Beginnings Guides Blog
Wednesday, May 21 at 10AM, the start of the 217th CenteringPregnancy group at Greenville Health Systems OB-Gyn Clinic in Greenville, SC. As participants
arrived, one with a friend, one with her cousin and her mother, one with her
husband, others on their own, Nora, an assistant facilitator, greeted them and gave them supplies to
make their name tags. She showed
each mom the routine for the first 30 minutes of each Centering session: Take your blood
pressure like this; record it here. This is what the numbers mean… Weigh
yourself; record it here. When she calls you, have a private visit
and brief exam with Vicki,
the nurse practitioner. Have a
snack, visit with other participants, or ask the midwife a private question.
Then for the next 90 minutes the
group of 9 expectant, mostly first-time mothers sat in circle with their supporters and three
facilitators, and me, the visitor there to learn about Centering. The initial
awkwardness faded quickly.
self-introductions and a lively, laughter-punctuated discussion of current
issues from morning sickness to cravings to farting; a basket of plastic food
items was passed around and we took turns talking about the items we chose. “So will you eat that during your pregnancy?”, Nora asked the group gesturing to the chocolate
dipped ice cream cone. Yes, the
group decided —after all
it is summer in SC. But not every day; as a special treat because it’s loaded with sugar and fat. At closing we each said
one thing we were going to do to stay or get healthy during this pregnancy… walk, drink water instead of sweet tea, try eating
CenteringPregnancy promote maternal health literacy?
opening session was also the kickoff of the CenteringPregnancy
Health Literacy Trial, although the group will not hear about until
their next session. The trial aims
to assess the capacity of CenteringPregnancy to promote maternal health
literacy and empowerment. A secondary aim to is validate the Maternal Health
Literacy Self Assessment designed for the project. We anticipate that the Centering model promotes mothers’ health literacy and health empowerment by supporting
knowledge gain and changes in health behaviors and healthcare utilization
practices. Previous studies
have shown that social support from home
visitors is a catalyst for improved health literacy. In those studies, visitors
were trained to “Teach by Asking”, that is to ask reflect questions instead of
delivering health education. In Centering, rather than teaching and informing,
facilitators ask questions to elicit the group wisdom. The group provides
luck of the draw, about 120 pregnant women participating in CenteringPregnancy at
this Greenville clinic will comprise the comparison group in the trial; other
than completing the Self-Assessment, they will receive “usual care” in the
CenteringPregnancy model. An equal
number of participants at a second site will incorporate Beginnings
Pregnancy Guide into the program along with the Self-Assessments. We will
see if providing additional information promotes health literacy more than “usual care”.
tuned for more on the Maternal Health Literacy Self-Assessment.
It started as liability protection for prenatal care providers
I started developing the Pregnancy Guide in 1988. At the time
over a third of
obstetricians had been sued for malpractice before they
Many family physicians had stopped delivering babies as the
cost of malpractice
insurance became prohibitive. Around this time the Million
Dollar Baby was
introduced in the literature - that was the baby whose medical
a million dollars before she left the hospital. One “bad
baby” could wipe out an
employer’s entire health
The thinking at the time was to tell pregnant women everything
there is to know
about pregnancy, especially things that could go wrong, in
order to avoid lawsuits.
If mothers were given information, they would be
informed, or uninformed by
choice and therefore liable for untoward outcomes.
And the research indicated
that families who felt informed were more satisfied
with their care and less likely
Mountains of printed material, little actionable,
I gave up on my long search for materials that I could recommend
to prenatal care
providers trying to respond to mandates from their
professional societies and malpractice
insurers to inform mothers on a long
list of topics related to birth outcomes. I had found
mountains of pregnancy
information. There were thick books that seemed
intent on giving mothers facts
and scaring them into compliance. There were mounds of
brochures, all on single
topics. These answered a specific question, and so were useful
only to those
who knew what to ask and had sufficient reading skill to make meaning from
jargon and medical facts.
Research defines key health behavior messages
In 1989 the landmark document Caring for Our Future: The
Content of Prenatal Care
was published. It presented the first
comprehensive guidelines for what defines a minimal
quality prenatal care
service. It called for more visits in early pregnancy to deliver the
promotion content of prenatal care. It detailed health behavior messages to be
discussed at each visit. Subsequently, research demonstrated direct links
recommended health behavior messages and outcomes, particularly low
Health promotion content of prenatal care rarely delivered
But providers said
it is just not feasible to keep track of each woman’s knowledge and
address their health behaviors and still meet production requirements. They
not trained to support behavior change. The typical prenatal visit
included about 7
minutes with the doctor and focused on screening and
intervention. The health promotion
content of care was addressed by
recommendations to attend childbirth classes, which
occurred too late in
pregnancy to have any impact on outcomes and were attended
Beginnings Pregnancy Guide introduces staged learning,
conversations for health
And so in late 1989 I published Beginnings: A Practical Guide
through Your Pregnancy.
It was designed to protect obstetricians from liability,
and at the same time to serve mothers
by providing easy-to-read, plain language
actionable information on what women across
cultures want to know about
pregnancy. It put the health promotion content of prenatal
care into text that
reads like the encouraging conversations a caring, articulate, culturally
competent obstetrician who was up on the research would have with each pregnant
and her partner, if time and economics allowed. I followed Pulitzer’s
mandate to provide
information that is “brief so they will read it, clear so
they will appreciate it, picturesque
so they will remember it, and accurate so
they will be guided by its light.”
Information alone is rarely enough to influence health
I soon learned that simple information giving is rarely enough to
People need assistance to make personal meaning from
information and act on it in context.
Information-givers need training -and
time- to use materials effectively for teaching and
learning. The OBs said,
rightly, I think, that health education is not their job. And so the
promotion content of prenatal care fell to home visitors serving Medicaid
and health plans providing online and print information to the
privately insured. (About 2-4%
of mothers were attended by midwives who embrace
pregnancy as a high state of health and
focus on the health promotion aspects
Designed for mothers, and health literacy promotion
From 1990 on, Beginnings Pregnancy Guide has been designed
for mothers, rather than providers.
Since 1993 when the first article on health
literacy appeared in the medical literature, it has
been a laboratory for
materials that promote health literacy.
Who uses Beginnings Guides
Beginnings Pregnancy Guide is now most frequently used by
home visitors, parent educators,
family support workers and case managers to
promote maternal child health and maternal
satisfaction ratings from both college educated and under educated mothers and
The new updated 9th! edition is just off the press. In English
and Spanish. Take a look.
If you have not see the
new Beginnings Pregnancy Guide, and the new Beginnings Guia
and the new Beginnings Parents Guide, take a look!
Great new photos.
All content checked and updated. A scan code instantly links your mobile device to new
Resources and Parents Resources that we have investigated
and found to be reliable,
easy to use and free of advertising. You service
providers will find lots of useful tools in
now all our printing, inventory management and fulfillment are
in one place, at ColorGraphics
Seattle. If you distribute Beginnings by mail,
we can print your envelopes, address, stuff
and mail them and manage returns.
What a Special Edition with program specific content
and your program name on
it? We can do that, too.
had 50,000 visitors. 2000-4000 of you read the blogs
each month. And we have
900 Twitter followers.
blogsNotes from the Field CenteringPregnancy, Promoting Maternal Health
Literacy“Health Illiteracy” is Not a Disease
Promoting Health Literacy Nationally &
Cape Town, South Africa April 17-19, 2013
got to keynote the first conference on Building Children’s
Nursing for Africa organized
by Univeristy of Cape Town School of Nursing and
Red Cross Children’s Hospital. My theme:
empowering mothers for health. Now I am delighted to be serving as a guest
Prof. Minette Cootzee for a special edition of South Africa’s national
featuring 12 articles from the conference.
Vancouver, BC, Canada May 1-4, 2013
I participated in an invitational international workshop that
initiated a new “knowledge hub”
University of British Columbia. The consensus was that health literacy involves
provider and system. I argued that this formula includes the provider
and the providers’
context (the system) but
omits the patient’s social context. View
participants’ brief videos
Bozeman, MT, USA August
I got to keynote the Montana State Early Childhood
first Family Support Summit.
Theme: promoting maternal health literacy through
home visiting. In
March 2014 I will return to MT to work with all staff of Ravelli Head Start in
Hamilton, MT whose director Kristin
Segall recognized at the Summit that “Health
Washington DC, October 26-28, 2013
This was a whirlwind as I
presented on the
and presented a workshop with colleague April Thayer of WellPoint
on the upcoming
pilot project to integrate health literacy promotion into CenteringPregnancy
and field test the new
Sydney, Australia November 26-29.
I was awarded a travel scholarship
to attend University of
Sydney’s conference on health
literacy and participate in the second meeting of the Worldwide
representatives to plan an international collaboration on
developing health literacy as a community
asset. That is just getting underway.
Health Literacy Training Videos Take 2
from our reviewers and we are revising accordingly. Stay tuned.
On to 2014. I so appreciate your partnership in serving mothers,
foundation of a healthy society. SS
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
Don't Order Fetal Ultrasound Videos As Souvenirs: FDA
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