Kathryn Taaffe Young, Karen Davis, and Cathy Schoen
August 1996

Opportunities for parents to get their infants and toddlers off to a good start are being missed by the health care system. American parents are struggling with the demands of rearing young children under considerable financial and time pressures. A nationwide representative survey of more than 2,000 mothers and fathers with children under age three finds that they want more information, services, and help from doctors on how they can help their children thrive and learn during the critically important first years.

• Early hospital discharge leaves parents on their own to cope with newborn demands. The increasingly common practice of discharging mothers and infants in the first day or two provides little opportunity for new parents to become comfortable and knowledgeable about newborn care. Follow-up home visits by a nurse occur only in one of five cases.
  
  
• Health professionals are missing opportunities to encourage breast-feeding. One-third of mothers do not breast-feed their infants, and only slightly more than half of mothers (53%) breast-feed for more than one month. Mothers are much more likely to breast-feed when encouraged to do so by their doctors or nurses (74% v. 45%).
  
  
• Parents are missing opportunities to stimulate infant brain development. Only two in five parents read daily to their infants and toddlers, despite research showing the importance of stimulating activities such as reading, looking at pictures, and playing music even in the very early months. Parents are more likely to read to infants and toddlers if doctors discuss with them what they can do to help their children learn (47% v. 37%).
  
  
• Parents are receptive to information from physicians. Parents indicate that they would find helpful more information on newborn care, sleep patterns, how to respond to a crying baby, toilet training, discipline, and encouraging their child to learn. Yet fewer than half of parents discuss these issues with their physician.
  
  
• Parents receiving special pediatric services rate physicians more highly. Some parents receive special pediatric services: packet of information on newborn care (89%), nurse home visit (20%), telephone advice line (32%), reminder service for immunizations and well-baby visits (42%), and child health record (66%). The majority of parents receiving these services find them very useful and are much more likely to give their doctor an excellent rating on overall quality of care provided (71% for those receiving three or more services v. 49% for those receiving none of the services).
  
  
• Parents' child rearing practices reflect strains on families. Parents are more likely to use harsher disciplinary measures with toddlers than with younger children. One-quarter of parents report spanking their two- to three-year-old toddlers sometimes or often, and 63 percent report yelling at them. Only half of all children have regular routines for meals, naps, and bedtimes; lack of regular routine is more common among single parents and lower income parents.
  
  
• Parent’s mental and emotional health influence child rearing practices. Nearly one out of ten mothers (9%) reports experiencing three to five depressive symptoms (including feeling depressed, sad, or that people disliked them, crying, or not enjoying life most or some of the time). Parents who exhibit at least three of the five depressive symptoms are twice as likely as parents with no depressive symptoms to become frequently frustrated with their child’s behavior (44% v. 21%), are more likely to yell (51% v. 34%) or spank (17% v. 11%) their children, and are less likely to read to their children (27% v. 43%) or maintain regular routines (31% v. 58%).
  
  
• Not all parents are ready and prepared. Preparation for parenthood is mixed. One-third of births are not planned. About two-thirds of parents do not attend a class or discussion about parenting. Higher income and better educated parents are more likely to attend parenting classes.
  
  
• Financial stress on families is also an issue. Half of children are in families with incomes less than $40,000, and one-quarter are in families with incomes less than $20,000. One-third of families with incomes less than $40,000 report some difficulty in paying for basic child supplies such as formula, food, diapers, clothes, and shoes. Twenty-three percent of families with incomes less than $40,000 report some difficulty in paying for the child’s medical expenses.
  
  
• Government programs lend a vital helping hand. Almost half of children (47%) have families who have received some form of government aid such as cash assistance, food stamps, or Medicaid since their birth. One-fourth (28%) of all children and 16 percent of parents are covered by Medicaid. For families with incomes less than $10,000, Medicaid covers 79 percent of children and 58 percent of parents.

The portrait of today’s parents of young children revealed in in-depth interviews is one of parents awed by the responsibility, wishing ardently that their children will grow up to be happy, healthy, productive citizens, but struggling under the enormous responsibility and often missing opportunities to assure good outcomes for their children. The health system and government programs provide only partial assistance during this critical period. Much more could be done to support parents in fulfilling their most important responsibility.

Opportunities for parents to get their infants and toddlers off to a good start are being missed by the health care system. American parents are struggling with the demands of rearing young children under considerable financial and time pressures. A nationwide representative survey of more than 2,000 mothers and fathers with children under age three finds that they want more information, services, and help from doctors on how they can help their children thrive and learn during the critically important first years.

METHODOLOGY

A nationally representative sample of 2,017 parents with children younger than three years of age was interviewed by telephone through a 26-minute questionnaire during the period July 1995 though January 1996. One-third of the parents talked about their experiences as the parent of a baby who had not yet reached a first birthday. A little over a third of parents talked about their child between the ages of one and two years. Another third talked about their toddler between the ages of two and three years. In each family, either the mother or the father was randomly selected to be interviewed. Altogether, the survey includes the responses of 697 fathers and 1,320 mothers.

The survey over-sampled black and Hispanic parents so their experiences could be analyzed in detail. The sample included 397 non-Hispanic black parents and 419 Hispanic parents. The data were weighted in analysis to compensate for this over-sampling, so the results are fully projectable to the total population of parents with very young children. The margin of sampling error for results based on the total sample is plus or minus three percentage points, at the 95 percent level of confidence. The Commonwealth Fund survey was designed and analyzed by Princeton Survey Research Associates of Princeton, New Jersey, in collaboration with the Fund. Interviewing was conducted by DataStat, Inc., of Ann Arbor, Michigan.

EARLY HOSPITAL DISCHARGE

Early discharge of mothers and infants from the hospital -- typically within one to two days -- leaves young families on their own to cope with the challenges of parenthood. Fewer than half of first time parents (44%) say they feel very confident about caring for their newborn when they leave the hospital.

Short hospital stays provide little time for helping parents learn about newborn care, and send a message to parents that they are on their own in caring for their child. Half of mothers (51%) who deliver vaginally are discharged in one day or less. One in five (21%) mothers who deliver by C-section is discharged in two days or less.

One-third of parents whose child is discharged after one day feel their child spent too

little time in the hospital. The survey finds that nearly one-fifth of newborns who were premature or weighed less than 5½ pounds were discharged after one day. About 17 percent of all infants -- mostly premature infants -- have some medical problem requiring attention in the first two weeks, and 4 percent are rehospitalized during this period.

Despite the trend toward shorter stays, however, home visits following a child's birth occur in a minority of cases. Only one-fifth of parents report a home visit by a nurse or other health professional to teach them about infant care and to check the baby. Two-thirds of parents (67%) who received a follow-up home visit found the visit very useful.

BREAST-FEEDING

Breast-feeding, widely recommended to help infants grow and thrive, is much more likely when encouraged by doctors or nurses. One-third of mothers (33%) do not breast-feed despite proven medical and health benefits to the newborn. Only slightly more than half of mothers (53%) breast-feed for more than one month. Mothers who are younger, lower income, or black are less likely to breast-feed their babies than other mothers.

Surprisingly, not all mothers are actively encouraged to breast-feed, and some feel that they were discouraged or received mixed messages. Only 72 percent of mothers are encouraged to breast-feed while in the hospital for the birth of their baby.

Seventy-four percent of mothers who are encouraged by their doctors to breast-feed do so, compared with fewer than 45 percent of mothers who are not encouraged to breast-feed. Visits to the home by a nurse in the days following hospital discharge can also help mothers adapt to breast-feeding.

STIMULATING BRAIN DEVELOPMENT

New scientific research has shown that the brain develops rapidly in children under age three, and that parental activities such as reading, singing, and being affectionate can influence healthy child development. Parents, however, are often missing opportunities to stimulate their infants' brain development. Only 39 percent of parents read or look at a picture book with the child at least once a day. Sixteen percent of parents do not read to their children at all. Although book-sharing activities are higher for toddlers, rates remain low. Fewer than half of parents with children age one to three years (48%) read to or show a picture book to their child at least once a day.

Physicians can make a difference. Parents are eager for guidance on how to help their babies grow and develop, and look to physicians for expert information. Parents who talk with their doctor about encouraging their child to learn are more likely to read to their child on a daily basis, compared with parents who do not discuss learning (47% v. 37%). Reading patterns are the same for both working and nonworking parents.

PEDIATRIC INFORMATION AND SERVICES

Parents are eager for information on six areas of child rearing -- newborn care, sleep patterns, how to respond to a crying baby, toilet training, discipline, and encouraging their child to learn. Most parents (79%) feel they could use more information in at least one of these six areas of parenting. More than half (53%) want more information or help in at least three areas. Parents say they would like more information from their health care professionals about encouraging their child to learn (54%), discipline (42%), toilet training (41%), sleep patterns (30%), and responding to a crying baby (23%).

Despite the eagerness of parents to receive expert information from their physicians, only a minority do so: 23 percent of parents discuss how to help child learn, 23 percent discuss how to discipline, 29 percent discuss toilet training, 41 percent discuss sleep patterns, and 35 percent discuss responding to a crying baby.

Parents are least satisfied with the extent to which their child's regular doctor helps them understand their child's care and development. Slightly more than half say their doctor or nurse gives them excellent guidance about how to care for their child (56%) and helps them understand their child's growth and development (58%), compared with two-thirds of parents who give excellent ratings on providing good overall pediatric care (69%) and in listening carefully and answering questions (66%).

Parents are also less satisfied with their ability to reach their child's doctor or nurse by telephone. Only 54 percent of parents give their doctor or nurse an excellent rating on this dimension and 12 percent have complaints, rating their provider as only fair or poor.

Special pediatric services are also valued by parents, yet again most parents do not receive such services from their health plan or pediatrician: 20 percent received a home visit from a nurse or other health professional, 32 percent had access to a special telephone advice line, 42 percent had a reminder service for immunizations or check-ups, 66 percent had a booklet to keep track of their child's health information, and 89 percent received a packet of information about how to care for a newborn. Those parents who receive additional services find them "very useful": a packet of information on newborn care (54%), a home visit by a nurse (67%), a special telephone advice line (87%), a reminder service (85%), and a booklet to keep track of their child's health information (83%). Receiving printed material or videos does not substitute for discussion with a physician or nurse; in-depth interviews with parents indicated some frustration that they were simply given such material without a demonstration or in-depth discussion.

Parents who do receive information and comprehensive services report much higher levels of satisfaction with their physicians. Seventy-one percent of parents who receive three or more special pediatric services, including a nurse home visit, telephone advice line, packet of information on newborn care, reminder service for well-baby visits and immunizations, and child health record, rate their child's doctor as excellent on providing good health care, compared with fewer than half (49%) of those who receive none of these services. Whether parents receive or do not receive such services, nearly two-thirds say they would be willing to pay $10 a month for these special pediatric services.

STRAINS ON PARENTS AND CHILD REARING PRACTICES

Rearing children in today's world can be stressful -- especially as a child grows older and parents balance work and family responsibilities. Six percent of parents with infants under the age of six months, compared with 38 percent of parents with toddlers age 18 months to three years, are frequently frustrated or aggravated with their child's behavior in a typical day. Harsher disciplinary measures are also more common with toddlers: 63 percent of parents report yelling at their young child, and one-quarter report spanking their child sometimes or often.

Regular routines are important for the healthy social and behavioral development of children. Yet only about half of parents (51%) have set routines that include meals, naps, and bedtimes. Regular routines are least common among single parents and among lower income families.

PARENTS' MENTAL AND EMOTIONAL HEALTH

Maternal depression affects mothers' ability to interact appropriately with their young child. Nearly one out of ten mothers reports experiencing three to five depressive symptoms at least some of the time during the week prior to the survey. These include feeling depressed, sad, or disliked, experiencing crying spells, and not finding life enjoyable. Yet depression, especially in women, often goes undetected and untreated. Pediatricians and obstetricians may be a mother's main source of contact with health care, placing a special responsibility on these physicians to take a broader responsibility for the mental health of parents.

Mothers and fathers who experienced three to five depressive symptoms in the previous week are twice as likely to say that they become frequently frustrated with their child's behavior in a typical day (44% v. 21%), are less likely to have established a daily routine for the child (31% v. 58%) or read to their child daily (27% v. 43%), and are more likely to yell at their young child (51% v. 34%). Parents who report that they were physically or sexually abused as a child are more likely to exhibit depressive symptoms and more likely to become frequently frustrated with their child.

FINANCIAL PRESSURES ON FAMILIES

Financial pressure on families also undermines their ability to provide proper care for infants and toddlers. More than half of the children (53%) live in families with incomes less than $40,000 per year, and one-quarter live in families with less than $20,000 annual income. Such families are more likely to report difficulties paying for their child's basic needs, as well as the baby's medical expenses. Nearly 33 percent of families with incomes less than $40,000 report some difficulty in paying for basic child supplies such as formula, food, diapers, clothes, and shoes. Twenty-three percent of families with incomes less than $40,000 report some difficulty in paying for the child's medical expenses.

Government programs do provide some assistance; nearly half of all children have parents (47%) who received some form of government aid such as welfare, food stamps, or Medicaid following the child's birth. Medicaid is a major source of health insurance coverage, covering 28 percent of young children under age three and 16 percent of parents.

PREPAREDNESS FOR PARENTING

Many parents are not prepared for the responsibilities of parenthood. One-third of all births were not planned. Rates of unplanned births are higher for single mothers (66%), mothers under 20 years of age (64%), and mothers in families with incomes under $10,000 (57%).

Attendance at childbirth classes has become much more commonplace. Only 29 percent of parents do not attend childbirth classes, although attendance is lower for younger and single mothers.

Parenting classes, however, to understand child development and appropriate child rearing practices are much less common. About two-thirds of parents (65%) do not attend a class or discussion about parenting. Rates are lower for those with less education and lower incomes. Sadly, parents are much more prepared for the 8-12 hours spent in childbirth than for the next 18 years spent rearing a child.

PROFILE OF PARENTS

The Fund's survey is unique in its sample of parents, which is nationally representative of all parents with children under three years of age in the U.S. Results show that:

• Eight out of ten children under age three are being reared by two parents, including 72 percent who are married and 10 percent who are living together as married.
• Fewer than one-fifth of young children are growing up with single parents.
• Ten percent of children are born to mothers under age 20.
• Forty-eight percent of parents are in the age range of 20-29 years at the time of their child's birth.
• In nearly one-third of two parent families, both parents are working full time.
• More than half of infants and toddlers (56%) have mothers in the full- or part-time workforce.
• More than half of all parents say they would like to spend more time with their child. Eight out of ten parents who work full time wish this the most strongly.
• Nearly nine out of ten parents have graduated from high school and more than half have had post-high school education.

In-depth interviews with selected parents (see Appendix A) reveal common aspirations on the part of parents. They uniformly want their children to grow into happy, healthy, productive citizens. Yet, they are awed by the responsibility of parenthood, and struggle against great odds to help their children off to a good start. They are hard-pressed financially. Even paying for diapers and food can be difficult for the half of families with incomes less than $40,000. They are typically working and wish they had more time to spend with their children. The information and support they need to fulfill their responsibilities as parents are too often lacking.

CONCLUSION

There is perhaps no greater responsibility than that of helping children grow into healthy and productive adults. We as a nation can not afford to miss opportunities to assure the healthy cognitive, social, and behavioral development of young children. Findings from the survey point to a number of steps that can be taken by the health system, communities, philanthropy, and government to provide a vital helping hand to parents as they carry out this awesome responsibility.

The survey findings will inform a new national initiative, Healthy Steps for Young Children, sponsored by The Commonwealth Fund and chaired by Margaret E. Mahoney, the Fund's immediate past president. Healthy Steps is based on a partnership of a number of private and community foundations and health care providers. The American Academy of Pediatrics is also a cosponsor of the program. The program is a new approach to help mothers and fathers in fostering the growth and development of their young children. It will expand services beyond those concerned solely with the physical health of young children to a more comprehensive model of pediatric care that supports the parents of young children and stresses the importance of their nurturing role in the emotional, behavioral, and intellectual growth of their young children. The program emphasizes a close partnership between health care professionals and parents, and provides an array of special pediatric services that the survey findings document as valuable to parents. Up to 25 pediatric health care sites will receive financial support to test this new approach to pediatric care.

But the findings also provide a compelling case for greater attention as a nation to the needs and concerns of parents of young children. Pediatricians, obstetricians, and other health care professionals can do much more to encourage healthy practices, detect and treat depression, and provide information and services to assist parents.

Government programs do lend a helping hand. Almost half of children live in families receiving some form of government assistance since their birth -- whether cash assistance, food stamps, or Medicaid. Yet an alarming percentage of low and moderate income families are facing difficulties in meeting even the basic needs of their children, such as diapers or food. Medicaid is an important source of health insurance coverage for children and mothers. It could provide an opportunity to serve as a model for supporting parents through home nurse visits and parenting information -- reaching many mothers and fathers who could benefit from greater attention and support.

But the concerns and needs of parents of young children are universal and require a broad response. If we are to assure that all children have the opportunity to grow into healthy and productive adults, all parts of society need to be mobilized. Most fundamentally, we as Americans must come to view all children as our children -- deserving and needing our support.

List of Profiles

Spyra, 29-year-old married mother of toddler Nicholas and another infant son, non-working, some college, New York resident. (Available for an interview.)

Rosario, 27-year-old single mother of 14-month-old Juan, living with Juan's father, working, college graduate, California resident.

Clay, 35-year-old married father of 2-year-old Dominic, both parents working, high school graduate, Montana resident. (Available for an interview.)

Teresa, 26-year-old single mother of 3-year-old Alex, working, some college, Georgia resident.

Patrick, 31-year-old single father of 2-year-old Allison, working, college graduate, Arkansas resident.

Beth, 36-year-old married mother of 2-year-old Julia, both parents working, master's degree, Illinois resident. (Available for an interview.)

Chrisie, 21-year-old single mother of 3-year-old Jashen and another infant son, working, high school graduate, South Carolina resident.

Profiles

Spyra, 29-year-old married mother of toddler Nicholas and another infant son, non-working, some college, annual family income more than $40,000, New York resident.

Spyra bucked the parenting trend of the '90s and decided to stay home with her two sons. "I don't want anyone else raising my kids," says Spyra. "I figured if there are going to be mistakes, they are going to be mine. I don't want to have any regrets in the future. They're my mistakes, nobody else's."

But it's not always easy. Spyra's husband has been a tremendous help ("He does the dishes, does the laundry, does the vacuuming. ...If I need a break, he'll tell me, 'Go out, I'll watch the kids."'). And she receives valuable guidance from her children's pediatrician ("He does everything, short of making house calls."). But they are basically the only support she has, since the couple has no family living nearby. "I know my neighbors, but everyone has their own life. There's not too many mothers that I know," Spyra says.

One thing that would have helped, says Spyra, was if she had been allowed to stay in the hospital a little longer following both of her sons' births. "I had a natural birth with Nicholas and could only stay two days. I was breast-feeding and the baby wasn't catching on, and I was getting frustrated, because I had no idea whatsoever," she remembers. While she did get the hang of it just before she was released, Spyra says, "I wish I stayed in a couple days more. You know, talk with other mothers and everything." When she had her second son by C-section, she stayed only three days, which was even harder. "That was definitely not enough time ... because I was coming home to another child, and I wasn't able to do much, she says.

Spyra says she wants her sons to grow up differently from the children she sees so often these days; "to go up and shake another person's hand when they say hello ... be able to take their hat off if somebody walks through." And she thinks that is her job, but it's not appreciated enough by the rest of society. "Mothers in general don't get enough credit for what they do," she says.

Rosario, 27-year-old single mother of 14-month-old Juan, living with Juan's father, working, college graduate, annual family income between $30,000-40,000, California resident.

Becoming a mother hasn't been easy for Rosario. Although she had considerable experience helping care for her six brothers ("that's how most of the Hispanic families do it -- they let the older sisters take care of the younger ones"), the Californian felt ill-prepared when she brought son Juan home from the hospital. "I don't know why babies don't come with a manual," she laughs now.

But Rosario was not laughing when she was faced with caring for Juan by herself at the beginning (Juan's father has since moved in with them). Although her mother was only a block away, "I felt like I shouldn't call her every minute for every little thing. So I had to go ahead and take care of things." But things didn't always go well. "I got depressed when he started crying, and I fed him, I changed him, I carried him, and things like that -- and it didn't work. ...It got me depressed, because I thought I was doing something wrong."

While Juan's father has been supportive ("When I'm cooking, he's taking care of him, entertaining him. ...He pretty much does everything with the baby."), Rosario wishes Juan’s pediatrician and staff were as helpful. "They answer my questions, but sometimes I would like more explanation of other choices or alternatives," she says.

Rosario also says she wishes she got more help in the hospital right after Juan's birth. During her one-day hospital stay, she was shown a video. "I felt like they should teach me or tell me more things, not just show me the video, but [send] a nurse to come and ask me if I have any questions or things like that. They never offer any extra help." Rosario tried to do as much as she could on her own, including going to the library and reading up on parenthood, but has since discovered that there's nothing like on-the-job training. "I am still learning how to be a mom. I think it never ends, " she says.

Rosario says her main hope is that Juan will "have self-confidence, but to be gentle... just to be nice to other people. ...It's going to be hard, especially with the kind of life that we are going through right now.

Clay, 35-year-old married father of 2-year-old Dominic, both parents working, high school graduate, annual family income between $30,000-40,000, Montana resident.

Clay thinks too many people are not serious enough about parenthood. 'It shouldn't be taken lightly," says the Montana father of two, a daughter and a son. "What happens in their early childhood will stick with them throughout their life, and I feel that will influence what kind of person they end up to be. I want Dominic to grow into a gentle, caring, and honest adult, preferably honest over anything," he says.

Clay says he's a much better father to his son, 2-year-old Dominic, than he was to his daughter, now 12, whose mother he divorced when the child was very young. "I didn't want to bring another child up without any parents," he says. He attributes part of his success with Dominic to being older and more experienced, but also credits Dominic's mother. "She lets me have my own time with just me and him. I go out in the yard, and she tells me to take my son along and have him out in the yard with me. She gives me my space with him."

Clay admits that even in a good relationship, parenting is hard work. "He can start to talk now, but before he couldn't tell me and I couldn't understand what he needed and why, and I'd get frustrated," he says. Clay also admits that he sometimes gets jealous of his son. "He would get all the attention" from his mom.

While Clay cherishes his time with Dominic, he is also depressed by "how much more my son has than my daughter did at that age. ...I shouldn't think about that a lot ... but that's what comes to mind right away." And he says he fears for the future for both of his children. "When I grew up ... you wouldn't have to worry about getting shot -- maybe get hit in the head with a fist, but not get shot. And then every kid is going to experiment with sex when they get older, and that will be a very dangerous situation now," because of the possibility of contracting AIDS. "I wouldn't want to be a child now," he says.

Teresa, 26-year-old single mother of 3-year-old Alex, working, some college, annual family income between $20,000-30,000, Georgia resident.

For Teresa, raising 3-year-old daughter Alex is a far cry from the way she was raised. "When I was growing up my mom never worked, she was always at home, you know, making cookies for the kids," she remembers. "Like now in the '90s, everybody has to work, so it's kind of like the kids are more at day care or the baby sitter's than they are at home."

A single mother and full-time law enforcement official, parenting is very different and difficult for Teresa. "Having to be the mother and the father, and work, and still be at home to cook the dinner, do the bath, read the books, play Barbies," she ticks off. "It's hard trying to do it all."

Teresa didn't set out to become a single mom. Indeed, when she found out she was pregnant at age 22, she knew the relationship she was in "was not going to work, and that kind of scared me, because I didn't know if I was going to be able to do everything by myself." She does get considerable advice from her family and co-workers, Teresa says, but often that is not always terribly helpful. "Everybody tells you something different. It's kind of like trial and error."

One source of support she did not get was from her job, to which she had to return only six weeks after giving birth. While she was provided maternity leave, it was actually only accumulated sick and vacation leave -- and Teresa burned up three weeks of it due to complications before undergoing an emergency C-section. Teresa also says that she did not breast feed Alex because of her work schedule.

Teresa's dream for her child is very simple. "I hope she finishes school, goes to college, finds a decent job ... is happy," she says.

Patrick, 31-year-old single father of 2-year-old Allison, working, college graduate, annual family income between $30,000-40,000, Arkansas resident.

As a single parent, Patrick worries about his ability to supply the nurturing, love, and compassion that kids need to grow and develop. "Can I provide the right environment for growing up," he wonders, "so that my kids will want to succeed at whatever they choose?" Patrick also has a 5-year-old son.

Patrick's current problems--his wife left him six months ago and moved from their home in Arkansas to another state 100 miles away--are very different from the environment he enjoyed growing up in a family of nine children. "My parents came from the old background. They raised us and they taught us what was right and wrong. And they allowed us to be nurtured and cared for and to grow ... and we all had opportunities to further our education."

Patrick's job only complicates the situation further--he works in a plant that requires him to rotate shifts. But he's lucky, he says, in the amount of support he gets from his parents and his four sisters, who do much of the baby-sitting. His family helps in other ways, too. "They probably do 95 percent of the shopping for the children," he says. "And they see to it that they are never lacking in anything."

Immaturity was a major factor in the break-up of his marriage, Patrick thinks. "If I had to do it all over again, I believe we would have waited several more years before we had children, simply because that would have given us time to grow up together. ...Once you begin to have children, you take on an extra responsibility. And, at times, instead of a bundle of joy, it may be a bundle of burden," he says.

The couple experienced financial problems, as well. Patrick was the sole wage earner. While they had enough money to live on, Patrick says, their social life was strictly limited, which was not helped by their single friends, who "could blow everything they had, Friday to Friday, and things were fine. ... We didn't have enough left over for outside activities and things like that."

Indeed, says Patrick, having children is a decision couples should make with more thought than many do now. "They need to think about the added responsibility that they're going to take on," he says. Just getting pregnant and having a baby, he adds, "didn't make us some kind of super parents. ... It's a big change. And it's something you have to adjust to."

Beth, 36-year-old married mother of 2-year-old Julia, both parents working, master's degree, annual family income more than $60,000, Illinois resident.

When it comes to parenting, Beth is very sure of one thing: she doesn't want to raise her daughter the way she was raised. A self-described "child of the Sixties," Beth says her parents and those of her friends were forever trying to emulate the family from the old TV show "Leave it to Beaver," saying "everything was always fine, even when things weren't fine.... I feel, and so do some of the other people I know who are raising young children right now, that it is our responsibility to keep that from happening again. We don't want to pass all that baggage on if we can help it."

Beth also wants to make Julia more a part of her life than she was in her family's life. "My parents believe to this day that children are to be seen and not heard, and sometimes not even seen." But Beth recognizes that including Julia in activities from which she was excluded as a child is an added source of stress. "It's very easy to put a child in the crib and let it cry itself to sleep -- in terms of your own needs."

Indeed, Beth says that despite the fact that her pregnancy was planned and she was 34 and had "already sown my wild oats," she was unprepared for the degree to which being a parent turned her life on end, and put a strain on her marriage. "Parenting is the hardest thing I have ever done. There are substantial periods of time where there is no time to take care of yourself," says Beth, a teacher who spends all day "taking care of other people's children, and then I come home and I take care of my child ... and then my husband comes home, and he wants me to take care of him. I can't do any work of any sort at home without being interrupted ... that is what frustrates me the most, and the source of the most stress for me."

While Beth and her husband do get some help from family, she wishes she got more support from her pediatrician. "He does a good job of taking care of Julia physically, but he never asks me how it's going. My own OB-GYN does, but the pediatrician doesn't. ...At some point it might be nice to have him ask, 'So, how is it going?"' On the other hand, Beth says she knows how lucky she is. "It would be nice if we lived in a country that really supported working parents differently, because there isn't a lot of support," she says. "My daughter was sick today, and I stayed home with her. But so many of my students come in -- I mean, hacking away or with fevers, and their parents can't afford to keep them home. They stay home with their kids, they don't get paid. And the result is that the country doesn't recognize the value of caring for its children -- or the difficulties."

Chrisie, 21-year-old single mother of 3-year-old Jashen and another infant son, working, high school graduate, annual family income less than $10,000, South Carolina resident.

At 21, Chrisie already has two sons, ages three and 13 months. And as she gets older, says the single mother from South Carolina, she is sorry to have started a family so young. "I wish I would have waited," she says. But being a young mother does have some advantages, she is quick to add. "I think it's helpful that I had them young, to grow up with them and teach them things." Finishing school also gave her the luxury of something many older mothers long for, the ability to spend "quality time" with her eldest, Jashen, before she began working full time.

Chrisie admits to feeling unprepared for motherhood when she found out she was pregnant, "but as I went on with my pregnancy I got better with it, started reading books and stuff." She also has a strong support network, including her mother, grandmother, and the mother of her children's father. "Basically I have a lot of help raising my babies, both financially and otherwise," she says.

One thing Chrisie does regret is not having breast-fed either of her children, although she says she received considerable encouragement to do so. "I thought it would be best to bottle-feed, and I wouldn't have go through all those changes," she says. She also says she thinks she was sent home from the hospital too soon after Jashen’s birth. "They say it helps to stay two days," she says, "so they can observe you and make sure you're all right."

Chrisie admits being a single mother of two is hard work, particularly in the 90s, when "there's more problems than there was when I was growing up." But she has already developed coping mechanisms for when the frustrations get to be too much. "I take time for myself," she says. "I can deal with it better."

EARLY HOSPITAL DISCHARGE LEAVES PARENTS
ON THEIR OWN TO COPE WITH NEWBORN DEMANDS

1. Short hospital stays for mothers and infants are common today and on the rise. Parents are feeling the stress.

• Half of mothers who deliver vaginally (51%) are discharged in one day or less, and 21 percent of mothers who deliver by cesarean section are discharged in two days or less. The proportion increases for recent births: 62 percent of mothers with vaginal births within the past five months leave the hospital after one day or less.
  
  
• Nearly one-fifth of newborns who are premature or weigh less than 5½ pounds (19%) are discharged after one day.
  
  
• One-third of parents (33%) whose newborn is discharged after one day feel their child spent too little time in the hospital.
  
  
• Nearly one out of five parents also faces a difficult period with newborns with medical problems: 17 percent of all newborns (mostly premature infants) experience a medical problem that requires them to see a physician in the two weeks after their hospital discharge. Overall, four percent of all newborns have to be readmitted to the hospital because of medical problems.

2. Despite short hospital stays, home health visits are still infrequent.

• Despite the trend toward shorter stays, home visits following a child's birth occur in a minority of cases. Overall, only 20 percent of new parents have a home visit by a nurse or other health professional to learn how to care for a newborn.
  
  
• Parents value home visits. A majority of parents (67%) who receive a home visit find it "very useful" and 57 percent of parents who do not receive a home visit think it would be very useful to them.
  
  
• Fewer than half of first-time parents (44%) say they feel very confident about caring for their baby at the outset.

HEALTH PROFESSIONALS ARE MISSING
OPPORTUNITIES TO ENCOURAGE BREAST-FEEDING

3. Despite medical evidence about the importance of breast-feeding, many mothers do not breast-feed their infants and only half continue breast-feeding for more than one month.

• One-third of all new mothers (33%) do not breast-feed their babies.
  
  
• Thirteen percent breast-feed for less than one month and slightly more than half (53%) breast-feed their infants for more than a month.
  
  
• Mothers who are younger, lower income, or black are less likely to breast-feed their babies than other mothers. More than half of teen-aged mothers (56%) do not breast-feed, compared with only 26 percent of mothers over age 30. Forty-three percent of mothers in families with incomes less than $20,000 do not breast-feed. More than half of black mothers (58%) do not breast-feed, compared with 30 percent of white and Hispanic mothers.

4. Mothers who are encouraged to breast-feed by a doctor or nurse are more likely to do so than mothers who are discouraged, get mixed messages, or do not discuss breast-feeding with someone in the hospital.

• Only 72 percent of mothers are encouraged to breast-feed while in the hospital for the birth of their baby.
  
  
• Nearly three-quarters of mothers (74%) who are encouraged to breast-feed actually breast-feed, compared with fewer than 45 percent of mothers who are not encouraged to breast-feed.

PARENTS ARE MISSING OPPORTUNITIES TO STIMULATE INFANT BRAIN DEVELOPMENT

5. Many parents do not provide frequent stimulating activities such as reading or looking at a picture book with their child.

• Only 39 percent of parents read or look at a picture book with the child at least once a day within the week before the interview. One out of six parents (16%) do not read or look at a picture book with their child at any time during the week before the interview.
  
  
• Although book-sharing activities are higher for toddlers, rates remain low. Less than half of parents with children age one to three years (48%) read to or show a picture book to their child at least once a day.
  
  
• Working at a job outside the home does not appear to interfere with parents' reading to their child. Reading patterns are similar by work status.
  
  
• Health professionals can make a difference. Parents who talk with their doctor or nurse about encouraging their child to learn are more likely to read to their child on a daily basis (47%) than do parents who do not discuss learning (37%).

 

PARENTS WANT MORE INFORMATION AND SERVICES FROM PHYSICIANS

6. Parents rate their child's physician lower on helping them understand their child's growth and development and on being accessible by phone.

• Parents are less satisfied with the extent to which their child's regular doctor or nurse helps them understand their child's care and development. Slightly more than half say their doctor or nurse gives them excellent guidance about how to care for their child (56%) and helps them understand their child's growth and development (58%), compared with two-thirds of parents who give excellent ratings on providing good overall pediatric care (69%) and in listening carefully and answering questions (66%).
  
  
• Parents are also less satisfied with their ability to reach their child's doctor or nurse by telephone. Only 54 percent of parents give their doctor or nurse an excellent rating and 12 percent have complaints, rating their provider as only fair or poor.
  
  
• A little more than half of Hispanic parents (55%), compared with 70 percent of white parents and 61 percent of black parents, give their doctor an excellent rating for his or her ability to listen carefully and answer questions.

7. Parents are eager for information on six areas of child rearing--newborn care, sleep patterns, how to respond to a crying baby, toilet training, discipline, and encouraging their child to learn.

• Most parents (79%) feel they could use more information in at least one of these six areas of parenting. More than half (53%) want more information or help in at least three areas.
  
  
• More than half of all parents (54%) say they could use more information about how to encourage their young child to learn.
  
  
• Four out of ten parents report that they could use more information about how to discipline their child (42%) and how to toilet train their child (41%).

8. Although a majority of parents talk with their doctor or nurse about newborn care, few parents actually discuss child rearing concerns with their doctor or nurse.

• Although a majority of parents (62%) have discussions with a health professional about newborn care, only 41 percent discuss how to deal with their child's sleep problems and what to do when their child cries (35%).
  
  
• Only 29 percent discuss how and when to toilet train their child with a health professional. Fewer than one-quarter of parents (23%) discuss how to discipline their child or how to encourage their child to learn.

9. Some parents receive a range of comprehensive services from a doctor or nurse, such as a packet of information on newborn care, home visit, telephone advice line, or child health record. Parents find these services "very useful."

• Some parents receive a home visit during the newborn period (20%), have a special 24-hour telephone advice line available to them (32%), or have reminder services for immunizations and well-baby visits (42%).
  
  
• Those parents who receive additional services find them "very useful": a packet of information on newborn care (54%), a home visit by a nurse (67%), a special telephone advice line (87%), a reminder service (85%), and a booklet to keep track of their child's health information (83%).

10. Parents report strong support for comprehensive pediatric services. A majority of parents who do not receive services such as a home visit, a telephone advice line, and child health record believe it would be useful to receive them. And, overall, parents say they would be willing to pay a modest fee for these services.

• More than half of these parents state that they feel additional pediatric services would be very useful--a packet of information on newborn care (73%), a home visit by a nurse (57%), a special telephone advice line (73%), a reminder service (56%), and a booklet to keep track of their child's health information (67%).
  
  
• Whether or not parents receive such services, nearly two-thirds (62%) say they would be willing to pay a monthly fee of $10 for the opportunity to receive "all of these services and this kind of information" from a health care provider.

11. When parents receive these additional services, they rate their doctor/nurse significantly higher on providing good health care and on giving guidance in understanding their child's growth and development.

• Fewer than half of those who receive none of these services (49%) give an excellent rating to their doctor for the overall quality of care provided, compared with 71 percent of parents who receive three or more additional services and give their child's doctor an excellent rating.
  
  
• Only 42 percent of those who receive no services gave an excellent rating to their doctor for helping the parent understand how their child is growing and developing, compared with nearly two-thirds of parents (63%) who receive three or more additional services and give their child's doctor an excellent rating on growth and development guidance.

 

PARENTS' CHILD REARING PRACTICES REFLECT STRAINS ON FAMILIES

12. Many parents become frequently frustrated with their child's behavior as the child grows older.

• Only six percent of parents with infants under the age of six months, compared with 38 percent of parents with toddlers age 18 months to three years, are frequently frustrated or aggravated with their child's behavior in a typical day.
  
  
• Hispanic parents (45%) are more likely than black parents (34%) or white parents (28%) to stay calm and not become frustrated with their child over the course of a typical day.

13. Parents are more likely to use harsher disciplinary measures with toddlers than with younger children.

• Parents of children age two to three years use harsher disciplinary measures: 63 percent of parents report yelling at their young child, and one-quarter report spanking their child sometimes or often.
  
  
• There are racial and ethnic differences in the use of disciplinary measures: both Hispanic (55%) and black (62%) parents use "time outs" less often than white parents (72%) do. Black parents (19%) are more likely to spank their children than either white (13%) or Hispanic (12%) parents.

14. A majority of children under age three have a predictable routine for bedtime, naps, and meals.

• More than half of all children (51%) have set routines that include meals, naps, and bedtime.
  
  
• Young children growing up in families that have annual incomes less than $20,000 or who are being reared by single parents are less likely to have set routines for bedtime and naps than children growing up in families with higher incomes or two parents. Daily routines are set by:

• 42 percent of single parents, compared with 53 percent of two parent families.
  
  
• 43 percent of families with incomes less than $20,000, compared with 61 percent of families with incomes of $60,000 or more.

 

PARENTS' MENTAL AND EMOTIONAL HEALTH INFLUENCE CHILD REARING PRACTICES

15. A high proportion of mothers caring for babies and toddlers report experiencing depressive symptoms.

• Two out of five mothers (41%) report one or more of five depressive symptoms during the week prior to the interview (report feeling depressed, sad, or that people disliked them, crying or not enjoying life most or some of the time), compared with 30 percent of fathers who report one or more of these symptoms.
  
  
• Half of mothers (50%) with annual incomes less than $20,000 report experiencing one or more depressive symptoms in the week before the interview, compared with one-third of mothers (36%) with annual incomes between $20,000 and $60,000, and one-fifth of mothers (18%) with annual incomes greater than $60,000.
  
  
• Nearly one out of ten mothers (9%) reports experiencing three to five depressive symptoms at least some of the time during the week prior to the interview.

16. Levels of depressive symptoms adversely affect a parent's ability to cope and child rearing practices.

• Parents who exhibit at least three of the five depressive symptoms are half as likely as parents with no depressive symptoms to report that they are coping well with the demands of parenthood. Only 32 percent of parents with three or more depressive symptoms believe they are coping "very well," compared with 63 percent of parents with no depressive symptoms.
  
  
• Parents who exhibit at least three of the five depressive symptoms are twice as likely as parents with no depressive symptoms to say they become frequently frustrated with their child's behavior in a typical day (44% v. 21%).
  
  
• Signs of depression negatively affect parental behavior across the board. Parents who exhibit at least three of the five depressive symptoms are less likely than parents with no depressive symptoms to have a daily routine for the child's bedtime, naps, and meals (31% v. 58%); play (72% v. 87%), cuddle (80% v. 90%), read (27% v. 43%), and sing or play music (54% v. 61%) at least once a day.
  
  
• Parents who exhibit at least three of the five depressive symptoms are more likely than parents with no depressive symptoms to yell (51% v. 34%) or spank (17% v. 11%).

17. Parents who were abused as children are more frustrated and depressed and less likely to say they are coping well with the demands of child rearing.

• In total, 12 percent of parents report they were physically and/or sexually abused as a child: 11 percent of mothers report physical abuse and seven percent report sexual abuse; ten percent of fathers report physical abuse and two percent report sexual abuse.
  
  
• One-fifth (19%) of those parents who were sexually abused and 11 percent of those who were physically abused as children report having at least three of the five depressive symptoms in the week prior to the interview.
  
  
• Nearly one-third of parents who were verbally, physically, or sexually abused (30%), but only one-quarter of parents who were not abused, become frequently frustrated with their child in a typical day. One-third of parents who were sexually abused (34%) and just under one-third who were physically abused (30%) become frequently frustrated with their child in a typical day.

 

NOT ALL PARENTS ARE READY AND PREPARED

18. Preparation for parenthood is mixed. Many mothers do not plan the birth, seek prenatal care, or take child birth or parenting classes.

• Thirty-four percent of pregnancies are not initially planned. The extent of planning is lower for low-income, younger, and unmarried mothers. In families with incomes less than $10,000, more than half of the mothers (57%) say the birth was not planned. Two-thirds of single mothers (66%) and mothers who are under 20 years of age at the time of their child's birth (64%) say the birth was unplanned.
  
  
• Nearly one-third of parents (29%) do not attend child birth classes. Attendance is strongly related to mother's age, family composition, and education. Just more than half of single mothers (54%) and two-thirds (66%) of teen-aged mothers do not attend classes.
  
  
• About two-thirds of parents (65%) do not attend a class or discussion about parenting. Attendance is related to education and income. Nearly three-quarters of parents (73%) who did not attend college and 69 percent who have an annual income of less than $40,000 do not attend classes.

 

FINANCIAL STRESS ON FAMILIES IS ALSO AN ISSUE

19. Parents have some difficulty paying for their child's health and medical expenses and their basic needs.

• Overall, nearly one out of five children (18%) have parents who have difficulty paying for their medical expenses and 17 percent of all parents have difficulty paying for their child's birth.
  
  
• About a quarter of children (23%) living in low or moderate income families (less than $40,000 annually) have parents who have difficulty paying for their children's medical expenses.
  
  
• Nearly one-quarter of young children (24%) are living in families that have at least some trouble paying for basic supplies for their child such as formula, food, diapers, clothes, and shoes. Budgets are particularly tight for low and moderate income families: almost half of children in families (47%) with incomes less than $10,000, 36 percent of children in families with annual incomes between $ 10,000 and $20,000, and nearly one-third of children in families (32%) with incomes between $20,000 and $40,000 have parents who have difficulty paying for their child's basic needs.

20. Children in low income families are less likely to be in excellent health and less likely to have a regular source of care.

• Only two-thirds of young children (68%) in families with annual incomes less than $20,000 are in excellent health, compared with 85 percent of children in families with annual incomes greater than $60,000.
  
  
• Nearly a quarter (21%) of children under three years of age in families with incomes less than $10,000 do not have a regular source of care.
  
  
• Uninsured children are less likely to have a regular source of pediatric health care than insured children (77% v. 89%).

21. Most children under age three are living in low or moderate income families. Many families feel financial pressure.

• More than half of young children (53%) live in families with incomes less than $40,000 per year. Twenty-five percent live in families with incomes less than $20,000.
  
  
• A high proportion of children have parents who have turned to government programs to make ends meet at some point since their child's birth: 47 percent of children have parents that have received some government assistance, such as Medicaid, food stamps, Aid to Families with Dependent Children, or Women and Infants Care Feeding Program.

22. Medicaid is a critical source of health insurance for young children.

• One fourth (28%) of all children are covered by Medicaid, as are 79 percent of young children in families with annual incomes less than $10,000, 51 percent in families with incomes between $10,000 and $20,000, and 25 percent in families with incomes between $20,000 and $30,000.
  
  
• Nearly all children under three years of age (94%) have health insurance coverage from private plans or Medicaid, with only six percent uninsured.
  
  
• Counting insured and uninsured children, 16 percent of all babies and toddlers have no insurance coverage for immunizations, 14 percent have no coverage for well-child care, and eight percent have no coverage for sick child visits.

23. Parents are twice as likely to be uninsured as their children.

• One out of eight parents (12%) has no health insurance, compared with only six percent of their children under three years of age.
  
  
• Low and moderate income parents are most at risk for being uninsured. One-quarter of parents with incomes less than $10,000, 33 percent with incomes between $10,000 and $20,000, and 17 percent with incomes between $20,000 and $30,000 are uninsured.
  
  
• Medicaid covers more than half of parents (58%) with incomes less than $10,000 per year and 22 percent of those with incomes between $10,000 and $20,000.
  
  
• Sixteen percent of all parents are covered by Medicaid.

 

PORTRAIT OF TODAY'S FAMILIES WITH CHILDREN UNDER AGE THREE

24. Families are juggling work and family responsibilities.

• More than half of infants and toddlers (56%) have mothers in the full- or part-time workforce.
  
  
• A third of infants and toddlers in two parent families (31%) have parents who both work full time at paying jobs.
  
  
• Mothers remain the primary care givers for young children. In two parent families, nearly two out of three mothers (63%) are the primary care givers.
  
  
• More than half of all parents (57%) would like to spend more time with their child. Working parents feel this tension most strongly. Eight out of ten parents who work full time wish for more time with their child.

25. The majority of babies and toddlers are growing up in two parent families with parents who were in their mid-twenties or older at the time of the child's birth.

• Eight out of ten children under age three (82%) are growing up in two parent households: 72 percent with parents who are married and ten percent with parents who are living as married.
  
  
• Almost one-fifth of young children (18%) are growing up with single parents. More than half of black children (53%), 19 percent of Hispanic children, and 11 percent of white children are growing up with single parents.
  
  
• Nearly two-thirds of children (64%) are born to mothers 25 years of age or older. Only ten percent of children are born to mothers under 20 years of age; however, 25 percent of children born to single mothers are born when their mother is under 20 years of age.

The Commonwealth Fund, a New York City based national foundation, supports independent research on health and social issues.

Title: The Commonwealth Fund Survey of Parents with Children
Authors: Kathryn Taaffe Young, Karen Davis, and Cathy Schoen
Publication Date: 1996
Publisher/Institutional Source: The Commonwealth Fund
Contact:
The Commonwealth Fund
One East 75th Street
New York, NY 10021-2692
Phone: (212) 606-3506
Fax: (212) 606-3500
E-mail: cmwf@cmwf.org
Internet: http://www.cmwf.org/

Copyright/Permission:
This text is copyright © 1996 by The Commonwealth Fund.
This text is reproduced on NPIN with the permission of The Commonwealth Fund.
Permission is granted for the reproduction and use of this publication for educational and nonprofit purposes.

NPIN Acquisition: N00032. March 1998.

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