It Takes a Village

by Hillary Rodham Clinton

  On a trip to the Philippines, I visited the Dr. José Fabella Memorial Hospital, in one of the poorest sections of Manila. Over the past decade, the hospital has kept newborns with their mothers, not in a separate nursery. In the maternity ward, dozens of new mothers lie in beds facing their babies. Mothers and their tiny ones learn each other’s touch, becoming comfortable together and starting to build a special intimacy.

  The doctors and nurses at the hospital spend time at each bedside, patiently teaching mothers how to breast-feed. To my astonishment, I also saw one- and two-day-old infants, mouths pursed, sipping from cups. I learned that the hospital began training mothers who could not breast-feed to use cups once they discovered how difficult it was for poor mothers living in unsanitary conditions to sterilize and clean bottles and nipples. It was much easier and simpler for them to keep a baby’s drinking cup clean. With the money saved from closing the nursery, the hospital hired additional staff to teach basic parenting skills.

  American hospitals have also instituted changes in recent decades that encourage both parents to begin caring for their babies in the hospital. Hospitals provide birthing rooms for both labor and delivery. Fathers are allowed to room in and are urged to be present at the birth. Most hospitals that provide delivery services offer basic classes in parenting and child care for new parents.

  Hospitals, as the primary point of contact with parents of newborns, have a natural opportunity and a responsibility to help babies and parents get off to a good start. No mother should leave the hospital without being given the opportunity to ask every question she has about proper baby care. A wallet-sized card listing the immunizations a baby needs, when and where to get them, and how much they cost is a useful item hospitals could provide. They could also make available lists of affordable pediatricians in the area.

  Perhaps most important, hospitals should evaluate the parent-child relationship to determine whether additional advice and help will be needed. This is critical for teenage mothers. Hawaii has pioneered such a program, Healthy Start, which currently screens more than half of the sixteen thousand babies born in the state each year.

  Healthy Start’s workers ask to visit new parents while they are still in the hospital. Most consent to the visit and are grateful that someone cares enough to talk to them. The workers ask them about their family histories and their current situation, noting potential problems. “We look for parents who were abused or neglected as children,” explains Gail Breakey, one of Healthy Start’s founders and the director of the Hawaii Family Stress Center. “We know from research there is an intergenerational pattern.”

  If the family is considered to be at risk, Healthy Start offers a follow-up home visitor. The home visitor helps the parents learn about their child’s developmental needs and acts as a liaison with other agencies to make sure that the family’s needs are attended to—from marriage counseling to employment training to drug abuse treatment. Healthy Start has been successful in reducing child abuse to less than 1 percent among the more than three thousand families who have accepted follow-up help over the last five years—far below the national child abuse rate of 4.7 percent. Healthy Start projects now operate in communities in more than twenty-five states.

  While Healthy Start operates on a consensual basis, states might also consider making public welfare or medical benefits contingent on agreement to allow home visits or to participate in other forms of parent education.

  Despite its proven success, funding for Hawaii’s Healthy Start is not secure. As the federal budget is cut and states are forced to pick up more costs, investments in prevention-oriented programs are likely to take a back seat to prisons, emergency medical care, or other programs with a political constituency.

  It is interesting to note that all Western European countries provide some form of home health visitors. England has a long history of providing home visits through its national health service. After mother and newborn child come home from the hospital, a qualified nurse-midwife from the local hospital visits each day for a minimum of ten days. A “family health visitor,” a fully qualified nurse who is usually associated with the local clinic, is also available for phone consultation or home visits upon request from birth until the child goes to school at age five.

  An American friend of mine who was living in England during her pregnancy quickly came to appreciate home visits. Before having her baby, she was sure that all the books she was reading would explain everything she needed to know. In any case, she reasoned, her mother planned to arrive by the time the baby did. But her mother became too sick to travel, and my friend found herself home alone with her new baby. Like me, she found that the reading she had done, interesting as it was, left her with lots of unanswered questions. When the nurse came knocking at the door, my friend pulled the startled woman inside and began babbling at her: “Why won’t she sleep for more than an hour? Will she ever open her eyes? Do you think she can hear me?”

  I cannot say enough in support of home visits, whether the visitor is a social worker or nurse from a program or an aunt who rides the bus on Saturday to see how her niece and the newborn are doing. Beginner parents need people to talk to and people to call on for help and encouragement.

  THE ELECTRONIC village can play a role in assisting rookie parents as well. Radio and television stations could broadcast child care tips between programs, songs, and talk show diatribes. Imagine hearing this kind of “news you can use” sandwiched in the middle of the Top Ten countdown: “So you’ve got a new baby in the house? Don’t let her cry herself red in the face. Just think how you’d feel if you were hungry, wet, or just plain out of sorts and nobody paid any attention to you. Well, don’t do that to a little kid. She just got here. Give her a break. And give her some attention now!”

  Videos with scenes of commonsense baby care—how to burp an infant, what to do when soap gets in his eyes, how to make a baby with an earache comfortable—could be running continuously in doctors’ offices, clinics, hospitals, motor vehicle offices, or any place where people gather and have to wait.

  I saw another promising innovation in action in the South Bronx in New York City, when I visited Highbridge Communicare Center, which provides basic medical services to the poor residents of the area. Highbridge offers parents a card with a twenty-four-hour toll-free number that connects them to a doctor or nurse who can give them immediate medical advice and help in determining whether a medical problem is serious enough to require either emergency care or an appointment at the clinic. In just a few months of operation, the hot line decreased substantially the number of visits to the local hospital’s emergency room.

  Can you imagine a hot line in every community? Local hospitals could pool their resources to sponsor one. Many hours of anxiety and millions of dollars in costs could be avoided if mothers and fathers had someone to call to talk through a baby’s problem instead of showing up at the only place they can think of to find help—the hospital emergency room.

  NO MATTER how much advice and information is available to a new mother, she and her baby need adequate time to recover from childbirth before she can put it to use. Yet increasingly, American insurance practices are forcing hospitals to discharge mothers and newborns as quickly as possible. As insurance companies look for more ways to cut costs, new mothers are often rushed out of the hospital only twenty-four hours after an uncomplicated birth and three days after a cesarean. For many women, that just is not enough time to emerge from exhaustion, let alone to learn how to breast-feed properly or adjust to a new sleeping schedule and the other changes that arrive along with the baby.

  I was hardly able to get around for the first three days after my cesarean. Fortunately, Bill roomed in at the hospital to care for both me and Chelsea. But almost as soon as I got home, five days after delivery, I had to turn around and go back to the doctor, with a high fever and acute pain from an infection.

  A friend of mine who was pregnant with twins began hemorrhaging during labor and h
ad to undergo an emergency cesarean under full anesthesia. After the delivery, she was severely anemic and was placed in intensive care. Even so, her insurance company, basing its decision on a “checklist” of medical factors, said it would not pay for more than three days in the hospital. In the end, the company did cover a longer stay, but only because her doctor spent hours on the phone arguing that it was medically unsafe to send her home. Some doctors won’t take on such battles, because they fear being dropped by the managed care companies with which they do business.

  Another friend’s wife was covered for seven days in the hospital after a complicated childbirth. But the insurance company insisted on considering the baby independently of his mother. When my friend was told that meant the child would have to leave after three days, he asked, “Do you expect the baby to walk down to the parking lot and drive himself home?”

  Insurance companies claim that limiting a baby’s time in the hospital not only is a money-saver but also reduces exposure to hospital germs. On the other hand, most experts agree that a minimum of forty-eight hours is required to assess the medical risks for mothers and newborns. Generally, new mothers and babies who are discharged in the first twenty-four hours do not develop medical complications. But what happens if the baby develops an infection or other problem—like jaundice, which can cause permanent brain damage or death if it is not treated—that becomes apparent on only the second or third day after birth? What if the new mother has difficulty learning to breast-feed properly, which could result in dehydration or other serious problems for her baby?

  In 1992, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics released a set of Guidelines for Perinatal Care, which recommended that discharge decisions take into account the medical stability of the mother and infant and whether the mother has learned to feed her baby adequately, been instructed in other basic care, and been informed about the availability of appropriate follow-up supports and services. All of these factors are dependent on the evaluations of doctors and nurses who care for mothers and babies, not of the accountants who pay bills or the patients themselves. (In the dizzying aftermath of childbirth, some mothers may decide they are ready to leave prematurely; others might choose to stay for weeks if permitted.)

  Insurance companies point out that most new mothers are entitled to home visits by a nurse, who can help spot problems after they leave the hospital. But the reality is that many insurance companies cover only one home visit per patient; others simply provide for a phone consultation with a nurse in the days after childbirth. And cases have been reported in which the nurse or home visitor simply didn’t show up.

  A retired transit worker in New Jersey, Dominick A. Ruggiero, Jr., told this story to the New Jersey legislature earlier this year: His niece had an uneventful pregnancy and childbirth and was discharged after twenty-eight hours. At home, however, her baby, Michelina, suddenly took a turn for the worse. A nurse was supposed to visit the home on the second day, but she never came. When the family called, they were told the visiting nurse wasn’t aware the baby had been born. Several times, the family called the pediatrician, who said the baby had a mild case of jaundice and did not need to be examined. The baby died from a treatable infection when she was two days old.

  Thanks in part to Ruggiero’s testimony, New Jersey now has a law that will make sure that insurance covers mothers for a minimum of forty-eight hours in the hospital after uncomplicated deliveries and ninety-six hours following cesarean deliveries. Maryland passed similar legislation last spring, and Congress is now considering a bill that would enforce such provisions nationwide. This is not a partisan issue. Maryland had a Democratic governor and legislature when it acted, and New Jersey’s bill was passed by a Republican legislature and signed by a Republican governor. Pending congressional legislation has sponsors from both parties. Although some have suggested that such laws are another example of unwarranted government intrusion, it is difficult to dispute that the health of new mothers and infants is important enough to be safeguarded by the government.

  THE WONDER, worry, and work of parenting does not end with concern about a baby’s physical health. Emotional health and development demand equal attention. The mother-infant ward I visited in Manila took special interest in promoting bonding, the initial contact between parents and child immediately following birth. Watching the mothers and babies there, I remembered how minutes after her birth, Chelsea was cleaned up and handed to me and her father to hold. This initial contact began our lifelong commitment to our child.

  My mother, like most American women giving birth in hospitals during the 1940s and ’50s, was under general anesthesia for each delivery. She didn’t breast-feed, because at the time breast-feeding was not encouraged, and she doesn’t remember even seeing me until she was able to walk to the nursery, the day after I was born. She is understandably skeptical about the significance of immediate bonding, but she subscribes wholeheartedly to the importance of establishing in a child’s first year what psychologists call a “secure attachment.” Secure attachment is the foundation of the love and trust children develop in response to warm, dependable, sensitive caregiving. It develops over the first weeks and months of a child’s life, not in the first few minutes.

  Our country’s favorite pediatrician, Dr. T. Berry Brazelton, describes how, in the islands of Japan’s Goto archipelago, a new mother stays in bed for a month after delivery, wrapped in a quilt, warmly snuggled with her baby. During that time she has but one responsibility—to feed and hold her newborn. All her female relatives attend her. She herself is considered a child during this time and is spoken to in a sort of baby talk.

  Personally, I could do without the baby talk, and a month strikes me as too long to be wrapped in a quilt, but I do admire the way this ritual celebrates and supports a new mother’s most important task: helping her child establish a secure attachment with at least one adult. The secure attachments babies form in the first year give them the security and confidence they will need to explore the world and to develop caring relationships with others.

  The smallest attentions to infants’ needs—picking them up when they cry, feeding them when they are hungry, cuddling and holding them—promote the kind of positive stimuli their brains and bodies crave. A psychologist at the University of Miami recently studied two groups of premature babies. Both groups of infants were given state-of-the-art medical care and proper nutrition, but one group also received gentle, loving stroking for forty-five minutes each day. The babies who were touched warmly every day gained weight and developed so rapidly that they were ready to go home six days earlier than babies in the other group. (This simple human contact, resulting in early hospital release of these infants, also saved medical costs of $3,000 a day.)

  Gentle, intimate, consistent contact that establishes attachment takes time, and as much freedom as possible from outside stress. The more rushed and harried new parents are, the less patience they will have for the considerable demands of newborns. Infants, of course, have no way of knowing the causes of their parents’ stress, whether it be marital conflict, depression, or financial worries. But we know that babies sense the stress itself, and it may create feelings of helplessness that lead to later developmental problems.

  Researchers at the University of Minnesota, one of the premier centers for the study of attachment, have followed almost two hundred people from birth into their twenties. Their findings echo the conclusion reached by scientists conducting research in the area of emotional intelligence: there is a connection between aggression and the lack of secure attachment. “To really understand violence in children,” explains psychologist Allan Sroufe, “you have to also understand why most children and people aren’t violent, and that has to do with a sense of connection or empathy with other people…that is based very strongly in the early relationships of the child and maybe most strongly in the earliest years of life.”

  Like other aspects of parenting, es
tablishing a secure attachment with an infant may not come naturally, except in the sense that we are likely to do to our children what was done to us, unless someone or some experience gives us a different model. However, with an open mind and informed guidance, most parents can learn to relate better to their children, regardless of temperament.

  Dr. Sally Provence, the child development expert I observed at the Yale Child Study Center, had a gift for reading the subtle signs of babies’ discomfort in the way they reacted to being fed or held, and for teaching parents to do the same so that they could adjust their own behavior accordingly.

  I remember standing behind a one-way glass, watching her work with a mother whose baby kept crying and arching his body away from her. The child looked as if he was trying to propel himself into space. I observed how Dr. Provence soothed the baby, speaking to him the same way she touched him, gently but firmly. She translated what she did into simple instructions, for instance showing the mother how to hold the baby less stiffly by using her whole hand instead of just her fingertips. If that kind of hands-on instruction were readily available to more parents, many behavioral and emotional problems could be prevented.

  THE VILLAGE can do much to give parents the time they need to establish their children’s well-being in the first weeks and months of life. The Family and Medical Leave Act, the first bill my husband signed into law as President, on February 5, 1993, enables people who work at companies with fifty employees or more to take up to twelve weeks’ leave in order to care for a new child, a sick family member, or their own serious health condition, without losing their health benefits or their jobs. Although the leave is unpaid, and employees at smaller firms are not covered at all, this is a major step toward a national commitment to allowing good workers to be good family members—not only after the birth or adoption of a child but when a child, parent, or spouse is in need.