Beginnings Guides Blog
Of the 10 most frequently performed
in-patient procedures, 5 are
related to maternity
care (2010 figures - latest available).
Bad news: the cesarean section
(surgical delivery) rate continues to rise; it is up 41%
since 2004, despite
global evidence that rates over 15% do more harm than good. This
is a place to
cut the cost of maternity care. A cesarean section costs on average $9956
more than vaginal delivery.
Good news: Fetal monitoring,
circumcision and stripping of membranes are performed
less frequently now than
in 1997. The reduction in procedures returns to mothers some
control over their
most significant life event, and begins to recognize that over-management
Number Performed in 2010 Increase in Frequency
Repair of obstetric 1,292,000 No change
Cesarean section 1,278,000 41%
Circumcision 1,164,000 -31%
Artificial rupture of 917,000 -5%
Fetal monitoring 875,000 -23%
greatest opportunity to make healthcare more affordable and improve
status of the population is to improve the way we deliver and pay
care. Investigations of the cost of maternity and newborn care
usually report charges made by providers. But charges are routinely discounted
varying rates, so the figures are not very informative re actual cost.
A new report shows actual payments made in 2010 (latest
figures) by employer
-based commercial insurers, Medicaid and parents.
delivery payments vary by state, by regions within states, by hospitals
regions, and by providers within
hospitals, so vaginal birth and cesarean
(surgical) delivery are reported
separately. A summary of findings in the table
below suggests where to focus
Item Employer Insurance + Public Insurance
Out of pocket Medicaid
Vaginal 32,093 29,800
Cesarean 57,125 50,374
Vaginal 18,329 + 2244 9,131
Cesarean 27,860 + 2669 13,590
Vaginal 3,180 (25%) 2,405 (39%)
Cesarean 3,580 (21%) 2,859 (36%)
Vaginal 9,048 (72%) 3,347 (55%)
Cesarean 12,739 (76%) 4655 (58%)
in hospital +
Vaginal 5,809 + 558 3,014
Cesarean 11,193 + 721 5,607
Vaginal 30,875 + 1241 13,875
Cesarean 45,496 + 1351 19,971
delivery costs are 50% greater than vaginal birth for all payers.
And cesarean delivery payments by commercial insurers
between 2004 and 2010. In addition, parents’ out-of-pocket costs
The best outcomes for women and babies
appear to occur with cesarean
section rates of 5% to 10%. Rates above 15% seem
to do more harm than
good (Althabe and Belizan 2006) Despite the evidence and the costs, the
cesarean rate for 2010 was 32.8%.
table suggests one explanation for the high cesarean rate is that surgical
birth is more lucrative than “the regular way”. Commercial payers paid
clinicians an extra $1464, and paid
hospitals an extra $7518 for cesarean
vs vaginal birth. Those incentives are
hard to ignore.
the table shows that 70-84% of all maternity payments went to
But the vast majority of mothers and newborns are healthy
have been shown to reduce preterm birth, failure to thrive, and other
land babies in Neonatal Intensive Care Units where costs were 3.7
to 5.6 times
those for other babies. More investment in prenatal care and support
reduce the need for cesarean, and
could help re-align financial incentives.
Truven Health Analytics (2013) The Cost of Having a Baby in the United States.
Connection, Catalyst for Payment Reform,Center for Healthcare Quality
Belizan JF. Caesarean section: The paradox. The Lancet 2006;368:1472-3.
term functional literacy
traditionally refers to basic literacy skills,
3Rs: reading, ‘riting, and ‘rithmatic. These autonomous skills for
knowledge were said to be functional, implying that they
enabled a person to
function in society. The idea was, if you can read
and use numbers, you can
learn what you need to know and do to
function in any context.
was true in 1852 when MA passed the first compulsory school laws.
It was still
true in 1918 when all American children were required to
that time, the Sisters of Providence were arriving in Seattle on mule
the Oregon Territory to establish the city’s first hospitals.
rode a circuit of the logging camps selling the first health
policies. For $10 a year a logger
was promised full care in
any injury or illness. The care consisted primarily of bandaging
amputations with handholding and whiskey for pain. The 3Rs were
understand the policy and to obtain the full benefits of care.
have changed, but thinking lags.
The term functional health literacy came into the healthcare discourse
1993. Starting with the
traditional understanding of functional
literacy, functional health
literacy, came to be understood
literacy skills applied in a clinical setting, in other words, a
ability to read and use numbers to understand medical, healthcare,
insurance related information. This conceptualization relies on the
assumption that basic reading and ‘rithmatic skills still enable a person
function in society, and specifically in healthcare settings that were
unimaginable even 50 years ago.
the thinking goes, a patient who can read will be able to function in
healthcare arena. Reading will enable a person to recognize a medical
understand the difference and appropriate uses of primary and
find an appropriate provider or collection of specialists,
manage transportation and child care, articulate
symptoms, understand the
diagnosis and treatment options, follow the
medication regimen, change
behaviors to prevent repeating or exacerbating
the problem, file insurance claims
and get reimbursed for costs that are
unknown until the bill arrives. All this in a complex, high
rapidly changing environment with its own language and
in the health arena takes more than reading.
literacy scholars say that the meaning of literacy is constantly
reflect society, so that what it means to be literate is context
different at different times and places for different ages and
cultures. Operationalizing health literacy simply as ability to
terms and documents surely oversimplifies the literacy tasks
managing personal and family health and healthcare. Time to
update the way we
think and talking about health literacy, and how it
enables a person to
function in the health arena.
Lucia, E.(1978). Seattle’s Sisters of Providence: The
Story of Providence
Medical Center~Seattle’s First Hospital. Providence Medical
infants show preference for others in distress
10 months of age, babies differentiate attackers from victims and neutral
They literally reach out to victims. Their second choice is a neutral
party. They avoid attackers.
scientific experiments by Japanese researchers, the players were shapes on a
like the early Pac-man games. The researchers suggest the
infants’ preference for the victim is the
foundation for sympathy.
negative impact as
experiencing it directly. This seems to be so even on an infant. The study
certainly confirms that babies observe and are shaped by what is happening
power of choosing
experiment further suggests a very early start for what David Emerald (The
Dynamic) describes as humans’ default way of looking at the world.
It’s a survival mechanism. In
order to keep us alive, our brains are pre-set to
keep us focused on problems and threats. Anything
unfamiliar or unexpected (including an aggressive square) is considered a threat, even as early as
months. Brain imaging shows that upon detecting a threat, real or imagined, the
brain floods the
body with chemicals to produce anxiety. It gives us just three
choices of how to react: fight, flee
or freeze. No thinking is involved.
Anxiety is the prime motivator,
and our default state.
writes that It takes intention and attention to notice when we are reacting
to anxiety, and to instead choose a purposeful response to the
source of the anxiety. A habit of
observing and choosing is the key. The process of choosing takes us out of
survival mode and
activates critical thinking.
together, these works make clear the importance of allowing very young children to make
choices. Even before they begin to
talk or to understand. Hold up two
shirts. Ask, red shirt or
green? Let Baby point. When out for a walk, ask Baby
which way he wants to go. He can point.
Maybe not the first time. But probably
sooner than you think.
choices and translating those choices into desired actions and outcomes” - that
definition of empowerment.
Kanakogi Y, Okumura Y, Inoue Y, Kitazaki M et al.
(2013) Rudimentary Sympathy in Preverbal Infants: Preference for Others
Distress.PLoSONE 8(6): e65292, doi: 10.1371/journal.pone.0065292
Emerald, D. (2006). The power of TED: The Empowerment
Island, WA: Polaris Press.
World Bank. (2005). "What is
in this space I told Mandy’s Story,
and then we saw how the story reflects
are many lessons in this story.
young child’s healing power and reason to live reside in the mother.
need their mothers not only present, but interacting with them.
interaction with mother is absent, even for short periods under
circumstances like Mandy’s mom’s vacation, children and mothers
Although a surrogate mom like me in this story can ease the pain.
child can become stuck in a state of anxiety
the interaction is removed under unpleasant, unplanned, unexpected
circumstances, like a hospital stay, research shows development
with lifelong consequences for the child, especially negativity and
A hospitalized child is at risk of getting stuck in a state of anxiety.
interaction, more hospitalization
recent study found that children of responsive, interactive mothers were
as likely to be hospitalized. That means children who are hospitalized
twice as likely to have mothers like Mandy. That’s the bad news.
the good news: Role models needed
learned this lesson a little later from Mandy’s mother. Seeing what mothering
seeing ways to relate to her child, seeing how her child responds is all
Mandy’s mom needed to transform herself into a mother who actively
child’s health and development.
mom did what we all do; she mothered as she was mothered. In this
case, not at
all. The fact that Mandy was failing to thrive and her mom clearly
mothered her well was not evidence that the mother was incapable or
unfit, or uncaring or lazy. Rather the facts indicated lack of a role model.
who were not well mothered themselves need a role model to see what
possible, to develop confidence in themselves and find the courage to engage
mothering and caregiving. How can
you use your position, skills, knowledge,
and compassion to be that model for a
mother who wants to be what her child
needs but does not know how?
I have been very impatient with the
narrow view of some health literacy
researchers who, as if looking through a
soda straw, focus on only a single
factor in a persons’ capacity to use information for health, usually reading
skill. Or who focus only on the clinical encounter. Or only on patients with
chronic disease. Or only on plain
language. Experts at the International
could not agree on a definition or a
measure of health literacy. I’ve called
for a broader view.
But maybe I’m wrong.
This week I was in Bozeman, MT working
with the public health nurses and
social workers who staff the Thrive Partnership
home visiting program.
They are the cutting edge of promoting maternal health
literacy. It has been
my honor to work with them since 2004. This time we
worked on practical
approaches to empower parents.
In this community, promoting health
literacy and empowering parents is
part of a county-wide coordinated effort to strengthen
The collaboration addresses the entire Web of
Interaction that affects MCH
maternal health literacy.
Thrive, voted Bozeman’s best
non-profit, under the tireless, gentle, powerful
direction of executive
director Deborah Neuman, has over 26 years forged a
collaboration to promote
maternal child health as the foundation for a healthy
society in Gallatin
County. Neuman has received a
growing number of requests
around the country for help to replicate the collaboration that extends
beyond the usual public health players. For example, two banks contributed
space for our 2-day workshop. The Hilton hotel comp’d rooms and breakfasts for
Neuman credits the soda-straw view of
each partner as the active ingredient in
the success of the Thrive model of
coordinated collaboration. She
says a common
broad view would cause the collaboration to degenerate to
groupthink. She points
out that the social workers in my workshop are employed
by Thrive; they were
hired for their ability to engage parents. The nurses in
the workshop are employed
by the health department and hired for their clinical
expertise. The PHNs and MSWs
work with the same families. They are acutely
aware and respectful of each others’
expertise. They closely coordinate their
efforts with each other, healthcare providers,
the hospital, the schools, food
banks, day care providers, , the Bozeman Adult Literacy
and Education service,
et al. Both the Health Department
and the agency use the
of LSP data (soon to be published) show remarkable
results,with effectiveness increasing
over time as the coalition grew and
Rather than of a common broad view,
Neuman says, what works is all those soda
straws trained on the needs and
strengths of the same vulnerable families to find
the combination of supports
that empower each family to function
as fully as possible
as part of the Gallatin County society. It seems many narrow views together
broad view without sacrificing the depth of understanding one gets
looking through a
soda straw. ss
*Credit for the soda straw analogy goes to Linda Wollesen, author of the LSP
Last time in this space I told Mandy’s
about the depressed 8-month old
who transformed over the course of
one week of simple everyday interactions.
The story illustrates the scientific
work of Bowlby and Robertson on the stages
children move through when separated
from their mothers due to hospitalization.
Mandy was well beyond the first stage
in a child’s response to separation: Protest.
This stage is marked by wailing and sobbing in confusion,
fear, grief at being
She was also beyond Stage 2: Despair.
The child becomes more hopeless and
apathetic. She withdraws. Like Mandy. This
going quiet is not settling in.
It is giving up and shutting down.
Mandy was well into Stage 3:
Detachment (or Denial). She had suppressed all
emotion, including - maybe
especially, feelings for her mother. She hardly
noticed when her mother left.
She was so withdrawn that she sought no
mothering at all. Now, i would recognize that as a sign
of major psychological trauma.
There are many lessons in Mandy’s
story. More on that next time. s
history of attachment theory and the stages of separation, plus a good
bibliography, see Van Der Horst, FCP
& Van Der Veer, R. (2009). Separation and Divergence:
The untold story of
James Robertson’s and John Bowlby’s Theoretical Dispute on Mother-Child
Separation. Journal of the History of the
Behavioral Sciences, Vol. 45(3), 236–252. Published
Wiley Periodicals, Inc.
month was interviewing a panel of three mothers of children with special needs
are cared for at the Red Cross Children’s Hospital in Cape Town. They talked like nurses
understanding of complex conditions, procedures, and medical jargon. I asked
them, “Thinking back on your experiences in the hospital, what do you want
Farahna is mother of Hamza*, now 11,
who relied on a tracheostomy
for 10 years and
whose remarks closed the conference. She responded simply in a
deep, quiet, powerful
voice, “ I am
And all the mothers
together said, “I could not have done it without you.”
huge and small sacrifices and loving kindnesses that mothers make for
children, most of which go unnoticed and unrecognized. And I am ever more
appreciative of the expertise, heroics, gentle touches and encouraging words
nurses bring to the mothers and their children to restore and maintain the
of both. You inspire
*Hamza and I won the award for Best
Dancers at the conference dinner!
was a young mother, I was married to a sailor. A submariner. With about
other men, he was at sea half the year. 100 days at a time. Underwater.
communication. As you might imagine, the wives and children were a close
community, a village if you will.
time a group of the wives decided to take a trip. I agreed to keep one of the
younger children for the week they would be away. The baby’s mother brought
her to me on a Saturday morning.
It was the first time I met the child. Her name
was Mandy. She was about 8
looked 80. Her skin was shriveled. She had a grey cast to her. She made no
sounds. Her eyes were dull and distant.
She hardly moved. She was clean, well
dressed and fed. Her Mom had all
kinds of equipment for her. But Mandy was
mother assured me Mandy would be no trouble. She said, “You can just put
the play pen. She will be quiet.”
baby girl made no protest when her mother handed her off to me. She never
looked to see her mother leave.
This child, Mandy, had not been in the
hospital, but it was as if she was
She spent her days lying in her crib, well tended, but
alone. Her mother was present;
met the baby’s physical needs. But she never engaged or interacted. Mandy’s
emotional needs, even the idea
that she had emotions, went totally unrecognized.
With observable physical
At the time I was 22, my daughter Lisa
was 2. I had a high school education, no experience,
no skills. So believe me,
I did nothing scientific or intentionally therapeutic for this child.
folded her into our usual routine. The three of us went to the grocery store
the park. We shared meals. I treated Mandy as my own.
And I watched an unforgettable miracle
That little girl bloomed before my
eyes. Hour by hour her appearance changed as she
came back to life. She started
to mimic Lisa’s sounds and to initiate contact. She
became interested in
everything around her. She laughed. She filled out. Her cheeks
turned rosy. She
started looking and acting like a baby.
When her mother returned to pick her
up, Mandy recognized and reached out to her.
She had regained the courage to
expect a response.
And, miracle #2, she got one. Her
mother gasped and covered her mouth. Her eyes
filled with tears. She said, “I
never knew she could be so beautiful!”
Much later I learned of Bowlby and
Robertson’s work on attachment and the stages
children go through when separated from their mothers due to
More on that in
Part 2. Stay tuned. ss
(c) Practice Development Inc. You are free to use this
story for teaching purposes
as long as you retain the attribution and do not change the story in any
Coloring is meditative. With crayon in hand one is able to
access a different
part of the brain, a non-thinking part that is intuitive and
Beginnings Guides Heartwork was designed to tap in to this powerful
The drawings were created by Laurel Burch
They invite reflection on one of
the key concepts found in the Beginnings
Guides curriculum the concepts are
related to managing personal and family
health. Each drawing is linked to a
booklet and key concept. The client is able
to learn the concept the drawing
illustrates while encouraging her to visualize
her future as a mother,to dream
ahead, to imagine and plan. Perhaps she may even
reflect on her own
childhood, things she would like to carry over in to her own
she would like to do differently.
Beginnings Guides Heartwork encourages
reflection, which is
key to understanding
health information, affects the ability to
decisions and therefore
improves outcomes. A simple, powerful
method to promote
maternal health literacy.
Using the coloring pages can help to set up
sharing quality to a visit, it is
hands on, and will encourage the client to
find deeper meaning and to speak from the
heart. She may uncover new
a previously unrecognized need. Therefore
the home visitors
handbook includes a chapter
on how to use the coloring pages safely and
effectively to color a conversation.
There are some key factors to keep in mind.
Client safety is very
important when working with the coloring pages. Because
the exercise has the
potential to bring up deep emotions and/or repressed
feelings it is important
to have program protocols in place to assist the home
visitor. A client may
bring up depression, domestic violence, child abuse or
substance abuse.Heartwork can be deeply powerful therefore if you do not
have a protocol set up through your organization avoid using this exercise until
something can be implemented.
Be sure to organize your visit effectively.
requites trust and a certain
level of comfort. They were not designed
to be used on the first or second visit. It
is also suggested that you wait until the
end of a booklet to do the coloring pages.
If needed you can introduce the page
leave it with them to complete on their
own time. They could also be
to journal or write about their experience
on the back of the page.
Be sure to provide
crayons or makers and encourage
your client to find a quite
place to do the work where she won’t be interrupted. Be sure
respond, follow their lead and listen to your instinct.
Do you use Heartwork in your practice? Would you like to
share your experiences and
clients drawings? We would love to hear from you.