Beginnings Guides Blog
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.
especially interested in what works for mothers in
the prenatal to preschool
healthy population. What mothers learn about health and
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
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
information about your diagnosis
or to follow treatment instructions.
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
What we find out from health
literacy-reading test scores is that almost everybody has
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
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
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
literacy and the public health approach to
maternal health literacy are
complementary rather than exclusive. Patients and parents need
information, accessible services, and assistance to use them effectively.
schorr Common Purpose: Strengthening Families and Neighborhoods to Rebuild
Read this book!
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
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
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.
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
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%.
national rate is down 12%. The
number births at >39 weeks gestation is up 9%.
bad news is disparities continue.
Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only
3% for blacks.
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—
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.
In a reversal of its recommendations
that have for years cautioned against children and pregnant or breastfeeding
women eating fish, the Food and Drug Administration’s new guidelines reflect recognition that fish is a great source
of protein and other essential nutrients. For the first time, the FDA has
specified a minimum intake of fish and other seafood.
8 to 12 ounces per week—
2 or 3 servings
That’s the new minimum
for a healthy diet. Beginnings
Pregnancy Guide (
2014) recommends 1 or 2 servings per
week, the previous maximum recommendation, now considered overly cautious.
The warning to avoid large, long-lived fish like swordfish,
mackerel and tile fish remains.
Those big fish live long enough to build up
organic mercury in their flesh. According to MedlinePlus
medical evidence suggests that being exposed to large amounts of the organic
mercury called methylmercury while pregnant can permanently damage the baby’s developing brain. Small exposures
are unlikely to cause any problems.
Choose canned light tuna
Salmon, shrimp. and other seafood that Beginnings lists as
safe and healthy, are still safe and healthy. It is important to caution mothers against canned white albacore tuna since it has three times the mercury of the recommended
canned light tuna. The FDA suggests limiting tuna to 6 ounces a week.
Beginnings Pregnancy Guide (2014) pg. 13
Use the Fish Safety Hotline
That’s 1-888-723-3366 to check the safety of fish in your area. This free 24 hour resource is listed on
the Pregnancy Guide’s Key Messages Poster
and on page 42.
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.