NEED FOR AN EXPANDED MATERNAL AND CHILD-HEALTH PROGRAM Statement by Dr. Martha M. Eliot, Associate Chief of the Children's Bureau of the United States Department of Labor

Evidence of the urgent need for an immediate and widespread expansion of our health and medical facilities to care for children has been dramatically demonstrated by the rejection in recent periods of nearly 50 percent of the men examined for the armed forces. The extent of need was well known before the war and has been repeatedly set forth, but it takes such a catastrophe as war to show us how poorly we have measured up to our responsibilities to the 40,000,000 children of the Nation in fitting them physically and mentally to take their places in the work of the Nation as they reach maturity. Great progress has been made under the provisions of the Social Security Act, title V, in establishing the administrative structure in all States and in many local areas, but coverage of the country is far from complete and the facilities and personnel to provide good care are still tragically inadequate in many areas, and wholly lacking in many others.

The result is that thousands of mothers and hundreds of thousands of children go without care that we know how to give, but are not able to provide because of inadequacy of facilities, of well-trained physicians, nurses, and other professional workers, and of administrative personnel.

If we are to wipe out this blot on our national life within the next decade we must take steps now, not next year or the year after. Nothing short of a large scale Nation-wide effort supported by adequate Federal and State funds will make it possible to assure proper care to all mothers in childbirth, to all newborn infants and to pre-school children, to children during the school years and throughout adolescence. We have the knowledge and skills to do the job.

What we lack is the resources to train personnel, to provide equipment and facilities, to place personnel where they are needed. The Federal Government will necessarily have to help materially with resources, but the program should be one of Federal aid to the States. It should be the responsibility also to the Federal Government to set national standards to assure the highest possible type of care and service to all the Nation's children regardless of where they live, of their economic status, their race, or any other factors that today interfere with equality in their health and medical care.

EVIDENCE OF NEED FOR AN EXPANDED MATERNAL AND CHILD-HEALTH PROGRAM

The evidence of need for a Nation-wide program of health and medical care of children and maternity care can be restated as follows:

I. Births.

The number of births has been increasing since 1936 and reached about 3,000,000 in 1942 and again in 1943. In 1942, 68 percent of the registered births were in hospitals, and 25 percent more were attended by physicians in the mothers' homes, but there were still 208,000 births unattended by a physician.

II. Mortality of mothers and children.

(a) Maternal mortality has been reduced from the disgraceful figure of 59.3 in 1934 to 25.9 per 10,000 live births in 1942. This rate can be lowered still more and must be, for even in 1942 more than 7,000 mothers died in childbirth. The maternal mortality rate for Negro mothers is still two and one-half times that for white mothers and the rate of decrease in deaths is much less. Even in 1942, 50 percent of maternal deaths might have been prevented if complete and proper care had been given throughout pregnancy and at delivery. That a reduction in maternal mortality is possible is shown by the fact that in 1942 16 States had rates under 20. In 5 States the rate was more than double this, the highest rate being 53.2-South Carolina. This unevenness is closely related to the variation in the provision of facilities and personnel for care.

(b) Infant mortality (40.4) is still much too high. We believe that it can be reduced at least 25 percent and possibly as much as 50 percent. Two States have already achieved rates less than 30 per 1,000 live births. In contrast to these 2 low States, some have very high rates-Arizona 80.1 and New Mexico 97.9. In all but 1 State mortality rates for the Negro are higher than for white. Though large cities used to be less safe for infants than the country, today the most advantageous place to be born is the large city. The small town of 2,500 to 10,000 is the least favorable environment, as far as the first year of life goes.

Great progress has been made in reducing deaths of infants over 1 month of age, and some progress in the reduction of deaths under 1 month. But still 1 infant out of every 48 born alive dies before the end of the first week of life, more than half of these on the first day. Prematurity is the most common cause of death at this age. In 1942 some 34,500 babies died because of prematurity. Many infant deaths could be prevented. This will require better maternity care as well as vast improvements in hospital and medical care for newborn and older infants.

(c) Childhood mortality.—In childhood, exclusive of the first year, the probability of dying is less than at any subsequent age period, but there still occurs some 42,000 deaths annually in this age group (1-14).

In the school age period 5-14 years, accidents are responsible for more deaths than any other cause, but 4 diseases still take a large toll; namely, influenza and pneumonia, rheumatic fever, tuberculosis, and appendicitis. Nearly 5,000 children 5-14 years die each year from these diseases.

In the adolescent years (15-19) tuberculosis alone kills about 3,000 annually. III. Illness of children and youth.

(a) Infants. Acute diseases of the respiratory system are the major disabling illnesses and outrank in frequency congenital malformations and conditions commonly desginated as diseases of early infancy which contribute so largely to infant mortality. In some sections of the country gastro-enteritis accounts still for large numbers of preventable infant deaths.

(b) Children and youth.-During childhood the number of illnesses per person exceeds that for adults.

By the time the age of 16 years is reached, people in representative urban and rural areas of the United States have had the following diseases:

The great scourge of the school-age period is rheumatic fever. Nearly half a million children in the country have been, or are being affected by this disease. Many die and many more are made ill for many months, or develop a permanent disability of the heart.

Poliomyelitis recurs in epidemics in different areas leaving behind from 600 to 2,000 children each year who are in need of treatment for the crippling effects of this disease.

IV. Handicaps of children and adolescents.

(a)_Physical_handicaps.-From all available sources of information estimates have been made of the number of children under 21 years in the United States with various physical handicaps. They are as follows:

In addition it is estimated that three-fourths of all school children have dental defects.

Examination of youth 14-17 years participating in National Youth Administration programs in 1941 revealed a startling number of conditions needing

correction.

Number of specific recommendations for medical services and corrections per 100 examined youths, aged 14-17

As supporting evidence of the incidence of defects, the findings at examinations of young men drafted under the Selective Service Act are given:

Incidence of defects of 18- and 19-year-old registrants examined at local boards and induction stations December 1942 and January and February 1943

(b) Nutritional handicaps.-Dietary deficiency diseases (scurvy, rickets, pellagra) in severe form are not so common among children as a decade or two ago, but they still exist and mild forms of these diseases are prevalent among children of low-income families. Secondary anemia in pregnant women and children is usually related to a diet deficient in one or more respects. Data from recent studies compiled by the National Research Council, indicate that in some parts of the country as high as 72 percent of pregnant women and as high as 85 percent of children of early school age are suffering from secondary anemia.

Many more children suffer from general malnutrition than from any one specific deficiency disease. These children grow at less than the normal rate; their musculature is poor; they have less than average resistance to infections. That the effects of childhood malnutrition may be lasting is indicated by a study of the data from school health examinations of a selected group of young men rejected for selective service, for whom records had been kept over a long period of years. The study showed that there was a definite association between the childhood state of nutrition and the development of defects that 15 years later disqualified the adult for selective service.

(c) Mental and emotional handicaps.-The number in this group have been estimated as follows:

With the disruption of family life due to the war-fathers in service, mothers at work, families moving about for war jobs-behavior difficulties as expressed in juvenile delinquency have increased.

V. Deficiencies in the Facilities and Personnel Needed to Assure Vigorous and Healthy Children.

(a) Hospital facilities.-1. Maternity: Though some States appear to have enough maternity beds, there is a large deficit in the country as a whole. Using the list of approved hospitals in the Journal of the American Medical Association, and assuming that one bassinet means one maternity bed available, it is found that the ratio of births to maternity beds is: 1

For 6 States__.

For 28 States..

For 6 States__.

For 9 States____

The inadequacy of maternity beds is shown by the following data:

In 1 State..

Births to residents of counties having no maternity beds

Percent 41

In 6 States.

35-39 In 6 States.

1.0 or less 1.1 to 1.8

2.0 to 2.9 3.0 or more

Percent 15-19

10-14

5- 9

Less than 5
None

In 2 States

In 2 States.
In 7 States.

In 6 States.

30-34 In 5 States.

25-29 In 8 States.

20-24 In 6 States---

To meet the need in 45 States where it is not now met would require about 50,000 new maternity beds.

2. Pediatrics: There is no way of estimating the number of beds available for children in the United States. In many hospitals children are placed in the general wards and receive no special pediatric care. In other hospitals there are special divisions for children staffed with personnel trained in the medical and nursing care of infants and children. There are also about 5,000 beds in children's hospitals. These special facilities, however, are localized in the large cities and are not available to a large part of the population. To reach a hospital where care can be given by a qualified pediatrician, many sick children must be transported many miles.

It is estimated that communities should have 50 pediatric beds per 100,000 population, or about 66,000 beds for the country as a whole. A survey State by State would be needed to determine how many beds in addition to those now in existence would be needed.

(b) Personnel.-1. Medical: There are in the United States about 1,400 certified obstetricians, or 1 to 2,000 registered births. There are about 1,700 certified pediatricians, or 1 to 19,000 children under 15 years. Obviously, these specialists cannot handle the actual service to all these patients. Even from the standpoint of consultation, the number is not sufficient because of the distribution. Some States have as few as 1 to 2 specialists in the entire State. Only 3 percent of the pediatricians are in communities of less than 10,000 population, yet 60 percent of the children live in communities as small or smaller. Many more specialists in pediatrics and obstetrics need to be trained and the general practitioners who see the bulk of mothers and children should have opportunity for further training in obstetrics and pediatrics.

2. Nursing: On January 1, 1944, there were 18,230 public-health nurses in the continental United States working as staff nurses, or 1 to 7,000 population. The best ratio in any State was 1 to 3,400. The worst recorded is 1 to 25,500. To give adequate service to people, especially to mothers and children, 1 public-health nurse to every 2,000 population is needed, or an increase of 48,000 nurses.

On February 1, 1944, only 16 States included a special consultant nurse in maternal and child bealth on the State agency staff. Every State and Territorial health department should employ at least 1 nurse on the official agency staff particularly prepared in maternal and child health who would be responsible for developing adequate nursing services for mothers and children in hospitals and in their own homes. In States having a population of a million persons or more,

This ratio is arrived at by dividing number of births by bassinet capacity. Bassinet capacity is number of bassinets times 21. This figure is derived from the assumption of 80-percent occupancy and a 14-day stay (80 percent of 365 equals 292; 292 divided by 14 equals 21).

additional consultant nurses should be added to the staff immediately to act as consultants to hospital personnel where maternity and pediatric patients are accepted. Every city or county having a population of 100,000 persons should include a maternal and child health consultant nurse on the staff of the official health agency.

It is estimated that a ratio of 1 general supervisor to 9 staff nurses should be adopted to insure the maintenance of satisfactory standards of nursing care in public-health agencies. Five thousand two hundred additional supervisors would be needed for 65,500 staff nurses, the number of staff nurses needed to maintain a ratio of 1 nurse to 2,000 population. These general supervisors all need some special training in maternity care and care of infants and children. There is great need for more highly trained and specialized pediatric and obstetric supervisors. In 1944, in a study of 919 schools of nursing, it was found that there are 200 unfilled obstetric head-nurse positions.

3. Midwives: In 1940 there were about 25,000 midwives in the United States, most of them totally untrained in modern obstetrics. The supply of trained nursemidwives is small. At present there are only about 175 in the United States and the capacity of the schools for training nurse-midwives is about 40 per year. This training should be increased to supply personnel to work with, or replace as fast as possible, the untrained midwives in those areas that today are so poorly supplied with medical personnel that it is not possible to have a medical attendant at all normal deliveries.

(c) Services.-1. Prenatal and child-hea'th conference: In 1942 approximately three-fourths of the rural counties were still without maternity cinic centers and over two-thirds had no centers where child-health conferences were conducted at least monthly under the administration of State health agencies.

The large cities are generally fairly well provided with health and medical services for young children, but of the small cities (10,000 to 25,000 population) onefourth have no child-health conferences, and nearly one-half have no prenatal clinics.

Services of this kind should be extended to every county in the United States and in many counties there should be numerous centers, so that no mother need go a long distance. In order to make available a well-baby clinic to those mothers who would want to make use of such a service, estimated to be approximately three-fourths of the infants and preschool children for whom such service would be desired, about 33,500 weekly sessions would need to be held.

2. School-health services: Although every State in the United States has some legislation to protect the health of school children, there are striking lacks of medical and nursing school-health services in many parts of the country, both in quantity and quality of personnel and services.

The lack of school-health services is especially marked in rural areas and small towns. According to a survey of school-health services in cities by the Children's Bureau in 1940, 16 percent of the small cities of 10,000 to 25,000 population had no school-health nursing service and 51 percent no school physicians.

In many places a school-health examination is nothing more than a brief “inspection" by the classroom teacher. Not half of the children and young people of school age are receiving medical examinations. Not 1 student in 10 in high school receives such an examination, and where examinations are done and defects found there is seldom any provision for remedial service.

The fact there is some sort of school-health supervision or service creates a dangerous complacency. The truth is that school-health service is woefully inadequate almost everywhere. Our concept of school-health service falls far short of that of other countries. It is necessary not only to establish good routine health supervision and protective services, but also adequate provision should be made for prompt and thorough diagnosis of abnormal conditions and provision for treatment when indicated. Well-trained supervisory staff should be provided and the qualifications of school health personnel should be raised.

A nourishing school lunch pays generous dividends in cutting down absenteeism and the proportion of children who have to repeat grades. Where malnutrition already exists, it can often be cured if dealt with promptly. The cost of cure, although greater than that of prevention, is still a good investment in terms of increased productivity and resistance to disease.

The conditions under which some children attend school impose obstacles to their optimal health. Schools may be so inaccessible that children leave home before 6 in the morning and return after 6 at night. In some sparsely settled counties, children from outlying ranches board themselves in the nearest village during the school week, often subsisting on food brought from home.