You don’t hear about it much anymore, but the Sheppard-Towner Act—or the “Better Babies Bill,” as some reporters referred to it at the time—was a big f’ing deal. No Congress in U.S. history had ever approved a federally funded social welfare program before S-T came up for debate in the early 1920s; aside from the Volstead Act, it was the most controversial law of its era. A Boston Globe writer summed it up this way: “It ranks next in importance, in the opinion of its advocates, to the legislation which finally gave women the right to vote.” And there are some striking parallels between the fight over Sheppard-Towner and the recent debate surrounding President Obama’s embattled health reform law. With the Supreme Court set to rule on the constitutionality of the Affordable Care Act next month, it’s worth investigating the legacy of its earliest legislative antecedent.
The story begins in 1912, when President Taft created the U.S. Children's Bureau and hired Julia Lathrop to run it. Housed within the Labor Department, the agency was designed to investigate and report “upon all matters pertaining to the welfare of children and child life among all classes of our people.” Lathrop (pictured above) had been doing essentially the same work for two decades at Chicago’s Hull House, undertaking extensive surveys to document the brutal living conditions in her city’s slums, mental health institutions, orphanages, and poorhouses. She was a natural fit. As one senator’s wife gushed to the Washington Post, choosing Lathrop was “the finest and most just recognition of a woman's ability, and her place in the nation, that has ever been made by any president" (November 6, 1912).
“Young America’s Aunt”* knew instantly what problem her department should tackle first: infant mortality. When she arrived in Washington, Lathrop’s office launched an eight-city examination into American childbirth habits. The results were startling; the nation’s overall infant mortality rate was a whopping 111.2 per 1,000 live births, higher than almost every other industrialized country in the world. Annually, 250,000 American babies died during their first year and another 23,000 mothers were killed during the delivery. (It was the second leading cause of death among women between the ages of 18 and 45, behind tuberculosis.) There was also a correlation between poverty and the mortality rate—for families earning less than $450 annually, one baby in six died before his or her first birthday. Respected Johns Hopkins pediatrician Dr. J. H. Mason Knox made clear at the time that nearly all of those deaths were preventable if families just received proper prenatal care. Only 20 percent of expectant moms did.
With firm data in hand, Lathrop set about drafting a piece of legislation that would use federal funds to provide “public protection of maternity and infancy.”** Like the newly-established Smith-Lever Act, which authorized the Department of Agriculture to distribute matching funds to the states for extension work by county agents, Lathrop envisioned a program in which Washington partnered with local nurses, universities, and social workers to subsidize the instruction of mothers on the care of infants. “The bill,” Lathrop wrote, “is designed to emphasize public responsibility for the protection of life just as already through our public schools we recognize public responsibility in the education of children.”
In 1919, U.S. Rep. Horace Mann Towner (R-Iowa) and U.S. Sen. Morris Sheppard (D-Texas) submitted a bill that contained the basics of Lathrop’s proposal. The Hull House veteran wasted no time stumping for her idea. Over the next three years, Lathrop enlisted support wherever she could, relying heavily on women’s associations that were emboldened by the recent extension of suffrage. The Children’s Bureau sponsored “The Year of the Child,” in which the agency appealed to groups across the nation and published catchy graphics to illustrate the country’s poor international standing. Lathrop convinced popular magazines like Good Housekeeping and the Ladies Home Journal to editorialize in favor of the measure. Ultimately, 13 of the most powerful women's groups in America rallied behind Sheppard-Towner, too; in the final weeks of negotiations, the Women's Joint Congressional Committee—a massive umbrella group—conducted interviews with congressman at the rate of 50 per day. “It is doubtful,” reported the Globe (December 18, 1921), “if any single piece of legislation enacted by Congress in recent years—apart from equal suffrage—has had the organized influence of so great a body of the citizenship of the country back of it.”
The final version of the bill passed both the House (279 to 39) and the Senate (63 to 7) by a wide margin in late 1921, in part because the law was modest in scope. Congress agreed to appropriate just $1.24 million annually (about $15 million today) for the program, with each participating state receiving $5,000 outright and then dollar-for-dollar matching funds as determined by its population. After five years, the funding would need to be reauthorized, as well. (The advocates of the bill were confident that half a decade was “sufficiently long to demonstrate the real value of the measure.”) One year after its passage, a reporter for the Detroit Free-Press described Sheppard-Towner as “mild and rather helpless” (December 1, 1922). He wasn’t wrong.
But the idea behind the bill, at least in the United States, was revolutionary. Social insurance, in any form, just didn’t exist. In her book “Protecting Soldiers and Mothers,” historian Theda Skocpol writes that Lathrop’s brainchild “extended what was once domestic action into a new understanding of governmental action for societal welfare.” Put another way, the new law was “a fragile seed growing in isolation from the then-traditional health programs.”***
That seed quickly bloomed. Within the first year of implementation, 45 out of 48 states passed enabling legislation to receive matching S-T funds. (Illinois, Connecticut, and Massachusetts never participated.) Each used their subsidy in different ways; some organized conferences where physicians ran demonstrations on maternal and infant care and hygiene, while others paid nurses to visit new or expectant mothers. However it was deployed, the money went a long way. Between 1922 and 1929, the Bureau distributed over 22 million pieces of literature, conducted 183,252 health conferences, established 2,978 permanent prenatal centers, and visited over 3 million homes. Lathrop’s successor at the Children’s Bureau, Grace Abbott, estimated that one-half of U.S. babies had benefited from the government's childrearing information.
Not surprisingly, infant mortality dropped precipitously while Sheppard-Towner was on the books. A new working paper published last month by the National Bureau of Economic Research estimates that Sheppard-Towner activities accounted for 12 percent of the drop in infant mortality during the 1920s, with one-on-one interventions creating the most statistically significant results. Combined with rising incomes and better nutrition, preventative health education helped cut down the infant mortality rate to 67.6 deaths per 1,000 live births in 1929. Considering how little money Congress actually spent on the law, the results were thrilling.
Not everyone was so excited by the precedent Sheppard-Towner was setting. During the initial debate in Congress, several opponents delivered unhinged criticism of both the bill and its supporters. U.S. Sen. James Reed (D-Missouri) declared (incorrectly) that Sheppard-Towner would permit officials to “invade” the homes of mothers-to-be. “We would better reverse the proposition,” he charmingly added, “and provide for a committee of mothers to take charge of the old maids (at the Children’s Bureau) and teach them how to acquire a husband and have babies of their own.” Not to be outdone, his colleague in the House, U.S. Rep. Henry Tucker (D-Virginia), characterized the bill as an attempt to “make Uncle Sam the midwife of every expectant woman in the United States.” And Mary G. Kilberth of the National Association Opposed to Woman Suffrage argued that Sheppard-Towner advocates were both “inspired by foreign experiments in Communism” and “connected with the birth-control movement.” A wealthy socialite from Boston went so far as to challenge the law before the U.S. Supreme Court, contending unsuccessfully that it violated the Tenth Amendment.
If ideologues couldn’t rescind the law, doctors had a better shot. The American Medical Association board was initially skeptical of Sheppard-Towner, calling it an “imported socialistic scheme unsuited to our form of government” at its annual meeting in 1922. Four years later, however, the association fully mobilized for the funding reauthorization fight, lobbying Congress and writing letters to the president. It’s clear that many physicians moved to incorporate preventive health education into their private practices only when they saw the benefits of prenatal care play out in new clinics across the country. In a very real sense, the Children’s Bureau had become a primary competitor, and its own worst enemy.
Desperate to keep their projects operating, directors of the state Sheppard-Towner programs and Abbott cut what the historian Skocpol deemed a “deal with the devil,” agreeing to terminate the law altogether in exchange for two more years of full financial support. In 1929, seven years after reformers printed their first informational flyers, Sheppard-Towner came off the books. Over the next four years, progressives introduced 14 different bills that would have funded maternity and infancy health programs using federal dollars. All of them failed. When the Great Depression hit, most states dropped their existing programs altogether.
The lesson, though, had been learned. And while the United States’ current infant mortality rate is still not where it should be, it’s decidedly safer for babies and mothers now than it was a century ago. For that, we can thank Julia Lathrop and her small, ambitious staff.
*Headline in the Post on June 9, 1912
** Children’s Bureau’s Fifth Annual Report of the Chief, 1917
***The Sheppard-Towner Era: A Prototype Case Study in Federal-State Relationships; June, 1967