Beginnings Guides Blog
Part 1 Maternal health
literacy as skills
A life skill
is a collection of skills necessary for full participation in everyday life.
Maternal health literacy is a life skill that mothers use to manage personal
child health and healthcare.
It has been defined as the
cognitive & social skills
that determine a mother’s motivation and ability
to act on information in ways
that improve health (Renkert and Nutbeam, 2001).
Cognitive skills are used to
understand information; they include basic literacy skills,
numeracy (ability to use numbers). A mother might use these basic skills
learn about ear aches, and make an appointment to take her child to see a clinician.
So basic literacy skills are the essential foundation for health literacy.
Social skills are used to make
personal meaning from information, including speaking
and listening. The mother
whose child has an ear ache uses these skills when she discusses
clinician the information on ear aches to understand why her child has them and
how she might prevent them.
Reflective skills combine
cognitive and social skills to think critically, make choices,
and take action. The mother in our
example uses reflective skills when
she mulls over what the doctor said, what
she read, her experience of her child’s ear ache,
her actions and parenting
practices, and her discussion with her mother about treatment
possible preventive measures. Some literacy scholars say that reflective skills
are so essential to applying information in context that it should be
classified as a basic skill.
So we could say there are 4Rs: reading, ‘riting,
‘rithmatic, and reflection.
Health literacy means
empowerment (WHO 2013)
A health literate mother
combines all these skills to make health related choices and transform
choice into desired action and outcomes. That is the World Bank’s definition of
empowerment. Say the mother
chooses to stop putting her baby to bed with a bottle. She takes
that step, and
she enjoys her desired outcome, a happy ear-ache free baby. We say this mother
is empowered for health.
Her health literacy skills
enable her to minimize risk, maximize protective factors, and optimize
promotion. In this way, a mother’s health literacy forms the foundation for her
her child’s health throughout their lives.
Many factors, in addition to
skills, interact to determine a woman’s maternal health literacy.
More on that
I’ve been in Washington
DC where I co-presented a workshop at CenteringHealthcare
national conference. I was drawn to this organization the first time
their motto: Transforming care through
(CP) is a rapidly spreading model of group prenatal care.
12 women with similar due dates have their prenatal visits together.
Each has the usual
individual health assessment with an obstetrician or midwife
in the group space. Meanwhile
the rest of the group engages in “self-care”;
they weigh themselves, take their own blood
pressures and chart the data. They can read their own lab results and
The rest of their 1.5 -2 hour appointment is dedicated
to education and support through
facilitated group discussion and activities.
and processes are the same as for conventional individual prenatal
schedule of visits and core content follow ACOG* guidelines.
founder and CEO, midwife Sharon Rising, emphasizes, “Content
should not get in
the way of process.” The women talk about what they want to talk about.
are games, activities and multiple ways of learning. Women test out what
heard; they explore their cultural beliefs and share sensitive issues
like violence that are
only rarely discussed in traditional prenatal care. They
build community and function as a
“March of Dimes wants all mothers to get prenatal care in
Judy Gooding, MOD’s Vice
President for Signature Programs. No wonder.
She describes CP as an
evidence-based program to prevent preterm birth and disparities
health outcomes. MOD’s 2012
Preterm Birth Report card shows the US rate at
11.7% of all births. Among women
in CP the rate is 5.5%. The national low-birth-weight
rate is 8.1% compared to
CP meets the Institute
of Medicine’s goals to make healthcare services safe, patient
equitable, timely and efficient.
Participating mothers seem to agree. There is
no waiting time, no need
to retell their story to strangers. They build a relationship with
provider. What they like best is being with other women.
Rising says, “Facilitation is the secret sauce.” Clinician
facilitators are trained
not to answer questions or instruct the group, but
rather to elicit the group wisdom and
listen to what drives behavior. They come
to understand and appreciate the needs, beliefs,
and struggles of the women and
the complexity of their live. Throughout the conference
there were reports of
clinicians coming out of CP sessions where they completed the
10-12 prenatal visits in 2 hours
beaming and talking in superlatives about
All this makes group
prenatal care the ultimate environment for promoting maternal health
I’ve been working for a year with WellPoint, the health insurance giant, to design
a pilot to test the
hypothesis that CP promotes MHL as a side effect, and with facilitator
awareness, tools and strategies it can be very effective.More on that next
Stay tuned. ss
FUD: Fear Uncertainty & Doubt. That is the foundation of the
Republican’ position on the Patient Protection and Affordable
Care Act of 2010.
That’s why they
call it Obamacare- in order not to say “protection” or “affordable”;
and to hide the fact that the law was
enacted 3 years ago, before the President
was soundly re-elected running
against an opponent who vowed to repeal it.
FUD, initially an IBM strategy to eliminate market competitors by
uncertainty and disinformation about their products, seems to be
working for the
House Republicans. At least to some degree, for now. Polls and
analyses of social
media suggest that some people favor the Affordable Care Act
while opposing Obamacare.
Home visitors: “Obama
snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper
tantrum until I saw
the Fox “news report” about the Affordable Care Act’s
expansion of home visitation.
a preventive strategy in which public health nurses, social workers or
paraprofessionals connect families to healthcare and community
resources and offer
health education and social support. It’s origins date back to the 1800s.
are run by county health departments, school districts, foundations,
partnerships. Home visiting programs are open to poor
parents who request assistance.
It’s worth noting that in many countries, home visiting has long
been standard for all
parents, because they acknowledge that parenting is a
challenge and everyone can
use assistance. And because research shows it
improves child developmental outcomes
and has immediate and long-term benefits
that extend to entire families and to the
healthcare, education and justice
systems. My research
shows that parents in home
improve their health literacy, capacity to manage personal and
child health and
A Fox announcer and a “business expert” called home visitors
They said in this “brand new federal program”,
“government home inspectors”
make random, unannounced “forced home visits” to snoop on parents. This is not
news. This is pure FUD -
disinformation (lies) that specifically intends to instill fear,
and doubt about the Affordable Care Act, to prevent people from learning
can afford good healthcare coverage.
I have worked for decades with home visitors and know them to be
among the most
respectful people on the planet, unlike the FUDders on Fox and in
FUD won’t work for long.
Yesterday, the heart of the Affordable Care Act started
(keep saying the real
name), opening access to healthcare for millions of poor and
citizens. Almost 3 million people visited www.heathcare.gov
similarly overwhelmed. People are
about to find out that the Affordable Care Act
makes good healthcare coverage
affordable -for them. That will help them see through
the FUD. Insurance companies are helping too.
They are enrolling people they previously
rejected because, with the ACA, it’s
good for business. Healthcare executives are calling
for more doctors, nurses
and allied health professionals - doesn’t really sound like a
On the other hand, the House Republicans just put hundreds of
thousands of people out of
work in hopes they can FUD us citizens of the
richest country in the world into continuing
denying healthcare to poor people
and sick people in order to preserve the freedom of
the rich to get richer.
beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
across cultures. They are skills that empower people to be what
they want to be, to make
choices and transform those choices into desired
actions and outcomes.
These life skills develop most easily
in early childhood given a stable
supportive family environment. Disparity in
brain development in children
growing in disadvantaged vs enriched environments
becomes apparent in
the first year.
Quality of family life matters more than the number of
income or education. But poverty and accumulated disadvantage
from doing their best to sustain the stimulating home
environments that support
optimal development, especially when they
themselves lack skills, resources and
role models. Early intervention ---
early childhood education, parenting
training, family support and home
visitation programs--- can produce positive
and lasting effects on children
in disadvantaged families.
Nobel Laureate and economics
professor James Heckman, makes the business
case for shifting public policy to
support programs that offer parents information,
choices and assistance. Promoting health literacy means
supplemental assistance that specifically and intentionally
enables parents to
develop and hone the range of life skills used to
participate in healthcare and
manage personal and family health at home.
Must read: Heckman, James J. (2013) Giving Kids a Fair Chance (A Strategy
That Works) MIT Press,
Cambridge, Mass. ISBN
In addition to Heckman’s monograph,
the book includes illuminating commentary
by 10 experts from multiple
My favorite feature of the upcoming 9th edition of the Pregnancy Guide recognizes
it is a
digital world. You told us that you and your families need print materials
few in your caseloads have computer access or devices to use digital
Other surveys confirm you’re right.
Poverty and the
In December 2010, 40% of US households, did not have a broadband connection in
home. Lack of access is a marker
of poverty. Mississippi is the poorest state
and has the highest proportion of
households without access, 65%. Similar rates of
poverty and no-access are
found in AR, TN, WV and OK.
Compare to wealthy
states led by HI with 74% connected, only 26% with
no-access. In cities, there is
commonly low access in the urban core suffering poverty while the wealthy
are fully wired.
Still, people find a
way to get online
In a survey of over 2000 Mississippi households, 79% said someone in the home had
the Internet. Outside locations included school, workplaces and the local
library. In some libraries, free
internet service is the biggest draw into the building.
reasons for having no access at home were cost and lack of equipment,
key reason seemed to be lack of understanding of the value of the Internet,
aspect of low health literacy. Of
those without access, 46% said they didn’t need
it or were not interested. Others, especially younger, less
educated, low income
adults said they mostly go online using their smartphones.
Access in steadily
A February 2011 survey found 68% of households with a
significant growth in just a few months. Some of the most rural areas seem to be
improving quickly; but the South has shown only modest improvement. The Obama
administration has directed billions of economic stimulus dollars to increase
access. And some companies have just begun offering low-cost broadband
to families with a child who qualifies for free school lunch.
information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide
intentionally focused on essential health behavior topics directly linked to
outcomes. Some parents want to know more.
New Resources for
Mothers coming to www.BeginningsGuides.com
For those who do have Internet access, and to motivate those
who don’t to find a way,
the new 2014 edition of Beginnings Pregnancy Guide
includes this icon to encourage
The new section provides links to
information and resources from reliable sources that
Beginnings Guides staff have reviewed and found easy to use. This reduces the need for
advanced searching and evaluation
skills. We envision the new Resources for Mothers
as an easy entry into online
self-directed learning about health and an opportunity for
parents to improve
their health literacy.
Dunbar, J. (2012) Poverty Stretches the Digital Divide, the Center for Public Integrity.
The 2014 9th! edition of Beginnings
Pregnancy Guide, in English and the 4th
Spanish edition are in production. Here
are some of the changes to look for.
A subtle but important revision is in who to call for information
Previous editions have said, “... call your doctor.” Since
physicians are not
always prepared or inclined to lead discussion of topics
that are sensitive or
not strictly medical, I added home visitors and sometimes doulas on topics
including breast feeding, smoking, abuse, weight gain, depressive symptoms,
conflicting advice, relationship issues, car seats, and labor pain management.
On these and similar subjects the new Beginnings
says, “Talk with your doctor,
home visitor or doula.” This supports a shift in parents’ thinking from “the
doctor takes care of my health” to ‘the doctor helps me take care of my
to a Healthy Baby, the health behavior messages that research links
to birth outcomes are modified slightly.“Do eat well” is expanded to “Do it
often” since a pregnant body easily and
quickly slips into starvation mode. Frequent
small meals best support fetal
“Do gain weight” is expanded to “Do
gain weight slowly” In response to concerns
over obesity and the trend to gaining in excess of guidelines. The latest
recommend an 11 pound gain for a woman who starts pregnancy
“Do take vitamins” is expanded to “Do
take vitamins everyday” to emphasize
the need for consistency to maintain a healthful level of nutrients in the
Early term inductions of labor for
vaginal birth more than doubled between
1990 and 2006 from 7.5 to 17.3%. And
the percentage of later preterm C-section
deliveries increased by 46% from 23.5
to 34.3%. A 2010 study found 44%
had their labor induced, often for convenience of the parent or the
Those women were twice as likely to have a C-section as women who waited
natural labor.( Ehrnethal et
al. July 2010 Ob&Gyn). In light
of that trend, the
updated Pregnancy Guide’s discussion of the course of
pregnancy (p46) includes a
statement that “Labor should not be induced before
week 40, except for medical
reasons. The section titled Baby’s Growth and Development, 9th
encourages readers to exercise their health literacy skills and
speak up about this
concern. “If your doctor talks to you about inducing labor,
ask if you wait until
Nuchal lucency test is added to the discussion
of prenatal testing.
Juice is de-emphasized in favor of
water. Juice was considered a
alternative. However, with the increase in obesity, extra
calories and sugars
in juice are
My favorite change.
Reference: National Center for Health
Statistics Data Brief 24, Nov 2009.
1. Health Literacy is a key determinant of
•Limited health literacy, measured as ability to read
medical terms and
documents, is linked to riskier health choices, less
participation in preventive
activities, more accidents, poor adherence to
medication, more hospitalization,
increased morbidity and premature death.
• Studies using more comprehensive measures
demonstrate that health
literacy has a specific direct and independent effect
on self-assessed health.
• Limited health literacy in mothers is linked to
increased risk of
delays and reduced participation in Early Intervention
when delays occur.
literacy means empowerment: the capacity
to make choices
and transform those choices into desired actions and
• Mothers cannot achieve their fullest health
potential and nurture a healthy
competent child unless they are able to take
control of those things which
determine their health. (Ottowa Charter for Health Promotion)
3. Efforts are highly leveraged in
pregnancy and early parenting
• Pregnant women exhibit readiness to learn and change
well above national
norms. They are becoming healthcare decision-makers for
their families. Developing their health literacy in pregnancy
can benefit entire
families across their lifetime with short and long term
benefits extending to the
healthcare system, the justice and to the schools; to
the public health and the
4. Mothers’ health literacy is an
important factor in prevention
noncommunicable diseases that are now the leading causes of death in
• Both limited health literacy and noncommunicable
affect poor, under-educated, and minority
• Limited health literacy reinforces inequities.
• Promoting maternal health literacy and empowering
mothers are recognized
global health strategies for reducing the burden of
with origins in early development, and associated
The American Medical Association House
of Delegates declared obesity a disease
last month. Is this good for maternal
and child health? For public
In 1995 the National Heart Lung and
Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten
years earlier, almost 30 years ago now,
NIH called prevention and treatment of
obesity a national medical priority.
With 90 million Americans now officially
obese, it seems few clinicians got the
prevention not a priority in maternity care
, I found that weighing is still the only procedure in
care that has shown any impact on outcomes. And yet it has
become uncommon for
a pregnant woman to be weighed at prenatal visits or
when being admitted to a
hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation
interfere with their patient/provider relationship. Others said they do not know how
do it for them. One can
only hope that calling obesity a disease will change these
mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a
mother with an excess of fat cells produces a baby
with an excess of fat cells. So we are building obesity
and the attendant health issues
into the next generation.
experiences - witnessing or experiencing interpersonal violence
related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical
many such women have lost weight, and gained it right back. That’s
how the lifelong
effects of ACEs were discovered.
Other mothers have said it doesn’t
matter if they gain too much in pregnancy since
they are just going to get
pregnant again; the weight can come off after that.
Only it rarelydoes.
people into patients
Google “obesity disease”. The first
thing that pops up is ad ad for weight loss surgery.
This may be more telling
than official statements.
Especially when we consider the Forbes
June 28 report that the AMA’s Council on Science
and Public Health, the group
appointed to address the question, advised against declaring
obesity a disease.
But the delegates chose ignore their own advisors.
We have to ask, what was so
Perhaps it is the implementation of
the Affordable Care Act that will bring healthcare
coverage to millions of
Americans previously excluded from the healthcare system.
At least a third of
them are obese. Now they can be patients.
According to CDC 35.7% of Americans
are obese, 49.5% of African Americans, 40% of
Mexican Americans. Rates vary
widely by state. Find your state rate at
in need of medical treatment.
Calling obesity a disease, again,
could draw attention to related health issues, but it
hasn’t in 20 years. It could result in better maternity
care, but the declaration is
unlikely to improve clinicians communication and
counseling skills. It could spark
Kennedy-style physical fitness craze, but that entails behavior change, and
communication issues. It
could increase research on obesity, but NIH already has a
Strategic Plan for
Obesity Research and funds nearly a billion
dollars worth of studies
annually. Grants.nih.gov lists 49 obesity-related
research solicitations currently open
for submission of grant
Only one thing seems certain, making
obesity a disease will increase medical treatments
and costs, and revenue to
2D, 3D or 4D. In-studio or at your
baby shower. Announce your pregnancy
with a “viewing party”. Get a video at the
mall. Post it on Facebook. Select the
premium package offered by a Miami
OB-GYN’s office and get a weekend discount.
American Institute of Ultrasound Medicine, American College of Obstetrician
and Gynecologists, American Academy of Family Physicians, March of Dimes,
Food and Drug Administration, England’s National Institute for Health and
Clinical Excellence, the UK’s
National Collaborating Centre for Women's and
Children's Health, and other
national and international experts all have published
against non-medical use of fetal ultrasound. The Society
of Obstetricians and Gynaecolgists of Canada
calls for a complete ban on non-
medical use of fetal ultrasound. The state of
Connecticut legislated a ban in 2009.
The FDA says that creating fetal
keepsake ultrasound images is “an unapproved
use of a medical device,” and
those who perform ultrasonography scans “without
a physician’s order may be in
violation of state or local laws or regulations.”
don’t need an excuse to be happy.”
Still internet ads for non-medical
ultrasounds abound, complete with slogans like
this, implying you don’t need a
medical reason for the “painless, relaxing procedure”.
The growing popularity
of “keepsake ultrasounds” is not due to cost or access issues.
companies pay for one or two doctor-ordered ultrasounds as part of
prenatal care, and commercial ultrasound is not cheap.
start at $175 for the 3D in-studio option. $500 for an “ultrasound party”
the location of your choice. The cheapest rate I saw was $75 for a basic
determination” scan; it’s discounted to $55 on Saturdays one OB-GYN’s office. These
services are not regulated or standardized.
sonographers say that ultrasound is safe. I found unclear statements like:
“All research provided has been proven to
be safe for expectant mothers and baby,
as long as the procedure is done by a
trained professional, and no longer that one
hour intervals.” First, we have to ask, research provided by
whom? and What about
the research that was not provided? Second, remember that no research ever proves
anything. It can only
offer statistical evidence. Then, a more accurate statement is
ultrasounds have not been proven harmful. Still the evidence has
convinced all the advisory and regulatory
agencies that entertainment ultrasounds
uses sound waves, not xrays. So radiation is not the issue. But the procedure
targets the fetus with heat and
pressure, especially prolonged, 4-D studies. New York
proposed a ban on ultrasonography for entertainment purposes, citing
showing that 4Dl ultrasound equipment can emit eight times more energy than the
machines commonly used in medical settings. The risk of effects on fetal development
demonstrated in both human and animal models, and remains, at least
so that the FDA
concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
concerns about non-medical ultrasonography include the possibility that
medical ultrasonography will fail to identify a problem with the baby,
the patient and her family; or that a false-positive result
could create unnecessary anxiety
and follow-up testing. Machines are
unregulated so may not be properly calibrated or
maintained. Technicians may
not be well-trained or proficient. “gender determination”
had never been an
accepted use of of ultrasound technology and raises thorny ethical issues.
are for doctors
Here’s the problem: In medical settings, the sonographer is commonly prohibited
explaining ultrasound results to the patient, who must then wait for days
or weeks to get the
results from the physician who ordered the scan. Family
members may be barred from attending
the ultrasound appointment to avoid
congestion in the radiology department. Parents may not
receive still pictures
or video to take home. If they do, they still cannot send it to a friend or
it online. Until these
disempowering practices change, parents and sonographers
to seek a more informative, convenient, family friendly experience.
Check Technician’s Credentials
sonographers are trained and certified. Find one, or check a technician’s
Pregnancy Guides says, “Ultrasound is
safe for you and Baby.” [p8] That
The 2014 edition will add this statement: Many healthy pregnancies do not need
ultrasounds may be harmful. The Registry of credentialed sonographers
iPhone helps too much; so we
inadvertently retweeted this,
and then the retweet was favorited: Health Illiteracy-- a disease that
afflicts doctors... I would not intentionally repeat this
hope you won’t either. Here’s six reasons why.
1. The term “health illiteracy” focuses on patients’
deficits and places
patients in a position of failure and incompetence. This
generates anxiety and resistance in patients and calls up their
It disempowers patients while requiring that they be active
and participants in their care.
2. The term “health illiteracy” equates lack of
medical and healthcare
vocabulary -jargon- and disease knowledge with illiteracy and all the
that goes with it. It situates in the patient systemic problems in
healthcare (indecipherable &
conflicting information, inefficiency, high
costs, poor outcomes); so that when
treatment is successful doctors get
credit, and when it’s not, patients get the
3. “Health illiteracy” is neither a disease nor an
affliction. This metaphor
tips the power imbalance. it implies health illiteracy is a problem
patients have and doctors need to treat or manage. It cements the
patients cannot grasp doctors’ specialized knowledge or use
it for their
personal benefit; so that an “appropriate health decision” is
compliance. And non-compliance is framed as cognitive deficit
4. Here is the first definition of “disease” produced
by a Google search:
disordered or incorrectly functioning organ, part, structure, or system
from the effect of genetic or developmental errors....
The metaphor adds stigma to stigma
implying cognitive deficits and
disabilities, rather than underdeveloped
skills, poor quality education,
inexperience with the healthcare system, or
poor communication and complex,
concept dense, jargon laden, overly technical
5. An “affliction” is defined as a condition of pain, suffering, or
adults who scored in the Basic or Below
Basic levels on the 2003 National
Assessment of Adult
Literacy reported that they read well. They are not
“afflicted”until the enter
the healthcare system.
tweeted blog is titled “Screening-illiterate physicians may do more
good”, which a tweeter translated to
the comment that health
illiteracy afflicts doctors as well as patients.
blog bemoans that many doctors are “functionally
concepts’” This language conflates functional literacy
(the 3Rs) refers to skills used to gain
knowledge. Lack of a
set of knowledge,
does not indicate inability
or to learn.
“functionally illiterate” means having reading
and writing skills
insufficient for ordinary practical
needs. Any one who got into medical school
read and write. If they do not
concepts, that says
more about their educators
than about their cognitive ability.
lack of knowledge as functional illiteracy - inability
to gain knowledge - is as
as it is to patients.
I agree with the
blog authors’ conclusion that more attention needs to be paid to
physicians knowledge (not their literacy) about screening tests in order to
reduce use of ineffective tests that expose patients to potential harm --
health literacy tests.
More attention also
needs to be paid to increasing understanding of literacy and
Here’s the blog: