Beginnings Guides Blog
Part 1 Maternal health
literacy as skills
A life skill
is a collection of skills necessary for full participation in everyday life.
Maternal health literacy is a life skill that mothers use to manage personal
child health and healthcare.
It has been defined as the
cognitive & social skills
that determine a mother’s motivation and ability
to act on information in ways
that improve health (Renkert and Nutbeam, 2001).
Cognitive skills are used to
understand information; they include basic literacy skills,
numeracy (ability to use numbers). A mother might use these basic skills
learn about ear aches, and make an appointment to take her child to see a clinician.
So basic literacy skills are the essential foundation for health literacy.
Social skills are used to make
personal meaning from information, including speaking
and listening. The mother
whose child has an ear ache uses these skills when she discusses
clinician the information on ear aches to understand why her child has them and
how she might prevent them.
Reflective skills combine
cognitive and social skills to think critically, make choices,
and take action. The mother in our
example uses reflective skills when
she mulls over what the doctor said, what
she read, her experience of her child’s ear ache,
her actions and parenting
practices, and her discussion with her mother about treatment
possible preventive measures. Some literacy scholars say that reflective skills
are so essential to applying information in context that it should be
classified as a basic skill.
So we could say there are 4Rs: reading, ‘riting,
‘rithmatic, and reflection.
Health literacy means
empowerment (WHO 2013)
A health literate mother
combines all these skills to make health related choices and transform
choice into desired action and outcomes. That is the World Bank’s definition of
empowerment. Say the mother
chooses to stop putting her baby to bed with a bottle. She takes
that step, and
she enjoys her desired outcome, a happy ear-ache free baby. We say this mother
is empowered for health.
Her health literacy skills
enable her to minimize risk, maximize protective factors, and optimize
promotion. In this way, a mother’s health literacy forms the foundation for her
her child’s health throughout their lives.
Many factors, in addition to
skills, interact to determine a woman’s maternal health literacy.
More on that
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
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?
Last time in this space I told Mandy’s
about the depressed 8-month old
who transformed over the course of
one week of simple everyday interactions.
The story illustrates the scientific
work of Bowlby and Robertson on the stages
children move through when separated
from their mothers due to hospitalization.
Mandy was well beyond the first stage
in a child’s response to separation: Protest.
This stage is marked by wailing and sobbing in confusion,
fear, grief at being
She was also beyond Stage 2: Despair.
The child becomes more hopeless and
apathetic. She withdraws. Like Mandy. This
going quiet is not settling in.
It is giving up and shutting down.
Mandy was well into Stage 3:
Detachment (or Denial). She had suppressed all
emotion, including - maybe
especially, feelings for her mother. She hardly
noticed when her mother left.
She was so withdrawn that she sought no
mothering at all. Now, i would recognize that as a sign
of major psychological trauma.
There are many lessons in Mandy’s
story. More on that next time. s
history of attachment theory and the stages of separation, plus a good
bibliography, see Van Der Horst, FCP
& Van Der Veer, R. (2009). Separation and Divergence:
The untold story of
James Robertson’s and John Bowlby’s Theoretical Dispute on Mother-Child
Separation. Journal of the History of the
Behavioral Sciences, Vol. 45(3), 236–252. Published
Wiley Periodicals, Inc.
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.
instrument. It will
complete the review of graphic elements begun in
Today we consider lists, tables, charts and forms.
can facilitate learning if they engage the reader to interact with the
information, make choices, and take action. To meet this goal, the purpose
of the list must be made
immediately clear through a headline or subhead
(see Road Signs
brief instructions, as needed.
Example: Beginnings Pregnancy Guide (Page 65) includes a list of what to
take to the hospital or birthing center for childbirth. This is important
content to increase confidence and reduce anxiety, especially for the
many women for whom childbirth is their
first hospital experience.
“Pack you bag” is a clear simple
headline that clarifies the purpose of the
list. Two short introductory
sentences tell when to pack and indicate the
list includes “all you will
need.” Check boxes are included to
interaction. The list is
broken up with a subhead: “Pack for
indicating the next
Explanations and directions are
essential. When presenting how-to
information, a bulleted list is easier and quicker to read and use than
paragraph. An example clarifies
the instruction and instills confidence.
When preparing instructions, think
through who will use the information
and how will they use it. Where are they
likely to be when the want and
need the information. What might they be doing?
Who might be with
them? What might get in the way? What might be confusing? What format
will be most accessible?
Focus on what-to-do. Be specific. Omit all
reference to what not to do (it is equivalent to static).
Example: Every pregnant woman
wonders how she will know she is in labor
and what to do when labor begins. Beginnings Pregnancy
Guide (page 72-73 )
presents step-by-step instructions under the headline “Are you in labor? Walk
to find out.” Steps are numbered and presented in
logical order: 1.Notice
contractions. 2. Walk 3. Time your contractions. 4. Call your doctor. Key
information is highlighted: “True labor
contractions get longer, stronger
and closer together” . Instructions for
calling include who to call, when to
call, what questions to anticipate, what
to say, what if you get an answering
service, what if you cannot call; and
finally, what to expect at the hospital.
shows a woman walking with hands on pregnant belly, noticing her
essential instructions with a few representative learners with no prior
experience and little knowledge of your topic. Invite them to read your
instructions and tell, or better show you what they would do. You will find
out quickly if the
directions are too brief to use the graphic or follow the
independently in likely circumstances. For Beginnings,our standard
is that the learner can find and follow the
necessary instructions in the middle
of the night while throwing up.
gets a Superior rating on the SAM for providing step-by-step
with examples that build self-efficacy. Graphics--lists, charts,
forms-- presented without explanations are not suitable in health
NEXT: Typography: type sizes, fonts,
The Nation & World section of
my morning newspaper reports, right next
he story re civil war in
Syria, on a doll that is making TV
The Breast Milk Baby makes suckling sounds when it
touches sensors sewn into a
halter top that comes with the doll. A Fox news
commentator thinks we “don’t
this kind of stuff”. It’s hard to
say what “stuff” he’s worried about. A father
says it’s “creepy”; maybe his daughter
could play with the doll at home, but not
on a play date or in public.
Somehow these men think breastfeeding has
something to do with sex. So the
doll’s suckling sounds are “too
mature” for little girls who want to grow up to
be mommies. Apparently,
dressing up the buxom Barbie doll in a cocktail dress
and heels for a date with
hunky Ken is a better way for “kids to be kids” and for
little girls to
envision their future and understand the purpose of breasts.
a health literacy standpoint
Critics of Breast Milk Baby are
showing a very limited ability to
use information for health. Breastfeeding, exclusively in the
baby’s first six months,
way to feed a baby with benefits to both mother and child over their
Breastfeeding is only X-rated in the
minds of some adults. Let’s think about what
we want to teach our daughters and
what we want to protect them from. What is
it we want to protect ourselves from
by banning a breastfeeding baby doll.
milk is made for your baby. It contains the right amount of all the nutrients
Baby needs. As the baby’s needs
change, your milk changes, too. Mother’s milk is
easy to digest. It is always
ready, clean and just warm enough. Breastfeeding creates
a special bond between
mother and baby. Breast fed babies have fewer infections
and allergies than
bottle-fed babies. And their brains develop faster.
Pregnancy Guide p 62
If you are not ‘creeped out’ by the
thought of little girls learning that breastfeeding
is normal, healthy and
health-promoting; if you believe breasts are engineered
primarily for feeding
babies, and if the sound of suckling does not distract you beyond
thought, you can order Breast Feeding Baby online at half-price. She is more
culturally competent than some of
her critics; choose a doll with one of eight names,
skin tones and facial
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012