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legal purposes. When complete returns of deaths are obtained by means of that essential requirement the burial permit it invariably happens that the completeness of the registration of births does not rise to the level attained by the registration of deaths. Consequently, it was not possible to establish a registration area for births as early as that for deaths (1880), and the tentative birth registration area established for 1908 includes a much smaller reporting population than the death registration area. The following table shows the births and birth rates for this area, which represents about one-fourth of the aggregate population of continental United States:

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The figures for 1910 are provisional, but approximately complete; that is, so far as the registration returns are accurate for the areas included. These are the six New England states, Pennsylvania, Michigan, the District of Columbia, and New York City.

Collection of Vital Statistics.-The vital statistics of greatest importance to the sanitary administration, namely, those of births and deaths, must be collected under a registration law. The births and deaths must be registered immediately or very soon after their occurrence, or some will be omitted and the records and statistics will be inaccurate. For a long time the movement for better legislation with respect to vital statistics in the United States proceeded without any general direction and supervision, and as a result of the lack of a definite policy and understanding of the necessary provisions of an adequate registration law many bills were presented to State legislatures, and some of them were given effect as laws, that were predestined to failure in practical operation. Some of these laws, as, for example, the recent Tennessee enactment, may prove to be of service in preparing the way for better laws, but others stand in the path of progress and remain obstacles to effective legislation.

About 1902 the question of the improvement of registration legislation was taken up in a practical way by a special committee of the American Public Health Association and, in conjunction with the Bureau of the Census, a circular was issued in which certain essential principles were defined as necessary, according to American experience, for successful results in the registration of deaths. The committee and An improved law was recently enacted in Tennessee, which will soon be

effective.

the Bureau of the Census did not go so far as to define the requirements for successful birth registration because there was, in fact, no. complete birth registration in the United States upon which to base their recommendations-nor to draft bills embodying those requirements. It seemed to be a distinct step in advance to point out some solid basis, however limited, which would serve as a foundation upon which to build better laws.

Later a bill was drafted for the registration of deaths, and subsequently, in order to carry out the desire expressed by Congress for cooperation by the state authorities in the more effective registration of births and deaths, drafts of a bill for the registration of births and for the registration of both births and deaths were prepared.

The essential principles upon which these drafts were based, having stood the test of practical criticism in the construction and administration of registration laws, were adopted as "Rules of Statistical Practice" by the American Public Health Association. The requirements for effective registration of births and deaths may be compared by means of the following tabular statement:

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THE MODEL REGISTRATION LAW.-Much of the improvement in methods of registering vital statistics in the United States has been

due to the active interest and coöperation of the medical profession. The American Medical Association has taken an especially prominent part in this movement and has circulated literature upon the subject and copies of what is known as the "model bill" or "model law" drafted in accordance with the essential requirements of registration. The following is an extract from the American Medical Association Bulletin, September 15, 1910:

"In The Bulletin for January 15, 1909, appeared the model bill drafted by a committee appointed at the 1906 conference on medical legislation. At the 1907 conference held in Chicago in December of that year the committee submitted its report, which consisted of a model bill patterned, in the main, after the Pennsylvania law. This bill has since been endorsed by the Census Department of the United States Government, the Section on Hygiene and Sanitary Science, and the House of Delegates of the American Medical Association, the American Public Health Association, the American Statistical Association, the Committee on Uniform Laws of the American Bar Association, the American Association for the Study and Prevention of Infant Mortality, and the general officers of the American Federation of Labor, as well as by numerous local and state associations and other public health bodies. It can therefore be said to represent the combined judgment of all those interested in securing better vital statistics legislation and registration for the United States, as well as the knowledge and experience of those best qualified to speak with authority on the subject. As this bill has been carefully prepared, it is especially urged that no changes be made in its verbiage or provisions, as apparently slight and unimportant changes may seriously affect the operation of the law."

The best general idea of the mode of operation of a modern registration law may be obtained by a careful examination of the provisions of this bill or of the state laws, e. g., those of Pennsylvania, Ohio, Missouri, Kentucky, that are practically identical with it.

The administration of a registration law is a matter of infinite detail. The State Registrar must be in constant touch with his corps of local registrars scattered throughout the state. It is extremely important in the organization of the system that there shall be a sufficient number of such local registrars and so distributed in each county. that there will be no great difficulty in the carrying out of the essential requirement of the law, namely, that all deaths shall be registered and

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Copies of this bill can be obtained from Dr. Frederick R. Green, Secretary, Council on Health and Public Instruction of the American Medical Association, 535 Dearborn Avenue, Chicago. The bill has been again revised by a special committee composed of representatives of the American Medical Association, American Public Health Association, American Bar Association, and Bureau of the Census, with aid from the committee on vital and penal statistics of the conference of Commissioners on Uniform State Laws and the Children's Bureau.

permits for burial or removal issued in advance of any disposition of the body. If this requirement is neglected in a few cases the number of violations will increase and soon the law will become a dead letter. But in sparsely settled districts the difficulty of communication may be very great at times, hence some provision is necessary as a safety-valve, especially during the first trial of such a law in a state in which no formalities have been observed relative to the burial of the dead. A plan whereby any registrar may issue a provisional permit for deaths not occurring in his district, afterwards seeing that the certificate is filed with the proper local registrar in time for his monthly return, or a special exemption for sparsely settled districts, with requirement of return within ten days after death, may be employed. A practical difficulty is found in rural districts where no undertakers are employed, interments being made by the relatives or friends of decedents. To secure complete returns under such circumstances will require long and patient education of the people as to the importance of such records, and also some check upon the sale of coffins by furniture dealers, so that a blank certificate and a copy of the law requiring registration may accompany each one sold.

The enforcement of the law for the registration of births is especially difficult because there is no ready check, analogous to the burial permit for deaths, which will indicate at once that the law has not been complied with. In some cities special enumerations of births are made and the registration records are supplemented by the additional births thus found. Local registrars may also "keep tab" on births reported in the press or otherwise coming to their knowledge, but probably the most effective method is the systematic examination of all returns of deaths of infants under one year of age in order to see whether their births were duly registered. For example, it is stated in the weekly vital statistics report for the District of Columbia, October 14, 1911, that "there were 14 District-born babies who died during the week covered by this report. Of these 11 had their births reported. The other three are now being investigated with a view to ascertain, if possible, who is responsible for the failure to make these reports." In New York City, beginning in October, 1910, many physicians and midwives were prosecuted and fined for failing to register births. A state inspector is constantly employed in Pennsylvania and has been instrumental in securing many thousands of births that would otherwise not have been recorded. Success depends mainly upon the enforcement of the law by means of the penalties provided therein, and if the law is not enforced it does little good to ascertain the fact of violation and receive the more or less hackneyed excuses of the delinquents. So much injury is done to the legal and personal interests of children and their parents by the unjustifiable neglect of physicians

and midwives who are charged with the duty of reporting births that it would seem that public sentiment should demand rigorous enforcement of registration laws.

The compensation of physicians and midwives for the reporting of births is not provided for in the model law recommended by the American Medical Association. This may perhaps be taken as an expression of medical opinion in general throughout the country, but in some localities the sentiment of the profession is urgent for a small fee, to be paid out of the county funds. The Michigan birth registration law of 1905, originally with no provision for fee, was amended in 1907 to give a compensation of fifty cents to the physician or midwife for reporting each birth. The Kentucky act of 1909 provides a fee of twentyfive cents to physician or midwife for births and of twenty-five cents to the physician for making out a certificate of cause of death. So far no provisions for fees to the undertakers, upon whom the chief burden. of filing certificates of death is imposed, has been provided in any registration law. Some of the authorities in charge of the most progressive state systems believe that a fee to the physician or midwife for birth or death registration is not only unnecessary but harmful, so far as securing complete returns is concerned. Physicians may suppose, in a given case of neglect to register a birth, that if the fee is not paid. the omission is excused. The payment of a fee would have no detrimental influence, and might perhaps with some individuals smooth the course of registration, provided it were understood, and the law expressly stated, that the failure to receive compensation on account of delayed or incomplete returns should not interfere with the prosecution of every such case and the recovery of the penalty provided by the law.

The work of a registration office, in addition to the responsibility for the thorough and uniform enforcement of the registration law and the proper preservation, binding, and indexing of the records, is really a continuous statistical Investigation and should be conducted throughout with direct reference to the statistical data which it is purposed to show. The chief processes of such an investigation may be summarized as follows:

(1) Planning the investigation, which includes the preparation of the schedules or forms used for the "returns"-the technical term defining the filled out blanks or reports which are received at the statistical office as the result of the inquiry.

(2) Scrutiny and correction of the returns. The thoroughness with which this is done obviously depends upon the time at the disposal of the registrar and the accessibility and reliability of the persons reporting.

(3) Hand or mechanical compilation. "Compilation" may comprehend the whole process of obtaining "statistics" from raw material, but is here restricted to the technical procedure of transferring the facts.

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