Counseling the Pregnant Woman

General strategies for providing effective nutritional care

• Assess nutritional status– anthropometric– biochemical– social– medical – dietary

Dietary Assessment: Selection of Methods

• Avoid collecting information that won’t be used:

• What is the language skill and literacy level of the woman?

• How will I use the information? How accurate and detailed does it need to be?

• What is the standard that will be used for comparison?

• What resources do I have for collecting, analyzing and interpreting the data?

Essential Steps for Patient Education (IOM Implementation Guide)

• Identify the problem(s)

• Develop a tentative clinical objective

• Discuss objective with the woman

• If woman does not perceive as a problem offer personalized information

Essential Steps for Patient Education (IOM Implementation Guide) Cont.

• With the woman:– Identify behaviors that support or impede

achievement of the clinical objective– Assess barriers to behavioral change &

strategize about removing barriers– Plan one or two behavior changes– Help to reduce barriers with referrals or

information– Offer feedback and reinforcement for success

Referrals to Food and Nutrition Programs

• WIC

• Temporary emergency food assistance program or food banks

• Food stamp program

• Cooperative Extension- Expanded Food and Nutrition Program

Family Food Hotline

• http://www.familyfoodline.org/

• Order outreach cards

• 1-888-4-food-wa

Cultural factors affecting diet and pregnancy

outcome in Mexican-Americans (Gutierrez, J. J Adolesc Health. 1999 Sep;25(3):227-37.

• N=48 primigravida adolescents aged 13-18 who self identified as Mexican-American.

• Questions:• In some parts of Mexican culture food is classified

into “hot” such as pork or “cold” such as fruit juices to balance good health. Do you practice or follow such classification?

• Some people believe that cravings during pregnancy should be satisfied or the infant may be marked by whatever food was craved. What do you think?

Cultural factors affecting diet and pregnancy

outcome in Mexican-Americans (Gutierrez, J of Adolescent health, in press)

• Questions (cont.)• Some people believe that nausea and vomiting

during pregnancy should be treated by drinking flour and water, cornstarch and lemon juice, or chamomile tea. What do you think?

• Do you believe that heartburn is caused by eating chili?

• Some people believe that during pregnancy, if the woman sleeps too much it causes the baby to stick to the uterus. What do you think?

Group IN=14

3-12 mos.

Group IIn-19

12-48 mos

Group IIIN=13

84-216 moHot & cold No Yes

86

145

130

Cravings No Yes

77

910

112

Nausea No Yes

616

615

21

Chili No Yes

68

910

94

Sleep/Uterus No Yes

410

217

85

Seven Domains of Cultural Competence

Cultural Competence: A Journey http://www.bphc.hrsa.gov/culturalc

ompetence/Default.htm#1

1. Values and attitudes

Promoting mutual respect . . . awareness of the varying degrees of acculturation . . . a client-centered perspective . . . acceptance that beliefs may influence a patient’s response to health, illness, disease and death. . .

2. Communications styles

Sensitivity . . awareness . . . knowledge . . . alternatives to written communication .

3. Community/consumer participation

Continuous, active involvement of community leaders and members . . . involved participants are invested participants, health outcomes improve. .

4. Physical environment, materials, resources

Culturally and linguistically friendly interior design, pictures, posters, and artwork as well as magazines, brochures, audio, videos, films. . . literacy sensitive print information . . . congruent with the culture and the language . . .

5. Policies and procedures

Written policies, procedures, mission statements, goals, objectives incorporating linguistic and cultural principles . . . clinical protocols, orientation, community involvement, outreach. . . multicultural and multilingual staff reflecting the community . .

6. Population-based clinical practice

Culturally skilled clinicians avoid misapplication of scientific knowledge . . . avoid stereotyping while appreciating the importance of culture . . . know their own world views . . . learn about populations . . . understand sociopolitical influences . . . practice appropriate intervention skills and strategies . .

7. Training and professional development

Requiring training . . . nature of cultural competence training . . duration and frequency of professional development opportunities . . .

Ethnomed

http://healthlinks.washington.edu/clinical/ethnomed/

Southeast Asian

“Traditional practices are heavily based in concepts of "hot" and "cold" conditions. Younger women may no longer follow traditional practices but the family (motheror mother-in-law) may insist on following traditions and it is important to understand how an individual woman and the greater family compromise.”

Southeast Asian Pregnancy Foodways - Ethnomed

• "Cold" foods are needed for the "hot" condition of pregnancy according to Chinese categories.

• There are a wide range of foods which are felt beneficial or harmful between cultural groups.

• Bean sprouts/green peas avoided - thought to cause SAB (Vietnamese)

• Homemade rice wine, herbal medicines, coconut juice are taken to help give the baby good quality skin. Beer is thought to make the delivery easier (Cambodian)

• Drinking milk and gaining too much weight will make baby fat and difficult to deliver (all SE Asian)

Southeast Asian Postpartum Foodways - Ethnomed

• Maternal diet balanced between "hot" (alcohol, ginger, black pepper & some high protein) and "cold" (fruits, vegetables, some seafood). No sour foods (cause incontinence), no raw foods. Pork felt very nutritious.

• Cold ice water offered post delivery in the hospital may be seen as unhealthy.

• Inability to follow traditional post-partum practices is thought to cause later health problems, especially abdominal pain in women (which may occur months or even years later). Once a woman becomes sick from symptoms thought due to violation of "d'sai kchey", she is sick for the rest of her life. (Cambodian)

“Related women and women within a neighborhood have very strong ties among each other in East African communities. In some cultures, such as that of ethnicgroups from Ethiopia, women have a daily coffee ritual where they gather each day in homes to share coffee and talk. This daily gathering of women established support networks for pregnancy, postpartum help, and child care.”

East Africa Pregnancy Foodways- Ethnomed

East Africa Pregnancy Foodways- Ethnomed

• Women try to have good nutrition and particularly may increase meat in their diet.

• Flax seed flour is mixed with warm water before delivery and drunk by the woman to help produce an easy delivery.

East African Post-Partum Foodways - Ethnomed

• Traditionally women rest in bed for 40 days postpartum and are attended by other women who prepare nutritious food and do housework.

• Special teas, soups, and porridge are provided for the mother.

• Flax seed porridge with honey is commonly given to mothers post-partum.

Adolescent Development (Drake P. J Obset. Gynacol. Neonatal Nursing, 1996)

Adolescent Development (Drake P. J Obset. Gynacol. Neonatal Nursing, 1996)

Early (11-14) Middle (15-17) Late (18-20)

Concrete, Egocentric,confused about bodyand sexuality, peeroriented, need toestablish independencemay conflict with needfor support

Begins to be capable ofseeing connectionbetween behavior andhealth, emerging senseof self, may affirm adultidentity throughpregnancy

Increased ability forabstract thinking andplanning, greatercomfort with bodyimage, stronger senseof self may facilitate roleas mother, may be ableto enlist support offather of baby

Responding to Developmental Differences of Adolescence: Goal Setting

Early Middle Late

Limited –may beunable toformulaterealisticgoals

Improving –mayformulategrandiose,unrealisticgoals

Often able toset goals –may not beinterested indoing so

Responding to Developmental Differences of Adolescence: Professional Approaches

Early

Middle Late

Offer simple, concrete choices

Respect need to make independent decisions, encourage negotiation with adults

Offer opinions as one adult to another, serve as sounding board