parent teaching

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Improving POSTPARTUM EDUCATIOJl

About Warn i ng Signs of

MATERNAL MORBIDITY and MORTALITY

PATRICIA D. SUPLEE LISA KLEPPEL

ANNE SANTA-DoNATO DEBRA BINGHAM

Maternal mortality or pregnancy-related death is the death of a woman from compli-

cations of pregnancy and childbirth occurring up to 1 year postpartum. In a report

using data from 2010, the United States ranked 49th out of 184 countries for mater-

nal mortality (Central Intelligence Agency, 2016); it is one of eight countries where

maternal mortality rates have been on the rise in recent years (Hogan et aI., 2010; Kassebaum et aI., 2014).

Abstract: Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of par- ticular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a woman’s discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is nat always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase women’s access to predischarge education about the risks for postbirth complications. http://dx.doi.org/ 10.1016/j.nwh.20 16.10.009

Keywords: maternal morbidity I maternal mortality I postpartum complications I postpartum education I pregnancy-related death

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Although the most current u.s. pregnancy-related mortal- ity rate shows a slight decrease in maternal deaths, from

17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per

100,000 live births in 2012 (Centers for Disease Control and

Prevention [CDC], 2016), this rate is more than double the

1987 rate of 7.2 deaths per 100,000 births. However, research-

ers working to better understand the measurement limitations

of maternal mortality trends found that the CDC estimates may

underreport maternal mortality rates. Recently, MacDorman,

Declercq, Cabral, and Morton (2016), using adjusted models,

reported an estimated maternal mortality rate for 2014 of 23.8

per 100,000 live births (included 48 states and the District of

Columbia). During this same time period, the rates of mater-

nal mortality in other developed countries decreased (Hogan et

aI., 2010). In addition to maternal mortality, the rates of severe

maternal morbidity in the United States have more than dou-

bled since 1998 (Callaghan, Creanga, & Kuklina, 2012).

The seven leading causes of pregnancy-related deaths for

2011 and 2012 in the United States are noncardiovascular dis-

eases 05.3%; not specifically described by the CDC), cardiovas-

cular diseases 04.7%), infection or sepsis 02.7%), hemorrhage

01.3%), cardiomyopathy (10.8%), thrombotic pulmonary

embolism (9.0%), and hypertensive disorders of pregnancy

(7.6%; CDC, 2016). Although any woman can experience one

of these complications during pregnancy or childbirth, women

with chronic conditions such as cardiac disease, obesity, or high

blood pressure are at higher risk of dying or nearly dying from

these complications.

Health disparities among racial and ethnic groups in the

United States have been well documented in the literature

(Elo & Culhane, 2010), and eliminating these disparities is an

overarching goal of Healthy People 2020 (U.S. Department of

Health and Human Services, 2016). In obstetrics, these dispari-

ties persist and are clearly evident in reported rates of mater-

nal morbidity and mortality. During 2011 and 2012, the CDC

reported the deaths per 100,000 live births as 1l.8 for White

women, 4l.1 for Black women, and 15.7 for women of other

races (CDC, 2016). These data show that maternal mortality

rates are approximately three to four times higher for Black

women compared with White women.

Understanding the timing of maternal deaths and their

possible preventability can help guide the development of

improvement efforts. In 2013, an international review of

Patricia D. Suplee PhD, RNC-OB, is an associate professor in the School of Nursing-Camden at Rutgers University in Camden, NJ. Lisa Kleppel, MPH, PMp, is a project manager at AWHONN in Washington, DC. Anne Santa-Donato, MSN, RNC, is director of obstetric programs at AWHONN in Washington, DC. Debra Bingham, DrPH, RN, FAAN, is a perinatal consultant and founder of the Institute for Perinatal Quality Improvement in Silver Spring, MD. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: suplee@camden.rutgers.edu.

554 © 2016, AWHONN

maternal mortality found that, on average, nearly 25% of deaths

occurred antepartum, another 25% occurred intrapartum or

immediately postpartum, and almost 50% occurred in the

postpartum period up to 1 year (Kassebaum et aI., 2014). Cre-

anga et ai. (2015), using more recent U.S.-only data, found that

of the maternal deaths reported, 39% of women died before or

on the day of birth and 61% died in the postpartum period.

These data make it clear that postpartum deaths are not just an

international issue but are also a problem in the United States.

Researchers estimate that 40% to 50% of U.S. maternal deaths

are preventable (Bacak, Berg, Desmarais, Hutchins, & Locke,

2006). When focusing on obstetric hemorrhage alone, 54% to

70% of these maternal deaths are estimated to be preventable

(Della Torre et aI., 2011; Main, McCain, Morton, Holtby, &

Lawton, 2015).

POSTPARTUM CARE AND EDUCATION Within hospital systems, establishing guidelines to optimize

and improve postpartum care is important. Recently the Amer-

ican College of Obstetricians and Gynecologists (2016) pub-

lished a Committee Opinion on optimizing postpartum care.

In addition, the Alliance on Innovation in Maternal Care is a

multidisciplinary national program convened to reduce severe

maternal morbidity and maternal mortality and is supported

by the Maternal and Child Health Bureau/Health Resource Ser-

vices Administration. The Alliance on Innovation in Maternal

Care is developing two postpartum safety bundles to be used

by all types of providers (medical, nursing, social service, and

public health) to address the basic elements of postpartum care

(Kleppel, Suplee, Stuebe, & Bingham, 2016). This first bundle

will cover the first 6 weeks postpartum, and the second bun-

dle will focus on interconception care and health up to 1 year

postpartum.

Nurses are the health care providers who perform the most

postpartum education in the United States. Thus, it is critical

that nurses work to improve discharge education so that the

information they provide is efficient, timely, and evidence

based. When women are discharged after birth, nurses playa

vital role in providing them with education on self-care and

infant care and a plethora of information related to transition-

ing home and caring for a newborn. Authors have reported

that the amount of information women receive is overwhelm-

ing (Alden, Lowdermilk, Cashion, & Perry, 2012; Murray &

McKinney, 2014). It is not clear how nurses currently decide

which information is a priority to provide face-to-face educa-

tion on and which information can be given to a woman to read

at home. Many hospitals require the discharging nurse to com-

plete some sort of checklist that includes a list of educational

topics. However, there is wide variation in discharge education

related to information on warning signs of maternal morbidity

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and mortality (Suplee, Bingham, & Kleppel, 2016). This holds

true for women being discharged from birth centers as well.

For rates of postpartum maternal morbidity and mortality

to be reduced, it is vital for women who have just given birth to

be instructed on specific warning signs so that they know what

to look for, when to call a health care provider, or when to go to

the nearest emergency department. Many of the complications

women experience can be successfully treated if they are identi-

fied quickly and women receive prompt medical attention. To

that end, below we describe the findings from the implemen-

tation phase of a pilot project of the Association of Women’s

Health, Obstetric and Neonatal Nurses (AWHONN) entitled

“Empowering Women to Obtain Needed Care” and discuss

implications for clinical practice.

WHY POSTPARTUM DISCHARGE EDUCATION NEEDS IMPROVEMENT The United States Agency for Healthcare Research and Qual-

ity defines quality health care as “doing the right thing, at the

right time, in the right way, for the right person-and having

the best possible results” (2003, p. 1). For

the past few decades, postpartum education

has evolved around maternal self-care and

infant care (Alden et aI., 2012; Murray et aI.,

2014). We conducted a literature review in

CINAHL and found no studies that focused

on educating women about specific potential

complications after birth. One recent study

(Suplee et aI., 2016) found a lack of standard

information and approaches to how nurses

meet the challenge of educating women who

are considered at risk for maternal mortal-

ity, as well as for all women at risk simply on

the basis of their postpregnancy health sta-

tus. National leaders have stated that earlier

recognition of warning signs by postpartum

women and earlier interventions by health

care providers may lead to a decrease in the

current growing maternal morbidity and

mortality rates in the United States (D’Alton,

Main, Menard, & Levy, 2014; The Joint Com-

mission, 2010).

Comprehensive improvement efforts to

advance postpartum education fOCUSing

specifically on potential risks for maternal

morbidity and mortality are needed. Future

education programs should include infor-

mation for both at-risk and healthy women,

because complications may not be clearly

identified or apparent before a woman’s dis-

charge after birth.

Dec ember 2016 I January 2017

THE “EMPOWERING WOMEN TO OBTAIN NEEDED CARE” PROJECT With support from the Merck for Mothers program, a 10-year initiative focused on improving the health and well-being of

women during pregnancy and childbirth, AWHONN initiated

the “Empowering Women to Obtain Needed Care” project.

Researchers estimate that 40% to 50% of lJ .S. maternal

deaths are preventable

The goal of this pilot project was to increase women’s access

to quality information about risks for postbirth complications,

especially before discharge from the hospital after giving birth.

Accurate and consistent information provided to all women

who give birth can better equip them to recognize health

changes or warning signs of postpartum complications. Early

recognition of postbirth warning signs enables women to seek

Nursing for Women’s Health 555

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and obtain health care for these potentially life-threatening

complications. The project was divided into two phases (see

Figure 1).

PHASE 1: BASELINE ASSESSMENT Baseline assessment included a comprehensive literature

review, a review of postpartum discharge materials currently

used by nurses to educate women about warning signs, and

focus groups with nurses held at selected hospitals to assess

what was currently taught to postpartum women and how the

education was delivered. Findings showed that inconsistent

information was provided to women about postbirth warning

signs and what they should do if they experienced any of these

signs once discharged (Suplee et aI., 2016) .

PHASE 2: IMPLEMENTATION The implementation phase included two components. First,

standardized evidence-based educational materials and dis-

charge teaching talking points were designed for nurses to use

when educating women about maternal morbidity and mor-

tality. Second, these educational materials were pilot tested in

four designated hospitals to identify barriers and facilitators to

FIGURE 1

implementation and to evaluate postpartum nurses’ satisfac-

tion using the materials.

The education materials were designed to be easy to use and

to have the ability to be integrated into current teaching tools

used by nurses across the country. The leading causes of mater-

nal morbidity and mortality in the United States formed the

basis of what was included by the Expert Panel on the educa-

tional tools before pilot testing in 2015. What follows is a report

of the results of the implementation phase (Phase 2).

METHODOLOGY Sample Four of the six hospitals from the baseline assessment (Phase

1) agreed to participate in the implem entation portion (Phase

2) . Hospitals chosen for this pilot project reflected diverse

populations of postpartum women in terms of race, ethnicity,

and socioeconomic status. Among the hospitals participating

in this project, African American and Hispanic women were

reported to make up 25% to 65% of the total birth demograph-

ics for 2012. In the same year, Medicaid-reimbursed births in

these hospitals ranged from 25% to 75% of their total births.

Although it was not possible to capture the exact number of

Phases of the Empowering Women to Obtain Needed Care Pilot Project

Phase One: Baseline Assessment

IV outcomes

556 Nursing f o r Wom e n ‘s Hea lt h

Phase Two: Implementation

• Design educational checklist tool for nurses

• Design patient education tool • Design nurses’ evaluation tool • Design audit tool • Review all tools with

Expert Panel • Train/orient nurse leaders • Pilot tools in 4 hospitals • Conduct & analyze health

records audit • Analyze nurse evaluations • Redesign tools based

on feedback

V o lume 2 0 Issue 6

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women who received postpartum education using the pilot

project tools, a cumulative estimated calculation of births over

a 3-month period included more than 3,000 women. In addi- tion, approximately 150 nurses were involved in providing the

education to the postpartum women before discharge.

Procedure

After recruiting nurse site leaders from the four hospitals, the

project manager sent copies of all of the tools to them. A con-

ference call was held to introduce the nurse site leaders to the

program tools and to explain how they should be implemented

and how to train staff nurses to use them. The education for

for nurses to use when beginning the conversation with new

mothers: Although the majority of women who give birth do not

have complications once they go home, all women are potentially

at risk. Knowing these postpartum warning signs can save your

life as many signs can indicate a life-threatening condition and

require immediate medical care.

Patient Handout The handout for women to take home, titled “Save Your Life”

(see Figure 3), includes sections on when to call 911, when

to call one’s health care provider, and descriptions of warn-

ing signs that could become life-threatening if women do not

Education ~rams should include information for both at-risk and healthy women, because complications may not be clearly

identified or aD-parent before a woman’s discharge after birth

nurses included background information on statistics related to

rising rates of maternal mortality to ensure that all of the nurses

participating in the pilot program had accurate and current

information to share with their staff. The pilot implementation

took place from October through December 2015. During this

time, nurse site leaders from all four hospitals reported that the

nurses who provided postpartum education at their hospitals

were using the new forms with all women after birth and before

discharge. Monthly conference calls were held to discuss real

and potential issues encountered with the use of the program

materials and to share feedback among the nurse site leaders.

PROJECT TOOLS Four tools were created by the principal investigators, project

manager, an expert panel of nurses and health professionals on

the basis of information gleaned from the literature review and

focus groups held with nurses from six hospitals in New Jer-

seyand Georgia. Two teaching tools were developed-one for

nurses to use when teaching women about potential warning

signs of maternal morbidity and mortality (see Figure 2) and

another for women to take home (see Figure 3).

Discharge Education Checklist

The Post-Birth Warning Signs: Postpartum Discharge Educa-

tion Checklist (see Figure 2) was deSigned to provide nurses

with a tool they could use when teaching all women to rec-

ognize warning signs of postpartum complications that could

occur after discharge. The hospitals were given permission to

integrate the checklist into their electronic health record. The

checklist defines each potential complication, lists specific signs

and symptoms, and explains where and when a woman should

seek medical attention. It also includes this suggested script

December 20161 January 2017

obtain prompt medical attention. The other important message

included in this handout is a reminder for women to tell pro-

viders caring for them during the first year after giving birth,

I had a baby on [specific date] and I am having the following

specific symptoms . … This message is intended to alert provid-

ers that a woman’s symptoms could be related to a recent preg-

nancy. Nurses instructed each woman to keep the handout in a

place where she could access and review it easily, such as on her

refrigerator. Women were also encouraged to include a partner

or family member in the discharge education sessions before

discharge so that they could also hear the education to support

earlier identification of warning signs and symptoms and help

mobilize timely care.

Education Evaluation Tool

Additional tools were designed by the AWHONN project team

to be used for data collection by the site leader and evaluation

of the teaching tools by the nurses. The Postpartum Education

Evaluation Tool was an online survey distributed to all post-

partum nurses at the participating hospitals. Nurses were asked

to describe the facilitators and barriers to using the discharge

checklist and patient handout by responding to open-ended

questions. They were also asked to rate six statements using

a Likert scale (strongly agree to strongly disagree) focusing on

such elements as satisfaction, ease of use, ease of understand-

ing, assistance with teaching, and their assessment of women’s

abilities to understand the warning signs and describe when to

obtain needed care.

Audit Tool A quality improvement health record audit tool was devel-

oped to be used by nurse site leaders when performing 30

Nursing for Women ‘s Health 557

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FIGURE 2 Discharge Education Checkl ist (Full-sized PDF version of Figure 2 appears online as Supplemental Figure 51.)

POST-BIRTH WARNING SIGNS: POSTPARTUM DISCHARGE EDUCATION CHECKLIST

This checklist is a teaching guide for nurses to use when educating all women about the essential warning signs that can result in maternal morbidity and/or mortality.

Instructions:

POST- BIRTH

WARNING SIGNS

• Instruct ALL women about all of the following potential complications. All teaching should be documented on this form or in your facility’s electronic medical record.

• Focus on risk factors for a specific complication first; then review all warning signs. • Emphasize that women do not have to experience ALL of the signs in each category for them to seek care. • Encourage the woman’s significant other or her designated family members to be included in education

whenever possible.

The information included on this checklist is organized according to complications that can result in severe maternal morbidity or maternal mortality. Essential teaching points should be included in all postpartum discharge teaching.

The parent handout, “Save Your Life”, is designed to reinforce this teaching. This handout is organized according to AWHONN’s acronym, POST-BIRTH, to help everyone remember the key warning signs and when to call 911 or a health provider. A portion of this handout is below for reference.

Call your healthcare provider if you ha ve:

( If you can ‘t reach your healthcare provider, ca ll 9 11 or go to an emergency room)

o P ain in chest

o O bstructed breathing or shortness of breath

o S eizures

o T houghts of hurting yourself or your baby

o B leeding, soaking through one pad/hour, or blood clots, the size of an egg or bigger

o I ncision that is not healing

o R ed or swollen leg that is painful or warm to touch

o T emperature of 100.4°F or higher

o H eadache that does not get better, even after taking medicine, or bad headache with vision changes

Below is a suggested conversation-starter: “A lthough most women who give birth recover without problems, any woman can have

complications after the birth of a baby. Learning t o recognize these POST- BIRTH warn –

ing signs and knowing what to do can save your life . I would like to go over these POST-

BIRTH warning signs with you now, so you will know what to look for and when to call

9 77 or when to call your healthcare provider.

Please share thiS with family and f riends and post the “Save Your Life” handout in a place where you can get to it easily (like your refngerator). JJ

•• u~o.”” Tn ,””.”, u’ , ;’ AWHONN .,,~., ,,,,,n””.,, © AWHONN 2016: All Rights Reserved POST-BIRTH Warning Signs: AWHONN’s Postpartum Discharge Education Project

© 2016 , AWHONN . All rights reserved. Requests for permission t o use or reproduce should be directed to permissions@awhonn.org.

(continued)

558 Nursing for Women ‘s Health Volume 20 Issue 6

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FIGURE 2 Discharge Education Checklist continued ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• j

POST-BIRTH Warning Signs: Postpartum Discharge

Education Checklist

Pulmonary Embolism Essential Teaching for Women

What is Pulmonary Emboli sm? Pulmonary embolism is a blood clot that has traveled to your lung.

Signs of Pulmonary Embolism • Shortness of breath at rest (e.g., tachypneic shallow, rapid respirations) • Chest pain that worsens when coughing • Change in level of consciousness

Obtaining Immediate Care Ca ll 91 1 or go to nearest emergency room RIGHT AWAY.

RN initials ______________________ Date Family/support person present? YES / NO

Cardiac (Heart) Disease Essential Teaching for Women

What is Cardiac Disease? Card iac disease is when your heart is not working as well as it should and can include a number of disorders that may have different signs and symptoms.

Signs of Potential • Shortness of breath or difficulty breathing Cardiac Emergency • Heart palpitations (feeling that your heart is racing)

• Chest pain or pressure

Obtaining Immediate Care Call 911 or go to nearest emergency room RIGHT AWAY.

RN initials ______________________ Date Family/support person present? YES / NO

Hypertensive Disorders of Pregnancy Essential Teaching for Women

What is Severe Hypertension? Hypertension is when your blood pressure is much higher than it should be.

Signs of Severe Hypertension • Severe constant headache that does not respond to over-the-counter pain medicine, rest, and/or hydration

What is Preeclampsia/Eclampsia? Preeclampsia is a complication of pregnancy that includes high blood pressure and signs of damage to other organ systems. Eclampsia is the convu lsive phase of preeclampsia, characterized by seizures.

Signs of Preeclampsia • Severe constant headache that does not respond to pain medicine, rest, and/or hydration • Changes in vision, seeing spots, or flashing lights • Pa in in the upper right abdominal area • Swellin g of face, hands, and/or legs more than what you wou ld expect • Change in level of consciousness

Signs of Eclampsia • Se izures

Obtaining Immediate Care Ca ll 911 for seizures. Ca ll healthcare provider immed iately for any other signs. If symptoms worsen or no response from provider/clinic, call 911 or go to nearest emergency room.

RN initials ______________________ Date Family/support person present? YES / NO

Obstetric Hemorrhage Essential Teaching for Women

What is Obstetric Hemorrhage? Obstetric hemorrhage is when you have an excess amou nt of bleeding after you have delivered your baby.

Signs of Obstetr ic Hemorrhage • Bleeding through more than 1 sanitary pad/hour • Passing I or more clots the size of an egg or bigger • Character of clots/differentiation of bright red bleed in g from dark with clots

Obtaining Immediate Care Call healthcare provider immediately for signs of hemorrhage. If symptoms worsen or no response from provider/clinic. call 911 or go to nearest emergency room.

RN initials ______________________ Date Family/support person present? YES / NO

Page 1 o f 2 ©AWH ONN 2016: All Rights Reserved POST-BIRTH Warning Signs: AWHONN’s Postpartum Discharge Education Proj ect

© 2016, AWHONN . All rights rese rved. Requests for permission to use or reproduce should be directed to permiss ions@awh onn .org.

(con tinued)

December 20161 January 2017 Nursing for Women’s Health 559

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FIGURE 2 Discharge Education Checklist continued

POST- BIRTH Warning Signs: Postpartum Discharge

Education Checklist

Venous Thromboembolism Essential Teaching for Women

What is Venous Thromboembolism? Venous thromboembolism is when you develop a blood clot usua lly in your leg (ca lf area).

Signs of Venous Thromboembolism • Leg pain, tender to touch, burning or redness, particu larly in the ca lf area • Swell ing of one leg more than the other

Obtaining Immediate Care Ca ll healthcare provider immediately for above signs of venous thromboembolism. If symptoms worsen or no response from provider/clinic, call 911 or go to nearest emergency roolTI.

RN initia ls _____________________ _ Date _________ _ Fami ly/support person present? YES / NO

Infect ion Essential Teac hi ng for Women

What is Infection? An infection is an invasion of bacteria or viruses that enter and spread through your body, making you ill.

Signs ofInfection • Temp is 2100.4°F (238°C) • Bad smelling blood or discharge from the vagina • Increase in redness or discharge from episiotomy or C-Section site or open wound not healing

M aternal mortality in the United States is on the rise. The average maternal mortality rate rose from 14.5 to 16 deaths per 100,000

live births when comparing rates from 1998– 2005 to 2006–2010 (Berg, Callaghan, Syver- son, & Henderson, 2010; Creanga et al., 2015) and rose to a high of 17.8 deaths per 100,000 live births in 2011 (Centers for Disease Control and Prevention, 2017). The most recently avail- able data report a maternal mortality rate of 17 deaths per 100,000 live births in the United States in 2013 (Creanga, Syverson, Seed, & Cal- laghan, 2017). Non- Hispanic Black women die

Do New Mothers Understand the Risk Factors for Maternal Mortality?

M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, Deborah Winders Davis, PhD, John A. Myers, PhD, MPH, Katlin M. Masterson, Jeffrey A. Rushton, MBA, and Adrian P. Lauf, PhD

July/August 2018 MCN 201

Abstract Purpose: The purpose of this study was to describe new mothers’ knowledge related to maternal mortality. Study Design and Methods: Using a cross-sectional design, new mothers were recruited from a postpartum unit of an academic health sciences center where the population was predominately low-income women. Before hospital discharge, they answered questions on their knowledge of potential postpartum complications that could lead to maternal mortality. Questions were based on recommendations from an expert nursing panel. Descriptive statistics were used for data analysis. Results: One hundred twenty new mothers participated. Results indicated that most new mothers knew that they should watch for heavy bleeding, a severe headache, and swelling after hospital discharge. However, fewer participants knew that a new mother could experience feelings that she could harm herself or her baby, have blood clots larger than a baby’s hand, a temperature of 100.4 °F or higher, and odor with vaginal discharge. Courses of action new mothers would take if experiencing any of the warning signs included 18% of mothers would take no action, 76.7% would tell their boyfriend/husband/partner, 72.5% would inform their mother. Only 60% who would call the labor and delivery unit. Only 38% of the sample knew that pregnancy-related complications can occur for up to 1 year after birth, and 13% of mothers reported not knowing that complications can occur for up to 6 weeks postpartum. Clinical Implications: Our fi ndings provide a foundation to enhance postpartum education for new mothers and their families and to potentially decrease rates of maternal mortality in the United States. Key words: Knowledge; Mortality; Mother; Postpartum; Teaching.

M o n ke

y B u si

n es

s Im

ag es

/ S

h u tt

er st

o ck

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 

 

202 volume 43 | number 4 July/August 2018

at a rate of 41.1 per 100,000 live births compared with 11.8 and 15.7 per 100,000 live births for non-Hispanic White and other races of women, respectively (Creanga et al.). Women who lack health insurance are three to four times more likely to die than those who are insured (Chang et al., 2003). Older women ≥ 35 years comprise 15% of live births, but account for 27% to 29% of all pregnancy- related deaths (Creanga et al.). Overall, more than 700 women die and another 60,000 suffer near-fatal complications related to pregnancy and childbirth, half of which are preventable, in the United States each year (Creanga et al.).

Pregnancy-related deaths may occur up to 1 year af- ter pregnancy and may be the result of thrombotic pul- monary embolisms, cerebrovascular accidents, infection, cardiovascular conditions, noncardiovascular medical conditions, cardiomyopathy (Creanga et al., 2015), and suicide (Wisner et al., 2013). See Table 1. If healthcare providers are unaware of the recent pregnancy, these women may not receive the appropriate care quickly enough to prevent mortal- ity or long-term morbid- ity. Unfortunately, many new mothers, particularly those with no consistent primary care provider, do not receive enough action- able information about complications and warning signs related to the post- partum period that could better equip them to seek needed treatment in a timely fashion and prevent maternal mortality (Amnesty Inter- national, 2011). Overall, 30% of women lack prenatal education classes (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2014). Women who are poor and/or of mi- nority status have been reported to lack a personal phy- sician or healthcare provider, to not enroll in childbirth education classes (Declercq et al.; Wolfe, 2006), and to receive lesser quality and uncoordinated prenatal care (Smedley, Stith, & Nelson, 2003), which put them at a disadvantage for having adequate health information af- ter birth. Recommendations from a variety of statewide mortality review committees support the urgent need for education of women and families (Georgia Department of Public Health, 2015; Main et al., 2011; New York Acad- emy of Medicine, 2011). However, before new educational programs are developed, baseline information is needed on accuracy of women’s knowledge about their risk for pregnancy-related mortality. The purpose of this study is to describe the knowledge of new mothers related to maternal mortality.

Theoretical Framework This study was framed by Thaddeus and Maine’s “Three Delay Model,” which identifi es barriers mothers face in receiving appropriate obstetric care. The “Three Delays” model proposes that pregnancy-related mortality is over- whelming due to delays in: (1) deciding to seek appropri-

ate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving ad- equate care when a facility is reached. This study focuses on the phase 1 delay: a “delay in deciding to seek care on the part of the individual, the family, or both” (Thaddeus & Maine, 1994).

Research Questions Our research questions were as follows: 1) How many new mothers correctly identify warning signs of the lead- ing causes of maternal mortality; 2) How would new mothers take action if they were to experience one of these warning signs after discharge from the hospital; and 3) Do new mothers understand how long after birth that they could have pregnancy-related complications?

Study Design and Methods A cross-sectional design was used to survey new moth- ers about their knowledge of postpartum complications

during the fi rst year after giving birth that could possi- bly lead to serious complications and maternal mortality. Data were collected from May 2016 to November 2016. The study was approved by the university human studies protection program and the study site. Data were ana- lyzed with descriptive statistics.

Sample

A convenience sample of new mothers was recruited from a mother–baby unit of an academic health sciences center and data were collected before hospital discharge. Inclu- sion criteria were having given birth to a live child within the last week, 18 years of age or older, and English-speak- ing. After providing informed consent, all participants were administered surveys and were given diapers valued at approximately $32.

Setting

Demographic information was not collected on partici- pants; however, data that describe the larger population are available. The academic medical center serves a high percentage of minorities and underserved patients. Ap- proximately 19% of patients are indigent, 29% receive Medicaid, over 40% are of a minority population, and 19% do not speak English. Of the 1,826 women who gave birth at the academic medical center in 2016, 28% were African American, 2% were Asian, and 63% were White. No statistics are recorded on Hispanic ethnicity,

Pregnancy-related deaths may occur up to one year after pregnancy and may be the result of thrombotic pulmonary embolisms, cerebrovascular accidents, infection, cardiovascular conditions, non-cardiovascular conditions, cardiomyopathy, and suicide.

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July/August 2018 MCN 203

but 5% of the metropolitan area self- identify as Hispanic. Seventy-seven percent of the new mothers who gave birth at the academic medical center in 2016 were single parents.

Survey

The surveys included three ques- tions, which were developed as part of a 2-year joint initiative by the Association of Women’s Health, Obstetric, and Neonatal Nursing and the Association of Maternal and Child Health Programs and described in a special In Focus series in the Jour- nal of Obstetrics, Gynecology, and Neonatal Nursing in 2016 (Logsdon, 2016). First, “Which of the following signs could a new mother experience after hospital discharge?” Response choices included nine possible warn- ing signs of the most common fatal pregnancy complications, such as shortness of breath, severe headache, and so on that a new mother could experience within the fi rst year after birth (D’Oria, Myers, & Logsdon, 2016). The second question asked, “If you had any of the signs above, what would you do?” Eight possible courses of action were listed, such as “Call labor and delivery,” “Call your doctor/nurse practitioner,” and so on. Then mothers were asked, “How long after birth could a new mother have complications from the birth?” Response choices included up to 1 day, 1 week, 6 weeks, or 1 year after birth.

Results How many new mothers correctly identify warning signs of the leading causes of maternal mortality? New mothers accurately responded that after hospital discharge they could experience bleeding that saturates more than one perineal pad in an hour, a severe headache, swelling, and leg pain, n = 74 (61.7%), n = 77 (64.2%), 85 (70.8%), n = 68 (57%), respectively. How- ever, fewer participants understood that after hospital dis- charge a new mother could experience shortness of breath n = 59 (49%), feelings that she could harm herself or her baby n = 58 (48%), blood clots larger than a baby’s hand n = 54 (45%), a temperature of >100.4 °F n = 49 (40.8%), or an odor with vaginal discharge n = 53 (44.2%). See Table 2.

How would new mothers take action if they were to experience one of these warning signs after discharge from the hospital? Eighteen percent of mothers (n = 11) would take no action. Almost 77% (n = 92) would tell

their boyfriend/husband/partner compared with only 60% (n = 72) who would call labor and delivery. Seventy- one percent (n = 85) would go to a hospital emergency department, but only 42.5% (n = 51) would call 911. See Table 3.

Do new mothers understand how long after birth that a new mother could have pregnancy-related complica- tions? Only 38.3% of mothers (n = 46) understood that pregnancy-related complications can occur for up to 1 year after birth. Most new mothers knew that pregnancy- related complications could occur after 1 day (99%), 1 week (94%), and 6 weeks (85%) after birth. See Table 4.

Clinical Implications Based upon the Three Delays Model, we identifi ed defi cits in new mothers’ knowledge about life-threatening preg- nancy complications and their warning signs, which could

Table 1. Essential Educational Content Related to Postpartum Morbidity and Mortality Educational Topic Brief Description

Headache Type and severity of headache persisting after usual therapies

Infection Temperature ≥ 100.4 °F for at least 6 hours; excessive pain or discharge from incision, odor

Leg pain Severity, location, intensifi ed with straightening of leg and fl exion of foot

Shortness of breath/

chest pain

Report immediately; may or may not be concerning (e.g., pulmonary embolism or cardiomyopathy)

Swelling Swelling of the face and extremities: description, time of day, duration

Vaginal bleeding

Blood clots larger

than baby’s hand

Explicit description of excess bleeding and/or clot size

Wanting to harm self

or infant

Report feelings of sadness, depression, withdrawal, or the desire to harm self or infant

Note. Essential educational topics are signs and symptoms of the most common pregnancy- related causes of maternal mortality and morbidity up to 1 year after birth.

Table 2. New Mothers’ Knowledge of the Most Common Postpartum Warning Signs

Warning Signs Yes No

Shortness of breath 59 (49.2%) 44 (36.7%)

Feelings that you may harm yourself or baby 58 (48.3%) 56 (46.7%)

Bleeding that saturates more than one perineal pad

in an hour

74 (61.7%) 39 (32.5%)

Blood clots larger than your baby’s hand 54 (45%) 52 (43.3%)

Severe headache 77 (64.2%) 37 (30.8%)

Leg pain that may include swelling, redness, or

warmth

68 (56.7%) 40 (33.3%)

Swelling 85 (70.8%) 32 (26.7%)

Temperature of 100.4 °F or higher 49 (40.8%) 60 (50%)

Odor with vaginal discharge 53 (44.2%) 49 (40.8%)

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contribute to a phase 1 delay in deciding to seek health- care (Thaddeus & Maine, 1994). As only 38% of mothers (n = 46) reported knowing that pregnancy- related compli- cations can occur for up to a year after birth, it is under- standable that a majority of new mothers were unaware of fi ve of the nine warning signs that could occur after hospital discharge. Few mothers may call 911 (42.5%) if experiencing a warning sign due to their lack of under- standing that these warning signs are indicators of poten- tially impending death without treatment.

Our fi ndings could enhance postpartum education for new mothers and their families (Simpson, 2017). Perinatal nurses are at the frontline in providing health education to new mothers and their families, and by incorporating the questions from this study into clinical practice, nurses could assess new mothers’ knowledge about life-threat- ening pregnancy-related complications before sending them home from the hospital after giving birth (D’Oria et al., 2016; Suplee, Bingham, & Kleppel, 2017). From this baseline knowledge, nurses can identify new mothers’ learning needs and individualize postpartum education, ensuring that new mothers understand life-threatening risks before they are discharged. New technologies, such as smart phone apps, are now available that may support the uptake and use of this critically important information (Logsdon, 2017). Research is needed to tailor the message and birthing methods to the needs of the women.

There are several limitations of the study that have an impact on generalizability. The sample was primar- ily low-income and from one site. Questions used in the survey were established by a nursing expert panel and, thus, include face and content validity, but other psycho- metrics have not been established. To our knowledge,

no standardized instruments exist to measure knowledge of symptoms in- dicating risk of maternal mortality. Demographics were not collected, so analysis of knowledge by race and age was not possible. This is important data because maternal mortality rates continue to be higher in Non-Hispanic Black mothers and older mothers, as well as low-income mothers. Further research should address these vari- ables. Our study adds to the minimal information that is currently available about knowledge of new mothers of potential complications of childbirth that can occur during the fi rst year postpartum and lead to maternal death. More data are needed on how to improve new mothers’ knowledge on this important issue and if addi- tional knowledge can lead to improve- ment in maternal mortality rates in the United States.

Acknowledgment

The authors acknowledge funding from two sources at the University of Louisville Hospital: University of Louisville Hospital Nursing Research Grant and Nursing & Interdisciplinary Research Committee Re- search Funds. ✜

M. Cynthia Logsdon is a Professor, School of Nursing, University of Louisville, Louisville, KY. The author can be reached via e-mail at Mclogs01@louisville.edu

Deborah Winders Davis is a Professor, Department of Pediatrics, School of Medicine; Director, Louisville Twin Study; and Director, Child and Adolescent Health Research, Design and Support, University of Louisville, Louisville, KY.

Table 3. Courses of Action New Mothers Would Take if They Experienced Warning Signs Action Yes No

Nothing, they are normal 11 (9.2%) 102 (85.0%)

Tell your boyfriend/husband/partner 92 (76.7%) 27 (22.5%)

Tell your mother 87 (72.5%) 32 (26.7%)

Call labor and delivery 72 (60.0%) 44 (36.7%)

Call your doctor/nurse practitioner 108 (90.0%) 12 (10.0%)

Go to urgent care center 72 (60.0%) 42 (35.0%)

Go to hospital emergency department 85 (70.8%) 31 (25.8%)

Call 911 51 (42.5%) 64 (53.3%)

Table 4. New Mothers’ Understanding of the Time Frame for Postpartum Complications

Time Frame Yes No

One year 46 (38.3%) 62 (51.7%)

Six weeks 102 (85.0%) 16 (13.3%)

One week 113 (94.2%) 5 (4.2%)

One day 119 (99.2%) 0 (0.0%)

Clinical Implications for Nurses • Low-income new mothers, women without health insur-

ance, and Non-Hispanic Black mothers have a greater risk of maternal mortality when compared with women without these demographic characteristics.

• Not all new mothers may be aware of potential compli- cations of childbirth that can occur during the fi rst year postpartum.

• Teaching new mothers prior to discharge home from the hospital after giving birth about potential complications that can be life-threatening (see Table 2 for the nine pos- sible warning signs of the most common fatal pregnancy complications) may save lives.

• Nurses are often the main healthcare provider offering post- partum discharge information to new mothers; adequate time to offer thorough information and make sure the wom- an and her family understand what has been discussed is essential to safe and quality perinatal nursing care.

204 volume 43 | number 4 July/August 2018

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John A. Myers is a Professor, Department of Pediat- rics, School of Medicine, University of Louisville, Lou- isville, KY.

Katlin M. Masterson is an Undergraduate Research Scholar, School of Nursing, University of Louisville, Louisville, KY.

Jeffrey A. Rushton is an Entrepreneur, Digital Media, Kentucky Marketing Consulting, Louisville, KY.

Adrian P. Lauf is an Assistant Professor, Speed School of Engineering, University of Louisville, Louisville, KY.

The authors declare no confl icts of interest.

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Women and Newborn Health Nursing

Parent Newborn Teaching Plan Assignment

 

 

Purpose: To demonstrate effective teaching/learning skills for the childbearing family. Topics: Choose a topic to teach: Newborn Feeding (breastmilk or formula), Infant Safety, Newborn Care (bathing, circumcision care) Car Seat Safety, or another newborn care topic of your choosing (do not select Safe Sleep Practices/SIDs as this topic is included in another clinical activity…additional topics may be chosen with instructor approval).

Instructions: ~Research your chosen topic, using websites, textbooks, patient teaching materials from clinical setting, observation in clinical setting etc. ~Create a teaching plan on your chosen topic using patient information handouts from the facility or create a brochure with information on your topic.

~ Find two articles from a nursing or allied health journal that relates to patient education or the topic you have chosen for your teaching plan. Include the citation with any other resources you used.

~Instructor may choose one of the following options:

1.) The student may role-play the teaching session, using a student chosen by the instructor as the “parent” and the rest of the clinical group observing.

2.) Choose one of the student’s assigned patients and deliver the teaching session. The student should invite the instructor or another student to sit in on the session.

 

Teaching Plan Guide:

 

Teaching Goals

What are the priorities? (“By the end of the teaching session, the patient will…”)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Content Outline

What will you teach? Use bullet points to organize topical information.

Methodology

How will you teach the content? What modalities will you use?

Rationale

Why have you chosen the teaching modalities?

Evaluation of Learning

How will you determine if the teaching/learning goals were met?

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