“Granny” Midwives

Before the twentieth century, childbirth usually occurred in the home with the assistance of a “granny” or lay midwife whose training came through an apprenticeship with a more experienced midwife. Physicians were involved in childbirth only for serious problems.

Although many women and infants fared well when a lay midwife assisted with birth in the home, maternal and infant death rates resulting from childbearing were high. The primary causes of maternal death were postpartum hemorrhage, postpartum infection, also known as puerperal sepsis (or “childbed fever”), and hypertensive disorders of pregnancy. The primary causes of infant death were prematurity, dehydration from diarrhea, and contagious diseases.

Emergence of Medical Management

By 1960, 90% of all births in the United States occurred in hospitals. Maternity care became highly regimented. All antepartum, intrapartum, and postpartum care was managed by physicians. Lay midwifery became illegal in many areas, and nurse-midwifery was not well established. The woman had a passive role in birth, as the physician “delivered” her baby. Nurses’ primary functions were to assist the physician and to follow prescribed medical orders after childbirth. Teaching and counseling by the nurse were not valued at that time.

Unlike home births, early hospital births hindered bonding between parents and infant. During labor, the woman often received medication, such as “twilight sleep,” a combination of a narcotic and scopolamine, that provided pain relief but left the mother disoriented, confused, and heavily sedated. A birth became a delivery performed by a physician. Much of the importance of early contact between parents and child was lost as physician-attended hospital births became the norm. Mothers did not see their newborn for several hours after birth. Formula feeding was the expected method. The father was relegated to a waiting area and was not allowed to see the mother until some time after birth and could only see his child through a window.

Despite the technologic advances and the move from home birth to hospital birth, maternal and infant mortality declined, but slowly. The slow decline was caused primarily by problems that could have been prevented, such as poor nutrition, infectious diseases, and inadequate prenatal care. These stubborn problems remained because of inequalities in health care delivery. Affluent families could afford comprehensive medical care that began early in the pregnancy, but poor families had very limited access to care or to information about childbearing. Two concurrent trends—federal involvement and consumer demands—led to additional changes in maternity care.

Impact of Consumer Demands on Health Care

In the early 1950s, consumers began to insist on their right to be involved in their health care. Pregnant women wanted a greater voice in their health care. They wanted information about planning and spacing their children, and they wanted to know what to expect during pregnancy. The father, siblings, and grandparents wanted to be part of the extraordinary events of pregnancy and childbirth. Parents began to insist on active participation in decisions about how their child would be born. Active participation of the patient is now expected in health care at all ages other than the very young or others who are unable to understand.

A growing consensus among child psychologists and nurse researchers indicated that the benefits of early, extended parent-newborn contact far outweighed the risk of infection. Parents began to insist that their infant remain with them, and the practice of separating the well infant from the family was abandoned.

Development of Family-Centered Maternity Care

Family-centered care increases the responsibilities of nurses. In addition to physical care and assisting the physician, nurses assume a major role in teaching, counseling, and supporting families in their decisions.

Traditional Hospital Setting

In hospitals of the past, labor often took place in a functional hospital room, often occupied by several laboring women. When birth was imminent the mother was moved to a delivery area similar to an operating room. After giving birth the mother was transferred to a recovery area for 1 to 2 hours of observation and then taken to a standard hospital room on the postpartum unit. The infant was moved to the newborn nursery when the mother was transferred to the recovery area. Mother and infant were reunited when the mother was settled in her postpartum room. Beginning in the 1970s, the father or another significant support person could usually remain with the mother throughout labor, birth, and recovery, including cesarean birth.

Although birth in a traditional hospital setting was safe, the setting was impersonal and uncomfortable. Moving from room to room, especially during late labor, was a major disadvantage. Each move was uncomfortable for the mother, disrupted the family’s time together, and often separated the parents from the infant. Because of these disadvantages, hospitals began to devise settings that were more comfortable and included family participation.

Birth Centers

Free-standing birth centers provide maternity care outside the acute-care setting to low-risk women during pregnancy, birth, and postpartum. Most provide gynecologic services such as annual checkups and contraceptive counseling. Both the mother and infant continue to receive follow-up care during the first 6 weeks. This may include help with breastfeeding, a postpartum examination at 4 to 6 weeks, family planning information, and examination of the newborn. Care is often provided by certified nurse-midwives (CNMs) who are registered nurses with advanced preparation in midwifery.

Birth centers are less expensive than acute-care hospitals, which provide advanced technology that may be unnecessary for low-risk women. Women who want a safe, homelike birth in a familiar setting with staff they have known throughout their pregnancies express a high rate of satisfaction.

The major disadvantage is that most freestanding birth centers are not equipped for obstetric emergencies. Should unforeseen difficulties develop during labor, the woman must be transferred by ambulance to a nearby hospital to the care of a back-up physician who has agreed to perform this role. Some families do not feel that the very short stay after birth, often less than 12 hours, allows enough time to detect early complications in mother and infant.

Home Births

In the United States only a small number of women have their babies at home. Because malpractice insurance for midwives attending home births is expensive and difficult to obtain, the number of midwives who offer this service has decreased greatly.

Home birth provides the advantages of keeping the family together in their own environment throughout the childbirth experience. Bonding with the infant is unimpeded by hospital routines, and breastfeeding is encouraged. Women and their support person have a sense of control because they actively plan and prepare for each detail of the birth.

Giving birth at home also has disadvantages. The woman must be screened carefully to make sure that she has a very low risk for complications. If transfer to a nearby hospital becomes necessary, the time required may be too long in an emergency. Other problems of home birth may include the need for the parents to provide an adequate setting and supplies for the birth if the midwife does not provide supplies. The mother must care for herself and the infant without the professional help she would have in a hospital setting.

Historical Perspectives

The nursing care of children has been influenced by multiple historical and social factors. Children have not always enjoyed the valued position that they hold in most families today. Historically, in times of economic or social instability, children have been viewed as expendable. In societies in which the struggle for survival is the central issue and only the strongest survive, the needs of children are secondary. The well-being of children in the past depended on the economic and cultural conditions of the society. At times, parents have viewed their children as property, and children have been bought and sold, beaten, and, in some cultures, sacrificed in religious ceremonies. At times, infanticide has been a routine practice. Conversely, in other instances, children have been highly valued and their birth considered a blessing. Viewed by society as miniature adults, children in the past received the same remedies as adults and, during illness, were cared for at home by family members, just as adults were.

Societal Changes

On the North American continent, as European settlements expanded during the seventeenth and eighteenth centuries, children were valued as assets to the community because of the desire to increase the population and share the work. Public schools were established, and the courts began to view children as minors and protect them accordingly. Devastating epidemics of smallpox, diphtheria, scarlet fever, and measles took their toll on children in the eighteenth century. Children often died of these virulent diseases within 1 day.

The high mortality rate in children led some physicians to examine common child-care practices. In 1748, William Cadogan’s “Essay Upon Nursing” discouraged unhealthy child-care practices, such as swaddling infants in three or four layers of clothing and feeding them thin gruel within hours after birth. Instead, Cadogan urged mothers to breastfeed their infants and identified certain practices that were thought to contribute to childhood illness. Unfortunately, despite the efforts of Cadogan and others, child-care practices were slow to change. Later in the eighteenth century, the health of children improved with certain advances such as inoculation against smallpox.

In the nineteenth century, with the flood of immigrants to eastern American cities, infectious diseases flourished as a result of crowded living conditions; inadequate and unsanitary food; and harsh working conditions for men, women, and children. It was common for children to work 12- to 14-hour days in factories, and their earnings were essential to the survival of the family. The most serious child health problems during the nineteenth century were caused by poverty and overcrowding. Infants were fed contaminated milk, sometimes from tuberculosis-infected cows. Milk was carried to the cities and purchased by mothers with no means to refrigerate it. Infectious diarrhea was a common cause of infant death.

During the late nineteenth century, conditions began to improve for children and families. Lillian Wald initiated public health nursing at Henry Street Settlement House in New York City, where nurses taught mothers in their homes. In 1889, a milk distribution center opened in New York City to provide uncontaminated milk to sick infants.

Hygiene and Hospitalization

The discoveries of scientists such as Pasteur, Lister, and Koch, who established that bacteria caused many diseases, supported the use of hygienic practices in hospitals and foundling homes. Hospitals began to require personnel to wear uniforms and limit contact among children in the wards. In an effort to prevent infection, hospital wards were closed to visitors. Because parental visits were noted to cause distress, particularly when parents had to leave, parental visitation was considered emotionally stressful to hospitalized children. In an effort to prevent such emotional distress and the spread of infection, parents were prohibited from visiting children in the hospital. Because hospital care focused on preventing disease transmission and curing physical diseases, the emotional health of hospitalized children received little attention.

Development of Family-Centered Child Care

Family-centered child health care developed from the recognition that the emotional needs of hospitalized children usually were unmet. Parents were not involved in the direct care of their children. Children were often unprepared for procedures and tests, and visiting was severely controlled and even discouraged.

Family-centered care is based on a philosophy that recognizes and respects the pivotal role of the family in the lives of both well and ill children. It strives to support families in their natural caregiving roles and promotes healthy patterns of living at home and in the community. Finally, parents and professionals are viewed as equals in a partnership committed to excellence at all levels of health care.

Most health care settings have a family-centered philosophy in which families are given choices, provide input, and are given information that is understandable by them. The family is respected, and its strengths are recognized.

The Association for the Care of Children’s Health (ACCH), an interdisciplinary organization, was founded in 1965 to provide a forum for sharing experiences and common problems and to foster growth in children who must undergo hospitalization. Today the organization has broadened its focus on child health care to include the community and the home.

Through the efforts of ACCH and other organizations, increasing attention has been paid to the psychological and emotional effects of hospitalization during childhood. In response to greater knowledge about the emotional effects of illness and hospitalization, hospital policies and health care services for children have changed. Twenty-four-hour parental and sibling visitation policies and home care services have become common. The psychological preparation of children for hospitalization and surgery has become standard nursing practice. Many hospitals have established child life programs to help children and their families cope with the stress of illness. Shorter hospital stays, home care, and day surgery also have helped minimize the emotional effects of hospitalization and illness on children.

Diagnosis-Related Groups

Diagnosis-related groups (DRGs) are a method of classifying related medical diagnoses based on the amount of resources that are generally required by the patient. This method became a standard in 1987, when the federal government set the amount of money that would be paid by Medicare for each DRG. If the facility delivers more services or has greater costs than what it will be reimbursed for by Medicare, the facility must absorb the excess costs. Conversely, if the facility delivers the care at less cost than the payment for that DRG, the facility keeps the remaining money. Health care facilities working under this arrangement benefit financially if they can reduce the patient’s length of stay and thereby reduce the costs for service. Although the DRG system originally applied only to Medicare patients, most states have adopted the system for Medicaid payments, and most insurance companies use a similar system.

Managed Care

Health insurance companies also examined the cost of health care and instituted a health care delivery system that has been called managed care. Examples of managed care organizations are health maintenance organizations (HMOs), point of service plans (POSs), and preferred provider organizations (PPOs). HMOs provide relatively comprehensive health services for people enrolled in the organization for a set fee or premium. Similarly, PPOs are groups of health care providers who agree to provide health services to a specific group of patients at a discounted cost. When a patient needs medical treatment, managed care includes strategies such as payment arrangements and preadmission or pretreatment authorization to control costs.

Managed care, provided appropriately, can increase access to a full range of health care providers and services for women and children, but it must be closely monitored. Nurses serve as advocates in the areas of preventive, acute, and chronic care for women and children. The teaching time lines for preventive and home care have been shortened drastically, and the call to “begin teaching the moment the child or woman enters the health care system” has taken on a new meaning. Women, parents of the child, and other caregivers are being asked to do procedures at home that were once done by professionals in a hospital setting. Systems must be in place to monitor adherence, understanding, and the total care of a patient. Assessment and communication skills need to be keen, and the nurse must be able to work with specialists in other disciplines.

Capitated Care

Capitation may be incorporated into any type of managed care plan. In a pure capitated care plan, the employer (or government) pays a set amount of money each year to a network of primary care providers. This amount might be adjusted for age and sex of the patient group. In exchange for access to a guaranteed patient base, the primary care providers agree to provide general health care and to pay for all aspects of the patient’s care, including laboratory work, specialist visits, and hospital care.

Capitated plans are of interest to employers as well as the government because they allow a predictable amount of money to be budgeted for health care. Patients do not have unexpected financial burdens from illness. However, patients lose most of their freedom of choice regarding who will provide their care. Providers can lose money (1) if they refer too many patients to specialists, who may have no restrictions on their fees, (2) if they order too many diagnostic tests, or (3) if their administrative costs are too high. Some health care providers and consumers fear that cost constraints might affect treatment decisions.

Case Management

Evidence-Based Nursing Care

Outcomes Management

The determination to lower health care costs while maintaining the quality of care has led to a clinical practice model called outcomes management. This is a systematic method to identify outcomes and to focus care on interventions that will accomplish the stated outcomes for children with specific issues, such as the child with asthma.

Public Health Insurance Programs

Preventive Health

Maternal Mortality

Infant Mortality

Between 1950 and 1990, infant mortality dropped from 29.2 to 9.2 deaths per 1000 live births. The infant mortality rate (death before the age of 1 year) has decreased slightly from 7 per 1000 in 2002 to 6.7 per 1000 in 2007. The neonatal mortality rate (death before 28 days of life) dropped to 4.4 deaths per 1000 live births in 2007. The five leading causes of infant mortality for 2007 include congenital malformations, deformations, and chromosome abnormalities; sudden infant death syndrome (SIDS); newborn problems related to maternal complications; and unintentional injury.