Beginnings Guides Blog
pregnant until 2018.
That is the
current public health message from El Salvador’s health minister. Colombian
women are warned to postpone pregnancy for 6 to 8 months. Jamaica just released
similar advice. The intent is to prevent mother-to-baby transmission of Zika.
known since 1947 as a rare mild disease limited to central Africa, is spreading
rapidly across dozens of countries in Latin America and the Caribbean. No one
knows why. The World Health Organization (WHO) warns Zika is likely to reach
every country in the Americas, except Canada and Chili. There is no treatment
or vaccine, largely because only about 20 percent of infected adults have any
symptoms. They might have a headache, body aches, a fever and red eyes for a
Here is the public health concern: in Brazil, since an outbreak of Zika
started there last May, more than 3800 babies have been born with microcephaly,
30 times the expected rate, according to WHO. Microcephaly is a rare birth
defect characterized by a very small head and incomplete brain development
leading to death or lifelong disability. There is little scientific evidence,
but the apparent association between Zika and microcephaly warrants public
health warnings, and delaying pregnancy seems wise. However…
The advice to women to avoid
pregnancy ignores the context in which they are expected to comply. In El Salvador and
Colombia there is little access to contraception, especially for poor rural
women. Abortion is illegal in all cases in El Salvador, where the teen
pregnancy rate is among the highest in Latin America accounting for a third of
all births. Abortion is illegal in
99% of cases in Colombia. In Jamaica, abortion is legal in some cases with the
approval of the father and two medical specialists. There is little or no sex
education in the schools. Sexual violence is prevalent. So women lack the
knowledge, services and power to heed the advice.
Colombia’s health minister explained that
his message to women is a good way to communicate risk. The minister seems to
forget that women do not become pregnant by themselves. No similar messages
have been directed to men. For sure, women who hear the warning will fear
pregnancy and birth defects more than they already do, but left to protect
themselves, this amounts to a “Just say No” campaign. It leaves women
vulnerable to blame for unplanned pregnancy and birth defects in their babies,
and to charges of non-compliance that could be misinterpreted as evidence of
low health literacy.
better message, free of gender bias, understandable and actionable, is to avoid
mosquito bites. CDC has issued Level 2 travel advisories (for all, not just pregnant women) for
the Caribbean, South and Central America, Puerto Rico, Cape Verde, Samoa and
Mexico. Travelers are advised to “practice enhanced precautions”.
In this case,
your doctor before and after travel to areas where Zika is active
insect repellant (safe and effective for pregnant women)
clothing to cover as much of your body as possible
under a mosquito net
doors and windows closed or screened
mosquitos bite in the morning, not just late afternoon and evening like other
lasts only a week or less. The danger is only to a current pregnancy. There is no danger to future
US Centers for
Disease Control and Prevention www.cdc.gov/zika
. Information is being updated
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.
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
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%.
national rate is down 12%. The
number births at >39 weeks gestation is up 9%.
bad news is disparities continue.
Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only
3% for blacks.
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—
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.
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
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
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.
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.
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
CenteringPregnancy promote maternal health literacy?
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
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”.
tuned for more on the Maternal Health Literacy Self-Assessment.
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
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.
A subtle but important revision is in who to call for information
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
to a Healthy Baby, the health behavior messages that research links
to birth outcomes are modified slightly.“Do eat well” is expanded to “Do it
often” since a pregnant body easily and
quickly slips into starvation mode. Frequent
small meals best support fetal
“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
recommend an 11 pound gain for a woman who starts pregnancy
“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
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%
had their labor induced, often for convenience of the parent or the
Those women were twice as likely to have a C-section as women who waited
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
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
Nuchal lucency test is added to the discussion
of prenatal testing.
Juice is de-emphasized in favor of
water. Juice was considered a
alternative. However, with the increase in obesity, extra
calories and sugars
in juice are
My favorite change.
Reference: National Center for Health
Statistics Data Brief 24, Nov 2009.
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
Don't Order Fetal Ultrasound Videos As Souvenirs: FDA
Of the 10 most frequently performed
in-patient procedures, 5 are
related to maternity
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
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%
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?
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.