- Email: [email protected]
Life on the “genius” track
SPECIAL FEATURE Life on the "Genius" Track R U T H W A T S O N LUBIC, E D D , C N M *
This article is based on the John P. McGovern Award Lecture presented at the American Association of Colleges of Nursing's semiannual meeting on October 26, 199Z BOVE ALL ELSE, I want each and all of you to understand how grateful I am to be with you to discuss the opportunities and great good fortune that have befallen me in my career as a nurse and as a nurse-midwife. I am especially happy because of the tensions that are at times found in relationships between nurses and nurse-midwives--tensions that for the sake of childbearing families are a luxury we can't afford and should repair. As to my own professional preparation, I have never seen these two aspects as mutually exclusive, although some do, and I regret their position. My view is that nursing made me a better midwife, and midwifery makes me a better nurse. But to what end? Not my career satisfaction, surely, but to the end of applying whatever knowledge and skill I have to the betterment of families, especially those who have been and are disadvantaged in and by our society. Mary Breckinridge, founder in 1925 of the Frontier Nursing Service, put it this way after her World War I experiences in Europe: In France midwives were not nurses. In America nurses were not midwives. In England trained women were both nurses and midwives. After I had met British nurse-midwives, first in France and then on my visits to London, it grew upon me that nurse-
*Washington D.C. Project Director, NACC Foundation; Adjunct Professor, School of Nursing, Georgetown University, Washington, DC; and Adjunct Professor,Department of Nursing, New YorkUniverity,New York,NY. Address correspondenceand reprint requests to Dr Lubic: 1425 4th St SW, Apt A805, Washington,DC 20024. Copyright © 1999 by W.B. SaundersCompany 8755-7223/99/1501-0006510.00/0
JournalofProfessionalNursing,
midwifery was the logical response to the needs of the young child in rural America... Work for children should begin before they are born, should carry them through . . . childbirth, and should be most intensive during their first six years of life. These are the formative years whether for their bodies, their minds or their loving hearts (Breckinridge, 1952, p. 111). Things have not really changed, have they? Now for the "genius" story--the "winning the lottery without buying a ticket," as I and others have characterized it. On a warm June evening in 1993, my husband and I returned home at about 9 PM after a dinner out. A recorded voice mail message caused me to call out to him to come and listen. A women's voice identified the caller as being with the MacArthur Foundation in Chicago. Her message, which had been left in late morning, was that it was important that I call back as soon as possible. "Has lightening struck?" we wondered aloud. "No, probably my opinion of some candidate for a Fellows Award was being sought," I suggested. But because I wanted to appear responsive, even though it was past business hours, I decided to return the call immediately. To my surprise, a "real person" answered the phone. She seemed to know that I had been called, but she would tell me no more than I should call back early in the morning. She did giggle a lot, so much so that I said to her, "The name of your organization has a certain healthy ring to it." At that she giggled even more. So I said I would call back in the morning and hung up. About an hour later, the phone rang. This time it was Margaret Mahoney, at the time the president of the Commonwealth Fund, who is also on the Board of the MacArthur Foundation. She in fact gave me the good news, but none of the details, which I got the next morning--a substantial fellowship was to be sent to me in quarterly checks
Vol 15, No 1 (January-February), 1999: pp 7-14
7
8
RUTH WATSON LUBIC
over a period of 5 years. I was to receive the highest stipend because of my age, which was advanced at the time and is even further advanced now that I am in the final year of my award! But a question to foundation staff, "Can you tell me who nominated me?" brought the response, "I can, but I won't." Since then I have heard from colleagues, one of whom is Claire Fagin, PhD, RN, who had been asked for references to be held in strictest confidence and especially kept from m e - - n o t an easy task, Claire told me after the fact! The stipend is subject to taxes as are the premiums of health insurance, which also are provided. It is made clear to the recipient that no reporting on the use of the stipend is required and that the award is personal and in no way connected to one's place of employment. All correspondance is sent to one's home. In fact, I was told I could put a new roof on the house or take a trip around the world if that appealed to me. An article, "Winning the Genius Lottery," in the October/November 1997 issue of Civilization, the magazine of the Library of Congress, has this to say: Now in their 17th year, the annual fellowships from the John D. and Catherine T. MacArthur Foundation are famous for their uncommon approach to philanthropy and are famous, as well, simply for being famous... The press has also pounced on the idea that a phone call from the MacArthur Foundation amounts to an anointment of genius (an idea that makes foundation officers, and many recipients, break out in hives)... You can't apply for a MacArthur Fellowship-you have to be chosen, in an almost Biblical sense, by a host of anonymous scouts... What the MacArthur Foundation will reveal is only the mechanics: that it hires between 100 and 125 nominators each year to ferret out new and deserving candidates; that nominators hail from a wide variety of regions and disciplines; that they must submit their recommendations to a 12-member selection committee; and that the selection committee, after calling the friends and enemies of candidates who intrigue them, narrows down the field of 300 or so to a much smaller group of winners (Senior, 1997, pp. 42, 46). Usually 25-30 fellows are selected. Some recipients have found the award to be a problem. One early awardee lost a science fellowship, he believes, because of envy among his peers. Jennifer Senior (1997), who wrote the article in Civilization, concludes that It's a giddily optimistic approach to fostering talent, built on the assumption that a great brick of cash given
directly to creative individuals will ultimately enrich the marketplace of ideas and pay perceptible public dividends. And implicit in that assumption is another: that money actually helps creative people, rather than terrifying, corrupting or spoiling them--or having no effect on them at all (p. 44). It is appropriate for me to say that although I have been the first nurse to receive a MacArthur Fellowship, as I gaze out at all the remarkable and creative talent before me, I'm sure that I won't be the last! My reaction to my great good fortune was an overwhelming sense of excitement that finally I would be able to address some problems that had long been on my professional conscience and to try to make inroads into their sources and solutions. Primary among those problems was and is the infant mortality rates in our nation among our disadvantaged populations, such as African-Americans, American Indians, and other low-income groups. The award came at the right time for me. I had had the extraordinary experience of setting up a family-centered, out-ofhospital maternity unit in the Southwest Bronx. Not only had it been successful in health care delivery terms, it also had revealed to me the enormous human resources in inner cities. I learned that there are many strong families living in low-income neighborhoods and that they too, as do you and I, want to improve their lives and their neighborhoods. Midwifery had taught me that there is no better time to assist and facilitate those families in their task than when they are bearing children.
My r e a c t i o n . . , was an overwhelming sense of excitement that finally I would be able to address some problems...
Nowhere in the country are the poor infant outcomes worse than in the nation's capital! In 1994, the last year for which there are final data, the United States of America, with an infant mortality rate of 8.0/1,000 live births, stood a discouraging 22nd among the nations of the world in terms of the survival of its children up to the first year of life. Japan led the nations with a rate of 4.2/1,000. Even more startling is the fact that the District of Columbia (DC), with a 1995 provisional rate of 16.1 (down from 18.2 in 1994), had a rate that exceeded that of 20 countries, including Cuba, Jamaica, Costa Rica, and
LIFE ON THE "GENIUS" TRACK
Kuwait as well as several of the Newly Independent States of the former Soviet Union (Wegman, 1996). The rate in DC's Ward 5 is 29.3/1,000, exceeding even those of Thailand and Mexico. In 1993, Ward 5's rate had increased by 53.4 per cent to 25/1,000. In 1994, it decreased to 20.2 but rebounded to the shocking 29.3/1,000 in 1995 (State Center of Health Statistics, 1996). In these years, the conventional system, which tends not to recognize or perhaps just not feel responsible for the social factors involved, had not been able to substantially change this deplorable situation. As a nurse-midwife who is commited to the idea that my profession is based in public health as well as clinical concepts, this situation seemed one I must address to the extent I was able, and suddenly I was !
And so I decided to engage my friends at the Division of Nursing to get their reactions. Maria Salmon, PhD, RN, director, brought her substantial talents to bear and offered me a role in her bailiwick at the Health Resources and Services Administration (HRSA). She also suggested that I speak to my good friend, Dr Philip Lee, who had recently reassumed the Office of the Assistant Secretary for Health, a position he had initiated in Lyndon Johnson's administration. He in turn offered me an office in the Humphrey Building (where I reigned happily for 2 years from August 1995 through July 1997), and he gave me the opportunity to provide consultation and assistance to the staffs of not only HRSA but also the many offices and bureaus over which he had oversight, including the Indian Health Service and the Office of International and Refugee Health. Dr Lee had been a supporter of freestanding birth centers from the outset. In fact, he dedicated the pioneering Childbearing Center on East 92nd Street in Manhattan in fall 1975, shortly after its opening. He also served on the first board of the National Association of Childbearing Centers when it was established in 1985. Although my work was pro bono, I was considered to be an employee, part time, of the federal government until this past July. By that time it had become apparent that I would need to engage in fund-raising for a project that I will soon describe, and fund-raising is a "no-no" for federal employees, even elected ones! At that point, another of my nursing colleagues, Elaine Larson, PhD, RN, dean of the School of Nursing, rescued me from "homelessness" and provided me with an adjunct professorship at prestigious Georgetown. Meanwhile, the nurses and nurse-midwives of the District at all levels coalesced and networked to
9
provide opportunities for the development of a demonstration solution to the problem at hand. Through Irene Sandvold, DPH, CNM, at the Division of Nursing, I met Irene Forsman, MS, RN, of the Maternal and Child Health Bureau, who was on loan to the DC Commission on Public Health. She in turn introduced me to Pat Tompkins, RN, chief/MCH director, Office of Maternal and Child Health, D.C. Commission of Public Health. She suggested that the demonstration I proposed based on my knowledge and experience be placed in Wards 5 and 6 of the District which, compared with Wards 7 and 8, where Healthy Start was operating, were in just as great need but were much less assisted. I also was referred to Dolores Farr, MPH, RN, who operates the Healthy Babies Project, an outreach and drop-in center for pregnant women who are abused or who themselves are substance abusing. On hearing the plan, she joined the effort and has been as extraordinary a partner as one could possibly wish. With the help of the Healthy Babies staff, we have been meeting with community groups at all levels, a very labor-intensive endeavor (no pun intended!). I have been very impressed by the commitment of DC citizens to improve matters. The sad truth is that, based on their experience, few feel something really can happen. I tell them not to worry. It took us 10 years to do a similar, although not as expansive, service in the Southwest Bronx and now, at just 3~ years of effort, one could say we are moving at dizzying speed! And remember, the heart and soul of midwifery is patience! What is the plan? The plan is to establish a community-based, nurse, nurse-midwife, and nurse practitioner-operated; homelike, personalized, comprehensive maternal and child care service that can improve outcomes and at the same time motivate mobilization for social change on the part of the families using the service, such as occured in the Bronx. That empowerment is graphically depicted in the Maternity Center Association's (MCA) video, produced during my tenure there, entitled "Hope Reborn: Empowering Families in the South Bronx" (MCA, 1993). Many of you may find this film a valuable teaching tool for tumbling negative stereotypes held about low-income families. Working with a group of interested colleagues called the Friends of the DCBC (District of Columbia Birth Center), the name of the demonstration evolved to become The District of Columbia Developing Families Center (DCDFC). The sponsors are the National Association of Childbearing Centers Founda-
l0
RUTH WATSON LUBIC
tion/MCA. The Healthy Babies Project and the National Child Day Care Association--the latter of which, under the guidance ofTravis Hardmon, MPA, operates 17 day care centers in low-income areas of the District--have signed on as collaborating agencies. The George Washington Center for Health Policy Research, through Mary Haack, PhD, RN, and Judith Larson, JD, will provide legal assistance to families while they develop a screening tool to determine which women and families can benefit from out-ofcourt resolution to problems of child abuse and neglect where substance abuse is involved. Their plan then is to educate the justice system and the bar concerning the downside of commiting substanceabusing pregnant women to jail and their children to foster care. As noted, services will be conducted by nurses, nurse-midwives, and nurse practitioners with medical consultation and hospital back-up services from Howard University. Many thanks to Dorothy Powell, PhD, RN, dean of the School of Nursing, who put together for us a meeting with all the stakeholders there. Services are to be seamless, and if all goes well, they will be placed in an empty supermarket building in Ward 5. Having received a Certificate of Need exemption and assurance of Medicaid reimbursement as a result of the pro bono assistance of two major law firms--Fried, Frank, Harris, Shriver and Jacobson and Dewey Ballantine--we are now working on a business plan to meet the request of the building's owner for assurance that success is "in the stars" and hopefully to obtain the building on favorable terms. In addition to my own contributions of time and the MacArthur stipend to work on the project, we have received a planning grant from the Robert Wood Johnson Foundation and are hopeful that they will respond to a request for further support. Other contributions have come voluntarily from private citizens, including Justice Ruth Bader Ginsburg, and a small DC-based foundation, the Rapidan. In sum, the services will include the following: 1. well-woman and preconceptional care; 2. counseling on matters of women's reproductive health, including sexually transmitted infections; 3. full-scope maternity services with linkage to the hospital system, including (a) pregnancy testing; (b) prenatal care and education for all women who seek care; (c) labor and birth in the setting appropriate to individual
women; (d) infant feeding and care education; (e) postnatal care, including at least one home visit and two returns to the center within 6 weeks; (f) postnatal education, including breast-feeding support from peers and staff available 24 hours a day, 7 days a week; and (g) interconceptional care; 4. well-child care; 5. drop-in services for abused and substanceabusing women; 6. legal counsel and assistance on site; 7. Early Head Start (0 to 3 years); 8. Head Start (3 to 5 years); 9. after-school programs for grade schoolers; and 10. job training for women. For all the above, the three collaborating agencies will operate in the same newly renovated building, sharing services where appropriate and supporting each others programs. The fact that the costs of birth center services are 30 per cent to 60 per cent less than the charges for in-hospital normal childbirth should serve us well!
•.. the midwife came from the birthroom. . . exclaiming, "'Russian women must have this/"
I would like to tell you of two more examples of the opportunities offered to me by my good fortune. Recall that through the Office of the Assistant Secretary for Health I was able to consult with other federal agencies, such as the Office of International Health and the Indian Health Service. Through the auspices of Connie Vance, EdD, RN, dean of the School of Nursing at the College of New Rochelle, I had been introduced to a remarkable Russian nurse-midwife. Dr Vance, in seeking educational opportunities for this young woman while she was in the United States at the College of New Rochelle for a semester, asked in 1994 if she might observe at the Childbearing Center in Manhattan. I was delighted to afford this opportunity but hadn't fully foreseen the impression birth center care would make. After she had observed her first birth in the center, the midwife came from the birthroom with tears streaming down her face exclaiming, "Russian women must have this!" My stipend
LIFE ON THE "GENIUS" TRACK
enabled me to join Dr Vance's next study tour of Russia and to evaluate whether in fact Russia was ready for its women "to have this." Indeed, I thought things were not in readiness, and so I advised the midwife to begin education in women's health to develop a cadre of consumer supporters. In the interim, a relationship with the federal Office of International and Refugee Health was established, and staff were informed of the midwife's work. This summer past, I returned to St. Petersburg, the midwife's home, and there saw the progress she had made through offering those educational sessions. The prenatal education she gave motivated the families to enable her to accompany them into the birth house, a heretofore unheard-of event. And now, with the assistance Dr Vance has been able to provide through the sale of Russian brooches, she is able to provide family-centered experiences for Russian families. Many thanks are owed to Dr Vance for her vision. The other remarkable experience has come about through consulting with the Indian Health Service and its Hospital's Tribal Health Coordinator at Sisseton, SD. The Sisseton-kYchhpeton Sioux Tribe there is working to develop a nurse-midwifery service and birth center as a result of seeing the video of which I spoke earlier. I showed them the film with some trepidation and uncertainty as to its cultural appropriateness in as much as it depicts the inner-city life of African American and Latino families. They watched it in silence, and when it concluded, I let all the trailer run out before asking, "Well?" With that, an 80-yearold nurse, who had been prepared at the Pennsylvania Hospital School of Nursing in the 1930'S and who is still active in her profession, struck the table with her fist and said with authority, "If they can do it, we can do it!" People everywhere resonate to the empowerment theme and want it for themselves! Now that you have seen how nurses and nursemidwives can work together to the mutual benefit of families living in disadvantaged areas, let me seek your interest and help with easing what to me is a pressing problem, often called the "epidural epidemic." In my estimation, the empowerment we witnessed in the Bronx came about as a result of partnering with the expectant mother along the continuum of prenatal and birth care. At prenatal visits, each woman had, and will have at the DCBC, complete access to her own record. With her nurse-midwife caregiver, she develops her own birth plan. She weighs herself, tests her own urine, and records the results. One mother expressed that she "was treated like an intelligent human being and felt that I was taking care of my own
11
pregnancy" (MCA, 1993). Is this not, after all, what we wish all our childbearing citizens would do? Do we not want them to take charge of their own health? In my opinion, we will never solve the enormous health care problems we have until people themselves take charge of their health. The secret is that there is no better time to encourage that "taking charge" than in the maternity cycle. As another one of the Bronx participants said, When you give birth, (as opposed to being delivered) you feel that you have given life. And if you can give life, then you can do anything; you can get a job and you can go to school, and you can do anything you want as long as you put your mind to it. That's the best thing about the birth center, it empowers women, and in turn they empower their families, which empowers the community and it just grows and grows (MCA, 1993). This from a 19-year-old African American woman! Partnering with women is an essential part of realizing this effect. Let me turn now to the epidural epidemic and its effects on empowerment. Morton et al. (1994), in a meta-analysis of six randomized clinical trials of the influence ofepidural on labor, concluded that epidural analgesia may increase the cesarean birth rate by 9 per cent. In a meeting of maternity care professionals-including obstetricians, family practitioners, anesthesiologists, nurses, nurse-midwives, childbirth educators, and consumers--convened by the National Association of Childbearing Centers Foundation on the topic early in 1997, it was readily agreed that, based on available evidence, epidural anesthesia does increase cesarean section rates. And women who deliver surgically, even though they are participating, are certainly not in charge! But another untoward outcome has come to light--the effect on the infant. Dr Ellice Lieberman presented her evidence regarding "Epidural Analgesia, Intrapartum Fever, and Neonatal Sepsis Evaluation" in an article that appeared in Pediatrics (Lieberman et al., 1997). Her findings include the fact that some 14 per cent of laboring women who choose epidural analgesia will run a fever of 100.4°F or higher in contrast to just 1 per cent of women not having epidural. This means that the neonate will be subjected to a sepsis work-up, often including a spinal tap and treatment with antibiotics. Figure 1 is from Dr Lieberman's (1997) article and is used with her permission and encouragement. She is well aware that nurses have it in their power to make a
12
RUTH WATSON LUBIC
The comparison is instructional not only according to length of labor but also according to the utilization of epidural, which, according to Hawkins, Gibbs, Orleans, Martin-Salvaj, and Beaty (1997), had increased 100 per cent between 1981 and 1992. Table 1 depicts the number of neonates treated with antibiotics according to epidural use. Lieberman explains in her text that
100 " 90" 80" 70" 60"
*
Epidural
-,=- No Epidural
50" 40" 30" 20" 10" 0
<=6 h
6-12 h
12-18 h
>18 h
Length of Labor
Figure 1. Percent of women with fever > 100.4°F according to length of labor and epidural use. (Reproduced with permission from PEDIATRICS, Vol 99 #3, Pages 416-417, 1997.) difference in epidural use. One wonders whether if women were told that epidural use increases 14-fold the chances of their newborn child having a spinal tap, their selection might be more measured. And it is up to us to let them in on this secret! I say "secret" because of a full-page advertisement from The Charlotte Observer Special Marketing Supplement, which I received recently. It is entitled " 'Walking Epidural' Eases Labor" and concludes with an invitation to women to sign up for epidural classes at a local hospital (Welling, 1997). Nowhere in the article are listed the downsides of epidural in labor, and this is my point. I do not argue the right to choose an epidural. I do insist that women must be given full information before making a choice. But let us return to the evidence. Lieberman explains her graph (Fig 1) entitled, "Percent of Women With Fever > 100.4F According to Length of Labor and Epidural Use," as follows: The rate of fever in the no-epidural group, 1% overall, remained low, regardless of the length of labor. The rate of fever in the group of women who received an epidural was consistently higher than the rate in the group of women who did not receive an epidural, regardless of the length of labor. For women who received an epidural, the rate of fever increased with longer labors, from 7% for women with the shortest labors (< than 6 hours) to 36% for women with the longest labors (>18 hours). Greater than 40% of women receiving an epidural had labors lasting at least 12 hours, putting them at high risk for intrapartum fever (p. 416).
Even in the absence of maternal fever > 100.4F, sepsis evaluations were performed at a higher rate in the epidural group. The rate in the epidural group was 25.1% compared with 9.1% in the no-epidural group . . . infants of women who had received an epidural remained more than three times as likely to be evaluated for the presence of sepsis (Lieberman et al., 1997, p. 417). O f great interest is the number who actually had documented sepsis. As you can see from the table, it is exceedingly small. Figure 2 depicts the percentage of neonates of afebrile women who received sepsis workups according to length of labor and epidural use. Here the higher incidence of sepsis evaluation in women with epidurals but without fever is apparent in labors longer than 18 hours. Lieberman states, "However, longer length of labor did not entirely account for the higher rate of sepsis evaluations, because these infants were more likely to have a sepsis work-up regardless of length of labor (Lieberman et al., p. 417). The population for Lieberman's study was the 1,934 nulliparous women enrolled in the active management of labor trial conducted at Brigham and Women's Hospital in Boston from May 1990 through October 1994. I eagerly encourage you to foster an understanding TABLE 1. Number of Neonates Treated With Antibiotics According to Epidural Use
Sepsis evaluation Any antibiotic treatment Antibiotics for ->3 days Documented sepsis
No. (%) Epidural (n = 1047)
No. (%) No Epidural (n = 610)
356 (34.0)
60 (9.8)
4.3 (3.2, 5.9)*
161 (15.4)
23 (3.8)
3.9 (2.4, 6.1)*
17 (1.6) 3 (0.3)
3 (0.5) 1 (0.2)
Odds Ratio (95% Cl)
3.3 (1.0, 17.9)t 1.7 (0.1,92.0)1-
Abbreviation: Cl, confidence interval. *Odds ratio from multiple logistic regression adjusting for birth weight, gestational age, induction, premature rupture of the membranes, and treatment with active management of labor. -j-Exact confidence limits; no adjustment in multiple logistic regression because of small number of cases. Reproduced with permission from PEDIATRICS, Vol 99 #3, Pages 416-417, 1997.
13
LIFE ON THE "GENIUS" TRACK
1°° I i" 80 70
•~
(n
60
•
50
~
40
• Epidural - o - No Epidural
30
9~
20
a.
10 0 <=6 h
f
6-12 h
I
12-18 h
I
>18 h
Length of Labor
Figure 2. Performance of sepsis evaluations among neonates of afebrile women according to length of labor and epidural use. (Reproduced with permission from PEDIATRICS, Vo199 #3, Pages 416-417, 1997.) in your educational and service staffs that if laboring women are tempted with offers of epidural analgesia and/or cesarean section, nurses become not only a powerful voice in their ability to decrease cesarean section and infant morbidity, but, more importantly, they can foster empowerment through fully informing women and encouraging their choice. But do nurses really have important influence on the laboring women under their care? In an article entitled "Nurses Care During Labor: Its Effect on the Cesarean Birth Rate of Healthy Nulliparous Women," Radin, Harmon, and Hanson (1993, p. 14) stated: "The study suggests that nurses' care during labor is an important factor influencing cesarean birth rates." In another article by the same nurse researchers, "Cesarean Birth Rates: Identification of Nurses With Low or High Rates," the low- and high-rate groups were described as follows: "The low C/B rate nurses were described as maternally focused, valuing vaginal birth, confident of their ability to assist the mother to birth vaginally and with a 'large bag of tricks' to assist labor" (Radin, 1995 (p. 28). On the other hand, nurses with a high rate of patients who had C/B were described as " . . . focused on the fetus, believing that nurses have no influence on birth route and that any birth route is fine as long as the infant is healthy, and focused on the technology" (Radin, 1995, p. 28). I offer an anecdote I recently heard from a family practitioner operating a birth center in Tennessee. A mother who was transferred to hospital care for labor as a precautionary measure reported that, even though she did not want epidural, she was offered such
analgesia 17 times during her labor! And from students enrolled in the Community Based NurseMidwifery Educational Program came the information that maternity nurses, not the mother's practitioner of record, were being expected to secure the mother's permission for epidural administration. Nurses need to be sure that such activity is appropriate to their practice and that the mothers are given all possible information about the positive and negative effects of the procedure. Recently, a brochure advertising meetings on "Safely Reducing Cesarean Rates" (Cambridge Health Resources, 1997) came to my desk. It discussed not only the increase in rates over the last 12 years and all that means to women, it also discussed national spending on the procedure--from $1.9 billion in 1980 to $7.2 billion in 1992. We should explain to administrators how much more effective it would be to invest in nursing care in sufficient amount so that each mother would be assured of support by a knowledgable person during her labor. While we are waiting for that day of enlightenment, I urge you to urge the nurses and nurse-midwives in your setting to join together in strengthening and empowering families through providing both full information and labor support that encourages them. In her comprehensive and groundbreaking new book, Midu,ifery and Childbirth in America Judith Rooks (1997, p. 310) cites a study undertaken in a hospital in Montreal in 1994, by Gagnon and Waghorn, as reporting that nurses " . . . spent no more than a fourth of their work time with patients and less than 10% of their time providing support to women in labor." In settings where epidural is extensively used, however, nurses spend much of their time dealing with the accoutrements of technology, such as intravenous infusions, catheterization, electronic fetal monitoring, and oxytocin: "The nurses who conducted these studies believe that the technical expertise is more valued by the people with the most status in hospitals, and that the need for technical care results in the deemphasis and devaluing of the supportive care needed by women in labor" (Rooks, 1997, p. 310). Together we must address this issue for the benefit of all women, especially for those whose lives do not offer many opportunities for them to be involved in their own health care. We must partner with each other and with the women we serve. While, in my opinion, those of us who provide the personalized care made possible by freestanding birth centers can most
14
RUTH WATSON LUBIC
easily empower families, most babies will be born-in hospital for decades yet to come, and nurses, with or without midwifery, offer the major hope that their mothers will have the opportunity to "give birth" rather than "be delivered." You can see that my life has been enriched by the opportunities the MacArthur Fellowship has given me. Lest you think my professional life has been a "bowl of cherries," I would like to close by sharing with you a list of principles for a successful professional life (Lubic, 1995), which I have assembled over the years based on the controversy surrounding my practice, in the hope that you will find them meaningful in your own life.
Begin with the needs of the people you serve. Take care of all the people of the nation. Trust your caring instincts. Learn to tolerate uncertainty. Choose your professional colleagues for their caring philosophy rather than their professional preparation. Be aware that the medical model has failed to serve all the people of the nation. Avoid anger; it consumes energy and clouds vision. Avoid bitterness against political opponents. Value the giving and receiving of truth. Base a design for change on the best science possible, then test your performance. Overcome the fear associated with leadership. Remember, the people you serve are your strength. Listen to them! You will be rewarded.
References
Breckinridge, M. (1952). Wide neighborhoods (p. 111). Lexington, KY: University of Kentucky Press. Cambridge Health Resources. (1997). Safely reducing cesarean rates [Brochure]. Gagnon, A., & X~7aghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth, 23, 1-6. Hawkins, J., Gibbs, C., Orleans, M., Martin-Salvaj, G., & Beaty, B. (1997). Obstetric analgesia work force survey, 1981 versus 1992. Anesthesiology, 87, 135-143. Lieberman E., Lang, J. M., Frigoletto, Jr., E, Richardson, D. K., Ringer, S., & Cohen, A. (1997). Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics, 99(3), 415-419. Lubic, R. (1995). Principles for a successfulprofessional l~. [Poster]. New York: Maternity Center Association. Maternity Center Association. (1993). Hope reborn: Empowering families in the South Bronx [Video; available from MCA, 281 Park Avenue South, New York, NY 100101. Morton, S. C., Williams, M. S., Keeler, E. B., Gambone, J. C., & Dahn, K. L. (1994). Effect ofepidural analgesia for
labor on cesarean delivery rate. Obstetrics and Gynecology, 83, 1045-1052. Radin, T. (1995). Cesarean birth rates: identification of nurses with low or high rates (p. 28). Unpublished manuscript. Radin, T., Harmon, J., & Hanson, D. (1993). Nurses' care during labor: Its effect on the cesarean birth rate of healthy nulliparous women. Birth 20(1), 14-21. Rooks, J. (1997). Midwifery and childbirth in America. Philadelphia: Temple University Press. Senior, J. (1997). Winning the genius lottery. Civilization, 4(5), 42, 46. State Center of Health Statistics, Commission of Public Health, DC Department of Human Services. (1996). Briefing paper on the 1995 infant mortality rate for the District of Columbia. Washington, DC: Author. Wegman, M. (1996). Some international comparisons of infant mortality. Pediatrics, 98(6), 1020-1027. Welling, L. (1997, August-September). Walking epidural eases labor. The Charlotte Observer, Special Marketing Supplement, Medical Center News, p. 9.
This article is based on the John P. McGovern Award Lecture presented at the American Association of Colleges of Nursing's semiannual meeting on October 26, 199Z BOVE ALL ELSE, I want each and all of you to understand how grateful I am to be with you to discuss the opportunities and great good fortune that have befallen me in my career as a nurse and as a nurse-midwife. I am especially happy because of the tensions that are at times found in relationships between nurses and nurse-midwives--tensions that for the sake of childbearing families are a luxury we can't afford and should repair. As to my own professional preparation, I have never seen these two aspects as mutually exclusive, although some do, and I regret their position. My view is that nursing made me a better midwife, and midwifery makes me a better nurse. But to what end? Not my career satisfaction, surely, but to the end of applying whatever knowledge and skill I have to the betterment of families, especially those who have been and are disadvantaged in and by our society. Mary Breckinridge, founder in 1925 of the Frontier Nursing Service, put it this way after her World War I experiences in Europe: In France midwives were not nurses. In America nurses were not midwives. In England trained women were both nurses and midwives. After I had met British nurse-midwives, first in France and then on my visits to London, it grew upon me that nurse-
*Washington D.C. Project Director, NACC Foundation; Adjunct Professor, School of Nursing, Georgetown University, Washington, DC; and Adjunct Professor,Department of Nursing, New YorkUniverity,New York,NY. Address correspondenceand reprint requests to Dr Lubic: 1425 4th St SW, Apt A805, Washington,DC 20024. Copyright © 1999 by W.B. SaundersCompany 8755-7223/99/1501-0006510.00/0
JournalofProfessionalNursing,
midwifery was the logical response to the needs of the young child in rural America... Work for children should begin before they are born, should carry them through . . . childbirth, and should be most intensive during their first six years of life. These are the formative years whether for their bodies, their minds or their loving hearts (Breckinridge, 1952, p. 111). Things have not really changed, have they? Now for the "genius" story--the "winning the lottery without buying a ticket," as I and others have characterized it. On a warm June evening in 1993, my husband and I returned home at about 9 PM after a dinner out. A recorded voice mail message caused me to call out to him to come and listen. A women's voice identified the caller as being with the MacArthur Foundation in Chicago. Her message, which had been left in late morning, was that it was important that I call back as soon as possible. "Has lightening struck?" we wondered aloud. "No, probably my opinion of some candidate for a Fellows Award was being sought," I suggested. But because I wanted to appear responsive, even though it was past business hours, I decided to return the call immediately. To my surprise, a "real person" answered the phone. She seemed to know that I had been called, but she would tell me no more than I should call back early in the morning. She did giggle a lot, so much so that I said to her, "The name of your organization has a certain healthy ring to it." At that she giggled even more. So I said I would call back in the morning and hung up. About an hour later, the phone rang. This time it was Margaret Mahoney, at the time the president of the Commonwealth Fund, who is also on the Board of the MacArthur Foundation. She in fact gave me the good news, but none of the details, which I got the next morning--a substantial fellowship was to be sent to me in quarterly checks
Vol 15, No 1 (January-February), 1999: pp 7-14
7
8
RUTH WATSON LUBIC
over a period of 5 years. I was to receive the highest stipend because of my age, which was advanced at the time and is even further advanced now that I am in the final year of my award! But a question to foundation staff, "Can you tell me who nominated me?" brought the response, "I can, but I won't." Since then I have heard from colleagues, one of whom is Claire Fagin, PhD, RN, who had been asked for references to be held in strictest confidence and especially kept from m e - - n o t an easy task, Claire told me after the fact! The stipend is subject to taxes as are the premiums of health insurance, which also are provided. It is made clear to the recipient that no reporting on the use of the stipend is required and that the award is personal and in no way connected to one's place of employment. All correspondance is sent to one's home. In fact, I was told I could put a new roof on the house or take a trip around the world if that appealed to me. An article, "Winning the Genius Lottery," in the October/November 1997 issue of Civilization, the magazine of the Library of Congress, has this to say: Now in their 17th year, the annual fellowships from the John D. and Catherine T. MacArthur Foundation are famous for their uncommon approach to philanthropy and are famous, as well, simply for being famous... The press has also pounced on the idea that a phone call from the MacArthur Foundation amounts to an anointment of genius (an idea that makes foundation officers, and many recipients, break out in hives)... You can't apply for a MacArthur Fellowship-you have to be chosen, in an almost Biblical sense, by a host of anonymous scouts... What the MacArthur Foundation will reveal is only the mechanics: that it hires between 100 and 125 nominators each year to ferret out new and deserving candidates; that nominators hail from a wide variety of regions and disciplines; that they must submit their recommendations to a 12-member selection committee; and that the selection committee, after calling the friends and enemies of candidates who intrigue them, narrows down the field of 300 or so to a much smaller group of winners (Senior, 1997, pp. 42, 46). Usually 25-30 fellows are selected. Some recipients have found the award to be a problem. One early awardee lost a science fellowship, he believes, because of envy among his peers. Jennifer Senior (1997), who wrote the article in Civilization, concludes that It's a giddily optimistic approach to fostering talent, built on the assumption that a great brick of cash given
directly to creative individuals will ultimately enrich the marketplace of ideas and pay perceptible public dividends. And implicit in that assumption is another: that money actually helps creative people, rather than terrifying, corrupting or spoiling them--or having no effect on them at all (p. 44). It is appropriate for me to say that although I have been the first nurse to receive a MacArthur Fellowship, as I gaze out at all the remarkable and creative talent before me, I'm sure that I won't be the last! My reaction to my great good fortune was an overwhelming sense of excitement that finally I would be able to address some problems that had long been on my professional conscience and to try to make inroads into their sources and solutions. Primary among those problems was and is the infant mortality rates in our nation among our disadvantaged populations, such as African-Americans, American Indians, and other low-income groups. The award came at the right time for me. I had had the extraordinary experience of setting up a family-centered, out-ofhospital maternity unit in the Southwest Bronx. Not only had it been successful in health care delivery terms, it also had revealed to me the enormous human resources in inner cities. I learned that there are many strong families living in low-income neighborhoods and that they too, as do you and I, want to improve their lives and their neighborhoods. Midwifery had taught me that there is no better time to assist and facilitate those families in their task than when they are bearing children.
My r e a c t i o n . . , was an overwhelming sense of excitement that finally I would be able to address some problems...
Nowhere in the country are the poor infant outcomes worse than in the nation's capital! In 1994, the last year for which there are final data, the United States of America, with an infant mortality rate of 8.0/1,000 live births, stood a discouraging 22nd among the nations of the world in terms of the survival of its children up to the first year of life. Japan led the nations with a rate of 4.2/1,000. Even more startling is the fact that the District of Columbia (DC), with a 1995 provisional rate of 16.1 (down from 18.2 in 1994), had a rate that exceeded that of 20 countries, including Cuba, Jamaica, Costa Rica, and
LIFE ON THE "GENIUS" TRACK
Kuwait as well as several of the Newly Independent States of the former Soviet Union (Wegman, 1996). The rate in DC's Ward 5 is 29.3/1,000, exceeding even those of Thailand and Mexico. In 1993, Ward 5's rate had increased by 53.4 per cent to 25/1,000. In 1994, it decreased to 20.2 but rebounded to the shocking 29.3/1,000 in 1995 (State Center of Health Statistics, 1996). In these years, the conventional system, which tends not to recognize or perhaps just not feel responsible for the social factors involved, had not been able to substantially change this deplorable situation. As a nurse-midwife who is commited to the idea that my profession is based in public health as well as clinical concepts, this situation seemed one I must address to the extent I was able, and suddenly I was !
And so I decided to engage my friends at the Division of Nursing to get their reactions. Maria Salmon, PhD, RN, director, brought her substantial talents to bear and offered me a role in her bailiwick at the Health Resources and Services Administration (HRSA). She also suggested that I speak to my good friend, Dr Philip Lee, who had recently reassumed the Office of the Assistant Secretary for Health, a position he had initiated in Lyndon Johnson's administration. He in turn offered me an office in the Humphrey Building (where I reigned happily for 2 years from August 1995 through July 1997), and he gave me the opportunity to provide consultation and assistance to the staffs of not only HRSA but also the many offices and bureaus over which he had oversight, including the Indian Health Service and the Office of International and Refugee Health. Dr Lee had been a supporter of freestanding birth centers from the outset. In fact, he dedicated the pioneering Childbearing Center on East 92nd Street in Manhattan in fall 1975, shortly after its opening. He also served on the first board of the National Association of Childbearing Centers when it was established in 1985. Although my work was pro bono, I was considered to be an employee, part time, of the federal government until this past July. By that time it had become apparent that I would need to engage in fund-raising for a project that I will soon describe, and fund-raising is a "no-no" for federal employees, even elected ones! At that point, another of my nursing colleagues, Elaine Larson, PhD, RN, dean of the School of Nursing, rescued me from "homelessness" and provided me with an adjunct professorship at prestigious Georgetown. Meanwhile, the nurses and nurse-midwives of the District at all levels coalesced and networked to
9
provide opportunities for the development of a demonstration solution to the problem at hand. Through Irene Sandvold, DPH, CNM, at the Division of Nursing, I met Irene Forsman, MS, RN, of the Maternal and Child Health Bureau, who was on loan to the DC Commission on Public Health. She in turn introduced me to Pat Tompkins, RN, chief/MCH director, Office of Maternal and Child Health, D.C. Commission of Public Health. She suggested that the demonstration I proposed based on my knowledge and experience be placed in Wards 5 and 6 of the District which, compared with Wards 7 and 8, where Healthy Start was operating, were in just as great need but were much less assisted. I also was referred to Dolores Farr, MPH, RN, who operates the Healthy Babies Project, an outreach and drop-in center for pregnant women who are abused or who themselves are substance abusing. On hearing the plan, she joined the effort and has been as extraordinary a partner as one could possibly wish. With the help of the Healthy Babies staff, we have been meeting with community groups at all levels, a very labor-intensive endeavor (no pun intended!). I have been very impressed by the commitment of DC citizens to improve matters. The sad truth is that, based on their experience, few feel something really can happen. I tell them not to worry. It took us 10 years to do a similar, although not as expansive, service in the Southwest Bronx and now, at just 3~ years of effort, one could say we are moving at dizzying speed! And remember, the heart and soul of midwifery is patience! What is the plan? The plan is to establish a community-based, nurse, nurse-midwife, and nurse practitioner-operated; homelike, personalized, comprehensive maternal and child care service that can improve outcomes and at the same time motivate mobilization for social change on the part of the families using the service, such as occured in the Bronx. That empowerment is graphically depicted in the Maternity Center Association's (MCA) video, produced during my tenure there, entitled "Hope Reborn: Empowering Families in the South Bronx" (MCA, 1993). Many of you may find this film a valuable teaching tool for tumbling negative stereotypes held about low-income families. Working with a group of interested colleagues called the Friends of the DCBC (District of Columbia Birth Center), the name of the demonstration evolved to become The District of Columbia Developing Families Center (DCDFC). The sponsors are the National Association of Childbearing Centers Founda-
l0
RUTH WATSON LUBIC
tion/MCA. The Healthy Babies Project and the National Child Day Care Association--the latter of which, under the guidance ofTravis Hardmon, MPA, operates 17 day care centers in low-income areas of the District--have signed on as collaborating agencies. The George Washington Center for Health Policy Research, through Mary Haack, PhD, RN, and Judith Larson, JD, will provide legal assistance to families while they develop a screening tool to determine which women and families can benefit from out-ofcourt resolution to problems of child abuse and neglect where substance abuse is involved. Their plan then is to educate the justice system and the bar concerning the downside of commiting substanceabusing pregnant women to jail and their children to foster care. As noted, services will be conducted by nurses, nurse-midwives, and nurse practitioners with medical consultation and hospital back-up services from Howard University. Many thanks to Dorothy Powell, PhD, RN, dean of the School of Nursing, who put together for us a meeting with all the stakeholders there. Services are to be seamless, and if all goes well, they will be placed in an empty supermarket building in Ward 5. Having received a Certificate of Need exemption and assurance of Medicaid reimbursement as a result of the pro bono assistance of two major law firms--Fried, Frank, Harris, Shriver and Jacobson and Dewey Ballantine--we are now working on a business plan to meet the request of the building's owner for assurance that success is "in the stars" and hopefully to obtain the building on favorable terms. In addition to my own contributions of time and the MacArthur stipend to work on the project, we have received a planning grant from the Robert Wood Johnson Foundation and are hopeful that they will respond to a request for further support. Other contributions have come voluntarily from private citizens, including Justice Ruth Bader Ginsburg, and a small DC-based foundation, the Rapidan. In sum, the services will include the following: 1. well-woman and preconceptional care; 2. counseling on matters of women's reproductive health, including sexually transmitted infections; 3. full-scope maternity services with linkage to the hospital system, including (a) pregnancy testing; (b) prenatal care and education for all women who seek care; (c) labor and birth in the setting appropriate to individual
women; (d) infant feeding and care education; (e) postnatal care, including at least one home visit and two returns to the center within 6 weeks; (f) postnatal education, including breast-feeding support from peers and staff available 24 hours a day, 7 days a week; and (g) interconceptional care; 4. well-child care; 5. drop-in services for abused and substanceabusing women; 6. legal counsel and assistance on site; 7. Early Head Start (0 to 3 years); 8. Head Start (3 to 5 years); 9. after-school programs for grade schoolers; and 10. job training for women. For all the above, the three collaborating agencies will operate in the same newly renovated building, sharing services where appropriate and supporting each others programs. The fact that the costs of birth center services are 30 per cent to 60 per cent less than the charges for in-hospital normal childbirth should serve us well!
•.. the midwife came from the birthroom. . . exclaiming, "'Russian women must have this/"
I would like to tell you of two more examples of the opportunities offered to me by my good fortune. Recall that through the Office of the Assistant Secretary for Health I was able to consult with other federal agencies, such as the Office of International Health and the Indian Health Service. Through the auspices of Connie Vance, EdD, RN, dean of the School of Nursing at the College of New Rochelle, I had been introduced to a remarkable Russian nurse-midwife. Dr Vance, in seeking educational opportunities for this young woman while she was in the United States at the College of New Rochelle for a semester, asked in 1994 if she might observe at the Childbearing Center in Manhattan. I was delighted to afford this opportunity but hadn't fully foreseen the impression birth center care would make. After she had observed her first birth in the center, the midwife came from the birthroom with tears streaming down her face exclaiming, "Russian women must have this!" My stipend
LIFE ON THE "GENIUS" TRACK
enabled me to join Dr Vance's next study tour of Russia and to evaluate whether in fact Russia was ready for its women "to have this." Indeed, I thought things were not in readiness, and so I advised the midwife to begin education in women's health to develop a cadre of consumer supporters. In the interim, a relationship with the federal Office of International and Refugee Health was established, and staff were informed of the midwife's work. This summer past, I returned to St. Petersburg, the midwife's home, and there saw the progress she had made through offering those educational sessions. The prenatal education she gave motivated the families to enable her to accompany them into the birth house, a heretofore unheard-of event. And now, with the assistance Dr Vance has been able to provide through the sale of Russian brooches, she is able to provide family-centered experiences for Russian families. Many thanks are owed to Dr Vance for her vision. The other remarkable experience has come about through consulting with the Indian Health Service and its Hospital's Tribal Health Coordinator at Sisseton, SD. The Sisseton-kYchhpeton Sioux Tribe there is working to develop a nurse-midwifery service and birth center as a result of seeing the video of which I spoke earlier. I showed them the film with some trepidation and uncertainty as to its cultural appropriateness in as much as it depicts the inner-city life of African American and Latino families. They watched it in silence, and when it concluded, I let all the trailer run out before asking, "Well?" With that, an 80-yearold nurse, who had been prepared at the Pennsylvania Hospital School of Nursing in the 1930'S and who is still active in her profession, struck the table with her fist and said with authority, "If they can do it, we can do it!" People everywhere resonate to the empowerment theme and want it for themselves! Now that you have seen how nurses and nursemidwives can work together to the mutual benefit of families living in disadvantaged areas, let me seek your interest and help with easing what to me is a pressing problem, often called the "epidural epidemic." In my estimation, the empowerment we witnessed in the Bronx came about as a result of partnering with the expectant mother along the continuum of prenatal and birth care. At prenatal visits, each woman had, and will have at the DCBC, complete access to her own record. With her nurse-midwife caregiver, she develops her own birth plan. She weighs herself, tests her own urine, and records the results. One mother expressed that she "was treated like an intelligent human being and felt that I was taking care of my own
11
pregnancy" (MCA, 1993). Is this not, after all, what we wish all our childbearing citizens would do? Do we not want them to take charge of their own health? In my opinion, we will never solve the enormous health care problems we have until people themselves take charge of their health. The secret is that there is no better time to encourage that "taking charge" than in the maternity cycle. As another one of the Bronx participants said, When you give birth, (as opposed to being delivered) you feel that you have given life. And if you can give life, then you can do anything; you can get a job and you can go to school, and you can do anything you want as long as you put your mind to it. That's the best thing about the birth center, it empowers women, and in turn they empower their families, which empowers the community and it just grows and grows (MCA, 1993). This from a 19-year-old African American woman! Partnering with women is an essential part of realizing this effect. Let me turn now to the epidural epidemic and its effects on empowerment. Morton et al. (1994), in a meta-analysis of six randomized clinical trials of the influence ofepidural on labor, concluded that epidural analgesia may increase the cesarean birth rate by 9 per cent. In a meeting of maternity care professionals-including obstetricians, family practitioners, anesthesiologists, nurses, nurse-midwives, childbirth educators, and consumers--convened by the National Association of Childbearing Centers Foundation on the topic early in 1997, it was readily agreed that, based on available evidence, epidural anesthesia does increase cesarean section rates. And women who deliver surgically, even though they are participating, are certainly not in charge! But another untoward outcome has come to light--the effect on the infant. Dr Ellice Lieberman presented her evidence regarding "Epidural Analgesia, Intrapartum Fever, and Neonatal Sepsis Evaluation" in an article that appeared in Pediatrics (Lieberman et al., 1997). Her findings include the fact that some 14 per cent of laboring women who choose epidural analgesia will run a fever of 100.4°F or higher in contrast to just 1 per cent of women not having epidural. This means that the neonate will be subjected to a sepsis work-up, often including a spinal tap and treatment with antibiotics. Figure 1 is from Dr Lieberman's (1997) article and is used with her permission and encouragement. She is well aware that nurses have it in their power to make a
12
RUTH WATSON LUBIC
The comparison is instructional not only according to length of labor but also according to the utilization of epidural, which, according to Hawkins, Gibbs, Orleans, Martin-Salvaj, and Beaty (1997), had increased 100 per cent between 1981 and 1992. Table 1 depicts the number of neonates treated with antibiotics according to epidural use. Lieberman explains in her text that
100 " 90" 80" 70" 60"
*
Epidural
-,=- No Epidural
50" 40" 30" 20" 10" 0
<=6 h
6-12 h
12-18 h
>18 h
Length of Labor
Figure 1. Percent of women with fever > 100.4°F according to length of labor and epidural use. (Reproduced with permission from PEDIATRICS, Vol 99 #3, Pages 416-417, 1997.) difference in epidural use. One wonders whether if women were told that epidural use increases 14-fold the chances of their newborn child having a spinal tap, their selection might be more measured. And it is up to us to let them in on this secret! I say "secret" because of a full-page advertisement from The Charlotte Observer Special Marketing Supplement, which I received recently. It is entitled " 'Walking Epidural' Eases Labor" and concludes with an invitation to women to sign up for epidural classes at a local hospital (Welling, 1997). Nowhere in the article are listed the downsides of epidural in labor, and this is my point. I do not argue the right to choose an epidural. I do insist that women must be given full information before making a choice. But let us return to the evidence. Lieberman explains her graph (Fig 1) entitled, "Percent of Women With Fever > 100.4F According to Length of Labor and Epidural Use," as follows: The rate of fever in the no-epidural group, 1% overall, remained low, regardless of the length of labor. The rate of fever in the group of women who received an epidural was consistently higher than the rate in the group of women who did not receive an epidural, regardless of the length of labor. For women who received an epidural, the rate of fever increased with longer labors, from 7% for women with the shortest labors (< than 6 hours) to 36% for women with the longest labors (>18 hours). Greater than 40% of women receiving an epidural had labors lasting at least 12 hours, putting them at high risk for intrapartum fever (p. 416).
Even in the absence of maternal fever > 100.4F, sepsis evaluations were performed at a higher rate in the epidural group. The rate in the epidural group was 25.1% compared with 9.1% in the no-epidural group . . . infants of women who had received an epidural remained more than three times as likely to be evaluated for the presence of sepsis (Lieberman et al., 1997, p. 417). O f great interest is the number who actually had documented sepsis. As you can see from the table, it is exceedingly small. Figure 2 depicts the percentage of neonates of afebrile women who received sepsis workups according to length of labor and epidural use. Here the higher incidence of sepsis evaluation in women with epidurals but without fever is apparent in labors longer than 18 hours. Lieberman states, "However, longer length of labor did not entirely account for the higher rate of sepsis evaluations, because these infants were more likely to have a sepsis work-up regardless of length of labor (Lieberman et al., p. 417). The population for Lieberman's study was the 1,934 nulliparous women enrolled in the active management of labor trial conducted at Brigham and Women's Hospital in Boston from May 1990 through October 1994. I eagerly encourage you to foster an understanding TABLE 1. Number of Neonates Treated With Antibiotics According to Epidural Use
Sepsis evaluation Any antibiotic treatment Antibiotics for ->3 days Documented sepsis
No. (%) Epidural (n = 1047)
No. (%) No Epidural (n = 610)
356 (34.0)
60 (9.8)
4.3 (3.2, 5.9)*
161 (15.4)
23 (3.8)
3.9 (2.4, 6.1)*
17 (1.6) 3 (0.3)
3 (0.5) 1 (0.2)
Odds Ratio (95% Cl)
3.3 (1.0, 17.9)t 1.7 (0.1,92.0)1-
Abbreviation: Cl, confidence interval. *Odds ratio from multiple logistic regression adjusting for birth weight, gestational age, induction, premature rupture of the membranes, and treatment with active management of labor. -j-Exact confidence limits; no adjustment in multiple logistic regression because of small number of cases. Reproduced with permission from PEDIATRICS, Vol 99 #3, Pages 416-417, 1997.
13
LIFE ON THE "GENIUS" TRACK
1°° I i" 80 70
•~
(n
60
•
50
~
40
• Epidural - o - No Epidural
30
9~
20
a.
10 0 <=6 h
f
6-12 h
I
12-18 h
I
>18 h
Length of Labor
Figure 2. Performance of sepsis evaluations among neonates of afebrile women according to length of labor and epidural use. (Reproduced with permission from PEDIATRICS, Vo199 #3, Pages 416-417, 1997.) in your educational and service staffs that if laboring women are tempted with offers of epidural analgesia and/or cesarean section, nurses become not only a powerful voice in their ability to decrease cesarean section and infant morbidity, but, more importantly, they can foster empowerment through fully informing women and encouraging their choice. But do nurses really have important influence on the laboring women under their care? In an article entitled "Nurses Care During Labor: Its Effect on the Cesarean Birth Rate of Healthy Nulliparous Women," Radin, Harmon, and Hanson (1993, p. 14) stated: "The study suggests that nurses' care during labor is an important factor influencing cesarean birth rates." In another article by the same nurse researchers, "Cesarean Birth Rates: Identification of Nurses With Low or High Rates," the low- and high-rate groups were described as follows: "The low C/B rate nurses were described as maternally focused, valuing vaginal birth, confident of their ability to assist the mother to birth vaginally and with a 'large bag of tricks' to assist labor" (Radin, 1995 (p. 28). On the other hand, nurses with a high rate of patients who had C/B were described as " . . . focused on the fetus, believing that nurses have no influence on birth route and that any birth route is fine as long as the infant is healthy, and focused on the technology" (Radin, 1995, p. 28). I offer an anecdote I recently heard from a family practitioner operating a birth center in Tennessee. A mother who was transferred to hospital care for labor as a precautionary measure reported that, even though she did not want epidural, she was offered such
analgesia 17 times during her labor! And from students enrolled in the Community Based NurseMidwifery Educational Program came the information that maternity nurses, not the mother's practitioner of record, were being expected to secure the mother's permission for epidural administration. Nurses need to be sure that such activity is appropriate to their practice and that the mothers are given all possible information about the positive and negative effects of the procedure. Recently, a brochure advertising meetings on "Safely Reducing Cesarean Rates" (Cambridge Health Resources, 1997) came to my desk. It discussed not only the increase in rates over the last 12 years and all that means to women, it also discussed national spending on the procedure--from $1.9 billion in 1980 to $7.2 billion in 1992. We should explain to administrators how much more effective it would be to invest in nursing care in sufficient amount so that each mother would be assured of support by a knowledgable person during her labor. While we are waiting for that day of enlightenment, I urge you to urge the nurses and nurse-midwives in your setting to join together in strengthening and empowering families through providing both full information and labor support that encourages them. In her comprehensive and groundbreaking new book, Midu,ifery and Childbirth in America Judith Rooks (1997, p. 310) cites a study undertaken in a hospital in Montreal in 1994, by Gagnon and Waghorn, as reporting that nurses " . . . spent no more than a fourth of their work time with patients and less than 10% of their time providing support to women in labor." In settings where epidural is extensively used, however, nurses spend much of their time dealing with the accoutrements of technology, such as intravenous infusions, catheterization, electronic fetal monitoring, and oxytocin: "The nurses who conducted these studies believe that the technical expertise is more valued by the people with the most status in hospitals, and that the need for technical care results in the deemphasis and devaluing of the supportive care needed by women in labor" (Rooks, 1997, p. 310). Together we must address this issue for the benefit of all women, especially for those whose lives do not offer many opportunities for them to be involved in their own health care. We must partner with each other and with the women we serve. While, in my opinion, those of us who provide the personalized care made possible by freestanding birth centers can most
14
RUTH WATSON LUBIC
easily empower families, most babies will be born-in hospital for decades yet to come, and nurses, with or without midwifery, offer the major hope that their mothers will have the opportunity to "give birth" rather than "be delivered." You can see that my life has been enriched by the opportunities the MacArthur Fellowship has given me. Lest you think my professional life has been a "bowl of cherries," I would like to close by sharing with you a list of principles for a successful professional life (Lubic, 1995), which I have assembled over the years based on the controversy surrounding my practice, in the hope that you will find them meaningful in your own life.
Begin with the needs of the people you serve. Take care of all the people of the nation. Trust your caring instincts. Learn to tolerate uncertainty. Choose your professional colleagues for their caring philosophy rather than their professional preparation. Be aware that the medical model has failed to serve all the people of the nation. Avoid anger; it consumes energy and clouds vision. Avoid bitterness against political opponents. Value the giving and receiving of truth. Base a design for change on the best science possible, then test your performance. Overcome the fear associated with leadership. Remember, the people you serve are your strength. Listen to them! You will be rewarded.
References
Breckinridge, M. (1952). Wide neighborhoods (p. 111). Lexington, KY: University of Kentucky Press. Cambridge Health Resources. (1997). Safely reducing cesarean rates [Brochure]. Gagnon, A., & X~7aghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth, 23, 1-6. Hawkins, J., Gibbs, C., Orleans, M., Martin-Salvaj, G., & Beaty, B. (1997). Obstetric analgesia work force survey, 1981 versus 1992. Anesthesiology, 87, 135-143. Lieberman E., Lang, J. M., Frigoletto, Jr., E, Richardson, D. K., Ringer, S., & Cohen, A. (1997). Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics, 99(3), 415-419. Lubic, R. (1995). Principles for a successfulprofessional l~. [Poster]. New York: Maternity Center Association. Maternity Center Association. (1993). Hope reborn: Empowering families in the South Bronx [Video; available from MCA, 281 Park Avenue South, New York, NY 100101. Morton, S. C., Williams, M. S., Keeler, E. B., Gambone, J. C., & Dahn, K. L. (1994). Effect ofepidural analgesia for
labor on cesarean delivery rate. Obstetrics and Gynecology, 83, 1045-1052. Radin, T. (1995). Cesarean birth rates: identification of nurses with low or high rates (p. 28). Unpublished manuscript. Radin, T., Harmon, J., & Hanson, D. (1993). Nurses' care during labor: Its effect on the cesarean birth rate of healthy nulliparous women. Birth 20(1), 14-21. Rooks, J. (1997). Midwifery and childbirth in America. Philadelphia: Temple University Press. Senior, J. (1997). Winning the genius lottery. Civilization, 4(5), 42, 46. State Center of Health Statistics, Commission of Public Health, DC Department of Human Services. (1996). Briefing paper on the 1995 infant mortality rate for the District of Columbia. Washington, DC: Author. Wegman, M. (1996). Some international comparisons of infant mortality. Pediatrics, 98(6), 1020-1027. Welling, L. (1997, August-September). Walking epidural eases labor. The Charlotte Observer, Special Marketing Supplement, Medical Center News, p. 9.