pinions I. CMUWtPCTSON NATKtNAL HEALTH
BySandraJ.Regenfe,C.N.M.,
INStRANCE
M.S.N.
MS Begenie is a crntrit uting editor to JNM end is chmpeison of the Leg&/atfcm Committee of AfCNM.
Durmg Committee heerfngs in Washington regarding natiinal taa% insurance, the question posed by some tagttlaton was a very bas.c ‘me. Does the U.S. need and/or sho,~ld tt have national health insurance? I \Xfould like to address the same questiorl incorporating my personal reactions to the comMeax issue 01 natiiaf health insurance . an issue posing moral and ethical dikmmss .a~ weil as being political in 8-m ‘re. In the soc~sl era of not so long ago, and grobably still seen :- rural Amorica. the prevailing moral atlitude of R commut.ny wss to utilize i!s own resources to provkie assistsn,e and succor to the community mamb.:rs not as healthy or sfffuent as others. This included giving cfothffg and food to the poor, nursing the sick, and ca, ing for the elders, In the 20th century, and particularly since the Second World War, society has plxed more and more of Me burden of caring for other onto government rather than contfntrng to maks it a personal moral responstbtlity. The shift in society tram an agricultural to an industrial society has greatly influenced this changa. Increasing numbers of people ars no bnger dependent on their own personal to4 to provide food and shelter for ‘hemselves and thJr families, but upor such things as labor unions, indus:ry. and taxsuooortad governmental prugrams to provide those monies and services necessary to obtain food and she:ter. It is estimated that the more industrialized 42
cur society becomes, the furlher away most people get from actual food procuction. the more poverty and malnutr;bon occur. This is because people first I ave to earn money and then must use toat money to obtain food and other goods. This is a change from the situation where one could pick fruit from a tree or dig up something planted m the garden without depending on an exchange of money for goods. The point I wish to make here is that there has been a shift, partmularf] during the past 30 years, toward govermrental responslbility in the solution of the 111sthat industrial society hss created. No one has been able to pl.lce an accurate price on national health insurance, but with the rising cor4.s of medical and hospital care and cor&nuing inffation such a program will bs very expensive for the U.S.A. Many figures have bean projected, but there is the possibility that such a program will cost well in excess of twenty billion dollars in tax money per year, with some estimates going as high as 70 billion dollars! If the financk,g for a national health insurancs plan is sdministsred as poorly se, and becomes the morass of the Medicaid and Metricare programs, the already high estmmes of cost could be much higher. It goes without raying that whenever government takes over programs, the bureaucratir processes cause large overttead. In fact, it has been estimated that as much as half or more of expanditures for governmental programs go for adm~nfs:rative expenses. We should be able to learn somethfng from Great Britain’s present situation. Britain faces ever increasing economic and intlationat-y Vo’Jlems and many have idenkfied thmr Neticnat Health Service as one of the contributing causes. The basic qusstion then becomes one of whsthe nat onal health insurance is a directiot thr U.S. really wants to go given the na
JOUHNAL
tfon’s pcesent economic situation and the foor track record established by Medr:are and Medicaid programs in this coun:ry. One wonders if the great cost of a national health insurance plan is a cost the tax payers can afford and what return they will get on their money. What is it that needs to be accomplished by a national health insurance program? First, discussion of national /tea/f/f insurance is misleading since legislative proposals actually deal with insurance for the treatment of illness and the provision of medical care rather than insurance for the promotion and maintenance of health. Heafth implies a sense of physical and mental well being on the part of an individual. The healthy state Is the result of many factors; not necessarily dependent on available, accessible, modern, scientific medical care. The basis of good health rests on a genetic heritage predisposing to full development and functioning. Adequate nutrition is another cornerstone of good health. Environmental factors, such as clean air, are major influence on one’s health. The fist goes on. Although the advances of modern science and medicine affect the health status of man, it may be fair to say that a majority of people are healthy for most of their life spans for reasons Othbr than the invsntions and instrumentation of modern medicine. It would appear that a program for health would of necessity have to address itself to the major health probfems in the U.S.A. The major killers of adults are cardiovascufar-renal disease and cancer. Death is inevftabfe and a result of some cause; so in a sense these dissases are not preventable. But, what would be the promotion of health would be the prevention of unnecessary premature deaths from these causes. Let me use cardfovascular deaths as an example. There is good evidence to show thst premature oardiovasoular deaths
OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977
can be Prevented by helping a person devebp a life=style of bw stress, regukr exercke, and a decreased lntahe of foods high in saturated fats. The main thrust Of modern medicine, however, has been the development of emergency medical services with elaborate ambulances, fancy communication systems, and more and biggel intensive care units. All of lhese geared to the treatment of the heart attack victim and not geared toward the prevention of the disease. The ironic thing is that all this fine equipment and instrumentation is not very valuable to the recovered person if he is still not taught the principles of health maintenance relevant to his disease. There is no available data on the cost-effectiveness of a teaching Program to prevent premature cardiovascular deaths versus a plan utilizing expensive scientific equipment, supertrained health manpower, and no teach. ing program. I would not be suprised, though, if such a study were done, that the health maintenance teaching program would prove to be the most costeffective and the most health promoting. As mother example, the single major cause of morbidity and mortatky in new. born infants ia bw birth Weight. In order to satvaQe bw birth welght infants, neonatal intensive care units have been devebpsd; and now, state-wide perlnatal programs are on the drawing board end are betno lmpkmented whkh designate hospttats tnto categories based on how much modern equipment and baked he&h manpower they have for the ewe of bw btrth weight snd sick newborns. Low btrth weight occurs more often in bw-income popuktions and poorty no&shed women. Much of It cwf be prevented through good prenatal care, adequate nutritkn with suffki. ent weiQht gak dtNinQ PreQnency, and Improved llvbtg conditkns. One wonders what the compeFative cost-effectivenws would be, for example, of a good program of htgh-protein nutritional ~ppkrn&&on for chttdbeerlng women as comp~ed with newborn intensive we units and pednakt programs. It would s@pw that a nutdtbnat suppkmentatkn pro~mm wouk resutt in a stgnifkmt reductkn of tow birth weight lnfants and wwld thereby be the most coat.effecttve poQrmn. The theme evolving throuQhout * Mat Pm&rfor mdksl WVICW whkh rectutre com~kx tnstrurnentatkn seem more worthy of OWtSXdObt~thNldOVogrsmSbased
on fairty simple concepts and ap proaches evlen though the more stmplistk approach might well be the most effective in promoting health in our PeoPk. To the extent that I am reactionary and romanticize times passed, I would like to make a few general comments about birth .md death. Our ancestors knew they would probably be born and die in the sane bed. in the ssme room, surrounded by their family. Although many childbearing women of our generation would prefer to give birth at home in their own beds with their family close by, modern society is denying them thii perogative by dictating that all births must take place in hospitals at a large cost. We are pwhaps one of the very few Societiis which separate our childbearing women from their families during labor and birth.. .a time of great emotional and physical stress. Similarly. many people in the terminal stages of an illness would rather remain at home with their families and in familiar surroundings, but are forced to die in the hospital, if at all possible, in intensive care units attached to monitors, tubes, and intravenous feedings, at an exorbitant cost. These approaches to birth and death are supported by the types of hospitalization insurance many of us have and are supported I” the proposed national healih msuranct :Jills. Birth and death are part of the human conditkn and it seems unjust to dictate where they should occur and to put such price tags on them. ACNM has taken thr official position that Certified Nurse-Midwives should be recogmzed in any national health insurance bill. ACNM has not taken a stand on national health insurance i!self. In terms of tax dollars, a national health insurance program will be very axpensive, will deal with illness and not health, and therefore will probably not be costeffective in terms of the nation’s health. Let us not lose SJQht of the fact that there might be other approaches taken to help Americans to be born safely, maintain their health status as long as possible and die peacefully and with dignity. I do not feel that the meny alternatives to national health insurance have been expbred ordiiussed tn any thorough way by the medical community or by the kgtstattve communtty. I think we are very remiss in not making the American public aware that there are Options not yet explored which
JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977
might be useful and successful in promoting health. We. the professionat% as well as the law-makers, have a responsibittty to the people of the United States to explore the alternatives involved in national health and nationat health insurance
II. A SAMPLE CENYERED
PATTERN MAlERNflY
FOR
FAMKY CARE
Ms. caffinQt0”. P Qmetfsfe of Me cohJnJhia univefsny RoQrsm Of Mare?niiy Nu&n~ and iVurse-W, sewed 88 the VfcbPmsidwt ot AClvAl fmm 1973-1975. she is the Ac4&?&t&or of the nurse-midwtfwy ser&ke at the l3fo&d& tWpW Medic& and bxnsvkb Fan& Rsnnbqj Id (MC) Clhic. She is amenfly the Chef~weon of the CcnnmMae on tntwOfgwl~atiom4 Menem 01 pmetr’ was pfepfued fof a tee of the tntwpro~~ Task Farce on He&h Care for Women and CMdfen.
Family-Centered ewe in obstetrks cmbedefkedasthedeKveryofssfe~ quslity hwlth cse whlb reccgnirihg. focusingon,andadaptkgtothaneeda of the client-pabent, her famity Elid her newbom.Theemphace then. eon&a pmvlsbn of optimun. numane werorttleobst&kapstk?lt~~ mal dlsruptkn of thehun’Ef unit.
INTROOUtXON In response to erican College (ACNM) as w&i concerned with he&h issues. Dr. utive Director of the re-crg=snizatii
requests from the Amof Nurse-Midwives as other orgeot&kns maternal and chit Warren Pears+ ~xecACOG anmxmc& thap meeting of the triter~cunhnurdon~ 43
organoational Committee of Cbs-Gyn lie&h Personnel, under the new name of the “Interprofessional Heelth Care Ccmnittee”, would take place April 26, 1976 at ths: O’Hare Hdton Hotel m Chicago. Official representatives of the participating groups: ACOG. ACNM. NAACOG. ANA and the American Academy of Pediatrics, subsequently changed the name of the Committee to the “lnterprofes..iona! Task Force for He&m Care of Women and ChiLJren”. Dorothea Lang, CNM and I represented the ACNM One of theagenda items drscussr3d at this first hteeting of the Interprofessional Task Force was the “Posdton Paper on Out-of Hospdal Matermty Care” adoptr!d by District II of the Amencan Col;>ge of Obstetricians and
A SAMPLE FAMILY-CENTERED
Racomrrrended
Gynecologists in January, 1976. Recognizing that consumers want a more ramily-centered approach to child-bearing in hospital settings and that family :entercd caie units are not widely ac~cessible across the country, this author recommended that a purpose of this .ksk Fcrce might be to formulate a statement. rationale, and a model for famrly-centered maternity care that would. when approved, be published for tne member organizations of the Task Force to support and adopt. To accomplish this purpose, a subcommittee of the Task Force was formeu with ACOG’s Richard Aubry. MD, ANA’s Ann Clark, R.N., and ACNM’s Srtty Carrington, CNM, serving as members. The modal and definition of 1 family-centered maternity care, which
PATTERN OF MATERNtTY
Fami;j--Centerrd
1) Educate 9 kwfa of staff ncfudkTg jaftitti and ofiice clerks, me&al, numa-m.dwlfery and nurrdng staff, s,~pervNory and administrative personnel on the objetti’/es of the Family-Centered Materrtity Program which rnsy include but are not limited to: (a) cwTent trends in chifdbirth practices (b) alternative childbirth practiies: safe and unsafe. as they are being practiced (c)“The Pregnant Patient’s Silf of Rights” (d) needs of childbearing families to share the total experience (ej explanation of the term “family” so that it in&des arr:r “signdicant” or %tpporting others” individual to the expectant mother (f) the advantages to famifies and to the larger society d -b’tg Ihe pl~~tlng bond fmmadiatefy affarbklh (g) the responafbiffbes of the consumer patients toward insuring a healthy outcome of the childbirth experience (h) the economic advantage to the hospital for initiiting the program and how this could benefit each employee (i) the satisfaction to be galned by each employee toward assisting families to adjust to thy new family member (j) how the Family-Centered Maternity Program is to function end the role each level employee is to perform to insure its success Ill. Family-Centered Program A. Family Waffrng Room and Early Labor Lounge shoufd be avai!abfe in or near the obstetrical suite where: ‘I) patjents in early tabor could watk and vidt with children and husbands 2) the “signlliont other” peram ooukl go for a ‘Teat br6sk,“‘llrlecmmy
CARE
A~gmach;
I. Prepamtron of Patients: Have availat;!s to consumers: two or more types of preparation for Childbirth CLsses taught by CaMii Nurse-Mfdwives and other personne’ A A ~ylaotfctnethod,i.e.lamaze B. 4 psychophysical method, I.e. Grantfy Dick-Read method of abdominal breathing as a technique C. A comprehensive course incorporating education about pregnancy and childbirth. breathing and relaxation techItiques with aspects of parenting and cnifd care Al class approaches should include a bibliography of reading materials. These classes: ‘I) increase the cons’ srs’ awareness of their respon_ sibifity toward insuring a healthy outcome for mother and chikf 2) serve as oppot~~nitiis for consumers and providers to match expectstions wo achieve mutual goals from the chifdbirth experience 3) serve as criteria to asak3t the conmem to be et@-blefcrpaioipatiMIintf~f~i~c~t~~~~ (a) a touI of me obstetrical suite and postpartum units shoukl be: (1) offered as an integral part of rhe preparation for cr ildbirth programs (2) available to consumers by appointment (b) a “hot Yrte” t&phorta ah&d be avakebfe in the ofxwrfd twlfa where patiarda wuld call in to requestlnkmiti orhavethelrinqulrlesanswered I II. Pr~paratt of Hospttat Staff: A. Ir.-depth contfn~ung educahon programs for all levels of staff hkudlng msdkral and sdmintstratNe, are to be conducted on an ongctn~ basfs to:
I 44
--
follows was written by the author to fulfill this subcommittae ass’gnment. The author realizes that there are institutions which already have familyoriented approacl’es which are more permissive than those expressed in this model. Reference to the father of the baby having to obtain a “pass” may be offensive to some, and in small obstetrical units, this pass could be eliminated, This model, however, was based on experience with an obstetrical unit where 4600 babies are delivered annually, Some ideas were included in the model for the information of hospital administrators as well as for care providers. The model on family-centered care is presently being reviewed by the Interprofessional Task Force for Health Care 1 of Women and Children.
JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, SlMln9 1977
3) 8 small kitchen could be available for fxeparation nourishments end for piacemant of snack machines
of
This Family Wai!ing Room is to: 1) be attractivety painted and furnished 2) include reading materials 3) include a nursery play area 4) include a telephone/intercom connection with the labor area B. A DkgnosUc-AdmiMing Room is to be adjacent to or near the family waiting room where: 1) patients could be examined to ascertain their status in labor without being formally admitted and put to bed if they’re in early hbor 2) any pregnant patient past 20 weeks gestation could be evaluated for any heatth problem during pregnancy Concept: The “supporting other or others” remain with the C))ent/fXttient throughout the childbirth process as long as her progress is normal C. “Birfhing Room” which is designed to be: 1) a combfnation labor and delivery room for patient and supporting others 2) brfghtty and attractively painted and famished to include: (a) wall pictures (b) cokrful drapes and throw rug (c) casual and comfortable lounge chairs or large fkoroushkns (d) cokrful commercial sheets. pillow-cases and ‘spreads to match the room decor 3) stocked for rnedkal ernergencles but concealed behlnd wsfl cblnets or drepeo or readily avallable to be whsebdlnbvhmneeded 4) wired for soft musk to be “piped” in, if desired 5) contain (a) modem hospital bed which can be totally lowered to floor to height of home bedding or which can be raised io”hospital height” for the delivery (b) combination t&or/delivery bed equipment if it is both safe and appealing (c) whichever equipment that allows the patient tc be in semi.Fowler’s (head raised) position for the actual delivery 6) have space for an infant cribbette. and 7) equipment for a normal spontaneous vaginal delivery Concept: Breastfeeding and handling of the baby by the mother and “supporting other” is encouraged to foster parenting bond 0.31her labor Rooms: 1) “supporting other” cr “others” ten be with laboring gatfent whether progress in fabor is normal or abnormal 2)womtdnr~ibn~~tincMln~ fetdmmitom,but ~wmuchaepoesibfe pdnted and fumkhed with 31rhoJdbOoobrfddnpumd4)tofncfudoakur~cNrcomfortclble~noughfor 6)uee@ppedforthePSrformmce
JOURNAL
OF NURSE-MIDWIFERY
ofdeuverfea
l
Vd.
XXII,
No.
1, Spring
E. Delivery Rooms: jLk$htiOg can be dimmed. &&corbing WJ need) 1) are for patients who do not destre to Use the B*ing Room” for normal Spontaneous vf+gfMt de&erieS 2) who need forceps defiverkS or 3) who require Cesareen sections delivery tables are to in&de adkstebfe backreSts and an overhead mirror is to be avaikbfe 5) breastfeeding and hendktg of the baby is eocm~aged immediately after delivery Concept: The “supportkg other” can accompany the Patient into the detiiary rocm as long as progress is expected to include a normal spontaneous vaginal delfvgr
4)
F. Ret Room” rooms, Room where in addition to medical monitoring 1) the infants are alkwed to be with tl’u? mothers and fatnerS for a minimum of 30 minutes after detivery 2) the “supportfng other” or “others” are atkwed towsit with the new mother in fmv&iGy 3) a “pass” is given to the father of the oeb; *o atkw him extended visiting privileges on the “new famJV unit G. The “New famr/y Unit”is to: 1) contain flexible rooming-in with a central nursery to allow for: (a) optional “rooming-in” (b) babree to be returned to the Central nursery for professional nursing ciye when desired by the mother (c)newbomsbeingwpsmtedfromthelrmothersno morethsnamaxfmum of 10 IlolsS in me &St 24 hours 2) have extended visiting hours for fathers of the new babres to allow them to assist with the care and feeding of their babies 3) have prescribed visiting hours for friends Since the emphasis of the family-centered approach is on the famiiy 4) contain a family room where (a) chrldren can visit with their mothers and fathers. and (b) where professional staff are available to answer questions about parenhng and adjustment issues of the enlarged family (c) where cafeteria-like meals can be served and eaten restaurant-styte by the mothers 5) have classes taught by nurse-midwives and professional nurses and other personN on infant feedkg. iofant care and parenting 6) allow visitmg and feeding by the mothers in the special nurseries such as: (a) newborn. vntensive ewe nursery (b) and isotatfon nursery 7) allow for breastfeeding on demend with P personnel avaitable forasststance
1977
INTERNATlOhAL
SURVEY OF MIDWIFERY PRACTICE (COVERING 210 COUNTRIES)
AND TRAINING
of the Joint Study Group
Report
of the
INTERNATIONAL INTERNATIONAL
CONFEDERATION OF MIDWIVES AND FEDERATION OF GYNAECOLOGY AND OBSTETRICS Second
Edition
1976
(588 Pages)
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Practice data over
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us information
and trends
on
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JOURNAL OF NURSE-MIDWIFERY . Vol. XXII, NO. 1, Spring 1977
BySandraJ.Regenfe,C.N.M.,
INStRANCE
M.S.N.
MS Begenie is a crntrit uting editor to JNM end is chmpeison of the Leg&/atfcm Committee of AfCNM.
Durmg Committee heerfngs in Washington regarding natiinal taa% insurance, the question posed by some tagttlaton was a very bas.c ‘me. Does the U.S. need and/or sho,~ld tt have national health insurance? I \Xfould like to address the same questiorl incorporating my personal reactions to the comMeax issue 01 natiiaf health insurance . an issue posing moral and ethical dikmmss .a~ weil as being political in 8-m ‘re. In the soc~sl era of not so long ago, and grobably still seen :- rural Amorica. the prevailing moral atlitude of R commut.ny wss to utilize i!s own resources to provkie assistsn,e and succor to the community mamb.:rs not as healthy or sfffuent as others. This included giving cfothffg and food to the poor, nursing the sick, and ca, ing for the elders, In the 20th century, and particularly since the Second World War, society has plxed more and more of Me burden of caring for other onto government rather than contfntrng to maks it a personal moral responstbtlity. The shift in society tram an agricultural to an industrial society has greatly influenced this changa. Increasing numbers of people ars no bnger dependent on their own personal to4 to provide food and shelter for ‘hemselves and thJr families, but upor such things as labor unions, indus:ry. and taxsuooortad governmental prugrams to provide those monies and services necessary to obtain food and she:ter. It is estimated that the more industrialized 42
cur society becomes, the furlher away most people get from actual food procuction. the more poverty and malnutr;bon occur. This is because people first I ave to earn money and then must use toat money to obtain food and other goods. This is a change from the situation where one could pick fruit from a tree or dig up something planted m the garden without depending on an exchange of money for goods. The point I wish to make here is that there has been a shift, partmularf] during the past 30 years, toward govermrental responslbility in the solution of the 111sthat industrial society hss created. No one has been able to pl.lce an accurate price on national health insurance, but with the rising cor4.s of medical and hospital care and cor&nuing inffation such a program will bs very expensive for the U.S.A. Many figures have bean projected, but there is the possibility that such a program will cost well in excess of twenty billion dollars in tax money per year, with some estimates going as high as 70 billion dollars! If the financk,g for a national health insurancs plan is sdministsred as poorly se, and becomes the morass of the Medicaid and Metricare programs, the already high estmmes of cost could be much higher. It goes without raying that whenever government takes over programs, the bureaucratir processes cause large overttead. In fact, it has been estimated that as much as half or more of expanditures for governmental programs go for adm~nfs:rative expenses. We should be able to learn somethfng from Great Britain’s present situation. Britain faces ever increasing economic and intlationat-y Vo’Jlems and many have idenkfied thmr Neticnat Health Service as one of the contributing causes. The basic qusstion then becomes one of whsthe nat onal health insurance is a directiot thr U.S. really wants to go given the na
JOUHNAL
tfon’s pcesent economic situation and the foor track record established by Medr:are and Medicaid programs in this coun:ry. One wonders if the great cost of a national health insurance plan is a cost the tax payers can afford and what return they will get on their money. What is it that needs to be accomplished by a national health insurance program? First, discussion of national /tea/f/f insurance is misleading since legislative proposals actually deal with insurance for the treatment of illness and the provision of medical care rather than insurance for the promotion and maintenance of health. Heafth implies a sense of physical and mental well being on the part of an individual. The healthy state Is the result of many factors; not necessarily dependent on available, accessible, modern, scientific medical care. The basis of good health rests on a genetic heritage predisposing to full development and functioning. Adequate nutrition is another cornerstone of good health. Environmental factors, such as clean air, are major influence on one’s health. The fist goes on. Although the advances of modern science and medicine affect the health status of man, it may be fair to say that a majority of people are healthy for most of their life spans for reasons Othbr than the invsntions and instrumentation of modern medicine. It would appear that a program for health would of necessity have to address itself to the major health probfems in the U.S.A. The major killers of adults are cardiovascufar-renal disease and cancer. Death is inevftabfe and a result of some cause; so in a sense these dissases are not preventable. But, what would be the promotion of health would be the prevention of unnecessary premature deaths from these causes. Let me use cardfovascular deaths as an example. There is good evidence to show thst premature oardiovasoular deaths
OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977
can be Prevented by helping a person devebp a life=style of bw stress, regukr exercke, and a decreased lntahe of foods high in saturated fats. The main thrust Of modern medicine, however, has been the development of emergency medical services with elaborate ambulances, fancy communication systems, and more and biggel intensive care units. All of lhese geared to the treatment of the heart attack victim and not geared toward the prevention of the disease. The ironic thing is that all this fine equipment and instrumentation is not very valuable to the recovered person if he is still not taught the principles of health maintenance relevant to his disease. There is no available data on the cost-effectiveness of a teaching Program to prevent premature cardiovascular deaths versus a plan utilizing expensive scientific equipment, supertrained health manpower, and no teach. ing program. I would not be suprised, though, if such a study were done, that the health maintenance teaching program would prove to be the most costeffective and the most health promoting. As mother example, the single major cause of morbidity and mortatky in new. born infants ia bw birth Weight. In order to satvaQe bw birth welght infants, neonatal intensive care units have been devebpsd; and now, state-wide perlnatal programs are on the drawing board end are betno lmpkmented whkh designate hospttats tnto categories based on how much modern equipment and baked he&h manpower they have for the ewe of bw btrth weight snd sick newborns. Low btrth weight occurs more often in bw-income popuktions and poorty no&shed women. Much of It cwf be prevented through good prenatal care, adequate nutritkn with suffki. ent weiQht gak dtNinQ PreQnency, and Improved llvbtg conditkns. One wonders what the compeFative cost-effectivenws would be, for example, of a good program of htgh-protein nutritional ~ppkrn&&on for chttdbeerlng women as comp~ed with newborn intensive we units and pednakt programs. It would s@pw that a nutdtbnat suppkmentatkn pro~mm wouk resutt in a stgnifkmt reductkn of tow birth weight lnfants and wwld thereby be the most coat.effecttve poQrmn. The theme evolving throuQhout * Mat Pm&rfor mdksl WVICW whkh rectutre com~kx tnstrurnentatkn seem more worthy of OWtSXdObt~thNldOVogrsmSbased
on fairty simple concepts and ap proaches evlen though the more stmplistk approach might well be the most effective in promoting health in our PeoPk. To the extent that I am reactionary and romanticize times passed, I would like to make a few general comments about birth .md death. Our ancestors knew they would probably be born and die in the sane bed. in the ssme room, surrounded by their family. Although many childbearing women of our generation would prefer to give birth at home in their own beds with their family close by, modern society is denying them thii perogative by dictating that all births must take place in hospitals at a large cost. We are pwhaps one of the very few Societiis which separate our childbearing women from their families during labor and birth.. .a time of great emotional and physical stress. Similarly. many people in the terminal stages of an illness would rather remain at home with their families and in familiar surroundings, but are forced to die in the hospital, if at all possible, in intensive care units attached to monitors, tubes, and intravenous feedings, at an exorbitant cost. These approaches to birth and death are supported by the types of hospitalization insurance many of us have and are supported I” the proposed national healih msuranct :Jills. Birth and death are part of the human conditkn and it seems unjust to dictate where they should occur and to put such price tags on them. ACNM has taken thr official position that Certified Nurse-Midwives should be recogmzed in any national health insurance bill. ACNM has not taken a stand on national health insurance i!self. In terms of tax dollars, a national health insurance program will be very axpensive, will deal with illness and not health, and therefore will probably not be costeffective in terms of the nation’s health. Let us not lose SJQht of the fact that there might be other approaches taken to help Americans to be born safely, maintain their health status as long as possible and die peacefully and with dignity. I do not feel that the meny alternatives to national health insurance have been expbred ordiiussed tn any thorough way by the medical community or by the kgtstattve communtty. I think we are very remiss in not making the American public aware that there are Options not yet explored which
JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977
might be useful and successful in promoting health. We. the professionat% as well as the law-makers, have a responsibittty to the people of the United States to explore the alternatives involved in national health and nationat health insurance
II. A SAMPLE CENYERED
PATTERN MAlERNflY
FOR
FAMKY CARE
Ms. caffinQt0”. P Qmetfsfe of Me cohJnJhia univefsny RoQrsm Of Mare?niiy Nu&n~ and iVurse-W, sewed 88 the VfcbPmsidwt ot AClvAl fmm 1973-1975. she is the Ac4&?&t&or of the nurse-midwtfwy ser&ke at the l3fo&d& tWpW Medic& and bxnsvkb Fan& Rsnnbqj Id (MC) Clhic. She is amenfly the Chef~weon of the CcnnmMae on tntwOfgwl~atiom4 Menem 01 pmetr’ was pfepfued fof a tee of the tntwpro~~ Task Farce on He&h Care for Women and CMdfen.
Family-Centered ewe in obstetrks cmbedefkedasthedeKveryofssfe~ quslity hwlth cse whlb reccgnirihg. focusingon,andadaptkgtothaneeda of the client-pabent, her famity Elid her newbom.Theemphace then. eon&a pmvlsbn of optimun. numane werorttleobst&kapstk?lt~~ mal dlsruptkn of thehun’Ef unit.
INTROOUtXON In response to erican College (ACNM) as w&i concerned with he&h issues. Dr. utive Director of the re-crg=snizatii
requests from the Amof Nurse-Midwives as other orgeot&kns maternal and chit Warren Pears+ ~xecACOG anmxmc& thap meeting of the triter~cunhnurdon~ 43
organoational Committee of Cbs-Gyn lie&h Personnel, under the new name of the “Interprofessional Heelth Care Ccmnittee”, would take place April 26, 1976 at ths: O’Hare Hdton Hotel m Chicago. Official representatives of the participating groups: ACOG. ACNM. NAACOG. ANA and the American Academy of Pediatrics, subsequently changed the name of the Committee to the “lnterprofes..iona! Task Force for He&m Care of Women and ChiLJren”. Dorothea Lang, CNM and I represented the ACNM One of theagenda items drscussr3d at this first hteeting of the Interprofessional Task Force was the “Posdton Paper on Out-of Hospdal Matermty Care” adoptr!d by District II of the Amencan Col;>ge of Obstetricians and
A SAMPLE FAMILY-CENTERED
Racomrrrended
Gynecologists in January, 1976. Recognizing that consumers want a more ramily-centered approach to child-bearing in hospital settings and that family :entercd caie units are not widely ac~cessible across the country, this author recommended that a purpose of this .ksk Fcrce might be to formulate a statement. rationale, and a model for famrly-centered maternity care that would. when approved, be published for tne member organizations of the Task Force to support and adopt. To accomplish this purpose, a subcommittee of the Task Force was formeu with ACOG’s Richard Aubry. MD, ANA’s Ann Clark, R.N., and ACNM’s Srtty Carrington, CNM, serving as members. The modal and definition of 1 family-centered maternity care, which
PATTERN OF MATERNtTY
Fami;j--Centerrd
1) Educate 9 kwfa of staff ncfudkTg jaftitti and ofiice clerks, me&al, numa-m.dwlfery and nurrdng staff, s,~pervNory and administrative personnel on the objetti’/es of the Family-Centered Materrtity Program which rnsy include but are not limited to: (a) cwTent trends in chifdbirth practices (b) alternative childbirth practiies: safe and unsafe. as they are being practiced (c)“The Pregnant Patient’s Silf of Rights” (d) needs of childbearing families to share the total experience (ej explanation of the term “family” so that it in&des arr:r “signdicant” or %tpporting others” individual to the expectant mother (f) the advantages to famifies and to the larger society d -b’tg Ihe pl~~tlng bond fmmadiatefy affarbklh (g) the responafbiffbes of the consumer patients toward insuring a healthy outcome of the childbirth experience (h) the economic advantage to the hospital for initiiting the program and how this could benefit each employee (i) the satisfaction to be galned by each employee toward assisting families to adjust to thy new family member (j) how the Family-Centered Maternity Program is to function end the role each level employee is to perform to insure its success Ill. Family-Centered Program A. Family Waffrng Room and Early Labor Lounge shoufd be avai!abfe in or near the obstetrical suite where: ‘I) patjents in early tabor could watk and vidt with children and husbands 2) the “signlliont other” peram ooukl go for a ‘Teat br6sk,“‘llrlecmmy
CARE
A~gmach;
I. Prepamtron of Patients: Have availat;!s to consumers: two or more types of preparation for Childbirth CLsses taught by CaMii Nurse-Mfdwives and other personne’ A A ~ylaotfctnethod,i.e.lamaze B. 4 psychophysical method, I.e. Grantfy Dick-Read method of abdominal breathing as a technique C. A comprehensive course incorporating education about pregnancy and childbirth. breathing and relaxation techItiques with aspects of parenting and cnifd care Al class approaches should include a bibliography of reading materials. These classes: ‘I) increase the cons’ srs’ awareness of their respon_ sibifity toward insuring a healthy outcome for mother and chikf 2) serve as oppot~~nitiis for consumers and providers to match expectstions wo achieve mutual goals from the chifdbirth experience 3) serve as criteria to asak3t the conmem to be et@-blefcrpaioipatiMIintf~f~i~c~t~~~~ (a) a touI of me obstetrical suite and postpartum units shoukl be: (1) offered as an integral part of rhe preparation for cr ildbirth programs (2) available to consumers by appointment (b) a “hot Yrte” t&phorta ah&d be avakebfe in the ofxwrfd twlfa where patiarda wuld call in to requestlnkmiti orhavethelrinqulrlesanswered I II. Pr~paratt of Hospttat Staff: A. Ir.-depth contfn~ung educahon programs for all levels of staff hkudlng msdkral and sdmintstratNe, are to be conducted on an ongctn~ basfs to:
I 44
--
follows was written by the author to fulfill this subcommittae ass’gnment. The author realizes that there are institutions which already have familyoriented approacl’es which are more permissive than those expressed in this model. Reference to the father of the baby having to obtain a “pass” may be offensive to some, and in small obstetrical units, this pass could be eliminated, This model, however, was based on experience with an obstetrical unit where 4600 babies are delivered annually, Some ideas were included in the model for the information of hospital administrators as well as for care providers. The model on family-centered care is presently being reviewed by the Interprofessional Task Force for Health Care 1 of Women and Children.
JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, SlMln9 1977
3) 8 small kitchen could be available for fxeparation nourishments end for piacemant of snack machines
of
This Family Wai!ing Room is to: 1) be attractivety painted and furnished 2) include reading materials 3) include a nursery play area 4) include a telephone/intercom connection with the labor area B. A DkgnosUc-AdmiMing Room is to be adjacent to or near the family waiting room where: 1) patients could be examined to ascertain their status in labor without being formally admitted and put to bed if they’re in early hbor 2) any pregnant patient past 20 weeks gestation could be evaluated for any heatth problem during pregnancy Concept: The “supporting other or others” remain with the C))ent/fXttient throughout the childbirth process as long as her progress is normal C. “Birfhing Room” which is designed to be: 1) a combfnation labor and delivery room for patient and supporting others 2) brfghtty and attractively painted and famished to include: (a) wall pictures (b) cokrful drapes and throw rug (c) casual and comfortable lounge chairs or large fkoroushkns (d) cokrful commercial sheets. pillow-cases and ‘spreads to match the room decor 3) stocked for rnedkal ernergencles but concealed behlnd wsfl cblnets or drepeo or readily avallable to be whsebdlnbvhmneeded 4) wired for soft musk to be “piped” in, if desired 5) contain (a) modem hospital bed which can be totally lowered to floor to height of home bedding or which can be raised io”hospital height” for the delivery (b) combination t&or/delivery bed equipment if it is both safe and appealing (c) whichever equipment that allows the patient tc be in semi.Fowler’s (head raised) position for the actual delivery 6) have space for an infant cribbette. and 7) equipment for a normal spontaneous vaginal delivery Concept: Breastfeeding and handling of the baby by the mother and “supporting other” is encouraged to foster parenting bond 0.31her labor Rooms: 1) “supporting other” cr “others” ten be with laboring gatfent whether progress in fabor is normal or abnormal 2)womtdnr~ibn~~tincMln~ fetdmmitom,but ~wmuchaepoesibfe pdnted and fumkhed with 31rhoJdbOoobrfddnpumd4)tofncfudoakur~cNrcomfortclble~noughfor 6)uee@ppedforthePSrformmce
JOURNAL
OF NURSE-MIDWIFERY
ofdeuverfea
l
Vd.
XXII,
No.
1, Spring
E. Delivery Rooms: jLk$htiOg can be dimmed. &&corbing WJ need) 1) are for patients who do not destre to Use the B*ing Room” for normal Spontaneous vf+gfMt de&erieS 2) who need forceps defiverkS or 3) who require Cesareen sections delivery tables are to in&de adkstebfe backreSts and an overhead mirror is to be avaikbfe 5) breastfeeding and hendktg of the baby is eocm~aged immediately after delivery Concept: The “supportkg other” can accompany the Patient into the detiiary rocm as long as progress is expected to include a normal spontaneous vaginal delfvgr
4)
F. Ret Room” rooms, Room where in addition to medical monitoring 1) the infants are alkwed to be with tl’u? mothers and fatnerS for a minimum of 30 minutes after detivery 2) the “supportfng other” or “others” are atkwed towsit with the new mother in fmv&iGy 3) a “pass” is given to the father of the oeb; *o atkw him extended visiting privileges on the “new famJV unit G. The “New famr/y Unit”is to: 1) contain flexible rooming-in with a central nursery to allow for: (a) optional “rooming-in” (b) babree to be returned to the Central nursery for professional nursing ciye when desired by the mother (c)newbomsbeingwpsmtedfromthelrmothersno morethsnamaxfmum of 10 IlolsS in me &St 24 hours 2) have extended visiting hours for fathers of the new babres to allow them to assist with the care and feeding of their babies 3) have prescribed visiting hours for friends Since the emphasis of the family-centered approach is on the famiiy 4) contain a family room where (a) chrldren can visit with their mothers and fathers. and (b) where professional staff are available to answer questions about parenhng and adjustment issues of the enlarged family (c) where cafeteria-like meals can be served and eaten restaurant-styte by the mothers 5) have classes taught by nurse-midwives and professional nurses and other personN on infant feedkg. iofant care and parenting 6) allow visitmg and feeding by the mothers in the special nurseries such as: (a) newborn. vntensive ewe nursery (b) and isotatfon nursery 7) allow for breastfeeding on demend with P personnel avaitable forasststance
1977
INTERNATlOhAL
SURVEY OF MIDWIFERY PRACTICE (COVERING 210 COUNTRIES)
AND TRAINING
of the Joint Study Group
Report
of the
INTERNATIONAL INTERNATIONAL
CONFEDERATION OF MIDWIVES AND FEDERATION OF GYNAECOLOGY AND OBSTETRICS Second
Edition
1976
(588 Pages)
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