The function of maternity insurance may be analyzed under the following four headings, corresponding to the four causes of economic loss, connected with childbirth: (a) extraordinary expenditures for medical aid and supplies connected with childbirth; (b) the period of enforced idleness and the consequent loss of wages; (c) the necessary period of rest before childbirth, to preserve the health of the mother; and (d) the equally necessary period of rest after childbirth, for the purpose of both strengthening the mother and improving the chances of the child. It appears, then, that maternity benefits have several distinct features, because the prophylactic factor is of greater importance and because the interests of the future generation are also directly concerned. Again there are three distinct aspects of the problem: (1) that of the married woman worker who combines the duty of a wage-earner with those of a housewife, or at least a wife, and is in most cases only partially dependent upon her earnings; (2) that of the unmarried wage-earning mother; (3) that of the wage-earner's wife who is "not gainfully employed" in the sense of not bringing any money revenue into the family treasury. The distinction between the first and second aspects is largely a moral one, that between the first two and the third primarily an economic one. The only fair way of handling this problem is by entirely omitting in the act any reference to distinctions between legitimate and illegitimate births. The maternity benefits of the British law have occasionally been referred to as the most liberal in Europe, but that is hardly correct. The basic maternity benefit is a flat amount of 30 shillings but this is payable both to the insured women and to the wives of insured men. However, in Hungary, Servia, Roumania, and Norway as well, maternity benefits to wives of insured persons are compulsory. In addition to the 30 shillings, insured women are entitled also to the regular sickness benefit during confinement. The 30-shilling provision is entirely free from any moral strings; all wives (or widows in case of posthumous children) of insured persons, and all insured women are entitled to it. Curiously enough, however, the additional sickness benefit 1 From article, Standards of Sickness Insurance, by I. M. Rubinow. Journal of Political Economy. 23 356-61. April, 1915. just referred to is payable only if the "insured woman" is married. Some discrimination against the unmarried mother was after all dragged in to satisfy Anglo-Saxon moral standards. Neither Germany nor Great Britain thus furnishes, at least in their laws (German practice being on the whole very much better than the minimum requirements of the law), the best that Europe can show in the development of this movement. Neither in Great Britain nor in Germany is proper medical, or rather obstetrical, aid required. Indeed, the British act specifically states that "medical benefit shall not include any right to medical treatment or attendance in respect of a confinement." As a matter of fact, that is probably the main purpose to which the money benefit is applied. But is not this purpose sufficiently important to be achieved directly? Under the present system two results are often observed in England: the physician's fees have increased, and instead of a guinea, all the 30 shillings is charged frequently; or the woman in her ignorance may be tempted to save on medical aid, or on foods necessary to her, for the purpose of utilizing the ready cash for other purposes. Neither of the two results is socially desirable. Proper attendance at childbirth is a matter of primary importance to preserve the life and health of both mother and child. So long as the very existence of a sickness insurance system presupposes some efficient and economic organization of medical aid, why, in this branch of the medical service, shall all the faults of private bargaining be left undisturbed? A maternity benefit should not accrue mainly to the benefit of the medical profession. Nothing can be so readily estimated as the approximate number of births, and nothing can, therefore, be so easily provided for in advance. In Austria, in Hungary, in Russia, in fact in almost all the compulsory systems enumerated above, such medical aid is required. It should not be forgotten that annually in the United States some ten thousand women lose their lives from childbirth, and that the number of those whose health is impaired because of unskilled aid is very much larger. To underscore the importance of these measures for purposes of health conservation, some figures of our mortality statistics may again be quoted. Some sixty thousand children in the United States die annually from diseases of early infancy, half from premature birth, and half from "congenital debility" which in many cases could be overcome by proper care. Some eighteen thousand per annum in addition die from inanition, debility, and marasmus, practically all preventable conditions. And while it would be idle to claim that in all or in the majority of the cases the lack of mother's care is the cause, yet recent investigations by the United States Children's Bureau leave no doubt as to the importance of its lack as a contributing cause. Of course the data prove that undiscriminating distribution of benefits alone will not solve the question of infant mortality, as the Webbs have so significantly pointed out. For this reason assistance in kind, by medical aid, by visiting nursing, etc., is of even greater importance. But it is statisically established that three months of breast feeding have a decided preventive effect upon the extent of child mortality. The practical conclusion, therefore, is: that maternity insurance should be made an essential part of sickness insurance, and that it should include: (a) sufficient medical aid, (b) at least a two weeks' period of rest before childbirth, (c) from four to six weeks' benefit after childbirth for the sake of the mother, (d) an equal period for the sake of the child, (e) optional extension of these benefits by sickness-insurance funds which possess the necessary means. MATERNAL BENEFITS 1 Avoiding the fine points of the different systems under discussions, it will suffice to point out one detail common to all of them. That is, the cash benefit. In some countries more emphasis is laid upon this than in others. In Australia the cash benefit is all there is to the system; in certain other places, notably England, and Saskatchewan in Canada, medical services may also be furnished. The point we next come to—and the most important of all —is this: have these systems produced the desired results? The whole proposition is one of health; we should have a right to demand results in the shape of a diminuation in maternal mortality and in infant mortality, especially during the first two weeks. 1 From article by Merrill E. Champion, M.D., C.P.H., Director, Division of Hygiene, Massachusetts Department of Public Health. The Public Health Nurse. 12 287-93. April, 1920. It must in all honesty be said that results have not borne out expectations so far. This is notably true in Australia. It would seem, nevertheless, that the cause is not far to seek. The inference is simply that people do not make the use of the cash benefit that was intended and which is calculated to produce results. Apparently maternity benefits, apart from cash grants, have not yet been fully tried out. Various suggestions have been offered for an act which would prove workable for the United States. The bill introduced into Congress in 1918, "to encourage instruction in the hygiene of maternity and infancy," was really in a way, a sort of maternity benefit scheme whose provisions would be carried out jointly by Federal and state authorities. An appropriation by the Federal Government would be contingent upon an equal appropriation on the part of the state legislature. This method of financing is in some ways a desirable one, though it has obvious disadvantages. As originally drawn up, however, this proposed legislation had one serious defect. It made possible the creation within the state, of a special maternity commission to handle the disbursements provided under the act. This was virtually asking for the establishment of a second State Health Department. Deplorable results might well be expected under such a system. There is altogether too great a centrifugal tendency as it is. Undesirable as this is among private agencies, it is intolerable in state agencies. From a legislative point of view, there is an inherent weakness in any proposal for maternity benefits. This results from the difficulty experienced in making any accurate estimate as to what a system of maternity benefits would cost. We know, for example, that the Australian plan costs about $3,000,000 a year. This system is, however, a strictly cash benefit scheme. One cannot make an accurate estimate from charity statistics, for this is a health, not a charitable proposition, and is intended to appeal to a wider class than those who are merely objects of charity. As a matter of fact, the key to the situation is the family physician. He it is who does most of the free obstetrics, aided often by the district nurse. The practising physician, on the other hand, rarely keeps accurate records, and so cannot, if he would, help us with statistics to the extent we might wish. It is the writer's belief that statistics as to the number likely to avail themselves of maternity benefits are bound to be |