THE HEALTH SITUATION OF NEGRO MOTHERS AND BABIES IN THE UNITED STATES A BRIEF STATEMENT OF HEALTH STATUS, HEALTH SERVICES, AND NEEDS By Elizabeth C.Tandy, Sc.D. Consultant on Infant and Maternal Mortality and Stillbirth Statistics Division of Statistical Research U. S. Children's Bureau U. S. DEPARTMENT OF LABOR CHILDREN’S BUREAU WASHINGTON, O.C JULY I. 1940 FIG. I-NUMBER OF LIVE BIRTHS AMONG NEGROES EACH YEAR, 1936-38 29 STATES WITH 500 OR MORE NEGRO LIVE BIRTHS EACH YEAR 0,000 OR MORE (8 STATES) 5.000 TO 10,000 ( 8 STATES) 2.000 TO 5,000 ( 7 STATES) 500 TO 2,000 ( 6 STATES) LESS THAN 500 (20 STATES) SOURCE ; REPORTS OF U. S. BUREAU OF THE CENSUS AVERAGE NUMBER OF LIVE BIRTHS The Health Situation of Negro Mothers and Babies in the United States Every year in the United States more than 260,000 Negro babies are born alive. Every year about 21,000 of these babies die. In addition, 17,000 Negro stillbirths occur, and 2,300 Negro mothers die from conditions directly due to pregnancy and child- birth. These are averages based on official statistics for the latest 3 years (193&-38) for which information is available. They show that the infant mortality rate for Negroes is 82 per 1,000 live births, that the stillbirth rate is 66 per 1,000 live births, and that the maternal mortality rate is 90 per 10,000 live births. The Children's Bureau, since its establishment by act of Congress in 1912, has been directly concerned with the health problems of the Negro child and mother. The research and informa- tional services of the Bureau have always been inclusive of the children of all races. All phases of maternal and child-welfare work in the social-security program include services for Negroes. Statistics are presented herein showing the areas where Negro babies are born, the areas with high mortality among Negro mothers and babies, the causes of this mortality, and the gains made in recent years. These statistics, unless otherwise indicated, are based on reports of the United States Bureau of the Census. Also presented herein are statistics showing the services conducted under the provisions of the Social Security Act in areas with con- siderable numbers of Negro births. These statistics are compiled from reports on maternal and child-health services received in the Children's Bureau from the State health agencies that administer and supervise the work directed toward reduction in mortality and improvement in health among mothers and babies. Health Status Negro births More than four-fifths (2L4,000) of the Negro babies are born in the Southern States; two-thirds (170,000) are born in rural areas; four-fifths (208,000)- are born in States where the per capita income is below the national average. In eight States—all southern—there are 10,000 or more Negro live births each year (Alabama, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Texas, and Virginia). In all these States except Texas, and also in the District of Columbia and in Florida, more than 25 percent of all live births are Negro. Practically all (99 percent) of the Negro births occur in 29 States. Each of these States has 500 or more Negro births each year (fig. 1). More than half (55 percent) of the Negro births in the United States are attended by nonmedical persons—generally untrained or poorly trained midwives. Only one-fifth of the Negro births occur in hospitals. One-fourth are attended by physicians in homes. This is in sharp contrast to the situation of white infants at birth, of whom 95 percent are attended by physicians and 4-8 per- cent are born in hospitals (fig. 2). FIG.2-ATTENDANT AT BIRTH; UNITED STATES, 1936-38 NEGRO WHITE note: midwife includes I percent for each race with other nonmedical attendant SOURCE: REPORTS OF U.S. BUREAU OF THE CENSUS Midwives attend more than two-thirds of the Negro births in Mississippi, South Carolina, Arkansas, Georgia, Florida, Alabama, and Louisiana. They attend from one-third to two-thirds of Negro births in North Carolina, Virginia, Delaware, Texas, and Oklahoma. In Tennessee and Maryland they attend slightly more than one- fourth and in Kentucky and Missouri, 11 and 8 percent, respective- ly. In the remainder of the 29 States, 2 percent or less of the Negro live births are attended by raidwives, 98 percent being at- tended by physicians (fig. 3)• FIG.3-PROPORTION OF NEGRO BIRTHS ATTENDED BY MIDWIVES; 29 STATES, 1936-38 APPROXIMATE NUMBER OF MIDWIVES PRACTICING UNDER . SUPERVISION 6 MISSISSIPPI SOUTH CAROLINA ARKANSAS GEORGIA FLORIDA ALABAMA LOUISIANA NORTH CAROLINA VIRGINIA DELAWARE TEXAS OKLAHOMA TENNESSEE MARYLAND KENTUCKY MISSOURI NEW YORK NEW JERSEY WEST VIRGINIA MICHIGAN KANSAS CONNECTICUT INDIANA PENNSYLVANIA ILLINOIS CALIFORNIA OHIO DISTRICT OF COLUMBIA MASSACHUSETTS 3,121 c3,l2 I MISS. 2,300 c 2,300 S.C. 1,923 1,07 5 ARK. 3,17 1 c 3,17 I GA. (d) C 1.300 FLA. 4,967 c 2,87 9 ALA. 2.000 c 2,000 LA. 2,113 2,113 N.C. (d) 1.865 VA. 73 73 DEL. 4.000 500 TEX. (d) 8 OKLA. 1.600 410 TENN. 201 c201 MO. 750 c 160 KY. (d) 25 4 MO. 539 165 N.Y 335 c 300 N.J. 300 225 W. VA. (d) 0 MICH. 15 8 KANS. 56 56 CONN, (d) 0 INO. 273 c 273 PA. (d) 0 ILL. 300 0 CALIF. 279 o OHIO 4 4 D.C. (d) 0 MASS. d(_ESS THAN I PERCENT. b GIVEN BY PUBLIC-HEALTH NURSES; INCLUDES INSTRUCTION IN MOST STATES. c IN SOME OR ALL AREAS OF STATE, INCLUDES ATTENDANCE WITH MIDWIFE AT ONE OR MORE DELIVERIES BY PERSON SUPERVISING. REPORTED SOURCES: DATA ON LIVE BIRTHS, REPORTS OF U.S. BUREAU OF THE CENSUS: DATA ON MIDWIVES,PROGRESS REPORTS SUBMITTED BY STATE HEALTH AGENCIES ON MATERNAL AND CHILD-HEALTH SERVICES ADMINISTERED OR SUPERVISED,YEAR ENDED JUNE 30, 1938. Stillbirths The 17,000 Negro stillbirths registered each year in the United States include only part of the Negro babies born dead. The registration of stillbirths (required in most States for products of conception advanced to the fifth month of gestation) is recognized as incomplete for all races and especially for the Negro race. Nevertheless, the stillbirth rate for Negroes during the period 1936-3B was 66 per 1,000 live births or more than twice the rate for the white race (29). A special study made by the Children's Bureau to point the way toward securing more satisfactory official statistics on causes of stillbirth gives much pertinent information on Negro stillbirths that occur in hospitals. The study includes 1,211 Negro stillbirths. l/ The findings point out that 68 percent of the Negro fetuses born dead died before onset of labor; only 32 percent died during labor. The comparable percentages for the white were 57 and 43. Mothers were delivered prematurely in a large proportion of cases; 69 percent of the Negro stillbirths were premature (less than 38 weeks' gestation); AS percent of the Negro fetuses that died during labor were premature deliveries. The most common causes of stillbirth among Negroes were syphilis (21 percent), placental and cord conditions (21 percent), toxemias of pregnancy (12 percent), difficult or prolonged labor (5 percent), and birth injury (4 percent). No other type of cause was responsible for more than 3 percent of the Negro stillbirths, but unknown or ill- defined conditions were responsible for 26 percent. The prenatal care received by practically all mothers of stillborn Negro babies was inadequate. Only 50 percent had tests for syphilis prior to the day of delivery; only 13 percent had tests early enough in pregnancy (prior to the fifth month of ges- tation) for treatment to give adequate protection to the fetus in case the test proved positive. Syphilis was probably a more com- mon cause of stillbirth than is indicated by the figures on cause. A positive diagnosis of syphilis was made in 32 percent of the cases in which tests were taken. The study has demonstrated that adequate care during preg- nancy is the fundamental approach to the stillbirth problem among all races and especially among the Negroes. Improvement, of course, also needs to be effected in the technique of delivery care, as almost one-third of the deaths occurred during labor. Infant Mortality Of the 21,000 Negro infants who die each year in the United States, 11,000 die in the first month of life and 10,000 die in the later months of the first year. Prenatal and natal causes are responsible for 41 percent of these infant deaths, respiratory diseases for 19 percent, gastrointestinal conditions for 11 per- cent., all other diseases for 13 percent, and unknown and ill- defined conditions for 16 percent. 17 This study, made with the cooperation of the Subcommittee on Stillbirths of the American Public Health Association, in- cludes 6,750 (5,539 white, 1,211 Negro) stillbirths that occurred in 223 hospitals located in 49 cities in 26 States. 16 States had rates higher than the national average for Negro infants (82). All States had rates'higher than the national average for white infants (50). source: reports of u.s bureau of the census FIG. 4.-INFANT MORTALITY AMONG NEGROES, 1936- 38 29 STATES WITH 500 OR MORE NEGRO LIVE BIRTHS EACH YEAR 83 OR HIGHER (16 STATES) 70- 82 ( 7 STATES ) 58 - 69 (6 STATES) LESS THAN 500 NEGRO BIRTHS DEATHS UNDER I YEAR PER 1,000 LIVE BIRTHS During the period 1936-38 the infant mortality rate for Negroes (82 per 1,000 live births) was two-thirds higher than the rate for white infants (50). Every one of the 29 States had a higher mortality rate for Negro infants than the United States rate for white infants; sixteen had a rate for Negro infants high- er than the United States rate for Negroes (fig. 4-)• The infant mortality rate among Negroes, though high, is showing improvement. The rate for the year 1938 (78) was 1A per- cent lower than that for 1934- (91), the year prior to the initia- tion of work under the Social Security Act. This is about the same decrease as that effected among white infants (15 percent) and a greater decrease than that which prevailed in the 5 years prior to the initiation of the work under the act (from 1930 to 1934- the decrease was only 9 percent). These decreases mean that many Negro babies are being saved each year. Had the 1934- rate prevailed in 1938 the number of deaths of Negro babies would have been greater by 3,500. Maternal Mortalit: Of the 2,300 Negro mothers who die each year from conditions of pregnancy and childbirth, almost one-fourth (22 percent) are veiy young mothers—under 20 years of age. Infection, largely preventable by avoidance of abortion and by strict cleanliness of attendants during labor and the postpartum period, is responsible for 38 percent of the deaths; toxemias of pregnancy, controllable by adequate care throughout pregnancy, are responsible for 29 per- cent; hemorrhage, also controllable by competent attendants at birth, is responsible for 9 percent. Other causes (mostly un- defined conditions) are responsible for 24- percent. The maternal mortality rate for Negroes in the United States during the period 1936-38 (90 per 10,000 live births) was more than double the rate for white women (4-4) . Every one of the 29 States had a higher mortality rate for Negro mothers than the United States rate for white mothers; 13 had a rate higher than the United States rate for Negroes (fig. 5)• Maternal mortality among Negroes, though high, is showing improvement. The rate for the year 1938 (86) was 8 percent lower than that for 1934- (93), the year prior to the initiation of work under the Social Security Act. This is not so great a decrease as that effected among white mothers (30 percent, 1934.-38) • It means, however, that almost 200 Negro mothers were saved in 1938 who would have died had mortality been as high as in 1934. FIG. 5- MATERNAL MORTALITY AMONG NEGROES, 1936- 38 29 STATES WITH 500 OR MORE NEGRO LIVE BIRTHS EACH YEAR 13 States had rates higher than the national average for Negro women (90). All States had rates higher than the national average for white women (4 4) , source: reports of u.s. bureau of the census 91 OR HIGHER ( 13 STATES) 65 - 90 ( 13 STATES ) 50 - 64 (3 STATES) LESS THAN 500 NEGRO BIRTHS 'N MATERNAL DEATHS PER 10,000 LIVE BIRTHS Health Services and Needs Reports on maternal and child-health services conducted under the provisions of the Social Security Act, received by the Children’s Bureau from State health agencies, indicate that all States are taking an active interest in work for improvement of conditions for mothers and babies. The reports for the fiscal year 1938 show that all the States with more than 2 percent of Negro live births attended by midwives are working to improve the quality of the care that mothers receive from midwives. Those from Mississippi, South Carolina, Georgia, Louisiana, North Carolina, Delaware, Maryland, Pennsylvania, Connecticut, and the District of Columbia indicate that all the midwives who are practicing are under supervision. This supervision, in most States, includes instruction by public health nurses, in some it also includes attendance with the mid- wife at one or more deliveries. Certain State health agencies have placed this instruction under the direction of specially trained nurse-midwives. Reports for the fiscal year 1939 show that some phase of maternal and child-health service is conducted in four-fifths of the counties with as many as 100 Negro live births a year. Two- fifths of these counties have maternity clinics giving prenatal and postpartum care to mothers; two-fifths have child-health conferences where physicians advise mothers how to care for the health of their children; about three-fourths have public-health- nursing services for mothers and young children; almost three- fourths have such nursing service for children of school age. The services of dentists or dental hygienists are made available largely for educational services in about half of the counties; those of nutritionists in slightly less than one-fifth. There is no question as to the urgent need for more services in these counties. In many, infant mortality is exceedingly high. During the period 1933-37, 68 percent of these counties had infant mortality rates for all races in excess of the United States rate (57); 13 percent had rates for all races in excess of the United States rate for Negroes (85)• The plane of living is below the national average in 90 percent of these counties, in 73 percent far below. A third of these counties are rural counties with no hospitals that afford care to mothers or babies of any race. All types of services for protection of the health of Negro mothers and babies need to be developed and expanded in the areas where Negro births occur. Negro mothers are in need of better care during pregnancy and childbirth and the postpartum period. Medical care or consultation should be provided for the women now cared for each year by midwives. Negro infants are in need of better medical care. Adequate facilities for the care of newborn infants are greatly needed. Mothers should be taught how to care for themselves and how to protect the health of their children. Mortality rates for Negro mothers and babies are far higher than those for the United States as a whole. Special studies have shown that two-thirds of the maternal deaths, two-fifths of the still-births, and one-half of the deaths of infants in the United States can be prevented. Reduction of mortality by these amounts would mean the annual saving of 1,500 mothers and 17,000 babies (stillborn or dying in their first year of life). Prevention of these needless deaths should be the first goal for Negro health— a goal to be attained through adequate services. Summary The high mortality rates of Negro mothers and babies of the present day indicate the great need for improvement in health con- ditions. The decreases effected in mortality in recent years show that the way is open and that much more may be done. The whole- hearted acceptance by the Negro race of the health facilities that have been made available gives encouragement for the development and expansion of activities which will bring Negro mothers safely through childbirth and Negro infants safely through the first year of life.