potential influence with political powers need ever be fined or seriously embarrassed in the United States for failure or neglect to perform his duty with respect to the filing of birth certificates. The few exceptions confirm the general rule. Midwives can be prosecuted successfully and are, as a class, more inclined to obey the law. The subject of births was included with that of deaths in the reports on vital statistics prepared by the Census Office for the Tenth, Eleventh, and Twelfth Censuses (1880, 1890, 1900), but only a brief discussion of the subject was given in the chapters allotted thereto. No attempt was made to enumerate births, but the number of births was taken as the sum of the infants enumerated in the census of population under 1 year of age and the number of infants born and dying during the census year. Unsatisfactory as this method evidently is, it gave better results for the great majority of states than were available from actual birth registration. The "total births" were thus: In 1880, 1,552,297, or 30.9 per 1,000; in 1890, 1,670,821, or 26.7 per 1,000; in 1900, 2,053,386, or 27 per 1,000. A continuance of the method applied to 1910, with perhaps too liberal an allowance for the "born and died" of 10 per cent of the infants under 1 year of age as enumerated, yielded an estimated "total births" of 2,439,076, or 26.5 per 1,000, for the United States. I am inclined to think that this is well within the limit and that previous rates, especially that for 1890, were perhaps too low.' We have in the United States some two and one-half millions of babies born every year, or rather this was the approximate estimate for the year 1910. For the calendar year 1908, with a view to ascer taining the exact condition of birth registration and the feasibility of establishing a permanent birth registration area, the Bureau of the Census undertook the collection, from every possible official source, of all births registered in the United States. Transcripts were received from all states having returns to the central registration office, from all cities with birth registration in other states, and from county officials in Illinois where the returns were then deposited in the offices of the county clerks. I remember that the collection was entirely exhaustive and complete so far as state or local records were available except for a certain county of Illinois, the clerk of which refused to make copies for the Government except at an exorbitant rate. The total, however, being all registered births which could be found in the entire country, was only 1,271,952, or 19.8 per 1,000 population. (That is to say, 19.8 per 1,000 of the population from which returns were received; for the entire United States the ratio was only 14.3 per 1,000.) The results showed that only about one-half of the births that occur each year in the United States are recorded. Many 'Appendix 3, p. 72. states had at that time no state laws and the degree of enforcement, even in some of our largest cities, was shamefully lax. The transcripts of births were continued for 1909 and 1910 for certain areas in which the birth registration seemed to be most efficient, and would have been regularly received and published at present were it not for the necessary discontinuance of the work due to the pressure of work incident to the Thirteenth Census. The provisional birth registration area" consisted, for the years 1909 and 1910, of the following states and cities: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, Pennsylvania, Michigan, New York City, and the District of Columbia (city of Washington). The birth rates, based on the reporting population of these areas, were 24.9 for 1909 and 25.4 for 1910. It is earnestly to be desired that the regular collection of transcripts of births should be resumed and that a compilation of the same be published annually with the mortality statistics. The collection should be restricted to areas having approximately complete registration and in which the laws are enforced, and careful investigation should be made before admitting states to the permanent birth registration area when it shall be established. Experience has shown, I believe, that it is not good policy to admit a doubtful state with the expectation that conditions will improve. THE MODEL LAW. As the satisfactory collection of vital statistics in the United States is primarily dependent upon the operation of state laws, thus requiring independent but harmonious and effective legislative action in 48 states, it is evident that to accomplish practical results in extending the registration area some general plan of procedure must be chosen. Many worthless laws for registering or attempting to register births and deaths have been adopted by various states. Often the plan of enumerating births and deaths at the end of the year has been selected—a plan proved to be inadequate by the repeated trials of the Census and by other experience. Or the favorite "county system," namely, the attempt to collect returns by or through county officials, would be chosen. The latter, indeed, is a very natural suggestion from the general process of government in this country, especially in the West and South where township organization does not prevail. Other laws were deficient in provisions for central control and enforcement of law, proper compensation to local registrars, and uniform and complete data on the certificates or other forms provided. There was no general directive influence in recommending proper legislation, and accordingly a large part of the efforts made by public health workers and others for the enactment of better registration laws was wasted. The beginning of the reform which resulted in the present Model Law which is now so extensively in force in this country may be referred to the following resolution which was presented at the meeting of the American Public Health Association, Denver, 1895: Resolved, That a committee be appointed to prepare a draft of a registration law (or to formulate the principles to which a registration law should conform) suitable for adoption by states not having at present an accurate system of registration of births and deaths. The resolution was not adopted by the association, but the committee on vital statistics in which it originated continued to occupy itself with the subject, and at Buffalo, 1900, reported: The development of the registration idea has in different areas followed only a general direction and presents many variations. Your committee proposed, therefore, to formulate the correct outlines of a registration law, emphasizing the essential features and indicating, in the order of their importance, those data which are demanded in the legal and private aspects of registration. The record of death has been generally recognized as of first importance in registration, and your committee has therefore set as its second task to prepare and present at the next or a future meeting a model form of a record of death. From this decision resulted the Model Law and the standard certificate of death, followed by the standard certificate of birth. These have played an important part in the development of American registration of vital statistics and in the procuring of uniform and thoroughly comparable returns from registration areas. The successful outcome was largely dependent upon the practical cooperation of the United States Census Office, which was organized as the permanent Bureau of the Census in 1902. Mr. William A. King, chief statistician for vital statistics, had prepared a circular ("Circular No. 71") in which he related the efforts of the Census Office in the preparatory work of the Twelfth Census (1900) to bring about greater uniformity in methods and to promote more effective legislation, from which the following extract is taken : A complete collection was then made of existing state laws and city ordinances, together with the forms in use and the rules, regulations, and instructions affecting the practice of collecting, recording, and preserving the records. This material was to be used in the preparation of an outline plan for a complete system of registration, including suggestions for necessary legislation and methods of treating the records so as to secure the maximum benefit from them. As this plan was about to be put into effect it was learned that the committee on "Demog raphy and Statistics in their Sanitary Relation" of the American Public Health Association had, at their recent meeting, concluded to take up the same subject, and it was immediately decided that the best results could be accomplished by acting in concert with the committee, which is composed of prominent registration officials of extensive practical experience and capable of treating the subject in the most comprehensive and effective manner. The committee's outline of the "Essential requirements of a law for the registration of deaths and the collection of mortality statis tics" was included in Census Circular No. 71 and subsequently reprinted in Census Pamphlet No. 100, Legislative Requirements for Registration of Vital Statistics, 1903, the first of a series of pamphlets devoted to the extension of registration. The following list of necessary provisions," extended to cover the registration of births, is taken from a later pamphlet-No. 108, Legal Importance of Registration of Births and Deaths: NECESSARY PROVISIONS FOR THE REGISTRATION OF DEATHS. BIRTHS. 1. Deaths must be registered imme- 1. Births must be registered immediately after their occurrence. 2. Certificates of death should be re- 3. BURIAL or removal PERMITS are essen- diately after their occurrence. 2. Certificates of birth should be re quired. 3. SOME CHECK is necessary to secure enforcement of the law. 4. Efficient local registrars are necessary. 5. The responsibility for reporting 5. The responsibility for reporting deaths to the local registrars births to the local registrars should be fixed. should be fixed. 6. The central registration office should have full control of the local machinery, and its rules should have the effect of law. 6. The central registration office should have full control of the local machinery, and its rules should have the effect of law. 7. The transmission and preservation of 7. The transmission and preservation of returns should be provided for. returns should be provided for. 8. Penalties should be provided and 8. Penalties should be provided and enforced. enforced. All laws recommended by the Bureau of the Census since 1901, many of which are now in successful operation, have been drafted on the basis of these essential principles. It was not thought feasible, in the original report of the committee, to prepare a bill for general adoption, but the demand for such a bill was insistent, and the early census pamphlet (No. 100) contained a "specimen form of law for the registration of deaths." This was followed in Census Pamphlet No. 104, Registration of Births and Deaths-Drafts of Laws and Forms of Certificates, by a draft of a law for the registration of births and deaths-the Model Law in its original form-together with a separate bill for births and a condensed form of law for both births and deaths. The first practical test of the model bill was in the preparation of a bill for introduction before the Pennsylvania Legislature of 1905. Pennsylvania had endeavored for many years to obtain effective registration of vital statistics, a law for that purpose having been passed as early as 1851. The Model Law was adopted in 1905, and the results were such as to warrant the admission of the state into the registration area for the following year, 1906. This gave a great M impetus to the movement and set the seal of practical achievement upon the legislation recommended. The Model Law, or model bill, as it should be called, when proposed for adoption, is by no means an ideal or perfect measure. It has many imperfections and is still undergoing a process of revision in connection with new or amendatory legislation in various states. Thus, for example, the revised California law passed this year has an important method or legal procedure for placing upon record births not properly recorded at the time fixed by law. The new Illinois law, also passed this year (1915), has several valuable additions. In time all new features of value will be incorporated in the standard draft. As it is, however, it has undergone several distinct and thorough processes of revision, the last being by a committee of the Public Health Council of the American Medical Association at Washington, 1912, in cooperation with committees or representatives of the American Public Health Association, the American Bar Association, the Children's Bureau, and the Bureau of the Census. The revised draft is published in a pamphlet, "Why Should Births and Deaths Be Registered?" by the American Medical Association, of which many thousands of copies, as well as of previous editions, have been distributed by the association and by the Bureau of the Census.1 ate d ( red been And The cardinal principles of the Model Law are two-first, the rigid requirement of burial or removal permits; and, second, prompt direct returns of the original birth and death certificates from the local registrars to the state registration office. The returns are made monthly, on a specified day of each month (4th, 5th, or 10th in different states), and include all certificates of births and deaths which occurred in the preceding calendar month. If no births or deaths occurred, the local registrar makes a postal-card report to that effect. The central office is thus in direct touch with all the local registrars of the state, can check carelessness or neglect promptly, and can utilize the monthly returns for valuable compilations of current mortality. Local registrars are paid by the county treasurers on warrant of the state registrar, but only for complete certificates promptly filed in accordance with law. They are also paid for prompt and correct reports of no births and no deaths. Local registrars are required to report violations of law coming to their attention and the state registrar is charged with the uniform and thorough enforcement of the law throughout the state, with the assistance of county prosecuting attorneys and of the attorney general, if necessary. Provision is made for the use of the standard birth and death certificates and for the compilation of the data collected in the form of an annual report. 1 Appendix 4, p. 77. of C And Fon dece Pub Bu |