Republic of the Philippines

President Ramon Magsaysay State University

Iba, Zambales, Philippines
COLLEGE OF NURSING

College/Department College of Nursing

Course Code NCM 107
Course Title Care of Mother, Child, Adolescent (Well Clients)
Place of the Course in the Program Professional Subject
Semester and Academic Year First Semester, AY 2020-2021

INTRODUCTION
The care of pregnancy and childbearing families is a major focus of nursing practice,
because to have healthy adults you must have healthy children. To have healthy children, it is
important to promote the health of the childbearing woman and her family from the time before
children are born until they reach adulthood.
Maternal and Child Health refer to philo-mother and child relationship to one another and
consideration of the entire family as well as the culture and socio-economic environment as
framework of the patient. The targets for MCH are all women in their reproductive age groups.
Nursing care includes during a prenatal checkup, maternal child health nurse assesses that a
pregnant woman’s uterus is expanding normally. And during a health maintenance checkup, a
maternal child health nurse assesses a child’s growth and development.
INTENDED LEARNING OUTCOMES
 Integrate concepts, theories and principles of sciences and humanities in the
formulation and application of appropriate nursing care during childbearing and
childbearing years. Specifically;
o Identify the goals and philosophy of maternal and child health nursing and
apply these to nursing practice.
o Identify 2020 National Health Goals as an important guide to understanding
the health of the nation and goals that nurses can help the nation achieve.
o Define and use common statistical terms used in the field, such as infant
and maternal mortality.
 o Use critical thinking to identify areas of nursing care that could benefit from
additional research or application of evidence-based practice.
o Integrate knowledge of maternal and child health nursing with the interplay
of nursing process, the six competencies of QSEN, and Family Nursing to
achieve quality maternal and child health nursing care.
 Understand the maternal and child nursing concepts and principles holistically and
comprehensively.
MODULE OULINE
I. Goals and Philosophies of Maternal and Child Health Nursing
a. Major Philosophical Assumptions About Combined Maternal and Child
Health Nursing
b. Maternal and Child Health Goals and Standards
i. 2020 National Health Goals
ii. Global Health Goals
iii. Health Setting Magnet Status
II. A Framework for Maternal and Child Health Nursing Care
a. Nursing Process
b. Nursing Theory
c. QSEN: Quality and Safety Education for Nurses
d. Evidence-based Practice
e. Nursing Research
III. A Changing Discipline
a. Trends in the Maternal and Child Health Nursing Population
b. Measuring Maternal and Child Health
i. Birth Rate
ii. Fertility Rate
iii. Fetal Death Rate
iv. Neonatal Death Rate
v. Infant Mortality Rate
vi. Maternal Mortality Rate
vii. Child Mortality Rate
 viii. Childhood Morbidity Rate
c. Trends in the Health Care Environment
i. Initiating cost Containment
ii. Changes in Health Insurance Coverage
iii. Increasing alternative Settings and Styles for Health Care
iv. . Increasing Use of Technology
v. Meeting Work Needs of Pregnant and Breastfeeding Women
IV. Legal Considerations of Maternal-Child Practice
V. Ethical Considerations of Practice
VI. Roles and responsibilities of a Maternal and Child Health Nurse
VII. WHO’s 17 Sustainable Development Goals
DISCUSSION
I. Goals and Philosophies of Maternal and Child Health Nursing
Obstetrics, or the care of women during childbirth, is derived from the Greek word
obstare, which means “to keep watch”. Pediatrics is a word derived from the Greek word
pais, meaning “child.” The care of childbearing and childrearing families is a major focus
of nursing practice, because to have healthy adults you must have healthy children.
The area of childbearing and childrearing families is a major focus of nursing practice
in promoting health for the next generation. Comprehensive preconception and prenatal care
is essential in ensuring a healthy outcome for mother and child. Although childbearing and
childrearing are often viewed as two separate entities, they are interrelated, and a deeper
understanding is achieved when they are viewed as a continuum.
The primary goal of both maternal and child health nursing is the promotion and
maintenance of optimal family health. Major philosophical assumptions about combined
maternal and child health nursing. Maternal and child health nursing extends from
preconception to menopause with an expansive array of health issues and healthcare
providers. Examples of the scope of practice include:
 Preconception health care
 Care of women during three trimesters of pregnancy and the puerperium (the 6
weeks after childbirth, sometimes termed the fourth trimester of pregnancy)
 Care of infants during the perinatal period (the time span beginning at 20 weeks
of pregnancy to 4 weeks [28 days] after birth)
  Care of children from birth through late adolescent
 Care in a variety of hospital and home care settings
Regardless of the setting, a family-centered approach is the preferred focus of
nursing care (Papp, 2012). The health of an individual and his or her ability to function as
a member of the family can strongly influence and improve overall family functioning.
Family-centered care enables nurses to better understand individuals and their
effect on others and, in turn, to provide more holistic care (Hedges, Nichols, & Filoteo,
2012). It includes encouraging rooming-in with the mother by the mother’s partner or
support person and with the child by their caregiver. Family members are encouraged to
provide physical and emotional care based on the individual situation and their comfort
level. Nurses provide guidance and monitor the interaction between family members to
promote the health and well-being of the family unit.

A. Major Philosophical Assumptions About Combined Maternal and Child

Health Nursing
Maternal and child health nursing is;
1. Family centered - assessment should always include the family as well as an
individual.
2. Community centered – the health of families is both affected by and influences
the health of communities.
3. Evidenced based – this is the means thereby critical knowledge increases.
4. A challenging role for nurses and a major factor in keeping families well and
optimal in functioning.

B. Maternal and Child Health Goals and Standards

Healthcare technology has contributed to a number of important advances in
maternal and child health care. Through immunization, childhood diseases such as
measles and poliomyelitis almost have been eradicated. New fertility drugs and fertility
techniques allow more couples to conceive. The ability to prevent preterm birth and
improve the quality of life for both preterm and late preterm infants has increased
dramatically. As specific genes responsible for children’s health disorders are
identified, stem cell therapy may make it possible to replace diseased cells with new
growth cells and cure these illnesses. In addition, a growing trend toward healthcare
consumerism, or self-care, has made childbearing and childrearing families active
participants in their own health monitoring.
Access to health care and social determinants of health impact the role of the
nurse and the health of the patient. These factors have expanded the roles of nurses in
maternal and child health and, at the same time, have made the delivery of quality
maternal and child health nursing care a challenge.
1. 2020 National Health Goals
The importance a society assigns to human life can best be measured by the
concern a nation places on its most vulnerable members—its elderly, its disadvantaged,
and its youngest citizens. In light of this, in 1979, the U.S. Public Health Service first
formulated healthcare objectives for the nation. Healthcare goals are reviewed every
10 years. In 2010, new goals to be achieved by 2020 were set (U.S. Department of
Health and Human Services [DHHS], 2010). The 2030 goals are scheduled for
presentation in 2020. Many of these objectives directly involve maternal and child
health care because improving the health of these age groups will have long-term
effects on the population. The two main overarching national health goals are:
 To increase quality and years of healthy life.
 To eliminate health disparities.
A new objective added in 2010 recommends that 100% of prelicensure
programs in nursing include core content on counseling for health promotion and
disease prevention, cultural diversity including for lesbian, gay, bisexual, and
transgender (LGBT) populations, evaluation of health sciences literature,
environmental health, public health systems, and global health, all important areas
for maternal and child health and discussed throughout this text (DHHS, 2010).
The 2020 National Health Goals are intended to help citizens more easily
understand the importance of health promotion and disease prevention and to
encourage wide participation in improving health in the next decade. It’s important for
maternal and child health nurses to be familiar with these goals because nurses play
such a vital role in helping the nation achieve these objectives through both practice
and research (see www.healthypeople.gov). The goals also serve as the basis for grant
funding and financing of evidence-based practice. Each of the following sections
highlights goals as they relate to that specific area of care.
2. Global Health Goals
The United Nations and the World Health Organization established millennium
health goals in 2000 in an effort to improve health worldwide. As with 2020 National
Health Goals, these concentrate on improving the health of women and children
because increasing the health in these two populations can have such long-ranging
effects on general health.
These Global Health Goals are:
 To end poverty and hunger.
 To achieve universal primary education.
 To promote gender equality and empower women.
 To reduce child mortality.
 To improve maternal health.
 To combat HIV/AIDS, malaria and other diseases.
 To ensure environmental sustainability.
 To develop a global partnership for development.
The establishment of global health goals is a major step forward in improving
the health of all people, as contagious diseases, poverty, and gender inequality do not
respect national boundaries but follow people across the world and into all nations (UN,
2000).
Health Setting Magnet Status
Magnet status is a credential furnished by the American Nurses
Credentialing Center (ANCC), an affiliate of the American Nurses Association, to
hospitals that meet a rigorous set of criteria designed to improve the strength and
quality of nursing care. Hospitals who achieve Magnet status meet criteria in five
major categories:
 Transformational leadership. This is the ability of nurses in the designated
organization to convert their organization’s values, beliefs, and behaviors
in order to create a high professional level of nursing care.
  Structural empowerment. This refers to the ability to provide an innovative
environment where strong professional practice can flourish with regard to
the hospital’s mission, vision, and values.
 Exemplary professional practice. The setting demonstrates a
comprehensive understanding of the role of nursing; the application of that
role with patients, families, communities, and the interdisciplinary team is
clear, so new knowledge and evidence can be applied to nursing care.
 New knowledge, innovation, and improvements. The organization
demonstrates strong nursing leadership, empowered professionals, and
exemplary practice while contributing to patient care.
 Empirical quality results. The hospital demonstrates solid structure and
processes where strong professional practice can flourish and where the
mission, vision, and values come to life as the organization achieves the
outcomes believed to be important for the organization (ANCC, 2012).

Magnet hospitals typically demonstrate a high level of nursing job satisfaction and
a low staff nurse turnover rate and have policies in place that include nurses in data
collection and decision making about patient care. These hospitals demonstrate they value
staff nurses,involve them in research-based practice, and encourage and reward them for
obtaining additional degrees in nursing. All nurse managers and nurse leaders in Magnet-
designated hospitals must have either a baccalaureate or master’s degree in nursing.
II. A Framework for Maternal and Child Health Nursing Care
Maternal and child health nursing can be visualized within a framework in which
nurses use nursing process, nursing theory, and Quality & Safety Education for Nurses
(QSEN) competencies to care for families during childbearing and childrearing years and
through the four phases of health care:
 Health promotion
 Health maintenance
 Health restoration
 Health rehabilitation
a. Nursing Process
 Nursing care, at its best, is designed and implemented in a thorough manner,
using an organized series of steps, to ensure quality and consistency of care (Carpenito,
2012). The nursing process, a scientific form of problem solving, serves as the basis
for assessing, making a nursing diagnosis, planning, implementing, and evaluating
care. It is a process broad enough to serve as the basis for modern nursing care because
it is applicable to all healthcare settings, from the home to ambulatory clinics to
intensive care units.
Because nurses rarely work in isolation but rather as a member of an
interprofessional team, interprofessional care maps and checkpoint questions on
teamwork and collaboration are included throughout the text to demonstrate the use of
the nursing process as well as to provide examples of critical thinking, clarify nursing
care for specific patient needs, and accentuate the increasingly important role of nurses
as coordinators of care for a collaborative team.
b. Nursing Theory
One of the requirements of a profession (together with other critical
determinants, such as members who set their own standards, self-monitor their practice
quality, and participate in research) is that a discipline’s knowledge flows from a base
of established theory.
Nursing theories are designed to offer helpful ways to view patients so nursing
activities can be created to best meet patient needs—for example, Calistra Roy’s theory
stresses that an important role of the nurse is to help patients adapt to change caused by
illness or other stressors (Roy, 2011); Dorothea Orem’s theory concentrates on
examining patients’ ability to perform self-care (Orem & Taylor, 2011); Patricia
Benner’s theory describes the way nurses move from novice to expert as they become
more experienced and prepared to give interprofessional care (Benner, 2011). Using a
theoretical basis such as these can help you appreciate the significant effect of a child’s
illness or the introduction of a new member on the total family.
Other issues most nursing theorists address include how nurses should be
viewed or what the goals of nursing care should be. Extensive changes in the scope of
maternal and child health nursing have occurred as health promotion (teaching,
counseling, supporting, and advocacy, or keeping parents and children well) has
become a greater priority in care (Salsman, Grunberg, Beaumont, et al., 2012). As
promoting healthy pregnancies and keeping children well protects not only patients at
present but also the health of the next generation, maternal–child health nurses fill these
expanded roles to a unique and special degree.
c. QSEN: Quality and Safety Education for Nurses
In 2007, the Robert Wood Johnson Foundation challenged nursing leaders to
improve the quality of nursing care and to build the knowledge, skills, and attitudes
necessary to help achieve that level of care into prelicensure and graduate programs
(Disch, 2012).
Because of this challenge, the QSEN Learning Collaborative created six
competencies deemed necessary for quality care (Cronenwett, Sherwood, & Gelmon,
2009). These competencies included five competencies that originated from a study by
the Institute of Medicine: (a) patient-centered care, (b) teamwork and collaboration, (c)
quality improvement, (d) informatics, and (e) evidence-based practice. The QSEN
Learning Collaborative added safety as the sixth competency.
Throughout all phases of QSEN, the overall goal is to address the challenge of
preparing future nurses with the abilities necessary to continuously improve the quality
and safety of the healthcare systems in which they work.
 d. Evidence-based Practice
Evidence-based practice existed as an important element of nursing practice
prior to the development of QSEN; it has since been incorporated into QSEN as one of
its competencies. Evidence-based practice is the conscientious, explicit, and judicious
use of current best evidence to make decisions about the care of patients (Falk, Wongsa,
Dang, et al., 2012). Evidence can be a combination of research, clinical expertise, and
patient preferences or values.
Use of evidence such as that obtained from randomized controlled trials helps
to move healthcare actions from “just tradition” to a more solid and therefore safer,
scientific basis. The Cochrane Database (listed in PubMed, Ovid, and MEDLINE) is a
good source for discovering evidence-based practices as the organization consistently
reviews, evaluates, and reports the strength of health-related research (Dong, Chen, &
Yu, 2012).
QSEN Checkpoint Questions: Evidence-Based Practice are included in chapters
throughout the text and contain summaries of current maternal and child health research
followed by questions to assist you in developing a questioning attitude regarding
 current nursing practice or in thinking of ways to incorporate research findings into
care.
e. Nursing Research
Nursing research (the systematic investigation of problems that have
implications for nursing practice usually carried out by nurses) plays an important role
in evidence-based practice as bodies of professional knowledge only grow and expand
to the extent people in that profession are able to carry out research (Christian, 2012).
Examining nursing care in this way results in improved and cost-effective patient care
as it provides evidence for action and justification for implementing activities.
A classic example of how the results of nursing research can influence nursing
practice is the application of research carried out by Rubin (1963) concerning mothers’
initial approaches to their newborns. Before the publication of this study, nurses
assumed a woman who did not immediately hold and cuddle her infant at birth was a
“cold” or unfeeling mother. After observing a multitude of new mothers, Rubin
concluded attachment is not a spontaneous procedure; rather, it more commonly begins
with only fingertip touching, then over the next few days, moves to “motherly” actions
such as hugging and kissing. Armed with Rubin’s findings, nurses today are better able
to differentiate healthy from unhealthy bonding behavior in new mothers. Additional
nursing research in this area has provided further substantiation regarding the
importance of this original investigation.

III. A Changing Discipline

Maternal and child health is an ever-changing area of nursing. This happens
because childhood infections, such as pertussis (whooping cough) and measles
(Rubeola), can now be prevented so children do not usually require care for these
conditions. At the same time, illnesses that could not be treated before, such as cystic
fibrosis or hypertension of pregnancy, can now be treated, so the number of settings
and critical aspects of care increases.
a. Trends in the Maternal and Child Health Nursing Population
 Not only patterns of illness but also variations in social structure, family
lifestyle (a way of living in which families cope with social, physical, psychological,
and economic variables in their life), and responsibilities continue to constantly change
b. Measuring Maternal and Child Health
Measuring what constitutes the area of maternal and child health is not as simple
as defining whether patients are ill or well because individual patients and healthcare
practitioners can maintain different perspectives on illness and wellness.
i. Birth Rate
Early in the century, births to teenage girls were steadily increasing; however,
due to additional counseling and increased availability of contraception,
particularly long–acting, reversible contraception such as the intrauterine device,
this rate is now steadily declining (presently at 24.2/1,000 from a high of 618/1,000
in 1961) (Finer & Zolna, 2016; Hamilton et al., 2015).
The birth rate for women 20 to 24 years of age (79.0/1,000) is gradually
declining as well, as women choose to postpone having children until past college
age. In contrast, the number of children born to women older than 40 years of age
is steadily increasing (presently at 10.6/1,000 from a low of almost no births in this
age group in 1901 (Hamilton et al., 2015).
ii. Fertility Rate
The fertility rate tends to be low in countries where there are fewer
nutritional resources because poor nutrition makes conceiving difficult, as well as
in countries where the proportion of young adult men is low because of war or
disease. This rate tends to be high in countries where the average woman has access
to good nutrition and feels safe to begin a family.
iii. Fetal Death Rate
Fetal deaths before birth but greater than 20 weeks gestation occur because of
maternal factors (such as premature cervical dilation and maternal hypertension) and
also because of fetal factors (such as chromosomal abnormalities or poor placental
attachment). The cause of many fetal deaths cannot be documented or occur for
unknown reasons. Fetal death rate is important in evaluating the health of a nation
because it reflects the overall quality of maternal health and whether common services
such as prenatal care are available.
iv. Neonatal Death Rate
This rate reflects not only the quality of care available to women during
pregnancy and childbirth but also the quality of care available to infants during the
first month of life. According to the Centers for Disease Control and Prevention
(CDC’s) most recent data, the number of infant deaths per 100,000 live births in
2014 was 582.1. The leading causes of death during this time are prematurity with
associated low birth weight or congenital malformations, maternal complications
of pregnancy, sudden infant death syndrome (SIDS), and injuries (Hamilton et al.,
2015).
The proportion of infants born with low birth weight is about 11.39% of all
births. The number of low–birth-weight infants has declined after steadily
increasing since 2006 and was 8.02% in 2013. Infants born to women under the age
of 20 years and between the ages of 40 and 54 years had the highest rate of neonatal
and infant deaths.
v. Infant Mortality Rate
The infant mortality rate of a country is a good index of its general health
because it measures the quality of pregnancy care, overall nutrition, and sanitation,
as well as infant health and available care. This rate is the traditional standard used
to compare the health of a nation with previous years or with other countries.
Thanks to the introduction of prenatal care and other community health
measures (such as efforts to encourage breastfeeding, require immunizations,
initiate better unintentional injury prevention measures [e.g., requiring car seats],
and reduce SIDS or the sudden death of an infant less than 1 year of age that cannot
be explained after a thorough investigation of the cause of death), in combination
with the many technologic advances available for care, the U.S. infant mortality
rate has decreased by 86%, from 47.0 in 1940 to 5.96 per 1,000 live births in 2013
(Heron, Hoyert, Murphy, et al., 2009; Matthews, MacDorman, & Thoma, 2015)
Factors that may contribute to national variances in infant mortality are
differences in reporting capability as well as the type of health insurance and care
available. In Sweden, for example, a comprehensive healthcare program provides
state-sponsored maternal and child health care to all residents. Women who attend
prenatal clinics early in pregnancy receive a monetary award, a practice that almost
guarantees women will come for prenatal care. This type of healthcare policy
contrasts sharply with the availability of health care in an occupation-linked
insurance system such as the one in the United States.
The main causes of infant mortality in the United States are problems that
occur at birth or shortly thereafter, such as prematurity, low birth weight, congenital
malformations, and SIDS.
Although other factors that contribute to SIDS are yet to be identified, the
recommendations made by the American Academy of Pediatrics (AAP) to place
infants on their back to sleep, use room sharing but not bed sharing, avoid exposure
to overheating or cigarette smoke, and possible use of pacifiers, have led to an
almost 50% decrease in its incidence (Moon, 2016). Nurses have been instrumental
in reducing the number of these deaths, as they are the healthcare professionals who
most often discuss newborn care and make recommendations for new parents.
vi. Maternal Mortality Rate
General improvements in the rates of maternal mortality can be attributed to
improved preconception, prenatal, labor and birth, and postnatal care such as:
 Increased participation of women in prenatal care
 Greater detection of disorders such as ectopic pregnancy or placenta previa
and prevention of related complications through the use of ultrasound
 Increased control of complications associated with hypertension of
pregnancy
 Decreased use of anesthesia with childbirth
 Ability to better prevent or control hemorrhage and infection
Although some of the causes for maternal mortality remain unclear, known
causes include:
 Noncardiovascular disease
 Cardiovascular disease
 Infection or sepsis
 Hemorrhage
 Cardiomyopathy
 Pulmonary embolism
 Hypertensive disorders of pregnancy
 StrokeAmniotic fluid embolism
 Anesthesia complications (CDC, 2016b)
vii. Child Mortality Rate
The most frequent causes of childhood death are shown in below. Notice
unintentional injuries are the leading cause of death in children, although many of
these accidents are largely preventable through education about the value of car
seats and seat belt use, the dangers of drinking/drug abuse and driving, and the
importance of pedestrian safety.
A particularly disturbing mortality statistic is the high incidence of
homicide and suicide in the 10- to 19-year-old age group (more girls than boys
attempt suicide, but boys are more successful). Although school-age children and
adolescents may not voice feelings of depression or anger during a healthcare visit,
such underlying feelings may actually be a primary concern (Bridge, McBee-
Strayer, Cannon, et al., 2012; CDC, 2016c). Nurses who are alert to cues of
depression or anger can be instrumental in detecting these emotions and lowering
the risk of self-injury.
Major Causes of Death in Childhood

Childhood Morbidity Rate

Health problems commonly occurring in large proportions of children today
include respiratory disorders (including asthma and tuberculosis), gastrointestinal
disturbances, and consequences of injuries. Obesity rates for children aged 2 to 19
years now average 17% (CDC, 2016a). Obesity in school-age children can lead to
cardiovascular disorders, self-esteem issues, and type 2 diabetes, so counseling
children about maintaining a healthy weight is an important nursing responsibility
(Junnila, Aromaa, Heinonen, et al., 2012). Morbid obesity in pregnant women can
lead to complications during pregnancy, at birth, and following birth (Machado,
2012).
As more immunizations for childhood diseases become available, fewer
children in the United States are affected by common childhood communicable
diseases. Continued education about the benefits of immunization against rubella
(German measles) is still needed because if a woman contracts this form of measles
during pregnancy, her infant can be born with severe congenital malformations.
Nurses play a vital role in helping to prevent the spread of HIV by educating
adolescents and late adolescents about safer sexual practices (Nachman, Chernoff,
Williams, et al., 2012). Follow standard infectious precautions in all areas of
nursing practice to safeguard yourself, other healthcare providers, and patients from
the spread of this and other infections.
A number of infectious diseases that are increasing in incidence include
syphilis; genital herpes; hepatitis A, B, and C; and tuberculosis. The rise in syphilis,
hepatitis C, and genital herpes probably stems from an increase in nonmonogamous
sexual relationships and lack of safer sex practices. The increase in hepatitis B is
due largely to drug abuse and the use of infected injection equipment. One reason
for the increase in hepatitis A is shared diaper-changing facilities in day care
centers. Tuberculosis, once considered close to eradication, has experienced such a
resurgence that one form occurs as an opportunistic disease in HIV-positive persons
and is particularly resistant to usual therapy (Hesseling, Kim, Madhi, et al., 2012).
Methicillin-resistant Staphylococcus aureus is an infection that often occurs in
hospitals, causes skin infections or pneumonia, and is also growing in incidence
(Moran, Krishnadasan, Gorwitz, et al., 2012).
 c. Trends in the Health Care Environment
The settings for health care as well as nursing roles are changing, with the goal of
being able to better meet the needs of increasingly well-informed and vocal consumers.
i. Initiating cost Containment
Cost containment refers to reducing the cost of health care by closely monitoring
the costs of personnel, use and brands of supplies, length of hospital stays, inpatient to
outpatient ratios as is clinically appropriate, number of procedures carried out, and
number of referrals requested while maintaining quality care (Dolopolous, 2016).
Examples of delegation responsibility or teamwork to make care more cost-effective
or family centered are highlighted in “Interprofessional Care Maps” throughout this
text.
ii. Changes in Health Insurance Coverage
 Prior to the Affordable Care Act (ACA) in 2010, the United States was unique
among developed countries in that its healthcare system was privately financed or
controlled by work sites. This contrasts with other countries where national health
insurance has been available to everyone and with no connection to a person’s
employment. Because of this unique system, the United States spent about 17.5% of its
gross national product on health care, whereas other countries, for example,
Switzerland, spent less yet had healthier citizens (A. B. Martin, Hartman, Benson, et
al., 2016). The increase in expenditure is related to the increase in numbers of
individuals who have health insurance and obtain healthcare services as a result of the
ACA. In the United States, populations most likely to not have health insurance both
prior to and after the ACA include late adolescents, individuals who have moved
recently or are unemployed, and those who have low incomes. Nurses have important
roles at healthcare agencies to ensure people receive comprehensive care and encourage
more children and women to receive preventive care.
iii. Increasing alternative Settings and Styles for Health Care
The past 100 years have seen several major shifts in settings for maternity and child
care. At the turn of the 20th century, for example, most births took place in the home,
with only the very poor or ill giving birth in “lying-in” hospitals. By 1940, about 40%
of live births occurred in hospitals. By 2014, the figure has risen to 98.5%. Out-of-
hospital births account for a total of 1.5% of births, with 68% of those occurring in the
home and 30.9% occurring in a freestanding birth center. This is the highest rate of
home births since 1989 (Hamilton et al., 2015).
An important outcome of this movement is that hospitals have responded to
consumers’ demands for more natural childbirth environments by refitting labor and
delivery suites as homelike birthing rooms, often called labor-delivery-recovery (LDR)
or labor-delivery-recovery-postpartum (LDRP) rooms (Fig. 1.6). Partners, family
members, and other support people can stay with the woman in labor as if they were
home and so can feel a part of the childbirth. Couplet care—care for both the mother
and newborn by a primary nurse—is encouraged after the birth. Whether childbirth
takes place at home, in a birthing center, or in a hospital, the goal is to keep it as natural
as possible while ensuring the protection experienced healthcare providers offer.
 Healthcare settings for children are also changing. Patients’ homes, community
centers, or school-based or retail setting emergent care clinics are examples of places
in which comprehensive health care may be administered. Retail clinics or emergent
care clinics located in shopping malls are often staffed by nurse practitioners, so nurses
play a vital role in seeing such healthcare settings do not limit continuity of care
(Rohrer, Garrison, & Angstman, 2012).
In ambulatory settings of this nature, a nurse practitioner may provide
immunizations, screenings, health and safety education, counseling, crisis intervention,
or parenting classes. This form of community-based care has the potential to provide
cost-effective health promotion, disease prevention, and patient care to large numbers
of children and families in an environment familiar to them.
More and more, children and women experiencing a pregnancy complication or an
acute illness, who might otherwise have been admitted to a hospital, are now being
cared for in ambulatory clinics or at home. Separating a child from his or her family
during a long hospitalization has been shown to be potentially harmful to the child’s
development, so any effort to reduce the incidence of separation has a positive effect.
Avoiding long hospital stays for women during pregnancy is also a preferable method
of care because it helps to maintain family integrity.
Ambulatory or non–hospital-based care requires intensive health teaching by the
nursing staff and follow-up by home care or community health nurses to ensure a
smooth transition to and from this setting. Teaching parents of an ill child or a woman
with a complication of pregnancy what danger signs to watch for that will warrant
immediate attention includes not only imparting self-care information but also
providing support and reassurance that the patient or parents are capable of
accomplishing this level of care.
iv. Increasing Use of Technology
The use of technology is increasing in all healthcare settings. The field of assisted
reproduction technology such as in vitro fertilization and the possibility of stem cell
research are forging new pathways (Palermo, Neri, Monahan, et al., 2012). Charting by
computer into electronic health records and monitoring fetal heart rates by Doppler
ultrasonography are other examples (Stewart, Letourneau, Masuda, et al., 2011). Using
an electronic charting system has the ability to allow different healthcare providers to
share information (e.g., an X-ray taken at one site can be reviewed at another, a
caregiver can be alerted to all the medicines a pregnant woman has been prescribed).
As long as privacy is maintained, the system allows for a coordination of care never
before possible.
To protect patient privacy, the DHHS has established a privacy rule (the Health
Insurance Portability and Accountability Act, commonly referred to as HIPAA) that
creates national standards to protect individuals’ medical records and other personal
health information and applies to healthcare providers who conduct healthcare
transactions electronically. The rule requires appropriate safeguards be put into place
to protect the privacy of personal health information and sets limits and conditions on
the uses and disclosures that may be made of such information without patient
authorization. The rule also gives patients rights over their health information,
including the rights to examine and obtain a copy of their health record and to request
corrections (DHHS, Office of Civil Rights, 2007).
In addition to learning these technologies and rules, maternal and child health
nurses must be able to explain their use and their advantages to patients. Otherwise,
patients may find new technologies more frightening than helpful to them.
v. Meeting Work Needs of Pregnant and Breastfeeding Women
As many as 90% of women work at least part time outside their home, and many
pregnant women want to continue to work during a pregnancy (in many families,
women earn more than their spouse or partner, making them the primary wage earner
in the family). Following the birth of their child, however, women may want or need a
leave from work to care for their newborn.
A serious health condition is defined as “an illness, injury, impairment, or physical
or mental condition involving such circumstances as inpatient care or incapacity
requiring 3 workdays’ absence” (U.S. Department of Labor, 1995). Specifically
mentioned in the law is any period of incapacity due to pregnancy or for prenatal care
with or without treatment. Illness must be documented by a healthcare provider. Nurse
practitioners and nurse-midwives are specifically listed as those who can document a
health condition, so they have an equal role with physicians in alerting women to this
benefit. Although not as generous a program as many other developed countries, paid
leave helps appreciably with the care of an ill child or a woman who is ill during
pregnancy.
vi. Increasing Use of Alternative Treatment Modalities
There is a growing tendency for families to use alternative forms of therapy, such
as acupuncture or therapeutic touch, in addition to or instead of traditional healthcare
measures. Nurses have an increasing obligation to be aware of complementary or
alternative therapies as they have the potential to either enhance or detract from the
effectiveness of traditional therapy (D. Adams, Cheng, Jou, et al., 2011). Unfortunately,
many nurses (47% to 52%) do not feel comfortable discussing these therapies with their
patients (Chang & Chang, 2015).
Healthcare providers who are unaware of the existence of some alternative
forms of therapy may lose an important opportunity to capitalize on the positive
features of that particular therapy. For instance, it would be important to know that an
adolescent who is about to undergo a painful procedure is experienced at meditation
because asking the adolescent if she wants to meditate before the procedure could help
her relax. Not only could this increase her comfort, but it could also offer her a feeling
of control over a difficult situation. People are using an increasing number of herbal
remedies, such as drinking herbal teas during pregnancy to relieve morning sickness.
Asking about these at a health assessment is important to prevent drug interactions
(Dennehy, 2011).
vii. Increasing Reliance on Health Care
Shortened hospital stays have resulted in a transition from hospital to home of many
women and children before they are optimally ready to care for themselves. In some
instances, ill children and women with complications of pregnancy may choose to
remain at home for care rather than be hospitalized. This has created a “second system”
of care requiring many additional care providers (Turnbull & Osborn, 2012).
Nurses can be instrumental in assessing women and children at hospital discharge
and help them plan the best type of continuing care, devise and modify procedures for
home care, and sustain patients’ morale so a transition to home is seamless.
IV. Legal Considerations of Maternal-Child Practice
Legal concerns arise in all areas of health care. Maternal and child health nursing
carries some legal concerns above and beyond other areas of nursing because care is often
given to patients who are not of legal age for giving consent. Additionally, reproductive
healthcare rights and laws are complex and vary from state to state. These issues require
specific attention when caring for expectant families. New technologies (e.g., assisted
reproduction, surrogate motherhood, umbilical cord sampling, safety of new medicines
with children, and end-of-life decisions) can lead to potential legal action, especially if
patients are uninformed about the reason or medical necessity for these procedures.
Nurses are legally responsible for protecting the rights of their patients, including
confidentiality, and are accountable for the quality of their individual nursing care and that
of other healthcare team members. New regulations on patient confidentiality guarantee
patients can see their medical record if they choose, but health information must be kept
confidential from others (Duffy, 2011). Unfortunately, although nurses recognize the need
for patient privacy, it is not practiced at the same rates. Patients are also not aware of the
importance for their own medical record privacy (Kim, Han, & Kim, 2016).
Understanding the scope of practice (the range of services and care that may be
provided by a nurse based on state requirements) and standards of care can help nurses
practice within appropriate legal parameters.
Documentation is essential for justifying actions. This concern is long lasting
because children who feel they were wronged by healthcare personnel can bring a lawsuit
at the time they reach legal age. This means a nursing note written today may need to be
defended as many as 21 years into the future. The specific legal ramifications of procedures
or care are discussed in later chapters as procedures or treatment modalities are described.
Personal liability insurance is strongly recommended for all nurses, so they do not incur
great financial losses during a malpractice or professional negligence lawsuit.
Nurses need to be conscientious about obtaining informed consent for invasive
procedures in children and determining if pregnant women are aware of any risk to the
fetus associated with a procedure or test. A parent can be contacted by phone or e-mail if
not present with the child at the time the consent is needed.
 In divorced or blended families (those in which two adults with children from
previous relationships now live together), it is important to establish who has the right to
give consent for health care. Adolescents who support themselves or who are pregnant are
frequently termed “emancipated minors” or “mature minors” and have the right to sign for
their own health care.
The term “wrongful birth” is the birth of a disabled child whose pregnancy the
parents would have chosen to end if they had been informed about the disability during
pregnancy. “Wrongful life” is a claim that negligent prenatal testing on the part of a
healthcare provider resulted in the birth of a disabled child. “Wrongful conception” denotes
that a contraceptive measure failed, allowing an unwanted child to be conceived and born.
As many genetic disorders can be identified prenatally, the scope of both “wrongful birth”
and “wrongful life” grows yearly (Whitney & Rosenbaum, 2011).
If a nurse knows the care provided by another practitioner was inappropriate or
insufficient, he or she is legally responsible for reporting the incident. Failure to do so can
lead to a charge of negligence or breach of duty.

V. Ethical Considerations of Practice

Some of the most difficult ethical quandaries in health care today are those that
involve children and their families. Examples include:
 Conception issues, especially those related to in vitro fertilization, embryo
transfer, ownership of frozen oocytes or sperm, and surrogate motherhood
 Pregnancy termination
 Fetal rights versus rights of the mother
 Stem cell research
 Resuscitation (and length of its continuation)
 Number of procedures or degree of pain a child should be asked to endure
to achieve a degree of better health
 Balance between modern technology and quality of life
 Difficulty maintaining confidentiality of records when there are multiple
caregivers
 Legal and ethical aspects of issues are often intertwined, which makes the decision-
making process in this area complex. Because maternal and child health nursing is so
strongly family centered, it is common to encounter some situations in which the interests
of one family member are in conflict with those of another or the goals of a healthcare
provider are different from the family’s. Maintaining privacy yet aiding problem solving
in these instances can be difficult but is a central nursing role (Kim et al., 2016). Nurses
can help patients by providing factual information and supportive listening, and helping
the family and healthcare providers clarify their values.
The Pregnant Woman’s Bill of Rights and the UN Declaration of Rights of the
Child (available at http://thePoint.lww.com/Flagg8e) provide guidelines for determining
the rights of women and children with regard to maternal and child health care.

VI. Roles and responsibilities of a Maternal and Child Health Nurse

 Considers the family as a whole and as a partner in care when planning or
implementing or evaluating the effectiveness of care.
 Serves as an advocate to protect the rights of all family members, including the
fetus.
 Demonstrates a high degree of independent nursing functions because teaching
and counseling are major interventions.
 Promotes health and disease prevention because these protect the health of the
next generation.
 Serves as an important resource for families during childbearing and
childrearing as these can be extremely stressful times in a life cycle.
 Respects personal, cultural, and spiritual attitudes and beliefs as these so
strongly influence the meaning and impact of childbearing ad childrearing.
 Encourages developmental stimulation during both health and illness so
children can reach their ultimate capacity in adult life.
 Assess families for strengths as well as specific needs for challenges.
 Encourages family bonding through rooming in and family visiting in maternal
and child healthcare settings.
  Encourages early hospital discharge options to reunite families as soon as
possible to in order to create a seamless, helpful transition process.
 Encourages families to reach out their community so the family can develop a
wealth of support people they can call on in a time of family crisis.
VII. WHO’s 17 Sustainable Development Goals
The Sustainable Development Goals (SDGs) are a collection of 17 global goals
designed to be a "blueprint to achieve a better and more sustainable future for all".
1. No Poverty - End poverty in all its forms everywhere.
2. Zero Hunger - End hunger, achieve security and improved nutrition and
promote sustainable agriculture.
3. Good Health and Well Being - Ensure healthy lives and promote well-being
for all.
4. Quality Education - Ensure inclusive and equitable quality education and
promote lifelong learning opportunities for all.
5. Gender equality - Achieve gender equality and empower all women and girls.
6. Clean water and sanitation - Ensure availability and sustainable management
of water and sanitation for all.
7. Affordable and clean energy - Ensure access to affordable, reliable,
sustainable and modern energy for all.
8. Decent work and economic growth - Promote sustained, inclusive and
sustainable economic growth, full and productive employment and decent work
for all.
9. Industry, Innovation, and Infrastructure - Build resilient infrastructure,
promote inclusive and sustainable industrialization, and foster innovation.
10. Reducing inequalities - Reduce income inequality within and among
countries.
11. Sustainable cities and communities - Make cities and human settlements
inclusive, safe, resilient, and sustainable.
12. Responsible consumption and production - Ensure sustainable consumption
and production patterns.
 13. Climate action - Take urgent action to combat climate change and its impacts
by regulating emissions and promoting developments in renewable energy.
14. Life below water - Conserve and sustainably use the oceans, seas and marine
resources for sustainable development.
15. Life on land - Protect, restore and promote sustainable use of terrestrial
ecosystems, sustainably manage forests, combat desertification, and halt and
reverse land degradation and halt biodiversity loss.
16. Peace, justice and strong institutions - Promote peaceful and inclusive
societies for sustainable development, provide access to justice for all and build
effective, accountable and inclusive institutions at all levels.
17. Partnerships for the goals - strengthen the means of implementation and
revitalize the global partnership for sustainable development.
ACTIVITY
Assignment
Written
1. After studying the section on the philosophy of maternal and
child health nursing, write a brief report discussing your own
personal philosophy as a nurse caring for mothers and their
children. Be sure to consider how maternal and child health
nursing is family-centered, community-centered, evidence-
based, and challenging. State how you would create a seamless
flow between maternal and child nursing in your own practice.
2. Use your critical thinking skills to develop a written care plan
for the following client:
A 40-year-old mother of two children (ages 8 and 10 years) is living
in her car after she lost her job at a restaurant. She brings her 8-year-
old to your clinic with a sore throat and high fever. The mother
confides in you that she “has no insurance and cannot afford food
for her children let alone medications.”
Group
 1. Divide into small groups to discuss the scope of practice for maternal
and child nursing care. Assign a group leader to direct the discussion
and write down the suggested activities involved in maternal and child
care. These may include preconception health care, care of pregnant
women, care of infants during the perinatal period, and care of children
from birth until adulthood. Be sure to include and define common
statistical terms used in the field and note how they relate to maternal
and child nursing care. Share the results of the group session with your
fellow students in a class discussion.
Web
1. Research the 2007 Robert Wood Johnson Foundation QSEN Learning
Collaborative focusing on the six competencies necessary for quality
care: patient-centered care, teamwork and collaboration, quality
improvement, informatics, evidence-based practice, and safety. Make a
list of nursing interventions in each competency related to providing
quality maternal and child health care.
EXERCISES
Online: Synchronous Learning
A. Pre Test:
The pretest consist of ten (10) items, five items TRUE/FALSE format and five items
fill in the blank. The test is published and available at testmoz.com/5710468 with a test
name NCM 107: Module 1. Password will be send to students five (5) minutes prior to
scheduled time.
B. Post Test: PATIENT CASE SCENARIO
A FAMILY IN NEED OF NURSING CARE
Robert Head is a young adult you meet in an ambulatory setting.
CHIEF CONCERN:
“I haven’t felt healthy since my wife announced she was pregnant.”
HISTORY OF CHIEF CONCERN:
The 26-year-old client states he has not felt well since a backpacking trip to
Vietnam 3 months ago. He experienced severe diarrhea while on the trip but was treated
at a local clinic with antibiotics with good results. He has had no reoccurrence of diarrhea
since his return to the Philippines but has had nausea off and on for the past 2 weeks.
FAMILY PROFILE:
The client lives with his 28-year-old wife, Denise, and 4-year-old son, Aaron, in a
two-bedroom apartment. Denise had a miscarriage at 12 weeks of pregnancy 2 years ago.
She’s now currently 2 months pregnant with a second pregnancy. She’s noticed extreme
morning sickness for the past 2 weeks. Her mother is temporarily living with the family
to help with housework until Denise is past the point she lost her last baby (at 3 months).
The client works part time as an assistant at a talent agency. He is writing a
screenplay about backpacking he hopes to sell and then make screenwriting his career.
Family finances are described as “not good.” Denise contributes more income to family
from a full-time job as a secretary at a law firm.
FAMILY HISTORY:
The client’s father died of a heart attack at age 55 years. An aunt has breast
cancer. His wife’s mother has hypertension and macular degeneration that limits her
vision. Denise has had diabetes since she was 5 years old; she takes daily insulin and
follows a diabetic exchange diet.
PAST MEDICAL HISTORY:
The client states he has been ill more than most people. He says, “I was even born
sick” because he was born prematurely and spent 2 months in an intensive care unit
before discharge. Weight and height were normal by school age. He had mumps at age 8
years; he broke an arm falling from a tree at age 10 years. He has an old knee injury from
playing soccer in high school; he admitted with difficulty he tried to kill himself
following this injury (age 16 years), as it cancelled out a sports scholarship to college he
was counting on. He has had chronic sinusitis and occasional nosebleeds since about age
20 years.
REVIEW OF SYMPTOMS:
Weight: No recent loss of weight despite frequent nausea
Head: Has always had trouble with headaches (“more than my share”)
CV: Never had any difficulty with heart; cholesterol is slightly elevated (240 mg); tries to
follow a “heart-healthy” diet
GI: No diarrhea since bout in foreign country 3 months ago; “on and off” nausea for past 2
weeks
GU: Is sexually active with wife; no protection as it is a monogamous relationship; does
not do self-testicular exams
Extremities: Right knee motion limited from old torn cartilage repair of knee
PHYSICAL EXAMINATION:
General Appearance: Well-appearing but pale and distressed-appearing young adult male
HEENT: Normocephalic; slight tenderness over anterior sinuses; thin watery discharge
from nostrils; several reddened erosions on gum line
Neck: Two shotty lymph nodes on anterior chain; full range of motion in neck
Chest: Heart rate: 82 beats per minute; regular rhythm; normal breath sounds
Abdomen: Soft to palpation; well-defined abdominal muscles
Extremities: Obvious horizontal scars across palmer surface of both wrists; old surgical
scar on inside of right knee
LABORATORY REPORTS:
Stool is negative for ova and parasites.

Robert is diagnosed as having couvade syndrome (a syndrome where men experience the
same symptoms such as morning sickness as their significant other during pregnancy).
STUDY QUESTIONS (Post-test)

The posttest has twenty (20) questions, a multiple choice format with four (4) choices per
question distributed from the revised Bloom’s taxonomy. The student are asked to choose
one correct answer and it will take 45 minutes to complete the test. Questions will be
shuffled during the test. The test is published and available at testmoz.com/5710564 with
a test name NCM 107: Module 1 Post-test. Password will be send to students five (5)
minutes prior to scheduled time.

Online: Asynchronous Learning

Asynchronous Learning: OPEN-ENDED QUESTIONS:
1. What if Robert asks you why the Philippine system of health care is so different from
other developing countries which have a health care system neither based on work site
nor on profit but on provision of care for all citizens through a tax-supported program?
The infant mortality rate in many of these countries is lower than in the Philippines. What
are some reasons a different health care base might contribute to these lower rates?
2. What if Robert asks you how he can be certain his local health care facility is the right
one for him?
Asynchronous Learning: Critical Thinking Care Study
Tommy is a 10-year-old who has asthma. He is home schooled after having two serious
asthma attacks at school because he is allergic to the cleaning product used in his primary
school classroom. His mother is pregnant with a new brother or sister but hasn’t come for
prenatal care because she noticed the clinic uses the same cleaning solution and doesn’t
want her new baby to develop an allergy to it. At the same time, she wants a sonogram so
she can see if she’s having a girl or boy.
a. Nurses work in a wide range of settings in maternal and child health. What
actions could you take to help Tommy get back to school and his mother begin
to come for prenatal care?
b. Cost containment along with limitations of health insurance make it important
for nurses to be aware of the cost of supplies and procedures. Is having a
sonogram just to know the sex of a fetus a good use of healthcare funds?
c. Homelessness is becoming an increasing concern in modern society. Suppose
Tommy’s family became homeless? How do you anticipate this will affect their
overall health?
Evaluation Description: For Critical Care Study and Open ended Questions.
Refer to the following rubrics:
1. Identifies the major issues/factors direct from the data given. (15 points)
2. Concisely explains the identified issues/ factors. (15 points)
3. Supports the use of best practices and application of evidences. (15 points)
4. Uses of citations/resources. (5 points)
Guidelines:

 Consultation will be done via facebook messenger group chat or google
meet.
 Output may be prepared in soft and hard copy.
  DOC or PDF will be accepted. Format: 1 inch margin, 1.5 spacing, Times
New Roman 12 font. Paper size A4
 Write/ type your name on the upper left corner with this sequence
Surname, First name, M.I. On the upper right corner your Block and
below Module number.
 Write your answer legibly (Printed) for those students opt handwritten
output.
 Submit your answer with your full name and block one week after the last
day of session/module through my institutional email address
(joelfedericornman@prmsu.edu.ph).

References
o Silbert-Flagg, JoAnne, Pililliteri, Adelle, (2018). Maternal & Child Health
Nursing 8th Edition, Lippincott Williams & Wilkins.
o Student resources on thePoint, including answers to the What If … and Critical
Thinking Care Study questions, http//thepoint.lww.com/Flagg8e
o Adaptive learning powered by PrepU, http://thepoint.lww.com/prepu

Prepared By: Approved By:

Joel D. Federico, RN, MAN Rene E. Pudadera, Ed.D., MAN

NCM 107 Lecturer 2020-2021 Dean, College of Nursing
Instructor I

Module 1: Framework for Maternal and Child Health Nursing