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TABLE 8.-Infant mortality; United States and each State, 1943 and 19421

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EXHIBIT 78

PROVIDING CONTINUITY OF MATERNAL CARE IN THE RURAL AREAS, AS THE PRIVATE PHYSICIAN SEES IT

(By Clyde Allison Boice, M. D., -Washington, Iowa. Read before the First American Congress on Obstetrics and Gynecology, Cleveland, Ohio, September 11-15, 1939)

The problem of providing an adequate maternal hygiene program in various rural areas without question varies according to the economic status of the population and the medical, nursing, and hospital service available. Believing that no single plan will fit all areas, this discussion will be confined to a description of the maternity demonstration program being carried out in Washington County (Iowa) by the members of the county medical society in cooperation with the county health unit and the county hospital.

Washington County is located in southeastern Iowa. It is a typical rural county having a population of approximately 20,000 and an area of 562 square miles. The county seat, Washington, is a city of 4,800 and there are 6 towns in the county with a population of less than 1,000. Each has one doctor. Half of the population live on farms. There are a few industries in the county but it is essentially a farming community. Practically all of the inhabitants are nativeborn and there are less than 50 Negroes in the county. Economic conditions in the county are essentially good. Approximately half of the farms are operated by tenants. About 4 percent of the people are on relief, which is less than onehalf the figure 3 or 4 years ago, and only about 4 percent of the farmers are receiving Government rehabilitation loans. For the last 2 years, relief has been taken care of by local funds.

During the past 10 years, the average number of live births per year was 333. The maternal mortality rate over this period was 4.2 per thousand. The infant mortality rate for the same period was 37.5. The stillbirth rate for this period was 25.2 per thousand.

The Washington County Medical Society has been very active for the past onethird of a century and has embraced in its membership every reputable physician practicing in the county. The county society has always taken an active interest in public affairs and was instrumental in having established a county hospital in 1908, the first of its kind in the entire country. In 1924, the society fostered the establishment of a health unit-county-wide and the first in the State. This unit has survived with two short intermissions through the vicissitudes of politics and by midyear, 1936, it became firmly established with a well-trained personnel in charge. At this same date, arrangements were made to establish a maternal and child hygiene unit as an adjunct to the health unit.

The reasons for the establishment of the maternal health demonstration unit in Washington County were: First, every medical practitioner in the county is a member of the society and has been for many years. The society has a record of activity in health matters over a period of years. Second, there is a county hospital which serves all residents of the county regardless of financial status. Communicable diseases and active tuberculosis are not admitted. Third, the county medical society has for a number of years had a contract with the county board of supervisors for the care of the indigent.

This contract obligates the physicians to give a full medical service for a reasonable fee and the sick person has the right of choice of physician. This contract has been eminently satisfactory to all concerned. Fourth, the hospital provides ample laboratory facilities for chemical and bacteriological examinations and X-ray and is at the service of the county. The laboratory is in charge of a graduate medical technician. Fifth, the educational work done by the county society over a period of years has laid excellent ground work for the medical service.

There had been conducted in the county over a period of years a constant educational campaign for better health-emphasizing first, a cooperative spirit of the physicians, and, second, an appreciative support of the public. This public includes the newspapers, many organizations, schools, etc., and the educational work has had for its aim the reaching of every family in the county. It has been realized from the beginning that without the active support of the physicians and the receptive support of the public no public-health measures could succeed. These objects are not obtained in a few weeks. But if they are to be permanent, a campaign must be continued over a period of years. There are in the county at the present time 19 active practicing physi

cians-about 1 to every 1,050 inhabitants. Of these, 14 are engaged in general practice, including obstetricts.

It is important to bear in mind that the physicians taking part in this demonstration are not specialists but general practitioners. From the first the necessity of adequate records being kept on every case was recognized and stressed repeatedly to the physicians. Gradually these records have grown toward completeness as experience and education have shown the need until at the present time these records are quite complete. At the first examination of the patient, the doctor is expected to obtain a satisfactory history, blood-pressure reading, urinalysis, and obtain blood for syphilitic examination. The importance of this requirement has been stressed upon the physician and the patient until at this time at the close of 3 years it is a recognized procedure. It is not now necessary for the doctor to argue with the patient the necessity of these examinations. They are taken as a matter of course. Blood examinations would indicate that syphilis among women is of very minor importance in Washington County-the figures being less than 1 percent. Iowa has just enacted a law, effective July 4, 1939, requiring that the physician take a blood specimen from the pregnant woman at first consultation, or within 14 days, for examination as to presence of syphilis. If a positive report is received, the husband and children must also be examined. Our county has been at least 3 years ahead of this beginning July 1, 1936. In the last 12 years, Kline tests have been routine on all patients in the Washington County Hospital. Positives are referred to the State laboratory for rechecking.

On July 1, 1936, this county was selected by the State department of health as a maternal demonstration area for the State of Iowa. Two public health nurses, specially trained in maternity work, were added to the staff of the county health unit to provide prenatal, postnatal supervision of mothers, and a home delivery nursing service. At the same time, an arrangement was made with the county medical society whereby all of the medical practitioners in the county doing obstetrical work agreed to give medical care and supervision to all expectant mothers. This service was to be given in the offices of the participating physicians, regardless of the individuals ability to pay.

Prior to the establishment of the health unit, hospital care was available to indigents in the county hospital and delivery service for the indigents had been taken care of by the county through the contract between the board of supervisors and the county medical society for the care of the indigents. Therefore, with the nursing service and provisions for prenatal care made available as a result of the maternity demonstration, it was possible to provide adequate medical, hospital, and nursing service to every expectant mother in the county regardless of ability to pay. For 6 years prior to the establishment of the service, the hospital births for this county were more than twice the United States figures for country counties.

Continuity of maternal care today is generally recognized as, first, adequate prenatal care beginning early before the third month in pregnancy, and medical and nursing supervision up to the time of delivery; second, good obstetrical and nursing care at the time of delivery-where nursing service is needed and the family is unable to provide for it, delivery nursing service should be provided in the home; and, third, there should be proper medical and nursing supervision of the mother and child following delivery. It is my personal belief that clinics have no place in rural areas and better continuity of service is maintained if all phases are in the hands of the physician.

In addition to arranging for medical, nursing, and hospital facilities, there were other objectives of the maternity program. Some of them were—

1. To educate expectant mothers as to the importance of seeking early prenatal

care.

2. To educate the physicians to provide good prenatal care with particular emphasis on routine, blood tests and the keeping of adequate records. The problem of getting general practitioners, many of them of the old school, to keep adequate records was a difficult one, but there has been a marked improvement in the manner in which records are kept, and it just can't be done unless it is a society matter. Getting physicians to take routine Wassermanns was difficult early in the program. This was largely due to the fact that in this county not over 1 percent of these tests are positive. However, during the last year about 90 percent of the records turned in have Wassermann slips attached.

3. To get the physicians to report every expectant mother to the nursing service for nursing supervision.

4. To provide for aseptic deliveries in the home by furnishing sterile obstetrical packs to the physicians for home deliveries.

5. To provide nursing delivery service in the home when it is desired by the physicians and the family income does not exceed $1,250 a year.

6. To provide nursing supervision of mother and infant immediately following the delivery. The nurses are, at all times, under the direction of the family physician. Particular emphasis is placed on supervision of premature or debilitated infants.

7. To stress the importance of post partum examination of the mother and regular medical supervision of infant, the latter to include mother and regular medical supervision of infant, the latter to include vacination and diphtheria immunization.

8. Last, but not least, the most important objective was to reduce the maternal mortality rate.

Throughout the United States in 1936, 14 percent of the births in rural counties were in hospitals; for Iowa, the same year, the figures were 18.2 percent, while in Washington County it was 40 percent, which indicates that education in Washington County was producing results far above the National or State average. Records show that in the year 1934, 29.4 percent were born in the hospital, which figure is at least twice that as attained through the whole country. In the year 1935, 38 percent were in the hospital; 1936, 42 percent were in the hospital; 1937, 40.7 percent were in the hospital; 1938, 51.9 percent were in the hospital. In the year 1937, in addition to those babies born in the hospital, the maternity nurses attended 68 at the homes and other nurses attended 53 more. This means that 70 percent of the deliveries were attended by graduate nurses. In 1938, in addition to those in the hospital, the nurses were present at the birth of 68 and other nurses at the birth of 51-which means that 83 percent of the deliveries were attended by graduate nurses. For the first half of 1939, we learn that 91 babies were born in the hospital, maternity nurses cared for 55 at the time of birth in the home, and other nurses cared for 23. That is 84 percent of the babies born during the first half of 1939 were cared for by graduate nurses. One of the emphasized objects of the health unit is adequate prenatal care. In 1930, 20.7 percent of the pregnant women had prenatal care by the end of the eighth month. In 1937, 43.4 percent had prenatal care at the end of the third month, 71 percent by the end of the sixth month, and 81.8 percent by the end of the eighth month. In 1988, at the end of the third month, 45.2 percent; the sixth month, 82.4 percent; and the eighth month, 91.4 percent. All births were attended by a physician.

During the 10 year period, 1929-38, there were 3,328 live births in the county. There were 84 stillbirths during the same period. The average infant mortality rate for the 5 years, 1930-34, was 38.7 per 1,000 live births. For the 4 years, 1935-38, the average infant mortality was 33.7 per 1,000 live births. Maternal mortality during the 5 years, 1930-34, was 4.2 per 1,000; during the succeeding 4 years, 1935-38, the rate was 3.5 per 1,000. During the past 31⁄2 years there have been 1,295 babies born in Washington County-589 of these in the hospital. There has been but one caesarean section. In the past 22 years, there has been but 1 maternal death in 932 deliveries.

Sterile packets containing basins, soap, gloves, gowns, towels, sheets, leggings, pads, in fact everything needed at delivery except ether and instruments are provided and used in every home delivery in the county. There have been no infections reported since this service was started and there has been but one maternal death in the past 2 years.

Maternity nurses visit each patient-having secured the name either from the doctor or from neighbors and more frequently as time goes on from the patient herself-at least five times, twice before delivery and three afterward. Additional visits are made when indicated or at the request of the physicians. In 1937 there were admitted to antepartum service 327 patients; 518 visits were made; 294 were admitted to postpartum care and 704 visits were made: 316 packets were prepared. In 1938, 585 visits were made to 302 patients, postpartum: 248 packets were prepared. In each of the above years, the nurses assisted at 68 home deliveries. These packets are used in above 95 percent of home deliveries. The nurses also conduct in various communities classes in public health, maternity care both prenatal and postnatal, and at all times urge immunization and vaccination.

A program for maternal health must first determine the need. Knowledge of the number of births per year in a given county and some knowledge of the morbidity and mortality not only of the mothers but of the babies is essential.

There should also be a knowledge of the capabilities of the medical practitioners of the county, the record of their willingness to cooperate with each other and with the organized agency.

It should be apparent that such a program cannot well be carried out unless there be a hospital in the county; the controlling body of which, with the superintendent, is interested in public health. This, then, means a well-organized medical profession which is public spirited and which has developed a leader whom the others are willing to follow. That the medical society be able to coordinate the agencies above mentioned, particularly the hospital and the welfare agencies, is essential.

The organization and success of a maternal health program can, we believe, only develop successfully when planned as above outlined. If the county has an organized health unit, so much the better. The organization or set-up for such a health program should and must be under the control-advisory at least of the medical society. If it should not be, it will not succeed. The administration should be by the agent of the medical society and the director of the health unit who represents all organized health activities of the county.

The Social Security Act of 1935-title V, part I, section 501 (2) (3)-authorizes the organization of such units as aboye in distinctly rural communities where the need is demonstrated; financial affairs be taken care of by Federal appropriation. The procedure of such a unit recognizes the services of two or more nurses who should be continually at work giving education as they may to expectant mothers, to assist during the delivery in proper cases-that is, those who are unable to finance their own care, by the provision of a sufficient quantity of sterile supplies that will insure that the home-delivery care shall be as near aseptic as possible. This means that there be a sufficient number of properly prepared O. B. packages on hand at all times to supply the needs of the doctors of the county for all home deliveries.

If the medical profession be not thoroughly organized and wholly in sympathy with this program of maternal health project, it is worse than useless to attempt to organize it because failure will be certain and sure and the time will not be long.

For fear that someone might think such a program bordered on State medicine, please bear in mind that this cannot succeed without the private physician, and his judgment is always final.

Having such a ground work of interest and education, the organized public health activities will succeed and maternity demonstration units such as we have in Iowa will save lives, both of mothers and children, and will, we are firmly convinced, cause a fuller and more complete medical service to be furnished by the physician and will cause the public to appreciate the same high type of service. The plan is good and under the conditions above specified, I am sure will merit the attention of the doctors, the public, and the interest and support of the Federal Government, Finally, as a private physician, I see in it (1) opportunity to improve the physicians' capabilities by the refresher courses, the insistance of full records; (2) the physician, having better training and increased interest and equipment, will be inclined to do better work or possibly more acceptable work for those whom this sort of unit is intended to reach; (3) making health conditions readily accessible will minimize illness, lessen deaths, and improve the business and social conditions of those reached.

WHY AND HOW POSSIBLE TO CARRY ON MATERNITY DEMONSTRATION WORK

It is our firm conviction after many years' experience in public health work that no plan approved by legislation will be successful without, first, the active interest and cooperation of the physicians of the community. This interest of the physicians must indicate a progressive spirit, a receptive attitude toward changes in methods of delivery of service, and appreciation of the privileges of medical practice and of the rights of the public to receive high-grade medical care and a wish to continually improve the type of medical service which is given. Second, there must be the education of the public as to the importance of good medical care, to the appreciation of good medical care, and to recognition of the standards of medical care available by the local physicians. This attitude of the public must include the knowledge that certain diseases are preventable and also recognize that child bearing and child birth have pathological significances all too frequently and that the physicians are able to minimize these dangers. The public, as mentioned, should include the newspapers, various organizations such as service clubs, chamber of commerce, PTA, Farm Bureau,

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