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Trend of infant mortality in the United States birth registration area by States, 1915-1924-Continued

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Mr. HOCH. Part of this Federal fund is apportioned to the States without being matched. As I recall the argument before we passed this bill, that was necessary in order to encourage the initiation of this work. Now, if this work is already started in all but five States, what reason do you have for continuing that part of the law?

Miss ABBOTT. It has another purpose-that is, the part that is given to be matched is apportioned on the basis of population, and in some of the States the amount that would be available is really

to small to be intelligently used unless something is given in addition.

Mr. HOCH. You do not quite get the question. As I recall, there is $240,000 a year which is unmatched

Miss ABBOTT (interposing). Smaller than most Federal aid unmatched.

Mr. Hocи. And then, out of the additional appropriation of a million dollars a year you first appropriate $5,000 to each State, and then the balance of that $1,000,000 is apportioned as set out in the act, according to population?

Miss ABBOTT. Yes.

Mr. HOCH. Now, I am asking with reference to the $240,000, why should the State now get any money without matching it?

Miss ABBOTT. Well, in so far as the way in which the bill prescribes-and that, of course, was written here in this committeewhat they get out of it is that the poorest States at least get $10,000, $5,000 of which they match, and $5,000 they do not.

Mr. HоCH. They get one $5 000 without matching?

Miss ABBOTT. The unit cost, as you all know, in a State in which the population is small, is enormously higher than it is in a thickly populated eastern State. Every element of transportation is higher. The cost for the numbers that attend the conferences is higher, and the unit cost of any service of that sort is very much greater than it is any place else, and it is largely for those Štates that we would like to have that additional money still made available.

Mr. HOCH. Well, the second $5,000 that you speak of, that has to be matched?

Miss ABBOTT. The second $5,000. A State can get at least this $10,000 plus an additional amount allotted on the basis of population.

Mr. HOCH. They only get $5,000 without matching. I do not recall that it was argued in those days that there were any States in this country that were not able to pay $5,000.

Miss ABBOTT. No; I do not think it was, and they are all matching except the last one that has come in, and that, I think, will. I hope that this unmatched may be continued as the amounts available to the large less populous States is very small.

Mr. BURTNESS. I have one or two questions to ask with reference to the figures given in the tables that have been furnished us, rela.tive to the mortality rates, both infant and maternal. The picture given us as compared with other countries is not a particularly pleasant one. Is it claimed that our relatively higher rate, higher than many other countries which we do not regard as quite as civilized, perhaps or at least not quite as up to date in many matters as the United States-is it claimed that our relatively higher rate is due to the fact that we have not done as much public social work, hygiene work, as these other countries, or are there other elements which are very material factors that should be taken into consideration in comparing our rates with the rates of other countries?

Miss ABBOTT. In the first place, our infant mortality rate has gone down so that we occupy a very much better position in the world than we used to occupy, largely as the result of work of the general sort that the State directors are promoting.

The maternal mortality rate is the one that is so seriously high as compared with other countries. There is no question but what the best of obstetrical care is furnished in this country-I should say better than obstetrical care in any other country-but it is not as generally widely diffused as there is in other countries, and there has been more and earlier effort to raise standards that extended over the whole area of other countries than has been the case with us. Our best demonstrations in cities where the work has been under way for a long time compare very favorably with demonstrations of the same sort in other countries. We have other complications, of course.

Mr. BURTNESS. Have our methods of living here in the United States anything to do with the high maternal mortality rate?

Miss ABBOTT. We have complications. We have diverse population, such as other countries do not have. We have a foreign population to be reached which is an added complication, because the methods have to be explained to groups that are not as easily reached as they would be if the population were homogenous. The very great extent of the country makes it much more difficult to do it than it otherwise would be, and we have not had the same period during which this has been considered as a national problem that other countries have had. We have been slower in coming to it than some other countries have.

Mr. BURTNESS. Have we not more trained nurses in proportion to our population than many of these foreign countries have?

Miss ABBOTT. They are very unevenly distributed. We have areas, for instance, in the South where the midwife takes care of very considerable areas, and an absolutely untrained midwife to a very considerable extent.

Mr. BURTNESS. In some of these foreign countries, where the death rates are very low, midwives take care of most of them, do they not?

Miss ABBOTT. There is no question about that, but they are educated, supervised midwives. Of course, the midwife is not used by the native American in the United States, and we have generally assumed that the midwife is a vanishing feature of our practice. I have figures here showing that with the supervision and educational measures that have been adopted since the maternity and infancy act went into effect, those numbers have been reduced and the number of women who are being attended in that way has been reduced. I will be glad to put these into the record if you will be interested in seeing those figures.

To some extent these rates are not entirely comparable, and we have indicated one or two on that table where stillbirths are not counted the same, or where deaths during the first three days are not counted the same way. As far as possible, though, that comparison is a fair one with those other countries.

There is a decrease in both the number of the midwives and in their activities. A reduction in numbers is reported by at least 22 States, notably Alabama (in Birmingham), Michigan, New Jersey, New York State, Pennsylvania, South Carolina, and Virginia. In New Jersey 30,000 cases were delivered by midwives in 1919, and

17,645 in 1924. In New York State 16 per cent of births were reported by midwives in 1916, and 8 per cent in 1924 a decrease of about 1 per cent a year. In Michigan 2,000 more births were reported in 1924 than in 1921, yet the percentage of midwife attend ance dropped from 6.9 per cent in 1921 to 4.4 per cent in 1924 lowering of 2.5 per cent. Virginia has reduced her total number of midwives from 9,500 to about 5,000, and South Carolina from 6,000 to about 3,000. At the same time real progress is being made in training and supervising the midwives who do practice.

Mr. ROBINSON. Miss Abbott, may I ask one question? Has this act in its practical outcome had the effect of originating and increasing both the helpfulness and mercy and service that it was originally intended for among the various States?

Miss ABBOTT. I think unquestionably so.

Mr. PHILLIPS. I would like to ask whether, in your opinion, Federal aid in general, in conjunction with State and local aid, has a tendency to stimulate the local authorities and local people to greater endeavor along this line or whether it has a tendency to make them feel that they can be relieved of the responsibility that properly and primarily belongs to them?

Miss ABBOTT. Of course, I am not altogether clear about what is meant by "paternalistic " legislation. I know that there are

Mr. PHILLIPS (interposing). The reason I used that word is because it has been referred to as "paternalistic" legislation, perhaps twenty times here this afternoon.

Miss ABBOTT. I understand there will probably be an emergency appropriation to reimburse farmers for their tubercular cattle that have been killed in the States, and that there will be continued Federal aid for the eradication of diseases in that connection, and I do not know why that is not paternalistic if other things are.

I feel very strongly that national discussion on a national scale and a comparison of methods between the States through a national organization stimulates rather than decreases a sense of State responsibility. What we are doing constantly is asking one State to measure up to another, and consequently to bring up the efforts that they are making to those of the other. We have indicated that in most of the States there has been an increased rather than a decreased sense of responsibility, not only on the part of the State but on the part of the local community as well, and an increased interest in the whole problem of the proper rearing of children.

Mr. PHILLIPS. You have not found any disposition on the part of the local authorities, then to side-step their responsibility and assume that the Federal Government is going to do it?

Miss ABBOTT. Most of the States make a practice, if they are introducing work in the counties, to aim at permanent work in the county. They undertake a demonstration over a period of time in the county, or they require the county to finance it in part, so that the State has assisted as a temporary loan rather than a permanent undertaking the development of county activities. It has in this way increased the county's sense of responsibility. Of the counties do not know, the people do not know as they should, the infant mortality rate. They know about other things,

course,

such as the baseball score, but the subject of infant mortality is not a subject of such intense local interest. We are trying to make it so, because it is a matter of very great importance in the community.

Now I could, if it seemed to be desirable, attempt to show what was the money value of the babies that have been saved by the maternity and infancy act, but I feel that such work has too high a value to put it on that basis, and that we do not want to make a money showing for the million dollars that has been expended each year. The value is vastly greater than the money would indicate. It is a small amount, as has been said, compared with the other great appropriations, but it is contributing a very great deal to the ends that we have in mind to accomplish.

Mr. PHILLIPS. Of course, we all understand that everybody is interested in the child and its welfare; the only question is, is this the way to bring about the best results?

Miss ABBOTT. I have not any questions about that. I have not any question but that America cares more for its children than does any other country. The only question is whether it appreciates what are the conditions among the children and what measures would greatly improve those conditions. I believe the United States is prepared to spend the money locally as well as nationally, that is needed for this work.

Mr. DENISON. That will conclude the hearings. The committee thanks all the witnesses who have given us information on this subject, and we regret that we did not have time to hear the others.

Mrs. Yost. On behalf of the National Woman's Christian Temperance Union I rise to ask permission to file a statement in favor of the extension of the act.

Mr. DENISON. You have that privilege, Mrs. Yost.

Mrs. GILBERT DAVIS. On behalf of the General Federation of Women's Clubs, may I file a letter showing support of the bill? Mr. DENISON. You may file that statement, Mrs. Davis.

If there are any others who desire to file statements, you may leave them here with the clerk.

Mrs. Rufus M. Gibbs, 1209 St. Paul Street, Baltimore, Md., representing the Federation of Democratic Women, filed the following statement in opposition to the bill:

FEDERATION OF DEMOCRATIC WOMEN OF BALTIMORE (INC.),
Baltimore, Md., January 15, 1926.

THE COMMITTEE OF INTERSTATE AND FOREIGN COMMERCE,

House of Representatives, Washington, D. C. GENTLEMEN: We stand with our party in Maryland in affirming those vital principles of local self-government whereby the State shall control matters pertaining to affairs within its borders which have no national significance, and we repudiate all measures that interfere with the functioning of our dual system of government. We, therefore, object to any further extension of the Shepherd-Towner Maternity Act, as we regard this act as a vicious encroachment on our right to direct our own affairs in a matter of public health.

Very truly yours,

MRS. MORTIMER W. WEST, President.

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