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Maternal Health Literacy: Foundation of personal and public health


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 and
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,
reading and numeracy (ability to use numbers). A mother might use these basic skills
to 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
with the 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,
formulate plans, 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
options and 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
those 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
health promotion. In this way, a mother’s health literacy forms the foundation for her health and
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 next time.

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.

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? 

Mandy’s Story Part 2 A true teaching story about infant depression

Last time in this space I told Mandy’s Story 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
abandoned.
 
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
 
Reference
For a 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
online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20380 © 2009
Wiley Periodicals, Inc.
 
 
 
 

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.
 
 
 

Promoting Health Literacy with Beginnings Guides Part 8 Lists & Charts

This segment continues our Suitability Assessment of Beginnings Guides using
the SAM instrument. It will complete the review of graphic elements begun in
Part 6 looking at cover graphicsand continued in Part 7 on illustrations and
captions. Today we consider lists, tables, charts and forms.
 
Lists 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) and 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 encourage
interaction.  The list is broken up with a subhead: “Pack for baby”, 
indicating the next appropriate action.
 
Provide instructions step-by-step
Explanations and directions are essential.  When presenting how-to
information, a bulleted list is easier and quicker to read and use than
a 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. 
A photo shows a woman walking with hands on pregnant belly, noticing her
contractions.
 
Test 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
directions 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.
 
Beginnings gets a Superior rating on the SAM for providing step-by-step
directions with examples that build self-efficacy. Graphics--lists, charts,
tables, forms-- presented without explanations are not suitable in health
education materials.
 
NEXT: Typography: type sizes, fonts, caps, color

Breast Milk Baby reveals nation’s low health literacy


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 conservatives squeamish.
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
need 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.
 
Seriously?
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.
 
From a health literacy standpoint                      
Critics of Breast Milk Baby are showing a  very limited ability to understand and
use information for health. Breastfeeding, exclusively in the baby’s first six months,
is recommended by virtually every health authority  on the planet as the healthiest
way to feed a baby with benefits to both mother and child over their lifetimes.  
 
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.


Breastfeeding is best.
Your 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.
Beginnings Pregnancy Guide p 62

Good News
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
rational 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 features.
 
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012  
 
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