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Prenatal Education

Evidence to Practice: Induction of Labor Rate Falling


My 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.
 
That 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  But the story, and the disconnect between the body’s wisdom and medical practice is not out of date.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


The 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%.
 
The national  rate is down 12%. The number births at >39 weeks gestation is up 9%.
 
The bad news is disparities continue. Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only 3% for blacks.

Questions 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— and  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.
 

New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.


 
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 recommendation 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
Call 1-888-SAFEFOOD 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.

CenteringPregnancy Health Literacy Trial Underway

 
It was 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.
 
After 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 vegetables.
 
Does CenteringPregnancy promote maternal health literacy?
This 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 social support. 
 
By 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”.
 
Read the project overview. Learn more about CenteringPregnancy
 
Stay tuned for more on the Maternal Health Literacy Self-Assessment.

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.

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

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

With few exception, childbirth is normal % healthy, but...

Of the 10 most frequently performed in-patient procedures,  5 are related to maternity 
and newborn care (2010 figures - latest available).
 
Bad news: the cesarean section (surgical delivery) rate continues to rise; it is up 41%
since 2004, despite global evidence that rates over 15% do more harm than good. This
is a place to cut the cost of maternity care. A cesarean section costs on average $9956
more than vaginal delivery.
 
Good news: Fetal monitoring, circumcision and stripping of membranes are performed
less frequently now than in 1997. The reduction in procedures returns to mothers some
control over their most significant life event, and begins to recognize that over-management
is not beneficial.
 
Procedure Frequency Rank       Number Performed in 2010           Increase in Frequency

Repair of obstetric                   1,292,000                                    No change
laceration      

Cesarean section                      1,278,000                                    41%

Circumcision                            1,164,000                                    -31%

Artificial rupture of                  917,000                                      -5%
membranes

Fetal monitoring                      875,000                                      -23%

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? 

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 3: Writing Style & Sentence Construction


We are using the SAM -Suitability Assessment of Materials to assess the suitability
of Beginnings Guides to promote maternal health literacy. So the Guides need to
fit the audience, US pregnant women including those with low resources and
limited literacy, and to facilitate use of health information and services. In Part
1, we covered factors related to content. Part2 addressed readability. This Part
3 addresses two additional factors that determine the literacy demand of information,
writing style and sentence construction.
 
Writing Style is Conversational
Easy-to-use health information uses a conversational tone. Read aloud the information
you are reviewing  It should sound like something you would actually say to a person
sitting with you. Some clinicians may pan a conversational style as “unscientific” or
“unprofessional”, a reflection of professional training that rewards multisyllabic latinized
terms in long  complex sentences like this one as demonstration of deep knowledge.
But that is not the point here.
 
The point is to make the information easy to understand, personalize, and apply in
real life. Conversational tone is familiar and expected, so quickly grasped and not
intimidating. Rather it invites reflection and interaction.
 
Conversation nearly always uses the active voice: “ Jason hit the ball” is active. I can see
the action in my mind’s eye.  “The ball was hit” is passive; it creates an incomplete mental
picture. It does not engage the reader.
 
Conversation uses short simple sentences, and sometimes incomplete sentences. No
embedded information. In the first paragraph above, the third sentence intentionally
contains multiple phases and embeds mostly irrelevant information about professional
training demonstrating that long involved sentences and extraneous facts slow reading
and reduce comprehension. So instead of  “Patients are advised to take vitamins daily”;
say it the regular way: “Take your vitamins every day”.
 
Beginnings Guides get a Superior rating for using conversational style and simple
sentences throughout. Take a look.
Sentence Construction: Context first
The way the sentence is built makes a big difference in comprehension. Readers recall
the last thing they read, that is, the end of the sentence. Starting with what the reader
already knows, provides context and increases understanding.
 
Start with the context - the part the reader already knows: “While you are pregnant....”;
end with new information: “...your uterus is big enough to hold the baby. Right after
birth, it shrinks to the size of a grapefruit.” (Beginnings Pregnancy Guide Book 6 page 77)
If I state the new information first, the reader is likely to miss or forget it.
 
SAM gives an Adequate rating to materials that present the context first half the time.
Beginnings Guides get a Superior rating for consistently providing context before new
information.
 
Next: Vocabulary & Road Signs
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