Current Issues in Maternal-Newborn Nursing:

1. Current Issues in Maternal-Newborn Nursing: No More Octamom!

2. What Are Current Issues in Maternal-Newborn Nursing?

3. Maternal Mortality • 28 countries have lower maternal mortality rates than the US • MM=# of women dying around the time of childbirth • US ranks 41st in the world (Amnesty International) • 37th(Lancet) • An American woman is at least twice as likely to die in pregnancy or childbirth as a woman in much of Europe.

4. The Numbers • Every year at least 1,000 women die around the time of birthing • That is 3 jumbo jets full of our sisters, daughters and mothers

5. Maternal Mortality • Lifetime risk of a maternal death during or shortly after pregnancy is 1 in 17,400 in Sweden • 1 in 8 in Afganistan #2 • 1 in 7 in Niger #1

6. jhpiego • Hemorrhage #1 cause of maternal death • Community based distribution of misoprostol • “3 little pills after you deliver the baby” • http://www.npr.org/templates/story/story.php?storyId=130180983&sc=emaf • Is there a connection between hypocalcemia and preeclampsia, can we distribute calcium to the general public cheaply? Yes $0.92 for 100 sachets of calcium to sprinkle on food.

7. “Be the change that you want to be in the world.”Gandhi • It’s Global • One woman dies every minute from a pregnancy complication • 300,000 • Most die in developing countries • One woman dies every 2 minutes from cervical cancer, 80% in the developing world • 10,000 pregnant women die each year from Malaria • 200,00 newborns die each year from Malaria • 60% of adults with HIV in Sub-Saharan Africa are women

8. Why? So high in the US • Two to three women die every day due to pregnancy-related complications • The three leading causes of maternal death nationally are: • Eclampsia/Pre-eclampsia • Embolism • Hemorrhage

9. Need Collaborative Approaches to Early Identification and Treatment • Risk assessment and preparation for possible hemorrhage, EBL, tx of hemorrhage, hypovolemia, development and implementation of Rapid Response OB • Education and simulation drills.

10. Why study maternal M & M • Evidence suggests that at least one half of pregnancy-related deaths may be preventable through changes in patient, provider, or system factors. • Mortality is disproportionally high among certain racial and ethnic groups. • Deaths are only the tip of the iceberg: morbidity represents a huge burden of disease for women and their families.

11. The Babies • 41 countries have lower infant mortality rates than the US • Infant mortality = babies dying before their first birthday • US ranks 31st of developed nations, falling behind South Korea, Cuba, Czech Republic

12. Infant Mortality • 2 per 1,000 live births in Iceland • 120 per 1,000 live births in Mozambique

13. Power of Nurses • 70-80% of the health care work force is nurses • 85% of the health care workforce in rural Africa is nurses.

14. Colorado Statistics LBW: less than 5.8 pounds National average is 8.3% Colorado is 9.6% Some of the top rated states are as low as 6%

15. B4Babies • B4Babies a program in Mesa County has given the county the best ranking in the state 8.4% • Offers every type of care an expectant mother could need: help filling out applications for financial assistance, help with medical appointments, translation, transportation • Started 19 years ago • Recognized by HHS in 1998 as a “Model that Works”

16. Costs for LBW babies in CO • $10,000 per day • March of Dimes has tallied the average cost nationally for the first year of life for LBW babies beyond intensive care at $49,000 • Prenatal care and education that helps expectant mothers stop risky behaviors is vastly cheaper than paying for the care of babies with problems

17. Colorado Infant Mortality • The infant mortality disparity seen nationwide among Black infants is observed in Colorado as well, and has been present over time. • In 2006, the infant mortality rate among Black infants in Colorado was 12.4 per 1,000 live births to Black mothers while that among White/non-Hispanic infants was 5.0

18. Women of Color in Colorado • After controlling for maternal age, education, prenatal care, short gestation and low birth weight, multiple births, medical risk factors, and labor and delivery complications, Black mothers still had 50 percent greater odds of infant death compared to White/non-Hispanic mothers (Odds Ratio: 1.5, 95% Confidence Interval: 1.3-1.8).

19. Where We Need to Be The Healthy People 2010 objective for infant mortality is less than 4.5 infant deaths per 1,000 live births across all race/ethnic groups.

20. WHY? • Among the myriad possible explanations for the increase in low-weight births are the use of fertility treatments and the increasing rates of multiple births (twins, triplets, etc.) • Research has shown that both multiple births and singleton births from assisted reproductive technologies (ART) have higher risks of low birth weight and prematurity compared to infants born without ART. • Colorado’s birth certificate included information about ART for the first time in 2007, which will allow for further study of this issue both in Colorado and nationwide. • More about ART later

21. Millennium Development Goals • In 2000, world leaders set far-reaching goals to free a major portion of the world’s population from poverty, hunger, illiteracy, and disease. • Targeted achievement by 2015 • Halve extreme poverty • Halt spread of HIV/AIDS • Universal primary education

22. Poverty’s Affect on Women’s Health • 44 Million Americans • 1 out of 7 adults, 1 out of 5 children • Lack of health insurance: 51 Million Americans in 2009

23. Poverty in CO • 12.3% in 2009, the 31st highest in the US • 16.3% Colorado poverty rate for children in 2009 • People living without health insurance in Colorado 16%

24. It is Global • Poverty, economic development, and the poor health of women are a lethal combination of elements, left untouched will result in continued poor health of families, continued high rates of maternal and child mortality and morbidity and limited national development in most resource-poor countries of the world.

25. MDGs • Aim of the United Nations Millennium Development Goals (MDGs) is to reduce the number of people throughout the world who live on less than $1 a day by 50%, by finding solutions to poverty, hunger, disease, illiteracy, environmental pollution, and discrimination against women.

26. Social Issues Affecting Women in Poverty • Divorce • Lower wages compared with men • Public assistance • Homelessness

27. Two thirds of Americans living in poverty are women and children

28. Our Children • One half of all children in the US and 90% of Black children will be on food stamps at some point during childhood • Children on food stamps are at risk for malnutrition and other ills linked to poverty

29. Temporary Assistance forNeedy Families (TANF) • Provides assistance for childcare • Promotes job preparation, work, and marriage • Reduces the incidence of unplanned pregnancies • Encourages two‑parent families

30. Wage Gap • 40% of U.S. workforce consists of women (2004) • Expanded career options for women • Male-to-female earnings ratio is 76.5% (2004) • Widest gap is between well-educated women and men • Lily Ledbetter Act: 1st bill signed by Obama

31. Lily Ledbetter Act

32. Causes of Wage Gap • Deliberate wage discrimination against women • Undervaluing of women’s work • Women’s socialization

33. Some women rely on the father to provide full-time child care at home while they pursue their career. Stay-at-home fathers provide only 1.5% of care to children under the age of 5 in the United States

34. Some mothers are able to combine professional careers with motherhood by telecommuting from a home office.

35. Family and Medical Leave Act (1993) • 12 weeks of unpaid leave following: • Birth or adoption of a child • Placement of a foster child • Also applies to: • Serious illness • Illness of a spouse, child, or parent

36. Childhood education centers provide preschoolers with advanced skills for early education and provide care while parents work outside of the home

37. Ethical Thinking About ART • Autonomy: right to independently chose health care options. • Informed Consent: risks, consequences, benefits, alternatives must be written and spoken in language the pt understands. Witness>18 (what they hear is based on dreams and desires for miracles, does not serve us in way we want) • Justice: equal distribution of life’s good. Canada “every person gets equal share of health care” donor eggs illegal , no free market exchange US according to your effort, free market exchange, can buy ART

38. What Happened at Kaiser Bellflower: A just thing??? • Walkin : no clue where she came from • Anticipated 7 got 8 • Had staff of 46 present for scheduled c/s (volunteer) • Had to divert admissions and other high risk pts to Hollywood • 2 nurses, one MD for each baby • NICU stay 805,500 to 3 Million • 50 (150) employees terminated for looking at the chart HIPPA

39. Justice? • Is this available to every citizen in the U.S. • Is everyone due the same? • The cochrane library metaanalysis of all data on mutiple gestation: • Findings: significant risk of morbidity and mortality to both gestation and life of mother • Conclusion: Regulation was needed • Should be based upon pt’s age and quality of embyos.

40. Regulation in Response to Cochrane • Canada • England • Sweden • “One Embryo, One Birth” (Karlstrom and Bergh, 2007)

41. American Society of Reproductive Medicine 2008 • Recommend (rather than regulate): • Women under the age of 25 should have no more than two embryos implanted. • Women ages 35-37 should have no more than three embryos implanted. • Women ages 38-40 should have no more than four embryos implanted. • Women age 40 and over should have no more than five embryos implanted. Yet in U.S. only 0.5-3% of all transfers are singletons Nadia Suleman, a woman under 35 received six embryos transferred.

42. Reduction • Few Families aware of exactly what the procedure was and what the consequences were • Traumatic, chaotic, depressed disturbing, turmoil, guilt • Grieving for the lost fetuses simultaneously compounded due to constant reminder of the non-reduced infants • Even when positive outcomes occurred, negative feelings emerge • Families made the right decision but insufficient respect for their loss

43. Disenfranchised Grief (Doka, 1989)“Grief Which is Not Openly Acknowledged or Publicly Mourned”

44. IN Conclusion • Bereavement support groups are lacking • Much work to be done on ethics related to multifetal gestation • Committee at ACOG • Increase in multiple gestation and prematurity • Preimplanation genetic diagnosis • What is a nurse to do?

45. FGM

46. Cultural Implications of Female Genital Mutilation • Practiced in male-dominated societies: • Patriarchal authority • Control of women’s bodies • Control of fertility • Done between 5 and 12 years of age • 200,000 women in the US • 130 Million women worldwide

47. FGM

48. Normal Anatomy • Normal female genitalia with clitoris, labia minora and labia majora intact

49. Type 2 • Type 2 FGM is the form of female circumcision most commonly seen.It involves excision of the clitoris with partial or total excision of the labia minora. The tissue is joined in the midline above, or just over urethra.A Type 2 presentation can be quite subtle and may be missed by some practitioners when undertaking an examination.There may be general or peri-urethral scarring or nerve damage, which makes penetrative procedures uncomfortable.

50. Type 3 FGM • Type 3 FGM is the most extreme presentation. It involves excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening. Infibulation - there will be obvious anterior midline scar tissue.The infibulation may obscure underlying dermatological problems such as abscesses, dermoid and sebaceous cysts, and other scarring. It may predispose to both short and long term health consequences for women.In Type 3 FGM, the extent to which genital tissue has been removed, varies with the individual.