Maternal Child Health
Center for Health Literacy Promotion Blog
Maternal Child Health
Can you name it?
It doubles+ the risk of eight of the ten leading causes of death, which account for about 75% of the $3Trillion Americans spend on healthcare annually. It explains half of learning and behavior problems in children. It is prevalent in all sectors of society, at home and around the world. It meets the criteria for a public health crisis. Can you name it?
It is ACEs — Adverse Childhood Experiences. I’ve written here before about ACEs. I’ve said that anyone working in maternal-child health, or early childhood education, K-12 education, child care, chronic disease, or health literacy needs to know about the lasting destructive power of ACEs.
But, after participating in the 30th Zero To Three national conference held last week here in Seattle, I understand ACEs are not just another related issue we should be tracking. It is time to acknowledge and address ACEs as the biggest barrier to personal and public health, and to improving heath literacy. As keynote speaker, pediatrician Nadine Burke Harris says, “ We — all of us — are the solution.”
Work in all the many fields that aim to build a strong foundation for healthy child development is futile where ACEs cause that foundation to crumble and leave children physically, mentally, and emotionally predisposed to impaired cognitive and emotional development, and to adulthood defined by diabetes, obesity, heart and lung diseases, cancers. In the context of health literacy, unacknowledged ACEs must be viewed as a looming barrier to health across the lifecourse, to literacy, and to effective participation in healthcare and society. It is a multigenerational problem. A mother with unaddressed ACEs cannot buffer her child from ACEs.
Early years last a lifetime, for better or worse, by default or by design. ACEs are the worse-by-default part that Zero To Three mantra. By definition an Adverse Childhood Experience occurs in childhood (< age 18) and the person remembers it as an adult. Here are the nine types of ACEs:
* physical abuse
* sexual abuse
* emotional abuse
* mental illness of a household member
* problematic drinking or alcoholism of a household member
* illegal street or prescription drug use by a household member
* divorce or separation of a parent
* domestic violence towards a parent
* incarceration of a household member
Why ACEs matter so much for so long
These are more than unhappy memories. A baby’s brain is only partially (about 25%) developed at birth so that it can be wired to enable the baby to survive in the environment into which s/he is born. Babies absorb everything they see, hear, feel and otherwise experience. Those experiences tell the brain what to expect and how to be ready for it. By Baby’s first birthday, brain wiring is 70% complete, by age 3, it’s 85% wired. So the earlier the experience, the greater and more lasting it’s impact.
With repeated ACEs, four or more of the listed experiences, or the same experience repeated frequently, the brain and all the body systems get stuck on high alert; living in a crouch, always expecting something bad to happen. The Fight, Flee or Freeze mechanism is designed as an emergency response system. When danger is past, it is supposed to switch off so the body returns to a normal relaxed state. When it is stuck in the On position, little energy and attention are available for learning and cognitive development. Self-regulation becomes a strident challenge; behavioral problems ensue. Eventually, the wear and tear of constant stress on the body’s systems manifest as non-communicable adult disease. The leading causes of adult deaths worldwide have their origins in early development. In ACEs.
Resources & Reference:
Find your ACE Score: See how ACEs have affected you. Use the questions to generate a reflective conversation with a mother about her ACEs and their impacts on her life and parenting. Testing shows the questions do not spur trauma or need for professional help. Download the questionnaire
View Dr. Burke Harris’ TED Talk “How childhood trauma affects health across a lifetime”
Next: How we can use information about Adverse Childhood Experiences
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, 2000).
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
I’ve been in Washington
DC where I co-presented a workshop at CenteringHealthcare Institute’s fourth
national conference. I was drawn to this organization the first time I read
their motto: Transforming care through
(CP) is a rapidly spreading model of group prenatal care.
Eight to 12 women with similar due dates have their prenatal visits together.
Each has the usual individual health assessment with an obstetrician or midwife
in the group space. Meanwhile the rest of the group engages in “self-care”;
they weigh themselves, take their own blood pressures and chart the data. They can read their own lab results and
ultrasound reports. The rest of their 1.5 -2 hour appointment is dedicated
to education and support through
facilitated group discussion and activities.
and processes are the same as for conventional individual prenatal care. The
schedule of visits and core content follow ACOG* guidelines.
founder and CEO, midwife Sharon Rising, emphasizes, “Content should not get in
the way of process.” The women talk about what they want to talk about. There
are games, activities and multiple ways of learning. Women test out what
they've heard; they explore their cultural beliefs and share sensitive issues
like violence that are only rarely discussed in traditional prenatal care. They
build community and function as a support group.
“March of Dimes wants all mothers to get prenatal care in
CenteringPregnancy,” says Judy Gooding, MOD’s Vice
President for Signature Programs. No wonder.
She describes CP as an
evidence-based program to prevent preterm birth and disparities in infant
health outcomes. MOD’s 2012
Preterm Birth Report card shows the US rate at 11.7% of all births. Among women
in CP the rate is 5.5%. The national low-birth-weight rate is 8.1% compared to
CP meets the Institute
of Medicine’s goals to make healthcare services safe, patient centered,
equitable, timely and efficient.
Participating mothers seem to agree. There is no waiting time, no need
to retell their story to strangers. They build a relationship with the
provider. What they like best is being with other women.
Rising says, “Facilitation is the secret sauce.” Clinician
facilitators are trained not to answer questions or instruct the group, but
rather to elicit the group wisdom and listen to what drives behavior. They come
to understand and appreciate the needs, beliefs, and struggles of the women and
the complexity of their live. Throughout the conference there were reports of
clinicians coming out of CP sessions where they completed the equivalent of
10-12 prenatal visits in 2 hours
beaming and talking in superlatives about their experience.
All this makes group
prenatal care the ultimate environment for promoting maternal health literacy.
I’ve been working for a year with WellPoint, the health insurance giant, to design a pilot to test the
hypothesis that CP promotes MHL as a side effect, and with facilitator
awareness, tools and strategies it can be very effective.More on that next
time. Meanwhile, visit http://www.centeringhealthcare.org/
Stay tuned. ss
beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in life
across cultures. They are skills that empower people to be what they want to be, to make
choices and transform those choices into desired actions and outcomes.
These life skills develop most easily
in early childhood given a stable supportive family environment. Disparity in
brain development in children growing in disadvantaged vs enriched environments
becomes apparent in the first year.
Quality of family life matters more than the number of parents, their
income or education. But poverty and accumulated disadvantage prevent parents
from doing their best to sustain the stimulating home environments that support
optimal development, especially when they themselves lack skills, resources and
role models. Early intervention --- early childhood education, parenting
training, family support and home visitation programs--- can produce positive
and lasting effects on children in disadvantaged families.
Nobel Laureate and economics
professor James Heckman, makes the business case for shifting public policy to
support programs that offer parents information, choices and assistance. Promoting health literacy means
providing direct supplemental assistance that specifically and intentionally
enables parents to develop and hone the range of life skills used to
participate in healthcare and manage personal and family health at home.
Must read: Heckman, James J. (2013) Giving Kids a Fair Chance (A Strategy That Works) MIT Press,
Cambridge, Mass. ISBN
In addition to Heckman’s monograph,
the book includes illuminating commentary by 10 experts from multiple
1. Health Literacy is a key determinant of
•Limited health literacy, measured as ability to read
medical terms and documents, is linked to riskier health choices, less
participation in preventive activities, more accidents, poor adherence to
medication, more hospitalization, increased morbidity and premature death.
• Studies using more comprehensive measures
demonstrate that health literacy has a specific direct and independent effect
on self-assessed health.
• Limited health literacy in mothers is linked to
increased risk of developmental
delays and reduced participation in Early Intervention when delays occur.
literacy means empowerment: the capacity
to make choices and transform those choices into desired actions and
• Mothers cannot achieve their fullest health
potential and nurture a healthy competent child unless they are able to take
control of those things which determine their health. (Ottowa Charter for Health Promotion)
3. Efforts are highly leveraged in
pregnancy and early parenting
• Pregnant women exhibit readiness to learn and change
well above national norms. They are becoming healthcare decision-makers for
themselves and their families. Developing their health literacy in pregnancy
can benefit entire families across their lifetime with short and long term
benefits extending to the healthcare system, the justice and to the schools; to
the public health and the economy.
4. Mothers’ health literacy is an
important factor in prevention
of noncommunicable diseases that are now the leading causes of death in the US
• Both limited health literacy and noncommunicable
disease disproportionately affect poor, under-educated, and minority
• Limited health literacy reinforces inequities.
• Promoting maternal health literacy and empowering
mothers are recognized global health strategies for reducing the burden of
noncommunicable disease with origins in early development, and associated
disparities. (WHO, United
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%
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 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.
2004, I have been training Maternal Child Health home visitors to
promote maternal health literacy, defined as the cognitive and social
skills and motivations that enable a mother to obtain understand and use
information [and services] in ways that maintain or enhance her health
and that of her child (Renkert & Nutbeam 2000). This is the WHO
definition made specific to mothers. It is broader than the US clinical
definition in several important ways: it includes social skills
(interactive skills) acknowledging that reading and numeracy are
insufficient to function in the Information economy, especially in the
high tech healthcare arena. It includes motivation, indicating that
factors other than communication skills determine a persons health
literacy. Perhaps most important, this broader conceptualization
includes use of information. Understanding is an essential
first step , but still a long way from health promoting action. Finally,
it specifies using info in ways that promote health, going
beyond decision making. In order to involve community health workers as
Farmer and Winston and Bonnie suggest, we need to broaden our thinking.
chose home visitors as a channel to promote health literacy for a long
list of reasons, chief among them: home visitors' unique access and
long-term trusting relationships enable them to observe and to influence
the interactions of multiple factors that determine a mothers' health
literacy.These factors are not readily visible or modifiable in a
trained visitors to build parents' interactive and reflective skills
while providing direct assistance to make meaning from selected health
education materials (Beginnings Guides) and information from healthcare
providers and to apply it in vivid real life circumstances. The primary
teaching and learning strategy in the intervention is reflective
questioning. This does not imply that practitioners forget what they
know, but rather that they use their expertise to formulate reflective
questions and lead reflective conversations that facilitate
self-discovery and action planning. This approach addresses the social
determinants of health and the empowerment aspect of health literacy. Health literacy is empowering because, and to the degree that it enables
a person to increase control over their health and its determinants. A
critical element is the routine use of data by practitioners to tailor
interventions to particular families and circumstances. Many home
visitation programs use the Life Skills Progression instrument (LSP)
approved to demonstrate progress to federal benchmarks of effectiveness
in home visitation (Maternal Infant Early Childhood Home Visitation
-MIECHV under the Affordable Care Act). Using the LSP, home visitors
routinely monitor parents' use of health information and services as
well as self-care, support of child development and health behaviors
important to both parent and child health (smoking, alcohol, drugs).
Among these are indicators of maternal health literacy, situated in
surrounding family conditions. Two health literacy scales derived from
the LSP enable home visitors to monitor "healthcare literacy" - use of
info and services and "self-care literacy" management of personal and
child health at home. Intimate knowledge and data on surrounding family
conditions suggest approaches to improving health literacy for a
particularly mother. The routine use of data - especially where it is
currently collected- enables visitors and partner researchers to
consider the context in which we expect people to use health
information, not as background noise, but as the primary determinant of
the health literacy task, a persons capacity to accomplish the task, and
the support needed.
studies funded by AHRQ/NICHD, National Library of Medicine and Missouri
Foundation for Health indicate the intervention is effective in
increasing health literacy regardless of reading ability and in spite of
depression. Low maternal health literacy is associated with child
developmental delays and reduced participation in early intervention.
average American spends 1 hour per year in a clinical setting. We need more community health workers
trained to promote health and health literacy in the community in the
course of their usual activities, along with routine use of data by
practitioners and their supervisors to continuously increase
effectiveness and sustain funding. One action step would be to review
existing data sets in search of indicators of health literacy and
influential surrounding conditions (eg social support, living
conditions). Repeated measures would show progress/regression. This is
to suggest a paradigm shift from health education, anticipatory
guidance, information giving that aims to increase knowledge and
compliance to an empowerment approach that aims to increase autonomy and
|The Nation & World section of
my morning newspaper reports, right next to the story re civil war in
Syria, on a doll that is making TV
conservatives squeamish. The Breast Milk Baby makes suckling sounds when it
touches sensors sewn into a halter top that comes with the doll. A Fox news
commentator thinks we “don’t need
this kind of stuff”. It’s hard to
say what “stuff” he’s worried about. A father says it’s “creepy”; maybe his daughter
could play with the doll at home, but not on a play date or in public.
Somehow these men think breastfeeding
has something to do with sex. So
the doll’s suckling sounds are
“too mature” for little girls who want to grow up to be mommies.
Apparently, dressing up the buxom Barbie doll in a cocktail dress and heels for a date
with hunky Ken is a better way for “kids to be kids” and for little girls to
envision their future and understand the purpose of breasts.
a health literacy standpoint
Critics of Breast Milk Baby are
showing a very limited ability to
understand and use information for health. Breastfeeding, exclusively in the
baby’s first six months, is recommended by virtually every health authority on the planet as the
healthiest way to feed a baby with benefits to both mother and child over their
Breastfeeding is only X-rated in the
minds of some adults. Let’s think about what we want to teach our daughters and
what we want to protect them from. What is it we want to protect ourselves from
by banning a breastfeeding baby doll.
If you are not ‘creeped out’ by the
thought of little girls learning that breastfeeding is normal, healthy and
health-promoting; if you believe breasts are engineered primarily for feeding
babies, and if the sound of suckling does not distract you beyond rational
thought, you can order Breast Feeding Baby online at half-price. She is more culturally competent than some of
her critics; choose a doll with one of eight names, skin tones and facial
milk is made for your baby. It contains the right amount of all the nutrients
Baby needs. As the baby’s needs
change, your milk changes, too. Mother’s milk is easy to digest. It is always
ready, clean and just warm enough. Breastfeeding creates a special bond between
mother and baby. Breast fed babies have fewer infections and allergies than
bottle-fed babies. And their brains develop faster.
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012