Maternal and Child Health in the United States and at the Harvard T.H. Chan

This essay frames Marie McCormick’s remarkable career in the context of the history of Maternal and Child Health as an evolving field over the past century, and the parallel development of Maternal and Child Health at the Harvard T.H. Chan School of Public Health. These linked histories are further connected to enduring efforts to draw attention to vulnerable populations and what would come to be considered the social determinants of health. 

Attention to maternal and child health stemmed in many ways from the apparent effects of late 19th century industrialization, immigration, child labor, and insufficient sanitation.  In this context, Lilian Wald famously lobbied for a federal Children’s Bureau, asking in 1903, “If the Government can have a department to look after the Nation’s farm crops, why can’t it have a bureau to look after the Nation’s child crop?”[i] The Children’s Bureau would be formed in 1912, employing fact-finding, advocacy, and action. Its initial efforts were geared towards documenting infant mortality rates, finding that these correlated with housing status, parental earnings, the health of the mother, and local sanitation and milk quality. It would successfully push for child labor and child welfare laws, with this era culminating in the 1921 passage of the Sheppard-Towner Act, providing federal funds to states for child and maternal health programs. While the Act, opposed and characterized as socialist by the AMA, would be repealed by 1929, it would further cement the importance of maternal and child health in the minds of would-be reformers. In this context, the Social Security Act of 1935 included Aid to Dependent Children, Child Welfare, and Title V, which entailed funding for Maternal and Child Health and Crippled Children’s Services.

That same era saw increasing attention given to normal growth and development, while after World War II, the federal government began an expansive extramural maternal and child health research program focusing on vulnerable populations and on programs to intercede on their behalf. At the same time, Martha May Eliot, chief of the Children’s Bureau from 1951 to 1956, worked with schools of public health to strengthen Maternal and Children’s Health teaching and research. Federal funding would be augmented during the Kennedy and Johnson eras, which witnessed the origins of the National Institute of Child Health and Human Development in 1962, and the launch of Head Start in 1965. And even as the Children’s Bureau was formally dissolved in 1969, with its programs distributed throughout other agencies, its legacy continued in the enduring focus on the linked status and development of maternal health, children, and vulnerable populations more generally.[ii] 

HSPH’s own efforts have paralleled, and at times driven, these developments. The school’s first 9 years saw scattered lectures devoted to infant mortality in its social, economic, and medical contexts. With the reorganization of the school in 1922, and reflecting the influence of the Children’s Bureau and Sheppard-Towner, HSPH initiated the first program in the country dedicated to “child hygiene,” through the instruction of Richard Smith.[iii] By 1929, Harold Stuart joined the program, and in the ensuing year began the landmark Longitudinal Studies of Child Health and Development, which would, among many other things, establish the very norms for pediatric growth in the following decades.[iv] 

The late 1930s through the early 1940s, perhaps in the wake of Title V, saw a more overt linking of maternal and child health, with an actual departmental name change to Maternal and Child Health in 1944.[v] By 1946, as HSPH itself became fully independent from HMS, Harold Stuart became department chair, broadly defining the department’s problems as having “to do with many fields of science,” some related “to the health and welfare of all age groups,” but some “of particular importance to the infant or the child.”[vi] In 1957, Martha May Eliot became chair of the department, with its programs presented as “based upon scientific knowledge of the mother and child and of medical, social, emotional, and cultural conditions during maternity and childhood.”[vii] 

William Schmidt succeeded Martha May Eliot in 1961; and we see, during this critical decade, still more overt attention given to health disparities and their causes.[viii] Moreover, while Schmidt could regard Maternal and Child Health Services “as a part of the total public health program, national and local, [to be] discussed in terms of integration with related health services and medical care for all segments of the population,”[ix] he noted in 1969 that planning for the care of mothers and children depended on the particular “aspirational values which society places upon them, their special vulnerability to biological and environmental hazards, and the successive phases of biological change.”[x] Again, maternal and child health were both linked to larger issues in public health and the lifespan of the individual, and described as a focus of unique inquiry in their own right.

This tension would persist throughout the 1970s. By 1976, the department transformed into a division of the short-lived Department of Health Services, itself composed of a Division of Health Services Administration and a Division of Maternal and Child Health, and with close association with the Department of Behavioral Sciences.[xi] By 1979, Health Policy was split off as a new department, with the return to departmental status of the renamed Department of Maternal and Child Health and Aging, chaired by Isabelle Valadian. This name change reflected a stated emphasis on the lifespan of the individual “from conception to senescence within the context of family and community,” related to the goal of the department to “provide in-depth understanding of the physical, social, and psychological determinants of health at various stages of the human life cycle and to promote practical application of this knowledge.”[xii] By 1985, while Aging would drop from the departmental title, the department’s attention to “factors affecting lifelong health” would persist.[xiii]

This was the department that incoming chair, Marie McCormick, inherited in 1991, the same year that Health and Social Behavior began as its own new department. A revised departmental description clearly articulated and divided its research among 6 key topics, including infant mortality and morbidity.[xiv] In 2003, the two departments merged, with Lisa Berkman as the inaugural chair of the new Department of Society, Human Development, and Health. The shared commitments of the two former departments would be evident within the revised mission statement of the following year “to improve human health throughout life with a special emphasis on children and adolescents,” as well as “to identify the social and behavioral determinants of health across the lifespan.”[xv] And such efforts would continue to expand during Ichiro Kawachi’s time as department chair, through to the 2013 departmental name change itself, to Social and Behavioral Sciences. At the same time, Maternal and Children’s Health would be funded at the school by the federal Maternal and Child Health Bureau as an inter-departmental “concentration” and Center of Excellence, drawing upon many faculty from the Social and Behavioral Sciences Department. 

What are the enduring themes and lessons from this more than century-long history of Maternal and Child Health? First, it’s been grounded in advocacy for vulnerable populations, considered amidst the long-term consequences of the social determinants of health across the lifespan. While research has become ever more sophisticated, we can see this enduring ethos from Lilian Wald, Martha May Eliot, and Marie McCormick onward. Second, while this ethos has endured, the challenges faced by women, children, and society first enunciated over a century ago – regarding social inequities and the burden faced by vulnerable populations – likewise endure today. Third, while this ethos has endured, it’s been parsed in different ways over the century, evincing the tension between a focus on maternal health and a broader focus on the lifespan and human society, and evidenced by the multiple and evolving name changes of the department, division, concentration, and field. And finally, from the very beginning of the formation of the Children’s Bureau, we see a critical linkage between research and its translation, and between the design and evaluation of interventions. These are linkages that Marie McCormick further developed during her tenure, and which would seem such a critical component of the department, as well as the Maternal and Child Health concentration, today.