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What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?
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What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?

This question was raised by Winston Wong, Director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, during the Institute of Medicine's recent workshop, Health Literacy: Past, Present and Future.
The workshop marked 10 years since  IOM released the landmark report Health Literacy: A Prescription to End 
Confusion.  A summary of the workshop proceedings was released this month. Download a summary of the 
workshop free from National Academy of Sciences. Definitely worth the read.

Here's the part that made me stop and applaud

In a discussion about health literacy and its role in achieving equity, Wong  recounted a conversation among
health plan leaders on patients' non-medical needs (social determinants of health), that led to the question: 
What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year? 
“One interesting proposition is that we should start the discussion with every person we come in contact with 
by asking 'what does a good day mean to you,’" Wong said,  "because that’s really a much more important 
question than ‘what hurts’ or ‘have you been taking your medicine today.’”

Why is this question more important than typical problem-focused inquiries?

It's empowering.
Wong said it reflects the fact that medicine can help with some problems, but what ultimately makes for a 
good day for someone is determined by a constellation of actors that foster good health. The question 
recognizes that on average Americans spend about one hour per year in a clinical setting; the healthcare 
professional is just one actors; s/he marshals resources that account for about 10% of health.  The other 
actors are the people the individual is with the other 8764.81 hours per year. The power to create health, 
and to live well with disease, is with the patient.

What is a good day like for you? addresses the person and his/her "real life",  instead of focusing narrowly
 on the patients' disease and treatment. It suggests the patient's selfcare is achieving some good days, rather 
than reducing the person to a medical problem and assuming that s/he has failed to comply with the medication
 regimen. 

What is a good day like for you? is a good reflective question.

> It cannot be answered yes or no. It requires the respondent to think critically about what matters to them,
 to reflect on what they want from medical care and how they will know they got it. It leads to conversation 
about what the person is able and willing to do now to achieve more good days.

> The response serves the patient, rather than simply informing the clinician.

> The response enables the clinician to hear and adopt the patient's words, so the patient is not expected 
to learn medical terminology, and the clinician is not expected to check a glossary of simplified terms.

>  The question allows the patient to figure out and articulate what they want and need, making it easier
 for the provider to achieve patient satisfaction.

> It shifts thinking and conversation from what patient and clinician do not want — disease and suffering— 
and how to get rid of it,  to what they do want —good days— and how to get more of them.

The hard part is waiting for the response

Patients are not accustomed to being asked reflective questions, especially by clinicians. Many, especially 
those who live in poverty and face daily discrimination, are rarely asked questions and may be trained not 
to think.  The reflexive first response is likely to be "I don't know".  They need a way to think about it. Try 
again; Can you remember a good day or a good moment?  Then the hard part: wait.  Let them be the one to
fill the silence.  Ask follow up questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good days. An effective
conversation will end with the patient articulating the action s/he will take and the clinician offering 
supportive information and services.

More on reflective questioning

Reference & further reading:
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active Policy Attention
To Health Promotion Health Affairs, 21, no.2 (2002):78-93 doi: 10.1377/hlthaff.21.2.78   Full text online at http://content.healthaffairs.org/content/21/2/78.full.pdf
 

 

2015 Kids Count Child Well-Being Report Released

Health disparities, low health literacy begin in poverty
Despite some encouraging news in the just-released annual state rankings for child well-being, Annie E Casey Foundation reports large numbers of children of all racial and ethnic groups are facing economic conditions that can impede long-term success.  In 2013 (latest figures) in the world's richest country, 22% of all children live below the poverty line —$24,250 annual income for a family of 4. According to the Economic Policy Institute it takes at least twice that amount to provide basic essentials. It's worse than the average suggests.  Here is where health disparities begin: 39% of African American children,  37% of Native American children, 33% of Hispanic children live in poverty. Compared to 14% of white children.

  
"When very young children experience poverty, particularly if that poverty is deep and persistent, they are at high risk of encountering difficulties later in life - having poorer adolescent health, becoming teen mothers, dropping out of school and facing poor employment outcomes." 



Implications for health literacy improvement                                            
These figures jumped out at me since preliminary findings from my current research suggest that basic essentials —- safe housing, adequate food, transportation, health insurance, and child care — are prerequisites for developing maternal health literacy, mothers' ability to use information and services to keep healthy and raise and healthy competent child. It makes sense that no amount of reading skill, understanding of healthcare, or knowledge of preventive practices can make those practices possible when feeding the children necessarily takes priority. National and international policy documents call for improving health literacy in parents to reduce health disparities. Progress in unlikely until we provide health insurance and economic supports to parents of very young children. 
 
Cheers for the Affordable Care Act
Thanks to Obamacare, the rate of insured kids improved 30% leaving 7% or 5.2 million uninsured, most in states that declined to expand Medicaid
 
Cheers for Alaska
Applause for Alaska governor Bill Walker. He announced last week that he will use executive authority to expand Medicaid. That means nearly 30,000 Alaskans will soon be able obtain insurance.  The annual Kids Count Datebook ranks Alaska 31 among the states for child health. The governor's action bodes well for a higher ranking in coming years.
 
Cheers for Minnesota
They're Number 1 overall in the Kids Count ratings, 2nd in health behind Iowa.
 
Oh Mississippi! Worst place for kids. Still.  
Mississippi ranked 50th overall as it has every year since the rankings were first published in 1990. The state was last in economic well-being, health, and family & community. It ranked 48th in education ahead of New Mexico and Nevada.
 
 
See your state rankings here.
 
 
References:
Economic Policy Institute. Family budget calculator. www.epi.org/resources/budget/  

BLEEP Gag Rules Threaten Public Health, Child Health Protect right not to think

In Florida, if someone scares you to death you can legally shoot them to death with your BLEEP.  But your 
family doctor or pediatrician or health worker cannot legally ask you if a BLEEP is kept in your house or how
it is stored.
 
Apparently even thinking about the risk of unsecured BLEEPs to their children’s and visitors’ safety threatens  
parents’ and patients’ right to keep BLEEPs anywhere and any way they want.  This BLEEP has been Florida law 
since 2011. (The part that made asking about BLEEPs a felony with jail time and a $5 Million fine did not pass). 
 
Physicians groups challenged the law. It was upheld as constitutional in Florida since BLEEP ownership and safety 
is a private matter unrelated to medical care.
 
BLEEPs and tobacco are the only products on the market that when used correctly kill people; BLEEPS kill lots 
of people, often children, in a seconds.  So BLEEPS can’t be a private matter.
 

Safety Checklist for a Crawler: 
BLEEPS are unrelated to medical care until a child -or some one 
else- or the owner- is injured by the patients’ BLEEPs. Then
taxpayers fund emergency response and medical care for totally 
preventable horrific injury or death, and related court costs, 
increased insurance premiums, and lost contributions to society. 
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP. 
The Texas legislature entertained a similar gag rule this month. 
BLEEP  
 


Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association.
Ann Intern Med. 2015 Feb 24. doi: 10.7326/M15-0337. [Epub ahead of print]
 
Ferrris S. Childrens Defense Fund report on ChildsBLEEP deaths, new BLEEP laws Data analysis: More preschool kids dead from BLEEPfire than 
police. May 19, 2014
 
Walters, E. Bill Would Prohibit Doctors From Asking About BLEEPs. The Texas Tribune March 18, 2015

Pitts, L. Republican  list of things you cannot say. Seattle Times March 19, 2015

Paid parental leave - finally

I’m proud of my city. We are catching up with the rest of the world.
 
Yesterday Mayor Ed Murray announced Seattle will provide paid parental leave for City employees.  All parents — foster parents, adoptive parents, mothers and fathers— will have the option to take four weeks off —with pay— to bond with a new child.  The mayor is encouraging other employers in the state to offer similar benefits.
 
This should not be the surprise, the bold move, the breakthrough that it is.
The US is the only developed country on the planet that does not give new parents paid time off to support attachment and bonding and infant brain development, and to put their newborns on a positive health trajectory. President Obama announced a similar new  policy to provide six weeks paid parental leave to federal workers in his State of the Union address.
 
A step toward gender equity in the workplace
I’m especially glad the paid leave policy will apply to fathers as well as mothers. That presents child care as a shared responsibility. It puts to rest arguments and  unfair choices that have plagued so many women’s career…You are on the mommy track, so you can’t be on the partnership track. The paid leave policy protects mothers’ earning potential, avoids unfair expectations and burdens and removes that awful choice between career and family.

Most of all, this investment in parents shows we are a society that values its children, including adopted children and those in foster care. It shows respect for the role of fathers in raising children, and the role of mothers in the workforce.  It acknowledges the contributions  of foster parents — special people who can love other people’s children as their own, and encourages foster parenting. Thank you Mr Mayor and Mr President for leadership toward a stronger city, region and society.

CLAMs for diverse populations can overcome language barriers Culturally & Linguistically Appropriate Materials

US residents speak at least 329 languages. In some US cities less than 60% of the population speaks English. About 32 million of us speak a language other than English at home. If your service population is not diverse now, it will be soon.  Pew Research projects the US Spanish speaking population will triple by 2050, and the Asian population will double. Success in improving the health of ethnic populations will substantially influence the future health of America as a whole.
 
Healthcare organizations have been working to develop their capacity to address language barriers and cultural differences, but it’s hard to make progress when the challenge is increasing along with the complexity of treatments and healthcare delivery and financing systems. Non-English speakers still face substantial communication barriers at almost every level of the health care system.
 
Studies show that communication barriers have a negative impact on health, discourage use of preventive services, and increase costs of treatment through unnecessary testing, delayed diagnosis, extended treatment times, and misinterpreted instructions. Without information that they can understand and use in their everyday lives, patients cannot engage in self-care or self-management. In short, they cannot take responsibility for their health and be partners in treatment, as effective care now requires.
 
In most cases, provider organizations and insurers have the means to overcome language barriers. But current practice in most communities still reflects an assumption that it is the patients' obligation to make themselves understood, to ask appropriate questions and to correctly interpret and comply with instructions. In most instances, this assumption is wrong as a matter of law. Federal and state civil rights laws and Medicaid regulations require access to linguistically appropriate care. These laws are the basis for accreditation standards that require providers and insurers to position themselves for our multicultural future.  

Studies show that print materials, particularly in combination with brief counseling, can increase recall, compliance, and behavior changes; and reduce consultations regarding discomforts that could be self-managed. Health information is increasingly available and accessed online, through mobile devices and virtual patient educators. Still a clear message from research participants is that written information should always be available, even in the presence of multiple other media.

While they are not a total solution, CLAMs remain the necessary foundation for a comprehensive communication effort, and an obvious starting place to promote health literacy. Organizations serving diverse populations will need to hone a process to develop and test English language materials, and to adapt essential proven materials for non-English speakers.  More on that next time. Stay tuned.
 
 
 
 
 

 

Measuring Health Literacy by its Consequences

Let’s welcome the new year with some new thinking about measuring health literacy.
 
It’s hard to say exactly what electricity is, but if the lights are on, we know we’ve got it. And we measure electricity by the light it produces. So it is with health literacy. It is hard to say just what health literacy is, but we know it by its consequences, and we can measure those consequences.
 
Services utilization, behaviors, self-care
Two recent systematic reviews and concept analyses (Sykes 2013, Sorenson 2012) identified the consequences of health literacy.  Both studies found the most frequently reported consequences of health literacy are improved use of services, behaviors, and self-care. These consequences reflect how people use their health literacy skills in everyday life and what they   actually do for health with the information and support available to them.  Although these consequences are supposed or anticipated rather than evidence-based (Sykes 2013), the documented presence of these consequences would indicate that the person possesses and has used health literacy skills to produce them. Studies using the Life Skills Progression instrument to assess maternal heath literacy are building the evidence base.
 
The LSP  Maternal Health Literacy Scales rate mothers health literacy by their health and healthcare-related actions practices and behaviors. Sequential measures show change —improvement or regression.  The LSP Healthcare Literacy Scale uses 9 items to rate mothers’ use of information, emergency services, medical and dental care and preventive services for herself and her child. The Selfcare Literacy Scale uses five items to assess risk behaviors and selfcare practices.  Three  published studies using LSP data on three different cohorts of mother-child dyads  provide evidence that mothers supported by home visitors trained to promote maternal heath literacy produced the consequences of health literacy at increasing levels over 12-18 months.  So the recent analyses of the consequences of health literacy confirm earlier findings that the LSP can be used as  meaningful measure of MHL.
 
Next: the recently identified unique consequences of critical health literacy add weight to our theory that critical thinking skill, particularly reflection, is the active ingredient in health literacy  that enables mothers (and others) to transform their decisions into health promoting actions and outcomes. Stay tuned
 
 
References
Sorenson K. Van den  Broucke S, Fullam J, Doyle G, Pelikan J, et. al. (2012). Health Literacy and Public Health: A systematic review and integration of definitions and models. BMC Public Health12:80. http://www.biomedcentral.com/1471-2458/12/80.
 
Sykes S, Willis J, Rowlands G & Popple K. (2013). Understanding critical literacy: a concept analysis. Biomed Central Public Health:13:150. http:www.biomedcentral.com1471-2458/13/150

Smith, S. A., & Moore, E. J. (2012). Health literacy and depression in the context of home visitation. Maternal and Child Health Journal16, 1500-1508. 

Carroll LN, Smith SA & Thomson NR. (2014). The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice pii: 1524839914538968. [Epub ahead of print]. Available on Internet at: http://hpp.sagepub.com/content/early/2014/06/23/1524839914538968.abstract

Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014) Maternal Health Literacy Progression Among Rural Perinatal Women. Maternal Child Health J 18: 1881-1892. 
Sandra Smith, PhD, MPH sandras@u.washington.edu

Reflections on 2014

Beginnings Pregnancy Guide 9th Edition Sold Out  
The second printing of the 2014 is underway. The scan code that instantly links Beginningsreaders to additional prescreened information via the Internet on a mobile device has proved popular. In a survey of pregnant women in SC, we found that respondents rarely use toll free numbers; while nearly all reported finding health information online.  The entire website is available on your mobile device. 
 
Websites Continue to Grow
Beginnings Guides had 155,00 visitors in 2014.  The Center for Health Literacy Promotion had 55,000 visitors. The blogs were read by 100,00 including 6900 reads in the last 30 days.  And we have 1310 Twitter followers. Kudos to Beginnings Webmother, Simone Snyder. 
 
Most read blogs 
On Healthliteracypromotion.com
      (this one was on the most-read list for 2013, too)
 
On BeginningsGuides.com:
 
Promoting Maternal Health Literacy Nationally & Internationally 
Free Health Literacy Training Videos
We produced a series of training videos in collaboration with the National Network of Libraries of Medicine Pacific Northwest Region. This from the National Libraries Website:
 
Center for Health Literacy Promotion offers free training
Together with the National Network of Libraries of Medicine, the Center for Health Literacy Promotion has put together three short training sessions on understanding and promoting health literacy designed for social and health services providers and programs. Each session includes a short video, a pre- and post-test (with answer key), a handout, and a facilitator's guide. All three sessions and their resources are available to download or view for free online.
To view these resources, visit the Center for Health Literacy Promotion:

Published Article:  Parents As Teachers Health Literacy Demonstration Project 
Carroll LN, Smith SA & Thomson N (2014). Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice pii: 1524839914538968. [Epub ahead of print] Read the article
 
Guest editor, Curationis Special Edition: 
This turned out to be a monumental work and an inspiring labor of love. It was a joy and a challenge to work with a dozen authors whose work is at the foundation of efforts in southern and eastern African countries to develop professional education curricula and build a workforce of nurses dedicated to care of children. With health systems only about 20 years old, this work is underway to differentiate care of children from care of adults. Therefore, the articles focus on issues in professional education and practice. There are many lessons we in the US can learn from their work to build a healthcare system grounded in child rights, and to effect systems change in the face of racism and limited resources.  Curationis, a South African nursing journal has published the special edition online with free access for all. It will appear in print in 2015. 
  
HARC VI Washington DC Nov 4-5
Family transitions precluded my travel to DC this year. But I was not totally absent. Linda Wollesen, developer of the LSP presented in my stead results of a study conducted in collaboration with Anne Turner and colleagues at University of Washington Northwest Center for Public Health Practice. Conclusion: parents can and do manage child oral health, even in the face of poverty, low education and limited English proficiency where service and supports to use them are in place. This is on the list to publish in 2015.
 
New & Contintuing in 2015
Worldwide Universities Health Literacy Network
Last year in Sydney I worked with an awesome group scholars/practitioners/patient representatives to instigate an international collaboration on promoting health literacy as a personal and community asset. The group has joined with others who began similar talks in 2012 at the first Worldwide Universities Health Literacy Network meeting in Southampton, and expanded to include representatives of countries in Europe, Asia, Africa , South America (and me). The collaborators have been holding monthly meetings via Skype and are developing funding proposals to address maternal health literacy globally.
 
CenteringPregnacy Health Literacy Trial
This project continues. I got to visit the site of the comparison group, Greenville Health System, Greenville, SC.  We're searching for a second site. Want to be an intervention site? Contact me!
 
Maternal Health Literacy: Untangling the "Web of Interaction"
The research project for 2015 is funded by the National Library of Medicine. The study addresses an urgent need to determine what promotes maternal health literacy, especially in historically underserved poverty populations. We are identifying factors in the home and family context that influence mothers'health literacy, and how those factors interact. Understanding the context in which mothers use information and services for personal and child health can guide intervention design, tailoring and evaluation. We are looking for ways to visualize data to suggest points of intervention and help home visitors to answer the ever-vexing question: where to begin?
 

Health Literacy & Maternal Health Literacy: What’s the difference?

Start with measurement
What we measure and how we measure it matters because it determines what we
find out about what works and what’s worth doing and who should do it.* Measurement
remains the most crucial issue for health literacy research; because we need to find 
out what works for whom,  and what’s worth doing and who should do it.
 
Im especially interested in what works for mothers in the prenatal to preschool 
period. Because they are the foundation of personal and public health. Healthy mother… 
healthy baby… healthy population. What mothers learn about health and healthcare
during pregnancy and early parenting can benefit entire families across their lifespans, 
and extend benefits to the healthcare, education and justice systems, and to the economy.

Health literacy focuses on patients understanding healthcare information
Health literacy research assesses patients health literacy by their scores on a single 
administration of a reading test using medical terms. Patients are marked poor, marginal 
or adequate. An adequate score means you will probably not need assistance to make 
meaning from information  about your diagnosis or to follow treatment instructions.  If 
you cannot pronounce most of the words,  you are assumed to have poor health literacy 
and to be unable to “obtain, process and understand basic information needed to make 
appropriate health decisions”. 

What we find out from health literacy-reading test scores is that almost everybody has 
limited medical vocabulary and difficulty making sense of information from the healthcare
system. We find out that information needs to be simplified and its delivery needs to be
improved. We find that patients score better when we give them better information and
conclude that what’s worth doing is improving information and its delivery.  Since most 
studies originate in academic medical centers, it is not surprising that studies position health 
professionals as the keepers and dispensers of health and medical knowledge and so it falls
to them to reduce the risk and mitigate the negative impacts of low [health] literacy on 
patients and the system.

Maternal health literacy focuses on parents using information for health
Maternal health literacy research assesses periodically what parents do with information, 
how they integrate it into their lives and households. Changes in parent’s health- and
healthcare-related actions, practices and behaviors provide evidence of progress (or 
regression) in developing the knowledge and social and cognitive skills needed to participate 
in healthcare and preventive practices. This approach captures effects of systems efforts to
improve information as well as public health efforts to directly assist parents to make meaning
from the information and apply it in real life.

By monitoring what parents actually do for health with the information available to them, we
find out that direct assistance to use information and services for health is most beneficial to 
lower functioning parents, while also benefitting higher functioning parents. We find that social
workers, parent educators, health educators, and trained paraprofessionals working in homes 
and communities can enable parents to better manage family health and healthcare, even with
the added challenges of poverty, limited education and limited English proficiency. 

Both approaches are needed
The dominant clinical approach to patient’s health literacy and the public health approach to 
maternal health literacy are complementary rather than exclusive. Patients and parents need 
quality information, accessible services, and assistance to use them effectively.

*    lisabeth schorr Common Purpose: Strengthening Families and Neighborhoods to Rebuild America. http://lisbethschorr.org   Read this book!

Discipline or abuse?

Social media and the NFL are enabling us to reflect together on what level of aggression and violence in family relationships is acceptable in our society. It's a fitting although inadvertent role for the NFL, whose players are de facto role models for American males, and whose recruiters, coaches and fans place high value on aggression and violence on the field. (Here is Seattle, we love the defense in Beast Mode - on the field.) The NFL's position on aggression at home is, well, evolving. Thanks to the inventors and users of social media.

There seems to be consensus that child abuse is unacceptable, and discipline is necessary. But the line between discipline and abuse is defined by a complex and dynamic web of personal beliefs, local culture, and state laws.

What is abuse?
It depends who you ask and where you are.  State law is largely focused on protecting parents' rights, and keeping the family free of government or social interference. Social workers focus on protecting the child from parental excess. The courts aim to balance parents' rights with children's welfare. There's controversy regarding how much weight should be given to potential effects on children's social and emotional wellbeing and healthy development, on what is "normal" in the child's community, on potential future harm, on how well the punishment fits the infraction, on a pattern of parental behavior.

State laws are intentionally vague about what constitutes abuse, so that cases can be decided on an individual basis.  The laws and their approaches to defining abuse vary widely. Interpretation on the ground varies by agencies and individuals. This can result in a "I know it when I see it" understanding of child abuse.  Judging by the Twitter traffic around Adrian Peterson, people who view the same video evidence interpret it very differently.

How to decide?
Ultimately, parents must decide whether, when and how to discipline their child. To me there are two important things to bring to mind when discipline is in order. First, every young child wants to be, tries to be like his or her parents. And every parental action teaches the child some lesson, by default or by design.

A clear distinction for me is that disciple is teaching by design.  It intends to teach the child appropriate behavior and right action. Abuse is teaching by default, it aims to punish inappropriate behavior. As a parent, the question to ask when provoked by a preschooler, or any child, is what do I want to teach now?

Adrian Peterson said he wanted to teach his son to be respectful and not curse at playmates. But his preschooler did not make up those swear words. He learned them from someone he is trying to be like. And hitting a person with a stick is about as disrespectful as one can get.  Peterson left a scar on his 4-year-old's head, which he said the child could have avoided by not trying to get away.  Would you try to get away from a brawny footballer coming after you with a stick? I sure would. Would you think he was abusing you or that he was teaching you appropriate social behavior?

Consider what that boy is going to say to himself as he grows up looking in the mirror at his scar? "I want to be respectful and polite like my dad". Probably not.

This from Beginnings Parents Guide
 
Reference:
Doriane Lambelet Coleman et al., Where and How to Draw the Line Between Reasonable Corporal Punishment and Abuse, 73 Law and Contemporary Problems 107-166 (Spring 2010)
Available at: http://scholarship.law.duke.edu/lcp/vol73/iss2/6

 

Evidence to Practice: Induction of Labor Rate Falling


My mother was expecting her first child. She was due in late July. Her OB was due to be on vacation. So he induced labor July 9.
 
That was 65 years ago.  But the story, and the disconnect between the body’s wisdom and medical practice is not out of date.
 
Induction of labor became more and more common, despite increasing evidence of the risks of preterm birth; 23 years later, my labor was induced. The doctor said it was time.  Over the last 20 years, the induction rate increased every year to 23.8% in 2010.
 
Finally, practice is beginning to follow the evidence. New data show the national rate of inductions began inching down in 2011 to 23.5% in 2012, the latest available figure.
 
"Pregnancy lasts 40 weeks...Labor should not be induced before 40 weeks except for medical reasons." 

"If your doctor talks to you about inducing labor, ask if you can wait until week 40."

Beginnings Pregnancy Guide


The good news is in induction rates for “late preterm” (34-36 weeks gestation) and “early term” births (37-38 weeks). Those rates started downward in 2006, with the greatest improvement (decrease)  at 38 weeks. In 36 states and DC, inductions at 38 weeks have been reduced by 5% to 48%.
 
The national  rate is down 12%. The number births at >39 weeks gestation is up 9%.
 
The bad news is disparities continue. Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only 3% for blacks.

Questions for research: How did the state that reduced its rate by  nearly half do that?  What is different about the states that reduced their rate by 30% or more —UT, ND, SD and NE— and  states where the rate continues to increase—AK, NY and NC?
 
Source: Osterman MJK, Martin JA. Recent declines in induction of labor by gestational age. NCHS data brief, no 155. Hyattsville, MD: National Center for Health Statistics. 2014.
 

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