26.1: Maternal Health
By the end of this section, you should be able to:
- Assess the global and national health status of childbearing clients.
- Examine major risk factors influencing the health of childbearing clients.
- Create evidence-based educational interventions to promote self-care for health promotion, illness prevention, and illness management of childbearing clients.
- Identify Healthy People 2030 goals established for childbearing clients.
- Describe health promotion and disease prevention actions applicable to maternal health.
- Discuss evidence-based strategies for integrating sociocultural and linguistically responsive health promotion and disease prevention interventions in maternal health clinical practice.
Maternal health begins at preconception and continues throughout the pregnancy. Childbearing is a critical period that requires special attention, as it impacts the health of the pregnant person and the child. This section describes the current health status of childbearing clients in the United States and globally, identifies risk factors that influence their health, and describes educational interventions and Healthy People 2030 goals specific to this population. It also reviews health promotion and disease prevention actions applicable to maternal health and health literacy efforts related to this population.
National and Global Health Status of Childbearing Clients
The infant mortality rate is an important measure of the well-being of infants, children, and pregnant clients. This is the number of children dying under 1 year of age divided by the number of live births that year. The infant mortality rate is associated with factors such as maternal health, quality of and access to medical care, socioeconomic conditions, and public health practices.
In the United States, the 2020 infant mortality rate was 5.4 deaths per 1,000 live births (Centers for Disease Control and Prevention [CDC], 2022g). The top five causes of infant death in 2020 were congenital anomaly , preterm birth and low birth weight (LBW), sudden infant death syndrome (SIDS), injuries such as suffocation, and maternal pregnancy complications. Many of these deaths may have been prevented by improving the childbearing client’s health. According to the CDC (2022g), about 1 in every 33 babies has a congenital disorder. Some examples include cleft lip or palate, heart defects, and hearing loss. Managing health conditions and adopting healthy behaviors before pregnancy can increase the chances of a healthy baby. Preterm birth occurs when a baby is born before 37 weeks of pregnancy. In 2021, preterm birth affected about 1 of every 10 infants born in the United States, increasing from 10.1 percent in 2020 to 10.5 percent in 2021. In Black women, the rate of preterm births is about 50 percent higher than that among White or Hispanic women (CDC, 2022q).
The CDC (2023g) also monitors trends in pregnancy-related mortality ratios in the United States through the Pregnancy Mortality Surveillance System. Since 1987, the number of reported pregnancy-related deaths has increased from 7.2 deaths per 100,000 live births to 17.6 deaths per 100,000 live births in 2019 (CDC, 2023g). The most common causes of these deaths from 2017 to 2019 included infections, cardiomyopathy, hemorrhage, and other cardiovascular and non-cardiovascular medical conditions (CDC, 2023g). Non-Hispanic Native Hawaiian or other Pacific Islanders, non-Hispanic Blacks, and non-Hispanic American Indian or Alaska Native (AIAN) clients had two or more times more pregnancy-related deaths than non-Hispanic White, non-Hispanic Asian, or Hispanic clients (CDC, 2023g).
Globally, the infant mortality rate in 2021 was 28 deaths per 1,000 live births (CDC, 2023g). An estimated 287,000 maternal deaths occurred in 2020, with an overall global maternal mortality rate of 223 maternal deaths per 100,000 live births (WHO, 2023c). This equates to about 800 maternal deaths daily and one every two minutes globally. The WHO (2023c) indicates that “almost all of these deaths occurred in low-resource settings, and most could have been prevented” (para. 1). The WHO (2022a) emphasized that maternal mortality is a health indicator that “shows very wide gaps between rich and poor and between countries” (para. 1). This has led to the World Health Organization et al. (2023) developing a Sustainable Development Goal , Target 3.1: Reduce the global maternal mortality ratio to less than 70 per 100,000 live births with a target date of 2030.
The U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion (ODPHP, n.d.-g) indicated that in 2016, women in the United States were more likely to die from childbirth than those in other developed countries. Subsequently, a study by Tikkanen et al. (2020) found that the United States has the highest maternal mortality rate among developed countries despite the fact that most maternal deaths are preventable. The study also found that about one-third of the pregnancy-related deaths happen after the client has given birth, which is considered the period up to a year post-birth.
(See Tikkanen et al., 2020.)
Risk Factors Influencing the Health of Childbearing Clients
Existing health conditions, age, and the client’s lifestyle can make a pregnancy high risk. Some risk factors related to health issues can occur before and during pregnancy, which the Eunice Kennedy Shriver National Institute of Child Health and Human Development (2018) refers to as “conditions of pregnancy” (para. 7).
Existing Health Conditions
Table 26.1 presents some of the most common existing health conditions that can lead to a high-risk pregnancy. Because each pregnancy is individual, an existing condition may not lead to a risky pregnancy. It is necessary for the nurse, however, to be aware of risk factors.
| Existing Condition | Management | Complications |
|---|---|---|
| Hypertension |
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| Polycystic ovary syndrome (PCOS) |
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| Diabetes |
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| Kidney disease |
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| Autoimmune disease, such as lupus, multiple sclerosis (MS), and myasthenia gravis (MG) |
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| Thyroid disease (hypothyroidism or hyperthyroidism) |
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| Obesity (adult body mass index [BMI] of 30 or higher) |
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| Human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) |
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| Sexually transmitted infections (STIs) |
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| Zika infection |
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Age
The U.S. birth rate per 1,000 females ages 15 to 19 decreased steadily from its peak of 61.8 births in 1991 to 15.4 in 2020 (Osterman et al., 2022). The birth rate for women ages 40 to 44 was 11.8, for women ages 45 to 49 was 0.9, and for women ages 50 and over was 1.0 (Osterman et al., 2022). Age at pregnancy can correlate with pregnancy risks and childbirth and fetal issues.
Pregnant adolescents are more likely to develop pregnancy-related high blood pressure and anemia and to have preterm labor and delivery. Adolescents may have unknown STIs, and they are less likely to seek prenatal care , which can lead to other risk factors. For example, a pregnant adolescent may not know to take certain medications or may not realize the importance of good nutrition (Chacko, 2023).
First-time pregnancies after age 35 are considered “older first-time mothers” and consist of nine percent of births in the United States (Fretts, 2022). These childbearing clients are at higher risk for spontaneous abortion or pregnancy loss, ectopic pregnancy, chromosomal abnormalities (particularly cardiac anomalies), placental problems, LBW newborns, and preterm delivery. Fretts (2022) also indicated that childbearing clients “40 years or older are at a sixfold increased risk of maternal death when compared with women less than 20 years of age” (para. 48); Black childbearing clients aged 40 or older are over three times more likely to die during pregnancy than White childbearing clients in this age group.
Lifestyle Factors
Drinking alcohol during pregnancy can increase the baby’s risk for problems such as fetal alcohol spectrum disorders (FASDs) and SIDS. FASDs are completely preventable; if a client does not drink alcohol during pregnancy, their child will not have an FASD (CDC, 2022s). Alcohol use can also lead to miscarriage or stillbirth. There is no safe amount of alcohol to drink during pregnancy (CDC, 2022s). Different FASD diagnoses are based on particular symptoms, as shown in Table 26.2.
| Diagnosis | Symptoms |
|---|---|
| Fetal alcohol syndrome (FAS) | Central nervous system (CNS) problems, minor facial features, growth problems; problems with learning, memory, attention span, communication, vision, and/or hearing. May have difficulties in school and trouble getting along with others. |
| Alcohol-related neurodevelopmental disorder (ARND) | Intellectual disabilities; problems with behavior and learning. May have difficulties in school, particularly with math, memory, attention, judgment, and poor impulse control. |
| Alcohol-related birth defects (ARBD) | May have problems with the heart, kidneys, bones, and/or hearing. |
| Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) |
The delivering client must have consumed more than 13 alcoholic drinks per month of pregnancy (that is, any 30-day period of pregnancy) or more than two alcoholic drinks in one setting. For diagnosis with ND-PAE, the child must have problems in:
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Smoking can have adverse health effects before, during, and after pregnancy. The CDC (2020a) indicates that childbearing clients who smoke tobacco have more difficulty becoming pregnant. Smoking tobacco during pregnancy can lead to preterm birth, LBW, miscarriage, congenital disorders, and SIDS. Pregnant clients exposed to secondhand smoke are more likely to have LBW babies. Babies exposed to secondhand tobacco smoke are more likely to die from SIDS and have weaker lungs, which can lead to additional health problems (CDC, 2020a). Childbearing clients who smoke marijuana may double their risk of stillbirth; using marijuana during pregnancy can interfere with fetal brain development (Chang, 2023).
Childbearing clients who use other drugs during pregnancy can experience problems with fetal and infant health. Use of opioids such as heroin, diverted or misused prescription opioids, or other morphine-like drugs is associated with substantial maternal, fetal, and neonatal risks (Seligman et al., 2023). Cocaine use by the pregnant client also leads to preterm birth and LBW. Methamphetamine exposure during pregnancy has been associated with maternal and neonatal morbidity and mortality (Chang, 2023). Self-reported data from 2019 indicated that 6.6 percent of pregnant clients reported prescription opioid use during pregnancy, and 21.2 percent of these reported drug misuse (Ko et al., 2020). The drug overdose mortality rate per 100,000 for pregnant or postpartum persons almost doubled from 2017 (6.56) to 2020 (11.85) in the United States (Bruzelius & Martins, 2022).
Neonatal abstinence syndrome (NAS) is a treatable condition in newborns exposed to certain drugs, particularly opioids, while in utero. The term neonatal opioid withdrawal syndrome (NOWS) specifically describes the symptoms experienced by infants exposed to opioids. Both NAS and NOWS include intense irritability, difficulty with feeding, respiratory issues, and seizures. To mitigate or prevent negative outcomes associated with NAS and NOWS, nurses and health care providers must engage the pregnant client with opioid and substance use disorders in substance use treatment and other supportive services as part of prenatal care (National Center on Substance Abuse and Child Welfare, n.d.).
Challenges and Complications of Childbearing
Table 26.3 lists other challenges and risks that can arise during pregnancy, childbirth, and the postpartum period for the childbearing client. Understanding the challenges and complications of childbearing is crucial for health care professionals. The goal is to support informed decision-making, promote proactive prenatal care, and ultimately contribute to the well-being of childbearing clients and their babies. Due to the risks and concerns with a rising rate of cesarean section deliveries, the WHO (2018) and ACOG et al. (2014) have suggested interventions to reduce the rate of unnecessary cesarean deliveries.
| Challenge | Risk Factors | Complications |
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| Multiple gestation |
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| Preeclampsia |
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| Gestational diabetes |
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| Preterm birth |
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| Delivery via cesarean section |
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| Maternal infections |
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| Postpartum hemorrhage |
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| Postpartum depression |
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In some cases, fetal anomalies or genetic conditions may be detected and treated in utero or immediately following birth. For example, spina bifida may be repaired before birth (Bowman, 2022). Certain heart problems common among infants with Down syndrome will require immediate surgical correction following birth (Altman, 2022).
Educational Interventions to Promote Self-Care in Childbearing Clients
Self-care for the childbearing client begins preconception and involves many of the same health promotion activities clients should engage in throughout their lifespan, including during adolescence. Education regarding risk assessment and screening, health promotion and counseling, and any appropriate topic based on identified risk factors will promote optimal health promotion and self-care during pregnancy. Once a pregnancy is identified, education moves toward anticipatory guidance, or what the childbearing client may expect to occur during pregnancy. This may include the normal discomforts during pregnancy, body changes, weight gain expectations, signs and symptoms of problems and when/how to report them, available community resources, nutritional needs, newborn care, and other topics (Lockwood & Magriples, 2023).
Healthy People 2030 Goals for Childbearing Clients
The overarching goal of Healthy People 2030 related to pregnancy and childbirth is to “prevent pregnancy complications and maternal deaths and improve women’s health before, during, and after pregnancy” (ODPHP, n.d.-g, para. 1). Healthy People 2023 includes several pregnancy and childbirth objectives related to this goal.
Healthy People 2030 Pregnancy and Childbirth Objectives focus on the broad goals of preventing pregnancy complications and maternal deaths while also helping women stay healthy before, during, and after pregnancy. They specifically address prenatal care; drug, alcohol, and tobacco abstinence during pregnancy; family planning; reduction of sexually transmitted infections; and vaccination of pregnant clients.
Health Promotion and Disease Prevention Activities to Improve the Health of Childbearing Clients
Health promotion activities can help prevent complications during pregnancy and childbirth, promote healthy behaviors throughout the lifespan, and improve the client’s and child’s overall health outcomes. The goal is to empower this population to take an active role in their health and well-being while promoting positive health outcomes for the pregnant person and child. A range of health promotion activities is available, including:
- Promoting healthy lifestyles (e.g., healthy diet, exercise, abstaining from alcohol and tobacco)
- Encouraging regular prenatal care
- Providing education on childbirth and parenting
- Supporting breastfeeding
- Providing education to decrease postpartum depression
Health promotion activities can also address social determinants of health (SDOH), such as access to health care, housing, and nutrition, ensuring these clients have the resources necessary to maintain good health. Collaboration among health care providers, community organizations, and other partners will provide childbearing clients with the support and resources they need for a healthy and successful pregnancy and birth.
Childbearing clients can take prevention efforts before and during pregnancy. The Client Teaching feature below lists some of the most important preventive measures for childbearing clients.
The community health nurse may teach childbearing clients the following:
- Get regular medical checkups.
- Eat healthy foods and maintain a healthy weight.
- Make sure any medical conditions are under control.
- Take a vitamin with folic acid every day.
- Do not smoke, drink alcohol, or use drugs.
- Talk with your doctor about any medications you are taking or thinking about taking, including prescription and over-the-counter medications and dietary and herbal products.
- Avoid exposure to toxic secondhand smoke, chemicals, and fumes.
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Get tested for infectious diseases and get these recommended
vaccination
s (Lockwood & Magriples, 2023):
- COVID-19
- Influenza , if pregnant during flu season, regardless of stage of pregnancy
- Tetanus and diphtheria ( Tdap ) immunizations and boosters should be up-to-date; receive Tdap in the third trimester of each pregnancy to protect the infant from pertussis regardless of prior maternal vaccination (Yawetz, 2023)
- Wash your hands often, especially after contact with diapers or secretions associated with a child who is in daycare.
- Avoid kissing children under age 6 on the mouth or cheek and sharing food or drinks with young children; clean all surfaces and toys that may come into contact with children’s secretions.
- Avoid contact with those who have fevers that could be infectious.
- Avoid changing or cleaning cat litter boxes.
- Avoid x-rays and other radiation.
- Use condoms during sex to prevent exposure to STDs.
- Avoid ingesting contaminated, undercooked, or cured meat or meat products; soil-contaminated fruits or vegetables; and contaminated unfiltered water.
- Wash utensils and surfaces that are used to prepare raw fish with hot, soapy water.
- If not immune to varicella infection, Varizig (VZIG) is recommended during pregnancy to prevent maternal complications.
- Avoid Zika virus by postponing travel to areas with ongoing mosquito transmission of the virus.
(See Office of the Surgeon General, 2020.)
Even if a childbearing client takes prevention measures, there is still a risk of having a child with a congenital disorder . Following healthy habits early and consistently throughout the pregnancy gives the best chance of having a healthy baby (New York State Department of Health, 2017).
Primary Prevention
Primary prevention for childbearing clients refers to activities aimed at preventing health problems before they occur. Some examples of primary prevention strategies to improve the health of childbearing clients include:
- Healthy lifestyle promotion
- Immunizations
- Preconception care
- Education on safe sex and family planning
- Screening for infectious diseases
Secondary Prevention
Secondary prevention for childbearing clients refers to activities aimed at detecting and treating health problems at an early stage, before they are even problematic, to prevent subclinical disease progression. Some examples of secondary prevention strategies to improve the health of childbearing clients include:
- Prenatal care
- Screening for genetic disorders
- Screening for gestational diabetes
- Early detection and treatment of infections
- Screening for postpartum depression
Tertiary Prevention
Tertiary prevention for childbearing clients refers to activities aimed at managing and treating health problems that have already occurred and preventing their recurrence or further complications. Some examples of tertiary prevention strategies to improve the health of childbearing clients include:
- Management of chronic health conditions, such as diabetes, hypertension, and asthma
- Treatment of postpartum complications, such as postpartum hemorrhage, infection, and thromboembolism
- Support for breastfeeding
- Mental health treatment
- Family planning to prevent unintended pregnancy in the postpartum period
Table 26.4 summarizes these three levels of prevention and incudes primordial and quaternary prevention as well.
| Levels of Prevention | Specific Example of Level of Prevention |
|---|---|
| Primordial | A state’s governmental policy increases taxes on cigarettes to discourage smoking. |
| Primary | Local advertisements are provided via different forms of media depicting the dangers of smoking to childbearing clients and their babies. |
| Secondary | A local women’s health center offers free tobacco cessation programs to childbearing clients. |
| Tertiary | The nurse provides care to a LBW newborn whose mother smoked during pregnancy and educates the mother to prevent further complications. |
| Quaternary | Over-screening for gestational diabetes during the first half of pregnancy is prevented by targeting early pregnancy screening to those at increased risk of undiagnosed type 2 diabetes. |
Integration of Sociocultural and Linguistically Responsive Interventions in Maternal Health
Providing high-quality maternal health care requires the nurse to integrate sociocultural and linguistically responsive interventions. Pregnancy and childbirth are influenced by a complex set of social, cultural, and linguistic factors that can affect health outcomes for the client and the baby. Nurses must consider their clients’ sociocultural and linguistic backgrounds and provide care sensitive to their needs and preferences. This section explores the reasons for integrating sociocultural and linguistically responsive interventions in maternal health care and provides examples of interventions that can improve health outcomes for childbearing clients.
Sociocultural Interventions
Addressing the sociocultural preferences of maternal clients is necessary to provide client-centered care . The WHO (2017) Standards for Improving Quality of Maternal and Newborn Care in Health Facilities recommend that health care professionals participate in regular education to improve their interpersonal communication, counseling skills, and cultural competence to encourage respectful maternity care. The Joint Commission, the National Institutes of Health, the International Confederation of Midwives, and the International Federation of Gynecology and Obstetrics have issued similar initiatives (Hodin, 2018).
Interventions to provide culturally appropriate maternal health services, specifically related to clients’ ethnicity , language, and religion , have positively affected pregnant people's continual use of maternity care, particularly prenatal care (Jones et al., 2017). In a review of 15 studies to examine how such interventions affected the use of pregnancy care, 10 studies found this to be true, and four themes evolved to describe the barriers and facilitators to ensuring socioculturally appropriate maternity care. These included (Jones et al., 2017, pp. 5–7):
- Access—Interventions should consider broader economic, geographic, and social factors that affect ethnic minority groups’ access to service.
- Community participation—Interventions should include community participation to understand problems with existing services and potential solutions from a community perspective as well as in developing and implementing interventions.
- Person-centered care —Respectful, person-centered care should be at the core of all interventions.
- Continuum of care —Interventions should be spread all along the continuum of care. For example, rather than focusing interventions on prenatal care, effective partnerships should extend interventions between the socioculturally appropriate service and all other health care professionals clients and their families encounter along the continuum of care from detection of pregnancy until after birth.
Several sociocultural interventions can be integrated into maternal health to positively impact maternal health outcomes. Providing cultural competency training for all health care workers will help them better understand the cultural beliefs, practices, and values of the populations they serve and promote the provision of care that is sensitive to that population’s needs and preferences. Community-based interventions, such as peer groups and community health workers, can help connect maternal clients with culturally appropriate resources and support. Addressing stigma and discrimination related to pregnancy and childbirth, such as discrimination against teen or single parents or those with HIV , can help promote equitable and respectful care for all clients. By providing each of these interventions, the nurse can work to improve the health outcomes for childbearing clients and their children.
Aligning Early Childhood and Medicaid is a national initiative funded by the Robert Wood Johnson Foundation that works to better align Medicaid and state agencies responsible for early childhood programs. Its goal is to improve the health and social outcomes of low-income infants, young children, and families. The initiative included eight states: Colorado, Minnesota, New Jersey, New York, Oregon, Rhode Island, Vermont, and Washington. A specific intervention taken within this initiative involved addressing racial and ethnic disparities in maternal and child health through home visiting programs.
Watch the video, and then respond to the following questions.
- Describe three sociocultural nursing interventions described in the video that could be used to positively impact the health of maternal clients in any sociocultural population.
- Now, connect these three nursing interventions to one of the five social determinants of health (SDOH).
SDOH).
Linguistically Responsive Interventions
A variety of interventions are available to provide linguistically responsive care, some of which are included in Culturally and Linguistically Responsive Nursing Care. Nurses can use the services of professional medical interpreters to ensure that the client can communicate with others effectively. Communication is essential when educating the client about prenatal care, labor and delivery , and postpartum care . Nurses should provide educational materials written in the client’s preferred language that consider the client’s sociocultural beliefs and practices. They can provide visual aids to explain more complex concepts to clients with limited English proficiency and use plain language to ensure clients understand the information being provided. Nurses should encourage clients to ask questions and clarify doubts regarding the pregnancy or other issues.
Nurses should also assess their clients’ health literacy levels and communicate accordingly to allow clients to best understand their health conditions and improve their health outcomes. Health literacy skills such as “reading, listening, analyzing, decision-making, and using these skills in health situations” (Solhi et al., 2019, p. 3), regardless of the client’s educational level or general reading ability, will have a definite impact on the health outcomes of a client and their child. The maternal client must be involved in health promotion and preventive care, but if they do not understand health concepts, they will have difficulty making informed decisions (Solhi et al., 2019). Even for those with health literacy skills, the first pregnancy may be full of surprises if their education is not specifically in this realm. Also, the maternal client’s understanding of health information directly impacts their child’s health. Solhi et al. (2019) determined that adopting interventions to increase health literacy in maternal clients, such as those previously described, promoted physical and mental self-care during pregnancy, particularly over time.