared by several State departments shows that
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there is much difference o f opinion among the writers o f such courses
as to the topics to be included, the emphasis given to different topics,
and the sequence in which they have been presented. Some States
have outlined short courses concerned primarily with the care o f the
baby; others have planned courses that combine lessons on personal
and community hygiene with lessons on child care. Minnesota, for
example, has 6 lessons on personal hygiene as part o f a, 20-le’sson
course, whereas in the 18-lesson course prepared by Wisconsin no
such general hygiene lessons are given. In the Minnesota course
these lessons are placed in the beginning, whereas in New York the
single lesson on personal hygiene is given almost at the end o f the
course. Since the study o f child care may be considered as an inte
gral part o f either the general health education o f a- school or the
home-economics course, the person writing the study material for
school use should consider such correlations with great care.
Self-directed study groups.
Self-directed study groups consist o f groups o f women who have
undertaken to study some aspect o f child care under the leadership o f
some one chosen from among their number. Such study groups have
three needs: Well-planned study material, an effective leader, and
some interested agency that will give expert advice and direction to
their work and help in the procuring o f adequate and authoritative
study material. There are several national agencies interested in the
development o f child-care study clubs.1 Cooperation with all these
agencies is most desirable. Members o f the staff o f the State childhygiene department can easily find out what groups in the community
are being reached by these agencies and should interest the women
that they meet in organizing lor study.
A large number of the child-study groups that have been formed
have given their attention primarily to the study of child behavior
and management rather than to the problems o f the physical develop
ment o f children and child hygiene. I f interesting study outlines
and study material on these topics are prepared by health agencies,
more attention will be paid in club groups to the health aspects o f
child care.
Classes and lectures for mothers.
The two types o f group work that we have been considering are
those in which the interest of the State child-hygiene department is
largely that o f a cooperating agency. Classes and lectures for
mothers, however, are quite generally considered as direct activities
o f the State staff.
The terms lectures and classes are used interchangeably by many
persons. Actually these two methods o f instruction represent quite
different types of work, serving different purposes. The purpose of
class work is to improve the practices o f a mother as well as to give
information. Some activity should be required from the mother, and
the topics studied should be related to her particular need or to the
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needs o f the whole class. Furthermore, class work necessitates lesson
material to guide the mother’s thinking and to provide/ projects on
which she can work. The purpose o f a lecture, on the contrary, is
primarily to create interest. It also is a means o f giving informa
tion, but it is the desire to do something or to know something that
is the real objective toward which the lecturer should work.
I f you will think back over your own experience as an auditor at
lectures given by various persons, you will doubtless realize that in
many cases you were a passive listener more or less interested, possi
bly more or less bored. Other lecturers, usually those talking about
something on which you have been working, have started you to
thinking and adjusting your ideas. A still smaller number may have
aroused you to do something—change your own behavior or do some
piece o f constructive work. The real .measure o f the value o f a
lecture is not the number of listeners, but the extent to which the
listeners have been inspired to do something.
Lectures on health topics should have as their purpose either to
arouse a desire to get accurate health information or to arouse a
desire to get adequate health facilities. This should be firmly borne
in mind when planning a lecture program for a given community.
Decide what the community needs and direct your lectures to that
end. A desire for permanent centers, itinerant clinics, or a com
munity nurse is not aroused by a general health talk, nor is a desire
to study child care created necessarily by a purely informational
lecture.
In a class as contrasted with a lecture it is the contributions of the
members of the class rather than those o f the teacher that are impor
tant. The real problem of the teacher is to help the members o f the
class to think clearly about the problems under discussion and to
adjust their ideas to the new idea that she wishes to present. This
means that every member o f the class must talk about her ideas.
How can this be done? How can you make class work an active
exchange o f ideas in which every mother participates but where no
one gives a long-drawn-out story of her experiences ? The answer to
these questions lies partly at least in the use of the proper type of
lesson materials. I f a group of people are given a practical piece
o f work to try out, especially if each person experiments at home,
there is usually no difficulty in getting a definite expression o f opin
ion from everyone as to the difficulties, values, or desirability o f the
project which was undertaken.
The most satisfactory method o f starting class work in a group of
women who have come together to study child-care problems is to
give out at the first meeting a questionnaire to be checked. This
questionnaire should provide space for entering some information
about the child or children that the mothers wish to study, such as:
His name, age, when last physical examination was given. It should
also have a list o f possible problems with which the mothers might
be concerned. The mothers should be asked to check the ones which
they would like to study. This procedure will give the teacher real
information as to the mother’s needs and interests and should serve as
the basis for the selection o f topics. The problems of a mother with *
her first baby are quite different from those of a'mother with both
preschool and older children. It is always desirable, therefore, to
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make some plan for meeting in separate groups or subgroups the
mothers having similar problems. It is possible to hold the interest
of mothers in class meetings, even though their problems are differ
ent, i f the lesson materials that are distributed are adapted to the
individual needs.
Lesson materials.
These, then, are the essential characteristics o f lesson materials for
class work: (1) Lesson materials must outline something for each
person to do. Several suggestions should be made, such as to observe
a child’s actions or habits, to study his posture or color, to select from
a list the best method o f procedure in a given selection. (2) They
should be planned for small units o f instruction. It is better to
study one or two things intensively than to be satisfied with halfformed general ideas. (3) They should contain exact, definite in
formation about the problems to be studied. This information
should be planned to answer the many questions that may arise in
the mothers thinking and give her simple yet accurate explanation
o f the reasons for carrying out a definite procedure in the care o f the
child. (4) They should be so simply expressed that they can be
used at home by the mother without much explanation. I f study
materials on a topic are given out at the meeting that precedes the
discussion the members o f the class will have time to try out the
ideas that they contain and be ready to express their opinions at the
next meeting.
Lesson materials that fulfill these several conditions should be
prepared on every topic that concerns the care o f children. The
Children’s Bureau is planning to complete a series o f 40 or 50 lessons
on some of the most important topics—physical condition, child
hygiene, prenatal care, and child management. This should be only
a beginning in the preparation o f materials of this type, however, as
the lesson materials to be used in a class for mothers should be
adapted to the particular needs o f the individual mothers and these
will vary with the ages o f the children and the customs o f the groups.
Problems must be real to a mother to make her try to understand the
reason for changing her own practices. And it is the mother who sees
the reasons for things that will be intelligent in the care o f her
children.
Lesson materials may be used in several ways by the physician or
nurse meeting groups o f women—in regular class work, as supple
mentary to lectures, and for distribution to mothers who are attending
weekly child-health conferences. Many health agencies feel that they
do not have a staff that is equipped to undertake regular class work
for mothers, the lecture being the only teaching method in which they
have had experience. As a transition toward class teaching it might
be desirable to arrange a lecture series that would cover a number of
topics included in available lesson materials and distribute these
materials to the audience. This would provide something definite
and tangible for the mothers to take home with them and would
probably start many to really working on their problems. The dis
tribution o f lesson material at health centers is probably the best
method o f using those materials for the doctors or nurse whose activi
ties in the centers and in home visits make it impossible to under
take regular classes. Many o f the advantages o f group work may
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be obtained even under these conditions if the same lesson materials
are given out to all the mothers attending the conference. This would
provide a common topic o f conversation among neighbors, and the
questions o f the mothers could be answered by the nurse or the physi
cian when she again attended the centers. This method is most
valuable when the mothers attend with some regularity.
Recommendations for the furthering of group teaching in child
care:
1. Group teaching is an important aspect o f a State
maternity and infancy program, and a definite policy in
regard to such work should be developed in each State.
Effective group teaching can not be carried out in a
sporadic way. It must be made a definite part of the
permanent program of communities.
2. The appointment of an educational specialist to
prepare materials and to develop group organization
should be o f great assistance in furthering such a plan.
3. The most effective method o f developing training
in child care for girls of school age is through state
wide cooperation with the State department o f edu
cation.
4. Lectures, classes, and self-directed study clubs rep
resent three stages o f group education for mothers.
Each o f these types o f work serves a particular func
tion—lectures stimulate a desire for study, classes teach
the method o f studying child-care topics, and clubs pro
vide more extended opportunities for mothers who are
able to carry out, a more comprehensive plan.
5. The development o f group instruction for mothers
in any community can be given greater impetus by co
operation with all other agencies that are working for
the establishment of study groups.
D IS C U S S IO N
The C h a i r m a n . Miss Miriam Birdseye, of the Bureau o f Home
Economics of the Department o f Agriculture, will discuss this paper.
We are very glad to have Miss Birdseye with us because so many o f
you are having help from the home-economics group, and i f we can
get more help in this educational work and relieve some o f these
county nurses we want to know about it.
Miss B i r d s e y e . I think I ought to say that I come not only from
the Bureau of Home Economics o f the Department o f Agriculture
but also from the extension service of the department. With such
a group as this it is not necessary to explain very much about the ex
tension work, because I am sure every one of you has had contact
with the State or county extension people. I know, too, that our
people feel that the divisions o f child hygiene and the county nurses
are among their best friends and closest cooperators and that the
work that is very near to our hearts is in many cases exactly the
kind o f work that you are doing. I see, for example, that you use
the food standards from which a good deal of our nutrition work
starts.
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Almost from the beginning the extension service has been working
with organized groups of women, of home makers; we have had what
Miss Hanna has called “ self-directed study clubs.” We call them
home demonstration clubs. Where we do not have permanent clubs
we have “ project groups,” which come together for meetings on one
particular line o f work, such as food selection or special feeding for
preschool children or child management. This is usually a series of
four to six meetings, winding up, if possible, with a meeting at
which the people can show their friends what they have done—what
in many States they are calling a “ county achievement day.” The
people work long enough to see results, and then partly by exhibits,
partly by interesting stunts, they not only reinforce their own enthu
siasm but interest friends and other onlookers.
I have just come back from a field trip during which I attended
such a meeting in the central part of Minnesota. Though there was
snow on the ground and more falling, about 300 people had come to
this county achievement day, the climax o f five meetings. Twentytwo communities had been carrying on the work, and 20 o f them had
made posters or other exhibits, which were on the armory walls.
Some o f these posters and some others are out here in the hall with
the label o f the University o f Minnesota above them. These posters
embody the ideas that had been given to these women; you will notice
that they include something about breast feeding and something about
sunshine. Each community had been asked to have two demonstra
tion babies, for whom they had kept a record o f weight and o f im
provement in diet and hygiene, and they brought these records with
them to this final meeting. So we find that it is possible to get women
to work for several months and to make a report that will influence
other people. We measure the success of our teaching very definitely:
First, by the practices that people adopt and continue to use; second,
by the number o f people that they reach with this information; and,
third, by the actual demonstrations that they make to the community,
such as the^children who may be particularly watched in connection
with the work o f the classes.
The extension service is working with the feeding o f the family,
and you can not talk about feeding the family without thinking about
the children and about the mother, especially if there is going to be
another child. W e are doing very little work in the actual physical
care o f the child, except the fundamental things like sunshine and
regular sleep and plenty o f rest and good sensible hours and the
schedule that the State recommends. But there is much that a nurse
might do in the groups already formed; she might carry on for two
or three meetings beyond a series already scheduled or she might
like to have a composite series, part o f it handled by the home demon
stration agent or the nutrition specialist, and part by herself. It
seems to me that this is one phase o f the help we need, and it is,
perhaps, help that you would like to give.
In our girls’ clubs little work is being done with the care of chil
dren, except for the food and the sunshine; but our girls are organ
ized, many o f them, to take up the preparation and selection o f foods.
It is very natural in this connection to discuss how the meals that the
girls are planning may be adapted for the younger children. So these
girls are doing a good deal to influence the proper feeding o f the
younger members o f the family.
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One thing the extension people can do which many organizations
can not is to give attention to the actual food supply on the farm.
It may be all right to say, “ The child should have spinach and this
and that and the other thing ” ; but if this food is not on the farm, the
farm child is not going to get it. The extension service is empha
sizing the necessity for a proper food supply on the farm with refer
ence to a definite food-selection standard, which calls for milk, vege
tables, whole-grain foods, a moderate amount of protein, plenty o f
liquid, and raw fruits or vegetables daily.
We have found it hard to interest a group of people in the feeding
o f children as a special problem. They think the children are getting
along well enough, so what is the use of fussing? W e have been
thinking and saying and acting that if we could hold up to the aver
age parent the picture o f a child just as fine as a child could possibly
be— properly built, with no signs o f rickets and with every sign of a
body mechanism in good working order, with good nutrition and good
circulation, with freedom from all preventable defects— so that parents
would always have this picture in their minds as they looked at their
own children, they would be much more ready to listen to suggestions
on child care and child feeding. So we are trying for the thing which
Miss Hanna was speaking about, to discuss with them the points to
work for in children. And here we need the intelligent help of physi
cians who have the point o f view not simply o f mending but of build
ing intelligently for the best that is possible. W e often need help at
a State or county meeting to demonstrate some perfect child for a
group o f leading women who are going back into their own communi
ties. I had an invitation this week, which I could not accept, to be
at the University o f Missouri during farmer’s week and to demon
strate before a group of representative women the best children to be
found in the city, showing the points that indicate good growth, a
body in good running order, and good posture.
We are trying to teach our boys and girls in the clubs to be their
own exhibits. We are trying not only to teach them good food habits
and good health habits along accepted lines but to show them that
many qualities of the finest human being are just the same as those
of animals that are being prepared for exhibit.
Many of you know that we are promoting health contests. There
is much to be said for and against health contests, and the way they
are being carried on now is not so good as the way I hope they will be
carried on shortly. I have just come back from the National T-H
Health Contest in Chicago, where 22 States sent their “ health cham
pions,” the ones who made the best showing in the State health con
tests. I have seen the tremendous amount o f work that those children
were interested to do to put themselves in shape for this contest,
working for better posture, working with their feet, improving their
habits, improving their color, having their teeth put in perfect condi
tion, and doing all kinds of other things to improve themselves.
Some boys and girls 17 and 18 years o f age had been working at it
for a couple o f years, and they are having a good deal o f influence
on the boys and girls back home. From these children who enter the
contests we want to select the specimens that we have been speaking
about.
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See this lovely picture o f the two girls, one from Iowa and one
from Mississippi, who tied this year at 98.4 per cent [exhibiting pho
tograph]. W e do not like the idea o f percentages, but that is the
way it seems necessary to handle the contests. Both the girls had
been working for this contest for two years. This girl from Missis
sippi is from a county which for three years has sent out the highestscoring girl. In the four years of these contests Iowa and Mississippi
have tied once and in the three others they have divided the honors.
It is interesting that 98 per cent o f the club members in the county
from which this Mississippi girl comes are having a physical exami
nation this year, and all the school children had a physical examina
tion as a result o f the interest that the girls’ 4-H clubs had created.
And the county medical association is helping. The people want the
children in their county to win, and by and by they are going to want
every child in the county and the children that are coming along in
the next generation to be as fine as the best.
What we need to help in this work is somebody that we can call on
from the State department o f health to give a demonstration o f one
o f these perfect children at the State fair or the county fair or some
big meeting. Many of our extension specialists in nutrition are pre
pared to give it, but many o f them are not. I f we call on some
physician from the department of health to show the people the
points that these fine specimens exemplify, I think it would have a
splendid influence not only on the women but on the men. This is
just one o f the many avenues o f cooperation which I have been glad
to speak about to-day.
(Meeting adjourned.)
TH U R S D A Y , JA N U A R Y 13—MORNING SESSION
S. JOSEPHINE BAKER, M. D., PRESIDING
The C h a i r m a n . I am going to claim the privilege, now that I have
the floor, o f speaking just for one minute before I read my paper,
about the papers yesterday— Miss Hanna’s in relation to teaching
girls and mothers and Doctor Richardson’s on breast feeding.
I wish to call attention to the part o f Miss Hanna’s paper about the
teaching o f young girls. The little mothers’ leagues were started
originally simply because it was clearly evident that-in our cities at
least the young girls were the greatest causes o f infant mortality,
though quite unwittingly. I f they were one o f the great causes of
infant mortality— showing they did not know how to take care of
their little brothers and sisters—it seemed wise to make them one of
the aids in reducing infant mortality. In the very beginning we
went to the public schools and asked them to put in these courses.
They all refused. In New Y ork they are still refusing. And
while I do not feel that the little mothers’ leagues are in any sense to
be taken as better than the courses in the schools, they are, for the
present moment at least, the only thing that we can do in some parts
o f the country. Some o f the large cities have introduced courses in
child care in the seventh or eighth grade, as Miss Hanna says; but
by and large through the country this is a movement that comes along
slowly. I should be glad to see the time when the little mothers’
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leagues go out of existence because the training in child care has been
made part o f our regular school curriculum; but at present we have
in the little mothers’ leagues one o f the greatest weapons at our com
mand in the reduction o f the baby death rate, because, after all, what
we are doing is laying a basis for a sound motherhood as well as for
the immediate results. And if the basis o f all o f our efforts is educa
tion, as I believe it is, the time to start education is the time when the
child or young person takes it as part o f her ordinary training.
Therefore I do hope that these classes for the teaching o f girls
will go on.
Just to throw a little side light on the question o f breast feeding
I might say that when we started our child-health centers in New
York City, as far as I can recollect we did not have at the centers
a single breast-fed baby. When I left New York three years ago,
65 per cent o f the mothers that came to the child-health centers
were nursing their babies and came simply for instruction. W ith
out question that has played a very large part in the reduction of
the baby death rate in New York City.
Another point which Doctor Richardson took up and which I
should like to speak about from experience is the use o f simple milk
dilutions when artificial feeding is necessary. I have a very strong
feeling indeed that most o f us do not get the results that we are
aimihg for because of the complexity of our organization; and i f my
experience is worth anything at all I should like to hand it over
to you and say that we have succeeded always in proportion as we
have simplified our methods. The more simple our milk feedings
are the more effective are our results; simply a dilution o f milk in
water, depending upon the age o f the child— one-third, one-half,
or two-thirds with the necessary milk sugar or malt sugar added—has
proved absolutely proper and now I believe is indorsed by most of
the pediatricians. It is a long way from the old percentage feeding
o f my college days and Doctor Roach’s idea, when we lay awake
nights considering how to work out the percentages for every in
dividual baby— it is a long way from that to the method o f simply
adding water to the milk and giving it to the baby, but it seems to
work as well or, if anything, better.
The particular topic this morning which I am going to present
to you is one that I am perfectly aware is as dry as dust, and I
think that nothing could be a more thankless task than to read a
paper on cost-accounting systems or on statistics. But I may say that
although the paper has a statistical basis I am going to spare you
the statistics just as far as I can and try to see whether we will
bring out a discussion o f your individual problems in regard to costs.
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A POSSIBLE COST-ACCOUNTING SYSTEM ON SEPARATE
ITEMS OF WORK CARRIED ON UNDER THE MATERNITY
AND INFANCY ACT
B
y
S. J osephine B aker,
M . D . , C onsultant , C hildren ’ s B ureau ,
U nited S tates D epartment of L abor
A t the third annual conference o f directors in charge of the admin
istration o f the maternity and infancy act in the States, held in
Washington in January, 1926, a resolution was adopted requesting the
Chief o f the Children’s Bureau to appoint a committee to take under
consideration the determination o f a proper cost-accounting system
for separate items o f work. In order to obtain the necessary data,
a letter and a questionnaire were sent to the director of each State
division o f child hygiene cooperating with the Children’s Bureau
under the provisions of the act. Forty of the States have answered
these letters and filled out the questionnaire. One reply was received
too late for tabulation. The three States not replying were appar
ently unable to furnish the information asked for, because o f the
short time that they have been administering the provisions o f the
act.
Before considering the information given in these letters and in
the questionnaires, I wish to express to the State directors my sin
cere appreciation o f the time and effort that they have given in
answering these questions. The predominant impression I have
received in reading the answers to my inquiry has been one o f work
carried on under great difficulty o f administration, with limited
appropriations, and in the face o f obstacles that at times have seemed
almost unsurmountable.
Almost without exception the problem faced in the States is a
rural one involving the question of transportation over great dis
tances. One State (New Mexico) reported the necessity of one of
its nurses making a trip of 220 miles each way in order to conduct a
baby-welfare conference, while the director o f the division o f child
hygiene of New York State gives us her opinion that “ good roads
and good snow removal could well be a part of the child-hygiene
program.” But another impression that comes from reading these
reports is that each State has certain problems that. differ from
those existing in other States. Thus the Southwestern States call
attention to the difficulties encountered owing to the migratory char
acter o f their population, with the need o f adjustment o f methods
to meet the particular problem presented by a population mostly
Mexican in origin. The Northeastern States practically all mention
their large alien population, involving the administrative considera
tion of the race habits and customs o f many nationalities. Through
out the Southeast the problem of the ignorant and untrained midwife
is a predominant one, and the high maternal and infant death rates
66982°— 27------ 8
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among the negro population claim earnest and serious consideration.
On the other hand, the States of the great Northwest, with their vast
territory and their comparatively small population, have little or no
concern with the midwife, who seemingly is not employed to any
extent. But these States have to meet the problem of long distances
to be covered and the proper expenditure o f an appropriation which
is based on population and not on the extent of territory to be served.
Though different sections o f the country show, in this way, what
may be called a group problem, we still find that each State is con
fronting certain difficulties of administration, which from the point
of view o f that State seem individual. Before considering these
differences, however, it is o f interest to mention the similarities that
exist. Nearly all the States feel the pressing need of larger appro
priations, if effective work is to be carried on, and practically all
report that it is impossible to cover more than a small part o f the
field and to meet more than a minor part of the need with the money
now available for this purpose. There is evidence that the State
directors are keenly alive to the need for more extensive and wide
spread work in bettering the conditions o f mothers, babies, and
young children, and they are attempting to reach as large a part of
the population needing this attention as may be possible.
One o f the questions asked in the inquiry related to the State
director’s impression o f the most important part o f the activities o f
that particular State. The answers can be grouped roughly as
follows: Nine States report that general health education of the
public is the most insistent need. Eight States mention the necessity
o f extending their work in prenatal instruction and care, and three
States report the supervision o f midwives as their most important
problem. In the remaining 19 States the most urgent needs were
as follow s: Extension o f work for the prevention o f infant mortality,
3 States; preschool work, 1 State; lectures on obstetrics before
medical societies and in medical colleges, 3 States; little mothers’
leagues, or their equivalent, as courses o f instruction to girls in ele
mentary and high schools, 5 States; the extension o f cooperative
work in the counties on a 50-50 basis o f appropriations between the
State and the county, 7 States. It should be understood that these
were given as the most pressing needs for immediate attention and
that many o f the State directors did not confine themselves to one
item. The more individual problems presented by the States can
.not receive detailed consideration at this time, but it is interesting
to note that in practically every instance the type o f work that each
State feels is o f the first importance is reflected in the proportion o f
the appropriation spent for this particular purpose.
In this connection I wish to mention the human, as opposed to
the merely statistical, impression given by these reports from the
States. We are all agreed, I am sure, that no effort can be main
tained under Government or other auspices that is so essentially
human as well as humane as this work for the conservation o f the
health and life of the mothers, babies, and children of this country.
To speak of life-saving in terms o f money, therefore, may well be an
anachronism; but for the purpose of effective work, I know we are
equally agreed that intelligent economy in money expenditure is
essential. In all probability it will never be possible to determine
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in terms o f dollars and cents either the value of a human life or
the cost o f saving it. It is this human element that makes our task
at once so difficult and so inspiring. I f inspiration was the only
quality needed to make our efforts wholly effective, I am confident
that our problems would vanish overnight. But from the point of
view o f our administrative programs, it is not only necessary but
also enormously helpful for us to take account o f one another’s
problems and to profit by one another’s experiences. Our purpose,
therefore, is to determine as far as we may, from the practical
experience of each State, the most economical and effective way o f
spending money in order to achieve our purpose o f improving the
health, and consequently reducing the death rate o f mothers and
young children.
Running throughout the reports from the States, one can find
evidences o f expenditures which seem to fall into two well-defined
classes: First, the use o f appropriations for the purpose of intensive
work directed toward the immediate saving o f lives, and, second, the
expenditure o f funds in such a manner that, though life-saving may
not be the immediate result, it will become more definitely assured
m the future. These two methods seem so well defined that it may
be well to discuss them a little more in detail. .
By the expenditure o f money for immediate life-saving we mean
the more intensive type o f work which concerns itself with instruc
tion and care o f the individual mother and her baby. With limited
appropriations efforts o f this type are necessarily restricted in scope.
The licensing and supervision o f midwives, detailed prenatal care
and instruction, the establishment o f baby-health centers with regular
and continued supervision o f the babies and education o f mothers in
methods o f baby care, the physical examination and continued health
supervision of children o f preschool age, the establishment o f either
permanent or itinerant clinics for correction o f physical defects, and
similar types o f intensive and direct work may be classified under
this heading. Efforts o f this kind must necessarily be confined to a
limited number o f mothers and babies. While our methods for this
type o f work are well established and almost standardized, the unit
costs vary to a great extent. We may assume that unit costs for this
work may be as definitely standardized as our methods have been;
but the factors o f population density9 areas to bo covered^ the number o f mothers and babies who can be reached within any given
limit o f time, and the complicated elements o f ignorance or social and'
racial maladjustment provide a background which is so complex that
it has not yet been possible for us to speak o f standardized unit costs
for this type o f work with any degree of assurance or finality.
The second method, which has been considered preferable by a
number of the States, is that o f general public-health education. Its
purpose is to provide for' the widespread dissemination of the meth
ods to be followed for the proper hygiene o f maternity and infancy.
Its aim is to reach not only all the mothers and babies o f the State
who would otherwise be without this instruction and resulting care
but also to build up a body o f well-informed public opinion which
will cooperate in furthering the reduction o f the maternal and in
fant death rates and give assurance o f better health for all mothers
babies, and young children. Methods o f this type include widespread
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publicity, the use of articles in newspapers regarding the health o f
mothers and babies, dissemination o f literature outlining the detailed
methods o f maternal and infant hygiene, the introduction into the
elementary schools, high schools, and colleges o f courses on personal
hygiene and the hygiene o f infancy, cooperative efforts o f medical
societies and medical schools in order to obtain better obstetrical
teaching and practice, and cooperative work with the medical pro
fession. We may also include lectures given before organizations or
clubs o f both men and women, child-health days or weeks and the
use of farm bureaus, agricultural units, home-economics groups, and
parent-teacher associations. W ork of this type, based on the idea of
universal public-health education, may not, and usually does not,
result in any immediate reduction o f the maternal or infant death
rates. On the other hand, it is definitely cumulative, and, when tried
over a sufficiently long period of time, has been found to be more
lasting in its effect upon health betterment and reduction o f death
rates than the possibly more costly, yet more immediate, intensive
work. In this connection, it .seems fair to state that while the direct
health education o f mothers and direct care o f babies is more imme
diately effective within the group under supervision, the appropria
tion for each State is .now so limited that this intensive work rarely
makes a marked impression upon these death rates in the State as a
whole. It is interesting to note how many of the States feel that
public-health education on a wider scale is, after' all, the more effi
cient and more lasting way o f achieving our purpose.
Still another method, which in a sense combines the types o f work
we have been discussing, seems' to be increasingly used as a way
o f achieving both purposes and often results in an immediate reduc
tion o f the maternal and infant death rates as well as in general
public-health education. This method is the stimulation o f the coun
ties in each State to carry on their own work under a county pro
gram, the appropriations being supplied under a 50-50 appropriation
by the State and the county. In nearly every instance where this
method o f work has been tried, it has been found possible to com
bine the best features o f intensive work with the health education
o f the community.
An interesting side light on this method o f county work is shown
by the reports o f practically every State where it is carried on. This
is the better understanding among the members o f the medical pro
fession and the increasingly interested cooperation o f the doctors
in these communities. In going over the reports from these States,
as well as those from many others, one can hot fail to be impressed
by the constantly repeated statement that the individual doctors who
are close to the work and who have an opportunity to observe it are
almost without exception interested and fully cooperative. In one
State, by request o f the medical school, the State division o f child
hygiene provides a course in pediatrics for the students and also gives
a graduate course in the same subject for physicians. In the second
State, by request, lectures on obstetrics have been given before medi
cal societies. In the third State physicians o f high standing are ac
cepting positions on the staff of the State division o f child hygiene
in the capacity of consulting obstetricians and pediatricians, and the
county medical societies are definitely cooperating with the State de
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partment of health in the county work. In a considerable number
of other States, less extensive but nevertheless effective instances of
this type o f cooperation are cited. A ll the reports give a definite
impression that as individual doctors learn to know the purpose o f
this form o f public-health work they are not only willing but often
eager to assume a share in it.
It is hardly within the province of this report to deal more spe
cifically with the individual problems presented by each State. It
would seem far better that such a presentation should be made at this.
conference by the directors themselves. Our purpose at the moment
is rather to determine, if we may, the most economical way of ob
taining the results we are seeking. We may mention, therefore, that
certain States have found it possible to effect economies in adminis
tration by a readjustment o f their methods. For instance, some
States have found that if infant and preschool care are carried
on as a unit, and not under separate divisions or as separate entities,
not only is the cost o f such work lessened, but the far more im
portant result of improving health throughout infancy and preschool
life is achieved more readily. This is because there is no break in
the program and because the chield is under continuous observation
from birth until the school age. Other States have found it more
economical to deal, at first, exclusively with children o f preschool
age. It has seemed, in such instances, that these children were more
readily reached and that this afforded an easy approach toward
gaining the confidence and interest of the mothers. From this be
ginning they have found it better to work backward to the matter of
infant care and then to prenatal care. Still other States seem to have
achieved their greatest economy and efficiency by concentrating on
prenatal and better obstetrical instruction. They report that by the
preparation and the distribution of obstetrical packages and by the
reference o f expectant mothers to physicians for prenatal care, they
have obtained cooperation from physicians to such an extent that the
establishment o f infant-welfare centers and the health supervision
o f children o f preschool age has been an easy second step. There
are, again, States which have found it expedient as well as economical
to concentrate upon the establishment of either little mothers’ leagues
or similar courses o f instruction in the elementary and high schools.
The secondary education o f mothers, as well as the training for po
tential motherhood, resulting from this type of instruction has been
reflected in the willingness o f the mothers to seek further informa
tion with regard to their own health and the health of their children.
It would be possible to cite other instances of similar import;
but the cumulative effect would only be to heighten our impression of
the exceeding difficulty o f evolving any standardized methods that
would be found equally effective in all, or even many, o f the States.
Possibly we are overambitious in even attempting to standardize
our procedure or our relative unit costs. It is only fair to remember
that child-hygiene work is still the newest part of our public-health
program. The first bureau of child hygiene under governmental con
trol was established in 1908 in New York City. There were only five
similar State bureaus up to 1914. Thirty-eight States began their
work o f this kind in 1922, two States in 1928, one State in 1924, and
two States in 1925. It may well be that a much longer time will have
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to elapse before we can, with any assurance of rightness, determine
the methods that may be followed with the greatest economy of time,
effort, and money expenditure.
As a beginning toward this end, however, it would seem that some
way o f determining the unit cost o f various items o f work might be
evolved. It would be difficult to set a hard and fast standard appli
cable to all the States. There can be no question that a unit cost
which might be considered proper in a closely populated community
would bear little or no relation to a proper cost for a rural territory.
Moreover, it is well known that proportionate overhead costs decrease
as the extent o f the actual work carried on increases. I f a nurse
must travel 100 miles to hold a baby clinic with, perhaps, a dozen
babies in attendance, the total expenditure of time and money will be
considerably greater, and the per capita rate higher, than if the clinic
is held within a 5-minute walk from her home and the attendance of
babies is from 100 to 150. And the same reasoning holds good in each
line o f work carried on by the State. The problems connected with
density o f population, area to be served, and the racial types o f the
people, all must be considered.
It is evident that each State must have a cost-accounting system
suited to its particular needs and conditions. As a basis for this it
is advisable to make from time to time intensive studies of each item
o f work. It should not be difficult to prorate the proportion o f over
head costs, the expense o f travel, the amount spent for salaries, and
the other costs o f such intensive work units. A comparison o f this
expenditure with the number o f people reached and served or the
items o f work performed will give a fairly accurate unit cost. Such
analyses need not be costly nor time consuming, and the results will
serve as a basis for economical administration. Comparison o f these
unit costs o f work may be made with those o f other States having
similar administrative problems, and such comparisons should point
the way to more effective efforts with a lessened expenditure o f funds.
Unit costs can be too low as well as too high. The test is not the
amount o f money expended but the results that have come about
because o f this expenditure. The understanding o f the value o f rela
tive unit costs in determining the proper type o f administrative pro
gram will inevitably lead to a sounder economic basis for our work
and to increased returns as shown by lowered maternal and infant
death rates and higher standards o f health for mothers and babies.
May I add that it is our hope that each State at definite periods o f
each year, January 1 and July 1, for instance, will make an intensive
study o f its work, apportioning its overhead, salaries, traveling ex
penses, incidentals, and cost o f supplies among the types o f work
carried on, then taking the number o f people actually reached, divid
ing the percentage cost among the population cared for, and deter
mining the unit cost o f caring for each person. (See suggested costtabulation sheet, p. 113.) Having obtained this information, each
State, it is hoped, will get into communication with the States that
are near to it and that have similar problems, and find out their unit
costs. It is only by such comparisons that you will know whether
you are spending your money to the best advantage.
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U. S.
D
epartm ent of
C h il d r e n ’s B
L
H 3
abor
ureau
WASHINGTON
Cost-tabulation sheet
Proportionate amount spent
on each item in—
Type of work
Salaries
Travel Overhead
Total
cost
Num ber
of persons
leached
Unit cost Unit cost
of each
of
specific
person
activity
reached
Combined prenatal and child-health
conferences________________________
Health conferences for children.........
Health conferences for prenatal cases
Health conferences conducted by
nurses only, no physician present.
Little mothers’ classes___ ....................
Mothers’ classes......................................
M idwives’ classes___________________
Dental conferences__________________
H om e visits:
(o) Prenatal......................................
(ft) Obstetrical_________ ________
(c) Postnatal____________________
(d) Infant____________ __________
(«) Preschool____________________
Nutrition w o r k ...__________________
Inspections of—
(o) Infant homes.............................
(6) Maternity homes___________
Talks and lectures___________________
Prenatal letters______________________
Correspondence courses_____________
Graduate courses for physicians____
Graduate courses for nurses_________
Preparation of exhibit material_____
Conducting of exhibits______ _______
Com m unity demonstrations...............
Campaigns_______________ :__________
Surveys______________________________
Preparation and distribution of
literature__________________________
Administrative work________________
Supervisory work___________________
Other activities______________________
D IS C U S S IO N
The C hairm an . Doctor Krause, director o f the division o f child
hygiene of Missouri, will open the discussion for us.
Doctor K rause. I think none o f us know how much time Doctor
Baker has had to put on the subject of determining unit costs. I
know that she was working on it even up to yesterday afternoon at
4 o’clock, because at that time I had the first opportunity o f going
over the paper with her. The paper was indeed enlightening to me
and to the rest o f us here. I am surprised that Doctor Baker can
make a paper on so dry a subject so pleasant to listen to.
In our program we have to acknowledge that each State is going to
spend its money in direct ratio to its public-health problems regard
less o f the department in which the public-health fund is expended.
In some States that are not in the birth-registration area, for ex
ample, we have had to include under infant work our birth-registra
tion program, our prevention of blindness campaign, and other
things. Many factors will make the unit cost o f work vary in the
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several States, as Doctor Baker said. I simply wish to add this:
In Missouri and in other Middle Western and Western States our
method o f travel is an item. In Missouri, for instance, to go north
and south costs approximately three times as much as to go east
and west to a clinic. In other words, we have to go to one o f the two
metropolises to get north or south. Our clinics in those areas are
small. It costs us much more to reach 10 or 12 children a day in
southern Missouri than 40 or 50 children a day in eastern Missouri or
western Missouri. In showing the cost of work for a State many sub
divisions must be made under the several main headings of maternity
and infancy work—birth-registration campaign, work for prevention
of blindness, etc.— activities that do not figure at all in some of the
Eastern States.
One thing that complicates this type of unit-cost accounting is the
very nature of some of the work that is carried on. In intensive
work such a cost-accounting system is very easy; it is a matter o f sim
ple bookkeeping. I f your work, however, is o f the type tending
toward general education o f the public, with the dissemination of
literature, with large mothers’ classes, the sending out o f prenatal and
postnatal letters, and dealing with woman’s clubs and other organi
zations, it is very difficult to get unit-cost figures. There I think
you must group your activities. You must see how much it costs, for
instance, to send out prenatal letters, to give a talk before a women’s
club, to hold a child-welfare conference, or to speak before a group
for the purpose o f teaching. In other words, your unit cost must
have an entirely different basis from the number of people reached,
and that has been one o f the complications of this report.
I have no doubt it is possible for the Children’s Bureau to work out
a simple form on one sheet which could serve as a basis for computing
the costs.
The cost o f personnel varies. In our State, for example, I hire
assistants at $10 a day—pediatricians or obstetricians to give gradu
ate courses to medical societies. Lecture courses in other States
cost $40 or $50 or $60 a day. A ll o f that enters, o f course, into our
unit o f cost, and we readily see why there is so much variation in the
expenditures.
The itinerant type of clinic which is carried on as a means o f edu
cation costs much more in proportion than the other types of work.
In our own State we can work much more cheaply in the 13 counties
in which we run a full-time maternity and infancy program than
we can in the remainder o f the State, in which we are dealing with
more or less the itinerant type of work or clinic.
I think the nurses should not be burdened too much, nor the doc
tors, nor any of our workers with the cost-accounting system. But
we all acknowledge that we must have a cost-accounting system,
because in dealing with National, State, and county governments
we must show definite, concrete costs to our public.
The whole program, as I see it, resolves itself into .this: Regardless
o f the type o f work that we are doing, whether in one State it is
mainly infancy work or in another State is mainly maternity work,
we are really dealing in salesmanship; we are trying to seli public
health, the idea o f preventability o f disease, and when we get our
total cost I think we might bring it down to a very sensible oper
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ating cost by taking the whole result and dividing it into the total
expenditure. W e would get a single unit o f cost in this way and
not try to subdivide it— at least for the purpose o f education.
Since all States differ and every State may have some suggestion
o make on this, I am not going to burden you any longer with
my own ideas. I just want to say again that I thank Doctor Baker
personally for the paper.
Miss A bbott. I should like to say a word just at this time. I
want to testify in the first place to the fact that the bureau under
took this because there was a request for it at the last conference
and because I was eager to show, in following it up, what the com
plications and difficulties are.
The Children’s Bureau spends a considerable sum o f money on its
cost-accounting system. The bureau employees are required to keep
track of their time, turning in every day what they do; that is, so
many hours’ in checking the State budgets as they come in (to dis
cover possible sources o f error), so many hours in correspondence,
so many hours on reports, field work, etc. After we have the facts
from which we could get the cost accounting, then what would be
useful to know and what would not is the next question. I used
to have put on my desk every month a cost accounting of all the
items o f the bureau’s program when I first came to the bureau, but
the cost of doing this was so great that we abandoned it because after
a few months it gave very little information that was o f value.
But we still have the information so that it can be made up at any
time; and if you were to ask me just what it costs to edit a report
or to get up a schedule in any one o f the different phases of the
^bureau’s work, we have the information if we choose to spend the
money and the time o f the clerical staff to determine it.
Now ours is enormously simpler than the State program; the States
have a promotion program, whereas our is mainly some form of re
search work. Ours, on the other hand, is more difficult than a
program such as Doctor Baker had in New York City, where most
o f the work was permanent-center work with a program that went
on day in and day out in each center. You need to know exactly
where your money is going and what it is going into—the amount that
is going into prenatal letters versus the amount that is going into
lectures by doctors; the amount that is going into mothers’ confer
ences versus the amount that is going into these other things. We
are sometimes asked, “ Are these mothers’ clubs paying us what they
are costing us, or are these other things paying what they are costing
us, or are they not?” W e should not be able to evaluate accurately
many of these services, but we ought to know what each costs as a
basis for judgment as to what we will do next. The results, as
Doctor Baker says, can be summarized on a single sheet, but assem
bling the information on which that summary is based is a costly
undertaking. I am willing to try anything that we are asked to try,
but I do not feel optimistic about working out a scheme which it
will be possible for all the States to adopt.
Doctor G ardiner. Y ou may think information was very scarce Iasi
year when I wrote that very inadequate paper for the third annual
conference o f directors, but what happened then was that we were
having a reorganization o f all departments in our State. About that
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time we had had our attention called to the cost o f prenatal work,
the per capita cost at that time seeming very high. The work hap
pens to be widely scattered. There is a large amount o f traveling.
We can not tell the penetration quality of education, nor can we
evaluate it in dollars and cents. But I do think we ought to know
how much we should be spending for prenatal work versus infancy
work at this stage o f the program, and I think the States that are
somewhat alike ought to hold their expenditures within certain
bounds. For instance, if 20 per cent is the average proportion that
you spend for prenatal work, let us look over our budget and see if
we can get somewhere near 20 per cent.
The same thing might apply to administration. When we come
before legislators, they are apt to say, “ How much of this is going
into salaries ? How much is it costing to administer this fund ? ”
Our salaries are mostly for field work. We are spending only about
10 or 12 per cent on actual administration; the rest goes into special
ized service in the field or actual financial assistance. I should like
to know what other States are spending for actual administration,
and I think it should not be very difficult to make some general
classification and find out what we are spending on the principal
types o f work from year to year.
The C h a i r m a n . I have not compiled the total overhead. That is
perfectly easy to do from the figures we have, but it did not seem
necessary for the purpose o f this study.
Doctor G a r d in e r . The director might be an administrator and also
spend time in the field. Doctor Schweitzer used to spend a great
deal o f her time in the field in Indiana, and yet she administered, too.
How are you going to divide that?
The C h a i r m a n . I should like to hear from some of the other
directors on the subject brought out by Doctor Gardiner, as to
whether it is at all possible to standardize in different States the
amount o f time or money that should be spent on any particular
object. My feeling from reading questionnaires is that this is not
possible; that one State, for instance, necessarily must spend a large
part o f its appropriation on midwife supervision, we will say, while
other States have no midwife problem at all, and to set an arbitrary
figure to be spent for midwife supervision would not be quite fair.
I think it is not possible to set an arbitrary proportion which must
be spent on infant care, or preschool care, or prenatal care. But I
should like to get your reaction on this question.
Doctor K n o x . I think we have all been very much helped by your
paper, especially because it has suggested the advantages and the
difficulties o f a cost-accounting system and it has not been at all
insistent about making us have a uniform method o f expenditure.
I agree thoroughly with Doctor Gardiner that we have to proceed
very carefully. In fact, I think most o f us look upon our work as
having a good deal o f spiritual value, i f you please. You do not go
to the churches here and estimate the value o f the pastor by whether
he visits two or three parishioners in one afternoon, or 10 the next
afternoon, or how he spends his time. As long as he is the right
kind o f man doing the right kind o f work he can be trusted. I
think, however, we ought to know in a general way what we are
spending on prenatal care, on obstetrical work, on work for infants,
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and for the preschool child; but these proportions will not be uniform
in the different counties. I think this report, together with Doctor
Ferrell’s yesterday, gives us all a good deal o f information which we
ought to have. The actual results in the work accomplished are
perhaps one way o f checking our efficiency and the time that we
spend on different pieces of work. But I do not believe that at this
time, with our methods all more or less sub judice, we can fairly
compare one State with another, because conditions are so very
dissimilar.
I am sending men from Baltimore into rural Maryland to hold
conferences where perhaps five years from now they will be held by
the counties themselves because o f the educational propaganda that
we are carrying on. Are we planning for a next year’s program?
Or are we planning for a 10-year program? Whether we are plan
ning for the immediate future or the long distant future depends a
good deal upon how well regulated our costs are each year.
The C h a i r m a n . Doctor Knox’s very able presentation of this
question calls attention to two points that I think we should em
phasize. I tried to speak o f one o f them in my paper, and he has
spoken o f the other. One o f them is, of course, that it is absolutely
impossible for us to determine in dollars and cents the value of
human life. We can not do it and we should not do it. I know
everyone o f you feels, as I do, that this is the most human as well
as the most humane work that can be carried on. But we do have
to account for our expenditures and it is well also for the purpose
o f self-analysis to work under some sort o f “ cost accounting ” or call
it “ a more detailed budget system,” if you choose. I think if we
find, taking the midwife again as a unit o f comparison, that it is cost
ing one State $10 each to supervise and register midwives, and that
another State that has an equally serious midwife problem is regis
tering and supervising midwives for $4 each, then the $10 State
ought to get in touch with the $4 State and say, “ What method do
you use ? How do you get efficient service for that price ? ”
Doctor K n o x . Or vice versa. “ W hy are you spending so much?
Are you getting better results than we are getting ? ”
The C h a i r m a n . Any cost-accounting system that could be devised
should be a very personal and intimate part o f your w ork; it should
primarily tell you how you can stop leaks or spend your money to.
better advantage.
Doctor G a r d in e r . The travel expense involved in carrying four or
five consultant nurses was quite large, and finding out how much it
cost did enable us to reduce expenses. The expense accounts were
running very high, and we found that by putting the nurses in cer
tain districts and having them work out o f local centers we could
reduce the cost o f that service by at least a third. Knowing your
costs has a value through making possible comparisons o f work
from year to year, if nothing else.
Doctor B r e e d in g . I certainly should be glad to cooperate in follow
ing out any reports that we are asked to get up, but I sincerely hope
that they will be made as simple as possible, as has been indicated by
the speaker.
The C h a i r m a n . I am sorry we shall have to close this discussion
now. The program has been changed, and we have two other papers.
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I f there is any time left at the end of the second paper we can revert
to this subject.
Doctor H a i n e s . I move that we accept this committee report with
a great deal of pleasure, and also that we should like to have the
chairman continue the committee and help us with further work.
[The motion was seconded, put, and carried.]
The C h a i r m a n . The next paper on the program is “ Itinerant con
ferences as an advance agent in developing permanent centers,” by
Dr. Cora Allen, o f Wisconsin.
Doctor A l l e n . Wisconsin has worked out two things on a perma
nent basis: The permanent centers and the infant-hygiene classes that
have been incorporated in our school system through the cooperation
of the State superintendent of schools. Mrs. Hasbrouck, who spoke
to you last year, is our full-time organizer, and she has taken as her
slogan, “ Every Wisconsin girl educated for intelligent motherhood.”
Her work has grown until this year she has a full-time assistant.
She has been able to go into any number o f rural schools, teacher
training schools, and normal schools.
We are getting out a new textbook, a manual, and a teacher’s
handbook that is on the press now. As soon as it comes off we are
going to send it to each o f the directors and supervising nurses, and to
anybody else who wants it. It is free for our school system. We have
been able to sell it outside the State for 5 cents, the manual for 5
cents, and the handbook for 3 cents. I am not advertising the prices
particularly. We are only too glad to send the books out as samples.
We are also proud to say that 38 States and Hawaii are using our
books in some form o f school work, in domestic-science work, or
infant hygiene centers.
I wish you would all look at our spot map o f the number o f schools
where this work is being taught. W e like to get our girls between
12 and 14 years of age, because they may leave school at the age o f
14 and because Mrs. Hasbrouck feels that at this time it is the per
fectly natural thing for the girls to be playing with dolls and it is
only a step to the normal baby.
The course can be presented to the boys as well as to the girls; it
has been done in some o f the schools. When our certificates have been
sent out for the little mothers the reading has been changed to include
the “ little fathers,” and the teachers write in that the boys are very
well pleased with this work.
My permanent hobby is permanent centers, and although Doctor
Haines gave me the subject o f itinerant conferences I am going to
dwell mostly on the permanent work, because we feel that that is
where we are ¿miner to show our results later on.
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ITINERANT CONFERENCES AS AN ADVANCE AGENT IN
DEVELOPING PERMANENT CENTERS
B y C ora S. A llen , M. D., D irector, B ureau of C hild W elfare and
P ublic-H ealth N ursing, S tate B oard of H ealth , W isconsin
Throughout Wisconsin’s public-health program the greatest need
seems to have been in rural communities, and even before the Sheppard-Towner Act was effective our child-welfare special— a motor
ized health center similar to the one sent out in 1919 by the Federal
bureau— was in the field carrying the gospel of preventive medicine
to parents in rural and more or less isolated regions.
With the acceptance of Federal funds the special continued a wellplanned five-year campaign, going into small villages or country
cross roads for one or two day stops so as to serve as many as possible
in each county visited. The examinations were made in the car,
which was fitted with tables, scales, running cold and hot water, and
its own heating and lighting devices. Small dressing rooms at each
end furnished protection and privacy during undressing, examina
tion, and dressing. The history o f each person to be examined was
taken in the adjoining schoolhouse or even the country store. From
one to three weeks was spent in each county. By this preliminary
contact it was hoped to arouse enough interest so that regular con
ferences might be established where expectant mothers and children
under 6 years o f age could be given thorough physical examination
and advice along hygienic and dietary lines. It has always been the
policy o f the State Board o f Health o f Wisconsin never to attempt
to correct defects, change formulas, or in any wTay encroach on the
family practitioner’s domain. From the first the work was under
stood to be entirely educational and was accepted as such.
The truck, staffed by a woman pediatrist, a trained public-health
nurse, and a mechanician, has now finished its term o f service with
24,000 examinations to its credit. Every county but one was served,
and many requests have been made for a return visit. The response
in the northern, or most rural part o f the State, was particularly
keen, and follow-up calls by nurses show advice has been taken in
many cases, and approximately 50 per cent of remediable defects have
been corrected.
Directly following the first week’s work o f the special, 16 coun
ties were chosen for the establishment o f regular monthly con
ferences as demonstration clinics. The intention was to stay in a
community one year or until the importance and worth o f the work
was demonstrated, then to move on to another point in the county,
leaving the regular conference in the hands of a local physician to be
carried on permanently. In a few places this plan was accepted, and
the regular centers held every week, two weeks, or monthly, as the
case may be, are well attended and bring satisfaction to mothers,
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doctors, and workers. But physicians in rural territories who have
the time to attend conferences regularly—to advise mothers with nor
mal children how to keep them well— are not always easy to find.
So after almost three years o f following the original plan we tried a
new way o f establishing permanent centers. Almost everywhere our
county nurses were convinced it had been a well worth while piece o f
work and were willing to carry on these permanent centers without
a maternity and infancy nurse. In every place the mothers objected
to having the centers moved just as they had become accustomed to
depending on the regular information and words of encouragement,
and always the workers watched with keen interest the babies’ growth
and gain from month to month. It did seem that the year’s work
was almost worthless if no one could be found to carry on. Women’s
clubs, Red Cross chapters, Kiwanis, Lions, Legion auxiliaries—any
number o f organizations—began to besiege us with requests to allow
them to pay for a State physician and let the centers continue.
The demands have been amazing. Communities in which no
public-spirited enterprise has had a hearing before have voted money
for their own health centers, and those held now only poorly repre
sent the number we might be having had we sufficient personnel.
One year ago we had but one permanent center, in a little country
town, paying with Red Cross funds for a physician sent by the
State at the request of the two local practitioners. Now 15 com
munities are holding “ paid, permanent centers,” with examinations
made by State doctors, and 9 more organized as itinerant centers
are being carried on regularly with examinations made by local
physicians, while 41 other centers are held in various parts of the
State where the only active part the State takes is in furnishing
literature.
Traveling expenses and hotel bills are borne by the State. The
permanent center is included in the regular itinerary of the State
physician---a plan that reduces traveling expenses to the minimum.
A ll other expenses, such as record cards, laundry, heat, light, and
comfortable rooms, are borne by some local organization. Members
o f women’s clubs act as hostesses and history takers. There are
uniform cards for histories and for the mother to take home which
can be purchased from a local printing firm, and the doctor to whom
a case is referred is given or sent a copy of the examination.
Literature on many subjects is furnished free. Government
bulletins, pamphlets on teeth, goiter, tonsils, etc., published by the
Wisconsin State Board of Health, and health literature obtained from
two prominent insurance companies are gladly accepted, and not only
save much o f the doctor’s time in the giving of advice but serve
the mothers as references. During the summer months the “ Sunlight
for Babies ” pamphlet was followed so religiously that an outsider
might have gained the impression that the coming generation was
reverting to sun worship.
It is early yet to expect results, but, during 1926, 1,425 infants,
616 preschool children, and 83 prenatal cases were seen in centers
held for an aggregate of 70 days, and 1,229 were regular return cases.
The average attendance for children was 294-, and the average of
return cases 17.54-. This does not take into consideration the addi
tional 50 weekly or bimonthly centers held by local men throughout
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the State. No reports of these are sent us, but we know they are
considered of sufficient value to be continued.
Although our babies are supposedly normal, we often find unsus
pected troubles, and our records show cretins referred for gland ther
apy ; babies with enlarged thymus, sent for X -ray diagnosis; .babies
with incipient diabetes and tuberculosis, congenital dislocations, and
bad heart conditions; and, of course, numerous cases of uncared-for
genitals and diet disturbances. The discovery of these troubles and
their correction by the family physician make the mothers and
fathers loyal supporters of a “ baby center,” and entitle the publichealth workers to a feeling of satisfaction in their share of lowering
our too high infant mortality rate.
In some centers young mothers, who as girls in school have had
instruction in the infant-hygiene classes, are regular, faithful attend
ants, and in such mothers one sees hopes o f a better and healthier
nation.
Very often a mother who has had the prenatal letters brings a 2
weeks to 4 weeks old baby to be admired and watched as he grows into
a “ Wisconsin better baby,” and more than one o f these babies o f
young mothers have been kept on breast feeding by timely advice and
the follow-up visits o f the nurse. One of our problems seems to be
the uprooting o f the idea that “ the mother’s milk is not agreeing
with the child.” W e don’t always win out, but we do have to our
credit a goodly number of babies returned to the breast who had been
weaned for a period o f two to seven weeks.
The big factor in the success o f the permanent center is the
trained public-health nurse, who with the vision o f one o f our
school nurses who conducts a monthly conference, says, “ I am firmly
convinced that the best piece o f school work a nurse can do is thor
ough prenatal and preschool work.” She reports fewer remediable
defects and fewer underweight children in this year’s kindergarten
class than ever before. A ll her children are examined, and 76 are
immunized for diphtheria.
One county nurse has succeeded in getting local physicians to give
their time for a series o f conferences during the summer. She re
ports 536 children from 4 to 6 years o f age in the rural districts. O f
these 396 (74 per cent) received a thorough examination. Sixty have
been vaccinated. Thirty have been immunized for diphtheria, and
the immunization program had just been begun. Her rural teachers
do the weighing and measuring and have a daily check-up on “ health
chores,” and in 6 rural schools 100 per cent of the children have the
teeth cared for. Another county nurse, besides holding a regular
monthly conference with large attendance, has “ health clubs ” in
70 per cent o f her rural schools, with a membership o f 2,108 children,
who are all urged to have at least one physical examination each year.
Reports for 1925 show that nurses, other than maternity and in
fancy nurses, throughout the State are interested in the prenatal and
infant phase o f their work as well as all other classes o f nursing that
fall to their lot. They made 18,242 home visits to babies and pre
school children, and 3,717 to expectant mothers. They transmit re
quests for prenatal letters to the State bureau. Many of these nurses
are responsible for their own baby centers. (These figures do not
include Milwaukee, a city of 500,000 inhabitants.)
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In one o f the most rural counties in the northern part of the State,
where it seems impossible to hold regular permanent centers because
o f climatic and financial conditions as well as the sparsely settled
population and great distances for travel to a central point, the State
holds yearly conferences lasting from one to two weeks, moving the
doctor and center from place to place and thus offering a service
similar to that given by the child-welfare special. Seventy per cent
o f the preschool and school children in this county are immunized,
and 75 per cent are having goiter-prevention treatment, while the
home conditions are greatly improved as a result of this partial
permanent plan.
The consensus o f opinion seems to be that one o f the most effective
ways o f reaching an entire family is through a permanent center
where homely truths can be told and retold, and results o f right
methods seen in the steady, normal growth and gain o f the children
who attend regularly.
Regular courses in public-health work are being given in many of
our State medical colleges, and better prenatal care and healthier
babies are almost bound to result. Bearing these young men and
women in mind always, we are hoping that our permanent centers
may be carried on under State physicians until trained public-health
physicians will relieve them and make the centers permanent in the
fullest sense o f the word.
D IS C U S S IO N
The C h a i r m a n . Mrs. Helen Moore, assistant director o f the
Michigan bureau o f child hygiene and public-health nursing, will
open the discussion o f Doctor Allen’s interesting paper. I hope that
during this discussion something will be said about the relative value
o f the permanent and the itinerant clinic.
Mrs. M oo re . In Michigan our work is conducted somewhat differ
ently from that in Wisconsin, as conditions are different to a certain
extent. Our itinerant clinic goes into a county and stays one, twp,
or in some instances three weeks only. I f the nurse making the
preliminary arrangements for the clinic finds that the physicians
are not friendly, the itinerant clinic simply does not go in. Very
frequently the next year when our clinic is in that vicinity the
physicians have had a change o f heart, and we can go in and do
our work with their help.
As in Wisconsin, a report is always sent to the physician; and if
there is a county nurse in the county a report is left with her in
order that she may do the follow-up work. Our object from the
beginning has been to make the work permanent. We have always
insisted that there be a committee o f lay people to assist at the clinic.
Sometimes the nurses doubted whether they assisted or not; but we
made them think they were helping anyway, because we wanted to
get across that educational part of the work to the lay people.
Outside Detroit and Grand Rapids we have 70 permanent centers.
Some o f them were not organized through our efforts, because in
many o f our towns there are health officers and a well-organized
staff who have done all the work themselves; but 21 of the 70 were
a direct result o f our itinerant clinics. These 21 are in small towns,
drawing from the rural communities. They are financed entirely
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by local funds. Often the physicians would offer their services free,
but we have discouraged that in every single instance, because we
have felt that the women who are sponsoring the clinic will appreci
ate it more if they have to work and pay for it.
These clinics hav reached many people; and, as Doctor Allen has
said, the babies are brought back week after week and month after
month. One mother said when the day came for the clinic it made
no difference whether she had a bridge club or what not, she had to
go to the clinic.
W e feel that the itinerant clinic has been a great factor in building
up our permanent centers in the smaller places. It has given these
women something practical to do and a vision o f what adequate
supervision for a baby means.
The C h a i r m a n . I think we should have some further discussion on
this important point. I know this question comes up for you all at
frequent intervals, and I think some o f the other States should report
upon their progress with either the permanent or the itinerant childwelfare clinics and upon their relative importance and value.
Doctor K n o x . I should like to ask both these speakers whether
there was any attempt to confine these services to indigent mothers
or whether the leading women in the communities attended these con
ferences. In Maryland we consider that the future success o f our
work is to be judged not by the number o f people that are coming to
the conferences but by the number o f the mothers who are calling in
their own attending physicians.
In Baltimore city, o f course, we have had for many years very
well-organized weekly dispensaries, and in some o f the larger towns
in Maryland—we have not many cities outside Baltimore—they are
establishing weekly conferences o f the same kind in the poorer dis
tricts where the mothers can not afford to have doctors of their own.
But the rural problem is different. It makes no difference how poor
a rural mother is ; I have never asked one yet who her doctor was that
she didn’t name one. But you ask the people who go to Johns H op
kins dispensary or the various free dispensaries who their doctors are
and they will say, “ We haven’t any doctor.” But the country people
have them, although they do not call them in as they should. What
we are trying to do, therefore, is: (1) To educate our lay public into
the importance o f going to their own physicians week by week or
month by month, and ( 2 ) giving obstetrical and pediatric lectures
to the doctors and seeing that they are willing to give advice and to
devote a larger portion o f their time to this preventive work.
Doctor A l l e n . In reply to Doctor Knox’s question, whether the
casesjhandled in the centers are indigent, I may say that they are not,
and we are very proud o f that fact. W e are very glad that our
mothers who could afford the services o f a specialist come to our
State health center for several different reasons. In the first place,
their influence is good. Another thing is that if anything is wrong
we do not correct i t ; we send those mothers to their doctors, and the
doctors therefore know that the State does not interfere with their
practice in any way. I f the mothers can not get from their local
physicians the kind o f help they are demanding now, I think they are
entitled to have it from an organization that is being maintained by
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their own taxes. Wherever we have a local practitioner who is will
ing to do that work we let him do it and are very glad to have him
do it. W e think it is very important for Wisconsin babies to grow
up right, and we think that they need supervision to do it. In this
way we are educating a whole lot o f people on this point. We have
had more than one local physician object when we first commenced to
hold permanent centers because women’s clubs demanded it, but they
have come our way now. They not only visit us but they are willing
to correct defects that we find and send to them. They are immuniz
ing, they are vaccinating, they are hearing more about preventive
medicine. W e think we have gone a long way when they are per
fectly willing for the State to hold a conference and for the women’s
organizations to pay for it or when local physicians ask us to organ
ize a State center and make no objection if the babies under their care
come to it. Many who at one time objected are sending for our
prenatal letters and other literature.
Doctor G a r d i n e r . It seems to me there are three things we have
to do. First, we have to show the woman what to expect in the way
o f a preventive program, then we have to convince the physician
that the woman should have this service, and then again we have to
go back to the woman and teach her that she must pay for the service.
So we go through these three phases, and they are! not all the same
in the various States.
Doctor Knox is near Johns Hopkins, where they give preventive
work and the people are ready to pay for it. In New York State I
know we are convincing the physicians that there is a great deal o f
preventive work to be done, and they are showing an inclination to
do it—to take it up as a county medical society project and do it on a
community-wide basis; and it seems to me the rest will follow in
natural course. That really should be their business after all—to
deliver the kind of service that the people demand and are willing to
pay for.
The C h a i r m a n . That is an important point, I think.
Doctor S t a d t m t j l l e r . Where we get the reaction on the part o f the
physicians that they would be perfectly willing to do this work but
are too busy, then if we attempt to do it we hear that we are doing
“ State medicine,” and the local physicians object. So we do not
have physicians from the State office go out to conduct a clinic on
salary paid by a local group. However, we often choose a local
physician, rather than send a pediatrician from some other part o f
the State, arid pay him a per diem fee while he is making the exami
nations. We have been able to meet the objection in this way.
Doctor A p p l e t o n . I do not know whether our health centers in
Hawaii would be called permanent or itinerant. W e drive across the
island somewhere and hold a consultation in one place one week and
another place the next week. We have been able to get cooperation
from the physicians more easily perhaps than some o f you, because
we have few physicians in the rural districts and there is a perma
nent man who is responsible for each district. W e go to this man
and ask him if he would like to have a center and ask him to take
charge of it. W e have no funds to pay him, but he usually is very
glad to do it. I f one of these district physicians does not want the
center, we ¿ 9 not go there* W e go into only the districts where we are
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wanted. A ll our territorial nurses are placed in counties; in place of
having our territorial staff in the main office we have them in the
counties. We have a consulting and supervising nurse for all centers,
and the director acts as consultant physician for them. I f the local
physician is unable to give the time the director takes charge o f the
center; he may not be able to be there every time but will be there
as often as possible, perhaps at intervals o f one or two months'.
In this way, by going only where the local physicians are willing,
we have been able to cover a large part o f the territory, and gradually
the physicians who were opposed to the work are falling into line. I
think one thing that has made this possible is that the director
refuses to take any practice. The other is that we have made our
program educational primarily and not at all curative. A t first we
were even very careful about being diagnostic and referred the cases
to the local physician, but that policy had to be changed. But as
long as the work is just educational and we are very careful to refer
each case to the family physician—who has charge o f the center with
our physician as consultant—that obviates any possible difficulty.
Doctor R ic h a r d s . I have been interested in this paper because it
helps in some o f my problems. We have just outside o f Salt Lake
City a suburb where we have organized what we might call, accord
ing to the usual classification, a permanent health center. It is one
in which weekly conferences are held, and the work there is confined
almost exclusively to infant welfare. W e follow the plan o f having
the local doctors do the work. There were six or eight doctors in that
community, and upon being interviewed they all expressed willing
ness to take their turns at holding these conferences. After we had
gone into the matter in detail with them, it was thought best that the
conferences be held weekly and that the physicians be grouped. Two
men or three were assigned to the conference for three months at a
time, and then another group for three months, and so on until they
had all taken their turns during the year. W e had the cooperation
o f the physicians and o f the local organizations, and we were able to
assist them in a directional way. During the past two years we
have been rather disappointed. The doctors were willing to give
their time, but some o f them realized that they were not especially
interested in pediatrics. Moreover, one drawback o f the rotation
method was that some o f the doctors beginning their terms did not
hesitate to change the children’s formulas, and some o f the mothers
became more or less dissatisfied because this changing seemed to them
haphazard, and some of the doctors became dissatisfied because other
doctors were changing their formulas. The condition has just de
veloped to the point that local people are more or less losing confi
dence in the rotating service o f the physicians and the physicians
themselves are not satisfied.
Now, I believe that these doctors will all be perfectly willing to
have an outside man who is doing nothing but itinerant work—that
is, who is paid for his entire time—come into that community and take
over the responsibility o f handling those conferences. That will give
the community one man who will handle the work uniformly. More
over, I think sometimes we gain a certain amount o f prestige by
having a doctor not from the community; it lends an incentive to
mothers to bring their children. Every once- in a while we get this
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from both sides: Mothers will say, “ Oh, I can take my children to
Doctor So-and-So any time I wish. I can always see him.” Then
we will have a doctor say, “ Oh, I see that child every once in a while,
and I don’t see any reason for seeing him every week.” I believe
that in certain instances the employment of an outside physician to
handle these conferences will solve some of these problems.
One o f you spoke o f the itinerant worker remaining in the com
munity for one to two or three weeks. I am wondering if I under
stood correctly, that they stay the entire time. The doctor and the
nurse probably made up the itinerant group. How did the physician
spend his time and how did the nurse spend her time during the
three weeks? Or were they just in and out on three definite days
o f the three weeks, spending the rest o f their time elsewhere ?
Doctor A l l e n . I think probably Doctor Richards means Michigan
instead o f my State, because I tried to make it plain that with the
child-welfare special we stay only one day or two days, then move
on to another point in the county. W e go into a county for two or
three weeks, but we just visit different places; and our permanent
centers are established after that. We stay in one place for, say,
a year, with demonstration work. Whenever a mother is able to pay
she is encouraged to go to her physician. I know that in Wisconsin
our mothers are willing to pay i f they can get the right kind of
service. Just as soon as our physicians are willing to take care of
our well babies and our prenatal cases we shall not need any State
workers.
Doctor S c h w e i t z e r . W e have had so many difficulties in Indiana
that it might be helpful to review some of them. W ith regard to
permanent conferences I think we have none that are actually being
supervised by the State department. We have a few that have been
the outgrowth of activities o f local departments. I have asked physi
cians and have asked other groups for suggestions concerning perma
nent conferences. The one that we particularly assisted in starting
was at Elkhart. The lay people sponsored it, chiefly the child-welfare
committee of the League o f Women Voters. It was financed first
through efforts on the part o f these women and later by the commu
nity fund. It is a permanent part o f the city’s activities at the
present time. The city started with one permanent child-health
conference in the municipal building. It now has four or five, one
o f which is for colored children. These conferences care for about
300 children, I think, on the average. A t first they tried to have
physicians on a rotating schedule, but they soon found the results
very much as Doctor Richards outlined a moment ago. Then they
tried having salaried physicians take charge o f this clinic, and that
worked very well so far as the clinic itself was concerned. The babies
were getting good service. They had a dietitian •who gave the
mothers advice concerning the preparation o f food and balanced
rations for the children o f preschool age.
A t that time there were no pediatricians in the town. The physi
cian who first had charge of the clinic found that he needed more
knowledge o f the feeding o f babies, so he took some special work in
Chicago. He went once or twice a week, I think, and visited the
baby clinics there, and he became much more proficient than he had
been at first. The women who come to the clinic are interested in
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having their babies cared for and fed properly; and naturally they
go to the physician in whom they have confidence ,as a person who
is proficient in baby feeding. So the men who are developing
pediatric practice in the town are the men who are in charge o f this
clinic.
In South Bend some o f the best men in the city have charge o f the
dispensary babies, where wonderful work is being done. The work
in the well-baby center is done only for indigent people, the physician
in charge believing that those who can afford to pay for such work
should go to physicians in private practice.
In Indianapolis the work is being done on very much the same
plan. But in the rural districts we have no permanent centers. All
the work has been done in the temporary centers and has been wel
comed by physicians as a temporary thing, which will make the
mothers understand that the babies should be supervised and should
be taken to the local physician for such supervision. Local physi
cians report that more mothers are bringing babies earlier for atten
tion and that they have fewer cases o f severe illness.
The C h a i r m a n . We shall have now a paper on “ Developing per
manent health centers,” by Dr. Mary E. Brydon, o f Virginia.
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Federal Reserve Bank of St. Louis
DEVELOPING PERMANENT HEALTH CENTERS
B
y
M
ary
E.
B
rydon
S
, M . D ., D
tate
B
ir e c t o r ,
oard of
H
B
ealth
ureau
, V
of
C
h il d
W
elfare,
ir g in ia
[Abstract]
The modern public-health movement has three objectives—cura
tive treatment, preventive measures, and constructive health educa
tion. The practicing physician, surgeon, o i specialist alone is con
cerned with the first. Health departments have initiated the second
and third but are urging that the physician take them over as a
part of his work and also that health education be made a part of
the educational system o f the State.
In the last 12 years the health center, the home o f the local health
department, has become an institution in public-health work.
Through lectures, literature, classes, conferences, posters, and demon
strations it aids in preventing disease and in spreading health educa
tion. It is recognized as a place from which everything connected
with health practice and health education may be disseminated.
In Virginia the health centers are varied both as to the types o f
organization and as to the nature o f their activities. The larger
cities, such as Richmond, have a central office which is often itself
the health department, in charge o f a medical director, supervising
the activities o f smaller branch centers and si^ations. Health surveys
are made from the central office, and every effort is made to prevent
disease and to promote health. The program o f the center usually
includes maternity and infancy work, the complete physical examina
tion o f children under school age, and the holding o f preventive
and diagnostic clinics. State laboratory auxiliaries are maintained
in some centers, aiding materially in the diagnosis o f disease. Some
centers also have a nursing staff, which, in addition to doing ma
ternity and infancy work, cooperates closely with the school authori
ties in forwarding the health o f the school children and helping
parents to have the children’s defects corrected. A n attempt is
always made to cooperate closely with all social-welfare agencies.
In 1 0 cities in Virginia there are health centers in which work o f
this character is done.
The State has 5 counties with a well-organized health center in
each, and 1 0 counties with a total o f 37 health stations. In rural
communities, where it frequently happens that only nurses’ services
are available, the health station is growing in popularity and in
usefulness. Each month the attendance at both centers and stations
has increased. It is hoped that eventually a sufficient number may
be established to make such services available to the entire popula
tion, both-urban and rural.
D IS C U S S IO N
The C h a i r m a n . N o w I want to call on Mrs. Dillon, who is in
charge o f the work in West Virginia, to open the discussion of Doctor
Brydon’s paper.
128
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D EVELO PIN G P E R M A N E N T H E A L T H
CEN TERS
129
Mrs. D i l l o n . West Virginia has 31 permanent health centers in
operation at the present time, the first one of which was established
five years ago, while the latest is only three months old. The
average attendance o f mothers ranges from 4 to 14, and the average
attendance o f children, from 4 to 25.
The term “ permanent health center,” as we are using it in this
meeting, is a relative one, varying greatly in meaning, and represents
widely varying personnel, equipment, and scope, depending on the
territory, length of period in operation, and finances available; as,
for instance, the health centers^ operating in the large cities versus
the half-year-old rural center in Paw Paw, W . Va. Therefore, from
the beginning o f this discussion, we are asking you to realize that we
in West Virginia are using the term for any center in our State
where the people support a definite place, which is open at definite,
regular periods, with a public-health nurse on duty, where persons may
secure health information and help. In all but three o f these centers a
measure o f medical service is available regularly, and in these three
provision has been made for the immediate future. Medical service
is available through volunteer service on the part of local physicians,
through physicians employed by coal companies and other industries,
(much o f our work being carried on in coal-mining territory and in
mill and manufacturing towns), and through full-time health officers
employed as directors o f city and county health departments.
The methods o f work leading up to the establishment of these
centers have varied slightly in communities and counties, but in the
main have been quite similar. The plan which is now being developed
in Cabell County is typical and will serve as an illustration. This
county began its program in September,.and the nurse has had the
advantage o f experience o f other workers upon which to rely.
Cabell County is unusually well organized through the Farm
Bureau, having 18 community organizations, in 13 o f which a
“ health committee ” was already appointed before the nurse was
employed. These formed a nucleus through which the public-health
nurse could function immediately.
Her program leading up to the establishment of permanent health
centers is outlined as follows: ( 1 ) Group teaching; ( 2 ) demonstra
tion child-health conference;* (3) development of regular,, periodic
child-health conferences. Her first step usually is to meet the
“ health committee ” o f the community. Together they discuss the
health needs of the community as already outlined at the community
country-life conference at the annual meeting, when the community
scoring was done. (The Farm Bureau encourages communities to
meet annually to “ take stock ” o f community needs. The people
score themselves on community spirit, citizenship, recreation, health,
homes, schools, churches, business, and farms. The scoring is doiie
on the basis o f 1 0 0 , and a program is outlined upon which to work
during the coming year in order to raise the community score at the
next annual meeting.)
The nurse suggests that the health committee be responsible for
getting together the adult women of the conaftnunity in a “ healthstudy group ” to discuss community health problems and plans for
meeting them and for some definite study on personal, home, and
community hygiene, prenatal and child care, and other problems.
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130
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
The women are really eager for this information, the men of the
community are interested in their having it, and little difficulty is
experienced in getting the study classes organized. Before the
course o f lessons is concluded plans are made to conduct a childhealth conference in the community, and this instructed group of
women is used in every way possible in the preparation for and
conduct o f the conference. During the course o f study the publichealth nurse has asked a physician to give one or more talks to the
group on communicable disease and other phases o f her outline so
that he is already interested in thgit group and their plans, the
women know him and want his help and advice in making the
community health program. Medical service therefore comes about
naturally and easily for the child-health conference. After the
demonstration conference is over and the report o f the findings
compiled, a community meeting is held at which this report is pre
sented and discussed and plans are made for corrections, further
health education, etc. This is the time when it is generally decided
to make provision for a permanent health center—a health center
of seemingly meager proportions and very limited usefulness in the
minds o f those who are accustomed to the large city centers with
their numerous departments in charge o f specialists. But such
highly specialized and elaborately equipped centers are neither pos
sible nor relevant at the present time in small cities, towns, and rural
communities. These small beginnings will develop as intelligent
public opinion is created, which, in our State, is rapidly crystallizing
into sentiment for full-time county health departments through
which all health activities for the territory can be administered.
Other activities which have entered into the gradual shaping o f
public sentiment in fa v o r'o f permanent health centers in various
places have been prophylaxis clinics, talks before organized com
munity groups, house-to-house canvasses, and publicity through pul
pit, press, and schools.
These centers are financed through county health-unit budgets, city
health-department budgets, combined State and county funds, county
or community health association budgets, Bed Cross chapters and
Tuberculosis League funds, and women’s clubs.
The nurses are using lay people as assistants in 29 o f the 31 centers
for the following duties: Securing suitable quarters, equipping and
preparing them for the reception o f children, motor service where
necessary, hostess service, writing up record cards and histories,
weighing and measuring, publicity, and, after the lay helpers have
been carefully selected and instructed by public-health nurses, a
limited amount o f follow-up work. The amount o f assistance ren
dered by lay people is determined largely as a rule by the nurse’s
vision and her ability to teach and use others.
In one county the women met as usual when the nurse was on
vacation, weighed their children, marked up their height-weight
records (using the Children’s Bureau weight chart), and studied a
lesson under their own leadership rather than miss the monthly meet
ing at the health center.
In another county where transportation from the county seat is
impossible for several months in the winter, the women met monthly,
weighed their children, and studied a lesson prepared and mailed to
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Federal Reserve Bank of St. Louis
DEVELOPING PERMANENT H EALTH CENTERS
131
them by the county nurse; the secretary o f the class mailed in a writ
ten report after each meeting until the nurse could get to them. I f
a problem arose, if a child failed to gain, or i f any phase o f the les
son was not understood, it was reported and discussed by corre
spondence.
Methods used to maintain attendance have been as many home
visits as possible by the public-health nurse, supplemented by a local
group o f carefully chosen and instructed lay women, and various
forms o f publicity. A few nurses on occasion have served simple
refreshments (fruit juice and crackers) for the children.
Prior to the preparation for this discussion a simple questionnaire
was sent from our office to local fields where permanent health centers
are in operation. A few excerpts from replies are illuminating on
certain points under discussion:
A health-unit director who has just taken charge o f a pioneer
county program says:
I have begun to interest mothers in certain localities in looking forward to
having health-study clubs instituted. One of the main features of these healthstudy groups in a community is to interest the women so that they will carry
a share of the responsibility, and I have found them o f material assistance in
carrying out the child-welfare program.
Another health-unit director who has only well begun his county
program wrote:
W e believe that the immunization stations of the past few months through
out the county will contribute greatly to a larger infant-welfare program as
soon as roads permit in the spring.
This health officer is making extensive plans for a “ child-health
week ” early in May and is Writing a personal letter to every baby, on
receipt of his birth report, inviting him to keep his eyes open for the
announcement o f the date o f the child-health conference. This will
be a county conference, and as a result of this demonstration he hopes
to establish several centers in the county.
The Logan County health unit, which is conducting 7 permanent
health centers, states that all its centers are rent free and are held
in the following places: A t the health-department offices in Logan,
in the women’s club rooms at Omar, at the Young Men’s Christian
Association in Mudfork, in the nurse’s office in the district school
building in Holden, in doctors’ offices in Big Creek and Chapmansville, and in a church in Man. Methods used in this county to in
crease the interest and maintain attendance, are home visits, talks
before clubs and other organizations, post cards mailed out from
the department office. The community leaders and club women set
the example by bringing their own children. The health officer
furnishes the medical service.
The directors o f our local full-time health departments, with one
or two exceptions, are favorably inclined toward the establishment
o f permanent health centers; more than 50 per cent have already one
or more in operation, and others are definitely working toward that
objective.
The C h a i r m a n . We are going to hear now a paper on support for
a permanent local program, by Miss Crough, who is in charge of the
work in New Hampshire.
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Federal Reserve Bank of St. Louis
FOUNDATION FOR PERMANENT CHILD-HYGIENE
PROGRAM IN NEW HAMPSHIRE
B
y
E
lena
fancy
H
,
M . C r o u g h , R . N ., D
and
C
h il d
H
y g ie n e
ir e c t o r ,
,
S
tate
D
iv is io n
B
oard
of
of
M
H
a t e r n it y
ealth
,
, I
n
N
ew
a m p s h ir e
In New Hampshire from the beginning of our maternity and in
fancy program we have endeavored to establish a foundation that
would be o f a permanent nature and o f a character to create in the
minds o f the people a desire for this type of work, leading them to
see its vital need, quietly and constructively teaching them how to
put into execution in a practical way, through their own effort, the
things most needed in the individual community.
In order to do this it was necessary to give a definite service of
some sort to every city, town, and village in the State. After careful
consideration and because of limited funds we decided that the
service which would be the farthest reaching and o f the greatest edu
cational value would be periodic, personal letters, books, pamphlets,
and leaflets on prenatal care, child care, and the general health
o f mother and child. Through these we would be able to reach into
the home of every newborn baby in the State and establish a close
contact. Since then every three months an envelope is sent con
taining a friendly little letter and information on certain phases o f
infant care and feeding that is helpful to the mother. A t the end
o f a year the mother receives several booklets on prenatal care and
a leaflet on breast feeding.
We also started a speakers’ bureau, an exhibit department, and a
loan library, and endeavored to secure the interest and close coop
eration o f the newspapers as a means o f teaching the people o f the
State what our program was and why it was needed.
This plan has been very closely adhered to up to the present time;
but during the first year, as a special means of emphasizing the
significance o f the work, two surveys were undertaken—one in a
city with a high infant mortality rate and one in a county with a
high maternal death rate. Following the surveys, at the request of
the local health authorities, two nurses were lent from the division
to put under way a prenatal and child hygiene program. Our staff
nurses are mature women with years of public-health experience and
excellent training as a background; they are very carefully selected,
not entirely because o f these qualifications but also because of ability,
personality, tactfulness, and love o f their fellow creatures.
In the sections where our nurses are located the first step in the
program is a visit to each physician, during which our entire pro
gram is closely gone over and the advice and cooperation of the
physician are requested. Thus from the beginning a clear under
standing in regard to what each physician desires is established,
132
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CHILD-HYGIENE PROGRAM IN N E W HAMPSHIRE
133
In every prenatal case the nurse endeavors to see that the patient
is immediately placed under a physician’s care, frequently arranging
to carry the prospective mother in her own car to the physician’s
office. She continues to visit the patient and give the necessary care
and advice if the physician desires. Cards are filled in immediately
following each visit to a prenatal case and are mailed to the phy
sician in charge. This keeps him in close touch with the patient
and is of special value in rural sections where travel is somewhat
difficult and the patients have not reached the point
seeing how
necessary it is to pay periodic visits to their physicians.
Letters from our State health officer and the monthly bulletin re
porting the progress o f the work are sent to the physicians o f the
State.
.
.
.
I
Talks are given before county medical societies; educational ma
terial is sent in quantity several times a year to physicians with our
postal cards which are used for sending in the names o f patients
desiring information and booklets. Our diet slips, furnished free
o f charge, ar§ almost universally used by the physicians o f the State.
Whenever we request a definite service from a physician requiring
time away from the office, he is remunerated sufficiently so that “ he
at least breaks even.” This is true o f all child-health conferences
and toxin-antitoxin clinics.
Because o f the close contact we are able to make with the medical
profession there is a very clear understanding o f our program, and
we are given the best o f help and cooperation. The local physicians
as a rule examine at each child-health conference. In sections where
there is no physician a children’s specialist does the work for us. It
frequently happens that a request for the children’s specialist comes
from the physicians themselves.
We are also in close touch with health workers and with our health
officers and town fathers.
A careful study is made o f each community, in order that we may
have a suitable and definite plan to better health, conditions ready to
present. Naturally the plan o f work varies in the different parts o f
the State. In one section the most urgent need is a public-health
nurse; i f this is the case we endeavor to stimulate public interest,
frequently loaning a nurse for a limited time to develop a suitable
program and making sure that sufficient emphasis is laid on prenatal,
infant, and preschool work.
A prenatal demonstration properly arranged and carried out has
proved a most successful way o f securing the lasting interest of
physicians, nurses, and, most important o f all, the women themselves
and their husbands.
The* mothers’ classes conducted as a part o f the prenatal demon
strations have been o f the greatest value in teaching large groups of
mothers the value and need of this type of work. These classes have
been well attended, the Manchester demonstration lasting for two
years and averaging 39 pupils per lesson.
Without doubt the keystone o f a permanent program is the good
.will, interest, understanding, and activities o f the people in a
community.
In New Hampshire there are 11 cities and 235 towns and villages.
In 153 o f these we have formed what is known as a permanent com
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Federal Reserve Bank of St. Louis
134
PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
mittee mad© up o f men and women o f the town who have a welldeveloped sense o f civic responsibility and a strong desire for civic
improvement, who are interested in whatever will improve the health
and well-being of the women and children in their midst. This
committee, when properly and carefully instructed, is largely re
sponsible for carrying out the plans o f the maternity, infancy, and
child-hygiene division.
The formation o f a permanent committee as a rule begins with a
child-health conference. Naturally the first conference must be
carefully handled by the staff nurse o f the section; she must assemble
her committee and go carefully into every detail o f organization
work, transmitting to them her own enthusiasm and absolute belief
in what she is doing, assigning the different duties to the various
members, always bearing in mind this fact—that people are far
more interested when they are a part o f a general plan and have
real, tangible service to render.
In the beginning it is necessary to hold frequent meetings with
the entire committee, the chairman, or a special group, in order to be
sure that the details are being carefully and properly carried out.
When the nurse in charge, fortunate enough to possess genuine
organizing ability, keeps in touch with her committee, and through
personal contacts, letters, and other means sends frequent reports
in connection with conferences and correction o f defects, she has
formed in that community a group o f citizens not only capable and
responsible, but able and eager to help continue the health work nec
essary to make that particular community an outstanding one in
the State. In many o f our towns such a committee, formed from
clubs, church organizations, schools, and professional and business
people, has become so deeply impressed with the results from the
first child-health conference that it has voted to be responsible for
one or more each year.
Groups o f women from the permanent committee also make and
keep replenished the obstetrical packages which are being used in
42 of the towns.
Members o f the committee have been o f the greatest help with the
follow-up work in sections where there are no public-health nurses.
They carry mothers and children to and from doctors’ offices, clinics,
hospitals, and conferences, and are very successful in stimulating the
interest o f the parents in carrying out recommendations with regard
to correction o f physical defects found as a result of the conference
examination.
.
Prenatal cases are reported to the main office, or direct to the county
nurse, by members o f the committee; they also keep in close touch
with the mothers and the entire group o f preschool children.
After one child-health conference is held in a community, there is
little difficulty in checking up on the quality o f work o f each mem
ber o f the committee, and then in a tactful way suggesting whatever
changes in personnel will be of benefit to the future of the work.
We have found it comparatively easy to arrange toxin-antitoxin
clinics for the preschool children. Our permanent committees,
through the children’s conference, have become acquainted with the
parents o f the preschool group and are very successful in making
heme visits to explain the nature o f the work and why it is needed.
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CH ILE-H YGIENE P&OGEAM I N STEW H A M P S H IR E
135
Eecently in a rural community covering three towns the commit
tee with very little help succeeded in having every family, with the
exception o f two, present for the first immunizing dose; 1 2 0 children
were immunized as a result of their endeavors. The clinic was most
systematically arranged and carried out Our staff nurse met with
the committee twice, called upon some o f the more difficult parents,
and arranged the details of the clinics. A ll the rest o f the work was
done by the women and men of these three villages.
Mothers’ classes, lectures to school girls, and health exhibits ar
also arranged for by the permanent committees. This greatly sim
plifies the work of the county maternity and infancy nurse and allows
her to extend the activities.
, „ .
^
Several o f these committees are now working out a plan to secure
from the town fathers a yearly fund that may be used for health
work. This is a most important development m our plan tor perma
nent work, as it would mean that the town itself could finance con
ferences, clinics, and a limited follow-up service Then if the divi
sion of maternity, infancy, and child hygiene of the New Hampsh
State Board o f Health should find it necessary to curtail its activi
ties in certain communities, a very commendable and satisfactory
program along similar lines could be maintained m each o f these
localities through a small staff working out from the State office
The public-health nurses in the State receive frequent bulletins
and letters showing the progress of the child-hygiene program. They
have cooperated wonderfully in the work and are carrying on much
better and more extensive prenatal and preschool programs than m
the past. Each nurse possesses a complete set o f index cards witn
names and addresses o f all preschool children m her community.
These cards are sent every month from the State office. In this way
it is comparatively easy for the 156 public-health nurses m the State
to keep a supervising eye on the preschool children. This, together
with the work being done by our staff nurses, establishes a very
thorough system o f follow-up work. The nurses of the division
meet with the local nurses at stated intervals to go over physicalexamination cards and check up on defects and other matters.
The development o f work of this type must be slow and gradual
if it is to be of a permanent nature. It requires an intensive, con
sistent, educational campaign that includes newspapers, churches,
clubs, civic organizations, schools, and every group ot men and
women in the State. An awakened conscience to the health needs
o f the community must be felt by every individual m order that
effective work be accomplished, the results o f which will be reflected
in the future in the physical, spiritual, and mental well-being ot
our boys and girls.
D IS C U S S IO N
The C h a i r m a n . This is a very interesting and very important
paper, it seems to me. I am going to ask Dr. Elizabeth A. Ingra
ham, director of the Bureau o f Child Hygiene o f Connecticut, to open
the discussion.
.
Doctor I n g r a h a m . Perhaps in New England more than _in any
other group of States we must show the citizens that child-health
work will be permanently beneficial and worth while financially. As
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Federal Reserve Bank of St. Louis
136
p r o c e e d in g s ,
m a t e r n it y
and
INFANCY CONFERENCE
the foundation for our work in Connecticut we seek the support o f
the local health officer and every local physician of good standing.
Generally this is given as soon as they understand our aims and
methods, see the advantages o f the work, and realize that indirectly
it accrues to their interest. We make it clear that no medical work
(not even first aid) is done at the conferences, that no advice is given
except as to hygiene, and that if medical or surgical care is needed
tli6 parents are urged to take the children to their family physicians.
As practically everyone needs medical services at some time, and as
doctors are often trusted friends as well as medical advisers, they
can be veritable child-health missionaries or, if prejudiced, serious
obstacles in our path.
Our procedure in a town in which a child-health conference is
planned is as follow s: The director of the bureau of child hygiene
calls upon the local health officer, outlines the plan, and discusses
methods. Having secured this officer’s approval the director calls
upon the local physicians o f good standing (in alphabetical order)
to present the aims o f the work, point out its purely educational
and advisory character, and emphasize the fact that it can not be
done except with their approval and cooperation. Each physician
is told that the bureau will report to him any defects found in his
patients at the conference. The request is then made that he give
his services in turn at the conference.
"We do- not get specialists for the conferences because we believe
that the local physicians might regard this as a reflection upon their
ability and take less interest than when we depend on each o f them
to give an hour or two o f his time once a month. ^Ve never offer to
pay for their services, and we do not invite them to come as specta
tors. We tell them that it is their work and until each is ready to
do his part no conference will be held.
At the conference each defect is recorded on our so-called doctors’
defect sheet, diagnosis to the mother being avoided if possible. At
the close o f the conference these sheets are mailed to the State depart
ment o i health, and the director o f the bureau o f child hygiene writes
to each local physician reporting the condition o f each" patient o f
ins who was examined, adding that the mother was advised to bring
the child to him for consultation and advice. I f the examining
physician reports that the services o f a specialist are needed, the child
is referred to the specialist through the family doctor, with whom
iru -^lrec^°r or assistant director of the bureau discusses the situation.
J his method o f referring the children avoids any local clashes, as
defects found by Doctor A are reported to Doctor B through the
bureau.
The bureau maintains constant contact with the local physicians.
It sends to each a so-called “ service calendar ” so that he may know
the dates o f his service at conferences, and on the morning o f the
conference he is reminded by telephone in addition.
After more than three years’ successful experience we believe that
tnis method holds the interest o f the physicians and that permanency
m the work can be achieved only through the active and friendly
support o f the local physicians and health officers. We have never
had any child-health centers except permanent ones in Connecticut.
Because the burden is laid upon the community from the outset the
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Federal Reserve Bank of St. Louis
CH ILD -H YG IEN E PEOGEAM IN N E W •H AM PSH IEE
137
citizens become accustomed, to the work, and as they realize its value
we can withdraw active assistance from one center after another,
finally functioning in an advisory capacity only. Thus we can cover
a wide field upon a comparatively small appropriation.
I may add that we do not allow any artificial feeding to be recom
mended at our centers. "We believe that artificial feeding is so im
portant that it should be done by direction of the family physician
and under his supervision, and if a conference physician advised
changing a formula he could properly be considered as infringing
upon the family physician’s province.
(Meeting adjourned.)
T H U R S D A Y , J A N U A R Y 13—A FTER N O O N SESSION
M ISS MAEIE T. PHELAN, R. N., EXPERT IN MATERNAL AND IN FAN T CARE, MATERNITY
AND IN FAN T HYGIENE DIVISION, CHILDREN’ S BUREAU, UNITED STATES DEPARTMENT
OF LABOR,
PRESIDING.
The C h a i r m a n . The program this afternoon is to be devoted to
subjects relating to' the maternity and infancy nursing problems.
We are very glad to have with us this afternoon Miss' Jane Allen, the
general director o f the National Organization for Public-Health
Nursing, who will discuss the supervision o f field nurses.
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Federal Reserve Bank of St. Louis
SUPERVISION OF FIELD NURSES
B
y
Jan
e
C.
A
llen
, R . N ., G
t io n
for
P
eneral
D
ir e c t o r ,
u b l ic - H e a l t h
N
N
a t io n a l
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The topic “ supervision o f field nurses ” has peculiar pertinency at
a conference of workers in maternity and infancy care held under the
auspices of the United States Children’s Bureau. Wherever there
exists a program of maternity and infancy care, we find public-health
nurses holding an important place. The program supported by
Sheppard-Towner funds are often carried on in sparsely populated
rural sections where such care would otherwise be negligible or
entirely lacking. This means isolation. for the nurse, and thus
supervision becomes a matter of paramount importance.
It is significant that public-health nursing, which has had such a
phenomenally rapid development in the last 1 0 years, has apparently
reached that stage where attention is beginning to turn to some o f
the finer phases. Public-health nurses, as a group, are beginning to
see more in their jobs than a routine performance o f assigned tasks.
This is indicated by the frequency of National, State, and local con
ferences, by more and more writing on public-health nursing, by a
steady flow of students between the field and the university courses
in public-health nursing, and by a noticeable spread o f the idea of
staff-education programs.
An increasing number of public-health nurses are seriously study
ing and evaluating public-health nursing procedures. Up to the
present time we have been so engrossed in meeting the urgently
pressing, immediate needs in our field that we have not had the time
to give to a much-needed analysis of purposes and functions. So
recent is all our thinking on this subject that, even now, such study
is going on, in the main, only in the older, well-established centers
o f public-health nursing.
O f all the functions involved in public-health nursing, supervision
is probably receiving the greatest attention. We are becoming
conscious of a growing conviction that this function is perhaps the
very hub of the whole wheel. We are also beginning to realize the
wide range o f possibilities it holds for strength and efficiency of
service, for economy o f time, effort, and funds, and for the develop
ment and professional growth o f our nursing staffs.
Although it is true that on the whole we do not yet know very
much about supervision, we have nevertheless made such progress
in our thinking that we can say that the principle o f supervision is
to-day unchallenged wherever good standards in public-health nurs
ing prevail. There are, however, many different ideas as to what
constitutes supervision. Taken by and large, the prevalent idea is
•the traditional one o f a routine “ checking up,” a more or less auto
cratic surveillance for the purpose of getting the work done efficiently
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and expeditiously. The majority o f nurses worked under this kind
o f supervision in their schools o f nursing. W e were submissive to
it as a part o f our necessary training, but it left in us a definite
impression o f chafing and rebellion and a desire to avoid a similar
relationship whenever possible. Under such autocratic supervision
the nurse was only a means to an end, rarely an end in herself. Initi
ative and independent thinking and acting were discouraged. Little
if any consideration was given the matter o f the nurse’s own growth
and development. The work in hand was the main object. A ll else
was subordinate to this end. But when a nurse who has come out
from under such a régime finds herself more or less “ on her own ”
in the public-health field, where the demands made upon her give her
the widest possible play for independence and initiative and where
she feels the spur o f ultimate responsibility not only for her own
success but for that o f her program as well—is it any wonder that
we see the pendulum sometimes swing to the other extreme and find
her on the defensive to preserve her new-found freedom? To the
average public-health nurse to-day, except in the comparatively few
larger centers o f public-health nursing, the term supervision carries
with it this more or less unpleasant connotation. It may be vague
and indefinite in her own mind. She may have heard o f or experi
enced a better form o f supervision which is less autocratic, but still
the old hang-over persists. It is well thus to remind ourselves of
the underlying reasons for the prevalent attitude on the part of
public-health nurses towards supervision which all in theory approve
but which many in practice seek to avoid or, at best, only tolerate.
In view o f this situation it is perhaps fortunate that o f all the
recent constructive thinking on public-health nursing, none is of
more importance or more encouraging and hopeful than the newer
interpretation o f supervision. We have now begun to look upon this
function as an educational one, which means a revolutionary change
in methods and technique. We are having to restate our purposes
and aims for this particular function, and we find ourselves looking
at our staff nurses and our programs o f community service in entirely
new relationships.
Efficient and acceptable field work still remains our ultimate aim,
but many o f us now realize that the best way to accomplish this is to
regard the field nurse, her growth, her development, her self-expres
sion in her job, as a specific aim also.
The focal point o f attention has become the nurse herself—the
nurse as an individual with latent possibilities for the development
o f new powers, the nurse as an intelligent, thinking being with an
inalienable right to self-expression and personal initiative. W e see
the supervisor, on the other hand, as teacher and guide, keeping in
the background as much as possible but at the same time with no
smallest detail escaping her; ready to help make the weak places
strong, making sure that standards are maintained and that the
program is efficiently carried on, and constantly awake to new oppor
tunities. Instead of the old, impersonal, arbitrary oversight, we
now think the desirable relationship is that o f friendly adviserexpert helper, staunch and loyal supporter.
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Field supervision o f public-health nurses as a State function,
although essentially the same in principle as supervision in a closely
knit city staff, necessarily differs somewhat in practice. Here the
factors o f distance and time enter in. With the nurses scattered
over a large area, many of them isolated workers, the problem is
largely one o f how to maintain contact and how to keep open the
channels of communication and understanding. On the one hand,
the supervisor needs to keep herself fully informed and sympathetic
with the local situation, not only its problems but also its resources
and its strategic opportunities. She should make it possible to
know the nurse, to make a case study o f her as an individual, as it
were, in order that she may appreciate better her special needs and
her possibilities for development and for professional growth. On
the other hand, the local nurse must be encouraged to turn gladly
to the supervisor for needed help. So close should be the contact
with the supervisor that the nurse is continuously aware o f this source
o i sympathetic understanding and expert advice, o f stimulation and
encouragement.
In addition to this all-important relationship between the two
individuals, the supervisor and the supervised, a definite supervisory
responsibility exists for linking up the local nurse and the local pro
gram with the larger groups and the broader programs, State and
National. In this we find the coordinating function o f supervision.
Here lies the means for establishing standards and for securing that
united effort toward the attainment o f a common goal which we are
more and more recognizing as of fundamental importance in the
modern public-health campaign.
These, then, are the immediate needs in the supervision o f field
nurses: ( 1 ) A supervisor well informed as to local program and
local nurse; ( 2 ) a cordial and sympathetic relationship between
supervisor and nurse; (3) open and well-used channels o f communi
cation ; and (4) coordination and unification o f nurses and programs
as a whole. It may be helpful to consider some practical means for
meeting these needs.
First o f all, good supervision requires a carefully worked out and
executed introduction of the new nurse to the field. Too much em
phasis can not be given to the bearing which this has upon the whole
situation, present and future. To permit a new nurse to begin her
work without a proper introduction is unfair not only to her but to
the community itself and to the program as a whole, to say nothing
o f the handicap which it furnishes in the establishment o f desirable
supervisory relationships. I f she is new to the State, she should
spend several days at supervisory headquarters following a definite
schedule o f contacts and making a general study of resources and
standard procedures. She should meet personally the staff o f State
workers. She should visit the State institutions, with which, as a
local nurse, she will have future contacts, and thus secure first-hand
knowledge o f the available resources within the State. She should
learn something about the development of the public-health program
in the State, the principal laws relating to health and disease, past
and present problems, plans for future development, and present
standards. She should familiarize herself with the facilities in the
State department of health, the rules and regulations governing the
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control o f communicable disease, the laboratory service, the publicity
program and how it functions in relation to local workers in assist
ing with speakers, loans of films, slides, and posters, the free healthliterature supply, and any other available services or sources of ma
terial that may later prove helpful. She should be instructed as
to records and reports and given general information as to the pub
lic health nursing program for the State. Thus, before she proceeds
to her own particular field o f work, she has become somewhat oriented
and has been made qn intelligent member o f a State group engaged
in a unified State program.
The second half o f the introduction should take place in the local
field, to which it is desirable that the supervisor plan to accompany
the new nurse. She should spend enough time with her to give her
personal introductions to the key people, to make sure that she is
established satisfactorily as to living quarters and that some arrange
ment for office room is made, and to give needed assistance in work
ing out a tentative program and schedule.
Such an introduction to the field, covering a period o f one week
to 1 0 days, is the best possible guaranty o f the kind o f supervisory
relationship desired and is an investment well worth the time and the
effort. It is a minimum below which no supervisory program should
go if it is to be successful. Subsequent supervision can be based on
this sound foundation as a beginning and consists in the main o f .
strengthening the initial bonds of contact and interest in every pos
sible way.
Much o f the contact is necessarily by means o f correspondence.
Supervisors o f field nurses have hardly tapped the possibilities in
this particular phase o f their work. We often read or hear the
statement that letter writing is fast becoming a lost art, but a suc
cessful supervisor o f field nurses is finding it an art in which she
must develop all the skill possible. T o respond unfailingly in a
helpful way to an expressed need—more, to become adept at reading
between the lines and realizing the unexpressed need—to be alert and
quick to follow a lead and write letters so friendly, so full o f genuine
interest, so helpful, that the nurse receiving them wants more; these
require real skill and conscientious, careful effort on the part o f
the supervisor.
How much such letters can mean to the nurse working alone no
one can ever know unless one has actually been in that situation.
The encouragement to stick to the job, the inspiration to see beyond
the difficulties and anxieties to the larger gains that will eventually
be secured, all this the supervisor’s letters may carry to the lonely
worker.
The analysis and appraisal o f the statistical andmarrative reports
sent in by the field nurse also present opportunities for supervision.
Careful study and evaluation o f the individual reports, month by
month, will give an insight into the status of the local program, how
it is measuring up to local needs, what new needs are becoming
evident, how much, if any, progress is being made, and how the
local is fitting into the State program. Properly studied and used,
these reports should also prove illuminating as to the nurse her
self, and a discerning supervisor should find in them rich oppor
tunities for increasing her insight into and understanding o f the
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nurse and her individual needs and possibilities, her weakness and
her strength. The successful supervisor recognizes the importance
o f reports and makes increasing use of them.
Having started the nurse out with a proper introduction to the
field and having subsequently maintained close contact with her
and the local program through correspondence and the proper use
of field-service reports, the supervisor uses the periodic visit to the
local field as a further means of supervision. Considerable thought
and careful planning are necessary if this is not to become a super
ficial, more or less perfunctory and routine procedure. The nurse
and her local groups, official and nonofficial, should be given the
opportunity to plan in advance for the visit o f the supervisor in
order that they may obtain the most satisfying returns. On the
other hand, the supervisor will want to make certain a well-rounded
visit that will include all those contacts which the special needs o f
the nurse and her local program indicate, would be helpful. I f the
right supervisory relationship exists the field visit will be eagerly
anticipated and warmly welcomed. A t this point we have one of
the observable tests o f good supervision, for we now recognize that
the right relationship between the supervisor and the field is funda
mental to all the other desirable assets we expect this office to produce.
Finally, it is a major responsibility of the supervisor to coordinate
the field work and to insure certain accepted standards in programs
and work. She needs to think of the State program as a whole and
to look upon each local program as an integral part o f that whole.
The question becomes paramount how to bring about a knowledge
and understanding and appreciation o f each other’s work that will
mean united effort toward a common goal. This must be accom
plished so as not to jeopardize local initiative nor to hamper any
honest effort to carry out plans best suited to specific local needs.
Two ways o f doing this have proved successful: ( 1 ) Occasional
regional conferences and ( 2 ) bulletins or news-letters issued regularly
and circulated throughout the State. A group consciousness, a reali
zation o f a common interest, and an appreciation of mutual helpful
ness in solving similar problems are brought about through this
exchange o f ideas. A wholesome stimulation o f local interest and
effort usually follows. I f supervision really means such oversight
as will bring the best help and stimulation to the workers, then the.
occasional group conference and the regular State bulletins are of
the utmost importance. Supervisors are justified in expending a
good deal o f time, thought, and energy on such projects, for, if rightly
managed, they bring rich returns in a better coordinated and more
efficient community service.
Granted that supervision as a function in public-health nursing
should mean all this, the most important factors are, after all, the
supervisor herself and her qualifications for success in her job. Not
tenure of office as a staff nurse, not maturity of years or experience,
not education nor technical preparation alone predicates the good
supervisor. In the supervisor, as in any teacher, that which, for
want o f a better name, we call personality counts for much. The
nurse who, in addition to sound academic and professional education
and a background o f successful professional experience, has the rare
g ift o f leadership, o f being able to work harmoniously with others, of
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sympathetic understanding and o f discerning insight into the needs
and promise in others is the nurse who is, as we say, good supervisory
material. She must be open-minded and flexible in her thinking,
she should have imagination and vision, she needs well-balanced judg
ment and a saving sense o f humor, and, most o f all, she needs plain
everyday common sense.
Too much emphasis can not be placed upon the importance ox a
properly qualified supervisor. We admit she is rare and difficult to
find to-day, but now that we are beginning to appreciate her strategic
position in the whole scheme o f successful public-health nursing, we
are urging more and more the necessity of definitely selecting nurses
who give promise of development and helping them to become fitted
for this kind o f work.
D IS C U S S IO N
The C h a i r m a n . Miss Allen’s paper will be discussed by Miss Mary
D. Osborne, supervisor o f public-health nursing o f the State board o f
health in Mississippi.
Miss O s b o r n e . Miss Allen’s paper is so replete with good things
and so comprehensive that in order to open the discussion it will be
necessary for me to restress certain outstanding facts.
It seems to me that first of all the supervisor must have the utmost
belief in and unselfish devotion toward her work, a vision o f results
to be obtained, self-confidence and yet the power o f self-effacement.
She needs an adequate background based upon theoretical and prac
tical experience. She not only must know how her particular work
should be done to obtain desired results but must possess the art
o f interpreting and imparting this knowledge to others, no matter
what particular activity is concerned. Expertness within a given
field which comes from good training and broad experience in varied
phases o f practical work is fundamental. “ An expert supervisor,”
it has been said, “ is so familiar with the basic principles and concepts
o f modern psychology, sociology, and philosophy that she applies
them in the solution o f each problem within her special field.”
Every nurse must do her own learning. No one can be educated
without first-hand individual effort and experience. An axiom of
pedagogy is to aid the pupil to think independently. To paraphrase
Miss Goodrich: A good supervisor should teach the nurse to become
habituated to thinking while learning by doing. In order to grow,
the individual worker must have interest in her work, actually think
out her own problems and develop her own initiative. It would seem
that one o f the faults o f educators is to keep in mind the ideal pupil
and her reaction rather than the average pupils. Much o f our litera
tu re has this fault.
The acid test o f the efforts o f the teacher is: Does she arouse m
the pupil an active interest in thinking and the urgent desire
diligently to work out the theory in practical detail % The supervisor
who can teach the nurse spontaneous action without arbitrary re
straint and at the same time inculcate in the pupil a plastic and
responsive desire to follow her lead, will do much to establish a
good morale. The good supervisor does not repress spontaneity but
by various and ofttimes subtle methods stimulates it to develop under
her guidance,
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Supervisorship must fill a felt need. A good supervisor is one
who is not simply a dictator to say that this or that shall be done
thus and so, but one who trains the supervised how to think out
the problems in their relation to the development o f a constructive
program o f work, one who teaches how to interpret a particular
phase o f work in its relation to the whole, one who teaches how to
organize an individual piece o f work so that it may be a smooth
functioning part o f the whole.
A supervisor should be a guide, a counselor, a friend, a support, but
not a dictator nor a prop upon which to lean. In addition to the
ability to lead, the supervisor must have the power to instill into her
coworkers the faith to follow her lead. Nor does it suffice to be
a leader only. The leader must keep on developing and holding the
sustaining power. A good supervisor does not launch new ideas
precipitately and yet does not lag.
Unstinted personal praise relative to lines o f action and results
obtained should be given at the right moment. Criticism should be
constructive. Problems should be thought out individually by the
supervisor and the supervised and later talked out together. An
impersonal attitude toward the work often clarifies problems as they
arise and hastens their solution. A good supervisor thinks in terms
o f the supervised, helps to clarify indefinite and muddled thoughts,
teaches how to differentiate between nonessentials which clutter up
and encumber and essentials which clarify. Such a relationship
preserves the individuality of the supervisor and the supervised and
tends to develop correct methods among the workers and in the
work.
With regard to methods used in supervising public-health nurses
affiliated with the State board o f health, it seems to be time well
spent and but fair to the nurse and the organization for which
she works to have her begin her services by spending a few
days at headquarters, where she may meet the heads of bureaus and
gain knowledge o f the field activities which will help her in her
local work. Group conferences also may be planned for publichealth nurses, either special conferences o f their own or conferences
in conjunction with the State nurses’ association o f which the publichealth section is a part.
In Mississippi after placement in the field the public-health nurse
works under direct supervision of the full-time county health officer,
the bureau o f public-health nursing acting as a clearing house and
rendering assistance and guidance as indicated.
The supervisor has the advantage o f the supervised, not because
she has more authority but because she is able to gain a comparative
vision o f all services and their relation to one another and to the •
whole. The reward o f the supervisor is automatic. T o stimulate
development in others in turn develops and improves one’s own
methods. It is most gratifying and stimulating to take an inexpe
rienced and untrained worker and watch her progress not only in
the technique o f her work but in her own development. To note her
self-development is sufficient reward, but it also develops the power
o f leadership in the supervisor.
Miss Fox. I should like to ask how you are going to get that two
weeks at the State health department headquarters financed? W ho
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pays for it? The State department, the municipality, or some private
agency ?
Miss O s b o r n e . In our State the county health unit does that.
Miss Fox. I think it is a splendid thing, but it would be difficult to
get it financed.
,
Mrs. D i l l o n . May I say in answer to Miss F ox’s statement that in
West Virginia we do not attempt any two weeks at headquarters, but
we do try to have all nurses coming into our State from the outside
at headquarters for at least two days. W e have never had any diffi
culty in getting the county to which a nurse was going to finance not
only those two days at headquarters but the additional expense in
volved in having her come to headquarters. They seem very glad to
do it, because they believe the experience to be worth far more than
the extra expense involved. W e have followed very much the plan
that Miss Allen has outlined for those two days—to get the nurse
acquainted with the personnel of our organization and of the related
State agencies. The nurse goes into her field with more self-con
fidence than she otherwise would have, and we have been assured
over and over again by them that they feel even the two days at head
quarters were very much worth while.
Miss A l l e n . My experience has been that success depends o n mak
ing the right contact wTith the community. They see the value of this
to their own local people and are glad to pay the expense. When I
was State supervising nurse we did not have the nurses at head
quarters as long as two weeks, but we were able—because all our
State institutions were right near headquarters—to have the neces
sary visits accomplished in a week; and our committees were always
willing to finance that.
Miss B e a u c h a m p . We have county health units in Arkansas, and
the relation o f the supervisor to the nurse who is employed by the
unit is just a little more complicated than her relation to the nurse
employed by the State. It has been perfectly Easy for us to bring
the nurses into the State department for one or several days where we
are subsidizing the service and where we organize a committee and
put the nurse in ; but I should like to hear from someone who has had
more experience with county health units and with the cooperation
of the directors o f those units, as we are beginning to have more
county units in our section.
Miss O s b o r n e . In the work o f the units in our State, Mississippi,
the nurses are under the direction o f the unit. W e are at their beck
and call to help, and we are called upon to help whenever they
want us.
Miss M a r r i n e r . I do not know whether what I have to say will
answer Miss Beauchamp’s question or not. The nurses in Alabama
are brought into headquarters for varying periods, one to several
days, or in some instances a week or more. The expense is carried by
the State board o f health as part of the preparation o f the nurse for
her office.
The C h a i r m a n . H o w much does that cost the State, Miss Mar
riner ?
Miss M a r r i n e r . It is not a large sum. I have not the average
figures in mind. I usually invite the nurses to my house, where they
are guests; the expense is not very great,
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
Miss O s b o r n e . May I ask if their salary begins at that time ?
Miss M a r r i n e r . Y es; they are on salary then.
The C h a i r m a n . I think there is quite a difference in the programs
in the States where they have county units and in those that have
only a state-wide public health nursing program.
Mrs. M c C a l e b . We do not bring our county health nurses into
headquarters. O f course the Sheppard-Towner nurses in Ohio are
on our pay roll, but I am wondering whether, with the large number
o f nurses we have, it would be possible to finance this. W e are con
stantly getting new nurses, and they are employed by the county
boards o f health; I doubt whether the State would be willing to
finance it.
The C h a i r m a n . What means do you use in the State for instruc
tion ?
Mrs. M c C a l e b . We have instructing nurses who visit the new
nurses. They spend probably a week with them in the beginning,
and they visit them as frequently as they think it is necessary.
Doctor G a r d i n e r . In New York we have consultant nurses that go
about the State visiting, and an extension course also is offered. In
fact the Sheppard-Towner nurses do not go to headquarters; we
really go to them.
Mrs. R e i d . In Florida the new nurses coming on the State! staff
report for duty at the State department o f health and remain there a
sufficient period o f time to become familiar with the records and
report blanks. (The bureau of child welfare and public-health nurs
ing is in the State department o f health.) The contact with nurses
who are employed locally is made by the field supervisor, who, as soon
as possible after a nurse has been employed locally (either by a
community organization or a county) visits that particular nurse,
acquaints her with all the facilities that she may have from the State
department o f health, and helps her as much as she can.
The C h a i r m a n . I recall that when I was with the Red Cross we
had nurses who were going to the various States to take positions
stop at the office when it was possible and spend two or three days
becoming familiar with the records and getting acquainted with the
office staff. W e felt that it was a great help to the nurses who went
.to far-distant parts o f the country, because they not only became
familiar with the records and the general routine o f the office work,
but also became acquainted with the workers in the office—the people
to whom they were writing and who were answering their letters.
Miss Fox. Another point I should like to know is the opinion
here on Miss Allen’s suggestion that the supervisor should go in
with the new nurse and get her started. That is a thing we have
long advocated in the Red Cross; but we get this comment from our
own nurses in the field, and I wonder whether the group agrees:
That the supervisor’s going with her takes away from the nurse’s
local prestige, the local feeling that she is competent to handle the
job. I f the supervisor can go in a few days later, making it appear
to be a casual routine visit that just happens to come at that time,
the same thing can be accomplished and the nurse’s standing in the
community can be saved. I am inclined to feel that our field people
are right in taking that stand about it,
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Doctor G a r d i n e r . Y o u presuppose that a county unit is made up
more or less of specialists and that they are in a measure self-sufficient.
Do you not think that i f they want help they can ask for it, rather
than to have things imposed upon them ?
The C h a i r m a n . I think that is understood.
Doctor S c h w e i t z e r . The system in Indiana is somewhat different
from that in some o f the other States. Whenever new people, either
doctors or nurses, come on the staff o f the division o f infant and
child hygiene, they not only come into headquarters to get informa
tion, to get acquainted with the staff and with the routine, but also
are sent into the field with the staff which is already at work, to
learn the field routine and organization. W e try always to stay
away from the county nurse until she is thoroughly established in
her own right before we offer any assistance from this department.
The C h a i r m a n . The next subject is “ Standards for training o f
public-health nurses,” by Miss Fox, national director o f public-health
nursing, American Fed Cross.
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STANDARDS FOR TRAINING OF PUBLIC-HEALTH NURSES
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What I am going to say is so obvious, so well known to you all,
that it hardly seems worth your while for me to present it. And yet
we are all more or less in the same predicament trying to live up to
our own accepted standards, for we all have more positions to fill
than we have well-prepared nurses to fill them. We are constantly
facing this question: Shall we compromise with our standards and
employ nurses who we know do not come up to the standard of prepa
ration that we feel is necessary? W e are facing this all the time in
the Red Cross, and I am sure that every State worker faces the same
question. Every time we are in a mood to compromise I think we
should stop and question whether that is in the long run the wise
thing to do, and what I want to do here to-day is a little thinking
out loud on that point.
Most of us are placing nurses in towns or counties where publichealth nursing is a new thing. This nurse may not be the first, but
the nursing service has not been there very long and the town or
the county is not advanced in public-health measures. With the ex
ception o f some two or three hundred counties there is no full-time
health department, and consequently there is no comprehensive health
leadership in the county. There is usually very little health work
going on in the schools. Probably there are no health clinics. There
may be some sick-baby clinics or some other special clinics for treat
ing disease, but no health clinic. There is almost nothing in the way
o f a health consciousness or an organization of the county for health
work. That is the setting into which we are often placing our usu
ally lone nurse to do maternity and infancy work in your case, gen
eralized nursing in ours.
Perhaps I am not the one to say what objectives you are setting
for the nurse in maternity and infancy work, but I think it is proper
to assume that ( 1 ) you want her to bring about in the town and
county in which she works a much higher valuation o f human life
and o f the need for adequate prenatal, maternity, and infant care; ( 2 )
you want her to supply the knowledge which will lead to better pre
natal hygiene and better care o f the infant ; and ( 3 ) you want her to
help produce the facilities which will make good prenatal care and
good child care possible. Now, what must the nurse be able to do
if she is going to “ put over ” such a job ?
First o f all, it seems to me that she must have a public-health point
o f view, a point o f view which leads her to see the individual as a
member o f a family and a member o f society and not simply as an
individual, to think of the problem presented by the individual and
then think of the family problem of which the individual’s problem
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may be either cause or effect, and then beyond that to the community
problem-, a point o f view which emphasizes prevention and education
rather than merely the alleviation of ills already existing. That may
seem very obvious, and yet it is not a point o f view that nurses are
born w ith; it is not a point o f view that nurses graduate from their
training schools with. It is an acquired point of view—the out
come o f special study and experience. And it is a first necessity.
The second requirement seems to me to be the desire and the ability
to teach, since we have said that an important function o f the nurse
is to diffuse knowledge. This means that the nurse must know the
why and how o f proper prenatal hygiene and the facts about the
growth and development o f the normal child both physical and psy
chological. I f we have not sound, scientific, and comprehensive
knowledge ourselves, our teaching is a farce. Beyond that the nurse
must have a knowledge o f how to present her subject so that it makes
an impression, so that it creates an enthusiasm, so that it brings about
a change o f heart, so that it ends in actual practice of the things she
is advocating.
Third, the nurse must have skill in getting people out to classes and
to clinics and to other centers where she hopes to instruct, or help
them. The nurse who doesn’t know how to get to the people, doesn’t
know how to make them enthusiastic, how to attract them to classes
and clinics, how to interest them after they come and make them
come again, is not going to get very far with, her educational pro
gram. She must be a promoter and an organizer.
Fourth, she must understand the control o f communicable diseases,
because that plays such an important part in our preschool program.
That means much more knowledge o f their spread and control and
prevention than any o f us received in our training.
Fifth, since her greatest opportunity and effectiveness are in the
homes she must have a knowledge o f good home visiting. She must
know what she is going into the home for, how to make a successful
approach to a home, how to take in the situation when she gets there,
and how to “ get over ” the right ideas and influence the situation
constructively—very important skills these, without which her work
will amount to almost nothing.
Sixth, she must know how to arouse community interest in a mater
nity and infancy program, in better care for mothers and babies.
That goes far beyond a mere publicity campaign. It goes into the
realm of knowing how to arouse and make use of the latent interest
o f every group in her community, and by actually tying it into her
program, making it come to life and amount to something.
Seventh—I don’t know but that this is almost the most important
factor and it doesn’t depend on education solely— she has to have the
ability to work with others. How many a program has gone on the
rocks because the nurse couldn’t get along with the doctors, because
she hadn’t any idea how a nurse functions alongside a health officer,
how a nurse relates her work to the school system, how she ties it in
with the health programs o f other agencies, how the activities of
public-health nurses and social workers are enterprises in partner
ship. She must know how to accommodate herself to other activities
in the community and adjust her program so that they become a
harmonious whole.
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Eighth, she must have the ability to plan her work to make her
time count for the most. She must be so familiar with the operation
o f each o f her duties that she can make them fit together in an effi
cient and workable schedule. It seems to me that those eight abilities
are indispensable if the work that you want done in the town or
county is actually going to result from the nurse’s appointment.
Now, the ability to do these things and to avoid the opposites of
these things, seems to me, leaving personality out of the question for
the moment, to be based on a knowledge o f hygiene, o f preventive
medicine, o f public-health administration, o f sociology (at least some
idea of the structure o f society and the way it functions), o f pedagogy,
o f psychology (most important), o f community organization, o f the
principles and practice o f public-health nursing. Miss Osborne
added a requirement which I had not thought o f before but which
now seems to me to be perhaps most important o f all, a knowledge
o f philosophy. I f we had that, I don’t know but that a good many
other problems would solve themselves.
I f you agree with me that a piece o f work being launched in a
community is not likely to meet with success unless the nurse can
do the things outlined, and if you agree that success in these things
depends largely on her possession o f the knowledge suggested, where
are we going to find satisfactory nurses to fill our vacancies ? There
are three sources from which we can draw: (1) The nurses who have
had no experience or special preparation for public-health nursing,
(2) those who have had experience, and (3) those who have had
a public health nursing course. Let us examine each o f these sources.
As for the nurse who has had no experience or special prepara
tion, what can we expect from her? Obviously unless she has
graduated quite recently and from one o f a score o f leading schools,
she has been taught none o f the subjects we have listed as essential.
But it is often argued that individuals without experience in publichealth nursing, without postgraduate training in public-health nurs
ing, but with common sense, can do an excellent piece o f work. I
agree in part with that statement. I think there are now and then
broadly educated, highly intelligent nurses who are so observant, so
quick-witted, who have so much common sense, so much judgment,
that they learn very rapidly, take advantage o f everything they learn,
and very soon are able to do a very good job. I f I didn’t think that,
I would be forgetting some o f the very leaders o f our profession than
whom we have none better, who many years ago stepped from the
hospital into the development o f visiting nursing. But let us re
member that they are our outstanding women o£ whom we have
only a few. Nurses o f their caliber are so rare that there is probably
not more than one for each State. Furthermore, in this day and
age any nurse with that exceptional quality o f mind and tempera
ment is the last one to be willing to undertake a piece o f work
unequipped for it, so that she would not be available until she had
equipped herself through postgraduate work. Witji all the more
intelligent nurses eliminated by their own insistence on adequate
postgraduate preparation before appointment, we have left only
those o f average or less than average intelligence, those who do not
have that wonder-working common sense, which it is argued will
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compensate for lack of knowledge and experience. It is obvious
that they are doomed to fall far short of the mark.
Our second source of supply is the staff nurse—the nurse who has
learned some o f these things through experience as a member o f a staff
where she has had teaching supervision. To be sure, she has not
had as much o f the theory o f preventive medicine, sociology, psy
chology, and the other subjects as she needs, but she can go a long
way toward handling the eight essential points. Fortunately this
source o f supply is relatively large, though almost totally lacking in
a few States.
Then there is the third group, the students who come out o f our
postgraduate courses, the group that we feel is best equipped to handle
the work. Unfortunately at present there are only two or three
hundred students coming out o f these courses annually, for the
courses are not well patronized. You hear it said often, and some
times I think truly, that the student coming out of some postgraduate
course is not so well equipped for pioneer county work as some one
who has learned through experience, because she is so full o f theory
and advanced ideas that she is not content to begin at the beginning
and go slowly. That is an indictment o f our courses; and if it is
true we should tell the directors o f those courses that their graduates
are failing us in this respect. It is not that education spoils the
nurse, but that she has not had the proper perspective given her as
a part of her education.
I am sure there is no one o f us who does not believe, indeed has not
been convinced by experience, that other things being equal, the
nurse who has had a postgraduate course has a great advantage
over one who has hot and a much greater chance o f success. You
notice I say “ other things being equal,” for no postgraduate course
can give character or common sense or personality; and if these are
lacking no amount o f education can compensate for their absence.
Eloquent testimony is given to the fact that we all believe in a
high standard o f preparation for public-health nursing in the report
in 1924 of the committee to formulate standards for positions in pub
lic-health nursing, a joint committee o f the Conference o f State and
Provincial Health Authorities, the American Public Health Asso
ciation, and the National Organization for Public Health Nursing.
This report was accepted by each o f these organizations. (See
p. 152.)
These standards represent a tremendous advance in the last 10
years. I remember well, right after the war, when the Red Cross
enunciated its standard for rural nursing, the outcry that went up
from within the Red Cross and from the State health officers all over
the country, that our standard was far too high, that we would surely
choke a new and strong interest by setting such a high standard.
To-day the standards that these three bodies I have just mentioned
have agreed to are higher than those set by the Red Cross.
I have just one thing to say in closing: When we consider the
situation honestly I believe we are all agreed that experience proves
that with very few exceptions the only nurse who makes good on the
job is the experienced or trained worker. We have compromised
from necessity over and over again only to find that half-way
measures do not meet the need. The nurse almost invariably falls
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far short, when we pursue a short cut, and it is a question whether
more injury than good is not done when that happens.
I f we do believe that it takes proper preparation to do a good job,
then we must see to it that more nurses enter the postgraduate courses
and that depends largely on our own enthusiasm for them. If, in our
hearts, we think a nurse who has not taken a course can do just as
well as a nurse who has, we are not going to be enthusiastic about
postgraduate courses. However, if we honestly believe that post
graduate education is the right thing, then we will talk about it
we will try to get the nurses to want it, and more than that, we will
reward those who have gone to the labor and expense o f taking
postgraduate work by seeing that they get greater emoluments than
those who have not, other things being equal.
It is the responsibility of all of us who are handling this problem
o f recruiting and placing nurses, and who believe in high standards
to do our share toward increasing the supply o f adequately prepared’
people before we accept compromise.
Report of the committee to formulate standards for positions in public-health
nursing (representing the Conference of State and Provincial Health Authori
ties,the American Public Health Association, and the National Organization
for Public Health Nursing)
I. For the nurse on a staff providing well-qualified nurse supervision
A . Minimum qualifications for 1925.
1. For nurses graduating from schools of nursing since 1920.
(а) A t least two years of high-school education.
(б ) Fundamental nursing education— nam ely: Graduation
from a school for nurses connected with a general
hospital having a daily average of 30 patients or more
and a continuous training in the hospital of not less
than two years. Training shall include practical- ex
perience in caring for men, women, and children, to
gether with the theoretical and practical instruction
in medical, surgical, obstetrical, and pediatric nursing.
Training may be secured in one or more hospitals.
(c) Registration under some State nurse practice law.
2. For nurses graduating from schools of nursing before 1920
(a ) No academic qualification stated.
(&) Professional training or experience which has developed
a wisdom , and judgment which is valuable in the
public health nursing field in spite of lack of formal
academic education.
(c) Same as A, 1 (&).
(d) Registration under some State practice law.
B. Desirable qualifications for 1925, to become the minimum qualifications
for 1930, or 1927 i f possible.
1. For nurses graduating from schools of nursing since 1920.
(а ) A t least high-school graduation or its educational
‘ equivalent.
(б ) Same as A , 1 ( 6 ).
(c) In addition to the services required in the fundamental
technical education (obstetric, pediatric, medical, and
surgical nursing), theoretical instruction and practical
experience in one or more of the following services:
Public-health nursing, communicable-disease nursing,
tuberculosis nursing, hospital social service, mental
hygiene. (These services may be given in the school
or taken as postgraduate work.)
(d) State registration in the State in which the nurse is to
be employed.
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I. For the nurse on a staff providing well-qualified nurse supervision— Contd.
B. Desirable qualifications for 1925, to become the minimum qualifications
for 1930, or 1927 i f possible— Continued.
2. For nurses graduating from schools of nursing before 1920.
( a ) No academic qualifications stated.
(b) Professional training or experience which has developed
a wisdom and judgment which is valuable in the public
health nursing field in spite of the lack of formal
academic education.
(c) Same as A , 1 (b) .
( d ) *In addition to the services required in the fundamental
technical education (obstetric, pediatric, medical, and
surgical nursing), theoretical instruction and practi
cal experience in one or more of the following
services: Public-health nursing, communicable-disease
nursing, tuberculosis nursing, hospital social service,
mental hygiene.
(e ) State registration in the State in which the nurse is to
be employed.
II. For the nurse working alone, i. e., without duly qualified nurse supervision.
A . Minimum qualifications for 1925.
1. For nurses graduating from schools of nursing since 1920.
( a ) A t least two years of high school.
(b) Same as A, 1 (b).
(c) Four months of instruction under one of the recognized
public health nursing courses, or four months’ organ
ized instruction for the special field, or one year’s
experience on the staff of a public health nursing
organization giving daily qualified nurse supervision.
(d ) Registration under some State nurse practice law.
2. For nurses graduating from schools o f nursing before 1920.
(a ) No academic qualifications stated.
(b) Professional training or experience which has developed
a wisdom and judgment which is valuable to the
public health nursing field in spite o f the lack of
formal academic education.
(c) Same as A, 1 (b).
( d ) Four months of instruction under one of the recognized
public health nursing courses, or four months’ or
ganized instruction for the special field, or one years’
experience on the staff of a public health nursing or
ganization giving daily qualified nurse supervision.
(e) Registration under some State nurse practice law.
B. Desirable qualifications for 1925 which should become the minimum
qualifications for 1930, or 1927 if possible.
1. For nurses graduating from schools of nursing since 1920.
(a) At least high-school graduation or educational equivalent.
(b) Same as A , 1 (b) .
(c) In addition to the services required in the fundamental
technical education (obstetric, pediatric, medical, and
surgical nursing), theoretical instruction and prac
tical experience in one or more o f the following serv
ices : Public - health nursing, communicable - disease
nursing, tuberculosis nursing, hospital social service,
mental hygiene.
(d) Four months of instruction under one of the recognized
public health nursing courses and one year’s experi
ence, or an eight months’ course in public-health
nursing and six months’ experience.
( e ) State registration in the State in which the nurse is to
be employed.
2. For nurses graduating from schools of nursing before 1920.
(a) No academic qualifications stated.
(b ) Professional training or experience which has developed
a wisdom and judgment which is valuable in thd
public health nursing field in spite of the lack of
formal academic education.
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I I . For the nurse working alone, i. e., without duly qualified nurse super
vision— Continued.
B. Desirable qualifications for 1925 which should become the m i n i m u m
qualifications for 1930, or 1927 if possible— Continued.
2. For nurses graduating from schools of nursing before 1920— Con.
(c) Same as A, 1 ( 6 ) .
( d ) In addition to the present requirements in fundamental
technical education (obstetric, pediatric, medical, and
surgical nursing), theoretical instruction and practi
cal experience in one or more of the following services:
Public-health nursing, communicable-disease nursing,
tuberculosis nursing, hospital social service, mental
hygiene.
(e) Four months of instruction under one of the recognized
public health nursing courses and one year’s experi
ence, or an eight months’ course in public-health
nursing and six months’ experience.
(f) State registration in the State in which the nurse is to
be employed.
Special personal qualifications desirable for all public-health nurses: Adapta
bility, tact, patience, tolerance, courtesy, a spirit o f cooperation, and an open
mind.
This report is submitted with the committee’s recommendation that further
study be made of the qualifications for nurse directors and supervisors, and
for continued revision of these qualifications from year to year.
It is further recommended that a committee be appointed to consider stand
ards for directors and supervisors in municipal health departments, based upon
a study of the report on the qualifications of superintendents and directors in 69
public health nursing organizations, made by the Provisional Section on PublicHealth Nursing o f the American Public Health Association.
D IS C U S S IO N
The C h a i r m a n . I am sure we all agree with Miss Fox in her
standards for public-health nursing. Some o f the nurses who are
on our large staffs probably would make admirable workers for.some
o f the districts that are calling for nurses at the present time i f we
could only win them away from their present civic positions. I
wonder if Miss Fox can tell us how to do that.
Miss Fox. We go to the superintendents o f nurses day in and day
out, and ask them for help.
The C h a i r m a n . I ask constantly for nurses who have had special
training in care o f the preschool child and the expectant mother. I
happen to know several nurses who have had many years’ experience
along this line; and I have been unable to persuade them or even to
get the superintendent to acquiesce and encourage them to go.
The discussion on this paper will be opened by Miss Ada Taylor
Graham, director o f the bureau o f child hygiene and public-health
nursing in South Carolina.
• Miss G r a h a m . It is rather embarrassing to follow Miss Fox on
this subject, because if I disagree with her on any point I lay myself
open to the charge o f being willing to have a lower standard.
My understanding o f standards is that they are the goal which
we set and toward which we work and that they are not absolute.
W e are seldom able to live up to our absolute standards, and I think
we fall just as far short o f it in public-health nursing as in anything
else. I agree that we want our public-hearth nurses to have all the
preparation that Miss Fox has said is desirable, but occasionally I
think that we can afford temporarily to compromise and get some
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thing that we can use to a very good end even though it is not the
best.
One thing that I have to complain o f in the standard courses for
public-health nursing is that from our point o f view they give the
nurses too little training in the maternity and infancy field. I con
sidered my o w q course very good indeed, but the amount of training
that I got in that particular line was much less than in many others.
With the Sheppard-Towner appropriation being jised by the differ
ent States I think we all feel that we want our public-health nurses
to have more training in this line, even if it has to be got at the
expense o f some o f the other branches o f public-health nursing.
I went to South Carolina four years ago and found many counties
with appropriations for public-health nursing and no nurses to put
into those positions. It was a difficult situation; and though I felt
that I had to uphold standards, I finally decided that we really
must do something about it. I got permission from the National
Organization for Public-Health Nursing and the Red Cross, who
were both interested in our State work, to try out a system o f train
ing nurses for our particular field of work. We were careful to make
it clear from the start that the four months’ practical work that we
offered in the field was not to be regarded as a training course for
public-health nurses; it was simply a stop gap between the time that
was past, when we were leaving these counties without nurses, and
the time to come, when we hoped that we should be able to get ample
material for our positions from the schools o f public-health nursing.
That time has not yet come, but we were able to get a sufficient num
ber o f nurses from the State to take a four months’ practical course
in our own field with our maternity and infancy nurses. The train
ing that those student nurses got was practically all maternity and
infancy work; that is, they had two months in the field with ma
ternity and infancy nurses, one month with a general county nurse,
who combined maternity and infancy work with her general pro
gram, two weeks o f clinic work, and two weeks o f lectures, which
included six lectures by the advisory nurse from the Children’s
Bureau.
When these nurses completed their four months’ course they were
put into the counties, working under supervision, and we tried to
get the thought in their minds that they would ultimately take the
course that the universities give in public-health work. So far we
have been successful in that our first students, who took our little
practical course in 1923, have gone to public-health schools and now
have taken their course and returned to us. They have told me that
they felt they got a great deal more from their university course
than they would have if they had not seen anything o f field work.
We gave this course, I frankly admit to you, to meet our own neces
sities. I am not recommending it by and large because it may not
be the thing your particular State needs. In that way, though, our
nurses did get the maternity and infancy training that we wanted
them to have, for we were very fortunate in having several field
nurses and one county nurse who were real teachers and who were
able to give the nurses not only the practical work but ideals o f
public-health nursing that I think are o f equal importance.
66982°— 27-------11
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In asking that our public-health nurses have all the training that
we have spoken of we have lost sight of the fact that the nurse in
many cases is unable to make the progress in her work that she
should. The positions o f responsibility and the positions that offer
her sufficient remuneration for the long period o f training and of
service in the field are few. Many people talk of establishing a maxi
mum salary for a public-health nurse working in a county. I have
heard over and over again that $1,800 should be the limit placed on the
salary o f the nurse working in a county; that if she wants to receive a
higher salary she should prepare herself for a supervisory position.
This is bringing a note into the discussion that perhaps is not the
one I would want to close on; but I do think it is something that we
have to reckon with. I would like to see the nurses who are in posi
tions where they have an opportunity to fight against that attitude
on the part of the public or officials or organizations employing
nurses, take a very definite stand that a nurse may remain a county
nurse and be just as valuable as a supervisory nurse, and that the
position that she has should not limit her as to salary i f she has
special ability and a particular county needs her services.
Another thing that I have to say in defense o f the practical course
that we gave in our State and that some other States are flirting with,
perhaps, is that the nurse in that way does learn the field in which she
is going to work. In the cities where the public-health courses are
given the public-health nurse is trained to work with so many co
operating agencies that when she comes into a rural district—-into
a county, say, in South Carolina— even if she is a person of ability,
she finds it very, very difficult to adapt herself to playing a lone
hand and having nobody to call on to handle the various things that
she has been accustomed to refer to other agencies; handling the so
cial work as well as the public-health nursing; perhaps serving as
probation officer and in other capacities. That is one reason why I
think that even if a nurse has had a public-health course in a recog
nized school, when she comes into a State to work she needs a little
more preparation for that particular piece of work in the State than
just two or three days spent at headquarters.
I believe that if every State could have one county in which there
was unusually good personnel, with a nurse who possessed the quali
ties o f a teacher, and if each nurse coming into the State could spend
a month in such a county, in that way she would be prepared for
the situation that she is going to find in her own county, and the
result for the work o f the State would be very good indeed.
Miss A ll e n . I think the matter of the teaching center in the State
itself is probably the solution. A few years ago we thought the
university course was going to answer the problem. To-day at the
headquarters o f the National Organization for Public-Health Nurs
ing—or up to January, when we had our vocational service located
at headquarters—for one nurse that applied for assistance in finding
a position, we had from 10 to 15 positions. The demand is away
ahead o f the supply. I venture to say that there is not a State super
vising nurse here this afternoon that will not back me up when I say
that you are just up against it. You are in the position, almost
everyone o f you, of saying to yourselves, “ Well, I am going to keep
away from the unorganized territory and not get the people inter
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ested, because I will get my appropriation and then I will be in the
embarrassing position o f not having a nurse to put in that position.”
So we think now that the university course is not the answer. It is
the ideal; we do not challenge the statement o f what the standards
for the public-health nurse are. W e should like to have them all
go to our university courses, but it just is not practical yet. The
demand that we have to meet is too great. I think the way to meet
it is to establish a teaching center or sell the idea to your State depart
ment o f health, that an additional program for instruction must be
financed.
W e find many States having regular institutes, calling their nurses
together in conferences, issuing reading lists, and resorting to all
manner o f devices. We must emphasize more good supervision. Per
haps we should think o f our university courses in public-health
nursing as for the preparation o f good supervisors and have our staff
educational programs in our State and in our cities. I think for a
while we shall have to resort to that alternative.
Doctor G a r d in e r . Sometimes it is a case o f our taking the nurse
that we can get, rather than telling you what kind o f nurse we
need.
The C h a i r m a n . Many o f the Eastern States, the Atlantic Coast
States, have been having institutes for nurses; but there are States
where the distances are so great that it is almost impossible to bring
nurses together at a given time. I wonder i f there are supervising
nurses here from some o f the Western States to tell us how they are
keeping in touch with the nurses and what they are doing to train
them.
Doctor S tadtmuller. I can tell you what we have done with the
nurses in California. A t the time we first started the work we
arranged separate institutes for the nurses of the northern and the
southern part o f the State, and we endeavored to supplement talks
on the technique o f maternity and infancy nursing with talks on
the theoretical and scientific questions. W e had our leading obste
tricians and pediatricians talk to them on the medical phases of the
w ork; we went over the local laws with them so that they would have
some knowledge o f the facilities and resources o f the State if they
were called on. W e had a good deal o f work about feeding and
nutrition, and since that time the University o f California, which
maintains a branch in southern California, has held an institute
each year for public-health nurses to which the State department
o f health contributes through talks from the head o f the department
and the heads o f bureaus. This gives to the nurses an opportunity
o f renewing their interest in the maternity and infant phase o f the
work. These talks are very well attended not only by nurses from
California but by nurses from a large group o f States; not only by
county and State nurses but also by school nurses and industrial
nurses.
I believe that the nurses derive a great deal o f benefit, and they
feel that they have got a good deal from these institutes. The
State issues a certificate o f attendance which can be used later to
meet the State requirement that public-health nurses shall receive
certificates. They can not receive that certificate from the State
board o f health until they have had at least four months o f theoretical
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w ork; that means attendance at two summer sessions or institute
work. They are not now permitted to take the examination without
the four months o f theory.
M iss D e L a s k e y . In Oklahoma county units we have to take the
nurses coming out o f the hospitals or have no one at all, no others
being available. So last spring we started having an institute for
nurses, particularly on maternity and infancy work; and the nurses
were permitted to come out o f their units and spend a week in
Oklahoma City, where intensive work o f this character was done.
Regular classes were held, and at the end o f the work nurses took
a regular examination and then went back to their units. O f course
that is only a beginning, but it is an attempt to meet the immediate
problem in the hope that further work may be done.
The C h a i r m a n . In the far Western States the supply o f nurses is
very limited, and it is difficult to secure nurses that have had any
training or experience in public-health nursing. This problem is so
serious that I think we public-health nurses should try to consider it
in some o f our meetings. Moreover, the distances are great, and the
communities are isolated, so that it is especially difficult to get nurses
to stay unless you are fortunate enough to find one who is resident
and knows the conditions.
Mrs. M a t h e w s . I should like to ask about the salary paid to nurses
in other States. Miss Graham said $150 a month was the maximum.
In Colorado we have not many nurses, and they are always in de
mand. No matter how poor the nurse is nor how good she is she gets
$150 a month. That is the maximum and that is the minimum. I
should like to know just how it should be worked out so there would
be an incentive for those nurses to start at less than $150 and then
go up to $150. It seems that there should be some way o f adjusting
their wages.
. . .
Miss G r a h a m . Speaking about what we did with the nurses to
whom we gave training in South Carolina—I do not know whether
you understood that we financed the four-month period o f training.
W e allowed the nurses who took the four months of field work their
living expenses during this course; and the understanding was that
those nurses began their work at $1,500 a year. Whatever county
they went to we recommended that their salary be increased to $135
a month the second year; and if they continued in the county or in
the State we recommended that their salary be raised to $1,800 the
third year. Regular increases in salary are good for morale. Some
counties have appreciated the work o f the nurse so much that even
without our asking them to they have raised salaries to $TT5 a month.
I think it is only fair, when the nurse has remained in the county,
and been faithful to her work, and given good service, that she
should have the chance o f increasing her salary as much as the
people are willing to pay; and I feel that the State departments
should recommend to the counties increases in the salaries o f nurses
who have been with them for a long period o f time and done good
work.
W e have usually had no difficulty in getting the regulation salaries
for our county nurses, but where we have not gotten them the nurses
are often very unselfish about it. In one county which was_ divided
a raise in salary was due to the nurse; but the county commissioners
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STANDARDS FOR TRAINING OF PU BLIC-HEALTH NURSES
^
159
came to her and said, “ W e want to raise your salary, but when we are
cutting our county demonstration agents and others we can not do
it this year.” She replied that she would not leave the county now,
because she had just got a lot o f things started that she could not
drop, and she stayed on. This year is her third in that county, and she
is still working for the same salary. Fortunately this is an unusual
case, but I feel it is the duty of the supervising nurses in the State
to try to “ get across ” to the people in the county the value o f their
keeping a nurse, so they will not be always changing. But I think
they should not expect a nurse to stay on and on with no prospect of
ever getting any higher salary.
Mrs. M a t h e w s . Suppose a nurse has reached a salary of $160 a
month but for some reason the program must be discontinued, and
the nurse is transferred elsewhere in the State. Does she then go
back to a salary o f $125, or does she get $150?
Miss G r a h a m . We have just had one instance o f that sort in South
Carolina. Last year one o f our most capable nurses, who was receiv
ing $160 per month, was needed to start the work in a county where
we had never had a public-health service. W e told her that we could
not get more than $1,800 salary for her; but she agreed to take the
work, even though it meant a sacrifice in salary. This year the com
missioners have increased it to the amount she was receiving from
the other county.
Mrs. M a t h e w s . H o w many States have to hire their nurses through
civil service ? W e have to get ours in that way, and we can not dis
charge a nurse unless we bring charges o f inefficiency, which it, is
very difficult to do.
Doctor G a r d i n e r . In New York for the past seven years the State
department o f health has been asked by the State civil-service com
mission to outline standards for each examination, and the commis
sion has been strict about living up to the standards and not allowing
nurses to take the examination who do not come up to the standards.
The C h a i r m a n . Does that relate to county nurses?
Doctor G a r d i n e r . It relates to any, mostly to county and State
nurses.
Doctor S t a d t m u l l e r . Might I suggest that in writing to the civilservice commission you go into a good deal o f detail as to the quali
fications that you want? I have done that and found that it often
resulted in my being requested to pick my own nurse.
Miss Fox. There is one thing I wish to say, referring back to the
question o f compromising on standards and taking people for posi
tions who have had little or no experience in public-health nursing.
In the last 10 years we have had four or five thousand nurses in the
public health nursing division o f the Bed Cross. Our standards you
all know. We have compromised with them in every direction,
largely because our chapters have compromised and we do not like
to wield the big stick over them. I think I am safe in saying that,
by and large, the chapters that have placed nurses without any knowl
edge o f public-health nursing have found their service a flat failure.
W e should be willing to compromise in that direction if we got any
where, but we don’t. Other compromises have resulted in an ascend
ing scale o f success. A little experience has resulted in some little
work, more experience in more good work, and a highly qualified
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worker with the right personality has resulted in very good work.
Our experience has taught us that preparation is the thing that turns
the trick, so I am speaking not from theory but from actual, wide
experience.
The C h a i r m a n . The last paper this afternoon is on “ Methods of
training staff nurses in prenatal and infant care,” to be given by
Miss Mathilde Kuhlman, director o f the bureau o f public-health nurs
ing o f New York. New York has had a very definite program along
this line o f work.
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METHODS OF TRAINING STAFF NURSES IN PRENATAL
AND INFANT CARE
By
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The training o f staff nurses in prenatal and infant care has been
more or less in process o f evolution in New York since 1922 when two
nurses were engaged in the child hygiene division work, one with a
traveling unit composed o f one doctor and one nurse to conduct field
clinics for the examination o f preschool children and to supervise
child-hygiene stations and one for state-wide supervision o f midwives.
During the 1922 session o f the New York State Legislature a reso
lution to accept the provisions o f the Sheppard-Towner A ct was
presented, but the legislature instead o f accepting Federal aid
passed a substitute bill called the Davenport-Moore Act. This act
provided an appropriation which with the budget already available
constituted an amount equal to that which would have been obtain
able through the Sheppard-Towner Act. It outlined the specific
functions o f the division regarding the safeguarding of motherhood
and the protection o f the health o f infants and children, and changed
the name o f the division from the division o f child hygiene to the
division o f maternity, infancy, and child hygiene. This appropria
tion made possible and necessitated an increased staff o f publichealth nurses to carry on the work. In the following year the legisla
ture accepted the Sheppard-Towner Act.
The public-health council o f the New York State Department of
Health required that nurses on the staff should be registered by the
Regents o f the University o f the State o f New York and that they
should have had not less than two years o f experience in publichealth nursing. An effort was made to secure for the maternity,
infancy, and child-hygiene work nurses who met these requirements,
whose hospital training included obstetrics and pediatrics, and who
had in addition postgraduate training and experience in mother and
child health work. Very few places available to us were carrying
on prenatal, maternal, and infant public-health work to the extent
that nurses experienced in these activities could be readily obtained.
General standards for conducting the work were outlined by the
Children’s Bureau at its regional conferences in 1919. Details,
methods, and the machinery for carrying on according to the stand
ards outlined were sought from various sources including many
organizations in New York City.
We were fortunate in securing our first five nurses with previous
experience on the staff o f Maternity Center Association, New York
City. Most valuable cooperation has been and is extended to us by
this association in instruction o f our nurses. Each nurse coming
on State duty is required to spend a period for observation and in161
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struction at the Maternity Center Association, where most careful
and painstaking supervision is given each nurse by the field director
with whom conferences are held regarding details o f visits, conduct o f
mothers’ health clubs, prenatal and infant nursing care, methods o f
record keeping with reasons for accuracy, and other subjects per
taining to the work.
Other organizations in New York City extending cooperation and
opportunities for instruction and observation were: The Judson
Health Center, the Henry Street Settlement, the New York Diet
Kitchen Association, and the East Harlem Nursing and Health
Demonstration. Much valuable aid was given our nurses by these
organizations, whose methods and standards were carried to the rural
coimnunities o f the State and modified to meet their needs and
facilities.
An instructor to nurses was secured with extensive experience
and postgraduate preparation for the conduct o f an extension course
in maternity hygiene for community public-health nurses. Members
o f our own nursing staff were given this course o f instruction to pre
pare them to teach mothers’ health clubs. Lectures and demonstra
tions were given to groups o f five or more nurses in near-by com
munities, at intervals o f four weeks. The course comprised lectures
on the following topics: General problems o f maternal and infant
mortality in Nation and State and factors in reduction; physiology
and hygiene o f pregnancy; discomforts and abnormalities o f preg
nancy; full prenatal visits; preparation for delivery; after care o f
mother and baby and breast feeding; mothers’ clubs; written exam
ination. The eighth and last class period was given over to a talk
on nutrition or diet in pregnancy by the nutrition specialist o f the
division o f maternity, infancy, and child hygiene. Demonstrations
accompanying the course consisted o f : Layette and patterns; breast
tray, care o f nipples; abdominal binder; shoulder garters; baby’s
tray; preparation o f delivery bed; preparation o f baby’s bed; baby’s
bath; taking the blood pressure; urinalysis.
In 1923 an intensive breast-feeding campaign wak organized on
Long Island and was carried on for one year. All nurses in the
maternity, infancy, and child hygiene division were assigned to a
period o f this work in order to become familiar with it and to dis
seminate this knowledge wherever any other type o f work was to be
undertaken in the future. This work was under the immediate super
vision o f the regional consultant in pediatrics', who was president
o f the Brooklyn Pediatric Society. He personally instructed each
nurse assigned to the work and held frequent conferences with the
directors o f the maternity, infancy, and child-hygiene division and
the public health nursing division and with the field nurses.
As the maternity and infancy work progressed it was demonstrated
that nurses could not be instructed properly and the work standard
ized without a definite teaching center where they could spend a
month or more and where Sheppard-Towner and other community
public-health nurses could be instructed and closely supervised, with
frequent conferences with the directors o f both divisions and the
consultant nurses. After careful consideration and elimination of
places offering opportunities Poughkeepsie was chosen; cooperation
Was extended by local health officials; a high infant and maternal
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TRAINING STAFF NURSES IN PRENATAL AND IN F A N T CARE
163
death rate offered a field worthy o f endeavor; and the location was
easy o f access from headquarters office. In 1924 a mother and child
health station was equipped, and an endeavor was made to start a
teaching center for nurses. It was carried on with more or less
difficulty, and after some months the State department o f health
found it necessary to withdraw.
Some time was spent in careful statistical study by the division
o f vital statistics and deliberate consideration o f other places avail
able where there was1urgent need for this work. In November, 1924,
the associate director o f the division o f maternity, infancy, and child
hygiene presented the matter o f establishing in Fulton, Oswego
County, a demonstration mother and child health center before the
Fulton Academy o f Medicine, which later voted unanimously for
such a service and consented to appoint a medical advisory com
mittee to work with the nurse to be detailed to the work. The serv
ice was started with the idea o f first establishing a model program
with a view to the reduction o f the infant and maternal death rates,
and second, to develop standard nursing procedures so that eventually
it might be used for teaching purposes. This was brought about in
September, 1926, when an exceptionally well-qualified nurse was
found to take charge, whose personality, interest, initiative, and
previous teaching experience fit her admirably for this work. Two
other nurses are permanently assigned to assist her in carrying on
the work o f the center.
Each State department o f health nurse as she comes on duty
will go to the Fulton teaching center for a period o f instruction.
Sheppard-Towner nurses will be assigned there, and any community
nurses employed from whatever source will be urged to spend some
time at the center. It is also available to out-of-State nurses desiring
instruction.
We hope that as the work progresses community nurses may be
able to spend not less than a month at the center; a shorter time is
inadequate. Those nurses who have attended the teaching center
since September, 1926, are most enthusiastic about the instruction
and the knowledge gained.
Our present facilities for training staff nurses are the Fulton
teaching center, the children’s consultation unit, prenatal consulta
tion units, staff conferences with consultant nurses and directors,
suggested reading (Federal and State literature, mental-hygiene
and social-hygiene bulletins, maternity-center routines, and litera
ture from other sources), occasional visits to the Maternity Center
Association field center and to other New York City organizations
previously mentioned. As each phase o f the work developed a cer
tain technique was worked out and improved upon from time to time.
This has been particularly true in the case o f the traveling units,
each o f which has served as an experience school for new nurses
coming on the staff, available only to our own nurses because o f the
travel expenses involved.
An annual conference o f all health officers and public-health nurses
is called by the State commissioner o f health and is an important
factor in the education o f our nurses and instrumental in establish
ing the good will and cooperation o f all public-health nurses in the
State.
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D IS C U S S IO N
The C h a i r m a n . One o f the points that Miss Kuhlman brought
out in her closing remarks is that the teaching staff and State work
ers are available to go into the various services in the State and
help the local nurses and other health workers devise plans in that
community to do a certain part o f the maternity and infancy pro
gram. I think that is one o f the most important parts o f our work
to get the cooperation o f all the other agencies in the State to help’
with this program which we think is so important.
I should like to ask whether any o f the other States have a teach
ing center or have thought o f adopting that plan o f instructing.
Miss M a r r i n e r . At various times we have operated a teaching
center in Alabama, but it is not continuous nor permanent.
Mrs. M c C a l e b . W e have in Ohio the prospect o f the health com
mission to be developed along with the International Health Board.
I am hoping that this may result in a training center for the nurses
as well as the health commission. The stronger we can make the
nursing service, o f course, the better for teaching all the way around.
The C h a i r m a n . I s there any unfinished business ? Are there any
committees that you wish to appoint ? I f not, the conference is readv
to adjourn.
J
. M i s s B e a u c h a m p . I move to express our appreciation to the
Children s Bureau for letting us come together here to discuss our
problems. I am sure we have been very much helped by this con
ference.
J
(The meeting adjourned sine die.)
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APPENDIX.— LIST OF PERSONS ATTENDING THE
CONFERENCE
Abbott, Grace, Chief, Children’s Bureau, United States Department of Labor,
Washington, D. C.
Allen, Cora S., M. D., director, bureau of child welfare and public-health nursing,
State board o f health (M adison), Wisconsin.
Allen, Jane C., general director, National Organization for Public Health
Nursing, New York, N. Y.
Anderson, Dorothy R., director, division of child hygiene and public-health
nursing, bureau of public health, State department of public welfare (Santa
F e ), New Mexico.
Anderson, G. M., M. D., State health officer; acting director, division of
maternal and infant welfare and child hygiene, State department of public
health (Cheyenne), Wyoming.
Anderson, Viola Russell, M. D., expert in infant hygiene, maternity and infanthygiene division, Children’s Bureau, United States Department of Labor,
Washington, D. C.
Appleton, Vivia Bell, M. D., director, division of maternity and infancy, Terri
torial board of health (H onolulu), Hawaii.
Baker, S. Josephine, M. D., Stamford, Conn.; consultant, Children’s Bureau,
United States Department of Labor, Washington, D. C.
Beauchamp, Linnie, supervising nurse, bureau of child hygiene, State board of
health (Little Rock), Arkansas.
Bennett, Mrs. Emily, bureau o f child welfare, State board of health (Richmond),
Virginia.
Birdseye, Miriam, extension agent, Office of Cooperative Extension W ork and
Bureau of Home Economics Cooperating, United States Department of
Agriculture, Washington, D. C.
Bowdoin, Joe P., M. D., director, division of child hygiene, State board of
health (A tlan ta), Georgia.
Boynton, Ruth E., M. D., director, division o f child hygiene, State department
of health (Minneapolis), Minnesota.
Breeding, W . J., M. D., director, division of child hygiene and public-health
nursing, State department of public health (N ashville), Tennessee.
Brown, Margaret S., instructor of nurses, Fulton Child Health Station, Fulton,
N. Y.
Brydon, Mary E., M. D., director, bureau of child welfare, State board of health
(Richm ond), Virginia.
Calvert, Charlotte J., M. D ., bureau of child welfare and public-health nursing,
State board of health (M adison), Wisconsin.
Coffey, Ada B., consultant nurse, division of maternity, infancy, and child
hygiene, State department of health (A lban y), New York.
Coffin, Susan B., M. D., State department of health (B oston), Massachusetts.
Crough, Elena M., director, division of maternity, infancy, and child hygiene,
State board of health (Concord), New Hampshire.
Crumbine, Samuel J., M. D., general director, American Child Health Associa
tion, New York, N. Y.
De Laskey, Mary, supervising nurse, bureau of maternity and infancy, State
board o f health (Oklahoma C ity), Oklahoma.
D e Normandie, Robert L., M. D., instructor in obstetrics, Harvard Medical
School, Boston, Mass.
Diez, M. Luise, M. D., associate director, division of maternity, infancy, and
child hygiene, State department of health (A lbany), New York.
Dillon, Mrs. Jean T., director, division of child hygiene and public-health nurs
ing, State department of health (Charleston), W est Virginia.
Dumm, I. B., M. D., consultant, child-welfare bureau, State department of public
instruction (D enver), Colorado.
165
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Eliot, Martha M., M. D., director, child-hygiene division, Children’s Bureau,
United States Department of Labor, Washington, D. C.
Erikson, Ella, director, division of child hygiene, State department o f health
(Seattle), Washington.
Farquhar, Margaret, consultant nurse, division of maternity, infancy, and
child hygiene, State department of health (A lban y), New York.
Ferrell, John A., M. D., Dr. P. H ., associate director, International Health Divi
sion, Rockefeller Foundation, New York, N. Y.
Fox, Elizabeth, national director of public-health nursing, American National
Red Cross, Washington, D. C.
Gardiner, Elizabeth M., M. D., director, division of maternity, infancy, and
child hygiene, State department of health (A lban y), New York.
Gardner, Emily, M. D., assistant director, bureau of child welfare, State board
of health (Richmond), Virginia.
Gleason, Marion A., M. D., director, division o f child welfare, State board of
health (Providence), Rhode Island.
Graham, Ada Taylor, director, bureau of child hygiene and public-health nurs
ing, State board of health (Colum bia), South Carolina.
Haines, Blanche M., M. D ., director, maternity and infant-hygiene division,
Children’s Bureau, United States Department of Labor, Washington, D. C.
Hall, Carrie M., president, National League of Nursing Education, New York,
N. Y.
Hanna, Agnes K., director, social-service division, Children’s Bureau, United
States Department of Labor, Washington, D. C.
Hayes, Clara E., M . D., director, division o f child hygiene, State board of
health (W au b ay ), South Dakota.
Hayne, James A., M. D., secretary, State board of health (Colum bia), South
Carolina.
Henshaw, W . T., M. D., commissioner, State department of health (Charleston),
W est Virginia.
Holmes, Rudolph W ., M. D., associate professor of obstetrics and gynecology,
Rush Medical College, University of Chicago, Chicago, 111.
Howe, Mrs. Charles R., director, child-hygiene division, State board oi health
(Phoenix), Arizona.
Ingraham, A . Elizabeth, M. D., director, bureau of child hygiene, State depart
ment of health (H artford), Connecticut.
Jackson, Edith B., M. D., medical officer, child-hygiene division, Children’s
Bureau, United States Department of Labor, Washington. D. C.
Jones, Nellie M., supervising field nurse, State department of public health
(Burlington), Vermont.
King, Ruth B., consultant nurse, division of maternity, infancy, and child
hygiene, State department o f health (A lban y), New York.
Knipp, Gertrude B., chief, division of public-health education, State depart
ment o f health (Baltim ore), Maryland.
Knox, J. H . Mason, jr., M. D., chief, bureau o f child hygiene, State depart
ment of health (Baltim ore), Maryland.
Krause, Irl Brown, M. D., director, division of child hygiene, State board of
health (Jefferson C ity), Missouri.
Kuhlman, Mathilde S., director, division o f public-health nursing, State de
partment of health (A lban y), New York.
Lauer, Edward H ., Ph. D., director, division o f maternity and infant hygiene,
extension division, State University of Iowa, Iowa City, Iowa.
Levy, Julius, M. D., consultant, bureau o f child hygiene, State department of
health (Trenton), New Jersey.
McCaleb, Mrs. Zoe, chief, division o f nursing, State department of health
(Columbus), Ohio.
Marriner, Jessie L., director, bureau of child hygiene and public-health nursing,
State board o f health (Montgomery), Alabama.
Mathews, Mrs. E. N., executive secretary, child-welfare bureau, State depart
ment o f public instruction (D enver), Colorado.
Miller, Elizabeth F., State department o f welfare (H arrisburg), Pennsylvania.
Minor, Nannie J., supervising nurse, bureau of child welfare, State board of
health (Richm ond), Virginia.
Monger, John E., M. D., director o f health, State department of health (Colum
bu s), Ohio.
Moore, Mrs. Helen de Spelder, assistant director, bureau o f child hygiene and
public-health nursing, State department of health (Lansing), Michigan.
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APPENDIX.---- PERSONS ATTENDING THE CONEERENCE
167
Morris, Agnes, director, bureau of child hygiene, State board of health (New
Orleans), Louisiana.
Murphy, Louise M., director, division of child hygiene, State department of
public welfare (Lincoln), Nebraska.
Noble, Mary Riggs, M. D., chief, preschool division, bureau of child health,
State department o f health (H arrisburg), Pennsylvania.
Osborne, Mary D., supervisor, public-health nursing, bureau o f child hygiene
and public-health nursing, State board of health (Jackson), Mississippi.
Patterson, Florence M., general director, Community Health Association, Boston,
Phelan, Marie T., expert in maternal and infant care, maternity and infanthy|iene division, Children’s Bureau, United States Department of Labor.
Washington, D. C.
.
Pickett, Alice N., M. D., instructor in obstetrics, director of prenatal clinics,
school of medicine, University of Louisville, Louisville, K y.
Reid, Mrs. Laurie Jean, director, bureau of child welfare and public-health
nursing, State board of health (Jacksonville), Florida.
Richards, H. Y., M. D., director, bureau o f child hygiene, State board of health
(S alt Lake C ity ), Utah.
,
^ . .
Richardson, Frank Howard, M. D „ New York, N. Y., regional consultant, division
of maternity, infancy, and child hygiene, State department of health (Albany),
New York.
. . .
..
Sargent, Clealand A., M. D., director, division of child hygiene, State board of
health (D over), Delaware.
. . . . .
„x
Schweitzer, Ada E., M. D., director, division o f infant and child hygiene, State
board of health (Indianapolis), Indiana.
Sheahan, Marion, assistant director, division of public-health nursing, State
department of health (A lbany), New York.
Smith, Lillian R., M. D., director, bureau of child hygiene and public-health
nursing, State department o f health (Lansing), Michigan.
Soule, Edith L., director, division of public-health nursing and child hygiene,
State department of health. (A ugusta), Maine.
;-L
_
Stadtmuller, Ellen S., M. D., director, bureau o f child hygiene, State board of
health (San Francisco), California.
4 „
. . ...
Stumbles, Gertrude, consultant nurse, division of maternity, infancy, and chud
hygiene, State department of health (A lban y), New York.
Sullivan, Mary, supervisor of midwives, bureau o f child hygiene, State depart
ment of health (Trenton), New Jersey.
Tallant, Alice W eld, M. D ., Philadelphia, Pa., consultant, Childrens Bureau,
United States Department of Labor, Washington, D. C.
Underwood, Felix J., M. D., executive officer, State board of health, acting
director, bureau of child hygiene and public-health nursing, State board of
health (Jackson), Mississippi.
.
Veech, Annie S., M. D., director, bureau o f maternal and child health, state
board of health (Louisville), Kentucky.
,
.
.
_
Whipper, Ionia R., M. D., expert in maternal and infant hygiene, maternity and
infant-hygiene division, Children’s Bureau, United States Department of
Labor, Washington, D. C.
. . . _ ...
William s, Maysil M., M. D., director, division o f child hygiene and public-health
nursing, State department of public health (Bism arck), North Dakota.
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis
@FedFRASER