It Takes a Village

by Hillary Rodham Clinton

  If, in scientific terms, the twentieth century has been the century of physics, then the twenty-first will surely be the century of biology. Not only are scientists mapping our genetic makeup, but new technologies are letting them peer into living organisms and view our brains in action. The question we must all think about is whether we will put to good use this accumulating knowledge. Can we find ways to communicate it to all parents, so that it can help them to raise their children and to seek out coaching if they need it? Will we give working mothers and fathers enough time to spend feeding their babies’ brains? Will we have the foresight and the political will to provide more and better early education programs for preschoolers, especially those from homes without adequate “brain food”? Will we challenge elementary school students with foreign languages, math, and music to reinforce brain connections early in a child’s life? Given the increasing level of violence and family breakdown we see around us, why wouldn’t we?

  IN THE next few chapters I will explore what happens in families during the first few years of children’s lives—the period that we now know is so vital in giving them a solid start. Researchers may differ over how particular experiences influence a child’s development, but no research study I have ever read has disputed that the quality of life within the family constellation strongly affects how well infants and young children will adapt to the circumstances that confront them throughout their lives. On the contrary, the research underscores the critical importance of constructive stimulation during a child’s earliest years.

  But if family life is chaotic, if parents are depressed and unexpressive, or if caregivers change constantly, so that children can rely on no one, their ability to perform the essential tasks of early childhood will be impaired. The next time you hear someone using the word “investment” to describe what we need to do for our younger, more vulnerable family members, think about the investments the village has the power to make in children’s first few weeks, months, and years. They will reap us all extraordinary dividends as children travel through the crucial stages of cognitive and emotional development to come.

  Kids Don’t Come with Instructions

  We learn the rope of life by untying its knots.

  JEAN TOOMER

  There I was, lying in my hospital bed, trying desperately to figure out how to breast-feed. I had been trained to study everything forward, backward, and upside down before reaching a conclusion. It seemed to me I ought to be able to figure this out. As I looked on in horror, Chelsea started to foam at the nose. I thought she was strangling or having convulsions. Frantically, I pushed every buzzer there was to push.

  A nurse appeared promptly. She assessed the situation calmly, then, suppressing a smile, said, “It would help if you held her head up a bit, like this.” Chelsea was taking in my milk, but because of the awkward way I held her, she was breathing it out of her nose!

  Like many women, I had read books when I was pregnant—wonderful books filled with dos and don’ts about what babies need in the first months and years to ensure the proper development of their bodies, brains, and characters. But as every parent soon discovers, grasping concepts in the abstract and knowing what to do with the baby in your hands are two radically different things. Babies don’t come with handy sets of instructions.

  How well I remember Chelsea crying her heart out one night soon after Bill and I brought her home from the hospital. Nothing we could do would quiet her wailing—and we tried everything. Finally, as I held her in my arms, I looked down into her little bunched-up face. “Chelsea,” I said, “this is new for both of us. I’ve never been a mother before, and you’ve never been a baby. We’re just going to have to help each other do the best we can.”

  In her classic book Coming of Age in Samoa, Margaret Mead observed that a Samoan mother was expected to give birth in her mother’s village, even if she had moved to her husband’s village upon marriage. The father’s mother or sister had to attend the birth as well, to care for the newborn while the mother was being cared for by her relatives. With their collective experience as parents, they helped ease the transition into parenthood by showing how it was done.

  In our own American experience, families used to live closer together, making it easier for relatives to pitch in during pregnancy and the first months of a newborn’s life. Women worked primarily in the home and were more available to lend a hand to new mothers and to help them get accustomed to motherhood. Families were larger, and older children were expected to aid in caring for younger siblings, a role that prepared them for their own future parenting roles.

  These days, there is no shortage of advice, equipment, and professional expertise available to those who can pay for it. If breast-feeding is a problem, for example, there are lactation specialists, state-of-the-art breast pumps, and more books on the subject than you can count. But nothing replaces simple hands-on instruction, as I can attest. People and programs to help fledgling parents are few and far between, even though such help costs surprisingly little. We are not giving enough attention to what ought to be our highest priority: educating and empowering people to be the best parents possible.

  Education and empowerment start with giving parents the means and the encouragement to plan pregnancy itself, so that they have the physical, financial, and emotional resources to support their children. Some of the best models for doing this come from abroad. I’m reminded in particular of a clinic I visited in a rural part of Indonesia.

  Every month, tables are set up under the trees in a clearing, and doctors and nurses hold the clinic there. Women come to have their babies examined, to get medical advice, and to exchange information. A large poster-board chart notes the method of birth control each family is using, so that the women can compare problems and results.

  This clinic and thousands like it around that country provide guidance that has led mothers to devote more time and energy to the children they already have before having more. The fathers, I was told, have also been affected by the presence of the clinic. They are more likely to judge their paternal role by the quality of life they can provide to each child than by the number of children they father.

  This community clinic program, which is funded by the government and supported by the country’s women’s organizations and by Muslim leaders, is a wonderful example of how the village—both the immediate community and the larger society—can use basic resources to help families. The honest, open, matter-of-fact manner of dealing with family planning issues that I observed in Indonesia provided me with a point of comparison to the approaches I have observed in many other places.

  The openness about sexuality and availability of contraception in most Western European countries are credited with lowering rates of unintended pregnancy and abortion among adolescent and adult women. By contrast, more than one hundred million women around the world still cannot obtain or are not using family planning services because they are poor or uneducated, or lack access to care. Twenty million women seek unsafe abortions each year.

  In October 1995, I saw a striking example of the consequences when I visited the Tsyilla Balbina Maternity Hospital in Salvador da Bahia, Brazil. I learned that half the admissions there were women giving birth, while the other half were women suffering from the effects of self-induced abortions. I met with the governor and the minister of health for the state, who have launched a campaign to make family planning available to poor women. As the minister pointed out to me, rich women have always had access to such services.

  We may think that our country is far from this end of the spectrum, but the statistics tell a different story. Two in five American teenage girls become pregnant by the age of twenty, and one and a half million abortions are performed in America each year. It is a national shame that many Americans are more thoughtful about planning their weekend entertainment than they are about planning their families. And it is tragic that our country does not do more to promote research into family planning and wider access to cont
raceptive methods because of the highly charged politics of abortion. The irony is that sensible family planning here and around the world would decrease the demand for legal and illegal abortions, saving maternal and infant lives.

  As usual, the children pay. When too-young parents have children, or when families expand without the means to support their growth, children are affected by the burdens and anxieties of parents who cannot meet their obligations. Family planning, more than just limiting the number of children parents have, protects the welfare of existing and future children.

  The Cairo Document, drafted at the International Conference on Population and Development in 1994, reaffirms that “in no case should abortion be promoted as a method of family planning.” And it recognizes “the basic right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information and means to do so.” Women and men should have the right to make this most intimate of all decisions free of discrimination or coercion.

  Once a pregnancy occurs, however, we all have a stake in working to ensure that it turns out well.

  THERE IS no experience more moving than to walk through a neonatal intensive care unit crowded with babies born too early—the whir of the ventilating machines, the rushing about, the smell of newborns mixed with the smells of hospital halls, the tangle of tubes inserted into wrinkled little bodies. I have walked through many such units in my lifetime, in Washington, Chicago, Little Rock, Boston, Oakland, Miami. The scenes are all the same—babies no bigger than my hand fighting for a life they’ve barely tasted.

  In a 1992 study by the World Health Organization, the United States ranked twenty-fourth among nations in infant mortality. That means twenty-three countries, led by Japan, do a better job than we do of ensuring that their babies live until their first birthday. Seventeen countries, led by Italy, have better maternal health than we do. We shouldn’t be surprised at these results, since nearly one quarter of all pregnant women in America, many of whom are teenagers, receive little or no prenatal care.

  We know that women who receive prenatal care, especially in the first trimester, are more likely to deliver healthy, full-term, normal-weight babies, while women who do not receive adequate prenatal care are more than twice as likely to give birth to babies weighing less than five and a half pounds, the definition of “low birth weight.” And women who do not receive complete prenatal advice on alcohol and drug use, smoking, and proper nutrition are also more likely to give birth to low-birth-weight babies. In 1991, such babies represented only 7 percent of all births but about 60 percent of all infant deaths, for they were twenty-one times as likely to die before their first birthday as babies born weighing more. Inadequate prenatal care also results in higher rates of preventable problems, including congenital anomalies, early respiratory tract infections, and learning difficulties.

  We spend billions of dollars on high-tech medical care to save and treat tiny babies. In 1988, a child born at low birth weight cost $15,000 more in the first year of life than a child born at normal birth weight. It is a modern miracle that we are able to save thousands of babies who would have died if they had been born a few years ago and that we can help thousands more to develop normally. In many cases, however, good prenatal care and emergency obstetric services could have averted the need for medical heroics altogether.

  FOR many pregnant women in America, prenatal care is not accessible or affordable. They live in isolated rural areas or in urban centers. Their employers do not offer insurance, and their families do not make enough money to buy it on their own. Even families who have insurance sometimes find that health care is out of their reach. A couple I met told me their story: Having limited resources, they decided to insure their children and the breadwinning father, but not the homemaker mother. When the mother unexpectedly became pregnant, they saved their money to pay the hospital bills and decided to forgo the expense of prenatal care and anesthesia during delivery. This purely economic decision put both mother and baby at risk.

  Many pregnant women are not even aware that they should be seeking prenatal care. They may be teenagers in denial about their pregnancy or trying desperately to hide their situation from their families. They may be women who do not have husbands, family, friends, or others concerned and informed enough to encourage them to seek medical attention or, at the very least, to stop smoking, drinking, or taking drugs during the pregnancy. In general, women whose already chaotic lives have been further complicated by pregnancy tend to be reluctant to seek services until the last possible moment, leaving their babies vulnerable to much greater health risks.

  Ultimately, we women must take responsibility for ourselves and our health, but many of us will need assistance and support from the village. Peer pressure can work. We all know instances where family and friends have consistently and firmly reminded an expectant mother to forgo an alcoholic drink or a cigarette. But such informal means of monitoring care are no substitutes for formal systems that have as their primary mission good health for all women and babies.

  Examples of the village at work can be found in countries where national health care systems ensure access to pre- and postnatal care for mothers and babies. Some European countries, such as Austria and France, tie a mother’s eligibility for monetary benefits to her obtaining regular medical checkups.

  While it is doubtful that our country will anytime soon develop a formal means of offering or monitoring prenatal care, there are things we can do now that will lower medical costs for all of us and prepare children for a lifetime of good health, starting before birth.

  Some states, health care plans, community groups, and businesses have created their own systems of incentives to encourage women to obtain prenatal care. In Arkansas, we enlisted the services of local merchants to create a book of coupons that could be distributed to pregnant women. This “Happy Birthday Baby Book” contains coupons for each of the nine months of pregnancy and the first six months of a child’s life. After every month’s pre- or postnatal exam, the attending health care provider validates a coupon, which can be redeemed for free or reduced-priced goods such as milk or diapers.

  The Arkansas Department of Health, which has run television and radio ads with a toll-free number to obtain the book, estimates that nearly seven out of every ten pregnant women in the state have received the coupon book. Preliminary reports indicate that women who have participated in the coupon program have had fewer low-birth-weight babies.

  Businesses have also begun to recognize that preventive care saves health care costs in the long run. Many have begun to provide incentives to encourage their employees to seek prenatal care. Haggar Apparel Company in Dallas, Texas, for example, offers to pay 100 percent of employees’ medical expenses during pregnancy if they seek prenatal care during the first trimester of pregnancy. Levi Strauss in San Francisco offers pregnant employees a $100 cash incentive to call a toll-free “health line,” which provides information and advice to callers and screens them to identify those at risk for early delivery.

  Insurance companies, particularly those offering managed care plans, are underwriting classes on healthy lifestyles for pregnant women and providing incentives like car seats and diaper services to encourage women to participate in baby-care training. Other insurance companies are offering one-on-one help, making nurse midwives or nurse practitioners available to pregnant women by phone around the clock.

  Projects that team pregnant mothers with knowledgeable counterparts on the phone or in person have been greeted with much enthusiasm. People want to learn to be good parents.

  In South Carolina, the Resource Mothers program has been linking pregnant teenagers with experienced mothers who live nearby since the early 1980s. The older women meet with the younger women before and after the baby is born, to teach them basic skills like bathing, changing, and feeding, and also to demonstrate constructive ways of interacting verbally and nonverbally with young children. The teens al
so receive counseling about the effects of substance abuse during pregnancy and information about child safety and development.

  Resource Mothers has already had an impact both in improving the health of babies and in reducing the incidence of child abuse, which is often triggered by parents’ not knowing how to cope with the demands of child rearing. The program is supported by state and federal funds for maternal and child health care and by Medicaid.

  In San Antonio, Texas, a program called Avance began teaching basic parenting skills to fifty mothers in 1973. By 1994, the program was serving five thousand individuals in the Mexican-American communities in San Antonio, Houston, and the Rio Grande Valley. Operating in public housing projects, elementary schools, and through its own family service centers, Avance not only enlists project graduates to pass on the basic skills they have learned but offers classes in child development, English-language tutoring, and employment training programs as well.

  Avance places a special emphasis on helping young fathers connect to and stay involved with their children. It uses home visits to monitor the progress of young families, keeping open the lines of communication as infants move into early childhood. The success of the program has been measured in the positive attitudes of the young parents it reaches, who learn that their responsibility as parents includes creating a more nurturing and stimulating environment for children. Avance recently received a state grant to build centers in Dallas, Corpus Christi, El Paso, and Laredo over the next few years.

  While programs like Resource Mothers and Avance contribute greatly to the success and good health of parents and their babies, there is much that hospitals can do to ensure that parents go home better equipped to cope with the demands of parenthood in the first place.