Maternal Child Nursing – Lecture 1

1. Maternal Child Nursing – Lecture 1

2. Childbearing in 20th Century • Pre 1900’s: Birth @ home with assistance of midwives. Physicians involved for serious problems. • “natural event” • Maternal & infant mortality high. • Main causes of maternal death: post partum hemorrhage, post partum infection (aka puerperal sepsis or “childbed fever”), toxemia • Primary causes of infant death: prematurity, dehydration d/t diarrhea, & contagious diseases. • 1900 -1930’s: Obstetrical training of physicians & use of forceps brought deliveries to hospitals.

3. 1940’s - 1950’s: 80% women gave birth in hospitals. • Male physicians . No midwives. • Heavy drugs (demerol) “twilight sleep” for labor & delivery. General for C/S • Fathers not allowed in DR; “waiting rooms” to “protect them from gruesome reality of childbirth”. Dr. Ferdinand Lamaze (France) “childbirth without pain” AKA Lamaze Method. Breathing patterns, relaxation techniques, concentration on focal point. “Monitrice” aka Doula/coach. Lamaze method popular in US - 1950’s. Dr. Bradley [USA-1955] supported natural childbirth. Noanesthesia, fathers in DR, breastfeeding. 12 weeks of classes.

4. 1960’s: Women wanted ^ control over their bodies. Took childbirth education classes & FOB present. Hospital deliveries were norm. • 1970 – 1980’s: Change from cold, sterile hospital environment to warmer setting [family present]. • Birthing rooms • “Epidural anesthesia” – women awake for vaginal & C/S. • Natural childbirth still popular – but more women opting for pain relief during labor & delivery. Fathers present for most types of deliveries except C/S. • “Rooming in” popular. M/B together for entire hospital stay.

5. Present: Focus is “family”; fathers active participants. • Analgesia/anesthetic agents monitored/used more. • Shorter hospital stay; Sibling visits encouraged. • Midwives or physicians used. • Infant stays with mother in DR to initiate breast feeding. • Childbirth Ed popular- allows couple to make informed choices about labor & delivery experience. • "Family-centered maternity care" popular marketing strategy. • ^ fear of pain & perineal trama. More C/S’s as a result. • C/S rate ^ from 10% 1970 – 40% 2009 in USA. • Less episiotomies.

6. Goal of maternity staff: • promote meaningful experience for childbearing family • Ensure health of mother & child. • Birth is significant life event. • Honor birth wishes of couple. • Family centered care respects autonomy of family members; approaches childbirth decisions in non-judgmental manner. • FOCUS: teach new mother self/infant care. “Independent” function of RN

7. Government Programs • High rates of maternal & infant mortality in early 1900’s among poor set stage for federal involvement in maternity care. • In 1921, Sheppard-Towner Act provided funds for state-managed programs for mothers & children. Other programs followed. • Partially solved mortality problem; distribution of health care remained unequal. • physicians practiced in urban/suburban areas; women in rural & inner city less access to health care. • Ongoing problem of unequal health care allowed nurses to expand their roles for advanced practice.

8. 1935: Social Security Act established system of grants for health & welfare programs. Included aid for dependent mothers/children. • 1963-1964: mandate established thru Children's Bureau of DOH & Human Services to establish 2 Maternity/Infant Care Projects in each state. • In New York City, a Maternal, Infant & Reproductive Health Program began. • 1984, Bureau of Maternity Services & Family Planning: * Community-based health education programs. • Since then, high-risk communities have comprehensive case management services, intensive counseling/education/home visits.

9. 1972: Supplemental Food Program – “WIC” • “Women, infants, & children” created as 2-year pilot program [1972] thru amendment to Child Nutrition Act of 1966. Permanent in 1975. • established during time of ^ public concern about malnutrition among low-income mothers & children. • delivers early nutrition & health intervention during critical times of growth & development • Used as prevention tool

10. 4 criteria: Categorical : Women: 1)pregnant 2) postpartum (up to 6 mos > delivery) 3) breastfeeding Infants -1st birthday. Children-5th birthday. Residential : live in State in which they apply Income: income at or below State standard Nutrition risk:medical and/or dietary-based conditions. ie. Anemia, underweight

11. How many get WIC? • > 7 million people each month (current) • In 1974, [first year] 88,000 people participated. • Children largest category of WIC participants. • WIC program available in each State, District of Columbia, 33 Indian Tribal Organizations, Puerto Rico, Virgin Islands, American Samoa, and Guam. • WIC foods include: iron-fortified infant formula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit and/or vegetable juice, eggs, milk, cheese, peanut butter, dried beans or peas, tuna fish and carrots. Special infant formulas.

12. PCAP Prenatal Care Assistance Program - • Medicaid program run by NYSDOH • prenatal care for uninsured mothers at/below poverty • Medicaid Obstetrical and Maternal Services (MOMS) provides complete pregnancy services where PCAP centers are not located. No cost to participate. Offers: • Routine pregnancy check-ups, lab work, specialists • Hospital care during pregnancy/delivery • HIV counseling/testing • Help in applying for WIC & low or no cost health ins. • Full health care for mom until 2 months after delivery • Health care for baby for 1 year after birth • Family planning services

13. Suffolk County Perinatal Coalition A community based organization dedicated to: • Educating expectant mothers to deliver healthy babies. • Promoting community's goal to achieve healthy birth outcomes, prevent infant mortality, low birth weight & prematurity throughout Suffolk County. • Works with SCDOH. • Founded 1985 by coalition of maternal health providers committed to reducing infant mortality & birth complications. • Suffolk Perinatal Coalition475 East Main Street Suite 20 Patchogue, NY 11772 Tel: 631.475.5400; info@scpc.net

14. Statistics • Birth Rate: # live births/1,000 population. • 2007 – U.S. birth rate increased (14.3 per 1,000) • Teen birth rate increased (last 2years) – 43/1000 aged 15-19 • ^ birth rates for women aged 35 to 39 (42.4 per 1000) • Women aged 40 to 44 (8.2 per 1000) • Infant Mortality Rate: deaths of infants < 1 yr./1,000 live births. 1950 @ 18%; 2000 @ 6.8%. ^ 2005 @ 6.86 • Most significant measure of maternal/child health & adequate prenatal care. USA ranks 29th. PTL = 36.5% of all infant deaths. Congenital defects & VLBW are 2 leading causes. • Neonatal mortality: deaths of infants < 28 days of age/ 1,000 live births. Rises slightly each year d/t premies being born earlier.

15. Maternal Mortality: deaths from any cause R/T pregnancy & 42 days PP /100,000 births. • 2005 = 15.1/100,000 live births. • 1900’s rate 600/100,000 live births. African American women’s rate of death in US was more than 4 times rate for white women (2001) • Overall decline attributed to improved prenatal, intrapartal, postpartum care & specialized healthcare personnel.

16. Healthy People 2010 Goals • National agenda to improve health care • Distribute health care equally among all ethnic/racial groups • Earlier prenatal care • High technology [3rd level NICU] < 32 wks. • US ranks 23rd for infant mortality d/t Hi rate LBW infants • 83.4% - prenatal care in 1st trimester (2002) • 3.9% - prenatal care in 3rd trimester or NONE at all [1998] • 8.1 million children without health insurance (2007) • 43.9 million people without health ins (2006) • 27.4% children covered by Medicaid, & other govt programs • African Americans, Hispanic, and Native American women less likely to receive early and adequate prenatal care

17. Standards of Nursing Care • Standards for Nursing care of women and children set by AWHONN: The Association of Women’s Health, Obstetric, & Neonatal Nurses. • Assesses family for strengths/needs • Encourages use of community resources; “rooming in” • Respects diversity in families; Encourages family-oriented care • Promotes using evidence-based practice as basis for nursing interventions [research studies] • ANA – standards of practice for maternal-child nursing • 2010 National Patient Safety Goals JCAHO

18. Ethical Issues Maternity Nursing = family-centered. Conflicts with following topics: • Abortion (fetal rights vs. rights of mother esp. with 2nd & 3rd trimester AB’s) • Embryonic Stem Cell Research • Cord Blood Banking • Terminating Life Support - “ To resuscitate or not” with very young fetus < 23 wks. Not viable. Looks at “quality of life” issues. • Conception issues involving surrogate mothers, embryo transfer, cloning. • Reproductive Assistance Technology [ART]

19. Ethical Issues • RN can help clients face difficult decisions by providing factual information, supportive listening, by helping family clarify values. • Maternal health care has both legal & ethical considerations more than with other areas of healthcare b/c of presence of both fetus & mother

20. The Family • “Family” - U.S. Census Bureau 2008 - “2 or more people joined by marriage, birth, or adoption living together” How well family works together against potential threats depends on its structure & function. • 2 Basic Family Structures: • Family of Orientation: Family one is born into. • Family of Procreation: Family one establishes.

21. Specific Family Types • Nuclear – traditional husband, wife & children • Extended – includes nuclear plus grandparents, aunts, or uncles, etc. living together.. Advantages: ↑ support, ↑ childcare options, ↑ role models • Single-Parent : Approx. 50-60% of families w. school-age children; 15% headed by males. D/T ^^ in divorce & common practice of women raising children alone. Disadvantages: • Lack of support (childcare) • Limited finances • Role strain – trying to fulfill maternal & paternal roles • Mental & physical strain

22. FAMILY FUNCTION: “ Ability to meet needs of its members thru developmental transitions (grows/changes).” • *Each new generation adapts values & traditions from previous generations. • *When doing family assessment - identify behaviors that are strengths and deficiencies.

23. FAMILY TASKS: 8 tasks to being successful family unit: • Physical maintenance (food, shelter, health care) • Socialization of family members (interaction outside family) • Allocation of resources (meeting family needs) • Maintenance of order ( communication, family rules) • Division of labor ( income, childcare, etc.) • Reproduction/release of family members (progression from infancy thru young adulthood) • Placement of family members into larger society (community activities, church, political group) • Maintenance of motivation & morale (family pride)

24. FAMILY LIFE CYCLES: Duvall 1977 Oldest child marks stage family is at • Marriage & family • Early child-bearing family • Pre-school child family • School-age child • Adolescent child • Launching Center (most difficult- disruption of family unit) • Family of middle years (empty nest) • Family in retirement age

25. Community Assessment • Look at surrounding community - tells how vulnerable it is to disease & mental/social problems. • Poverty level & many young children strongly assoc. w. ^ community health needs. • Increased abuse in families. D/t ^ stress & better reporting. NURSE RESPONSIBILITIES: • Be aware that it exists in all communities. • Careful screening of abuse

26. Cultural Competency(March of Dimes) • Immigration to U.S. ~ 1 million immigrants come to U.S. each year (U.S. INS,1991). [Immigration & Naturalization] • More than half are women of childbearing age (U.S. INS, 1991) • 2006-2008 -12.5% FOREIGN BORN in USA [1.25 in every 10] (National Center for Cultural Competence, 1999). What is Cultural Competence? • Providing services, supports and assistance: • Responsive to beliefs, interpersonal styles, attitudes, language and behaviors of individuals with greatest likelihood of ensuringmaximum acceptance and participation. • Respect for individual dignity, personal preference and cultural differences. (Developmental Disabilities and Bill of Rights Act of 2000)

27. Suffolk County is Very Diverse ~ 1.5 million residents • 8% African American • 13% Hispanic/Latino • 4% Asian American • 1% American Indian • 74% White

28. SCDOH Clinics - even more diverse • 55% Latino/Hispanic • 17% Black • 2% Asian (1% Asian Indian) • 19% White 2009 3rd quarter Health Information Systems

29. Importance of Cultural Competence.. • U.S. demographics are changing. • Health disparities exist between ethnic groups • Health care organizations require increased, documented cultural competence. • Cultural competence enriches professional nursing practice. What is Culture? • Distinct way of life that characterizes particular community of people. • Includes learned practices, beliefs, values, customs passed through generations. • Provides sense of identity

30. Acculturation • Integration into mainstream culture • Depends on age at time of arrival, reason for moving to new area and residence in predominantly ethnic neighborhood • Generally takes three generations in USA (Spector, 2000) Ethnocentrism • Ethnocentrism belief that one’s own culture is best. • Providers must be aware of own ethnocentrism. Cultural Perspectives • depends on if you are member of culture or observer of culture

31. Cultural Traditions • Functional tradition – enhances health and well-being • Neutral tradition neither enhances nor harms health and well-being • Non-functional - potentially harmful Cultural Characteristics Individual vs. group identity Decision-making Eye contact Being polite Family oriented Time orientation Father’s participation at birth Nutrition No Male hcp Pregnancy as healthy natural state

32. Female Genital Mutilation: Curb sexual desire of girls/women and preserve "sexual honor" before marriage. It is irreversible and extremely painful, and is usually done to young girls.

34. Instruments Used

35. Common Cultural Beliefs Hot and cold: Illness d/t imbalance -causes body to be hot/cold. Needs balancing to correct illness. Chinese theory “ying/yang” – similar • Pregnancy- “hot”: consume cold foods • Post Partum- “cold”: consume hot foods Example: Vietnamese culture: spinach, melons, beans [pregnancy] and soup w. chili peppers, salty fish, meat w. herbs & wine [post partum] Iron supplement = considered “hot” Found in parts of Asia, India, Latin America Evil Eye Theory: 80% world’s population believes in this. Hispanics term “mal ojo” - belief that certain actions invite evil spirits to cause illness/death.

36. Populations and Conditions • African American--Sickle cell disease • Amish--PKU, hemophilia B • Greek--Thalassemia • Jewish--Tay-sachs, Gaucher’s disease • Native American--Type 2 diabetes mellitus Note: Conditions not limited to a single population group.

37. Ways to Relate to Other Cultures • Common practices • Avoiding people from other cultures • Refusing to recognize cultural differences • Recognizing differences, but feeling own way is superior (ethnocentrism) • Best practice • Acknowledging and seeking to understand cultural differences

38. Cultural Assessment • What are your religious practices? Food preferences? • Economic situation? • What languages do you speak and read? • How would you like to manage labor pain? • Who will provide labor support? • Who will care for the baby? • Do you use contraception? • Where were you born? • How long have you lived in the United States? • Who are your major support people? Childbearing Assessment • What does childbearing represent to you? How do you view childbearing? Are there any maternal precautions or restrictions? Is birth a private or social experience?

39. Assessment Techniques • Use conversational approach. • Ask open-ended questions. • Integrate cultural and childbearing assessments. • Listen with interest. • Nonjudgmental Interpreters: • Interpreters communicate verbally. • Should be female • Should not be family member • Can work with written communication. • Maintain strict confidentiality. • Do not paraphrase • Use Translator Phone