PROTECTION OF MATERNITY. 
17 
It has been shown in the investigation that by using the sum of the 
living and still births reported and the number of the deaths of women 
from causes connected with the puerperal state, rates are calculated 
expressing the actual risk of dyin" for women exposed to childbirth 
with a fair degree of specificity and much more accurately than those 
obtained by the methods in common use. When this method is 
applied to "the data for births and maternal deaths in the birth 
registration area of the United States for 1918, the total rate and the 
rates for causes under the important rubrics are conspicuously high. 
The total rate is more than double that for England and Wales 
calculated on live births alone, and this is due to the great excess in 
the United States rates for puerperal albuminuria and convulsions 
and septicemia, and accidents of pregnancy and labor. In the 
birth registration area of the United States for 1918, the total rate 
in urban communities was considerably greater- 10 per cent —than 
in rural communities. In the other four States, Kentucky, Maryland, 
North Carolina, and Virginia, and in the cities, Washington, D. C., 
and Baltimore, Md., the total rates and the rates for the most im 
portant rubrics are much higher for Negro than for white women, 
and the Negro rates are markedly in excess of the whole in both city 
and country. The rates for both whites and Negro women are higher 
in urban than in rural communities. 
The excess in total rates, in relation to both race and location, is 
due chiefly to higher rates for puerperal albuminuria and convul 
sions and septicemia. As determined for the birth registration area 
of the United States for 1918, the age of mothers exerts a marked 
and progressive influence upon maternal mortality from causes 
connected with childbearing. As compared with Birmingham, 
England, and with Stockholm, Sweden, the maternal risk rate in 
childbearing is much higher in New York, Philadelphia, Baltimore, 
Boston, and Washington, D. C., and in the order named. The 
total rates in these American cities are lower than the urban and 
rural total rates for the birth registration area of the United States 
for 1918. The proportion of stillbirths to total births varies con 
siderably in different places and in different races. In the birth 
registration area of the United States the proportion for urban and 
rural communities is approximately the same, and the proportion 
for the Negro is double that for the white, and for the urban Negro 
somewhat greater than for the rural Negro. By intensive analysis 
of the data available in municipal and State health departments, it 
would be possible to determine with considerable accuracy to what 
degree some of the causes of high stillbirth rates and most of the 
causes of high maternal death rates in childbearing are due to poor 
obstetrical service on the part of physicians and midwives, the 
extent to which particular individuals are responsible for these 
fatalities, and the measures necessary to reduce them. 
Now, the Children’s Bureau has been interested in discovering the 
conditions under which the people live who suffer from these ailments, 
all of which are in a very large degree preventive, as this medical 
authority has pointed out; and it has been because of the discoveries 
made as to the remoteness from medical care, whether it has been 
the remoteness created by poor industrial quarters or whether it 
has been remoteness because of the great homesteading areas, 
47819—21 2