Beginnings Guides Blog
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
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.
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
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?
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!
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.