Part Three: Maternal Morbidity and Mortality in the United States: where do we go from here?

According to Glanz, Rimer and Viswanath in Health Behavior and Health Education (2008):

Change strategies are most effective and likely to be sustained when they are directed at multiple levels of the organization, while simultaneously taking the external environment into account.” (p. 337)  This idea is actually drawn from an article published by Dennis Embry of the PAXIS Institute, in the Journal of Community Psychology (2004).  Embry explains that community change at the organizational level is best achieved when rooted in teaching, and utilizing “evidence-based behavioral kernels.” (p. 578)

While there are many root causes of maternal morbidity and mortality—some being non-preventable events—preventable causes ought to be a major target of health behavior change campaigns.  An example of this is elective early labor induction—an increasingly common initiator of a complex cascade of interventions which can and often includes: increased pain and intensity of labor, uterine hyper-stimulation (which can result in uterine rupture and/or amniotic fluid embolism), requests for intramuscular and epidural narcotic analgesia, and increased frequency of cesarean delivery (with its potential, numerous side effects) (Simpson & Atterbury, 2006).

Glanz, Rimer and Viswanath delineate the stages of Organizational Change in Table 15.1 (p. 340). The basic steps are: 1) Define problem 2) Initiate Action 3) Implement Change 4) Institutionalize Change.  In order to reduce elective inductions at a specific facility (organization), local stake holders and change agents might first be identified, who collectively understand the topic of labor induction and its various implications, and who are likely to support efforts of decreasing the incidence of unnecessary labor inductions.  Labor and delivery nurses at the hospital’s maternity ward would be excellent stakeholders and potential change agents within the hospital setting.  Key issues to touch on, when working to galvanize this group of potential change agents might include:  nurse-to-patient ratios (smaller ratios typically result in better patient outcomes and decreased stress for nurses) and maternity ward census statistics (scheduled labor inductions utilize hospital beds in L&D units—leaving less space for women who are in spontaneous labor); the former being a topic addressed in the legislative bill currently under debate in the House of Representatives, H.R. 876—Registered Nurse Safe Staffing Act of 2011.   Enticing a local maternity care provider who supports the notion of delaying labor induction as long as possible, barring any medical complications, to be a spokesperson for the campaign would also be hugely beneficial.  Likewise, incorporating community members in the campaign efforts would be important as well.  Key stake holders such as women of childbearing age, their partners, childbirth educators, doulas, midwives, and other interested parties could be invited to join forces with L&D staff, to create a labor and delivery care improvement coalition.

This type of coalition would start by familiarizing itself with up-to-date information (“evidence-based kernels”) regarding the risks and benefits of labor induction prior to 39 completed weeks of gestation, such as those discussed in the article, Misoprostol for Induction of Labour: A Systematic Review (Hofmeyr, Gulmezoglu & Alfirevic, 1999) and in the Cochrane Collaboration Review, Induction of Labour for Improving Birth Outcomes for Women at or Beyond Term (Gülmezoglu, Crowther, Middleton, 2011).  Gathering this information would serve to define the problem (Organizational Change theory) and help to prepare coalition members for the empowerment of expanding their ability to create change in the community, as described in the Key Concepts of Community Organizing (Glanz, Rimer, Viswanath, 2008, p. 294). With information in hand, the coalition could then enter the second step of organizational change:  Initiate Action.

Initiating the action of reducing unnecessary labor inductions would be directed at both maternity care staff and community members (pregnant women) to affect the desired outcome.   As Embry suggested, this can be achieved through teaching and applying evidence-based information. The Coalition could plan a series of communication tools, aimed at different target groups as follows:

Target Group Mode of Communication Key Message(s)
Maternity Care Providers Continuing Education Meeting Review risks of elective inducation & encourage waiting to offer inducations until 39+ completed weeks gestation
L&D Nurses Guest speaker at staff meeting Make use of teachable moments to explain risks of early inducation: women in for late pregnancy non-stress test & childbirth ed. classes
Ancillary birth professionals (doulas, childbirth educators) Direct mail letter/brochure Encourage clients/students to await spontaneous onset of labor and avoid asking for elective, early inductions.
Community members/expectant women Brochures/handouts at local women's expo March of Dimes messaging: Health Babies are Worth the Wait (and moms benefit too!)


Following this dissemination of information, implementation and institutionalization of change would begin—both likely requiring continued support by stakeholders and modeling by the chosen spokesperson maternity care provider.

Tomorrow, I will discuss economic policy approaches to tackling the issue of escalating maternal mortality and morbidity rates in the U.S.  To read this series from the beginning, go here.

Posted by: Kimmelin Hull, PA, LCCE, FACCE

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