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Need for an Expanded Maternal and Child-Health Program: 1944

NEED FOR AN EXPANDED MATERNAL AND CHILD-HEALTH PROGRAM

 

 Statement Submitted to the Subcommitte on Wartime Health and Education

of the Senate Committee on Education and Labor

 

by Dr. Martha M. Eliot, Associate Chief of the Children’s Bureau of the U. S Department of Labor

 

August 1, 1944

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 million 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 access to proper care for all mothers in childbirth, for all newborn infants, and for preschool children, and for 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 of 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 maternity care and of health and medical care of children can be restated as follows:

I. Births.

The number of births has been increasing since 1936 and reached about 3 million 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

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 in South Carolina. This unevenness is closely related to the variation in the provision of facilities and personnel for care.

B. Infant mortality

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 Negroes are higher than for whites. 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 year, the probability of dying less than at any subsequent age period, but some 42,000 deaths still occur annually in this age group (1 – 14).

In the school-age period, 5 – 14 accidents are responsible formore deaths than any other cause; but four diseases still take a toll; namely, influenza and pneumonia, rheumatic fever, tuberculosis, and appendicitis. Nearly 5,000 children of 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 system are the major disabling illnesses and outrank in frequency congenital malformations and conditions commonly designated as diseases of early infancy which contribute so largely to infant mortality. In some sections of the country gastro-enteritis accounts for numbers of preventable infant deaths.

B. Children and youth

During childhood the number of illnesses per person exceeds that 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:

89% have had measles

77% have had whooping cough

59% have had mumps

52% have had chickenpox

6-12% have had scarlet fever

5-10% have had diphtheria

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 effects of this disease.

IV. Handicapps 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:

Orthopedic and plastic conditions…………………..500,000

Rheumatic fever or heart disease…………………….500,000

Congenital syphilis………………………………………..980,000

Tuberculosis ………………………………………………..400,000

Major allergic disorders………………………………4,000,000

Asthma…. 1,250,000

Convulsive disorders (epilepsy) …………………….150,000

Diabetes ……………………………………………………….35,000

Visual defects…………………………………………..10,000,000

Totally blind•••••••••• 15,000

Partially seeing •••.•• 50,000

Refractive errors ••••• 9,935,000

Hearing defects, impaired hearing, including deaf……2,000,000

Deaf 17,000

————————————-

TOTAL…………………………. 18,565,000

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

Examination of youth of 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 Youths Examined, Ages 14 — 17

_____________________________________________________________________________________________________________________

Nature of service or defect                                       Percentage

Dental care……………………………………74.5

Refraction……………………………………..15.2

Glasses…………………………………………..12.2

Surgery on eye and annexa………………  0.3

Tonsillectomy………………………………….15.1

Circumcision……………………………………3.8

Hemorrhoidectomy…………………………..0.3

Hernia repair…………………………………..0.8

Other major surgery………………………….0.9

Other minor surgery………………………….9.0

Hookworm……………………………………….2.6

Minor nonsurgical procedures……………6.0

Repeated medical therapy………………….2.4

Special diet (medical advice)………………9.3

Study by specialist……………………………..9.3

Additional diagnostic procedures………..11.5

 

        As supporting evidence of the incidence of defects, the findings 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.

Defect                                                               Number of cases found per 1,000 examined

Eyes

Ears

Asthma

Tuberculosis.

Cardiovascular

Kidneys & urinary system

Syphilis

Mental deficiency

Mental diseases

Neurologic

Musculoskeletal

Feet…………………………………………………

Endocrine disturbances………………………

B. Nutritional handicapps

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 by 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 handicapps

The number in group have been estimated as follows:

Mentally deficient ••••• •••••••••••• 6,500,000

Feeble-minded……… . . 850,000

Intellectually subnormal •• 5,6501000

Well-marked behavior difficulties •••• 2,500,000

TOTAL……… 9,00,1000

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.

  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 1/ of births to maternity beds is

For 6 States……………1.0 or less

For 28 States ………. 1.1 to 1.8

For 6 States…………. 2.0 to 2.9

For 9 States………….3.0 or more

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

Birth to residents of counties having no maternity beds

In 1 State 41

11 2 States 35 – 39′

u 2 11 30 – 34

II 7 fl 25 – 29

fl 6 II 20 – 24

II 6 II 15 – 19

II 6 II 10 – 14

II 5 II 5 – 9

II 8 II less than 5

If 6 II none

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

…………………………………..

1/ 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).

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 59000 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 1700 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 or 2 specialists in the entire State., Only 3 percent of the pediatricians are in cominunities 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, one 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 health on the State agency staff. Every State and Territorial health department should employ at least one 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, 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 or 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 one 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 (5,200) 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

nurse-midwives is small,. At present there are only about 175 in the.United

States and the cg,paci\y of the sohools 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.

  1. Prenatal and child-health conference.

In 1942 approximately three-fourths of the rural counties were

still without maternity-clinip centers and over two-thirds had no centers where

child-health conferences were conducted at least monthly under the administration

of State health agenciesm

The large citie(3 are generally fairly well provided with health ,

and medical services for young children, but of the small cities (10,000 ~ 25,000

popUlation) one-fourth 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 mo~hers who would want to make use of such a service, a number

estimated to be approximately three-fourths of the number of infants and preschool

children for whom such service would be desired, about 33,500 weekly

sessions would need to be held.

  1. 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.

lack of

areas towns.,

cities made by the Children’s Bureau

of 10,000 – 25,000population had no

cent no school physicians,.

is

a survey of

in 1940, 16

In many places a school-health

11inspection11 by the classroom teacher.. Not

young people of school age are receiving medical

in 10 in high school Teceives such an examination, and

made and defects found is seldom any provision

nothing more than a

children and

., Not one student·

when examinations are

remedial service.

The fact that there is some sort of school-health supervision or

creates a dangerous complacency.. The truth is that school-health

is woefully inadequate almost everywhere., Our concept of school-health

service of that of other countries. It is necessary not only

establish eood routine health supervision and protective services, but

adequate should be made prompt thorough diagnosis of abnormal

and provision when • Well-trained

staff should be provided, and the qualifications of school-health personnel

be ·

. A nourishing school lunch pays generous dividends cutting

absenteeism and the proportion of children uho have to repeat grades. Where

already it can often be cured dealt with promptly.

The cost of cure, although grea·l:,er than that of prevention, a good

investment in terms of increased productivity and resistance to disease ..

The conditions under uhich some children attend school impose

obstacles to their optimal health., Schools may be so inaccessible that

leave home before 6 in the morning and return after 6 at night.

some sparsely settled co’linties, children from outlying ranches.board themselves

in the nearest village during the school week, often subsisting on food

brought from home.

In the fall 1943 only about one-fourth of the children

school were being served school lunch.

1., Prenatal and delivery care.

Me~ical supervision during the prenatal period and care at

and in the postpartum period are essential to save the lives and health of

mothers and of infants. Many women to<;lay because of inadequate incnme,

from service, or ignorance do not receive this necessary cnre.,

  1. Pediatric care.

That many infants die without the benef1t of medical care is

known. In 1940 nearly 6,000 infant deaths were ascrj.bed to the category of

“ill-defined and unknown causes,rr which means that these 6,000 infants either

had no medical care at the time of death or that the medical attendant was so

inadequately trained that he was unable to make a diagnosis. In one State

36 percent of the infant deaths were recorded in this way, and in another

27 percent.

It was shown in the National.Health Survey that a smaller proportion

of the disabling illnesses of children than of adults received medical

care” In the small cities more than 75 percent of the disabling illnesses of

persons 25 years of age and over were attended by a physician, while only

58 percent of such illnesses of children under 15 years had medical~£are.

4

In 1942 nearly 14,000 deaths of children of 1 – 14 years were

caused by infec:tious diseases, pneumonia and influenza, and diarrhea and

enteritisn Many of these deaths could have been prevented if adequate medical

care had been available in the early stages of the diseases.

Medical care for those unable to pay, though available to some extent

in the large cities, is woefully lacking in small cities and rural areas. In

a study of 654 cities in 1940 it nas found that 46 percent had no outpatient

clinics and 13 percent no hospital services for sick children.

The poor distribution of pediatricians in small cities and rural

areas and the inadequacies of hospital beds where care is given by pediatricians,

has already been referred to. Rural children and children in our smaller cities

do not have the benefit of medical skills that their urban brothers and sisters

have. Deficiencies in the rural States are even greater than in the rural

areas of highly urbanized States because of the inaccessibility to large cities

that are virell provided with facilities and personnel for the care of children.

Nothing short of a long-time, planned program of maternity care and health

and medical services to children on a Nation-uide basis will meet these inadequacies.

This program must be begun at once, since it will take time to

get it under way. Under title V of the Social Security Act a beginning has

been made, but coverage is far from complete and the best ne know how to give

is being provided to but a relatively small number of children. Experience

with the wartime emergency maternity and infant-care program for wives and

infants of enlisted men has shmm that careful planning and organization should

be made in advance if high quality of care is to be maintained and service

extended to all mothers and children entitled to it.

Conviction of the necessity for action is

generally, know that do not need

poorly developed. Children do not need to

defects and disorders that could have been prevented in infancy

The people still have to learn, however, that the seeds of much

adult life

or childhood.

illhealth

among adults were sown in childhood, that much can be

appropriate mental-Health service is provided to children and

prevented

parents.

The combined effort of Federal3 State and local Governments and the

professional groups involved in rendering be needed to plan and

d~velop the program of care that is necessary. planning

developing a Nation-wide program of health and care for children is

the responsibility of national and local organizations and agencies. Professional

groups should contribute the knowledge of hov.i their skills can be

best provided. Agencies with administrative experience should help plan

organization. Citizens! groups will behind a plan of action, for they

are aware of the necessity of for children more adequately than

at present if the Nation is to be healthy and vigorous in the future. Action

Congress as well as State legislatures be necessary to assure a Nationr;

ride program& Provision must be made for funds to the States in

the knovJledge and skills that we have today to the communities and

neighborhoods 1·vhere children live.

A nell-organized plan for maternity care and for health service and

care for children must ultimately fit into a total care plan,

but there are elements in this program that can and should be C.c;·:eloped now.

‘I’he following steps should be takon at once as an expansion of ·C,he

grants-in-aid programs under the administration of State health

in collaboration with physicii:ms and other. professional personnel rendering

health service and medical care:

L Organization of a maternity-care St?rvice radiating out

from the chief medt~al centers and hospitals? th:rou;h

community hospitals} hc;el .. .:.h centers; and local

reaching families in all areas~

  1. Expansion of child-health (medical, dental, nursing,

nutrition, and mental health) and medical care for infants

and preschool children, including care in hospitals

health centers, and by local physicians •

.3.. Organization and development of a health and medical service

for school children (including those high school) through

the provision of health service in the schools and diagnostic

and treatment service in the community.

I

  1. Expansion of existing crippled children’s program to

providea.

More adequate service for crippled

children, rJi th special emphasis on

paralysis and spastic conditions.

be A Nation-wide plan of care for children

id th rheumatic fever and those

nith heart disease resulting from

rheumatic fever.

  1. Construction of health centers and subsidiary child-health

centers reaching out into every neighborhood where children

live, with a view to providing coverage within 3 to 5 years.

Co’nstruction of necessary hospitals, general or special, to

provide pediatric beds and maternity beds in all areas as

needed to assure hospital delivery care for all maternity

patients, with a view to providing Nation-wide coverage

within 5 to 10 years.

  1. Development and expansion of existing facilities for training

pediatricians, obstetricians, and general practitioners in

maternity and child care, with special emphasis on the development

of resources for giving additional training and experience

to physicians as they retu:cn from military to civilian service.

Expansion of training facilities for public-health nurses

and for hospital and clinic nurses with special emphasis on

their training in the care of maternity patients, infants, and

children, well and sick. Development of facilities for training

specialized nursing supervisors, consultants, or teachers

in the maternity, pediatric, and orthopedic fields,,

Expansion of training facilities for other health workers with

children, dentists, nutritioriists, medical-social workers,

health educators.

(CB 45-146)

AND RELATED ASPECTS OF

COMMUNITY WAR SERVICES

REVISED, OCTOBER 1942

FEDERAL SECURITY AGENCY

OFFICE OF DEFENSE HEALTH AND WELFARE SERVICES

COMlvfUNITY ORGANIZATION SECTION

WASHINGTON, D. C . …

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