National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse’s role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women’s Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.     

Attitudes of Clinicians and Patient Safety Culture Before and After the ARRIVE Trial

ObjectiveTo assess the attitudes of intrapartum clinicians about elective induction of labor before and after A Randomized Trial of Induction Versus Expectant Management (ARRIVE) and to assess the effect of different attitudes on patient safety culture.DesignRepeated cross-sectional design.SettingOnline surveys.ParticipantsClinicians (883 nurses and 201 physicians in the before-ARRIVE group and 1,741 nurses and 574 physicians in the after-ARRIVE group) who provided intrapartum care at 35 hospitals in California in 2017 and 57 hospitals in Michigan in 2020 and participated in statewide quality improvement efforts to reduce use of cesarean.MethodsWe used annual nulliparous, term, singleton, vertex cesarean rates to stratify hospitals into performance quartiles. We used cumulative proportional odds logistic regression to examine induction attitudes before and after ARRIVE by role and hospital performance quartile as well as induction attitudes and patient safety culture among clinicians. We used content analysis to examine qualitative data.ResultsAfter ARRIVE, physicians’ attitudes shifted in favor of induction at hospitals within the top three performance categories (top quartile: M = 3.48 vs. 2.81, p < .0001), whereas nurses’ attitudes did not change (p = .388). After ARRIVE, attitudes among clinicians were more aligned at hospitals with stronger patient safety cultures. Qualitative themes included The Timing of Induction is Important, Who Should Have Inductions, Need for Clear Protocols and More Staff, and Ideas to Improve the Induction of Labor Process.ConclusionPhysician attitudes about induction were significantly different before versus after ARRIVE, whereas nurse attitudes were not. Differences in attitudes may erode the quality of team-based care; intentional interdisciplinary engagement is essential when implementing ARRIVE findings.     

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension‐related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.     

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators

ObjectiveDevelopment and validation of a set of quality indicators for vulnerable women during the perinatal period.DesignA three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals.SettingThe Flemish Region and the Brussels Capital Region in Belgium.ParticipantsHealthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals.FindingsThe literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care).Key conclusions and implications for practiceImplementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.     

Effects of 3D-Printed Models and 3D Printed Pictures on Maternal– and Paternal–Fetal Attachment,Anxiety, and Depression

ObjectiveTo compare the effect of a 3D-printed model versus 3D printed pictures on maternal– and paternal–fetal attachment, pregnancy-related anxiety, and depression in parents in the third trimester.DesignRandomized controlled trial.SettingUniversity- and clinic-affiliated hospital system.ParticipantsBetween August 2020 and July 2021, we screened 419 women for eligibility. A total of 184 participants (n = 95 women and n = 89 men) were included in the intention-to-treat analysis, of whom 47 women and 44 men received the 3D-printed model, whereas 48 women and 45 men received the 3D printed picture.MethodsParticipants completed a set of questionnaires before they received third trimester 3D ultrasonography and a second set of questionnaires approximately 14 days after the study ultrasonography. The primary outcome was the global Maternal and Paternal Antenatal Attachment scale scores. Secondary outcomes included the Maternal and Paternal Antenatal Attachment subscale scores, global Generalized Anxiety Disorder–7 scores, global Patient Health Questionnaire–9 scores, and global Pregnancy-Related Anxiety Questionnaire–Revised (second version) scores. We used multilevel models to estimate the effect of the intervention.ResultsWe found a statistically significant increase in mean attachment scores after the 3D printed picture and 3D-printed model intervention of 0.26, 95% confidence interval (CI) [0.22, 0.31], p < .001. Additionally, we found statistically significant improvement in depression (mean change = –1.08, 95% CI [–1.54, –0.62], p < .001), generalized anxiety (mean change = –1.38, 95% CI [–1.87, –0.89], p < .001), and pregnancy-related anxiety (mean change = –2.92, 95% CI [–4.11, –1.72], p < .001) scores. We found no statistically significant between-group differences related to maternal or paternal attachment, anxiety, depression, or pregnancy-related anxiety.ConclusionsOur findings support the use of 3D printed pictures and 3D-printed models to improve prenatal attachment, anxiety, depression, and pregnancy-related anxiety.     

Women’s Experiences of the Effect of Financial Strain on Parenting and Mental Health

ObjectiveTo develop a conceptual theory to describe how financial strain affects women with young children to inform clinical care and research.DesignQualitative, grounded theory.SettingParticipants were recruited from the waiting area of a pediatric clinic and an office of the Special Supplemental Nutrition Program for Women, Infants, and Children embedded within the largest safety-net academic medical center in New England. Participants were interviewed privately at the medical center or in the community.ParticipantsTwenty-six English-speaking women, mostly single and African American/Black, with at least one child 5 years old or younger, were sampled until thematic saturation was met.MethodsWe used grounded theory methodology to conduct in-depth, semistructured interviews with participants who indicated that they experienced financial strain. We analyzed the interview data using constant comparative analysis, revised the interview guide based on emerging themes, and developed a theoretical model.ResultsFive interrelated themes emerged and were developed into a theoretical model: Financial Strain Has Specific Characteristics and Common Triggers, Financial Strain Is Exacerbated by Inadequate Assistance and Results in Tradeoffs, Financial Strain Forces Parenting Modifications, Women Experience Self-Blame, and Women Experience Mental Health Effects.ConclusionFor women with young children, financial strain results in forced tradeoffs, compromised parenting practices, and self-blame, which contribute to significant mental health problems. These findings can inform woman-centered clinical practice and advocacy interventions. Women’s health care providers should identify families experiencing financial strain, provide referrals to financial services, and join advocacy efforts to advance social policies that address the structural causes of poverty, such as increased minimum wage and paid family leave.     

Facilitators and Barriers to Implementation of Safe Infant Sleep Recommendations in the Hospital Setting

ObjectiveTo identify facilitators and barriers to the implementation of safe sleep recommendations from the American Academy of Pediatrics from the perspective of hospital staff as part of a needs assessment that was used to design a successful quality improvement intervention to change clinical practice.DesignQualitative design.SettingMultiple sites of three hospitals in the northeastern and southern United States.ParticipantsWe used purposeful sampling to identify 46 participants who cared for infants on inpatient hospital units (nurses and other staff members).MethodsA qualitative researcher used grounded theory to moderate the focus groups. We constructed the initial interview guide and then changed it as needed to capture more information about new ideas as they arose. Researchers from diverse backgrounds participated in the analysis and used the constant comparative method to select important concepts and to develop codes and subsequent themes. We continued to collect data until saturation was reached.ResultsWe identified themes and subthemes, and the taxonomy fit into the Grol and Wensing framework for change in clinical practice. The six primary themes included The Innovation Itself, The Individual Health Care Professional, The Patient, The Social Context, The Organizational Context, and The Economic and Political Context.ConclusionParticipants described facilitators and barriers to the implementation of the American Academy of Pediatrics recommendations for safe infant sleep. Identification of these themes informed our quality improvement intervention to promote safe infant sleep. Findings can be used by others when faced with the need for similar change.     

Meta-Synthesis of the Needs of Women Cared for by Midwives During Childbirth in Hospitals

ObjectiveTo identify and meta-synthesize results of qualitative studies on the needs of women cared for by midwives during childbirth in hospitals.Data SourcesMEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and the Cochrane Library.Study SelectionWe restricted the bibliographic search to articles published in English to July 31, 2020. The initial search yielded 6,407 articles, and after 2,504 duplicates were removed, we screened the titles and abstracts of 3,903 articles. We conducted a full-text review of 89 articles and included 13 qualitative studies about the needs of women who were hospitalized during childbirth and had midwives as their primary maternity care providers.Data ExtractionWe extracted data (e.g., authors, publication date, type of study, sample size, results, and quotes) from the full text of each article into a standardized table. Two authors reviewed all articles using the Critical Appraisal Skills Programme tool to assess study quality and to independently score each study.Data SynthesisWe analyzed the findings of each study and synthesized them to develop themes. We found 14 major themes that reflected the needs of women during hospitalization for childbirth: Nutrition, Hygiene, Privacy, Information, Bodily Respect, Respect for Social Role, Family Intimacy, Shelter, Pain Management, Partnership, Movement, Reassurance, Support, and Empowerment. We categorized these themes in Maslow’s hierarchy of needs to better understand the phenomenon.ConclusionWe identified 14 needs that midwives and nurses can meet when they care for women in hospitals during childbirth. Standardized methods to assess these needs and to link them to specific interventions can be used by midwives and nurses, which will likely affect women’s satisfaction with their experience and overall quality of care.     

Health Behaviors and Prenatal Health Conditions in Repeat Vs First-time Teenage Mothers in the United States: 2015-2018

Study ObjectiveRepeat teenage mothers, those who give birth to a second or higher-order infant before age 20 years, are at elevated risk for adverse perinatal outcomes compared with first-time teenage mothers. The objective of the current study was to compare the prevalence of negative pregnancy-related behaviors and gestational health conditions in the national United States population of first-time and repeat teenage mothers.Design, Setting, and ParticipantsWe conducted a retrospective, population-based cohort study using annual US birth data files from 2015 to 2018, N = 799,756 (673,394 [84.2%] first, 126,362 [15.8%] repeat) births to women ages 15-19 years.InterventionsNone.Main Outcome MeasuresPregnancy-related behaviors (including adequacy of prenatal care and weight gain, sexually transmitted infection, smoking, and breastfeeding) and gestational health conditions (gestational hypertension and gestational diabetes).ResultsRepeat (vs first-time) mothers had higher prevalence of negative pregnancy-related behaviors: inadequate prenatal care, smoking, inadequate weight gain, and sexually transmitted infection during pregnancy; they were also less likely to breastfeed. Conversely, repeat teenage mothers experienced lower prevalence of gestational hypertension and gestational diabetes.ConclusionRepeat teenage mothers experienced lower prevalence of physical health complications during pregnancy but engaged in more negative pregnancy-related health behaviors. Negative health behavior in pregnancy can lead directly to poor perinatal outcomes for infants. To prevent adverse outcomes from repeat teenage childbearing, we must ensure access to quality, timely, prenatal and postpartum care so teenage mothers can receive support for healthy pregnancy-related behaviors as well as linkage to highly effective contraception to prevent unintended repeat births.