Abstract On April 9, 1912, an Act establishing the Children’s Bureau was signed by President William Howard Taft. The original mission of the Children’s Bureau was to “investigate and report … upon all matters pertaining to the welfare of children and child life among all classes of our people.” This two-part paper provides an overview of the 100-year history and mission of the federal Maternal and Child Health Research program, beginning with its origins in the U.S. Children’s Bureau in 1912 through the present day. Part 1 of the paper covers the period from the founding of the Bureau through the Social Security Act of 1935, with special attention to the ways in which research findings motivated changes in policies and practice. Part 2 covers the years from 1935 through the present day, with special attention to the vision underlying the extramural MCH research program (established in 1963), and the impact of the 1969 reorganization of the Children’s Bureau, which moved the MCH Research Program into the Public Health Services into what is now the Health Resources and Services Administration (HRSA). Discussion focuses on the mission of the MCH Research program, how that has been realized in the past and present, and what we can learn from that for the future.
Maternal and Child Health
Maternal and Child Health Bureau
Remembering our Past,
Building the Future:
100 Years of the Maternal and Child Health
Part 1: 1912-1935 “Perhaps herein lies the perspective of the past and the forecast for the future: Society moves forward in terms of what its care, hopes, and aspirations are for its children.”
--Katherine B. Oettinger, Fifth Chief of the Children’s Bureau, 1960
Through its 100-year history, the Maternal and Child Health Research Program has served as a focal point in the expression of national concern for children. Currently housed in the Health Resources and Services Administration (HRSA) within the U.S. Department of Health and Human Services, the MCH Research Program traces its roots back to 1912 when Public Law (PL) 62-116 established the Children’s Bureau under President William Howard Taft.
The creation of the Children’s Bureau on April 9, 1912, represented the culmination of over 6 years of effort on the part of determined citizens and child welfare organizations to persuade Congress to establish an agency primarily focused on the health and wellbeing of children. Lillian Wald, a nurse and founder of both the Visiting Nurse profession and the Henry Street settlement in New York City, was the first person to suggest a federal Children’s Bureau: “Experience in Henry Street, and a conviction that intelligent interest in the welfare of children was becoming universal, gradually focused my mind on the necessity for a Federal Children's Bureau."1 Wald famously went on to ask, “If the Government can have a department to look out after the Nation’s farm crops, why can’t it have a bureau to look after the Nation’s child crop?”2,3The creation of the Children’s Bureau constituted the first public recognition that the federal government has a vested interest in and responsibility to promote the welfare of the nation’s children.4 From the Children’s Bureau “would flow knowledge of the conditions surrounding children’s lives, ideas on how to improve these conditions, and plans and programs for action.”5
Early Mission and Research Efforts
The original mission of the Children’s Bureau was to “investigate and report… upon all matters pertaining to the welfare of children and child life among all classes of our people,” with special concern for “infant mortality, the birth rate, orphanages, juvenile courts, desertion, dangerous occupations, accidents and diseases of children, employment, [and] legislation affecting children in the several States and Territories.” Congress’s intent was that the studies and reports of the Children’s Bureau would inform state and local efforts to improve the care of mothers and children.6 As stated by Senator Borah, reporting for the Senate Committee considering the 1912 Act: “The design and purpose [of the Bureau is] to furnish information . . . to the respective States to enable them to deal more intelligently and more systematically and uniformly with . . . the betterment of the condition of children and the more careful guarding of their welfare.”7
The Children’s Bureau existed as a single entity responsible for the health and wellbeing of the whole child from its establishment in 1912 until a 1969 reorganization split the Bureau, separating Maternal and Child Health activities (now in HRSA) from Child Welfare services (now in the Administration for Children and Families, or ACF). During the roughly 60 years that the Children’s Bureau existed as a unified entity, it worked tirelessly on a variety of topics aimed at promoting the health and social wellbeing of the entire child. Key efforts of the Children’s Bureau from its inception through the 1960s centered on:8,9,10
Health and Education Issues, with a focus on infant and maternal mortality, child nutrition, parent education, provisions for the care of crippled children, and maternal and child health.
Social and Economic Issues, with a focus on pressing social issues of the day, including: protecting the legal rights of children born out of wedlock (1913-1916); developing the first Standards for Child Welfare (1919); generating legislation designed to provide pensions to mothers (1914-1920); contributing to the formulation of the Social Security Act (1934-1935); and leading national work on day care, child refugees, and child abuse legislation (1958-1962).
Labor and Justice Issues, with a focus on child labor legislation (1916-1940); and juvenile delinquency, including issuing the first edition of Juvenile Court Standards (1923).
Through these initiatives and others, the Children’s Bureau had a critical role to play in improving the health and wellbeing of children in the 20th century.
Reducing Infant Mortality
Under its originating Act of 1912, the Bureau was especially directed by law to investigate infant mortality. Efforts to comply with the law, however, were hampered by imperfect collection of birth statistics across the country. In 1913, the U.S. as a nation did not know for certain how many infants were born each year, how many died, or why they died. The first work of the Children’s Bureau was to remedy this. 11
Birth Registration. In order to study infant mortality, it is necessary to know how many infants are born in a given year, and how many die before their first birthday. As a way to build accurate information, Julia Lathrop, first Chief of the Children’s Bureau, spearheaded birth registration drives across the Untied States. She wrote:
“We have no national bookkeeping to account for the ebb and flow of human life as an asset and a liability of our civic organism. We have no national records to give our sanitarians and students a basis for their preventive studies…. It is fair to say that there is a steadily increasing sense of the value of vital statistics, and that the number of States with good laws increases yearly.”12
With cooperation from the American Medical Association, the American Public Health Association, the American Bar Association, and the Bureau of the Census, the Children’s Bureau was eventually successful in its drive for birth registration across the country.
Johnstown Study. In 1913, birth registration was reported to be complete in Johnstown, PA, and the newly-created Bureau started “at once”13 on a study of infant mortality there. The study found that poor parents lacked medical care during childbirth, depending instead on midwives, neighbors, or self-care. In addition, Johnstown and similar studies conducted by the Children’s Bureau in eight other cities concluded that poverty was the single most important factor in infant mortality;14 as Katherine Oettinger, fifth Chief of the Children’s Bureau, noted: “low earnings and high infant death rates went hand in hand.”15 Specifically, high infant mortality rates were associated with unsanitary conditions such as poor housing, open sewers, and unsterilized milk and nursing bottles.16 These early studies of infant mortality in nine cities also established a connection between the health of the mother and the child’s own capacity to survive and flourish. These findings had an enormous impact on policies and practices:17
“These studies, the first of their kind ever undertaken by any nation, showed that the greatest proportion of infant deaths resulted from remedial conditions existing before birth. Death rates of babies went down as fathers’ earnings went up. Breastfed babies had a better chance to survive the dangerous first year than bottle-fed babies. A baby with his mother in the home during the first year of life had a better chance than a baby deprived of his mother’s care….These early studies had repercussions far beyond the Bureau. They gave great impetus to the drive for improved sanitary conditions…and for extending the pasteurizing of milk. They were used as an argument for minimum wage legislation and for widow’s pensions. They resulted in improvement of measures for safeguarding infant and maternal health in many States and communities.”18
These early studies thus resulted in changes not only in sanitation practices within the home, but also in changes in national policies affecting public health and welfare.
Child Care Publications for Mothers. The Children’s Bureau turned the knowledge they gained from these early infant mortality studies into practical advice aimed at saving the lives of mothers and children. “Prenatal Care,” first published in 1913, and “Infant Care,” first published in 1914, quickly became all-time best-selling Government publications. Published through the 1980si, these booklets for parents emphasized the importance of good nutrition, sanitation, and adequate medical care during pregnancy. As one mother wrote to the first Chief of the Children’s Bureau:
“I should like very much all the publications on the care of myself, who am now pregnant, also on the care of a baby. I live sixty-five miles from a Dr…. I am 37 years old and I am so worried and filled with perfect horror at the prospects ahead. So many of my neighbors die at giving birth to their children. I have a baby 11 months old now in my keeping, whose mother died. When I reached their cabin last Nov. it was 22 below zero, and I had to ride 7 miles on horse back. She was nearly dead when I got there, and died after giving birth to a 14 lb. boy…. Will you please send me all the information for the care of myself before and after and at the time of delivery. I am far from a doctor, and we have no means…”19
In addition to the promotion of birth registrations and parental education, the second Chief of the Children’s Bureau, Grace Abbott, continued to work on reducing infant mortality through Bureau efforts to facilitate cooperation between state health officials and health professionals, and to establish infant welfare and maternity centers.
In 1922, the Surgeon General of the United States, H.S. Cumming, reported that a conservative estimate of the U.S. infant mortality rate in 1910 was 124 deaths per 1000 live births.20 By 1920, the infant mortality rate in those areas for which birth registration was completed was 86. By 1950, the U.S. infant mortality rate was 29.2,21 and in 2009 it was 6.4.22 The efforts of the Children’s Bureau towards registering births, studying and addressing causes of infant mortality, training care providers to change their clinical practices, and educating parents regarding healthy prenatal and infant practices all contributed significantly towards the reduction in infant mortality that occurred in the nearly 100 years between 1910 and 2009.
Child Health and Nutrition
Among its original mandates, the Children’s Bureau was directed to investigate “diseases of children.” One of the first diseases selected for study was rickets. As Grace Abbott, Children’s Bureau Chief 1920-1934, wrote in her annual report to Congress in 1924: “The importance of preventing rickets arises from the great prevalence of the disease, the resulting danger to the lives of infants . . . and the consequent economic loss to the community.”23 Specifically, by impairing nutrition and the child’s resistance to infection, rickets left the child vulnerable to diseases such as severe pneumonia, measles, whooping cough, respiratory illnesses, and death related to these diseases. In 1924-1927, Martha Eliot, then Director of the Children’s Bureau’s Division of Child and Maternal Health, studied rickets in New Haven, Connecticut, and demonstrated how mothers could be taught simple measures which greatly reduced the incidence of rickets.24 According to Charles P. Gershenson, director of research in the Children’s Bureau from 1963-1972, the fact that U.S. children are rarely seen with rickets today is due, in no small part, to Children’s Bureau studies in the 1920s of vitamin D nutrition.25
Julia Lathrop, founding Chief of the Children’s Bureau, wrote in 1916: “The sickness or death of the mother inevitably lessens the chances of the baby for life and health. . . . The Children’s Bureau studies of infant mortality in town and country reveal clearly the connection between maternal and infant welfare and make plain that infancy can not be protected without the protection of maternity.”26 The Children’s Bureau studies of maternal death during childbirth had a profound impact on the health of women and children. One such study, conducted in 1927-28, involved investigating the deaths of about 7500 women:
“Just what did such a study involve? A look at some of the field reports showed that it meant riding muleback over remote trails in the Kentucky mountains, driving over the endless Western prairies, visiting big hospitals in crowded cities, and the cabins of granny midwives in the far South. It meant going anywhere and everywhere that the records showed a mother had died and filling in a detailed schedule with information which might throw light on the cause of her death.”27
The results of this study indicated that a large proportion of women had little or no prenatal care, and little or very poor care during birth. Forty percent of deaths were due to sepsis. The recommendations drafted by the Children Bureau’s advisory committee on obstetrics on the basis of this study led to the adoption of standards for maternal care, and to increased efforts to educate the public regarding the need for adequate medical care during childbirth. In 1915, the maternal mortality rate in the U.S. was estimated at 607.9 deaths per 100,000 live births for the birth registration area; by 2003, this number had dropped to 12.1 deaths per 100,000 live births.28 Once again, the research undertaken by the Children’s Bureau had a marked impact on the health and wellbeing of women and children in the United States.29