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Notes from the Field CenteringPregnancy, Promoting Maternal Health Literacy

I’ve been in Washington DC where I co-presented a workshop at CenteringHealthcare
Institute’s fourth national conference. I was drawn to this organization the first time
I read their motto: Transforming care through disruptive design.
 
CenteringPregnancy (CP) is a rapidly spreading model of group prenatal care. Eight to
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 ultrasound reports.
The rest of their 1.5 -2 hour appointment is dedicated to  education and support through
facilitated group discussion and activities.
 
Reimbursement levels and processes are the same as for conventional individual prenatal
care. The schedule of visits and core content follow ACOG* guidelines. 
 
Process trumps content
CenteringPregnancy’s 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.
There are games, activities and multiple ways of learning. Women test out what they've
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
support group. 
 
March of Dimes wants all mothers to get prenatal care in CenteringPregnancy,” says
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
in infant 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’s 6.3%
 
CP meets the Institute of Medicine’s goals to make healthcare services safe, patient
centered, 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
the provider. What they like best is being with other women.
 
Sharon 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
equivalent of 10-12 prenatal visits in 2 hours  beaming and talking in superlatives about
their experience.
 
All this makes group prenatal care the ultimate environment for promoting maternal health
literacy. 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 time. Meanwhile,
 
Stay tuned. ss
 
 
 

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
life 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
parents, their income or education. But poverty and accumulated disadvantage
prevent parents 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 providing direct
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 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary
by 10 experts from multiple disciplines.

Promoting Health Literacy with Beginnings Pregnancy Guide New Online: Resources for Mothers

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 since
few in your caseloads have computer access or devices to use digital information.
Other surveys confirm you’re right.
 
Poverty and the Digital Divide
In December 2010, 40% of  US households, did not have a broadband connection in
the 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 suburbs
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
used the Internet. Outside locations included school, workplaces and the local
library.  In some libraries, free internet service is the biggest draw into the building.
 
Among the reasons for having no access at home were cost and lack of equipment,
but the key reason seemed to be lack of understanding of the value of the Internet,
an 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 increasing
A February 2011 survey found 68% of households with a connection, suggesting
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 Internet
access. And some companies have just begun offering low-cost broadband connection
to families with a child who qualifies for free school lunch.
 
Finding reliable information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide
is intentionally focused on essential health behavior topics directly linked to pregnancy
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
readers to visit the new Resources for Mothers pages of www.BeginningsGuides.com 
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.
 
 
 





Reference
Dunbar, J. (2012) Poverty Stretches the Digital Divide,  the Center for Public Integrity.

Beginnings Pregnancy Guide Update

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.
 
Who to call
A subtle but important revision is in who to call for information or assistance.
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 health”.
 
Keys to a Healthy Baby, the health behavior messages that research links directly
to birth outcomes are modified slightly.“Do eat well” is expanded to “Do it well and
often”  since a pregnant body easily and quickly slips into starvation mode. Frequent
small meals best support fetal development.
 
“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 guidelines
recommend an 11 pound gain for a woman who starts pregnancy overweight.
 
“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 body.
 
Early Inductions
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% of women
had their labor induced, often for convenience of the parent or the physician.
Those women were twice as likely to have a C-section as women who waited for
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 month (p61)
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
week 40.”
 
Other revisions
Nuchal lucency test is added to the discussion of prenatal testing.
 
Juice is de-emphasized in favor of water.  Juice was considered a healthful
alternative. However, with the increase in obesity, extra calories  and sugars
in juice are of concern.
 
Next: My favorite change. 
 
Reference: National Center for Health Statistics Data Brief 24, Nov 2009.
http://www.cdc.gov/nchs/data/databriefs/db24.pdf

Pregnancy Guide Update: Obesity a disease?

The American Medical Association House of Delegates declared obesity a disease
last month. Is this good for maternal and child health?  For public health? 
 
It’s not new
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
memo.
 
Obesity prevention not a priority in maternity care
In researching issues of weight gain in pregnancy for  the update of the
Beginnings Pregnancy Guide, I found that weighing is still the only procedure in
early prenatal 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 will
interfere with their patient/provider relationship. Others said they do not know how
to calculate BMI. They also must not know about the many BMI calculators that will
do it for them. One can only hope that calling obesity a disease will change these
attitudes. 
 
Healthy 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.
 
ACEs -Adverse childhood experiences - witnessing or experiencing interpersonal violence
is closely related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical treatment,
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.
 
Turning 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 compelling?
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
http://www.cdc.gov/obesity/data/adult.html.  Now all those people are diseased
and 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 a
Kennedy-style physical fitness craze, but that entails behavior change, and the same
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 applications. 
 
Only one thing seems certain, making obesity a disease will increase medical treatments
and costs, and revenue to AMA constituents.
 
 
 
 
 
 
 

Beginnings Pregnancy Guide Update: “Entertainment Ultrasound” Warning

Choose 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.
 
The American Institute of Ultrasound Medicine, American College of Obstetrician
s and Gynecologists, American Academy of Family Physicians, March of Dimes,
US 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
strong recommendations 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.”
 
“You 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.
Most insurance companies pay for one or two doctor-ordered ultrasounds as part of
routine prenatal care, and commercial ultrasound is not cheap.
 
Prices start at $175 for the 3D in-studio option. $500 for an “ultrasound party”
at the location of your choice. The cheapest rate I saw was $75 for a basic “gender
determination” scan; it’s discounted to  $55 on Saturdays one OB-GYN’s office. These
commercial services are not regulated or standardized.
 
Safety Concerns
Commercial 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
that repeated ultrasounds have not been proven harmful. Still  the evidence has
convinced all the advisory and regulatory agencies that entertainment ultrasounds
are worrisome.
 
Ultrasound 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
state legislators proposed a ban on ultrasonography for entertainment purposes, citing
data 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
has been demonstrated in both human and animal models, and remains, at least theoretically,
so that  the FDA concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
 
Additional concerns about non-medical ultrasonography include the possibility that non-
medical ultrasonography will fail to identify a problem with the baby, falsely reassuring
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.
 
Medical ultrasounds are for doctors         
Here’s the problem:  In medical settings, the sonographer is commonly prohibited from
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 post
it online.  Until these disempowering practices change, parents and  sonographers  will continue
to seek a more informative,  convenient, family friendly experience. 

Check  Technician’s Credentials                      
Qualified sonographers are trained and certified. Find one, or check a technician’s credentials,

Beginnings Pregnancy Guides says, “Ultrasound is safe for you and Baby.”  [p8] That remains true.
The 2014 edition will add this statement: Many healthy pregnancies do not need ultrasound.
Extra  “keepsake" ultrasounds may be harmful.  The Registry of credentialed sonographers
will be posted on the new Mothers’  Resources page at www.BeginningsGuides.com  More on that later.

Don't Order Fetal Ultrasound Videos As Souvenirs: FDA

References:  http://www.aafp.org/afp/2005/1201/p2362.html#afp20051201p2362-b6
http://www.ct.gov/governorrell/cwp/view.asp?A=3675&Q=442298
 
www.guideline.gov/content.aspx?id=14306&search=ultrasound+pregnancy#Section427

The Power of Choosing


Preverbal infants show preference for others in distress
At 10 months of age, babies differentiate attackers from victims and neutral parties.
They literally reach out to victims. Their second choice is a neutral party. They avoid attackers.
 
In scientific experiments by Japanese researchers, the players were shapes on a screen, something
like the early Pac-man games. The researchers suggest the infants’ preference for the victim is the
foundation for sympathy.
 
The findings seem to confirm other research that says witnessing violence  has nearly the same
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 around them.
 
The power of choosing
This experiment further suggests a very early start for what David Emerald (The Empowerment
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
10 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.
 
Emerald writes that It takes intention and attention to notice when we are reacting automatically
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.
 
Give Baby choices
Taken 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.
   
“Making choices and translating those choices into desired actions and outcomes” - that is the
definition of empowerment.
 
 
References
Kanakogi Y, Okumura Y, Inoue Y, Kitazaki M et al. (2013) Rudimentary Sympathy in Preverbal Infants: Preference for Others
in Distress.PLoSONE 8(6): e65292, doi: 10.1371/journal.pone.0065292
 
 
Emerald, D. (2006). The power of TED: The Empowerment Dynamic. Bainbridge Island, WA: Polaris Press.

World Bank. (2005). "What is empowerment?"  http://go.worldbank.org/V45HD4P100.
 
 
 
 

Mandy’s Story Part 3: Lessons

Recently in this space I told Mandy’s Story,  and then we saw how the story reflects
the science on separation of mother and child due to the child’s hospitalization.
There are many lessons in this story.
 
A young child’s healing power and reason to live reside in the mother.
 
Children need their mothers not only present, but interacting with them.
When interaction with mother is absent, even for short periods under
pleasant circumstances like Mandy’s mom’s vacation, children and mothers
suffer. Although a surrogate mom like me in this story can ease the pain.
 
A child can become stuck in a state of anxiety
When the interaction is removed under unpleasant, unplanned, unexpected
and extended circumstances, like a hospital stay, research shows development
is arrested with lifelong consequences for the child, especially negativity and
aggression. A hospitalized child is at risk of getting stuck in a state of anxiety.
 
Less interaction, more hospitalization
A recent study found that children of responsive, interactive mothers were
half as likely to be hospitalized. That means children who are hospitalized
are twice as likely to have mothers like Mandy. That’s the bad news.
 
Here’s the good news: Role models needed
I learned this lesson a little later from Mandy’s mother.  Seeing what mothering
looks like, seeing ways to relate to her child, seeing how her child responds is all
that Mandy’s mom needed to transform herself into a mother who actively
promotes her child’s health and development.
 
Mandy’s 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
had not 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.
 
Mothers who were not well mothered themselves need a role model to see what
is possible, to develop confidence in themselves and find the courage to engage
in 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? 

Honoring Mothers & Nurses


One of my favorite duties at the first conference on Building Children’s Nursing for Africa 
last month was interviewing a panel of three mothers of children with special needs who
are cared for at the Red Cross Children’s Hospital in Cape Town.  They talked like nurses
with full understanding of complex conditions, procedures, and medical jargon. I asked
them, “Thinking back on your experiences in the hospital, what do you want nurses to
know?”
 
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 the mother.” 
 
And all  the mothers  together said, “I could not have done it without you.” 
 
In this National Nurses Week  leading up to Mothers’ Day. I am deeply appreciative of
the everyday huge and small sacrifices and loving kindnesses that mothers make for
their children, most of which go unnoticed and unrecognized. And I am ever more
appreciative of the expertise, heroics, gentle touches and encouraging words that
nurses bring to the mothers and their children to restore and maintain the well-being
of both.  You inspire me.
 
*Hamza and I won the award for Best Dancers at the conference dinner!

Heartwork: Reflective Drawings and Coloring Conversations

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 reflective.
Beginnings Guides Heartwork was designed to tap in to this powerful place.
 
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 experience, things
she would like to do differently.
 
Beginnings Guides Heartwork encourages
reflection, which is key to understanding
health information, affects the ability to
make healthy decisions and therefore
improves outcomes. A simple, powerful
method to promote maternal health literacy.
 
Using the coloring pages can help to set up
thinking and 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 information or
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.
Heartwork 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 and
leave it with them to complete on their
own time. They could also be encouraged
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
to listen, 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.
 
 
 
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