The Washington PostDemocracy Dies in Darkness

History shows how to fix abysmal U.S. maternal and infant mortality rates

The maternal health intervention from a century ago that worked

Vice President Harris speaks during a Maternal Health Day of Action event in the South Court Auditorium of the White House in Washington on, Dec. 7. (Shawn Thew/Bloomberg News)

An earlier version of this piece incorrectly stated that 2 out of 2 deaths among the 20 women per 100,000 live births who die were preventable. In reality, it is 2 out of 3 deaths among these women that are preventable.

This month, the United States celebrated its first Maternal Health Action Day on Dec. 7. In a national address, Vice President Harris harked back to rhetoric popularized 100 years ago, when women first entered the federal government and directed its attention to the problems of high maternal and infant mortality. Harris pointed out the “hard truth” that “women in our nation are dying … before, during, and after childbirth at a higher rate than any other developed nation in our world.”

The United States has abysmal maternal mortality rates. Data for the year 2019 showed that in the United States, for every 100,000 live births, 20 women died. That same year, Poland lost just two. The Centers for Disease Control and Prevention (CDC) has estimated that 2 out of 3 of these deaths were preventable. Babies fare even worse. In 2019, the United States lost six infants per 1,000 live births — three times more than Slovenia, which lost two. Moreover, U.S. maternal mortality numbers are nearly three times higher for Black mothers than for White mothers, and infant death rates are more than twice as high for Black and Native American babies as for White babies.

Poor health outcomes for mothers and babies in the United States have been a problem for over a century, and the federal government has been largely indifferent. For a brief period in the 1920s, lawmakers mounted a national effort to begin addressing the problem. But it came to an abrupt end after only eight years, and Congress has tried nothing so ambitious since. This history shows that treating maternal and infant health as a national issue can be key to addressing this problem.

World War I exposed the ill health of the country’s young men: nearly one third of eligible draftees were unable to serve because of preventable illnesses contracted in early childhood. These new statistics shaped ideas about the nation’s health and drove changes in public policy.

The U.S. Children’s Bureau, established in 1912, just before the war, was the first federal agency run and staffed by women. World War I and new state statistics provided the bureau with an effective rallying cry: Mothers and babies were in as much grave danger at home as young American men were on the war front. In the 1910s, pregnancy was notably risky for women, with more than 700 mothers dying for every 100,000 live births, and extremely dangerous for babies. Nearly 10 percent of infants did not survive their first year of life.

Julia Lathrop, chief of the Children’s Bureau, seized upon the war effort to publicize the problem. She organized national publicity campaigns to raise awareness about infant mortality rates, including national Baby Week in 1917 and Children’s Year in 1918. Lathrop said these efforts were “device[s] for arousing public opinion.” With wartime headlines such as “The Cradle More Fatal Than The Trench” and “America’s Waste of Babies,” her efforts worked.

Unlike today, the United States’ infant mortality rate in the 1910s did not drastically lag behind other industrialized nations. Yet Lathrop and her staff shrewdly capitalized on feelings of nationalism that the war had ignited by comparing America’s infant mortality rates with other “principal countries.” The press followed suit, citing Children’s Bureau statistics and reprinting its “Infant Mortality Thermometer” — which showed the United States ranking 11th and behind many Western European countries as well as Australia and New Zealand.

Though these efforts succeeded in arousing public concern, they didn’t immediately translate to legislative action. It was only after the 19th Amendment had been ratified in 1920, granting women the right to vote, that Congress took action. To appeal to this new constituency — particularly newly enfranchised White women — lawmakers passed the Sheppard-Towner Maternity and Infancy Protection Act, commonly referred to as the “Better Baby Bill” in November 1921. It was the first federal social welfare program and the first federal health care subsidies in the nation’s history, providing federal funding to states for preventive prenatal and pediatric care for all women and children, regardless of income.

Lathrop hoped to model Sheppard-Towner after the nationally run maternal and infant health programs in New Zealand and the United Kingdom but ultimately opted for a matching grant model that limited federal control over state programming to appease states’ rights conservatives. Crucially, the law provided funding for only five years and required reevaluation and reapproval by Congress in 1927.

Most state legislatures approved the matching funds within the first two years, but three states (Connecticut, Illinois and Massachusetts) refused the federal dollars outright. Even with compromises, some thought the law went too far. Massachusetts even sued the chief of the Children’s Bureau and the secretary of labor in 1923, arguing that it violated the 10th Amendment — the states’ right to self-govern. The Supreme Court dismissed the case and the matching grant model survived.

Yet the matching grant model had serious limitations beyond a few northern states opting out. In the South, funds were funneled through Jim Crow state structures that targeted and demonized Black midwives while continuing to starve Black communities of equal access to the licensed doctors and nurses Sheppard-Towner provided. In the West, some states refused to use Sheppard-Towner funds to work with Native American women and children, claiming that they were “wards” of the federal, not state, government.

But with these critical exceptions, the law achieved important successes. States used funds for preventive public health campaigns, expanding access to medical care to many populations that had previously had none. Most states ran pediatric well-baby visits, home-visiting programs, midwife training and licensing, public health demonstrations at state fairs and prenatal and child-rearing courses in-person and by correspondence.

Programs were popular; more than 100,000 American women from every region, class and educational background wrote to the U.S. Children’s Bureau. They described abusive husbands, requested information about family planning methods, asked about mothers’ pensions and detailed their fears that another pregnancy might lead to physical or financial ruin.

The letters revealed how invested women were in accessing programs that could improve their lives. These women frequently asked for copies of the law to read for themselves, to share with friends and relatives and to read before book clubs and civic societies. State and federal agents fielded so many requests for copies of the law that they often complained about running out of copies for themselves.

National infant mortality rates declined precipitously between 1915 and 1939, and experts since have found that Sheppard-Towner programs — particularly nurse home visits and permanent health clinics — had a significant effect in lowering these rates.

Still, the program was defunded in 1929, only eight years after it passed. The American Medical Association (AMA) lobbied lawmakers against it, fearing the law would lead to state-run medicine. Moreover, politicians no longer feared the threat of the “women’s block”; after only a few election cycles it had become clear that women did not vote as one unified constituency.

Without the federal matching grants, state investment in preventive maternal and infant health services reverted to pre-Sheppard-Towner levels. States that had invested heavily in maternal and infant health programs before federal funds were made available continued to do so; states that had not invested in these programs stopped funding them all together.

During the New Deal, Title V of the Social Security Act rehabilitated many of the Sheppard-Towner programs — but with one major difference: Its programs were targeted to rural and poor families, not universal.

Today, Title V programs provide the bulk of federal funding for infant and maternal health. While providing critical services to many, these programs are often starved for resources, exclude many in need of their services and are complicated to access for those who qualify. The shift from a universal program to a targeted one may have been justified as a financially prudent move. But it has not adequately addressed the enduring problem of maternal and infant mortality — a problem that is literally life and death for many Black, Native American and rural women and children.