Center for Health Literacy Promotion Blog
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
Frequency Number Performed Increase in
in 2010 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%
greatest opportunity to make healthcare more affordable and improve
status of the population is to improve the way we deliver and pay
care. Investigations of the cost of maternity and newborn care
usually report charges made by providers. But charges are routinely discounted
varying rates, so the figures are not very informative re actual cost.
A new report shows actual payments made in 2010 (latest
figures) by employer
-based commercial insurers, Medicaid and parents.
delivery payments vary by state, by regions within states, by hospitals
regions, and by providers within
hospitals, so vaginal birth and cesarean
(surgical) delivery are reported
separately. A summary of findings in the table
below suggests where to focus
Item Employer Insurance + Public Insurance
Out of pocket Medicaid
Cesarean 57,125 50,374
Vaginal 18,329 + 2244 9,131
Cesarean 27,860 + 2669 13,590
Vaginal 3,180 (25%) 2,405 (39%)
Cesarean 3,580 (21%) 2,859 (36%)
Vaginal 9,048 (72%) 3,347 (55%)
Cesarean 12,739 (76%) 4655 (58%)
in hospital +
Vaginal 5,809 + 558 3,014
Cesarean 11,193 + 721 5,607
Vaginal 30,875 + 1241 13,875
Cesarean 45,496 + 1351 19,971
delivery costs are 50% greater than vaginal birth for all payers.
And cesarean delivery payments by commercial insurers
between 2004 and 2010. In addition, parents’ out-of-pocket costs
The best outcomes for women and babies
appear to occur with cesarean
section rates of 5% to 10%. Rates above 15% seem
to do more harm than
good (Althabe and Belizan 2006) Despite the evidence and the costs, the
cesarean rate for 2010 was 32.8%.
table suggests one explanation for the high cesarean rate is that surgical
birth is more lucrative than “the regular way”. Commercial payers paid
clinicians an extra $1464, and paid
hospitals an extra $7518 for cesarean
vs vaginal birth. Those incentives are
hard to ignore.
the table shows that 70-84% of all maternity payments went to
But the vast majority of mothers and newborns are healthy
have been shown to reduce preterm birth, failure to thrive, and other
land babies in Neonatal Intensive Care Units where costs were 3.7
to 5.6 times
those for other babies. More investment in prenatal care and support
reduce the need for cesarean, and
could help re-align financial incentives.
Truven Health Analytics (2013) The Cost of Having a Baby in the United States.
Connection, Catalyst for Payment Reform,Center for Healthcare Quality
Belizan JF. Caesarean section: The paradox. The Lancet 2006;368:1472-3.
term functional literacy
traditionally refers to basic literacy skills, the
3Rs: reading, ‘riting, and ‘rithmatic. These autonomous skills for gaining
knowledge were said to be functional, implying that they enabled a person to
function in society. The idea was, if you can read and use numbers, you can
learn what you need to know and do to function in any context.
was true in 1852 when MA passed the first compulsory school laws. It was still
true in 1918 when all American children were required to attend elementary
that time, the Sisters of Providence were arriving in Seattle on mule back from
the Oregon Territory to establish the city’s first hospitals. The Sisters
rode a circuit of the logging camps selling the first health insurance
policies. For $10 a year a logger
was promised full care in case of
any injury or illness. The care consisted primarily of bandaging and
amputations with handholding and whiskey for pain. The 3Rs were sufficient to
understand the policy and to obtain the full benefits of care.
have changed, but thinking lags.
The term functional health literacy came into the healthcare discourse in
1993. Starting with the
traditional understanding of functional literacy, functional health
literacy, came to be understood
as basic literacy skills applied in a clinical setting, in other words, a
patient’s ability to read and use numbers to understand medical, healthcare,
and insurance related information. This conceptualization relies on the
assumption that basic reading and ‘rithmatic skills still enable a person to
function in society, and specifically in healthcare settings that were
unimaginable even 50 years ago.
the thinking goes, a patient who can read will be able to function in the
healthcare arena. Reading will enable a person to recognize a medical problem,
understand the difference and appropriate uses of primary and tertiary care,
find an appropriate provider or collection of specialists, make appointments,
manage transportation and child care, articulate symptoms, understand the
diagnosis and treatment options, follow the medication regimen, change
behaviors to prevent repeating or exacerbating the problem, file insurance claims
and get reimbursed for costs that are unknown until the bill arrives. All this in a complex, high
tech, fragmented, rapidly changing environment with its own language and
in the health arena takes more than reading.
literacy scholars say that the meaning of literacy is constantly changing to
reflect society, so that what it means to be literate is context-specific. It’s
different at different times and places for different ages and genders and
cultures. Operationalizing health literacy simply as ability to read medical
terms and documents surely oversimplifies the literacy tasks involved in
managing personal and family health and healthcare. Time to update the way we
think and talking about health literacy, and how it enables a person to
function in the health arena.
Lucia, E.(1978). Seattle’s Sisters of Providence: The
Story of Providence Medical Center~Seattle’s First Hospital. Providence Medical
infants show preference for others in distress
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.
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.
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
power of choosing
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.
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.
together, these works make clear the importance of allowing very young children to make
choices. Even before they begin to
talk or to understand. Hold up two
shirts. Ask, red shirt or green? Let Baby point. When out for a walk, ask Baby
which way he wants to go. He can point. Maybe not the first time. But probably
sooner than you think.
choices and translating those choices into desired actions and outcomes” - that
is the definition of empowerment.
Emerald, D. (2006). The power of TED: The Empowerment
Island, WA: Polaris Press. www.PowerofTED.com
World Bank. (2005). "What is
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.
young child’s healing power and reason to live reside in the mother.
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.
child can become stuck in a state of anxiety
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.
interaction, more hospitalization
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.
the good news: Role models needed
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.
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.
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?
I have been very impatient with the
narrow view of some health literacy researchers who, as if looking through a
soda straw, focus on only a single
factor in a persons’ capacity to use information for health, usually reading
skill. Or who focus only on the clinical encounter. Or only on patients with
chronic disease. Or only on plain
language. Experts at the International Roundtable on Health Literacy at
University of British Columbia last month could not agree on a definition or a
measure of health literacy. I’ve called for a broader view.
But maybe I’m wrong.
This week I was in Bozeman, MT working
with the public health nurses and social workers who staff the Thrive Partnership
home visiting program. They are the cutting edge of promoting maternal health
literacy. It has been my honor to work with them since 2004. This time we
worked on practical approaches to empower parents.
In this community, promoting health
literacy and empowering parents is part of a county-wide coordinated effort to strengthen
vulnerable families. The collaboration addresses the entire Web of
Interaction that affects MCH and
maternal health literacy.
Thrive, voted Bozeman’s best
non-profit, under the tireless, gentle, powerful direction of executive
director Deborah Neuman, has over 26 years forged a collaboration to promote
maternal child health as the foundation for a healthy society in Gallatin
County. Neuman has received a
growing number of requests from
around the country for help to replicate the collaboration that extends well
beyond the usual public health players. For example, two banks contributed
space for our 2-day workshop. The Hilton hotel comp’d rooms and breakfasts for
Neuman credits the soda-straw view of
each partner as the active ingredient in the success of the Thrive model of
coordinated collaboration. She
says a common broad view would cause the collaboration to degenerate to
groupthink. She points out that the social workers in my workshop are employed
by Thrive; they were hired for their ability to engage parents. The nurses in
the workshop are employed by the health department and hired for their clinical
expertise. The PHNs and MSWs work with the same families. They are acutely
aware and respectful of each others’ expertise. They closely coordinate their
efforts with each other, healthcare providers, the hospital, the schools, food
banks, day care providers, , the Bozeman Adult Literacy and Education service,
et al. Both the Health Department
and the agency use the Life Skills Progression to monitor their
effectiveness and family progress.
Ten years of LSP data (soon to be published) show remarkable
results,with effectiveness increasing over time as the coalition grew and
Rather than of a common broad view,
Neuman says, what works is all those soda straws trained on the needs and
strengths of the same vulnerable families to find the combination of supports
that empower each family to function
as fully as possible as part of the Gallatin County society. It seems many narrow views together
cover the broad view without sacrificing the depth of understanding one gets
looking through a soda straw. ss
*Credit for the soda straw analogy goes to Linda Wollesen, author of the LSP
May 15, the TimesRecordNews of Wichita Falls, TX posted this headline: US pays billions, and lives, for poor
health literacy. This morning it
showed up on the Google Health Literacy Alert.
story features the following as an example of how low literacy in a medical
setting (which the writer incorrectly equates to health literacy) is costing us
A 5-month-old child
asphyxiated when a cap from a pre-filled syringe was ejected into his throat
during the administration of medicine. The father had taken his son to an
emergency room and was sent home with instructions to give his son medication
through a new syringe every few hours. The young father assumed the cap to be
part of the syringe, and it looked attached to the medicine vial. While placing
the medication into the child’s mouth, the cap came off and lodged in the
baby’s airway. The baby was rushed to the hospital but died. Was he a bad
parent? No, it was a tragic mistake, the result of low health literacy.
The father and his literacy
is not the problem here.
As the writer points out,
proper use of the syringe was not demonstrated. This father demonstrated health
literacy by recognizing an emergency and appropriately bringing his child for
The providers failed him and
his son by not ensuring safe use
of the prescribed treatment. The author omits the fact that federal, state, and
local laws, regulations and accreditation criteria require healthcare providers
to provide full explanation of recommended treatments and related risks in a
language that patients and families can understand. The responsibility is the providers’.
The suggestion that if this
father just had better literacy he would know how to use a syringe, his child
would not have died and he would not have consumed extra services, we taxpayers
would not have wasted our healthcare dollars on them is unfounded,
unsubstantiated, damaging to an already devastated family and a disservice to
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
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.
I conducted a pre-conference
workshop on engaging and empowering mothers whose children are
hospitalized with 15 nurse trainers and a whole class of nephrology students,
we talked about the importance of basic literacy skills as the foundation for
health literacy. We reviewed
screening questions that can be used to identify individuals who might benefit
from adult literacy training. One
nurse said, “But using these questions, I would have to refer everyone who
comes to my clinic.” Another said, “Yes,
that’s how it is.”
That’s how it is in some disadvantaged
US communities, too.
This discussion, and others during my
whirlwind week at Cape Town University and the Red Cross Children’s
Hospital, led to insights about
the undeniable links between basic literacy skills (the 3Rs - reading, ‘riting,
and ‘rithmatic), health and health literacy.
The 3Rs are fundamental skills for acquiring knowledge. So it is not
surprising that any way “health”
and “literacy” are defined, any way they are measured, they are
inextricably linked. More literacy translates, directly and indirectly, to more
health and more options and opportunities to regain, maintain and improve
health, accomplish one’s goals and fulfill one’s potential. Basic literacy is
the foundation for health literacy, computer literacy, science literacy,
financial literacies and other “types” of literacy used to function in
different social contexts.
In addition, we now have hundreds of
health literacy studies that show most people in most developed nations have
difficulty understanding and using information to manage their health and
illness and healthcare.
Since health and literacy are so
closely linked, healthcare organizations, especially hospitals and health
plans, should consider their ethical duty and the compelling financial and
practical benefits of taking the lead to improve adult literacy in their
service areas. As primary prevention. As a way to increase the effectiveness of
all other efforts. As the foundation for a healthy population, a pathway out of
poverty and the key to the advancement of women and society.
Simple, inexpensive steps include
collaborating with literacy enhancing services, and in their absence,
establishing programs, providing
space for on-site classes, providing health content for literacy training,
advocating for adequate funding, training personnel to understand and talk to
patients about the role of literacy in their health, expanding Reach Out and
Yes we rely on the schools to teach
literacy. And yes, many, perhaps most schools need to do a better job. But we
in Healthcare cannot reform Education; and we cannot wait for Education to
reform. To reduce the burden on
healthcare systems, to improve outcomes, to increase people’s capacity to
obtain the benefits of healthcare, address basic literacy in your service
Hamza, age 11, speaking to the conference about living with a "trachy".
With him is his mother Farahna, and his nurse, Jane Booth.
was a young mother, I was married to a sailor. A submariner. With about 100
other men, he was at sea half the year. 100 days at a time. Underwater. No
communication. As you might imagine, the wives and children were a close
community, a village if you will.
time a group of the wives decided to take a trip. I agreed to keep one of the
younger children for the week they would be away. The baby’s mother brought her to me on a Saturday morning.
It was the first time I met the child. Her name was Mandy. She was about 8
looked 80. Her skin was shriveled. She had a grey cast to her. She made no
sounds. Her eyes were dull and distant.
She hardly moved. She was clean, well dressed and fed. Her Mom had all
kinds of equipment for her. But Mandy was barely there.
mother assured me Mandy would be no trouble. She said, “You can just put her in
the play pen. She will be quiet.”
baby girl made no protest when her mother handed her off to me. She never even
looked to see her mother leave.
This child, Mandy, had not been in the
hospital, but it was as if she was
hospitalized. She spent her days lying in her crib, well tended, but
alone. Her mother was present; she
met the baby’s physical needs. But she never engaged or interacted. Mandy’s emotional needs, even the idea
that she had emotions, went totally unrecognized. With observable physical
At the time I was 22, my daughter Lisa
was 2. I had a high school education, no experience, no skills. So believe me,
I did nothing scientific or intentionally therapeutic for this child. I simply
folded her into our usual routine. The three of us went to the grocery store
and the park. We shared meals. I treated Mandy as my own.
And I watched an unforgettable miracle
That little girl bloomed before my
eyes. Hour by hour her appearance changed as she came back to life. She started
to mimic Lisa’s sounds and to initiate contact. She became interested in
everything around her. She laughed. She filled out. Her cheeks turned rosy. She
started looking and acting like a baby.
When her mother returned to pick her
up, Mandy recognized and reached out to her. She had regained the courage to
expect a response.
And, miracle #2, she got one. Her
mother gasped and covered her mouth. Her eyes filled with tears. She said, “I
never knew she could be so beautiful!”
Much later I learned of Bowlby and
Robertson’s work on attachment and the stages children go through when separated from their mothers due to
hospitalization. More on that in
Part 2. Stay tuned. ss
(c) Practice Development Inc. You are free to use this
story for teaching purposes only
as long as you retain the attribution and do not change the story in any