parent, teaching

M aternal mortality in the United States is on the rise. The average maternal mortality rate rose from 14.5 to 16 deaths per 100,000

live births when comparing rates from 1998– 2005 to 2006–2010 (Berg, Callaghan, Syver- son, & Henderson, 2010; Creanga et al., 2015) and rose to a high of 17.8 deaths per 100,000 live births in 2011 (Centers for Disease Control and Prevention, 2017). The most recently avail- able data report a maternal mortality rate of 17 deaths per 100,000 live births in the United States in 2013 (Creanga, Syverson, Seed, & Cal- laghan, 2017). Non- Hispanic Black women die

Do New Mothers Understand the Risk Factors for Maternal Mortality?

M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, Deborah Winders Davis, PhD, John A. Myers, PhD, MPH, Katlin M. Masterson, Jeffrey A. Rushton, MBA, and Adrian P. Lauf, PhD

July/August 2018 MCN 201

Abstract Purpose: The purpose of this study was to describe new mothers’ knowledge related to maternal mortality. Study Design and Methods: Using a cross-sectional design, new mothers were recruited from a postpartum unit of an academic health sciences center where the population was predominately low-income women. Before hospital discharge, they answered questions on their knowledge of potential postpartum complications that could lead to maternal mortality. Questions were based on recommendations from an expert nursing panel. Descriptive statistics were used for data analysis. Results: One hundred twenty new mothers participated. Results indicated that most new mothers knew that they should watch for heavy bleeding, a severe headache, and swelling after hospital discharge. However, fewer participants knew that a new mother could experience feelings that she could harm herself or her baby, have blood clots larger than a baby’s hand, a temperature of 100.4 °F or higher, and odor with vaginal discharge. Courses of action new mothers would take if experiencing any of the warning signs included 18% of mothers would take no action, 76.7% would tell their boyfriend/husband/partner, 72.5% would inform their mother. Only 60% who would call the labor and delivery unit. Only 38% of the sample knew that pregnancy-related complications can occur for up to 1 year after birth, and 13% of mothers reported not knowing that complications can occur for up to 6 weeks postpartum. Clinical Implications: Our fi ndings provide a foundation to enhance postpartum education for new mothers and their families and to potentially decrease rates of maternal mortality in the United States. Key words: Knowledge; Mortality; Mother; Postpartum; Teaching.

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at a rate of 41.1 per 100,000 live births compared with 11.8 and 15.7 per 100,000 live births for non-Hispanic White and other races of women, respectively (Creanga et al.). Women who lack health insurance are three to four times more likely to die than those who are insured (Chang et al., 2003). Older women ≥ 35 years comprise 15% of live births, but account for 27% to 29% of all pregnancy- related deaths (Creanga et al.). Overall, more than 700 women die and another 60,000 suffer near-fatal complications related to pregnancy and childbirth, half of which are preventable, in the United States each year (Creanga et al.).

Pregnancy-related deaths may occur up to 1 year af- ter pregnancy and may be the result of thrombotic pul- monary embolisms, cerebrovascular accidents, infection, cardiovascular conditions, noncardiovascular medical conditions, cardiomyopathy (Creanga et al., 2015), and suicide (Wisner et al., 2013). See Table 1. If healthcare providers are unaware of the recent pregnancy, these women may not receive the appropriate care quickly enough to prevent mortal- ity or long-term morbid- ity. Unfortunately, many new mothers, particularly those with no consistent primary care provider, do not receive enough action- able information about complications and warning signs related to the post- partum period that could better equip them to seek needed treatment in a timely fashion and prevent maternal mortality (Amnesty Inter- national, 2011). Overall, 30% of women lack prenatal education classes (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2014). Women who are poor and/or of mi- nority status have been reported to lack a personal phy- sician or healthcare provider, to not enroll in childbirth education classes (Declercq et al.; Wolfe, 2006), and to receive lesser quality and uncoordinated prenatal care (Smedley, Stith, & Nelson, 2003), which put them at a disadvantage for having adequate health information af- ter birth. Recommendations from a variety of statewide mortality review committees support the urgent need for education of women and families (Georgia Department of Public Health, 2015; Main et al., 2011; New York Acad- emy of Medicine, 2011). However, before new educational programs are developed, baseline information is needed on accuracy of women’s knowledge about their risk for pregnancy-related mortality. The purpose of this study is to describe the knowledge of new mothers related to maternal mortality.

Theoretical Framework This study was framed by Thaddeus and Maine’s “Three Delay Model,” which identifi es barriers mothers face in receiving appropriate obstetric care. The “Three Delays” model proposes that pregnancy-related mortality is over- whelming due to delays in: (1) deciding to seek appropri-

ate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving ad- equate care when a facility is reached. This study focuses on the phase 1 delay: a “delay in deciding to seek care on the part of the individual, the family, or both” (Thaddeus & Maine, 1994).

Research Questions Our research questions were as follows: 1) How many new mothers correctly identify warning signs of the lead- ing causes of maternal mortality; 2) How would new mothers take action if they were to experience one of these warning signs after discharge from the hospital; and 3) Do new mothers understand how long after birth that they could have pregnancy-related complications?

Study Design and Methods A cross-sectional design was used to survey new moth- ers about their knowledge of postpartum complications

during the fi rst year after giving birth that could possi- bly lead to serious complications and maternal mortality. Data were collected from May 2016 to November 2016. The study was approved by the university human studies protection program and the study site. Data were ana- lyzed with descriptive statistics.

Sample

A convenience sample of new mothers was recruited from a mother–baby unit of an academic health sciences center and data were collected before hospital discharge. Inclu- sion criteria were having given birth to a live child within the last week, 18 years of age or older, and English-speak- ing. After providing informed consent, all participants were administered surveys and were given diapers valued at approximately $32.

Setting

Demographic information was not collected on partici- pants; however, data that describe the larger population are available. The academic medical center serves a high percentage of minorities and underserved patients. Ap- proximately 19% of patients are indigent, 29% receive Medicaid, over 40% are of a minority population, and 19% do not speak English. Of the 1,826 women who gave birth at the academic medical center in 2016, 28% were African American, 2% were Asian, and 63% were White. No statistics are recorded on Hispanic ethnicity,

Pregnancy-related deaths may occur up to one year after pregnancy and may be the result of thrombotic pulmonary embolisms, cerebrovascular accidents, infection, cardiovascular conditions, non-cardiovascular conditions, cardiomyopathy, and suicide.

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July/August 2018 MCN 203

but 5% of the metropolitan area self- identify as Hispanic. Seventy-seven percent of the new mothers who gave birth at the academic medical center in 2016 were single parents.

Survey

The surveys included three ques- tions, which were developed as part of a 2-year joint initiative by the Association of Women’s Health, Obstetric, and Neonatal Nursing and the Association of Maternal and Child Health Programs and described in a special In Focus series in the Jour- nal of Obstetrics, Gynecology, and Neonatal Nursing in 2016 (Logsdon, 2016). First, “Which of the following signs could a new mother experience after hospital discharge?” Response choices included nine possible warn- ing signs of the most common fatal pregnancy complications, such as shortness of breath, severe headache, and so on that a new mother could experience within the fi rst year after birth (D’Oria, Myers, & Logsdon, 2016). The second question asked, “If you had any of the signs above, what would you do?” Eight possible courses of action were listed, such as “Call labor and delivery,” “Call your doctor/nurse practitioner,” and so on. Then mothers were asked, “How long after birth could a new mother have complications from the birth?” Response choices included up to 1 day, 1 week, 6 weeks, or 1 year after birth.

Results How many new mothers correctly identify warning signs of the leading causes of maternal mortality? New mothers accurately responded that after hospital discharge they could experience bleeding that saturates more than one perineal pad in an hour, a severe headache, swelling, and leg pain, n = 74 (61.7%), n = 77 (64.2%), 85 (70.8%), n = 68 (57%), respectively. How- ever, fewer participants understood that after hospital dis- charge a new mother could experience shortness of breath n = 59 (49%), feelings that she could harm herself or her baby n = 58 (48%), blood clots larger than a baby’s hand n = 54 (45%), a temperature of >100.4 °F n = 49 (40.8%), or an odor with vaginal discharge n = 53 (44.2%). See Table 2.

How would new mothers take action if they were to experience one of these warning signs after discharge from the hospital? Eighteen percent of mothers (n = 11) would take no action. Almost 77% (n = 92) would tell

their boyfriend/husband/partner compared with only 60% (n = 72) who would call labor and delivery. Seventy- one percent (n = 85) would go to a hospital emergency department, but only 42.5% (n = 51) would call 911. See Table 3.

Do new mothers understand how long after birth that a new mother could have pregnancy-related complica- tions? Only 38.3% of mothers (n = 46) understood that pregnancy-related complications can occur for up to 1 year after birth. Most new mothers knew that pregnancy- related complications could occur after 1 day (99%), 1 week (94%), and 6 weeks (85%) after birth. See Table 4.

Clinical Implications Based upon the Three Delays Model, we identifi ed defi cits in new mothers’ knowledge about life-threatening preg- nancy complications and their warning signs, which could

Table 1. Essential Educational Content Related to Postpartum Morbidity and Mortality Educational Topic Brief Description

Headache Type and severity of headache persisting after usual therapies

Infection Temperature ≥ 100.4 °F for at least 6 hours; excessive pain or discharge from incision, odor

Leg pain Severity, location, intensifi ed with straightening of leg and fl exion of foot

Shortness of breath/

chest pain

Report immediately; may or may not be concerning (e.g., pulmonary embolism or cardiomyopathy)

Swelling Swelling of the face and extremities: description, time of day, duration

Vaginal bleeding

Blood clots larger

than baby’s hand

Explicit description of excess bleeding and/or clot size

Wanting to harm self

or infant

Report feelings of sadness, depression, withdrawal, or the desire to harm self or infant

Note. Essential educational topics are signs and symptoms of the most common pregnancy- related causes of maternal mortality and morbidity up to 1 year after birth.

Table 2. New Mothers’ Knowledge of the Most Common Postpartum Warning Signs

Warning Signs Yes No

Shortness of breath 59 (49.2%) 44 (36.7%)

Feelings that you may harm yourself or baby 58 (48.3%) 56 (46.7%)

Bleeding that saturates more than one perineal pad

in an hour

74 (61.7%) 39 (32.5%)

Blood clots larger than your baby’s hand 54 (45%) 52 (43.3%)

Severe headache 77 (64.2%) 37 (30.8%)

Leg pain that may include swelling, redness, or

warmth

68 (56.7%) 40 (33.3%)

Swelling 85 (70.8%) 32 (26.7%)

Temperature of 100.4 °F or higher 49 (40.8%) 60 (50%)

Odor with vaginal discharge 53 (44.2%) 49 (40.8%)

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

contribute to a phase 1 delay in deciding to seek health- care (Thaddeus & Maine, 1994). As only 38% of mothers (n = 46) reported knowing that pregnancy- related compli- cations can occur for up to a year after birth, it is under- standable that a majority of new mothers were unaware of fi ve of the nine warning signs that could occur after hospital discharge. Few mothers may call 911 (42.5%) if experiencing a warning sign due to their lack of under- standing that these warning signs are indicators of poten- tially impending death without treatment.

Our fi ndings could enhance postpartum education for new mothers and their families (Simpson, 2017). Perinatal nurses are at the frontline in providing health education to new mothers and their families, and by incorporating the questions from this study into clinical practice, nurses could assess new mothers’ knowledge about life-threat- ening pregnancy-related complications before sending them home from the hospital after giving birth (D’Oria et al., 2016; Suplee, Bingham, & Kleppel, 2017). From this baseline knowledge, nurses can identify new mothers’ learning needs and individualize postpartum education, ensuring that new mothers understand life-threatening risks before they are discharged. New technologies, such as smart phone apps, are now available that may support the uptake and use of this critically important information (Logsdon, 2017). Research is needed to tailor the message and birthing methods to the needs of the women.

There are several limitations of the study that have an impact on generalizability. The sample was primar- ily low-income and from one site. Questions used in the survey were established by a nursing expert panel and, thus, include face and content validity, but other psycho- metrics have not been established. To our knowledge,

no standardized instruments exist to measure knowledge of symptoms in- dicating risk of maternal mortality. Demographics were not collected, so analysis of knowledge by race and age was not possible. This is important data because maternal mortality rates continue to be higher in Non-Hispanic Black mothers and older mothers, as well as low-income mothers. Further research should address these vari- ables. Our study adds to the minimal information that is currently available about knowledge of new mothers of potential complications of childbirth that can occur during the fi rst year postpartum and lead to maternal death. More data are needed on how to improve new mothers’ knowledge on this important issue and if addi- tional knowledge can lead to improve- ment in maternal mortality rates in the United States.

Acknowledgment

The authors acknowledge funding from two sources at the University of Louisville Hospital: University of Louisville Hospital Nursing Research Grant and Nursing & Interdisciplinary Research Committee Re- search Funds. ✜

M. Cynthia Logsdon is a Professor, School of Nursing, University of Louisville, Louisville, KY. The author can be reached via e-mail at [email protected]

Deborah Winders Davis is a Professor, Department of Pediatrics, School of Medicine; Director, Louisville Twin Study; and Director, Child and Adolescent Health Research, Design and Support, University of Louisville, Louisville, KY.

Table 3. Courses of Action New Mothers Would Take if They Experienced Warning Signs Action Yes No

Nothing, they are normal 11 (9.2%) 102 (85.0%)

Tell your boyfriend/husband/partner 92 (76.7%) 27 (22.5%)

Tell your mother 87 (72.5%) 32 (26.7%)

Call labor and delivery 72 (60.0%) 44 (36.7%)

Call your doctor/nurse practitioner 108 (90.0%) 12 (10.0%)

Go to urgent care center 72 (60.0%) 42 (35.0%)

Go to hospital emergency department 85 (70.8%) 31 (25.8%)

Call 911 51 (42.5%) 64 (53.3%)

Table 4. New Mothers’ Understanding of the Time Frame for Postpartum Complications

Time Frame Yes No

One year 46 (38.3%) 62 (51.7%)

Six weeks 102 (85.0%) 16 (13.3%)

One week 113 (94.2%) 5 (4.2%)

One day 119 (99.2%) 0 (0.0%)

Clinical Implications for Nurses • Low-income new mothers, women without health insur-

ance, and Non-Hispanic Black mothers have a greater risk of maternal mortality when compared with women without these demographic characteristics.

• Not all new mothers may be aware of potential compli- cations of childbirth that can occur during the fi rst year postpartum.

• Teaching new mothers prior to discharge home from the hospital after giving birth about potential complications that can be life-threatening (see Table 2 for the nine pos- sible warning signs of the most common fatal pregnancy complications) may save lives.

• Nurses are often the main healthcare provider offering post- partum discharge information to new mothers; adequate time to offer thorough information and make sure the wom- an and her family understand what has been discussed is essential to safe and quality perinatal nursing care.

204 volume 43 | number 4 July/August 2018

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John A. Myers is a Professor, Department of Pediat- rics, School of Medicine, University of Louisville, Lou- isville, KY.

Katlin M. Masterson is an Undergraduate Research Scholar, School of Nursing, University of Louisville, Louisville, KY.

Jeffrey A. Rushton is an Entrepreneur, Digital Media, Kentucky Marketing Consulting, Louisville, KY.

Adrian P. Lauf is an Assistant Professor, Speed School of Engineering, University of Louisville, Louisville, KY.

The authors declare no confl icts of interest.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

DOI:10.1097/NMC.0000000000000434

References Amnesty International. (2011). Deadly delivery: The maternal health

care crisis in the USA: One year update. Retrieved from https:// www.amnestyusa.org/wp-content/uploads/2017/04/deadlydeliv- eryoneyear.pdf

Berg, C. J., Callaghan, W. M., Syverson, C., & Henderson, Z. (2010). Pregnan- cy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology, 116(6), 1302-1309. doi:10.1097/AOG.0b013e3181fdfb11

Centers for Disease Control and Prevention. (2017, No- vember 9). Reproductive health: Pregnancy mortal- ity surveillance system. Retrieved from www.cdc.gov/reproduc tivehealth/MaternalInfantHealth/PMSS.html

Chang, J., Elam-Evans, L. D., Berg, C. J., Herndon, J., Flowers, L., Seed, K. A., & Syverson, C. J. (2003, February 21). Pregnancy-related mortality surveillance - United States, 1991-1999. Morbidity and Mortality Weekly Report: Surveillance Summaries, 52(SS-2), 1-8. Retrieved from https://www.cdc.gov/mmwR/preview/mmwrhtml/ ss5202a1.htm

Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., & Cal- laghan, W. M. (2015). Pregnancy-related mortality in the United States, 2006-2010. Obstetrics and Gynecology, 125(1), 5-12. doi:10.1097/AOG.0000000000000564

Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-related mortality in the United States, 2011-2013. Obstetrics and Gynecology, 130(2), 366-373. doi:10.1097/ AOG.0000000000002114

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2014). Major survey fi ndings of listening to mothers(SM) III: New mothers speak out: Report of National Surveys of Women’s Childbear- ing Experiences conducted October-December 2012 and January- April 2013. The Journal of Perinatal Education, 23(1), 17-24. doi:10.1891/ 1058-1243.23.1.17

D’Oria, R., Myers, J., & Logsdon, M. C. (2016). Strategies to reduce ma- ternal mortality during the fi rst year after birth. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, 45(6), 885-893. doi:10.1016/j. jogn.2016.04.013

Georgia Department of Public Health. (2015). Georgia maternal mortal- ity 2012 case review. Retrieved from http://dph.georgia.gov/sites/dph. georgia.gov/fi les/MCH/MMR_2012_Case_Review_June2015_fi nal.pdf

Logsdon, M. C. (2016). Nursing strategies to address maternal morbid- ity and mortality. Journal of Obstetrics, Gynecology, and Neonatal Nursing, 45(6), 857-860. doi:10.1016/j.jogn.2016.06.010

Logsdon, M. C. (2017). Smart phone apps and maternal child nursing. MCN. The American Journal of Maternal Child Nursing, 42(5), 247. doi:10.1097/NMC.0000000000000364

Main, E., Morton, C., Hopkins, D., Giuliani, G., Melsop, K., & Gould, J. (2011). Cesarean deliveries, outcomes, and opportunities for change in California: Toward a public agenda for maternity care, safety, and quality. Retrieved from https://www.cmqcc.org/resource/cesarean- deliveries-outcomes-and-opportunities-change-california-toward- public-agenda

New York Academy of Medicine. (2011). Maternal mortality in New York: A call to action fi ndings and priority action steps. Retrieved from www.albany.edu/sph/cphce/maternalmortality/2011_maternal-mor- tality-in-new-york-a-call-to-action.pdf

Simpson, K. R. (2017). Avoiding adverse events after postpartum hospital discharge. MCN, The American Journal of Maternal Child Nursing, 42(1), 124. doi:10.1097/NMC.0000000000000319

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press.

Suplee, P. D., Bingham, D., & Kleppel, L. (2017). Nurses’ knowledge and teaching of possible postpartum complications. MCN. The Ameri- can Journal of Maternal Child Nursing, 42(6), 338-344. doi:10.1097/ NMC.0000000000000371

Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mor- tality in context. Social Science & Medicine, 38(8), 1091-1110. doi:10.1016/0277-9536(94)90226-7

Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L., …, Costantino, M. L. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen- positive depression fi ndings. Journal of American Medical As- sociation, Psychiatry, 70(5), 490-498. doi:10.1001/jamapsychiatry. 2013.87

Wolfe, M. W. (2006). Mother and child: A multi-determinant model for maternal and infant health outcomes in urban, low-income commu- nities and the effectiveness of prenatal care and other interventions. Journal of Public & International Affairs, 17(9), 169-189. Retrieved from https://jpia.princeton.edu/sites/jpia/fi les/2006-9.pdf

In this sample of low income new mothers, some did not know that after leaving the hospital they could have complications that include experiencing feelings that she could harm herself or her baby, have blood clots larger than a baby’s hand, have a temperature of >100.4 degrees Fahrenheit, and have odor with vaginal discharge.

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