Enumeration of Public Health Nurses in the United States: Limits of Current Standards.

Recent national initiatives in nursing and public health have emphasized the need for a robust public health nursing (PHN) workforce. In this article, we analyze the extent to which recent national enumeration surveys base their counts of this workforce on the definitions, scope, and standards for practice and practice competencies of the PHN nursing specialty. By and large, enumeration surveys continue to rely on practice setting to define the PHN workforce, which is an insufficient approach for meeting the goals of major nursing and public health initiatives. We make recommendations for the development of new standards for PHN enumeration to strengthen the broader public health infrastructure and evaluate PHN contributions to population-level outcomes. (Am J Public Health. 2022;112(S3):S292-S297. https://doi.org/10.2105/AJPH.2022.306782).

Factors influencing birth setting decision making in the United States: An integrative review.

BACKGROUND: The United States has the highest perinatal morbidity and mortality (M&M) rates among all high-resource countries in the world. Birth settings (birth center, home, or hospital) influence clinical outcomes, experience of care, and health care costs. Increasing use of low-intervention birth settings can reduce perinatal M&M. This integrative review evaluated factors influencing birth setting decision making among women and birthing people in the United States. METHODS: A search strategy was implemented within the CINAHL, PubMed, PsycInfo, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. The Whittemore and Knafl integrative review framework informed the extraction and analysis of the data and generation of findings. RESULTS: We identified 23 articles that met inclusion criteria. Four analytical themes were generated that described factors that influence birth setting decision making in the United States: "Birth Setting Safety vs. Risk," "Influence of Media, Family, and Friends on Birth Setting Awareness," "Presence or Absence of Choice and Control," and "Access to Options." DISCUSSION: Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

BACKGROUND: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Women's childbirth experiences: A content analysis from the Listening to Mothers in California survey.

BACKGROUND: The World Health Organization's recent recommendations on intrapartum care regard women's experience of care as an essential aspect of high-quality maternity care. A better understanding of women's perspectives on their childbirth experiences in the United States is needed to place women in the center of care and optimize their experience of childbirth. METHODS: This study analyzed data from the Listening to Mothers in California survey completed by a representative sample of women who gave birth in 2016 in California hospitals. Responses to one or both open-ended questions about the best and worst part of respondent's hospital stay for childbirth were subject to a content analysis. RESULTS: Findings from 2539 participants included 2336 best and 1410 worst part responses. References to the attitudes and behaviors of health care practitioners were the most commonly reported (47% best and 29.1% worst part). Nurses were the most frequently mentioned practitioner type. Additional best part categories in rank order included the quality of physical care of the mom and feelings about the care experience. Additional worst part categories in rank order included the quality of the facility and food, delays in care, infant feeding, the quality of physical care of the mom, and lack of privacy. DISCUSSION: Women's hospital experiences during childbirth, while multidimensional in nature, are primarily shaped by their relationships with health care practitioners, the care provided, and the facility in which childbirth occurs. Women's feedback provides actionable information to promote a positive birth experience.

Decreasing Barriers to Research Utilization Among Labor and Delivery Nurses.

BACKGROUND: Intermittent fetal monitoring (IFM) is a recommended strategy for intrapartum fetal heart rate assessment in low-risk pregnancies; however, this "high touch, low tech" approach is underutilized. OBJECTIVE: The aim of the study was to examine the relationships between labor and delivery nurses' intellectual capital and their perceptions of barriers to research utilization in the work setting. METHODS: A cross-sectional correlational design using data derived from a larger study of labor and delivery nurses (N = 248) was used. Covell's theory of nursing intellectual capital was used as the conceptual and analytic framework to examine labor and delivery nurses' intellectual capital and their perceived barriers to research utilization. RESULTS: Nurses who receive paid time off from their employer to attend conferences (p < .01) and nurses who do not report nurse-to-patient ratios as a problem in providing IFM (p < .01) perceive fewer barriers to research utilization. DISCUSSION: Time, especially available time, has an effect on labor and delivery nurses' attitude toward IFM and their perceptions of barriers to research utilization.

Continued Disparities in Postpartum Follow-Up and Screening Among Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review.

The postpartum period represents a critical window to initiate targeted interventions to improve cardiometabolic health following pregnancies complicated by gestational diabetes mellitus and/or a hypertensive disorder of pregnancy. The purpose of this systematic review was to examine studies published since 2011 that report rates of postpartum follow-up and risk screening for women who had gestational diabetes and/or a hypertensive disorder of pregnancy and to identify disparities in care. Nine observational studies in which postpartum follow-up visits and/or screening rates were measured among US women following pregnancies complicated by gestational diabetes and/or a hypertensive disorder of pregnancy were reviewed. Rates of postpartum follow-up ranged from 5.7% to 95.4% with disparities linked to black race and Hispanic ethnicity, low level of education, and coexisting morbidities such as mental health disorders. Follow-up rates were increased if the provider was an obstetrician/endocrinologist versus primary care. Payer source was not associated with follow-up rates. The screening rate for diabetes in women who had gestational diabetes did not exceed 58% by 4 months across the studies analyzed, suggesting little improvement in the last 10 years. While women who had a hypertensive disorder appear to have had a postpartum blood pressure measured, it is unclear whether follow-up intervention occurred. Overall, postpartum screening rates for at-risk women remain suboptimal and vary substantially. Further research is warranted including reliable population-level data to inform equitable progress to meeting the evidence-informed guidelines.

Labor induction and cesarean delivery: A prospective cohort study of first births in Pennsylvania, USA.

BACKGROUND: Mode of delivery at first childbirth largely determines mode of delivery at subsequent births, so it is particularly important to understand risk factors for cesarean delivery at first childbirth. In this study, we investigated risk factors for cesarean delivery among nulliparous women, with focus on the association between labor induction and cesarean delivery. METHODS: A prospective cohort study of 2851 nulliparous women with singleton pregnancies who attempted vaginal delivery at hospitals in Pennsylvania, 2009-2011, was conducted. We used nested logistic regression models and multiple mediational analyses to investigate the role of three groups of variables in explaining the association between labor induction and unplanned cesarean delivery-the confounders of maternal characteristics and indications for induction, and the mediating (intrapartum) factors-including cervical dilatation, labor augmentation, epidural analgesia, dysfunctional labor, dystocia, fetal intolerance of labor, and maternal request of cesarean during labor. RESULTS: More than a third of the women were induced (34.3%) and 24.8% underwent cesarean delivery. Induced women were more likely to deliver by cesarean (35.9%) than women in spontaneous labor (18.9%), unadjusted OR 2.35 (95% CI 1.97-2.79). The intrapartum factors significantly mediated the association between labor induction and cesarean delivery (explaining 76.7% of this association), particularly cervical dilatation <3 cm at hospital admission, fetal intolerance of labor, and dystocia. The indications for labor induction only explained 6.2%. CONCLUSIONS: Increased risk of cesarean delivery after labor induction among nulliparous women is attributable mainly to lower cervical dilatation at hospital admission and higher rates of labor complications.

Public Health Nursing Practice in the Affordable Care Act Era: A National Survey.

OBJECTIVES: To explore public health nurses' knowledge, perceptions, and practices under the Affordable Care Act (ACA). DESIGN AND SAMPLE: A cross-sectional, web-based survey was completed by a sample of 1,143 public health nurses (PHNs) in the United States. MEASURES: Descriptive statistics were analyzed for variables related to general knowledge and perception of the ACA and for the extent of involvement in activities related to the implementation of the ACA. Qualitative analysis was conducted on free text comments to two open-ended questions about current and future PHNs involvement in the ACA. RESULTS: Approximately 45% of PHNs reported changes in their daily work due to the ACA. PHNs reported being very or somewhat involved in these activities of the ACA: integration of primary care and public health (62%), provision of clinical preventive services (60.3%), care coordination (55.4%), patient navigation (55.3%), establishment of private-public partnerships (55.3%), population health strategies (53.6%), population health data assessment and analysis (53.8%), community health assessments (49%), involvement in medical homes (37.8%), provision of maternal and child health home visiting services (32.1%), and involvement in Accountable Care Organizations (29.2%). CONCLUSION: PHNs are making substantial contributions to implementation of the ACA.

Variation in Vaginal Birth After Cesarean by Maternal Race and Detailed Ethnicity.

Objective Our objective was to examine the likelihood of vaginal birth after cesarean (VBAC) for women in Massachusetts. Methods We used birth certificate data among term, singleton, vertex presentation births by repeat cesarean or VBAC to conduct logistic regression models to examine the likelihood of VBAC for women categorized into standard classifications of race and ethnicity and into 31 detailed ethnicities. Data were analyzed for the entire study period (1996-2010, N = 119,752) and for the last 5 years (2006-2010, N = 46,081). Results The adjusted odds of VBAC were lowest for non-Hispanic Black mothers (0.91, CI [0.85, 0.98]) and highest for Asian/Pacific Islander mothers (1.41, CI [1.31, 1.53]) relative to non-Hispanic White women. VBAC rates ranged from 5.8 % among Brazilians to 29.3 % among Cambodians. The adjusted odds of VBAC were lower for 7 of the 30 ethnic groups (range of AORs 0.40-0.89) and higher for 8 of the 30 ethnic groups (range of AORs 1.18-2.11) relative to self-identified American mothers. For the last 5 years, Asian/Pacific Islander mothers had a higher adjusted VBAC rate (1.39, CI [1.21, 1.60]), as did 9 of the 30 ethnic groups (range of 1.25-1.84). Only Brazilian mothers had lower rates (0.37, CI [0.27, 0.50]), relative to self-identified American mothers. Conclusions Detailed maternal ethnicity explains the variation in VBAC rates more precisely than broad race/ethnicity categories. Improvements in our public health data infrastructure to capture detailed ethnicity are recommended to identify and address disparities and improve the quality of maternity care.

Fear of Childbirth and Preference for Cesarean Delivery Among Young American Women Before Childbirth: A Survey Study.

BACKGROUND: Fear of birth and mode of delivery preferences are similar among pregnant and nonpregnant women, suggesting that attitudes toward birth are formed in young adulthood or earlier. Understanding why some young women fear birth and prefer obstetric interventions can inform public health initiatives aimed at reducing fear and promoting birth as a normal life event. METHODS: We conducted an online survey with 752 American nulliparous young women to assess their preferences and attitudes toward childbirth. We identified explanatory variables associated with reported fear of childbirth and cesarean delivery (CD) preferences. RESULTS: A preference for CD was reported by 14 percent of young women and 27 percent had scores indicating elevated fear of birth. Fear of birth increased the likelihood of cesarean preference (adjusted relative risk (ARR) 3.84 [95% CI 2.49-5.95]) as did a family history of CD (ARR 1.65 [95% CI 1.13-2.42]). The likelihood of reporting elevated childbirth fear was increased among young women who reported concerns about the physical changes pregnancy and birth have on women's bodies (ARR 2.04 [95% CI 1.50-2.78]). Young women who reported a high degree of confidence in their knowledge about childbirth were significantly less likely to report childbirth fear (ARR 0.61 [95% CI 0.42-0.87]). Access to childbirth information was also associated with a decreased likelihood of fear of birth (ARR 0.75 [95% CI 0.59-0.95]). CONCLUSIONS: Young women reporting high levels of childbirth fear are nearly four times more likely to prefer a CD. Specific fears, such as worries over the influence of pregnancy and birth on the female body, need to be addressed before pregnancy.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts.

BACKGROUND: Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts. METHODS: Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research. RESULTS: While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women. CONCLUSIONS: Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.

Uncertainty in Maternity Care.

The Editor in Chief reflects on uncertainty in maternity care.

Updates for Journal of Obstetric, Gynecologic, & Neonatal Nursing in 2024.

to follow.

Switzerland's Midwifery Model of Postpartum Care.

Switzerland's midwifery model of postpartum care is described and compared to postpartum care in the United States.

Experiences of Midwives Attending Home Births in Massachusetts During the COVID-19 Pandemic.

INTRODUCTION: Public interest in home birth in the United States increased during the COVID-19 pandemic. Midwives attend the vast majority of home births and are experts in providing home birth care. However, limited data are available about the experiences of midwives attending home births during the pandemic in the United States. METHODS: We developed a cross-sectional survey comprising 34 questions, which included 5 open-ended questions. The survey was distributed online in June 2021 to midwives attending home birth in Massachusetts. We calculated descriptive statistics for the quantitative survey responses and identified qualitative free-text responses illustrating the results. RESULTS: Eighteen midwives and 2 midwife apprentices responded to the survey, approximately 50% of Massachusetts' total number of midwives known to attend homebirths. The majority of the 20 respondents reported an increase in public interest in home birth (n = 17) and higher caseloads (n = 14) since the start of the pandemic. Respondents reported an increase in the number of clients transferring to their practices at a later gestational age (n = 13) and who identified as people of color (n = 8). They described both better and worse transfer of care to hospital experiences. Work-life balance and unpredictable income were the top 2 reported obstacles to home birth practice. DISCUSSION: The results of our study indicate that midwives providing home birth care in Massachusetts witnessed a surge in demand for their services during the pandemic. Implementing policies and practices that provide support for certified professional midwives could strengthen the home birth workforce, enhance access to home birth options, and optimize transfers to hospital settings when necessary.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review.

INTRODUCTION: Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication. METHODS: We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations. RESULTS: Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations. DISCUSSION: Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Nurses' Perceived Effects of Visitor Restrictions in Hospital Maternity Units.

PURPOSE: To explore how perinatal nurses perceive the effects of visitor restrictions on patient care within a hospital setting. STUDY DESIGN AND METHODS: We distributed a cross-sectional survey online to perinatal nurses in May of 2022. Characteristics of respondents were analyzed using descriptive statistics. Responses to an open-ended question were analyzed via conventional content analysis. RESULTS: Among our sample of 101 nurses, we identified seven codes representing positive effects and seven codes representing negative effects. The most frequently reported positive effects were ability to provide person-centered care ( n = 36, 35.6%) and less patient stress and more rest ( n = 29, 28.7%). The most frequently reported negative effects were limited patient support ( n = 22, 21.8%) and emotional distress to the patient ( n = 15, 14.9%). Fourteen percent ( n = 14) of respondents cited both positive and negative effects. CLINICAL IMPLICATIONS: Nurses perceived that visitor restrictions resulted in both positive and negative patient experiences. Balancing clinical needs and safety considerations with emotional needs of the childbearing individual requires careful consideration by maternity care clinicians and health care systems. Subsequent research is needed to determine optimal visitation policies during intrapartum and postpartum with consideration to hospital context and patient preferences for optimal care.

"It's my Home away from Home:" A hermeneutic phenomenological study exploring decision-making experiences of choosing a freestanding birth centre for perinatal care.

PROBLEM: The high-value, midwifery-led birth centre (BC) model of care is underutilized in the United States, a country with high rates of obstetric intervention and maternal morbidity and mortality. BACKGROUND: Birth setting decision-making is a complex, preference-sensitive, and resource-dependent process. Understanding how people choose BCs for care may help increase the utilization of BCs and generate positive perinatal outcomes. AIM: This study explores the decision-making experiences of people with Medicaid insurance who chose to give birth in a BC in Massachusetts by gathering interview data to interpret and provide meaning about their selection of birth setting. METHODS: We employed a hermeneutic phenomenology study to interview people about their decision to give birth in a BC. Interview data were coded using a hybrid deductive-inductive approach and analyzed using reflexive thematic analysis to interpret and provide meaning. FINDINGS: Twelve women participated in the study. Five themes emerged that described participants' decision-making processes: 1) Stepping Away from "the System," 2) Decision-Making with External Influences, 3) Accessing BC Care, 4) Finding a Home at the BC, and 5) Decision-Making as a Temporal Process. DISCUSSION: The decision to choose a BC was a dynamic process that occurred over time and was influenced by factors such as the quality of care, accessibility, external influences, and the physical environment. CONCLUSION: Prioritizing an individual's capacity to choose their birth setting and fostering awareness about options in the context of informed decision-making are pivotal steps toward attaining equity in perinatal health. Securing public insurance coverage and equitable reimbursement for BCs represent essential policies aimed at facilitating universal access to the BC model for all people.

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study.

BACKGROUND: Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center. METHODS: A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006-2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups. RESULTS: The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor. CONCLUSIONS: Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.