This idea is not entirely new. As early as 1913 the eminent pediatrician Dr. Emmett Holt, Sr., said in an address we are coming to see that the child belongs to the State in respect to health also and the right of a mother to neglect her child may come to be regarded as an cffense against society much as we now regard absence from school. What parents will not do voluntarily, the State will compel them to do or will step in and do for them.

More recently Dr. Borden Veeder, a former president of the American Academy of Pediatrics, said in an address.

I can see no way in which the promise, that if an American child is entitled to an education he is entitled to health, can be refuted.

The acceptance of the fundamental principle of the national interest in the health and welfare of all children places S. 1318 in the forefront of the progressive health legislation.

HENRY F. HELMHOLZ.

I am informed he is the Director of Pediatrics Section of the Mayo Clinic, Rochester, Minn.

Senator DONNELL. May the record show, Mr. Chairman, that Dr. Helmholz' name likewise appears on a report submitted by Senator Pepper this morning along with the names of Drs. Butler and Garrison, from the Medical Advisory Board of the Children's Bureau. I take it he is not an employee of the Children's Bureau. I do not mean to leave that implication.

Senator PEPPER. The next witness is Dr. Joseph H. Howard, obstetrician, representing the American Medical Association.

STATEMENT OF JOSEPH H. HOWARD, M. D., OBSTETRICIAN, ON BEHALF OF THE AMERICAN MEDICAL ASSOCIATION

Dr. HOWARD. My name is Dr. Joseph H. Howard, practicing obstetrician, Bridgeport, Conn. I am a fellow of the American Medical Association, fellow of the American College of Surgeons, and diplomat of the American Board of Obstetrics and Gynecology.

Rather than read this statement I would ask permission to have it submitted to the committee, and simply make a few remarks. (The statement is as follows:)

STATEMENT ON BEHALF OF THE AMERICAN MEDICAL ASSOCIATION, BY JOSEPH H. HOWARD, M. D., OBSTETRICIAN, BRIDGEPORT, CONN.

During the recent war, the wives and children of air cadets and those in the four lowest grades of the armed forces were given maternity and infant care under the emergency maternity and infant care program. The policy was directed from the Children's Bureau, and although many doctors considered this to be dictation from Washington, the physicians of America gave splendid service to the women and children of those who were sacrificing so much for our country. It was the belief of the medical profession that this was strictly an emergency measure that would terminate 6 months following cessation of hostilities. However, on January 28, 1945, the steering committee on health service advisory to the Children's Bureau adopted recommendations urging the extension of the program for maternal and child health to include all women and children in every State. These recommendations appear to be incorporated in several bills introduced into the House and the Senate.

The question that arises in the minds of the medical profession, and perhaps also in that of many laymen is this-have we fallen down so badly in the medical care of these women and children that it becomes necessary for the Federal Government to take over and finance a program involving almost one-third of our population? To clarify this point it is well to take an inventory of our work over the past several years in an effort to determine what are the weaknesses, if any. Since I am an obstetrician, my remarks will be confined to maternal care.

The goal we are trying to reach is the reduction in maternal deaths to an irreducible minimum. There will always be maternal deaths, but the number that now occur will be reduced considerably. As idealistic as we may be, we bever can expect to have well-trained obstetricians available in every area of this vast country, and especially in sparsely settled sections.

DEPARTMENT OF COMMERCE
BURERU OF CENSUS

Vol. 23, N85 May 8, 1945

Vibet Statistics - Special Reports

"Danth's From PUERPERAI CROSES BY RACE +By Sence U.S.. 1943"

So often we hear a comparison of maternal mortality rates in the United States with other nations which includes a statement that we stand fourteenth according to statistics. A Children's Bureau publication, No. 229, on Comparability of Maternal Mortality Rates in the United States and Certain Foreign Countries states that statistical procedures are inconsequential after a study of methods of assignments of causes of death in various countries, and yet on page

5 of this pamphlet, it shows a difference of 20 percent in England and Norway as compared with the United States. If the same standard in compiling statistics were used in America, the United States would not be lower than fifth place. It is the opinion of many that it is rather appalling to think that America, the most progressive, and the wealthiest nation on earth-a country that is considered the medical center of the world-should present such a record in maternal care. Many factors are to be considered before conclusions are finally drawn.

The northern half of our country has a maternal mortality rate that compares favorably with most other countries. The high rate in the South brings the average to a level that arouses criticism.

Most physicians who have observed maternity care in European countries will agree that obstetrics as practiced in those countries is far inferior to that in comparable groups in the United States.

The United States is a young country. Previous to 1930, the maternal mortality rate remained rather constant in most countries. In 1936 a sharp drop occurred, chiefly in the United States, Switzerland, South Africa, Mexico, Scotland, New Zealand, Eire, Australia, Canada, England, and Wales. This may have been due to a wider use of transfusions and the introduction of the sufa drugs, but strangely enough the reduction was not only evident in cases of infection and hemorrhage, but also in toxemias. This reduction has continued at a more rapid rate in this country than in others.

It was not until 1933 that all States were included in the birth registration area, and in 1943 the first opportunity was offered to compare births and deaths over a 10-year period. During this 10-year period, maternal mortality declined 60 percent from 61.5 deaths per 10,000 live births directly due to pregnancy in 1933 to 24.5 in 1943. No other country has made such progress. These figures are more striking when we realize that in this same period there was an increase in births of 30 percent.

The birth rates for the United States from 1933 to 1943 are as follows:1

The rate for all obstetrical deaths was reduced 60.4 percent-from infection, 62.6 percent; from toxemia, 57.8 percent; from hemorrhage and other causes, 59.9 percent.

In 1940 only 2 States in the United States had maternal mortality rates less than 2.5; in 1942, 29 States had achieved this position. In 1933, Florida had the highest rate-115 per 10,000 live births. Idaho had the lowest-43 per 10,000 live births. In 1943 New Mexico was high with 47 which was only slightly higher than the low record of Idaho 10 years before; Oregon and Minne sota shared the low record with rates below 15. During these 10 years every State has shown marked reduction; the smallest being 41 percent in North Dakota and the largest being 76 percent in Nevada.

The proportion of Negro births decreased slightly in this period, Mississippl having the highest, 54 percent, and Idaho and North Dakota, 0.1 percent. There has been a slight decrease in States with highest Negro births recently due to migration into industrial centers during the war, and with this came a decrease in maternal mortality among the Negroes since a larger number were delivered in hospitals. Maternal deaths per 1,000 live births1

maternal death rates1

The goal we are trying to reach irreducible minimum. There will: that now occur will be reduced c never can expect to have well-tra this vast country, and especially i

gional and depends to a great extent on local factors tion in rates in different sections of the country. The North Central and West North Central. The South tes below the national rate: Pacific, New England, highest rate with the East South Central zone second comprise sections with large colored population. In 1943

was 21 per 10,000 live births whereas for the

on per physician, 3,000-5,300 population per dentist, 500-1,100 es are the most underprivileged in medical facilities, having

300-700 population per hospital bed. The more fortunate to one-third such ratios.

medical problems are economic in origin. We are becoming to a point so often stressed by the medical profession that a complications of pregnancy and labor, and assures in many inand results indicate that a properly balanced diet tends to lessen the value of proper nutrition during pregnancy. Many studies personal observation during the war that those patients participatFull-term and healthier babies. ergency maternity and infant care program showed more complica

An analysis of approximately 500 emergency maternity and showed twice as many complications as those not in the

Several factors have been considered for this increase; nervous tension and the fact that many of these girls were traveling about the these conditions also existed in patients who were not traveling.

in so many of these cases was the fact that the girls were

one or with their parents, and the amount of focd obtainable was not

their needs. Supplemental foods by ration boards were not allowed women, and it was not possble with a single ration book to maintain onsidered essential during the period of gestation. The value of meat proteins is known to be important in the diet of pregnant women, and ficient amount is held to be one of the factors in the causation of toxemias 4 less than 35 percent of all births took place in hospitals, and in 1943, 72 Proportion of births in hospitals 1

10.8

9.8

6.7

One of the great problems so frequently mentioned is the lack of facilities in rural areas. In 1943, 73 percent of all births occurred in urban areas but only 58 percent of mothers lived in urban areas, i. e., 15 percent of women having babies in 1943 lived in rural areas but went to a city for delivery.

Age is a factor in maternal mortality. The highest number of deaths occur among the very young (15 years) and also in the older groups. The lowest rate was in the age group of 20 to 24 years. Since there has been an increasing number of first births and births to young mothers during 1933-43, the total reduction is more impressive.

In the Annals of the American Academy of Political and Social Science, Philadelphia, January 1945, Jacob Yerushalmey, Ph. D., principal statistician of the United States Public Health Service, Bethesda, Md., said in speaking of reduction of maternal and infant mortality, "The countries now enjoying low rates were only several decades ago on the same high plane of infant and maternal mortality. Whether the time interval could be shortened is more of a social economic than a medical problem. The reductions thus far attained are primarily from conditions and causes which are environmental in nature; consequently, they result from general improvements in sanitary conditions and the elevation of the standard of living."

We, in Connecticut, are proud of our record in health activities, and I believe Senator Pepper, less than a year ago, stated that if other States could do as well as Connecticut, many lives of mothers and infants could be saved. However, in 1941, the Children's Bureau distributed a map which delineated maternal and child health activities administered or supervised by State health departments, and this map designated those States held to be below average in all selected activities by a blackened area of the map. This map showed that Connecticut was one of the "dark spots." Connecticut had to report "no admissions" to this service as the State health department in our State does not administer nor supervise prenatal clinics which are conducted at the various hospitals. However, there were 6,711 admissions to prenatal clinics throughout the State for which Connecticut received no credit on this map to which I refer. This State has a conservative estimate of more than 20 percent admitted to prenatal clinics besides those treated in doctors' offices. Only South Carolina and the District of Columbia had a higher rate of admissions than Connecticut for antepartum care, and yet Connecticut was considered below average in all selected activities in spite of the fact that out infant mortality rate was among the lowest in the country. The medical profession is vitally interested in good maternity care for all women. We are proud of the reduction in maternal mortality in our country— a record not exceeded by any other country. We believe that this reduction will continue under the present system of medical care. We believe that aid should be extended to those States not financially able to carry on an efficient maternal and child health program.

We do not believe that services and facilities should be available to all who elect to participate regardless of economic status. We do not believe that authority for such a vast program should be vested in the Chief of the Children's Bureau who would have power to (1) veto any State program and cut off Federal aid; (2) force adoption of Children's Bureau standards of medical care and administration; (3) establish maximum remuneration for all professional participants.

We do not believe that the enactment of this bill will improve the quality of maternal care.