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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 23, 1921
FISCAL YEAR ENDED JUNE 30, 1924

Bureau Publication N o . 146

WASHINGTON
GOVERNMENT PRINTING OFFICE
1925

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SINGLE COPIES OF THIS PUBLICATION MAT BE
OBTAINED FREE UPON APPLICATION TO THE
CHILDREN’ S BUREAU.

ADDITIONAL COPIES MAY

BE PROCURED FROM THE SUPERINTENDENT OF
DOCUMENTS, GOVERNMENT PRINTING OFFICE,
WASHINGTON, D . C.
AT

10 CENTS PE R COPY

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ilS fC .

CONTENTS
Letter of transmittal________________________________
Introduction______________ ___ 1 ____________ '
Funds available under the act_____ ZZJj_____
The Federal board of maternal and infant hygiene____
State administration_______
Summary of State activities.”
____ ” ” V _T
A f a n t and prenatal centers or stations_______I ________
County health units______________________ '________ ________ ~~__~
Home visits______________ ____________ _
Nutrition work___ ________________ 1______________ ________
Dental hygiene___________ 1__________________________ _______
~
Correction of defects________________ 1 ____ _____________
Prenatal care_________________________________
Confinement care_________ _________________
Postnatal care_________________________________
Inspection o f maternity and infant h om es.Jl________1 _ _ ~ T ~ V
Mid wives______________ _______________ ___
Mothers’ classes and correspondence courses_____________~ ~~~
Little mothers’ classes_______________________________
Birth registration_______s_____ ________________________ ___ ~
Other activities_____________________ _______
General educational work_____ ______ _________ ________
Cooperation of the medical profession and of lay associations’
Personnel of the administrative staffs_____________________
Summary of principal activities of the individual States. _ ”
Alabam a_____ _________________________
Arizona
_____________________________ ___ ____ ^
Arkansas..___________________________
California________________
Colorado___s___________________________
Connecticut______________________________
Delaware_______________________________
Florida________________________________ ________ I I I
[
Georgia_____ ___________________________
Idaho__________ ___ ___________________
Indiana_____ ____________________ I ______’
Iowa________________________1________ ___ ___________
”
Kentucky_________________________
Maryland
______________________ ' _ _ 3 _______ I — I I I I I "
Michigan_______________________________________ _ J _
Minnesota_____________________________________ ____ 1
Mississippi________:______ ,_________ ~~~_______ “__ ~~~~~~~
Missouri.______________________ ____
Montana___________________________________________
Nebraska_______________________________________
Nevada______________ ____ _________ ~ ______ | __
New Hampshire___ ______ 1______________ _
New Jersey_________________ ________ __
New Mexico__________________________
New York_____________________|j|
North Carolina____________ ±______ _______I ____
North Dakota_____ _____________
Ohio___________ t ___ ____ ___________ “ _____ ---------------------------------- Oklahoma__________ __________________________
■'
Oregon______________ _____________ ________ ___ J____
Pennsylvania____________________ I
hi

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CONTENTS

State administration— Continued.
Principal activities of the individual States— Continued.
South Carolina------------------------------------------------------------------------------------South Dakota------------------- ------------------------------- -----------------------------------Tennessee---------------------------------------------------------- --------------- *------------------Texas------------------------------------------------------ -------- ------- -------------- 1--------------Utah_________________________________ — ----------------------------------------------Virginia— .------------- —
--------------------------------------------------- ------------ —
W ashington---------------------— ------------- ------------------------------------------------W e st Virginia-------------------------------- ~— --------------------------------|------------W isconsin------------------------------- J ------------------------------------------------------------Wyoming---------- ?--------------------------------- — — 7 — - ------------------ — ------------

Federal administration---------------------------- —------- ------------------ — ---------

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Federal staff---------------------------------------------------------- ------------------------------------ Conference'of State directors--------------------------------------p— — --------------Research and educational work-------------------------------------------------------- --—
Maternity-home study— ------------------------JL---------------------------- — 7 ------Maternal-mortality study---------- ------------------------------------- -------------------Stillbirth and neonatal-death study-------------------------------------- ----------Community control of rickets------------------------------------------------ ---------Bibliography on growth and development o f the normal child-----Child management--------------------------------------------- --------- ------ ----------------Film “ W ell b orn ” ------------------------ --------------------------------------------—
------------ -------------------------- ---------- Publications------------------------- -------T
Accomplishments under the maternity and infancy act-----------*— -----------Appendixes :
A.
— Text of the act for the promotion of the welfare and hygiene o f
49
maternity and infancy--------------------- ---------------------------------------------52
B.— List of administrative agencies and officers__------— — ------- kl-'-M--'
54
C. — Maternal and infant mortality rates--------------------------— ---------D.
— List of Children’s Bureau publications bearing upon maternity,
55
infant, and child welfare and hygiene------------------- ---------------------

MAPS
States accepting the benefits of the act--------------------------------------------- Frontispiece
23
Activities in California during 1923-24---------------------------------- -— ------- -------Activities in Michigan during 1923-24-------- v-— -------------------------------------- —
28
Activities in Mississippi during 1923-24--------------------------- -----------------------------31
Activities in Missouri during 1923-24-------------------------------------------------------------32
Activities in South Dakota during 1923-24----------------------------------------------- -—
40

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LETTER OF TRANSMITTAL

U. S.

epartm en t

h il d r e n ’s

abor,

u reau

Washington, February 11, 1925.
S i r : There is transmitted herewith a report o f the activities
undertaken for the promotion of the welfare and hygiene o f mater
nity and infancy under the act o f Congress o f November 23, 1921,
during the fiscal year ended June 30, 1924. Since the resignation
$■' o f Dr. Anna E. Rude and Dr. Ethel M. Watters, Dr. Florence E.
raker, associate director o f the maternity and infant-hygiene divi
sion o f the Children’s Bureau, has been in immediate charge o f this
work for the bureau and has been responsible for the preparation
o f this report.
Respectfully submitted.
G

Hon.

am es

J. D

a v is

race

bbott,

Chief.

Secretary of Labor,
v

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THE PROMOTION OF THE WELFARE AND HYGIENE
OF MATERNITY AND INFANCY
INTRODUCTION
The act for the promotion o f the welfare and hygiene of maternity
and infancy o f November 23, 1921, popularly known as the Sheppard-Towner Act, makes available to the States, if matched by State
funds, Federal aid for reducing maternal and infant mortality and
promoting the health of mothers and infants.1
A t the close o f the fiscal year 1924, 40 States— all except Con
necticut, Illinois, Kansas, Louisiana, Maine, Massachusetts, Rhode
Island, and Vermont2—were cooperating under the provisions o f the
act, and by action o f the Sixty-eighth Congress its benefits had been
made available to the Territory o f Hawaii. Official requests that
Alaska and Porto Rico be included in the benefits o f the act have
been made but have not yet been acted upon by Congress.
FU NDS A V A IL A B L E U N D ER TH E ACT

The funds authorized by the maternity and infancy act became
available in March, 1922. The administration o f the funds from
that date until June 30, 1923, has been reported in the first annual
report.3 The Federal appropriation for the years 1922, 1923, and
1924, with the amounts accepted by the States iir each o f these years,
is shown in Table 1.
Under the terms o f section 2 o f the maternity and infancy act
“ so much o f the amount apportioned to any State for any fiscal year
as remains unpaid to such State at the close thereof shall be avail
able for expenditures in that State until the close o f the succeeding
fiscal year.” 4
1 For text o f the law see Appendix A, p. 49.
2 The benefits of the act have since been accepted by the Legislatures o f Vermont (Feb.
20, 1 9 2 5 ), Louisiana (July 14, 1 9 2 4 ), and Rhode Island (Apr. 17, 1 9 2 5 ).
8 The Promotion o f the W elfare and Hygiene of M aternity and Infancy. U. S. Children’s
Bureau Publication No. 137. Washington, 1924.
4 In this connection reference may be made to rulings of the Comptroller General of the
United States Treasury in regard to the appropriations for carrying out the maternity
and infancy a c t :
“ 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 monay 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 interest.”
(M ay 12, 1922.)
“ 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 considered as making the
appropriated funds of the State equal to the allotments authorized by the Federal appro
priation, unless it is established that the fact that the other appropriation was available
for the ‘ services and facilities provided for in this act ’ controlled the State legislature
in making its specific appropriation, in which case there would be justification for con
sidering these moneys in determining that the amount appropriated by the State is equal
to the Federal allotm ent.”
(June 23, 1 923.)

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THE WELÈAÌIE AND HYGIENE O f MATERNITY AND IN FAN C Y

T a b l e 1.-

-Amounts available 1 to States from Federal maternity and infancy
funds and amounts accepted, 1922, 1928, and 1924

States

Alabama_________
Arizona__________
Arkansas_________
California________
Colorado_________
Connecticut...........
Delaware_________
Florida___________
Georgia___________
Idaho....................
Illinois___________
Indiana__________
Iowa______________
Kansas___________
K entucky_______ _
Louisiana...............
M aine____________
M aryland-----------Massachusetts—
Michigan------------Minnesota_______
Mississippi______
Missouri----- —¿7 ..
M ontana_________
Nebraska...... .........
N evada__________
N ew Hampshire _
N ew Jersey--------N ew Mexico_____
N ew Y o rk _______
North Carolina..
North D a k o ta ....
Ohio_____________
Oklahoma..............
Oregon....................
Pennsylvania-----Rhode Island—
South C arolin aSouth D akota—
Tennessee_______
Texas........ ..............
U t a h . .. .........—
Vermont________
Virginia_________
W ashington------W est V irgin ia...
W isco n sin ...........
W yom ing..............

Maximum
amounts
available
from 1922
appropria
tion 2>3

$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
477, 500.00

Amounts
accepted
by States
from 1922
appropria
tion

Maximum
amounts
available
from 1923
and 1924
appropria
tions

10,209. 61
4,998. 70
5.000. 00
10,015.85
4,998.87

$25,836. 95
0012,253. 71
0021,817. 51
33.112.01
0016,337. 20
19,311.48
11.504.01
0016,531. 72
29,530. 55
0012,912. 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. 70
34.741.11
26,099. 65
22,076.58
32,958.19
13,701. 91
18,743. 21
0010,522. 06
12,988. 31
31,284. 55
12,430. 33
80,041. 78
27,259.66
0014,362. 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
0013,030. 89
12,376. 90
25,574. 00
19,149. 55
19,871. 74
27,751. 62
11.311.12

317,674. 84

1,190,000.00

$10,297. 56
5.000.
5.000.
(')
5.000.
8,114. 75
5,503.10
5.000.
6,750. 00
5.000.
(6)
8,199.09
10,423. 56
8,991. 51
10,452.00
7,913.57
13,253.97
10,385.44
9,039. 70
12,573.15
6,238. 31
7,924. 66
5.000.
5.000. 00
12,119. 83
5,812.96
10,773.47
5.000.
7,187.95
5.000. 00
6,232.61
24,667.12
8,797. 50
6,436.07
5.000. 00
9,363. 93
5.000.

.0)

Amounts accepted by
States from—
1923
appropriation 2
$25,836.95
5,000.00
6,855. 75
24.280.00
9,986. 54
9,655.74
11.504.01
8,621. 28

11,000. 00
6,250.00

24,995. 00
26, 213. 60
12,097.33
26,298. 64

1924
appropria
tion4
$25,836.95
12,253. 71
16,817.51
15,620.00

10,000.00
11,504.01
16,531. 72
17,450.00
7,912.66
26,250.00
26,213.60
26,298. 64
22,129.80

19,277.05

34.741.11
26,099.65
22,076. 58
32,958.19
13,701. 91
17.700.12
5.000. 00
5.000. 00
31, 284. 55
12,430.33

34.741.11
26.099.65
22,076. 58
21,762.17
13,701. 91
7,409. 50
10.522.00
12,988.31
31,284. 55
12,430.33
80,041. 78
27.259.66

27,259. 66
6, 000. 00
11,900.00
5.000.

8.000. 00

68,810.99

21,355.65
14,293.11
18,521.94
33,056.48
6,365.00
25,574.00

10,000.00

5.000. 00
27,751.62
5.000.

722,752.78

6,000.00

43.843.46
00 23,679.48
15.283.46
68,810. 99
5.000. 00
21,355.65
14.293.11
21.825.00
41,450.52
13.000.
00
5.000.
00
25.574.00

10.000. 00
10,000.00
27,751. 62
00
00 11.000.
918,280.49

i Under the terms of the act each State accepting receives $5,000 outright; an additional feOOO is ^ a ilable to each State if matched and the balance of the appropriation is distributed among the states on the
k^Amountsshown are the amounts actually accepted by the States less refunds of unexpended balances

r63 Owing to the^act that o i^ a 'fe w months of the 1922 fiscal year remained at the time the appropriation

«• ^ t $5,000.
£ g jrHowever,
js s t i .
6 California and Illinois accepted the full amount available, and Vermont accepted
these funds were not spent but were returned 4o the Federal Treasury.

TH E FE D E R A L BOARD OF M A T E R N IT Y A N D IN F A N T H Y G IE N E

Section 3 o f the act creates a Federal Board o f Maternity and
Infant Hygiene, to consist o f the Chief o f the Children’s Bureau,the Surgeon General of the Public Health Service, and the United
States Commissioner of Education. At its first meeting (April,

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TH E WELFARE AND HYGIENE OF MATERNITY AND IN FAN C Y

1922) this board elected as its chairman the Chief o f the Children’s
-Bureau, who has continued to serve in that capacity.
Section 8 o f the act provides that to receive the benefits o f the
act detailed plans for carrying out the provisions o f the act within
the State must be submitted to the Children’s Bureau and be subiect
to approval by the board. It is specified, however, that “ if these
plans shall be m conformity with the provisions o f this act and
t
~
b ly a p p r iipiriaxt1e ^n d ^equate to carry out its purposes they
shall be approved by the board.
(Sec. 8, Appendix A , p. 50.)
Thus plans originate in the States and are administered by the
Dlanln
& and it bx°ard
baS
been to conside/each
plan
m the spirit o f the act,
has not
attempted
to control or
»hC actl? .ties t(? Pe undertaken. It has interpreted the term
fha
as endmg with the preschool period, which means that
the funds are not available for work with school children, and has
ruled that Federal funds or State funds used in matching Federal
funds can not be expended in subsidies to private agencies.
46774°—25----- 2

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STATE ADMINISTRATION
SUM M ARY OF ST A T E A C T IV IT IE S

The activities of the States have had for their object (1) better
infant care through the teaching o f mothers, (2) better care for
mothers through education as to the need and value o f skilled super
vision during pregnancy, childbirth, and the lying-in period, and
(3) more widespread medical and nursing facilities so that adequate
maternity and infancy supervision will be available.
In order to make a program suited to the needs o f a State, careful
analyses by cities and counties o f the causes o f infant and maternal
deaths, local sanitary conditions, available medical attention and
nursing service, and the general facts as to racial, social, and eco
nomic conditions are necessary. In a number o f States these facts
are still not available, but as a result o f the previous years’ work
they were much better understood than at the initiation o f the
maternity and infancy work in 1922. Consequently, the activities
undertaken have been better correlated with local needs.
INFANT AND PREN ATAL CENTERS OR STATIONS

Children’s health centers or health conferences and prenatal or
maternity centers or conferences are everywhere recognized as the
best teaching agencies. While the term is variously used in differ
ent parts o f the country and the service available differs widely, a
“ permanent conference,” “ station,” or “ center” means in this dis
cussion an established place and time at which a doctor and nurse
are present for the examination o f well children and for the instruc
tion o f the mothers on the essentials in the feeding and care o f babies
and preschool children.
In some States in which it is not possible to have regular medical
attendance at the conferences the center provides the opportunity
for conferring with a nurse, who explains the essentials in child care
and may inspect and weigh the children brought. (In this discussion
the word “ center” is used for the established agency and “ confer
ence” for the “ demonstration” o f the type o f activities which are
carried on by the “ center.” )
An objective in most o f the States is state-wide establishment o f
permanent, locally supported children’s health centers and prenatal
centers accessible to all the population in need o f such assistance and
instruction. In New Jersey permanent center activities are con
ducted by the State staff. Infant or children’s conferences or centers
had been established in the larger cities in many o f the States, but in
only a few-places had a county-wide service been provided before
1922. In order to acquaint local communities with the work that
these conferences would do, demonstration conferences have been
held by the State agencies administering the act, and help has been
given through the loan o f personnel or through subsidies in the
formation o f permanent local conferences or centers.
4

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THE WELFARE AND HYGIENE OF' M ATERNITY AND IN FAN C Y

The reports o f the States show 15,547 child-health conferences held
by the State agencies administering the Federal funds during the
fiscal year ended June 30, 1924, with 303,546 infants and children of
preschool age examined and 1,084 children’s health centers estab
lished through the efforts o f the States. The number o f these con
ferences conducted by the State staff varied greatly.
An automobile or truck outfitted as a center has been found to be
o f especial advantage in initiating a maternity and infancy program
in areas where the nature o f the work is little understood. Since it
attracts attention all along the route it has great educational value.
The State Board o f Health o f South Carolina has such an automo
bile, which has been used by the child-hygiene and other divisions
o f this board. Conferences are held and films shown to the general
public. Maryland has a “ healthmobile,” the staff o f which has ex
amined some 8,700 children in the 14 counties visited. Talks on
infant and prenatal care were also given and health films shown.
Georgia reached by the aid o f its “ healthmobile ” 20 counties in the
poorest section o f the State, also a number o f mountain communities
which are quite shut off by bad roads and long distances from rail
roads. Florida has a “ health movie truck ” which was used for two
months in rural districts, giving 26 shows at which an average o f
three health films were exhibited, with some conference work and the
distribution o f suitable literature. In Arkansas two automobiles are
used for the “ health caravan,” which on request goes into various
counties to hold conferences. The staff consists o f a doctor, two
nurses, and the chauffeur for the apparatus automobile, who operates
the motion-picture machine, using a portable electric motor. The
Tuskegee movable school, with which the Alabama bureau o f child
hygiene and public-health nursing cooperates by assigning a colored
nurse to help in the demonstrations, has found this productive o f
excellent results. That specialized work, as well as that o f general
conference, may be done with the aid o f trucks and automobiles
properly equipped was shown the past year in New Jersey with a
“ traveling dental ambulance.”
COUNTY HEALTH UNITS

The county has been increasingly used as the local administrative
unit in the work, and there has been an encouraging increase during
the past year o f undertakings jointly supported by State and county,
also o f instances in which the county has takjen over the work in
full after a brief period o f demonstration or subsidy by the State
with State and Federal funds. In the States in which full-time
county health units have been organized in a number o f the counties
a special maternity and infancy service has often been added by the
State (usually for a specified period). I f this demonstration
aroused general interest and met with approval o f the county, full
responsibility for its maintenance frequently has been assumed by
the local community.
In some States a maternity and infancy nurse has been sent to the
ounties for periods o f two or three months to assist the general
public-health nurse in the maternity and infancy program. In one
State a public-health nurse is lent to give demonstrations for periods
o f three months to one year, with the understanding that at the end
o f that period the community shall assume in whole or in part the

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TH E WELFARE AND HYGIENE OF M ATERNITY AND IN FAN C Y

salary and expense o f the nurse. The majority o f the States have
generalized nursing programs, and records are kept o f the time
spent in maternity and infancy work with proper division o f funds
in accordance with these accounts.
HOME VISITS

Home visits give to the nurse an opportunity to observe the living
conditions o f the patient, and the mothers visited are more at ease
and hence more willing to ask questions and to discuss their prob
lems than at a conference. Demonstrations made on almost every
conceivable point connected with maternal and infant hygiene and
the health and welfare o f preschool children are o f still more value
when made with the equipment which the home affords. In this
connection it may be noted that the line between demonstrations and
visits in which only advice or instruction is given can not be strictly
drawn, nor is it possible to classify under Mvisits ” the incidental
nursing care which many nurses have found it imperative to give in
remote districts.
Home visits are a part o f the center routine, the usual custom
being for the nurse to make a first visit promptly after the birth
registration. In some places where there are no center activities
and where demonstration conferences are impracticable the home
visits o f the nurse are the only possible method o f reaching the
mother. After demonstration or itinerant conferences the home
visits are made by local cooperating nurses. Because o f inadequate
records in some States the total *6f approximately 149,000 visits re
corded by the States cooperating under the maternity and infancy
act probably does hot indicate more than a large proportion of the
visits and home demonstrations actually made.
The distances traveled and the difficulties overcome in order to
attend conferences indicate the mothers’ appreciation o f help. A
photograph sent by a nurse working in a western State shows a
mother and child crossing a river in a basket swung on an overhead
cable in order to attend a child-health conference. Among the
mothers present at other conferences was one who had driven 14
miles with horse and buggy to bring her three children, another who
brought her 6-weeks-old baby from a point in the country IT miles
distant, one who had driven 20 miles, and two others who had driven
10 miles each; and some mothers travel by mules, over trails in
stead o f roads. The difficulty o f having mothers (especially pre
natal cases) assemble for conferences or classes under such condi
tions o f isolation and travel is evident. Although the distances are
quite as great for the nurses to cover, a means of transportation has
become part o f the necessary equipment for a nurse, and generally
she can so route her trips as to make the greatest possible number
o f visits on each. Some o f the journeys made by the nurses in the
course o f their routine work involve actual hardship. This is per
haps especially true in some sparsely populated western States, yet
there are isolated and inaccessible communities in every State. -A
nurse in a western State, who wrote that it was all in a day’s wor
to drive 60 miles or more before 9 a. m. to hold a conference, and to
take another long trip at night to the next town, added, “ Some o f
the roads are just trails, but they all lead to mothers and babies.”

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TH E WELFARE AND HYGIENE OF MATERNITY AND IN FAN C Y

NUTRITION WORK

Physicians and nurses throughout the country have noted the
prevalence o f undernourishment of malnourishment among the chil
dren whom they encounter in their work. Pathological conditions
caused by badly selected food or lack o f food are clearly apparent;
and these are noted at conferences and centers, where the physician
or the nurse teaches the general principles of nutrition and gives
advice on the special nutritional needs o f the children under exami
nation. In the course o f visits to the home the nurse again empha
sizes these matters and reiterates the main points o f the instruction.
The subject receives much attention in mothers’ classes, little mothers’
classes, and demonstrations and exhibits at State and county fairs.
Literature bearing on the general topic o f proper foods for infants,
expectant mothers, and young children has been widely distributed;
and in addition newspaper articles for occasional or for regular dis
tribution have been prepared by a number o f the State staffs.
The first lesson on nutrition for the child is properly a part o f the
instruction on prenatal care to be given to the expectant mother.
The second lesson consists o f information concerning the importance
of breast feeding, which is widely recognized as a conspicuous factor
in the reduction o f infant morbidity and mortality. The methods by
which the nutritional needs o f the child after the nursing period can
best be imparted to the mother are still largely experimental.
Much information concerning the value o f individual foods both
for normal children and in the correction o f pathological conditions
has been acquired in recent years; and new data are constantly being
brought to light. In some States the nutrition worker specializes
in the preparation of food formulas ordered by physicians for under
nourished children; and the conducting o f nutrition classes or courses
was reported by a number o f States. Since some States, as Dela
ware, mentioned merely “ occasional ” classes on this subject, the
total o f 309 classes reported, 82 o f which were in New Jersey and 73
in Texas, is doubtless quite incomplete for the 40 cooperating States.
DENTAL HYGIENE

Some States note that dental attention was included in the childhealth conferences held. Others report that the inspection o f chil
dren by nurses included sufficient observation o f the teeth to deter
mine that the child should be referred to a dentist. Dental clinics
or conferences have been specifically reported by only 10 States.
Over 11,000 children received examination. In addition to the 28
dental conferences (with a total o f 1,120 children examined) which
California reported, a special campaign for the complete physical
examination o f preschool children (see p. 22) was made possible in
this State by the cooperation of dental as well as medical organiza
tions. The dental hygienist on the staff is reported to have done
successful work and to have been instrumental in obtaining dental
clinics. A ll corrective work was referred to the local dentists.
^ In Indiana 1,649 children were examined and the cases (1,519)
o f decayed teeth noted; instruction on the care o f the teeth was
given in mothers’ classes, and a chart was exhibited showing the
relation between nutrition and the development o f teeth. An edu
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cational film dealing with the care o f the teeth was shown in Indiana
and a number o f other States. Although Michigan made no especial
report concerning dental conferences or clinics, statistics on defects
noted during physical examinations at health conferences were re
corded. New Jersey reported accomplishing dental care for 1,300
children through its two clinics and traveling dental ambulance. In
Pennsylvania the State division o f dental hygiene cooperates with
the preschool division o f the bureau o f child health by detailing two
members o f its staff to give full time to work among preschool chil
dren and prenatal cases, while 38 members o f the staff give part time.
West Virginia had a dentist at every child-health conference during
four weeks o f intensive work in four counties. Iowa has a dental
adviser upon the administrative staff. An exhibit on oral hygiene
was prepared and used especially at the meeting of the State dental
society. It was noted here that defects o f the teeth, although found
among the four chief kinds o f defects noted in the examination o f
children (diseased tonsils, malnutrition, adenoids, defects in teeth),
are nevertheless practically 100 per cent correctible.
The problem o f the expense involved in dental treatment was
partly solved in South Carolina by charging each child treated the
nominal sum o f 50 cents, though the work done in manv cases was
actually quite costly. The State dental association furnished a
dentist, who organized the work in a county with the county nurse
and the local physicians. The county wishing the work done con
tributed a sum of money, and the State dentist assigned a dentist to
do the work. In Virginia the dentist on the staff works in coopera
tion with the State dental association and submits all plans to the
dental member of the State board of health for approval. Dental
clinics were held by the State in the summer, and a dentist attended
the child-health conferences. Altogether dental care was given to
69 mothers and 848 children. Since 17 counties have no resident
dentists the child-hygiene division has been trying to create a de
mand for dentists, and the local dentists, in fact, seemed to have more
work than ever before.
CORRECTION OF DEFECTS

Although centers and consultations are for “ well ” babies, defects
are frequently found which require correction before the child is
“ free to gain ” a maximum of general health and physical fitness.
When the mother and baby are seen regularly by the physician in the
well-established center and the nurse visits the mother in her home,
the facts as to the correction o f defects are easy to ascertain. F ol
low-up on demonstration conferences is more difficult. The defects
most frequently encountered are refractive errors in the eyes, naso
pharyngeal growths and abnormalities, orthopedic defects, glandular
enlargements or evidences of glandular insufficiencies, dental caries,
and malnutrition (always the large percentage in every group).
Children are always referred to the family physicians for the correc
tion o f these defects, if there is a physician. Poverty, inaccessibility,
or lack o f physicians necessitates special arrangements. A fe,
States have arranged for clinics at which defects may be corrected by
a staff physician or by a specialist engaged for this purpose. In most

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places the work is done by local physicians or specialists, the nurses
having explained the need to the parents and made special arrange
ments for the indigent.
Some States have furnished calculated or estimated percentages of
defects corrected, ranging usually from 20 to 40 per cent. Indiana
has made a series o f surveys to find just how much has been done in
correction of defects found in the course o f examinations previously
made. In Oklahoma a total o f 15 corrections in 42 cases was noted in
the records o f one conference. South Dakota reported 490 correc
tions in 2,725 cases examined; Pennsylvania reported 8,678 correc
tions, o f which 1,107 involved adenoids and tonsils and 5,296 involved
the teeth. In one county in Colorado two clinics were held at which
48 nasopharyngeal corrections were made.
PR EN ATAL CARE

Special efforts have been made in all the States to get the program
for prenatal car© well under way. In many parts o f the United
States women do not have medical supervision during pregnancy
nor medical care during the confinement and lying-in period. ^ Since
the importance o f prenatal care is not appreciated by a very large
part o f the public, the prenatal program is still fundamentally edu
cational for the general population as well as for the individual
woman who is reached through the conference. As indicated by
figures from studies made in New Hampshire, New Jersey, and else
where, better prenatal care results in fewer stillbirths, less maternal
mortality, a lower infant mortality rate during the first month o f
life, and better health for both mother and baby. The technique
and unit costs o f the prenatal or maternity conference for urban
districts have been well worked out and the modifications necessary
for a rural district are being learned in the activities now under way.5
The States report 6,088 prenatal conferences during 1923-24, with
38,662 women in attendance. As yet only a few (188) permanent
prenatal centers have been established, but a steady increase o f
attendance has been noted at most o f these and also at the itinerant
or demonstration conferences.
Wisconsin has each mother and baby center visited every four
weeks by one o f the physicians from the State staff, who spends the
remaining conference time at other points in the same counties. The
State prenatalist o f Michigan has traveled about holding prenatal
clinics and conferences and giving talks. Demonstrations were
given in homes in the more isolated regions, where it was not possible
to collect the women in groups. The bureau o f child hygiene con
ducted a series o f home demonstrations in a county in the lumber
region. In New York the State obstetricians held prenatal con
sultations at different towns at regular intervals. Midwives are
required to bring their patients for examination. Local physicians
A worth-while detail on some programs for prenatal care has been the preparation and
demonstration of model obstetrical packages, also persuading clubs to prepare such sterile
obstetrical packages and to equip and maintain “ loan closets ” for indigent or incommothers. In Minnesota such a sample obstetrical package was demonstrated in 66
of the 87 counties. In some States hospitals have generously sterilized the packages for
the loan closets. Many physicians have expressed their appreciation o f these obstetrical
packages.

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may send their patients for consultation, but no woman who is known
to be the patient o f a physician is examined except upon presentation
o f a written request from him.
In Iowa, where infant and preschool conferences have been held
in every county, the foundation for a prenatal program has also
been laid. In cooperation with the State medical society prenatal
and obstetrical standards have been agreed upon and published;
and through lectures to county medical societies the rural doctors
are kept informed on the most recent developments in obstetrical
practice. The obstetrician who gives these lectures carries a com
plete equipment o f instruments as well as slides and films. Mis
souri held no regular prenatal conferences, but reported that general
advice and instruction was given by the staff physicians to 8,024
mothers. In Minnesota two well-known Minneapolis obstetricians
held conferences for pregnant women in outlying districts. Later
they addressed group meetings o f all the women in the neighbor
hood and impressed upon them the importance o f proper medical
care during the prenatal period as well as at the time o f delivery.
They also met local doctors in consultations.
Prenatal letters have been used in many States. More letters
were distributed on request o f physicians than in any other way.
Prenatal letters were sent out in such numbers as 14,957 in Idaho,
37,713 in North Carolina, 7,168 in Michigan, 1,350 in Oregon, and
in other States in lesser numbers. In Texas the letters were printed
in Spanish as well as in English.
The matter o f dental care during pregnancy and the nursing
period has not as yet been given the attention it should receive. The
importance o f care o f the mother’s teeth is stressed in prenatal con
ferences, and actual treatment has been arranged for in a few
communities.
CONFINEMENT CARE

A survey o f available hospital facilities for maternity cases in
certain rural districts was undertaken in Michigan. The findings indi
cate that the hospital facilities in the State greatly exceed the use
made o f them, and suggest the need o f well-conducted small hos
pitals for lying-in patients. In Utah also the possibility o f small
county hospitals for confinement cases is under consideration.
The entire lack o f professional confinement care in some localities
is a grave problem. Many births occur with no attendance except
that o f members o f the household or neighbors. The director o f
the work in W yoming reports having noted that in some counties
40 per cent o f the women were not attended by doctor, nurse, or mid
wife during childbirth. The help which can be given by a wellmeaning even though uneducated midwife is doubtless in most cases
better than the attention o f neighbors alone or merely members o f
the family. More than one field nurse has reported cases in which
the father was the only attendant, and a number o f nurses have been
unexpectedly called upon to take entire charge o f delivery cases.
Yet in isolated regions the distances to be traveled by patient or at
tendant are a serious matter, further complicated at times by heavy
snowfalls, washouts, and the like. Consequently mothers who desire
medical attention are sometimes as unable to obtain it as are mothers

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who do not appreciate its advantages. In many parts o f the country
during certain parts of the year doctors and even u near” neighbors
find it impossible to reach some confinement cases.
POSTNATAL CARE

When the problem o f adequate confinement care is met the prob
lem of adequate postnatal care will doubtless be solved at the same
time. In the face o f difficulties of prenatal care and confinement
care the necessity of further aid for even a brief period has not
always been easy to emphasize. Provision of trained nursing care in
home confinements is still, therefore, a problem o f considerable
magnitude. It is possible, however, to make clear in literature, as
well as in many personal contacts, the value o f a physical examina
tion o f the mother six weeks after confinement. The fact that this
last step in well-conducted confinement care may prevent the invalid
ism which ^would otherwise follow a large proportion of childbirths is being impressed upon as wide a public as can be reached.
The extent and kind o f postnatal care received has been reported as
a subject o f investigation in a number o f States.
INSPECTION OF M ATERNITY AND INFANT HOMES

The authority to license maternity homes and lying-in hospitals or
children’s boarding homes is generally vested in other bureaus of
State boards o f health than those designated to administer the ma
ternity and infancy act, or in other State boards altogether (such
as boards o f charities and corrections). Although the majority o f
States require that maternity and infant homes obtain licenses, the
supervision exercised by the licensing authority or other designated
authority varies from the strict regulation of standards and man
agement to a mere right of inspection, which in many instances can
not fail to be quite perfunctory. Some States have no legislation
permitting inspection o f such institutions. Much latitude also
exists with regard to the keeping o f records of admissions, dis
charges, births, deaths, withdrawals, and other data concerning
patients, or data concerning persons removing infants ; and reports
to specified authorities may or may not be required.
Inspection o f maternity and infant homes has been reported by
21 States, the work usually being done by field nurses in connection
with their other activities. In some States, as Ohio, Nebraska, and
Texas, the full time of one member o f the staff (a nurse or a social
worker) is devoted to this work. Inspection o f 289 maternity homes
and 459 children’s homes is reported; and o f 278 maternity and
infant homes, giving a total o f 1,026 institutions inspected. These
ligures include 26 hospitals inspected in one State and 87 in another
MID W IVES

Steady progress has been made in acquiring definite information
on the number and character o f midwives practicing legally or
'illegally, also in registering, supervising, and instructing the best o f
these women and eliminating those who seem unscrupulous as well
as wholly untrained. A number o f States (especially New Jersey,
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New York, and Indiana) report that mid wives unwilling to comply
with the State laws are ceasing to practice and that further diminu
tion in the total number has been observed. A complete program o f
education, registration, licensing, and supervision was first developed
in New York City. New Jersey has a comprehensive scheme in oper
ation, and a number o f cities are carrying out well-planned pro
grams on this matter. Satisfactory laws or methods o f administra
tion, or both, are now in process o f development in most o f the States.
Midwife inspectors or supervisors were reported on the staffs o f New
York, New Jersey, Michigan, California, Virginia, South Carolina,
and Connecticut.6
Surveys o f the midwife situation have been undertaken in a num
ber o f States and have been completed in several. California made
a state-wide survey, during which 500 midwives were interviewed.
Four-fifths o f these were well-trained Japanese women; half of the
remaining number seemed capable o f receiving and assimilating
instruction, and the others were rated undesirable. Texas is listing
its midwives and reports that the names and addresses o f 1,889 have
been obtained. Copies o f the law on the practice of midwifery and
the use o f silver nitrate as a prophylaxis are being distributed to
these women. Investigation in Colorado disclosed that in a county
where no midwives were registered 25 women and 2 men were prac
ticing midwifery.
In some, instances educational work among midwives has been
undertaken by physicians, and much is also accomplished by State
and county nurses. Texas reports the employment o f a Mexican
nurse to instruct Mexican midwives and a negro nurse to instruct"
negro midwives. In most o f the Northern States the proportion o f
births attended by midwives is large only among the foreign-born
element. Pennsylvania .selected four coal-mining counties where the
need has seemed greatest and reports substantial progress as the
result o f the efforts o f a staff physician who is able to cope with the
linguistic difficulties arising from the varying nationalities o f the
midwives.
In the South the births among negroes and also among the white
population in remote areas are attended as a rule by midwives, and
the problem o f the untrained negro midwife is serious. Special
attention has been given to training the midwives in a number o f
these States. Virginia, North Carolina, South Carolina, Florida,
and Mississippi are developing a state-wide system o f instruction
with the immediate purpose o f supervising the best midwives and
eliminating the least desirable. Mississippi, which has more than
3,200 midwives and regards them as at least temporarily necessary
fo r prenatal and confinement care, reports 1,116 classes conducted
by the State with a total attendance o f 12,961 midwives and other
women wishing to learn something o f midwifery. Rural negro
mothers were encouraged to attend these classes so that they would
understand what constitutes adequate maternity care. South Caro
lina reports that 1,083 women completed the midwife course organ
ized by the State staff. Several States employ negro nurses with a
view especially to such educational work. A negro physician added
8 During six months of 1923 Connecticut was cooperating on a six-months’ continuance
of the governor's acceptance after the adjournment of the legislature.

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to the staff o f the Children’s Bureau to assist in the work among
negro midwives has aided the health department o f Tennessee in an
investigation and educational campaign among the negro mid wives
o f that State.
In IT States the holding o f classes for midwives is reported, with
a total o f over 2,300 classes held, 24,899 women in attendance, and
2,841 women completing a full course o f instruction. But these
figures are an imperfect indication o f the amount o f work actually
being done, as some States kept accurate record o f only the attend
ance totals, without full details concerning the number o f classes
in the different counties; others reported only the number o f classes
held or the number o f women completing courses o f instruction. In
some ^States much instruction is given to individual midwives in
addition to class work or in the place o f it.
MOTHERS’ CLASSES AND CORRESPONDENCE COURSES

Classes for the instruction o f mothers were reported by 29 States.
It would seem from the majority o f reports that single group meet
ings are regarded as belonging to this category o f activity. New
York may be cited as an example o f a State holding classes in the
more precise meaning o f the term. A course o f seven consecutive
lectures was given by a nurse in each o f 29 communities, the 55 groups
or “ clubs” taking this course having an average membership o f
about 15 mothers. The work may be described as a mothercrait
class, the subjects considered including preparation for confinement,
establishment and maintenance o f lactation, clothing, bath, and
general care o f the baby and the mother. A semisocial atmosphere
is frequently created by the discussion o f problems among the
mothers, and refreshments are served by the club after the class
meeting. A State nurse in West Virginia succeeded in organizing
10 “ study clubs ” in one county for instruction in maternal and
infant hygiene. The general aim o f such work is to impart an
appreciation o f the importance o f early and continuous medical
supervision for both mothers and children, together with some
mastery o f the simpler rules o f maternal and infant hygiene.
A special “ mothers’ lesson outline ” was prepared for use in Michi
gan (see p. 18), and some other States mentioned less formal material.
The largest number of mothers’ classes reported by any one State
was 499 in Indiana. Florida reported 484 “ neighborhood institutes,”
228 of these for negro mothers. New Jersey reported 354 classes.
The largest attendance reported in any one State was 47,544 in New
Jersey ; Indiana reported an attendance o f 7,547, Florida 7,703,
Georgia 5,041, South Carolina 3,929, Minnesota 1,842. The total
number o f classes was over 3,000, with a total attendance o f over
95,500 mothers. Complete figures can not be furnished because some
States did not record attendance at all classes, and some recorded
total attendance but not total number o f classes, or gave merely
estimated averages o f attendance, or in some cases reported only the
number o f women completing the entire course o f -instruction.
More or less formal correspondence courses have been organized
in a number o f States. In at least two the lessons were returned
to be sent in again after revision. These courses vary from regular
instruction to mothers listed on a correspondence-course registry to

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the sending out o f prenatal letters in a series of 9 to 13, or personal
replies to all letters asking for help or information which can not
be adequately and fully furnished by the forwarding o f a suitable
pamphlet or leaflet.
LITTLE MOTHERS’ CLASSES

Teaching girls of the seventh or eighth grade or older the proper
care o f infants seems productive o f excellent and far-reaching re
sults. These young girls are often u mother’s helpers ” and have
full opportunity to demonstrate the information which they acquire.
The method o f instruction varies from single and comparatively
informal meetings to classes in which the pupils complete a course
o f a definite number o f lessons and receive certificates signed by
State or other public authorities. Minnesota has prepared a text
book for use in such classes conducted by nurses in the rural schools
(see p. 30.)
Little mothers’ classes have been reported by 24 States, with a
total of nearly 3,000 classes. The largest attendance figures were
reported by New Mexico (9,825), Michigan (5,327), Minnesota
(4,461), Wisconsin (2,317), and North Carolina (1,826). Compu
tation of the total attendance is not possible, since not all the States
furnished the attendance figures; some gave only the number o f
girls receiving certificates and others kept no special record o f at
tendance.
BIRTH REGISTRATION

Since accurate vital statistics are necessary for intelligent planning
o f a child-health program special attention has been given to im
proving the registration, especially in those States not now in the
birth-registration area. The public-health nurses have always made
registration o f statistics a matter o f observation and report. They
furnish to bureaus o f vital statistics information which they obtain
in the course of their work, and frequently distribute the blank
forms. The importance of registering births is always explained to
expectant mothers who are visited, and the women are taught to ask
the doctor to fill and return certificates without fail. In New
Mexico 475 unregistered births were noted by nurses and reported
to the health department. Montana distributed 1,500 birth-registra
tion postcards,, and Missouri sent out 38,685 certificates. A six
months’ birth-registration campaign was conducted in Oklahoma,
and more or less informal campaigns were carried on in several
States. In Arkansas it has been the practice to have the local
registrar present at child-health conferences.
Iowa and North Dakota were admitted to the birth-registration
area during the fiscal year under review in this report, and Florida’s
later admission7 made the total number o f States in the birth-regis
tration area 33, and the percentage o f the population 76.1. This
situation has been brought about partly by general increased atten
tion to the reducing o f infant mortality since the Sheppard-Towner
Act, and partly also by the activities o f the maternity and infancy
staffs.
7 Florida was admitted in October, 1924.

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Because the vital-statistics divisions o f the State health depart
ments are frequently understaffed it has been necessary in some
States to use maternity and infancy funds temporarily for the com
pilation o f vital statistics and the distribution o f birth certificates
For tables showing the trend of infant and maternal mortality in
the birth-registration area during the period 1915-1923 see Appendix
C, p. 54.
OTHER ACTIVITIES

^Many other types o f activities are undertaken by individual States,
ox which the following are perhaps the most important :
An antidiphtheria campaign has been carried on for nine months
in Pennsylvania. Antitoxin was supplied to physicians working
through child-health centers for preschool children. It is reported
that at the close o f a two-year period a total o f 135,598 infants had
been immunized (figures for preschool children are not yet avail
able). The Schick test will be given to immunized children after
the six months’ period. In some other States similar activity has
rePorted, as in Virginia where 16 toxin-antitoxin clinics were
held with an attendance o f 558, and in one county in Michigan
where the county supervisors voted $500 for the expenses o f carry
ing on this work for preschool children.
Through arrangement for the distribution o f silver-nitrate solu
tion for prevention o f opthalmia neonatorum, prompt care o f in
fants eyes has been stimulated. The use o f this prophylaxis or an
equivalent is compulsory in 24 States, and its distribution is provided
for m 23 States.8 Practically all State health boards distribute the
silver nitrate solution where its use in the eyes o f the newborn is
required, whether or not the statutes specifically order such distributmn. The number o f ampoules distributed was mentioned in the
reports o f a few States; for example, Georgia, 13,291; North Caro
lina, 49,200; and Montana, 1,374. Cooperation has been given in
goiter-prevention campaigns in connection with surveys or investi
gations on the part o f States which have noted the prevalence o f
goiter m certain regions within their borders. Special campaigns for
the physical examination o f preschool children before their entrance
into school were made in 20 counties in California and in certain
regions m Michigan. Assistance in insuring a supply o f pure milk
was given (and part o f the expense was met by maternity and in
fancy funds) m Oregon and Delaware; and aid or publicity Was
given to fly-destruction campaigns in Virginia, Delaware, and A ri
zona.
Surveys or studies o f one kind or another were reported by many
States and also were made in a number o f States which gave no
specific report o f them. These vary from comprehensive compila
tion and analysis o f statistical data to an assembling o f certain
minimum facts preparatory to the organization o f health conferences
or classes in a certain community. A preliminary survey o f this
general nature is evidently a wise first step in the undertaking o f
maternity and infancy work in any region. Thus in Utah such sur
veys were made m 11 counties, covering such items as the social
and economic status of the inhabitants, housing, sanitation, water
Legislation of 1922.

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and milk supply, and other conditions affecting the welfare o f the
child Similar work was done in Indiana, New Hampshire, Ne
braska, North Dakota, Texas, and other States. Florida made a sur
vey o f the condition o f Cuban mothers and children in Key West,
likewise seeking to determine the amount o f assistance that could
probably be obtained locally for work among them. New Mexico
made a survey o f conditions among several communities o f Pueblo
Indians. The number of preschool children or o f undernourished
preschool children was investigated in a number o f States, as New
York, Wisconsin, Nevada, and Kentucky. Maternity and infancy
divisions took part in the study o f prevalence o f goiter in Michigan
and Colorado. Midwife surveys preceded work among or relating
to midwives in most o f the States devoting special attention to this
problem (see p. 12). Local maternal and infant mortality studies
were made in New York, South Dakota, Oregon, and Idaho, and the
matter of birth registration in California, Oklahoma, and Utah.
Hospital facilities for confinement cases were ascertained in Michi
gan and some other States, and postnatal care in others. Data on the
milk supply and the extent o f artificial feeding in selected areas were
gathered as a preliminary step to campaigns in some States.
GENERAL EDUCATIONAL WORK

Opportunity for direct contact with mothers and for examination
o f children is provided by health conferences and the establishment
o f permanent health centers, also by home visits by nurses. More
specialized instruction is communicated by way o f instruction and
supervision o f midwives, m the mothers classes, little mothers
classes, and nutrition classes or institutes. In addition much educa
tional work of more general character is accomplished in all the
States. Activity among communities consisting o f certain racial
groups has been found necessary in some States. Indians in Min
nesota have been given instruction in the care and feeding o f infants
and children and on related matters by two Indian nurses who held a
number o f conferences and also went among their people teaching
them in their homes. W ork among Indians was done in Nebraska
and New Mexico also. Special attention to the Mexican population
was necessary in a few States, the nurses discovering a number o f
lines in which help was greatly needed. Much Instruction has been
given to negroes in certain areas in the Southern States, where
the percentage o f this population is especially high (see p. 12).
Lectures and talks by members o f the administrative staff have
been found productive o f beneficial results. The largest number o f
lectures or talks reported from any one State was 2,413 in New
Jersey. From Indiana 991 were reported, from Georgia T56, from
Ohio 661. South Dakota reported 130 lectures, o f which 60 were said
to have been illustrated. The total for 40 States8 was over 11,000.
Lectures were given by field or county nurses also in some States,
as Alabama, New Hampshire, Oklahoma, and Texas. The number
o f persons reached by this kind o f activity is difficult to estimate.
Only a few States attempted to calculate or even to estimate the
numbers present in all their respective audiences. Ohio reported
Including Connecticut during the six months of cooperation.

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the figure 74,904; North Carolina, 16,913; Kentucky, 49,441; Ala
bama, 14,175; Michigan, 13?584; Iowa, about 14,450.
Visual instruction was given in a number o f States. In addition
to the illustrative material consisting o f slides or motion pictures
used_ in connection with lectures mentioned in a number o f States,
as North Dakota, Utah, Colorado, Texas, Indiana, Georgia, Arkan
sas, and Virginia, the exhibition o f moving pictures o f some length
has been found well worth while. (F or mention o f the Children’s
Bureau film see p. 46.)
A ll the cooperating States distribute many bulletins and leaf
lets directly from the administrative office in response to requests
from mothers, physicians, and local organizations. An equal or
possibly greater quantity is distributed indirectly at conferences,
demonstrations at State or county fairs, and other places o f public
assembly where the subject o f maternal, infant, and child welfare
may appropriately be given attention. Lastly the nurses engaged
m field work or other phases o f activity distribute a large number
o f pamphlets and other printed material in connection with their
work.
*'
Children’s Bureau publications (see pp. 46-47) furnish the major
part o f the material used, although in many States these were supple
mented by pamphlets or leaflets prepared by the State for special
use within- its borders or in certain localities. Posters and charts
were also found useful, and within the category o f printed matter
may be mentioned diet cards, which were used in quantities. Care
fully planned examination outlines or blanks were prepared and
used in Indiana, Iowa, Colorado, and other States for recordin°r
o f findings at conferences and clinics. Beport forms for field work
and details o f results were well worked out in New York especially.
Patterns (as for layettes, abdominal belts, and the like) have been
included in general mention of distribution o f printed material
by many States.
Translations into Spanish were made o f certain o f the Federal
publications for use in some States, especially Texas and New
Mexico, and these were used among the Spanish-speaking element
o f those States. French translations were similarly used in New
Hampshire.
Many States have found exhibits very useful, whether at meetings
o f professional character or at popular assemblies; at State and
county fairs, which furnish especially good opportunity; and in the
windows o f local stores whose proprietors are willing to help by giv
ing space for exhibit material. Everv children’s health center is a
place for exhibits, and rarely is a conference held in any place with
out a good supply o f posters and charts and a display o f clothing
and simple home equipment for the care o f babies. Arkansas has
shown an “ electrical health exhibit” 58 times and a food exhibit
55 times. New Mexico has used child-health exhibits, and Oklahoma
had an exhibit covering the care o f mothers and infants and pre
school children at 48 o f 62 county fairs. From the State o f Washmgton 11 special exhibits were reported, and Indiana prepared suit
able exhibits for special occasions. New York has done a great deal
in the preparation o f exhibit and demonstration material.

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welfare and hygiene of maternity and infancy

Books or pamphlets on special subjects were prepared in a number
o f States. Special mention may be made here o f a nurses’ manual,
mothers’ lesson outline, and little mothers’ league manual in Michi
gan; a nurses’ manual on breast feeding in New Y ork; pamphlets on
breast feeding in California and other States; a pamphlet on ma
ternal and delivery care in O hio; pamphlets or leaflets o f instruction
for midwives in several States, as North Carolina, South Carolina,
Tennessee, and North Dakota, or containing merely a summary o f
the law dealing with midwives, as in Texas. Iowa has issued a
pamphlet on children’s teeth, and Pennsylvania one on sleep for
little children. The feeding o f children has been made the content
o f special pamphlets in a number o f States.
Oklahoma furnished the material (20,000 Children’s Bureau bulle
tins) for use in courses on child care and maternal and infant care
which the university, normal schools, and high schools in the State
offer in connection with certain o f their regular courses.
Publications prepared by the Children’s Bureau are reported to
have been used ip the States in Quantities indicated by such figures as
35.000 in Nebraska, 40,700 in Indiana, 42,600 in New Hampshire,
120.000 in Wisconsin, and 8,000 monthly in Oregon.
COOPERATION OF THE MEDICAL PROFESSION AND OF L A Y ASSOCIATIONS

The success o f a maternity and infancy program depends upon
the interest and cooperation o f the mothers and fathers and o f the
medical profession. Mention has been made elsewhere in this report
o f the assistance given by State and local medical societies and by
individual physicians in conducting infant and maternity confer
ences and centers, in giving lectures to mothers’ classes, in providing
names o f expectant mothers to receive prenatal letters or other litera
ture from the maternity and infancy division o f the State board o f
health or other local administering agency, in helping with the mid
wife program, and in acting as general consultants on State and local
plans o f work, as it is the policy to lay the plans before local physi
cians before work is undertaken in any district. Although in a few
States it has been possible to pay these cooperating physicians a
nominal fee for the help given, most o f the States do not have
budgets large enough for even this; and they have had to depend
upon the generous aid o f local physicians who appreciate the im
portance o f such fundamental educational work. Many examples o f
such service have been reported by the States. For example, in West
Virginia, where there is no staff physician, 265 child-health confer
ences have been made possible through the cooperation o f local
physicians. Florida reported 13 physicians helping on a volunteer
part-time arrangement. The help of leading pediatricians and ob
stetricians who have served as consultants in practically all the
States has been no less freely given; and dentists and dental societies
have also assisted very generously.
Steady progress has been made in the utilization o f all community
resources in the promotion o f the work. In some States, especially
Iowa, West Virginia, Alabama, and Mississippi, a program of co
operation has been worked out with the home and farm demonstra
tion agents, with granges, and with farm bureaus. This usually
takes the form o f assistance in arranging for local conferences, par
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ticularly rural ones, and in giving suitable place in their own pro
gram o f ^activities to problems of infant and maternal hygiene.
Preparation and preservation of foods recommended in the infant
conferences are sometimes made a matter o f especial demonstra
tion. Women’s clubs and fraternal organizations o f both men and
women, and in a few States the local commercial organizations, havegiven increasingly effective support to the work. Superintendents
o f schools and teachers have also helped, especially in the campaigns
fo r general physical examinations and correction o f defects before
the children enter school.
Cooperation o f all such organizations and agencies is important in
any health program. It is particularly so in the promotion o f the
scientific care o f children, since practically the entire adult popula
tion must be interested in the subject before the best results can be
obtained.
*
PERSONNEL OF THE ADMINISTRATIVE STAFFS

Since the size o f the budget and the kind o f work undertaken vary
considerably in the different States, the personnel o f the adminis
trative staffs varies greatly also. The following brief summary
gives the main facts according to figures submitted by the States for
the period January 1 to June 30, 1924:
There were over 50 physicians serving full time upon the State
staffs. A physician was director on 28 staffs in the 4110 cooperating
States, and 15 o f these 28 States reported additional physicians on
the staff. A nurse was director in 9 States (Alabama, Delaware,
Florida, New Hampshire, New Mexico,11 South Carolina, West V ir
ginia, Wisconsin, and W yom ing). In Io w a 12 and four other States
the director was neither a physician nor a nurse. Three staffs (in
New Jersey, Colorado, and Idaho) had part-time services o f a phy
sician. On only 10 o f the administrative staffs were there no physicians, all the medical work being done by physicians detailed by
the State boards o f health or by volunteer physicians.
Public-health nurses were employed in every State. In some
States it is the policy to have the local nurses devote themselves to
the maternity and infancy program exclusively, while others, believ
ing that a generalized nursing program is best adapted to the rural
work, arrange with the counties or local communities for a definite
part o f the nurse’s time. For example, Pennsylvania reported 132
nurses devoting part o f their time to maternity and infancy work.
New York reported 32 nurses giving full time to maternity and in
fancy work, and 46 nurses giving part time. New Jersey reported 36
nurses and Texas 31 nurses devoting full time to this work. A l
together 13 o f the States which reported that they employed full-time
nurses had m addition from 1 to 46 nurses doing part-time maternity
and infancy work. The total number o f nurses employed in the
States, m addition to the 9 who served as directors, was 595; o f these
nearly 300 were giving part time to the maternity and infancy proii

Connecticut during the six months o f cooperation

See footnote 6 n 12

bureius
M i i ^ had
In.f V CI- P rostaffs
g ra S T
a s did
¿dm indenendont
i^ilte^d « u gwrfrir
h t w oa
oureaus, wnica
nad their separate an/
administrative
and
AppmimxSB,1ixC52r ° f ° De ° f theSe bureaus> a Physician of the other.

See pp. 3 4 - 3 5 ,'and

. 12 I a . I® ya
State university (under the State board of education) was desienatpd
to administer the maternity and infancy program, and a division w as established for this
B ? p 52.Un
dlrection o£ a member
the faculty of the u n fv e r s it? See A p p en d ^
4 6 7 7 4 °— 25—

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gram. These nurses were on the staff, in the field, or detailed to
counties.
There was a dental hygienist on the staff in California, and a
dental advisor on that o f Iowa. Virginia employed a dentist for
three months, and Maryland employed a dentist for special work for
short periods. Reference has previously been made to New Jersey’s
itinerant dental service. Dental societies and local dentists also gave
considerable assistance to dental work.
Other members o f the staff mentioned in addition to clerical as
sistants in some States were midwife supervisors or instructors, in
spectors o f maternity hospitals, social workers, nutrition workers,
laboratory technicians, and educational directors.
SU M M ARY OF PRINCIPAL ACTIVITIES B Y STATES

* A brief summary o f the activities reported by the States is sub
joined. In these outlines no attempt is made to mention all the lines
o f activity in which each State has been engaged. Some activities
common to practically all the cooperating States, as, for example,
general distribution o f informative literature, have not been men
tioned. That branch o f work to which the State paid especial atten
tion, or in which there was notable achievement in results obtained
or in the overcoming o f difficulties hampering the work, has fre
quently been made the theme o f the major part o f these tabular sum
maries. It should perhaps be stated that with very few exceptions
the States have done little or no work in the larger centers except
for training or demonstration purposes, or surveys or consultation
on request from urban centers, but have attempted to carry out faith
fully the spirit ’o f the act by expending the funds thereby made
available in reaching rural districts, isolated groups, or special ele
ments among the population. They have thus rightly chosen the
more difficult fields.
Because o f the cost it is not possible to publish maps showing the
geographical extent o f the work in all the States, but a few believed
to be fairly typical o f the widely different methods and forms of
organization used have been chosen. These indicate both the extent
and the limitations o f the work that can be done in a year with the
available resources.
ALABAM A

Administrative agency:
State board of health, bureau of child hygiene and public-health nursing.
S ta ff:
Director, 3 staff nurses, 20 public-health nurses, 2 vital-statistics clerks,
1 stenographer.
A ctivities:
Home visits— the nurses are under the direction of the county health
officer, who initiates and conducts the maternal and infant hygiene pro
gram which was prepared by the child-hygiene bureau and approved by
the Federal board. The State board of health acts in an advisory ca
pacity. The principal activity of the nurses has been home visits, of
which a large number have been made.
M idwife classes— 16, with an attendance of 626. These have been held
by the health officers in some counties, with the nurses assisting.
Permanent preschool clinic— 1 established, as the result of a house-to-house
survey made in Covington County.
Through cooperation with the Alabama Sunday-school council of religious
education, 80 addresses on the hygiene of maternity and infancy were given
by the director at a series of community-life institutes held in 40 counties.

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T H E W E L F A R E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y

nuf e
assigned to the Tuskegee movable school. This is a demJ S f f S J f 1 automobile with a staff of instructors consisting of a carpenter in
structor in home economics, and agriculturist. They travel through rural com
mumties, spending several days in each to show families how to emodel'

their homes- The nurse gave in“

During the summer a second negro nurse was assigned to the State denarf
ment of education to instruct the negro mothers in the hygiene o f m a t S v
and infancy in connection with the adult schools for the illiterate.
ternity
ARIZONA

Administrative agency:
State board of health, child-hygiene division.
S ta ff:
Director, 5 field nurses, 1 stenographer.
A ctivities:
Children’s health conferences— 181, at which 1,183 children were examj s . also. ^ ven to prenatal cases, and dental care is
in ti fito ! ? 2 j ? fadvie® glven at these conferences. The State is divided
into five districts and a nurse is assigned to each. She is responsible
t°pmaL mfhny a ctm ties as ?he can develop. The conferences are mostly
held by the nurses, who give advice, distribute literature, and urge exntrIa n n mt therS t0 C0i lsui t a Physician and have systematic prfnatal
care. Doctors can not often be secured to aid at the conferences as
necesitary.relatlVely

the regions where conferences seem ¿ o s t

Mothers’ classes— 50, with an attendance o f 1,040
Little mothers’ classes— 45.
H fant
prenatai cases> 537 to postnatal cases, 2,697 for in
fant care, 2,935 for care o f children of preschool age, In these visits
the nurses give demonstrations of maternity, infant and child care
One
w
X-rSeS BpeaSa s Panish, and pamphlets in this language are dis
tributed m connection with her work.
s
s
e ais
Midwife instruction— The nurses seek out the midwives, giving them in
struction and visiting prenatal and postnatal cases with them
No
areToPtschaatte S d .been

t0 h° ld regular classes because the midwives

Campaigns— for birth registration and for “ swat the fly.”
have inaugurated and conducted these.
A few nutrition classes have also been held.

The nurses
.

ARKANSAS

Administrative agency:
State board of health, bureau of child hygiene.
S ta ff:
A raphe? dlrector’ 3 nurses> 1 midwife supervisor

(a nurse), 1 stenog-

Activities:
C m w en’S health conferences— 142, at which 3,823 children were examined
These were held in connection with the “ health caravan,” which con
sists o f a doetor, 2 nurses, a chauffeur (who operates the moving-picture
machine). Two automobiles are used for transportation of the staff
and apparatus. Preliminary arrangements were made by a nurse who
went in advance to secure local cooperation.
Mothers’ classes— 40, with an attendance of 1,508.
Midwife classes 31, with an attendance of 388 women, 315 o f whom re
ceived licenses to practice. A state-wide midwife survey has been be
gun. An active birth-registration campaign has been undertaken.
CALIFORNIA

Administrative agency:
State board of health, bureau of child hvgiene
'S ta ff:
Activities^’ 7 nUrSeS’ 1 dental hygienist, 1 midwife inspector, 2 clerks.
Children s health conferences— 57 ( in 14 counties), at which 10,548 children
were examined. O f these, 6,318 were examined in San Joaquin County,

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where the State nurse acted for a time in a supervisory capacity for in
fancy and maternity work in cooperation with the county health unit.
An endeavor was made in holding health conferences to stimulate local
agencies to establish permanent centers.
Dental conferences— 28 in 9 counties.
Little mothers’ classes— 14 in 2 counties.
Permanent child-health centers— 25 in 5 counties.
Prenatal centers— 8 in 4 counties.
Midwife survey— the state-wide survey undertaken the previous year was
completed, o f the 500 midwives who were interviewed 111 were licensed,
and 80 per cent o f these had been fairly well trained in Japan. The con
clusion was that one half of the remainder could be trained and that the
other half should be eliminated. An investigation has been begun to as. certain how far the midwives may be held responsible for maternal and
infant deaths.
A campaign was made during April and May in 26 counties where co
operation from medical and dental associations was obtainable to have all chil
dren who were to enter school in the fall given a complete physical examina
tion, so that all defects might receive attention before the beginning of the
school year. The examinations were made by local physicians, but pediatri
cians were provided to assist where -county medical societies requested such
help. Local organizations and superintendents of schools, as well as publichealth nurses, aided in the campaign.
Three new publications were issued: Breast Feeding, Care of the Baby, and
a series of prenatal letters.
COLORADO

Administrative agency:
Department o f public instruction, child-welfare bureau.
Staff:
Executive secretary, 1 pediatrician, 2 nurses, 1 clerk, 1 stenographer, 1 in
terpreter.
A ctivities:
Children’s health conferences— 45, at which 5,412 children were examined.
(Advice on the hygiene of pregnancy was also given, and some prenatal
examinations made.)
O f these conferences 15 were held in connection
with county fairs.
Permanent health centers— 29 established. Conferences were previously
held in a group of three or more towns not far apart. These were con
ducted by the extension division of the State university, the State
board o f health, State tuberculosis association, and the child-welfare
bureau. A month after the first conference a nurse returns to supervise
or assist at another conference, and this usually means the beginning
of a permanent child-health center conducted by local physicians.
Midwife classes— 5, at which 30 midwives were instructed.
Although
many of the mid wives were too old or too ignorant to receive instruction,
it is believed impracticable to eliminate them. It was therefore planned
that one reliable registered midwife should be placed in each district and
trained by local doctors, with the unregistered midwives permitted to
assist, but not allowed to have any responsibility. For this work 3
midwives (1 Mexican,, a graduate nurse) have been selected.
Community demonstrations— 68, some of them at county fairs.
A goiter survey disclosed the fact that there was quite a goiter belt running
from the central western part of the State to the central southern part.
CONNECTICUT18

Administrative agency:.
Department of health, bureau of child hygiene.
S ta ff:
Director, 1 doctor, 4 nurses, 1 midwife supervisor, 1 vital-statistics clerk,
1 clerk, 1 stenographer.
A ctivities:
Children’s health conferences— 11, at which 1,380 children were examined^
Prenatal conferences— 5, with an attendance of 225 (but no examinations
m ad e).
18 During six months o f cooperation in 1923.

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THE WELFAEE AND HYGIENE OF MATEBNITY AND IN FAN C Y

A C T IV IT IE S IN C A L IF O R N IA D U R IN G 1923-24

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TH E WELFARE AND HYGIENE OF MATERNITY AND IN FAN C Y
Community demonstrations— 17, some on food values and preparation of
food for children. Some of the demonstrations were a t State and county
fairs.
DELAW ARE

Administrative agency:
State health and welfare commission.
S ta ff:
Supervisor of nurses, 10 nurses (three-fourths tim e), 3 clerks (h alf tim e).
A ctivities:
Health conferences— 144, at which 11,872 children were examined.
As
there are only three counties, the county nurses can be stationed at
convenient centers where the conference for mothers and preschool
children is held regularly each week. Much educational work has been
accomplished in the way o f persuading mothers to realize the need of
correction o f defects in their children. Only three stations are equipped
for prenatal examinations, but as a result of the educational work done
a greater number o f women are consulting doctors early in their
pregnancies.
M idw ife inspection— This is a responsibility of the county nurse in her
district. General conferences with the midwives are held by the super
visor, but the midwives understand that they must report to the nurse
the prenatal cases and the births. Improvement in birth registration
and in maternal care has resulted from such supervision.
H om e demonstrations— Many on infant care and preparation o f food and
home hygiene.
FLORIDA

Administrative agency:
State board of health, bureau of child welfare and public-health nursing.
S ta ff:
Director, 6 nurses (1 negro), 1 secretary, 1 auditor’s clerk (h a lf tim e), 1
stenographer (h alf tim e).
Activities:
Child-health conferences— 50 at which 1,393 white' children were exam ined;
38 at which 1,390 negro children were examined. These were conducted
with the aid of the district health officers or local physicians, and
attempts were made to have every case recommended for corrective
work followed up by a nurse or by some local representative.
The
“ health movie tru ck ” was used for nearly two months in rural dis
tricts. Besides the time spent in conference, films were shown and
literature distributed.
Prenatal visits— 2,406 white women and 4,033 negro women were advised
in their own homes.
Midwife classes— 43 for white m idw ives; 261 for negro midwives. These
were conducted by the nurses, who also visited all patients for whom
the midwives reported stillbirths. They sought to ascertain the causes
and made a report to the State board of health.
Mothers’ classes— 256 for white w om en; 288 for negro women. (These are
called neighborhood institutes.)
A n intensive birth registration campaign was carried on.
A survey was made in Key W est to ascertain the conditions among Cuban
mothers and children and what local assistance could be obtained for them.
A s a direct result of the maternal and infant hygiene work 4 public-health
nurses have been employed (2 for counties and 2 for communities), each to
do part-time maternal and infant hygiene work under the supervision o f the
State bureau but paid by local funds.
GEORGIA

Administrative agency:
State board of health, division of child hygiene.
S ta ff:
Director, 1 doctor, 7 nurses (1 negro), 1 laboratory worker, 2 stenogra-phers.
A ctivities:
Children’s health conferences— 870, at which 4,773 children were examined,
literature was distributed, and advice was given to mothers. Prelim
inary arrangements were made by a nurse, who went in advance to

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TH E WELFARE AND HYGIENE OP M ATERNITY AND IN FAN C Y

secure the cooperation of local organizations. A doctor, nurse, and
chauffeur (who also operates the motion-picture machine) compose the
staff for these “ healthmobile ” conferences. A white nurse and a negro
nurse work in the county after healthmobile conferences, visiting the
homes of children in need of corrective work. Many parents promised
to have the children cared for during the summer vacation.
Permanent child health centers— 5 established.
Permanent prenatal clinics— established in 6 communities.
Educational work— 2 field nurses attended county fairs, giving talks to
mothers and distributing literature. Nutrition work was done by county
home-demonstration agents through cooperation with the extension
bureau of the State department of agriculture.
Midwife classes— 17 have had complete courses in 17 counties.
Much
personal work was done among doctors in an effort to have them appre
ciate the importance of instructing and supervising midwives. A t the
annual meeting o f the State medical association a resolution was passed
approving any midwife work which might be done by the State board
o f health.
Maternity and infancy work has increased during the past year. Nurses
who were not devoting time to this branch o f public-health nursing are now
giving part time to it, while others have enlarged their program. Two full
time maternity and infancy nurses have been placed in counties.
IDAHO

Administrative agency:
Department of public welfare, bureau of child hygiene.
S ta ff:
Director (part tim e), 3 nurses, 1 clerk.
A ctivities:
Children’s health conferences— 24, at which 2,463 children were examined.
(Letters were previously sent to every mother in the county for whom a
birth certificate had been received within the year.)
Prenatal confer
ences were conducted at the same time and 371 women were examined.
After the conferences a nurse remained in the county advising parents
on the necessary corrective work. Letters were sent if personal visits
could not be made, and over 50 per cent o f the letters were answered.
Infant-welfare center— established by one community, with the work done
by local people. Literature for distribution is supplied by the State
bureau.
Midwives few in number and working under the supervision o f physicians.
Vital statistics— much attention has been paid to birth and death reporting.
INDIANA

Adminstrative agency:
State board o f health, division of infant and child hygiene.
S ta ff:
Director, 3 doctors, 5 nurses, 1 secretary, 1 statistician, 3 stenographers,
1 publicity worker, 2 chauffeurs.
A ctivities:
Children s health conferences— 279, at which 7,581 children were examined.
County-wide examination o f all preschool children was planned. The
publicity worker went in advance, making preliminary arrangements
and securing the aid o f local organizations. A physician, nurse, and
exhibit director followed, remaining from 2 to 3 weeks in the county,
holding conferences.
Permanent children’s health centers— 10 established by local agencies as a
result o f the child-health conferences, and 47 maternity and infancy
centers conducted. A t the centers 2,178 children were examined, making
a total of 9,759 examinations.
Mothers’ classes (run as a series o f 5 lessons)— 499 lessons given to an
attendance of 7,547.
Midwives reports from the State registration board and from physicians
indicate the gradual elimination of midwives unwilling to comply with
the State laws.
Maternity and infancy demonstrations— booths demonstrating this work
were in operation at the Congress on Internal Medicine at St. Louis, the

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annual meeting o f the American Medical Association, the State Normal
College at Terre Haute, and elsewhere.
In conjunction with the Winona-Lake Chautauqua the director, aided by a
corps of assistants, held children’s health conferences, conducted 8
classes for mothers and distributed literature, held 2 open-forum meet
ings, gave 10 lectures, and 6 talks illustrated by motion pictures.
Better-baby conferences and a day nursery were conducted at the State
fair, and a demonstration was made at the better-homes exposition.
IOW A

Administrative agency:
State University o f Iowa, division of maternity and infant hygiene.
Staff :
Director, 6 physicians, 1 dental advisor, 6 nurses, 1 social worker, 3
stenographers.
Activities :
Children’s health conferences— 574, at which 13,030 children were ex
amined. A t prenatal conferences in conjunction with these 5,249 women
were given advice. After the advance worker has visited all the
physicians in the territory, a letter is sent to each physician from the
State office informing him that certain children have been chosen for
examination and inviting him to attend the conference. The findings
of the pediatrician are sent to the State office and the references to the
local physician, this letter giving the physician specific data as that
certain findings in certain cases were made.
Dental clinics— 51, at which 1,088 children were cared for.
Lectures— The staff obstetrician has been placed at the service o f the
State medical society to bring before rural doctors the most advanced
methods in obstetrics. He has delivered lectures before county medical
societies, illustrating them with slides and films, also by the use of a
complete equipment of obstetrical instruments. The dental advisor does
similar work for the State dental society.
About 40 per cent of physical defects were corrected.
I t is hoped to publish soon a complete outline of a plan for establishment of
permanent prenatal centers and to devote the services of one person to aiding
communities to organize their own resources.
KENTUCKY

Administrative agency :
State board of health, bureau of maternal and child health.
Staff : •
.
Director, assistant director, 6 nurses, 25 part-time nurses, 1 stenographer,
1 vital-statistics clerk, 2 clerks, 1 typist, 1 bookkeeper.
A ctivities:
„ <
.
Children’s health conferences— 442, at which 6,648 children were examined.
Prenatal clinics— 54, at which 2,959 women were examined.
Dental clinics— 2, at which 100 children were cared for.
Mothers’ classes— 22, with an attendance of 255.
Permanent health centers— 72 established. This means a permanent health
center in every county where there is a county nurse. The nurses also
give advice to expectant mothers in the centers and in the homes.
Community demonstrations— 31, most of them in connection with county
or community fairs. A physician and nurse were in attendance, many
preschool children were examined, talks given to mothers, and much
literature distributed.
,
. ,
Articles on maternal and child health written by the director (or the assist
ant director) have been published each week in all the county newspapers and
also in the chief agricultural monthly of the State.
_
.
A nurse is assigned to act as registrar at the prenatal clinics and obstetrical
wards, also the syphilitic mother and child clinics, of the University of Louis
ville Medical School. This nurse keeps the record cards o f the clinic patients,
and these records are of value to the obstetrician in charge, who contributes to
a State medical journal monthly reports of abnormal obstetrical cases caredfor in the maternity ward. Data on abnormal cases are thus put in the hands
of many physicians, and readers of the column also write asking for the leaflets
on maternal care. This work has so aroused interest in maternal and child
health that a department of child health has been created in the medical school
o f the university, with assistance given from the Carnegie Foundation.

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Local organizations cooperate most helpfully in the work, and in almost every
community women act as conference aids.
The instruction of midwives is a difficult problem. These women are in
isolated districts, mostly hemmed in by mountains, and are old, decrepit, and
ignorant. Only a small number will attend classes, but in the summer when
the roads are passable the nurses seek them out to give what instruction is
possible. Some progress is being made among negro midwives, who are appar
ently extremely ignorant but anxious to learn.
M ARYLAND

Administrative agency:
Department of health, bureau of child hygiene.
S ta ff:
Director, 6 doctors (5 part tim e), chief nurse, 3 child-hygiene nurses, 3
public-health nurses detailed to counties, 2 stenographers, 1 educational
director.
A ctivities:
Child-health conferences— 168, at which 3,487 children were examined.
The “ healthmobile ” visited 14 counties. About 8,700 children were ex
amined, and a number of community meetings were held at which mov
ing pictures were shown and talks given on prenatal and infant care.
In 24 communitiesi child-health conferences in which the mothers were
given advice and instruction were repeated two or more times.
Dental clinics— 3, at which 60 dental treatments were given by dentists
employed by the bureau. The State dental association is planning to
cooperate so that more preschool children may have dental care.
Community demonstrations— 46, covering the bathing, feeding, and clothing
of babies. These have been held at county fairs, women’s, clubs, com
munity meetings and elsewhere. Also 210 home demonstrations during
the year are recorded.
Nutrition classes— 26, for preschool children.
Midwife classes— 3, with enrollment of 18.
A set o f 20 lantern slides depicting various phases o f child health work was
prepared and distributed in groups o f two to each of the rural motion-picture
houses in the State.
A series of articles entitled “ Talks to mothers about their children ” was
prepared and appeared weekly in practically all o f the county papers for 10
months. Other articles were also prepared for the county papers and published
by them.
Demonstration layettes, bottle-feeding and breast-feeding outfits have been
assembled and sent to various counties for exhibition.
MICHIGAN

Administrative agency:
Department of health, bureau o f child hygiene and public-health nursing.
Staff:
Director, 1 pediatrician, 1 prenatalist, 1 research worker (a physician), 12
nurses, 1 midwife inspector (a nurse), 1 vital-statistics clerk, 2 clerks.
2 stenographers.
Activities:
Children’s health conferences— 255 (in 42 counties), at which 5,518 chil
dren were examined by the State pediatrician (whose entire time is
given to holding these conferences).
Prenatal clinics— 33, held by the State prenatalist, who travels about for
this purpose and has examined 40 expectant mothers. She also held
89 prenatal conferences (in 15 counties), and gave talks on‘ the hygiene
of maternity and infancy. The attendance was 2,239. Many expectant
mothers were referred to local physicians.
Mothers’ classes— 89 (in 15 counties), with atten'dance of 1,403.
Little mothers’ classes— 167 (in 17 counties), with attendance of 3,254.
Permanent' children’s health centers— 18 established (organized under the
maternity and infancy act, but not financed by Federal funds).
Permanent prenatal clinic— 1 established (organized under the maternity
and infancy act, but not financed by Federal funds).
Prenatal letters— A course of prenatal letters is sent out.

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T H E W E L P ABE A N D H Y G IE N E

OF M A T E B N I T Y A N D I N F A N C Y

A C T IV IT IE S IN M IC H IG A N D U R IN G 1923-24

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OF M A T E B N IT Y A N D IN F A N C Y

Maternity and infancy demonstrations— A demonstration was made in a
county in the lumbering region in the northern part of the State. The
work took place in homes, as it was not possible to collect the women
in groups. Similar demonstration work is under way in a county in the
farming region in the southern part of the State. The communities in
both counties are awakening to their responsibilities in regard to
maternal and infant death rates.
A desire to’ cooperate with tlie
division was evident.
A survey was made of the maternity bed capacity in 111 hospitals.
It
was found that more beds were available than had been u sed ; and that small
maternity hospitals were needed to meet the problems of isolation, deep snows
and lack of physicians; but in order to secure patronage for such hospitals a
moderate charge would be necessary, together with education of the public
in regard to the desirability of hospital maternity care.
County health committees have been established in 18 counties.
Doctors and nurses of the division gave 1,108 hours of service to the State
health department goiter survey, and this work resulted in a preventive
program. Among 6,797 infants-and preschool children examined there were
found 257 cases of goiter.
A state-wide midwife survey has been begun but has not yet been com
pleted.
MINNESOTA

Administrative agency: >
State board of health, division of child hygiene.
Staff:
Director, 1 doctor (temporary, for midwife survey), 16 nurses, 2 vitalstatistics clerks, 3 clerks.
A ctivities:
Children’s health conferences— 7 among the Indians, at which 126 children
were examined. By means of a gift from the American Child Health
Association, which by State law can be included in State funds used for
matching Federal funds, 2 Indian public-health nurses were provided for
work among the Chippewa Indians, where the infant mortality rate is
very high and where there is much tuberculosis as well as trachoma.
The work has consisted largely o f house-to-house visits and home demon
strations.
Prenatal conferences— Monthly since January, in different places in 3
counties, conducted by two well-known obstetricians from Minneapolis.
A t the close of each conference the physicians gave a lecture on prenatal
hygiene, to which all of the women o f the community were invited.
Preliminary arrangements were made by a nurse who went into the
county a week before the conference. In the month after the conference
the nurse visited all of the women who had attended, emphasizing to
them again the necessity of seeing a physician.
Demonstrations— A nurse gave demonstrations in connection with 123
infant clinics held throughout the State by the Minnesota Public Health
Association.
Similar demonstrations were given at 28 county fairs.
A t meetings o f the Farm Bureau women 2 field nurses gave demonstra
tions on infant care and preparation of infant food.
Little mothers’ classes— 671, with 4,641 girls in attendance. These were
held by county and school nurses.
Correspondence course— 3,110 women registered. Many of these have been
organized into classes under the direction of a county or community
nurse.
Prenatal letters— sent in response to 1,710 applications. The number of
physicians referring women to the division for these letters is gradually
increasing.
A midwife survey showed that the number of midwives in the State is
gradually decreasing with the decrease in the foreign-born population.
Intensive programs for maternity and infant welfare work are under way
in St. Louis and Olmsted Counties.
St. Louis County is the only county in the State having a full-time county
health officer. W ith funds which were matched by Sheppard-Towner funds
they are employing one full-time maternity and infancy nurse in the county.
In addition to this full-time nurse, one-third of the time of each of the four
county nurses is spent in maternity and infancy work. The program carried

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w elfare and

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out by these nurses has consisted of class work in maternal and infant
hygiene for the women, little mothers’ classes for girls in all of the schools in
the unorganized districts of the county, and home visits for prenatal and in
fant cases.
MISSISSIPPI

Administrative agency:
State board of health, bureau of child welfare and public-health nursing.
S ta ff:
Director, 16 nurses (8 part time, 2 of whom are detailed to counties), 3
stenographers (2 half tim e).
A ctivities:
Children’s health conferences— 187 (in' 24 counties), at which 8,457 children
were examined. The offices of 10 county nurses serve as health centers.
The nurse remains in her office one day each week for consultation with
mothers of small children, expectant mothers, and midwives.
The
county health officer is often present at these times, and volunteer serv
ice of local people is encouraged.
Community demonstrations— 187, many in private homes, on the hygiene
of maternity and infancy.
Midwife classes— 1,116 for negro midwives (in 27 counties), with an at
tendance o f 12,961 women. Such classes covered a period o f two months
or more. This number includes not only midwives but other women en
couraged to attend in order to learn what constitutes proper maternity
care. An effort is being made to interest young intelligent negro women
in the study of midwifery, since midwives are an .economic necessity in
the State. A ll of the midwives have been registered and are under
supervision. In addition to the classes, county meetings of midwives
were held in 53 counties.
Prenatal conferences— held in 28 counties.
Little mothers’ classes— held in 10 counties.
Nutrition classes— held in 7 counties.
A s a result of the conferences and of midwife instruction, two counties have
established health units, with the nurse devoting half of her time to maternity
and infancy work. Another county has employed a public-health nurse who
gives half o f her time to such work. Four nurses spend their entire time in
field work, each giving two months to a county.
MISSOURI

Administrative agency:
State board o f health, division o f child hygiene.
Staff:
Director, 4 doctors (3 part tim e), 3 nurses, 8 county nurses, 1 vitalstatistics clerk, 1 clerk, 1 stenographer.
A ctivities:
Children’s health conferences— 262 (in 56 counties), at which 9,431 pre
school children were examined. A series of preschool clinics covering
six or seven communities in a county was arranged, a physician and
nurse being sent to assist with the organization. Wherever possible the
nurse and local physicians continue the clinics at regular times. Through
home calls the nurse keeps the interest of the parents and induces them
to have physical defects corrected. The report for the second half of
the year shows that 37 per cent had defects corrected.
Mothers’ classes— 188 (in 17 counties), with an attendance of 2,688.
Little mothers’ classes— 18 in 11 counties.
Dental clincs— 8, at which 98 children received attention.
Home demonstrations— 2,798. These covered care of mothers and babies,
food preparation, and other matters.
There were no regular prenatal conferences, but advice was given to 8,024
mothers and 66 expectant mothers were examined.
Permanent prenatal clinics— 2 established.
Permanent children’s health centers— 11 established.
Inspection was made of 18 maternity homes and 28 infant homes.
In 7 counties a maternity and infancy nursing service was begun.
Cooperation with the department of health in a survey and pure-milk cam
paign resulted in the securing of better milk supply for four towns having a
high infant mortality rate.

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

A C T IV IT IE S IN MISSISSIPPI D U R IN G 1923-24

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

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T H E W E L F A B E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y

A survey of birth reporting in six counties where there was unusual laxity
was made to assist in a birth-registration campaign. During this period 38,685
birth certificates were issued.
Assistance was rendered to public health service trachoma clinics by ad
vertising them in connection with the infant and preschool conferences in 11
counties.
MONTANA

Administrative agency:
State board of health, division of child welfare.
S ta ff:
Director, 7 nurses (4 part tim e), 2 clerks, 1 bookkeeper.
A ctivities:
Children’s health conferences— 590, at which 7,518 children were examined.
Because of extreme difficulty in securing county nurses it was impossible
to accomplish as much follow-up work as was desired.
Prenatal conferences have been held in conjunction with the children’s
conferences with a small number of women in attendance. A good deal
of education in maternal and infant hygiene is accomplished by nurses
in home visits as well as conferences.
Permanent children’s health centers— 7 established.
Demonstrations— A special effort was made to have maternity and infancy
work explained at every county fair. The bureau was represented at two
Indian fairs. Talks were given, literature distributed, and health demon
strations held where possible.
In several cases the county gradually took over more and more of the respon
sibility as the value of county nursing service was appreciated.
*

NEBRASKA

Administrative agency:
'Department of health and welfare, division of child hygiene.
S ta ff:
Director, 2 nurses, 1 maternity home inspector (part tim e), 1 vital-statistics
clerk, 1 office assistant.
Activities:
Children’s health conferences— 85, at which 3,421 children were examined
by local doctors. Some follow-up work was done, and in one town every
child examined at the conference received afterwards the necessary cor
rective treatment.
An Indian woman who is a trained public-health nurse has succeeded in
initiating a maternity and infancy program among the Indians. The Indian
doctor employed by the United States Indian Service has given the nurse much
assistance.
During June, 10 public-school nurses were employed by the division for spe
cial maternal and infant demonstrations in their' respective counties. The
results of this service were very satisfactory.
Inspection was made of 78 maternity and infant homes.
NEVADA

Administrative agency:
State board of health, child-welfare division.
Staff:
Executive secretary, 5 public-health nurses in counties.
A ctivities:
Children’s health conferences— 62, conducted by nurses, at which both pre
natal ai^d infant conferences are held. Advice has been given to 450
mothers and 1,406 children have been examined.
Little mothers’ classes— 4 organized, as a result of home demonstrations
by the nurses.
One county-wide survey was made by a nurse, and a local committee was
organized to seek out the undernourished preschool children. Classes for gen
eral health improvement were also formed among the mothers and children.
One county has undertaken to pay all expenses of the nurses except $65 a
month, which is supplied by the child-welfare division.

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a n d in f a n c y

NEW HAMPSHIRE

Administrative agency: '
State board of health, division of maternity, infancy, and child hygiene.
S ta ff:
Director, 7 nurses, 1 stenographer.
A ctivities:
Children’s health conferences— 111, at which 2,021 children were examined
by 26 physicians, who gave their services for an honorarium. Through
the efforts of the nurses 287 children then had necessary defects cor
rected and 618 prenatal cases were placed under the care of physicians.
The county nurses of the New Hampshire Tuberculosis Association assist
at all child health conferences as a part of their regular duties. They
take histories, meet the mothers, weigh and measure children, etc. Local
doctors and nurses have had a large part in making the conferences a
success. The nurses have given invaluable assistance before and during
the conferences, bringing the children and telling the mothers how a
physical examination benefits the children.
Mothers’ classes— 55, with an attendance of 480.
Community demonstrations— 89. State nurses are endeavoring to obtain
for every child of preschool age in the counties covered a thorough
physical examination once during the year. This has been accomplished
in several towns.
A demonstration of maternity and infancy care was made in W est Manches
ter by a nurse detailed to this service. She visited expectant mothers, persuad
ing them to consult physicians; held mothers’ classes; directed the preparation
of obstetrical packages; encouraged breast feedin g; and is trying to establish a
registry o f “ practical ” nurses. This demonstration is to be continued another
year, in the hope that actual figures can be secured showing that the lives o f
mothers and babies can be saved by this type of work.
NEW JERSEY

Administrative agency:
Department of health, bureau of child hygiene.
Staff:
Director, 36 nurses, 2 social workers, 4 vital-statistics clerks.
A ctivities:
Children’s health conferences— weekly, in the 83 “ keep-well stations,” with
74,024 children in attendance. During 1924, 14 new stations were opened.
Mothers’ classes— 332 conducted, of which 16 were held in the State re
formatory for women. A total o f 47,500 women were present.
Midwife classes— 114, with an attendance of 2,312. Several o f ‘ these were
monthly meetings.
Dental work— by means o f the traveling dental ambulance 1,300 children
were treated.
Permanent prenatal conferences— 2 established. In general the plan fol
lowed has been that o f instructing individual mothers in their homes, and
referring them to physicians rather than having them attend prenatal
conferences.
Inspection was made o f 27 maternity homes and 262 infant homes.
NEW MEXICO
A 14

Administrative agency:
Department of public welfare, bureau of child welfare.
Staff:
Director, 2 doctors (part tim e), 1 nurse, 1 stenographer (part tim e).
A ctivities:
Children’s health conferences— 163, at which 4,611 children were ex
amined.
Mothers’ classes— 249, with an attendance of 3,311.
Little mothers’ classes— 931, with attendance o f 9,825.
Permanent children’s health center— 1 established.
Surveys and clinics among the Pueblo Indians showed that there is no milk
supply in the communities studied,- the diet is inadequate, and the death rate is
high. It was necessary to visit Indian and Spanish-American mothers in their
homes in order to advise them as to the hygiene of maternity and infancy.
14 See fo o tn o te 1 1 , p. 1 9 , a n d A p p en d ix B , p. 5 2 .

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B 15

Administrative agency:
Department of public welfare, bureau of public health, division of child .
hygiene and public-health nursing.
Staff :
Director, 1 doctor (part tim e), 2 nurses (part tim e), 1 vital-statistics clerk,
1 clerk (part tim e), 1 stenographer (part tim e).
Activities :
Children’s health conferences— 30, at which 870 children were examined.
Mothers’ classes— 106, with an attendance o f 365.
Midwife classes— 92, with enrollment of 48 women, 38 of whom completed
the course. After instruction the midwives showed marked improve
ment. Some of the more ignorant have been eliminated.
Home demonstrations— 1,550 given by nurses to expectant mothers and
mothers o f small children.
The nurses of the county health units give part time to maternity and
infancy service.
NEW YORK

Administrative agency:
Department of health, division o f maternity, infancy, and child hygiene.
Staff:
Director, 1 associate director, 1 obstetrician, 2 pediatricians, 1 doctor, 76
nurses (46 part tim e), 1 nutrition worker, 2 midwife inspectors, 5 clerks,
8 stenographers.
Activities :
Children’s health conferences-—230, at which 5,765 children were examined
by the children’s health consultation unit, composed of 2 pediatricians
and 2 nurses. Local doctors were urged to attend and every effort was
made to secure their interest. Notice of defects found was sent to the
fam ily doctor as well as to the parents of the child. Follow-up visits
were made by the local nurse, or by the State nurse where there was no
community nurse.
Prenatal consultations— held by the State obstetrician in health centers in
different towns at regular intervals. For a total of about 500 women
771 physical examinations were made, including 346 reexaminations.
Many doctors send their cases for consultation, but no woman under the
care of a local doctor is examined except with his written consent.
Women who have not secured the services of a physician for confinement
are urged to engage a physician at once. Patients o f midwives are
not referred to physicians except when medical attention is indicated.
Midwives must bring their patients to these consultations fo r regular
prenatal observation. Follow-up work is done by the local nurse.
Midwife classes— now regularly held, with instruction given by an obste
trician, another physician, a nutritionist, the associate director, 2 dis
trict State officers, 4 local health officers, and 2 midwife inspectors.
The midwives in different sections of the State are called together for
meetings from time to time, and must attend or file a reasonable excuse
for nonattendance. During the past year 10 such meetings were held
with an attendance of 252.
Extension course for nurses— held in 25 communities. This included 7
lectures on maternity hygiene. The nurses later organized mothers’
health clubs in 45 communities, following the approved outline of
lectures.
Nutrition institutes— held in three communities by the Nutritionist, who
gave a series of 7 lectures to nurses and others interested in the feed
ing of children.
Permanent health centers— 28 in operation, 9 o f which were previously in
existence but have been extended in scope by the aid o f Federal funds.
Many local communities are initiating maternity and infancy work as
a result of the educational work done by thè State department.
Prenatal clinics— 11 established, including one station where demonstra
tion consultations are still being held.
15 See fo o tn o te 11, p. 1 9 , an d A p p en d ix B , p. 5 2 .

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Demonstrations of sterile obstetric packages were given in 144 communi
ties by three nurses giving fu ll time to this work, and 36 sample pack
ages were sent to localities in which some organization plans to supply
the packages.
A demonstration of breast feeding is carried on in Nassau County to stimu
late and promote an interest in breast feeding and to make instruction in the
technique available to mothers, nurses, and physicians. An attempt is being
made to reach all the babies born within the year. To date 2,805 cases have
been under observation, and the demonstration is to continue until 1,000 cases
have been followed for nine months. This demonstration has served a further
purpose,- in that it has furnished a teaching center in the technique and promo
tion of breast feeding for all the nurses of the State staff.
A demonstration teaching center has been organized in Poughkeepsie at
which the methods and procedure for model child hygiene stations are being
tried out. This will be used as a teaching center for nurses coming into State
service and for others who have no instruction in this branch of public-health
work.
Surveys o f three cities and one county were undertaken to discover causes
contributing to high infant and maternal mortality rates, in order to devise
efficient methods of reduction. Methods suggested w ere: Promotion of edu
cation in the hygiene of m aternity; prenatal care; instruction in methods of
increasing breast m ilk; periodic examination o f preschool children; free or
low-priced hospital care.
NORTH CAROLINA

Administrative agency:
State board of health, bureau of maternity and infancy.
Staff:
Director, 3 physicians, 6 nurses, 2 stenographers, 1 clerk.
A ctivities:
Children’s health conferences— 186, at which 1,840 children were examined.
Prenatal conferences— 5 were held and 9 women examined, but no record
kept of the total attendance.
Local doctors assist in some o f the county infant and prenatal conferences.
The three physicians of the staff serve as medical field supervisors, and in
struct new county workers in the hygiene o f maternity and infancy, and in
the establishment of prenatal and infant clinics. They continue to supervise
the work after it has been established. The health work o f this State is
based mainly upon the county unit system.
Mothers’ classes— more than 86, with an attendance o f 1,159.
Midwife classes— held in several places, and 1,433 women completed the
course. In some counties Wassermann tests were made on all mid
wives, and those showing a positive reaction were forbidden to prac
tice until they had undergone proper treatment.
Little mothers’ classes— attended by 1,826 girls.
Permanent children’s health centers— 21 established.
Permanent prenatal clinics— 20 established.
Home demonstrations— 22,835 visits reported by county nurses who do
house-to-house visiting for home demonstrations.
NORTH DAKOTA

Administrative agency:
Department #of public health, division o f child hygiene and public health
nursing. *
Staff:
Director, one nurse, one clerk (part tim e).
Activities:
Children’s health conferences— 58, at which 1,621 children were examined.
Pour o f these conferences were held at State fairs.
Prenatal conferences— 53, at which 20 women were examined, advice was
given, and literature distributed.
Midwife classes— 5, with attendance o f 15. This work is comparatively
new. Circular letters o f instruction are being sent every two weeks
to the midwives.
Dental clinic— 1, with an attendance o f 43.
Permanent children’s health centers— 13 established.
Permanent prenatal clinics— 5 established.

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OHIO

Administrative agency.
Department of health, division of hygiene.
Staff:
Director, 1 physician, 1 chief nurse (part tim e), 22 nurses (20 part tim e),
1 nutrition lecturer, 1 lecturer, 1 maternity hospital inspector (part
tim e), 1 vital-statistics clerk, 1 clerk, 1 publicity worker (part tim e).
Activities :
Children’s health conferences— 21, at which 880' children were examined,
with the aid o f local agencies.
Mothers’ classes— 87, with an attendance of 705.
A midwife survey was made, and lists prepared of midwives by counties.
These are available for the use of district or city health commissioners.
Nursing demonstrations— 4, of which 3 were in counties and 1 in Cin
cinnati. The latter was in a densely populated negro district.
Exhibitions— for the State fair and 17 county fairs, illustrating various
phases of the work for promotion o f child hygiene.
Inspection was made o f 200 maternity homes.
OKLAHOMA

Administrative agency:
Department o f health, bureau of maternity and infancy.
S taff:
Director, 3 doctors (part tim e), 7 nurses first six months (4 staff, 3
county), 2 to 4 staff nurses last six months, 1 bookkeeper, 1 stenographer.
A ctivities:
Children’s health conferences— 529, at which 6,339 children were examined
by local physicians. Dental clinics were held in connection with most
o f these conferences.
Mothers’ classes have been held, and many home demonstrations made.
Demonstrations— at county fairs, made by nurses who showed the prepara
tion of infant foods, of maternity bundles, layettes, e tc .; they also gave
advice to mothers and distributed literature.
Permanent children’s health centers— 2 established.
OREGON

Administrative agency:
State board o f health, bureau of child hygiene.
Staff:
Director, 3 doctors (part tim e), 8 nurses (6 part tim e-' 1 clerk (part
tim e), 2 stenographers.
Activities:
Children’s health conferences— 122, at which 3,107 children were ex
amined. The director also served as medical director for 103 well-baby
clinics o f the Portland Visiting-Nurse Association at which the attend
ance was 1,318.
Prenatal conferences— 52, with an attendance o f 201, at which 188 women
were examined. These conferences were held under the joint auspices
of the State bureau of child hygiene, the department of obstetrics of
the medical school o f the University o f Oregon (which supplies the
medical service and equipment), and the visiting-nurse association of
Portland, which attends to the follow-up work in the homes. Local
physicians have cooperated well, and have sent patients who can not
pay the full amount o f fee for obstetrical care. A full history of such
prenatal cases is turned back to the physician for use at delivery.
Permanent children’s health centers— 16 established.
Permanent prenatal clinics— 4 established.
Literature— a series of prenatal and postnatal letters is issued.
A t the county farm exhibitions fo r the demonstration o f raising o f crops
' and animals Oregon stationed a nurse to teach child culture also. A t these
conferences babies and children were examined. Now these meetings in col
laboration with the child-hygiene division are a regular institution.

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PENNSYLVANIA

Administrative agency:
' Department of health, bureau of child health, preschool division.
S ta ff:
Chief, 2 physicians (1 temporarily part tim e), 3 field workers, 132 nurses
(part tim e), 3 file clerks, 3 stenographers.
A ctivities:
Children’s health conferences— 178 under State control, with a staff nurse
in charge. Affiliated with the preschool division are 226 local children’s
health conferences, which use record forms furnished by the State and
in most instances report regularly to the chief of the State preschool
division. The three field workers travel over the State to organize infant
hygiene work where called for, giving advice and aid to both State
and local organizations. Prenatal clinics are also held in many of these
health centers. The child-health centers have 695 doctors connected
with them. In many instances the doctors of a community take turns
in serving on the child-health center staff. A t the health centers 25,928
children were exam ined; at the prenatal clinics and in their homes 6,203
women were examined.
M idwife classes— a doctor employed to teach and supervise midwives in
four counties made a preliminary survey and is teaching four classes
subdivided into groups. She speaks five languages, an important asset
•in this work as the midwives are largely foreign.
Through child-health centers physicians are supplied with toxin-antitoxin to
administer to children under 6 years of age, and 135,598 preschool children
have been immunized. Schick testing is done six months later.
In eight towns reports o f high infant mortality resulted in organizations,
to be approved and standardized by the State department o f health, by which
definite undertakings would be launched within the community to lower the
infant death rate. Four towns have now undertaken the work.
SOUTH CAROLINA

Administrative agency:
State board of health, bureau of child hygiene and public-health nursing.
S taff:
s
Director, 2 district supervisors (nurses, part tim e), 1 midwife supervisor
(nurse, part tim e), 4 field nurses (1 negro), 3 assistant field nurses,
1 county nurse, 1 vital-statistics clerk, 1 clerk (part tim e), 2 stenog
raphers, 1 chauffeur, 1 moving-picture operator (part tim e)..
A ctivities:
Children’s health conferences— 272, at which 5,487 children were examined.
Prenatal conferences— 168, with an attendance of 475, at which 172 women
were examined.
Children’s health centers— established in 3 places with an attendance (for
one month) o f 48.
The child-health truck visited 15 counties, and 2,050 preschool children
were examined. A part-time pediatrist attended 17 child-health confer
ences in connection with the truck; and an orthopedist assisted at 11
conferences.
Midwife classes— conducted in 6 counties, with certificates given to 773
women completing the course. The instructors, 2 white nurses and 2
negro nurses, have remained 3 to 4 months in each of 26 counties.
.
Demonstrations— community demonstrations by the maternity and infancy
nurses have aroused, in every county in which they were made, an
interest in the matter of establishment o f permanent health service.
Home demonstrations have also been made, covering preparations for
delivery, care o f the baby, and preparation of food.
Nutrition work— one city has a nutrition worker who prepares formulas
and special foods ordered by physicians for undernourished children
and teaches these to mothers. This community has assumed part of the
nutritionist’s salary.
As a result of the field nurses’ work, two counties have undertaken to main
tain their own nurses-

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T H E W E L F A R E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y

SOUTH DAKOTA

Administrative agency:
State board of health, division of child hygiene.
Staff:
Director, 8 nurses, 1 lecturer (h alf tim e), 1 stenographer.
Activities :
Children’s health conferences— 74 (in 26 counties), at which 1,811 children
were examined.
Prenatal conferences— 65 (in 21 counties) in connection with children’s
conferences.
County health departments— 2 established during the last 6 months, with
two nurses in each; and one nurse added to a third.such department.
A ll three of these departments are full time.
Permanent child-health centers— 3 established.
Permanent prenatal centers— 3 established.
Lectures— The lecturer carriers a motion-picture machine and has visited
many isolated country districts.
Prenatal letters— 1,071 sent out.
,
TENNESSEE

Administrative agency :
Department of public health, division of maternity and infant hygiene;
Staff:
Superintendent, 1 staff nurse, 1 supervising nurse, 24 field nurses (¡21 part;
tim e), 1 vital-statistics clerk, 1 clerk, 1 stenographer.
Activities :
-in
Children’s health conference— in the office of the county nurse or àt privA
vate homes, with 1,981 children examined.
Home visits— 596 to prenatal cases, 4,192 for preschool children. The'
women were advised to consult physicians early and were instructed on V
the importance of proper medical supervision during pregnancy.
In .
addition to giving advice on the hygiene of the small child the nurses
aided the parents in securing correction of defects.
“ W ell b a b y ” clinics— 26 established, with an average attendance of 987.t ,
Little mothers’ classes— 20 held.
Home hygiene classes for women— 141 held.
Midwife instruction— An investigation and educational campaign amongSnegro midwives has been carried on, with the assistance of a negroC^
doctor assigned to this work by the United States Children’s Bureau.
rj
Birth registration— Aid in this matter has been given to the State de- "r
partment of vital statistics.
TEXAS

Administrative agency :
State board of health, bureau of child hygiene.
Staff:
Director, 31 nurses (1 supervisor, 2 advisory), 1 maternity and infant
home inspector, 1 midwife supervisor, 2 midwife instructors, 24 county
nurses, 1 clerk, 6 stenographers, 1 lecturer (h alf tim e).
Activities :
Children’s health conferences— 469, at which 10,146 children were examined.
Prenatal conferences— 350, with an attendance of 1,034 women; Most of
these consisted of lectures, and the women were advised to go to local
doctors for examination.
Dental clinics— 52, at which 380 children received attention.
Mothers’ classes— 130, with an attendance of 758. Demonstrations were
given to 460 mothers in their homes.
Midwife classes— 136, with an attendance of 158. Individual instruction
was given to 67 other midwives. During M ay and June the supervisor
of midwives gave instruction on the teaching of midwifery to all of the
county nurses.
Midwife classes and mothers’ classes were conducted among negro women
by the two negro nurses on the staff. A Mexican nurse is employed to instruct
the Spanish-speaking midwives.
Nutrition classes— 73, on the nutrition of preschool children.
Little mothers’ classes— 143.

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40
t h e

W E L F A R E - A N D H Y G I E N E OF M A T E R N I T Y A N D ' I N F A N C Y

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

Community demonstrations— 167, including the attendance of a nurse at
35 fairs for baby conferences in which local doctors cooperated.
Permanent children’s health centers— 49 established.
Inspection was made o f 87 maternity homes and 91 infant homes.
Birth registration— an active campaign to secure birth returns is in
progress.
A cooperative agreement has been completed with the Mexican Federal
health department whereby Mexican consuls and other influential Mexicans
in the State assist in enabling State and county workers to do maternity and
infant welfare work among the Mexican population.
UTAH

Administrative agency:
State board o f health, bureau of child hygiene.
S ta ff:
Director, 5 public-health nurses (2 detailed to counties), 1 vital-statistics
clerk, 1 stenographer.
Activities:
Children’s health conferences— 173, at which 7,094 children were exam
ined. The director made notes on dental defects also and gave instruc
tion to those cases. After child-health conferences with local physi
cians volunteering, all cases which upon examination show defects are
reported to the State department. Correction was made in a number
of cases and many needy children placed in the care of physicians.
Prenatal clinics— held at health centers, at which 180 women were advised
and referred to physicians for examination.
Community demonstrations— 21.
Home demonstrations— 9.
Permanent health centers— established in 48 districts. A t each of these
a representative local group assumes the responsibility of permanent
organization. In many of these centers the local doctors hold children’s
health conferences at regular intervals. A t others the State director
holds conferences once a year, oftener if possible. A nurse from the
State staff makes a survey of sanitation, food supply, water supply, and
other factors which influence the health of the district, as a preliminary
to organization.
Inspection was made of 3 maternity homes and 2 infant homes.
Assistance is being given to the State epidemiologist in a campaign for the
study of prevention o f goiter in expectant mothers and preschool children.
VIRGINIA

Administrative agency:
State board of health, bureau o f child welfare.
Staff:
Director, 2 doctors (1 for 3 months only), 1 midwife supervisor, 3 nurses,
1 dentist (for 3 m onths), 1 vital-statistics clerk, 1 clerk, 2 stenographers.
A ctivities:
Child health conferences— 1,071, at which 14,196 children were examined.
Prenatal clinics— 126, with an attendance o f 288.
Midwife classes— 342, with an attendance of 2,601. The full course of
instruction was completed by 28.
Dental clinics— held in the summer, during which 69 mothers and 848
preschool children were treated.
Clinics— These cover child welfare, orthopedic, dental, prenatal, nose and
throat, tuberculosis, and toxin-antitoxin work. Special clinics were
held in remote sections, with a pediatrist in attendance in addition to
the usual personnel.
Permanent children’s health center— 1 established. In two counties and
three towns which did not previously have local nurses such service has
been started.
Correspondence course— this is distributed to groups as well as to indi
viduals. It is conducted by one of the staff nurses.
A rural training center to prepare graduate nurses for various fields of
public-health nursing has been established in cooperation with the school of
social work and public-health nursing. A county immediately outside o f Rich-

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THE welfare and hygiene of maternity and infancy

mond is used. Two periods of training are given, one o f four months and one
of nine months. Three nurses have completed the long course and 15 the
short course.
WASHINGTON

Administrative agency:
Department o f health, division of child hygiene.
S ta ff:
Director, 2 doctors (part tim e), 1 nurse, 4 vital-statistics clerks (3 part
tim e), 1 clerk (part tim e), 1 publicity writer (part tim e). .
A ctivities:
Children’s health conferences— 20, at which 1,970 children were examined.
In addition there were 52 conferences in a Seattle store which furnished
the conference room and advertised the conferences. The medical work
was under the supervision of the State board of health in collaboration
with the child-welfare division of the Seattle Board of Health. An
average o f 60 children were examined each week.
Prenatal conferences— 12, with an attendance o f approximately 1,200. (No
examinations were made.)
Community demonstrations— 15, including talks on nutrition and the care
o f children.
Permanent children’s health centers— 2 established.
Correspondence course— A series of 15 lessons on the hygiene o f maternity
and infancy has been prepared and widely circulated.
WEST VIRGINIA

Administrative agency:
Department of health, division of child hygiene and public-health nursing.
S ta ff:
Director (serving as public-health nurse part tim e), 9 nurses (1 part tim e),
1 vital-statistics clerk, 2 stenographers.
A ctivities!
Children’s health conferences— 265, at which 3,341 children were examined
and given dental inspection.
Prenatal conferences— 19 held, at which 92 expectant mothers were ex
amined. This led to the establishment of two permanent prenatal
clinics.
Permanent child-health centers— 22 established.
Mothers’ classes— 260, with an attendance of 9,432. Many individual con
ferences with mothers included demonstrations of child feeding and
care, maternity bundles, layettes, etc.
Mothercraft classes— with total attendance of 7,253 girls. The lessons
were outlined by the State board, and certificates signed by the State
health commissioner were given.
Community demonstrations— 220, held by nurses with the assistance of
mothers’ clubs and classes.
Correspondence course— slightly over 4,000 mothers are enrolled in the
motherhood correspondence registry. They have received the series of
prenatal letters, and 14,199 personal letters in addition.
Survey— made of a rural community by lay workers (members o f the
community health committee) and valuable data summarized in seven
recommendations submitted by the State department o f health.
WISCONSIN

Administrative agency:
State board of health, bureau o f child welfare and public-health nursing.
Staff:
Director, 4 doctors (2 part tim e), 5 nurses (1 part tim e), 3 vital-statistics
clerks, 2 clerks, 3 stenographers (1 part tim e), 1 chauffeur (part tim e).
A ctivities:
Children’s health conferences— 442, at which 9,715 children were examined.
Prenatal conferences— at the 16 county mother and baby health centers
193 expectant mothers were examined.
Little mothers (or infant hygiene) classes— 102, with an attendance of
2,317. In March a full-time organizer was added to the staff to conduct
such work in the State normal and public schools.
Prenatal letters— a series is available, and many have been sent out.

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T H E W E L F A R E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y

The director has induced the vocational schools throughout the State to
include regular courses in infant hygiene in their curricula the past two years.
Mother and baby centers are moved each year to different parts of counties.
Under this stimulation five communities have established such centers of
their own. As a result of the activities of the nurse in one county where such
a health center is located, a county nurse has for the first time been employed
by the county board of supervisors. One physician o f the staff visits each of
12 mother and child health centers regularly every four weeks and spends one
week out of every four at other points in the same counties holding con
ferences. Another physician (who served part time during 1924 but will give
full time for the future) similarly visits four such centers every four weeks
and spends the remainder of her time holding conferences in various places
throughout the State. A third doctor conducts child-health conferences on the
“ child-welfare special ” from the middle of April to the middle of November,
spending her remaining time in preparation of material for publication and in
holding conferences in cities which are not reached by the child-welfare special.
WYOMING

Administrative agency:
Department of public health, division of maternal and infant welfare and
child hygiene.
S ta ff:
Director, 2 nurses, 1 stenographer.
Activities:
Children’s health conferences— 79, at which 2,644 children were examined.
A t 50 of these conferences dentists assisted by examining 1,524 children
and giving advice.
Prenatal conferences— none in the precise meaning of the term, but nurses
gave several talks on the hygiene o f pregnancy to groups of mothers.
Mothers’ classes— 22, with an attendance of 150.
Demonstrations— at two State fairs, at summer school at Laramie, and
at the extension-workers’ conference. Staff nurses also made 380 home
demonstrations.
Permanent children’s health centers— 18 established.

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FEDERAL ADMINISTRATION
FED ERAL STAFF

For the administration o f the maternity and infancy act the
United States Children’s Bureau added to its already existing six
major divisions a division o f maternity and infant hygiene. The
staif o f this division has consisted o f a director and associate director,
both of whom are physicians, a public-health nurse, an accountant, a
secretary, and a stenographer. For a part o f the year two additional
physicians and one social worker were added to the staff to conduct
research and to aid in consultation work.
The director and associate director have not only performed the
various duties involved in the administration o f a central office but
at least once during the year either the director or the associate
director has visited each State cooperating under the act.
The public-health nurse visits the State supervisors o f nurses in
an advisory capacity and observes field work in rural districts,
bringing to each State the experience of the others. She has also at
tended institutes for public-health nurses, giving addresses and con
ducting classes.
The accountant has visited all the States accepting Federal funds
and has audited the accounts o f all cooperating State agencies.
C O N F E R E N C E O F S T A T E D IR E C T O R S

After a period o f cooperation in Federal and State maternity and
infancy activities, it was felt that a meeting devoted to the discus
sion o f problems confronting the different States would be beneficial.
The directors o f all o f the State bureaus o f child hygiene were there
fore asked to attend a conference at the Children’s Bureau in Wash
ington (September 19 to 21, 1923). Representatives from 40 States
were in attendance, including two from States not cooperating under
the Federal maternity and infancy act. No formal papers were pre
sented, opportunity being given instead for general discussion on
the subjects listed in an outline program. At the request of the
State directors the following topics were discussed: Prenatal care
(distribution o f literature, consultation facilities, public-health nurs
in g), confinement care (hospital, home, m idwife), postnatal care
(rest, infant feeding, discharge examination); early birth registra
tion; health conferences (methods and standards); nutrition work
for the preschool child; dental hygiene; public-health nurses (ways
o f increasing number and decreasing turnover; training; extent of
activities in maternity and infancy program s); development of
county “ projects” and relative value o f projects undertaken on
small budgets; cooperation of the medical profession; utilization of
lay workers; methods and value o f surveys.
44

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

RESEARCH A N D E D U C A T IO N A L W O R K
Maternity-Home Study.

This investigation was undertaken in order to secure definite in
formation regarding the organization, management, attention to
health and social aspects o f the work o f such institutions. Minne
sota and Pennsylvania were selected for study because the two States
offered a marked contrast in the legal status o f maternity homes. In
the two States 35 maternity Iiomes were made the basis o f the study.
It was found that hospitals cooperated extensively with them. Tho
fact that not all the available beds in these homes were constantly in
use Suggests that an increasing proportion o f unmarried mothers are
cared for in their homes. After the field work had been practically
completed, officials from the institutions and investigators from the
Children’s Bureau came together for a conference with the State
officials.
Maternal-Mortality Study.

A statistical study o f maternal mortality in the United States
(together with data from certain foreign countries) is about com
pleted. An apparent upward, trend in the mortality rate from all
puerperal causes is indicated by the figures returned for the deathregistration area o f the United States for the last 20 years, but after
allowance is made for the improvement in the certification of causes
o f death and certain other complicating factors, the true trend from
all causes appears to be slightly downward, while the trend o f mor
tality d'ue to puerperal septicemia appears to have been very sharply
downward through the period, the figures indicating a decrease o f 36
per cent from 1900 to 1920. A factor known to be preventable, as
puerperal septicemia is, should show lower figures as a greater num
ber o f those who officiate at childbirth possess adequate knowledge
and training. I t is unfortunately true that the number o f deaths
does not indicate the whole o f the u cost ” in mothers’ lives o f bring
ing babies into the world. Many mothers suffer serious injury or
invalidism, although this can not well be expressed statistically.
Reduction o f morbidity is also a matter o f grave concern.
Stillbirth and Neonatal-Death Study.

An investigation o f stillbirths and neonatal deaths (conducted at
the University o f Minnesota) has included 250 examinations cover
ing deaths which had occurred at various times during gestation as
well as shortly after birth. The study will be continued until 500
examinations have been made. The final report will include a bib
liography on the pathology and physiology o f the developing fetus
and the newborn child. The examinations already made show that
practically the same factors which cause death before birth are
responsible for deaths occurring within the first few days o f life.
After the first four or five days o f extra-uterine life other causes
appear, chief o f which is infection. Prematurity is, o f course, a very
prominent factor in neonatal deaths, either alone or in association
with other ca'uses.
Community Control of Rickets.

The child-hygiene division o f the Children’s Bureau is cooperating
with the pediatric department o f the school o f medicine o f Yale
University and the New Haven department o f health in gtn attempt

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

to demonstrate that rickets can be eradicated from a community. A
district including three wards, with a population o f about 13,000, has
been selected in New Haven, Conn. The prevention o f rickets in the
babies born within the district for a period of two years is one part
o f the demonstration, while another involves the study o f many of
the older children in the district to determine to what extent the
disease is already present. The lowered resistance which endangers
the lives o f infants with rickets, also the decrease in the mechanical
efficiency o f individuals deformed by it, indicate the important char
acter o f work leading toward prevention o f this widely prevalent,
disease.
Bibliography on Growth and Development of the Normal Child.

A bibliography which will contain approximately 3,000 annotated
references on the growth and development o f the normal child has
been practically completed by the child-hygiene division o f the
Children’s Bureau. The following subjects are included: General
growth (principally height and weight changes); development of
special parts of the body; metabolism; adolescence and puberty;
methods and standards o f judging normal development.
Child Management.

A pamphlet on child management has been written for the Chil
dren’s Bureau by the director of the division o f mental hygiene in
the department o f mental diseases o f Massachusetts, who is also the
director o f the habit clinics o f Boston. Since the health, happiness,
and efficiency o f the adult depend largely upon the type o f habits
acquired in early life, it is important that parents be informed con
cerning the mental life o f the child, methods o f developing desirable
habits, and also methods of overcoming undesirable habits.
Film “ W ell B om .”

To present in popular form the need of medical care throughout
the period o f pregnancy, a film which tells an interesting story while
constantly emphasizing the importance of prenatal care has been
produced. It has been loaned to 28 States and purchased by 25.
Although it was prepared primarily for the use o f health workers,
it has been used by clubs, colleges, dental associations, commercial
companies, and a labor union.
Publications.

A number o f Children’s Bureau publications bear directly upon
the hygiene o f mothers, infants, and preschool children. There has
been a growing demand for the series o f bulletins issued for mothers.
During the fiscal year under review 190,000 copies of Prenatal Care
were distributed, 400,000 copies o f Infant Care, and 157,297 copies
o f Child Care. These figures include distribution in response to
requests from individuals and organizations, as well as from State
bureaus. W ith the printing appropriation available, however, it
has been impossible to meet all requests. Several States have pur
chased copies of these bulletins directly from the Government Print
ing Office, in addition to quotas supplied free; 16 and others have
reprinted them wholly or in part. During the fiscal year under
review there was also issued a bulletin entitled “ Hafyit Clinics for
i6 rpjie S u p erin ten d en t o f D ocu m en ts ordered 1 2 5 ,0 0 0 ' cop ies Of P r e n a ta l C are, 1 5 0 ,0 0 0
copies o f I n fa n t C are, an d 7 5 ,0 0 0 copies o f C hild C are fo r sales in 1 9 2 4 .

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T H E W E L F A R E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y

the Child of Preschool A g e : Their Organization and Practical
Value.” Since the preschool period is the habit-forming period, the
method set forth in this bulletin is o f interest to all those concerned
with the physical and mental health o f children. The entire edition
(10,000 copies) was distributed, but a new edition is being printed.
O f a folder entitled “ Minimum Standards o f Prenatal Care ”
42,976 copies were distributed. A folder entitled “ W hy Drink
Milk ? ” was prepared, but was not ready for distribution until after
the close o f the fiscal year. Dodgers have been distributed as fol
lows: Books and pamphlets on Child Care, 82,682 copies; Is Your
Child’s Birth Recorded? 25,574 copies; Breast Feeding, 41,545
copies; Bottle Feeding, 60,749 copies^ Feeding the Child, 58,267
copies; The Care o f the Baby, 60,602 copies; What Do Growing
Children Need? 44,850 copies. For prices of these publications in
quantities, and for a list o f other bulletins, reprints, and charts issued
by the Children’s Bureau which touch upon maternal and infant or
child welfare and hygiene, see Appendix D, pp. 55-56.
ACCOMPLISHMENTS UNDER THE MATERNITY AND
INFANCY ACT
In the report for 1923 the general trend o f activities under the act
and the essentials o f a program for promoting the health o f mothers,
infants, and preschool children were summarized as follows:
1. The education o f the general public as to the need and value
o f 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 o f 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 o f 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 o f 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 o f 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:

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TH E

welfare

a n d h y g ie n e

of m a t e r n it y a n d in f a n c y

1. Continued education -to develop public appreciation of the
value o f prenatal, confinement, and infant care.
2. Stimulation o f complete and early registration o f births.
3. Development and èxtension o f facilities for reaching areas
where no maternity and infancy work is now done.
4. Establishment o f permanent health conferences for prenatal,
postnatal, infant, and preschool consultations.
5. Establishment and maintenance o f community public-health
nursing service and o f follow-up work after health consultations.
6. Provisio*n of hospital facilities for all complicated pregnancies
and confinements at least and for illnesses o f infants and young
children, or, where. this is impracticable, provision of 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.
In some States progress along all these lines has been made during
the past year as this report shows ; in some very considerable prog
ress has been made along some lines and little or nothing along
others ; in others only the preliminary educational work on which the
permanent local work must be later developed, has been possible with
the available time and money. In no State can the whole field be
said to have been plowed the first time. While the States report
encouraging results o f intensive local efforts in lowered mortality
rates, it is still too soon to expect such concrete results except in those
few States in which the preliminary educational work had been done
and the local work was under way before the Federal funds became
available. For the present it is possible only to report that methods
which will produce results are being successfully adjusted to local
conditions and the territory in which permanent educational centers
are available is being greatly extended.

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APPENDIXES
A P P E N D IX A .— T E X T OF TH E ACT FOR TH E PROMOTION OF TH E
W E L F A R E A N D H Y G IE N E OF M A T E R N IT Y A N D IN F A N C Y
[S. 1039— Sheppard-Towner A c t ; Public 97— 67th Congress; 42 Stat. 135.]
A n A c t F o r the p ro m otio n o f th e w elfa re an d h y gie n e o f m a te rn ity an d in fa n c y , an d fo r
o th e r purposes

B e it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled, That there is hereby authorized to
be appropriated annually, out of any money in the Treasury not otherwise
appropriated, the sums specified in section 2 of this Act, to be paid to the
several States for the purpose o f cooperating with them in promoting the wel
fare and hygiene of maternity and infancy as hereinafter provided.
S e c . 2. For the purpose of carrying out the provisions of this Act, there is
authorized to be appropriated, out of any moneys In the Treasury not other
wise appropriated, for the current fiscal year $480,000, to be equally appor
tioned among the several States, and for each subsequent year, for the period
o f five years, $240,000, to be equally apportioned among the several States in
the manner hereinafter provided: Provided, That there is hereby authorized
to be appropriated 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,
and annually thereafter, for 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
States in the proportion which 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 appro
priation 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 re
mains unpaid to such State at the close thereof shall be available for expendi
tures in that State until the close of the succeeding fiscal year.
S e c . 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
of the United States Public Health Service, and the United States Commis
sioner of Education, and which is hereafter designated in this A ct as the
Board. The Board shall elect its own chairman and pei^orm the duties pro
vided for in this Act.
The Children’s Bureau of the Department of Labor shall be charged with
the administration of this Act, except as herein otherwise provided, and the
Chief of the Children’s Bureau shall be the executive officer. I t shall be
the duty of the Children’s. Bureau to make or cause to be made such studies,
investigations, and reports as will promote the efficient administration of
this Act.
S e c . 4. In order to secure the benefits of the appropriations authorized in
section 2 of this Act, any State shall, through the legislative authority thereof,
accept the provisions of this Act and designate or authorize the creation of a
State agency with which the Children’s Bureau shall have all necessary powers
to cooperate as herein provided in the administration of the provisions of this
A e t : Provided, That in any State having a child-welfare or child-hygiene divi
sion in its State agency of health, the said State agency o f health shall admin
ister the provisions of this Act through such divisions. I f the legislature of
any State has not made provision for accepting the provisions of this Act
4he governor of such State may in so far as he is authorized to do so by 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 of the legislature in such State
following the passage of this Act.
49

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THE welfare

and hygiene of maternity and infancy

Sec. 5. So much, not to exceed 5 per centum, o f 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.
' .,
- i
S e c . 6. Out of the amounts authorized under section 5 o f this Act the Ohi\
dren’s Bureau is authorized to employ such assistants, clerks, and other per
sons in the District o f Columbia and elsewhere, to be taken from the eligible
lists of the Civil Service Commission, and to purchase such supplies, material,
equipment, office fixtures, and apparatus, and to incur such travel and other
expenses as it may deem necessary for carrying out the purposes o f this Act.
S e c . 7. Within 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 e c . 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
he subject to the approval o f the b oard: Provided, That the plans o f the States
under this Act shall provide that no official, or agent, or representative in carry
ing out the provisions o f this Act shall enter any home or take charge o f a n y
child over the objection of the parents, or either of 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 o f this Act and reasonably appropriate and
adequate to carry out its purposes they shall be approved by the board and due
notice o f such approval shall be sent to the State agency by the chief o f the
Children’s Bureau.
‘
S e c . 9. No official, agent, or representative of the Children s Bureau shall by
virtue o f this Act have any right to enter any home over the objection o f the
owner thereof, or to take charge of any child over the objection o f the parents,
or either of them, or of the person standing in loco parentis or having custody
o f such child. Nothing in this Act shall be construed as limiting the power
o f 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 e c . 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 th e legislatures o f the
several States accepting the provisions o f this Act and shall certify to the
Secreary of the Treasury the amount to which each State is entitled under
the provisions o f 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 o f 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 o f this Act, as provided in sec
tion 2 hereof; and (4) the amount to which the State is entitled under the
provisions o f 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 e c . 1 1 . 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
provisions o f this Act. Such certificate may be withheld until such time or

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T H E W E L F A R E A N D H Y G I E N E OF M A T E R N I T Y A N D I N F A N C Y

upon such conditions as the Children’s Bureau, with the approval o f 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 any
such certificate shall be withheld from any State, the chairman o f 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
o f this Act.
S e c . 12. No portion o f any moneys apportioned under this Act for the benefit
o f 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 o f any buildings or lands, nor shall any such money 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 any
maternity or infancy pension, stipend, or gratuity.
S e c . 13. The Children’s Bureau shall perform the duties assigned to it by
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 e c . 14. This Act shall be construed as intending to secure to the various
States control of the administration o f this Act within their respective States,
subject only to the provisions and purposes of this Act.
Approved, November 23, 1921.

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APPENDIX B.— LIST OF ADMINISTRATIVE AGENCIES AND OFFICERS

State administrative agencies and names o f the executive officers for the
administration of the act for the promotion of the welfare and hygiene of
maternity and infancy (as of June 30, 1924)
State

Department and executive officer

Alabama____________

State board of health, D r. S. W . W elch .

Arizona........................

State board of health, D r. F . T . Fahlen.

State board of health, D r. C . W . Garri
son.
California..................... State board of health, D r. W alter M .
Dickie, secretary.
Colorado__________ _ Department of public instruction, M rs.
M ary C. C . Bradford, superintendent.
Connecticut1_______ Department of health, D r. Stanley H .
Osborne.
Delaware................... . State health and welfare commission,
Dr. Arthur T . Davis, executive secre
tary.
Florida......................... State board of health, D r. R . C . T u rck ..

Arkansas____________

Georgia................. .......
Hawaii_____ ________
Idaho........................ . .
Illinois1....................
Indiana........................
Iowa------------------------K ansas1......... - ..........-

State board of health, D r. T . F . Aber
crombie.
Board of health, D r. F . E . Trotter,
president.
Department of public welfare, D avid
Burrell.
Department of public health, D r. Isaac
D . Rawlings, director.
State board of health, D r. W illiam F.
King.
State University of Iowa, D r. W alter A .
Jessup, president.
Department of the State board of health,
Dr. M ilton 0 . Nyberg, secretary.

State board of health, D r. A . T . M cC or
mick.
State board of health, D r. Oscar Dowling,
president.
M a in e 1_____________ Department of health, D r. C. F. K en
dall, commissioner.
M aryland________. . . Department of health, D r. John S. Ful
ton, director of health.
M assachusetts1_____ Department of public health, D r. Eugene
R . Kelley, commissioner.
Department of health, D r. Richard M .
M ichigan__________
Olin, commissioner.
M innesota__________ State board of health, Dr- A . J. Chesley.

K entucky___________
Louisiana___________

Mississippi__________

State board of health, Dr. F. J. Under
wood.

State board of health, Dr. Cortez F.
Enloe, secretary.
State board of health, Dr. W . F . Cogs
well.
Department of health and welfare, D r.
Nebraska............... .
J. D . Case.
State
board of health, D r. S. L . Lee,
N evad a.........................
Secretary.
State
board
of health, D r. Charles D un
N ew Hampshire____
can.
Department
of health, D r. J. C . Price.. .
N ew Jersey_________
M issouri___________

M ontana____________

N ew M e x ic o .............

Board of public welfare, M rs. Francis S.
W ilson, president.

1 T h ese s ta te s w ere n o t cooperating.

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Division and director

Bureau of child hygiene and public health
nursing, Jessie L . Marriner, R . N .
Child hygiene division, M rs. Charles
s R . Howe.
Bureau of child hygiene, D r. Margaret
Koenig, associate director.
Bureau of child hygiene, D r. Ellen S.
Stadtmuller.
Child welfare bureau, M rs. E . N .
Mathews, executive secretary.
Bureau of child hygiene, Dr. A . E .
Ingraham.
Marie T . Lockwood, R . N ., supervisor
of nurses.
Bureau of child welfare and public-health
nursing, Laurie Jean Reid, R . N .
Division of child hygiene, D r. Joe P .
Bowdoin.
Bureau of child hygiene, D r. F . W .
Alm ond.
Division of child hygiene and publichealth nursing, Dr. R . C. Cook, acting
director.
Division of infant and child hygiene*
D r. Ada E . Schweitzer.
Division of maternity and infant hygiene,
Dr. Edward H . Lauer.
Division of child hygiene and public,
health nursing, Lillian FitzpatrickR. N.
Bureau of maternal and child health,
D r. Annie S. Veeeh.
Bureau of child hygiene, Agnes Morris.
Division of public-health nursing and
child hygiene, Edith Soule, R . N .
Bureau of child hygiene, D r. J. H . M ason
Knox, jr., chief.
Division of hygiene, Dr. Merrill E .
Champion.
Bureau of child hygiene and public-health
nursing, D r. Blanche M . Haines.
Division of child hygiene, Dr Ruth E .
Boynton.
Bureau of child welfare and public-health
nursing, Dr. F . J. Underwood, acting
director.
Division of child hygiene, Dr. Irl Brown
Krause.
Division of child welfare, Dr. Hazel Dell
Bonness.
Division of child hygiene, M rs. C . H .
England.
Child welfare division, M rs. S. H .
Wheeler, executive secretary.
v
Division of maternity, infancy, and
child hygiene, Elena M . Crough, R. N .
Bureau of child hygiene, Dr. Julius
Levy, consultant.
Bureau of child welfare, D r. Janet Reid.2
Bureau of public health, D r. G. S.
Luckett, executive officer; Division of
child hygiene and public health nurs
ing, Helen B . Fenton, R . N .

2 Resigned Apr. 7, 1924.

T H E W E L F A R E A N D H Y G IE N E

OF M A T E R N IT Y A N D IN F A N C Y

State administrative agencies and names of the executive officers for the
administration of the act for the promotion of the welfare and hygiene of
maternity and infancy (as of June>30, 1924) — Continued
State

Department and executive officer

Division and director

N ew Y o rk __________

Department of health, D r. M . Nicoll,
commissioner of health.
State board of health, D r. W . S. Rankin.

Division of maternity, infancy, and
child hygiene, D r. Florence L . M cK a y .
Bureau of maternity and infancy, D r.
K . P. B . Bonner.
Division of child hygiene and publichealth nursing, D r.M aysil M . Williams.
Division of hygiene, D r. R . G . Leland,
chief.
Bureau of maternity and infancy, Dr.
Lucile S. Blaehly.
Bureau of child hygiene, D r. Estelle F.
Warner.
Bureau of child health, Dr. J. B.
M cCreary; preschool division, Dr.
M ary Riggs N oble, chief.
Division of child welfare, D r. Marion L.
Gleason.
Bureau of child hygiene and public
health nursing, A d a Taylor Graham,
R. N .
Division of child hygiene, D r. Clara E .
Hayes.
Division of maternity and infant hygiene,
D r. E . A . Lane, superintendent.
Bureau of child hygiene, D r. H . Garst.

North Carolina_____
North D a k o t a _____

Department of public health, D r. A . A .
Whittemore.
Ohio............................ . Department of health, D r. J. E . M onger.

Oklahoma____ ______
O regon........................
Pennsylvania.............

Department of public health, D r. Carl
Puckett, commissioner of health.
State board of health, D r. Frederick
D . Strieker.
Department of health, D r. Charles H .
M iner.

Rhode Island 3.......... State board of health, D r. B . U . Rich
ards, secretary.
South Carolina. . . . State board of health, D r. James A .
H ayne, State health officer.
South D akota............

State board of health, D r. P . B . Jenkins,
superintendent.
Department of public health, D r. C . B.
Crittendon, commissioner of health.
Texas.......................... .. State board of health, D r. Malone
Duggan.
Utah_____ __________ State board of health, D r. T . B . Beatty,
State health commissioner.
V erm ont3.......... ......... Department of public health, Dr.
Charles F . Dalton, secretary.
Virginia.................... .
State board of health, D r. E . G . W illiam s.
Tennessee................

Washington................
West Virginia_______
Wisconsin.......... .......
W yom ing___________

Bureau of child hygiene, Dr. H .
Richards.

Bureau of child welfare, D r. M ary E .
Brydon.
Department of health, D r. Paul A .
Division of child hygiene, D r. George
Turner.
Mohr.
Department of health, D r. W . T . Hen- Division of child hygiene and publicshaw.
health nursing, M rs. Jean T . Dillon. .
State board of health, D r. C . A . Harper. Bureau of child welfare and public-health
nursing, M rs. M ary P . Morgan, R . N .
Department of public health, D r. G. M ,
Division of maternal and infant welfare
Anderson.
and child hygiene, Louise Buford, R .N .

8 These states were not cooperating.

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A P P E N D IX C.— M A T E R N A L A N D IN F A N T M O R T A L IT Y RATES
T able

I.—Trend

of maternal mortality in the United States birth-registration
area, by States, 1915 to 1923 1
Maternal mortality rates in the birth-registration area in—

State

1922

1921

1920

1919

6.1

6.2

6.6

9.2

5.6

4.9

5.1

7.5

7.4
8.0
6.2

8.0
7.7
6.8

6.8
6.8
5.3
6.3

5.7
6.7
5.2

7.8
6.4
6.0
6.8
5.5

7.2
7.6
6.0
6.7
6.8
6.5
7.4
5.6

10.4
11.4
8.0
8.6
9.5
9.2
8.6
7.8

8.4
8.2
6.3
8.6
8.4
7.1
7.7
6.7

8.7
8.4
6.4
8.5
7.6
7.5
9.3
7.9

6.9
6.4
6.3
7.4
6.7
6.5
6.9
5.7
9.5

6.1

7.2

7.0

7.8

8.0

7.1
7.1

5.9

5.4

5.7
8.2
7.1

8.0
10.8
9.7

6 .4
6.6

7.0
5.8

6.5
6.3

ÌÒ.5
9.8

6.1

7.8

5.9
6.3
8.2
7.4
5.7

8.6
8.0
10.7
9.9
6.0

6.2
9.3
7.4
10.1
6.8
(2)
11.2
8.4
8.0
8.2
8.6
4.8

6.9
10.0
8.0
9.4
7.8
(2)
12.2
7.9
7.0
8.6
9.2
6.7

6.6
6.2
5.9
6.3
7.3
7.2
7.4
6.8
7.1
9.8
7.3
7.3
7.0
7.8
5.8

7.0

10.1

8.5

9.1

8.5

8.8

10.1

6.8

i U . S. Bureau of the Census.
T able

1918

1917

1916

1915

6.6
7.2
5.7
6.6
6.3
6.6
7.6
6.1
7.6
5.9
6.8
6.9
4.9
8.3
7.9
5.8
6.5
6.4
6.0
8.0
6.6
8.3
6.2
5.5
10.7
5.5
7.4
7.2
7.9
5.6
7.1
7.1

1923
6.7
6.7
5.7
8.4
6.4
6.5
6.8
6.0
8.7
6.0
6.3
7.0
6.0
8.8
7.5
5.8
7.4
5.7
5.7
8.0
7.2
6.9
6.6
6.3
9.7
5.0
7.0
774
6.7
6.8
7.3
10.1

2 Dropped from the birth-registration area.

II. — Trend of infant mortality in the United States birth-registration
area, by States, 1915 to 1923 1
Infant mortality rates in the birth-registration area in—
State

1915

1918

1919

1920

1921

87
70
86

86
74
92

76
66
73
98

79
70
82
91
105
88
90
67

82
73
73
102
104
91
92
66

71
63
62
88
94
76
79
59
68

113

64
88

91
100
92

97
102
94

111
108

129
126

69
85
98
69
78

64
93
103
69
79

84
84
90
63
100
(2)
113
71
85
91
63
80

86
85
83
62
97
(2)
116
71
96
84
66
77

112

101

101 '

107

101

107

101
86
70

108
121
100
96
70

86
77
87
93
120
98
88
67

87
80
93
101
140
113
89
71

Ì1Ò

115

110

110
120

114
111

111

106

i D , S. Bureau of the Census.

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Federal Reserve Bank of St. Louis

1917

100

105

District of Columbia-------------

1916

„

87
74
75
75
75
51
88
93
96
73
78
79
55
72

1922
76
71
77
100
76
67
65
69
86
94
81
75
58
68
70
57
80
79
77
80
72
58
88
85
93
69
73
77
62
71
79
85

2 Dropped from the birth-registration area.

1923
77
73
77
104
82
71
63
72
89
95
78
80
62
68
71
57
93
72
72
81
75
57
90
94
96
59
76
84
57
70
80
92

APPENDIX D.— LIST OF BULLETINS, REPRINTS, A N D CHARTS
ISSUED B Y T H E C H ILDREN’S BUREAU W H IC H B EA R UPON
M A TE R N A L A N D IN F A N T OR CHILD W E L F A R E A N D H YG IE N E ,
W IT H T A B U L A R STA T EM E N T OF Q U A N T IT Y PRICES ON T H E
PUBLIC ATIO N S MOST W ID E L Y USED TO D A T E
BULLETINS

The Promotion of the W elfare and Hygiene of Maternity and Infancy— Report
of the Administration of the Act of Congress «¿cff November 21, 1921, for the
period March 20, 1922, to June 30, 1923. No. 137. 42 pp.
Child Management, by D. A. Thom, M. D. No. 143. 24 pp.
Physical Status o f Preschool Children, Gary, Indiana, by Anna E. Rude, M. D.
No. 111. 84 pp.
Children o f Preschool Age in Gary, Indiana.— Part I, General Conditions Affect
ing Child W elfare, by Elizabeth H u gh es; Part II, Diet of the Children, by
Lydia Roberts. No. 122. 175 pp.
H abit Clinics for the Child of Preschool A g e ; their organization and practical
value, by D. A. Thom, M. D. No. 135. 71 pp.
Nutrition W ork for Preschool Children, by Agnes K . Hanna. No. 138. 25 pp.
Maternity and Infant Care in a Mountain County in Georgia, by Glenn Steele.
No. 120. 58 pp.
Maternity and Child Care in Selected Rural Areas o f Mississippi, by Helen M.
Dart. No. 88. 60 pp.
Causal Factors in Infant M ortality; a statistical study based on investigations
in eight cities, by Robert Morse Woodbury, Ph. D. A consolidated report of
the Children’s Bureau studies in this field. No. 142. 245 pp.
Infant Mortality— Results of a Field Study in Baltimore, Md., based on births
in one year, by Anna Rochester. No. 119. 400 pp.
REPRINTS

Economic Factors in Infant Mortality, by Robert Morse Woodbury, Ph. D.
(Reprinted from the Quarterly Publication o f the American Statistical Asso
ciation, June, 1924.) 19 pp.
Decline in Infant Mortality in the United States Birth-Registration Area, 1915
to 1921, by Robert Morse Woodbury, Ph. D.
(Reprinted from May, 1923,
issue o f the American Journal o f Public Health.) 7 pp.
CHARTS

A tabular Summary of State Law s Relating to Public Aid to Children in Their
Own Homes in Effect January 1, 1925, and the text of the laws o f certain
States. Revised Edition. Chart No. 3. 37 pp.
Deaths Under 1 Year of Age, by Cause o f Death.
Deaths Under 1 Year of Age, by Monthly Age Groups.
Decline in Infant Mortality, from Selected Causes, 1915-1921.
Decrease in Summer Deaths, 1915-1920; deaths under 2 years o f age from
diarrhea and enteritis.
Infant Mortality Thermometer; deaths1 under 1 years o f age per 1,000 live
births.
Maternal Mortality Thermometer; deaths from puerperal causes per 1,000 live
births.
Relative Motality among Artificially and Breast Fed In fan ts; deaths among
artificially fed infants compared with number expected at mortality rates
prevailing among breast-fed infants.
Summer Peak o f Infant Deaths ; deaths under 2 years o f age from diarrhea
and enteritis.
55

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Federal Reserve Bank of St. Louis

the

w e l f a r e a n d h y g ie n e

q u a n t it y

p r ic e s

m o st

of m a t e r n it y a n d in f a n c y

w id e l y

used

p u b l ic a t io n s

The following table shows prices of bulletins, dodgers, and folders ordered
in quantities (see pp. 46 -4 7) :
N um ber of copies
Title of publication
100

500

1,000

Each ad
ditional
1,000

BULLETINS

Prenatal Care, 41 p p .............................. .....................................................
Infant Care, 1Í8 pp___________________ __________________________
Child Care, 82 pp___________________________________ _____________
Child Management, 24 pp_______ ________________ ________ _______

$3.00
6.00
5.00

$20.00
40.00
38.00
0)

$25.00
60.00
42.00
25.25

$25.00
60.00
42.00
13.75

5.00
5.00
6.00
6.00
6.00
5.00
9.00
5.00

2.75
2.75
2.75
2.75
2.75
2.75
4.75
1.75

DODGERS

Books and Pamphlets on Child Care (M ar. 1,1925).......................
The Care of the M other (revised)________________________________
Is Y our Child’s Birth Reoorded (revised Jan. 1,1925)__________
Breast Feeding (revised)________________________________ ______ _
Bottle Feeding___________________________________________________
Feeding the Child______________ ,___ _____________ . ________
T h e Care of the B aby (revised)__________ -.______________________
W h at D o Growing Children N e e d ? .......... - ......................... .......
FOLDERS

M inim um Standards of Prenatal Care (revised)...............................
W h y Drink M ilk ? M ilk is the Indispensable Food for
Children__________________________________________ ____________
W hat Builds Babies? The M other’s D iet in the Pregnant and
Nursing Periods (in press)........... ..........................................................
1 3 cents per copy.

2 6.50
0

2 In lots of 10,000.

https://fraser.stlouisfed.org
Federal Reserve Bank of St. Louis

4.00
0

12.00

7.50

Full text of The Promotion of the Welfare and Hygiene of Maternity and Infancy : The Administration of the Act of Congress of November 21, 1921, Fiscal Year Ended June 30, 1924, Bureau Publication No. 146

FRASER