Abstract
We take advantage of unique data on specific activities conducted under the Sheppard-Towner Act from 1924 through 1929 to focus on how public health interventions affected infant mortality. Interventions that provided one-on-one contact and opportunities for follow-up care, such as home visits by nurses and the establishment of health clinics, reduced infant deaths more than did classes and conferences. These interventions were particularly effective for nonwhites, a population with limited access to physicians and medical care. Although limited data on costs prevent us from making systematic cost-benefit calculations, we estimate that one infant death could be avoided for every $1,600 (about $20,400 in 2010 dollars) spent on home nurse visits.
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Notes
Infant mortality trended strongly downward despite the fact that the BRA continued to expand until 1932 and many of the states that entered later had higher mortality rates than earlier entrants. Figure 1 also plots infant mortality for only those states that were in the BRA as of 1915 to show that the addition of later states does not obscure the strong downward trend. We include this graph to illustrate the trend in infant mortality, but we acknowledge that there are difficulties associated with comparing infant mortality across time, as discussed in Condran and Murphy (2008).
Prior to Sheppard-Towner, the federal government had also provided money to states to assist in venereal disease control and prevention under the Chamberlain-Kahn Act of 1918.
See, for instance, Bill and Melinda Gates Foundation (2013).
These permanent health centers were not necessarily newly constructed, stand-alone clinics. They often were just regularly scheduled sessions where physicians and nurses would see patients in a given location. For example, some states used rooms in municipal buildings or schools (U.S. Children’s Bureau 1927a:10).
Moehling and Thomasson (2012) discussed evidence of such cost shifting by the states of New Jersey and North Carolina.
We also estimated the model over the periods 1922–1929 and 1915–1929 (excluding the years of the influenza pandemic), making the assumption of zero activity levels for the years prior to 1924. The results were similar to those reported in this article. The degree of cost shifting may have varied across states. As long as states engaged in consistent levels of cost shifting from year to year, the state fixed effects included in the model will account for this variation. However, states may have engaged in different levels of cost shifting from year to year. This would mean that the year-to-year variation in the activity levels reported by the Children’s Bureau could overstate the true variation. Such variable cost shifting would bias the results against finding statistically and economically significant effects of the Sheppard-Towner activities on infant mortality.
We also estimated all models including state income per capita and the number of federal income tax returns filed per capita to capture the effects of rising income and changing income distributions over this period. These data were generously provided by Price Fishback. In none of the estimated models, however, could we reject the hypothesis that these variables had no effect on infant mortality after allowing for state and year fixed effects and state time trends. In addition, the inclusion of these variables did not substantively alter the estimated effects of the Sheppard-Towner activity measures.
As a robustness check, we also estimated models including one-year lags of the Sheppard-Towner activities. The lagged activity measures did not have statistically significant effects on infant mortality rates.
New Jersey was quite open about the fact that it used the federal grants to replace state appropriations. For instance, in 1922, the New Jersey legislature appropriated almost $100,000 less for the Department of Health than it had in 1921. This move was explained in the Department’s annual report in quite plain terms: the appropriations for the Bureau of Child Hygiene and the Bureau of Venereal Disease Control were being reduced because both would be receiving federal monies for their work (New Jersey Department of Health 1922:19).
Another challenge for making comparisons across states when using the Financial Statistics data is the difference in timing of the “fiscal year” for different states. Although most states defined their fiscal year to match that of the federal government, many states used alternative definitions. In fact, in some states, the definition of the “fiscal year” varied across departments (U.S. Census Bureau 1926:13).
To be included in the BRA, a state had to have a systematic procedure in place for recording all births. When the BRA was established in 1915, it consisted of only 10 states. Following is a list of the states that entered the BRA during the study period, along with their years of entry: West Virginia (1925); Arizona (1926); Alabama, Arkansas, Louisiana, Missouri, and Tennessee (1927); Colorado, Georgia, and Oklahoma (1928); and Nevada and New Mexico (1929). South Carolina was part of the BRA in 1924, was dropped in 1925, and then was readmitted in 1928. The two states not part of the BRA by 1929 were South Dakota and Texas (Linder and Grove 1947:97).
We also estimated all models using the balanced panel consisting of states in the BRA for all five years; the basic findings did not change. All estimated models we present in this article include the three states that did not participate in Sheppard-Towner: Connecticut, Illinois, and Massachusetts. Excluding these states does not alter the basic findings.
The widening of the racial gap in infant mortality later in the twentieth century can be attributed to the fact that whites had better access to improved medical care than blacks (see Almond et al. 2006).
We also cannot discount the possibility of selection bias; mothers who were more aware of the value of hygiene may have been more likely than other mothers to attend child health conferences.
In results not presented, we found that the impact of prenatal letters was most pronounced in states with larger rural populations, suggesting that women with limited access to medical care benefited most from this type of intervention.
If such a bias exists, it would mean our estimates of the effects of Sheppard-Towner activities are understated.
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Acknowledgments
The authors thank seminar participants at the 2011 Cliometric Society meetings, the University of Colorado, the University of Michigan, the University of Chicago, and Chapman University. The authors assume all responsibility for any errors or omissions.
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Moehling, C.M., Thomasson, M.A. Saving Babies: The Impact of Public Education Programs on Infant Mortality. Demography 51, 367–386 (2014). https://doi.org/10.1007/s13524-013-0274-5
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DOI: https://doi.org/10.1007/s13524-013-0274-5