Knowledge is the Key to a Healthy Pregnancy

During a home visit with a social worker, in her second trimester of pregnancy, Kalia Yang stares at a chart that shows how many packs of cigarettes an unborn baby is exposed to if the mother smokes: Sixty-seven packs - or 1,350 cigarettes - if she smokes five cigarettes a day in the course of a full-term pregnancy. Yang is expecting twins in November. She no longer smokes; she quit as soon as she suspected she was pregnant. It's a big win for the babies and a small victory in Milwaukee's battle against infant mortality. (View the Journal Sentinel article here)

Health officials will take it. In some corners of the city, smoking during pregnancy is seen as a positive that leads to a smaller baby and a smoother delivery. In reality, smoking can cause miscarriage, premature birth and low birth weight. Some women consider breast-feeding uncivilized and unattractive. They don't grasp its benefits, including possibly providing protection against sudden infant death syndrome, or SIDS.

Knowledge gaps, which exist everywhere - even in a community's most stable neighborhoods - can be life-threatening if a woman is at risk of having a baby born too early or too small. Health professionals call this "health literacy." It's the ability to obtain and understand accurate health information, to manage one's behavior and to navigate the health care system. It can mean knowing when to see a doctor. It can mean asking the right questions, getting a timely diagnostic test or properly filling out a medical form.

Research shows a strong link between health literacy, health outcomes and medical expenditures. The cost of low health literacy in Wisconsin is estimated at $3.4 billion to $7.6 billion annually, according to John Vernon, principal analyst for a 2007 health literacy costs study by the University of Connecticut School of Business. Those with low health literacy are less likely to get preventive care and more likely to be hospitalized with bad outcomes, driving up costs.

"You can be very literate and be health illiterate," said Jackie Tillett, a nurse midwife and director of the Midwifery & Wellness Center at Aurora Sinai Medical Center in Milwaukee. "Parenting is about being empathetic with your child and caring for your baby. Many people who never graduated from high school are good parents. And I know physicians with advanced degrees who are not good parents."

A pregnant woman who understands how to care for herself, gets regular prenatal checkups and has support to navigate the health care system has the best chance of delivering a healthy baby."It's not about being stupid or uneducated," said Nicole Angresano, vice president for community impact at the United Way of Greater Milwaukee, which has joined the city's fight against infant mortality. "Information is only as good as it is understandable."

Yang takes extra precautions this time
Yang chose the Wheaton Franciscan-St. Joseph Women's Outpatient Center for this pregnancy because her sister-in-law had a good experience there when she gave birth . This is Yang's third pregnancy. The previous two ended in miscarriages, both in the first trimester. Yang blames her miscarriages on smoking, but no one can say for sure why she didn't carry the babies to term.

Yang first came to the Women's Outpatient Center because she was bleeding and didn't know she was pregnant. She was having a miscarriage. She returned several months later to confirm a second pregnancy, but she miscarried again before her first checkup. This pregnancy is the first with regular checkups, frequent ultrasounds and the guidance of a social worker, she said.

Yang, 23, and her boyfriend of six years, Andy Moua, 25, are taking extra precautions this time, trying to do everything right. The couple are in a committed relationship in the Hmong tradition."God blessed us with this purpose," Yang said. "I'm learning how to take care of myself and my babies." Yang hadn't been to a dentist in several years. Untreated gum disease can lead to premature birth, so social worker Annie Janisch, who is helping Yang navigate pregnancy, encouraged her to set up a dental appointment.

Yang was studying information technology at Milwaukee Area Technical College before she became pregnant. She now is thinking about becoming an ultrasound sonographer because of her interest in technology and her pregnancy experience. Moua, who also studied information technology at MATC, left school for a full-time job to pay the bills. He plans to return in the spring to study computer science. For now, the two are focused on learning about pregnancy and healthy babies.

Literacy skills are the strongest predictor of health - more than age, income, employment status, education level, race or ethnicity, according to the Partnership for Clear Health Communication. Older patients, recent immigrants, people with chronic diseases and those living in poverty are especially vulnerable to low health literacy. One study shows that 40% of what shapes a person's health is related to behavior - a higher proportion than genetics (30%), social/environment (20%) and access to care (10%). To address behavior, changes are necessary on both sides of the doctor-patient relationship. A patient may not ask questions or share critical information because she doesn't want to feel dumb. A doctor may assume a message is getting through and not take the time to make sure.

Most brochures that doctors give women to help them better understand pregnancy and possible complications are written at a 10th-grade reading level or higher, said Geoffrey Swain, medical director for the Milwaukee Health Department. But one in five people can't read above a fifth-grade level, he said."Low health literacy makes it harder to get good medical care." Meanwhile, a pregnant woman's friends or family members may pass along misinformation. They may not know doctors now say a baby should sleep on his or her back to help prevent SIDS. Or, one generation may pass a negative stereotype about breast-feeding to the next.

"Health literacy can be overcoming culture," said Mary Mazul, a nurse midwife at the Women's Outpatient Center at St. Joseph. "We all have our own ideas. No matter what culture we come from, what our mothers taught us - not all things are correct."

Providers try to give helpful information
Health care providers are homing in on how to better help women have healthy babies. Obstetrician Tina Mason often writes things down for her patients.

"If you have a patient with a medical problem, the stress of the problem can impact their ability to understand," said Mason, who also is program director of Aurora Sinai Medical Center's obstetrics and gynecology department. "I approach a patient woman to woman - not as a hotshot doctor." At the end of appointments, she may ask patients to repeat what she told them so she's sure they understand. She also coaches medical residents to speak to patients in plain language. Efforts are under way both locally and nationally to get reader-friendly information into the community.

"We need to reach them in churches, beauty salons and the grocery store - not just the doctor's office," said Janice Whitty, chief of obstetrics for Nashville General Hospital at Meharry, who spoke during an Infant Mortality Summit in Milwaukee in May. "Many women only go to the doctor's office if they have a problem." Social media, such as Twitter and Facebook, are valuable tools to help educate women about healthy pregnancy, she said.

Pregnant women also can get free weekly text messages on their cellphones. The messages in English or Spanish are timed to specific stages of pregnancy. The text4baby service is from the National Healthy Mothers, Healthy Babies Coalition.

Hospitals aim to lower premature births
Premature birth - birth before 37 weeks of pregnancy - is the No. 1 reason babies die in Milwaukee, according to the Milwaukee Health Department's 2010 infant mortality report. The more time a baby has to develop inside the uterus, the more likely the baby will be born healthy.

Among the many contributors to preterm birth: smoking; poorly managed blood pressure and diabetes often associated with obesity; untreated sexually transmitted infections and urinary tract infections; and a period of time between pregnancies that is too short. In Milwaukee, African-Americans experience preterm birth and infant mortality rates double to triple those of whites. Black babies die at a rate of 15.7 per 1,000 live births, based on data from 2005 to 2008; in comparison, white and Hispanic babies die at a rate of 6.4 and 7.4, respectively.

Hospitals can play a key role in bringing down the numbers. Without a regular doctor, some pregnant women end up in hospital emergency rooms - often, too late to avoid complications. They may not have a regular doctor because they don't realize they are eligible for temporary insurance under BadgerCare Plus. Or, they may have issues with transportation or child care. Two of the area's top hospitals for infant care are in the ZIP codes with Milwaukee's highest infant mortality rates: Wheaton Franciscan-St. Joseph in 53210 and Aurora Sinai Medical Center in 53233.

In recent years, both hospitals developed safety nets because they saw so many pregnant women in emergency rooms. At Sinai, a nurse midwife staffs the emergency room 24 hours a day and sees every woman who comes in who is at least 20 weeks pregnant, Tillett said. By staffing the ER with a nurse midwife, the hospital can guide pregnant women toward regular prenatal care.

In 2009 - the most recent year that statistics are available - 450 babies were born to patients of Sinai's Midwifery & Wellness Clinic. Less than 5% were born preterm and less than 4% weighed below 5½ pounds, which is considered low birth weight. Two babies died within 60 days of birth, the time frame the center tracks. Clinic officials say that puts them below the city's overall infant mortality rate. At the Sinai clinic, prenatal appointments average 20 to 30 minutes, Tillett said. "If it's a teen with low literacy, I'll ask for more time," she said.

St. Joseph's stepped up its efforts after it saw 3,500 pregnant women in its emergency center in 2008. Most were not getting regular prenatal care, so the hospital hired an "early engagement coordinator." Today, if a pregnant woman goes to the ER and doesn't have a regular doctor, the coordinator talks with her about where she can go for regular prenatal care. The coordinator touches base throughout her pregnancy, regardless of who provides her care, troubleshooting obstacles to regularly scheduled appointments. The hospital also has a program called the Stork's Nest, which offers incentives for women to keep medical appointments and participate in educational programs. After a baby is born, the mother can cash in points for supplies and baby clothing.

Before the Stork's Nest, patients had an average of eight kept medical appointments during pregnancy. That average is up to 10.5. "Because we offer so many services here, it is hard to say scientifically that they come for their appointments specifically because of the Stork's Nest," Mazul said. "But I can tell you that many of them watch the educational videos and take some of the education classes because they want the points." Patients of the Women's Outpatient Center at St. Joseph had 520 babies during the budget year that ended July 1. The preterm birthrate for African-American patients was 12%, according to Mazul. Seven years ago, the rate was 16%. The center received a grant from health insurer Wellpoint-Anthem to create a resource guide with simple health information for patients and local resources for physicians and patients. The new guide, written in clear, simple English, is used at the Women's Outpatient Center and by Wheaton Franciscan physicians elsewhere. It is being translated into Spanish.

Program reaches out to smokers
Yang, the Milwaukee woman expecting twins in November after experiencing two miscarriages, gets most of her information about pregnancy from her doctor or social worker, who regularly meets with her through the Women's Outpatient Center at St. Joseph's. At a recent ultrasound appointment, Yang and Moua breathed a sigh of relief when they learned their twin boys weighed a healthy 1 pound, 5 ounces and 1 pound, 6 ounces at 24 weeks into the pregnancy. When Yang miscarried the first time, she was still smoking. The second miscarriage was a planned pregnancy, and she had dramatically cut her smoking before getting pregnant. She quit completely as soon as she knew she was pregnant again.

Yang participates in First Breath, a program that helps pregnant women in Wisconsin stop smoking for good, not just during pregnancy. First Breath has a new outreach campaign to help pregnant women age 24 and younger stop smoking. Pregnant young women in the First Breath program can get weekly text messages with information or motivational messages for up to six months after giving birth. The campaign also uses Facebook. During a home visit early in her pregnancy with Janisch, the social worker, Yang reviewed ways she can relieve stress as a new mom without turning to cigarettes, and ways to provide safe sleeping positions for the babies.

Health centers offer care in community
Once a baby is born, a mom quickly leaves the hospital. That pushes the concerns back into the community, where myths take hold. The city's federally qualified health centers play a key role in caring for pregnant women. In addition to providing health care, the centers have social workers who help women conquer issues that prevent them from getting good care, including lack of insurance, transportation and child care. The centers, operated by four nonprofit organizations, focus on low-income patients. Those without insurance pay on a sliding-fee scale. The obstetrician and the nurse midwife who work at the Lisbon Avenue Health Center, 3522 W. Lisbon Ave., in 2010 delivered 122 babies. Not all of the mothers were the center's patients, but 116 babies had a healthy birth weight.

Sometimes, just knowing someone with answers makes a difference, said Nicole Wells, the nurse midwife at the center. Wells regularly teams up with dental hygienist Lisa Foley and social worker Sofia Thorn at sessions that give expecting moms the basic information about pregnancy. The sessions stress that prenatal care is a team effort. They encourage women to involve the baby's father or other family members for support. The nurse midwife and dental hygienist go over warning signs of complications, as well as healthy choices. "We need you to be present and involved, and if you miss a visit, you need to call and reschedule as soon as possible," Wells told a handful of women at one recent session.

At the end of the session, the women had a short checkup with Wells, received prenatal vitamins, made an appointment for a thorough physical and got a dental screening. They discussed other concerns with Thorn, the social worker. "We attempt to meet clients where they're at," she said. "We make no assumptions about their life."