INTRODUCTION
A person’s ability to lead a fulfilling life and to participate fully in society depends largely on his or her health status. This is especially true for women, who commonly are responsible for not only their own health, but also that of others: their children and families. Thus, it is important to concentrate on the health of women, children, and families. Children are the future of our society. Their overall health has improved, and rates of death and illness in some areas have decreased but we still must focus on children’s health both in the United States and globally. Habits and practices established in childhood have profound effects on health and illness throughout life. As a society, creating a population that cares about women, children and families and promotes preventative and quality health care and positive lifestyle choices is crucial. Nurses play a major role in this task. They are often “in the trenches” advocating on various issues, drawing attention to the
importance of health care for children, encouraging focus on education and prevention, and assisting families who lack resources or access to health care and legal issues related to caring for children. Maternity care is an integrated care process, which consists of different services (prenatal, intranatal, and postnatal), involves different professionals, and covers extended time frames. Maternal and newborn nursing encompasses a wide scope of practice typically associated with childbearing. It includes care of the woman before pregnancy, care of the woman and her fetus during pregnancy, care of the woman after pregnancy, and care of the newborn, usually during the first 6 weeks after birth. The overall goal of maternal and newborn nursing is to promote and maintain optimal health of the woman and her family. Providing quality maternity care includes client satisfaction and achieving best evidence-based outcomes with the fewest interventions. Child health nursing, commonly referred to as pediatric nursing, involves the care of the child from infancy through adolescence. In the United States, the number of children under age 18 years is approximately 73.7 million, accounting for 23% of the population (Federal Interagency Forum on Child and Family Statistics [FIFCFS], 2018). Since the 1960s, children have
decreased as a percentage of the total U.S. population and are projected to slowly decline through 2050 (FIFCFS, 2018). The overall goal of pediatric nursing practice is to promote and assist the child in maintaining optimal levels of health, while recognizing the influence of the family on the child’s well-being. This goal involves health promotion and disease and injury prevention as well as assisting with care during illness. The common thread in both of these is the care of the family. This chapter presents a general overview of the health care of women, children, and families and describes the major factors affecting maternal and child health as well as legal and ethical issues involved in maternal and child health care. Nurses need to be knowledgeable about these concepts and factors to ensure that they provide safe, professional care.
HISTORICAL DEVELOPMENT
The health care of women and children has changed over the years due in part to changes in childbirth methods, devastating epidemics, social trends in our country, economic circumstances, physical environment, safety, exposure to violence, illicit substance misuse, changes in the health care system, and federal and state regulations. By reviewing historical events, nurses can gain a better understanding of the current and future status of maternal and child health and
how maternal and pediatric nursing care has evolved. The History of Maternal and Newborn Health and Health Care Childbirth in colonial America was a difficult and dangerous experience. During the 17th and 18th centuries, women giving birth often died as a result of exhaustion, dehydration, infection, hemorrhage, or seizures. Death in childbirth was sufficiently common that many colonial women regarded pregnancy with dread (Digital History, 2019). Approximately 43% of all children died before age 5 (Roser, 2019), compared with the 5.8 infant deaths per 1,000 live births of today (Centers for Disease Control and Prevention [CDC], 2019a). This decrease in infant and child mortality rates reflects centuries of advances in public health, living standards, medical science, technology, and clinical practice. There was a time when nearly every infant that came into this world was attended by a midwife. Centuries ago, “granny midwives” handled the normal birthing process for most women. They learned their skills through an apprenticeship with a more experienced midwife. Physicians usually were called only in extremely difficult cases, and all births took place at home. The rise of obstetrics in the 1800s drove midwifery to the periphery, but within the last century, midwifery has reemerged as an organized profession,
appearing everywhere from home births to hospital labor units. Women who labored and gave birth at home were traditionally attended to by relatives and midwives. Continuous companionship support during childbirth has been demonstrated to yield better outcomes (see Evidence-Based Practice 1.1). During the early 1900s, physicians attended about half the births in the United States. Midwives often cared for women whom could not afford a doctor. Many women were attracted to hospitals because this showed affluence and they provided pain management, which was not available for home births. In the 1950s, “natural childbirth” practices advocating birth without medication and focusing on relaxation techniques were introduced. These techniques opened the door to childbirth education classes and helped bring the father back into the picture. Both partners could participate by taking an active role in pregnancy, childbirth, and parenting (Fig. 1.1). EVIDENCE-BASED PRACTICE
1.1 Perceptions and Experiences of Labor
Companionship: A Qualitative Evidence Synthesis
STUDY Companionship during labor refers to support provided to a woman during childbirth and may be provided by a partner, family member, friend, doula or health care professional such as a nurse. A previous Cochrane systematic review concluded that having a
continuous labor companion improves outcomes for women and their infants. Labor companions are regarded as an important aspect of improving quality of care for the laboring woman. The purpose of this review was to explore how women, families, and health care workers experience women going through labor and childbirth with a continuous support person present. A total of 51 studies were included in the synthesis. Findings Labor companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating nonpharmacologic pain relief. Companions were advocates, which resulted in their speaking up in support of the woman’s needs. Companions provided practical support by encouraging women to move around, providing massage, and holding her hand. Finally, companions gave the woman emotional support, using praise and reassurance to help women feel more in control and confident, and providing continuous presence. Companionship helped women to have a positive birth experience. Nursing Implications Based on the research findings, it is important for all laboring women to have a companion throughout her childbirth experience. Nurses can
apply this evidence-based research to their practice by encouraging women how important it is to have a support person with them during their laboring timeframe. Women have traditionally been attended by a companion throughout their childbirth experience, but initiatives to foster this have not necessarily respected this tradition. Formal hospital policy changes may be needed in some facilities to allow for companionship during the childbirth experience. Nurses can take a lead role in bringing about these changes. Adapted from Bohren, M. A., Berger, B. O., Munthe-Kaas, H., & Tuncalp, O. (2019). Perceptions and experiences of labor companionship: A qualitative evidence synthesis. Cochrane Database of Systematic Reviews, 2019(3), CD012449. https://doi.org/10.1002/14651858.CD012449.pub2. Box 1.1 shows a time line of childbirth in America. In many ways, childbirth practices in the United States have come full circle, as we see the return of nurse midwives and doulas. Today, childbirth choices are often based on what works best for the mother, child, and family. FIGURE 1.1. Today fathers and partners are welcome to take an active role in the pregnancy and childbirth experience. A. A couple can participate together in childbirth education classes. (Photo by Gus Freedman.) B. Fathers and partners can assist the
woman throughout her labor and delivery. (Photo by Joe Mitchell.) The History of Child Health and Child Health Care In past centuries in the United States, the health of the country was poorer than it is today; mortality rates were high and life expectancy was short. Infectious diseases were rampant, and unsanitary food sources contributed to illness in children. Devastating epidemics of smallpox, diphtheria, scarlet fever, and measles hit children the hardest. During this period, the prevalent view was that children were a commodity; their role was to increase the population and share in the work to be done. This view changed over the years. Public schools were established and the court system began viewing children as minors. The health of children began to receive more and more attention. BOX 1.1
Childbirth in America: A Time Line 1700s Men did not attend births because it was considered indecent. Women faced birth not with joy and ecstasy but with fear of death. Female midwives attended the majority of all births at home. 1800s There is a shift from using midwives to doctors among middle-class women. The word obstetrician was formed from the Latin, meaning “to stand before.” Puerperal (childbed) fever was occurring in epidemic proportions. Louis Pasteur demonstrated that streptococci were the major cause
of puerperal fever that was killing mothers after delivery. The first cesarean section was performed in Boston in 1894. The x-ray was developed in 1895 and was used to assess pelvic size for birthing purposes. 1900s Twilight sleep (a heavy dose of narcotics and amnesiacs) was used on women during childbirth in the United States. The United States was 17th out of 20 nations in infant mortality rates. Of all women, 50% to 75% gave birth in hospitals by 1940. Nurseries were started because mothers could not care for their baby for several days after receiving chloroform gas. Dr. Grantley Dick–Reed (1933) wrote Childbirth Without Fear, which reduced the “fear–tension–pain” cycle women experienced during labor and birth. Dr. Fernand Lamaze (1984) wrote Painless Childbirth: The Lamaze Method, which advocated distraction and relaxation techniques to minimize the perception of pain. Amniocentesis was first performed to assess fetal growth in 1966. In the 1970s the cesarean section rate was about 5%. In 2011 it rose to 32%, where it stands currently. The 1970s and 1980s see a growing trend to return birthing back to the basics— nonmedicated, nonintervening childbirth. In the late 1900s, freestanding birthing centers—LDRPs—were designed, and the number of home births began to increase. 2000s One in three women undergoes a
surgical birth (cesarean). CNMs once again assist couples at home, in hospitals, or in freestanding facilities with natural childbirths. Research shows that midwives are the safest birth attendants for most women, with lower infant mortality and maternal rates, and fewer invasive interventions such as episiotomies and cesareans. Childbirth classes of every flavor abound in most communities. According to the latest available data, the United States ranks 48th in the world in maternal deaths. The maternal mortality ratio is approximately 28 in 100,000 live births. According to the latest available data, the United States ranks 55th in the world (compared to 224 other countries) in infant mortality rates. The infant mortality rate is approximately 6.17 in 1,000 live births. Adapted from Kieter, L. (2018). Making the personal historical: Reflections on pregnancy and birth. Retrieved June 16, 2020, from https://earlyamericanists.com/2018/07/25/makingthe-personal-historical-reflections-on pregnancy-andbirth/; Withycombe, S. K. (2019). Women and reproduction in the United States during the 19th century. Retrieved June 16, 2020, from https://oxfordre.com/americanhistory/view/10.1093/a crefore/9780199329175.001.0001/ acrefore9780199329175-e-426; and Dion, E. (2019). Maternity
nursing, midwives, and mothers-to-be. Retrieved June 16, 2020, from https://www.womenshistory.org/articles/maternitynursing-midwives-and-mothers-be. As the end of the 19th century neared, doctors and scientists gained a better understanding of the root causes of illness. This knowledge helped fuel public health efforts such as the campaign for safe milk supply, which lead to pasteurizing milk and to dispensing free milk in some cities (U.S. Department of Agriculture [USDA], 2019). Compulsory vaccination programs began during this time. In the late 1800s some states mandated smallpox vaccination as a condition of school attendance. These public health efforts led to a decrease in infant and child deaths (Maternal and Child Health Bureau [MCHB], Health Resources and Services Administration [HRSA], U.S. Department of Health and Human Services [USDHHS], n.d.). In the late 19th and early 20th centuries, cities became healthier places to live due to urban public health improvements such as sanitation services, treated municipal water, and improvements in hygiene (MCHB, HRSA, USDHHS, n.d.). Diseases such as diphtheria, cholera, polio, and yellow fever began to take less of a toll on children (MCHB, HRSA, USDHHS, n.d.). The turn of the 20th century brought new
knowledge about nutrition, sanitation, bacteriology, pharmacology, medication, and psychology. Penicillin, corticosteroids, and increased numbers of vaccines, which were developed during this time, assisted with the fight against communicable diseases. Thus, by the end of the 20th century, unintentional injuries surpassed disease as the leading cause of death for children greater than 1year-old. Today, unintentional injuries remain the number one cause of death among people 1 to 44 years old (National Safety Council [NSC], 2020). Technologic advances have significantly affected all aspects of health care and led to increased survival rates in children. However, many children who survive illnesses that were previously considered fatal are left with chronic disabilities. For example, before the 1960s, extremely premature infants did not survive because of the immaturity of their lungs. Newer ventilation methods and the use of medications to foster lung development have increased survival rates in premature infants, but survivors are often faced with a myriad of chronic illnesses such as chronic lung disease (bronchopulmonary dysplasia), retinopathy of prematurity, cerebral palsy, or developmental delay. This increased survival has resulted in a significant increase in chronic illness relative to acute illness as a
cause of hospitalization and mortality. Chronic diseases are illnesses that last more than 3 months and cannot be prevented by vaccination, cured by medication, and do not disappear. Today, more than 54% of American children are suffering from one or more chronic illnesses (Children’s Health Defense, 2019). In recent years advances in biomedicine have created a trend toward earlier diagnosis and treatment of disorders and diseases. Additionally, genetics have been linked with pathophysiologic processes. For example, female fetuses diagnosed with congenital adrenal hyperplasia, a genetic disorder resulting in a steroid-enzyme deficiency leading to disfiguring anatomic abnormalities of sexual characteristics reducing virilization, are able to receive treatment before birth (Marco et al., 2019). In addition, early genetic defect identification allows for appropriate counseling. Advancements in diagnostic technology and treatment methods continue to improve child health. For example, less invasive ways to monitor blood glucose levels—such as using a transdermal patch that will read blood glucose levels through the skin—are currently under development (Bruen et al., 2017). In addition to improvement in technology and biomedicine, a number of national and international organizations have been formed in
recent years to protect children’s rights both in the United States and worldwide. These organizations focus on such issues as violence and abuse, child labor and soldiering, juvenile justice, child immigrants and orphaned children, and abandonment and homelessness—all of which have a negative impact on children’s health. A child whose rights are restored and upheld has an improved opportunity for growth, development, education, and health. The gains in child health have been huge but, unfortunately, these gains are not shared equally among all children. Certain health concerns, such as poor nutrition, obesity, infections, lead poisoning, digestive issues, and asthma, affect poor children at higher rates and with greater severity than affluent and middle-class children (Woolf et al., 2015). Approximately one in five children today live in families with incomes below the federal poverty line (Child Trends Databank, 2018a). Unintentional injuries continue to be the leading cause of death in children greater than 1 year but children’s health remains threatened by illnesses and other health-related conditions in the 21st century (CDC/National Center for Health Statistics [NCHS], 2017). Obesity, environmental toxins, allergies, drug abuse, child abuse and neglect, and mental health problems are among some of the key issues that
endanger children’s health today. Evolution of Maternal and Newborn Nursing The history of maternity nursing is characterized by innovations that became common practice in later years. These innovations include fetal monitoring, mother/baby care, and early postpartum discharge. The driving forces behind changes in care within the social context of the times were scientific/medical developments and families’ desires for the best possible childbearing experience. Before World War II, American women moved from home to the hospital for childbirth in part because they were convinced that setting would improve birth outcomes. Hospitals were the major employers of maternity nurses. Early ambulation and rooming-in induced changes in the focus of care for the growing numbers of mothers and infants. Maternity nurses’ focus shifted away from carrying out tasks and performing procedures to teaching mothers about self and infant care. Improved staffing patterns within hospitals meant longer hospital stays for the mothers, which allowed maternity nurses to spend more time with mothers for teaching purposes. Maternity nursing has changed dramatically since the baby boom era. The natural childbirth movement became a catalyst to bring about a change in nursing practice on the postpartum
nursing units. Other innovations that came later included breastfeeding and rooming-in to facilitate maternal–newborn bonding. Maternity nurses were then able to help the new mothers learn better how to care for their infants, to promote breastfeeding and bonding. The mid-1960s and early 1970s ushered in a consumer revolt which brought back home births, prepared childbirth, birth centers, a more humanizing maternity care focus, the father’s/partner’s involvement in the birthing process, and nurse midwives—which had all but disappeared from the American health system (Martucci, 2018). Maternal–infant bonding became recognized as an essential part of postnatal care, and maternity nurses took a lead role to facilitate it. With innovations becoming commonplace, maternity nursing practice has become more complex. How maternity nurses’ approach present-day challenges of increasing technology of birth, looming threats of litigation, and providing care under time and economic restraints is continuing to evolve. A certified nurse midwife (CNM) has postgraduate training in the care of normal pregnancy and delivery and is certified by the American College of Nurse-Midwives (ACNM). Midwives are primary care providers for women with a special emphasis on pregnancy, childbirth, and
reproductive health. They are committed to providing ethical, individualized, evidence-based care for all women throughout their life cycle (ACNM, 2019). A doula is a nonmedical birth companion who provides continuous emotional, physical, and educational support to the woman and family during childbirth and the postpartum period. Doulas do not perform clinical or medical tasks; they are there to comfort and support the mother and to enhance communication between the mother and medical professionals (DONA International, 2019). Many nurses working in labor and birth areas today are credentialed in their specialty so that they can provide optimal care to the woman and her newborn. Evolution of Pediatric Nursing In 1870, the first pediatric professorship for a physician was awarded in the United States to Abraham Jacobi, known as the father of pediatrics. For the first time, the medical community realized the need to provide specialized training and education about children to health care providers. In the early 1900s, Lillian Wald established the Henry Street Settlement House in New York City; this was the start of public health nursing. This facility provided medical and other services to poor families. These services included home nurse visits to teach mothers about health care. During this time, health care personnel
were trained to take care of children in hospitals, but parents of hospitalized children were discouraged from visiting to prevent the spread of infection. Restricting parents from being involved in their child’s care was also thought to minimize emotional stress. Nursing in public schools began in 1902 with the appointment of Lina Rogers as a full-time, publicschool nurse in New York. A professional course in pediatric nursing was started in the early 1900s at Teachers’ College of Columbia University. In the 1960s, changes in the health care delivery system and shifts in the population’s health status led to the development of the nurse practitioner role. Loretta Ford was the founder of the first nurse practitioner program. The 1970s brought cost-control systems from the federal government because of rapid escalation of health care expenditures. In addition, the considerable changes in the U.S. health care system in the 1980s have affected pediatric nursing and child health care. The emphasis of care was on quality outcomes and cost containment. Some of these changes brought more advanced practice nurses into the field of pediatrics. In the 1980s, the Division of Maternal–Child Health Nursing Practice of the American Nurses Association developed maternal child health standards to provide important guidelines
for delivering nursing care. In the 1990s, the Institute of Medicine published reports pointing out the need to improve quality and safety of the American health care system. This led to an increased focus on improving health care outcomes. As the health care environment continued to increase in complexity and patients hospitalized got sicker, programs were created for nurses to obtain a level of expertise and validate mastery of their skills and knowledge by passing a national standardized examination. Registered nurses and nurse practitioners can be certified in their specialty, such as pediatrics. These certifications show a commitment to lifelong learning and the ability to stay up to date in the rapidly changing health care environment. In recent years, pediatric nursing certifications have become increasingly specialized, such as a certified pediatric hematology/oncology nurse or a certified pediatric emergency nurse.