themselves and their babies, in obtaining adequate maternity care in a hospital, and in finding their places in the community after the baby is born. Too many of the babies of such young mothers get into the black market.

Because of the seriousness of the situation, the Bureau plans to devote time and effort to investigate this problem and determine steps that can be taken to eliminate it. Advice will be sought from legal, medical, social work, and other professional groups, from adoptive parents and law enforcement agencies, and legislative problems will be explored. Facts will be brought together, drawing on the experience of all groups concerned with the practice, especially those in local communities. Consultations with the professional groups were begun this year, and the work will be more fully developed in 1955.

FETAL AND NEONATAL MORTALITY

An increasing number of public health officials, pediatricians, and obstetricians see the need for a concerted attack on fetal and neonatal mortality in the United States. The need is documented by a report now in preparation by the Bureau dealing with the size and locations of fetal and neonatal losses as indicated in official statistics for the several States.

About 143,000 infants annually lose their lives in the mid or late fetal and neonatal periods. These losses suggest that about 1 in 25 pregnancies which reach 20 weeks or more of gestation results in death of the infant before, during, and just after birth. These deaths comprise nearly 10 percent of the total mortality in the United States, from all causes and at all ages.

An estimated 35,000 fetal and neonatal deaths, or about 25 percent of the annual national loss, could probably now be prevented if it were possible to reduce excessive risks in some areas of the country to match the best experience in other parts of the United States. Beyond this, wider gains can also be expected, as ways are found to improve further what seems today to be the best experience. The program must be essentially a preventive one if the number of fetal deaths is to be reduced. More knowledge as to causes of fetal deaths is needed, but there is great need to make more effective in action the knowledge we already have.

Training Personnel for Programs With Children

If services for children are to be of value, they must be manned by competent workers. The recognition of the need for services has advanced much more rapidly than the production of an adequate number of competent workers to fill the increasing demand. To overcome this strategic gap States are investing a substantial part of

their funds to increase the number of skilled workers through specialized courses in training centers, in-service training programs, and fellowships for advanced training of staff members.

CHILD HEALTH

In an attempt to improve service both in the hospitals and in public health departments, the State health departments have developed extensive and well-planned institutes and workshops and other methods of in-service training for their personnel. However, due to the fact that there has been a reduction in funds for the programs of many State health departments, such training programs have had to be severely curtailed in some of the States this year.

The Massachusetts Department of Public Health and the Harvard School of Public Health presented a 2 weeks' institute on Child Growth and Development for medical social work faculties from many parts of the country. The purpose of the institute was to present new knowledge of a multidisciplined approach to child growth and development which those attending could incorporate in their teaching programs.

A 2 weeks' institute for nurses was conducted by the Harvard School of Public Health. The focus of the institute was to help nursing leaders interested in parent education enrich their understanding of child growth and development and explore methods for utilization of this knowledge. This institute was sponsored jointly by the American Red Cross and the Children's Bureau. The Child Study Association of America participated in the latter phase of the program. Registration included nurses from 23 States and Puerto Rico.

As a result of the Institute on Care of Premature Infants for physicians and nurses conducted at the New York Hospital-Cornell Medical Center, similar programs for physicians and nurses have been established in other States. In the Mountain States of the West where programs for care of premature infants have not progressed as rapidly as in other areas, there has been increased interest in the preparation of personnel to initiate programs on a local or State level.

Fifteen States conducted institutes, conferences, or workshops in maternity or pediatric nursing. All of these report enthusiastic attendance and several of them have reported improvements in hospital care or public health nursing service following these opportunities for learning.

Postgraduate training programs for physicians in the field of maternal and child health are under way at a number of places. The Conference on Public Health Aspects of Rheumatic Fever and Pediatric Cardiology at New Haven and the Conference on Premature Care at the New York Hospital are among the best known. Others are the

Chart 11.-PREVENTION OF PREMATURITY AND BETTER CARE OF PREMATURE BABIES WOULD GREATLY REDUCE MORTALITY IN THE FIRST MONTH OF LIFE

Tristate Obstetric Seminar at Daytona Beach, Florida, the pediatric and obstetric conferences in Texas, the postgraduate training program at Bowman Gray University. Colorado, as a new development, held a 22-day institute on the care of newborn and premature infants for physicians and hospital administrators. This is the first year the administrators were included, but the response was so good and the effects so valuable that the inclusion of administrators may be an annual affair. Six States, in addition to Colorado, were represented at the institute.

The Medical School of the University of Puerto Rico graduated its first class in medicine this June. Forty-five students received an M. D. degree. Emphasis in Puerto Rico is on training personnel. This is being done largely by training Puerto Rican residents as specialized personnel. The crippled children's program developed a working agreement with the School of Physical Therapy and Occupational Therapy in Puerto Rico whereby the students will receive field practice in clinics and treatment centers of the crippled children's program. The newly organized Association of State and Territorial Directors of Public Health Nutrition has formed a committee to explore possible sources of financial assistance to students of public health nutrition as the first step in a recruiting campaign. The Nutrition Section of

the Bureau has been asked to work with the Association of State Directors in this and other concrete activities.

The number of local health departments employing full-time nutritionists has increased by about 15 percent during the year. The major handicap to the development of programs has been the dearth of qualified candidates to fill vacancies and newly created positions. Enrollment in graduate programs in public health nutrition has dropped off as few nutritionists are eligible for GI educational benefits and as some State health agencies have curtailed training programs. With the addition of the University of California School of Public Health to the facilities for graduate training in public health nutrition, there is for the first time a course on the West Coast.

CHILD WELFARE

The extent of professional training in social work that has been obtained by child welfare workers throughout the country remains It is, of course, directly related to availability of funds as well as to conviction within the State as to the value of professional competence and the State's responsibility to contribute to this. In some States such professional training is considered the very heart of the child welfare program and is carefully protected when funds diminish. In others, it is the first area to be affected by fluctuation of funds. Some States are spending less for this as they use more funds for salaries of workers returning from educational leave.

Various other methods of in-service training are in use. Institutes and workshops continue to be widely used. Some States have full-time consultants on training and others are trying to get such consultants. Most States are focusing on the quality and quantity of supervisory staff, giving all possible help to such staff, helping them to define function and perfect methods. In some States supervisory caseloads are too high and geographic areas too great for even qualified supervisory staff to give effective supervision. The number of requests for consultation by the State agencies for assistance in reorganizing their training programs in order to make them more effective indicates a more dynamic approach to training on the job. Consultation has been given by Children's Bureau staff to a number of States in their efforts to bring about continuity in their training and to devise methods by which all forms of training will be more closely tied in with day-to-day practice.

Community efforts to make service available to children wherever they may live, coupled with the continued difficulty of securing personnel with professional training, has led to an increased use of untrained staff for beginning social work positions in a number of States. To overcome this, some States are setting up training units for the preliminary training of workers who have not attended schools

of social work, before they are given regular work assignments. In other instances, States may place workers in counties, but only under a well-formulated plan of training that includes joint planning with State and local administrative staff in regard to what will be expected from these workers and in regard to orientation programs and plans for continued on-the-job training. The Children's Bureau consultant on training has participated in such planning in several of the States. During the 12 months ended August 31, 1952, 500 persons concluded the educational leave they had been granted by State and local public child welfare agencies. These individuals are equal in number to about 10 percent of the persons employed full-time in the child welfare services programs of State and local public welfare agencies. The Children's Bureau contributes to in-service training programs for child welfare staffs through such activities as: (a) consultation to State and local agencies by regional child welfare representatives and by special consultants, individually or in joint meetings, at the request of the agencies; (b) consultation in the planning of institutes and workshops; (c) provision, through child welfare funds, for the costs of such institutes and for the cost of attendance by staffs of public agencies; and (d) actual leadership of such institutes and workshops.

In Texas, a series of three workshops planned jointly by the Regional Child Welfare Representative and the Consultant on Group Care, led by the latter in Dallas, El Paso, and Corpus Christi, included broad representation from public and voluntary agencies, institution staff members, and planning groups. The focus was around the constructive use of institutions in treatment of children and resulted in effective community planning in that area.

In West Virginia, at the May 1954 State conference, the Regional Child Welfare Representative of the Bureau presided and acted as discussant at a 1-day institute led by a member of the faculty of the School of Social Work at the University on services to children in their own homes when the request for help comes from the family itself. Persons participating were from public and voluntary agencies having responsibility for this type of service. In addition, during the week of June 7, 1954, two consecutive 2-day institutes were held to cover the total public child welfare supervisors and workers of the State on services to children in their own homes when a complaint has been made by someone outside of the family. These were led by a member of the faculty of the Western Reserve School of Social Work. Original planning was by the staff of the West Virginia Division of Child Welfare and the Regional Child Welfare Representative of the Bureau. Child welfare services funds were used for the expenses and honorarium to provide the leader and the travel costs of the child welfare staff who participated. Both of these institutes were focused on developing the skills of the workers attending.