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Prenatal Education

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.

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

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

Cesarean section                      1,278,000                                    41%

Circumcision                            1,164,000                                    -31%

Artificial rupture of                  917,000                                      -5%

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
Next: Vocabulary & Road Signs

Beginnings Guides: Health Education Materials that Work

Beginnings Guides to pregnancy and parenting translate the science of prenatal
care and early child development into practical guidance for parents.
The Pregnancy Guide, first published in 1989 as Beginnings: A practical guide
through your pregnancy, is now in its 8th edition (2011). It has been distributed
by home visitation programs, prenatal care providers and health insurance plans
to more than 310,000 families. In surveys, mothers report sharing Beginnings with
their partners, friends and relatives, and their doctors. Six  months after close
of service, nearly all mothers who participated in New Mexico’s Families First
program were able to report where their copy of the Pregnancy Guide would be
found. For example, one mother said, “They are stored with the newborn clothes
for my next pregnancy.” Another said, “I gave it to my cousin who is pregnant.”
Beginnings Pregnancy Guide is not your usual pregnancy book.  Let me count
the ways:

1) Conversational tone is easy, encouraging. It sounds like something you would
actually say to a mother sitting next to you. The text reflects the conversations
a caring, articulate, “patient-centered” practitioner who is up-to-date on the
research would have with each mother at each visit if time allowed. Readability
pioneer Rudolf Flesch documented that conversational tone using personal
pronouns and common words increases readability and comprehension.
2)  Staged learning keeps info immediately applicable. Information is like
medication; it is easier to take and more effective is small doses. Adults learn
in order to solve problems they have now. Information that is not immediately
applicable is likely to be ignored or discarded and may be overwhelming. So
the Beginnings Guides present essential information in a series of six booklets
referenced by gestational age and the usual course of prenatal care. Selectively
cover the content of each booklet in one or more visits depending on the family’s
interests and needs and your frequency of visits.
3)  It’s short. Short words in short sentences in short paragraphs in short booklets
increase readability, comprehension and recall. This “commitment to short” means
focus is on the essentials. Even experienced mothers and educated first-timers
who read everything about pregnancy welcome Beginnings’ focus on what really
matters at a particular point in pregnancy. We converted to the  8.5 x 5.5” booklets
after mothers told us that format is easy to carry and store and “they don’t look or
feel like homework”.
4) It’s designed to promote maternal health literacy.
More on that next time. ss

Spanking hurts for a life time

Spanking, slapping, shoving are common punishments for children in the
US and Canada. Hitting a child is socially acceptable by many parents as
a form of discipline or to protect children by teaching them to respect
authority.  A large new Canadian study documents that these punishments
are associated with lifelong mental and emotional problems.
ACEs - Adverse Childhood Experiences- are a frequent topic in this space. 
ACEs include experiencing or witnessing physical or sexual violence or abuse.
ACEs are closely linked to a surprisingly long list of physical and mental
problems in adulthood. But that is not what we’re talking about here.
Here’s the main survey question put to over 20,500 adults: “As a child
how often were you ever pushed, grabbed, shoved, slapped or hit by
your parents or any adult living in your house?"

Never,   Almost never,  Sometimes,   Fairly often,   Very often
If you answered Sometimes or more often, these researchers would say
you experienced harsh physical punishment and you would be among the
6% of study participants whose experience is similar. Those who also
reported ACEs were excluded from the analysis. 
Adults who were punished as children, but not to the point of full-scale
maltreatment, were at increased risk for depression, mood swings,
anxiety, alcohol and drug abuse, and personality disorders.
This from Beginnings Parents Guide: 
What do you want to teach?
Teaches self-control
Teaches fear
Teaches your child that hitting is not OK. It hurts
Teaches here that hitting is OK if you are the biggest and strongest
Teaches your child to keep the rules out of respect for herself and other
Teachers her to keep the rules so you will not hit her
Shows your child she is a good person who learns from mistakes and practice 
Teaches her she is bad; she does not learn well; she deserves to be hurt
Teaches your child to think for herself and do the right thing
Teaches her not to think for herself, and to do what keeps her from getting hit
Leaves you and your child feeling OK about yourselves and each other 
Leaves your child in pain, feeling bad about herself and you.

Resource: Parents can talk anonymously with a counselor, 24-7,  free in 150
languages by calling Childhelp USA National Hotline 800-422-4453


New Guidelines for Obesity Screening: Good plan, but missing underlying social issues

All physicians should screen all adults for obesity. So say new guidelines published
this week by he US Preventive Services Task Force. The guidelines recommend
measuring each persons height and weight to calculate their body mass index or
BMI. Everyone with BMI of 30+ should be referred to counseling and behavior
change support programs.

It’s a good plan. Screening for obesity and managing weight is particularly
important during pregnancy.  Extra weight contributes to complications and is
rarely lost after birth. Fat bodies produce fat babies building obesity and its
attending health risks into the next generation. Weighing is the only prenatal
care procedure shown to affect outcomes.

If your doctor does not discuss weight, that does not mean it doesn’t matter.

Although weight management has long been part of a minimum quality prenatal
care service, providers infrequently weigh mothers. They say weight is a touchy
subject and they don’t want to embarrass or alienate patients, so they don’t
talk about it. Others say they do not know how to calculate BMI.  (Calculate it
yourself with this handy gadget from the Beginnings Guides resources collection.)

The guidelines emphasize traditional approaches that frame weight management
as a battle involving diet diaries, calorie counting, exercising and tracking activity
levels. An approach unlikely to be engaging or popular.  One of the authors said,
“We also need to help people understand why they’re not eating more healthfully
or being more active, and help them address those issues.”  He is right, partly.

What’s missing from the guidelines is recognition of the links between obesity
and sexual abuse. Research demonstrates that obesity is not just about an
individual’s lousy eating habits or laziness. It is shockingly often about a history
of abuse, experienced or witnessed, called ACES - Adverse Childhood Experiences.
Fat is protective. 

Counseling and support services will need to do more than “get people to eat right”;
they will have to recognize and address underlying social issues, starting with
sexual abuse.  


Virginia A. Moyer, on behalf of the U.S. Preventive Services Task Force. Screening for and Management
of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal
Medicine. 2012 Jun 26. Available free online at

U. S. Department of Health & Human Services, Public Health Service (1989) Caring for our future: The
content of prenatal care. A report of the Public Health Service Expert Panel on the Content of Prenatal
Care. NIH Publication No. 90-3182 Washington, DC: National Institutes of Health.

Kogan, M.D., Alexander, G.R., Kotelchuck, M., Nagey, D.A. (1994). Relation of the content of prenatal
care to the risk of low birth weight. Journal of the American Medical Association, 271(17), 1340-1345.

The Adverse Childhood Experiences Study http://www.acestudy.org/

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