Maternal Child Health Nursing

My Specialty

Maternal Child Health Nursing

Serving patients at a defining moment in their lives

By Elizabeth Hanink, RN, BSN, PHN
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Maternal child health nursing is one area of our profession that concentrates on the normal. Babies and mothers — what could be more natural? And yet, things do go wrong; and even when everything goes right, pregnancy lends itself to worry. Nurses in this specialty need to be ready to embrace patients across several age brackets and all socio-economic levels. They serve patients who are experiencing a defining moment in their lives.

Esther Edber, RN, CMN, midwifeEsther Edber, RN, CNM, still recalls two incidents that led her into midwifery. At the first delivery she witnessed the expectant couple said, over and over, through labor, “I hope it’s a boy, I hope it’s a boy.” Then, at baby’s birth, when the doctor announced they had a girl, the couple immediately exclaimed, ”It’s a girl! Just what we always wanted!”

As a nursing student, Ms. Edber was lucky enough to watch an old documentary on the “granny midwives” of Georgia. All My Babies features uneducated, but in many cases skilled, women who helped deliver the babies of the rural poor. Ms. Edber’s delight in watching the midwife in the film place twins into their first crib — a set of dresser drawers — sparked in her a desire to be part of something similar.

Today her enthusiasm remains palpable. For the last 23 years she’s practiced as a certified nurse midwife (CNM) at Los Angeles County-University of Southern California Medical Center (LAC+USC).

Now she spends her days delivering babies, teaching medical interns how to do it and providing clinical care. Patient teaching is also a part of her role, and it includes working with mothers on childbirth education and breastfeeding.

On a typical clinic day Ms. Edber sees about 25 patients, including young girls from juvenile detention and the homeless. Often her patients schedule to see her for new pregnancies, and she’s had the joy of watching families grow. “I have delivered thousands of babies, seen women through three and four pregnancies, and when that baby comes out, it is a miracle every single time.”

Ms. Edber considers herself lucky — in California jobs like hers are scarce. Most employment is in the public sector, such as county hospitals, although the Kaiser Group does use midwives. In general, says Ms. Edber, because physicians do not like the competition, only the occasional private hospital offers employment opportunities. The military employs midwives, as do several international organizations.

Although midwifery is legal in all 50 states, it does not enjoy universal acceptance; Arizona has 191 midwives and California about 1,185. Altogether, 11,000 CNMs practice in the United States and 95 percent of the births at which they assist occur in hospitals. Some staff birthing centers and some attend home births.

How did Ms. Edber prepare professionally? After graduating from nursing school, she obtained an advanced degree as an adult nurse practitioner. One additional year of study at LAC+USC led to her certificate as a nurse midwife. That’s the usual route, although programs vary. Many offer part-time, online or distance learning. Almost all lead to a master’s degree, and by 2010 a graduate degree will be the entry to practice. Completing a midwifery program prepares a nurse to sit for the exam given by the American Midwifery Certification Board; state boards of nursing provide continuing regulation.

Neonatal Nursing

Joan Eaton, RN, neonatal nursingJoan Eaton, RN, sees the “second patient” in the maternal child matrix. Much of her job is also teaching, but her focus is the baby that has been born too early, too little or too sick. She works in a Level III NICU in Odessa, Tex. She has also worked as a transport nurse, delivering medically unstable neonates from one hospital to another. Her greatest pleasure is that so many of the very small patients do survive and go home to their families.

Unlike midwifery, becoming a specialist in neonatal intensive care nursing involves a series of advanced in-services, clinical ladders, specialty seminars and extensive on-the-job learning. Employers require particular credentials in advanced pediatric life support and resuscitation, but education is hands-on and not, in most cases, a formal didactic program. Certifications are available through various bodies, but these are earned concurrently with employment and experience. They require testing and, sometimes, the presentation of a portfolio. Several graduate programs offer a clinical nurse specialist degree at the master’s level; there are also nurse practitioners who specialize in neonatology.

The workload varies. On a recent day, Ms. Eaton had just finished a 12-hour shift caring for two infants, both on ventilators, both with multiple (five) IV lines including such powerful drugs as insulin, TPN, dobutamine, dopamine and antibiotics. You could hear the exhaustion.

On a slower day she might work with three to four babies who are more stable, whose parents now require teaching to be able to care for their child on discharge. “You can’t rush the baby learning to eat and you can’t rush the parent,” she says. Still, Ms. Eaton appreciates the challenges of her role and remembers when she herself was a young mother with a desperately ill newborn. “The nurses were cold and uncommunicative. I wanted to change that, and I have.”

A high-level NICU in a children’s hospital might also employ an ECMO (extra-corporeal mechanical oxygenation) nurse. These are the highly trained nurse perfusionists who care for babies experiencing heart/lung assist. Somewhat less daunting but equally important in the scheme of recovery are nurses who are experts in the developmental needs of these highly compromised babies. In some hospitals, physical and occupational therapists assume the role, but Newborn Individualized Developmental Care and Assessment Program (NIDCAP) evaluators are usually nurses.

Other Maternal Child Specialties
Lactation consultants offer assistance with breastfeeding and work in and out of hospital. Lamaze and other childbirth instructors usually lead community classes for expectant parents. Their expertise comes from extensive continuing education rather than formal academic preparation, although some is available. Labor and delivery nurses also learn their role at the bedside.

Mary Ellen Cunningham, RN, MPA, high-risk perinatal programInteresting administrative jobs also abound. Mary Ellen Cunningham, RN, MPA, is in charge of the high-risk perinatal program of the Arizona Department of Health Services. She guides an effort that ensures that every mother and baby in the state, regardless of ability to pay, receives care at the appropriate level.

To that end, she contracts with facilities that utilize hundreds of maternal child health nurses. Some work in traditional delivery units or NICUs; some are transport nurses; and some 50 to 60 work throughout the largely rural state as community health nurses who follow up on mothers and babies after discharge. Maternal child nurses also cover the extensive discharge planning some families require. Recognizing that one premature birth statistically predisposes to another, these community nurses address health concerns of mothers before another pregnancy occurs. They also assess when the care of a child is overwhelming a family or, through a tool such as the Edinburgh Post Natal Depression Scale (EDPS), determine when a mother is unable to care for her child due to depression.

Issues Facing Maternal Child Nurses
What are some of the issues in nursing these practitioners face? Both Ms. Edber and Ms. Eaton, without hesitating, list liability. In maternal child health it continues for years. Unless you are employed by an institution, the cost of insurance remains prohibitive, especially for mid-level providers. Some NPs are employed by physician groups and gain coverage that way.

Funding is also a worry. According to Ms. Cunningham, while the state of Arizona provides for a unique and apparently seamless referral system, good care costs money. Proving it is worthwhile takes time and effort. “You can’t say because a baby today was cared for appropriately, tomorrow you are going to have better outcomes,” she says. “It is down the road that you are going to see it.” One of her primary reasons for choosing her job was the opportunity to influence those decisions on a broad scale, and clearly her master’s in public administration along with her nursing degree provides an ideal educational background.

Are you thinking of this type of nursing? The websites of the specialty organizations listed below offer an overview, including advocacy issues. Pay scales vary widely but follow the usual pattern in nursing; more advanced credentialing leads to higher paying jobs. Competency testing overlaps somewhat but the American Nurses Association, through its credentialing center, offers certification in multiple areas, as does the National Certification Corporation.

You’ve heard of l’chaim — “to life.” These nurses have treasured and nurtured life, and they flourish in a special kind of nursing. It just might be for you!

For More Information About This Specialty:

Midwifery Programs

University of California–San Francisco
(415) 206-5106

California State University–Fullerton
(714) 278-3336

San Diego State University
(619) 594-2540

*There are no midwifery programs in Arizona

Other Specialties

Doctoral Nurse Practitioner Program
Arizona State University at Phoenix
(602) 496-0857

Neonatal Nurse Practitioner
Loma Linda University
(800) 422 4558

Lactation Consultant
International Lactation Consultant Association

NIDCAP Training
Newborn Individualized Developmental Care and Assessment Program

Web Resources:

National Association of Neonatal Nurse Practitioners:
Association of Women's Health, Obstetric and Neonatal Nursing:
American College of Nurse Midwives:
American Nurses Association:
Arizona State Board of Nursing:
California Board of Registered Nursing:

Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.

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