NSG210 Durham Ch. 1: Trends and Issues

Source: Durham & Chapman, Maternal-Newborn Nursing: The Critical Components of Nursing Care 4e, Chapter 1, pp. 3-17 (textbooks/DURHAM_OB_CH01.pdf, also in textbooks/exam01/). Exam 1 reading (the exam01 folder holds Durham Ch. 1-5; the weekly outline lists only Ch. 3-5 for Week 03). See also nsg210-week-03-summary.

Learning Outcomes

1. Discuss evidence-based nursing care that promotes optimal outcomes in labor and birth.
2. Examine US maternal and infant outcomes and how social determinants of health lead to disparities.
3. Identify leading causes of maternal and infant morbidity and mortality in the US.
4. Create a framework for representative, comprehensive, holistic women’s and gender health services.
5. Identify the primary maternal and infant goals of Healthy People 2030.

I. Health and the Social Determinants of Health

• WHO: health is complete physical, social, and mental well-being, not merely absence of disease; highest attainable standard of health is a fundamental right
• Social determinants of health (SDOH, Fig. 1-1):
  • Economic stability
  • Housing and neighborhood environment
  • Access to health care and quality of care
  • Access to and quality of education
  • Community and social context, including racism
• Example: obesity increases gestational diabetes, gestational hypertension, miscarriage, stillbirth, birth defects - nurses assess access to healthy food, safe exercise, affordable prenatal care
• Text uses both the social and medical models of health
• Nurses as change leaders and advocates for equitable health policy (for example the Protecting Moms Who Served Act, 2021)
• Welcoming and inclusive care: gender-affirming care for all birthing people, including transgender and gender-diverse people; welcoming care for LGBTQIA+ families
• 12% of US population identifies as LGBTQIA+ (20% of Millennials)

II. Childbirth in the United States

• Over the last 100 years birth moved from home to hospital (under 5% of births in hospitals in 1900; 75% by late 1930s)
• Medicalization of birth discredited Indigenous midwives and midwives of color, a key factor in ongoing disparities for Black, Hispanic, and Indigenous communities
• 1950s advocacy for physiologic birth; childbirth education formalized in 1960s; birth center movement early 1970s

Past vs present trends (Table 1-1):

• Physiologic focus leads to family-centered maternity care (physiologic and psychosocial)
• Home births leads to mostly hospital births, with rising home and birth center births
• Separate labor and delivery rooms leads to labor, birth, recovery in one room
• Cold sterile delivery rooms leads to warm homelike birthing rooms
• Fathers and family excluded leads to partner, family, friends included, including in cesarean births
• “Twilight sleep” leads to labor support, analgesics, epidurals, nitrous oxide
• Postpartum stay 10 days leads to 48 hours or less in hospital; 6 hours in birth center
• Infant mortality 50.1 per 1,000 (1915) leads to 5.7 per 1,000 (2020)
• Leading infant death cause: diarrhea and enteritis (1915) leads to birth defects, prematurity, low birth weight (2018)
• Maternal mortality 607.9 per 100,000 (1915) leads to 17.4 per 100,000 (2018)
• Induction 9.5% (1990) leads to 24.5% (2016)
• Cesarean 20.7% (1996) leads to 31.7% (2019)
• Improved survival of infants born 24-28 weeks

Nurse-led developments:

• Electronic fetal monitoring (1970s): continuous EFM for high-risk births; intermittent auscultation safe for low-risk births
• La Leche League International (1956): reestablished breastfeeding; nurses must provide equitable, culturally sensitive, gender-affirming breastfeeding support
• AWHONN (1969): best practices such as postpartum depression screening and hemorrhage prevention
• Baby-Friendly Hospital Initiative (WHO/UNICEF, 1991): protects and promotes breastfeeding
• Back to Sleep (NICHD, 1996) and Safe to Sleep (2012): infants on their backs to reduce SIDS
• Interprofessional consensus statements and safety bundles
• Community-led initiatives by people of color and ACNM programs to reduce disparities and increase providers of color

US status:

• Highest maternal mortality of any high-resource country; one of few countries (with Afghanistan and Sudan) where maternal mortality is rising
• Women more likely to die in pregnancy and the year after birth than in 48 other high-resource countries
• Infant mortality improving more slowly than peer countries, with wide racial and geographic disparities

III. Fertility and Birth Rates

• Total fertility rate (TFR): average children per woman over her childbearing years; over 2 means growing population, under 2 shrinking
• US TFR 1.64 (2020), down from 1.98 (2010); fell 4% from 2019 to 2020 during COVID-19 - US population shrinking and aging
• Birth rate: live births per 1,000 people; 23.7 (1960), 18.4 (1970), 10.9 (2020) - a 58% decrease
• Reasons for decline: effective contraception, women delaying childbirth for careers or remaining child-free, legal elective abortion, rising cost of raising children
• 1990-2020: birth rates fell for ages 15-29 and rose for 30-45+; greatest increase over 40; greatest decrease 15-19
• 3,605,201 US births in 2020: White 51%, Hispanic 24%, Black 14.7%, Asian 6.1%, AI/AN 0.7%, NH/PI 0.3%

IV. Preterm Births

• Very premature: under 32 weeks
• Moderately premature: 32-33 completed weeks
• Late premature: 34-36 completed weeks
• Globally about 15 million preterm births a year (10.6%); preterm complications are the leading cause of death under age 5
• US preterm rate fell 24% (2000-2015) to 9.62%, then rose; 10.23% in 2019
• Racial disparity: Black non-Hispanic 14.35% (about 50% higher) vs Hispanic 9.83% vs White 9.10% (Table 1-3: AI/AN 11.57, Asian 8.51, NH/PI 11.98)
• Lifelong effects: respiratory disorders, cerebral palsy, vision and hearing disorders, developmental delays
• 36% of infant deaths relate to preterm birth; families face economic, social, educational challenges

V. Neonatal Birth Weight

• Normal: 2,500-3,999 g; high: 4,000 g or more
• Low birth weight (LBW): under 2,500 g (but over 1,500 g); rose from 8% (2014) to 8.3% (2019)
• Very low birth weight (VLBW): under 1,500 g; about 1.4%
• Birth weight predicts future morbidity, including lifetime diabetes and heart disease
• Infants 4,000-4,999 g have the lowest first-year mortality
• VLBW infants are 100 times more likely to die in the first year than infants over 2,500 g

VI. Infant Mortality

• Death before age 1
• Global: 65 per 1,000 (1990) leads to 29 per 1,000 (2016)
• US: 26 per 1,000 (1960) leads to 5.7 (2018)
• Improvements: ECMO, exogenous surfactant, better prenatal care, infant safe-sleep education
• Leading causes (Table 1-4, 2020 order): congenital malformations and chromosomal abnormalities (111.9 per 100,000), short gestation and LBW (87.1), SIDS (38.4), accidents (33.0), maternal complications of pregnancy (30.9)
• SIDS deaths fell markedly (Safe to Sleep)
• Respiratory distress syndrome fell from 4th (1995) to 9th (2018) leading cause

VII. Maternal Death and Mortality

Definitions:

• Maternal death (WHO): death during pregnancy or within 42 days of its end from causes related to or aggravated by pregnancy or its management; excludes accidents and injuries
• Direct obstetric death: from complications of pregnancy, labor, birth, postpartum, including interventions, omissions, incorrect treatment (for example postpartum hemorrhage)
• Indirect obstetric death: preexisting or developing disease aggravated by pregnancy (for example lupus)
• Late maternal death: more than 42 days after pregnancy ends from direct or indirect cause
• Pregnancy-related death: during pregnancy or within 1 year of its end from a pregnancy complication, chain of events, or aggravated condition (for example PE from DVT)
• Maternal mortality ratio (MMR): maternal deaths per 100,000 live births

Statistics:

• US MMR fell from 607.9 (1915) to 12 (1990), rose to 17.4; US ranks last among high-resource countries
• Black women 37.1 (2.5 times White 14.7, three times Hispanic 11.8)
• About 700 women die each year and 500,000 have severe complications
• Black women twice as likely to have severe complications (cardiomyopathy, eclampsia, embolism)
• College-educated Black mother has 60% greater risk of maternal death than a White or Hispanic mother without high school education
• AI/AN women: 3-4 times higher mortality, 2 times higher severe morbidity (postpartum hemorrhage, preterm birth)
• Systemic racism and provider bias contribute to disparities
• Global decreases from female education, contraception, antenatal care, skilled birth attendants
• Leading global causes of maternal death: severe hemorrhage, infections, eclampsia, obstructed labor, abortion complications, other (anemia, HIV/AIDS, cardiovascular disease)

VIII. Key Issues Affecting Mothers and Infants

Primary US issues: teen pregnancy, tobacco and e-cigarettes, substance abuse, medication use, obesity, violence, STIs, climate change, depression and perinatal mood disorders, racism and disparities.

A. Teen pregnancy

• Teen birth rates declining since 1990 (ages 15-17 down 83.2% from 1990 to 2020; ages 10-14 down 85.7%)
• Long-acting reversible contraceptives (LARCs: implant, IUD) key to reducing teen pregnancy
• US teen birth rate 17 per 1,000 (2020) - higher than Switzerland (3) and Canada (9)
• Teen mothers: 50% earn a high school diploma (vs 90%); under 2% finish college by 30; 66% poor, 25% on welfare within 3 years; 17% have a second child before 20; STI risk; hypertensive disorders
• Children of teen mothers: prematurity, LBW, infant death (highest for mothers under 15), behavior problems, foster care, school failure, incarceration, becoming teen parents
• Teen fathers: 30% less likely to graduate high school
• Clinical judgment: advocate comprehensive sexuality education; teach contraception options and efficacy and the right to obtain birth control per state law

B. Tobacco and e-cigarettes

• Tobacco: LBW, IUGR, miscarriage, abruptio placentae, preterm birth, SIDS, newborn respiratory problems
• Pregnancy smoking fell from 19.5% (1989) to 7.2% (2016); 20.6% of prepregnancy smokers quit in pregnancy; smokers less likely to breastfeed
• Highest rates: ages 20-24, American Indian and Alaska Native women, less than high school education
• E-cigarettes not FDA controlled; contain carcinogens; nicotine impairs fetal brain and lung development; not proven to help quitting - advise against all e-cigarette use in pregnancy
• Critical Component: no tobacco or e-cigarettes in pregnancy

C. Substance abuse

• Illegal drug and cannabis use highest in women 18-25; alcohol highest 26-34
• Cannabis use in pregnancy more than doubled (2010-2017); 12.1% in first trimester, 7% overall; affects growth, LBW; stop during pregnancy and when considering pregnancy
• Heroin, cocaine, methamphetamine, MDMA: stillbirth, preterm birth, birth defects; 5% report illegal drug use; screen all pregnant women
• Alcohol: 14% use, 5% binge drink; fetal death, LBW, IUGR, intellectual disability, fetal alcohol spectrum disorders (FASDs)
• Illegal drugs: preterm birth, abruption, neonatal withdrawal, congenital defects; cocaine - fetal strokes, seizures, later cognitive problems; marijuana - preterm birth, LBW, neural tube defects

D. Medication use

• 9 in 10 pregnant women use an OTC or prescribed medication; most drugs never tested in pregnancy; discuss all substances including supplements and herbals with a provider
• Opioid use disorder at delivery quadrupled 1999-2014
• Nursing: preconception counseling; screen for substance use throughout pregnancy, postpartum, and breastfeeding

E. Overweight and obesity

• Overweight BMI 25-29; obesity 30 or more; severe obesity over 40
• 42.4% of US adults obese; severe obesity 9.2%; 28% of pregnant women obese
• Maternal risks: infertility (2 times), miscarriage, gestational hypertension, preeclampsia (2-3 times), gestational diabetes (2-3 times), thromboembolism, cesarean birth, wound infection, shoulder dystocia from macrosomia (over 4,000 g), sleep apnea, anesthesia complications, maternal death
• Fetal and infant risks: spina bifida, heart defects, anorectal atresia, hypospadias; 20% more oral clefts, 39% more neural tube defects, 50% more spina bifida; 20% more stillbirth; intrauterine death; birth injury from macrosomia; childhood obesity and diabetes; lifelong hypertension and diabetes
• Nursing: address SDOH (healthy food, safe play spaces, affordable care); preconception weight loss; refer if lifestyle change fails; prevent excessive gain in first pregnancy

F. Violence

• More than 1 in 3 women experience IPV, rape, physical violence, verbal abuse, or stalking; 10 million IPV incidents yearly
• 1 in 6 pregnant women experience IPV; over 320,000 pregnant women abused yearly
• Abuse in pregnancy: poor weight gain, substance abuse, depression, PTSD, suicide, homicide; infant LBW, preterm birth, SGA, neonatal death
• 1 in 5 adolescent girls report dating violence
• 1 in 10 older adults experience elder abuse
• Immigrant women face cultural, linguistic, economic, legal barriers (fear of deportation)
• Women with disabilities assaulted at 3 times the general rate; 83% sexually assaulted in their lifetime
• Nursing: screen all women for IPV at first prenatal visit, each trimester, and postpartum; counseling and home visits; screen for PTSD, depression, suicide risk; include older women and women with disabilities; screen for adverse childhood experiences (ACEs); homicide risk increases 5 times with IPV and a gun in the home - ask about guns

G. Perinatal depression and mood disorders

• 1 in 7 women have postpartum depression; 13-21% perinatal anxiety; 2 of 3 young pregnant women report a mental health issue
• About 20% of postpartum deaths are suicides
• Maternal effects: less participation in care, smoking and substance use, poor self- and infant care, stopping breastfeeding, suicide
• Infant effects: poor weight gain, more illness, poor bonding, sleep problems, developmental delays, infanticide
• Nursing: Consensus Bundle on Maternal Mental Health (Readiness; Recognition and Prevention; Response; Reporting and Systems Learning); screen each trimester and for 1 year after birth; earlier and more frequent postpartum visits; universal PPD screening and teaching before discharge; community services

H. Sexually transmitted infections

• COVID-19 created “pandemics within pandemics” (overdoses, IPV, STIs)
• Reportable STIs up 30% (2015-2019); congenital syphilis quadrupled; congenital syphilis neonatal deaths up 22%
• STI rates 5-8 times higher for Black Americans; 3-5 times for AI/AN and Pacific Islanders; 1-2 times for Hispanic women
• HPV may increase preterm birth and maternal complications
• Nursing: prevention, screening, diagnosis, treatment; education on vaccination, safer sex, consent, violence reduction

I. Climate change

• Threatens maternal, neonatal, and global health; low-resource communities hit hardest
• Six areas: extreme heat, outdoor air quality, flooding, vector-borne infection, water quality and drought, mental health
• Climate change increases emergence of new infectious diseases; poor air quality linked to more COVID-19 deaths
• Nursing: educate patients; know local threats and disaster plans; advocate for climate policy; monitor heat exposure and hydration; check Air Quality Index; emergency plans; limit travel to vector areas
• Critical Component: pregnant women are vulnerable to temperature extremes and dehydration, which releases labor-inducing hormones

J. Health disparities, racism, discrimination

LGBTQIA+ care:

• Disparities come from societal discrimination, not individual vulnerability
• Bisexual and lesbian women have higher miscarriage, preterm birth, LBW, stillbirth
• LGBTQIA+ youth suicide 2-3 times higher; highest tobacco, alcohol, drug use; more asthma, diabetes, uninsured
• 1 in 2 transgender people report provider discrimination; 40% postpone preventive care
• Nursing: advocate against legal discrimination; welcoming, gender-affirming environments, forms, signage; inclusive EHRs collecting gender identity and orientation; publicize nondiscrimination policies; staff training on preferred names and pronouns; Medicare and Medicaid facilities must let patients choose visitors and decision makers regardless of orientation, gender identity, marital status

Racism and discrimination:

• Black women: 3-4 times higher maternal mortality, 2 times severe complications, independent of education and income; a college-educated Black woman is 3 times more likely to have severe complications than a White woman without high school
• Black infants: 2 times infant death rate of White infants
• AI/AN women: 3-4 times maternal mortality, 2 times severe morbidity
• Physiologic “weathering” from chronic stress: elevated cortisol, higher BP, shortened telomeres leads to hypertension, preterm birth, earlier chronic disease
• 74% of Black women give birth in predominantly Black-serving hospitals with worse outcomes
• Provider bias: less postpartum diabetes screening, less pain medication, fewer epidurals for women of color
• What improves outcomes: more providers of color, community-led initiatives, leadership by people of color, addressing racism in practice, racial equity training
• Community resources: Black Mamas Matter Alliance, SisterSong

IX. Healthy People 2030 Maternal and Infant Goals (Table 1-6)

High-Yield Numbers

• Infant mortality 5.7 per 1,000; maternal mortality 17.4 per 100,000 (Black 37.1, White 14.7, Hispanic 11.8)
• Cesarean 31.7%; induction 24.5%
• TFR 1.64; birth rate 10.9 per 1,000
• Preterm: under 37 weeks; very under 32; moderate 32-33; late 34-36; US rate about 10.2%; Black 14.35%
• LBW under 2,500 g; VLBW under 1,500 g; high birth weight 4,000 g or more
• Maternal death within 42 days; late maternal death after 42 days; pregnancy-related death within 1 year
• 1 in 6 pregnant women experience IPV; 1 in 7 postpartum depression; 20% of postpartum deaths are suicide
• Obesity BMI 30 or more; 28% of pregnant women
• Pregnancy smoking 7.2%; alcohol 14%; cannabis 7%
• Teen birth rate 17 per 1,000

Priority Nursing Actions

• Assess every patient’s social determinants of health
• Screen for IPV at first visit, each trimester, postpartum; ask about guns in the home
• Screen for depression and anxiety each trimester and through 1 year postpartum
• Screen for tobacco, e-cigarette, alcohol, cannabis, illegal drug, and medication use
• Advise against all e-cigarette use in pregnancy
• Preconception counseling (weight, substances, folic acid)
• Teach safe sleep (back to sleep) and support breastfeeding
• Provide gender-affirming, inclusive, unbiased care; recognize and address racism

Related

• nsg210-durham-ch02-ethics-and-standards
• nsg210-week-03-summary
• INDEX