That the problem is regional and depends to a great extent on local factors is evident by the variation in rates in different sections of the country. The following areas have rates below the national rate: Pacific, New England, Middle Atlantic, East North Central and West North Central. The South Atlantic area has the highest rate with the East South Central zone second highest. These areas comprise sections with large colored population. In 1943 the rate for the white population was 21 per 10,000 live births whereas for the colored it was 51, or over twice as high.

The Southern States are the most underprivileged in medical facilities, having 1,300-1,500 population per physician, 3,000-5,300 population per dentist, 500-1,100 population per nurse, 300-700 population per hospital bed. The more fortunate States have one-half to one-third such ratios.

This brings us to a point so often stressed by the medical profession that a large part of our medical problems are economic in origin. We are becoming more conscious of the value of proper nutrition during pregnancy. Many studies have been made and results indicate that a properly balanced diet tends to lessen the chances of complications of pregnancy and labor, and assures in many instances, more full-term and healthier babies.

It was my personal observation during the war that those patients participating in the emergency maternity and infant care program showed more complications than others. An analysis of approximately 500 emergency maternity and infant care cases showed twice as many complications as those not in the program. Several factors have been considered for this increase; nervous tension and anxiety and the fact that many of these girls were traveling about the country, but these conditions also existed in patients who were not traveling. The most striking in so many of these cases was the fact that the girls were living alone or with their parents, and the amount of focd obtainable was not sufficient for their needs. Supplemental foods by ration boards were not allowed pregnant women, and it was not possble with a single ration book to maintain a diet considered essential during the period of gestation. The value of meat and other proteins is known to be important in the diet of pregnant women, and an insufficient amount is held to be one of the factors in the causation of toxemias of pregnancy.

In 1934 less than 35 percent of all births took place in hospitals, and in 1943, 72 percent.

Since the hospital is the safer place to be delivered, the mortality rate decreases as the number of hospital confinements increase.

Connecticut, with an excellent mortality record admits 97.9 percent of maternity cases to hospitals for delivery, whereas Mississippi admits 26.6 percent.

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 countrya 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.

Dr. HOWARD. There is nothing I could say that would be more impressive on the decline of maternal mortality in this coutry than as shown on the graph on the first page of my statement. There is no country in the world that has had such a rapid decline in maternal deaths as the United States.

The comparison is often drawn that the United States has a high maternal mortality rate as compared with other countries. There are so many factors that enter into this, and when we consider the northern half of our country, the maternal mortality rate there compares very favorably with other countries.

As a matter of fact, perhaps to emphasize that more clearly, recently published in the past 2 weeks, the maternal mortality rate for Connecticut, for 1945, was 1.0, which is the lowest maternal mortality rate ever published anywhere in the world.

Senator DONNELL. 1.0 per what?

Dr. HOWARD. Per thousand live births, or 10 per 10,000.

The latest records of the United States so far as I know have not been published, but I am very certain that many of the Northern States will have a reduction comparable to that of Connecticut.

The big problem, therefore, is in certain sections of this country, and we realize the high maternal mortality rate that exists in the South. This rate among the colored folks is over twice as high as among the white people.

The problem, therefore, seems rather definite. We have the problem among the colored folks in the South. The northern section is doing exceedingly well.

Senator PEPPER. Doctor, to save time, you do not mean to say that the problem is exclusively among the colored people in the South?

Dr. HOWARD. The decline in the maternal mortality rate in this country is going on in both the North and the South, but the reaching of this minimum rate that we are trying to establish, of course, is much closer in the North than in the South. It is still rather high in the South.

That is all I have to say at the moment.

Senator PEPPER. Senator Donnell?

Senator DONNELL. Have you examined S. 1318, Doctor?
Dr. HOWARD. Yes, I have.

Senator DONNELL. Would you care to give us your opinion as to that bill?

Dr. HOWARD. My reaction is very much like that of Dr. Wall. The feeling that the Government should sponsor, and should appropriate funds for the care of these women in pregnancy, does not seem to us to be the American way of doing things. It does not seem necessary except in those States where conditions are such that the State cannot carry on a suitable maternal and infant care progrm.

In those States where it is needed, then some means must be taken to guarantee that the mothers in those States will have good maternity

care.

Senator DONNELL. Doctor, I understood your testimony as to the decline in maternal mortality rate applies with varying degrees throughout both the North and South in this country.

Dr. HOWARD. That is right.

Senator DONNELL. That there is a general decline.

Dr. HOWARD. Yes, sir.

Senator DONNELL. Though that decline has not been as marked in the southern part of the country, generally speaking, as it has in the north. Is that right?

Dr. HOWARD. Yes, sir.

Senator DONNELL. I take it that the applicability of that testimony was as to whether or not there exists as great a need as might be argued in the first instance for legislation of this kind. Is that your point?

Dr. HOWARD. Yes, sir.

Senator DONNELL. You are inclined to think, as I understand it, that some of the statements made as to the appalling conditions in this country are fallacious because of the fact that they reflect the extremes, and a very high degree of mortality in some sections of the country, and therefore do not give a proper picture of the conditions in our country, generally speaking. Is that your point? Dr. HOWARD. That is correct.

Senator DONNELL. I notice on the list of witnesses here today that you are marked as representing the American Medical Association. Is that correct?

Dr. HOWARD. I am, sir.

Senator DONNELL. Would you tell us please the authority under which you act in speaking for the American Medical Association? Dr. HOWARD. Well, I was appointed by the American Medical Association to appear here.

Senator DONNELL. Who appointed you, please?

Dr. HOWARD. The board of trustees.

Senator DONNELL. The reason for my inquiry primarily was the point that Senator Aiken made, indicating that there has been no official action taken, as I understand it, by the house of delegates with respect to S. 1318.

Dr. HOWARD. I was not a member of the house of delegates at the December meeting.

Senator DONNELL. Last year?

Dr. HOWARD. Yes, sir. It seems to me that some action had been taken, but I cannot be sure of that because I was not a member of the house. But, I thought there was some action taken at that time.

Senator DONNELL. The board of trustees acts in the interim between meetings of the house of delegates, does it, in expressing the opinion of the American Medical Association?

Dr. HOWARD. Yes, sir.

Senator DONNELL. And you have been directed by the board of trustees, this interim body, to appear here and express the view of the American Medical Association?

Dr. HOWARD. That is right.

Senator DONNELL. Do you deem yourself to be expressing the views of the trustees of the board of that organization when you do not advocate S. 1318?

Dr. HOWARD. I am advocating-I am following the instructions from the board of trustees to appear against this bill.

Senator DONNELL. And you, accordingly, are appearing against S. 1318.

Dr. HOWARD. I am; yes, sir.

Senator DONNELL. And opposing it, and expressing your view that it would be an unwise piece of legislation.

Dr. HOWARD. That is true.

Senator PEPPER. Dr. Howard, has the American Medical Association adopted any affirmative proposal and recommendation for a plan to provide all needed medical care and care for crippled children and welfare care for the mothers and children of the country?

Dr. HOWARD. No. The American Medical Association has not any definite plan except the belief that the voluntary type of insurance should be sponsored in the various States and improved to the point where it will do a pretty comprehensive job.

Senator PEPPER. When you say "a pretty comprehensive job" that means that there would still be segments that would not be covered. Dr. HOWARD. I do not believe that anything can be done to cover every person in the United States.

Senator PEPPER. This bill, if it were passed, its declared purpose is to make medical, hospital nursing, and other care available to the mothers and children of the country. We can at least provide money if we chose to do so, could we not?

Dr. HOWARD. Yes, sir; but what the outcome would be, I do not know.

Senator PEPPER. We could provide more personnel and offer more incentive and offer them an education.

Dr. HOWARD. Yes, sir.

Senator PEPPER. We could provide more hospitals if we appropriate the money.

Dr. HOWARD. I think the Hill-Burton bill has done that already. Senator PE R. I know, but we could provide the facilities if we appropriated the money for it.

Dr. HOWARD. Yes, sir.

Senator PEPPER. And we could employ diagnostic facilities and clinics and all of those things if we passed this bill and provide enough money, could we not?

Dr. HOWARD. Yes; but that is just in the bill. We have no way of determining whether the bill will work out or not except possibly to think of some of the other countries where similar programs are in progress.

Senator PEPPER. You do not mean that you have any doubt, do you, that if we pass this bill that it would actually save lives of mothers and children in this country and provide more healthy and wholesome child population in this country? Do you deny that?

Dr. HOWARD. In maternal mortality the decline might be a little more rapid, but not much more rapid than at the present time.

Senator PEPPER. When you speak of "a little more rapid" do you realize you are speaking of the mothers of children, and the wives, and the future children that will give a great deal to this country! If it were your child, it would be a little more than statistics, would it not?

Dr. HOWARD. It would. I am not attempting to simply use statistics, and I certainly have as much sentimental feeling toward the children and the mothers in this country as anyone else. That is why I am a physician.

Senator PEPPER. You are not advocating a program that will certainly provide more hospitals for them, and provide more nurses for