Ohio History Journal

KRISTE LINDENMEYER

Saving Mothers and Babies: The

Sheppard-Towner Act in Ohio,

1921-1929

In 1985 (the year for which the latest statistics are available), 10.6

American babies died for every 1,000 live births in the United States.

This is a dramatic improvement over the country's 1921 infant mortal-

ity rate of 76 per 1,000, but as in 1921, the United States' rate continues

to compare poorly with many other industrialized countries. In 1921,

the United States rate ranked seventeenth out of twenty "modern"

nations.¹ The 1985 rate placed the U.S. eighteenth, and a Children's

Defense Fund report contends that, contrary to popular opinion, infant

mortality is actually worsening in some categories. Dr. Marsden

Wagner, director of the World Health Organization's maternal and

child health program, maintains that "infant mortality is not a health

problem ... [but] ... a social problem" which should be addressed

through "more social education for families" and by insuring that the

"basic level of financial and social support ... be provided to families. "2

But, his is not a new idea. In 1921, the United States Congress passed

legislation designed to attack the country's high infant mortality rate by

"promoting" better prenatal and infant care.

The Sheppard-Towner Maternity and Infancy Act was passed in 1921

as the first federal health care legislation to "promote the welfare" and

prevent unnecessary deaths of mothers and babies in America.³

Kriste Lindenmeyer is a Ph.D. candidate in history at the University of Cincinnati.

1. For a comprehensive list of the nations cited in the 1921 Congressional Hearing on

Sheppard-Towner, see Promotion of the Welfare and Hygiene of Maternity and Infancy:

The Administration of the Act of Congress of November 21, 1921, Fiscal Year

Ended June 30, 1929, (Washington, D.C., 1931), Children's Bureau Publication

(CB pub.) No. 203, 139.

2. Associated Press, "High Infant-death Rate in U.S. Blamed on Skimpy Social

Help," Cincinnati Enquirer, 3 February 1988, sec. B, p.8; see also Children's Defense

Fund, A Children's Budget: An Analysis of Our Nation's Investment in Children,

(Washington, D.C., 1988), 61-62.

3. The Sheppard-Towner Act passed the U.S. Senate by a vote of 63-7 on July 22,

1921. An amended version passed the House on November 21, 1921, by a vote of 279-39.

106                                                          OHIO HISTORY

Administered by the Children's Bureau (established in 1912), it was

also the first peacetime health care legislation which provided grants-

in-aid to the states.⁴ Some scholars investigating the Sheppard-Towner

Act have concentrated on the question of why or how the United

States, alone among western industrial nations, did not enact a

compulsory health insurance or maternity benefits program. Others

have focused on the important role women reformers played in the

Act's passage. Some have argued that this law was a forerunner of the

1935 Social Security Act.⁵ An evaluation of the legislative history of the

Sheppard-Towner Maternity and Infancy program illuminates beliefs

about gender roles, rights of parents and children, professionalization,

medical care, and the role that the government should play in the lives

of U.S. citizens. But, as Molly Ladd-Taylor recently remarked: "an

evaluation of the bill must rest ultimately on an analysis of the actual

work that Sheppard-Towner funded in the states."⁶

The Senate quickly approved the amended version and President Harding signed the

measure on November 23, 1921. Congressional Record, 67th Congress, 1st session,

4215-17, 7916-8178; Public No. 97, U.S. Statutes At Large, April 1921 to March 1923,

67th Cong., 1st sess., (Washington, D.C.), 224.

4. The Army Appropriation Act approved July 8, 1918, established the Interdepart-

mental Social Hygiene Board to fight venereal disease. This board functioned until July

1, 1922, with an annual expenditure of $100,000. A permanent Division of Venereal

Diseases in the Public Health Service with an annual appropriation of $1,400,000 was

also established under the terms of the Act. This was the only other federal legislation

which dealt directly with health care appropriations to the states. U.S. Statutes At

Large, 886-87, (Washington, D.C., 1919). Also see years 1920 forward for subsequent

appropriations.

5. For a historiographical discussion of the development of U.S. public health care

policy, see Daniel M. Fox, "History and Health Policy," Journal of Social History, 18

(Spring, 1985), 349-64. The following deal with the legislative history of the Sheppard-

Towner Act: Edward R. Schlesinger, "The Sheppard-Towner Era: A Prototype Case

Study in Federal State Relationships," American Journal of Public Health, 57 (June,

1967), 1034-40; Joseph B. Chepaitis, "The First Federal Social Welfare Measure: The

Sheppard-Towner Maternity and Infancy Act, 1918-1932," (Ph.D. dissertation,

Georgetown University, 1968); Chepaitis, "Federal Social Welfare Progressivism in the

1920's," Social Service Review, 46 (June, 1972), 213-30; J. Stanley Lemons, The Woman

Citizen: Social Feminism in the 1920's, (Urbana, 1974); Lemons, "The Sheppard-

Towner Act: Progressivism in the 1920's," Journal of American History, 55 (December,

1969), 776-86; Louis J. Covotsos, "Child Welfare and Social Progress: A History of the

United States Children's Bureau, 1912-1935," (Ph.D. dissertation, University of Chica-

go, 1976); Sheila M. Rothman, Woman's Proper Place: A History of Changing Ideals

and Practices, 1870 to the Present, (New York, 1978); Kristine Siefert, "An Exemplar

of Primary Prevention in Social Work: The Sheppard-Towner Act of 1921," Social Work

in Health Care, 9 (Fall, 1983), 87-102; Molly Ladd-Taylor, Raising Baby the Government

Way: Mothers' Letters to the Children's Bureau, 1915-1932, (New Brunswick, 1986);

Kriste Lindenmeyer-Dick, "Saving Mothers and Babies: The Sheppard-Towner Mater-

nity and Infancy Act 1921-1929 With Emphasis on Its Effects in Ohio," (M.A. thesis,

University of Cincinnati, 1987).

6. Molly Ladd-Taylor, "Protecting Mothers and Infants: The Rise and Fall of the

Sheppard-Towner Act," paper presented at the June 1987 Bershire Conference.

Saving Mothers and Babies                                            107

Debate concerning federal promotion of maternal and infant care

moved to state legislatures after President Harding signed the Sheppard-

Towner Act on November 23, 1921. Powerful lobbying efforts led by

the various state Leagues of Women Voters and Departments of Health

eventually secured approval in every state but Connecticut, Illinois,

and Massachusetts.⁷ The history of the Sheppard-Towner Act in Ohio

illustrates the attitudes and complications encountered by an attempt

to prevent the needless deaths of mothers and their babies in the 1920s.

The Controversy in Ohio

On December 7, 1921, just two weeks after the bill became law,

Roscoe G. Leland, M.D., chief of the Ohio Department of Health's

Division of Child Hygiene, wrote to Children's Bureau chief, Grace

Abbott, requesting copies of the Sheppard-Towner Maternity and

Infancy Act. He explained that the members of the Ohio Department of

Health desired "to qualify as early as possible in order that our work

may start with the least possible delay." His chief, State Director of

Health Dr. Harry H. Snively, supported state acceptance of the bill.⁸

Subsequently, Governor Harry L. Davis (R) made Ohio one of the first

states to accept the provisions of the act in December 1921 when he

agreed to the provisions of the law until a vote of the legislature could

be held.

However, in the final analysis, Davis' and the Health Department's

quick reaction to federal passage of Sheppard-Towner was not enough

to permit Ohio to take full advantage of the program. Because the

7. The Connecticut legislature claimed that such programs infringed on state's

rights, and lobbying by the Illinois State Medical Association prevented approval of the

act in that state. Massachusetts and one of its citizens, Harriet A. Frothingham, a

member of the Woman Patriots (an anti-woman's suffrage organization), brought

separate suits against the act on constitutional grounds. The cases were combined and

argued before the U.S. Supreme Court. The Court judged that Frothingham's claim of

unfair taxation was so minor that the Court had no jurisdiction, and thus avoided ruling

on the act's constitutionality. See Chepaitis, "The First Federal Welfare Measure ..,"

161-214; Massachusetts v. Mellon and Frothingham v. Mellon, 262 U.S. 447.

8. Letter from Robert G. Leland to Grace Abbott, December 7, 1921, Children's

Bureau Papers (CBP), Record Group (RG) #102, Box 251, 11-37-1, National Archives

(NA); Harry H. Snively (1869-1931) was born in Brownsville, Ohio. He taught school

and received his medical degree from Ohio State University, served as medical director

of the American Red Cross in Russia in 1915, and directed health inspection work in

Bordeaux, France, during World War I. In 1919, he was appointed chief of staff to the

American Red Cross typhus expedition in Poland. In 1920, he returned to Columbus as

the surgical, medical, and sanitary director of the Ohio National Guard. "Introducing

Ohio's New Health Director," The Ohio State Medical Journal (OSMJ), 17 (July, 1921),

529.

108                                                      OHIO HISTORY

state's biennial legislature did not meet until January 1923, no matching

funds could be voted and the Ohio Department of Health was only able

to accept 40 percent of the federal funds available to it for 1922. A state

allotment of $550 for publicity from the Ohio State Emergency Board

and $1,637.95 from the Department of Health Budget constituted the

state's only contribution to Sheppard-Towner work during 1922.⁹

When the Ohio legislature met in January 1923, former Cleveland

Director of Welfare, Representative Dudley Blossom (R-Cleveland),

introduced H.B. No. 583 providing for state acceptance of the provi-

sions of the Sheppard-Towner Maternity and Infancy Act. The new

Democratic governor, Victor Donahey, appointed John Emerson Mon-

ger, M.D., as director of the Ohio State Department of Health on

January 8, 1923.10 Monger's predecessor, Harry Snively (health direc-

tor from July 1, 1921, to January 8, 1923), had asked for $38,843.46 to

implement an appropriate Sheppard-Towner program in the depart-

ment's 1923 budget. Monger, however, was hesitant about, if not

antagonistic to, the federally assisted maternity and infancy plan.11

Lucia Johnson Bing, executive secretary of the Ohio League of

Women Voters (OLWV), wrote Grace Abbott in February, 1923,

expressing concern about Monger's attitude.¹²

She explained that after a confidential interview with Dr. Leland,

(who retained his position as chief of the Division of Child Hygiene),

she went to see Ohio's new health officer. She asked Monger if he

would appear before the Ohio joint state legislative council of women's

9. The maximum appropriation available to Ohio for 1922 was $17,993.41, but only

$7,187.95 was actually accepted. "Promotion of the Welfare," CB pub. No.203, p.3;

Letter of acceptance of the Maternity and Infancy Act from Governor Harry L. Davis to

Grace Abbott, December 27, 1921, CBP, RG #102 Box 251, 11-37-1, NA; Letter from

W. Albert Davis, Ohio Director of Finance, to Snively, April 11, 1922, CBP, RG #102

Box 251 11-31-1, NA.

10. John E. Monger (1878-1932) was born in Connersville, Indiana. In 1890, his

family moved to Greenville, Ohio. In 1902, he was graduated from the University of

Cincinnati College of Medicine. After graduation, he set up a general practice in

Greenville until 1917 when he became state vital statistics registrar (1917-1920) and

moved to Columbus, Ohio. "Ohio's New Health Director," (OSMJ), 19 (February,

1923), 76.

11. Juliette Sessions, "Report of State President," The Ohio Woman Voter (OWV),

I (June, 1923), no.12, 4; Grace R. Peters, "The Sheppard-Towner Act in Ohio," OWV,

11 (February, 1923), no. 8, 9.

12. Lucia Johnson Bing was born in North Amherst, Massachusetts, and received an

A.B. from Smith College. Her husband, Simeon H. Bing, taught at Ohio University. She

served as the executive secretary of the OLWV and as the NLWV chairperson for child

welfare as well as a state representative on the NLWV board. During World War I she

served on the Women's Committee for National Defense and later as head of the

child-placing department of the Cleveland Humane Society and superintendent of state

charities for the Ohio Department of Public Welfare. Ruth Neely, ed., "Lucia J. Bing,"

Women of Ohio, (Cleveland?, circa 1939), vol.3, 941.

110                                                   OHIO HISTORY

patronizing tone of Monger's remarks, Sessions and Bing must have

regretted his reliance on members of the American Medical Associa-

tion (AMA) for an opinion about the bill. The AMA was the Sheppard-

Towner Act's strongest opponent, and the Ohio State Medical Asso-

ciation was the most vocal state organization which helped to shape the

national organization's official anti-Sheppard-Towner policy.¹⁴

Ample evidence of opposition to Sheppard-Towner by Ohio's pro-

fessional medical organization exists in editorials of the Ohio State

Medical Journal (OSMJ). For example, the journal's editorial board

endorsed the congressional testimony of Dr. Charles E. Humiston,

president of the Illinois State Medical Society who contended that the

"principle of federal state aid as a means of financing public health

activities, is financially and economically unsound, and is unfair and

unjust as a method of taxation." The journal agreed that "public health

work is a function of the state and local governments and should be

paid out of state and local funds and directed by state and local

officials." The rationale was that the "furnishing of instruction or care

to mothers or any other persons needing such instruction is just as

much a function of local government as is the providing of food and

clothing for the destitute . .." and that the "assumption and exercise of

these functions by the Federal Government is an invasion of the

legitimate activities of the state." In 1923, as the Ohio legislature

deliberated about matching funds, the journal praised opponents of the

Sheppard-Towner Act and contended that "the federal encroachment

upon state rights is brought about through sympathetic appeals and

'sob-sister' yarns" and argued that "taxpayers pay every cent of it and

much more than they probably would if the states looked after affairs

rightfully their own, because, the farther the supply depot is from the

place where the supplies are to be used, the more it costs to deliver

them." ¹⁵

and was graduated from the University of Michigan in 1893. She also did some graduate

work at Harvard and Columbia. Sessions taught history and civics in the Columbus

public schools for 24 years, then served as a Board of Education member from 1922-27

and as its president from 1927-29. She was active as a suffragist and in the OLWV until

her death. "Miss Juliette Sessions," OWV, 8 (January, 1930), no.6, 5.

14. In 1920, there were 7,802 physicians in Ohio, 2,432 of whom were members of the

AMA. Only New York (5,302), Pennsylvania (4,407), and Illinois (4,584) had more AMA

members. The Ohio State Medical Association had joined with the state medical

societies in Massachusetts, New York, Illinois, and Indiana to lead the medical lobby

opposing Sheppard-Towner. During the AMA's 1923 San Francisco convention the Ohio

delegation exceeded that of any state not directly bordering California; James G.

Burrow, AMA: Voice of American Medicine, (Baltimore, 1963), 399, 402; Lemons, "The

Sheppard-Towner Act," 780.

15. "Ohio Again to the Front," OSMJ, 19 (July, 1923), 553; "Federal-State-

Saving Mothers and Babies                                     111

At its annual meeting in Cincinnati on May 4, 1922, the Ohio State

Medical Association had adopted a resolution stating "that it was the

opinion of the Association that the Sheppard-Towner Act may not

function in the best interest of the public and resolving that the

committee on public policy and legislation be directed to use its every

honorable means to deter the Ohio Legislature from the appropriation

of any monies for the purpose of providing medical attendance under

the provisions of the said law.^"16 In response to criticism from the

OLWV, Dr. J.H.J. Upham of Columbus, chairman of the Ohio State

Medical Association, explained that members of the State Medical

Association had helped to prepare the state's proposed Sheppard-

Towner Plan sent to Washington for approval. Upham and other

members of the Ohio State Medical Association contended that they

believed "earnestly in the dissemination of proper educational material

and adequate supervision of obstetrical practice." But they argued

"that this work can best be done by the states; themselves or their local

subdivisions rather than through a federal, detached, impersonal,

expensive and paternalistic system." Throughout the life of the

Sheppard-Towner program, OSMJ articles condemned it. 17

Another group of opponents in Ohio pointed to the fact that the

program's benefits were available to all citizens, and not just those

unable to afford private medical services. Bleeker Marquette, head of

the Cincinnati Community Chest, feared that he would have a difficult

time gaining support for such a program in Cincinnati. Marquette

wondered why "it was deemed advisable to make provisions of the Act

available not only to those who might need assistance, but for all

residents of the state regardless of their financial condition." While he

denied that he held such a belief, he maintained that he could "foresee

opposition to the Bill on this point." Marquette believed that some

Cincinnatians might oppose any plan which threatened to violate local

control over charity work. This interpretation was a misunderstanding

of the Sheppard-Towner Act's intention because it failed to recognize

Medical Problems," OSMJ, 17 (September, 1921), 603-04; see original testimony

U.S. Congress, House, Committee on Interstate and Foreign Commerce, Hearings on

H.R. 2366, 67th Congress, 1st session, (Washington, D.C., 1921).

16. "Two Resolutions:" OWV, I (June, 1922), no.l, 14; "Maternity and Infancy,"

OSMJ, 18 (August, 1922), 540; for a reprint of the resolution see "The Seven Years

History of the Sheppard-Towner Maternity and Infancy Act With Special Reference to

Activities in Ohio," OSMJ, 25 (July, 1929), 563-64.

17. "Medical Men vs. Mothers?" OSMJ, 18 (October, 1922), 700-01; "The Seven

Years History," p.564; see for example these articles in the OSMJ: "Facing Federal

Fallacies," 19 (March, 1923), 200; "Modern Meiosis," 19 (April, 1923), 277; "The

Federal Aid Fallacy," 19 (April, 1923), 2; "The Sheppard-Towner Act," 22 (March,

112                                                     OHIO HISTORY

that the purpose of the legislation was to encourage good maternal and

infant care for all Americans regardless of socioeconomic status.18

Major support for the Blossom Bill, in Ohio and elsewhere, was led

by the state League of Women Voters. The OLWV had adopted

a resolution at its state convention May 11-12, 1922, advocating

"an appropriation by the legislature to the State Department of Health

for administration of the Sheppard-Towner Law." An article in

the OLWV's publication, The Ohio Woman Voter, characterized hos-

tility to the bill as "Medical Men vs. Mothers." Members of the

OLWV lobbied state legislators and "some progressive men in the

state Medical Society" were asked to see Dr. Monger to gain his

backing. In addition, Bing and Sessions persuaded Abbott to send a

Children's Bureau staff physician, Ethel M. Walters, M.D., to Ohio to

help lobby for passage of the bill. There were some pro-Sheppard-

Towner physicians, like the Cincinnati obstetrician who wrote Abbott

that he was "heartily in favor of it," but the majority of the state's

organized doctors opposed such legislation.19

The Ohio Woman Voter urged passage of the Blossom bill by noting

that "Ohio loses 800 mothers and 11,000 babies each year from

preventable causes." In an effort to quiet fears that the act breached

parental rights, it explained that "no official under this Act may enter

any home over the protest of the parents or guardian of a child." And

finally, it emphasized that the "service contemplated in Ohio under

this Act is purely educational." The OLWV instructed its members to

"KNOW the Sheppard-Towner Act, THINK it, TALK it, and USE

ALL YOUR INFLUENCE that the State Legislature MAKES the

1926), 203; "Purpose of Federal Maternity Aid," 22 (October, 1926), 835; "Sophistry of

Paternalism," 23 (January, 1927), 19-20; "Sheppard-Towner Activities," 24 (January,

1928), 56; "The Sheppard-Towner Act," 24 (February, 1928), 107; "Maternity and

Infancy Developments in Ohio Under Sheppard-Towner Act As Set Forth in An Official

Report," 24 (November, 1928), 886-88; "The Seven Years History," 25 (July, 1929),

563-67.

18. Bleecker Marquette, Cincinnati Community Chest, to Julia Lathrop (then chief of

the Children's Bureau), November 24, 1920; Lathrop answered that the "bill is designed

to emphasize public responsibility for the protection of life just as already through our

public schools we recognize public responsibility for the education of the child....

otherwise I fear that the service would degenerate into poor relief." December 1, 1920,

CBP, RG #102 Box 232, 10-6-0 NA.

19. "Two Resolutions," 14; Upham's explanation of the Ohio State Medical Asso-

ciation's position was in response to this editorial. Bing and  Sessions

to Abbott, February 9, 1923, and letter from Cincinnati Obstetrical Society Member,

Dr. Emil J. Alban, to Lathrop, December 13, 1920, CBP, RG #102 Box 232, 10-6-0,

NA; Memo from Mrs. Lucia Johnson Bing to Miss Abbott, February 18, 1923, Caro-

line E. Newburgh to Abbott, March 3, 1923 and Bing to Abbott, March 10, 1923, CBP,

RG #102, Box 251, 11-37-2, NA.

Saving Mothers and Babies                                             113

FULL APPROPRIATION and ACCEPTS the ACT which will give

Ohio a greater chance to protect the mothers and babies of the state."²⁰

Along with drawing support through the Ohio Woman Voter, Juliette

Sessions lectured and led discussions throughout the state. In March,

1923, she spoke to a meeting of the Cincinnati League of Women

Voters (CLWV). Significantly, the CLWV felt that the topics of Miss

Session's speech-maternity and infant health care, equal guardianship

of children, and child care-would not be of sufficient interest to the

mostly male members of the Cincinnati Chamber of Commerce and

therefore did not seek a suggested joint meeting of the two organiza-

tions. They apparently felt that the Maternity and Infancy Act was

solely a women's issue.²¹

Mainly due to the efforts of the OLWV and political pressure applied

by a female member of the state senate, Maude C. Waitt (R), H.B. No.

583 passed the Ohio House (81-2) and Senate (31-0).22 This bill and the

matching funds appropriation bill (H.B. No. 622) were signed into law

by Governor Vic Donahey on April 24, 1923, making a total of

$43,843.46 (a $5,000 outright grant, plus a match of $38,843.46) of

federal funds available annually to Ohio beginning July 1, 1923. While

amendments attached to the Ohio acts reflected some of the concerns

of the program's opponents, Sheppard-Towner supporters had suc-

cessfully persuaded Ohio politicians that efforts to save the lives of

mothers and babies were worthy of such an experiment.²³ The Ohio

Sheppard-Towner program was designed to reduce the state's maternal

20. Ibid.; See also Minutes of the Executive Board of the Cincinnati League of

Women Voters (CLWV), April 2, 1923, Mss qL434, box 18, folder 1, Cincinnati

Historical Society (CHS); Peters, "The Sheppard-Towner Act in Ohio," 9.

21. Minutes of the Executive Board of the CLWV, January 22, 1923, Mss qL434 box

18, folder 1, CHS.

22. The other female members of the Ohio legislature included Nellie B. Loughead

(Senate: R-Cincinnati), May M. Van Wye (House: R-Cincinnati), Lulu T. Gleason

(House: R-Toledo), Adelaide Ott (House: R-Mahoning County), and Nettie M. Clapp

(House: R-Cuyahoga County); "Ohio's Female Legislators," OWV, 1 (February, 1922),

no.8, 1-2.

23. Amendments adopted in Ohio also reflected the concerns of the program's

opponents. Similar to a condition attached to the federal law, Section 2 of Ohio 1237

declared that "no official, or agent, or representative, in carrying out the provisions of

this act shall enter any home or take charge of any child over the objection of the parents,

or either of them or the person standing in loco parentis or having custody of such child."

Furthermore, Section 4 specified that "[N]othing in this act shall be construed as

authorizing, or permitting, the expenditure of any public moneys to provide medical or

nursing attendance or service." "Policies Formulated for Application of Sheppard-

Towner Maternity and Infancy Provisions in Ohio," OSMJ, 19 (June, 1923), 448; "The

Seven Years History," 564; R.G. Leland, "Ohio Sheppard-Towner Activities," (Colum-

bus: State Department of Health, November 22, 1924), CBP, RG #102, Box 251, 11-0-1,

NA; H.E. Kleinschmidt, M.D., "Administration of Sheppard-Towner Act in Ohio,"

OSMJ, 22 (August, 1926), 697.

114                                                      OHIO HISTORY

and infant mortality rates by promoting the "welfare and hygiene of

maternity and infancy.^"24 Accomplishing this task was the responsi-

bility of the State Department of Health.²⁵

Designing Ohio's Program

In 1921, the Ohio State Department of Health consisted of eight

divisions, each responsible for a separate aspect of public health:

Administration, Communicable Disease, Sanitary Engineering, Labo-

ratories, Vital Statistics, Industrial Hygiene, Public Health Nursing,

and Hygiene. The provisions of the federal act required that each state

have a separate office of child or maternal and infant hygiene to

administer the Sheppard-Towner program, so a separate Division of

Child Hygiene with Roscoe G. Leland, M.D., as head was installed.²⁶

After the Ohio legislature funded Sheppard-Towner, State Director

of Health Monger formed a state advisory committee of physicians,

nurses, and representatives from some of the state's health organiza-

tions to formulate a maternity and infancy health program. These

individuals met in Columbus on May 11, 1923, with officers of the State

Department of Health and the Public Health Council. The group

recommended that the "entire program of activity under the provisions

of this law should be educational and preventive including the educa-

tional work to be carried on under the State Department of Health

jointly with the approval and cooperation of the local profession [and]

should be limited to instruction and to demonstrations accruing as

benefits to the entire community and not as personal service to

individuals." It maintained that if "in exceptional cases or in emer-

24. The state's 1922 infant mortality rate was 72 per 1,000 live births, placing it

twelfth of thirty-one reporting states. The maternal mortality rate was 66 deaths per

10,000 live births ranking thirteenth; "Promotion of the Welfare," CB pub. No. 203,

132-37.

25. An Ohio State Board of Health was established in 1886. In 1917, the Board was

abolished and the State Department of Health created by the Hughes-Griswold Health

Law. This legislation required that each of Ohio's 93 cities and 88 counties establish

departments of health headed by medical professionals. Both physicians and nurses

served as district health officers. Prior to 1917, there were approximately 2,150 city and

township health departments headed by medically and non-medically trained political

appointees. The 1917 law also created the positions of Ohio Commissioner and Assistant

Commissioner of Health, and a four member Public Health Council. In 1921, the

Commissioner of Health position became the Director of Health. H.G. Southard, M.D.,

Ohio Department of Health, An Historical Review: Its Powers, Duties, and Organiza-

tion, (Columbus, 1933).

26. Ohio had established a Division of Child Hygiene on October 1, 1915, but on July

1, 1919, this separate division became a part of the Division of Hygiene. Thirty-first

Report of the Department of Health, (Columbus, 1930), 197.

116                                               OHIO HISTORY

By including members of the State Medical Association in the

planning stages, Monger was able to gain the cooperation of many Ohio

doctors. In a memo summarizing the state's earliest Sheppard-Towner

work, he concluded that Ohio already had many of the necessary

programs and facilities needed to begin to combat the unnecessary

deaths of mothers and babies, but he was especially pleased to have

"that most powerful of allies, a well organized and devoted medical

profession."²⁸ According to the OSMJ, the Ohio law which "properly

limited" state programs to educational and diagnostic work was a

necessary "safeguard," designed to eliminate from the work possible

abuses of the program and made cooperation by many physicians

possible.²⁹

The state advisory committee, with Monger as chairman, outlined

three programs for spending Sheppard-Towner funds. First, the Health

Department would conduct research programs about three problems: a

statewide survey of the causes of infant and maternal mortality; a study

of hospital reporting procedures in an effort to standardize statistical

records; and a statewide study of midwives practicing in Ohio. Second,

create a series of "district demonstrations" which would "show the

application of practical, specific health education in which every

agency in the community is invited to take part." Third, set up a series

of conferences run by pediatricians, orthopedic surgeons, or other

specialists designed to "interest the public in regular, periodic health

examinations for expectant [sic] mothers and children as well as the

presumably normal adult and to enlist the complete sympathy, under-

standing and cooperation of the medical profession." Monger stated

that another part of this effort was to "exert a definite part of our

energy in the direction of immunizing the preschool child against

smallpox, diptheria and typhoid fever." He again noted that it "should

be kept in mind that this entire work is solely educational and

diagnostic in nature."30

Monger wanted to combine the support of physicians, nurses, and

women volunteers to make the Ohio Sheppard-Towner program a

success. Although he did not choose to include non-medically trained

women on the state's advisory committee, he argued that "to none is

28. "Ohio Sheppard-Towner Activities," undated memo (summer, circa 1923) from

John E. Monger to the Children's Bureau, CBP, RG #102, Box 251, 11-37-1 1-2, NA.

29. "The Sheppard-Towner Act," OSMJ, 22 (March, 1926), 203.

30. Ibid., 1-2, and "Policies Formulated for Application," OSMJ, 448; Dr. Monger

believed that the support of the organized medical profession was necessary if he was

successfully to reduce Ohio's maternal and infant mortality rates under the Sheppard-

Towner program, and he continually declared that all levels of the state program

preserved the "professional relationship between patient and physician." 4.

Saving Mothers and Babies                                  117

the interest greater, nor should it be, than to the women of the state,

wherever they may be found, or in what circumstance of life." He

concluded that "there is no phase of public health administration and

work that does not touch the home and woman who is the center of the

home."31 In cooperation with Monger, the OLWV urged its members

to participate in the organization of local health conferences for the

public and "to become active in assisting both the local and central

[health] department[s] in the furtherance of their work." Women

volunteers, under the direction of the local health director, could help

with well baby and child health conferences across the state.³²

One aspect of the Ohio plan for general health educational activities

appeared opposed to the Children's Bureau's instructions directing

that state Sheppard-Towner programs deal exclusively with maternal

and infant health care, yet Ohio's general health plan was deliberately

designed so that none of the Department's nurses would be restricted

to maternal and infant matters. Leland explained that Ohio's proposed

program took into consideration the fact that "for a number of years

we have struggled to establish throughout Ohio a system of generalized

public health nursing and at the present time this form of public health

nursing is accepted as the most desirable, efficient and productive."

The Children's Bureau's Dr. Anna M. Rude wrote Leland that

"allowing a general health program  would absolutely defeat the

purpose" of the Sheppard-Towner Act. But, she continued, "I agree

with you entirely that it is not possible in rural areas to do specialized

public health nursing and consequently it will be possible for you to

continue upon a general nursing program, paying only for so much of

the nurse's time as is spent specifically for maternity and infancy from

Federal or State funds used in matching."³³ The Ohio Department of

Health accepted this practical expedient.

In an August 20, 1923, letter Grace Abbott told Monger that all

phases of the Ohio plan for fiscal 1923 and 1924 except the goal to

"emphasize those general public health measures which are essential

to the success of any personal or public health program" had been

approved. Abbott explained that both state and federal matching funds

"must be used for specific maternity and infancy activities," not

general health work.³⁴

31. John E. Monger, M.D., "From Before Birth to Death: State Department of

Health Protects Ohioans," OWV, 5 (January, 1927), no.7, 7.

32. "Sheppard-Towner Work Begins," OWV, 2 (November, 1923), no.5, 9.

33. Letter from Dr. R.G. Leland to Anna M. Rude, August 9, 1923, CBP, RG #102,

Box 251, 11-37-1, NA; According to Rude, this expedient was followed by other states

which used from one-sixth to one-half of a nurse's time. Letter from Anna M. Rude to

R.G. Leland, August 14, 1923, CBP, RG #102, Box 251, 11-37-1, NA.

34. Letter from Grace Abbott to Dr. John E. Monger, copy to Dr. Leland August 20,

118                                                      OHIO HISTORY

The Ohio Program at Work

The first Ohio Sheppard-Towner project was a survey of approxi-

mately fifty midwives practicing in the state during 1922. In this survey,

midwives were divided into three groups: those licensed and practic-

ing, those unlicensed but practicing and those licensed but not prac-

ticing. Another such study was done in 1923. The names of midwives

who delivered babies during these two years were taken from birth

certificates and checked against a roster of midwives registered with

the Ohio State Medical Board, the state licensing body. At the time, all

midwives practicing in Ohio were required to qualify before the State

Board of Medical Examiners and were licensed by the State Medical

Board. The names of midwives found in this study were grouped by

county and sent to district health commissioners. Efforts to regulate,

and in many cases to eliminate, midwives had been part of the health

reform movement in the United States since the mid-nineteenth

century. Many physicians and women's health reformers argued that

midwives contributed to the nation's high maternal mortality rates.³⁵

By the 1920s, at least in urban areas, the goal to eliminate the midwife

from obstetrics was largely successful. In Cincinnati in 1880, for

example, 71 percent of all births in the city were attended by midwives,

each of whom delivered an average of 70 babies per year. During 1924,

midwives attended only 2.8 percent of the births in Cincinnati. This

meant that eleven practicing Cincinnati midwives assisted an average

of only 22 deliveries each.³⁶ Midwives continued to practice in greater

1923, CBP, RG #102, Box 251, 11-37-1, NA: Abbott's letter officially opened the way for

the institution of specific projects designed by the Ohio State Department of Health as

addressed by the State Advisory Committee and the Public Health Council. The Ohio

Department of Health Divisions of Vital Statistics and of Public Health Nursing

cooperated with the Division of Child Hygiene in implementing the state's Sheppard-

Towner program. The Division of Child Hygiene directed the work with its eleven-

member staff. The Division's staff included director Leland, one part-time physician,

two staff nurses and seven "Sheppard-Towner nurses," one nutritionist, one vital

statistics clerk, one individual in charge of publicity, one financial clerk, two movie

projector operators, and one lecturer. For a general summary of the early Ohio

Sheppard-Towner Activities, see "Ohio Sheppard-Towner Activities," (circa 1926) an

undated and unsigned report, CBP, RG #102, Box 251, 11-37-1, NA; and Kleinschmidt,

"Administration of," 697-700; The Ohio Department of Health's official report for the

entire period (1923-29) appears in Thirty-first Report, (1929).

35. See Frances E. Kobrin, "The American Midwife Controversy: A Crisis of

Professionalization," in Judith Walzer Leavitt, ed., Women and Health in America:

Historical Readings, (Madison, 1984), 318-25; Charles Edward Ziegler, "How Can We

Best Solve the Midwifery Problem?" American Journal of Public Health, 12 (May,

1922), 405-13.

36. "The Midwife in Cincinnati," Cincinnati's Health, (October 14, 1925), 9.

Saving Mothers and Babies                                       119

numbers in states where either few physicians were available or high

numbers of immigrant or black populations lived.37 In Ohio, like most

areas of the country, the number of midwives continued to dwindle. By

1931, midwives delivered only 1,131 Ohio babies, a mere 1.1 percent of

state births.³⁸ The Ohio midwifery studies undertaken with Sheppard-

Towner funds were an example of the desire by many physicians and

other health reformers to restrict and eliminate midwives from the

obstetrical profession. A Department of Health report on the first two

years of Sheppard-Towner program in Ohio lamented that "[t]hou-

sands of mothers of Ohio pass through pregnancy and labor alone or

attended only by incompetent midwives."³⁹ Many, if not most, Ohio

physicians must have shared this sentiment.

A second research project, done by the Department of Health's

Division of Vital Statistics, gathered data pertaining to maternity and

infancy. These were used to compile tables showing maternal, infant,

and stillborn death rates by city, county, ethnicity, and age. Another

set of tables was assembled showing the major causes of death for both

infants and mothers. The results of this project demonstrated that the

incidence of preventable infant deaths was declining. They also showed

that Ohio's black babies died at three times the rate of white infants.

The research identified three major causes of death for mothers:

puerperal septicimia, toxemia, and "accidents of pregnancy." The first

was especially disturbing because septicimia infection was preventable

through simple sanitary techniques. Moreover, it was largely through

the carelessness of birth attendants, most often physicians, that the

deadly infection was spread from one woman to another. Physicians

were more often guilty than midwives because they frequently attend-

ed patients sequentially. This was especially true in hospitals. The

second highest cause of death to pregnant women was toxemia, also a

largely preventable cause of death. Maternal deaths caused by toxemia

were usually a result of poor prenatal care. The third category,

37. For an instance of successful use of midwives to help save the lives of rural

women and babies, see Nancy Schrom Dye, "Mary Breckinridge and the Frontier

Nursing Service, and the Introduction of Nurse Midwifery in the United States,"

Leavitt, ed., Women and Health in America, 32744; for a discussion of Sheppard-

Towner and Midwives in southern states see Molly Ladd-Taylor, " 'Grannies' and

'Spinsters': Midwife Education Under the Sheppard-Towner Act," Journal of Social

History, 22 (Winter, 1988) no.2, 255-76.

38. Ohio State Department of Health, "Summary of Statistics for Deaths and Births,

1930, 1931 and 1932," (Columbus: State Department of Health Division of Statistics),

mimeographed report, 24. The Sheppard-Towner reports on Ohio Midwives have not yet

been found.

39. Kleinschmidt, "Administration of," 697-98.

120                                                OHIO HISTORY

"accidents of pregnancy," included criminal abortions, complications

caused by syphilis, and accidents which occurred during labor which

could have been caused by an incompetent birth attendant. Some

critics attributed the rise in death due to accidents in labor to the

growing tendency by physicians to use instruments to aid or hasten

labor. Dr. H.E. Kleinschmidt, Ohio's Chief of the Division of Child

Hygiene after Leland's resignation in 1925, claimed that it was the use

of new obstetrical techniques by the "less apt" that resulted in many

deaths. This Sheppard-Towner project was continued by Ohio after the

federal act expired.⁴⁰

The third research project gathered information about Ohio's mater-

nity homes and hospitals with maternity beds. This was an especially

important task due to the increasing number of babies being born in

hospitals during the 1920s and 30s. In Cincinnati, for example, in 1910

a small minority (estimated at fewer than 15 percent) of babies were

delivered in hospitals. By 1922 that percentage had increased to 42.3

percent; it would reach 90 percent by 1939. This phenomenon was part

of a national trend.⁴¹ The Ohio Department of Health found that by

1925 there were 198 maternity homes and hospitals in the state which

provided 2262 maternity beds. Sheppard-Towner funds made annual

inspection and licensing possible.⁴²

The second program instituted during the first two years of Ohio

Sheppard-Towner work was the establishment of four "district dem-

onstrations." Instead of spreading the "meager" funds appropriated

under the Sheppard-Towner Act "all over the state, the Director of

Health decided upon four demonstrations, one each in a mining

settlement, a rural district, a small town community and an urban

center."⁴³ A state report explained that many "factors determined the

placing of a district demonstration but since these were to be used to

show local communities practical methods of saving the lives of

mothers and babies, one of these determining factors was a high

maternal and infant death rate." Sheppard-Towner funds paid for

"eight Ford coupes" purchased for use by the Department's public

40. Ibid., 698; The Department of Vital Statistics included these numbers in its yearly

annual report.

41. Cincinnati Department of Health, Cincinnati Sanitary Bulletin, (January, 1923);

By 1939, 90 percent of all Cincinnati babies were born in hospitals; Neal Devitt, "The

Transition from Home to Hospital Birth in the United States, 1930-1960," Birth and the

Family Journal, 4 (Summer, 1977), no.2, 47-58.

42. The Department's count included both maternity homes and hospitals; "Ohio

Sheppard-Towner Activities," CBP, Box 251, 11-37-1, 5.

43. "Cincinnati's Participation in Sheppard-Towner Work," Cincinnati Sanitary

Bulletin, 8 (September 10, 1925), no.3, 6.

Saving Mothers and Babies                                        121

health nurses. Ultimately, public health nurses performed the bulk of

the work in the first four district demonstrations and established the

pattern followed in all subsequent Ohio Sheppard-Towner demonstra-

tion projects. The first four projects were established in Belmont,

Richland, and Athens counties, and in Cincinnati.⁴⁴

The Belmont County, Ohio, demonstration began in September 1923

and continued for thirty-five months. Like the other three demonstra-

tion sites, Belmont was chosen because of its high maternal and infant

mortality rates, "there being many mining villages of foreigners and a

large colored population," and "because the health agencies are

especially interested."⁴⁵ Both the county health department and the

county medical association were anxious to participate. Dr. Monger

explained to the Belmont County Medical Society that work in all

Sheppard-Towner demonstrations with expectant mothers would en-

courage "the necessity of securing early and competent medical

attention . . ." and "after the work was well under way and the plan

'sold' to the districts, the state would gradually withdraw and allow the

work to continue under local auspices." Dr. Leland described Belmont

as "an agricultural and mining county of large area" with "energetic

but over-worked health department personnel."⁴⁶ Two nurses from the

State Department of Health were added to the county health depart-

ment's staff of three public health nurses. Under the plan devised by

the Ohio Department of Health and the state advisory committee, the

work done in the demonstration in this county was general public

health nursing. But since the combined Federal-State funds supplied

salaries for two nurses, it followed that to satisfy federal requirements

each of the five nurses was expected to devote at least two-fifths of her

time to the welfare and hygiene of mothers and babies, as provided for

in the agreement with the Children's Bureau.⁴⁷ This pattern of

Sheppard-Towner nurse use was generally followed statewide.

44. "Ohio Sheppard-Towner Activities," CBP, 6.

45. "Sheppard-Towner Work Begins," OWV, 9-10; "Infant Hygiene in Belmont

County," OSMJ, 19 (August, 1923), 609. From 1919-1922 the county's infant mortality

rate was 99.4 and the maternal mortality rate was 72, as opposed to state wide figures of

76 and 68; The Promotion of the Welfare and Hygiene of Maternity and Infancy: Fiscal

Year Ended June 30, 1928, (1929), CB pub. No.186.

46. "Infant Hygiene," 609; Monger met with the County Medical Society on July 10,

1923: "Progress of the State Department of Health in Maternity and Infancy Work,"

OWV, 2 (March, 1924), no.9, 15.

47. "Ohio Sheppard-Towner Activities," CBP, p.6; Kleinschmidt, 699. The first

public nursing service in Ohio was provided by the Cincinnati Maternity Society

beginning in 1882. See Kriste Lindenmeyer Dick, "The Silent Charity: A History of the

Cincinnati Maternity Society," Queen City Heritage, 43 (Winter, 1985), no.⁴, 29-33. A

state Bureau of Public Health Nursing was established in 1913.

122                                               OHIO HISTORY

The second demonstration was in Richland County in northcentral

Ohio. Again, two state nurses were added to the county's staff of three.

In 1922, prior to Ohio's acceptance of the federal Maternity and

Infancy Act, the National Child Health Council had begun coordinating

a "Child Health Demonstration" in Mansfield, the county seat. The

Council, made up of representatives from the American Child Hygiene

Association, American Red Cross, Child Health Organization, Nation-

al Organization for Public Health Nursing, and the National Tubercu-

losis Association, set aside $200,000 to be spent over five years to

encourage coordination of children's welfare organizations in "a

typical American community." According to the project's director, Dr.

Walter H. Brown, the "chief purpose was to select a city and county

which would be fairly typical of the average of American life, the city

to have a population of between 20,000 and 30,000 and the rural area

surrounding it an equal number." The plan included some other

specific requirements:

... that a normal percentage of the population should be engaged in manufac-

turing; there should not be any striking predominant racial stocks; there should

be a variety of industries; the surrounding area should be an agricultural

territory; the community should be located in the birth registration area and

vital statistics should be fairly complete; the mortality of infants and children

should not be strikingly abnormal. Finally, and most important of all, the

[local] medical, dental, and social organizations ... would welcome the

opportunity of cooperating in such a Demonstration.48

After "a long and careful study of approximately eighty communities

which applied for the Demonstration," the Child Health Council

decided Mansfield and Richland County "most nearly met the require-

ments." Only the project director, Walter Brown, was sent by the

Child Health Council. Local health professionals and social workers

formed the project's staff. Funds from the Council established a

primary health clinic in Mansfield and secondary centers throughout

the county. To avoid attack by medical conservatives the project's

director denied that it was a form of "State Medicine" or a violation of

the "rights and privileges of the physician in the field." By March 1924

the Child Health Council had helped local Richland and Mansfield

officials to coordinate a plan for a joint city and county health

department, and the Council began to taper off its own direct partici-

pation in the project.⁴⁹

48. Walter H. Brown, M.D., "Child Health Demonstration Conducted in Mansfield

by National Child Health Council and Cooperating Agencies," OSMJ, 18 (September,

1922), 629.

49. Ibid., 630; "Progress of the State Department of Health," 15.

Saving Mothers and Babies                                      123

Later that year the Ohio Department of Health sent two Sheppard-

Towner nurses to assist the three Richland County staff nurses. From

1924 to 1926, there were 442 live births and seven stillbirths to mothers

who received prenatal instruction under the combined state and county

health demonstration. None of the women receiving prenatal care died.

During the same period, there were 795 live births and 28 stillbirths to

Richland County women who received no prenatal instruction, and five

of these mothers died. In the supervised group, the infant mortality rate

was 22.6 (deaths of children under one year of age per 1,000 live

births); it was 84.6 in the unsupervised group. Thus stillbirths were less

than half as frequent among mothers with prenatal care (1.6 percent as

opposed to 3.4 percent) and the infant mortality rate was 235 percent

higher among babies whose mothers were not included in the project.⁵⁰

The third demonstration was in Athens county, a rural area in

southeastern Ohio. One Sheppard-Towner nurse was sent "to do some

intensive work in maternal and infant hygiene" from 1924-1926.

Mining was the primary industry in the county. In the three years prior

to the beginning of work by the state's Sheppard-Towner nurse

(1921-1923), Athens county had a maternal mortality rate of 85 per

10,000. During the two years of work under the Maternity and Infancy

Act. the maternal mortality rate dropped to 67.⁵¹ Again, the same type

of instructional and diagnostic program was delivered to the women of

Athens County as in the two previous examples.

The fourth demonstration took place in Cincinnati. It differed from

the other three projects because it took place in an urban area

(population approximately 414,000) and was specifically focused on

saving the lives of only one group: black mothers and babies. The city's

1920 population was 81.8 percent native-born white, 10.7 percent

foreign-born white, and 7.5 percent black. A study of the city's health

services in 1926 found that the maternal death rate for black women in

Cincinnati was 143 per 10,000 live births while for white women it was

102. The infant mortality rate for black babies was 133 per 1,000 live

births and 69.7 for white.⁵² With an appropriation of approximately

50. "Promotion of the," CB pub. No. 186; These figures do not include statistics from

the cities of Mansfield and Shelby. The combined city and county health department was

not fully in place until after the close of the project.

51. "Progress of the State Department of Health," 15; "Promotion of the," CB pub.

No.186: No separate statistics for women who received prenatal and infant care

supervision are available, but maternal mortality rates before and during the implemen-

tation of Sheppard-Towner work are obtainable.

52. Although after Sheppard-Towner work in Cincinnati, the most specific maternal

mortality rates for Cincinnati women during the 1920s are in An Appraisal of Public

Health Activities in Cincinnati, Ohio for the Year 1926, (New York and Cincinnati, 1927),

58-60.

124                                             OHIO HISTORY

$6,500 the State Department of Health purchased some equipment for

two Cincinnati Department of Health clinics, sent two of the state's

eight "Ford coupes" there, and paid the salaries of two black nurses

hired to perform maternity and infant care in Cincinnati's downtown

basin and West End neighborhoods where 68 percent of the city's black

population lived. These women worked with three black nurses already

on the city's staff. This Sheppard-Towner project began in late 1923

and continued until June 30, 1925.⁵³

The "primary object was to secure, as far as possible, medical care

of mothers and babies before, at, and after birth" by maintaining a

roster of all black babies born in Cincinnati from the beginning of 1923

to the end of the project. From this roster the nurses made home visits

and encouraged new mothers to bring their infants to health clinics

established at Frederick Douglass and Harriet Beecher Stowe schools

located in the area. Clinics were open daily during the summer and one

afternoon per week the rest of the year. Seven hundred thirty-eight

different children were brought to the stations for "physical examina-

tions, advice, and observation." One of the nurses also made daily

visits to the St. Andrew's Day Nursery. The importance of the nurses'

home visits and inquiries in the neighborhood which identified expect-

ant mothers was recognized by the Cincinnati Department of Health

when it reported that there "were times when but for the intervention

of the nurse we might have lost babies and mothers.... 54

In one case, reported in typically 1920s social work terms, a "girl

barely sixteen years old [was] taking care of a sick father, two little

brothers shut in the house becauses of measles, doing the washing for

her illegitimate baby, all in one room with the only facility for heating

water a bucket placed on the coals in a grate." A Sheppard-Towner

nurse directed the girl to the city's clinics where six months later with

"her baby shining and spotless, her own clothing clean; how proud she

was when the nurse complimented her on the beautiful care she gave

her baby." During the period of Sheppard-Towner work in Cincinnati,

839 prenatal, 5,118 infant care, and 2,064 preschool nursing visits were

made.⁵⁵

Another part of the Cincinnati program was a series of lectures for

the "colored doctors" sponsored by the pediatric department of the

University of Cincinnati College of Medicine, the Cincinnati General

53. Special attention from government health officials had been directed at the

specific health problems of Cincinnati blacks in an article of the city's Department of

Health publication, the Sanitary Bulletin, (July 10, 1919), 1.

54. Ibid., 1.

55. "Cincinnati's Participation," 6-7.

Saving Mothers and Babies                                            125

Hospital (the city's municipal hospital), and the State Department of

Health during the observance of Negro Health week in spring, 1924.

The city's Department of Health also held a "Better Babies Contest"

in conjunction with this event. Cincinnati was awarded "first prize for

the best observance in the United States" by the National Negro

Business League.⁵⁶ This was the only effort focused solely on black

mothers and babies undertaken with Sheppard-Towner funds in Ohio.^5-

After the precedent of these first four projects, State Department of

Health nurses were lent to county and city Departments of Health

throughout the life of the Sheppard-Towner program. Local health

departments supervised these women, but their salaries were paid by

the State Department of Health. Home visits to instruct mothers about

maternal and infant care were an important part of the tasks performed

by these nurses. They were considered extremely valuable because

they gave the nurses "an opportunity to see the living conditions of the

family," and to make demonstrations "with the equipment which the

home affords." In theory, as soon as the State Department of Health

judged that "funds [were] provided for their permanent continuance

[by the local community], the federal-state funds [were] diverted to

assist other communities.^"58

In another example of the use of Sheppard-Towner funds for public

health nursing, two State Department of Health nurses were assigned

to arrange examination clinics in communities under the auspices of the

local health department with the assistance of local civic groups.

Mothers were invited to bring their children to a specified place for a

56. Cincinnati Council of Social Agencies, Public Health Federation Bulletin,

(January-February, 1923), 3; Cincinnati first observed Negro Health Week in 1922; see

the same publication February-March, 1922, 14-15; For a further discussion of health

programs for blacks in Cincinnati see Andrea Tuttle Kornbluh, "Metropolitan Plural-

ism," (Ph.D. dissertation, University of Cincinnati, 1988).

57. Public Health Federation Bulletin, (January-February, 1923), 6; There is no

readily apparent evidence of reaction from blacks in Cincinnati, but Cincinnati Depart-

ment of Health director, Dr. William H. Peters, spoke about the city's Sheppard-Towner

activities for black mothers and babies at the National Interracial Conference which met

in Cincinnati in March, 1925; Toward Interracial Cooperation: What Was Said and Done

at the First Interracial Conference, (Cincinnati, 1925). Reprint edition, (New York,

1969).

58. Thirty-first Report, 199-200; Kleinschmidt, 699; "Policy Regarding Nursing

Service in Ohio Under Sheppard-Towner," OSMJ, 19 (December, 1923), 888; Athens

County (34 months), Belmont County (35 months), Cincinnati (40 months which involved

more than the district demonstration), Columbus (36 months), Coshocton County

(1 month), Darke County (22 months), Gallia County (23 months), Geauga County

(13 months), Highland County (14 months), Hocking County (17 months), Lawrence

County (13 months), Miami County (9 months), Perry County (17 months), Preble

County (22 months), Richland County (17 months), Wayne County (14 months);

Thirty-first Report, 198; "Progress of State Department of Health," 15.

126                                             OHIO HISTORY

free diagnostic examination by a community pediatrician who was paid

for this service by the State Department of Health. In January 1925

Dr. O. L. Baldwin of Columbus was added to the State Department of

Hygiene's staff to oversee these clinics. In the presence of the mother

and the family physician (if it could be arranged) the child was

"carefully examined" by a doctor paid for his services with Sheppard-

Towner funds.⁵⁹ No treatment was prescribed or given, but the mother

was "urged to visit her private physician for treatment" of the child if

that was necessary, and "if not, for periodic checking-up of the child's

health." Local physicians were interviewed by the nurses several days

in advance and invited to come to the clinic. The clinics were limited to

children under six years of age and were usually held in a school. In

connection with these clinics, an afternoon or evening was set aside for

a meeting to which mothers and older girls were invited. A movie on

pregnancy and child care was shown and a baby was examined by a

pediatrician before the audience. Under all of these arrangements the

Sheppard-Towner nurses did not "engage in so-called case work; their

efforts were not bedside nursing, but instructional."⁶⁰ The educational

work done by these nurses provided the bulk of Ohio's third phase of

the Sheppard-Towner program: "general education."

Another often-used educational tool was the health exhibition. "The

Ohio exhibit," explained a State Department of Health report, consists

of "charts, posters, a model layette, a baby's bed, articles necessary

for the baby's bath and simple home equipment for the care of

infants." This exhibit was carried around the state in an automobile

called the "Gypsy." A nurse accompanied the exhibit to county fairs

or other public gatherings where the display could be used. The State

Department of Health also used a "Health Mobile" truck which

traveled the state equipped with a generator, tent, movie projector,

health films, and literature promoting good health care.⁶¹ Films pro-

duced by both public and private health care organizations on cancer,

child hygiene, communicable diseases, care of eyes, problems of pests,

milk, public health nursing, prenatal or maternal care, smallpox,

venereal disease, teeth, and tuberculosis were frequently shown. Ohio

Department of Health physicians and nurses who accompanied this

Department's exhibition and "Health Mobile" placed special emphasis

59. "What the Divisions Are Doing-Field Notes," Ohio's Health, (January 1,

1925), 3.

60. Kleinschmidt, 699-700; Children's Conferences," Ohio Health News, (November

15, 1925), 4.

61. "Health Education by Truck," Ohio Health News, 1 (December 1, 1925),

no.23, 2.

128                                               OHIO HISTORY

Sheppard-Towner nurses also conducted educational classes in

which infant care techniques were taught to seventh and eighth grade

girls. These "Little Mothers' Leagues" were retitled "Health Build-

ers' Leagues" in 1927 when boys were included in the program.

Instruction covered the care of the baby and the preschool child,

bathing, dressing and feeding the baby, "regulation of his habits,"

methods of preparing formulas, diet of the preschool child, "social

hygiene" (which involved the prevention of venereal disease), and the

prevention of communicable diseases. The Division of Child Hygiene

prepared a handbook for leaders of these groups.⁶³

In addition to health instruction, the League booklet reinforced

popularly held beliefs concerning the "nature" of women. It claimed

that the "urge to live, protect and guide the young is a natural attribute

of all normal women" and that the "little girl's fascination for her doll

is an early manifestation of the motherhood instinct." But, the booklet

warned, the "high infant mortality rate of Ohio is a sad commentary on

the intelligence of our people. For want of knowledge our babies die."

According to the booklet, "Little Mothers' Leagues afford the oppor-

tunity to train the oncoming generation of mothers in mothercraft."

The Division recommended that these classes be led by a public health

nurse, meet weekly for fifteen weeks, and include no more than twenty

individuals.

Concern that Sheppard-Towner type programs might constitute state

interference with parental authority was evident in a note cautioning

instructors against encouraging members of the class to assume "the

responsibility of appearing to instruct their own mothers .. . ," but, it

concluded that in instances where it seemed "advisable," the mothers

could be invited to the meetings and perhaps benefit from the instruc-

tion. Despite this possible conflict, the benefits of Little Mothers' and

Health Builders' groups outweighed such concerns for 1920s reformers

because they perpetuated the important ideal that "the responsibility

for the health of her children lies with the mother" in the next

generation of parents.⁶⁴

The distribution of literature concerning the prevention of maternal

and infant mortality and morbidity was another important aspect of the

63. Thirty-first Report, 200; Little Mothers' Leagues were first proposed by Dr. S.

Josephine Baker of the New York State Department of Health. Ohio Department of

Health, Division of Child Hygiene, "Little Mothers' Leagues: A Handbook for Lead-

ers," undated pamphlet (ca.1926) located in Ohio Health Department files at the State

Library of Ohio, in Columbus.

64. Ibid., 2-12; also sees the 1927 and 1930 revised versions of the booklet entitled

The Care of Baby, provided to Health Builders' Leagues, Ohio Department of Health,

Division of Child Hygiene, (Columbus, 1930).

Saving Mothers and Babies                                   129

state's educational program. These pamphlets were largely prepared

by the U.S. Children's Bureau and the Ohio Department of Health and

were "perhaps more far-reaching than any other [effort] in its educa-

tional effect." Literature was distributed at conferences and other

meetings. And, according to a Department of Health report, "[s]carce-

ly any home was too isolated for postal service." Significantly,

materials were sent to local health departments for distribution in order

to insure that local officials and physicians retained control over the

program. The number of materials dispensed increased yearly, rising

from 100,000 pamphlets in 1925 to 242,000 in 1929.65

A similar type of program mailed "prenatal letters" to expectant

mothers at the request of their doctors or local health department.

These letters included prenatal health care advice and emphasized "the

need of keeping in close touch with the doctor." As in the case of all

efforts undertaken in Ohio with Sheppard-Towner funds, this program

did not "replace the functions of the physician, but rather create[d] a

demand for such medical service." Women who did not have a private

physician were sent letters encouraging them to select one.⁶⁶

Physicians were also the targets of maternity and infancy educational

work. The state's Director of Health and the Chief of the Division of

Child Hygiene addressed doctors through lectures and publications.

They urged higher standards of obstetrical and child care, "in the hope

that slipshod, inadequate methods which are still in vogue in some

localities will give way to a higher class of medical service." They also

urged doctors to use only state licensed and inspected maternity

hospitals for their patients.⁶⁷

Over the seven years of the act's existence, mothers and infants in

82 of Ohio's 88 counties benefited from Sheppard-Towner activi-

ties.⁶⁸ The infant mortality rate fell from 75 per 1,000 live births in 1921

to 68 in 1929, and the maternal death rate dropped from 72 per 10,000

live births to 62. During this period approximately 906,782 babies were

born in Ohio, and the State Department of Health claimed that it

reached 10 percent of the state's expectant mothers.⁶⁹ Federal funds

totalling $150,978.75 were spent, but this was only 42 percent of the

possible $359,897.63 actually available to Ohio. In combined state and

65. Thirty-first Report, 201.

66. Kleinschmidt, 700.

67. Ibid., 700; "Standards for Maternity Hospitals," OSMJ, 107-08.

68. Available State Department of Health records do not show which six counties

failed to participate in the Ohio program.

69. Ohio Department of Health, "Birth Rates by County, report #877; Thirty-first

Report, 389; "Promotion of," CB pub. No.203, 132-37; Historical Statistics, 57; U.S.

rates were: 1921 I.M. 75.6, M.M. 68.2; 1929 I.M. 67.6, M.M. 69.5.

130                                             OHIO HISTORY

federal funds, $289,849.01 were spent to save the lives of Ohio's

mothers and babies during the seven years of Sheppard-Towner's

existence.⁷⁰

State Health Director Monger wanted local communities eventually

to take on the responsibility for programs started with Sheppard-

Towner funds. This was realized in only nine Ohio counties and two

cities: Athens, Geauga, Hocking, Perry, Richland, Wayne, Preble,

Darke, and Miami counties and Columbus and Cincinnati. Private,

municipal, and county agencies combined to continue maternity and

infancy work in these areas. The state legislature did continue state

appropriations at roughly the same level, but since there were no longer

federal matching funds, the amount of money spent on maternity and

infancy work in Ohio was cut in half after June 30, 1929.71

Throughout the years of the federal Sheppard-Towner Maternity and

Infancy Act the Ohio Department of Health continued to develop its

decentralized health program established under the state's 1917

Hughes-Griswald Act. In addition, the Sheppard-Towner Act almost

exclusively involved diagnostic and educational programs. The only

exceptions were a program immunizing children against diphtheria and

another project which distributed silver nitrate to prevent blindness in

newborns.⁷² These efforts did not cause a conflict with the OSMA

because it appears that such measures were not viewed as medical

treatment. They were defined in the same context as accepted govern-

mental responsibilities for providing clean water, pure milk, and

sewers. The diagnostic and educational policy followed by the Depart-

ment of Health was formulated largely under the influence of Ohio

physicians. But ironically, the OSMA continued to condemn the

Sheppard-Towner program. OSMJ editorials denounced extension of

the program, and its criticism continued until the act's expiration on

June 30, 1929, and beyond. The OSMJ argued that it was "interested

in the reduction of unnecessary maternal and infant mortality ... "

but it was not able to support a federal maternity and infancy program

due to its "sound opposition to federal centralization; impersonal and

detached supervision; unnecessary expenses; duplication of activities

... [and] the possible development from 'education' to actual 'care and

treatment.' "73

70. U.S. Children's Bureau, The Promotion of the Welfare and Hygiene of Maternity

and Infancy: Fiscal Year Ended June 30, 1929, (1931), CB pub. No.203, 2-3; "Promotion

of the," CB pub. No.203; "The Seven Years History," 564.

71. Thirty-first Report of, 390; "The Seven Years History," 566.

72. Thirty-first Report of, 566-67.

73. "Maternity and Infancy Developments, 886.

Saving Mothers and Babies                                   131

At first it appeared to Sheppard-Towner supporters that the success

of the Maternity and Infancy Act would enable an extension to pass

easily.⁷⁴ However, the program's opponents were better organized by

1926 when the act was due for renewal. A compromise not only

extended the program for two years, but also terminated it on June 30,

1929. Efforts to sway physicians to support a federal maternity and

infancy bill had not only failed, but backfired.

Saving Mothers and Babies?

The Sheppard-Towner program in Ohio was probably not exception-

al, although no definitive statement may be made until we have some

studies of other states. It is difficult to quantify the program's

successes. One important result of the program, however, is clear.

Public awareness concerning the value of preventive prenatal and

infant health care was significantly increased, so that Ohio efforts

designed to save the lives of mothers and babies never returned to

pre-Sheppard-Towner levels.

The state's lower infant mortality rate cannot be attributed to

Sheppard-Towner alone. The infant death rate had been declining

steadily for a number of years. In 1914, 99 Ohio babies died for every

1,000 live births in the state. By the close of 1922, the number had

decreased to 74 and by the end of the Sheppard-Towner program had

fallen to a rate of 66 per 1,000.⁷⁵

A similar but less dramatic decline in the state's maternal mortality

rate occurred. In 1917, (the first year state wide maternal mortality

rates are available, and the year Ohio joined the United States

Birth-death registration area), 71 Ohio mothers died of causes associ-

ated with pregnancy for every 10,000 live births. By the close of 1928,

the maternal mortality rate declined to 64.76 Admittedly, while both the

infant and maternal mortality rates simply reflect a continuing trend,

the efforts of the Ohio Department of Health under the Sheppard-

Towner program must have contributed to this decline.

The data reported by the Ohio Department of Health show the extent

of Sheppard-Towner influence. From July 1, 1928, to June 30, 1929,

74. For example see Julia Lathrop, "Mothers and Babies First!" Woman Citizen,

7 (December, 1926), 41.

75. Ohio Division of Vital Statistics, Summary of Statistics for Deaths and Births

1930, 1931 and 1932, 23; the infant mortality rate did show a slight increase in 1929 to 68,

but again resumed its decline in 1930 to 61.

76. U.S. Children's Bureau, Promotion of the Welfare: Fiscal Year Ended June 30,

1929, CB pub. No.203, 137.

132                                               OHIO HISTORY

alone, 4,528 children were examined in 118 infant and preschool health

conferences (clinics). Department of Health nurses made 219,064 home

visits. Of the individuals visited, 6,181 were pregnant women, 3,215

were postnatal women, and 32,725 were infants and preschool chil-

dren. The Department claimed to have reached by either literature or

a visiting nurse 17,118 (ie., 10 percent) of the infants born during that

period, and a similar percentage of the state's expectant mothers

received prenatal instructions.⁷⁷

Another contributing factor to the decline in Ohio infant and

maternal mortality was generally improved health care provided for

women and children either directly or indirectly as a result of Sheppard-

Towner programs. Prior to 1918 no public child health work was

carried on in any rural territory in Ohio, although a small amount was

done in a few cities. By the expiration of Sheppard-Towner in Ohio,

23 percent of the nursing service directed by local health departments

in rural counties included child hygiene. In the cities, 51 percent of

similar nursing time was devoted to children's health care. Improved

standards in maternity homes and hospitals providing maternity care

were a direct result of the state's Sheppard-Towner inspection pro-

gram. During 1928, 192 hospitals and maternity homes were inspected.

There were 35,527 infants born in Ohio hospitals and maternity homes

during that year (29 percent of all Ohio births).⁷⁸ Another significant

impact of Sheppard-Towner was the fact that the Ohio Department of

Health's Division of Child Hygiene remained intact after the act's

expiration. Efforts to promote the welfare of mothers and babies in

Ohio which had begun in 1915 became a permanent and discrete part of

the Ohio Department of Health's public health care program. Howev-

er, the withdrawal of federal funding for maternity and infancy work

cut the state's total expenditure for that purpose in half.

The controversy over the beginning of Sheppard-Towner contributed

to the atmosphere of concern over the country's unnecessarily high

rate of mother and infant deaths. As part of this concern some Ohio

doctors, especially obstetricians and gynecologists, began to call for

better maternal and infant care.⁷⁹ The increasing use of instruments,

77. Thirty-first Report, 388-89.

78. Ibid., 388-90.

79. L.R. Fast, M.D., "A Plea for Better Obstetrics," OSMJ, 17 (January, 1921),

23-25; other OSMJ articles: William D. Fullerton, M.D., "The Care of the Pregnant

Woman," 17 (January, 1921), 25; Arthur H. Bill, M.D., "Anesthesia in Obstetrics,"

17 (April, 1921), 613; William H. Gillespie, M.D., "Relief of Pain in Labor,"

17 (October, 1921), 669.

Saving Mothers and Babies                                        133

caesarian sections, and anesthesia was demanding a professionalization

(and hospitalization) of medical care.⁸⁰

Historian Clarke Chambers has discussed the growing trend toward

professionalism in America during the 1920s.⁸¹ Medicine was especial-

ly susceptible to this phenomenon. The 1910 Flexner Report served as

the chief catalyst for standardizing medical education in the United

States. The AMA aggressively lobbied states to allow only physicians

and nurses graduated from "standardized" medical and nursing schools

to treat illness or teach preventive health care.⁸² Even members of the

Children's Bureau increasingly placed the ultimate responsibility for

saving the lives of mothers and babies with physicians. But, it was

through the phenomenon of professionalization that physicians outside

the Children's Bureau began to take control of maternal and child

health. A 1923 advertisement for infant formula in the OSMJ clearly

illustrates the changing position of physicians and infant health care.

The advertisement declared:

THE DOCTOR IS THE PILOT-The life-saver of the infant-

BRING ON THE PILOT

It's time for the infant to come into its own

It's time that the doctor should roll up his sleeves

and take infant feeding into his own hands.

It's time to establish the doctor in the eyes of the

citizenship-that he is the first man in the community.

It's time to have mothers point out strong, healthy,

happy babies fed by the family doctor.

SUCCESS. Put infant feeding where it belongs-in the

hands of the doctor.⁸³

This trend toward professionalization placed the well-established

OSMA in a strong position to insure that the Ohio Sheppard-Towner

program would remain purely educational and diagnostic in nature.

The founders of the national program envisaged state maternity and

80. See Judith Walzer Leavitt, Brought to Bed: Birthing Women and Their Physi-

cians, 1750-1950, (New York, 1986), Chapter 5; Leavitt, "Birthing and Anesthesia: The

Debate Over Twilight Sleep," Signs: Journal of Women in Culture and Society,

6 (Autumn, 1980), no. 1, 147.

81. Clarke A. Chambers, Seedtime of Reform: American Social Service and Social

Action, 1918-1933, (Minneapolis, 1963); Robert W. Wiebe, The Search for Order,

1877-1920, (New York, 1967).

82. Paul Starr, The Social Transformation of American Medicine, (New York, 1982);

James G. Burrow, AMA, (1963); Ellen Corwin Cangi, "Principles Before Practice: The

Reform of Medical Education in Cincinnati Before and After the Flexner Report,

1870-1930," (Ph.D. dissertation, University of Cincinnati, 1983).

83. Advertisement for Mead's infant formula, OSMJ, 19 (July, 1923), 550.

134                                                OHIO HISTORY

infancy programs being run by and for women. But, in the final

analysis, the Ohio Sheppard-Towner program failed to set such a

course for maternal and infant care.⁸⁴

Two important assumptions, ultimately proved false, were held by

the designers of the Sheppard-Towner Act. First, Julia Lathrop and

Florence Kelley (who developed the idea for such a program to be

administered through the Children's Bureau as early as 1916) expected

that the women's movement would remain strong and that women

would vote as a bloc. Instead, as historian J. Stanley Lemons main-

tains, women, although politically active, did not vote as a bloc and

"social feminism" entered the "famine years" during the 1920s.85

Second, the Sheppard-Towner advocates assumed that health care for

mothers and babies would be managed by a strengthened women's

movement. Instead, trends toward professionalization, a more conser-

vative political atmosphere, and an already falling infant mortality rate

combined to create a climate of opinion in which ending a federal act

designed to "promote the welfare and hygiene of maternity and

infancy" could be countenanced.

In 1935, Children's Bureau Chief Katharine F. Lenroot (Abbott's

successor in 1932) wrote that the maternity and infancy section of Title

V of the Social Security Act covered essentially the same efforts (and

more) and had the same general purposes as the earlier Sheppard-

Towner Act.⁸⁶ Some scholars have argued that this fact is the most

significant aspect of the Sheppard-Towner Maternity and Infancy

Act.⁸⁷ Others have focused on the program as evidence of progressiv-

ism and women's political power in the early 1920s.⁸⁸ But, neither of

these approaches confronts the strengths and limitations of the pro-

gram itself. The major accomplishment of the first Maternity and

Infancy Act was its ability to raise the public's consciousness about

preventing the deaths of mothers and babies. The act's chief weakness

lay in its limited "education only" approach. An analysis of the

historical significance of Sheppard-Towner should not focus merely on

its ability or inability to blaze a path for the future or as evidence of the

political power of its supporters, but should also consider what it

contributed to saving and improving the lives of mothers and babies.

84. In 1922, forty-five of forty-eight state directors of child welfare were women. By

1939, three quarters of these positions were held by men. S. Josephine Baker, Fighting

for Life, (New York, 1939), 201, cited by Ladd-Taylor, Raising A Baby, 32.

85. Lemons, The Woman Citizen, 228-47.

86. Letter from Katharine F. Lenroot to Senator Morris Sheppard, June 19, 1935,

CBP, RG #102, Box 613, 13-0-1, NA.

87. Chepaitis, "The First Federal Social Welfare Measure,"; Schlesinger, "The

Sheppard-Towner Era,"; Siefert, "An Exemplar of Primary Prevention,"; Ladd-Taylor,

Raising A Baby.

88. Lemons, The Woman Citizen, 228-47.