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Many Nurses Lack Knowledge of Health Risks for New Mothers, Study Finds


By Nina Martin, ProPublica, and Renee Montagne, NPR News 

In recent months, mothers who nearly died in the hours and days after giving birth have repeatedly told ProPublica and NPR that their doctors and nurses were often slow to recognize the warning signs that their bodies weren’t healing properly. Now, an eye-opening new study substantiates some of these concerns.

The nationwide survey of 372 postpartum nurses, published Tuesday in the MCN/American Journal of Maternal/Child Nursing, found that many of them were ill-informed about the dangers new mothers face. Needing more education themselves, they were unable to fulfill their critical role of educating moms about symptoms like painful swelling, headaches, heavy bleeding and breathing problems that could indicate potentially life-threatening complications.

By failing to alert new mothers to such risks, the peer-reviewed study found, nurses may be missing an opportunity to help reduce the maternal mortality rate in the U.S., the highest among affluent nations. An estimated 700 to 900 women die in the U.S. every year from pregnancy- and childbirth-related causes and 65,000 nearly die, according to the Centers for Disease Control. The rates are highest for black mothers and women in rural areas. In a recent CDC Foundation analysis of data from four states, nearly 60 percent of maternal deaths were preventable.

Forty-six percent of nurses who responded to the survey were unaware that maternal mortality has risen in the U.S. in recent years, and 19 percent thought maternal deaths had actually declined. “If [nurses] aren’t aware that there’s been a rise in maternal mortality, then it makes it less urgent to explain to women what the warning signs are,” said study co-author Debra Bingham, who heads the Institute for Perinatal Quality Improvement and teaches at the University of Maryland School of Nursing.

Only 12 percent of the respondents knew that the majority of maternal deaths occur in the days and weeks after delivery. Only 24 percent correctly identified heart-related problems as the leading cause of maternal death in the U.S. In fact, cardiovascular disease and heart failure — which, according to recent data, account for more than a quarter of maternal deaths in this country — were “the area that the nurses felt the least confident in teaching about,” says Patricia Suplee, an associate professor at the Rutgers University School of Nursing in Camden, New Jersey, and the lead researcher on the study.

Nurses also said they spent very little time instructing new moms about worrisome symptoms — usually 10 minutes or less. Many of the nurses said they were only likely to discuss warning signs of such life-threatening conditions aspreeclampsia (pregnancy-related high blood pressure), blood clots in the lungs, or heart problems “if relevant” — even though, as the study noted, “it is impossible to accurately predict which women will suffer from a post-birth complication.”

The post-delivery education provided by nurses is particularly important because, once a mother leaves the hospital, she typically doesn’t see her own doctor for another four to six weeks. Up to 40 percent of new moms — overwhelmed with caring for an infant, and often lacking in maternity leave, child care, transportation and other kinds of support — never go back for their follow-up appointments at all.

Figuring out the best way to instruct new mothers is all the more crucial, the survey noted, because the first days after giving birth are “exhausting, emotionally charged, and physiologically draining” — hardly an ideal learning environment. But like so many other important aspects of maternal health care, postpartum education has been poorly studied, Bingham said.

The respondents, of whom nearly one-third had master’s or doctorate degrees, were members of the Association of Women’s Health, Obstetric and Neonatal Nurses, the leading professional organization for nurses specializing in maternal and infant care. AWHONN began looking at the education issue in 2014, when Bingham was the association’s vice president of nursing research and education. “We had to start really from the ground up, because we didn’t know exactly what women were being taught,” she said.

In focus groups conducted in New Jersey and Georgia, two states with especially high rates of maternal mortality,researchers discovered that postpartum nurses spent most of their time educating moms about how to care for their new babies, not themselves. The information mothers did receive about their own health risks was wildly inconsistent, and sometimes incorrect, Bingham said. The written materials women took home often weren’t much better.

Some nurses were uncomfortable discussing the possibility that complications could be life-threatening. “We had some nurses come out and say, ‘Well you know what, I don’t want to scare the woman. This is supposed to be a happy time. I don’t want to seem like all I want to talk about is death,’” Bingham said.

But the researchers also found that nurses could be quickly educated with short, targeted information. Using insights from the focus groups, an expert panel developed two standardized tools — a checklist and script that nurses could follow when instructing new mothers and a one-page handout of post-birth warning signs that mothers could refer to after they returned home, with clear-cut instructions for when to see a doctor or call 911. Those tools were tested in four hospitals in 2015. “Very quickly we started hearing from the nurses that women were coming back to the hospital with the handout, saying, ‘I have this symptom,’” Bingham said.

One of them was a Georgia mom named Sarah Duckett, who had just given birth to her second child. A week later, she recognized the warning signs of what turned out to be a blood clot in her lung — an often fatal postpartum complication. “Those were anecdotes, but they were very powerful anecdotes,” Bingham said. “I’ve led multiple projects over the years and rarely do I get such immediate feedback that something is working.”

The shortcomings documented by the national survey could foster wider use of these tools, suggested Mary-Ann Etiebet, executive director of Merck for Mothers, which funded the study as part of a 10-year, $500 million initiative to improve maternal health around the world. “Something as simple as creating educational and training programs for nurses … can have a real impact,” she said.

This story was co-published with NPR. Photo courtesy of Propublica.

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‘Obamacare’ Offers Young Adult Health Care and Peace of Mind


 By Charlene Muhammad, Final Call

Motivated, and armed with an architectural degree, Rumeisha Bowyer set out to obtain employment in her field, with health care benefits thrown in.

Two years and several full- and part-time jobs later, however, the 24-year-old is still searching for both.

“It’s very frustrating because I know I’m very, very educated but nothing’s happening at the moment,” Bowyer noted. “And health care is very important because if I get really, really sick, I won’t be able to afford my own health insurance.”

Bowyer’s mother, Deanna Bressler-Montgomery, is grateful that her daughter still has access to health care, thanks to the Affordable Care Act (ACA), comprehensive health care reform signed into law by President Obama in March 2010. ACA will allow Bowyer to remain on her mother’s health care insurance plan until she turns 26.

Prior to the ACA, Bowyer, who is minimally obese, has asthma and eczema, would have aged out of her mother’s health insurance plan a lot sooner. Parents could only cover their children until they turned 19, unless they were disabled; or up to their 24th birthday if they were enrolled in college full time.

Under the ACA, young adults can remain on their parents’ plan up to age 26, even if they are out of school, married or living on their own, if they cannot get health insurance through an employer.

Now, Bowyer can continue receiving medications and treatment for her health problems, as well as preventive care services, like the kickboxing and nutrition classes she currently attends.

“The weight training class is very beneficial because I’ve been struggling with weight for years. They offer free programs with the health insurance I have. If I didn’t have it, I would have to pay for a gym membership or do the basic run around the block, run around the corner, or run around the park,” Bowyer explained.

Scheduling time for such activities during safe, daylight hours is challenging because she works two part-time jobs, the incomes from which don’t add up to even $1,000 a month. Still, Bowyer is saving the money she earns working her part-time jobs so she can start paying for her own insurance when she turns 26 and is dropped from her mother’s plan. Meanwhile, she continues to search for a job with benefits that will kick in before then, she said.

According to the Center for Consumer I n f o r m a t i o n and Insurance O v e r s i g h t, an arm of the Centers for Medicare and Medicaid Services and a part of the Department of Health and Human Services,prior to the ACA, 42 percent of young adults switched or lost coverage once they graduated. In addition, 76 percent who were then uninsured did not get needed medical care.

“The Affordable Care Act requires plans and issuers that offer dependent coverage to make the
coverage available until the adult child reaches the age of 26. Many parents and their children who worried about losing health insurance after they graduated from college no longer have to worry,” explains the center on its website.

In California, 435,000 young adults gained insurance coverage as of December 2011 due to the health care law, according to the National Health Interview Survey, a data collection program of the National Center for Health Statistics. Nationally, the provision has allowed 3.1 million young adults to get health coverage.

“The ACA has meant my family saves money because I couldn’t afford to pay the $500 a month for her
insurance. I can at least try to afford the 10 percent and not go into debt. It’s better than paying the whole thing,” Bressler-Montgomery said.

For Bowyer, being able to stay on her mother’s health insurance plan has meant being able to buy asthma medication and keeping the disease under control. The 30-day supply of medication needed for her skin condition costs more than $100, and even with the $10 co-pay the family is able to cope, noted Bressler-Montgomery. She said she shudders to think of how much they would have had to pay out of pocket for Bowyer’s treatment had the young woman not been able to stay on her health insurance plan.

“I don’t like the fact that (some people) call it ‘Obamacare,’’ she said. “I think it’s negative but if they want to call it that, that’s okay. It’s the best care they can get right now.”

This article was made possible by a New America Media fellowship sponsored by The California Endowment.

Photo caption: Rumeisha Bowyer and, seated, her mother Deanna Bressler-Montgomery. Photo courtesy of Deanna Bressler-Montgomery

 

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New Census Numbers Mean New Responsibilities for Latinos


The Hartford Guardian’s Week-long Focus on Census 2010

La Opinión, Editorial

AMERICA NOW — There are 50 million Latinos in the United States—an enormous number that entails responsibilities, especially for immigrants, who represent a significant percentage of the total.

This fast-growing number also sends a powerful signal to the political establishment that the country’s future is connected to this community’s progress. Today, one out of every six Americans is Latino, as well as one out of every three children. By 2050, an overall racial or ethnic majority will no longer exist, and minorities will become the majority, due in large part to the increase in the Latino population.

Within this context, it is worrisome that members of the Latino community are not ready for a future where they play a central role.

Now is the time to become aware of this reality and obtain the government’s commitment at all levels to strengthening education, so tomorrow’s workforce is prepared to be competitive. A solid health care system is also necessary so young adults stay healthy and become productive citizens who achieve their potential.

President Obama is taking the right steps with the health care reform and a renewed emphasis on education.

Improving the areas of health care and education in the Latino community will have positive effects on society as a whole. To accomplish this, people must stop perceiving Latino immigrants as a threat to be eradicated through deportations, and look beyond the stereotype.

At the same time, Latinos must control their own destiny, as being 50 million strong demands. Otherwise, this number may give them a false, frustrating sense of power because the idyllic dream of Latino unity is unachievable.

The way to start is assuming responsibilities to become active participants of society. For example, by learning English and participating in civic and community events. Immigrants must also respect the local laws and regulations of their new country. They should adapt to their new surroundings rather than wait for everyone to adapt to them.

People who are permanent residents should become citizens and vote, expressing their opinions instead of being anonymous members of a silent majority. Everyone can complain as much as they want, but without solid political participation, complaints have no impact.

The number revealed by the census is a compelling argument for an implicit commitment between government leaders, who have the mission of preparing for the future, and Latinos, who should do everything in their power to be ready for the upcoming years. The destiny of the United States is firmly linked to the future of Hispanics. Recognizing this reality will be a good start.



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Doctor’s Word: Colonoscopy Can Save Lives


It’s exceedingly uncommon for a healthy middle-aged man to walk into his doctor’s office and demand a colonoscopy. But even though he lacked a family history, Stanley Thornton, an African-American engineer who was then in his mid-40s, wouldn’t take no for an answer.

“I was concerned that African Americans do get colorectal cancer earlier, and I said, ‘hey, let me lead by example,’” he said. “We argued about it for a month or two. He felt I should wait until I was 50.”

Eventually, Thornton got the test, and was found to be clear of cancer. He describes the “prep” – the liquid that he had to drink to clean out his intestines the night before the procedure – as “not the nicest thing in the world” – and said he was apprehensive as his wife drove him to his appointment that morning, since he didn’t know what to expect. But he said the only uncomfortable part of the test, in which a doctor put a thin tube up his rectum in order to inspect his large intestine, was when the nurse inserted an intravenous needle to give him a sedative. “All I remember is talking and then being wheeled back to the room.”

Colorectal cancer is the second leading cause of cancer death in the United States, after lung cancer. It’s one of the easiest cancers to detect early, since it usually begins as a growth called a polyp that grows silently for many years before spreading into the body. Screening people between the ages of 50 and 75 for colorectal cancer is so effective at preventing deaths that the United States Preventive Services Task Force (USPSTF) gives it an “A” rating, higher than its ratings for breast and prostate cancer screening.

People who have a family history or medical condition that increase their risk of colorectal cancer usually need to start getting colonoscopies before age 50. One doctors’ group, the American College of Gastroenterology, recommends that black men start getting colonoscopies at age 45, because they are at higher risk of being diagnosed with colorectal cancer after it’s already spread (and is thus more difficult to treat), and dying of the disease.

A colonoscopy is considered the “gold standard” screening test for colorectal cancer, since it’s the best at detecting pre-cancerous changes and since it’s the only test in which the doctor can remove the polyp right away. But it can be expensive (running anywhere from $500 to $3,000 if you’re paying out of pocket) and has some small risks, such as perforating the colon (which occurs in fewer than 1 out of 100 people) and bleeding, which is more of a risk if you are on a medicine that interferes with clotting.

For most people, the most bothersome thing about a colonoscopy is the “prep,” or strong laxative that they must use to clean out their colon in advance of the test. Colonoscopies need to be done in a closely monitored environment, since they require that the person receive a sedative. If the first screening colonoscopy doesn’t show anything abnormal, most “average risk” people can wait 10 years before repeating the test.

Many, if not most, insurance plans cover screening colonoscopy in people 50 and older. But what if you lack insurance, have a plan that doesn’t cover it, are at high risk for a complication, or simply can’t stand the thought of the test? The USPSTF says it’s also OK to screen “average risk” people with fecal occult blood tests, which look for blood that’s concealed in the stool. This test is a lot less expensive (usually costing under $20 if you are paying out of pocket; many insurance plans will cover it), but it must be repeated every year to be most effective at catching colorectal cancer early. To do the fecal occult blood test correctly, you have to take home three cards on which you will smear your stool after three different bowel movements. The doctor’s office or lab will then put a chemical on the cards to detect any blood that might be hidden in the stool. You should also be aware that simply having your stool smeared on a single card (which doctors sometimes do as part of an office rectal exam) is not an adequate screening test for colorectal cancer.

The USPSTF also says it’s acceptable to do a flexible sigmoidoscopy every five years as a screening test. This test is similar to a colonoscopy, except that the tube the doctor uses is shorter, so that he or she can only see the lower part of the large intestine, and might miss a cancer that’s higher up. It’s often done in combination with the fecal occult blood test, in order to pick up more cancers. It doesn’t require sedation and is less expensive, usually running less than $300 if you are paying the full cost

Keep in mind that if your fecal occult blood test or flexible sigmoidoscopy show anything concerning for cancer, you’ll need to undergo a full colonoscopy, so that the doctor can look more thoroughly and remove any suspicious tissue for additional tests. Also, even if you’ve had a clean colonoscopy within the past 10 years, you may need to repeat the test if you notice blood or other changes in your stool – so don’t ignore such symptoms.

In recent years, many doctors have been offering their patients a slightly easier colonoscopy prep, involving either a smaller amount of liquid laxative than in the past, or laxative pills instead. It’s important to drink plenty of water and/or clear fluids on the day before the test, to keep yourself hydrated. (Avoid anything red or pink, though). Some people also suggest putting yellow lemonade Crystal Light powder in the liquid prep and refrigerating it for a day to make it a bit more palatable. If you have a history of kidney problems, tell your doctor, since there are certain types of preps that you may need to avoid.

Thornton, who is now in his 50s, underwent a second screening colonoscopy recently, and said the prep was “much cleaner and nicer.”

Many of my patients want to get a colonoscopy, but simply can’t afford the upfront costs. The U.S. Centers for Disease Control and Prevention funds some limited programs (http://wwwtest.cdc.gov/cancer/crccp/about.htm) to screen low-income people for colorectal cancer. New York City has a relatively generous colonoscopy screening program for people who lack insurance.

Thornton, who is active in the American Cancer Society, urges everyone 50 and older with financial access to a colonoscopy to get the test.

“The ‘big C’ is something we don’t like to talk about in the black community, but we need to take charge of our health and get it done,” he said. “Anything short of that, we’re shortchanging ourselves.”

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A Doctor’s Word: Uneasy About the Real Beneficiaries of Obama’s Health Care


New America Media, Commentary, Erin Marcus, M.D.

I don’t know about you, but as I watched coverage of President Obama signing the health care bill last month, it was hard not to notice the constant ads for power wheelchairs. Emblazoned across the ads was a flashing notice reminding viewers: Medicare may cover this!

Don’t get me wrong. As a primary care doctor who takes care of low-income patients, I was glad to see something being done to address the appalling health disparities that exist in this country. But as the president signed the legislation, I had the queasy feeling that he was essentially writing a big fat check to several hugely influential, multi-billion dollar interest groups – including, most notably, the pharmaceutical and insurance industries.

And so, the persistent flashing ads for power wheelchairs seemed a bit ironic. As heavily marketed devices that cost the system thousands of dollars individually – and earn millions in profits for their parent companies – power wheelchairs exemplify what’s wrong with the system. Individually, they’re a small part of the overall picture, but in aggregate, they cost a lot. And though they’re clearly necessary for patients whose arms and legs are paralyzed, they’re often prescribed inappropriately for people who would be better off getting intensive physical therapy and using a manual wheelchair instead.

(To be fair, under the new healthcare law, Medicare will only pay for renting, and not purchasing, power wheelchairs in many situations – which should cost the system slightly less money).

From my vantage point in the trenches of public primary care, here are a few of the good things about the new health plan.

It pours more money into neighborhood health centers, which have a long track record of making primary care accessible to low-income people.

It will put more doctors, dentists, nurse practitioners, and physician assistants in these clinics by expanding the National Health Service Corps.

It will encourage primary care doctors and general surgeons to work in low-income areas by offering a bonus.

The law also promises to make it easier for low-income people to get general medical care by paying primary care doctors the same amount for patients with Medicaid as for those with Medicare. (But it won’t do anything to raise Medicaid payments for specialists, meaning primary care providers will still be scrambling when our patients need a cardiac catheterization or other intervention).

The law also raises the Medicaid income cap to 133 percent of poverty level . Many governors are kicking and screaming about this provision, but it will help a lot of people who do jobs that, while important, pay poorly. For example, under the new rules, a single home health aide with two kids who earns $21,500 annually (approximately the average wage for that job ) should qualify for Medicaid coverage. Under present rules, only 10 states, and the District of Columbia, provide Medicaid to a single mother with that income. More than half of the states in this country don’t provide Medicaid to adults without children.

On the flip side, the law will push millions of people to buy expensive insurance policies from private companies. Many of these policies will have steep deductibles, so having insurance won’t necessarily protect people from financial ruin if they develop a serious medical condition. It’s also likely that expanding the private insurance system will make people’s care even more fragmented and difficult to navigate, since, in my experience, the private companies are far more likely than public programs to restrict what tests and medications the patient can get, and where they can get their lab tests done.

To subsidize these policies, the government will pay millions to private health insurance companies, many of which are for-profit. This is a bitter pill to swallow, when you consider these companies’ chief executive salaries and when you keep in mind that these companies make their profits by minimizing what they pay health providers and denying payment for as many services as possible. Just this week, a surgical colleague told me of a heavily marketed local Medicare HMO (with a multimillionaire chief executive) that routinely denies coverage for complicated cancer procedures. “They make it impossible,” he said.

The law is also a triumph for the pharmaceutical industry, which blocked efforts to allow Medicare to negotiate what it pays them for medications. (In contrast, Medicare can negotiate with hospitals and doctors by telling them exactly what it will pay for specific services – and requires lots of documentation to prove that those services were provided). One policy analyst told the Associated Press that he predicts a $30 billion increase in revenues over the next decade for the drug industry, adding, “I don’t see how they could have done much better.”

And so, my feelings are mixed. I’m really hoping that after the law goes into effect, I won’t see more cases like the nurse’s aide who declared bankruptcy after the bills came in for her CT scans, or the mechanic who couldn’t pay the upfront costs for the colonoscopy to figure out why he had blood in his stool. But I’m not so sure. And I worry that the plan is just an expensive, complicated way to address the symptoms of our broken health system, not a daring cure.

Dr. Erin Marcus is associate professor of clinical medicine at the University of Miami Miller School of Medicine. A Doctor’s Word is supported by a grant from the Ford Foundation.

Related Articles by Erin Marcus

A Doctor’s Word: How to Keep Your Blood Pressure Down

A Doctor’s Word: Take Food Without a Grain of Salt

A Doctor’s Word–Tips from Al on Managing Diabetes

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