On-time Deliveries
Nurses participate in education and awareness campaigns to research and help prevent premature births
By Melissa Gaskill
January 10, 2005
Every year, more than 470,000 infants in this country are born prematurely — before 37 weeks’ gestation. That’s about 12% of all births and an increase of more than 29% since 1981. Although great strides have been made in neonatal intensive care, prematurity is the leading cause of death within the first month of life and the second-leading cause of all infant deaths.
Premature babies who survive aren’t out of the woods, either. According to the March of Dimes, about 100,000 children develop health problems each year because of their early birth.
The March of Dimes is investing $75 million in research, education, and awareness programs to find the causes of premature birth and develop ways to prevent it. The organization also is advocating for an additional $50 million to support prematurity-related research at the National Institutes of Health.
Many factors — smoking, poor nutrition, domestic violence, infection, and stress — contribute to prematurity, but half of all premature births are still unexplained.
“Prematurity obviously has multiple causes, and we need to come at it from a variety of ways,” says Margaret Comerford Freda, RN, EdD, FAAN, professor of obstetrics, gynecology, and women’s health at the Albert Einstein College of Medicine of Yeshiva University-Montefiore Medical Center in Bronx, N.Y. “In an odd way, that is good news because we don’t need to wait for a major break in the research. We know some of the things that cause prematurity. Nurses can look at these things and try to do what we can about each of them.”
One of the most effective — and simplest — things nurses can do is educate women about the symptoms of premature labor. (See “Warning signs of preterm labor.”)
“A lot of women have symptoms of premature labor but don’t know it, so they just wait,” Freda says. “Nurses can teach every single patient they come in contact with what those symptoms are and what to do if you have them. I’d also like nurses to stop telling patients about Braxton Hicks contractions, because it confuses them.”
“We have to encourage women to be checked when they aren’t sure,” says Barbara Peterson Sinclair, RNP, MN, FAAN, professor emeritus and chair of health science at California State University, Los Angeles. “Women are reluctant to do that. They are embarrassed and made to feel bad. We need to educate the whole medical community, because one woman coming in and avoiding preterm labor is worth having many women come in early.”
Knowledge is power
“One of the most expensive beds in a hospital, by and large, is in NICU,” says Mary Brucker, RNC, DNSc, program director for women’s health education at the University of Texas Southwestern Medical Center at Dallas, department of ob/gyn. “And prematurity has so many long-term health ramifications. We have to strike a happy medium between women trusting their bodies, yet being aware something isn’t quite right so they come in. We empower women with knowledge of what is normal and what is not.”
Nurses can provide this education no matter what type of patients they see. “Nurses work everywhere in health care,” Sinclair says. “They also work in their families and neighborhoods and among their friends. They can provide information about premature labor and its symptoms to all women.”
Nurses also can talk to women about domestic violence, which increases during pregnancy and is known to increase the risk of preterm birth.
“We can try to find out which women are involved in these situations and talk to them about how to get out of the situation,” Freda says. “That won’t solve all the preterm problems in the world, because thank goodness not all women are beaten, but it will solve some.”
Smoking is another major risk factor in premature birth, and even though helping women stop smoking is difficult, nurses can help, Freda says, at the least by simply asking about it and plugging women into community resources, or by actually offering smoking cessation programs.
Carrying multiple fetuses increases the risk of premature labor, says Jeanne Ruiz, RNC, PhD, WHCNP (women’s health care nurse practitioner), assistant professor at the University of Texas Health Science Center at San Antonio. A protocol Ruiz developed for advanced practice nurses to follow with multiples saved about $2 million by decreasing NICU length-of-stays. She is now working to extend the protocol to women carrying a single baby.
“Nurses need to look for the presence of stress, anxiety, and depression, which are all interrelated and all cause changes in body physiology,” Ruiz says. “We know that infections play a role in causing premature labor and stress affects the immune system.”
Down the right path
In addition to identifying stress, nurses can provide ways to alleviate it. At Banner Good Samaritan Medical Center in Phoenix, prenatal massage is offered twice a week. Patients are also given a spiritual assessment, and nurses formed a spiritual care group representing many different faiths that offers support separate from chaplain services.
“Anything that you can do to decrease stress ought to help with preterm labor symptoms,” says Terry Brisley, RN, MFN, WHNP, assistant director for antepartum, postpartum, and gyn surgery. “Nurses need a good list of resources they can refer women to.”
Stress can result from low socioeconomic status, which also affects the level of prenatal care and plays a role in other factors like nutrition and high-risk behavior. But even in these high-risk populations, nursing intervention makes a dramatic difference. LifeCycles is a multifaceted program of San Antonio’s Christus Santa Rosa Hospital, with a mobile and a freestanding clinic in a low-income area, staffed by nurses. In two years, the number of premature births among the clinics’ patients has been cut in half, says Margie Lieck, RNC, MSN, a certified childbirth educator, lactation consultant, and nurse manager for women’s services at Santa Rosa.
Stress may be one of the main culprits in the higher preterm rates for Hispanic and African-American women. Socioeconomic status explains some of these differences, but even African-American women in higher socioeconomic groups have more preterm births.
It is, therefore, especially important for nurses to assess stress in their Hispanic and African-American patients. “If screening determines that a woman is high-risk due to stress, we have to work on what is protective for them,” Ruiz says. “Find out if they are good problem-solvers or have good family support and build on that. Find resources and make sure they get plugged into those that are available.”
Nurses also must ensure — and not assume — that a patient is able to do what she is being asked, Ruiz added. If a woman is given a prescription, for example, a nurse can make sure she can read it, knows where to take it, and has transportation.
The bottom line is making sure all women are as healthy as possible, before pregnancy as well as during it. “Perhaps we should be seeing pregnant women weekly in the first or second month, the way we do in the last month,” Sinclair says. “We’ve been talking about that for a long time, but we haven’t seen the typical schedule change at all.”
“Nurses need to advocate for women to get appropriate education, to be notified and encouraged to come in for early and regular prenatal care,” Sinclair says. “I would love to see the general health care system be more receptive to educating women, and to see more nurse practitioners or midwives on the scene.”