This paper examines the shift in childbirth from home to hospital that occurred in the United States in the early twentieth century. Using a panel of city-level data over the period 1927-1940, we examine the shift of childbirth from home to hospital and analyze the impact of medical care on maternal mortality. Results suggest that increased operative intervention on the part of physicians and a resultant greater risk of infection increased maternal mortality prior to the introduction of sulfa drugs in 1937. However, the introduction of sulfa enabled doctors to reduce maternal mortality by enabling them to do potentially life-saving procedures (such as cesareans) without the risk of subsequent infection. Regressions estimated separately by race suggest that the impact of medical care on maternal mortality differed for blacks and whites. Relative to whites, hospitals posed a greater risk for black mothers prior to the availability of sulfa drugs in 1937, and were less beneficial for them afterwards, suggesting that blacks may have received lower quality medical care.

Enacted in 1922 and repealed in 1929, the Sheppard-Towner program gave federal matching money to states to provide public health education to mothers. We examine variation in state participation in the program, and find that the timing of women's suffrage had an important impact. However, we find that the effect of suffrage was short-lived and did not influence public health spending after the program's repeal. We also find no evidence of a “demonstration effect.” On average, the states that continued activities after Sheppard-Towner ended were those that had sizable public health budgets before the program had even begun.

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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