NOVEMBER 23, 1921: SHEPHERD-TOWNER

WOMEN AND CHILDREN FIRST?

On November 23, 1921, President Harding signed the National Maternity and Infancy Protection Act, also known as Shepherd-Towner.  It planned to reduce the number of infant and maternal deaths by opening public health centers, providing visiting nurses, licensing midwives and educating mothers about prenatal care.  In 1920, with 111 infant deaths per 1000 live births, the United States ranked last among twenty industrial nations.

For public health statistics, an infant death is the loss of a live-born child before the baby’s first birthday.   Maternal mortality is the death of a woman while pregnant or within forty-two days of delivering a baby or terminating a pregnancy, from causes related to pregnancy, rather than accidents or other causes.

In 1912, Congress created a Children’s Bureau within the Department of Labor.  President Taft appointed Julia Lathrop its director, the first female head of a federal agency.  A graduate of Vassar, where she studied statistics, and an alumna of Jane Addams’ Hull House, where she investigated Chicago’s slums, Lathrop had been the first woman appointed to the Illinois State Board of Charities. 

The Children’s Bureau’s made infant mortality its priority, beginning with field work.  Between 1913 and 1915, the Bureau found that 80% of expectant mothers received little or no care.  Pregnant women in rural areas had an even higher risk of death due to lack of access to nurses and hospitals.  Before 1920, more than half of Americans, including the majority of African Americans, lived in agrarian communities.  Lathrop concluded that poverty, inadequate housing, poor sanitation, lack of information and access to professional care contributed to infant and maternal mortality.   

Asserting that infant deaths were preventable, Lathrop proposed a federal program empowering states to promote prenatal and infant health.  In July 1918, Jeannette Rankin (R-Montana), the first woman elected to Congress, introduced H.R. 12634, “A Bill to Encourage Instruction in the Hygiene of Maternity and Infancy.”  The first “baby bill” was the country’s first federally funded social welfare bill and the first legislation specifically addressing a woman’s issue. Congress failed to act.

In 1919, Senator Morris Shepherd (D-Texas) and Representative Horace Towner (R-Iowa) introduced a bipartisan bill, modeled on the Lathrop-Rankin original.  It offered states matching federal funds for five years, to underwrite programs designed and overseen by the Children’s Bureau.  Participation was voluntary.  It passed the Senate but died in the House.

Senator Morris Shepherd (D-TX) and Representation Horace Towner (R-IA)

The bill’s prospects improved after the Nineteenth Amendment was ratified.  In the 1920 presidential campaign, the Republican candidate, Ohio Senator Warren Harding, promised women equal pay for equal work, an eight-hour day, enforcement of prohibition, prevention of lynching, an end to child labor, expansion of the Children’s Bureau and protection of maternal and infant health. 

The Women’s Joint Congressional Committee, a coalition of eight white women’s organizations, made protecting infants its priority.  Hailed as “the most powerful and highly organized lobby in Washington,” the WJCC claimed a combined membership of two million women, including the League of Women Voters and the Women’s Trade Union League. 

During Senate hearings in 1921, testifying on behalf of the WJCC, Florence Kelley passionately asked, “Why does Congress wish mothers and children to die?”  Opposition was equally intense.  Female members of the National Association Opposed to Suffrage and the Woman Patriots claimed the bill was a communist plot.  The American Medical Association (AMA) condemned it, contending it would undermine the role of doctors and lead to socialized medicine.  Other opponents found it intrusive or an infringement on states’ rights.

The leading Senate opponent was James Reed (D-Missouri).  He ignored his Iowa colleague, who cautioned, “The old maids are voting now.”  Reed sneered, “It seems to be established doctrine . . . that the only people capable of caring for babies and the mothers of babies are ladies who have not had babies.”  He offered a final amendment to rename Shepherd-Towner “A Bill to Organize a Board of Spinsters to Teach Mothers How to Raise Babies.”  It failed.

The prospect of a female backlash inspired support.  As the AMA concluded, “Nearly every congressman [feared] . . . having all the women in his district against him.”  The Senate passed Shepherd-Towner, 63 to 7, after limiting its scope, cutting its funding and adding an expiration date.  The bill languished in the House Rules Committee before passing, 279 to 39.  Rankin, who had lost her 1918 election, sat in the gallery, watching the roll call.

Jeannette Rankin (R-MT, 1917-19) & Alice Robertson (D-OK, 1921-23)

The only woman elected to Congress in 1920, Representative Alice Robertson (R-OK), voted against Shepherd-Towner.  Echoing Senator Reed, she criticized “clubwomen [who] sit at ease in comfortable homes, worrying about other people’s children, and get a thrill over teacups by passing resolutions designed to bring about a new order.”  Swept up in Harding’s landslide, Robertson, 66, was a Muskogee dairy farmer, cafeteria worker and president of the Oklahoma Anti-Suffrage Association.  An advocate of Indigenous rights and lynching, she “came to Congress to represent my district, not women.”  Robertson retired after one term.

Two cases challenging the constitutionality of Shepherd-Towner were combined in 1923.   A Massachusetts man named Frothingham claimed he was being illegally taxed.  The Supreme Court concluded unanimously, in Commonwealth of Massachusetts v. [Secretary of Treasury Andrew] Mellon, that “indefinite” suffering was not an adequate cause for judicial review.

In 1927, Shepherd-Towner’s antagonists rallied to oppose the bill’s renewal.  They wanted to shift oversight from the Children’s Bureau to the predominantly male Public Health Service.  Mormon Senator William King (D-Utah) filibustered, claiming the bill was championed only by “neurotic women . . . [interfering] social workers . . . and Bolsheviks.”  The bill was not renewed but its funding was extended until 1929. 

In 1929, the “Pediatric Section” of the AMA broke ranks to support reinstating the Maternity Act.  Overridden by the organization’s House of Delegates, the mostly male pediatricians walked out and formed the American Academy of Pediatricians.  Shepherd-Towner was dismantled.  Some historians have argued that women’s failure to vote as a bloc or vote at all removed any pressure on politicians to support women’s issues.

Supporters had lobbied every state legislature to participate and fund their part of the project.  Connecticut, Illinois and Massachusetts never participated.  The Act established 3000 maternal care centers, many in rural areas.  In eight years, infant mortality dropped to 67 out of 1000 live births, with the greatest improvement among non-white rural women.  States began to collect vital statistics and register births.  Elements of the bill were included in the Social Security Act (1935), based on need.  Shepherd-Towner was the only major legislative victory former suffragists won in the 1920s. 

An unintended consequence was a decline in midwifery, whose skills were traditional and handed down among healers, due to licensing requirements.  Between 1920 and 1930, midwife-attended childbirths dropped nationally from 50% to 15%.  Black women especially relied on midwives because access to medical care was segregated or non-existent. 

Black midwives in Mississippi in the 1920s

While infant deaths declined during the 1920s, maternal mortality remained high.  Conservative legislators had forbidden any actual medical procedures to be performed under Shepherd-Towner.  Mothers at risk in childbirth required actual medical care.  Lacking medical attention or access to hospitals, many died. 

Today, despite spending 17.8% of GDP on health care, nearly twice as much as other countries, the US has the highest infant mortality rate of any high-income country:  5.4 deaths per 1000 live births in 2020, compared to 1.6, the lowest rate, in Norway.  In 2022, the number of babies dying before their first birthdays rose for the first time in two decades, according to the National Center for Health Statistics.  Findings published in the Journal of the American Medical Association Pediatrics concluded that infant mortality jumped as much as 7% above the pre-Dobbs baseline.

The most significant increases were among infants with congenital anomalies or birth defects.   When numerous states, post Dobbs, introduced full or partial abortion bans, mothers may have carried fetuses “incompatible with life” to term, according to the Guttmacher Institute.  As of October 2024, thirteen states had total abortion bans; eight states banned abortion at or before eighteen weeks of gestation.  There is an additional impact on the physical and mental health of mothers in this situation.  Research shows that women with unwanted pregnancies are less likely to obtain basic maternity care.  The most marginalized suffer most, especially in states which have become health-care deserts.

The US is the only high-income nation that does not guarantee access to provider home visits or paid parental leave in the postpartum period.  US maternal mortality in 2020 was three times the rate of comparable countries, with 23.8 maternal deaths for every 1000 live births.  Before 2018, when every state adopted a maternal mortality check box on death certificates, those deaths were notoriously underreported. 

Causes include inadequate prenatal care; high rates of Cesarean sections; poverty, which contributes to chronic disease; and now where women live.  There are also stark racial and ethnic disparities.  Black and Native American/Alaskan Native women are three times more likely than white women to die of pregnancy-related causes.  Black infants are twice as likely as white children to die before their first birthdays.  Before Dobbs, in 2021, Mississippi had the highest maternal mortality rate, with 82.5 deaths per 100,000 live births, followed by New Mexico with 79.5 per 100,000 live births.

Experts believe 60% of maternal and infant deaths could be prevented with proper medical intervention.  In recent years, maternal and infant death rates have fallen by almost half in all developed countries, except the US.  Among developed nations, the US has the highest rate of pregnancy-related deaths.  Globally, we rank forty-sixth. 

Previously, women without resources could access clinics like the Jackson Women’s Health Organization, for basic maternity care.  Because it offered abortions as well as birth control, prenatal care and breast cancer screenings, it was shuttered by the 2022 Dobbs decision.

When will we put the lives of women and children first?

SOURCES

Photo credits:  public domain unless specified.  Bar chart: Centers for Disease Control and Prevention, “Infant Mortality,” September 13, 2023, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm

Molly Ladd-Taylor, Mother-Work: Women, Child Welfare and the State, 1830-1930 (University of Chicago Press, 1994).

Kriste Lindenmeyer, A Right to Childhood:  The  US Children’s Bureau and Child Welfare, 1912-1946 (University of Illinois, 1997).

Deborah Mozer, “For Mothers and Children:  The Shepherd-Towner Act of 1921,” (1998), https://repository.library.georgetown.edu/handle/10822/1051380

J. Stanley Lemons, The Woman Citizen: Social Feminism in the 1920s (University of Illinois Press, 1975).

Jone Johnson Lewis, “Shepherd-Towner Act of 1921,” ThoughtCo (November 15, 2019), https://www.thoughtco.com/shepherd-towner-act-of-1921-3529478

Justina Petrullo, January 31, 2023, AJMC (American Journal of Managed Care), https://www.ajmc.com/view/us-has-highest-infant-maternal-mortality-rates-despite-the-most-health-care-spending

OECD (Organization of Economic Cooperation and Development), Infant mortality rates (indicator). doi: 10.1787/83dea506-en (Accessed on 26 November 2023), https://data.oecd.org/healthstat/infant-mortality-rates.htm

Elisabeth Griffith, Formidable: American Women and the Fight for Equality, 1920-2020 (Pegasus, 2022).

"Commonwealth of Massachusetts v. Mellon." Oyez, www.oyez.org/cases/1900-1940/262us447.

https://usafacts.org/articles/which-states-have-the-highest-maternal-mortality-rates/

 Roni Caryn Rabin, “Infant Mortality Up for 1^st Time in Two Decades,” New York Times (November 1, 2023), https://www.nytimes.com/2023/11/01/health/infant-mortality-rate-rise.html

Ariana Eunjung Cha, “Infant Mortality Worsened After Roe’s Reversal, Study Finds,” Washington Post (October 23, 2024), https://www.washingtonpost.com/people/ariana-eunjung-cha/