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The Making of Beginnings Guides

It started as liability protection for prenatal care providers
I started developing the Pregnancy Guide in 1988. At the time over a third of obstetricians had been sued for malpractice before they finished residency. Many family physicians had stopped delivering babies as the cost of malpractice insurance became prohibitive. Around this time the Million Dollar Baby was introduced in the literature - that was the baby whose medical bills approached a million dollars before she left the hospital. One “bad baby” could wipe out an employer’s entire health insurance program.
The thinking at the time was to tell pregnant women everything there is to know about pregnancy, especially things that could go wrong, in order to avoid lawsuits. If mothers were given information, they would be informed, or uninformed by choice and therefore liable for untoward outcomes. And the research indicated that families who felt informed were more satisfied with their care and less likely to sue.
Mountains of printed material, little actionable, understandable information
I gave up on my long search for materials that I could recommend to prenatal care providers trying to respond to mandates from their professional societies and malpractice insurers to inform mothers on a long list of topics related to birth outcomes. I had found and reviewed mountains  of pregnancy information. There were thick books that seemed intent on giving mothers facts and scaring them into compliance. There were mounds of brochures, all on single topics. These answered a specific question, and so were useful only to those who knew what to ask and had sufficient reading skill to make meaning from the jargon and medical facts.
Research defines key health behavior messages
In 1989 the landmark document Caring for Our Future: The Content of Prenatal Care was published. It presented the first comprehensive guidelines for what defines a minimal quality prenatal care service. It called for more visits in early pregnancy to deliver the health promotion content of prenatal care. It detailed health behavior messages to be discussed at each visit. Subsequently, research demonstrated direct links between the recommended health behavior messages and outcomes, particularly low birth weight.
Health promotion content of prenatal care rarely delivered
 But providers said it is just not feasible to keep track of each woman’s knowledge and address their health behaviors and still meet production requirements. They were -are- not trained to support behavior change. The typical prenatal visit included about 7 minutes with the doctor and focused on screening and intervention. The health promotion content of care was addressed by recommendations to attend childbirth classes, which occurred too late in pregnancy to have any impact on outcomes and were attended primarily by college-educated women.
Beginnings Pregnancy Guide introduces staged learning, conversations for health
And so in late 1989 I published Beginnings: A Practical Guide through Your Pregnancy. It was designed to protect obstetricians from liability, and at the same time to serve mothers by providing easy-to-read, plain language actionable information on what women across cultures want to know about pregnancy. It put the health promotion content of prenatal care into text that reads like the encouraging conversations a caring, articulate, culturally competent obstetrician who was up on the research would have with each pregnant woman and her partner, if time and economics allowed. I followed Pulitzer’s mandate to provide information that is “brief so they will read it, clear so they will appreciate it, picturesque so they will remember it, and accurate so they will be guided by its light.”
Information alone is rarely enough to influence health behavior
I soon learned that simple information giving is rarely enough to influence behavior. People need assistance to make personal meaning from information and act on it in context. Information-givers need training -and time- to use materials effectively for teaching and learning. The OBs said, rightly, I think, that health education is not their job. And so the health promotion content of prenatal care fell to home visitors serving Medicaid populations, and health plans providing online and print information to the privately insured. (About 2-4% of mothers were attended by midwives who embrace pregnancy as a high state of health and focus on the health promotion aspects of pregnancy.)
Designed for mothers, and health literacy promotion
From 1990 on, Beginnings Pregnancy Guide has been designed for mothers, rather than providers. Since 1993 when the first article on health literacy appeared in the medical literature, it has been a laboratory for materials that promote health literacy.
Who uses Beginnings Guides
Beginnings Pregnancy Guide is now most frequently used by home visitors, parent educators, family support workers and case managers to promote maternal child health and maternal health literacy. There is training, a users manual, and an evidence base. It is earns high satisfaction ratings from both college educated and under educated mothers and their families.
The new updated 9th! edition is just off the press. In English and Spanish. Take a look.
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