Maternity units with high-risk patients see nursing shortages

Photo: Dean Mitchell/Getty Images

Nurse/patient ratios in hospital maternity departments are oftentimes inconsistent with national nurse staffing standards, especially in departments that care for high-risk patients, according to a new study in Nursing Outlook.

The findings reveal one of many factors that may be contributing to poor maternal health outcomes in the U.S. for the most vulnerable childbearing populations, including Black mothers and those insured by Medicaid.

Recent data shows that patients at high risk for severe maternal complications are more likely to give birth in teaching hospitals and have Medicaid as their insurer. Teaching hospitals – which are often safety-net hospitals providing a significant amount of care to low-income and uninsured patients – are also more likely to have high volumes of births.

In the study, the researchers aimed to determine the levels of nurse staffing at hospitals with vulnerable maternity patients, using high-birth volume and teaching status as proxies for high-risk patients.

WHAT'S THE IMPACT

Nurses play a central role in the 3.6 million births that take place in U.S. hospitals each year, authors said. The Association of Women's Health, Obstetric and Neonatal Nurses' (AWHONN) issues guidelines on nurse staffing levels for maternity units; its 2010 guidelines call for one nurse to one birthing person during many parts of labor, two nurses at birth, one nurse for each mother-newborn pair during the first few hours after birth, and one nurse for every three pairs of mothers and babies after that period. 

These same nurse-to-patient ratios were included in the AWHONN nurse staffing standards published in 2022.

The researchers surveyed 3,471 registered nurses from 271 hospitals across the country. Nurses were asked about levels of staffing on their maternity units during labor, delivery, and recovery using AWHONN guidelines. The researchers compared nurses' responses on staffing with hospital characteristics from the American Hospital Association Annual Survey.

Overall, nurses reported strong adherence to AWHONN staffing guidelines in their hospitals, with more than 80% of respondents saying their unit frequently or always met the staffing guidelines. Adherence to guidelines was particularly high for certain stages of labor, including a nurse being continuously present at the bedside during second stage labor (93.3%) and one-on-one care during epidural initiation (84.1%).

Adherence was lower for having a dedicated nurse for postpartum recovery in the two hours right after delivery (71.8%), one-on-one care for mothers with high-risk conditions (72.6%), a nurse dedicated to fetal heart rate monitoring (61.3-77.2%), and one-on-one care during oxytocin administration in labor (54.6%).

Analyzing hospital characteristics, the researchers found that teaching hospitals, as well as hospitals with higher birth volumes, neonatal intensive care units, and higher percentages of births paid by Medicaid, were associated with lower staffing guideline adherence – all of which have been shown to serve high-risk maternity patients.

"These gaps in staffing are particularly troubling for our most at-risk patients," said Dr. Audrey Lyndon, the Vernice D. Ferguson Professor in Health Equity and assistant dean for clinical research at NYU Rory Meyers College of Nursing. "Many maternal complications can be prevented or quickly addressed through timely recognition of risk factors and clinical warning signs, and, when issues are identified, the escalation of care and coordination with the care team – but this is only possible when there are enough nurses monitoring patients."

The researchers note that one possible cause of nurses in these types of hospitals having more patients than recommended may be poor reimbursement from Medicaid for childbirth services.

They encourage the Centers for Medicare and Medicaid Services and the Joint Commission to consider safe staffing requirements for inpatient maternity care, similar to CMS working to establish minimum staffing regulations for nursing homes to promote patient safety.

THE LARGER TREND

Last fall the Department of Health and Human Services said that more than half of all states across the country have expanded access to 12 months of Medicaid and Children's Health Insurance Program coverage after pregnancy. Georgia and Pennsylvania are the 25th and 26th states to be approved for the extended coverage, made possible by provisions in the American Rescue Plan signed into law by President Biden in March 2021.

It's estimated that up to an additional 57,000 people in those two states will now be eligible for Medicaid or CHIP for a full year after pregnancy. In total, an estimated 418,000 Americans across 26 states and Washington D.C. now have expanded access to postpartum coverage.

The administration has consistently framed the ARP and postpartum coverage push as part of a larger effort to expand health insurance coverage, particularly in underserved areas and among disadvantaged populations.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com