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1 Number of cases incomplete as of Apr. 1, 1946, in 37 States differs from number of cases incomplete as of Mar. 31, 1946 because of corrections submitted by State agencies.

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1 Number of cases incomplete as of Apr. 1, 1946, in 20 States differs from number of cases incomplete as of Mar. 31, 1946, because of corrections submitted by State agencies.

12

TABLE 3.-Cumulative case count through Apr. 30, 1946, by State 11

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1 Data in this table are subject to revision on the basis of corrections submitted by State agencies on reports for months prior to April 1946.

iTime period covered is from the beginning of the EMIC program in the individual States through April 1946. The beginning of the time period varies among the States from April 1943 to March 1944. The separation of the cumulative case count into maternity and infant cases is estimated for some months prior to April 1946.

EXHIBIT 77

TEN YEARS OF PROGRESS IN REDUCING MATERNAL AND INFANT MORTALITY WITH FIGURES SHOWING CHANGES IN THE RATES BETWEEN THE 2 YEARS 1942-43

(By Marjorie Gooch, Sc. D., Division of Statistical Research, U. S. Children's Bureau)

With publication by the Bureau of the Census of data on births and deaths for 1943, it is possible for the first time to compare infant and maternal mortality rates over a 10-year period. Although much information on these subjects has been available for a number of years, the first year in which reasonably satisfactory data were available for every State in the Union was 1933.

Between 1933 and 1943 the maternal mortality rate declined 60 percent-from 61.9 deaths directly due to pregnancy and childbirth in 1933, per 10,000 live births, to 24.5 such deaths in 1943. The infant mortality rate during the same years dropped from 58.1 deaths of infants under 1 year of age, per 1,000 live births, to 40.4 in 1943-a decrease of 31 percent.

The reporting of these comparable figures for the entire United States is a milestone in the history of vital statistics.

Development of birth and death registration in this country has been a long, slow process.

The first vital statistics published by the Federal Government were for the year 1850; these were based on data collected during the decennial population census of that year. Although the information covered the entire United States, the method of obtaining the data made it inevitable that they would be incomplete and inaccurate.

In some of the earlier-settled States, official registration of certain facts about births and deaths at the time the birth or death occurred had been in force since early colonial times. This principle-registration rather than enumeration-was used in the establishment in 1900 of the death-registration area. Only 10 States, the District of Columbia, and a small number of cities were included in this first registration area. But even this small beginning required that some central agency be given responsibility for the annual collection, compilation, and publication of the information. The Bureau of the Census was given this responsibility, and from this small beginning the structure of the present-day vital statistics has grown up. Similarly a birth-registration area was begun in 1915, with only 10 States and the District of Columbia included. Gradually States were added to each of these registration areas until in 1933 all the States were included in both the birth- and the death-registration areas.

Admission of a State to either registration area required proof that certain standards of completeness of registration had been met.

The registration procedure that is, the filing of an official document giving specified information about the birth or death soon after it occurred-involves many persons and procedures. The certificate is filed with a local registrar, forwarded by him after he has made a record of certain facts, to the State registrar. In the office of the State registrar copies are made of the statistical information and sent on to the Federal Bureau of the Census which makes the Nation-wide tabulations and analyses of the data.

It is obvious that with the millions of records involved each year, definite classifications of many items must be agreed upon. Sometimes it becomes necessary or advisable to change some of the definitions and when this is done direct comparisons of current data with those published earlier are sometimes difficult or even impossible to make.

The classifications of causes of death are made according to the International List of the Causes of Death. This list is revised every 10 years to keep pace with advancement in medical knowledge. The latest revision was made in 1938, and deaths that occurred from 1939 through 1943 were classified according to this latest edition. Deaths that occurred from 1933 through 1938 were classified according to the 1929 edition. There were more extensive changes in the classification of causes of maternal deaths than of infant deaths, but the major discrepancies brought about by the revision have been overcome by the use of broad groups of causes. There are hidden variations, however, that cannot be corrected by this practice.1

Another change which was made in the tabulations of the Bureau of the Census during the 10-year period from 1933 to 1943 was the change from a place-of

For a discussion of the problem of classification of causes of death, see Vital Statistics Rates in the United States, 1900-1940, by Forest E. Linder and Robert D. Grove (U. S. Bureau of the Census, Washington, 1943).

occurrence to a place-of-residence basis. From 1933 through 1936 all births and deaths were tabulated according to the place where the birth or death took place. Data tabulated according to place of residence, however, have much more public-health significance. For this reason, from 1937 on most tabulations have been made on this basis. This change does not affect the statistics for the United States as a whole, except those relating to urban and rural areas. For most States, figures for births and maternal and infant deaths are not greatly different whether on an occurrence or on a residence basis. The Bureau of the Census has continued to publish some data on an occurrence basis as well as on a residence basis. For data that are not available on an occurrence basis direct comparisons between 1933 and 1943 for geographic subdivisions are not valid.

As a whole, however, in spite of limitations, the figures for both maternal and infant mortality are comparable.

Before examining the mortality rates, let us look at the figures for births during the decade 1933-43.

Birth rates

BIRTHS

In the 10 years from 1933 to 1943 there was an increase in the birth rate of 30 percent. For 1933, 2,081,232 live births were registered in the United States; this meant a birth rate of 16.6 per 1,000 estimated population. For 1943, 2,934,860 live births were registered-a birth rate of 21.5 per 1,000 estimated population including the armed forces overseas.

The birth rates for the United States from 1933 to 1943 are as follows:

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The proportion of Negro births decreased slightly from 1933 to 1943. In the earlier year 11.8 percent of all live births were Negro; in 1943, 11.1 percent. In both years Mississippi had the highest proportion of Negro births (54 percent in 1933 and 53 percent in 1943). Idaho and North Dakota had less than 0.1 percent in each year. The greatest concentration of Negro births occurs in fewer than one-fourth of the States and during the 10-year period there was little change in the picture. Between 1933 and 1943 the States with the highest proportion of Negro births showed a slight decrease in this proportion. In other words, there has been a shift in the Negro population away from the southern States.

Attendant at birth

Data for 1933 on the number of births occuring in hospitals and attended by physicians are not available from the Bureau of the Census, but from data published in the Journal of the American Medical Association for March 31, 1934, it seems probable that in 1933 less than 35 percent of the births took place in hospitals. By 1943 this percentage had risen to 72 percent.

The percentage of hospital births from the first year for which such data are available from the Bureau of the Census to 1943, and the percent increase from each year to the next, are as follows:

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