Racial disparities in low-risk cesarean birth rates across hospitals.

BACKGROUND: We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women. METHODS: In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories. RESULTS: Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean. DISCUSSION: Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.

Effects of Nurse Staffing on Missed Breastfeeding Support in Maternity Units With Different Nurse Work Environments.

PURPOSE: To examine the effect of nurse staffing in varying work environments on missed breastfeeding teaching and support in inpatient maternity units in the United States. BACKGROUND: Breast milk is the optimal food for newborns. Teaching and supporting women in breastfeeding are primarily a nurse's responsibility. Better maternity nurse staffing (fewer patients per nurse) is associated with less missed breastfeeding teaching and support and increased rates of breastfeeding. We examined the extent to which the nursing work environment, staffing, and nurse education were associated with missed breastfeeding care and how the work environment and staffing interacted to impact missed breastfeeding care. METHODS: In this cross-sectional study using the 2015 National Database of Nursing Quality Indicator survey, maternity nurses in hospitals in 48 states and the District of Columbia responded about their workplace and breastfeeding care. Clustered logistic regression models with interactions were used to estimate the effects of the nursing work environment and staffing on missed breastfeeding care. RESULTS: There were 19 486 registered nurses in 444 hospitals. Nearly 3 in 10 (28.2%) nurses reported missing breastfeeding care. In adjusted models, an additional patient per nurse was associated with a 39% increased odds of missed breastfeeding care. Furthermore, 1 standard deviation decrease in the work environment was associated with a 65% increased odds of missed breastfeeding care. In an interaction model, staffing only had a significant impact on missed breastfeeding care in poor work environments. CONCLUSIONS: We found that the work environment is more fundamental than staffing for ensuring that not only breastfeeding care is not missed but also breastfeeding care is sensitive to nurse staffing. Improvements to the work environment support the provision of breastfeeding care. IMPLICATIONS FOR RESEARCH AND PRACTICE: Both nurse staffing and the work environment are important for improving breastfeeding rates, but the work environment is foundational.

Examining sustained impacts of two teacher professional development programs on professional well-being and classroom practices.

We examine second-year impacts of a 1-year pre-primary teacher training and coaching program, delivered with and without parental-awareness meetings, evaluated with a school-level randomized trial. Outcomes included teachers' professional well-being and classroom practices. Most gains observed during the program year faded out. However, there were small sustained impacts on the implementation of training activities. Counteracting effects of the parental-awareness meetings were evident, with suggestive evidence that teachers in this treatment group displayed lower scores on one dimension of classroom quality-Supporting Student Expression-compared to controls. Implications for professional development and educational quality are discussed.

Nursing Resources by Type of Maternity Unit Across Regions of the United States.

OBJECTIVE: To examine variation in nursing resources across three different types of maternity units in five regions of the United States. DESIGN: Cross-sectional descriptive. SETTING: Maternity units in hospitals in 48 states and the District of Columbia that participated in the 2016 National Database of Nursing Quality Indicator survey. PARTICIPANTS: Staff nurses (N = 19,486) who worked in 707 maternity units. METHODS: We conducted a secondary analysis of survey data examining nursing resources (work environment, staffing, education, specialty certification) by type of maternity unit, including labor and delivery, labor/delivery/recovery/postpartum, and postpartum. We used descriptive statistics and analysis of variance. RESULTS: Participants worked in 707 units (269 labor and delivery units, 164 labor/delivery/recovery/postpartum units, and 274 postpartum units) in 444 hospitals. The work environment was not significantly different across unit types (mean = 2.89-2.94, p = .27). Staffing, education, and specialty certification varied significantly across the unit types (p ≤ .001). In terms of staffing, postpartum units had, on average, almost twice the number of patients per nurse as labor and delivery units (7.51 patients/nurse vs. 4.01 patients/nurse, p ≤ .001) and 1.5 times more patients than labor/delivery/recovery/postpartum units (5.04 patients/nurse vs. 4.01 patients/nurse, p ≤ .001). CONCLUSION: Nursing resources varied significantly across types of maternity units and regions of the United States. This variation suggests that improving nursing resources may be a system-level target for improving maternity care in the United States.

Policy Evaluation Of The Affordable Care Act Graduate Nurse Education Demonstration.

The US is experiencing a shortage of primary care providers, which could be reduced by the addition of nurse practitioners. However, the ability to increase the supply of nurse practitioners is limited by a shortage of clinical preceptors. The Affordable Care Act's Graduate Nurse Education Demonstration provided federal funding to offset the clinical training costs of advanced practice nurses. We used data from the American Association of Colleges of Nursing from academic years 2005-06 through 2017-18 to determine whether the demonstration was associated with increased nurse practitioner enrollment and graduation growth. The demonstration was associated with a significant increase in nurse practitioner enrollments and graduations. A promising model of organizing and implementing funding for graduate nursing education nationally was identified. Findings suggest that modernizing Medicare payments for nursing education to support nurse practitioner clinical training costs is a promising option for increasing primary care providers.

Domains of Childhood Disadvantage and Functional Limitation Trajectories Among Midlife Men and Women in China.

Objective: To examine the impacts of four childhood disadvantage domains-parental behavior, hunger, health, and socioeconomic status (SES)-on functional limitation trajectories among midlife adults in China. Method: Data (2011-2015) from the China Health and Retirement Longitudinal Study (N = 8,646) were used to examine the associations between different domains of childhood disadvantage and functional limitation trajectories among adults aged 45 to 64. Results: Adverse parental behavior was not associated with baseline functional limitation but was associated with steeper trajectories for men. Health, hunger, and SES were associated with more functional limitations at baseline, and SES with steeper trajectories for men and women. Adulthood SES largely accounted for the associations between childhood SES and functional limitations for men. Discussion: It is important to examine multiple domains of childhood conditions because the type and magnitude of disadvantage may influence functional limitations in different ways among men and women in China.

Childhood Conditions Predict Chronic Diseases and Functional Limitations Among Older Adults: The Case of Indonesia.

Objective: Limited knowledge exists about whether childhood health and socioeconomic status (SES) conditions influence health among older adults in Indonesia. Method: Data from Wave 5 (2014/2015) of the Indonesian Family Life Survey (N = 6,530) was used to examine associations between childhood health and SES and hypertension, lung conditions, diabetes, lower body functional limitations (LBFL), and instrumental activities of daily living limitations (IADL). Results: Poor childhood health was associated with 34% higher odds of hypertension (odds ratio [OR] = 1.34, p < .05), 37% higher odds of diabetes (OR = 1.37, p < .05), and 32% higher odds of lung conditions (OR = 1.32, p < .05). Household overcrowding was associated with 22% higher odds of a LBFL (OR = 1.22, p < .05) and 24% higher odds of an IADL (OR = 1.24, p < .01). Lacking a household toilet was associated with 18% higher odds of a LBFL (OR = 1.18, p < .05). Adjusting for adult SES and current health did not account for these relationships. Discussion: Childhood conditions appear to shape older adult health in Indonesia.