For most couples, the first year of parenthood is a complicated blend of joy and tension, exhilaration and sleep deprivation. But depending on where you live, it can be a lot easier or harder to care for your newborn. The reason: States are chock-full of laws, mandates, requirements, and standards that affect parenting.
Desperately searching for quality childcare? Some states permit a maximum ratio of three infants per caregiver, others allow twice that. Sick of slipping into a bathroom stall when your baby is hungry in the middle of a shopping trip? Twenty-eight states give you the green light to nurse in public. Trying to pay for mountains of diapers, wipes, and baby food while still saving money for your child's college education? Five states offer partial paid leave and 26 give tax breaks for childcare expenses. Want to make sure your newborn receives all the screening tests recommended by the March of Dimes? Just nine states mandate them. Aside from pro-parenting legislation, some states boast wide selections of children's hospitals, pediatricians, childcare centers, certified poison-control centers, and even car-seat inspection stations, while others offer little variety.
To help you determine where geography is on your side, Child embarked on a four-month investigation of baby-rearing issues in 50 states -- the first report of its kind. Guided by pediatric experts, we sorted through recent data in 20 categories -- many of them mentioned above -- that are crucial for new parents, wanna-be parents, and of course, babies. The result: a state-by-state ranking of the best places to have and raise a newborn.
- Is home to 14 children's hospitals, the highest number in any state
- Issues a state-tax credit of up to $1,050 per year for childcare expenses -- one of the best credits in the nation, according to a recent report by the National Women's Law Center
- Mandates special training in sudden infant death syndrome for firefighters and emergency medical technicians; just eight states do this
Despite the political upheaval involving Governor Gray Davis, California is still a great place to start a family, offering the nation's most comprehensive paid parental and medical leave program. In addition to Temporary Disability Insurance, which provides women who have recently given birth with partial wages, usually for six to eight weeks, a law that goes into effect next year will entitle them to about half their salary -- up to $728 per week -- for six more weeks. Plus, it allows dads and adoptive or foster parents to take six weeks of paid leave.
"Only four other states -- Hawaii, New Jersey, New York, and Rhode Island -- have Temporary Disability Insurance, but it doesn't apply to dads and foster or adoptive parents," says Lissa Bell, a senior policy associate at the National Partnership for Women and Families, a Washington, DC-based advocacy group.
California's bill, introduced by State Senator Sheila Kuehl (D) in 2002, passed the legislature in just one session. "Although we had to make some compromises -- for instance, the initial legislation called for 12 weeks of leave -- we never thought the bill would make it onto the books so quickly," says Netsy Firestein, director of the Labor Project for Working Families in Berkeley. "Californians rose to the occasion, coming out in droves to support this legislation. They really made it happen."
Another reason for the speedy turnaround: Employers couldn't contend that it would cost them too much money. California's workers foot the bill for paid leave, having on average $27 more taken out of their paychecks annually. The money goes into a fund and the state handles the distribution.
Firestein's immediate goal is to get the word out to the state's residents about how to take advantage of the program. "But in the long term," she says, "we're working to make California a springboard for other states. Paid parental leave is such a basic need. It's totally ludicrous that we're the only state that offers it."
- Is one of 10 states that require licensed childcare providers to undergo background and child-abuse registry checks, in addition to both state and FBI criminal-background checks
- Has enacted breastfeeding legislation that makes it illegal to demote or penalize an employee because she nurses or expresses milk at work
- Offers a wide selection of pediatricians, boasting 1 for every 936 children under 18 -- the eighth-highest ratio in the U.S.
Hawaii has some of the most pristine air in the country, according to the recent American Lung Association (ALA) state-by-state air-quality rating. Three factors join to keep the state's air super-clean. "Because we're not as industrialized as many other states, we don't have as many pollutants being emitted into the atmosphere," says Wilfred Nagamine, manager of the Clean Air Branch of the Environmental Management Division at the Hawaii Department of Health in Honolulu. "We're also blessed with frequent trade winds that blow the air pollution we have away from the island. And since we don't have any neighboring states, we don't have to contend with another state's air pollution affecting the quality of our air."
But Nagamine stresses that even though the state's air is clean, he's doesn't take it for granted. Hawaii's industries are subject to strict air-quality regulations and are fined if they don't comply. The state also promotes clean-air strategies in schools. And through brochures, presentations, and visits, farmers and gardeners are strongly encouraged to mulch their yard waste rather than burning it, which can be a source of pollution.
- Recently strengthened its lead-poisoning-prevention program; it now tests all the state's 1- to 2-year-olds who live or spend more than 10 hours weekly in a house built before 1950 or one built before 1978 that was remodeled in the last six months
- Is one of eight states that ban smoking in all restaurants
- Doubles the state's childcare tax credit if a child attends an accredited facility
Maine is one of nine states that require all the newborn screenings recommended by the March of Dimes. Shortly after birth, the state's babies receive a hearing exam plus a heel prick to test for nine rare but life-threatening conditions, such as sickle cell anemia (an inherited blood disease) and medium-chain acyl-CoA dehydrogenase deficiency (a metabolic disorder that can cause sudden death in infancy). In addition, the state is in the midst of a pilot program to check for 12 additional illnesses. Some states, by contrast, screen for just three conditions.
"Every year, our program identifies dozens of infants who have hearing loss and 10 to 15 newborns who are suffering from life-threatening illnesses," says Ellie Mulcahy, director of the genetics program at the Maine Department of Human Services in Augusta. "By diagnosing these conditions within days of birth, we can start treatment immediately and hopefully save lives."
- Boasts one pediatrician for every 676 kids under 18 -- the highest ratio in the country -- and is home to a top-rated children's hospital
- Was the first state to require insurers to cover fertility diagnosis and treatment, including in-vitro fertilization
- Has the lowest rate of infant mortality (the number of children who die before age 1) in the country -- 5 deaths per 1,000 births
With stringent standards covering everything from close supervision to developmental activities, Massachusetts is a leader in offering quality childcare -- especially for babies. The state is one of only three that mandate a 3:1 ratio of kids under 18 months to caregivers; some states permit an infant-to-caregiver ratio twice as high. Massachusetts also enforces strict requirements for caregivers (it's one of 10 states stipulating background and child-abuse checks) and infant play and learning (it was the first in the country to set curriculum standards for family-operated childcare centers).
"We require our providers to help infants develop socially, emotionally, and intellectually, so we are not warehousing children," says Ardith Wieworka, commissioner of the Massachusetts Office of Child Care Services in Boston. Since 2001, the state has doled out more than $1 million in grants to childcare centers interested in making quality improvements such as those relating to curriculum or staff training. A large percentage of the grant money has come from the sale of license plates that read, "Invest in Children."
What's more, the state offers an above-average number of licensed childcare centers (3,242, or one for approximately every 123 kids under 5), which gives parents plenty of choices and helps prevent long waiting lists. Massachusetts also makes childcare more affordable by allowing parents to deduct expenses of $4,800 for one dependent or $9,600 for two or more when filing their state income tax returns.
5. Rhode Island
- Requires the state's department of health to prepare mercury-alert notices, explaining the danger of consuming mercury-contaminated fish to pregnant or breastfeeding women
- Offers the third-highest number of pediatricians per capita in the U.S. -- one for every 725 children under 18
- Has the the third-lowest percentage of uninsured children in the nation, with less than 5% going without coverage
Rhode Island boasts the highest rate of early-childhood vaccinations in the country. By age 3, 82% of the state's children have received the full complement of vaccines suggested by the American Academy of Pediatrics. In some states, just over 60% of kids are up-to-date with their immunizations.
Rhode Island is able to get more children vaccinated than its neighbors because the state calls the shots. "We're one of 10 states that buy vaccines for kids and distribute them free to doctors," says Susan Shepardson, chief of immunizations for the state of Rhode Island in Providence.
Elsewhere, she explains, physicians purchase vaccines from pharmaceutical companies, then fill out paperwork to get reimbursed by insurers. Kids who don't have health insurance may not be vaccinated. Says Shepardson: "We're fortunate that children are never denied vaccinations because of the cost."
- Offers 114 car-seat inspection stations -- a high number in proportion to the population of young children in the state
- Has very good air quality, especially for an industrialized state, with all counties earning a grade of A or B from the American Lung Association
- Requires all childcare providers to receive training in reducing the risk of sudden infant death syndrome at least once every five years -- one of the strictest mandates on the subject
When Minnesota State Senator Ellen Anderson (D) returned to the legislature six months after giving birth to her son Jack, she stumbled upon a big problem that she later learned affects many new moms. "I was still breastfeeding, and I realized there was no place in the Capitol building besides my office to express my milk," says Anderson, who nursed Jack for a year and a half. After checking with her friends and colleagues, she realized that her situation wasn't unique -- and some employers wouldn't even give their workers time to express milk.
Outraged, she drafted a bill requiring businesses to provide a private area for pumping milk -- and the break time to do it. In 1998, Minnesota became the first state to have such legislation; since then, eight other states (California, Connecticut, Georgia, Hawaii, Illinois, Tennessee, Texas, and Washington) have passed laws relating to breastfeeding in the workplace. The same year, the state also passed a law protecting a mother's right to nurse in public, even if some of the breast is exposed. "Our laws are making it easier for women to breastfeed longer," she says.
Anderson was able to take advantage of the law herself when she gave birth to her son Nicki in 1999. "By then, there was a lactation room in the Capitol building with a lock on the door and a refrigerator to store pumped milk," she says. "I ended up nursing Nicki for two and a half years."
- Covers 20-plus tests in its newborn screening program
- Has few uninsured kids, with more than 95% receiving coverage
- Offers an innovative statewide training program for the caregivers of infants and toddlers at childcare centers and has close to 1,500 licensed centers for the state's high percentage of working parents
Poison-control centers handle nearly 140,000 cases of infant poisoning each year. Iowa is one of only five states that require their centers to be certified by an independent agency in order to receive state funding. Among the criteria for certification: being open 24 hours and maintaining a staff of healthcare professionals who have additional training in poison emergencies and toxicology. Linda Kalin, managing director of the Iowa Statewide Poison Control Center in Sioux City, says the center not only meets but exceeds the certification standards: "For instance, our center's staff averages a little over 17 years of critical-care nursing experience. Most other states hire registered nurses, but they don't typically have as much experience."
The high-quality personnel pays off. Nine out of 10 calls relating to Iowa children under 5 were safely managed at home in 2002, reports Klein. The national average: 80%. "We want to keep children out of the hospital whenever we can," she says. "Not only does it cut down on healthcare costs, but it's far less traumatic for little ones and their parents."
- Has the sixth-highest number of pediatricians per capita in the country -- one for every 847 kids under age 18
- Boasts a high early-childhood vaccination rate; nearly 80% of 3-year-olds are current with their immunizations
- Requires all restaurants to be smoke-free as of this month; cafes and taverns with limited seating have until April to comply
Connecticut is among the country's leaders in ensuring that pregnant women receive the examinations, tests, and counseling they need, with 86% getting satisfactory prenatal care. In some states, more than 40% of moms-to-be don't receive adequate prenatal care, doubling their risk for delivering a low-birth-weight baby, according to a recent report by the March of Dimes.
"Since 1989, we've been offering free prenatal care to women whose incomes are 185% of the federal poverty level or below, " says Martha Okafor, director of the Family Health Division for the state of Connecticut in Hartford. For instance, a family of three making $28,321 or less would qualify for the no-cost care.
Moms-to-be get medical attention at one of the more than 25 Community Health Centers in the state. Convenience is key. "They can see an ob-gyn, a social worker, a nutritionist, even a dentist all in one place," says Okafor. "In some locations, we also provide transportation to the center."
- Offers the highest number of car-seat inspection stations per capita, with one station for every 666 children; some states have as few as one station for every 37,782 children
- Operates the most licensed childcare centers per capita in the U.S.: one for every 55 children under age 5
- Has the third-highest early childhood vaccination rate in the country, with 80% of toddlers receiving the full complement of appropriate shots
A healthy baby can easily rack up $15,000 in hospital and doctor bills during the first year of life. In Vermont, nearly 97% of children have health insurance -- the most in the nation -- to foot the majority of the costs, while in some other states fewer than 80% of children are covered.
One of the main reasons for the difference: In most states, children are eligible for government-supported insurance if their parents' income is 200% above the federal poverty level -- about $37,000 annually for a family of four. Vermont's program, called Dr. Dynasaur, accepts families of four that earn up to $55,200 per year -- 300% above the federal poverty level.
"Since 1989, we have been providing for middle-income families who can't afford the high cost of health insurance," says Charles Smith, secretary of the Vermont Agency of Human Services in Waterbury. Only Connecticut, Maryland, Missouri, New Hampshire, New Jersey, and Tennessee have income cutoffs as high as Vermont's, according to a recent report by the Children's Defense Fund.
10. New York
- Provides excellent healthcare for babies; the state boasts a large number of pediatricians, children's hospitals, and newborn screenings
- Offers one of the best childcare state-tax credits in the U.S.
- Was the first state in the nation to enact pro-breastfeeding legislation
More than 6 million Americans suffer from infertility, but the majority of problems can be overcome with medications and procedures. New York is one of only 12 states that require all insurers to provide coverage for infertility treatments; an additional three states mandate that insurers offer at least one health plan with fertility coverage. "Under a law passed last year, insurers in New York state are required to cover the diagnosis and treatment of infertility for everything excluding in-vitro fertilization (IVF)," says Belle Degenaars, advocacy chair for the New York City chapter of RESOLVE, The National Infertility Association. "And couples whose fertility problems do require IVF may be eligible for a covered cycle through the state's $10 million pilot grant project."
Before the current law, Degenaars says, insurance coverage for fertility procedures and drugs was limited at best, with many plans in the state offering little or none. "Couples scrimped and saved for treatments, which could cost several thousand dollars per cycle, and some just couldn't afford them," says Degenaars. "You shouldn't need a huge bank account just to get a chance at parenthood."
Child's Panel of Experts
The following experts and organizations provided data or guidance for this story:
American Academy of Pediatrics; American Association of Poison Control Centers; American Lung Association; American Medical Association; Annie E. Casey Foundation; Centers for Disease Control and Prevention; Children's Defense Fund; Susan Friedman, M.D., attending physician in the neonatal follow-up program at The Children's Hospital of Philadelphia; La Leche League International; Kate Weldon LeBlanc, coordinator of child health policy and education at Children's Hospital Boston; March of Dimes; National Association of Children's Hospitals and Related Institutions; National Child Care Information Center; National Conference of State Legislators; National Highway Traffic Safety Administration; National Newborn Screening & Genetics Resource Center; National Partnership for Women and Families; National Women's Law Center; and RESOLVE, The National Infertility Association.
The Rest of the Nation
If your state didn't make the top 10, find out where it ranked.
12. New Jersey
14. New Hampshire
22. North Carolina
37. West Virginia
40. New Mexico
42. South Dakota
46. North Dakota
47. South Carolina