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U. S. DEPARTMENT OF LABOR JAMES J. DAVIS, Secretary CHILDREN’S BUREAU << GRACE ABBOTT, Chief THE PROMOTION OF THE WELFARE AND HYGIENE OF MATERNITY AND INFANCY THE ADMINISTRATION OF THE ACT OF. CONGRESS OF NOVEMBER 21, 1921 For the Period March 20, 1922, to June 30, 1923 & Bureau Publication N o. 137 WASHINGTON GOVERNMENT PRINTING OFFICE 1924 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OWING TO LIMITED APPROPRIATIONS FOR PRINTING, IT IS NOT POSSIBLE TO DISTRIBUTE THIS BULLETIN IN LARGE QUANTITIES. ADDITIONAL COPIES MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D . C. AT 10 CEN TS P E R C O P Y https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CONTENTS. Page. Letter of transmittal________________ y (h https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis i) ¿51 3 ^ 7 VI C O îO « ^ * ^ 0 5 0 ( ^ I s î | - i | - i M a c t I L_egiSlatiVe acceptance ~by the States o f the mliter‘nitÿ"ând"rnfâricÿ The law_______ __________ ~~~ Summary of provisions____________________ IZ IIIIIIIII Funds available under the a ct-____________ States accepting the terms of the actZ_______ Z____ Z__ Payment o f Federal funds to the States______________ __I____ I " The Federal Board of Maternity and Infant Hveiene State administration______________ ,_______________ _ — Administrative agencies and their personnel_I___________ General education_________________________________ 7 Hygiene of maternity____________ _____ ~_________ Health conferences_______________ _____ ~ _______ % Dental hygiene__________________ I I ______________ _ Nutrition classes_________ _____I ___________________ II I I I Vital statistics_____^__________________________ ~ Surveys_______________ Z_ZZI__I _____ _____ ~" Inspection of maternity and children’s homes County-unit schemes_________ _________ _________ I__II__ Cooperation of lay workers-________________ Cooperation of the medical profession_______ Federal administration__________________________ — Federal staff____________________________ I__ZIIII ~ — Institutes for public-health nurses__________ ___________ Publications and other literature_______I ___________ _ 1“ Research_________________________________ ___ g Accounting_______ ________________________ “ __~~ Reporting of State activities__ I _________ I_ I I I I I I _I ’"IIH Accomplishments under the maternity and in fan cvact Appendixes : Text of the act for the promotion of the welfare and hygiene of maternity and infancy_____________________________ _ B. — Constitutionality of the act__________ _________ _ ~ C. —Rulings of the Comptroller General of the Treasury D. — Instructions for accounting under the act__________ 16 18 19 20 21 22 23 24 25 27 27 27 28 29 30 30 32 35 38 41 42 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis LETTER OF TRANSMITTAL. U . S. D e p a r t m e n t of L abor, C h il d r e n ’s B ureau, Washington, February 11, 1921},. S i r : There is transmitted herewith a report o f the activities un dertaken for the promotion of the welfare and hygiene o f maternity and infancy under the act o f Congress o f November 21, 1921, during the period from March 20, 1922, when the first appropriation became available, to June 30,1928. Dr. Anna E. Rude, director o f the mater nity and infant-hygiene division of the Children’s Bureau, was in immediate charge o f this work for the bureau and has prepared this report. Respectfully submitted. Hon. G race A J am es J. D a v is , Secretary o f Labor. (v) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis bbott, C h ief. LEGISLATIVE ACCEPTANCE B Y THE STATES OF THE M ATERN ITY A N D IN F A N C Y ACT. (JULY 1, 1923.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE PROMOTION OF THE WELFARE AND HYGIENE OF MATERNITY AND INFANCY. THE LAW . SUM M ARY OF PROVISIONS. Nation-wide acknowledgment of the need for better health protection o f motherhood and infancy became a reality with the passage of “ An act for the promotion o f the welfare and hygiene o f maternity and infancy and for other purposes,” more popularly known as the Sheppard-Towner Act. The original bill, with subsequent amend ments, came up for consideration before three Congresses, the Sixtyfifth, Sixty-sixth, and Sixty-seventh. It was passed on November 21, 1921, and was signed by the President on November 23, 1921. The measure in its original form was offered as a means of begin ning the solution o f the long-neglected problems o f maternal and infant hygiene which were pointed out in the series o f investigations on maternal and infant mortality made by the Children’s Bureau during the nine years o f its existence. While certain minor provisions o f the original bill were omitted and a few new stipulations added, the bill as passed carried out the original purpose o f the measure in that provision was made for (1) Federal financial aid to the States, (2) the administration o f this aid by the Children’s Bureau, (3) the application o f such aid to tile problem o f reducing maternal and infant mortality and its use in protecting the health of mothers and infants, and (4) the' vesting in the States of complete authority to initiate and to administer plans subject to approval by the Federal Board of Maternity and Infant Hygiene. Briefly analyzed, the provisions o f the act are: I. Benefits available to the States. (1 ) Funds authorized for year ended June 30, 1922__________ $490, 000 To be equally apportioned among the States and granted outright to States accepting the provisions of the a c t ------- i — ;__________ ________________ ____ ____________ 240, 000 To be apportioned to the States if matched dollar for dollar by State appropriations in the proportion which their population bears to the total population of the States of the United States______ .____ _________ 1237, 500 (2 ) Funds authorized for each of five years after June 30, 1 9 2 2 ---------- ----------------------------------------- ---------------------------- * 1, 240, 000 1 F o r F ed era l a d m in is tra tio n o f the a ct, n o t to exceed $12,500. O f th is a m ou n t $ 2 4 0 ,0 0 0 is t o be eq u a lly a p p o rtio n e d a m o n g th e S ta te s a n d g ra n te d o u t r ig h t ; $ 2 4 0 ,0 0 0 a d d itio n a l is t o be e q u a lly a p p o rtio n e d to th e S ta te s and gra n te d i f m atch ed d o lla r f o r d o l la r ; a n d $ 7 1 0 ,0 0 0 is to be a p p o rtio n e d to th e S ta te s on the b asis o t p o p u la tio n an d p a n t e d i f m a tch e d d o lla r f o r d o lla r . A sum n o t to ex ce e d $50 ,00 0 is a llo w e d fo r F ed era l a d m in istra tion . 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 TH E PROMOTION OP THE WELFARE AND HYGIENE I. Benefits available to the States— Continued. (3 ) Prohibitions. (а) Funds may not be used (1 ) for the purchase, erection, preservation, or repair of any building or buildings or equipment nor for the purchase or rental of any buildings or lands; (2) for the payment of any maternity or infancy pension, stipend,-or gratuity. (б ) Acceptance of benefits must be voluntary on part of both State and individual. II. How the States may secure the benefits of the act. (1) The State legislature must (or the governor may for a period limited to six months after the adjournment of the first regular session of the State legislature after the passage of the act) — (a) Accept the provisions of the act. (b) Designate a State agency with which the Children’s Bu reau is to cooperate in carrying out the purposes of the act. Any State having a child-welfare or child-hygiene division in its health department or board must desig nate that division. (2) The child-hygiene or child-welfare division of the department of health or other designated agency must— (a ) Submit detailed plans for carrying out the provisions of the act within the State to the Children’s Bureau for approval by the Federal Board of Maternity and In fant Hygiene. (b ) Make such reports to the Children’s Bureau concerning its operations and expenditures for the purposes of the act as shall be prescribed or requested by the bureau. III. Powers and duties of the Children’s Bureau under the act. (1) To cooperate with the agency designated by each State for local administration. (2 ) To make such studies, investigations, and reports as will promote the efficient administration of the act. (3 ) To certify to the Secretary of the Treasury o f the United States and to the treasurers of the States the amount which has been apportioned to each State for the fiscal year. (4 ) To carry on the general administration of the act. IV. The Federal Board of Maternity and Infant Hygiene. (1 ) Membership: The Chief of the Children’s Bureau, the Surgeon General of the Public Health Service, and the Commissioner of ^ Education. (2 ) Chairman: To be elected by the board.* (3 ) Powers: (a) To approve or disapprove plans submitted by the States. (b ) To withho’ d further certification of Federal funds to a State if the money is not properly expended.4 FU N D S A V A IL A B L E UNDER TH E AC T . Fiscal year 1922. Although the act was passed in November, 1921, the funds au thorized by the act did not become available until March, 1922. Onefourth o f the fiscal year ending June 30, 1922, then remained, and Congress concurred in the recommendation o f the appropriation committee decreasing the initial appropriation authorized by the act. Consequently the second deficiency appropriation act, approved March 20, 1922, carried an appropriation o f $490,000. The follow ing table shows the population of the several States in 1920 and the maximum amounts o f money which the several States were eligible to receive in 1922 from the Federal Government for cooperative 8 T h e C h ie f o f the C h ildren ’ s B u rea u w a s elected ch airm a n a t th e first m e e tin g o f th e s t a t e m ay a p p ea l fr o m th e d e cis io n o f t h e h oa rd to th e P re s id e n t o f th e U nited S ta tes. . https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATERNITY AND INFANCY, 3 work under the maternity and infancy act, and the amounts which they accepted: T 3 . — Maximum amounts available to the States from the appropriation for the fiscal year ending June 80, 1922, and amounts accepted by States. able Maximum amounts available. State. A labam a............ Arizona.............. Arkansas........... California........... Colorado............. Connecticut____ Delaware........... Florida................ Georgia................ Idaho................. . Illinois.......... . Indiana............... Iow a.......... . ........ Kansas___ . . . . . . K en tu cky........... Louisiana.......... . Maine................. . Maryland............ Massachusetts.. . Michigan............. Minnesota........... Mississippi.......... Missouri.............. Montana............. Nebraska............. Nevada................ N ew Hampshire. N ew Jersey......... New M exico....... New Y ork........... North C arolina.. North D a k ota ... O h io..................... Oklahoma........... Oregon................. Pennsylvania___ R hode Island___ South C arolina.. South D akota. . . Tennessee........... Texas................... U tah.................... Verm ont.............. Virginia............... W ashington........ W est V irgin ia .. . W isconsin........... W yom ing............ Population, 1920. 2, 348,174 334,162 1, 752,204 3, 426,861 939,629 1, 380,631 223,003 968,470 2, 895,832 431,866 6, 485,280 2, 930,390 2, 404,021 1, 769,257 2, 416,630 1, 798,509 768,014 1, 449,661 3, 852,356 3, 668,412 2, 387,125 1, 790,618 3, 404,055 548,889 1, 296,372 77,406 443,083 3, 155,900 360,350 10, 385,227 2, 559,123 646,872 5, 759,394 2, 028,283 783,389 8, 720,017 604,397 1, 683,724 636,547 2, 337,885 4, 663,228 , 449,396 352,428 2, 309,187 1, 356,621 1, 463,701 2, 632,067 194,402 Granted outright. $5, 000.00 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 00 5, 000:00 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5, 000)00 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. Granted if matched. $5, 297.56 00 753.88 00 3. 953.03 00 7, 731.12 00 2. 119.83 3, 114.75 503.10 00 2, 184.90 00 6, 533.10 00 974.30 0014, 631.03 00 6, 611.07 00 5, 423.56 00 3, 991.51 00 5, 452.00 00 4, 057.50 00 1. 732.66 00 3, 270.49 00 8. 691.06 00 8. 276.07 00 5, 385.44 00 4, 039.70 7. 679.67 00 1, 238.31 00 2, 924.66 00 174.63 00 999.61 00 7. 119.83 00 812.96 0023, 429.70 00 5, 773.47 00 1, 459.36 0012. 993.41 00 4, 575.88 00 1. 767.35 0019, 672.69 00 1. 363.54 00 3. 798.54 00 1. 436.07 00 5. 274.35 0010. 520.41 00 1, 013.85 00 795.09 00 5, 209.61 00 3, 060.58 00 3, 302.16 00 5. 938.04 00 438.57 Total. $10, 297.56 5. 753.88 . 8, 953.03 12, 731.12 7, 119.83 8, 114.75 5, 503.10 7, 184.90 11, 533.10 5. 974.30 19. 631.03 11, 611.07 10, 423.56 8, 991.51 10, 452.00 9, 057.50 6. 732.66 8,270.49 13. 691.06 13. 276.07 10, 385.44 9, 039.70 12,679.67 6.238.31 7. 924.66 5, 174.63 5, 999.61 12, 119.83 5, 812.96 28, 429.70 10, 773.47 6, 459.36 17. 993.41 9. 575.88 6, 767.35 24, 672.69 6. 363.54 8. 798.54 6, 436.07 10, 274.35 15. 520.41 6, 013.85 5, 795.09 10,209.61 8, 060.58 8, 302.16 10. 938.04 5, 438.57 Amounts accepted b y States.1 $10, 297.56 5. 000. 00 5. 000. 00 212, 731.12 5. 000. 00 8, 114.75 5, 503.10 5. 000. 00 6. 750.00 5. 000. 00 219, 631.03 8.200.00 10, 423.56 8, 991.51 10, 452.00 8, 270.49 13, 276.07 10, 385.44 9, 039.70 12, 679.67 6, 238.31 7, 924.66 5. 000. 5. 000. 00 12, 119.83 5, 812.96 10, 773.47 5. 000. 7, 275.00 5. 000. 6, 625.13 24, 672.69 8, 797.50 6, 436.07 5. 000. 00 9, 363.93 5. 000. 00 25, 000.00 10, 209.61 5. 000. 5. 000. 00 10,938.04 5. 000. 1 In clu d e s u n m a tch ed a llo tm e n t. * C a lifo rn ia , Illin o is , an d V e rm o n t d id n o t u se th e ir fu n d s . Fiscal year 1923. The funds available to the States under the 1923 appropriations were the amounts authorized to be appropriated annually for a period o f five years under the provisions of the act; namely, $240,000, to be distributed as an unmatched grant o f $5,000 to each State ac cepting the provisions of the act, and an additional sum of $1,000,000. O f this additional amount not more than 5 per cent, or $50,000, may be used for Federal administration, and the balance, or $950,000, is to be apportioned to the States and granted if matched dollar for dollar by State appropriations on the basis of $5,000 to each State and the remainder, or $710,000, prorated on the basis of population. 91062°— 24------2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 00 00 00 00 00 THE PROMOTION OP THE WELFARE AND HYGIENE 4 The following table shows the maximum fund which the several States are eligible to receive from the Federal Government for cooperative work under the maternity and infancy act and the amounts which were paid to them or are to be p a id 6 from the appro priation for the fiscal year ended June 30,1923: T 2 . — Maximum amounts available to the States from the appropriation for the fiscal year ended June 30, 1923, and amounts accepted by States. able Maximum amounts available. State. Population, 1920. A labam a.............. Arizona................ Arkansas............. California............. Colorado............... Connecticut........ Delaware............. Florida................. Georgia................ I d a h o . . . , ........... Illin ois................ Indiana................ Iow a..................... Kansas............. K en tu cky___ — Louisiana............ Maine................... Maryland............. Massachusetts.. . Michigan............. Minnesota........... Mississippi.......... Missouri............... Montana.............. Nebraska............. N evada................ N ew Hampshire. N ew Jersey......... New M exico....... New Y ork ........... North Carolina.. North D a k ota ... O hio..................... O k la h o m a ....... Oregon................ Pennsylvania.. . R hode Island— South Carolina.. South D a k ota ... Tennessee.......... Texas............... U ta h .................. V erm ont............ Virginia............. Washington-----W est V irginia... Wisconsin......... W yom ing.......... 1Includes 2, 348,174 334,162 1, 752,204 3, 426,831 939,629 1,380 631 223,003 968,470 2, 895, 832' 431,866 6, 485,280 2, 930,390 2, 404,021 1, 769,257 2, 416,630 1, 798,509 768,014 1, 449,661 3, 852,356 3, 668,412 2, 387,125 1, 790,618 3, 404,055 548,889 1, 296,372 77,407 443,083 3, 155,900 360,350 10, 385,227 2, 559,123 646,872 5, 759,394 2, 028,283 783,389 8, 720,017 604,397 1, 683,724 636,547 2, 337,885 4, 663,228 449,396 352,428 2, 309,187 1, 356,621 1, 463,701 2, 632,067 194,402 Granted outright. 15, 000.00 5. 000. 5.000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5. 000. 5)000.00 5. 000. 5, 000.00 5, 000.00 5. 000. 5. 000. 5. 000. 5, 0C0 .00 5. 000. 5. 000. 5. 000. Granted if matched. «20, 836.95 00 7, 253.71 0016. 817.51 0028, 112.01 0011. 337.20 0014. 311.48 00 6, 504.01 0011, 531.72 0024. 530.55 00 7, 912.66 0048. 739.10 0024. 763.62 0021, 213.60 0016. 932.52 0021. 298.64 0017, 129.80 0010. 179.77 0014, 777.05 0030, 981.70 0029. 741.11 0021.099.65 0017, 076.58 0027,958.19 00 8, 701.91 0013. 743.21 00 5, 522.06 00 7, 988.31 0026. 284.55 00 7, 430.33 0075. 041.78 0022. 259.66 00 9. 362.74 0043. 843.46 0018. 679.48 0010. 283.46 0063, 810.99 00 9, 076.28 16, 355.65 00 9. 293.11 20. 767.55 36. 450.52 00 8. 030.89 00 7. 376.90 0020, 574.00 14. 149.55 0014. 871.74 0022. 751.62 00 6. 311.12 Total. $25, 836.95 12. 253.71 21. 817.51 33. 112.01 16. 337.20 19. 311.48 11. 504.01 16. 531.72 29. 530.55 12, 912.66 53. 739.10 29. 763.62 26, 213.60 21. 932.52 26. 298.64 22, 129.80 15. 179.77 19. 777.05 35, 981. 7» 34. 741.11 26. 099.65 22, 076.58 32, 958.19 13, 701.91 18. 743.21 10. 522.06 12, 988.31 31. 284.55 12, 430.33 80. 041.78 27. 259.66 14. 362.74 48. 843.46 23. 679.48 15. 283.46 68, 810.99 14, 076.28 21, 355.65 14. 293.11 25. 767.55 41. 450.52 13. 030.89 12. 376.90 25, 574.00 19. 149.55 19. 871.74 27. 751.62 11. 311.12 Amounts accepted b y States.i $25, 836.95 5, 000.00 6, 855.75 24. 280.00 10,000.00 9, 655.74 11. 504.01 8, 621.28 11,000.00 6, 250.00 25, 000.00 26, 213.60 12, 500.00 26, 298.64 19, 277.05 84, 741.11 26, 099.65 22, 076.58 32, 958.19 13, 701.91 18, 743.21 5. 000. 5. 000. 00 31, 284.55 12, 430.33 27, 259.66 6,000. „0 11, 900.00 5. 000. 8.000. 00 00 68, 810.99 21, 375.65 14, 293.11 19, 000.00 35, 313.93 0, 365.00 25, 574.00 10,000.00 5. 000. 90 27, 751.62 5. 000. unmatched allotment. STATES ACCEPTING TH E TERMS OF TH E AC T . By June 30, 1922, 42 States had accepted the terms o f the act, 11 by legislative enactment— Delaware, Kentucky, Maryland, Min nesota, Mississippi, New Hampshire, New Jersey, New Mexico, Oregon, South Carolina, and Virginia— and 31 through the approval o f the governor pending the next regular session of the legislature. > T h ese a m ou n ts w ere n ot n ecessa rily exp en d ed in 1 9 2 3 ; som e S ta tes w ill use th e 1923 fu n d s d u rin g th e fiscal yea r en d in g in 1924. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 00 00 OF MATERNITY AND IN FAN C Y. 5 O f the six States not cooperating with the Federal Government under the act in 1922 and during the first half of the fiscal year 1923, the legislatures of Louisiana, Massachusetts, New York, and Rhode Island met and did not accept the act, and the Governors o f Maine and Washington did not accept. By the close o f the fiscal year ended June 30,1923, all State legis latures had met since the passage o f the act and 40 States had ac cepted the terms o f the act, the 8 States not accepting being Con necticut, Illinois, Kansas, Louisiana, Maine, Massachusetts, Rhode Island, and Vermont. In Maine the bill providing for acceptance was vetoed by the governor after it had passed the legislature by a substantial vote. In Illinois, Kansas, and Louisiana tbo act passed the senate but in the first two States it did not come to a vote in the house and in Louisiana it was rejected by the house. The legisla tures o f Connecticut, Illinois, Kansas, and Vermont failed to uphold the governors’ provisional acceptance of the previous year. The original plan o f paying Federal funds to the States provided for two payments to each State out o f the appropriation for any fiscal year. J P A Y M E N T OF FE D E R A L FU NDS TO TH E STATES. Fiscal year 1922. The act provides that the appropriations shall be available to the States for one year after the close o f the fiscal year. The ^rst Payments to the States were not made until May, 1922. This delay was caused by necessary preliminary correspondence with tne States in regard to outlining plans o f work and by waiting for the approval o f certain forms requiring preliminary decisions by the Comptroller General o f the Treasury.6 The first payment from the 1922 appropriation covered the amount which the State estimated it would expend by June 30, 1922 A second payment was made after June 30, 1922. This payment’ was made as soon as the Board o f Maternity and Infant Hygiene ap proved the State plans, including the budget for the remainder of the 1922 appropriation. The States which did not submit plans in time to have them con sidered prior to June 30, 1922, were paid the entire amount o f the fund due them as soon after June 30,1922, as their plans and budgets covering these funds were approved. Separate reports o f expendi tures were asked for the 1922 and 1923 appropriations. Payments were made to 43 States from 1922 funds.7 ’ O f these 22 matched the full allotment available, 6 matched it in nart a n d i* accepted only the $5,000 grant outright. ' Fiscal year 1923. O f the 41 States which conducted cooperative work with 1923 funds, 17 matched the full apportionment, 18 matched it in part and 6 accepted only the $5,000 grant without matching. While 3 States— California, Kansas, and Maryland—which matched in full the three months’ appropriation for 1922 matched only in part the ® S ee A p p e n d ix C fo r ru lin g s a s t o a p p ro p ria tio n s . t u S l o 't h e T S S y f n d V erm on t d id n o t s^ n d th eir 1922 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis w h ich w ere la te r re- 6 THE WELFARE AND HYGIENE OF MATERNITY AND IN FAN C Y. 1923 funds, and 2 States—Illinois and Vermont— did not accept any Federal funds for 1923, 6 States— Colorado, Florida, Idaho, Tennes see, Utah, and Washington—which accepted only the $5,000 granted outright for 1922 increased their State appropriations and matched in part the 1923 funds. . By June 30,1923, all State legislatures had met, and the appropria tion acts passed enabled 40 States— all having budgets in excess of the unmatched $5,000—to cooperate during the fiscal year 1924. New York, which had not accepted in 1922, accepted the act in 1923 and made its first appropriation to cover the fiscal year ending June 30 1924. Since the maternity and infancy act became effective, 33 States which have accepted the act have made definite increases in their appropriations for the promotion of maternal and infant hygiene work, 6 have continued to appropriate the same amount as before, and 2— California and New Jersey—have decreased their appropria tions. California’s reduction is part of a general economy program in all State departments. New Jersey reduced the appropriation it had been making for its division of child hygiene, $150,000, by $75,000, the amount, available for that division from the Federal Government. TH E FED ERAL BOARD OF M A T E R N IT Y A N D IN F A N T H YG IE N E . The first meeting o f the Federal Board o f Maternity and Infant Hygiene was held on April 18, 1922, in the office of the Children’s Bureau. A t this meeting the Chief o f the Children’s Bureau was elected chairman o f the board, and the plans of 23 States for the remaining three months o f the fiscal year 1922 were approved. While the board agreed that the act was intended to promote the welfare of mothers and children during the first few years of life,^ it was recognized that some flexibility was necessary, especially m those States in which only school health work had been done. The plans of six of these States were accepted with the proviso that the ap proval o f certain items, such as work with the school child and courses in the hygiene of maternity and infancy in girls’ and women’s schools, should not constitute a precedent for the approval o f such items in subsequent plans. ’’ . , T The Federal board held six meetings from April 18, 1922, to June 30 1923, and approved 358 State plans for the last quarter of the fiscal year ended June 30, 1922, and 40 8 State plans for the fiscal year ended June 30, 1923.9 8 In clu d es Illin o is , w h ic h w a s p rev en ted b y S ta te la w fro m u s in g F e d e ra l fu n ds. » One p lan fo r 1922 an d th re e fo r 192 3 w e r e a p p ro v e d b y th e b o a r d m in te rv a ls b etw een m eetings. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis STATE ADMINISTRATION. A D M IN IST R A T IV E AGENCIES A N D THEIR PERSONNEL. State agencies cooperating with the Children’s Bureau. The maternity and infancy act provides that in States in which there is a child-welfare or child-hygiene division in the State agency of health this division shall he the local administrative agency. Otherwise, the State legislative authority must designate or author ize the creation of a State agency with which the Federal Govern ment may cooperate in the administration of the act. In the majority of the States the administration is lodged in a child-hygiene division of a State department o f health, but excep tions may be noted in the following list of State agencies cooperat ing in the administration of the act : State. Department. Division. Bureau of child hygiene and public-health nursing. __ _ do_____ __________ Child-hygiene division. Arizona. do. _ _______ __ __ Bureau of child hygiene. Arkansas - _ _ Do. .. d o . _ . California _ _ _ _ C o lo ra d o _______ Department of public in Child-welfare bureau. struction. Connecticut_____ Department of health___ Bureau of child hygiene. Delaware __ _ _ State health and welfare Child-welfare department. commission. Florida. ~______ State board of public health Bureau of child welfare. State board of health____ Division of child hygiene. G e o rg ia __ __ I d a h o _______ __ Department of public Bureau of child hygiene. welfare. Indiana. ______ State board of health___ Division of infant and child hygiene. Iow a. _ ________ State university, board Division of maternity and in fant hygiene. of education. Kansas__________ Department of the State Division of child hygiene and public-health nursing. board of health. Kentucky_______ State board of health____ Bureau of maternal and child health. M a r y la n d .__ __ Department of health.__ Bureau of child hygiene. Michigan. . _ _ _____do_____ __ _ _____ Bureau of child hygiene and public-health nursing. State board of health____ Division of child hygiene. Minnesota. __ Mississippi ____ __ .d o ________ ____ _____ Bureau of child welfare. Missouri. _ ___ __ __do._ ________ ______ Division of child hygiene. _ _ _ _ Division of child welfare. Montana__ __ ____d o ______ Nebraska _______ Department of health and Division of child hygiene. welfare. State board of health____ Child-welfare division. Nevada________ New Hampshire.. State board of health____ Division of maternity, infancy, and child hygiene. New Jersey Department of health___ Bureau of child hygiene. New Mexico_____ Board of public welfare__ Bureau of child welfare; Bureau of public health, division of child hygiene and p u b l i c health nursing. Alabama _ ______ State board of health_ 7 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 TH E PROMOTION OF THE WELFARE AND HYGIENE State. New York. Department. Division. Department of health----- Division of maternity, infancy, and child hygiene. Bureau of maternity and infancy. Division of child hygiene and public nursing. Division of child hygiene. Bureau of child hygiene. Do. Preschool division, bureau of child health. Bureau of child hygiene and public-health nursing. Division of child hygiene. Division of maternal and infant hygiene. Bureau of child hygiene. Do. Bureau of child welfare. Child-hygiene division. Division of child hygiene and public-health nursing. Bureau of child welfare and public-health nursing. Bureau of maternal and infant hygiene. State board of health ____ Department of public health. Ohio____________ Department of health____ Oklahoma_______ State department of health Oregon__________ State board of health-----Pennsylvania____ Department of health-----North Carolina. North Dakota__ South Carolina__ State board of health____ South Dakota Tennessee____ Texas________ Utah________ Virginia_____ Washington. West Virginia. ____do__________________ Department of public health. State board of health____ ___ _do________ __________ ____ do__________________ Department of health-----____ do__________________ Wisconsin State board of health____ Wyoming Department health. of public Personnel of the administrative agencies. The personnel of the State administrative agencies must neces sarily vary with the size o f the budget and the type and the size of the staff developed. A ll of the States report difficulty in securing well-trained and experienced personnel. This difficulty has been greatest in States initiating their work in this field. Full-time personnel has been more or less subject to change during this first year, but the following brief summary gives the various types and numbers employed according to figures submitted after State work was well established and reported in the second activities report, covering the period January 1 to June 30, 1923: (a) Physicians.— Only 23 o f the 41 cooperating States (56 per cent) reported full-time physicians on their staffs. Eight States reported part-time physicians only, and 9 had none at all. Indiana employs 5 full-time physicians, Pennsylvania and Michigan 3 each, and 9 other States employed 2 each. Three States that had one full-time physician had in addition physicians employed on part time, Montana having 7, Minnesota 3, and Arkansas X. (b) Public-health nurses.—There was no State which did not employ at least one public-health nurse. Pennsylvania and New Jersey employed 146 and 83, respectively, who devoted part of their time to infancy and maternity work. Alabama, Delaware, and Mis sissippi have the next largest numbers—28, 18, and 16, respectively. Tennessee reports 12 and Texas 10 giving full time to this field. Fourteen o f the States employing full-time nurses had in addition from 1 to 39 nurses doing part-time maternity and infancy work, Indiana having 11 and Kentucky 6. (c) Dental staff.—Virginia and Idaho employ dentists, Virginia on full time and Idaho on part time; and California, Delaware, and https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF M ATERNITY AND IN FAN C Y. 9 Georgia employ dental hygienists. Volunteer services by dentists and dental hygienists were reported in several other States. (d ) Other members o f the staff.— In addition to the clerical staff, some o f the States reported social workers, community organizers, inspectors, health teachers, and dietitians. An exhibit director, a moving-picture operator, and a chauffeur were each listed in one or more of the reports. G EN ERAL E D U C A T IO N . Educational activities have necessarily played a large part in the development of State maternity and infancy programs during this initial period because the success o f the undertaking was to a very great extent dependent upon the understanding, response, and co operation o f the general public. These activities have usually consisted o f lectures, talks, demon strations, exhibits, educational films, and so forth, by the director or other members of the State staff. No effort was^ made by the Children’s Bureau to determine the numbers o f individuals reached by literature, by meetings, or by individual contact in this educational work. Obviously, even though the local worker may have kept reports with a fair degree o f accu racy, it is impossible to record or measure the far-reaching effect o f any educational work. Practically every local nurse or other health worker does a considerable amount o f incidental educational work. In some few States appeal or approach to the general public or even to special groups seems to have been entirely overlooked and the promotion o f the program left entirely to the individual con tacts made by a county or community public-health nurse. Work under such a regime naturally develops slowly and thus raises the question not only as to whether the program should not be developed more rapidly, but also as to whether a responsive com munity group would not create enthusiasm for the work and be an added incentive to the public-health nurse. H Y G IE N E OF M A T E R N IT Y . Prenatal hygiene. The usual methods by which information as to the hygiene o f pregnancy is given are: (1) Distribution o f literature and (2) con sultations. L iterature— Twenty-five States reported using booklets, pam phlets, or letters, devoted wholly or in part to prenatal care. Only a few States have issued pamphlets on this subject, as most o f them prefer to use the bulletin o f the Children’s Bureau, but several ex cellent and attractive leaflets stressing the fundamentals o f prenatal care have been issued. A number o f State directors of child hygiene have compiled bibliographies on all phases o f infant and maternal hygiene for lay readers and have arranged with State libraries to furnish books on these subjects. The demand for the bureau’s pamphlet, Prenatal Care, has been so far in excess o f the number that the bureau has been able to https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 TH E PROMOTION OF TH E WELFARE AND HYGIENE supply, that several States have purchased thousands of copies from the Government Printing Office or have reprinted the bulletin. In an effort to reach individually a large number of expectant mothers, the use o f serial prenatal letters has been increased. Sets o f 5 to 12 prenatal letters, usually sent monthly, were found to be in use in many States. The number of women reached in this way apparently varied directly with the importance attached to it in each State and with the methods employed in obtaining names o f expectant mothers. Usually the physicians of the State were notified by the State child-hygiene division o f the availability of these letters, and many responded by requesting that such infor mation be sent to their patients. Recent reports indicate that this cooperation on the part o f physicians provides by far the largest single source of names. The prenatal letters were also mailed on requests from publichealth nurses, State public-health associations, local registrars, women’s clubs, cradle rolls, and the press. One ^State which had been using these letters for several years had a mailing list of 2,300; another State had increased its list between February and November of the same year, largely through the cooperation of the publichealth nurses m the State, from 600 to 2,000. As a part of Minnesota’s general plan for promoting the hygiene o f maternity and infancy a definite study course has been developed, which is conducted as a correspondence course for individual mothers or as a group-study course conducted by a leader or teacher in con nection with a women’s club. Both of these are cooperative activi ties, their efficiency being dependent largely upon the interest and cooperation o f a State advisory board, on which are represented the extension service and home-economics department o f the State university and the most prominent women’s clubs o f the State. The study course in the hygiene of maternity and infancy covers a 15-week period and consists o f one lesson each week. These lessons were prepared by the director of the division in collaboration with the departments of obstetrics and pediatrics of the University o f Min nesota Medical School and circulated by the extension division of the State university. The object o f these lessons is to give instruction in the care of women in motherhood, which secondarily means a gradual improvement in the general public health. Summary o f the course. Lesson 1. Introduction. Lesson 2. Pregnancy—description and changes. Lesson 3. The unborn child. Lesson 4. Prenatal hygiene, Part I. Lesson 5. Prenatal hygiene, Part II. Lesson 6. Complications and accidents o f pregnancy. Lesson 7. Confinement and preparations for confinement. Lesson 8. Labor and the lying-in period. Lessons 9 to 15. Care and feeding o f the child from birth to school age. Each lesson concludes with definite questions which are to be answered by mail, and upon a satisfactory completion of the course a certificate is sent from the university to the candidate certifying https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF M ATERNITY AND IN FAN C Y. 11 that such a course has been completed. These courses have been well received, as shown by their increasing popularity, the correction of the replies already having become a considerable task. The methods used in securing applicants for the courses were: 1. Explaining the purpose o f the course, the contents in general, and the method o f applying to many types o f women’s organizations, such as : Tourist clubs, community clubs, church ladies’ aid societies, sewing clubs, farmers’ clubs. 2. Interviewing individual members o f communities. 3. Talking to women who attended poultry shows, farmers’ insti tutes, county fairs, and so forth. M aternity consultations or centers.— Thirty-six States reported infant-health conferences, and 31 States reported maternity confer ences or instruction. Nineteen reported the organization o f health centers, and 12 reported the organization of maternity centers. While the maternity center or consultation project can not be considered o f more recent development than the children’s health center or confer ence for the examination of infants and other children, its popularity has not developed simultaneously, largely because of the commonly accepted but mistaken belief that all educational approaches to ma ternal welfare must be made indirectly through the child. A maternity consultation center is a place where expectant mothers may report for individual or group conferences on the hygiene o f pregnancy and preparation for confinement. As developed in the large centers of population a maternity center also provides physical examination by physicians and in many instances follow-up visits by nurses, especially in all abnormal cases. Since the practicability and success of all State activities are dependent in a large measure upon the character and extent o f pre vious preliminary educational activities, it was not surprising to find that few States had sufficiently matured plans for the establish ment o f maternity consultation centers, although plans had been made looking to their eventual establishment. Consultations at centers where women may be given personal in struction and examination have been developed under several methods. In States doing their first educational work o f this kind confer ences and examinations o f preschool children appear to have been considered the best or the only means of approaching mothers. In lowa a woman physician accompanied the pediatrician who ex amined the preschool children and had individual talks with all mothers, especially young ones, regarding the value and need of early prenatal care. As the character and availability o f these per sonal conferences become known other prospective mothers volunta rily seek such consultation. In Pennsylvania the establishment o f maternity centers had been undertaken on a state-wide scale. The work is conducted in the previously established health centers for infants and preschool chil dren, certain days being designated for maternity work. In strictlv rural sections the prenatal work is conducted by State nurses who do urinalyses and take blood pressure for the local physicians 91062°— 24----- 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 TH E PROMOTION OP TH E WELFARE AND HYGIENE making examinations. Many physicians rely on^ such centers for the prenatal care of their private patients. Wisconsin is promoting consultative rural or small-town services by having an obstetrician and a nurse conduct either a single dem onstration conference or repeated conferences at stated intervals. The service includes prenatal instruction to the individual mother and a complete physical examination, including internal examina tion. The types of expectant mothers who are reached by the plan are: (a) Those without preparation for confinement, (b) those sent or brought by physicians for consultation or advic65 and. (c) those brought by midwives. . . . . , , . . Another plan for extending prenatal service is being developed in Ohio along the lines which have proved successful in tuberculosis and venereal-disease work-—that o f haying obstetricians from the larger cities conduct consultations in adjacent extraurban territories. Local physicians, midwives, and public-health nurses bring the prenatal cases for these consultations. _ . , , A ll follow-up work from maternity consultations is done by pub lic-health nurses, and the service varies from one or more routine home visits with reports to physicians, to assistance in preparation for home confinement. . The laboratory facilities for blood tests, examination o± smears, and urinalysis— all necessary for standard prenatal care—differed widely in 30 States. Such facilities were available frequently m central or branch State laboratories, but urinalysis is usually done by a local laboratory or private physician, although in a number of States the public-health nurses are equipped with simple apparatus for making such analyses. In other States the physicians rely upon the public-health nurses to see that specimens are sent regularly to them for examination. Confinement care. Comparatively few specific developments for adequate confine ment care appear in this first year’s reports. W ith the educational work directing attention to the value and need of prenatal supervi sion the provision of facilities for skilled medical and nursing care at confinement will undoubtedly develop. The training and supervision of the midwife (see p. 14) as now undertaken promise some improvement in home confinements by midThe individual instruction given by public-health nurses to ex pectant mothers as to preparation for home care and procuring com petent medical care will probably bring about a public demand for better medical and nursing facilities. Minnesota is.the one State which has attempted on an extensive scale a specific undertaking for assistance to rural physicians in better home-confinement care. The doctors in rural communities complain that one of their big problems in confinement work in the country is the lack of sterile supplies for use in delivery. Recog nizing the necessity for cleanliness in home deliveries the State childliygiene division outlined as one definite project the supplying of sterile emergency obstetrical packages in communities where the need exists. An approved model package containing the minimum obstetrical supplies, the material for which was purchased at regular https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATERNITY AND IN FAN C Y. 13 retail prices, and which any woman o f ordinary intelligence can make for herself, was evolved and explicit directions for its prepara tion were printed. On request a nurse from the State child-hygiene division is sent out to demonstrate this package, or a sample pack age is sent to groups interested in making them. Appeals are made to civic, religious, or social organizations to raise the funds and to undertake^ the making and distribution o f these sterile obstetrical packages in cooperation with the county nurse. Women’s organiza tions are much interested in preparing and providing these pack ages, and incidentally useful knowledge as to the necessity for hav ing supplies sterile is disseminated. The sterilising o f the packages is done in a near-by hospital or at the homes of responsible and properly instructed women. State reports during the last year showed that few States had even attempted to survey the hospital facilities available for obstetrical cases. This important problem will naturally assume larger propor tions as the result o f the present educational activities and should be considered in future plans, as well as the need for standard obstetri cal technique in hospitals. Postnatal care. The importance o f adequate care for mothers during the period immediately following confinement has been emphasized in com paratively few programs during the past year. The provision of trained nursing care in home confinements is a tremendous problem still awaiting solution. The value o f a post-partum or discharge examination six weeks after confinement is important enough to be emphasized frequently, both in personal contacts and through literature. Much o f the invalidism following childbirth may be overcome by the simple pro cedure o f having the pelvis examined, which should be the last step in well-conducted confinement care. Mothers’ classes. The term “ mothers’ classes,” while implying group teaching on the subject o f prenatal, infant, and preschool health, seems to have been variously interpreted, in some instances a single group meeting having been considered a “ class.” While 15 States reported class instruction, analysis o f the reports indicated that a much smaller number had definitely planned courses of instruction for class work. Many o f the reported “ classes ” had befen conducted by public-health nurses throughout the State in selected counties or in a few cities, as the initial effort toward the establishment o f a consultation center. Without disparaging the value o f such work it is obvious that no single general meeting can be considered class instruction. In Pennsylvania a series o f eight “ lessons for mothers ” was pre pared in the summer of 1922 with the idea that doctors should be asked to conduct regular classes in the various baby centers through out the State. A personal letter from the State commissioner o f health was addressed to all doctors in such centers, and they were asked to undertake the instruction o f mothers, using the lessons which had been prepared. Simultaneously letters went to the nurses with the suggestion that mothers be regularly enrolled and that every https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 TH E PROMOTION OP TH E WELFARE AND HYGIENE effort be made to keep the group together until the series was fin ished. The plan was to have the talk made by the doctor, the les son sheets given to the mothers and studied at home, and questions asked on the subjects at a subsequent time. Seventy-two physicians have agreed to give this instruction. Midwives. One o f the significant concrete achievements o f the maternity and infancy act during this first year is the focusing of attention on the midwife problem o f the United States. Since the initiation o f activi ties under the act, 31 States have undertaken to investigate their midwife problems. The plans o f the States show a wide variety o f activities dependent entirely upon local conditions. Thirteen States have begun with state-wide surveys, and 6 States are making county or community surveys. Ten States acknowledge that they know very little about midwives; others claim that the problem is a negligible one. Six States do not register, examine, or license midwives, but in all except one the reporting o f all births is required. The midwife problem throughout the country varies with the population. The task which confronts the Southern States with their enormous numbers o f illiterate, aged negro midwives, untrained ex cept by observation, is scarcely comparable to the undertaking which has been successfully carried out by New Jersey in obtaining the cooperation o f well-trained foreign midwives. Mere numbers in dicate the degree o f effort which must be made to influence the mid wives. According to replies to a questionnaire sent out by the Chil dren’s Bureau, Mississippi has 4,000 midwives, North Carolina 6,500, Virginia 6,000, and New Hampshire only 7. New York State, ex clusive o f New York City, has an annually diminishing number of midwives. A t present there are 22 counties with no licensed mid wives. The 428 midwives practicing in the State in 1922 represented 23 nationalities, Poles, Italians, Germans, Americans, and Slavs other than Poles predominating. Doubtless a similar situation exists in the densely populated industrial and mining States. For instance, the 15 registered midwives reported by Colorado represent six foreign nationalities. The Southwestern States with the Mexican midwives and the Pacific Coast States with the Japanese midwives illustrate still further the racial and language complications. The 1920 occupational report of the Bureau of the Census enumer ated 4,773 midwives practicing in the United States. The check up by the States indicates a total o f 26,627 midwives authorized to practice in 30 o f the States. This figure, however, is only partial inasmuch as with few exceptions these States report that they have not been able to ascertain the total number actually practicing. A rough estimate by the States places the total at 45,000, but even this estimate probably falls short of the actual number. The importance of_the midwife in maternal and infant hygiene varies with the number o f births attended by them in the different States. Thus it is o f great importance in Mississippi, where 48 per cent o f the births are reported by midwives, and relatively insigni ficant in Nebraska, where only 2 per cent are thus reported. In one State midwives attended 73.5 per cent o f the negro births in 1921. The total number o f births for that year in another State was 69,116, one-third o f which were reported by the 6,036 registered midwives. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATERNITY AND IN FAN C Y. 15 A recent survey in Michigan shows that 96,035 births were regis tered in 1921, that 6,632 birth certificates were returned by 1,162 midwives, and that at least 1 birth in every 12 was not attended by a physician. Confronted by the results o f their study, the State health depart ments are seeking practical means of handling the midwife situa tion. Eighteen health officers have decided that training, licensing, and supervising the midwives in their rural communities is at pres ent the only practical means o f attempting to solve the problem. In 9 States— Connecticut, Delaware, Kentucky, Mississippi, New Jersey, New Mexico, Pennsylvania, South Carolina, and Virginia— supervisors o f midwives have been appointed, and in others some type o f instruction has been provided, either through letters, simple rules and regulations, or bulletins, or through classes. This class in struction has been given by physicians, usually the health officers, by public-health nurses, or, as in Connecticut, by registered mid wives. The classes meet once only in some States and in others they meet at regular intervals, weekly or monthly, for a period. The in struction consists o f an explanation o f the State laws governing the practice of midwifery, o f the technique which should be em ployed in caring for mother and baby, and o f the limitations of the midwife. In Pennsylvania two women physicians who speak several lan guages are on the staff of the State department o f health. They instruct midwives, using their mother tongues. In another State a well-trained obstetrician travels about the State as a consultant and in rural districts both physicians and midwives bring their cases, especially the complicated ones, for consultation. As a result o f these methods of instruction States report the marked improvement in the type of care which the midwife gives and also that physicians are being called by the midwives much more frequently for abnormal or complicated cases. In New Jersey and New Hampshire supervision and instruction over a period o f years have caused a decided decrease in the number of registered mid wives. Improved reporting o f births has been credited to the midwife a$ soon as she comes under supervision. The fundamental importance o f early and accurate birth registration is appreciated by all those interested in preventive health measures. A marked decrease in ophthalmia neonatorum has occurred among midwives’ cases since legislative enactment in recent years has made the use o f a prophylactic by physicians and midwives compulsory in 29 States. Free prophylactic outfits are being distributed in many States, and the reporting o f inflammatory eye conditions is com pulsory in a far larger number. Complete registration and supervisibn o f the midwife still in volve many unattacked problems. So far the majority o f midwives have welcomed assistance. Many o f the untrained negro midwives are pathetically eager to attend classes. New Jersey, a State which demands high qualifications before granting a midwifery license, reports: . Every puerperal death in this State is referred to this bureau (child hygiene). A letter is then sent to the physician signing the certificate to inquire whether a midwife has been connected with the case. An affirmative https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 16 TH E PROMOTION OF TH E WELFARE AND HYGIENE reply is followed by an investigation. Stillbirths and infant deaths where midwives have been in attendance are investigated. The department depends upon personal contact and individual instruction to each midwife in addition to demonstrations at meetings. Experience has indicated that literature does not reach the midwife who most needs instruction. Every investigation, whether of a delivery, puerperal death, or ophthalmia neonatorum, is used as the basis for teaching that particular midwife. In Pennsylvania, a State that has selected four counties for inten sive work with midwives, in addition to monthly meetings for in struction and demonstration, and frequent inspection o f equipment and home, the attempt is made to have all delivery cases visited within 48 hours o f birth by the inspector or deputy inspector (a woman physician). The midwife campaign in this State is sum marized as follows: 1. To limit the survey work to four counties. 2. To make the census absolutely complete, listing all licensed women, making their acquaintance, and securing their cooperation. 3. To get as complete information as possible about all unlicensed women, warning them that they must stop confinement work. 4. To arrest unlicensed women who continue to act as midwives in spite o f warnings, fining them for first offenses and putting them in jail on second offense. 5. To have all delivery cases visited by the inspector or deputy within 48 hours o f birth. 6. To oversee the midwife’s personal cleanliness and to inspect her home and her equipment. 7. To hold at least monthly meetings for instruction and demon strations. H EA LT H CONFERENCES. In a number o f States health conferences appear to have been con sidered the only feasible approach in initiating work with mothers and young children. These conferences afford a means o f contact indirectly through the child, with groups o f mothers as well as with individual mothers and subsequent individual home instruction. Health conferences have generally been developed in one o f the three following ways: 1. By a county health unit. 2. Independently by county or community public-health nurse. 3. By interested lay groups in cooperation with local doctors and nurses. In many States county public-health nurses whose employment has been made possible by Federal funds have begun the first childhealth work in rural localities. The following excellent procedure has been adopted in Kentucky. When a nurse enters a county to organize the work a letter is sent from the State board o f health, acquainting the physicians o f the county with her coming and asking their cordial reception o f her and her work and their cooperation in it. She meets first all the doctors and explains the work, asking their help. Next she meets the active organizations in the community and puts her plan before them. A committee chairman is selected, who appoints a corps o f lay hélpers to visit each home and ask that the mother bring all preschool chil dren to the child-health conference. A motor corps is formed, and https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OS' M ATERNITY AND IN FAN C Y. 17 those mothers who are not able to attend unless transportation is provided are brought to the conference by the motor corps. Another group o f about six women assist in weighing and measuring the chil dren and do the record work, as well as undressing the children for the physical examinations, which are made by the attending physi cian. Under this plan 40 children are examined in a two-hour period. Follow-up work in the homes is, o f course, done by the county nurse. In many counties where the only public-health worker is the county nurse the beginning of a conference center may be the nurse’s office or other centrally located room in the county seat. It may also be used as a rest room for mothers coming into town. It is possible for the county nurse to arrange to spend one day a week in the center, preferably market day, to become acquainted with mothers, answer questions, weigh infants and other children, and dispense literature. Analysis o f the State reports on “ children’s conferences arranged ” and. “ health centers organized,”—the former indicating a single meeting or mere examination or inspection of infants and preschool children and advice to the mothers with or without definite follow-up work, the latter implying a permanently established center for con tinued work and home follow-up— shows that only two States reported neither conferences nor health-center activities. Establish ment o f both conferences and health centers—the latter being the permanent outgrowth o f the previous conferences— was reported by 17 States. Nineteen States reported only the holding o f conferences. The number o f conferences reported by States varied from 2 to 316. Granting that single or itinerant conferences, including ex amination o f children, may serve purely as effective educational propaganda, the objectives to be attained by this method should be weighed in order that the development o f local permanent com munity work be not overlooked. Several States reporting large numbers o f conferences last year reported no permanent health centers established. In one State conferences have been conducted for a number o f years, and an increased budget under the maternity and infancy act with an increased staff only increased the number o f these conferences without any apparent attempt to enlist local initiative and responsibility for carrying the work on permanently. The aim may be to set uj> a State organization sufficiently large to undertake entire supervision o f physical examinations of children o f various age groups at stated intervals, but the opportunity to stimulate local initiative and responsibility which these examinations afford should not be overlooked. Several States provide for reaching rural districts by means o f motor cars specially equipped for making physical examinations and demonstrations. Kansas has a fully equipped railroad car, and other States use motor trucks to facilitate transporting from one community to another their equipment for conferences. Where local physicians do the examining it has been found possible to plan for at least monthly conferences. In some places one local pediatrician may voluntarily conduct the examinations, always safe guarding the ethics o f his profession by not prescribing or doing corrective work on any of the children, but always referring them to the family physician. In other localities a number o f local physicians rotate in contributing voluntary services for these conferences. It is https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 THE PROMOTION" OP THE WELFARE AND HYGIENE a debatable question as to whether a community should indefinitely accept gratis the service of generous public-spirited physicians. At present there is a definite tendency toward providing nominal re muneration for such public consultative service. One State has been able to develop permanent consultations exten sively by paying local medical examiners $1.50 for each hour o f con sultation. Other localities pay $5 a consultation, the consultations varying in length from two to four hours. In a number o f States the medical director of the State child-hygiene division plans to make the physical examination sometimes at all conferences and sometimes only in areas where no local cooperative medical service is available. In some States, where the director is not a physician or is a physi cian who has had no special training in pediatrics, a pediatrician has been added to the staff to conduct the conferences. This method has the advantage o f insuring not only thorough modern physical examinations such as specialized training provides but also o f afford ing an opportunity for consultations between local general practi tioners and a child specialist on difficult or obscure cases. D E N T A L H YG IE N E . Only 6 States reported dental clinics in connection with their ma ternity and infancy programs. The dental work that has been under taken in our large city schools has almost conclusively demonstrated the futility o f attempting a satisfactory system o f reparative work, because o f the great expense involved. Those who have been inter ested in the solution o f the problems of mouth hygiene are now al most unanimously agreed that public service in this field must be con fined at first largely to educational and preventive measures to remedy the abnormal prenatal and preschool causative factors. California, Delaware, and Georgia reported the employment o f dental hygienists on full or part time, who cleaned, polished, and examined the teeth o f preschool children brought to health con ferences for examination and instructed mothers in health habits, dietetics, and the importance of mouth hygiene as maintained by the use o f the toothbrush. That many dentists are beginning to appreciate the importance of beginning prophylactic dental care before the school age is shown by the fact that Arkansas, Kentucky, New Mexico, and Delaware re ported the cooperation o f local dentists at preschool conferences. A t least two State dental societies—those in Colorado and Cali fornia— are reported as cooperating. The importance o f dental care during pregnancy has been em phasized in a number o f leaflets on prenatal care issued by the States; yet none o f the prenatal or maternity consultations reported has pro vided for such care. Literature and reports o f research during the last year indicate a realization o f the importance o f and need for further investigation o f the formation and the structural qualities o f teeth in relation to diet during the period of pregnancy and maternal nursing. -Whether or not actual dental repair work should be provided in centers in conjunction with an obstetrical examination may be a moot question, but there can be no question as to the desirability and necessity for https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OP MATERNITY AND IN FAN C Y. 19 impressing upon the general public the importance o f the mother’s dental hygiene both to her general health and to the dental develop ment o f the child. ^ N U TR ITIO N CLASSES. In most States reporting nutrition classes, doctors and nurses emphasized nutrition incidentally in connection with mothers’ classes, demonstration work, conferences, home visiting, and by distribution o f literature, diet slips, and so forth. Only 13 States—Alabama, rizona, Arkansas, Delaware, Kentucky, Maryland, Mississippi, Missouri, New Mexico, Ohio, Texas, Utah, and Virginia—reported distinct nutrition classes as a part o f their maternity and infancy programs, and a special nutrition worker was employed on full tnne m only one State Ohio— and on part time in three—Missouri, Mississippi, and Indiana. ’ Ohio reported that considerable time had been devoted to the preparation o f a series o f weekly menus for the children o f the averap workingman’s famdy, to be published by the newspapers o f tne btate, and Mississippi, employing a part-time nutrition worker reported giving talks, exhibits, and demonstrations to groups o f mothers, and also special help and suggestions to nurses. The best results were said to have been obtained through personal contacts in home visits and at infant consultations, where proper feeding and other phases o f nutrition have been emphasized. Comparatively little has been done to apply to the preschool period such nutritional methods as have been successfully developed m nutrition work in schools. The shifting o f emphasis to the earlier age period would m this, as in other fields o f preventive work, lessen the need for such activities during the school age The director o f the Kentucky State Child-Hygiene Division in addition to supervising nutrition classes in connection with health centers, is cooperating with the home-economics department o f the State university by outlining a short course for teaching in the schools, colleges, universities, and normal schools in the State, on child anmng and preparmg o f food for the infant and preschool A State holding itinerant infant conferences (Minnesota) sends out a letter to the mother of each child under 2 years of age in the county to be visited, inviting and urging attendance. A t this con ference the mother is furnished with a copy o f the recipes, and the nurse then demonstrates the preparation o f the food. Breast-feeding campaigns, or special efforts to promote maternal nursing, were •mentioned in the plans o f several States. In New Jersey the visiting nurses follow up all newborn babies and super vise unmarried mothers to prevent the early separation o f the child from its mother, while in Delaware they follow up the mothers who come to the prenatal centers and see that instructions as to breast feeding are carried out. A study by Indiana showed that o f breast-fed babies 13 per cent were poorly nourished, while o f babies fed on cows’ milk, 15 per cent, T 0se *ed on condensed milk, 22 per cent were poorly nour ished. It was reported that only 70 per cent o f the mothers included m this survey were nursing their babies. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 TH E PROMOTION OP TH E WELFARE AND HYGIENE The importance o f breast feeding as a factor in the reduction o f neonatal deaths can not be overestimated. Proper emphasis on the preventive aspects would reduce manyfold the need tor special nutritional work after the period o f infancy. V IT A L STATISTICS. Birth registration. # Discussion o f the maternity and infancy act and its passage have given fresh impetus to birth registration in many States. Recogni tion o f the fundamental importance of accurate vital statistics is general, judging from the number o f States (21) which included birth registration as an item in contemplated plans. _ _ O f the 17 States which are cooperating under the Federal act and which are not in the birth-registration area,, 11 have instituted spe cial work to obtain more complete registration. ^ . O f the 21 States stressing accurate birth registration, 10 are already in the area, but the authorities recognize the need_ for con tinued vigilance and local stimulation if the required standard is to ^e^ d S c r ip tio n o f the methods used by several States in this field m a y be suggestive. A. state-wide test o f birth and death registration was made in Arkansas by the combined efforts of the League of Women Voters, the Federation o f Women’s Clubs, and the ParentTeacher Association. In making this test the counties were divided into districts, and each worker visited 10 or 12 homes assigned to her. The small staff o f the bureau o f child hygiene directed the sur vey furnished questionnaires, and tabulated resulting information for county officials. Though the test was made by untrained workers, hundreds o f previously unrecorded births were reported. The value o f the test must be measured not from a statistical but from an edu cational standpoint. As a publicity project also, the question qt birth and death registration received far more general and illumi nating discussion through such a canvass than a more efficient test m a d e by experts would have received. . . . . . . ,. A second and more intensive checking up of birth and death regis tration was made in three counties. The finding of many unre corded births resulted, and as a result o f a house-to-house canvass in one county, the local chamber o f commerce called together the doc tors and undertakers and earnestly appealed to them to redeem and maintain the reputation o f the city by assuming their estab lished responsibility in reporting births and deaths. . In several States seeking admission to the birth-registration area, checking up records has been attempted only incidentally at health conferences at the time the children are examined. B y this method Arizona reports the sending of approximately 3,000 copies o f orig inal certificates to mothers who were uncertain as to whether or not births had been recorded as well as 444 supplemental records adding the name of the child. In addition 93 supplementary reports were sent to correct errors in data on certificates. _ , . ., . Florida reports that through the cooperation of the bureau of vital statistics the public-health nurses, who during the rest o f the year conduct midwives’ classes, devote their entire time during the rainy months, when class work is impossible, to checking up birth regis- https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATEBNITY AND IN FAN C Y. 21 tration, concentrating their efforts on counties where registration is most unsatisfactory. Under State plans cooperation with bureaus o f vital statistics has varied from paying the salary o f a full-time clerk to paying for part-time work by two or more clerks, depending upon the amount o f additional statistical work required. These clerical as sistants also use the data received in the bureau of vital statistics as an aid in sending out literature to the parents. Some divisions have also stimulated birth registration by furnishing attractive certiorates to be sent to the parents on receipt o f a properly pre pared birth record. In a number of other States every public-health nurse is instructed to supplement the work of the bureau o f vital statistics by continued efforts to improve birth registration. -As a result o f the work done by a public-health nurse who gave special attention to the improvement of birth registration in a se lected group o f counties in Kentucky, the State reports a 10 per cent increase in birth registration in the counties visited. Maternal mortality. Reports from several States show that coincidentally with check ing up on birth registration these States are making efforts to collect more definite information on maternal mortality. In one State during the last year questionnaires have been sent to each physician signing the death certificates o f women of child-bearing age, in order to determine whether pregnancy was a contributory cause o f death. J SU R V E YS. In the planning o f State programs it was early 'recognized that more accurate knowledge concerning conditions affecting the welfare o f maternity and infancy was necessary, not only as a foundation upon winch to build an efficient program, but because such knowledge would increase public interest in a preventive program. Conse quently, 20 States have made surveys or studies, and nearly all of these States have undertaken more than one survey or study. O f primary importance in a number o f States have been the sur veys made to secure more complete birth and death registration and to determine the number and status o f midwives. (These sub14^20^ ^ scusse(^ under their specific headings. See pages Causes o f infant and maternal deaths were made a subject o f sur veys in six States— Connecticut, Idaho, New Hampshire, South Dakota, Arkansas, and Colorado— during the fiscal year 1923. These surveys were the result o f investigations by the itinerant staff visit ing each county to hold conferences; the sending o f a letter to each physician signing a death or stillbirth certificate requesting detailed information; and cooperation with bureaus o f vital statistics in check ing up their reporte. These statistics will be used by Connecticut as the basis o f graphic charts showing infant mortality by age groups distribution, causes, geographical location, and showing causes and effects o f maternal mortality. New Hampshire reported that as a result o f a study o f several hundred families in a locality where the infant death rate was unusually high they found that no' prenatal care or advice was given; that a great many mothers weaned their https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 TH E PROMOTION OP TH E WELFARE AND HYGIENE babies early or did not nurse them at all, and that an intensive educa tional program was necessary in order to lower the infant death rate. A nurse was put in charge o f the work, and at the end o f six months it was taken over by the city, which had thus been awakened to its own responsibility in the matter. A survey o f available qualified medical service and maternity hospitals was made by Connecticut, and a list of physicians and'nurses was published. In Idaho a survey o f county and city health officials, county nurses, midwives, and hospitals where obstetrical care was available was made in order to determine the facilities for maternity care. Michigan secured data regarding the number o f county nurses, prenatal and infant health conferences, other child-health activities, and hospital facilities. Statistical studies were also made in Indiana as to the kind and extent o f prenatal and obstetrical care which mothers in remote and small-town districts had received. Two State universities—the department o f sociology of the Uni versity o f Kansas and the department of sociology o f Reed College, Oregon— cooperated with the State bureaus o f child hygiene in mak ing a study o f child-caring institutions and maternal welfare. Publication o f data collected through these surveys has in many places been immediately beneficial, the locality interested assum ing a larger responsibility for health conditions and manifesting greater interest and cooperation with States and local officials by both physicians and laity. In several instances the work o f such surveys was participated itt by local groups, such as clubs and organi zations o f various kinds. While the statistical information collected was probably not so reliable as if it had been done by specially trained workers, the work was locally stimulating and educational and the results valuable. INSPECTION OF M A T E R N IT Y A N D CHILDREN’S HOMES. Thirteen States reported inspection of either maternity homes or children’s homes or both. In all o f these States the inspecting is done under the direction o f the State hygiene divisions administering the maternity and infancy act, although the authority to license these homes is usually vested in another bureau, or in State boards o f charities and corrections. Although this phase o f the work has been incidental in most o f the child-hygiene divisions, and although only one State— Texas—employs a full-time maternity-home inspec tor, the reports for January-June, 1923, give a total of 149 inspec tions o f maternity homes and 219 of children’s homes. Private homes where young children are boarded as well as State and philanthropic institutions are included in these inspections. Several States have no law whereby the State exercises supervision over, these institutions. Texas reported that while this was a pioneer undertaking, during the fiscal year 1923 it inspected 193 maternity homes, 78 infant homes, and 128 boarding homes (private). In some o f these the conditions were very poor, but inspection caused a notice able improvement, and local health authorities cooperated in effecting better sanitary conditions. In another State one community was found which had an unusually large number o f women who were https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATERNITY AND IN FAN C Y. 23 supplementing their incomes by taking children to board and a number o f these were reported and refused a license. o f f i k T ’ •Wi ii j haS 110 Pr?vision f °r supervision, reported that its stall had visited day nurseries and maternity homes and had given 3t.ratl0ns and advi^ regarding maternal and infant careT In Comectmut where the child-welfare bureau in the State department n-m n 1C-Wel:T re has suPeryislon ov?r such agencies, the bureau of c lid hygiene has cooperated by detailing a nurse to act as inspector m order that sanitary standards may be investigated and coordinated with the social-welfare work. Utah also reported cordial cooperatl® \ 1P ,the improvement o f hygienic and sanitary conditions? the °f ^ r a n t m e regulations for contagious disease ? e s u M aspecStio„ ^ ° n a scientifica% * * * * diet as a C O U N T Y -U N IT SCHEMES. • Prot®ctlon o f health has in the past developed principally m the larger towns and cities rather than in country districts In asmuch as rural health facilities have hitherto been either inadequate' Sr ^ S t telL ^ ^ b o t h iov general and for specialized t r v i c l is with real satisfaction that one finds the funds provided by the Federai act being used to extend to rural areas the services7 and facilities so well developed m urban localities. To provide such facilities for rural areas was the obiect soue-ht bv those who urged the adoption o f the maternity and infancy act-and though the act does not restrict the work to extraurban localities the intent o f its sponsors has been largely carried out, for few urban activities have been contemplated in any o f the State plans the ex ceptions being m the nature o f temporary urban demonstrations or the provision o f training centers for State workers. .county aPPears to be the logical unit in state-wide health un dertakings In State plans for maternal and infant hygiene where Federal and State funds have been used in matching county funds the funds have been applied to the furtherance o f county7 publichealth nursing service. In nearly all o f the Southern States, where the county health unit plan has been most extensively developed__ argely as a natural outgrowth o f the special campaigns conducted C°nt^01 ° f malaria and hookworm disuse—?he imi- ternal and infant nursing service has frequently developed as a Dart o f this general health unit plan. V ueveiopea as a part ha™ S as an objective the establishment o f full time county health units (usually a full-time health officer, a sanitarv in je cto r , a public-health nurse, and a clerical assistant), maternity and infancy work has been considered as a part o f the general public7 health program In general, few public-health programs hadUeLn sufficiently complete to include specific maternal and infant service although such work was m some instances incidental. In some States where the establishment of county health units or employment o f a county public-health nurse is thought to be the ideal way o f developing a public-health program, the plan has been to Provide each county with a nurse paid by the State or jointly by the State and county. To pay the nurses supported https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 THE PROMOTION' OF THE WELFARE AND HYGIENE iointly by State and county funds, the county has contnbuted from one-half to four-fifths of the expense. The ultimate aim o f this plan is the stimulation of local communities to assume full responsibility for a maternity and infancy program. . •A Inasmuch as generalized public-health nursing has been consid ered preferable to specialized service— at least m rural areas where specialized service has seemed impracticable—the plan generally fol lowed has been a division o f the nurse’s time between maternity and infancy work and general public-health activities, only such tune at> is devoted to maternity and infancy work being paid for from ma ternity and infancy funds. This procedure naturally entails the keeping o f daily reports on a time-accounting system. In one State a maternity and infancy nurse is lent to the coun ties for periods of two or three months to assist the general publichealth nurse in working out her maternity and infancy program. In another State a public-health nurse is lent to give demonstra tions for periods o f from three months to one year, with the un derstanding that at the end o f that period the community shall assume in whole or in part the salary and expense o f the nurse. COOPERATION OF L A Y W O RK ER S. Preliminary and general educational work done by the States usually has resulted in the organization of local lay groups if the definite objective o f the State maternity and infancy plans was PeThenmost°successfui results were obtained where one carefully planned project at a time was undertaken and its development guided in accordance with the State program. . , ■. The plan o f working through and enlisting the support o f alreadyexisting organizations, rather than attempting the formation of new volunteer groups, has much to commend it since the utilization of already-functioning groups places the responsibility largely within the organization itself. The formation of small committees or sub committees within women’s organizations to function as aides to the division o f maternity and infancy or to a local nurse by sending in names o f prospective mothers and mothers of young children, to whom literature may be sent or to whom home visits may be made, is one popular method o f enlisting interest and assistance from lay workers. Such a committee frequently assists m arranging for a nurse’s return visit, or for consultation about an infant at stated intervals; it sometimes serves as a hospitality committee during the conference period. . i Enlistment o f volunteer groups to act m cooperation with and under the direct supervision o f the State staff m furthering a State programs has been found useful. The director o f one especially well-orgamzed State division o f maternal and infant hygiene writes the following: “ X believe that one of the most interesting and satisfactory aspects o f our work will be the development o f a group o f volunteer workers in each community. W e will try to educate S is group along the lines o f public health by pamphlets sent to them and by tails which we will give them They will learn much of their own community needs by visiting the homes and asking the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis OF MATERNITY AND IN FAN C Y. 25 mothers to bring the preschool child to the conference, and they will also learn much by helping in weighing and measuring and in record work at the conferences. * * * I f these women and men under stand the needs o f their community and the worthwhileness o f our work, there is no question about the continuance o f such work.” The organization o f local committees has been undertaken in Pennsylvania through three field organizers who have visited during the first year 48 o f the 67 counties and have organized lay committees to help get the necessary local machinery for opening and maintaining health or conference centers. Repeated visits o f the organizers are sometimes advantageously stimulating until the work is permanently established. In many States the director of the division o f maternal and infant hygiene has been the organizer, covering only those territories which request such assistance. Usually such a successful community dem onstration generates enough momentum to perpetuate itself. In many States the local public-health nurses organize committees, make the initial preparation for State workers, and give full-time assistance to the work. Many local agencies bear certain local ex penses, thus assuming a definite responsibility. While committee work o f a temporary nature has, o f course, a certain limited educational value, the success o f this work can best be measured by its permanency. While some o f this year’s reports give large numbers o f local committees organized, results may be measured best by permanently organized and functioning groups. In far too many States local work utilizing lay workers appears to have been not only too limited, but also too evanescent, having no definite objective in view. COOPERATION OF TH E M E D IC A L PROFESSION. The year’s reports show an astonishing number o f physicians who have become interested and are cooperating locally in furthering the maternity and infancy programs in the States. The basic im portance o f developing maternal and infant health upon modern scientific standards has been recognized and indicated in State devel opments throughout the year. In a few States where the initial work has not been outstandingly successful it is largely due to lack o f understanding o f the purposes and plans o f the State program. In order that medical cooperation might be assured, a number o f State plans definitely stipulated that the State health department should not undertake work in any county or community even though a demand existed for it, until the project had been placed before and indorsed by the local or county medical society. Thus the responsibility o f fulfilling a recognized local need, demanded by the .public, was placed entirely upon the local medical profession. In sections without medical societies the contemplated maternity and infancy work, even though limited to a single county publichealth nurse, is usually brought to the attention o f individual doctors. Frequently the State health officer sends letters to every physician in the county, announcing the coming o f the public-health nurse or of other health workers and soliciting their cooperation and assistance. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 THE WELFARE AND HYGIENE OF M ATERNITY AND IN FAN C Y. Response and approval by local physicians o f the State programs o f maternal and infant hygiene have manifested themselves in tangible form in— (1) Indorsement by county medical societies, the members divid ing the time to serve at consultation centers. (2) Conducting maternity centers which secondarily serve as training centers for physicians and nurses. (3) Giving lectures to prenatal classes, mothers’ classes, etc. (4) Providing names of expectant mdthers to receive prenatal letters or other literature from the State board o f health. (5) Carrying on research as to the causes o f stillbirths and of maternal and infant mortality. Locating and reporting midwives for registration. (7) Conducting classes o f instruction for mid wives. (8) Giving examinations at children’s health conferences. _ Obviously any program which contemplates physical examinations o f either mothers or young children necessitates the services o f welltrained physicians. Few States have budgets sufficiently large to allow the employment o f the number o f physicians required to de velop the State programs, and the success o f the work during this past year has been largely dependent upon the generous cooperation o f local physicians with vision and ideals o f furthering preventive medicine through public service. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis FED ERAL ADMINISTRATION. FE D E R A L STA FF. With the passage o f the act, the Children’s Bureau added to i J then existing six major divisions a division o f maternity and in fant hygiene, which is immediately responsible for the Federal ad ministration o f the act. The permanent staff o f this division during the last year has included (1) a medical director, (2) an associate medical director, (3) a public-health nurse, (4) an accountant, (5) a secretary^ and (6) a stenographer. The general administrative duties in connection with State plans submitted for approval, such as checking o f budgets and accounts, has involved much detail and correspondence during this initial period. As a clearing house for plans with regard to organization, activities, publications, exhibits, and other details of the State pro grams, the central office has rendered service to individual States. Besides attending to the general office activities, the director and as sociate director, both physicians, have visited during the year every State department cooperating under the act and discussed plans of work and activities. In only a few States, however, was it possible to observe actual field work. I f the central administrative bureau is to be able to supply details as to the actual working out o f plans to the States seeking such information more time will have to be spent in the field. IN STITU TE S FOR PU B L IC -H E A LT H NURSES. In the beginning o f the work under the maternity and infancy act one of the apparent needs for successfully and speedily furthering the programs seemed to be to make available for State and local publichealth nurses in the various States information as to the types of work successfully undertaken in the promotion o f maternal and infant health as well as to review or teach new and up-to-date technique, especially in prenatal, obstetrical, and postnatal care of mothers and in the care o f infants. Consequently the services o f a public-health nurse were offered to the State departments administering the act. The response from the States was indicative o f the approval and value o f this type o f service. Between December 1, 1922, and June 30, 1923, institutes were held in 16 States. In one State two institutes were held, one in the northern half o f the State and another in the southern half o f the State. In another State it was possible to plan for six gatherings of three days e^ch, geographically distributed so as to reach the largest numbers o f public-health nurses. 27 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 TH E P R O M O T IO N OF T H E W E L F A R E A N D H Y G IE N E The course of instruction included periods devoted to— (1) The provisions o f Federal maternity and infancy act. (2) Prenatal care. (a) Hygiene and complications of pregnancy. (b) Prenatal conferences, classes, and visits. (3) Maternal and infant care. (4) Prenatal and infant care as a part o f a county health program. The average length o f the sessions was three days, and while the attendance naturally depended on the interest and extent to which maternity and infancy work was being planned in the State, the numbers of nurses attending varied from approximately 150 in Indiana, where six conferences were held, and 100 each in Wisconsin and Kansas, to smaller groups in the other States. In fjve States where it was not feasible to hold institutes or where numbers o f publichealth nurses are still too small to warrant the holding of an in stitute, it has been possible, while en route to other States, to confer with one or more of the public-health nurses responsible for the maternity and infancy program in those States. The State agency administering the act has usually arranged to hold the institutes in connection with other State nursing or public-health meetings, and organizations with allied interests (especially the Red Cross) have cooperated with the State agency in making the institutes successful. In Alabama both the State health officials and the midwives were invited to attend, and in most States many graduate as well as undergraduate nurses have attended the institutes. In a number o f States the institute served as the first “ get-together ” o f the publichealth nurses o f the State and this opportunity for contact and discussion o f problems o f common interest proved so stimulating that requests for annual institutes have resulted. The continuance of this special service seems desirable. P U BLICATIONS A N D OTHER LITERATURE. News-letters. During the last six months o f the period covered by this report, when most State programs were well under way, the news-letters to directors of State child-hygiene divisions, which for some time had been sent out at irregular intervals by the child-hygiene division of the bureau, were resumed, this time being sent ©ut by the maternity and infant-hygiene division and confined exclusively to the problems connected with the administration o f the maternity and infancy act. Material for these news-letters is compiled from replies to questiorinaires sent to the State directors. Not only does this summary of replies along special lines of State activities serve as a means of contact and exchange o f methods, but the questionnaire in itself is acknowledged as informative and stimulating to the State reply ing. The subjects of the news-letters for January, 1923, “ Methods of Promoting the Hygiene o f Pregnancy,” and May, 1923, “ Midwives in the United States,” were chosen because o f inquiries from many States for information on these subjects. Statements as to the practices in the various States were compiled, and attention was called to especially good points and to questionable https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis O F M A T E R N IT Y A N D IN F A N C Y . 29 and incorrect technique. The subject matter o f these news-letters is discussed in the section o f this report dealing with State activities. Leaflets. (a) A t the request o f and in cooperation with the National Organi-. zation for Public-Health Nursing, 100,000 copies were issued of a folder entitled “ The Nursing Profession and the Maternity and Infancy Act.” This folder briefly outlines the purposes o f the act and the nurse’s relation to it as a teacher o f public health, concluding with the de tailed minimum standards for the public protection of the health of mothers, infants, and preschool children, as adopted by the Children’s Bureau Conferences on Child Welfare, 1919. The plan of distribution was to reach every trained nurse in the United States with this generally accepted outline of standards of maternal and infant hygiene. (b) In order to present in a new, attractive, and concise form the fundamental elements o f modern standard maternal hygiene, the first o f a contemplated series of leaflets to cover prenatal, natal, and postnatal care was prepared and printed. This folder (Children’s Bureau Folder No. 1), “ Minimum Standards o f Prenatal Care,” describing the least care at all adequate for a prospective mother, is supplied to the States upon request in quantities for distribution. Bulletins. The demand for the bureau’s series o f publications for mothers— Prenatal Care, Infant Care (revised), and Child Care—has greatly increased during the 15 months under review. With the printing appropriations available it has been impossible to meet all these re quests. It has been possible at times to furnish monthly allotments o f bulletins to the State departments administering the act, but in lieu of an adequate supply many States have either purchased ad ditional copies from the Government Printing Office or asked per mission to reprint the bulletins in whole or in part. The Superintendent of Documents reports that the distribution and sales for the last year not only far exceeded those o f previous years but that at the close o f the last fiscal year there were on hand from various organizations and individuals orders for 165,000 copies. RESEARCH. In addition to assigning the work of administration to the Chil dren’s Bureau the act also makes mandatory “ such studies, investiga tions, and reports as will promote the efficient administration o f the act.” During the year three definite pieces o f research have been under taken -a study o f maternity homes, a study o f maternal and neonatal mortality, and a study o f the mortality and morbidity o f early in fancy. Maternity homes. The need for definite information regarding the organization, management, and health and social-service standards o f maternitv homes has become increasingly apparent. In many States where the numbers o f such institutions are known and licenses are required the licensing is largely a perfunctory process, and little has been done https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 TH E P R O M O T IO N O P T H E W E L F A R E A N D H Y G IE N E to require the observance of the standards and technique which modern hygiene and sanitation require. In cooperation with the Pennsylvania Department o f Public W el fare a survey of the maternity homes in that State has been made. This study has been planned and directly supervised by Dr. Ethel M. Watters, the associate director of the maternity and infant-hygiene division o f the bureau. The field staff consisted of a physician, Dr. June Madison Hull, and a social worker, Miss A. Madorah Donahue, in order that both the medical and social problems involved might be studied. Several other States requested similar cooperation, and it was decided to extend the study to Minnesota. Maternal and neonatal mortality. In order to obtain morfe explicit information regarding actual causes o f maternal deaths and infant deaths during the first month of life— an(l especially to find means by which these deaths may be prevented— it is necessary to have careful analyses made o f re ported deaths in different parts of the country. With this in mind, as well as the desirability o f stimulating local communities to deal with their individual problems, a schedule and a method o f analysis have been worked out in cooperation with a State child-hygiene division. This initial inquiry shows that the number o f stillbirths is appalling, and also that authentic and accurate information can not be uniformly obtained from the certificates for these deaths. Mortality and morbidity of early infancy. It is now generally recognized that in many communities further material reduction in the infant mortality rates is dependent primar ily upon factors connected with deaths during early infancy or those occurring at birth or during the first month of life. Singularly, there is a dearth of scientific information regarding both morbidity and mortality for this early age period, so that scientific research" must precede success in reducing the rate in these communities. In Minnesota the bureau is conducting a cooperative piece o f re search, covering a year, on the etiology, pathology, and prevention o f fetal deaths, on stillbirths, and on neonatal mortality and mor bidity. ACC O U N TIN G . The financial accounting for Federal funds and for State funds used in matching has involved much detail. The necessary forms and reports were worked out after consultation with the United States General Accounting Office, with other departments and boards administering similar Federal acts, and with a special representative appointed by the Association o f State and Provincial Health Officers. During the year the division accountant has visited all but one of the States in which Federal funds were expended.10 REPORTING OF STA TE A C T IV ITIE S. Semiannual reports covering the various activities included in their programs have been required o f the States. Report forms for listing such a multiplicity o f activities as were involved in 42 States with public-health work at varying stages of 10 See Appendix D , p. 42, fo r accounting in stru ctio n s. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis O P M A T E R N IT Y A N D IN F A N C Y . 31 development could only be considered tentative during tbe first year o f work. It was practically impossible to evolve any form which would include all o f the activities undertaken in the several States, inasmuch as the State plans involved a great diversity in undertak ings, each dependent upon the size of the local budget and upon pre vious local developments in maternal and infant hygiene. The numerous items contained in these preliminary reports of activities were not clearly enough defined to insure that the figures reported were o f value statistically. These first reports were in tended to suggest the great variety of activities covered in the vari ous State programs. With lines of work now fairly well outlined and activities well under way, future reports should more nearly record actual accomplishments along clearly defined lines. After listing the full or part time staff members, such as doctors, public-health nurses, dental hygienists, inspectors, social workers, clerks, and stenographers, the report forms covered activities under taken under the following subdivisions: Educational work.—Lectures, demonstrations, exhibits, films for the general public, clubs, organizations, and special groups, such as doctors, teachers, midwives, nutrition workers, and mothers’ classes. Organization work.— This work included the organization o f local committees, maternity centers, mothers’ classes, midwives’ classes, little mothers’ leagues, health or infant centers, dental clinics, and nutrition classes. Field work.—Under this heading a narrative report on such o f the following as have been undertaken by the State is requested: Surveys, birth-registration campaigns, maternity conferences, in fant-health conferences, midwives’ classes or inspections, institutional inspections (maternal and infant), and so forth. The original report forms will undoubtedly need revision as the work develops. Inadequacies in some of the detail in the forms used have been compensated by requesting a narrative report in ad dition to the information supplied on the forms. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ACCOMPLISHMENTS UNDER THE M ATERNITY AND INFANCY ACT. Obviously it is too early, at the end of 15 months’ work, to measure definite achievements in such extensive programs as are covered by state-wide plans in maternal and infant hygiene, but the fore going discussion o f specific activities serves to indicate the work already well under way. The general trend o f activities may be summarized briefly as follow s: 1. The education of the general public as to the need and value of skilled supervision during pregnancy and medical and nursing care during and following confinement. 2. Better infant care through the teaching o f mothers. 3. Stimulation of the medical and nursing professions to meet the public demand for better health protection of mothers and infants, since the result o f the activities now in progress must ultimately be the provision o f adequate medical and nursing facilities as ap plied to the hygiene of maternity and infancy. As a successful Federal-aid measure the act has already demon strated its value in that it has— (1) Stimulated State activities in maternal and infant hygiene. (2) Maintained the principle of local initiative and responsibility. (3) Improved the quality o f the work being done for mothers and babies by disseminating through a central source—the Federal Government—the results o f scientific research and methods o f work which have been found to operate successfully. (4) Increased State appropriations with the passage o f the act. From the appropriation for the fiscal year 1922, 15 States were able to accept only the $5,000 unmatched funds. Six States were able to accept only the $5,000 unmatched from the Federal appropriation for the fiscal year 1923. However, all o f the States cooperating under the act either have already accepted more than the $5,000 unmatched allotment from the 1924 Federal appropriation, or will be able to do so. The fundamentals of a comprehensive and forward-looking pro gram for furthering health promotion as it refers to expectant mothers, infants, and preschool children might be outlined as follow s: 1. Continued education to develop public appreciation of the value of prenatal, confinement, and infant care. 2. Stimulation o f complete and early registration of births. 3. Development and extension o f facilities for reaching areas where no maternity and infancy work is now done. 4. Establishment of permanent health conferences for prenatal, postnatal, infant, and preschool consultations. 5. Establishment and maintenance of community public health nursing service and o f follow-up work after health consultations. 32 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T H E W E L F A R E A N D H Y G IE N E O F M A T E R N IT Y A N D IN F A N C Y . 33 6. Provision o f hospital facilities for all complicated pregnancies and confinements at least and for illnesses of infants and young children, or where this is impracticable, provision o f adequate medical attention and home nursing. 7. Increased local appropriations to cover all public maternity and infancy activities. 8. Improved training by medical schools in obstetrics and pedi atrics, especially in their preventive and public-health aspects. Postgraduate work for general practitioners, especially those in rural areas. 9. Cooperation between State public-health authorities and medi cal practitioners for the effective carrying out o f preventive meas ures. 10. Development o f local responsibility for providing the facili ties necessary to carry on permanently such public-health activities as are warranted by the demonstrations now being made. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis APPEN D IXES. APPS P I i ^ T l i ! S ? ri 0 F THE ACT F 0R THE PROMOTION OF THE WELFARE AND HYGIENE OF MATERNITY AND INFANCY. [S. 1039— Sheppard-Towner A c t; Public 97— 67th Congress; 42 Stat. 135.] An A ct F o r the prom otion o f the w elfare and hygiene of m atern ity and in fa n cy , and for other purposes. if enacted by the Senate and House of Representatives of the United a es of America in Congress assembled, That there is hereby authorized to t»e appropriated annually, out of any money in the Treasury not otherwise the ««m s specified in section 2 of this Act, to be paid to the seveial States for the purpose of cooperating with them in promoting the welare and hygiene of maternity and infancy as hereinafter provided. hEe. 2. For the purpose of carrying out the provisions of this Act, there is authorized to be appropriated, out o f any moneys in the Treasury not other wise appropriated, for the current fiscal year $480,000, to be equally apportioned among the several States, and for each subsequent year, for the period of five years, $240,000, to be equally apportioned among the several States in the manner hereinafter provided: Provided, That there is hereby authorized o»fbe* ap?i'opi iate1d for the use of the States, subject to the provisions of this act, for the fiscal year ending June 30, 1922, an additional sum of $1,000,000, nnn *the ,period of five years, an additional sum not to exceed $1 000,000: Provided further, That the additional appropriations herein authorized shall be apportioned $5,000 to each State and the balance among the i f 1 ,the pilopo^ io.n wpich their population bears to the total population of the States of the United States, according to the last preceding United States census: And provided further, That no payment out of the additional approE S J “ » herein authorized shall be made in any year to any State until an equal sum has been appropriated for that year by the legislature of such State for the maintenance of the services and facilities provided for in this Act. So much of the amount apportioned to any State for any fiscal year as remains unpaid to such State at the close thereof shall be available for ex penditures in that State until the close of the succeeding fiscal year Ssc. 3. There is hereby created a Board of Maternity and Infant Hygiene which shall consist of the Chief of the Children’s Bureau, the Surgeon General ?-tates Fubp? Health Service, and the United States Commissioner of Education, and which is hereafter designated in this Act as the Board this A c t rd ShaH 6leCt ltS ° Wn chairman and Perform the duties provided for in Children’s Bureau of the Department of Labor shall be charged with l hhe. administration of ^this Act, except as herein otherwise provided, and the Chief of the Children s Bureau shall be the executive officer. It shall be the duty of the Children’s Bureau to make or cause to be made such studies in vestigations, and reports as will promote the efficient administration of this S ec . 4. In order to secure the benefits of the appropriations authnriVcii in section 2 of this Act, any State shall, through the legislative authority thereof tbe Pr° V-1(-l10nt .°£ Act and desi^nate or authorize the creation of a State agency with which the Children’s Bureau shall have all necessary power! to cooperate as herein provided in the administration of the provisions of this Act. Provided, That in any State having a child-welfare or child-hygiene division in its State agency of health, the said State agency of health shall ad minister the provisions o f this Act through such divisions. I f the legislature o f any State has not made provision for accepting the provisions of this Act the governor o f such State may in so far as he is authorized to do so b y the laws of such State accept the provisions of this Act and designate or create a State agency to cooperate with the Children’s Bureau until six months after the adjournment of the first regular session o f the legislature in such State following the passage of this A c t 35 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 TH E P R O M O T IO N OP T H E W E L F A R E A N D H Y G IE N E Sec. 5. So much, not to exceed 5 per centum, of the additional appropriations authorized for any fiscal year under section 2 of this Act, as the Children’s Bureau may estimate to be necessary for administering the provisions of this Act, as herein provided, shall be deducted for that purpose, to be available until expended. S ec . 6. Out of the amounts authorized under section 5 o f this Act the Chil dren’s Bureau is authorized to employ such assistants, clerks, and other per sons in the District of Columbia and elsewhere, to be taken from the eligible lists o f the Civil Service Commission, and to purchase such supplies, material, equipment, oflice fixtures, and apparatus, and to incur such travel and other expense as it may deem necessary for carrying out the purposes of this Act. S ec . 7. W ithin sixty days after any appropriation authorized by this Act has been made, the Children’s Bureau shall make the apportionment herein pro vided for and shall certify to the. Secretary of the Treasury the amount esti mated by the bureau to be necessary for administering the provisions of this Act, and shall certify to the Secretary of the Treasury and to the treasurers of the various States the amount which has been apportioned to each State for the fiscal year for which such appropriation has been made. S ec . 8. Any State desiring to receive the benefits of this Act shall, by its agency described in section 4, submit to the Children’s Bureau detailed plans for carrying out the provisions of this Act within such State, which plans shall be subject to the approval of the board: Provided, That the plans of the States under this Act shall provide that no official, or agent, or representative in carry ing out the provisions of this Act shall enter any home or take charge ef any child over the objection of the parents, or either o f them, or the person stand ing in loco parentis or having custody of such child. I f these plans shall be in conformity with the provisions of this Act and reasonably appropriate and adequate to carry out its purposes they shall be approved by the board and due notice of such approval shall be Sent to the State agency by the chief of the Children’s Bureau. S ec . 9. No official, agent, or representative of the Children’s Bureau shall by virtue of this Act have any right to enter any home over the objection of the owner thereof, or to take charge of any child over the objection of the parents, or either of them, or of the person standing in loco parentis or having custody of such child. Nothing in this Act shall be construed as limiting the power of a parent or guardian or person standing in loco parentis to determine what treatment or correction shall be provided for a child or the agency or agencies to be employed for such purpose. S ec . 10. W ithin sixty days after any appropriation authorized by this Act has been made, and as often thereafter while such appropriation remains un expended as changed conditions may warrant, the Children’s Bureau shall ascertain the amounts that have been appropriated by the legislatures of the several States accepting the provisions of this Act and shall certify to the Secretary of the Treasury the amount to which each State is entitled under the provisions of this Act. Such certificate shall state (1) that the State has, through its legislative authority, accepted the provisions of this Act and des ignated or authorized the creation of an agency to cooperate with the Chil dren’s Bureau, or that the State has otherwise accepted this Act, as provided in section 4 hereof; (2) the fact that the proper agency of the State has sub mitted to the Children’s Bureau detailed plans for carrying out the provisions of this Act, and that such plans have been approved by the board; (3 ) the amount, if any, that has been appropriated by the legislature of the State for the maintenance of the services and facilities of this Act, as provided in sec tion 2 hereof; and (4) the amount to which the State is entitled under the provisions of this Act. Such certificate, when in conformity with the pro visions hereof, shall, until revoked as provided in section 12 hereof, be suffi cient authority to the Secretary of the Treasury to make payment to the State in accordance therewith. S ec . 11. Each State agency cooperating with the Children’s Bureau under this Act shall make such reports concerning its operations and expenditures as shall be prescribed or requested by the bureau. The Children’s Bureau may, with the approval of the board, and shall, upon request of a majority of the board, withhold any further certificate provided for in section 10 hereof whenever it shall be determined as to any State that the agency thereof has not properly expended the money paid to it or the moneys herein required to be appropriated by such State for the purposes and in accordance with the https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis O P M A T E R N IT Y A N D IN F A N C Y . 37 provisions of this Act. Such certificate may be withheld until such time or upon such conditions as the Children’s Bureau, with the approval of the board may determine ; when so withheld the State agency may appeal to the President o f the United States who may either affirm or reverse the action of the Bureau with such directions as he shall consider proper: Provided, That before anv S^Cii c®r^-1®ca^e shall be withheld from any State, the chairman of the board shall give notice in writing to the authority designated to represent the State, stating specifically wherein said State has failed to comply with the provisions til tills ACi. S*;0- J2. No portion of any moneys apportioned under this Act for the benefit ot the States shall be applied, directly or indirectly, to the purchase, erection preservation, or repair of any building or buildings or equipment, or for the purchase or rental of any buildings or lands, nor shall any such moneys or moneys required to be appropriated by any State for the purposes and in ac cordance with the provisions of this Act be used for the payment of anv maternity or infancy pension, stipend, or gratuity. Sec . 13. The Children’s Bureau shall perform the duties assigned to it bv this Act under the supervision of the Secretary of Labor, and he shall include in his annual report to Congress a full account of the administration of this Act and expenditures of the moneys herein authorized. S ec . 14. This Act shall be construed as intending to secure to the various States control of the administration of this Act within their respective States subject only to the provisions and purposes o f this Act. Approved, November 23, 1921. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX B.— C O N STITU TIO N A L IT Y OF TH E ACT. A test case by Massachusetts. In 1922 when a bill for the acceptance of the maternity and infancy act was pending before the legislature of Massachusetts the question o f Congress s power to enact legislation of this sort was raised. The legislature thereupon requested the opinion of the attorney general of the Commonwealth as to whether in his opinion the act was or was not constitutional. The attorney • general gave it as his opinion that the act was “ an attempted exercise of power over the subject of maternity and infancy, and thus an incursion into the held of the local police power, reserved to the States by the tenth amendment to the Constitution. He further advised that as the money derived from Federal taxation was in his opinion to be illegally divided among States accepting the act the property rights of the citizens of Massachusetts who were Federal tax payers were involved, and the Commonwealth could find a basis for a suit for the protection of the property rights and welfare of its citizens, as well as the defense of its rights as a sovereign State. The attorney general recommended a proceeding in equity against the officials of the Federal Government who were carrying out its provisions.1 * , A t the same time the legislature was informed by the supervisor of admin istration that Massachusetts was accepting aid under 22 different appropria tion acts. The State department of agriculture was receiving Federal funds which were classified under the following heads: White-pine rust, European corn borer, marketing work, soil survey; the State department of conservation under the following: Suppression of gypsy and brown-tail moths, prevention of forest fires; the State department of education for vocational education and vocational rehabilitation education; the State Agricultural College under the Morrill Fund and under the Adams, Nelson, and Smith-Lever A c t s ; the State nautical school, the division of highways and the State militia also accepted Federal subsidies. It was generally recognized that this measure merely ex tended the well-established principle of Federal and State cooperation, the benefits of which Massachusetts had accepted in the past and was still con tinuing to accept, to a new field— the protection of maternity and infancy. A complaint was accordingly filed in behalf of the Commonwealth of Massa chusetts in October, 1922 (Commonwealth of Massachusetts v. Andrew W . Mellon Secretary of the Treasury; Grace Abbott, Chief of the Children’s Bu reau of the Department of Labor; Hugh S. Cumming, Surgeon General of the Public Health Service; John J. Tigert, Commissioner of Education) in which the alleged unconstitutional acts of Congress were recited, and an injunction was sought restraining the Federal officers charged with the enforcement of the maternity and infancy act from carrying out its provisions. A taxpayer’s suit. A taxpayer’s suit was started (Frothingham v. Andrew W . Mellon, Secretary of the Treasury, et a l.) in the Supreme Court of the District of Columbia, in December, 1922, apparently because those interested in having the act held unconstitutional realized the weakness of the Massachusetts case. The second comnlaint contained substantially the same allegations as the Massachusetts case except that where the latter alleged that “ its rights and powers as a sovereign State and the rights of its citizens have been invaded and usurped bv the act, the Frothingham complaint alleged that the act made appropria tions unauthorized by the Constitution of the United States, resulting in the taking of her (plaintiff’s) property without due process of law, m violation of the fifth amendment.” _ , . . . ... . The Supreme Court o f the District of Columbia dismissed the plaintiff s bill of complaint in this case, and later the Court of Appeals o f the District of Columbia affirmed its decree. An appeal was then taken to the United States Supreme Court and it was argued, with the Massachusetts case, in May, 1928 In addition to the brief submitted by the Solicitor General, other briefs in defense of the act were filed on behalf of 10 States— Arkansas, Arizona, i M assachusetts H ouse Docum ent No. 1660, 19 22 . 38 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis T H E W E L F A R E A N D H Y G IE N E O F M A T E R N IT Y A N D IN F A N C Y . 39 Colorado, Delaware, Indiana, Kentucky, Minnesota, Oregon, Pennsylvania and Virginia and the Association of Land-Grant Colleges, as amici curiae These cases raised two questions: (1) As to whether a justiciable question 0V^r /^ T lch the court had jurisdiction was presented in either or both cases and infancy ° a j hetlier C° ngreSS exceeded its authority in passing the maternity Questions as to jurisdiction are often “ merely technical,” but here, broad questions of public policy and the interrelations of the various departments of the Government were involved, so that the decision of the court on this pomt wouid either support or undermine the basis of the plaintiff’s argument that the act was unconstitutional. 6 T n n Í T 1 Q9 Q f É the decision rendered by the Supreme Court on S " 5 s * Ttha* b° t h these cases must be disposed of for want of juris^ Sutherland, in delivering the opinion of the court, said • . .,W hat- tben> 1S the nature of the right of the State here asserted and how Í? ^ statute? Reduced to its simplest terms, it is alleged that the statute constitutes an attempt to legislate outside the powers granted to Congress by the Constitution and within the field of local powers exclusively reserved to the States. Nothing is added to the force or effect of this assertion by the further incidental allegations that the ulterior purpose of Congress thereby was to induce the States to yield a portion of their sovereign rights; that the burden of the appropriations falls unequally upon the several S tates; and that there is imposed upon the States an illegal and unconstitu tional option either to yield to the Federal Government a part of their reserved rights or lose their share of the moneys appropriated. But what burden is imposed upon the States, unequally or otherwise? Certainly there is none unless it be the burden of taxation, and that falls upon their, inhabitants who are within the taxing power of Congress as well as that of the States where they reside. Nor does the statute require the States to do or to yield anything I f Congress enacted it with the ulterior purpose of tempting them to yield ^ p u r p o s e may be effectively frustrated by the simple expedient of not In the last analysis, the complaint of the plaintiff State is brought to thf» naked contention that Congress has usurped the reserved powers of the several States by the mere enactment of the statute, though nothing has been done and nothing is to be done without their consent; and it is plain that r w question, as it is thus presented, is political and not judicial in character p o w e r^ ref° re ÍS n<>t a matter which admits o f the exercise of the judicial A s to the taxpayer’s suit, the court called attention to the fact that__ The right of a taxpayer to enjoin the execution of a Federal appropriation act, on the ground that it is invalid and will result in taxation for i l l S purposes, has never been passed upon by this court. * * * The interest nf a taxpayer of a municipality in the application of its moneys is direct and im mediate and the remedy by injunction to prevent their misuse is not inannronri ate. * * * The reasons which support the extension of the equitable^remedy to a single taxpayer in such cases are based upon the peculiar relation of t S corporate taxpayer to the corporation, which is not without some resemblance to that subsisting between stockholder and private corporation But the relation of a taxpayer of the United States to the Federal Government ffv e r v different. H is interest m the moneys of the Treasury— partly realized fm™ taxation and partly from other sources— is shared with millions of others comparatively minute and indeterminable; and the effect upon future taxatiní, of any payment out o f the funds, is so remote, fluctuating, and uncertain that no basis is afforded for an appeal to the preventive powers of a court of en n it? “ The administration of any statute likely to produce additional taxation to be imposed upon a vast number of taxpayers, the extent o f whose several lia bfiity is indefinite and constantly changing, is essentially a matter of nub t and not o f individual concern. I f one taxpayer may cMmpion and litSate such a cause, then every other taxpayer may do the same, not only in resnect of the statute here under review but also in respect of every other aDDronriation act and statute whose administration requires the outlay of public m o n ev and whose validity may be questioned.” y money, 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 THE WELFARE AND HYGIENE OF MATERNITY AND IN FAN CY. The court further called attention to the fact th at: “ It is o f much significance that no precedent sustaining the right to main tain suits like this has been called to our attention, although since the forma tion o f the Government, as an examination of the acts of Congress will dis close, a large number of statutes appropriating or involving the expenditure of moneys for non-Federal purposes have been enacted and carried into effect.” Thus, the merits of the question of the constitutionality of the act were not 'discussed, because the court found that a justiciable question was not pre sented. Congress acted in the belief that the welfare of mothers and babies is a matter of national as well as local interest and that legislation making possible cooperation in reducing the death and morbidity rates is constitutional. The Supreme Court has indicated that on this matter the opinion of Congress is final. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis APPENDIX C.— RULINGS OF THE COMPTROLLER THE TR EASURY. GENERAL OF The rulings o f the Comptroller General of the United States Treasury in connection with the appropriations for carrying out the maternity and infancy act have been in substance as follow s: 1. That so much of the 1922 appropriation as was paid to a State and as re mained unexpended on June 30, 192'2, was to be available for expenditure within the State until the close of June 30, 1923. (M ay 12,1922.) 2. That so much of the 1922 appropriation as was apportioned to a State and as remained unpaid to such State at the close of June 30, 1922, was to be avail able for payment to the State at any time during the fiscal year 1923 and for expenditure until the close of June 30, 1923.1 (M ay 12, 1922.) 3. That any interest accruing while the moneys are held by the State inures to the benefit of the United States as owner of the funds and not to the States as trustees, and should be accounted for and paid into the United States Treasury accordingly. The law does not contemplate, however, that the money shall be held by the States and bear interest, but shall be promptly applied to the purpose for which furnished and the amounts should not be furnished in amounts necessarily resulting in large sums being held and thus bearing in terest. (M ay 12, 1922.) 6 4. That in case the State fails to appropriate an amount specifically equal to the amount of the allotment authorized by the Federal appropriation, moneys applied to the same purpose through other State appropriations may not be con sidered as making the appropriated funds of the State equal to the allotments authorized by the Federal appropriation, unless it is established that the fact that the other appropriation was available for the “ services and facilities pro vided for in this Act ” controlled the State legislature in making its specific appropriation, in which case there would be justification for considering these moneys in determining that the amount appropriated by the State is equal to the Federal allotment. (June 23, 1923.) T h is sam e ru lin g app lied to app ro p riatio ns fo r succeeding fisca l years— th a t is , so m uch of an app ro p riatio n for an y F e d e ia l fisca l ye ar as w as apportioned to a State w as a v a ila b le for paym ent to and expenditure in such State fo r a tw o-year period, th a t period b eginning J u ly 1 off the fisca l ye ar fo r w hich the ap p ro p riatio n w as m ade, and ending J une 30 of the succeeding fisca l year. 41 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis A P P E N D IX D.— INSTRUCTIONS FOB ACT. A CC O UNTING U N D ER TH E Accounts and vouchers. Accounts and vouchers for both Federal and State funds used in promoting the welfare and hygiene of maternity and infancy under the Sheppard-Towner Act should be regularly kept at the State agency responsible for the local ad ministration of the act so that if examined at any time by a representative of the Children’s Bureau it will be possible to ascertain the exact expenditures made. I f the original accounts and vouchers are kept in the office of the State treasurer and the responsible State agency keeps only duplicate vouchers, these duplicates should bear evidence of their payment by reference to the warrant or otherwise. Expenditures from both Federal and State funds which are in cluded in the account of an appropriation for any Federal fiscal year should be confined to those actually made in the maintenance of the services and fa cilities provided for in the Sheppard-Towner Act during the two-year period for which the appropriation is available. Separate accounts for expenditures of the Federal fund and the State fund used in matching the Federal fund should be kept in accordance with the provisions of the financial schedules pre scribed by the Children’s Bureau and should be supported by vouchers ap proved by the director of the State agency. I f the State appropriation for the hvgiene of maternity and infancy is larger than the amount used to match the Federal allotment, a separate account of so much of the State’s appropriation as is used to offset the Federal fund should be kept. The classification of expenditures in accordance with the headings prescribed by the Children’s Bureau should be indicated on all vouchers or accompanying jackets. Every voucher should further indicate the fund, whether Federal or State, from which the expenditure is made. There should be a pay roll or an individual voucher which should indicate the period for which the salary charge is made, the annual rate of salary, general description of duties (grade or title), and, if paid by cash, should con tain the personal signature of each individual and the indorsement of the director of the State agency. Separate pay rolls for salaries under the Sheppard-Towner Act should be kept. _ _ . ■;" . Vouchers for travel should give the purpose and dates for each trip and show an itemized account of all railroad and boat fares, livery, bus, and street car expenses payments for subsistence, and miscellaneous items. The voucher should contain the personal signature of the individual paid and the indorse ment of the director of the responsible State agency. There should be vouch ers to show the purchase of mileage books and subvouchers to show how and when the mileage was used. Expenses for supplies and other material should not be included in travel accounts. . ,„ ,. There should be an itemized account of all supplies and miscellaneous arti cles purchased and the vouchers should indicate the date_when the goods were received and the date of payment, and should bear the signature of the payee and indorsement of the director. Classification o f expenditures. The first scheme for classification o f accounts by items of expense provided for eight ledger headings as follow s: l Salaries— Entire staff, both office and field, professional and clerical. 2. Printing— Publications, etc. 3. Supplies— Office and scientific supplies. 4 Furniture— Typewriters, office desks, tables, and so forth. 5. Express and freight— Cartage, drayage, and so forth. 6. Telegraph and telephone. , , . 7 Traveling expenses— In connection with promoting the welfare and hygiene of maternity and infancy only— running expenses of automobile, purchase of automobile, railroad fare, subsistence while in the field, and so forth. 8. Miscellaneous— To be itemized in detail. 42 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
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