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  • An important lesson from the Sheppard-Towner experience is that big ideas enacted democratically, rather than as public charity, have powerful and positive effects. Tweet This
  • "Make Birth Free" would enhance the life prospects of children, reduce the turn to abortion, and could allow more humane and less medicalized birthing alternatives to flourish. Tweet This
  • Importantly, the Sheppard-Towner Act set no income test on potential clients: this would be an “entitlement” available to all, without cost. Tweet This

In recent years, several pro-life advocates have called for the adoption of a federal policy to “Make Birth Free” by covering 100% of the pregnancy costs of all affected American women. Writing in The Atlantic in 2022, Elizabeth Bruenig called for free childbirth, urging the foes of abortion within the Republican Party to break from “business” and “fiscal conservatives” who deplore expensive new entitlements for mothers and babies. More recently in Compact magazine, Catherine Glenn Foster of Americans United for Life and Kristen Day of Democrats for Life offered a bipartisan plan under the same label to overcome our nation’s “disordered politics and warped economy” so as to encourage pregnant women and protect both preborn and newborn children.

These advocates have actually resurrected a sharp, if now largely forgotten, policy debate over the very same issues conducted a century ago: the triumph and eventual failure of The Sheppard-Towner Maternity and Infancy Act. In 1919, the Children’s Bureau of the U.S. Department of Labor reported that maternal deaths in childbirth during the prior year numbered 23,000, an increase of 7,000 since 1916. According to the Bureau, 80% of expectant American mothers still received no prenatal advice or care, while the infant mortality rate stood at 100 deaths per 1000 live births, nearly twice the figure found in West European lands.

Dedicated to “Baby Saving,” the Bureau organized “National Baby Week” in 1916. Over 4,200 communities and an amazing 11 million women took part in baby-care seminars and good-natured “Best Mother” contests and heard orators praise motherhood as a vital element of national welfare. As historian Molly Ladd-Taylor recounts: “Like military heroes, mothers with infants in arms paraded down Main Street to the applause of flag-waving townspeople.”1 As a next step in this campaign, Bureau Chief Julia Lathrop drafted a measure to provide federal funds for state-level programs of instruction in maternal and infant hygiene, prenatal child health clinics, and visiting nurses for pregnant and new mothers. Importantly, the proposal would set no income test on potential clients: this would be an “entitlement” available to all, without cost.

The next phase was one of the largest and most effective lobbying campaigns in American history. Proponents of the “Sheppard-Towner bill," as the measure was called, rallied an impressive array of allies, including the Settlement Houses of Chicago, New York, and other large cities (and the wealthy donors who funded them), the hundreds of upper-crust Women’s Clubs spread across the land, the League of Women Voters, the Women’s Trade Union League, the National Council of Jewish Women, and even the doughty Daughters of the American Revolution. The American Medical Association fiercely opposed the bill as the opening wedge of socialized medicine, calling it “sob stuff.” However, the physicians were overwhelmed by the literal millions of letters that poured into Washington, DC, in response. When a powerful Congressman blocked the measure in a House of Representatives committee, advocate Florence Kelley appeared2 before its members and compared Congress to King Herod and his slaughter of the innocents, asking: “Why does Congress wish women and children to die?” The bill won early endorsements from the Democratic, Socialist, Prohibition, and Farmer-Labor parties; Republican Presidential candidate Warren G. Harding eventually pledged his support in a Social Justice Day speech.

Notably, the pending 1920 election would be the first time that fully enfranchised women would vote nationwide, courtesy of the Nineteenth Amendment to the Constitution. A nervous, almost exclusively male Congress finally resolved to give the women what they wanted. After amending the measure to ensure that participation would be strictly voluntary, Sheppard-Towner passed overwhelmingly in the House and Senate and was signed into law by President Harding.

Forty-five states participated in the program (only AMA-dominated Illinois, Massachusetts, and Connecticut stayed out). Sheppard-Towner nurses, commonly in distinctive uniforms with dramatic, flowing capes, spread out across the land. They were especially noticeable in rural locales. The nurses accomplished much.3 By 1929, they had held 183,252 prenatal and child-health conferences, helped to establish nearly 3,000 permanent maternity clinics, visited 3,131,996 homes, and distributed 22,030,489 pieces of literature, including the popular booklets Prenatal Care and Infant Care. Home visits provided direct support for mothers breastfeeding their babies The overall infant mortality rate fell by about 10 percent. Deaths from gastrointestinal disease—those most preventable through education—fell by 45 percent.

“Make Birth Free” would be a wonderful affirmation of all young families. It would enhance the life prospects of children. It should reduce the turn to abortion. And it could allow more humane and less medicalized birthing alternatives to flourish.

All the same, Congress ended Sheppard-Towner in 1929.4 The AMA had continued its relentless opposition to the measure, joined now by the arch conservative “Woman Patriots” and “Sentinels of the Republic.” They labelled Julia Lathrop, Florence Kelley, and their allies as Bolsheviks, a label which tended to stick. The DAR withdrew its support in 1926, further showing lawmakers that the “women’s vote” was not monolithic. Congress did renew Sheppard-Towner in 1927, but only on condition of its automatic termination in 1929. Subsequent efforts to reverse this repeal failed. The cadres of excited and dedicated nurses in their caped uniforms disbanded. When a federal program of pre-natal and maternal care returned in 1935 as Title V of the New Deal’s Social Security Act, it was strictly means-tested, a welfare program for the destitute. The Sheppard-Towner experiment in a universal program resting on a nationwide affirmation of motherhood and babies failed in the end.

And so matters remain today. American rates of infant and maternal mortality are still appallingly high, when compared to other lands. In 2020, for example, there were 24 maternal deaths per 100,000 live births, nearly three times the figure for neighboring Canada. Infant deaths were 23% higher. According to family advocates, the AMA has successfully protected its monopoly control over pregnant women for many decades, using well-honed strategies to keep midwives and doulas out of the maternity wards, to medicalize ever more the natural process of birth, to oppose home births, to deemphasize breastfeeding, and to favor C-sections over vaginal births. As mother-advocate Rebecca Skabelund wrote in 2022 (albeit with strong echoes from 1922):5 

the problem for most women is that they have never been taught how to give birth other than on their backs, hooked up to tubes and monitors, with drugs coursing through their veins. They haven’t been taught how to feed themselves so that they have the strength and vitality to avoid complications in their pregnancies and meet the intensity of labor… They haven’t been taught how to care for their babies once they hold them in their arms.

And she adds: “they haven’t been taught the beauty of a sisterhood, uncorrupted by money, where each woman takes her turn supporting and being supported as the seasons of life pass.” In short, Sheppard-Towner or its equivalent was not—and is not—there to help. 

All this comes at enormous expense, paid for in both higher welfare costs and swollen private health insurance fees. Reliable figures show that the cost of the average medicalized birth in America is near $19,000, the highest figure on earth. While Medicaid, the successor to Title V, covers the costs incurred by eligible women, that system is rigidly bureaucratic, a failure in providing less expensive birth alternatives, and weak in postnatal support. Mothers with private insurance can receive staggering bills even for routine deliveries. They also commonly face complicated negotiations with hospitals and insurance companies over disputes, and still may end up with $3,000 or more in out-of-pocket expenses. It has been said that American health care exhibits the worst aspects of both “market-based” and “socialized” systems, without the benefits of either. Giving birth in America seems to prove the point.

The alternative advanced by Foster and Day has three components. 1) It would legally exempt all pre-natal and birth related expenses from co-pays and deductibles under both public and private insurance. 2) It would create a national health care program providing every American mother with comprehensive prenatal, childbirth, and postpartum care, delivered through existing Medicare and Medicaid frameworks. Provisions would end the favoritism shown to C-sections, create incentives for the use of midwives and doulas and the choice of homebirth, and mandate at least four months of postnatal care. As under Sheppard-Towner, home visits would support breastfeeding mothers. 3) Finally, Foster and Day’s plan would create a year-long cash birth stipend, paid monthly, for families to use in whatever way they might choose.

Such a program, though, would bear its own considerable expenses: perhaps $75 billion per annum, depending on the size of the monthly stipend. Even some pro-lifers who acknowledge the flaws in the existing system, such as Leah Libresco Sargeant and Patrick T. Brown, are put off by this price tag. Instead, they propose relatively modest reforms to Medicaid, including expanding eligibility to lower middle-class mothers, an extension of post-partum care to a full year, and an expanded Medicaid staff to handle the workload. For those with private insurance, they would open greater access to under-insured mothers on the Affordable Care Act exchanges, while capping out-of-pocket birth expenses at $2,000.

These very proposals, though, would simply add to the complexities and bureaucratic sinkhole of the existing program. Some bear little scrutiny. Why, for example, retain the $2,000 out-of-pocket expense for the privately insured? It has no apparent relationship to market forces and mandates that so-called private insurers keep a parallel phalanx of administrators who will continue to argue with their federal counterparts over who pays what. For the families involved, the $2,000 would actually operate as an indirect tax, and little more. It would be a fig leaf to maintain the illusion of “private” in the existing quagmire. That said, I do believe that the very wealthy in America are somewhat undertaxed. The solution to this, though, would lie in adjustments to the upper rates found in the federal progressive income tax, but not in a special charge when a mother bears a child. 

An important lesson from the Sheppard-Towner experience is that big ideas enacted democratically, rather than as public charity, have powerful and positive effects. “Make Birth Free” would be a wonderful affirmation of all young families. It would enhance the life prospects of children. It should reduce the turn to abortion. And it could allow for more humane and less medicalized birthing alternatives to flourish.

But is this even possible in a time of toxic political rhetoric and Congressional paralysis? There is a promising precedent. In its 1991 Final Report, the bipartisan National Commission on Children unanimously endorsed creation of “a $1,000 refundable child tax credit for all children” to age 18. This measure was central to the Commission’s view that child well-being was best served by strengthening the family home, economically and otherwise. In reaching this consensus, conservatives on the panel had to overcome libertarian objections in the think tanks and within the “Bush One” White House. Liberals, meanwhile, had to shelve socially radical arguments dominant during the prior 20 years. 

The idea gained momentum. In Newt Gingrich’s 1994 “Contract with America,” Republicans endorsed creation of “a $500 per child tax credit.” In 1997, President Bill Clinton—who as Governor of Arkansas had been a member of the Children’s Commission—signed into law a relatively modest, nonrefundable $500 credit for middle-income families. The 2001 tax measure advanced by the “Bush Two” White House raised the credit in stages to $1,000 per child and introduced refundability for some working, low-income families. In 2017, President Donald Trump signed into law an increase of the credit to $2,000 per child and drew some upper-income families in, as well [excluding only married-couple families earning over $400,000 a year]. Finally, the Biden administration’s 2021 Covid emergency measure temporarily raised the credit to $3,000 per child (and $3,600 for those ages 0-5), expanded refundability, and included 17-year-olds for the first time. 

Now, it is true that that last increase in the CTC’s value disappeared in 2022. Democratic efforts to make it permanent ran into stiff Republican opposition. As with the Daughters of the American Revolution in 1926, the GOP’s ability to consider policies in favor of motherhood and babies outside the usual libertarian box seems to be wobbling. Still, the credit proposed in 1991 has, 30 years later, triumphed through a series of remarkably bipartisan steps. Perhaps good will combined with effective lobbying might rally similar support in 2023 for a most worthy plan to “Make Birth Free” for all.

Allan Carlson served on The National Commission on Children, via appointment by President Ronald Reagan. His books include The American Way: Family and Community in the Shaping of the American Identity, and Fractured Generations: Crafting a Family Policy for Twenty-first Centry America

Editor's Note: The opinions expressed in this article are those of the author and do not necessarily reflect the official policy or views of the Institute for Family Studies.

1. Molly Ladd-Taylor, "'My Work Came Out of Agony and Grief': Mothers and the Making of the Sheppard-Towner Act," in Seth Koven and Sonya Michel, eds., Mothers of a New World: Maternalist Policies and the Origins of the Welfare State (New York: Routledge, 1993): 321-37. See also: Richard A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929 (Baltimore: Johns Hopkins University Press, 1990): especially 147-51. 

2. Ibid., Ladd-Taylor.

3. Ibid., pg. 336.

4. Ibid., pgs. 337-38.

5. Rebecca Skabelund, "Birth Is Not a Curse," The Natural Family: An International Journal of Research and Policy (Vol. 35, numbers 3-4. 2022): 124.