Maternal Child

Nursing Lecture 1

Childbearing in 20th Century

Pre

1900s: 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 -1930s: Obstetrical training of physicians &
use of forceps brought deliveries to hospitals.

1940s - 1950s:
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 - 1950s.
Dr. Bradley [USA-1955] supported natural childbirth. No
anesthesia, fathers in DR, breastfeeding. 12 weeks of
classes.

1960s: Women wanted ^ control over their bodies. Took

childbirth education classes & FOB present. Hospital
deliveries were norm.
1970 1980s: 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.

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/Ss as a result.
C/S rate ^ from 10% 1970 40% 2009 in USA.
Less episiotomies.

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 nonjudgmental manner.
FOCUS: teach new mother self/infant care.
Independent function of RN

Government Programs

High rates of maternal & infant mortality in early 1900s

among poor set stage for federal involvement in maternity
care.
In 1921, Sheppard-Towner Act provided funds for statemanaged 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.

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.

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

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

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.

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

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 Coalition
475 East Main Street Suite 20
Patchogue, NY 11772
Tel: 631.475.5400; info@scpc.net

Statistics

Birth Rate: # live births/1,000 population.

2007 U.S. birth rate increased (14.3 per 1,000)

Teen birth rate increased (last 2 years) 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.

Maternal Mortality: deaths from any cause R/T

pregnancy & 42 days PP /100,000 births.
2005 = 15.1/100,000 live births.

1900s rate 600/100,000 live births. African American

womens 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.

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

Standards of Nursing Care

Standards for Nursing care of women and

children set by AWHONN: The Association of
Womens 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

Ethical Issues
Maternity Nursing = family-centered.
Conflicts with following topics:

Abortion (fetal rights vs. rights of mother esp.

with 2nd & 3rd trimester ABs)
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]

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

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.

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

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.

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)

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

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

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 ensuring maximum
acceptance and participation.
Respect for individual dignity, personal preference and cultural differences.
(Developmental Disabilities and Bill of Rights Act of 2000)

Suffolk County is Very Diverse

~ 1.5 million residents
8% African American
13% Hispanic/Latino
4% Asian American
1% American Indian
74% White

SCDOH Clinics - even more diverse

55% Latino/Hispanic
17% Black
2% Asian (1% Asian Indian)
19% White

2009 3rd quarter Health Information Systems

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

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 ones 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

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

Fathers participation at birth

Nutrition

No Male hcp

Pregnancy as healthy
natural state

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.

Instruments Used

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% worlds population believes in this.
Hispanics term mal ojo - belief that certain actions
invite evil spirits to cause illness/death.

Populations and Conditions

African American--Sickle cell disease

Amish--PKU, hemophilia B
Greek--Thalassemia
Jewish--Tay-sachs, Gauchers disease
Native American--Type 2 diabetes mellitus

Note: Conditions not limited to a single population group.

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

Cultural Assessment

Where were you born?

How long have you lived in the
United States?
Who are your major support
people?

What are your religious

practices? Food preferences?
Economic situation?
What languages do you speak
and read?

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?

How would you like to manage

labor pain?
Who will provide labor
support?
Who will care for the baby?
Do you use contraception?

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