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them, and provide more doctors for them, and provide more diagnostic facilities for them.

How can you say you want to save more children and more mothers and yet oppose legislation that would provide that care for them? That is, care which they are not getting?

Dr. HOWARD. I think that in the areas which are in need of this, very badly in the South, that something should be done in the


of establishing prenatal clinics, and in establishing, perhaps, obstetrical wards and hospitals for the case of these women.

But there are certainly some areas that do not need it, and Connecticut, does not need it.

Senator PEPPER. The State is not required to take it under this bill, is it?

Dr. HOWARD. No; but I do not think any State would pass it up.

Senator PEPPER. They would be putting up their own money, matching a large part of the funds, if they did avail themselves of it.

But you say the American Medical Association has not gotten up a plan of its own except through the voluntary part. Dr. HOWARD. Yes, sir. Senator PEPPER. I believe that is all, Doctor. Thank you very much.

Senator PEPPER. Dr. M. Edward David, University of Chicago School of Medicine.



Dr. Davis. I am professor of obstetrics and gynecology at the University of Chicago. I am the obstetrician at the Chicago Lying-In Hospital. I am a member of the various national special medical societies. I will not enumerate them. I am a diplomat of the American Board of Obstetrics and Gynecologists. I have been interested in maternal and child welfare for many years, and I have taken an active part in the postgraduate education of doctors in at least 17 States during the past 12 or 15 years.

I come here today at the invitation of Senator Pepper, and I paid my own expenses.

In the limited time at my disposal I should like to summarize briefly my attitude toward bill S. 1318, a bill to provide for the general welfare by enabling the several States to make more adequate provision for the health and welfare of mothers and children.

It is with the welfare of mothers that I am concerned primarily, but mother and child are so closely linked that what concerns one necessarily concerns the other.

To simplify this discussion I have asked myself several questions, and in their answers I think that you will learn what I think about the bill.

In the first place, is there need for Federal funds for maternal welfare in the United States?

Senator PEPPER. Excuse me, Doctor, I think it will add to the understanding of your testimony if you would give us a little bit about your own background, what education and experience you have had.

Dr. Davis. I have been with the Lying-In Hospital in Chicago, which is the leading maternity hospital.

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Senator PEPPER. What about yourself? What has been your own personal education?

Dr. Davis. I am a graduate of Rusk Medical College. I was born in the West, in the wide open spaces of Wyoming: I am a graduate of Rusk Medical College of 1922. I was trained in obstetrics in the Chicago Lying-In Hospital. At that time it was affiliated with Northwestern University. Subsequently I went to Europe and spent a year in European clinics.

. On my return to this country, I worked at the Carnegie Institute of Embryology in Baltimore, then I spent more time in postgraduate studies, and came back to the Chicago Lying-In Hospital, where I have been ever since.

At the present time, as you have heard, I am professor of obstetrics and gynecology at the University of Chicago.

Senator PEPPER. Do you do any private practice as well?

Dr. Davis. No, the faculty of the University of Chicago Medical School is what is known as a faculty on a full-time basis. We have the same standing in school as the professor of physiology, professor of chemistry and professor of anatomy. We receive a full-time salary and devote all of our time to our position.

Senator PEPPER. I see. Thank you very much.
Now, go right ahead.

Dr. DAVIS. The first question I raised is the need for Federal funds for maternal welfare in the United States.

You have heard Dr. Howard tell you that there has been a tremendous decline in maternal mortality in the United States particularly during the last decade. It is gratifying to all of us that this decline has taken place, and we are proud of the effort of everyone that has been identified with the work.

But there are still some 7,000 women that die every year in the United States, and most of us who have studied the statistics concerning these deaths are convinced that at least half of these women can be saved, and it is about these women that we are concerned.

The deaths alone are important. However, they are not the most important consideration. Vital statistics are cold; they are a brutal analysis of what is taking place.

What concerns us, too, are the various damages that are the result of child bearing. Women are permanently invalided as a result of poor obstetrics, and a permanent invalided mother is a much more serious problem than one who has gone to heaven.

Then we are concerned with the many babies who lose their lives unnecessarily. Many of these deaths are preventable.

And then there is the larger group of babies that do not die; they are the crippled, hopelessly crippled; they fill your State institutions; they are the idiots and the imbeciles; and they are a constant source of worry and grief to their families; and you have to support them out of taxes because we support our institutions for the insane and the feeble-minded.

And so they, too, are very important when you consider the entire problem.

Another thing that concerns us is the tremendous discrepancy between the type of care that is available in the various parts of the country, and in the various parts of the individual States.

Dr. Howard has called attention to the fact that in the State of Connecticut they are proud of the record that they have set in maternal mortality. We are proud of the State of Illinois, too. It is not as good a record as that of the State of Connecticut, but we have a larger number of people, and we have other problems.

But the fact that in one State you can have a maternal mortality of 10 per 10,000, and in other States, 40 or 50 per 10,000, is not right, particularly when we can provide the same means in those States with a high mortality that we have available for saving mothers and babies in the States in which mortality is low. That knowledge is known to us now.

We could do at least as good work in one State as we can in another State. That, too, concerns us.

In the State of Illinois, where I am familiar with conditions, in the city of Chicago, the maternal mortality is low; the results are excellent.

But you get down to southern Illinois and you find that you have an entirely different problem. There is a lack of facilities, few hospitals, few well-trained obstetricians, few nurses, and so in one State there may be areas of need and areas where more can be done, but at least we are doing a fairly decent job.

The second question that I asked myself, and which I should like to answer: "If the need for these funds had been established, how can they be spent in a most constructive manner?"

I am one of those individuals who are very much interested in spending our money intelligently. I do not begrudge spending money, but I insist that it be spent intelligently.

It is our feeling that the funds initially, the small appropriations which you asked for in your bill, should be used in those parts of the country where they are most likely to do good. Parts of the country that have the greatest need.

If a State is to receive funds from your appropriation for work in that State, the plan layed down by the State should provide primarily for better maternity care in those parts where that care is needed. We will get the most for our money, and we are likely to establish an ideal maternity care program.

Now, when you go into an area, a rural area, or an area in which there is little or no facility for maternal care, and you establish an ideal program, it yields dividends in many ways. It saves the lives of mothers and babies, but it will do much more than that. If I had the time, I could go into the question of just what additional revenues are derived by having a good maternity care program in an area where there is none today.

You can use that set-up for the training of personnel; and that is one of the weak links in our entire medical care program today. We do not have enough well-trained individuals, doctors, nurses, social service workers at the present time for the extensive program you envisage in this Pepper bill.

Now, the third question I asked myself: "What agency should be designated to use these funds most appropriately?”

I have been identified with the Children's Bureau, Department of Labor, for a number of years, but long before I had anything to do with the Children's Bureau I heard about the wonderful study that


they conducted in 1927 and 1928, a study of maternal mortality in 15 States. That is that study that encouraged many of the subsequent studies that followed.

The New York Academy of Medicine made a study in the city of New York. There was a study made in the city of Philadelphia, and another in the city of Chicago, and I think that, as a result of this initial effort on the part of the Children's Bureau, we all became interested in conditions as they were in the United States, and much of what followed, you are as familiar with as I am.

We had to have some organization, some group of individuals, who would call our attention to the fact that many women that had no business dying in child birth were losing their lives every year in the United States.

The work subsequently, as far as I am concerned, and as far as many


my associates are concerned, has been excellent. They used good judgment. They spent their money wisely, and we feel that this down-hill curve in maternal mortality that you have heard about is in a large part due to the efforts of the Children's Bureau.

So that if there is any extension of maternal care, I think that the Children's Bureau is the appropriate agency to carry on.

Lastly I asked myself the question: "What are the goals toward which we should work ?

At a recent meeting of the advisory committee, the goal was set as the safe delivery of every mother, rich and poor, in the small town, on the farm and in the city, in a good hospital, by a physician who has had some training in obstetrics. We know this is Utopia, but you have to set for yourself high standards toward which to work. If you do not, why you might as well not work, because you do not have the urge to do things.

The delivery of mothers with complications by specialists, qualified to cope with these problems, and the restoration of these mothers to normal health, because a healthy mother is the best safeguard against delinquency in the family, discontent between husband and wife, and is the best guaranty of a happy family.

I have read some of the arguments against the Pepper bill. Some of them say: "Let us wait until we have a national health program. Let us postpone it for a year or two or three.” That argument does not appeal to me. It is very much like withholding bread from the starving people of Europe because we cannot send along a lot of butter and a lot of

Let us make a beginning. We can begin, and begin where the need is greatest, and we can learn and progress.

Progress is slow and tedious, but it is the only way in which you can build on a solid foundation. Obstetrics has led the way in medicine in many many ways.

Obstetrics has pioneered the next epoch in medicine. Years ago our physicians were interested in acquiring knowledge concerning the nature and character of disease, and then there followed the present epoch during which science and medicine provided the cures for many of the ills that afflict mankind.

We are on the threshold of a new epoch in which most of our efforts will be directed toward the prevention of disease. It is easier to prevent th" to cure. Obstetrics has long heralded this period of pre

jam to go with it.

vention. Prenatal care with its many ramifications is designed primarily to prevent the complications of pregnancy and labor. Its aim is to weed out the fit from the unfit, maintain the normal mother in good health, and provide special care for the mother who has complications.

New maternity medical centers and trained personnel will have to be built and developed in order to bring intelligent obstetrical care to all of our underprivileged mothers, and in spite of the splendid achievements of the last decade, and we are all proud of these achievements as I have indicated, we feel that much can be done in the future.

Senator PEPPER. Senator Donnell?

Senator DONNELL. Doctor, you addressed yourself very largely of course to the maternal phase of the bill.

Dr. Davis. That is all I am interested in. I am interested in obstetrics.

Senator DOXNELL. I wanted to ask you in regard to the treatment of children. Would you prefer not to go into that phase of it?

Dr. Davis. I would, sir.

Senator DONNELL. Very well, I shall not ask you about that. I shall ask some other witness on that.

That is all.

Senator PEPPER. Thank you very much, Doctor. I appreciate your coming

Dr. Davis. Thank you, sir.
Senator PEPPER. IS Dr. Underwood here?
(No response.)

Senator PEPPER. Dr. Ella Oppenheimer, director, Bureau of Maternal and Child Welfare, Health Department of the District of Columbia.



Dr. OPPENHEIMER. I have been asked to come here and discuss very briefly, I understand, the situation in the District of Columbia with regard to maternal and child health services and services for crippled children in relation to the need for legislation of this type.

As a Director of the Bureau of Maternal and Child Welfare in the District of Columbia Health Department I have had the responsibility for the administration of services for maternal and child health, and services for crippled children, since the latter part of 1936 and then in recent years for the administration of the emergency maternity and infant care program.

I would like to say that we have made amazing progress in the District of Columbia in the development of these services, largely as a result of the grants in aid which have been available through the Social Security Act.

Our experience in connection with this leads us to feel that there is a very real need for extension of the services. I would like to speak, first, because not much has been said about this, since I have been here this morning, about crippled children. There are a large group of

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