• Evaluate contemporary issues and trends in maternity nursing. • Compare selected biostatistical data among races and countries. • Explain risk management and standards of practice in the delivery of nursing care. • Discuss legal and ethical issues in perinatal nursing. • Examine the Healthy People 2010 goals related to maternal and infant care. • Describe the main characteristics of contemporary family forms. • Identify key factors influencing family health. • Relate the impact of culture on childbearing families. • Compare community-based health care and community health (population- or aggregate-focused) care. • List indicators of community health status and their relevance to perinatal health. • Describe how home care fits into the maternity continuum of care. • Discuss safety and infection control principles as they apply to the care of patients in their homes. Additional related content can be found on the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/ • Critical Thinking Exercise: Community Resources for Families • Critical Thinking Exercise: Cultural Health and the Family • Nursing Care Plan: Community and Home Health Care • Nursing Care Plan: The Family Newly Immigrated from a Non-English-Speaking Country • Nursing Care Plan: Incorporating the Infant into the Family Maternity nursing encompasses care of childbearing women and their families through all stages of pregnancy and childbirth, as well as the first 4 weeks after birth. Throughout the prenatal period, nurses, nurse practitioners, and nurse-midwives provide care for women in clinics and physicians’ offices and teach classes to help families prepare for childbirth. Nurses care for childbearing families during labor and birth in hospitals, in birthing centers, and in the home. Nurses with special training may provide intensive care for high risk neonates in special care units and for high risk mothers in antepartum units, in critical care obstetric units, or in the home. Maternity nurses teach about pregnancy; the process of labor, birth, and recovery; breastfeeding; and parenting skills. They provide continuity of care throughout the childbearing cycle. An excellent model for nurses who care for women and children is the International Confederation of Midwives’ (www.internationalmidwives.org) Vision for Women and Their Health. Although tremendous advances have taken place in the care of mothers and their infants during the past 150 years (Box 1-1), serious problems exist in the United States related to the health and health care of mothers and infants. Lack of access to prepregnancy and pregnancy-related care for all women and lack of reproductive health services for adolescents are major concerns. Sexually transmitted infections, including acquired immunodeficiency syndrome (AIDS), continue to affect reproduction adversely. Every 10 years the U.S. Department of Health and Human Services (USDHHS) revises and updates this agenda. Healthy People 2020, has four recommended overarching goals: (1) attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieving health equity, eliminating disparities, and improving the health of all groups; (3) creating social and physical environments that promote good health for all; and (4) promoting quality of life, healthy development, and healthy behaviors across all life stages (www.healthypeople.gov/2020/about/default.aspx). Of the objectives of Healthy People 2020, 33 are related to maternal, infant, and child health. The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world’s main development challenges. The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations and signed by 147 heads of state and governments during the United Nations Millennium Summit in September 2000 (www.un.org/millenniumgoals/goals.html). Goals 3 through 5 of the MDGs relate specifically to women and children (Box 1-2). The changing health care delivery system offers opportunities for nurses to alter nursing practice and improve the way care is delivered through managed care, integrated delivery systems, and redefined roles. Consumer participation in health care decisions is increasing, information is available on the Internet, and care is provided in a technology-intensive environment (Tiedje, Price, & You, 2008). Nurses have been critically important in developing strategies to improve the well-being of women and their infants and have led the efforts to implement clinical practice guidelines and to practice using an evidence-based approach. Through professional associations, nurses have a voice in setting standards and influencing health policy by actively participating in the education of the public and of state and federal legislators (e.g., www.nursingworld.org; www.cna-nurses.ca; www.awhonn.org). For example, in 2008 the American Nurses Association (ANA) published ANA’s Health System Reform Agenda, and in 2009 a nurse was appointed the Administrator of the Health Resources and Services Administration, the agency that oversees approximately 7000 community clinics that serve low-income and uninsured people (Obama chooses UND’s Mary Wakefield as Health Resources and Services Administration Leader, February 20, 2009). Medical errors are the leading cause of death in the United States and result in as many as 98,000 deaths per year (Gauthier & Serber, 2005). In Canada, adverse events are implicated in up to 23,750 deaths per year (French, 2006). Since the Institute of Medicine released its 1999 report, To Err Is Human: Building a Safer Health System, a concerted effort has been under way to analyze causes of errors and develop strategies to prevent them. Recognizing the multifaceted causes of medical errors, the Agency for Healthcare Research and Quality (2000) prepared a Patient Fact Sheet with 20 Tips to Help Prevent Medical Errors for patients and the public. Patients are encouraged to be knowledgeable consumers of health care and ask questions of providers, including physicians, midwives, nurses, and pharmacists. In 2002 the National Quality Forum published a list of Serious Reportable Events in health care. The list was updated in 2006 and 2011 with a total of 29 events. Of these events, four pertain directly to maternity and newborn care (Box 1-3). The National Quality Forum also published Safe Practices for Better Healthcare (www.qualityforum.org). The 34 safe practices included should be used in all applicable health care settings to reduce the risk of harm that results from processes, systems, and environments of care. Box 1-4 contains a selection of practices from that document. In August 2007, the Centers for Medicare & Medicaid Services issued a rule that denies payment for eight hospital-acquired conditions effective October 2008 (O’Reilly, 2008). Five of the conditions are also on the National Quality Forum list. Conditions that might pertain to maternity nursing include a foreign object retained after surgery, air embolism, blood incompatibility, falls and trauma, and catheter-associated urinary tract infection. Almost 1300 U.S. hospitals waive costs associated with serious reportable events (O’Reilly). Health care is one of the fastest-growing sectors of the U.S. economy. Currently, 17.4% of the gross domestic product is spent on health care (Squires, 2012). A shift in demographics, an increased emphasis on high-cost technology, higher incidence of obesity, and the liability costs of a litigious society contribute to the high cost of care. Most researchers agree that caring for the increased number of low-birth-weight (LBW) infants in neonatal intensive care units contributes significantly to the overall health care costs. Barriers to access must be removed so pregnancy outcomes can be improved. The most significant barrier to access is the inability to pay. The number of uninsured people in the United States in 2010 was 49.9 million or 16.3% of the population (DeNavas-Walt, Proctor, & Smith, 2011). Lack of transportation and dependent child care are other barriers. In addition to a lack of insurance and high costs, a lack of providers for low-income women exists. Many physicians either refuse to take Medicaid patients or take only a few such patients. This circumstance presents a serious problem because a significant proportion of births are to mothers who receive Medicaid. The Health Resources and Services Administration (HRSA) Health Disparities Collaboratives are part of a national effort with the goal of eliminating disparities and improving delivery systems of health care for all people in the United States who are cared for in HRSA-supported health centers (Calvo, 2006). The National Institutes of Health has a commitment to improve the health of minorities and provides funding for research and training of minority researchers (www.nih.gov). The National Institute of Nursing Research (www.ninr.nih.gov) has included the goal of reducing disparities in its strategic plan and supports research for this purpose. A broad public health perspective is needed to reduce these disparities (Satcher & Higginbotham, 2008). Fertility trends and birthrates reflect women’s needs for health care. Box 1-5 defines biostatistical terminology useful in analyzing maternity health care. In 2009 the fertility rate, the number of births per 1000 women from 15 to 44 years of age, was 66.7 (Kochanek et al., 2012). The highest birthrates (the number of births per 1000 women) were for women between ages 25 and 29 (110.5 per 1000). The teen birthrate was 39.1 per 1000. More than one third of all births in the United States in 2009 were to unmarried women, with much variation in proportion among racial groups (non-Hispanic black, 72.8%; Hispanic, 53.2%; non-Hispanic white, 29%) (Kochanek et al., 2012). Births to unmarried women are often related to less-favorable outcomes such as LBW or preterm birth. A large number of teenagers are typically found in the unmarried group. In 2009, the birthrate to women under 20 years of age was 39.1 per 1000 (Kochanek et al., 2012). The risks of morbidity and mortality increase for newborns weighing less than 2500 g (5 lb, 8 oz)—LBW infants. Multiple births contribute to the incidence of LBW. In 2009 the incidence of LBW births was 8.1%, and the incidence of very low-birth-weight (VLBW; less than 1500 g [3.3 lb]) births was 1.4% (Kochanek et al., 2012). Racial disparity exists in the incidence of LBW. Non-Hispanic black babies are twice as likely as non-Hispanic white babies to be LBW and to die within the first year of life. By race the incidence of LBW for non-Hispanic black births was 13.6%; for non-Hispanic white births, 7.1%; and for Hispanic births, 6.9%. Cigarette smoking is associated with LBW, prematurity, and intrauterine growth restriction. In 2005, 10.7% of pregnant women smoked, a proportion that has declined slightly from 2004 (Kochanek et al., 2012). The proportion of preterm infants (i.e., those born before 37 weeks of gestation) was 12.1% in 2009. Racial variation in rates has been found: 17.4% for non-Hispanic black births, 12.1% for Hispanic births, and 11.9% for non-Hispanic white births (Kochanek et al., 2012). Multiple births accounted for 3.4% of births in 2006, with most of the increase associated with increased use of fertility drugs and older age at childbearing (Kochanek et al.). A common indicator of the adequacy of prenatal care and the health of a nation as a whole is the infant mortality rate, the number of deaths of infants younger than 1 year of age per 1000 live births. The neonatal mortality rate is the number of deaths of infants younger than 28 days of age per 1000 live births. The perinatal mortality rate is the number of stillbirths plus the number of neonatal deaths per 1000 live births. The preliminary infant mortality rate for 2009 was 6.4 (Kochanek et al., 2012). The infant mortality rate continues to be higher for non-Hispanic black babies (13.3 per 1000) than for non-Hispanic white babies (5.66 per 1000) and Hispanic babies (5.55 per 1000) (Kochanek et al.). Limited maternal education, young maternal age, unmarried status, poverty, and lack of prenatal care appear to be associated with higher infant mortality rates. Poor nutrition, smoking and alcohol use, and maternal conditions such as poor health or hypertension are also important contributors to infant mortality. To address the factors associated with infant mortality, a shift must occur from the current emphasis on high-technology medical interventions to a focus on improving access to preventive care for low-income families. The infant mortality rate of Canada (5.1 per 1000 in 2008 [data not available for 2009]) ranks twenty-fifth, and that of the United States ranks thirtieth (6.4 per 1000 in 2009) when compared with other industrialized nations (Kochanek et al., 2012). One reason for this statistic is the high rate of LBW infants born in the United States compared with other countries. The fifth Millennium Development Goal is to improve maternal health and reduce the maternal mortality rate by 75% between 1990 and 2015. Worldwide, approximately 800 women die each day of problems related to pregnancy or childbirth, with hemorrhage being the leading cause of death. Great disparities exist in maternal mortality rate between developing and developed countries. For example, in the United States in 2007 the annual maternal mortality rate (number of maternal deaths per 100,000 live births) was 12.7 (USDHHS, HRSA, Maternal and Child Health Bureau, 2010), whereas the rate in Africa in 2010 was 500 (World Health Organization [WHO], 2012). In the United States, significant racial differences exist in the rates: black or African-American women have a maternal mortality rate three times higher than that of non-Hispanic white women. The maternal mortality rate was 28.4 per 100,000 for black or African-American women, in contrast with 10.5 per 100,000 for non-Hispanic white women (USDHHS, HRSA, Maternal and Child Health Bureau, 2010). The Healthy People 2020 goal of 11.4 maternal deaths per 100,000 poses a significant challenge. The number of high risk pregnancies has increased, which means that a greater number of women are at risk for poor pregnancy outcomes (www.nlm.nih.gov/medlineplus/highriskpregnancy.html). Escalating drug use (ranging from 11% to 27% of pregnant women, depending on geographic location) has contributed to higher incidences of prematurity, LBW, congenital defects, withdrawal symptoms in infants, and learning disabilities. Alcohol use in pregnancy has been associated with miscarriages, mental retardation, LBW, and fetal alcohol syndrome. The twin birth rate was 33.2 per 1000 in 2009. The downward trend in the birthrate of higher-order multiples (triplet, quadruplet, and greater) continued in 2009, with a rate of 153.5 per 100,000 (Kochanek et al., 2012). More than one third of women in the United States are obese (body mass index of 30 or greater), with adults ages 40 to 59 having the highest prevalence. Obesity in women demonstrates significant racial disparities: 49.6% of non-Hispanic black women, 45.1% of Mexican-American women, and 33% of non-Hispanic white women ages 20 years and over are obese (Flegal, Carroll, Ogden, et al., 2010; Shields, Carroll, & Ogden, 2011). Almost 20% of women who give birth in the United States are obese. The two most frequently reported maternal medical risk factors are hypertension associated with pregnancy and diabetes, both of which are associated with obesity. Obesity in pregnancy is associated with the use of increased health care services and hospital stays that are longer (Chu et al., 2008). The Centers for Disease Control and Prevention (CDC) began working with national and international groups in 2001 to develop and implement programs to promote safe motherhood (Jones, 2008). Maternal mortality and morbidity is a measure of a nation’s commitment to the status of women and their health. The leading causes of pregnancy-related deaths in the United States are hemorrhage, blood clots, hypertension, infection, stroke, amniotic fluid embolism, and heart muscle disease. The CDC estimates that more than half of these deaths can be prevented with better access to care, better quality care, and positive changes in the health and lifestyle habits of women. The CDC continues to invest resources to improve positive outcomes and prevent negative outcomes of pregnancy (Jones). Prenatal care may promote better pregnancy outcomes by providing early risk assessment and promoting healthy behaviors such as improved nutrition and smoking cessation. In 2006, 69.9% of all women received care in the first trimester. Disparity can be seen in the use of prenatal care by race and ethnicity; Native American, Hispanic, or non-Hispanic black women were more than twice as likely as non-Hispanic white women to receive late care (i.e., care beginning in the third trimester or no care at all) (Heron, Sutton, Xu, et al., 2010). In spite of this statistic, substantial gains have been made in the use of prenatal care since the early 1990s, which is attributed to the expansion in the 1980s of Medicaid coverage for pregnant women. Women can choose physicians or nurse-midwives as primary care providers. In 2009, physicians attended 92% and nurse-midwives attended approximately 7.4% of all births (Martin, Hamilton, Ventura, et al., 2011). Hospital births accounted for 99% of births. Of the out-of-hospital births, 67% were in the home, 27% in free-standing birth centers, 0.9% in clinics or physician’s offices, and 5% other or not specified (Martin et al., 2007). Cesarean births increased to 32.9% of live births in the United States in 2009, the highest rate ever in the United States, whereas the rate of vaginal births after cesarean declined (Martin, Hamilton, Ventura, et al., 2011). This cesarean rate is significantly higher than the Healthy People 2020 goal of 23.9%. With family-centered care, fathers, partners, grandparents, siblings, and friends may be present for labor and birth. Fathers or partners may be present for cesarean births. Fathers may participate by “catching the baby” or cutting the umbilical cord or both (Fig. 1-2). Doulas—trained and experienced female labor attendants—may be present to provide a continuous, one-on-one caring presence throughout the labor and birth. Newborn infants remain with the mother and mothers are encouraged to breastfeed immediately after birth. Parents participate in the care of their infants in nurseries and neonatal intensive care units.
21st Century Maternity Nursing
Culturally Competent, Family and Community Focused
Web Resources
Contemporary Issues and Trends
Healthy People 2020 Goals
Millennium Development Goals
Integrative Health Care
Integrative health care encompasses complementary and alternative therapies in combination with conventional Western modalities of treatment. Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the patient’s input and honor the individual’s beliefs, values, and desires. The focus of these modalities is on the whole person, not just on a disease complex. Patients often find that alternative modalities are more consistent with their own belief systems and allow for more patient autonomy in health care decisions (Fig. 1-1). Complementary and alternative therapies are identified throughout the text with an icon:
Problems with the U.S. Health Care System
Structure of the health care delivery system
Reducing medical errors
High cost of health care
Limited access to care
Efforts to reduce health disparities
Trends in Fertility and Birthrate
Low Birth Weight and Preterm Birth
Infant Mortality in the United States
International Trends in Infant Mortality
Maternal Mortality Trends
Increase in High Risk Pregnancies
Care during Pregnancy and Childbirth
Safe motherhood
Childbirth practices
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