21st Century Maternity Nursing

21st Century Maternity Nursing

Shannon E. Perry

Maternity nursing encompasses care of childbearing women and their families through all stages of pregnancy and childbirth and 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 (e.g., www.birthcenters.org), and in the home. Nurses with special training may provide intensive care for high risk neonates in special care units and 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; and parenting skills. They provide continuity of care throughout the childbearing cycle.

Nurses caring for women have helped make the health care system more responsive to women’s needs. They 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 practice using an evidence-based approach. Through professional associations nurses can have a voice in setting standards and influencing health policy by actively participating in the education of the public and state and federal legislators (e.g., www.nursingworld.org; www.can-nurses.ca; www.awhonn.org; www.capwhn.ca). Some nurses hold elective office and influence policy directly. For example, Mary Wakefield, a nurse, is the administrator of the Health Resources and Services Administration, the agency that oversees approximately 7000 community clinics that serve low-income and uninsured people.

Advances in the Care of Mothers and Infants

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 the lack of reproductive health services for adolescents are major concerns. Sexually transmitted infections, including acquired immunodeficiency syndrome (AIDS), continue to affect reproduction adversely.

Box 1-1   Historic Overview of Milestones in the Care of Mothers and Infants

1847—James Young Simpson in Edinburgh, Scotland used ether for an internal podalic version and birth; the first reported use of obstetric anesthesia

1861—Ignaz Semmelweis wrote The Cause, Concept and Prophylaxis of Childbed Fever

1906—First U.S. program for prenatal nursing care established

1908—Childbirth classes started by the American Red Cross

1909—First White House Conference on Children convened

1911—First milk bank in the United States established in Boston

1912—U.S. Children’s Bureau established

1915—Radical mastectomy determined to be effective treatment for breast cancer

1916—Margaret Sanger established first American birth control clinic in Brooklyn, New York

1918—Condoms became legal in the United States

1923—First U.S. hospital center for premature infant care established at Sarah Morris Hospital in Chicago, Illinois

1929—The modern tampon (with an applicator) invented and patented

1933—Sodium pentothal used as anesthesia for childbirth; Natural Childbirth published by Grantly Dick-Read

1934—Dionne quintuplets born in Ontario, Canada, and survive partly due to donated breast milk

1935—Sulfonamides introduced as cure for puerperal fever

1941—Penicillin used as a treatment for infection

1941—Papanicolaou (Pap) tests introduced

1942—Premarin approved by the Food and Drug Administration (FDA) as treatment for menopausal symptoms

1953—Virginia Apgar, an anesthesiologist, published Apgar scoring system of neonatal assessment

1956—Oxygen determined to cause retrolental fibroplasia (now known as retinopathy of prematurity)

1958—Edward Hon reported on the recording of the fetal electrocardiogram (ECG) from the maternal abdomen (first commercial electronic fetal monitor produced in the late 1960s)

1958—Ian Donald, a Glasgow physician, was first to report clinical use of ultrasound to examine the fetus

1959—Thank You, Dr. Lamaze published by Marjorie Karmel

1959—Cytologic studies demonstrated that Down syndrome is associated with a particular form of nondisjunction now known as trisomy 21

1960—American Society for Psychoprophylaxis in Obstetrics (ASPO/Lamaze) formed

1960—International Childbirth Education Association founded

1960—Birth control pill introduced in the United States

1962—Thalidomide found to cause birth defects

1963—Title V of the Social Security Act amended to include comprehensive maternity and infant care for women who were low income and high risk

1963—Testing for PKU begun

1965—Supreme Court ruled that married people have the right to use birth control

1967—Rho(D) immune globulin produced for treatment of Rh incompatibility

1967—Reva Rubin published article on Maternal Role Attainment

1968—Rubella vaccine became available

1969—Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) founded; renamed Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and incorporated as a 501(c)3 organization in 1993

1969—Mammogram became available

1972—Special Supplemental Food Program for Women, Infants, and Children (WIC) started

1973—Abortion legalized in United States

1974—First standards for obstetric, gynecologic, and neonatal nursing published by NAACOG

1975—The Pregnant Patient’s Bill of Rights published by the International Childbirth Education Association

1976—First home pregnancy kits approved by FDA

1978—Louise Brown, first test-tube baby, born

1987—Safe Motherhood initiative launched by World Health Organization and other international agencies

1991—Society for Advancement of Women’s Health Research founded

1992—Office of Research on Women’s Health authorized by U.S. Congress

1993—Female condom approved by FDA

1993—Human embryos cloned at George Washington University

1993—Family and Medical Leave Act enacted

1994—DNA sequences of BRCA1 and BRCA2 identified

1994—Zidovudine guidelines to reduce mother-to-fetus transmission of HIV published

1996—FDA mandated folic acid fortification in all breads and grains sold in United States

1998—Newborns’ and Mothers’ Health Act went into effect

1998—COGNN becomes AWHONN Canada

1999—First emergency contraceptive pill for pregnancy prevention (Plan B) in women who had unprotected sex approved by FDA

2000—Working draft of sequence and analysis of human genome completed

2006—HPV vaccine available

2010—Centenary of the death of Florence Nightingale

2010—Patient Protection and Affordable Care Act signed into law by President Obama

2011—AWHONN Canada becomes the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN)

2012—U.S. Supreme Court upheld individual mandate but not the Medicaid expansion provisions of the Patient Protection and Affordable Care Act

2012—Scientists reported findings of the ENCODE (Encyclopedia of DNA Elements) project showing that 80% of the human genome is active

HIV, Human immunodeficiency virus; HPV, human papilloma virus.

Efforts To Reduce Health Disparities

Racial and ethnic diversity is increasing within North America. It is estimated that by the year 2050, 54% of the population will be minority, with 46% of the population European-American, 15% African-American, 30% Hispanic, 9.2% Asian-American, 2% American Indians and Alaska Natives, and 0.6% Native Hawaiian and Other Pacific Islanders (U.S. Census Bureau, 2008).

Significant disparities in morbidity and mortality rates are experienced by African-Americans, Native Americans, Hispanics, Alaska Natives, and Asian/Pacific Islanders compared to Caucasians. Shorter life expectancy, higher infant and maternal mortality rates, more birth defects, and more sexually transmitted infections are found among these ethnic and racial minority groups. The disparities are thought to result from a complex interaction among biologic factors, environment, and health behaviors. Disparities in education and income are associated with differences in morbidity and mortality.

The Health Resources and Services Administration (HRSA) Health Disparities Collaboratives are part of a national effort to eliminate disparities and improve delivery systems of health care for all people in the United States who are cared for in HRSA-supported health centers. Over 900 community health centers have implemented the collaboratives and are successful in improving quality of care (Chin, 2011). 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 includes in its strategic plan support of research that promotes health equity and eliminates health disparities.

The Centers for Disease Control and Prevention (CDC) released the First Periodic Health Disparities and Inequalities Report—United States, 2011 (CDC, 2011). The report includes recent trends and variation in health disparities and inequalities in some social and health indicators and provides data against which to measure progress in eliminating disparities. Topics specific to perinatal nursing that are addressed are infant deaths, preterm births, and adolescent pregnancy and childbirth. Also in 2011 the U.S. Department of Health and Human Services (USDHHS) released an HHS Disparities Action Plan that provides a vision of “a nation free of disparities in health and health care” (USDHHS, 2011). Through this plan HHS will promote evidence-based programs, integrated approaches, and best practices to reduce disparities. The Action Plan complements the 2011 National Stakeholder Strategy for Achieving Health Equity prepared by the National Partnership for Action. This strategy proposes a comprehensive, community-driven approach to achieve health equity through collaboration and synergy (National Partnership for Action, 2011). Through these initiatives the United States is making a concerted effort to eliminate health disparities.

This chapter presents a general overview of issues and trends related to the health and health care of women and infants.

Contemporary Issues and Trends

Healthy People 2020 Goals

Healthy People provides science-based 10-year national objectives for improving the health of all Americans. It has four 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). The goals of Healthy People 2020 are based on assessments of major risks to health and wellness, changes in public health priorities, and issues related to the health preparedness and prevention of our nation. Of the objectives of Healthy People 2020, 33 are related to maternal, infant, and child health (Box 1-2).

Box 1-2

Healthy People 2020 Maternal, Infant, and Child Health Objectives

• Reduce the rate of fetal and infant deaths.

• Reduce the 1-year mortality rate for infants with Down syndrome.

• Reduce the rate of child deaths.

• Reduce the rate of adolescent and young adult deaths.

• Reduce the rate of maternal mortality.

• Reduce maternal illness and complications caused by pregnancy (complications during hospitalized labor and delivery).

• Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women.

• Reduce low birth weight (LBW) and very low birth weight (VLBW).

• Reduce preterm births.

• Increase the proportion of pregnant women who receive early and adequate prenatal care.

• Increase abstinence from alcohol, cigarettes, and illicit drugs in pregnant women.

• Increase the proportion of pregnant women who attend a series of prepared childbirth classes.

• Increase the proportion of mothers who achieve a recommended weight gain during their pregnancies.

• Increase the proportion of women of childbearing potential with intake of at least 400 mcg of folic acid from fortified foods or dietary supplements.

• Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations.

• Increase the proportion of women delivering a live birth; increase those who receive preconception care services and practice key recommended preconception health behaviors.

• Reduce the proportion of people ages 18 to 44 years who have impaired fecundity (i.e., a physical barrier preventing pregnancy or carrying a pregnancy to term).

• Decrease postpartum relapse of smoking in women who quit smoking during pregnancy.

• Increase the proportion of women giving birth who attend a postpartum care visit with a health worker.

• Increase the proportion of infants who are put to sleep on their backs.

• Increase the proportion of infants who are breastfed.

• Increase the proportion of employers who have worksite lactation programs.

• Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.

• Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

• Reduce the occurrence of fetal alcohol syndrome (FAS).

• Reduce the proportion of children diagnosed with a disorder through newborn blood spot screening who experience developmental delay requiring special education services.

• Reduce the proportion of children with cerebral palsy born as LBW infants (less than 2500 g).

• Reduce occurrence of neural tube defects.

• Increase the proportion of young children with an autism spectrum disorder (ASD) and other developmental delays who are screened, evaluated, and enrolled in early intervention services in a timely manner.

• Increase the proportion of children, including those with special health care needs, who have access to a medical home.

• Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems.

• Increase appropriate newborn blood-spot screening and follow-up testing.

• Increase the number of states, including the District of Columbia, that verify through linkage with vital records that all newborns are screened shortly after birth for conditions mandated by their state-sponsored screening program.

• Increase the proportion of screen-positive children who receive follow-up testing within the recommended time period.

• Increase the proportion of children with a diagnosed condition identified through newborn screening who have an annual assessment of services needed and received.

• Increase the proportion of VLBW infants born at level III hospitals or subspecialty perinatal centers.

Adapted from HealthyPeople.gov: Maternal, infant, and child health, 2012, www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26.

Millennium Development Goals

The United Nations Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the main development challenges in the world. They 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 three through five of the MDGs relate specifically to women and children (Box 1-3).

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 also allow for more patient autonomy in health care decisions (Fig. 1-1). Examples of alternative modalities include acupuncture, macrobiotics, herbal medicines, massage therapy, biofeedback, meditation, yoga, and chelation therapy.

The National Center for Complementary and Alternative Medicine (NCCAM) (http://nccam.nih.gov/) is a United States government agency that supports research and evaluation of various alternative and complementary modalities and provides information to health care consumers about such modalities. It is one of the 27 institutes and centers included in the National Institutes of Health.

Problems with the U.S. Health Care System

Structure of the Health Care Delivery System

The U.S. health care delivery system is often fragmented and expensive and is inaccessible to many. Opportunities exist 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 is increasing, and health care providers include them in decision-making; information is available on the Internet; and care is provided in a technology-intensive environment (Tiedje, Price, and You, 2008).

Reducing Medical Errors

Medical errors are a leading cause of death in the United States and result in as many as 98,000 deaths per year (Pham, Aswani, Rosen, et al., 2012). In Canada adverse events are implicated in up to 23,750 deaths per year (French, 2006). Since the Institute of Medicine (IOM) 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 (AHRQ) (2000) prepared a fact sheet, 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 Healthcare. The list was updated in 2006 and again in 2011, resulting in a total of 29 events. Of these 29 events three pertain directly to maternity and newborn care (Box 1-4). The National Quality Forum published Safe Practices for Better Healthcare in 2003 and updated it most recently in 2010 (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. Table 1-1 contains a selection of practices from that document.



Safe Practice 2:
Culture Measurement, Feedback, and Intervention
Health care organizations must measure their culture, provide feedback to leadership and staff, and undertake interventions that reduce patient safety risk.
Safe Practice 5:
Informed Consent
Ask each patient or legal surrogate to “teach back” in his or her own words key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent.
Safe Practice 11:
Intensive Care Unit Care
All patients in general intensive care units (both adult and pediatric) should be managed by physicians who have specific training and certification in critical care medicine (“critical care certified”).
Safe Practice 12:
Patient Care Information
Ensure that care information is transmitted and appropriately documented in a timely manner and a clearly understandable form to patients and all of the patients’ health care providers/professionals, within and between care settings, who need that information to provide continued care.
Safe Practice 19:
Hand Hygiene
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
Safe Practice 34:
Pediatric Imaging
When CT imaging studies are undertaken on children, “child-size” techniques should be used to reduce unnecessary exposure to ionizing radiation.

CT, Computed tomography.

From National Quality Forum (NQF): Safe practices for better healthcare—2010 update: a consensus report, Washington, DC, 2010, NQF.

In August 2007 the Centers for Medicare & Medicaid Services (CMS) issued a rule that became effective October 2008 that denies payment for eight hospital-acquired conditions (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 infections. Almost 1300 U.S. hospitals waive (do not bill for) costs associated with serious reportable events (O’Reilly, 2008).

High Cost of Health Care

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). Higher spending in the United States compared to 12 other industrialized countries is related to higher prices, readily accessible technology, and greater obesity (Squires, 2012). Most researchers agree that caring for the increased number of low-birth-weight (LBW) infants in neonatal intensive care units contributes significantly to overall health care costs.

Midwifery care has helped contain some health care costs. However, not all insurance carriers reimburse nurse practitioners and clinical nurse specialists as direct care providers. Nor do they reimburse for all services provided by nurse-midwives, a situation that continues to be a problem. Nurses must become involved in the politics of cost containment because they, as knowledgeable experts, can provide solutions to many health care problems at a relatively low cost.

Limited Access to Care

Barriers to access must be removed so pregnancy outcomes and care of children 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, and 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 because many physicians either refuse to take Medicaid patients or take only a few such patients. This presents a serious problem because a significant proportion of births are to mothers who receive Medicaid.

Health Care Reform

In early 2010 President Obama signed into law the Patient Protection and Affordable Care Act. The Act aims to make insurance affordable, contain costs, strengthen and improve Medicare and Medicaid, and reform the insurance market. There are provisions to promote prevention and improve public health; improve the quality of care for all Americans; reduce waste, fraud, and abuse; and reform the health delivery system. There are some immediate benefits, but implementation of the act will occur over the next several years.

In 2012 26 states, several individuals, and the National Federation of Independent Business brought suit challenging the constitutionality of the individual mandate (requirement for most Americans to have minimum essential health insurance) and the Medicaid expansion (expand the scope of coverage and increase the number of individuals the states must cover). The Supreme Court upheld the individual mandate but not the Medicaid expansion (Sacks, 2012). The debate continues on how the plan will be implemented.

Health Literacy

Health literacy involves a spectrum of abilities, ranging from reading an appointment slip to interpreting medication instructions. These skills must be assessed routinely to recognize a problem and accommodate patients with limited literacy skills. Most patient education materials are written at too high a level for the average adult (Wilson, 2009). According to the National Assessment of Adult Literacy, only 12% of English-speaking adults in the United States have health literacy skills that are proficient (Kutner, Greenberg, Jin, et al., 2006). The CDC has a health literacy website (www.cdc.gov/healthliteracy) that highlights implementation of goals and strategies of the National Action Plan to Improve Health Literacy (USDHHS, Office of Disease Prevention and Health Promotion, 2010). Health literacy is part of the Patient Protection and Affordable Care Act.

As a result of the increasingly multicultural U.S. population, there is a more urgent need to address health literacy as a component of culturally and linguistically competent care. Health care providers contribute to health literacy by using simple, common words; avoiding jargon; and assessing whether the patient understands the discussion. Speaking slowly and clearly and focusing on what is important increase understanding.

Trends in Fertility and Birth Rate

Fertility trends and birth rates reflect women’s needs for health care. Box 1-5 defines biostatistical terminology useful in analyzing maternity health care. In 2009 the fertility rate (i.e., births per 1000 women from 15 to 44 years of age) was 66.7 (Kochanek, Kirmeyer, Martin, et al., 2012). The highest birth rates occurred among women between 25 and 29 years of age (110.5). The birth rate (i.e., number of live births in 1 year per 1000 population), was 13.5 in 2009; the teen birth rate was 39.1. In 2009 the proportion of births by unmarried women varied widely among racial groups in the United States: non-Hispanic black, 72.8%; Hispanic, 53.2%; and non-Hispanic white, 29% (Kochanek, Kirmeyer, Martin, et al., 2012).

Maternal Mortality

Worldwide approximately 800 women die each day of problems related to pregnancy or childbirth. In the United States in 2009, the annual maternal mortality rate (number of maternal deaths per 100,000 live births) was 17.8 (CDC, 2013). Although the overall number of maternal deaths is small, maternal mortality remains a significant problem because a high proportion of deaths are preventable, primarily through improving the access to and use of prenatal care services. In the United States there is significant racial disparity in the rates of maternal death: non-Hispanic black women (35.6), non-Hispanic white women (11.7), and women of other races (17.6) (CDC, 2013).

The leading causes of maternal death attributable to pregnancy differ over the world. In general three major causes have persisted for the last 50 years: hypertensive disorders, infection, and hemorrhage. Unsafe abortion is an additional factor. The three leading causes of maternal mortality in the United States today are gestational hypertension, pulmonary embolism, and hemorrhage. Factors that are strongly related to maternal death include age (younger than 20 years and 35 years or older), lack of prenatal care, low educational attainment, unmarried status, and non-Caucasian race. Worldwide strategies to reduce maternal mortality rates include improving access to skilled attendants at birth, providing postabortion care, improving family planning services, and providing adolescents with better reproductive health services (MDGs, 2008).

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Sep 16, 2016 | Posted by in NURSING | Comments Off on 21st Century Maternity Nursing

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