Some Nursing and Midwifery Faculty Say They Are Not Reading Mainstream Media Reports of US Maternal Outcomes

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At the same time the United States is grappling with a maternal health crisis, its maternal mortality rate second only to Mexico in the group of 37 most developed countries, the COVID-19 pandemic is accelerating unabated. The converging maternal mortality and COVID-19 syndemics are compelling maternity nurses to continually review numerous sources of data to inform their practice. But previous research calls into question the extent to which some nurses engage with the evidence. Although maternal mortality increased 2.5-fold in the last three decades, almost half of about 400 nurses responding to a survey conducted by Bingham et al indicated they were not aware of the rising maternal mortality rate. Such uneven penetration of trends in pregnancy-related deaths amongst nurses within maternal health contexts is particularly troubling given the potential to cause harm if the same nurses adopt practices that are not supported by up-to-date evidence. Bingham et al highlighted the potential to cause harm when two-thirds of respondents endorsed that they spent less than ten minutes discussing postpartum warning signs with new mothers on the day of discharge despite evidence that majority of maternal deaths occur after delivery.

Evidence characterizing maternal outcomes in the United States has been fragmented at best and inherent challenges to data collection are not restricted to the period we have been confronting COVID-19. Between 2007 and 2020, the Centers for Disease Control and Prevention (CDC) withheld releasing an official estimate of the national maternal mortality rate until data collection procedures were harmonized across all 50 states. When the maternal mortality rate for 2018 was reported at the beginning of this year, it confirmed views long held by scientists and academics that maternal outcomes were just as bad or worse than they thought. Nurses endeavoring to understand the interaction between COVID-19 and pregnancy, and its effect on the trajectory of both conditions, were similarly constrained by the dearth of high quality research, which takes time to produce. Early in the outbreak, the only available data consisted of a series of case reports whose limited generalizability created a temporary vacuum devoid of reliable evidence. Between mid-January and late July, 35 pregnant women with COVID-19 died, according to the CDC, but it was not until late June that the risk profile for this population was first properly appreciated. Even then, there were glaring gaps in the CDC’s data primarily due to missing variables in reports submitted by state health departments to a central database. Delays in conducting robust research, Nina Martin, the staff reporter at ProPublica reported, placed pregnant women in peril because frontline clinicians lacked timely and reliable evidence to guide clinical decisions. 

In general, clinical practice lags behind research by approximately 17 years. While this delay in translating clinical research into practice could partly explain the limited absorption and utilization of up-to-date evidence on maternal outcomes by some maternity nurses, the discrepancy also presents a paradox given that widespread dissemination of significant events in response to the maternal health crisis has reached a critical mass in the mainstream media. Publication of the NPR+ProPublica award-winning series titled Lost Mothers in 2017 was followed by successive media reports, widely publicized advocacy campaigns, such as the March for Moms, and active lobbying by a consortium of professional organizations representing obstetric care providers culminating in enactment of the landmark Preventing Maternal Deaths Act of 2018. Sociologist Tressie McMillan Cottom wrote about poor treatment of Black women during pregnancy and childbirth in her 2019 book, Thick and Other Essays, which was excerpted in Time magazine. Similarly, some devastating consequences during the COVID-19 pandemic have been recounted in real time in media reports. One account published at the height of the COVID-19 pandemic in New York State in April 2020 described the fragmented care Amber Isaacs received when prenatal care schedules were modified as a strategy for preventing the spread of contagion. Amidst the upheaval, she could not regularly access an obstetrician at crucial junctures in her pregnancy causing complications to cascade unsupervised until she died.

If mainstream media reports on maternal health and the maternal health crisis offer a useful lens through which nurses can assess the zeitgeist and respond by critically appraising and adapting their practice, then the existing evidence is confounding. A mixed picture of the interplay between nurses and the mainstream media stymies understanding of the limited penetration and utilization of maternal health-related content amongst nurses. On one hand, nursing presence in the mainstream media remains underdeveloped. Mason et al found that nurses were cited as sources in just 2% of randomly selected health-related media reports. On the other hand, nurses are avid consumers of health-related media. In a survey assessing social media practices of more than 400 nurses, 80% endorsed accessing the internet for health-related information at least once a week. Nearly universal consumption of health-related content suggests it is highly likely that nurses have encountered robust reportage on contemporary events related to maternal health or the maternal health crisis and interdisciplinary knowledge on the same subject derived from diverse disciplines. Yet, only some nurses implement critical interventions with potential to mitigate harm to women during pregnancy and childbirth. Bingham et al propose that when nurses neglect to translate research into clinical practice, ineffective education strategies are the essential contributing mechanism.

This study turned to literary attributes of nursing faculty entrusted with preparing the next generation of maternal health providers for their future roles to gain insight on provenance of the wavering posture towards scholarship exhibited by some maternity nurses. At a time when an urgent response to relieve the maternal health crisis is rapidly being assembled, Logsdon et al urge nurses to participate through targeted dissemination of critical knowledge to key stakeholders. Students form an important constituency of maternal health stakeholders. Rapid advancement of the COVID-19 pandemic in the midst of a maternal health crisis has demonstrated conditions in which conventional delays in translating research into clinical practice are no longer tenable and set the imperative to impart skills necessary to continuously review literature originating from diverse disciplines that can be applied to benefit patients attending maternity services. Yet, research indicates deficiencies in preparing students for the maternal health care role. Nursing students face barriers during their training that prevent acquisition of sufficient expertise to provide care for women undergoing low-risk childbirth. These barriers include limited clinical placement slots resulting in fewer clinical hours and differences between didactic content and actual clinical practice, which make it difficult to reinforce classroom material in the clinical setting. Given the enumerated challenges associated with teaching maternal health care to nursing students, known delays in translating research into clinical practice and the deleterious effects when nurses are unaware of up-to-date evidence, this inquiry sought determine the extent to which faculty members engage in discourse on contemporary events related to maternal health and the maternal health crisis by eliciting and examining contemporary literature read or recommended in classroom bibliographies. For the purpose of this study, contemporary literature was defined as works developed in disciplines other than nursing, such as sociology, journalism, technology, the arts (for example, film), activitist campaigns and other relevant branches of knowledge.

what contemporary literature addressing maternal health and the maternal health crisis are you and your students reading?

Between December 2019 and February 2020, faculty members affiliated with schools of nursing and midwifery in the United States accredited by the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) were invited via email to participate in a brief cross-sectional survey. Because some nurses studying maternal health at the graduate level are enrolled in midwifery programs and many schools of midwifery are embedded within schools of nursing, their classroom bibliographies were deemed relevant. Therefore, faculty members teaching midwifery were included. Faculty members were identified through a search of publicly advertised biographical information and email addresses on institutional websites. They were eligible to participate if they taught a didactic or clinical course on care of the childbearing family at the baccalaureate level or higher during the 2018-2019 academic year. Of the 610 invitees, 133 (22%) interacted with the introductory email and of those who interacted with the email, 56 (42%) sent responses. Twenty three (41%) of respondents indicated their highest academic credential was a PhD, 15 (27%) possessed a DNP and 18 (32%) had a masters degree. Of the 56 respondents, 10 indicated that they did not teach a class on the childbearing family during the 2018-2019 academic year and as directed, they did not provide any responses to queries about their classroom bibliographies. Twenty eight (61%) of respondents identified their role as assistant professor, 10 (22%) as associate professor, 5 (11%) as adjunct instructor and 3 (6%) as full professor. Participants reported teaching in 26 states, one taught in an online program available to students in multiple states and 5 did not specify the state in which they taught. Thirty two (70%) of respondents taught at the baccalaureate level, 10 (21%) at the masters level, 3 (7%) at the doctoral level and 1 (2%) at both the masters and doctoral levels.

Did you include in your required or recommended reading list any contemporary/non-nursing literature addressing maternal health in general or the maternal health crisis in the US?

Review of specific examples of contemporary literature addressing maternal health or the maternal health crisis required or recommended by 26 faculty members to their students revealed that an additional 9 (35%) actually referred to scientific literature in peer-reviewed journals such as the Journal of Obstetric, Gynecologic and Neonatal Nursing and Health Affairs as well as grey literature published on the websites of organizations such as the CDC, Agency for Healthcare Research and Quality, Association of Women’s Health, Neonatal and Women’s Health Nurses (AWHONN), and UpToDate, the digital platform utilized to aid decision support in clinical settings.

Besides the literature you required or recommended your students to read, did you read any contemporary/non-nursing literature addressing maternal health in general or the maternal health crisis in the US that you did not discuss in class?

Similarly, review of specific examples of contemporary literature addressing maternal health or the maternal health crisis read by 31 faculty members revealed that an additional 6 (19%) actually referred to scientific literature in peer-reviewed journals such as the Journal of Midwifery and Women’s Health as well as grey literature published on the websites of organizations such as the American College of Nurse Midwives, AWHONN and Nurse Practitioners in Women’s Health and the memoir Josie’s Story.

perhaps the most astonishing discovery was that some nursing and midwifery faculty say they did not read any contemporary literature addressing the maternal health crisis during the 2018-2019 academic year

This inquiry aimed to compile a catalog of classroom bibliographies comprising contemporary literature on maternal health and the maternal health crisis read by nursing and midwifery faculty, and their students, to gauge penetration of multidisciplinary knowledge on maternal outcomes in our country. While 67% of faculty members reported that they read newspaper articles, books, advocacy campaign materials and watched films on the maternal health crisis, and that 57% recommended the same to their students, it was surprising to learn that 33% did not immerse themselves in the same rich compendium as their colleagues and 43% did not expose their students to the same. Further analysis revealed a higher proportion of faculty members did not read and recommend or require the same of their students. When sample reading lists provided by faculty members were taken into account, 46% of faculty did not read any contemporary literature on the maternal health crisis and 63% did not recommend or require their students to do the same.

Despite a small sample size, the immediate impression is that a cohort of nursing and midwifery students missed the opportunity for a classroom introduction to contemporary literature describing a major turning point in the maternal health crisis marked by enterprising diverse interdisciplinary groups developing and implementing interventions, from standardized clinical guidelines to federal legislation. Along with the lost chance to engage with contemporary literature on the maternal health crisis, some faculty members have ceded socializing their students with an appreciation for lifelong study of new evidence originating from broad bodies of knowledge, which in turn could perpetuate troubling downstream consequences similar to those described by Bingham et al. Almost half of maternity nurses surveyed by Bingham et al were not aware of the rising maternal mortality rate in spite of robust coverage across numerous media platforms when keeping up with up-to-date evidence to inform clinical practice is a fundamental professional duty. These students will eventually become practicing nurses and midwives with an obligation to adhere to professional standards that require clinicians to prioritize their patients’ well-being. Importantly, it is within the faculty members’ role to instill the necessary skill set and establish a minimum level of engagement with contemporary literature that students will require to fulfill their professional duty.

More than a decade ago, Sawatzky et al proposed a caring framework for teaching excellence in nursing education in which they reinforced the notion that the principal responsibility assigned to faculty members is the preparation of “new graduates with the competencies necessary to provide safe, competent and ethical nursing care.” Within Sawatzky’s framework are five tenets - an individual teaching philosophy, ethic of caring and excellence in teaching practice, leadership and scholarship - which unify to outline fundamental attributes possessed by superior nurse educators who demonstrate expertise, promote scholarship and model professional and personal growth to produce caring nurses and midwives. For some faculty members their best intentions to exhibit these attributes of superior nurse educators are overshadowed by the reality of their professional environments, which they shared in additional comments sent together with survey responses to provide additional insight on their perspectives regarding preparation of nursing and midwifery students for their future role as maternal health care providers. Structural factors were put forward as one rationale for excluding contemporary literature on the maternal health crisis from classroom bibliographies. A faculty member was hesitant to assign extra readings given time constrains. That faculty member wrote “my course has been taken down to such a short period of time that in order to teach them what they need to know (basics) for care of patients and to pass the NCLEX I don't have time to assign literature. I wish I could!” On the contrary, utilizing classroom discussions to introduce contemporary events relevant to maternal health offers an auspicious opportunity for faculty members to engage students on important aspects of delivering maternity care.

“I would like to see more dialog on this issue, especially discussion on our training and preparation of nursing students to become change agents in this area...”

 

Recommending or requiring contemporary literature on the maternal health crisis to nursing and midwifery students and utilizing media reports to guide classroom discourse is on par with scholarly practice across diverse disciplines ranging from medicine to political science, sociology and law. A review of the literature by Oxford University professor, Eric Meyer, found that newspaper articles were increasingly cited in scholarly publications and are considered to be important sources. One faculty member, expressing forward-facing sentiments about the future of nursing and midwifery education, wrote “I would like to see more dialog on this issue, especially discussion on our training and preparation of nursing students to become change agents in this area. I teach prelicensure masters level nursing students as well as family nurse practitioner students, both groups who will provide point of care services for women during their childbearing years.” One way faculty members can shape the next generation of nurses and midwives to participate in the national dialog on improving maternal outcomes is by including contemporary literature on maternal health and the maternal health crisis in their classroom bibliographies and using that literature to advance the discourse.

Interpretation of findings reported here should take into account inherent limitations owing to the study design, which features a non-random sampling method, and the resulting small sample size. Notably, a small sample size does not distinguish this study from some other investigations of nurses and nursing faculty members published in peer reviewed journals. Of the 3,759 nurses recruited by Bingham et al, 1,128 (28%) interacted with the email invitation and 372 (9%) completed the survey. Similarly, Raymond et al reported a response rate of 14.5%, which they attributed to research participation fatigue amongst nursing faculty members and concerns about revealing potentially undesirable information to a colleague. Nevertheless, there is value in reporting even unanticipated results. Publishing only significant results, as is customary in the scientific community, reinforces publication bias where theoretical and methodological contributions of the work are disregarded. Executing the search strategy described previously mimics observations reported by Mason et al that many schools of nursing websites are outdated and not optimized for external users, which made it difficult to retrieve nursing and midwifery faculty members’ biographical data and email addresses. Some nursing and midwifery faculty, especially adjunct instructors, are not listed on institutional websites, and were therefore excluded from the invitation to participate.

This study revealed uneven utilization of contemporary literature on maternal health and the maternal health crisis in the preparation of nursing and midwifery students for their future roles as maternal health care providers. Transforming the methods of instruction used by nursing and midwifery faculty presents an opportunity for nurse researchers to dedicate future investigative endeavors to examining education strategies that instill in nursing and midwifery students the skill set needed to continually review diverse sources of evidence, including contemporary literature, to inform their clinical practice.