Jessie Marshall, M.D.
Nowadays we hear much about planning—town planning, city planning, nation planning. The elder and younger statesmen are going to see to it that we are well-housed, well-fed, suitably employed according to our abilities, and provided for in our old age. Good. This, as I understand it, has always been the American plan. I am sure that no American who is willing to work deserves less than the fullness of the earth. And I shall assume that this country is going to be well enough planned to enable you to raise a family—with suitable planning. For family planning is the most important planning. Indeed, the whole point of national planning is to enable us in turn to plan the nation. The nation rests on the family. Your family rests on you and your mate. What are you planning to do about it? How, when, and why?
In our children we live over our own childhood and project ourselves into the future. Until our own children come along we tend to forget that the world, to which we are now so thoroughly and sometimes wearisomely accustomed, once struck us as a thing of mysterious glamour, promising an endless opening vista of keen excitement.
And yet, if life is to continue worth the living, we must continue to hold onto that early attitude. We must continue to find ecstasy in simple sources. And often it is our children—easily yet deeply pleased, ceaselessly busy with their paints and blocks and animals, ready for every new adventure, never jaded, never dull—who must remind us, their elders, how to get the most out of life. In their love for flowers and animals, paints and song, we may rediscover the submerged or forgotten purpose of our own lives. Or our talent may be for building happy lives from the ground up, in which case the children themselves are the answer to our search for pure-hearted, never flagging excitement.
As for projecting ourselves into the future through our children, reaching ahead through them in order to affect, if possible, generation after generation of people yet unborn—this is a kind of immortality snatched from death and a satisfaction, though composed entirely of hope, that parents prize. Strong-souled people feel that their personalities are worth perpetuating, especially in conjunction with their beloveds'! In proportion to their love of life, to the strength of their joy and the clarity of vision of even better things, people find one lifetime all too short to fulfill the expanding urges within them. In their children they see human beings who may carry on their work, or at any rate transmit their traits to grandchildren and great-grandchildren.
Just at present people who have found life good, the ideal parents, feel the need of entrusting the future to people like themselves, the desperate need to keep power from falling into the hands of morbid madmen who, under the pretext of enlarging life, precipitate horrible wars precisely because they themselves, starved, oppressed, or humiliated from the cradle, have never found life good. Yes, our children can make all the difference between a life full of hope for the future of the race and one of pessimism and despair. It is this sense of children as carrying something of ourselves, our tempers, our hopes, into the future which is at the bottom of what we call the eugenic urge—the desire, that is, to beget good stock and pass on only the best in us.
About the obvious pleasures that children bring, the fascination of seeing their characters unfold, the happiness of festivals like Thanksgiving, Christmas, and Easter, which without children lose half their charm, it is not necessary to speak.
For our purposes, however, the point is that there are literally dozens of reasons why nearly all of us want children. The problem is when to have them and in what numbers. For modern man likes to know what he is about in this world and to direct and control his destiny in the light of other knowledge and experience.
The time for the first baby is a question of readiness on the parents' part. Are they ready physically, psychologically, economically? These are not, of course, three separate ways of being ready; they are interdependent ways, but they offer suitable heads under which to discuss the subject.
Economic readiness is of utmost importance. Insecurity of employment, insufficient means to provide the mother and baby with medical supervision and good food, or looming debts are in themselves sufficient to prevent prospective parents from attaining the other kinds of readiness—physical and psychological. On the other hand, young people with steady incomes should not postpone having children merely because those incomes are not high. Three can live almost as cheaply as two, especially in the child's first years. It is the expense of hospitalization and doctor's care, during pregnancy and throughout the first year or two following the birth, that sometimes threatens to unbalance the family budget. This additional expense must be provided for. It need not be great—a matter of a few hundred dollars, often less in various parts of the country. The doctor's fee for pre-natal care and delivery will correspond roughly, unless he is a senior specialist of great reputation (by no means a necessity for healthy people), to the expense for hospitalization. The latter can frequently be obtained for a hundred dollars or less—though rarely, if ever, in a big city—making the total cost of getting the baby about two hundred dollars. In many parts of the country hospital schemes, into which you make a monthly or yearly payment, make it possible to get two weeks' hospitalization for mother and baby, with semi-private room, use of delivery room, and nursing care, for about ten dollars. This effects an obvious saving, and has done a great deal to bring children within the reach of all. During the first year or so the mother needs to be quite free to call on her doctor for service or advice whenever she wishes. Sometimes the doctor will be glad to arrange a flat charge for a year's attention, say a hundred dollars, or more or less, depending on the family income. Such an arrangement often does the parents a great deal of good, putting their minds at rest, for they feel they can call on the doctor in all reasonable emergencies, ask him all necessary questions, expect periodic visits to their baby, and receive all necessary vaccinations and immunizations for a fee they can afford. The sum may be paid in monthly or quarterly installments.
Money for the child may be saved out of monthly earnings. This well-known phenomenon is called saving for children. Very often the parents of the married couple are glad to help them with the extra expense involved in having their first child. I do not mean by loans—for it is not good for young people to be in debt, even to loving creditors—but by actually undertaking to pay the hospital and the physician. If people are ready for a baby in all other ways and only money keeps them from parenthood, the prospective grandparents often feel it their duty to help in this way. Dr. Josephine Hemenway Kenyon, director of the Health and Happiness Club of Good Housekeeping, has often made the wise suggestion that fathers give, in addition to any other wedding present, a $500 or $1000 bond, called "The Baby Bond," to be kept to meet the expenses of bringing the first baby into the world and protecting its first year of life. This idea appealed so strongly to some parents that Dr. Kenyon went even further, suggesting that young parents who can afford it take out a ten-year endowment policy of $1000 for their thirteen-year-old children, to be available when these children are twenty-three, if needed, to help them start their own families.
The question of the right age for parenthood is naturally of importance. But it depends on many factors, chief among which, after the economic problem has been disposed of, are physical and psychological health. Some time between twenty-three and twenty-eight seems to me to be a satisfactory time for a woman to bear her first baby; but any time up to thirty-five presents no difficulty, provided the physical and mental conditions are healthy and propitious. Plenty of women of forty and over have been known to go through first and subsequent pregnancies successfully, but there is no reason for postponing children to this age except failure to find the right mate earlier in life. People who have their first child when over thirty-five are themselves over fifty when the child goes through adolescence—an age which may make it difficult to help the child meet its crucial problems in the tone of one good friend to another. If you cannot have your children before thirty-five, you must make every effort to remain young enough for spiritual companionship with them. The best age for parenthood is to be determined, not in terms of years, but of physical and psychological health and happiness.
In marriage psychological health and happiness are largely dependent on love. It is of the utmost importance that every child should be a love child, in the best sense of the term. Love is a splendor that eludes definition, but it is characterized by an inexhaustible desire for the beloved's company and a steadily burning fire of enthusiasm and admiration. So-called disillusion in love comes from the failure of these emotions. Young lovers, through plenty of courting and companionship, should try to make sure of the lasting quality of their love. This is sometimes impossible, however, and for this reason and others I think it is just as well for married people to wait a year or even two before having their first child. In the happiest marriages there are many adjustments, unforeseen before the wedding, to be made. And it may very well be that only in the continued intimacy of marriage can the strength of love be tested. Only there can love gutter out or prove itself stronger than death—so much stronger indeed, that, as it deepens and widens in fullness and power, it turns of its own accord directly toward the creation of more life.
In other words, the best time to have children is when the lovers, sure of themselves and of each other, feel an imperious need to stamp the gold of life with each other's images. I feel no hesitancy in urging married couples to take a year or so to make sure of their love, if only for the children's sake. Economic conditions being adequate, there is no reason to suppose that real lovers will put off having children until it is too late to obtain the best eugenic results. To paraphrase the poet, we may say that those who restrain their desire for children do so because their desire is weak enough to be restrained. Such people will probably not make good parents. True lovers will beget children after a year or two, nor will they mind making a few so-called sacrifices, as of parties and new automobiles, for the sake of having children. They recognize the distinction between entertainment and joy. Man may be a laughing animal, but he is more essentially a creative animal. His deepest pleasures are simply the by-products of his activity. In building a home around a family of children both men and women often find the deepest of all possible pleasures. And when it is in this spirit of vital affection that the child is begotten, we get, as the eugenists say, a vital fertilization. The chances are that children so begotten will themselves be capable of strong, sound, deep-seated feelings. As Dr. Kugelmass says in Growing Superior Children, "The degree of emotional devotion of one parent to another is reflected dominantly in the transmission of the more vital elements in the constitution of the progeny."
To the question of physical readiness for childbirth I come last, but not because it is of least importance. Without physical health the parents cannot expect to beget healthy children, nor indeed can they, in many cases, manage even to bear them. As everyone knows, women afflicted with tuberculosis, heart disease, and kidney changes should probably refrain from bearing children. But this is a matter for the doctor to decide. Such people, if their troubles are not severe, may safely bear at least one child, sometimes two. They should put themselves in the hands of a good physician and rely implicitly on his findings and advice. Sufferers from venereal diseases should not attempt to beget children till they have been given a clean bill of health. Nor should children be begotten when the body is weakened by temporary disease or during the stage of debilitating after-effects. For disease and fatigue affect sex cells unfavorably. So do mental strain, depression and overexcitement. Unhealthy physical and mental states in the parents lead to debilitated or deficient offspring. They open the way to the operation of undesirable hereditary factors which generations of self-controlled parents have been driving into the background and attenuating to the point of disappearance. It is possible for the father, too, to weaken his vitality by excessive sexual activity. In fine, the best time for conception to take place is when the lovers' sense of well-being, physical as well as mental, is at its fullest.
Full-bodied passion, which we may think of as a kind of crisis of love and health, will give us offspring to be proud of. One thing we cannot plan, however, is the sex of the child to come. Nor should we, in general, wish to. It was the limited sphere of feminine activities that once tended to make girls a debit, boys a credit. Nowadays girls have just as many opportunities of becoming interesting human beings as have boys. It is a favorite theory of my husband's that they may, and often do, become more interesting, because they can do not only everything that boys can do but one thing more—they can bear children, a humanizing experience of the greatest possible value.
Should you wish to know what are your chances of having twins, I must remind you that the tendency to give birth to them is an inherited trait, especially through the father. Twins are much more likely to be girls than boys, and to be born later rather than earlier in the mother's married life. Thus it is three times more likely that a woman of thirty-eight will give birth to twins than that a woman of twenty-four will do so. Should you fear that the unpredictable appearance of twins will unbalance your baby budget, you can, for a moderate sum, insure yourself against this chance with many of the larger insurance companies. The insurance must be taken out before the existence of twins in the uterus can be diagnosed—that is, in the first two or three months of gestation. One twin birth occurs to about 90 single births, one triple to about 8000, and one quadruple to about 650,000. In all medical literature only about 30 cases of quintuplets have been recorded. Multiple births are not only rare, but the babies are often so delicate that they are extremely difficult to rear. We can be well pleased if our first pregnancy eventuates in a single healthy baby of either sex.
All the reasons for wanting the first child apply in the case of the second, and to them are added more. What was in the first instance simply a hope and a vague if powerful urge has now grown into a conscious desire, based on the self-knowledge and experience gained from loving and looking after the first child. We have had a real taste of the joys of home and family building, and now nothing short of economic catastrophe is likely to stop us from building higher. I assume, of course, that the mother did not encounter any severe difficulties in giving birth to her first child. If she was in good medical hands, she probably did not, though certain unusual formations of the pelvis may have made her labor longer than usual. I do not say more painful, because medical science has found ways of minimizing the pains of childbirth. Even if it was found necessary to deliver the first child by Caesarean operation, a woman in normal health can without danger bear at least two children by this method. And at the very least a family should include two children.
Quite apart from the parents' natural desire to go on expressing their mutual love by building a full-voiced home on the foundations laid by the first child, it soon becomes apparent that this first child, for the sake of its own social and moral development, needs a little brother or sister. It needs companionship. It needs to share its toys and its parents. Otherwise it will tend to grow self-centered. By being too much with grown-ups it may become moody and negative.
After the question, "Can you afford it?"—and I sincerely hope you can—the next question facing the mother who wants a second child is, "When can I bear it with the maximum amount of benefit to it, to my first child, and to myself?" Clearly, if it is to be a playmate for the first child, you will want to have it as soon as possible. But, in fairness to both the mother and the child-to-be, there should elapse a period of about two years between the birth of the first and the conception of the second offspring. Less time than that will seldom allow the mother, who put so much of her best blood and bone into building and nursing the first baby, to recover fully her maximal physical health and strength. All authorities are agreed on this point. There may be exceptions, of course, and there are always mothers who, by reason of having married late, perhaps, are anxious to have as many babies as quickly as possible. But most women neither can nor will nor should produce children in this fashion. There is too much risk of weakening the mother's body and of begetting poor stock.
Later children may be spaced to suit the desires of the parents, a recovery period of two years or more always being allowed the mother. But will there be any later children? Dr. Ellsworth Huntington in his contribution to this volume has told us that most of us who are not shiftless and incompetent, on one hand, or wealthy and well-established, on the other, belong to a group in which the average number of children, including those who die young, is fewer than three. Dr. Huntington rightly deplores this "rapid fall of the birthrate, especially among intelligent, far sighted, industrious, progressive people whose ideals of family life are high." The trouble with a family of fewer than three is that it cannot be counted on to project very far into the future those sound souls, that good biological inheritance, which the parents flatter themselves are so definitely worth preserving. A family of two or even three children will not, on the average, produce two who, by becoming parents, may be thought of as replacing their father and mother. Thus a family of fewer than four children may be said to be dying out. This is a sorry state of things for those parents who, as I said above, like to think of themselves as affecting the destinies of the race by transmitting their best characteristics from generation to generation.
When intelligent people are forced to limit their families to one or two children by lack of money, it is a great pity. There is a great abundance of good things in America, but we do not seem to be able to get these things distributed in such a way as to do the most good. We are all working for a better world, but are we working hard enough? I sometimes think that we are not working so hard as we might, because our stake in that better scheme of things is not large enough. If we dared to have three or four children, with all the sacrifices implied, I wonder whether this fact would not sharpen our scent on the trail of the better America.
Lord Bacon said that those who have children have given hostages to fortune. But I am inclined to think that those who have made large and important bargains with chance are just those who will move heaven and earth to guard against mischance. One aspect of the better America, proposed by the American Eugenic Society, will perhaps be the adoption of a sliding-wage scale, characterized by a rise in pay upon marriage and with the arrival of each successive child.
That thoughtful people of our time, whether rich or not, will soon return to having families as large as our grandparents' is extremely unlikely. To bear ten or fifteen children would probably kill most modern women or so completely wear them out that the remnant of their lives would not be worth living. And families of this size would similarly exhaust even unusually large pocket-books, leaving most fathers insolvent. Though it is probably true, as economists say, that our land and its resources, if more equitably distributed and scientifically exploited, are capable of supporting many more millions of Americans than at present, there seems to be no good reason for stepping up the modern middle-class family beyond four or five children.
The reader will notice that I have been going on the assumption that people can have children, and fine specimens at that, to order—when and as they please. This is to a large extent true. The key to the mystery is the doctor. Modern medical schools and modern law have entrusted into his hands not only the physical but the mental well-being of his patients. The tight interlocking of the body and spirit has been everywhere recognized, and the impossibility, in many illnesses, of healing one without treating the other. Positive well-being in the body, so important for the begetting of strong children, is practically inconceivable apart from positive happiness in the mind.
Thus it has become a prime tenet of eugenics that babies must not be conceived under conditions of excessive mental worry or strain. Children begotten in deprivation or the fear that they are going to lower the whole family's standard of living to a painful pinch are not going to have much chance, even while in the womb, to turn out fit and strong. Judicious limitation of birth for reasons of health, the whole health of the parents, in behalf of the best possible grade of offspring has therefore become a routine part of the physician's service to his patients. Every married couple should put themselves in the hands of a physician whom they respect and admire, making him an indispensable third partner to their family planning. This crucial role of the doctor in eugenics is one of the few really deeply encouraging signs of our times.
The Woman Asks the Doctor, by Dr. Emil Novak of Johns Hopkins, gives some idea of the role the modern physician may play in helping parents plan the vigorous citizenry of the future. When the married lovers are ready to have their children, it is naturally with the woman that the doctor is most concerned, correcting structural or functional deviations or mild organic disease before the pregnancy has advanced too far, seeing to it that the glandular mechanisms do their important work, that nutritional intake is sufficient, that digestion is kept successfully functioning, that metabolic processes are raised to more than ordinary efficiency, and that the body is kept free from all toxins and infections. After the birth of the child the doctor will not only look after the child but also see to it that the mother suffers no adverse after-effects and is restored to her maximal health and efficiency as soon as possible, ready to bear her next healthy baby when the time shall come.
Should a baby be conceived unexpectedly, the doctor is often the best person to help the parents handle the untoward situation. He can give the mother's physical condition that special attention which it will probably need if she has borne another child quite recently. If the objection to the child arises from economic or psychologic unpreparedness, there is no one better fitted, possibly, than the modern physician for changing negative fear to positive desire. By the force of his own enthusiasm for new life, by his vision of the modern family, by a skillful combination of his common sense and psychiatric training, and by his ability to arrange fees within the range of his worried clients, he can usually turn the unplanned conception into a happy accident.
It is often to the physician, too, that the father must look for practical guidance and encouragement in those unforeseeable cases when the mother perishes in connection with childbirth. It is he who is in the best position to prevent the father from unconsciously attaching blame to the unoffending child and harboring an undefined resentment which may adversely affect both lives. The doctor can help the bereaved father to cling to his dream of family life, can assist him in building a happy home for his motherless child or children, or can advise him on problems which may arise out of finding a new mother for them.
Another important function of the physician is to give aid to couples who have difficulty in begetting children. The question of sterility comes up frequently in our time, especially among cultivated and intellectual people. Persistent failure to conceive we term absolute sterility; persistent failure to carry pregnancy to a successful end, we call relative sterility. The latter is an obstetric problem and can usually be dealt with successfully. So can the former in about forty percent of the cases. We must remember the rule formulated by Matthews Duncan, that the marriage of persons between twenty and thirty cannot be regarded as sterile until at least four years of normal, happy sexual intercourse have elapsed. I have known half a dozen instances in which a child was born after five, six, ten, and, in one case, fifteen years of complete failure to conceive. In these cases no special efforts were made by the couple to bring about conception.
Couples who wish to make special efforts should have complete physical examinations, both husband and wife, for though failure to conceive used to be attributed solely to the wife, we now know that in about thirty percent of cases it is the husband who is the cause. Many remediable physical conditions may be responsible for sterility, and the doctor, by correcting them, has a wonderful chance to contribute to human happiness. Many families feel the tragedy of not having children, and yet do not realize the need of finding out what the trouble is. They just drift along, assuming that nothing can be done, and often they could be made fertile. This subject is ably discussed in Human Sterility by Dr. Samuel R. Meaker of the Boston University School of Medicine.
When the doctor decides that there is practically no chance of a couple's having children of their own, their strong family urge may lead them to adopt some. They can find useful information in E. G. Gallagher's The Adopted Child. It often happens that people get as much satisfaction out of adopted children as they could have got out of their own, finding cause for pride, inspiration, and comfort in their unfolding toward maturity.
The question of whether we should adopt children when infants or later—at some age under six—is worth considering. It may seem at first glance that only infants raised from the cradle can really take the place of children of our own. While this is partly true, there are drawbacks to be considered. To begin with, the supply of infants for adoption is not by any means large enough to meet the demand. Second, more than half the number of small babies available are illegitimate, and one can often learn little about the parentage. Though various child-placing agencies find it difficult to allocate those children who do not become available for adoption till the age of three or four or later, there are many things to be said in favor of taking an older child. More often they are legitimate and more facts about their parentage can be ascertained; also, it is possible to apply intelligence tests which will disclose whether their intelligence is normal or above. Often those parents who want to adopt children tend to be intellectual, and will find greater happiness in—and give greater happiness to—a child who is of normal or superior intelligence.
You may object to the older child's early environment, thinking that it must have permanently injured even the fairest of capacities. But psychologists tell us that this is not really the case, and that the unhappy effects of poor environment during the first five years of a child's life can be removed, and the child reconditioned without too much trouble. Couples who are no longer young should, perhaps, adopt older children in order that they may stand in the most helpful age relation to them.
Children adopted as infants should always be told that they are not the flesh-and-bone children of the foster parents. This information, which is bound to come to them, will come with less shock from the parents themselves. At the age of five or six, when they first begin to be interested in where children come from, is a good time to tell them. It is agreed that the foster parents should use the word "chosen" rather than "adopted"—they chose their children out of all the thousands available, just as the foster father chose his wife, and the wife her husband.
This attitude toward the question makes for a feeling of family solidarity and loyalty no less profound than that between other parents and children. Everything must be done to prevent feelings of inferiority from growing out of the adoptive relationship: the children must never be reminded of the fact of adoption, the parents must not expect more gratitude from them than they would from offspring of their own, and they must never, never shout thanks to God, in a moment of anger, that the children are not really theirs. To do so is not to play the game. After all, under most state laws, children may be adopted on trial for a year. If the children are kept after that date, the parents bind themselves in law and in morality to bring them up exactly as if they were their own. I keep using the plural throughout this paragraph because I assume, of course, that you will adopt at least two children if it becomes necessary for you to plan in this way your version of a splendid American family—strong, loving, and creative of an ever finer future.