On completion of this chapter, the reader will be able to: • Describe the scope of maternity nursing. • Evaluate contemporary issues and trends in maternity nursing. • Examine social concerns in maternity nursing. • Explain risk management and standards of practice in the delivery of nursing care. • Discuss legal and ethical issues in perinatal nursing. • Examine Healthy People 2020 goals related to maternal and infant care. 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. 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. 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). 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. 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). 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 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. 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). 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. TABLE 1-1 SELECTED SAFE PRACTICES FOR BETTER HEALTH CARE 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). 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. 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. 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 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. 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). 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).
21st Century Maternity Nursing
Advances in the Care of Mothers and Infants
Efforts To Reduce Health Disparities
Contemporary Issues and Trends
Healthy People 2020 Goals
Millennium Development Goals
Integrative Health Care
Problems with the U.S. Health Care System
Structure of the Health Care Delivery System
Reducing Medical Errors
SAFE PRACTICE
PRACTICE STATEMENT
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.
High Cost of Health Care
Limited Access to Care
Health Care Reform
Health Literacy
Trends in Fertility and Birth Rate
Maternal Mortality
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