The maternal death rates for the 26 States and the District of Columbia in the birth-registration area from 1921 through 1928 show a downward trend throughout the period. In 1928 the rate from all puerperal causes was 64 per 10,000 live births as compared with 67 in 1921. The rates from puerperal hemorrhage, puerperal septicemia, and puerperal albuminuria and convulsions were lower in 1928 than in 1921. It may be reasonably concluded that although the maternal mortality rates show no substantial decreases during the period of the maternity and infancy act, the lives of many mothers have been saved in rural areas as a result of the educational programs in regard to the need of prenatal care.

The maps which follow show the maternal mortality rates in the States in the United States birth-registration area in 1921 and in the rural areas of these States, also the rates in these same States in 1928.

TABLE 8.-Maternal mortality rates, by cause of death, in the United States birth-registration area as of 1921, exclusive of South Carolina; 1921-19281

1 Including California, Connecticut, Delaware, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, Wisconsin, and the District of Columbia. These are the States that were in the birth-registration area every year from 1921 to 1928. South Carolina was dropped from the area in 1925 and reinstated in 1928. Rates are for the period 1921-1928 because 1921 immediately preceded the enactment of the maternity and infancy act and the 1928 figures are the latest available.

Comparison of maternal mortality rates of the United States birth-registration area with those of foreign countries gives the United States a less favorable position than the comparison of infant mortality rates. The maternal mor

Maternal mortality rates in 1921 in the birth-registration States of 1921 (deaths from causes associated with pregnancy and childbirth per 10,000 live births)

tality rate for the United States in 1927 (65 per 10,000 live births) was higher than that of any of the 20 other countries for which rates are available; in 1928 the rate (69) exceeded all but one of the 9 other countries reporting figures at this time. The country with a rate most nearly approximat.ng that of the United States was Scotland, which had a rate of 64 in 1927 and 70 in 1928.

Maternal mortality rates in 1928 in the birth-registration States of 1921 (deaths from causes associated with pregnancy and childbirth per 10,000 live births)

Maternal mortality rates in 1921 in rural areas of the birth-registration States of 1921 (deaths from causes associated with pregnancy and childbirth per 10,000 live births)

Most of the other countries had rates considerably lower. The country with the lowest rate was Uruguay (22 in 1927 and 24 in 1928).

Figures for both 1921 and 1927 are available for 18 foreign countries. In 7 the rate for 1927 was higher than that for 1921; in 2 the 1927 rate was the same as the 1921 rate; and in the United States and 9 other countries the rate

was lower. The foreign countries showing 1927 rates lower than those of 1921 were Chile, Czechoslovakia, Finland, Irish Free State, Japan, New Zealand, Northern Ireland, Switzerland, and Uruguay.

In the expanding United States birth-registration area the 1928 maternal mortality rate was 69 as compared with 68 in 1921. The rates of a constant area (such as that of the States in the United States birth-registration area from 1921 to 1928) are, however, more comparable with those of foreign countries, which are generally constant in size, than the rate of the expanding United States birth-registration area. The rate for such an area composed of the States in the United States birth-registration area during the entire period from 1921 to 1928 shows a decrease from 67 in 1921 to 64 in 1928. The 1927 rate for this area was 62. The tendency toward higher rates in 1928 is also apparent in foreign countries, as 6 of the 9 foreign countries for which 1928 rates are available (England and Wales, Irish Free State, Netherlands, Northern Ireland, Scotland, and Uruguay) had higher rates in 1928 than in 1927. The rates for Japan and New Zealand were the same for both years, and that for Chile was lower.

The phase of the work dealing with the importance of prenatal care for both mother and child has been well begun. Good prenatal care is a factor

Maternity mortality rates in 1928 in rural areas of the birth-registration States (deaths from causes associated with pregnancy and childbirth per 10,000 live births) in preventing puerperal albuminuria and convulsions; and the downward trend in the rate of deaths from this cause of maternal mortality during the operation of the maternity and infancy act has been noted. The number of women seeking such care is still relatively small, and much more education of the public as to the importance of early and regular medical supervision of the expectant mother is needed. Encouraging features are the increased interest shown by women in seeking and by physicians in giving such care and the recognition of the services of the maternity and infancy nurse as the most effective means of reaching expectant mothers.

Great interest on the part of the public was aroused in the welfare and hygiene of maternity and infancy as a result of the passage of the maternity and infancy act. The regular work of the State agencies and the United States Children's Bureau in the administration of the act has provided additional stimulation of this interest, which has developed quite outside of the actual information disseminated concerning maternal and infant care. Newspapers and magazines have carried columns on the care of mothers and babies.

The

public has been informed about the essentials of proper care for mothers and babies by material from these unofficial sources, which have been based largely on official information. Editorials have been written, both pro and con, on the Sheppard-Towner Act. In 1921 it was still a moot question whether child hygiene and maternal hygiene were necessary divisions in a good State public-health program and whether they belonged in a diseaseprevention program. Now, however, the general public, as well as official State agencies, rceognize the necessity of including in public-health programs the prevention of morbidity and mortality of mothers and babies.

Obstetrical procedures and the feeding and care of babies are topics on medical-society programs much more frequently than before the passing of the maternity and infancy act, and sections on infant and child hygiene contribute to the growing interest of public-health programs and meetings. The welfare of the child and the mother is a topic of increasing a conference of public-health nurses and social workers also. The active support of the great organizations of lay groups that have sponsored the maternity and infancy act from its inception continues and is not confined solely to women's organizations. Some loss of public interest may be expected, however, as a result of the curtailment of the work through the lack of appropriations of Federal funds.

CONTINUATION OF MATERNITY AND INFANCY WORK

Will the States carry on this joint work unaided by the Federal Government so that there will be no loss to the mothers and babies? Can we expect the expansion of programs on the basis of the demonstrated successes of the last few years without Federal assistance?

Nation-wide interest in this problem of the health of mothers and babies has been almost as important in promoting the work as the money contribution, but funds are essential if gains that have been made are to be conserved and extended. When the Federal maternity and infancy act came to an end every effort was made by its supporters to secure State appropriations equaling at least the combined Federal and State funds that were expended in the fiscal year ended June 30, 1929. This effort for increased appropriations was made in order to continue the work that was being done and also because in the event of the enactment of a law continuing Federal cooperation the increased appropriation would make possible an expansion of activities along the lines that experience had indicated were desirable.

At the expiration of the maternity and infancy act 16 States and the Territory of Hawaii reported that their legislatures had appropriated an amount equaling or exceeding the combined Federal and State funds available for the previous year. These States are: Deleware. Maine, Maryland, Michigan, Missouri, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Pennsylvania, South Dakota, Tennessee, Vermont, and Wisconsin. In some of these the appropriation was made because the women of the State requested it in such overwhelmring numbers that refusal seemed impossible. In Florida the support for the work comes from a millage tax for the health department, and the States reported that it expected the returns to enable it to expend an amount equal to the States and Federal funds for maternity and infancy work of 1929.

In five States-California, Indiana, Minnesota, Montana, and Texas-the legislatures had made appropriations that represented large increases over those for the previous year but did not quite equal the amount of combined State and Federal funds which the States had under the maternity and infancy act. The legislatures of seven States-Georgia, Kansas, Ohio, Oklahoma, Rhode Island, 10 West Virginia, and Wyoming-had made appropriations that represented increases over State appropriations for 1929 but were considerably less than the combined State and Federal funds for 1929. In six States-Arkansas. Colorado, Iowa, Nebraska, Oregon, and South Carolina-the appropriations made were the same or less than the State appropriations for 1929, so that the work had to be greatly curtailed. In Arizona, where the legislature made an increased State appropriation, and in Utah, where the appropriation was the same as in the previous year, the State funds might be spent only if Federal funds were available. In Idaho no State funds might be spent after December 31, 1929, unless Federal funds should be available.

10 In Rhode Island the 1930 legislature appropriated an amount equaling the combined Federal and State funds that the State had under the maternity and infancy act.

Two States-Nevada and Washington-made no appropriations for carrying on the work. The legislatures of Alabama, Kentucky, Louisiana, Mississippi, and Virginia did not meet in 1929.11

The threat of withdrawal clearly acted as a two-edged sword, stimulating some States to greater expenditures and influencing others to reduce the work if the Federal Government withdrew. In a third of the cooperating States the money appropriated was sufficient to continue the present activities; in the others physicians and nurses had to be dismissed and cooperative arrangements with counties and local communities curtailed when the Federal Government failed to continue promoting the health of mothers and babies through some sharing of the expense involved. Even the States securing an appropriation equaling the combined State and Federal funds reported a drop in the interest in the program since July 1, 1929. In other words, the participation of the Federal Government contributed something else as important as money.

THE PART OF THE UNITED STATES CHILDREN'S BUREAU DURING THE SEVEN YEARS OF OPERATION OF THE MATERNITY AND INFANCY ACT

A maternity and infant-hygiene division of the Children's Bureau was organized in 1922 to administer the maternity and infancy act. The existing childhygiene division of the bureau continued its research in the general field of child health but had no responsibility for the administration of the act. To the maternity and infancy division, after approval of the State plans and budgets submitted to the Federal Board of Maternity and Infant-hygiene were intrusted the details of the Federal administration of the act. Its work included auditing annually the State accounts covering the Federal and matched funds allotted to the States under he act, checking financial reports and reports of work submitted by the States with heir plans and budgets, compiling annual reports of the joint work of the State and the Federal Governments in this field, establishing contacts with the States through advisory visits made by the administrative and field staffs of the division, and conducting surveys designed to promote the purposes of the act.

The visits to the States by the director, the other physicians, and the consulting nurse kept the bureau informed of the types, amount, and character of the work in the States. To the States these specialists brought an outside point of view of the work they were doing and accounts of what other States were finding helpful. Sometimes an obvious need for special personnel was noted, and this resulted in the lending of personnel from the Children's Bureau for demonstration or some other special work in the States. In addition to its administrative work the maternity and infant-hygiene division served as a clearing house for information on maternal and infant care for the publicwhich included mothers, authors, scientists, social workers, nurses, and other groups.

Through this division field studies relating to maternity and infancy were directed. The child-hygiene division also conducted studies and research re lating to the infant and the child, and both divisions assisted in the preparation of publications, films, and other educational material relating to maternal and child welfare issued by the bureau.

THE STAFF OF THE MATERNITY AND INFANT HYGIENE DIVISION

For the purpose of administration $50,000 was allotted annually to the Children's Bureau from the maternity and infancy fund for 1923 and 1924 and $50,354 from 1925 to 1929. The headquarters staff of the maternity and infant hygiene division and the number of other persons regularly employed were kept at a minimum. This policy left available sufficient funds for certain studies and demonstrations and for the lending of specially trained personnel to do

11 In Alabama the State board of health allotted from its appropriation the sum of $74,173 for child hygiene and public-health nursing" in 1929. In Kentucky and Virginia the 1930 legislatures made appropriations equaling the combined Federal and State funds the States had under the maternity and infancy act. In the interim the work in Kentucky has been carried on with funds raised by private subscription. In Mississippi the 1930 legislature appropriated a sum equal to the State appropriation for the previous biennium. In Louisiana the 1930 legislature made no appropriation for maternity and infancy work.