Hospitals serving more patients at risk for complications during childbirth are less likely to have enough nurses to care for patients during labor, delivery, and recovery, according to a new study in Nursing Outlook.

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

Nurses play a central role in the 3.6 million births in U.S. hospitals each year. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) issues guidelines on nurse staffing levels for maternity units; its 2010 guidelines call for one nurse to one birthing person during many parts of labor, two nurses at birth, one nurse for each mother-newborn pair during the first few hours after birth, and one nurse for every three pairs of mothers and babies after that period. These same nurse-to-patient ratios were included in the AWHONN nurse staffing standards published in 2022.

Recent data show that patients at high risk for severe maternal complications are more likely to give birth in teaching hospitals and have Medicaid as their insurer. In addition, teaching hospitals—often safety-net hospitals providing a significant amount of care to low-income and uninsured patients—are also more likely to have high volumes of births. In this study, the researchers aimed to determine nurse staffing levels at hospitals with vulnerable maternity patients, using high-birth volume and teaching status as proxies for high-risk patients.

“Patients at risk for serious maternal complications are particularly vulnerable and are likely to need more intensive nursing care based on their medical and psychosocial circumstances,” says Audrey Lyndon, PhD, RN, FAAN, the Vernice D. Ferguson Professor in Health Equity and assistant dean for clinical research at NYU Rory Meyers College of Nursing.

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

Overall, nurses reported strong adherence to AWHONN staffing guidelines in their hospitals, with more than 80% of respondents saying that their unit frequently or always met the staffing guidelines. Adherence to guidelines was particularly high for specific stages of labor, including a nurse being continuously present at the bedside during second-stage labor (93.3%) and one-on-one care during epidural initiation (84.1%). However, adherence was lower for having a dedicated nurse for postpartum recovery in the two hours right after delivery (71.8%), one-on-one care for mothers with high-risk conditions (72.6%), a nurse dedicated to fetal heart rate monitoring (61.3-77.2%), and one-on-one care during oxytocin administration in labor (54.6%).

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

“These gaps in staffing are particularly troubling for our most at-risk patients,” added Lyndon. “Many maternal complications can be prevented or quickly addressed through timely recognition of risk factors and clinical warning signs, and, when issues are identified, the escalation of care and coordination with the care team—but this is only possible when there are enough nurses monitoring patients.”

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

“Studies show that Medicaid pays hospitals less than half of what commercial insurers pay for a birth. This inequity in reimbursement creates a fiscal challenge in hospitals with a high percentage of maternity patients insured by Medicaid,” says Kathleen Rice Simpson, PhD, RNC, FAAN, a perinatal clinical nurse specialist in St. Louis, MO, and the study’s lead author. “Better funding for teaching and safety-net hospitals caring for high-risk maternity patients could support better nurse staffing.”

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

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