A new commentary from the R Street Institute examines the 100-year legacy of the Sheppard-Towner Maternity and Infancy Protection Act, passed by Congress in 1921 to combat high maternal and infant mortality rates. The piece, published June 22, 2026, by Courtney Joslin, argues that the fierce political battle over the law wasn't dysfunction—it was American democracy working exactly as intended, with dissent shaping better policy outcomes.
The data from the early 20th century was grim. In 1921, the U.S. Children's Bureau reported that the United States ranked 17th among "civilized nations" in maternal mortality with 68 deaths per 10,000 live births. At the same time, 1 in 10 babies died before reaching their first birthday. State outcomes varied dramatically—by 1934, South Carolina's maternal mortality rate hit 87 per 10,000 births while Vermont's was just 39. For comparison, 2024's maternal mortality rate was 17.9 per 100,000 live births—nearly 40 times lower. In 1900, 40 percent of maternal deaths were due to sepsis, and 80 percent of pregnant women received no formal prenatal care. Birth outcomes were especially dire for women who were poor, Black, or in rural areas; in 1933, when most Black women lived in rural communities, the infant mortality rate for babies born to Black mothers was twice as high as for babies born to white mothers.
The Sheppard-Towner Act provided modest funding—about $1 million annually for five years—in matching funds to states for sending nurses to counsel new mothers, producing educational pamphlets on hygiene, and training midwives. According to the commentary, the bill "took several years to pass and was highly controversial," with some considering it "a serious violation of privacy by the federal government" while advocates argued it was crucial to prevent more deaths from lack of basic hygiene practices. The debate wasn't gendered—many women, including the only woman in Congress at the time, opposed the bill. Rep. Alice Mary Robertson of Oklahoma voted no, and a Baltimore resident wrote in opposition that "Think of the embarrassment it would cause, should a prospective mother have to appear before the Public Health Board." One Harvard professor called the Act "medical communism," arguing the medical field was already making progress and that private efforts would work better than federal spending.
The commentary explains that the controversy represented competing truths: maternal mortality deserved national attention, and education programs did improve outcomes, but there were real consequences to government power over family affairs. Even during Sheppard-Towner's implementation, multiple state-led child welfare programs were based in eugenicist thought and often imposed ideals on immigrants. Private-sector innovation also played a massive role—medical research was primarily funded by private and charitable funds into the 1930s, with federal funding almost nonexistent until World War II. The report argues it took all three forces—women's advocacy, private-sector medical advances, and government investments—to sustainably drive down maternal and infant deaths. Congress eventually let the Act's funding lapse after several years, partly due to lobbying from the American Medical Association, which called it "socialized medicine."
The commentary's core argument is that dissent itself protected the policy from overreach. Joslin writes that "dissenting (and even unenfranchised) voices could still influence policy through voluntary association, open debate, and advocacy" during the Sheppard-Towner debate. The piece invokes James Madison's Federalist No. 51, noting that society broken into "so many parts, interests, and classes of citizens" protects "the rights of individuals, or of the minority" from majority whims. The takeaway: what looked like political chaos was actually the system working—harnessing disagreement rather than eliminating it, and using serious debate among competing interests to shape better outcomes. As America marks 250 years of governance, the lesson is that dissent isn't a bug in democracy—it's the feature that makes it work.