he deputy State health officer or one of the local practitioners for advice.

The public-health-nursing consultant n maternity care is likewise a certified urse-midwife, who operates out of the entral health-department office and goes from county to county helping the general staff nurses with their mater-1 nity work, advising the nurse-midwives, and instructing and inspecting the granny midwives. She helps in the establishment of clinic routines, homevisit techniques, and all aspects of prenatal, delivery, and postpartum care that relate to nurses, nurse-midwives, and granny midwives. In this capacity she visits, from time to time, all the 23 counties of the State.

The last member of the maternity team is a physician, the obstetric consultant. This position was first created 10 years ago on a part-time basis, but as the work developed, it became apparent that it demanded the full-time services of at least one person. At the present time, there is a single obstetric consultant who is able to devote his entire time to this work without having to take time for private patients of his own. The great disadvantage of employing a man in this capacity on a part-time basis had proved to be the fact that so often he found it necessary to cancel clinic visits at the last minute because of his private practice.

The consultant travels from county to county on a prearranged schedule and visits certain of the prenatal clinics while they are in operation. All clinic

JANUARY 1948

patients having abnormalities or suspected of having them are referred to the clinics he attends. His major function in respect to the clinics is, therefore, the examination of abnormal cases and the making of necessary arrangements for their proper care. In this way he comes into contact with the deputy State health officers, the local physicians, the staff public-health nurses, the nurse-midwives, and on occasion, the granny midwives.

Matters of maternity care in general, and those relating to specific patients, are discussed at these clinics. In addition, the consultant renders, when requested, free consultant service to any of the physicians of the State. He remains on 24-hour call for this purpose and sees patients in either the physician's office, the patient's home, or the hospital.

When time and travel permit, he will go to help out with difficult deliveries. He appears before local medical-society groups to give talks on obstetric subjects and holds informal discussion groups. Recently there has been a gratifying move on the part of the rural hospitals to ask his advice in improving their maternity sections, and in one instance, he has been placed on the consultant staff of a local hospital.

Lest you think he must be like a cat with nine lives to be able to accomplish all this, it must be admitted that the demands upon him are not equal to his willingness to help. Free consultation service is a new idea, and like every

thing else that is free is looked upon with some skepticism of its value. The progress along this line is slow, but is still progress.

An extremely important feature of the obstetric consultant's status is a close working arrangement with a teaching hospital. In addition to his position with the health department, he is likewise on the staff of a teaching hospital in Baltimore. This makes it possible for him to arrange hospitalization in a teaching hospital with a large obstetric service for any patient, regardless of her financial status, who presents any major obstetric abnormality needing specialized care. He can obtain any special form of study or treatment which cannot be gotten locally. His association with a teaching hospital further serves to keep him abreast of current advances in obstetrics. And lastly, it facilitates arrangement of postgraduate courses in obstetrics for rural practitioners. This was done for the first time this year, when a total of 31 physicians attended a 10-day postgraduate course at the two teaching hospitals in Baltimore.

From the patient's point of view, here is a plan that assures that any expectant mother in Maryland, irrespective of her financial status, can obtain modern obstetric care and advice.

Clinic examination includes all the usually accepted basic examinations: Pelvic measurements; blood studies, in(Continued on page 109)

99

B

ASIC to all the work of the Chil

dren's Bureau is its responsibility, under the act of Congress creating the Bureau in 1912, for investigating and reporting "upon all matters pertaining to the welfare of children and child life among all classes of our people."

Little occurs in the economic, social, and cultural life of the Nation that does not in one way or another impinge on the welfare of children and child life. Since the Bureau must work within the limits of its personnel and budget, it must be selective in its investigations and reporting, focusing its efforts on areas where there is most need for information and where information can best be used in helping public and private services increase their usefulness to children.

Research

The year 1945 was a banner year for the United States in the safeguarding of mothers and children from fatal risks in childbearing and in infancy. The maternal mortality rate, 20.7 deaths for each 10,000 live births, was the lowest ever recorded in this country and 9

percent below the 22.8 recorded for 1944. The infant mortality rate as conventionally computed declined from 39.8 for each 1,000 live births in 1944 to 38.3 in 1945. When adjusted for the changing number of births, the rates were 39.4 in 1944 and 38.2 in 1945, a decline of 3 percent. Preliminary figures for 1946 indicate a further decline.

Despite the encouraging showing in national rates, maternal mortality in some States, particularly among nonwhite mothers, was disproportionately high. Analysis of mortality rates in 1944 indicates that reduction in maternal mortality among nonwhite mothers lags 15 years behind that for the rest of the population.

A study of neonatal deaths emphasized again the importance of concentrating attention on risks in the first month of life if the infant mortality rate is to be lowered significantly in coming years. While death rates for the first year of life dropped 29 percent from 1935 to 1944, rates for the first month declined only 24 percent. Sixtytwo percent of all infant deaths in 1944 occurred when the infants were less than a month old. Prematurity is the great

est single cause of infant mortality: least two-thirds of these deaths fr prematurity could be prevented if t infants could receive care in mode "premature centers" with specia trained medical and nursing person

By June 30, 1947, all States were pa ticipating in the study of child-healt services undertaken by the Americal Academy of Pediatrics with the of operation of the Public Health Servis and the Children's Bureau. The B reau has aided this study, the most co prehensive one of its kind ever under taken in this country, by lending th director of its Division of Research Child Development and a research & sistant to the executive staff of t study.

Studies to develop plans for denta health services for children continue during the year. One was an evalu tion of a dental-health program for ele mentary-school children, involving t analysis of dental records collecte through the Cleveland Department Education Dental Health Servic Records of mobile dental units servin children in rural areas in Kentuck were studied to obtain data on cost, co erage, man-hours, types of services, an the time necessary for various oper tions. A study of the budgets and e penditures for dental-health program of all State health departments fro

1937 through 1946 was started. In June 1947 the Bureau held a conference with authorities on orthodontic needs of children and the methods, services, and problems involved in meeting those needs.

In cooperation with the National League of Nursing Education, the Bureau made a controlled study of the elements that go to make up good pediatric nursing care in hospitals. Results of the study have been published by the National League and so made available to hospitals and others responsible for standards of nursing care of sick children.

A conference was held of representatives from the fields of education, medicine, nursing, medical social work, and welfare, to advise on a study of the various vision-testing procedures commonly used in elementary schools. The study is to be made jointly by the Bureau and the National Society for the Prevention of Blindness, with the cooperation of a State health agency.

The increasing number of children entitled to benefits under various public programs makes timely a study of laws and procedures governing the legal guardianship of children. Many such laws are antiquated, and practices under them have lagged far behind modern knowledge of the social needs of children. The Bureau will soon issue the final report on its study of court records, procedures, and cases of children under guardianship in two local jurisdictions in each of six States. Advisory services on problems affecting children Consultation service was given to States and local groups in the field of juvenile delinquency and community planning for children and youth. In addition, the Bureau completed several special studies in that field. The report of the Bureau's 7-year project in St. Paul, Minn., demonstrating the value of integrated community services for children showing early behavior problems, was published under the title, "Children in the Community."

The method of reporting juvenilecourt statistics, collected by the Bureau each year since 1927, was revised to attain broader coverage through collection of local data by State agencies, and to yield information both on the types of cases disposed of and on the

number of children involved. Final figures for 1945 show a 6-percent increase over 1944 in the number of delinquency cases disposed of by courts reporting to the Children's Bureau in both years.

Much staff time went into preparing material for consideration by the National Conference on Prevention and Control of Juvenile Delinquency, called by the Attorney General.

There have been reports of inadequate, if not positively bad, care and treatment of boys and girls in training schools in many States, because of poorly qualified personnel and inadequate facilities. Several State schools were visited, and suggestions were given on improving standards of service and integrating State training-school programs into State child-welfare programs. At the request of the Child Welfare Division of the American Legion, a study was made of the policies and practices of 22 States in admitting pregnant feeble-minded and epileptic girls to State training schools.

In connection with the wide variety

of requests that come to the Bureau for information and counsel on problems connected with the care of children away from their homes, considerable exploratory work was done during the year in collating facts about current and desirable practices on such aspects of foster care as foster-home finding, intake policies, size of case loads, board rates, costs of institutional care, personnel practices, in-service training programs, foster-parent education, licensing, and general standards of care. Special attention was given to problems of interstate placement.

Agencies seek help

It becomes increasingly evident that the public is looking to public welfare agencies for guidance and assistance in adoption matters. These agencies, in turn, look to the Children's Bureau for counsel in the development of their policies. Advice on adoption policies was given also to private agencies. The Bureau's consultant on adoptions worked with the March of Time on its

What the Social Security Administration recommends on Children's Bureau programs

Legislation and appropriations providing for the progressive development of State-wide programs at a rate consistent with availability of personnel and with facilities that meet standards established under State plans, for the purpose of assuring that child health and welfare services will be available as needed for all children in all political subdivisions of each State. Provision of such services without discrimination as to race, creed, nationality, residence, citizenship, or economic status.

Development within the health and welfare programs of measures necessary to assure that children in migrant families will receive the services they need.

Priority of attention to development of programs of health, medical, and dental services for children of school age.

Safeguarding the rights of parents and children to such services by requiring that State plans provide an opportunity for fair hearing before the State agency responsible for the program, whenever a claim for care or services under the plan is denied; and adequate restrictions on the use or disclosure of information concerning persons applying for or receiving such services to purposes directly connected with the administration of such services.

Special provision of financial aid in training of professional and technical personnel needed in making child

health and welfare services available throughout the country.

Effective coordination of the health and welfare services for children with other health and welfare services.

Administration of the maternal and child health and crippled children's services by the same State health agency in each State by the end of a 5-year period.

Appointment by each State agency administering maternal and child health and crippled children's services of a general advisory council providing adequate representation of the public as well as of the professions.

More adequate financial implementation of the basic act of 1912 creating the U. S. Children's Bureau, to enable that Bureau to strengthen and broaden its work as a center of information related to children; to evaluate current research in the physical, biological, and social sciences that pertain to the growth and development, the health and well-being of children and young people; to assist in financing specific research projects by competent research authorities to fill in recognized gaps in these fields of research; and to undertake research and investigations that deal with the child as a whole or with specific problems that require Nation-wide study or that have Nationwide significance to State and community health and welfare programs for children or mothers.

special feature, "Nobody's Children." The Bureau's folder on adoption was reissued under the title, "When You Adopt a Child.”

There is a continuing need for daycare services for children, but the supply is diminishing. Requests for counsel received from Federal, State, and local agencies by the Bureau covered problems of licensing, standards, building requirements and equipment, and methods of appraising need for programs. An interpretation of fosterfamily day care was published under the title, "Mothers for a Day."

Interest in improving services to unmarried mothers and their babies has become Nation-wide. The Bureau was called into consultation by public and private agencies in several States. Improvements were reported during the year in methods of birth registration as one means of safeguarding the welfare of children, particularly those born out of wedlock.

The Bureau's advice on homemaker service has been sought by both private and public welfare agencies, which are making more use of homemaker services to give trained and supervised care for children in their own homes.

Increasingly, agencies are recognizing the therapeutic value of group work, as distinct from individual casework, with children. The Bureau advised several States on the use of group work in convalescent-care programs and camping programs for children with physical handicaps.

For migratory workers' children

Evidence of the health and welfare needs of children of migratory workers, among the most neglected in the Nation, was presented by the Bureau at meetings of the Federal Interagency Committee on Migrant Labor, of which the Children's Bureau is a member. In recommending that all appropriate State and Federal agencies carry through practical measures "which will insure adequate housing, health, nutrition, welfare, and related services," the committee made suggestions on how conditions. for children might be improved.

Advice on services for children in minority groups was given by the Bureau to several national organizations, public welfare agencies, and private child-caring agencies.

Great increases in college enrollments of married students with families have created problems for public health and welfare agencies. At the request of the American Council on Education, the Bureau cooperated in a survey of community services needed for the care of these families.

To meet the growing volume of requests for guidance in the use of psychological and psychiatric services by public health and welfare agencies in all programs of foster-family and institutional care of children, the Bureau conducted a number of field investigations during the year. Visits were made to public and private agencies in several States to observe services for children with disturbed behavior.

On behalf of the Interagency Committee on Youth Employment and Education, the Chief of the Children's Bureau, who was chairman of the committee, late in 1946 submitted a report and recommendations to the Director of War Mobilization and Reconversion. The report summarizes the observations of 11 Federal agencies on problems of school and employment opportunities for young people and lack of community preparation to deal with youth's needs in the postwar period.

Reporting services

Information about the research findings mentioned here and about other studies now under way is available on

request from the Bureau. Results the Bureau's studies and surveys a communicated to public and priva agencies administering programs f children. In its monthly periodica The Child, and through other med ums, the Bureau discharges its respons bility of reporting to the public and professional workers on all aspects o child life.

In the fiscal year 1947, 234,000 letter came to the Children's Bureau. Man could be answered with a publication others needed, and got, the personal at tention of the Bureau's experts.

During the fiscal year 2,100,000 pub lications were sent out in response requests. The great majority were the Bureau's well-known bulletins for par ents. More than a million copies of "Infant Care" were requested from the Bureau, and another 397,000 were sold by the Superintendent of Documents From 1914, when the first edition of this bulletin was brought out, to the end of June 1947, more than 20 million copies had been distributed. Requests during the year for free copies of "Prenatal Care" totaled 232,100 and for "Your Child From One to Six." 237.000 The Bureau issued 35 new and 14 revised publications.

As one way to report to the people what it knows and to learn from the people what they want from public serv ice, the Bureau has always kept in clos

touch with the many National, State, and local groups concerned with the welfare of children. During the war, eaders from many of these groups formed a national body, known as the National Commission on Children in Wartime. This organization was imnensely valuable in counseling the Bureau and in focusing public attention on the needs of children under war pressures. In December 1946 the Commission reconstituted itself as the National Commission on Children and Youth and voted to continue as a body advisory to Federal agencies and to citizen groups supporting programs for children and youth. Members are appointed, on advice of the Executive Committee, by the Commission's chairman and by the Chief of the Bureau.

At its first meeting in December the new Commission adopted an "Action Program for 1947 and 1948." This action program emphasized again the need for expansion of social-security programs affecting family income; child-welfare and child-health services; Federal and State aid for education; nental-health and guidance programs; recreational opportunities for children; improved child-labor legislation and employment opportunities for boys and girls ready to start work; State and community planning for children and youth, with youth participation in the planning; and international action to strengthen services for children and youth in all countries. The Commission strongly recommended that a 1950 White House Conference on Children be held and that in anticipation States and local communities measure the progress made since the last conference and, on that basis, determine problems that need to be taken up at the 1950 conference.

Grants-in-aid programs

The three programs for maternal and child welfare under the Social Security Act are substantial expressions of the principle that only through the sharing of responsibility by Federal, State, and local governments can the Nation's children be assured of their right to a good start and a fair chance in life.

Title V of the Social Security Act authorizes annual appropriations for grants to the States to improve and extend their health and welfare services

for mothers and children. Under the amendments of 1946 these grants are $11,000,000 for maternal and child health services, $7,500,000 for services for crippled children, and $3,500,000 for child-welfare services. All 48 States, the District of Columbia, Alaska, Hawaii, Puerto Rico, and the Virgin Islands receive grants for all three programs. The Virgin Islands were brought under coverage of the act, as of January 1, 1947. The 1946 amendments marked the second time that grants had been increased. In 1935, when the act was passed, they totaled $8,150,000. That sum was stepped up to $11,200,000 in 1939 and to $22,000,000 in 1946.

Unlike the insurance and publicassistance programs under the Social Security Act, which are designed to strengthen a family's economic security by furnishing a basic minimum income when earnings are interrupted, the grants-in-aid programs administered by the Children's Bureau are intended to promote and improve the family's general welfare through providing public health and welfare services. None of the Federal money under these programs is paid directly to any parent or child. It goes to State agencies to strengthen, extend, and improve the work of these agencies and their counterparts in local communities. . . .

To develop standards of good service, to meet requests from States for advice in the development of their programs, and to work on the many problems involved in reaching children needing care, the headquarters staff of the Children's Bureau includes a wide range of professionally trained people-obstetricians, pediatricians, medical social workers, nurses, nutritionists; a psychiatrist and a psychologist; a dentist, a physical therapist, a hospital-administration consultant; and social workers with special training and experience in child-welfare services, in public welfare administration, in group work, and in foster-home and institutional care of children. In most of the Social Security Administration regions the Bureau has teams of regional workers whom the State agencies can consult about their federally aided programs. Owing to inadequate funds, some regional staffs are incomplete. Advisory committees in various technical fields assist

the Children's Bureau in developing policies relating to the administration of grants in aid.

Immediately after increased funds were appropriated by Congress in August 1946, the Bureau called together its advisory committees to make recommendations on how the States might best improve their health services for mothers and children. The State and Territorial Health Officers' Association was another source of guidance in developing these Federal-State programs. It was agreed that increased effort should be put into (1) extending or developing new programs for children with rheumatic fever, cerebral palsy, hearing defects, and other crippling conditions; (2) demonstrating school health service projects in selected areas; (3) increasing development of maternity-care programs; (4) increasing and improving facilities for care of prematurely born infants; (5) developing medical and dental care programs for children; and (6) promoting mental-hygiene programs for children.

Maternal and child-health services

In all States, maternal and childhealth programs are administered by State departments of health, through divisions or bureaus of maternal and child health. In 40 States, such divisions are directly under the State health officer. Other States vary in their administrative organization.

The function of the State division or unit is to develop and provide, with the help of local health departments, Statewide health services for children from birth through school age, and for mothers before and after childbirth. The staff may include obstetricians, pediatricians, psychiatrists, psychologists, dentists, nutritionists, public-health nurses, medical social workers, and health educators; a physician is in charge. Through financing postgraduate education and through consultation, the division helps professional workers in private practice or public service to improve the care they give mothers and children.

Services provided by local health departments are primarily for the promotion of health and the prevention of illness. Many health departments also furnish medical, dental, nursing, and hospital care to a limited number of