THE ROLE OF PROFESSIONAL NURSING IN THE ORIGIN OF THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF 1996 FROM A FEMINIST PERSPECTIVE, 1981-1996
A Dissertation Presented By
JAN-LOUISE LEONARD
Submitted to the Graduate School of the University of Massachusetts Amherst in partial fulfillment Of the requirements for the degree
DOCTOR OF PHILOSOPHY September 2006 Ph.D. Program in Nursing University of Massachusetts Amherst
Copyright by Jan-Louise Leonard 2006 All Rights Reserved PROFESSIONAL NURSING’S ROLE IN THE ORIGIN OF THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF 1996 FROM A FEMINIST PERSPECTIVE, 1981-1996
A Dissertation Presented by JAN-LOUISE LEONARD
Approved as to style and content by:
______Eileen T. Breslin, Chairperson
______Gail Russell, Member
______Joyce Berkman, Member
______Eileen T. Breslin, Dean, School of Nursing DEDICATION
To my children, Michael and Mark, who encouraged and took pride in me. And to my parents, who encouraged perseverance in any daunting task. ACKNOWLEDGEMENTS I wish to thank my committee chair, Eileen T. Breslin, for the many years of patience, support, and encouragement in this research project. Her critical questions about the who’s and the why’s in this research made me think about the origins of professional nursing’s input into health care policymaking. I hope this study’s research method serves as a model for other nurses the University of Massachusetts Amherst School of Nursing doctoral program to which they can improve upon. Many thanks also go to Joyce Berkman of the History Department, and a member of my committee. As my methods advisor, I was particularly impressed with her ability to find a missing linkage (1950s’ unionization of nurses) on the path to nursing’s self- determination as a profession. Her depth and breadth of historical knowledge provides an inspiration for all future professors. Gail Russell, a nurse health care policy expert, recalled events in professional nursing that re-directed the course of nursing history. She saw those events as crucial in making linkages with the role of nursing in health care policymaking and the research question. Dr. Linda Kahn-D’Angelo, a dear friend and colleague, is acknowledged for the access she provided to numerous documents and books in my research for this project. I also want to acknowledge the secretarial staff at the School of Nursing for their assistance during this research project, Karen Ayotte and Ann York.
v ABSTRACT THE ROLE OF PROFESSIONAL NURSING IN THE ORIGIN OF THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF 1996 FROM A FEMINIST PERSPECTIVE, 1981-1996 SEPTEMBER 2006 JAN-LOUISE LEONARD, BS, UNIVERSITY OF ROCHESTER MS, BOSTON UNIVERSITY Ph.D., UNIVERSITY OF MASSACHUSETTS AMHERST Directed by: Eileen T. Breslin
This social historiography tells the story of the origin of the Newborns’ and
Mothers’ Health Protection Act of 1996. In the 1980s when the federal government reduced allocations to states’ Medicaid programs as a cost saving measure, hospitals, initiated early discharge of patients to save costs. Given four million births annually, childbirth is the most frequent reason for hospitalization in the United States. Hospitals discharged Medicaid insured mothers and newborns very early at twenty-four hours for a normal birth and seventy-two hours for a cesarean. Other insurers adopted similar managed care strategies in the early 1990s.
By 1995, unionized nurses from New Jersey, bolstered by a national outcry against early maternal discharge, and individual states legislative actions, met with staff in
Senator Bradley’s (Democrat, NJ) Washington, DC office to request a federal law that would extend hospital length of stays for maternity patients. The result was the creation of the Newborns’ and Mothers’ Health Protection Act of 1996 (Newborn’s Act).
Insurers must now reimburse hospitals a minimum length of maternity stay of forty- eight hours for a normal birth and ninety-six hours for a cesarean birth.
vi This historical investigation found that a revival occurred in professional nursing organizations’ voice in health care policy. The American Nurses Association, the
National Association of Pediatric Nurse Practitioners, and the Association of Women’s
Health, Obstetric and Neonatal Nursing, not only testified at the congressional hearing for the Newborn’s bill, but also helped craft the bill that became law. One nursing specialty, Public Health Nursing, at one time a cornerstone for autonomous nursing practice, was omitted from the NMHPA policymaking. As a nursing section of the
American Public Health Association, it is now considering options to become more visible in health care policy development.
Second, this study suggests that the federal government may have attempted price- fixing when it recommended in 1982, and again in 1983, that other insurers also limit reimbursements to hospitals to contain costs. In one last finding, congressional lawmakers omitted costly Medicaid insured mothers from the NMHPA law, but regulations formulated in 1999 captured this vulnerable group of mothers and newborns.
vii TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS…………………………………… ...... v
ABSTRACT……………………………… ...... vi
LIST OF TABLES……………………………… ...... xiii
LIST OF FIGURES…………………………...... xiv
LIST OF ABBREVIATIONS……………………………… ...... xv
INTRODUCTION………………………………………………………………………..1
Endnotes……………………………………………………………………………7
CHAPTER
1. STATEMENT OF THE PROBLEM…………………...... 9
Statement of the Problem...... 9
How Laws are Made in the United States...... 10
Background of Maternity Length of Stay in the United States ...... 11
Position Statements on Maternity Length of Stay ...... 11
Professional Nursing and Maternity LOS...... 13
Professional Nursing Defined...... 13 Relevance of Maternity LOS to the Future of Professional Nursing...... 15 Ethics in Nursing ...... 16 National Public Health Objectives...... 16
Research Questions...... 19 Summary...... 19 Endnotes...... 23
2. REVIEW OF THE LITERATURE ...... 28
Introduction ...... 28 Research into Maternity Length of Stay...... 29
viii Quantitative Research Studies on EMD for Mothers and Newborns...... 31 Qualitative Research Studies on EMD for Mothers and Newborns...... 48 Quantitative Research Studies on Newborn Early Discharge...... 50 Psychosocial Impact of EMD Studies That May Have Been Available to Congress...... 53
Summary …………...... 56 Endnotes …………...... 66
3. METHODOLOGY...... 73
Social History and Feminist Theory as Methods...... 73 The Science and Art of Historical Inquiry...... 73
Social History of Maternity LOS ...... 75
Sources for Data Collection...... 76
Oral History...... 76 Primary Data...... 77 Secondary Data...... 78 Trustworthiness, Validity and Reliability...... 79
Data Analysis: A Theoretical Framework...... 80
Feminist Theory Framework ...... 80 Why Use Feminist Critique in This Study ...... 81 Feminist Research Method...... 82
Summary...... 83 Endnotes ...... 85
4. PROFESSIONAL NURSING IN MATERNAL HEALTH CARE IN THE 18TH, 19TH, AND 20TH CENTURIES IN THE UNITED STATES ...... 89
Introduction ...... 89 Childbirth Practices in the United States...... 90
18th Century Home Births...... 90 19th Century and Early 20th Century Childbirth Practices...... 91
The Medicalization of Childbirth ...... 93
The Invention of Obstetrical Interventions...... 93 Obstetricians versus Midwives...... 95 Improved Obstetrical Education and Childbirth...... 96
ix Hospital Control of Childbirth...... 97
Hospital Control in the 19th and 20th Centuries ...... 97 Early Hospital Finances...... 99 Modern Hospital Finances...... 100
Health Insurance and Childbirth...... 103
Early 1900s……...... 103 Latter 1900s ……...... 104 Evolution of Maternity Health Insurance Benefits...... 105
The Influence of the Women’s Movements of the 19th & 20th Century on Childbirth……...... 113
Women’s Views on Childbirth Interventions by Physicians...... 113 The Second Women’s Movement and Childbirth...... 115 The Feminist Voices on Childbirth Practices...... 118
The Nursing Movements of the 20th Century and Childbirth Practices ...... 119
Professional Nursing in the Political Arena ...... 120 Nurses’ Autonomy in Family Care in the Early 1900s ...... 126 The Influence of the Women’s Movement on the Nursing Movement of the 1900s...... 127 Nurses’ Transition into Hospital Nursing...... 130
The Beginning of the Nursing Movement of the 1970s and 1980s...... 133
Professional Nursing and the Political Arena...... 133 An “Uneasy Alliance” Between Nursing and Feminists...... 138 Feminists and the Caring Professions...... 142 Nursing and Politics ...... 145 Nursing and the Political Socioeconomics of Maternity LOS ...... 147
Summary...... 150 Endnotes ...... 154
5. THE HISTORICAL PATH: FROM HUMAN RIGHTS TO MOTHER’S RIGHTS…………..…...... ………………………..179
Introduction…………...... 179 How the Newborns’ and Mothers’ Health Protection Act of 1996 Became a Law… ...... 179
The Urge to Curb Expenses, 1970s-1980s ...... 179 Historical Definitions of Early Discharge ...... 182
x Shortening Hospital Length of Stay ...... 182 Current Early Discharge Defined ...... 184 Regulations of LOS by States...... 184
Why Maternity LOS Became a Federal Law ...... 185
Getting NMHPA Through Congress...... 185 Nursing’s Involvement in NMHPA Legislation...... 188 Strategies to Test and Gather More Support From the Public For NMHPA: The Media...... 199 Congressional Support and Opposition to the NMHPA Bill...... 200
Summary...... 206 Endnotes ...... 208
6. MEDICAID-INSURED MOTHERS AS A VULNERABLE MATERNITY POPULATION IN THE HEALTH CARE SYSTEM...... 224
Introduction…………… ...... 224 Targeting Consumer Reforms on Birthing Practices to Decrease Maternity LOS……...... 225 Nurses’ Demands for Change in Childbirth Practices...... 226
The Role of Professional Nursing Organizations in Changes in Childbirth Practices ...... 231 Nurses and Shortened Maternity LOS in the 1990s ...... 232 Impact of Early Discharge on Newborns ...... 236
Maternity LOS for Medicaid-Insured Mothers and NMHPA ...... 236
What is Medicaid?...... 237 States’ Medicaid Reimbursements for Childbirth ...... 237 Medicaid-Insured Mothers Under NMHPA...... 238 How NMPHA Eventually Applied to Medicaid-Insured Mothers...... 240
Hospital Utilization by Medicaid-Insured Mothers...... 244
Hospitals’ Discriminatory Utilization Practices...... 245 Background of Hospital Utilizations Statistics for Medicaid Recipients...... 247 Description of NHDS and HCUP Databases...... 248 Sources of Payment for Childbirth...... 252 Medicaid Mothers Under Managed Care ...... 255
Childbirth LOS Abroad Compared to the U.S...... 257 Summary………………...... 258 Endnotes………………...... 267
xi
7. CONCLUSION: PROFESSIONAL NURSING’S ROLE IN THE POLITICAL AND SOCIOECONOMIC EXTENSION OF MATERNITY LENGTH OF STAY IN THE UNITED STATES ...... 286
Introduction ...... 286 Renewal of Political Activism in Professional Nursing...... 288
Quest for Autonomy in Professional Nursing Abated in the Early 1900s...... 288 Intra-professional Nursing Issues...... 289 Revival of Autonomy in Nursing ...... 293 Education in Nursing...... 295
The Issue of Maternity Length of Stay: The Expansion and Contraction of Maternity LOS from 1890-1996...... 296 Endnotes……………...... 300
APPENDICES
A. APPROVAL FORM FOR NURSING RESEARCH ...... 302 B. CONSENT TO PARTICIPATE INA RESEARCH PROJECT ...... 304 C. INTERVIEW GUIDE ...... 308
BIBLIOGRAPHY ...... 310
xii LIST OF TABLES
Table Page
1.1 Provisions in the Code of Ethics for Nursing ...... 21
1.2 Progress in Eight Objectives ...... 22
2.1 Summary of Quantitative Research Studies on Maternal-Newborn EMD ...... 58
2.2 Summary of Qualitative Research Studies on Maternal-Newborn EMD ...... 64
2.3 Summary of Quantitative Research Studies on Newborn Early Discharge ...... 65
6.1 Average Length of Stay by First Diagnosis (Delivery) and Other Variables: Before DRGs, 1981 through 1989 ...... 261
6.2 Average Length of Stay by First Diagnosis (Delivery) and Other Variables: After DRGs, 1990 through 1995...... 261
6.3 Average Length of Stay by First Diagnosis (Delivery) and Other Variables: After NMHPA, 1996 through 1998...... 262
6.4 United States and Canadian ALOS, 1984-1995...... 262
6.5 Comparison of Maternity ALOS in Select Industrialized Countries...... 263
7.1 Maternity LOS in the 19th and 20th Centuries… ...... 299
xiii LIST OF FIGURES
Figure Page
4.1 Influential Nurses ...... 124
4.2 Timeline of Significant Influences on Childbirth in America and on Public Sentiment Regarding Obstetrical Interventions: 18th, 19th and 20th Centuries...... 153
6.1 Sources Billed for Obstetric Care...... 264
6.2 Cesarean Section Rate by Payment Source...... 265
6.3 Average Length of Hospital Stay for Vaginal Delivery...... 266
xiv LIST OF ABBREVIATIONS
Abbreviations
AAP – American Association of Pediatricians
ACNM – American College of Nurse Midwives
ACOG – American College of Obstetricians and Gynecologists
ALOS – Average Length of Stay
AMA – American Medical Association
ANA – American Nurses Association
APHA – American Public Health Association
AWHONN- Association of Women’s Health, Obstetric,
and Neonatal Nursing
CBO - Congressional Budget Office
CMS – Center for Medicare and Medicaid Services
DRG – Diagnostic Related Group
HCFA – Health Care Finance Administration
HCUP – Health Care Utilization Project
HMO – Health Maintenance Organization
LOS – Length of Stay
MCO – Managed Care Organization
NAACOG – Nurses’ Association of American College of Obstetricians and
Gynecologists
N-CAP - Nurses Coalition for Action in Politics
NAPNP – National Association of Pediatric Nurse Practitioners
xv NHDS – National Hospital Discharge Survey
NIH – National Institute of Health
NINR – National Institute for Nursing Research
NLN – National League for Nursing
NLNE – National League of Nurse Educators
NMHPA – Newborns’ and Mothers’ Health Protection Act of 1996
NOPHN – National Organization of Public Health Nurses
PHN – Public Health Nurses
PPS – Prospective Payment System
xvi INTRODUCTION
In 1996, Congress enacted the Newborns’ and Mothers’ Health Protection Act of
1996 that ensured all mothers and their newborns in the United States a minimum length
of stay in the hospital of 48 hours for vaginal deliveries and 96 hours for cesarean
deliveries (herein referred to as 48/96 hours). It was the backlash to the Social Security
Amendments of 1983 that reduced grant allocations to states that applied to all their
Medicaid recipients as part of a plan to reduce federal expenditures. 1 The reduction of
allocations led states to further reductions in reimbursements to hospitals for all inpatient
length of stays, including Medicaid insured mothers and newborns. Eventually, the
shortened length of stay applied to all mothers and newborns in the United States.
For maternity patients, the length of stay was reduced to 24 hours from the usual average of four days for vaginal deliveries, and to 72 hours for cesarean deliveries when the usual was six days, (herein referred to as 24/72 hours). The decrease in maternity length of stay (maternity LOS) was made without a priori clinical research into appropriate discharge timing. Also, at that time, the federal grants to states required states
to transition to a prospective payment system from a fee-for-service payment system.
Medicaid health care reformers used fiscal balance sheets to determine length of stay for
mothers and newborns instead of using evidenced-based criteria developed by research
scientists for optimal maternal-newborn discharge timing. By 1996, it was apparent that
federal legislation to extend maternity LOS was “was needed to protect the public.”2 and
restore mothers and their newborns what the federal government had limited in 1983.
This paper is a historical inquiry into professional nursing’s contribution to the
origin of these legislative actions on maternity LOS in hospitals in the United States
1 during the years 1981-1996. Three areas of focus are: the effects of reduced hospital
length of stays on maternity, that is, the experience of mothers and newborns after
childbirth; the lack of choice that mothers had in their length of hospitalization; and the
public patient advocacy role of professional nursing in the origin of the 1996 Newborns’
and Mothers’ Health Protection Act that required insurers to pay for longer
hospitalization after childbirth.
Using the historical method, this inquiry seeks to establish an explanation as to why Congress reduced maternity LOS in 1983, and then extended it in 1996, and who initiated such actions by examining the antecedent sociopolitical and economic events that surrounded the federal legislation and maternal LOS. The consequences of the events culminated in the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) that expanded maternity LOS to 48/96 postpartum.3 Both the 1983 and the 1996 bills became laws without sufficient research into the consequences of such legislative action.4
The findings of this historical study are organized into six chapters that trace the
historical pathway to legislation on maternity LOS for mothers and their newborns. The
phrase “maternity length of stay” is used because maternity refers to the mother and
newborn and the milieu surrounding childbirth.5 These chapters describe the
socioeconomic and political conditions that influenced maternity LOS for mothers and
their newborns from 1981 through 1996, employing feminist critical analysis of these
conditions to enhance the understanding of the myriad of influences surrounding the
passage of these two laws. Some of those influences include nursing, medical, and
hospital practices. Others, such as the women’s health movement and federal health care
2 programs, are examined. One especially influential group, the federal congressional
policymakers themselves, merits attention.
Chapter 1 sets forth the over-arching research question examined in this research project is to discover why, and to what extent, professional nursing became involved in the origin of the public health care policy NMHPA. A definition of professional nursing is stated. Multiple research questions stemming from the overarching research question are explicated in each chapter. How laws are made in the United States is described. The background of maternity LOS is reviewed, why LOS was reduced to 24/72 hours, and why maternity LOS was subsequently expanded to 48/96 hours by NMHPA in 1996. The
1983 legislation enacting limited reimbursements to states, and hence, for maternity LOS was without supportive research for optimal LOS. Likewise, the extension to 48/96 by
NMHPA in 1996 was inadequately researched. Position statements from nursing and various professional organizations detail their reactions to maternity LOS of 24/72. This chapter establishes why it is important for professional nursing to study maternity LOS underpinned by the Code of Nursing Ethics and national public health objectives.
Chapter 2 reviews the literature on research studies conducted on maternity length of stay that appeared á posteriori 1983 and á priori NMHPA. This dissertation investigates only maternity LOS in hospitals, since 1% of childbirths in the U.S. currently occur outside of hospitals.6 The studies use various concepts, measurement criteria, and
terms for maternity LOS, such as maternal length of stay, early maternal discharge
(EMD) or early postpartum discharge, shortened length of stay, or postpartum length of
stay. But all terms refer to childbirth and the subsequent length of hospitalization for
mothers and their newborns.
3 Chapter 3 presents the research method used in this study. The historical method
was chosen to trace the socioeconomic and political influences from 1981 to 1996 that led to the making of NMHPA. How professional nursing and the influences interfaced with health care policy on maternity LOS throughout the study years . It is important for nurses to know the fluctuating level of involvement that professional nursing had in the history of newborns’ and mothers’ health care policy and how policymaking influenced the practice of professional maternity nursing.7
Feminist theory and content analysis underpin the historical method used in this research. Feminist theory scrutinizes the influences and events by gender, class, race and ethnicity.9 Therefore, by viewing maternal LOS through the feminist lens, we can better
understand who was involved in making the policies, who benefited from the policies and
why. Was gender-dominance or oppression involved in policymaking, and, if so, how
did it impact nursing and maternal LOS? As each chapter evolves, evidence will be
presented to answer these compelling questions.
Chapter 4 presents the role of professional nursing in childbirth practices in the
United States. Maternity LOS is examined through the lens of class, race, and ethnicities and the web of socioeconomic influences created by nurses, physicians and hospitals since colonial days. An overview is included on the ways in which the women’s movements of the 19th and 20th century influenced maternity LOS and the tacit role
nursing had in the early feminist movement. Reasons are revealed for the lack of
influence by professional nursing on maternity LOS until the 1990s. A Venn diagram
crystallizes the span of social history surrounding childbirth in America.
4 Chapter 5 outlines the fifteen-year trajectory from 1981 to 1996 when the federal
government issued mandates that controlled maternity LOS for Medicaid recipients that
sets the backdrop for professional nurses’ concerns in 1995, culminating in the NMHPA.
This chronological format allows the salient socioeconomic and political boundaries
surrounding NMHPA to be presented. Also included are primary source interviews with
Senator Bradley, one of the sponsors of NMHPA, Colleen Meiman and Dr. Margaret
Heldring, two of his staff assistants who crafted the bill; Ruthann Johnson, R.N., from
New Jersey, and who helped Dr. Heldring finish crafting NMHPA; Ann Twomey, RN,
and Jeanne Otersen, two of the several nurses who met with Senator Bradley and Colleen
Meiman in March 1995 regarding hospitals’ unsafe practice of early maternal discharge
before recovery because insurers limited payments for childbirth. Another nurse
preferred to remain anonymous, but advocated for her patients in 1995 by requesting
Senator Bradley to pass a law to protect mothers’ and newborns’ postpartum health.
Chapter 6 illuminates Medicaid’s historical involvement as a leader in the maternity LOS issue, as well as the practices of hospitalization for childbirth for this population. The different medical approaches to childbirth experienced by women enrolled in Medicaid from 1981 through 1996 are described. The chapter provides an overview of the Medicaid grant program as it applies to U.S. Health Maintenance
Organizations (HMOs) and private insurers. Childbirth practices in industrial countries around the world are compared and contrasted to those in the U.S. International data show that, though there was a trend to decrease maternity LOS, the United States decreased LOS more sharply and in less time than other industrial countries.
5 Each chapter provides mounting evidence upon which Chapter Seven rests.
Chapter 7 synthesizes this study to present the findings that prompted the legislation of maternity LOS, as well as the extent of professional nursing’s involvement in the legislative process. The social, economic and political arenas are integrated to present an overview of the interests groups controlling women’s childbirth experiences and the reasons for their involvement. The chapter includes professional nursing’s role in the creation of NMHPA: the findings as to why nursing was absent from involvement in the development of the categorization of medial diagnoses, now called diagnostic-related groups or DRGs; what moved nursing from lobbying for just intra-professional issues such as nursing education or advanced practice, into the more public realm of health policymaking in the 1990s, i.e., maternity LOS; and why professional nursing should be on the cutting edge in future health care policymaking with a direct role in crafting health care laws, even as legislators.
6 Endnotes
1. Congressional Budget Office (1979). Controlling Rising Hospital Cost: Report to
Congress. Washington, DC: Congress of the United States. Congressional
Budget Office (1981 to 1987). Reducing the Deficit: Spending and Revenue
Options. Annual Report to the Senate and House Committees on the Budget:
Parts I, II, III. Washington, DC: Congress of the United States. Also, Senate
Report 104-969, 1996.
2. Dr. Margaret Heldring, staff assistant to former Senator Bill Bradley, United States
Senate. In personal communication, May 17, 2002.
3. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204,
September 26, 1996, page 110 STAT 2935. . Also online at
bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ204.104.pdf:> 4. U.S. Senate (July 19, 1996). Senate Report: Newborns' and Mothers' Health Protection Act of 1996 (104-326). Washington, DC: U.S. Government Printing Office. Also on the Internet: U.S. Senate. (1996, April 17). Senate Report 104- 326-Newborns' and Mothers' Health Protection of 1996. Retrieved April 2, 2005, from bin/cpquery/T?&report=sr326&dbname=cp104&> 5. Lowdermilk, D. L., Perry, S. E., & Bobak, I. M. (2000). Maternity and Women's Health Care (6th ed.). Boston: Mosby. Reeder, S. J., Martin, L. L., & Koniak- Griffin, D. (1997). Maternity Nursing: Family, Newborn and Women's Health Care (18 ed.). New York: Lippincott. 7 6. Centers for Disease Control & Prevention. Trends in length of stay for hospitalized delivery in the United States 1970-1992. MMWR Morbidity & Mortality Weekly Report (1995); 44: 335-337. 7. Wertz, R., & Wertz, D. (1977). Lying-in: A History of Childbirth in America. New York: The Free Press. Milstead, J. (Ed.). (1999). Health Policy and Politics: A Nurse's Guide. Gaithersburg, MD: Aspen Publishers, Inc. 8. Hooks, B. (2000a). Feminist Theory (2nd ed.). Cambridge, MA: South End Press. Hooks, B. (2000b). Feminism is for Everybody: Passionate Politics. Cambridge, MA: South End Press. Pollitt, K. (2001). Subject to Debate: Sense and Dissents on Women, Politics, and Culture. New York: Modern Library. Roberts, J. I., & Group, T. M. (1995). Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession. Westport, Ct: Praeger. Ruzek, S. B., Clarke, A. E., & Olesen, V. L. (1997). Social, Biomedical, and Feminist Models of Women's Health. In S.B. Ruzek, V.L. Olesen & A.E. Clarke (Eds.), Women's Health: Complexities and Differences (pp. 11-28). Columbus: Ohio State University Press. 8 CHAPTER 1 STATEMENT OF THE PROBLEM This chapter states the problem to be researched and describes the background of NMHPA from 1981-1996. It includes how laws are made, position statements on maternity LOS from various professional organizations and the relevancy of maternity LOS to professional nursing in the context of nursing ethics and national public health objectives. Other research questions branching from the over-arching research question are presented. Statement of the Problem Shortened maternity LOS has been a social, economic and political problem since the early 1980’s. As a result of increases in the cost of new technological developments and increased access to medical care under Medicare and Medicaid grants, hospital costs began to soar in the 1970’s. And with four million births a year in the U.S., childbirth was and remains the most common reason for hospitalization.1 In 1981, the federal government amended public health assistance program regulations (Medicare/Medicaid) in an effort at welfare reform to reduce government health care spending.2 In 1981, the federal Omnibus Reconciliation Act (Public Law 97-35) placed limitations on allocations to states’ Medicaid public assistance programs.3 In 1983, the federal government further reduced Medicaid grants to states with the enactment of Public Law (PL) 98-21 , the Medicare Payment Reform Act of 1983, that instituted the prospective payment system, an alternative method of Medicaid reimbursement, which reduced payments for all health diagnoses.4 This study’s focus is on the childbirth diagnosis. States’ Medicaid reimbursements for childbirth to hospitals were limited to 24/72 for 9 maternity LOS. Until these cuts took effect, the average maternity LOS for all mothers in the U.S. in the was four days for vaginal delivery and six days for cesarean delivery.5 Mothers and their newborns who enrolled in states’ Medicaid programs were the first group of mothers and newborns to have reduced hospital stays. Their LOS was initiated without adequate research underpinning the safety of shortening maternity hospitalization by 75%. The reduced maternity LOS for Medicaid recipients was to start in 1983, but was delayed until 1986.6 By the early 1990’s, health maintenance organizations (HMO’s) and private insurers also began limiting their payments for maternity LOS to 24/72 based on a 1983 recommendation from the federal government.7 The shortened LOS was a 75% reduction in LOS for vaginal deliveries, from four days to one day (24 hours), and a 50% reduction for cesarean deliveries, from six days to three days (72 hours).8 In response to widespread public concern for the dramatically reduced maternity hospital stays in the mid 1990s, the federal government passed the Newborns’ and Mothers’ Health Protection Act of 1996 that extended maternity hospital stay to 48/96.9 That decision was also made with inadequate research into optimal timing for the safe discharge of mothers and newborns after childbirth. How Laws are Made in the United States Although most legislation is generated by Members of Congress, any U.S. voter has the constitutional ‘right to petition’ a Member of Congress with a proposal for legislative consideration that should their congressperson agree to introduce the idea may become a bill and then law.10 Once the “idea” is taken up by a member of the U.S. Senate or House of Representatives, it is referred to a subcommittee or full committee responsible for that particular topic. If the subcommittee approves the proposal, a draft is 10 crafted and put in a “hopper” (a box on the desk of the Speaker of the House or Senate), given a number and explained to the full committee for hearings, amendment and vote. If the bill is of sufficient importance the committee may set a date for a public hearing, to be advertised in the “Daily Digest.” After the hearings are completed a subcommittee may go into a “markup” session where changes are made to the bill that must be voted on in both Houses of Congress. If the bill passes in both Houses, it goes to the President of the U.S. who can choose to sign the bill into law or veto it in which case it goes back to Congress for reconsideration. Alternatively, if it sits for ten consecutive days without executive action it automatically becomes law. The pathway from an idea to law has shortened over the past century from 18.4 years to fifteen months as evidenced by the NMHPA law11 that was prompted by the constituents of Senator Bradley in the state of New Jersey.12 NMHPA was introduced into the Senate on June 19, 1995 and revised over the next year. A senate hearing was conducted on July 19, 1996,13 and, after meeting some partisan hesitation, NMHPA was further revised and included as an amendment to an appropriations bill for the Departments of Veterans Affairs and Housing and Urban Development as a way of getting it through Congress. President Clinton on September 26, 1996, signed NMHPA into law.14 Background of Maternity Length of Stay in the United States Position Statements on Maternity Length of Stay In 1992, physicians expressed concern with the lost revenues from Medicaid’s former fee-for-service payment system,15 and soon all health care providers questioned the medical safety of sending mothers and newborns home so quickly after delivery.16 In 11 response, professional nursing and medical organizations developed position statements on the patient conditions needed for early discharge. In 1992, the American Academy of Obstetricians and Gynecologists (ACOG) together with the American Academy of Pediatricians (AAP) defined early discharge of the mother and newborn as a stay of up to forty-eight hours for vaginal delivery and ninety-six hours for cesarean delivery.17 Additionally, they clarified what criteria should be met prior to discharge and recommended that the hospital stay should be, in consultation with her physician, "long enough to allow identification of problems and to ensure that the mother is sufficiently recovered and prepared to care for herself and her baby at home...to be based on the unique characteristics of each mother...and should not be based on arbitrary policies of third party payers."18 The Association of Women’s Health and Obstetric and Neonatal Nursing (AWHONN) published a similar statement in 1994 concerning the 24/72-hour discharge.19 The American Nurses’ Association (ANA) also supported the ideology of optimal nursing care during the postpartum period but added that a home visit should be part of the professional nursing care of the mother and newborn. It was not until 1998 that the American College of Nurse-Midwives’ (ACNM) position statement was published. Although they did not state a specific time commitment, they recognized that the timing for discharge ultimately lies with the patient, her provider, and the newborn’s provider.20 Midwives believed that discharge timing should be based on the readiness of the mother to assume care of the newborn. Professional nursing’s conduit for advocating for its maternity patients was through lobbying by its own organizations, such as the American Nurses Association, the 12 Association of Women’s Health, Obstetric and Neonatal Nursing, and the American College of Nurse Midwives, among others, situated in Washington, DC. It was not always that way. Until the 1990s, patient advocacy was often through nursing organizations and their standards of practice as will be seen in future chapters. But nursing was recognized when nurses’ voices where heard by lawmakers in 1995 who began to work with professional nursing in developing the NMHPA health care policy. Professional Nursing and Maternity LOS Professional Nursing Defined Nursing is a professional career responsible and accountable for facilitating optimal health in caring for patients. In this paper, professional nursing is defined as within the discipline of nursing. A profession is defined by preparation and commitment to a specialized body of knowledge.21 Practitioners within a profession are autonomous in their vocation and take individual accountability and responsibility for their activities and policies. Preparation for practitioners of a profession takes place in colleges or universities and involves intellectual studies and the mastery of skills and competence through formal technical training.22 This formal training within a specialized body of knowledge is developed through research and scholarship. The professional is committed to the vocation and to the social responsibility of improving the human condition. Values, beliefs and ethics are enlisted in the formal preparation of a profession. The discipline of nursing is understood as the body of knowledge that gives syntactical and substantive boundaries to nursing.23 Nursing’s body of knowledge is born out of the spheres of research, scholarship, service, accountability and responsibility, 13 values, beliefs and ethics. 24 Collectively, these spheres denote nursing as a discipline. The discipline of nursing, seated in colleges and universities around the nation, has produced its own body of knowledge through research, scholarship and practice.25 For example, many of the research studies on maternity LOS cited in Chapter Two are the scholarly works of nurse scientists. It is evident that nursing’s body of knowledge demonstrates that it is a caring profession dedicated to their clients’ achievement of optimal health as anticipated in the profession’s Code of Ethics for Nurses as well as Nursing’s Social Policy Statement, Second Edition , both published by American Nurses’ Association.26 The knowledge base of the discipline of nursing is outlined in the ANA’s recent publication Nursing’s Social Policy Statement, Second Edition.27 The social policy statement was first published in 1980, revised in 1995, and then updated in 2003. Its evolutionary process progressed from what society could expect from nurses to what nurses could do for society, and that nurses would also participate in forming public health care policy. In 1980, it declared nursing’s social contract with society to provide optimal health care to patients through anticipatory guidance and therapeutic counseling for individuals and communities. It recognized that, even before the 1983 DRG’s, that the future of health care would be controlled by social and political regulatory activities. Working relationships with other health care workers were defined as collaborative. The ANA web site provides a definition for nursing’s knowledge boundary of what nurses are accountable and responsible for in the professional practice of nursing: 14 • Provision of a caring relationship that facilitates health and healing, • Attention to the range of human experiences and responses to health and illness within the physical and social environments, • Integration of objective data with knowledge gained from an appreciation of the patient or group's subjective experience, • Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, • Advancement of professional nursing knowledge through scholarly inquiry, and • Influence on social and public policy to promote social justice.28 By 1995, the 1980 definition of nursing was embellished. Nursing was defined as the diagnosis and treatment of human responses to potential health problems. The dimensions of caring and understanding in nursing practice to facilitate the patient’s health and healing derived from scientific research and the use of judgment and critical thinking signify an autonomous position in professional nursing. Relevance of Maternity LOS to the Future of Professional Nursing Professional nursing believes that maternity LOS should be decided upon by the patient and her provider of care. Maternity nurses took an active political role to have maternity LOS extended. In the early 1990s, research studies by nurse scientists and others attempted to determine the safety and efficacy of early maternal discharge. Unfortunately, most research was done a posteriori, that is, after 24/72 was initiated. Position statements were adopted by three professional nursing organizations (AWHONN, ANA, and ACNM) based on recommendations brought to the organizations by their constituents in the clinical practice of nursing. These position statements were underpinned by the then Code of Ethics for Nurses and supported by national public 15 health objectives. The current Code of Ethics for Nurses and the public health objectives are outlined in the following sections and make this dissertation’s findings relevant to nursing practice in the future. Ethics in Nursing The ANA’s Code of Ethics for Nurses lists nine provisions that frame the future of nursing practice.29 Listed in the Center for Ethics and Human Rights web site they are: Four of these provisions refer to the nurse’s responsibility to the individual patient, the patient at large, to the public’s safety, and to social policy. The reader is directed to provisions: 2) applies to the individual patient/community; 3) the nurse strives to protect patients; 8) the nurse collaborates with other professionals; and 9) nursing is responsible for helping to shape social policy. In this study the “community” as referred to in Provision #2, comprises mothers and their newborns. Whether the patient is an individual or a community, all nurses are responsible to ensure that public health objectives are met. Public health objectives are developed through social policy and professional nursing is also responsible to help shape social policy. National Public Health Objectives The nation’s public health objectives during the study period were outlined in the Department of Health and Human Services publication Healthy People 2000,31 seventeen of which were specific to maternal and infant health. Davis et al in 1998 extracted the objectives pertaining to maternal-child health care and listed the eight areas that improved in the prior decade (Table 1.2). 32 These areas improved when maternity LOS was four days for a vaginal birth, and six days for a cesarean birth. 16 The provisions of the Code of Ethics for Nurses dovetail with Healthy People 2000’s public health objectives for the nation. The nursing profession is in an optimal position, not only to advance general public health objectives, but also to direct public health policy critical to these public health objectives.33 The future health of the nation depends to a great extent on the health of present-day mothers and babies: professional nursing’s future involvement in policymaking will help mold policies so that maternal/newborn public health objectives are achieved.34 Maternity LOS is a national socioeconomic health care concern. It affects mothers, newborns, and their families. Given that nurses are responsible for supporting patients, the community and social policy, it is appropriate for professional nurses to study the web of influencing factors in maternity LOS policy. Though maternity LOS is not listed specifically in the Healthy People 2000 document, one can infer from the specific mention of breastfeeding (#4) and newborn screening (#8) that mothers and newborns are areas of concern. Support for maternity LOS concern is revealed in Healthy People 2010, a document not available to nurses during the time frame of this study. In this newer document mother/newborn objectives were added and included: increasing the proportion of mothers who breastfeed their babies; ensuring appropriate newborn bloodspot screening for metabolic disorders and follow-up testing, and referring mothers and newborns to services such as visiting nurses or well-baby services.35 Nurses’ effectiveness in conforming to public health objectives was limited by the 24/72 discharge time and lack of follow-up services. Maternity nurses found it difficult to complete their teaching of new mothers and nurses were greatly concerned about how 17 much content was absorbed, since new mothers were not fully recovered from the fatigue and pain of childbirth before discharge.36 As with the reduction of discharge time to 24/72 in the late 1980s, the extension of discharge to 48/96 hours by January 1998 was instituted with limited research. No replicate research was subsequently published to establish whether nurses found that the additional time in hospital improved new mothers’ content absorption or achievement in areas such as caring for themselves and their newborns. In addition to concerns over the health and well-being of mothers and newborn, maternity LOS is also important financially to the nursing profession.37 If hospitals are reimbursed at a lower rate for services, as in the current prospective payment insurance reimbursement system, it follows that hospital expenditures have to be limited. One of the ways hospitals can save money is to reduce the number of employees, including nurses.38 A 1995 Boston Globe article claiming there were too many nurses for the positions available given the prevalence of preventive care, shorter hospital stays, and recuperation in at-home or non-hospital facilities exemplifies what was happening at that time across the nation.39 Nursing positions were either eliminated in an effort to reduce hospital expenditures or professional nurses were replaced with lower paid, unlicensed personnel. The nation’s awareness that women’s health care should be addressed is apparent by the NMHPA policy passed by Congress. When Congress reformed Medicaid as part of the effort to reduce government spending many of those affected by the cuts were poor women and children who were without political sponsors to advocate for them.40 But when the reduction in maternity LOS affected privately insured, mostly middle-class 18 women, lawmakers responded to their constituency by sponsoring extended maternity LOS despite the strong opposition from the insurance industry.41 Research Questions The health care policy Congress legislated in the NMHPA compelled this author to investigate length of stay for maternity hospitalization in the United States. The over- arching question is: What was the role of professional nursing in the origin of the Newborns’ and Mothers’ Health Protection Act of 1996? Other questions emerged from the initial investigation into the nurses’ role. Those questions raised include: 1) what was the rationale behind the mandated 75% reduction in maternal discharge time seen in the 1980’s? 2) what was the research – or lack of it – on LOS for mothers and newborns informing that reduction? 3) what research informed the decision to subsequently extend the LOS a decade later by only one day? 4) what was nursing’s political involvement in1983 and in 1996 in the policy decisions for LOS for mothers and their newborns? 5) what was public opinion on maternity LOS? 6) what other voices were heard for, or against, the change in LOS? Summary As part of a wider effort at welfare reform, in 1981, the federal Omnibus Reconciliation Act, Public Law 97-35, placed limitations on reimbursement for enrollees in states’ Medicaid public assistance programs. Additional Medicaid payment limitations were federally mandated in 1983 with the enactment of Medicare Payment Reform Act of 1983, Public Law 98-21, instituting the Prospective Payment System, an alternative method of Medicaid reimbursement, which reduced payments for all health diagnoses. These reduced payments resulted in hospitals limiting lengths of stay for all patients, 19 including maternity patients. Subsequently, mothers and their newborns who enrolled in states’ Medicaid programs were limited to hospital stays of 24 hours postpartum for vaginal deliveries and 72 hours postpartum for cesarean deliveries without adequate research underpinning the safety of shortening maternity hospitalization by 75%. Congress subsequently suggested that private insurers follow suit, which is a tacitly conspiratorial request. In response to national public concern for the dramatically reduced maternity hospital stays by the mid 1990s, the federal government passed the Newborns’ and Mothers’ Health Protection Act of 1996 that extended maternity hospital stay. Professional nursing has a responsibility to advocate for mothers and their newborns. The Code of Ethics for Nurses, Nursing’s Social Policy Statement, Second Edition, and the nation’s public health objectives outlined in Healthy People 2000 support nursing’s involvement in advocacy and policymaking. It is important for professional nursing to be involved in maternity LOS policymaking so that mothers and newborns receive optimal care. Additionally, nursing research can contribute to optimal discharge timing through the knowledge gained by studies testing the achievement of public health objectives in maternity LOS. Future involvement by nurses in policymaking will secure professional nursing’s position in helping to create, implement and evaluate national public health objectives. The social history of professional nursing’s involvement in previous and current policymaking instructs future nurses to be at the forefront in national health care policymaking to improve and retain professional autonomy. 20 Table 1.1. Provisions in the Code of Ethics for Nurses ______1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations for social or economic status, personal attributes, or the nature of health problems. 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patients. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. ______ From ANA, http://nursingworld.org/ethics/chcode.htm30 21 Table 1.2. Progress in Eight Objectives ______1. Reduction in Infant Deaths 2. Reduction in Fetal Deaths 3. Reduced rate of Cesarean Delivery 4. Increase in Breastfeeding Rate 5. Improved use of Early Prenatal Care 6. Increased Hospitalization for Pregnancy Complications 7. Improved Rates of Smoking Cessation during Pregnancy 8. Improved Screening for Fetal Abnormalities and Genetic Disorders From Davis et al, 2000. 22 Endnotes 1. Annas, G.J. (1995). Women and children first. Legal Issues in Medicine 333(24): 1647-1651. Centers for Disease Control & Prevention (1995). Trends in length of stay for hospitalized delivery in the United States 1970-1992. MMWR Morbidity & Mortality Weekly Report 44(17): 335-337. 2. Office of Technology Assessment (1984). Medical Technology and Costs of the Medicare Program: Summary. Washington, DC: U.S. Congress, OTA H-227, October. Congressional Budget Office (1981 to 1987). Reducing the Deficit: Spending and Revenue Options. Annual Report to the Senate and House Committees on the Budget: Parts I, II, III. Washington, DC: Congress of the United States. 3. Omnibus Reconciliation Act of 1981, Public Law 97-35. 4. Social Security Amendments of 1983, Public Law 98-21, Short Title: Medicare Payment Reform Act of 1983. 5. Center for Disease Control & Prevention, MMWR, 1995. 6. Congressional Budget Office Report, 1981. 7. Congressional Budget Office Report, 1983. 8. Center for Disease Control & Prevention, MMWR, 1995. 9. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204, September 26, 1996, or online at bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ204.104.pdf:> page 110 STAT 2935. 23 10. Johnson, Charles W., Parliamentarian, (2000). House: How Our Laws Are Made, Revised and Updated, United States House of Representatives January 31, 2000 11. Declercq, E., and Simmes. D. (1997). The Politics of “Drive thru Deliveries”: Putting Early Discharge on the Legislative Agenda. Milbank Quarterly, 75(2), 175-202. 12. Dr. Margaret Heldring, personal communication, (2002). 13. U. S. Senate Report 104-969. 14. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204, September 26, 1996, or online at bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ204.104.pdf:> page 110 STAT 2935. 15. Wagner, L. (1992). AHA totals the losses from all-payer Medicare rates. Modern Healthcare, April 13, p.8. 16. American Academy of Pediatrics and American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care 4th ed. Washington, DC, 1997. 17. American Academy of Pediatrics and American College of Obstetricians and Gynecologists (1992, 1997). Guidelines for Perinatal Care 4th ed. Washington, DC. 18. Guidelines for Perinatal Care 4th ed., 1997, p. 164. 19. AWHONN Position Statement, AWHONN Voice, Feb. 1994. However, it has not been updated since the Newborn’s and Mothers’ Health Protection Act of 1996 became law per Anne Foster, Librarian, AWHONN national office, personal communication, Dec. 19, 2000; and Sheleagh Roberts, Executive Administration, 24 AWHONN, personal communication, Dec. 19, 2000. American Nurses Association Position Statement on “Home Care for Mother, Infant and Family Following Birth” 20. Position Statement on State and Federal Standards for Postpartum Discharge, American College of Nurse-Midwives, 1998. Website 21. Chitty, K. K. (1997). Professional Nursing: Concepts and Challenges (2 ed.). Philadelphia: W.B. Saunders Co. 22. Chitty, 1997. Waddington, I. (1996). Professions. In Kuper, A., & Kuper, J. (Eds.), The Social Science Encyclopedia (2 ed., Rev., pp. 677-678). New York: Routledge. 23. Donaldson, S.K., & Crowley, D.M. (1978). The Discipline of Nursing. Nursing Outlook, 26 (2), 113-120. 24. Ibid. 25. Chitty, 1997. Omery, A., Kasper, C. E., & Page, G. G. (1995). In Search of Nursing Science. Thousand Oaks: Sage Publications. Parsons, T. (1968). Professions. International Encyclopedia of the Social Sciences, Vol. 12, pp. 536-542. New York: Macmillan Co. & the Free Press. 26. American Nurses’ Association. (2001, June 30). Code of Ethics for Nurses: Provisions. Retrieved July 24, 2001, from American Nurses’ Association Web Site: 27. American Nurses Association (2003). Nursing’s Social Policy Statement, Second Edition. Washington, DC: American Nurses Association. Additionally, this edition compares the 1980 and the 1995 statements. 25 28. American Nurses Association. (n.d.). Definition of Nursing. Retrieved June 3, 2006, from American Nurses Association Web Site: 29. American Nurses’ Association. (2001, June 30). Code of Ethics for Nurses: Provisions. 30. Ibid. 31. U.S. Dept. of Health and Human Services (2000). Healthy People 2000. Washington, D.C. Healthy People 2010 Access Project < http://www.healthypeople.gov/Search/publications.htm > 32. Davis, L. J., Okuboye, S., & Ferguson, S. L. (2000). Healthy People 2010. AWHONN Lifelines, 4(3), 26-33. See < http://www.healthypeople.gov/Search/publications.htm > for a complete list of Maternal-Child health objectives. 33. U.S. Dept. of Health and Human Services (2000). Healthy People 2000. 34. Mason, D., & Leavitt, J. (1998). Policy and Politics in Nursing and Health Care (3rd ed.). Philadelphia: W.B. Saunders Company. 35. U.S. Department Of Health And Human Services. (2000). Healthy People 2010. op cit. Also in Davis, Okuboye & Ferguson, 2000, op cit. 36. Brown, L.P. (1996). Controversial issues surrounding early discharge. Nursing Clinics of North America, 31(2), 333-339. Eidelman, A., Kaitz, M., Rokem, A., & et al (1988). Deficits in Cognitive Tasks in Postpartum Women: Implications for Maternal-Infant Care. Pediatric Research 21:180A. Rubin, R. (1984). Maternal Identity and Maternal Experience. New York: Springer. 26 37. Mason & Leavitt, 1998. 38. Buerhaus, P. I., & Staiger, D. O. (1996). Managed Care and the Nurse Workforce. Journal of the American Medical Association, 276, 1487-1493. Gordon, S. (1997). The Impact of Managed Care on Female Caregivers in the Hospital and Home. Journal of the American Medical Women's Association, 52(2), 75-78. Himali, U. (1995). Managed Care: Does the Promise meet the Potential? The American Nurse, 27(4), 1,14,16. Kovner, C., & Gergen, P. J. (1998). Nurse Staffing Levels and Adverse Events Following Surgery in U.S. Hospitals. Image: Journal of Nursing Scholarship, 30, 315-321. 39. Cassidy, T. (1995). No Nurses need Apply: Hospital Cuts and Recession Quickly Ended '80's Shortage Now There's a Nursing Glut. Boston Globe Feb 19, p.97. AACN News, (1994 Mar). Nurse Layoffs: Are Hospitals Cutting Costs or Cutting Corners? AACN News. 40. Annas, 1995. 41. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, To Require that Health Plans Provide Coverage for a Minimum Hospital Stay for a Mother and Child Following the Birth of the Child. In Hearing of the Committee on Labor and Human Resources United States Senate, 104th Congress, First Session. (pp. 1-84). Washington, D.C.: U.S. Government Printing Office. Note that 1996 was an election year. 27 CHAPTER 2 REVIEW OF THE LITERATURE Introduction This chapter reviews research on maternity LOS conducted in the U.S. and available to Congress as evidence-based research for the creation of the 1996 NMHPA. Although some of the studies were published in 1997, the research findings were available to Congress during the NMHPA legislative process prior to publication from conference proceedings.1 The literature demonstrates that the 1981 congressional decision to limit Medicaid grants to states that resulted in reduced maternity LOS for Medicaid recipients was made without adequate research. The scant literature available by 1981 consisted mainly of program descriptions of mothers who volunteered for early maternal discharge usually due to bed shortages. The resulting lack of nursing and medical observation from these early discharges was replaced by voluntary or mandated home visits or by clinic services in most instances, but the visits were not consistently performed. Likewise, by 1996, the studies on extending maternity LOS for one-to-two more days similarly neglected the effects of discharge timing. Criticism by health care researchers in five review articles speaks to the inadequacy of the research design on early maternal discharge. Following a discussion of these review articles, I critically analyze additional research studies on maternity LOS using such parametrics as sample size, statistical power, significance, generalizability, randomization, clinical 28 significance, Hawthorne effect, and limitations of the studies.2 Study outcomes varied widely and often conflicted. Research into Maternity Length of Stay The genesis of this study began with this author’s discussions on maternity length of stay with maternity patients, obstetricians, pediatricians and public health nurses in a large metropolitan teaching institution in the Northeast. Even with a LOS extended to 48/96, there was still concern about the well-being of new mothers at discharge. Because mothers are usually the primary caretakers of their newborns, both mothers and health care providers remained concerned that mothers were still going home not fully recovered physiologically or psychologically from childbirth even at 48/96 hours after delivery. 3 The following literature review supports this clinical observation. Research studies on maternity length of stay, conducted during the years of the 24/72 hour discharge, suggested that mothers may not have had enough time recover physically from the effects of childbirth.4 These studies focused on the physiological components of recovery and demonstrated that pain and fatigue were still present at discharge. Although the research conducted on the physiological effects of childbirth was limited in scope, it was even more limited in the case of the psychological impact of early discharge after childbirth.5 Early discharge of mothers precluded much of the pre-discharge teaching by hospital nurses in the first days after delivery.6 It is well documented that in the first postpartum day, physiological and psychological changes experienced by the new mother prevent her from absorbing most of what is being taught due to the interference of fatigue, pain and medications.7 But, even more than the effects of hospital LOS on mothers, it was the well-being of the newborn transitioning from intrauterine life to 29 extrauterine life that raised concerns, leading the medical and legal communities to examine maternity LOS more closely. Pediatricians became alarmed by the effects of the 24/72 hour LOS when the results of newborn screenings for metabolic disorders, such as phenylketonuria (PKU), necessarily performed within 24 hours of birth due to early maternity discharge, were shown to be inaccurate. Thus, the American Pediatric Association published an article on newborn blood screening detailing optimal times when various blood tests should be performed, noting that blood tests collected within 24 hours after birth needed to be repeated for accurate results.8 Prior to the 1970s, few studies were published regarding shortened maternity length of stay. Norr and Nacion reviewed nine early maternity discharge (EMD) programs published in the literature from 1962 to 1985.9 Eight of the programs were self- selected, voluntary early dismissal with the discharge time ranging from two hours after birth to about 48 hours. Seven of the nine programs included one or more home visits by a nurse or physician. The other two programs included post-discharge telephone calls. Morbidity for mothers ranged from 0-11%, and for infants 10-40%. The high incidence of morbidity rates was attributed to small sample numbers or differences in categorizations of problems. An example is the Bradford Experiment conducted in England in 1951 that alleviated bed shortages by discharging low-risk mothers early from the hospital. Notably, home care visits by midwives were provided to make up for lost hospital care.10 Research studies conducted on the safety of discharging mothers and newborns after implementation of 24/72 hours began to appear in the literature in the early 1990s.11 30 Four additional review articles between 1991 and 1997 analyzed the literature for the purpose of forming guidelines of care for EMD; of these, two review articles focused on maternal-newborn EMD, while the other two reviews focused solely on newborn early discharge.12 In one review of multidisciplinary research from the 1950’s to 1997, the authors discovered that the disparity in results made development of EMD guidelines impossible.13 The following is my critical review of quantitative and qualitative research literature available to Congress at the time they were developing NMHPA. The purpose of the review is to highlight the numerous disparities in outcomes such that Congress could not really make an informed decision. Therefore, Congress used the guidelines in the Guidelines for Perinatal Care by American Academy of Pediatrics and American College of Obstetricians and Gynecologists. The research is divided into quantitative and qualitative studies pertaining to EMD for two groups: 1) mothers and newborns combined; 2) and just well newborns. Quantitative Research Studies on EMD for Mothers and Newborns The following studies investigate the effect of EMD on well mothers and their term newborns. Scholars’ reviews and critiques of scientific merit support the assertion in the July 1996 Senate report that not enough research was available to safely curtail maternity LOS to 24/72.14 A summary of quantitative maternal studies is found in Table 2.1 and qualitative studies in Table 2.2. Quantitative studies on newborn early discharge are summarized in Table 2.3. Several publications highlighted voluntary EMD programs already in progress dating back to 1943, but since the LOS was typically from 10 days to 31 two weeks in 1943, and was steadily reduced over the years, only programs that are more recent are sampled here. In 1982, Carr and Walton described the EMD program in a birthing center in Seattle, WA, where mothers were discharged <24 hours after birth, with most being discharged less than or equal to 6 hours after birth.15 In this program, extensive prenatal preparations ensured a smooth transition from hospital birth to home, with pediatric health care provided in the home and a transport back to a hospital if needed. Program directors recognized that maternal fatigue increased with EMD and therefore emphasized the need for family member support at home after discharge. Telephone consultations were available to patients after discharge if needed. A nurse practitioner visited the mother on days one and three. Harrison, in Alabama, offered essentially a similar EMD program for low-risk mothers and also strongly advised a follow-up home visit.16 Moreover, she advised two visits within the first two weeks postpartum for low-income mothers. Jansson, in Chicago, described a program developed on the assumptions that shortened LOS would decrease mothers’ and infants’ exposure to hospital pathogens, limit hospital routines (which would benefit feeding times and visiting hours for this particular patient population), as well as reduce hospital costs.17 Moreover, for those mothers at social risk, such as teen parents, home visits were instituted for the first month after birth. She based the EMD program components on earlier research by Kennel and Klaus about maternal infant attachment and bonding.18 The effects of EMD were quantitatively studied by several groups of investigators over the years (Table 2.1 Quantitative Studies). In these studies, the LOS was divided 32 into time segments of various lengths, measured in hours. Typically, there were two groups: a study group and a control group. It is unclear how LOS was defined in these studies: from admission to the labor and delivery unit to discharge home from the maternity unit, or from admission to the maternity unit after delivery to discharge home. Hence, interpretation of outcomes is hampered. All participants were volunteers for shortened LOS and the numbers of participants usually small. In the studies prior to 1987, regular LOS was usually three-to-five days for vaginal deliveries and six-to-eight days for cesarean deliveries. The diverse research designs and methods made drawing conclusions about the body of information elusive for nurses, physicians, and lawmakers. There was a lack of standardization for time of discharge; some were from admission or from time of discharge and some used the number of midnights in the hospital. The number of vaginal deliveries was not separated from cesarean deliveries. EMD was defined as anywhere from 3 hours after vaginal delivery to 48 hours. Researchers rarely studied EMD cesarean deliveries. Control groups may or may not have been employed, and at times unevenly grouped. Often participants were eliminated after randomization. The disparities just noted between research outcomes made clinical decisions on optimal discharge timing difficult. Hellman et al studied the effects of EMD on 2,257 indigents; a racially diverse low-risk maternity patients discharged at day three during a bed shortage were compared to 315 randomized controls discharged at day five (Table 2.1).19 The number of primiparas and multiparas was not reported yielding un-interpretable results when compared to other studies. Home visits by nurses for the EMD group were provided 48 33 hours after discharge (day five after birth) and at weeks one and three. The control group had home visits only at weeks one and three, since they were still hospitalized on day five after birth. Sample questions from the questionnaire were reported but no statistics reported in the study. There was no discussion of how data were gathered or computed, but the authors stated that there were no significant differences between groups for maternal-newborn morbidity, transportation home, conditions at home or for family assistance at home, or for newborn readmissions. They reported a significant difference, but no statistics displayed for the EMD group needing education on care of self and infant. Anecdotal comments from patients revealed a LOS preference of three to four days. Four EMD newborns (0.24%) and one control newborn (0.46%) died unrelated to LOS. In the study group, causes of death for two EMD newborns on autopsy were bronchopneumonia and congenital heart disease. The third newborn, without autopsy, was assumed to have died from aspiration. No autopsy was done on the fourth newborn, and the cause of death was unknown. In the control group, the one newborn death was from bilateral pyelonephritis. These neonatal deaths in the 1960s from pyelonephritis and pneumonia the 1960s may have been prevented in the 1990s with ultrasound and x-ray technology and more advanced antibiotics. Yanover et al studied the effects of EMD, cost savings and patient satisfaction in 88 low- risk middle class families (Table 2.1) for the Kaiser –Permanente Medical Center in San Francisco and the Kaiser Foundation Research Institute under a 501R grant.20 A pilot test of low-risk mothers determined newborn stability criteria (table provided in study) to be met within the first six hours after delivery in order for EMD to occur between 24 and 48 hours after discharge. Of the 88 matched participants, forty-four were prepared for 34 EMD with extensive prenatal patient education on early discharge. The control group of 44 received childbirth preparation classes. Thirty-two of 44 participants in the study group went home at <48 hours after delivery, and 39 of the control group left >48 hours after delivery (5 of the control group left <48 hours but were not included in the study group). The researchers used a questionnaire with four questions on satisfaction with LOS. A chi square analysis determined that there was no significant difference in satisfaction with LOS between the study and control groups because the participants chose which LOS they preferred thereby invalidating the outcome. Additional screening for morbidity through interview, chart reviews and perinatal nurse practitioner home visits the sixth week at home revealed no significant differences between groups. The morbidity rate determined from the article’s tables was about 10% (n=4) for the study group newborns and 20% (n=9) for the control group newborns, that is, assuming the investigators used the sample of 44 participants in each group. If n=32 and 39, respectively, were used, the rate would be 12% and 23% respectively. The high morbidity rate for the control group may be accounted for by the lack of intensive prenatal education and home visits that the study group received. The morbidity rate for the mothers was not discussed in the article. The cost of the EMD program (nurse salaries, paramedical personnel, medical consultants, automobile and home-care expenses included) equaled the expense of the control group’s LOS in the hospital. The immediate inpatient savings were 30%. The sample size was adequate; no sample questions or reliability or validity of the questionnaire was reported nor were statistical tables or acceptable probability. 35 Mehl et al proposed that EMD might be acceptable at two-to-three hours after delivery for middle-class mothers (Table 2.1).21 From 1970-1975, in a retrospective chart audit of 188 participants, EMD was offered to 130 eligible mothers who met specific low-risk criteria and compared them to 58 controls with regular LOS, p<0.025. Home visits were provided for the first three days after discharge with an office visit on day seven for evaluation and newborn PKU screening. The chart audit revealed that there was no significant difference for maternal-newborn morbidity. This suggests that there was morbidity at a lower probability. The sample was rather small for study that spanned five years of maternity LOS at two-to-three hours after delivery. The results could not be compared to any other study. Hickey et al in 1977 included EMD outcomes and cost-by-payment source (Table 2.1)22 and were supported by Blue Cross and Blue Shield of Massachusetts (BCBS). Fifteen middle class mothers volunteered for EMD that included five hours a day of homemaker services contracted by BCBS for five days. Intense patient teaching after delivery was given on self and newborn care before the 24-hour discharge, and then home visits on days two, three and six. Discharge time for controls or home visits was not reported. No maternal-newborn morbidity or readmissions were reported but “unusual findings” (no explanation given by the investigators) were reported to the obstetrician or pediatrician. Undefined complications were treated at home but none were described, and the authors stated that none were related to EMD. No sample questionnaire was given, no reliability or validity, no statistics reported on outcomes, the sample was small, and the cost savings were negligible according to the authors. This study did not contribute support information for EMD. Participants volunteered for EMD 36 skewing results for the satisfaction with EMD question outcomes. The outcome of the second research question on costs compared between hospital care and five days of homemaker services was negligible. Furthermore, undefined complications or unusual findings disallowed comparison to other studies. In 1981, a midwife in Miami, Florida studied a multicultural population of Caucasian, African-American, and Hispanics, to determine outcomes of EMD at 12 hours after delivery, plus the cost effectiveness of the program (Sculpholme, Table 2.1).23 A small sample of 35 volunteers was prepared with prenatal instruction classes. The participants were ambulated two hours postpartum, and the newborns were given three feedings (no description on method) prior to discharge, then monitored at home with phone calls and nurse visits for two-to-three days after discharge. A physician saw the newborns in clinic at 7-10 days. Patients were asked to participate in a questionnaire to gauge levels of satisfaction with EMD. The return rate was 63% for participants revealing a high degree of satisfaction with EMD even though they volunteered. No sample of the questionnaire was provided; there was no report on reliability, validity, or how the results were computed. Figures for savings were provided without stating how they were computed. This study and Mehl et al’s study combined might provide some support for voluntary EMD with daily support at home by nurses and/or home health aides. Avery et al studied 12-24 hour EMD outcomes and patient satisfaction in a 154 participant cohort (Table 2.1).24 A telephone check-up call was provided within 24 hours of discharge along with a home visit within 48 hours of EMD. Patients completed a questionnaire to gauge levels of satisfaction with EMD. Sample questions were provided in the article but only those that evaluated complications in the mother and newborn. The 37 questionnaire return rate was 61%. No reliability or validity was provided on the questionnaire. Five mothers had complications with three readmitted to the hospital. Eight newborns were readmitted to the hospital for treatment yielding a 5.2% readmission rate. This study offered complication rates and readmissions and could not be compared with Mehl et al or Sculpholme’s studies. In 1985, Thurston and Dundas in Calgary, Ontario, Canada studied EMD in four hospitals (Table 2.1).25 The ALOS in Canada at that time was three-to-five days for a vaginal delivery. Insurance and hospital costs were not a concern in Canada, unlike the United States. Volunteers meeting program criteria were solicited, and 267 self-selected for the EMD program. Home visits were provided on days three (including newborn screening), four, and five. Patients were asked to participate in a satisfaction-with-EMD questionnaire. The authors reported “no serious outcomes,” and the mothers were reluctant to leave less than sixty hours after delivery when the ALOS in Canada was 3-5 days at the time. The questionnaire return rate was 69%. No item samples were provided, or reliability or validity. Self-selection for EMD renders this study inconclusive. The first study to report parametrics was Lemmer’s in Canada which compared a convenience sample of 21 primiparas who volunteered for EMD of less than 24 hours, and 21 primpara controls who stayed greater than 24 hours (Table 2.1).26 Both of Lemmer’s groups attended prenatal classes, though the content was not listed. Postpartum home visits were provided for the EMD group only. Independent t-tests and chi square were used to evaluate the first of two questionnaires that requested information on social support, prenatal education, reasons for choice of LOS, physical and emotional concerns, compensatory services after discharge, and morbidity occurrences. Internal consistency 38 was reported only on the second questionnaire administered, with a Cronbach’s alpha of .97. The second questionnaire was briefly described but without validity or reliability statistics. The EMD participants’ reasons for choosing short LOS included feeling more comfortable at home, feeling as medically stable at home as in the hospital, and financial reasons. On the other hand, the longer stay mothers’ reasons for extending their stay were listed as concern for the mother's health and recovery, need for rest, and infant care education. The EMD group needed more home support, resources and more follow-up visits for evaluation and testing of newborn jaundice. All but one participant had family help in the home after discharge. Types of compensatory services offered post discharge were not clearly explained for either group. The reported results of the two questionnaires administered at one and three weeks showed that maternal morbidity and time of discharge were not significant, p<.05. Other maternal concerns for both of Lemmer’s groups focused on breastfeeding and recognition of illness for themselves and their infants. Few women expressed concern related to partner, family unit, community and employment. Morbidity for infants was significant at p<.05 with seven of 21 infants needing follow-up. Lemmer’s sample was small, making differences between groups difficult to ascertain. The author was explicit when trends offered non-significant results, but descriptions were inadequate for results related to variables such as help with infant feeding, or recognition of illness in relation to EMD. The psychological impact of mothers’ concerns regarding their infants (11 items on the questionnaire), the infant’s father (six items), the family unit (four items) and the community (seven items) were not 39 adequately addressed, the study stating merely that few women expressed concerns about these issues. No reasons were offered for the lack of mothers’ concerns about these issues. With twenty-eight items on the second questionnaire alone, a sample of 280 participants would be minimum to achieve adequate power. Norr et al studied 333 inner city low-income mother-infant couples in a quasi- experimental design to determine if EMD between 24-48 hour discharge was safe (Table 2.1).27 Three groups were created: in the first group, EMD was 24 to 47 hours after delivery (n=124 pairs) where mothers and infants were discharged simultaneously with a home visit; the second group, 24 to 47 hours (n=94) with mothers going home, but the infants remaining more than 48 hours for observation, followed with a home visit; the third group, 48 to 72 hours discharge with no home visit (n=115 pairs). No mention was made as to whether the mothers in group two returned to the hospital to care for their infants during the infants’ extended hospital stay. All three groups were evaluated at the clinic during the second postpartum week. The results showed that all mothers had health problem of some kind related to the postpartum period. Infants had problems also, namely, constipation, inadequate weight gain, and eye, thrush or diarrhea infections. Incidence of hyperbilirubinemia was not significant using chi square test of significance. The only group to have jaundiced babies was the first EMD group. The authors eliminated a total of 13 newborns and one mother, all readmitted for complications, yet reported that all three groups were not significant for morbidity when, in fact, all groups demonstrated morbidity. Since two of the three groups received home visits, comparison is difficult and the small groups size hampered statistical differences and power. 40 Furthermore, elimination of 13 infants and one mother affected morbidity outcomes rendering it incomparable to Sculpholme’s study. In a blinded, prenatally randomized study to determine whether EMD led to any differences in outcome for discharge groups, Carty and Bradley compared morbidity between 93 EMD at 12 to 48 hour to 38 late mothers discharged on the 4th day (Table 2.1).28 Maternal and infant physical and psychological health was studied as well as any effects on breastfeeding. Psychological functioning was defined as confidence in the mothering role. Both groups received home visits from project nurses and were asked to complete questionnaires at four time intervals: at 37 weeks gestation; during the hospital stay; one week postpartum; and one month postpartum. Project nurses cared for EMD mothers during hospitalization and in-home visits. Hospital nurses cared for late- discharge mothers. Notably, elimination after prenatal randomization occurred after delivery. Forty-five mothers were ruled out because they did not meet study criteria when delivery aids such as forceps, cesarean section, etc, were used. Statistical power was not achieved on the morbidity, breastfeeding, and confidence in mothering variables but was achieved in the depression and anxiety, and patient satisfaction variables. The study was non-significant for morbidity, psychological functioning (state /anxiety), and depressive affect. (Mandl et al reported similar results from a very large sample published outside this review’s time frame).29 Mothers discharged within 24 hours scored significantly higher in confidence in mothering than those discharged between 25 and 72 hours. Had the 45 mothers with morbidity been included, however, the morbidity and psychological functioning may have produced a significant difference between groups. 41 Tulman et al, investigated changes in functional status after childbirth in the U.S. using adaptation and role theories (Table 2.1).30 Functional status was defined as a woman’s role performance in five functional activities such as caring for her baby and herself, as well as resuming household social and community and work responsibilities. This study was done at a time when maternity LOS was trending towards 24/72. The main research purpose was to assist the then timely debate surrounding maternity leave proposals with the secondary benefit of linking LOS with maternal functional status. The participants were middle-class, educated white women who, at the time of the study, were entitled to a maternity LOS of four days for vaginal childbirth and six days for cesarean birth. The instruments used in the study were described in detail offering validity and reliability. Participants were queried four times: at three weeks postpartum (n=87); at six weeks; and at three and six months (n=97). Previous research by the same authors, had suggested that the functional status changes which took place after childbirth occurred typically during these intervals. Using repeated measures of analysis, women’s regained functional status was significant at three to six weeks and at six weeks to three months, but not significant from three to six months. Women were not at full functional status at six weeks postpartum, and several were still lacking some functionality at six months. No mention was made of statistical power (the ability of a test statistics to detect a difference between 2 or more groups) with a sample of 87 at three weeks and a sample of 97 at six weeks, three and six months. A sample of at least 110 was required for statistical power since the questionnaires had 11 subscales. 31 The results suggest a trend and should be replicated given the current LOS of 48/96. Though LOS was not an issue for this study, perhaps an 42 even shorter LOS, might have revealed the functional status trends being similarly affected at the intervals selected by the authors in the study described above. In 1992, Campbell (Table 2.1) published a study to determine how many mothers in Edmonton, Canada would choose EMD (72 hours) as opposed to regular discharge (120 hours).32 Data from questionnaire responses gathered over the period from November 1989 to July 1990 was analyzed. Of 151 participants, 28 were antenatal patients, 46 postpartum primiparas and 101 postpartum multiparas mothers. The postpartum patients consisted of vaginal deliveries (n=108) and cesarean deliveries (n=15). The questionnaire asked participants for the number of hospitalized hours they would have preferred from birth to discharge. Fifty-one percent of vaginal delivery patients chose 72 hour EMD. Of the 15 cesarean patients respondents, five chose a three- day discharge, five opted for four days, and three patients wanted two days, leaving two patients who did not respond. Sixty-three percent of respondents answered an open-ended question on reasons for choosing, or not choosing, EMD. Respondents were classified into two groups: one that supported EMD, and the other which did not. Those that did not support EMD reported several reasons. Some felt that they needed 24 hours surveillance, as well as teaching and help with breastfeeding. Multiparas with other children at home felt they would not get enough rest even with homemaker help. This group was also concerned with the potential for postpartum complications and stated that the hospital hotline number was not adequate support. Eight other respondents noted that EMD should be based on maternal-child discharge criteria. Respondents who supported EMD listed the following reasons for satisfaction with early discharge: the ability to be more relaxed at home; enhanced breastfeeding 43 environment; and the ability to incorporate the new baby into the partner and siblings family group. Generally satisfied with EMD, this group also felt that EMD was good idea only if supporting services were available. Campbell noted that this was a predictive study. Predictive research hypothesizes causality between dependent and independent variables. The statistical method used to test that particular type of hypothesis is regression analysis, which attempts to predict the efficacy of each dependent variable.33 Campbell’s research however, while very informative, used chi square analysis rather than predictive analysis to determine the effect of variables. Usually chi square analysis is employed in testing a dichotomous outcome. Analytical shortcomings notwithstanding, Campbell’s research is richly descriptive and offers useful information as a foundation for more research. From April 1988 to December 1989, W.E. Feldman, an HMO physician, collected data on LOS, morbidity and cost savings in an EMD program instituted in four maternity units in Virginia hospitals (Table 2.1).34 EMD was defined as the number of midnights spent in the hospital, a definition not provided in other studies. Mothers volunteered for EMD accompanied by a home visit by a nurse within 36 hours of discharge. A total of 541 EMDs in 1988 and 684 in 1989 were compared with discharge logs of 143 ALOS’s in 1986 and 327 in 1987. Home visits were negotiated at a flat rate of $40 per visit for EMD mothers in 1988-1989. These were significant cost savings. Despite limited discussion of interventions, outcome, or rates of co-morbidity, Campbell concluded that EMD was safe for selected patients. No mother or infant was readmitted to the hospital and home phototherapy for hyperbilirubinemia was initiated in 4% of infants. Outcomes for home treatment were not reported, nor were any other complications or rates for 44 mothers or infants treated in an office or clinic visit. Once again, this study’s outcomes cannot be compared to other studies based on LOS definition and complication rates, The next study on EMD, conducted by a private obstetrical practice in California, reported on low-risk cesarean patients who met specified criteria for early discharge (Strong et al, Table 2.1).35 Morbidities in 117 mothers discharged on day two (ALOS 44 +/- 8 hours) were compared to 93 mothers discharged at the usual time, day three (ALOS 71 +/- 17). Both groups were prepared for cesarean births prenatally and no home visits were offered for either group. Student t-test and chi square analysis were used to calculate a 67% morbidity for the control group after day four and a 71% morbidity occurred in the EMD group after day three with no p value given. Both groups received antibiotics, but it is unclear whether it was before, during or after surgery. Length of stay in hours was significant at p<0.00005 but the ranges, EMD=36-52, and controls=54-86, almost overlap, confounding the clinical significance of the findings and rendering it un- interpretable for comparison to other studies. If most complications occur on or after day four, either an extended hospital stay for surveillance or nurse home visits should be provided to this surgical population. Cost savings were noted; the average national hospital savings could approach $778 million. No office, clinic or home visits were factored in the follow-up. Welt et al. selected 289 urban mothers who had volunteered prenatally for an EMD program with discharge between 12-36 hours postpartum (Table 2.1).36 The researchers hoped to establish the magnitude of medical risk and readmission rates for maternal- infant EMD as well as patient satisfaction with the program. As in most studies, the patients were extensively prepared prenatally for EMD. Five percent of those who met 45 the study criteria chose either not to participate, for reasons not stated, or became medically unstable and were eliminated. The sample was divided into two groups: the study group was discharged less than 36 hours after delivery (n=160) with follow-up home visits; the control group was discharged more than 36 hours after delivery (n=129), with no home visits. The control group contained mothers with cesareans or other maternal complications. Infant complications included prematurity, hyperbilirubinemia, respiratory distress syndrome. The infants had a 1.8% readmission rate. This study found a rate of seven and a half percent of EMD maternal or newborn medical problems that developed within 72 hours of delivery. (By contrast, Lemmer, reviewed above, found morbidity was not significant at p<.05 but the sample was small.37 Welt et al, supported home visitation, noting the trend to discharge mothers and newborns without home visits to evaluate for complications. Blue Cross and Shield of Tennessee and the Kingsport Area Business Council on Health Care, Inc funded this research study. Brooten et al, randomized 122 mothers with unplanned cesarean births into an EMD group (LOS=86 hrs ± 20hrs) and a traditional discharge group (116hrs ± 30hrs) to study maternal and infant morbidity, rehospitalization and costs as they relate to LOS (Table 2.1).38 The sample was not described except for its matched demographics. The EMD group received evaluation by a nurse specialist for physical and emotional readiness for discharge including areas such as, self care, infant care, reaction to unplanned cesarean, coping skills support systems and the mothers’ perceptions on their readiness for discharge. If a problem arose prior to discharge, the nurses consulted with a physician and if unresolved the mother stayed longer thereby negating randomization.39 Nurse specialists visited the EMD mothers a minimum of two times and telephoned the 46 mothers twice a week for the first two weeks after discharge, then weekly for the next six weeks. No mention was made of the disposition of the EMD participants who stayed longer after the nurse-evaluation. Elimination after randomization skewed the results making the study un-interpretable. There was greater patient satisfaction in the EMD group than in the traditional group that did not receive post-discharge nurse visits or phone calls. No statistical difference was reported in maternal acute care visits or rehospitalization (the mothers with problems were eliminated from the EMD group), or infant acute care visits or rehospitalization. There was a significant difference in febrile morbidity in the control group. An overlap of LOS was observed between the EMD and the traditional group in this study similar to the Strong et al study. The small sample, with limited power, was too small to detect a difference in readmission rates. The ALOS for EMD was 10 hours earlier than the current 96 hours provided by NMHPA. The cost benefit analysis was 18% savings for the overall study intervention, but the disposition of the eliminated patients is unknown and it is possible that that cohort might have impacted the results. Furthermore, assigned charges for the home caregiver, that is a family member, was $92 and $48 for the EMD and traditional groups respectively, but no mention was made on how it was costed out. Another Canadian study published in 1995 explored maternal fatigue and mothers’ functional ability during the first six weeks at home after EMD (less than 60 hrs) versus traditional (greater than 60hrs) discharge (Smith-Hanrahan & DeBlois, Table 2.1).40 The mothers functional ability was defined as meeting at-home demands namely, physical recovery from childbirth; caring for the new infant and establishing the infant’s 47 place in the family; meeting the challenge of a new lifestyle and fostering relationships to accommodate the new family member. Under a prospective, three-group, quasi-experimental design, participants were initially randomly assigned to one of two groups receiving traditional care (n=17) or EMD (n=35). Elimination after randomization in both groups occurred when the actual discharge time did not meet the criteria for the group to which they were assigned, when maternal or infant complications occurred, or by maternal request. Furthermore, a third group was created when, due to a bed shortage, 29 participants were transferred from the original traditional care group to an EMD status. No other study compared to the design of this three-group study. A visual analog scale and a functional status inventory after childbirth were analyzed using chi square analysis and analysis of variance. The results demonstrated that fatigue among all groups decreased with time and was not statistically significantly different even when 30% of mothers reported severe fatigue at two-to-three days, and 50% reported moderate-to-severe fatigue at six weeks. However, the results are unreliable since the sample was very small and elimination occurred after randomization. Qualitative Research Studies on EMD for Mothers and Newborns In a follow-up study to Tulman et al’s 1991 quantitative study, Tulman et al used qualitative interviews to capture 96 mother’s perceptions of their postpartum experience six months after delivery (Table 2.2).41 Equal numbers of primiparas, multiparas women having had vaginal and cesarean deliveries were included. Topics explored were: the mothers’ physical, mental and emotional well-being, how their recoveries where helped or hindered during the postpartum period, what they would have done differently, and 48 finally, their evaluation of their expectations compared to what actually happened. Content analysis developed categories of responses. The mothers summarized their six months as being more difficult than expected, and that husbands and family members were of great assistance. Furthermore, the mothers related that prolonged labor and cesarean birth hindered recovery. However, by definition recalling an event, even as memorable as childbirth is an inexact process, and recollections of events six months old may be a confounding factor, as memories of events may fade or be inaccurately recalled.42 Ruchala and Halstead (Table 2.2) conducted a descriptive, qualitative ethnography of equal cohorts of low-risk primiparas (n=25) and multiparas (n=25).43 Personal interviews asked the mothers within two weeks of discharge what their feelings and concerns were about the postpartum experience, their support systems, and resources used after discharge. Interview questions were piloted, and a computer program developed the categories of experiences, support systems and resources. Both were provided in the article. Intercoder agreement was high, averaged at 86% after analysis. Fatigue in both groups was described as an overarching theme (76%). Emotional concerns and depression were expressed as a major concern with a combined 46% reporting frequent crying episodes. Sixty percent reported a changed social life. Mothers reported that infant temperament impacted how they felt about themselves and their ability to care for their infants. Mothers felt overwhelmed with feelings about having to care for self and baby, about changes in their social life, and time-management adjustments. Primiparas were more likely to have negative feelings about their postpartum experience than multiparas, but the authors did not provide a rate or excerpts 49 from the interviews to support the findings. Furthermore, the authors state “the overwhelming majority of women in the study attributed their fatigue and physical discomforts to the little time for recuperation after childbirth because of the short hospital stays”44 without supporting evidence, such as direct quotes from participants. Since the effects of EMD were the focus of their research, this was a glaring omission. Quantitative Research Studies on Newborn Early Discharge Since 1980, the American Academy of Pediatricians has recommended that healthy newborns remain in the hospital more than 24 hours to monitor their transition from intrauterine life to extrauterine life.45 The safety of well-newborn early discharge has been studied to determine the necessary criteria for early discharge and to determine if follow-up services are needed. The following studies are summarized in Table 2.3. EMD often not defined or dissimilar compared to other studies, leaving outcomes indeterminate of optimal discharge time. In 1984, Britton and Britton studied newborn early discharge for safety and cost outcomes in a non-randomized, descriptive, retrospective chart audit of a mixed, middle- class population.46 A cohort of 1,735 full-term, healthy neonates born between1981 to 1982 was reviewed for any complication developing within 72 hours after birth in an effort to predict which newborns would eventually develop complications and should remain hospitalized, while other may be discharged early. Within the first six hours after birth, 28% of the newborns displayed were significant for some signs of abnormal transition. Of the total cohort, 152 (0.7%) had complications requiring continued hospitalization for complications other than jaundice. Of the 152, 108 (71%) experienced complications before six hours of age. Chi square analysis was used to determine that 50 newborn complications that occurred within the six-hour transition period resulted in hospitalization within 72 hours of birth, p<0.02. Eventually, two percent of 1,735 newborns had complications, including jaundice. Statistical power was adequate with 1,735 newborn charts reviewed. This means that about 98% of newborns who transitioned well in the first six hours after birth will probably stay well in the first 72 hours after birth and could be discharged safely at six hours of age; and may well support Sculpholme’s and Mehl et al’s studies. Statistics were not provided though raw numbers were listed in tables. Probability was <0.02 suggesting that the wellness during the first six hours was not significant at p=0.01. Cost analysis figures showed that if discharge was at six hours followed by readmission, it was still less expensive than if the newborn remained in the nursery from birth to 72 hours. Newborn well-being at six weeks after an EMD of 24-48 hours was studied by Pittard et al in a sample with 58% indigent women during January 1985 to December 1985.47 A descriptive, nonrandomized retrospective chart audit on a cohort of 1,714 EMD sample newborns from an indigent, racially mixed population was compared to 622 control newborns who were not discharged because their mothers remained hospitalized for postpartum complications. The EMD mean LOS was 31 +/- 5 hours (range 26-36) with the control mean LOS 92 +/- 44 hours (range 48-136) leaving an unexplained gap between 36-48 hours. Chi square analysis in unpaired Student t test was used as well as 95% confidence intervals that determined a three percent (n=52) readmission rate for EMD newborns in keeping with other studies reviewed here. This study found, with 95% confidence, that 97% of newborns will not need rehospitalization after discharge. Two EMD newborns died, one from a herpes infection at day 12 and one from Sudden Infant 51 Death Syndrome. There were no other comments on the mortality rate (0.1%). No significant differences were found between groups for jaundice, readmission rates, race, private or publicly insured, or by type of delivery. Means and standard deviations were listed in tables in this non-randomized study that had an adequate sample and power, though the outcome was inconclusive because of the gap between 36-48 after delivery. Conrad et al also found a 2.3% readmission rate for EMD newborns who were discharged 24-36 hours after birth in an indigent population.48 A non-randomized retrospective chart audit in 1984-1985 divided the sample into three discharge groups: 1) n=1091 EMD at 24 to 36 hours; 2) n=343 between 36 to 48 hours; 3) n=563 greater than 48 hours. Student t test, chi square for discrete variables and Fisher’s exact test were performed but no tables or statistical results were published. Group one EMD was significant for readmissions when compared to group three, p<0.05, but no descriptions were given for types of morbidity. In-home visits were preferred (91%) over office visits when assessed for compliance. Lee et al in Toronto conducted a descriptive, retrospective chart audits using case- mix group (CMG) coding for jaundice and dehydration similar to ICD-9 coding in the U.S.49 A multi-hospital discharge database was utilized that was created by the Canadian Institute for Health Information in Ontario, Canada. Covering the years 1987-1994, the study found that readmission hospital rates for neonatal jaundice and dehydration skyrocketed as LOS grew shorter and shorter over the study years. Infants (n=920,554) admitted to a hospital 14 days or less after birth were considered at risk from their EMD. The 14-day time frame for this study was chosen because data from a previous Canadian 52 hospital discharge abstract system indicated that 97% of all readmissions of jaundiced and dehydrated neonates occurred within the first two weeks after birth. Statistics used by the authors to compare LOS with readmission rates were chi- square, odds ratio with 95 percent confidence intervals, with p<0.05. The LOS for infants decreased from 4.5 days in 1987-1988 to 2.7 days by 1993-1994. Readmission rates for newborns were compared between each of the study years. In 1987-1988, the readmissions rate for various diagnoses was two per 1000, increasing to seven per 1000 by 1993-1994 For jaundice alone, the readmission rate increased from 1.4 to 3.0 per 1000 (p=0.000) by 1993-1994. For dehydration, the readmission rate rose from 0 to 0.76 per 1000 (p=0.000) over the same seven-year period. The earlier the newborn is discharged, the greater is the risk for dehydration, jaundice, and subsequent re-hospitalization, and the need for continued surveillance by providers. The limitation of the study noted by the authors was the subjective CMG code assignment done by clerical assistants when diagnoses appeared vague. Psychosocial Impact of EMD Studies That May Have Been Available to Congress There is no evidence that the following studies were available to congressional committees preparing background work for NMHPA. However, studies published in 1997 were conducted in 1994-1995 and submitted for publication with a one to two year timeline by publishers. Therefore, the information was available to AAP and ACOG offices in Washington, DC. Once the physical effects of EMD for mothers and newborns were studied, investigators turned toward the psychological effects of EMD and mothers recovering at home with family caregivers. The psychological effects of EMD indicate that, though 53 early discharge may be desirable for some mothers, EMD may also lead to unrecognized symptoms of postpartum depression.50 Postpartum depressive symptoms occur at a rate of 80% of postpartum mothers, but true clinical depression occurs in 20% of postpartum mothers,51 prompting some obstetricians to have their postpartum patients make the first postpartum checkup visit within two weeks of early discharge to assess psychological well being.52 The psychological preparation for early discharge was briefly studied in 1997. Two studies were done abroad, one in Sweden and one in England. But because the EMD was considerably longer in those countries than in the U.S., these studies will not be reviewed. And although studies on the psychological effects of early discharges on mothers volunteering to return home soon after delivery indicated that early discharge may be desirable, design flaws hampered those studies.53 Mandl et al followed a prospective voluntary cohort of 1,200 low-risk, mother- infant couples discharged on the day following birth, on the condition that they attended preparatory antenatal educational classes, postpartum breast-feeding classes and accept home visitation.54 The database comprised information collected in 1995 from maternity patients at the Brigham & Women’s Hospital in Boston, Massachusetts. Investigators assessed health service use or needs, such as clinic, office, or emergency room visits, status of breastfeeding after discharge, maternal depressive symptoms and mothers’ sense of competence as well as satisfaction with provider care. Health outcomes that were logistically regressed on LOS were breastfeeding, mother and newborn readmission for complications, maternal depression, maternal sense of competence, and satisfaction with care. 54 The study population was composed of mothers of differing socioeconomic status, race and ethnicity (African American, Hispanic, Caucasian) with various types of insurance. Initially, LOS was divided into three groups, less than 30 hours, 31 to 39 hours, and greater than 48 hours stay but the mean was found to be 41.9 hours, so LOS was regrouped to less than 40 hours and more than 40 hours. Three percent chose less than 25 hours LOS and, of those, 61% had managed care and were offered incentives to leave early. Few health outcomes were significantly related to postpartum LOS except for maternal emergency room visits. While Lemmer’s study discussed earlier had similar findings but a very small sample, Mandl’s study offered extensive support that offset the occurrence of morbidity attributed to those mother-infant couples hospitalized for a longer stay due to complications associated with childbirth. Mothers who stayed more than 48 hours made more emergency room (ER) visits for infant complications. A subsequent study by Mandl, using the 1986-1988 NIMHS database found that even one ER visit by the mother was significantly related to maternal depression. However, these findings were refuted in Britton et al’s study (published outside the time frame of this paper) where researchers found no significant difference between early and late LOS where there was good mother-infant interaction and attachment.55 Britton et al’s nonrandomized, prospective, longitudinal study used the same 1986-1988 NMIHS database of medical chart reviews, questionnaires and observations of mother-infant interaction and attachment in reviewing 65 EMD and 81 late-discharge mother-infant pairs. LOS was defined as less than 36 hours or more than 36 hours. A power analysis of 80% found the sample size to be adequate, with α = 0.05 and β = 0.1. 55 The different outcomes between these two studies make psychosocial adjustment and maternity LOS a compelling issue for further study. Summary Prior to the 1970s, published research on early maternal discharge was limited to studies profiling low risk, extensively prepared, self-selected, prenatal volunteers, whose postpartum progress would be monitored by nurses during follow-up visitations. Consequently, in the early 1980s, research on maternal length of stay and early maternal discharge available to Congress throughout deliberations on deficit reduction, and in particular, on welfare reform, was inadequate. The resulting 1981 legislation led to Medicaid payments to states to become block-grants for the states to spend the money tailored to their specific needs. The reduced monies limited reimbursements to hospitals that in turn reduce LOS for all inpatients, including maternal lengths of stay to 24 hours for vaginal births and 72 hours for cesarean births (24/72). Private insurers followed suit. Concerned that reduced LOS might adversely affect mothers and newborns, the medical community began to examine the effects in socio-economically and racially diverse populations, and voiced concern. This in turn, led Congress in the mid-1990s, to revisit the curtailing of maternity length of stay enacted in the previous decade and to legislate its extension to 48/96. Unfortunately, once again, there were no adequately designed studies published in the early 1990s to determine criteria for early maternal discharge. Indeed, incomparable study outcomes in the 1990s led to un-interpretable results for clinical use and conflicting results such as those in the studies by Britton et al, Lemmer, and Mandl et al reviewed above left researchers unable to offer recommendations for optimal discharge timing for maternity LOS. As in the early 1980s, there was inadequate 56 research to inform Congress’s 1996 legislation to extend maternity length of stay to 48/96 or beyond. Even with the limitations of the studies, it appeared that morbidity for mothers was about 1%. For newborns morbidity settled at about 3% and that follow-up surveillance for newborns was necessary either in the office, clinic, or by home visit. 57 Table 2.1. Summary of Quantitative Research Studies on Maternal-Newborn EMD Authors/Year/ Objective Sample Research Design Results Critique Hellman et al, N=2257 Randomized Not significant No n for 1962; effects of mandatory control group. for morbidity primiparas/ EMD and EMD; Prospective cohort except for multiparas; no costs. N=316 study group. EMD patient sample controls at 2-3 days; home education for questionnaire or indigent visits at 48 hrs, 1 & EMD group; not statistics population 3 weeks; home significant for available. of Blacks, visits at 1 & 3 newborn Whites, weeks; ALOS 5 readmissions Hispanic days for controls; groups. groups surveyed by questionnaire. Yanover et al, N=44 EMD Randomized. Chi No significant No description of 1976; HMO; <24 hours square analysis. differences in questionnaire; no effects of N=44 Prenatal ed for morbidity statistics; no p EMD, patient controls > both groups; home through 6th value; 12 EMDs satisfaction, 48 hours visits for effects of week stayed >48hr; 5 cost. Middle EMD. postpartum; controls stayed Class good patient <48hr. Invalid satisfaction conclusions about EMD. Mehl et al, N=130 EMD Descriptive. No significance Small sample 1976; EMD 2-3 Hours Retrospective between over 5 years; outcomes postpartum cohort. Chart audit groups, variables not compared to N=58 1970-1975, p<.025. Some listed; no home delivery controls; compared jaundice statistics low risk variables at middle class p<.025. Home visits 1st 3 days; physician office visit day 7. Newborn PKU on day 7. Continued, next page. 58 Table 2.1, cont’d.: Authors/Year/ Objective Sample Research Design Results Critique Hickey et al, N=15 EMD Descriptive. High patient Small sample; 1977; at <24 Questionnaire. satisfaction. low power; no outcomes & hours Inpatient teaching; Complications questionnaire cost of EMD N=15 home visits days treated at home, samples, no by payment controls 2,3,6. Five hours of none related to reliability/ source. >24 hours; daily homemaker EMD both validity; no middle care x 5 days. mother & baby. statistics class Cost savings negligible. Sculpholme, N=35 Descriptive. No maternal or Small sample, 1981; EMD; no Prospective newborn no comparison outcomes of controls; Cohort. Patient morbidity; high group; no EMD at 12 High-risk satisfaction patient sample hours, cost urban questionnaire. satisfaction; cost questions, no savings. population. Prenatal education effective. reliability/ by midwives; validity ambulatory after 2 questionnaire; hours; newborn no cost analysis. given 3 feedings prior to discharge; home visits; telephone support. Avery et al, N=154 Descriptive. 5 maternal Sample 1982; cohort Prospective complication adequate for 5- outcomes of EMD <24 Cohort. Prenatal with 3 question survey, 12-24 hour hours education; admissions; 4 but 8 non- EMD, patient No telephone call newborns with EMDs surveyed satisfaction. controls. within 24 hours of jaundice; 8 too; no discharge; home readmissions statistics. visit within 48 hours; satisfaction questionnaire. Continued, next page. 59 Table 2.1, cont’d.: Authors/Year/ Objective Sample Research Design Results Critique Thurston & N=367 cohort Descriptive. No “serious No statistics, Dundas, of EMD Prospective cohort. outcomes”; comparison 1985; No controls. Patient education; Mothers group, outcomes of home visits on days reluctant to reliability/validity 60 hour 3,4,5 with newborn leave <60 or sample EMD, patient screen day 3; hours when questions. satisfaction questionnaire. ALOS was 3-5 days by choice. Lemmer, N=21 EMD Descriptive. High Small sample; 1987; Effect N=21 Controls Convenience satisfaction; low power; no of EMD on Low risk sample of only infants validity or mothers middle class. primiparas with significant reliability prenatal education; for reported. home visit for morbidity EMDs only; questionnaire. Norr et al, N=333 in 3 Descriptive. Morbidity 13 infants & 1 1989; effect uneven groups Observation & non- mother of EMD of various survey; ANOVA, significant eliminated after EMD hours; p<.05; Tukey-b all 3 groups complications, low Test with good skewing results socioeconomic patient education & home visits Carty & N=44 EMD Randomized. Significantly Elimination after Bradley, N=49 longer Blinded. Chi- higher randomization 1990; effect EMD square and one- satisfaction small sample; low of EMD N=38 controls way analysis of in all areas power. variance. Surveys for EMD for morbidity, group 1. breastfeeding, patient satisfaction, anxiety/depression; Continued, next page. 60 Table 2.1, cont’d.: Authors/Year/ Objective Sample Research Design Results Critique Tulman et al, N=87, then Descriptive. Functional Low power; 1990; Link later n=97; Prospective status needed n=110; maternal middle class cohort. Repeated significantly Ten functional Caucasian. measures of increased participants status with analysis. Surveys between 3 to 6 missing from 3 LOS. at 3 & 6 weeks weeks but not week interval. postpartum then between 3 & 6 at 3 & 6 months. months Participants p<.0005. added after data collection began. Campbell, N=28 Descriptive. 53% not Author stated 1992; how antenatal Prospective interested in this was many prefer N=123 cohort. Chi- EMD. predictive EMD postpartum; square analysis. research. middle class Choice of EMD=72 hrs or regular 120 hour discharge; Feldman, 4 sample Descriptive. 4% jaundice Maternal 1993;EMD groups ALOS Retrospective morbidity; no physiological/ morbidity & 1986-1988, discharge logs. readmissions; psychological cost savings of compared to Extensive patient substantial costs morbidity EMD. EMDs in education for savings. ignored. 1988 to 1989; EMD; Compared no population EMD logs for description. morbidity, hospital LOS cost savings, fixed cost home visits. Continued, next page. 61 Table 2.1, cont’d.: Authors/Year/ Objective Sample Research Results Critique Design Strong et al, N=117 EMD Descriptive. 6% morbidity ALOS for both 1993; <48 hours Retrospective both group; groups very close, outcomes of N=93 controls review. Student no EMD=36-52, EMD for with LOS 72 t-test, chi- readmissions controls 54-86; no Cesarean hours; middle square analysis. both groups. p value for mothers; and lower Prenatal morbidity. private patients socioeconomic education for class. cesarean and meeting EMD criteria both groups. Welt, 1993; N=160 EMD Descriptive. No readmits 1 Outcomes of volunteers EMD at 24/72 for mother or day=12midnight- EMD at <36 N=129 with hospital baby; 4% 11:59pm; hours, >36 Controls; and home visit infant maternal hours. economically interviews morbidity for morbidity ignored; mixed within 36 hours jaundice. no instrument population. of discharge for reported for the mother/baby interviews. assessment; patient education before hospital discharge. Continued, next page, 62 Table 2.1, cont’d.: Authors/Year/ Objective Sample Research Results Critique Design Brooten et al, N=61, 2 day Randomized. EMD had greater Elimination of 1994; EMD EMD, Analysis of satisfaction, p EMD mothers morbidity, LOS, N=61 variance =<.001; no with rehospitalization, controls, 4 survey significant complications costs for cesarean day LOS; instrument; differences in after patients. population home visits maternal randomization mix not for EMD rehospitalization affected cost described. group only anxiety, benefit analysis; with telephone depression & limited power. call x2 weekly functional status; for 6 weeks. febrile morbidity significant in controls. Smith-Hanrahan N=35 EMD Randomized. No significant Exclusion after & DeBlois, 1995; <60 hrs; Analysis of differences in randomization; maternal fatigue N=29 variance. Chi- functional ability small sample, and functional randomized square between groups. needed 360 for ability at home as controls analysis. adequate power. but Survey transferred questionnaire to EMD of 36 items. N=17 LOS >60 hrs. 63 Table 2.2. Summary of Qualitative Research Studies on Maternal-Newborn EMD Authors/Year/ Objective Sample Research Design Results Critique Tulman et al, N=47 Ethnography. Experiences more Recall 6 months after 1991; mothers’ primiparas, N= Content analysis; difficult than event may not be perceptions of 49 multiparas; inter-rater reliability expected even with accurate. childbirth multicultural 86%. Audiotaped family help (45%); recovery. and multiracial home interviews 6 recovery time but 85% lived months postpartum of varies, 25% still in suburbs. multicultural not fully recovered primiparas & at 6 months, multiparas with sample answers vaginal & cesarean included. births; participants recruited from childbirth classes & postpartum unit; 5 open-ended questions. Ruchala & N=25 Descriptive. 76% described No diversity Halstead, 1994; primiparas Qualitative fatigue as major; socioeconomically; mothers’ N=25 ethnography. Semi- 16% of total reliance on concerns after multiparas; structured home primiparas= computer software for EMD at 48/96. mix of vaginal interviews 2 weeks overwhelmed, coding may omit and cesarean postpartum; pilot trapped, “total important concepts; deliveries; low tested; coded nightmare”; minimal focus on risk categories developed “some” primiparas EMD middleclass using computer felt LOS too short, software; averaged not rested enough. intercoder agreement averaged 86.5%; interview guide and coding categories provided 64 Table 2.3. Summary of Quantitative Studies on Newborn Early Discharge Authors/Year/ Objective Sample Research Design Results Critique Britton & N=1735 well Descriptive using chi 91% (1583) No mention of the Britton, 1984; newborns. square analysis. transitioned other 44 out of 152 safety of Middle class. Retrospective cohort. normally; 9% (152) newborns in the 1st 6 newborn Chart audit from 1981- became ill hours of life; EMD EMD by 1982 for validity and <72 hours with 71% not defined; not evaluating the predictability of an (108) identified in randomized but 1st 6 hours of abnormal transition the 1st 6 hours; 2% adequate power. life. within 6 hrs after birth to total readmission extrauterine life; rate, p<0.02. Pittard & N=1714 Descriptive using chi No significance Non-randomized; Geddes, EMD square analysis, unpaired between groups for variables not 1988; safety N=315 Student t –test, 95% CI.. jaundice and described; wide outcomes of controls; Retrospective chart audit readmissions rates, ALOS range nearing newborn 58% year 1985. insurance type or approximation EMD of 24- Indigent, vaginal/cesarean; leaving gap between 48 hours racially EMD group mean 36 to 48 hours not mixed LOS 31+/-5 hours; explained. population. control group mean Inconclusive. LOS 92+/-44 hours Conrad et al, 1)N=1091 at Descriptive using chi 2.3% readmission Non-randomized; 1989; safety 24-36 EMD; square for discrete rate significant for variables not listed; outcomes of 2)N=343 at variables + Fisher’s Group 1 compared to no chi square tables. EMD 24-36 36-48 EMD; exact test; Student’s t – Group 3, p<.05. hours & 3)N=563 test. Retrospective chart Home visits compliance controls >48. audit 1984-5. successful in 91% of with office Indigent sample. visit follow- population up vs. in- home visit. Lee et al, N=920,554 Descriptive using odds As LOS decreased Canadian CMG 1995; EMD ratios & critical incident. readmissions coding for main readmission Multi-hospital discharge increased diagnoses, or rates of well databases compared LOS significantly the 1st concurrent diagnoses newborns & readmissions year-to- week, p=0.000 may contain human year from 1987-1994, primarily from error in assigning using Canada’s case-mix jaundice & codes. group dehydration 65 Endnotes 1. U.S. Department Of Health And Human Services (1997). Beyond the 4th Dimension: Assuring Quality Health Care for Moms and Babies--Proceedings of the Scientific Summit. Arlington, VA: National Center for Education in Maternal and Child Health. The Summit was held June 6-7, 1996 an included the presentation of yet unpublished research findings. 2. Burns, N., & Grove, S. (2001). The Practice of Nursing Research: Conduct, Critique, & Utilization (4th ed., Rev.). New York: W.B. Saunders Company. 3. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204, September 26, 1996, enacted as Title VI of the Department of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1997. 4. Fishbein, E., & Burggraf, E. (1998). Early Postpartum Discharge: How are Mothers Managing? JOGNN, 27(2),142-148; Ruchala, P. & Halstead, L. (1994). The Postpartum Experience of Low-Risk Women: A Time of Adjustment and Change. Maternal-Child Nursing Journal, 22(3),83-89; Ruchala, P. & James, D. (1997). Social Support, Knowledge of Infant Development, and Maternal Confidence Among Adolescent and Adult Mothers. JOGNN 26(6), 685-689; Troy, N. & Dalgas-Pelish, P. (1995). Development of a Self-Care Guide for Postpartum Fatigue. Applied Nursing Research, 8(2), 92-101; Tulman, Fawcett, Groblewski, & Silverman, (1990). Changes in Functional Status after Childbirth. Nursing Research March/April, 39(2), 70-75. 66 5. Gagnon, A.J. et al., (1997). A Randomized Trial of a Program of Early Postpartum Discharge with Nurse Visitation. American Journal of Obstetrics and Gynecology, 176(1), 205-211. 6. Dershewitz & Marshall (1995). Controversies of Early Discharge of Infants from the Well-Newborn Nursery. Current Opinion in Pediatrics 7:494-501.Eidelman, A., Hoffmann, N., & Kaitz, M. (1993). Cognitive Deficits in Women after Childbirth. Obstetrics and Gynecology, 81, 764-767. 7. Brown, L.P., Town, S.A., York, R. (1996). Controversial issues surrounding early discharge. Nursing Clinics of North America, 31(2), 333-339.; Dershewitz & Marshall, 1995; Eidelman, A., Kaitz, M., Rokem, A., & et al (1988). Deficits in Cognitive Tasks in Postpartum Women: Implications for Maternal-Infant Care. Pediatric Research 21:180A.; Rubin, R. (1984). Maternal Identity and Maternal Experience. New York: Springer. 8. American Academy of Pediatrics (1996). Newborn Screening Fact Sheets. Pediatrics, 93, parts 1 & 2, 473-501. Annas, G. (1995). Women and Children First. New England Journal of Medicine, 333, 1647-1651. 9. Norr, K.F., & Nacion, K. 1987. Outcomes of Postpartum Early Discharge 1960-1986. A Comparative Study. Birth, 14(3), 135-141. 10. Theobald, G. W. (1959). Home on the Second Day: the Bradford Experiment: the Combined Maternity Scheme. British Medical Journal, 2, 1364-1367. 11. Senate Report 104-326 July 19, 1996, (Appendix B). Parisi, V. M., & Meyer, B. A. (1995). To Stay or Not to Stay? That is the Question. New England Journal of Medicine, 333, 1635-1637. 67 12. Beck, C. T. (1991). Early Postpartum Discharge Programs in the United States: A Literature Review and Critique. Women & Health, 17(1), 125-138. Braveman, P., Egerter, S., Pearl, M., Marchi, K., & Miller, C. (1995). Problems Associated with Early Discharge of Newborn Infants. Pediatrics, 96(4), 716-726. Britton, J.R., Britton, H.L., Beebe, S.A. (1994). Early discharge of the term newborn: A continued dilemma. Pediatrics 94(2): 291-295. Grullon, K. E., & Grimes, D. A. (1997). The Safety of Early Postpartum Discharge: A Review and Critique. Obstetrics & Gynecology, 90(5), 860-865. 13. Grullon & Grimes, 1997. 14. U.S. Senate (July 19, 1996). Senate Report: Newborns' and Mothers' Health Protection Act of 1996 (104-326). Washington, DC: U.S. Government Printing Office. Also on the internet: U.S. Senate. (1996, April 17). Senate Report 104- 326-Newborns' and Mothers' Health Protection of 1996. Retrieved April 2, 2005, from bin/cpquery/T?&report=sr326&dbname=cp104&> 15. Carr, K., & Walton, V. (1982). Early Postpartum Discharge. JOGN, January/February, 29-30. 16. Harrison, L.L. (1990). Patient education in early postpartum discharge programs. MCN American Journal of Maternal Child Nursing, 15(1), 39. 17. Jansson. P. (1988). Outcomes of postpartum early discharge 1960-1986. A comparative review. Birth, 15 (Letter) (2). 107-108. 68 18. Klaus, M. H., & Kennell, J. H. (1976). Maternal-Infant Bonding. St. Louis: C.V. Mosby Company. J. H. (1976). Maternal-Infant Bonding. St. Louis: C.V. Mosby Company 19. Hellman, L. M., Kohl, S. G., & Palmer, J. (1962). Early Hospital Discharge in Obstetrics. Lancet, 1, 227-232. 20. Yanover, M. J., Jones, D. J., & Miller, M. D. (1976). Perinatal Care of Low-Risk Mothers and Infants: Early Discharge with Home Care. New England Journal of Medicine, 294, 702-705. 21. Mehl, L. E., Peterson, G. H., Sokolosky, W., & Whitt, M. C. (1976). Outcomes of Early Discharge after Normal Birth. Birth and the Family Journal, 3, 101-107. 22. Hickey, L. A., DeRoeck, E. F., & Shaw, M. I. (1977). Maternity Day Care Program Offers Economical, Family-Oriented Care. Hospitals, 51, 85-88. 23. Sculpholme, A. (1981). Postpartum Early discharge: An Inner City Experience. Journal of Nurse Midwifery, 26, 19-22. 24. Avery, M. D., Fournier, L. C., Jones, P. L., & Sipovic, C. P. (1982). An Early Postpartum Hospital Discharge Program: Implementation and Evaluation. JOGNN, 11, 233-235. 25. Thurston, N. E., & Dundas, J. B. (1985). Evaluation of an Early Postpartum Discharge Program. Canadian Journal of Public Health, 76, 384-387. 26. Lemmer, C.M. ( 1987). Early discharge: outcomes of primiparas and their infants. Journal of Obstetrical, Gynecological and Neonatal Nursing, 16(4), 230-236. 69 27. Norr, K. F., Nacion, K. W., & Abramson, R. (1989). Early Discharge with Home Follow-up: Impacts on Low-Income Mothers and Infants. JOGN, March/April, 133-141. 28. Carty, E., & Bradley, C., (1990). A randomized, controlled evaluation of early postpartum hospital discharge. Birth 17(4): 199-204. 29. Mandl et al, 1997. 30. Tulman et al, 1990. 31. Burns & Grove, 1997. 32. Campbell, I.E. (1992). Early postpartum discharge -an alternative to traditional hospital care. Midwifery, 8(3), 132-142. 33. Burns & Grove, 2001. 34. Feldman, W. E. (1993). Evaluation of an Early Newborn Discharge Program. HMO Practice, 7(1), 48-50. The title is misleading for the study evaluated both mothers’ and newborns’ morbidity. 35. Strong, T. H., Brown, W. L Jr., Brown, W. L., & Curry, C. M. (1993). Experience with Early Postcesarean Hospital Dismissal. American Journal of Obstetrics and Gynecology, 169, 116-119. 36. Welt, S.I. (1993). Feasibility of postpartum rapid hospital discharge: a study from a community hospital population. American Journal of Perinatology, 10(5), 384- 387. 37. Lemmer, 1987. 70 38. Brooten, D., Roncoli, M., Finkler, S., Arnold, L., Cohen, A., and Mennuti, M. (1994). A randomized trial of early discharge and home follow-up of women having cesarean birth. Obstetrics and Gynecology, 84(5), 832-838. 39. Brooten et al, 1994, p. 833. 40. Smith-Hanrahan, C., & DeBlois, D. (1995). Postpartum Early Discharge. Clinical Nursing Research, 4(1), 50-66. 41. Tulman, L., & Fawcett, J. (1991). Recovery from Childbirth: Looking Back 6 Months After Delivery. Health Care for Women International, 12, 341-350. 42. Denzin, N., & Lincoln, &., (1994). Handbook of Qualitative Research Thousand Oaks: Sage Publications. 43. Ruchala, P. & Halstead, L. (1994). The postpartum experience of low-risk women: A time of adjustment and change. Maternal-Child Nursing Journal, 22(3):83-89. 44. Ruchala & Halstead, 1994, p. 88. 45. Committee on Fetus and Newborn, & American Academy of Pediatrics (1995). Hospital Stay for Healthy Term Newborns. Pediatrics, 96, 788-790. 46. Britton, H. L., & Britton, J. R. (1984). Efficacy of Early Newborn Discharge in a Middle-class Population. American Journal of the Disabled Child, 138, 1041- 1046. 47. Pittard, W. B III, & Geddes, K. M. (1988). Newborn Hospitalization: A Closer Look. Journal of Pediatrics, 112, 257-261. 48. Conrad, P. D., Wilkening , R. B., & Rosenberg, A. A. (1989). Safety of Newborn Discharge in Less Than 36 Hours in an Indigent Population. American Journal of the Disabled Child, 143, 98-101. 71 49. Lee, K., Perlman, M., Ballantyne, M., Elliott, I., & To, T. (1995). Association Between Duration of Neonatal Hospital Stay and Readmission Rate. Journal of Pediatrics, 127(5), 758-766 50. Arborelius, E, & Lindell, D. (1989). Psychological Aspects of Early and Late Discharge after Hospital Delivery. Scandinavian Journal of Social Medicine 17:103-107. 51. Britton, J., Britton, H., & Gronwaldt, V. (1999). Early Perinatal Hospital Discharge and Parenting During Infancy. Pediatrics 4(5): 1070-1076. Dowswell, T., Piercy, J., Hirst, J., Hewison, J., & Lilford, R., (1997). For Debate: Short Postnatal Hospital Stay: Implications for Women and Service Providers. Journal of Public Health Medicine 19(2): 132-136. 52. Dr. Derna DeMaggio on current physicians’ practice, personal communication, March 14, 2002. 53. Zuckerman et al, Cooper et al, Hopkins et al, in Mandl, K. D., Tronick, E. Z., Troyen, A., Alpert, H. R., & Homer, C. J. (1999). Infant Health Care Use and Maternal Depression. Archives of Pediatrics & Adolescent Medicine, 153, 808-813. 54. Mandl, K. D., Brennan, T. A., Wise, P. H., Tronick, E. Z., & Homer, C. J. (1997). Maternal and Infant Health: Effects of Moderate Reductions in Postpartum Length of Stay. Archives of Pediatrics & Adolescent Medicine, 151, 915-921. 55. Britton et al, 1999. 72 CHAPTER 3 METHODOLOGY Social History and Feminist Theory as Methods This study seeks to ascertain the extent of the involvement of professional nursing in the origin of NMHPA. To that end, in this chapter I will employ a socio-historical methodology in addition to feminist theory. Some of the philosophical concepts involved in the historical interpretation are perception and intentionality, causal explanation, and understanding and meaning. These concepts then lead to the process of collecting, synthesizing, analyzing and interpreting historical data. The study uses feminist theory to scrutinize the political and socioeconomic climate from 1981-1996 that eventually brought about the 48/96 hour LOS law to protect newborns’ and mothers’ rights to health care. History seeks to know what human action happened in the past, when it happened, how it happened, and why.1 The historical method was selected for this study because it was human action that prompted policymakers to write the NMHPA law. The Science and Art of Historical Inquiry History is an explanation about the past using empirical and hermeneutical methods to arrive at the truth.2 The method that historians use to arrive at the truth is both a science and an art that exposes the causes and effects of a phenomenon. The empirical application determines the causal antecedent conditions that preceded the event being studied; in this study, the interface of nursing, medicine, lawmakers, mothers and newborns, social (gender, race, class, ethnicity) and economic factors. The effect is the consequence, that is, NMHPA whose antecedents require analysis. The antecedent- 73 consequence “pattern” gives history “form” or organization to the names and events of the past.3 Analysis of “factual sequences” by the historian includes economic, political and social phenomena that offer understanding and meaning as to why an event such as NMHPA happened.4 By asking “why did the event occur?” such as” why was NMHPA legislated?” the historian exposes the historical influences that caused the event to occur. Additional questions that the historian asks include what happened, when, and where. Some of the influences that assist in explanation may include social factors such as individual actions, collective actions, social structures, state activity, forms of organizations, and social relations.5 The art of historical inquiry is the subjective interpretation of the antecedent conditions discovered by the historian that explains why the event occurred. Interpretation, following careful critical analysis of evidence, may yield a logical coherence of data over time.6 Primary sources, such as interviews with the politicians, or recorded text from congressional documents, help to provide explanations about the circumstances of what happened, and why, surrounding the event. The historian is responsible for the hermeneutical interpretation of historical facts.7 The explanation collates meaning and understanding of human behavior and social practices. The art of interpretation is the “heart” of the historian’s craft.8 This paper investigates maternity LOS using social history as method. Social history gained momentum in the 1960s/1970s and involves studying community life and its influencing factors within a specified period of time in order to derive understanding and meaning of the past.9 Social history…provides the trunk on which the other branches hang. The social historian is a generalist whose purpose is to depict 74 the whole with a special interest in composition and perspective…brings in politics and economics, like religion, education or other aspects as they affect the central theme, the development of the social structure.10 The social historic method critically analyzes documentation pertaining to daily life, such as the working class, women, the poor, the criminal and different cultural groups.11 In this paper, the community is understood to be the community of mothers and their newborns from 1981 to 1996. The political factors include the political parties in Washington, DC, congress, nursing organizations, and lawmakers. The organizations include the nursing organizations AWHONN and ACNM, and the medical organization, American Medical Association, members of which testified at a congressional hearing on NMHPA. Socioeconomic factors included were the spiraling health care costs of Medicaid and other insurers. Social History of Maternity LOS In my exploration of the social historical pathway to the current law on newborns’ and mothers’ LOS, I collected and analyzed the antecedent data that contributed to the social milieu that led to maternity LOS policymaking. The socioeconomic data included: political parties, the economics of health care, the role of nurses and professional nursing on health care in the 19th and 20th centuries, and the impact of maternity LOS on families. Other social influences examined are: professional nursing’s involvement in the policymaking of NMHPA, the role of gender in the politics of the law, and the experiences of women from different races, class and ethnicities (Chapter 6). Nursing’s articulation with medicine in policymaking for LOS for mothers and newborns is analyzed in the context of the history of nursing, nursing education, and the women’s 75 health movement (Chapters 4,5,7). These historical social influences surrounded and influenced policymaking toward LOS for newborns and mothers in the U.S. and are the findings interpreted in this study. Sources for Data Collection Oral History This study utilizes interviews of participants to obtain knowledge of the role of nursing in the origin of NMHPA. Primary sources may be documents or people who give a firsthand account of the event.12 The recorded oral histories and commentaries from Senator Bradley, his assistants, and nurses involved in providing evidence to support the creation of NMHPA, help to document the history of the origin of NMHPA.13 These oral sources are useful because they record the moment at the time of the historical event or within a recent time of the event.14 An interview becomes an oral history only when it has been recorded, processed in some way, made available in an archive, library or other repository, or reproduced in relatively verbatim form as a publication.15 Availability of the oral history offers others a way of researching, re-interpreting and verifying historical data. The interview, as data, is as reliable or unreliable as other sources. Memories of interviewees may fade, but the job of the researcher is to ask questions for confirmability.16 The researcher must determine if the interviewees’ statements are fact or fiction using open ended and broad questions, then narrower and more specific questions. Broad questions allow interviewees to tell their stories in their own words. The researcher’s challenging questions require critical thought on the issue or event and require answers that give insights into how and why the event occurred.17 76 Primary Data Primary data sources are used as much as possible in investigating the social history behind maternity LOS and NMHPA. Interviews from people who were involved directly or peripherally are primary data sources in the creation of NMPHA. They give behind-the-scene insights into the eleventh-hour political negotiations on Capital Hill just days before the bill was signed into law. The congressional testimony of September 12, 1995 from the Congressional Record is examined for gender and political economic factors. Primary source interviews include interviews with such people as Senator Bill Bradley, a sponsor of NMHPA; Colleen Meiman who wrote the first draft and Dr. Margaret Heldring, health care policy fellow and staff assistant to Sen. Bradley; Ann Twomey, RN, and Jeanne Otersen (a public policy expert and not a nurse), along with other New Jersey nurses, who met with Senator Bradley and Colleen Meiman to initiate the beginning of the campaign for the NMHPA bill; RuthAnn Johnson, RN, one of New Jersey Nurses who helped Dr. Heldring with revisions to NMHPA. An additional nurse in New Jersey requested anonymity based on her current job position. Data collection continues until the data begins to repeat and data collection is saturated.18 Other sources include government documents, i.e., Congressional Hearing on NMHPA in the 104th Congress, First Session, Senate Hearing 969, September 12, 1995, printed by the Government Printing Office (GPO). Many web sites were accessed for this study including Library of Congress is records and actual laws on maternal health cited in this study. Other websites used were 77 link. Publications from the Congressional Budget Office (CBO) and the Office of Technical Assessment are also primary sources and were found at: the University of Massachusetts Worcester, Amherst and Lowell sites; Middlesex Community College Library, Lowell, MA; and Northeastern University in Boston, MA. Secondary Data Secondary data sources are those that give opinions or interpretations of the event.19 In this study secondary sources include history books and articles written on Medicaid and policymaking for mothers and newborns, history texts on childbirth in America, hospitals and nursing, nursing education and their place in American society. Physicians and medical education influenced mothers’ maternity LOS and the explanations were found in medical and nursing history textbooks used in this study. Libraries used for obtaining secondary texts include, Amesbury Public Library, Amesbury, MA, Lawrence Public Library, Lawrence, MA; Memorial Hall Library, Andover, MA; and Stevens Library, North Andover, MA. Nursing practice also influenced the care of mothers with standards of nursing practice. These practice guidelines were developed as late as the 1960s/1970s, and the reasons why are developed and analyzed from explanations found in nursing history textbooks and nursing organization websites. Other secondary sources include newspapers, such as the Boston Globe and The New York Times, magazines such as Newsweek , Good Housekeeping, and the Ladies Home Journal, and computerized nursing and medical databases, such as Medline, Cinahl, PubMed, and PsychInfo. Search terms obtained through MeSH mapping include 78 early maternal discharge, early maternity discharge, early postpartum discharge, maternal LOS, maternity LOS, postpartum LOS, and perinatal hospital stay, all of which refer to hospital length of stay after childbirth. Other websites include U.S. State and Local Gateway, U.S. Department of Health and Human Services (DHHS), U.S. Government Printing Office, and the Center for Studying Health System Change. Within the DHHS website is a link for the Office on Women’s Health for updated regulations. Trustworthiness, Validity and Reliability Trustworthiness of sources is of paramount concern in the historical method. Genuineness and authenticity, along with validity and reliability of documents used in this study have been established by cross-checks and multiple independent sources which provide coherence.20 External and internal criticism of primary and secondary sources establishes the validity and reliability of sources by asking who, what, when, where and why. External criticism concerns the genuineness of the document, whether or not it is an original document. External criticism establishes the validity of the source. If the document is valid it accurately presents the event or issue being studied, and is considered genuine. For example, a congressional hearing document is a genuine document of people’s testimony. Internal criticism establishes reliability or consistency of the data in the document. If various sources consistently present the same data, then the sources are more likely making true statements and are more likely reliable and authentic sources.21 For example, in this study the congressional documents obtained from governmental websites have been authenticated by cross-checks for consistency with paper copies at the University of Massachusetts Lowell or Northeastern University libraries. These universities hold 79 documents that were printed by the GPO in the original year that the document was created. Citations of documents in history books have been authenticated in a library’s holding of government documents. Data Analysis: A Theoretical Framework While investigating the initial documents leading to the law, it became apparent that lawmakers in the late 1970’s and early 1980’s were attempting health care reform by limiting grants to states for Medicaid recipients, and, hence, maternity LOS reimbursements to hospitals. Shortening maternity LOS for the most frequent of all hospital admission diagnoses, childbirth, appeared sound at the time, for it reduced the outlay of Medicaid dollars. Yet, lawmakers failed to consider the needs of women on public assistance.22 Feminist analysis offers a theoretical framework to assist in the investigation of why lawmakers placed poor women at health risk by shortening maternity LOS.23 Feminist Theory Framework The historical creation of NMHPA is studied from a feminist theoretical perspective. It is a perspective that investigates patriarchal oppression in women’s lived experiences by gender, race, class and ethnicity and socioeconomic status.24 This section discusses feminist theory, feminist research and method, and finally, why the feminist perspective is woven into this study. Feminist theory is a philosophical perspective underpinned by theories about how to gain emancipation from power structures within social, economic and political arenas.25 Using a feminist theory framework to guide research allows events to be 80 investigated for “patterns of oppression,” modes of resistance, and ways to achieve gender equality.26 Critical theory underscores feminist theory. Popkewitz in Guba writes that ‘critical’ could have two meanings.27 The first in the sense that “criticism comes from analytical questioning of argument and method…focus on the theoretical reasoning and…procedures for selecting, collecting an evaluating empirical data.” It also means “criteria for scrutiny…skepticism toward social institutions…that ties ideas, thought and language to social and historical conditions…. Critical considers the conditions of social regulation and unequal distribution of power.” In feminist theory both definitions are incorporated. Feminist critique is a method to analyze values and beliefs. The knowledge gained from critical analysis can be enlightening and liberating for women. The knowledge prompts reforms to alleviate oppressive social economic and political human conditions. Feminist research in this study critically analyzes historical events for social, economic and political oppressive power structures, be they gender, racial, or socioeconomic, as it relates to maternity care. Why Use Feminist Critique in this Study Mothers on Medicaid and professional nurses are women who have been subjugated to patriarchal and racial domination by white male physicians, politicians, and hospital administrators. Feminist critique exposes who the actors were, how the domination evolved, under what circumstances, and who advocated for corrective action. For instance, David Hyman MD, JD, Professor of Law, University of Maryland, stated in 2001 that the “first victim of the managed care backlash was rapid postpartum discharge.” 28 This declaration echoed earlier sentiments by others in the health care field. 81 For instance, George Annas, JD, MPH, Professor of Law, Boston University, wrote in 1995 in “Women and Children First” that the “health care market-driven choice” to limit maternity LOS was the responsibility of “health care entrepreneurs and politicians.”29 When Congress reformed health care in 1981 to reduce government spending, the participants were poor women and children. With four million births annually in the U.S., Annas believed that poor women and children were “easy targets for welfare reform” since they do not generally have sponsors with political influence or financial support.30 In 1995, several states initiated legislation requiring insurers to pay for minimum lengths of stay for childbirth. It was at a time when middle class women were also affected by reduced maternity LOS and who had the financial and political means to exert some control over their childbirth experience. When poor women, white women, and women of color, and their children were targeted first by third party payers, feminist critical analysis illuminates the struggle against oppression.31 Feminist Research Method Feminist research focuses on women’s issues and values,32 using a qualitative methodology in which women’s voices, language and expressions are heard in order to understand women’s lived experiences.33 However, feminist researchers need to identify and eliminate their own biases so that just the voices of the participants are heard.34 This in turn assists readers to identify the appropriateness of the research method design, data collected and interpretation of the findings for greater understanding and meaning. My bias in this study is that gender and class oppression occurred when poor women on Medicaid were required to submit to a 75% reduction in maternity LOS, while middle class women were allowed to continue to stay longer in the hospital, although eventually 82 private insurers also reduced maternity LOS at the behest of the federal government.35 In the 1990s mothers were discharged at 24/72 hours not yet recovered from childbirth and not ready to assume the care of their newborns. Many mothers did not have social support at home, and many first time mothers were neither competent in childcare, nor able to evaluate the onset of newborn complications such as dehydration or jaundice. Though prenatal classes were offered, many could not attend, giving various reasons: 1) they worked and could not take the extra time off; 2) could not afford extra transportation for additional appointments other than for regular prenatal visits; 3) could not afford babysitting for their other children; 4) brought their other children anyway but could not concentrate because of necessary childcare where the facility could not assume “babysitting” liability. The feminist theory framework in this research highlights the sociopolitical and economic influences on decreased LOS for mothers and their newborns in the history leading to NMHPA of 1996. This study views the regulation of reimbursements for maternity LOS, first by Medicaid health care reform in 1981 and 1983, then by private insurers, without adequate a priori research as an example of governmental autocratic ruling that eliminated freedom of choice for women. Summary The history behind the NMHPA legislation is an investigation that exposes the antecedent socioeconomic and political conditions leading up to and including the study years from 1981-1996. Feminist critique highlights that the maternity population most vulnerable to the cost-benefit analysis of a dominant group of primarily white men, the congressional lawmakers in 1981 and 1983, were poor women, and freedom of choice 83 was restricted for all mothers when maternity LOS was regulated in 1983 and in 1996. The social history of professional nursing’s role in the origin of NMHPA analyzed from a feminist perspective clarifies that nursing needs to maintain an active role in health care policymaking to protect the interests of all women. 84 Endnotes 1. Barzun, J., & Graff, H. (1992). The Modern Researcher (5th ed.), New York: Harcourt Brace Jovanovich. 2. Little, D. (1991). Varieties of Social Explanation. Boulder: Westview Press. Hamilton, D (1993). The Idea of History and the History of Ideas. IMAGE: Journal of Nursing Scholarship, 25(1), 45-48; Lusk, B (1997). Historical Methodology for Nursing Research. Image: Journal of Nursing Scholarship, 29, 355-359; Ricoeur, 1965; Streubert, H., & Carpenter, D. (1999). Qualitative Research in Nursing: Advancing the Humanistic Imperative (2nd ed., Rev.). New York: Lippincott. Marius, R. & Page, M. (2002). A Short Guide to Writing About History. 4th Ed. New York: Longman 3. Barzun, p. 191 4. Barzun, 1985, p. 24; Little, 1991. 5. Little, 1991. 6. Little, 1991. 7. Howell, M., & Prevenier, W. (2001). From Reliable Sources: An Introduction to Historical Methods. Ithaca: Cornell University Press, p. 19 8. Howell & Prevenier, 2001. 9. Poster, M. (1997). Cultural History and Postmodernity: Disciplinary Reading and Challenges. New York: Columbia University Press. 10. Poster, 1997. p. 89 11. Poster, 1997. 12. Marius & Page, 2002; Streubert & Carpenter, 1999. 85 13. Ritchie, D. (2003). Doing Oral History. (2nd ed.). New York: Oxford University Press. 14. Marius & Page, 2002. Ritchie, 1995. 15. Ritchie, 2003, p. 36 16. Carey, H., & Greenberg, J. (1983). How to Use Primary Sources. New York: Franklin Watts. 17. Ritchie, 2003. 18. Denzin, N., & Lincoln, Y. (1994). Handbook of Qualitative Research Thousand Oaks: Sage Publications. Streubert & Carpenter, 1999. 19. Marius & Page, 2002. Streubert & Carpenter, 1999. 20. Marius & Page, 2002. Cristy, T. (1975). The Methodology of Historical Research: A Brief Introduction. Nursing Research, 24, 189-192. Sarnecky, M.T. (1990). Historiography: A Legitimate Research Methodology for Nursing. Advances in Nursing Science, 12(4),1-10. Streubert & Carpenter (1999). Internet government documents have been crosschecked with paper copies at Northeastern University Library’s collection of government documents. Interviews with primary sources have been crosschecked for script likeness in verbal descriptions of events. 21. Cristy, 1975. Streubert & Carpenter, 1999. 22. Annas, 1995. Congressional Budget Office, 1981, 1983; Code, L. (1991). What Can She Know? Feminist Theory and the Construction of Knowledge. Ithaca: Cornell University Press. Harding, S. (1991). Whose Science? Whose Knowledge? Thinking from Women’s Lives. Ithaca: Cornell University Press. 23. Annas, 1995. 86 24. Code, L. (1991). Donovan, F. (1985). Feminist Theory: the Intellectual Traditions of American Feminism. New York: Frederick Ungar Publishing Co. Hooks, B. (2000a). Feminist Theory (2nd ed.). Cambridge, MA: South End Press. Hooks, B. (2000b). Feminism is for Everybody: Passionate Politics. Cambridge, MA: South End Press. Pollitt, K. (2001). Subject to Debate: Sense and Dissents on Women, Politics, and Culture. New York: Modern Library. Roberts, S. J. (1983). Oppressed Group Behavior: Implications for Nursing. Advances in Nursing Science, July, 21-30. Ruzek, S. B., Clarke, A. E., & Olesen, V. L. (1997). Social, Biomedical, and Feminist Models of Women's Health. In S.B. Ruzek, V.L. Olesen & A.E. Clarke (Eds.), Women's Health: Complexities and Differences (pp. 11-28). Columbus: Ohio State University Press. 25. Meleis, A.I. (1997). Theoretical Nursing: Development & Progress. 3rd Ed. New York: Lippincott. 26. Meleis, 1997. 27. Popkewitz, T. S. (1990). Whose Future? Whose Past? In E. Guba (Ed.), The Paradigm Dialogue. (pp. 46-66). Newbury Park: Sage. 28. Hyman, D. A, MD, JD (2001). What Lessons Should We Learn From Drive-Through Deliveries? Pediatrics, 107, 406-408. 29. Annas, 1995. 30. Annas, 1995, p 1648. 31. Hooks, 2000a,b. 32. MacPherson, K. I. (1983). A New Paradigm for Nursing Research. Advances in Nursing Science, January, 17-25. 87 33. Reinharz, S. (1992). Feminist Methods in Social Research. New York: Oxford University Press. 34. MacPherson, 1983. 35. Congressional Budget Office (1981). Reducing the Deficit: Spending and Revenue Options. Annual Report to the Senate and House Committees on the Budget: Parts I, II, III. Washington, DC: Congress of the United States. 88 CHAPTER 4 PROFESSIONAL NURSING IN MATERNAL HEALTH CARE IN THE 18TH, 19TH, AND 20TH CENTURIES IN THE UNITED STATES Introduction This chapter examines the role of professional nursing in maternity health care, and the myriad of influences on nursing’s role throughout the 300 years of childbirth practices in the United States. Societal influences, such as the evolution of professional nursing, physicians’ obstetrical practices, hospital finances, the rise of the health insurance industry, and the influence of the women’s movements of the 19th and 20th centuries shaped women’s childbirth experiences. These influences were at times oppositional and other times coalescing forces, determined by prevailing social, economic and political trends. To understand the rationale behind NMHPA legislation, it is necessary to examine these forces to expose the foundation upon which NMHPA was built. The answers to questions raised by the role that influences played on childbirth in America provide an explanation that underpins an understanding as to why NMHPA was necessary. The questions that frame this chapter are: 1) what were the forces on childbirth practices in the United States in the 18th, 19th and 20th Centuries? 2) how influential was professional nursing on the evolution of childbirth practices in the United States? 3) how did the women’s movements in the 19th and 20th Centuries affect childbirth, and, also, professional nursing? 4) why was nursing involved in health care policymaking in the 1990s, but not in the 1980s? The tale of American childbirth is a transition from a home-centered, domestic experience to a hospital-based practice, controlled by physicians, hospital administrators, 89 and the health care insurance industry. Using a feminist critique, this chapter explores the reasons why nurses and mothers had little say in how babies were birthed. However, in the 1990s, a small number of nurses in New Jersey spoke out, not physicians, hospital representatives, or legislators, and approached then Senator Bill Bradley (Democrat of New Jersey) to request that he introduce a bill to change the health insurance reimbursement structure in the United States for maternity LOS.1 Childbirth Practices in the United States 18th Century Home Births Childbirth in early 18th century America took place in the home, attended by female midwives and other women relatives and friends in the community.2 Home births provided a favorable environment for integrating the new baby into the family and community. Until the 1920s, home births were the norm. European immigrants, mostly English, brought their traditional childbirth practices to America. Typically, women learned the art of midwifery in their communities by apprenticing with skilled midwives. By 1750, colonial physicians traveled to England to study midwifery to practice obstetrics in America as male midwives.3 Thereafter, the management of childbirth in the U.S. from colonial times to the early 1800’s was shared between female midwives and male midwives.4 Male midwives began attending home births bringing with them forceps, invented in Germany, to expedite the delivery.5 Diaries kept by some midwives are the only records available to explain the relationship between female and male midwives. The diaries often gave only brief descriptions of births, sometimes mentioning the presence of others such as a male midwife. Generally, female midwives attended but 90 if a difficult birth was expected, midwives would occasionally invite a male midwife or physician into the home for assistance. Unlike their male counterparts, female midwives did not adopt the use of forceps, preferring to let nature take its course while offering emotional support and a variety of home and herbal remedies. Male and female midwives differed too in their access to hospital maternity care. Male midwives in the 19th century were paid by charity hospitals, also called voluntary hospitals, to attend childbirths for some of the poor who could not afford home births. Hospital administrators and physicians banned female midwives from hospital practice. 19th Century and Early 20th Century Childbirth Practices By the mid 1800s male midwives or physicians began to market their skills and the success of their medical interventions causing midwifery to lose favor as middle and upper class women increasingly chose doctors for their maternity care. Charity hospitals accounted for 5% of urban births by the late 1800s and accepted poor women and unmarried women, or women with medical complications. Normal home births for rural and urban dwellers who were unable to pay male midwives for childbirth in their homes were attended by female midwives.6 After 1840, childbed fever (puerperal fever) rates rose in home births due to unknowing transfer of the fever from one patient to another by male midwives or obstetricians. Statistics on deliveries in hospitals in the 1800s were available for public scrutiny, whereas midwives’ recorded statistics are vague and satisfactory outcomes were reported for the most part.7 Diaries of female midwives rarely reported septic cases since mothers delivered without much intervention.8 For instance, an 18th century midwife, 91 Mrs. Ballard from Maine, chronicled only 4 maternal deaths out of 996 mothers during her career.9 Poor outcomes may simply have been omitted by the midwives in their diaries. Midwifery continued to flourish in immigrant and minority communities where traditional home childbirth practices from their countries of origin continued. In the Northern states, maternity clinics were established in the early 1900s, such as the Maternity Center Association of New York City in 1918 where nurse-midwives were trained. Frontier Nursing Service of Hayden, Kentucky established by Mary Breckinridge in 1925 also trained nurse midwives to serve women of rural Appalachia. By 1955, the nurse-midwifery profession was truly established with the founding of the American College of Nurse-Midwifery organization, which in 1968 became the present American College of Nurse-Midwives (ACNM). Southern states continued using lay midwives until the 1950s. Writings on African-American midwifery history describe black midwife slaves birthing other black slaves as well as their white owners.10 The first African-American midwife, a slave from Africa, was recorded in 1619.11 African-American midwives were their community’s healers, since white doctors did not give medical care to slaves in the communities. By 1930, 80% of lay midwives were practicing in the South caring for African-American and Mexican-American women who were unable to obtain sufficient medical care because of the racial and cultural barriers.12 Strict state licensing policies for midwives began in the 1950s, and combined with urban migration, led to the decline of traditional rural midwifery in the 1950s. The licensing of lay midwives in the South was stopped by the 1970s in favor of certified nurse-midwives employed by hospitals.13 By the early 1970s, 92 the number of midwife births nationwide was only 0.5 percent. This downward trend, however, slowly reversed, and by the 1980s nurse midwifery re-emerged in hospital practice as a less expensive way to care for women with uncomplicated births who chose not to have a physician in attendance. The practice continues to the present. The ACNM web site claims 2500 members in 1984, and by the year 2000 there were over 7000 members.14 Currently, there are approximately 6000 members and 600 student members. About 70% of actively working CNMs are members of ACNM. The Medicalization of Childbirth The Invention of Obstetrical Interventions As female midwifery waxed and waned, male midwifery proliferated and so did the proliferation of intrusive interventions by the male midwives. Childbirth became medicalized by interventions, such as forceps, medicine, and anesthesia that were designed to hurry the birthing of babies by impatient male midwives. By the mid-1800s, male midwives in Europe, later known as physician obstetricians (Greek for “to stand before”),15 developed several interventions to assist in the mechanics of childbirth that at the same time lengthened convalescence. The birthing process was aided by tools such as forceps to deliver the infant. Chloroform, an anesthetic gas first used in Scotland in 1847, controlled the pain of childbirth.16 The use of anesthesia in obstetrics was the cause of heated debate when in 1847, Dr. James Simpson, an obstetrician in Edinburgh, Scotland, pioneered the use of anesthesia in childbirth.17 He declared that obstetrical pain was equal to surgical pain. Because American physicians studying obstetrics often did postgraduate work in Edinburgh, Scotland, home of obstetrical anesthesia, the use of anesthesia crossed the 93 Atlantic with their return to America provoking vigorous debate. Dr. Channing of Boston, Dean of Harvard Medical School, sided with Dr. Simpson.18 Dr. Meigs of Philadelphia, head of the opposition camp, believed childbirth pain was a part of birthing babies and that anesthesia should not be used. Confusion surrounds the first use of chloroform in the U.S.: Wertz and Wertz report that chloroform was first used in 1848 at the Boston Lying–In Hospital.19 However, Caton states that in April, 1847, chloroform was used on Fanny Appleton Longfellow, wife of Henry Wadsworth Longfellow, in Boston, Massachusetts.20 Regardless of the actual date, by 1900 the consequences of anesthesia were apparent with mothers requiring longer convalescence, and if birthed in the hospital longer hospitalization, because of the sleepy narcotic effect of the gas.21 Newborns, too, were affected: they were lethargic for several days after birth and were unable to suck properly necessitating forced feedings by bottles.22 The increase in physician interventions caused puerperal fever epidemics, supporting those who urged caution with interference in childbirth. In the mid-1800s, Louis Pasteur, founder of the science of microbiology, had demonstrated that puerperal fever was caused by either Staphylococcus Aureus or Streptococcus A bacteria spread by physicians going from patient to patient, examining birth progress without hand washing between patients. In 1883, a large epidemic of puerperal fever occurred at the Boston Lying-In, causing a morbidity rate of 75% and mortality rate of 20%.23 By 1885, aseptic technique and hygienic hospital practices, such as hand washing, were developed and used in hospitals to reduce infections.24 Improved aseptic technique and the addition of sulfa to combat infection decreased the infection rates making hospital births safer.25 By the 1890s, urban women delivered in hospitals with less fear of infections. But despite 94 improved hygiene and treatments for infections, outbreaks persisted for the next 50 years, extending convalescence in both hospital and home births. Obstetricians versus Midwives Physicians convinced upper and middleclass women that they were safer in the hands of doctors and hospitals. Educated, skilled physicians who offered forceps and obstetrical anesthesia were promoted as better than midwives for quicker or for difficult births. Furthermore, physicians pointed out medical and financial benefits to hospital births, namely that interventions were not offered for home deliveries and that insurance companies paid for hospital deliveries but not home deliveries.26 The new interventions and equipment were also easier to house in one place, a hospital, for physician use. Physicians, who had an economic stake in hospitalized childbirth, also attempted to undermine consumer confidence in midwives, portraying them as unclean and uneducated. Although lay midwives in the early 1890s continued to serve working class and immigrant women who could not afford the services of hospitals and doctors, childbirth by midwives was almost eliminated in the early 1900s except in rural areas and in the south.27 States’ licensing laws, prompted by the medical societies of the AMA, successfully undermined midwifery until the 1950s when a resurgence in midwives occurred.28 In 1918, midwives attended 42% of childbirths at home, but by 1930 only 19% of births were attended by midwives.29 By 1920, 30-50% of mothers preferred to deliver in hospitals because the facilities offered painless childbirth and medical assistance not offered in home births.30 Believing childbirth to be safer with forceps and anesthesia, women’s social groups campaigned for improved women’s health for all races 95 and classes and supported physicians’ desire to have women deliver in hospitals. Thus began the hospitalization of childbirth. The efforts by women’s groups to improve women’s health resulted in passage of the first federal legislation to promote safe comprehensive maternity care, the Sheppard- Towner Maternity and Infancy Act of 1921, which provided grants to states to develop health services for all socioeconomic classes of mothers and their children.31 Though it was repealed in 1929, through successful AMA lobbying efforts claiming it was the precursor of socialized medicine, the Act served to lay the foundation of the 20th century’s women’s movement vision for the future of women’s health care. Improved Obstetrical Education and Childbirth Physicians and hospitals continued to dominate medical care in the 20th century. The American Medical Association (AMA) founded in 1848, aimed to standardize medical practice among all physicians and various non-physician groups.32 The AMA’s Flexner Report of 1910 discovered that 90% of doctors were still not college educated.33 The response to the report by the AMA was to accredit medical schools, encourage enrollment, and replace apprenticed female midwives with college-educated male physicians. Standardized formal medical education, developed in universities in England, Scotland and Germany, was adopted in America, initially in Philadelphia, New York and Boston. Medical technology in the United States became more sophisticated as the country became industrialized and urbanized. The most widely regarded medical school was founded in 1893 at The Johns Hopkins University, in Baltimore. Dr. J. Whitridge Williams, Professor of Obstetrics, who succeeded Dr. William Osler, the founding 96 Professor of Obstetrics, concurred with the Flexner Report of 1910 that most physicians had poor training in obstetrics resulting in poor patient outcomes due to high infection rates and hemorrhagic operative results.34 Williams advocated for better obstetrical education, with medical students trained and supervised in hospitals under standardized obstetrical procedures. He also advocated for the elimination of lay midwives, preferring that all mothers, poor, middle and upper class, deliver their babies in hospitals. Essentially, he wanted to transfer childbirth out of the traditional home setting, out of the hands of midwives, and into the hospital under the patriarchal control of doctors Hospital Control of Childbirth As the U.S. transformed from an agricultural society to a more industrialized society in the 1800s, large numbers of people moved into urban areas, many entering the working class as paid factory laborers and domestics. Hospitals became a source of free care for those who could not pay physicians for treatment. By 1873, there were 120 charity hospitals in the United States.35 Hospital Control in the 19th and 20th Centuries After the American Civil War (1861-1865), veterans and war widows moved into cities seeking work to support their families as domestics for middle and upper class families.36 Medical care transitioned from homes to urban hospitals, now often owned by physicians and known as proprietary hospitals. The hospitals provided staff obstetricians and a place for convalescence for some women who could not afford to pay for home births. Once viewed as charity institutions for the poor and unfortunate, these hospitals were staffed with educated physicians who were paternalistic toward working class 97 patients: “…hospitals generally were moralistic and authoritarian even as they were benevolent and humanitarian…patients could easily feel patronized and degraded.”37 In the 1890s, only 5% of childbirths were in hospitals, but by 1939, the majority of childbirths were in hospitals because physicians promised mothers that childbirth was safer in hospitals than at home.38 Nonetheless, the hospital environment exposed women in childbirth to iatrogenic disease from doctors and nurses going from patient to patient. But, after 1935, when 60% of white women delivered in hospitals, infection rates in hospitals plummeted due to better aseptic technique, less physician intervention, the use of blood transfusions, and the availability of antibiotics such as sulfa, and, after 1946, penicillin. By 1939, 50-75% of all women delivered in hospitals, though there were regional and racial differences. Race and class in childbirth were stratified with black midwives caring for black mothers in the rural south. In the southern hospitals in the U.S. hospital births for black women from rural areas were rare.39 While the numbers of northern midwives dwindled, southern midwives flourished. In 1930, 80% of midwives in the U.S. were in the rural south, and they were African American midwives who birthed women of color in rural home births.40 As late as 1960 almost half of all U.S. proprietary hospitals, 15% of government hospitals, 20% of church-related hospitals, and 22% of other nonprofit hospitals declined patients by race.41 Aseptic technique and new antiseptic medicines available in the 1930s to combat infection rates provided a sterile, clinical hospital environment that “dehumanized” childbirth compared to traditional home births. While childbirth became less painful in hospitals, mothers went “from home to hospital… from suffering to painlessness… from 98 patient care to disease care” with the intrusion of obstetrical medical interventions.42 Not only did the social image of hospitals in the 1800s change by the early 1900s, but what once was a place for only the indigents in society became places of business driven by hospital finances. Early Hospital Finances In 1873, the AMA initiated a hospital report in response to physicians’ plans to standardize the way medical care was taught to doctors-in-training in hospitals.43 Hospitals, once charity institutions for the socially marginal, were increasingly financed by the wealthy upper class, often the proprietors of industries such as shipping and railroads, for the care of their workers injured on the job.44 Nepotism was rife, with physicians who owned the hospitals appointing medically trained friends and relatives as staff physicians. Eventually, even the wealthy sought treatment in hospitals, albeit in specially appointed private rooms instead of the customary multi-bed wards. By the 1920s, not only the socially marginal but also the elite agreed that hospitalization offered better and safer medical treatment than home care where morbidity and mortality occurred at more frequent rates. Patients paid a fee-for-service, but poor, non-paying patients stayed longer, on average 81 days, than the patients who could afford hospitalization.45 Social care of the patient was important to the hospital community in the late 1800s. The popular belief was that inpatient holistic therapy was aimed at not only medical care but also social care of the patient. This may have been a device of the AMA for doctors to have a supply of patients to study the human condition. Hospital trustees and the chief physician set rates for patients, but, in time, control of charges shifted to hospital physicians. Eventually 99 annual donations from owners of corporations, such as railroad and steamship companies who had contributed funds to support charity hospitals, began to pay for blocks of beds for their employees. This practice ceased in 1911 when various states began passing workman’s compensation acts.46 Since not all patients were workers covered by workman’s compensation, private insurance was conceived and insurers offered hospital insurance. The American Association for Labor Legislation in 1915 introduced non- workman’s compensation health insurance proposals in three states. Private health insurance plans such as Blue Cross developed in the 1930s beginning in Texas then spreading across the U.S.47 The concept of hospitals as social charity institutions transformed into hospitals as places of business. Insurance reimbursements for hospital services fueled hospital finances. The hospital as a business continues to the present day. Modern Hospital Finances Between the two world wars (1920s-1930s), hospital accreditation developed and further standardized hospital practice by consolidating hospital finances, medicine, nursing, and patient care. By the 1930s, the accreditation rules governing the practice of physicians, hospitals and nursing were created by national committees consisting mainly of physicians.48 Medical education was upgraded and hospital nursing education programs were subsumed under physicians and hospital administration. The two world wars coalesced hospitals, nursing, and the medical profession, and also created a division among them with each group staking its own territorial claims. Medicine had its own science. Hospitals had their own financial interest, yet hospitals and medicine worked together to form an economic alliance. Professional nursing, however, did not yet have its own science and, therefore, did not have its own voice.49 Nurses came under the 100 supervision of physicians and hospitals. Hospitals became the physician’s “workshop” by the 1930s.50 In the 1940s with the advent of World War II, many nurses and physicians were called abroad to care for the wounded leaving a shortage of nurses and doctors at home.51 After World War II more hospitals, physicians, and nurses were needed to care for the returning war veterans and the booming population-at-large. President Roosevelt proposed federal grant money to construct 50 new civilian hospitals to accommodate returning war veterans, but his idea was defeated.52 Hospitals did not want veterans admitted at the same facilities that civilians utilized because of the veterans’ horrific trauma and associated behavioral problems. Although Roosevelt’s proposal was defeated the idea of federal monies appropriated for medicine began, and public policy entered hospital administration. By 1946, the idea of constructing new hospitals with federal monies resurfaced, and the Hill-Burton Act was passed giving states federal money to aid in the construction of local civilian and veterans’ hospitals. To help with re-supplying the nation with nurses, the Cadet Nurse Corps (1943- 1948) was established to bolster the military nursing workforce.53 In 1943, the federal government recognized the serious need for more nurses in the military. The government provided federal grant scholarships and stipends to student nurses recruited in hospital schools of nursing in return for the students’ continued service in the military for the duration of World War II. The program was successful in educating 124,000 nurses, including 3,000 African Americans. However, many military nurses when they returned home traumatized by war often found careers outside of nursing in jobs such as 101 secretaries, x-ray and lab technicians, or dental hygienists. Others married and became housewives exacerbating the short supply of nurses.54 Many of the hospitals constructed under the Hill-Burton law developed their own schools of nursing to address the re-supply of nurses.55 A common hospital practice was to use nursing students to boost the numbers of nursing staff on hospital floors. As one 1948 graduate nurse stated “the hospitals used nursing students to staff the hospital as free labor; there weren’t enough nurses to go around. You’d work the night shift then go to class the next morning.”56 The 1950s was characterized by the introduction of expensive high-technology medicine, with intensive care units established throughout the nation’s hospitals. The increased costs incurred, along with a shortage of nurses post World War II, demanded reduction in hospital expenses. Therefore, in the early 1960s maternity LOS was curtailed then gradually rose again to 10 days by the 1970s. 57 The increase in maternity LOS was a function of an increase in numbers of people who held health insurance. The widespread availability of private insurance spurred not only hospitals but also physicians to compete for the widespread availability of dollars. The introduction of more anesthetic choices for childbirth increased patients’ recovery and lengthened LOS, boosting revenue that helped to cover the cost of the high technology. By 1965, the majority of mothers were opting for hospital childbirths with 97% of all births occurring in hospitals and the LOS for maternity patients was 3.9 days for vaginal deliveries and 7.8 for cesarean deliveries.58 Attempts to cut maternity care benefits by insurers led hospital administration to reconsider a shortened maternity LOS once more. And by the 1970s, mothers and feminists, seeking less medicalization for childbirth, also wanted to shorten the maternity 102 LOS making it easier for hospitals to discharge mothers on the fourth to day for a vaginal delivery and the sixth day for a cesarean. The desire by mothers and hospitals to reduce maternity LOS lasted until the late 1980s when health insurers, led by Medicaid, drastically limited payments for childbirth to the 24/72-discharge time frame necessitating a precipitous drop in maternity LOS by hospitals. Health Insurance and Childbirth Early 1900s Health insurance and later its stepchild, maternity insurance, have driven the health care industry since the early 1900s. Prior to the 1940s, consumers purchased health insurance through hospitals, but gradually employers began to purchase health insurance for their employees as an employment benefit. The shift of purchasing insurance from employers instead of hospitals was a device of the federal government who preferred not to subsidize a federal program for national health insurance for all Americans. In effect, subsidizing health insurance would increase taxes for businesses in order for the government to pay for the program.59 By 1960, 63 % of hospital reimbursements came from private insurers whose premiums were paid by employers.60 In the early 1950s, supporters of health insurance believed that the elderly and poor should have “hospital” insurance. In 1957, the Forand bill was introduced by Democrats as a forerunner of the 1965 Medicare Part A law.61 By 1965, Medicare/Medicaid for the elderly and needy put the U.S. government in the business of health care finance, offering reimbursement-for-services to hospitals and physicians. The expectation was that hospital costs for services would be voluntarily curtailed. But by the 103 1970s, costs had spiraled upward due to the explosion in technological advances. Hospitals continued to pass these costs on to insurers. Latter 1900s By the early 1960s, the insurance industry had ballooned to over 700 private insurers who provided incentives for physicians and hospitals to charge fees without restraint.62 As hospitals and physicians passed inflated costs on to insurers, insurance companies passed the costs on to subscribers in the form of insurance premiums, creating an “expansionary spiral” lasting to the present.63 Physicians and hospitals profited from the practice of receiving separate payments. The Hill-Burton law of 1946 fostered the construction of not-for-profit, private and government hospitals. Hospitals, involved in costly scientific medicine and research, became known as the “teaching” hospitals, most with over 300 beds.64 In 1965 there were 5,736 private hospitals with 10% classified as teaching hospitals.65 Hospitals had become purveyors of medical care, research, and the training of doctors and nurses. By the late 1980s, Medicaid began to limit reimbursements to hospitals. Private insurers followed suit in the early 1990s at the suggestion of the federal government, as discussed in previous chapters. The federal government re-tooled the Medicare/Medicaid reimbursement structure in the early 1980s to limit prospectively set payment rates with the hope of reducing federal expenditures. Maternity health insurance impacted not only childbirth practices but hospital finances as well. Chapter One reviewed the consequences of that decision and the impact on childbirth in the 1980s and 1990s.When Medicaid grants to states were curtailed, reimbursements to hospitals were reduced. 104 Hospitals had to discharge mothers and newborns at 24/72 because states’ Medicaid programs only paid for a 24/72 LOS. Evolution of Maternity Health Insurance Benefits Maternalist legislation in the 19th and 20th centuries evolved from the agendas set forth by the first women’s movement and led to maternity benefits in public and private insurance in the United States.66 The evolution of and the subsequent need for insurance for mothers’ hospitalized births and recuperation produced generous maternity insurance benefits. At first it induced hospitals and physicians to increase fees whereby extended maternity LOS yielded increased revenue; then insurers drastically reduced reimbursements that resulted in hospitals discharging mothers at 24/72. The first women’s movement spanned 1848-1920, beginning with the Seneca Falls Convention of 1848. 67 The focus was to campaign for and win suffrage for women and other goals of political and economic equality in the United States. Following the Civil War the movement gathered momentum and a host of women’s suffrage and other women’s groups arose to promote female equality rights that included increased economic, social, political, and legal status for women. Organizations of the early 1900s included the General Federation of Women’s Clubs, the National Association of Colored Women, and the National Congress of Mothers (in 1924 renamed the Parent-Teachers Association). Medical health care for women did not escape the agenda of the women’s movement. Maternity conditions in hospitals such as the puerperal fever epidemics, operative obstetrics, and weeks-long recovery, led women in the late 1800s and early 1900s to favor less interference from the medical profession. By the late 1800s, the 105 vortex of feminism focused on improving women’s socioeconomic status through federal policymaking such as mothers’ pensions, the first federal maternal social policy in the United States, which was developed shortly after the Civil War.68 Over the next 65 years the mothers’ pensions social policy was revised, expanded and rewritten to become the foundation for the Social Security Act of 1935, within which Medicare/Medicaid is contained.69 Some nurses were also involved in the women’s movement in the late 1800s and early 1900s, namely Barton, Thoms, Wald, Dock, Robb, Nutting, Sanger and others who advocated for women’s socioeconomic equality and health care rights. After the Civil War (1861-1865), rapid industrialization transformed the U.S. from an agricultural to an industrial society.70 At the same time, scientific-based medical technology began to shape modern medicine, which in turn influenced people worldwide. The rapid changes in industry and technology led to great social upheaval. Industrialization led veterans, and often their wives or widows, to find work in factories located in urban centers. In the late 1800s until the early 1920s, a period that came to be known as the Progressive Era, social activists, or progressives, sought to improve the often harsh conditions of life for workers in the new factories and urban slums in the United States.71 These reforms led to the introduction of the first social insurance, federal pensions for civil war veterans and, later, their widows (called mothers’ pensions).72 Shortly, workers’ industrial accident injuries were financed by early forms of accident and disability insurance through their employers.73 Soon, disability insurance became hospital insurance, then, later, health insurance. Maternity benefits evolved as a stepchild from hospital insurance and health insurance. Despite failed attempts as early as 1912 to develop national health insurance for families in the U.S., health insurance evolved into 106 an employer-based benefit. The United States feared socialist forms of activity would limit individual and economic freedoms and, therefore, did not adopt universal health insurance, unlike Germany, the first country to develop universal health insurance in 1883, and other industrialized countries.74 The United States maintains its position to this day. In the late 1800s and early 1900s, labor unions arose to address the often untenable conditions of workers’ compensation, occupational health and safety, and child labor. Rapid industrialization demanded more workers and poor children were included in the potential pool of workers. The harsh labor conditions and child labor led to demands for improvement and in 1905 to the formation of the American Association for Labor Legislation (AALL).75 In 1915, the AALL offered a national health insurance bill that included sick benefits, maternity benefits and a death benefit for funeral expenses.76 The plan’s premium payment was to be divided between workers, employers and the state. Though the plan was limited to just workers and dependents, it failed to pass in Congress. The national AMA initially supported the plan and then later lobbied against it. State medical societies were strongly opposed, citing socialized medicine issues. There was not yet a great demand for government subsidized medical care from the general public, and physicians feared limited payment from the federal government for what little patient business they could generate. The physicians, therefore, wanted to be paid in full by their patients. Professional nursing’s presence was absent since the national health insurance was written to pay for physician’s fees. But, professional nursing was not idle; it had an agenda to convince nurses of their right to vote, to continue efforts to obtain state licensure in every state, and continue concern for public health care objectives. 107 The federal government controlled public maternal health insurance long before NMHPA was legislated. Maternal and child health insurance in the United States evolved from the social policies and mother’s pensions of the late 1800s to the present form of maternity benefits that provide comprehensive payments for prenatal care and maternity LOS in the hospital. The first federal maternal social policy in the U.S. was “protective” legislation that provided pensions for Civil War soldiers and their widows and children.77 The roots of the continued support for a maternal social policy after war veterans and their widows died of old age are described by Skocpol in the context of the origin and founding of the Children’s Bureau (1912), the Sheppard-Towner Maternal and Infancy Act of 1921, (to be discussed) and the proclivities of formally organized social reformist women’s groups during the Progressive Era (1890-1913). Millions of women both white and women of color in the United States belonged to organizations such as the National Congress of Mothers, the General Federation of Women’s Club, and the National League of Women Voters, the National Association of Colored Women, among others, and campaigned for women’s rights and health care issues. Since the United States government did not embrace universal public health care, women and children who were swept into the industrialized workforce in the late 1800s had high morbidity and mortality rates from long hours, harsh working conditions, and industrial accidents.78 Immigrant workers seeking new opportunities in the United States and their families created an urban concentration of health care needs recognized by middle-class American women reformers involved in women’s civic organizations. At the turn of the 20th century, settlement houses for public health care operated by public health nurses, such as Lillian Wald’s Nurses’ Settlement on Henry Street in New York 108 City, were developed to address the needs of all urban dwellers. Women activists in organizations such as the National Congress of Mothers and the General Women’s Federation Association spurred legislative protection laws for children in the workforce such as the number of hours per day per week a child may work, and age limits for child hires. Wald was also instrumental in helping to create the U.S. Children’s Bureau in 1912 for the protection of child welfare. African-American women were also involved in organizing professional nursing in the 1800s and 1900s.79 During the Civil War they struggled against racism in their efforts to care for wounded African-American men. African-American reformist organizations, such as the National Association of Colored Women (NACW), established in 1896, also organized to promote public health and welfare in the early 1900s. White (one million in 1920) and African American women (50,000 in 1914) reformers usually maintained separate organizations, but joined together to achieve the common goals of protective legislation for mothers and children in the workforce.80 Some organizations were racially integrated, such as the National Child Labor Committee, the National Urban League, and the National Consumers’ League. The Children’s Bureau, founded in 1912 by Lillian Wald, sponsored the first public grants-in-aid program, the Sheppard-Towner Maternity and Infancy Act of 1921.81 Written by the director of the Children’s Bureau, Julia Lathrop, the Act provided grant money to be matched by states to develop clinics across the nation for maternal and child health care aimed at reducing the morbidity and mortality rates. Public health nursing, led by nurses such as Wald, Dock, Robb, Sanger, and others, was at the forefront in improving the care of pregnant women, infants and children under the Act. 109 Maternal-child health clinics scattered across the United States were sponsored by the Sheppard-Towner Act and were widely successful in health care prevention for mothers and children.82 Unfortunately, the Sheppard-Towner Act was not renewed in 1929 due to the heavy lobbying of the AMA. As with the national health insurance bill of 1915, the AMA opposed the legislation, again claiming the onset of “social medicine”83 Other political influences in the early1930s that drained funding for public programs for national health care included the Great Depression, and a populist anticommunist backlash towards European communist countries that counted national health care as a form of social communism. Support by women’s clubs to continue the Sheppard-Towner Act declined because of the federal government’s position was not to subsidize many of socioeconomic policies at that time.84 This soon changed when President Franklin D. Roosevelt was elected in 1933 under a New Deal campaign. His idea was to create economic opportunities that would provide social relief and financial recovery from the Great Depression. Though the Sheppard-Towner Act was not renewed, federal block grants to states continued maternal-child health programs already in progress. Just as the social conscience of the American people for the plight of the elderly paved the way for the Social Security Act of 1935 with public benefits for those over 65 years, the national success of the Sheppard-Towner Act laid the groundwork for the federal Medicaid public health assistance program that began in 1965. Medicaid, a grants-in-aid program with the states, provides public health care assistance for low- income maternal-child health, and disabled persons. Meanwhile, the number of private insurance companies proliferated in the 1940s and 1950s.85 Private health insurance was initially called disability insurance offered by 110 employers as the country industrialized and workers were injured on the job.86 Insurance companies paid hospitals, physicians and nurses. In 1929, Blue Cross and Blue Shield (the Blues) Insurance was first created in Texas.87 The Blues eventually became a part of each state’s network of insurance companies and remains one of the largest companies. Employers offered health insurance benefits to employees as an incentive for workers to apply for employment and to encourage workforce stability. Maternity benefits were tied to employment with the result that either the married woman had to be employed, or she had to be married to an employee with insurance coverage in order obtain maternity benefits.88 In 1933, the first baby was born in Durham, North Carolina, under a family health insurance plan carrying maternity benefits.89 The maternity hospital LOS was 10 days and cost $60. Maternity benefits, if included in the plan, were usually a small flat cash rate that merely supplemented the total cost of childbirth.90 Further, it usually paid only if the mother delivered in a hospital, though some private plans covered home births. The tangled web between physician, hospital, and insurance began to grow: The hospital-only payment practice providing yet another incentive for childbirth to be moved from the home into the hospital.91 In 1940, less than 10% of the population had private health insurance coverage, but by 1955 almost 70% were covered.92 The limited financing of childbirth by insurance companies lasted until the mid 1970s when federal legislation mandated broader reimbursement coverage. The small cash amounts paid prior to the legislation were less than those awarded for other health conditions. Additionally, many women were either not hired if they were pregnant, or fired if they became pregnant, or lost their jobs after childbirth. American mothers and 111 feminists such as the members of the National Organization of Women (NOW) led by Betty Friedan, declared this practice discriminatory based on unequal opportunity in the job market, spearheading the federal Pregnancy Discriminatory Act of 1978 (PDA) which required insurance companies to make childbirth coverage, if offered, more comprehensive. 93 The PDA prohibited employers from firing an employee if she was pregnant, or firing her while out on maternity leave, or discriminating against her training, compensation, or any other aspect of employment because of pregnancy. Insurers at that time did not dispute the ample LOS for postpartum recovery in the hospital. The Act, in the evolution of maternity benefits, showcased maternity benefits, thereby giving social and political recognition to the importance of family health care needs in U.S. society. Several of the legislators involved in NMHPA’s policymaking in 1996 were also members of congress during the policymaking of the Pregnancy Discriminatory Act of 1978.94 In the 95th Congress (1977-1979), there were 55 members in the House of Representatives and 26 members in the Senate who were also in the 104th Congress (1995-1996), none of them women. The PDA of 1978 passed in the Senate 75-11, and in the House 376-43.95 In each house of congress it is notable that there was a gender vote for PDA of 1978 and for NMHPA in 1996. That is, all females voted in favor of the bills, regardless of party affiliation.96 The 95th Congress in 1978 included 15 female Representatives; eleven Democrats including three African Americans and four Republicans. There were two female Senators, one Democrat and one Republican. In the 104th Congress in 1996, there were forty-eight women Representatives comprised of thirty Democrats, including 112 eight African Americans, two Hispanics, and one Hawaiian. There were seventeen Republicans (all white) and one from the Independent party (white). Clearly, political representation for all women increased from 1978 to 1996, but remained quite limited in minority representation. The only female Representative from the 95th Congress who was also a Representative in the 104th Congress was Cardiss Collins, a Democrat from Illinois and an African American. Another woman who was a Representative in the 95th Congress was listed as a Senator in the 104th Congress, Barbara Mikulski (D-MD). An description of the voting records for NMHPA is described in Chapter Six. The Influence of the Women’s Movements of the 19th & 20th Centuries on Childbirth Women’s Views on Childbirth Interventions by Physicians Public sentiment considered childbirth a natural biological phenomenon; yet, mothers and obstetricians in the early 1900s, viewed the associated pain as needless suffering. Consequently, mothers and most physicians supported the use of anesthesia for childbirth. However, their support for childbirth anesthesia waxed and waned over the years. Mothers wanted relief from childbirth pain, but by the 1960s some physicians cautioned against using anesthesia for various reasons such as increased bleeding from uterine relaxation and depressed newborn respirations.97 Even Dr. Meigs, a century earlier, wrote that childbirth pain should be experienced because it, in his view, promoted maternal attachment.98 Though mothers expressed a need for relief of childbirth’s associated pain and suffering, physicians, scientists and philosophers of the 18th and 19th centuries believed that childbirth pain was experienced differently by different classes of women and that education and culture varied the perception of pain.99 “Lacking sensibility, animals do not 113 experience labor pain…savages and lower-class women experience less labor pain than women who are educated and cultured.”100 Class differences notwithstanding, in 1914, Austrian and German obstetricians combined two anesthetic agents, morphine and scopolamine, to produce Twilight Sleep, which offered analgesia, partial pain relief, and amnesia for obstetrical patients. In 1938, Twilight Sleep was first used in the U.S. Lay accounts of Twilight Sleep led women to believe that they would “sleep through labor and awaken 12-24 hours later feeling refreshed.”101 Unfortunately, the lay literature did not adequately describe the potential side effects of the medicines used in Twilight Sleep. These omissions placed women and physicians at odds with each other. While women, unaware of any potential risks, wanted anesthesia, some physicians were reluctant to use the Twilight agents knowing their side effects. In addition to weakened uterine contractions and depressed respirations of the newborn, patients’ reactions had included hallucinations, excitability and thrashing in pain even though the patient had no memory of any pain, due to the medicine’s effect. In the 1930s and 1940s, mothers had to stay in the hospital an average of two to three weeks after birth to recover from the lasting effects of the narcotic medicine.102 Cost concerns arose also. Monitoring of anesthetized mothers required extended nursing care that decreased the economic viability of Twilight Sleep.103 The Twilight Sleep intervention lasted well into the 1960s when physicians became increasingly concerned about newborns’ respiratory depression and general lethargy at birth, the result of the mothers’ Twilight Sleep medication. Other methods of analgesia and anesthesia, such as general and spinal anesthesia as well as other opiates, were developed over the next 50 years to replace Twilight Sleep. 114 Physicians believed that interventions such as anesthesia and operative procedures, i.e., forceps use, episiotomies and cesarean sections, decreased complications of delivery. A notable rise in induced labor and cesareans occurred in the 1950s with the development of these procedures resulting in longer maternity LOS that infused hospital revenues.104Along with these interventions was the need for more hospital beds for the longer recovery from childbirth. Physicians collected more fees from insurers as they visited their recovering patients each day with the longer LOS. Except during the early 1900s when physician interventions such as forceps or anesthesia were thought to be helpful, feminists generally believed that childbirth should have little interference from physicians.105 Many mothers, on the other hand, rejected interventions and the sometimes insensitivities of male obstetricians in the 1800s. Elizabeth Blackwell, MD, (1821-1910) was the first female physician graduated in the United States (Geneva College, Geneva, New York, just eleven miles west of Seneca Falls, New York). She established New York Infirmary for Women and Children in New York City, a hospital owned and operated for women, to offer the kind of sensitive care women wanted. By the early 1900s, some mothers came to accept the obstetrical interventions physicians offered in hospitals believing in physicians’ safety rhetoric. The interventions also insured physicians’ remuneration and validation for their skills. But, mothers’ opinions on obstetrical interventions began to change and many mothers once again became critical of the interventions by the 1960s. The Second Women’s Movement and Childbirth The very idea that there was a first, and then second women’s movement implies that there was a gap between movements. If the first women’s movement spanned 1848- 115 1920, the second began during the 1950s and continues to the present, though its most dramatic gains took place from1965 to 1980.106 Social theorists have put forward a myriad of rationales for the emergence of the new feminism. For example, Stevens postulated that the springboard for the modern women’s movement’s may have started in the 1950s with the exposure of harsh labor room birthing practices in the lay literature as discussed earlier.107 Rosen, however, believed it was born out of the discontent of two generations of women who had experienced inequality in the workplace, as well as the tumultuous times of the 1960s.108 Rosen argues that the reason why the first wave of feminism abated in the 1920safter the unifying suffrage movement was that feminists, with their new political clout from suffrage, splintered to work on a variety of special interests, such as child labor protection, prenatal care, unionization, and peace; by the 1930s, antipoverty initiatives, and how to respond to the rise of Fascism dominated the agenda; by the 1940s, many activists joined the anti-Fascist Left movement, organized industrial unions, and, in the 1950s, guided civil rights movements. Post-World War II saw the American social landscape become more conservative. In 1948, Harry Truman, a Democrat, was elected President of the United States, with a mission for domestic development and foreign security, a carry-over from his years as vice president under Roosevelt’s New Deal campaign in 1933. Men returning from the war expected to resume their jobs and the many women who had filled factory jobs vacated by men when they joined the armed forces, returned home to become homemakers once again. But a tide of discontent began with the feeling of isolation that many women experienced in the confinement of their homes. They yearned to return to public life and contribute to society by leading a 116 fulfilling life. Employed women, no less restive, experienced many injustices, such as being fired if they became pregnant, or not paid equal wages for equal work compared to men’s wages. By the 1960s, social unrest heightened, marked by: the sexual revolution; the struggle for civil rights for minority races, women and gays; the anti Vietnam war protests; the rise of Students for a Democratic Society, and the National Organization of Women (NOW,1966); the eruption of the Watts riots in Los Angeles; the assassinations of President Kennedy, Martin Luther King, and Robert F. Kennedy; and the 1972 election of a conservative Republican president, Richard Nixon. Feminists, riding the wave of social unrest, moved for equality in the workplace, and birth control.109 Some historians claim two main catalysts for the second women’s movement.110 First, President Kennedy’s decision in 1963 to appoint a commission to determine issues important to women in the U.S. and second, also in 1963, the publication of the Feminine Mystique by Betty Friedan, a freelance writer and a feminist who advocated liberation for women from domestic, economic and social barriers to full equality with men. However, nurse feminists Chinn and Wheeler claim that the civil rights and peace movements of the 1950s and 1960s fueled the second women’s movement.111 MacPherson noted that a women’s health movement was also under way.112 In addition to these scholarly explanations, international women’s conferences fueled the movement to re-invent feminist activism. But despite all these formative conditions, professional nursing groups did not enter the movement until the 1980s.113 117 The Feminist Voices on Childbirth Practices Beginning in the late 1940s and 1950s, women started questioning the medicalization of childbirth.114 Although eighty-eight percent of births took place in hospitals, the midwifery section of the National Organization for Public Health Nurses declared childbearing and childbirth a normal process, advocating it as a family-centered event.115 The position statement ignored the physician and his “workshop.” Hospitals were criticized by the women’s health movement of the last half of the 20th century as sterile and aesthetically cold environments with intrusive obstetrical interventions.116 Long silent on their experiences in labor wards, women’s voices were soon to be heard. The practices frightened many mothers who expressed their fears in lay literature such as Family Circle, Redbook, Good Housekeeping and Ladies Home Journal magazines. By 1960, ninety-seven percent of births were in hospitals, and the Children’s Bureau began to fund educational programs for nurse midwives. By 1970, the start of national certification programs in midwifery began. In the 1960s and 1970s, mothers and feminists campaigned for fewer obstetrical interventions for childbirth. Individual feminists, such as Betty Friedan and Doris Haire, advocated for humane treatment of mothers in childbirth.117 Haire, among others, was an activist for natural childbirth in the 1970s. She founded the Childbirth Education Association to promote family centered maternity care. She, and her colleagues and disciples, advocated for less medical intervention in maternity care. Birth International‘s web site still lists her name. Haire wrote The Cultural Warping of Childbirth in 1972, an analysis of worldwide obstetrics published by the International Childbirth Education Association. The feminist Boston Women’s Book Collective (1984) authored Our Bodies Our Selves that advocated 118 women’s empowerment through education about women’s bodies and other socio- medical issues, including childbirth. By the 1970s and 1980s feminists and women’s efforts for less intervention in childbirth resulted in reductions of LOS from 10 days to four days for vaginal deliveries and eight days for cesarean deliveries.118 Nurse legislators and other women legislators carried the torch by lobbying for women’s and mother’s rights for equality with the passage of the PDA and NMHPA.119 However, physicians, hospitals, and insurance providers still maintain control over childbirth practices in the U.S. Mothers to this day still report high intervention rates in childbirth. A 2002 national survey of 1,583 mothers titled Listening to Mothers was conducted on the internet and by phone by the Maternity Center Association in New York City in conjunction with the Johnson & Johnson Pediatric Institute.120 Mothers rated their providers well, but noted high interventions in obstetrical health care: 93% had fetal monitoring during labor; intravenous lines were in place for 86% of mothers; 63% had epidurals; 74% labored on their backs; 55% had their membranes artificially ruptured; 53% had oxytocin augmentation; 52% had bladder catheterization; and 52% had a repair of a laceration or episiotomy. Emotionally, of the 1,583 mothers surveyed, 25% experienced fear, isolation, and/or anxiety while hospitalized. The Nursing Movements of the 20th Century and Childbirth Practices Private duty and public health nursing flourished at the turn of the 20th century.121 But by the 1920s, nursing’s quest for professional autonomy became mired in social and political issues recounted in this section. The following is an account of the transition 119 from private duty and public health nursing to hospital nursing that stalled autonomy and advocacy for patient care. Professional Nursing in the Political Arena Historically, nurses have demonstrated political pragmatism in their dealings with the entrenched male socio-political establishment.122 From its beginnings in antebellum America, the women’s movement has recognized the need to challenge all aspects of the status quo – but has also been constrained by the realities of the power of male hegemony.123 One of the earliest American nurses to initially show some initial reluctance in campaigning for women’s issues in the 1860s and 1870s, and may have helped set the precedent for the profession, was Clara Barton (1821-1912). She is noted to be an early foremother of organized nursing in the United States, and, later, became a proponent of female liberation, a suffragist, and a trailblazer for women in nursing. Like Florence Nightingale earlier in the Crimea, Barton fought successfully against the military’s and medical establishments’ opposition to female nurses on the battlefields and in field hospitals during the Civil War. She became the superintendent of Union nurses in 1864, charged with organizing the care of wounded soldiers on and off the battlefield. After the Civil War, she traveled to Europe where the European Red Cross impressed her. She returned to America and lobbied for the provision of the American Red Cross in Washington, DC. The American Red Cross organization finally gained full support of Congress and was established by May 21, 1881. She then campaigned for American membership in the International Red Cross after traveling to Europe numerous times.124 She went on to lobby for the Geneva Agreement, an international treaty recognizing the 120 neutrality of the International Red Cross and guaranteeing the humane treatment of soldiers, the wounded and those who care for them. America signed the Second Geneva Agreement in 1882. Barton’s devotion to the Red Cross organization left little time for the suffragists’ movement until the mid 1880s.125 Though Barton believed in the ideology of the women’s movement, she originally hesitated in offering full nursing support to the politically charged women’s movement for fear of antagonizing the same male politicians whose support she needed for the success of her project, the American Red Cross.126 For these reasons, she did not give her full support to the women’s movement until the 1880s. For example, she compared her level of involvement with the feminists’ level stating to the feminists, “I have not toiled as you have toiled.”127 She ignored the argument that nursing was a women’s profession and she should, therefore, support and campaign for women’s issues. Barton deftly distanced herself from indicting men who opposed suffrage so that they would vote for the funds that would help her obtain funding for her Red Cross organization. She believed most men would eventually support suffrage whence they become “right-minded” stating: whenever I have been urged as a petitioner, to ask for this privilege for women, a kind of dazed, bewildered feeling has come over me. Of whom should I ask this privilege? Who possessed the right to confer it? …Virtually there is no one to give her the right to govern herself, as men govern themselves…but in one way or another sooner or later she is coming to it. And the number of thoughtful and right-minded men who will oppose, will be smaller than we think…128 Her point was that women should not have to petition men for the right to vote. It is a birth right as a human being. 121 In a newspaper clipping from The Women’s Journal in 1904, it noted Barton’s presence in Washington, and also reported a White House reception for suffragists given by President and Mrs. Roosevelt, but no mention was made of Barton’s presence at the reception.129 Yet, in the very next paragraph was a report of another reception for the same suffragists later that day at Barton’s Glen Echo home outside of Washington, DC. The review of the Barton reception described the journey to her residence and of her home, but not the content of the suffragists’ conversations with her. In the same issue of the journal, a suffragist convention review recalled the loan from Barton of flags and jewels from various countries and other mementos that supported the “woman question”, but again no mention of her presence at the convention. Barton reasoned that her absence at the many conventions was due to her full commitment to the Red Cross. However, Pryor believed feminists questioned her loyalty to suffrage, but, in truth, she was just so busy with the Red Cross. By 1888, after the American Red Cross and the American membership in the International Red Cross was soundly in place, she agreed to speak at seven conventions that year.130 Could it be that she was an example of the kind of politically pragmatic savvy that was necessary at that time for women to take in order to get men to support their initiatives? Or that as a nurse, she valued the direct impact of the Red Cross and patient advocacy as opposed to the more abstract arguments of women’s rights? Barton may have set the precedence in the U.S. for the majority of nurses to retreat from full involvement in the women’s movements. According to Kathy Woods, curator of the Clara Barton Museum in North Oxford, MA, Barton seemed to withhold an indictment against men who rejected suffrage. Men in politics feared the women’s 122 movements because it signified independence and power for women at a time when women were supposed to be subordinate to men. She made her point stating in 1869, “the cause is not to be hastened by quarreling with men as men…”131After the American Red Cross and the American membership in the International Red Cross was fully established, she signed on to speak at eight engagements in 1888 for the women’s movement, one of which she was the featured speaker at the First International Woman's Suffrage Conference in Washington, D.C.132 The precedence for political discretion continued in nursing until the early 1900s when two polemic camps emerged on the interface between nursing and politics. One group of nurses believed that pursuing suffrage would help achieve nursing’s interests in professional autonomy for nursing. This group, who represented the minority opinion, included influential nurses such as Dorothea Dix, Lillian Wald, Adelaide Nutting, Lavinia Dock (Figure 4.1) and others who campaigned for causes they believed in passionately even though the majority of nurses believed that nursing and the women’s movement should not mix.134 Such causes included Margaret Sanger’s crusade for women’s birth control rights from 1914-1950s, or Adah Thoms campaign for inclusion of black nurses in the Red Cross (1918), Mabel Stauper’s armed services (1918), and in the ANA (1951). 123 Dorothea Dix (1802-1887) 133 Lillian Wald (1867-1940) Mary Adelaide Nutting (1858-1948) Lavinia Dock (1858-1956) Figure 4.1. Influential Nurses 124 The majority of nurses favored gaining autonomy through professional organizations such as ANA or National Organization of Public Health Nursing (forerunner of the National League of Nursing), rather than through politicians. Lavinia Dock wrote a long letter to the editor of AJN, Sophia Palmer, in August 1908 chastising the majority vote of nurses at a San Francisco nursing convention who chose not to support the suffrage movement: …I read with humiliation…that a negative vote ‘by a large majority’ was recorded at San Francisco against the reasonable and temperately expressed suffrage resolution offered to it!135 Dock attributed the lack of involvement to the nurses’ intense focus on caring for their patients, but she thought that they should have given “moral support and endorsement” to suffrage. Dock admonished that the very health issues that nurses believed in passionately, improving poor social living conditions such as housing, overwork, underpay or neglect of childhood health, could be improved if nurses were empowered to change issues through suffrage. However, in the very same issue of American Journal of Nursing, an editorial appeared addressing the journal’s position on “the suffrage question,” noting that the nursing profession was divided on the issue of suffrage: those for, those against and those taking a neutral position. The editor admitted to siding with the neutral position. She reminded the readership that American Journal of Nursing’s policy “must remain neutral” but welcomed readers’ “free expression” in response to the editorial.136 As the campaign for women’s suffrage waged on, the majority of nurses believed that if professional nursing aligned itself with the suffrage movement, politicians’ support for nursing’s own internal issues, such as nurse registration, would be lost. Consequently, eschewing broader feminist activities, the nursing profession pursued two 125 primary goals: professional registration to regulate the profession and a voice in Congress on issues affecting public health.137 For example, in an article in American Journal of Nursing in 1900, Dock outlined the effect that states’ nurse registration laws would have, namely, the elimination of the six-week course of study offered by training schools in favor of a standardized two-year curriculum towards nurse licensure, followed by a comprehensive state nursing exam.138 Finally, by 1912, nurses voted to support the suffrage campaign when they were persuaded that suffrage would empower them to achieve political influence both for their professional and personal issues.139 Suffrage for women became law in 1920, but two World Wars diverted much of nurses’ attention away from gaining professional autonomy to caring for wounded soldiers and veterans. The issue of professional nursing autonomy would have to wait until the second women’s movements of the 1960s to renew its struggle. Nurses’ Autonomy in Family Care in the Early 1900s Nurse activists such as Wald, Dock, Robb, Nutting and others campaigned for professional nursing reforms in education and legal licensure for registered nurses in order to gain more autonomy and professional prominence. By 1904, thirteen states had passed laws requiring that nurses take examinations after a period of formal training in schools of nursing in order to be legally registered to practice nursing.140 From 1873 to 1920 nurse training schools proliferated, to a great extent due to Nutting’s activism.141 During the Progressive Era, Lillian Wald and activist Jane Addams, among others, became leaders in public health nursing with the establishment of social settlement houses in large American cities. The houses were outreach institutions that provided public social services and civic advocacy for the working class, particularly immigrant families. Wald was also a supporter of mothers’ pensions legislation and the 126 Sheppard-Towner Act of 1921.142 The mothers’ pensions and the Sheppard-Towner Act are examples of the enormous influence that the women’s movement had on American society during the Progressive Era. The women’s movements during the 19th and early 20th centuries supported reforms specific to women’s equality rights as women, mothers and wives. However, the women’s movements and nurse activists had little influence on medical childbirth practices in the 19th and most of the 20th centuries. The intrusive obstetrical interventions led to longer lengths of stay for recovery, and financially benefited physicians, hospitals, and insurers.143 By the first half of the 1900s, the protracted maternity LOS was as long as 10-14 days post delivery. Nurses, under the direct supervision of physicians, were powerless to address the obstetrical interventions. The Influence of the Women’s Movement on the Nursing Movement of the 1900s In England in the 1860s, nursing began to organize as professed set of learned skills under the tutelage of Florence Nightingale (1820-1910), as an outgrowth of her work during the Crimean War.144 Her ideas were adopted in America by 1873 when professional American nursing education began to organize as schools of nursing in New York, Boston and New Haven. Nightingale's counterparts in America were nurse activists and public health nurses Barton, Dix, Thoms, Dock, Robb, Isabel Stewart, and Nutting, among others, all of whom challenged male domination. They were influenced by the feminists of the late 1800s and early 1900s, and sought to have a voice in nursing practice, nursing education, hospital administration, and patient care. The nurse activists believed that nursing education would foster professional autonomy, and so developed schools of nursing, albeit segregated, that educated not only white nurses but also 127 African-American nurses. They also achieved their goal of instituting a nursing licensure and state registration after formal professional education. Segregated from white nurses and denied admission into the ANA, African- American nurses formed their own nursing organization in 1908, the National Association of Colored Graduate Nurses, founded by Martha Franklin, and their own schools of nursing in hospitals for African-Americans. Later, in efforts to serve their country, they struggled against racial barriers to participate in the American Red Cross, led by Adah Thoms, and in the Army Nurse Corp where Mabel Staupers successfully challenged the whites-only policy. In 1951, African-American nurses were integrated into the ANA after previously being denied admittance based on race. By 1971, the specific needs of the minority nurse community were recognized and the National Black Nurses Association was formed. As a predominantly female vocation, the nursing movement had concerns similar to the concurrent women’s movement in the quest for autonomy and equality in socioeconomic and political arena.145 While suffragists of the 1800s and early 1900s were challenging the political landscape for the right to vote, professional nursing sought a consensus among resistant nurses to join forces with the feminists hoping that suffrage would also aide nurses in their liberation from social, economic and professional subordination.146 However, when hospital nursing began to flourish - especially after World War I - patriarchal physicians, and the hospitals in which nurses trained, subsumed nurses' training under their own rubric. Nurse leaders resisted physicians’ and hospitals’ control by organizing professional associations such as the National League for Nursing (1893, originally named the American Society of Superintendents of Training Schools for Nurses, then the National League of Nursing Education), the 128 American Nurses Association (1896, originally named the National Association of Nursing Alumnae), and the Nurses Organization for Public Health Nursing (1912), to be the voices for professional nursing's coalition for autonomy during the Progressive Era. But, as nurse and non-nurse reformers created federations to improve women’s social and economic well-being, nurses found themselves alone in their battle for autonomy, unaided by activists in the women’s movement.147 A tension has existed between feminists and the very nurses who needed their help. Nurses have long been subordinated by social and economic male-domination. Some feminists did not like the submissiveness exhibited by nurses and took “potshots” at nursing.148 Feminists omitted nursing as a career opportunity for women because of the handmaiden image of professional nursing. Feminists and nurses could have joined forces to elevate nurses from subordination that would have made nursing an exemplary autonomous female profession. Unfortunately, the contentious control of professional nursing in hospitals by hospital administrators and physicians in the early 1900s was unaided by feminists. Physicians wrested control of nursing practice and education from nurses.149 The same submissive conservativeness by most nurses may have been a factor in nurses’ inability in the 1980s to publicly protest the rapidly shortened maternity LOS for Medicaid mothers. By the same token, the five nurses who approached Senator Bradley’s office in 1995 have not all identified themselves despite repeated attempts asking them to come forward. As two world wars drew nurses into service in hospitals in the United States and abroad, nurses’ quest for control over their profession lost momentum.150 Early nursing leaders such as Wald, Dock, Robb, Nutting and others began to age and their protégés’ did not continue the quest for professional autonomy.151 Professional nursing 129 organizations such as the ANA carried on the quest but under a “collaborative” umbrella with physicians and hospitals.152 Hospitals and physicians still controlled nursing education in hospital-based nursing schools.153 Fortunately, the influential wave of women’s movements in the latter 20th century eventually engulfed nursing in the 1970s such that nurses educated in the 1980s galvanized nurses in the 1990s to advocate for mothers and their newborns. Nurses’ Transition into Hospital Nursing The demands on nursing services changed with World War I.154 Prior to World War I, most nurses worked independently as private duty or public health nurses.155 During the war and afterwards nurses were needed in hospitals to care for patients and veterans returning home. But, they were also needed overseas to care for wounded soldiers. These conflicting demands depleted the nursing workforce in the U.S. Many private duty nurses found jobs in hospitals especially after the Great Depression (1929) when the U.S. economy plummeted and patients could not afford to pay private nurses. By the 1930s, nursing skills were in demand as medical technology became more sophisticated with diagnostic tools, such as laboratory tests, medicines such as insulin, blood typing and transfusions, proliferation of medical subspecialties, and x-rays. More nurses were needed in hospitals to carry out these numerous newly developed procedures. Nurses “…had to guide and oversee patients and other hospital workers through the daily maze of activities, procedures, tests and tasks” instead of the usual tasks of caring for the patients through cleanliness and comforting.156 Nursing education curricula expanded to accommodate the new technology, and most hospitals had a school of nursing to re-supply the nation’s nursing workforce. 130 Until the 1930s, nursing services were billed separately from hospital and physician fees.157 Hospitals and physicians viewed nurses’ fees as competition for payment from patients, therefore nursing care was absorbed into the cost of hospital charges. Health insurance was developed to help patients pay hospitals and physicians for the higher cost of technology as costs continued to increase. In an effort to reduce costs, hospitals began grouping patients in patient wards utilizing a nurse-to-patient ratio system and using their student nurses to staff the wards. The move to the group nursing of patients alarmed nursing organizations, such as the NLN and ANA, as well as nursing education institutions. They rightly perceived that grouping patients was a way for hospitals to reduce personnel costs by using student nurses instead of graduate nurses. The management practice created a national surplus of graduate nurses.158 Therefore, nursing organizations argued that experienced graduate nurses should staff hospitals rather than student nurse novices. Doing so would ensure continuity of care rather than interrupted care when students had to leave for classes. The resulting compromise was a mixture of graduate and student nurses. By the 1930s, the results of nurses’ transition to hospital-based nursing were clear: long hours, low pay, no pensions, lack of continuing education, split shifts, and poor shift scheduling.159 The shortage of nurses after World War I and the aging of early nurse activists left a gap in nursing leadership in the 1920s and 1930s.160 The long sought-after autonomy for nurses by early nursing leaders was replaced by ANA’s focus for “collaboration” with hospitals and physicians. A 1919 editorial by Sophia Palmer in The American Journal of Nursing admonished the hospital nurses for being silent, letting the male physicians coordinate hospital administration, hospital committees, and patient care.161 Private duty nurses, whose numbers dwindled with the transition of nurses into 131 hospital nursing, felt abandoned by the ANA which focused on education, nurse registration, and hospital nursing services.162 As nurses were absorbed into hospitals as employees with low wages and long hours, the autonomy envisioned by the first generation of nursing leaders unraveled. Membership in professional nursing associations declined, and in its stead, unionization was sought by many nurses in hospitals to correct what nursing leaders could not control: wages and hours. The beginning of unionization in nursing was patterned after what Denton calls the first professional union, the American Medial Association.163 After describing the medical hegemony that the AMA possessed in the history of medicine in the United States, he commented that all other allied health care professions, the first group to be nurses, patterned their quest for professional autonomy after the AMA’s showcased activity, followed by speech and hearing pathology, social work, clinical laboratory, etc. Unionization gripped the national economy soon after the industrialization of the U.S., and health care was not spared. Some nurses began joining labor unions for economic relief prompted in response mainly by the Great Depression, but in non-nurse hospital worker unions. The ANA opposed all unionization, collective bargaining, or strike efforts, believing that nursing would no longer be a profession if nurses unionized. But many nurses pursued unionization with the first state ANA-affiliate, the California Nurses Association (CNA), to offer a statewide nurse-unionization effort with the first contract signed between hospitals and the CNA in 1946. Oregon and Washington state nurses followed suit. As the wave of nurse wage and labor discontent moved across the nation, Minnesota was the next ANA affiliate to actively unionize for better wages and hours. 132 Since the ANA maintained a no-strike position for its nurses in bargaining negotiations, the action by nurses in labor disputes was mass resignation, though not used until 1966. In May 1966, joining the wave of women’s discontent in U.S. society, New York City pubic health nurses and some hospital nurses used mass resignation to win labor demands, followed by nurses in Boston and Chicago. In October 1966, 3,000 nurses stood firm against hospital administrators in San Francisco and threatened mass resignation. The hospitals conceded wage and working condition improvements. In 1968, the ANA re-tooled its position on no-unionization, allowing collective bargaining and strike clauses. The next round of large-scale militancy by nurses was mid 1970s, again in San Francisco. Nurses, though female and altruistic, finally found their voice in demanding better economic conditions for themselves through collective bargaining for fair wages and better staffing and working conditions that allowed for quality patient care. The Beginning of the Nursing Movement of the 1970s and 1980s Professional Nursing and the Political Arena By the 1970s and 1980s, several nursing scholars, such as Barbara Carper, Rosemary Ellis and Dorothy Johnson, began voicing concern over lack of professional autonomy and the vague future direction of professional nursing.164 Scholarly nursing literature focused on the state of the discipline by defining nursing’s science as a profession with its own body of knowledge: a multifaceted holistic approach to the caring of persons through the human lifespan. But lack of autonomy in nursing would not make it a profession by definition (Chapter One). Other nursing scholars learned from our foremothers believed that professional autonomy would be achieved if states' nurse registration, formal nursing education 133 requirements, and public health issues were passed by political activism. Indeed, these were nursing’s intra-professional issues from the beginning of organized nursing in the 1860s Civil War until 1920.165 A vigorous debate ensued in the 1970s within the nursing profession on the merits of re-engagement of political activism for autonomy in nursing.166 The concurrent feminist movement at that timed aimed for equality and rights for women was already under way helped prompt nursing to enter the women’s movement. In the 1970s, Bunting and Campbell reported that a few nurses in the New York City chapter of the National Organization for Women (NOW) had organized a small task force of nurse feminists, the Cassandrans, to bring feminist ideology into the nursing loop.167 In fact, one of the early the presidents of NOW from 1971-1974, was the late Wilma Scott Heide, a nurse! (Brooklyn State Hospital, 1945)168 Their activism was noted by nurse scholars who published articles exposing the absence of the profession in the women’s movement.169 Bunting and Campbell published a call for nurse researchers to include the feminist tradition in nursing research, a call also echoed in MacPherson’s paper.170 In the 1981 January edition of Advances in Nursing Science, editor Chinn devoted the entire edition to highlight the need for nursing research on women’s health.171 In 1985, Chinn again published a call for nursing to enter the women’s movement noting similarities between nursing and the women’s movement in the pursuit of common goals surrounding autonomy.172 Roberts encouraged nursing to become more autonomous after linking oppressed group behavior to nursing’s reticent nature in becoming involved politically.173 Nurse educators, prompted by nursing’s scholarly interest in the women’s movement instructed nursing students to become politically involved in the development of health care issues.174 134 The activism sought by a small number of nurses in the 1970s to have professional nursing move into the public arena of politics to advance nursing’s voice became a reality. One author in 1978 stated, “Nurses by 2003 will have… political awareness …to define the aims of the health care industry and to markedly influence the decision-making processes.”175 That became a reality in the 1980s, much earlier than predicted when many more nurses began to get involved in state legislatures such as in Florida, New York, Virginia.176 In New York state, two nurses, Susan Talbott and Connie Vance, joined the New York City chapter of NOW with the goal of getting nurses active in, and recognized by, the women’s movement. I interviewed both nurses. Dr. Connie Vance, a professor at New Rochelle College in New York, and Susan Talbott, politically active in Maryland, recalled their 1980 political activities as nurses, also chronicled in their articles.177 According to their lived experiences with non-nurse feminists in New York, many feminists did not accept the nature of nursing as a caring profession. Nurses were considered “good girls” who followed the male status quo to be subordinate. In their experiences in the 1970s, many feminists objected to certain features of nursing because nursing was everything feminists were not: selfless, conservative, subordinate to physicians, and servile to patients.178 Dr. Edelstein, professor in the departments of Nursing and Psychology at Northern Illinois University, and Syracuse University, Syracuse, New York, in 1971, and a member of NOW, wrote that “Ardent feminists have been advising women not to become nurses because by doing so they will perpetuate their inferior status as women.…feminists would be well advised to encourage …people to enter the field…for its [nursing’s] massive membership has a major impact on the status of women.”179 135 Talbott observed that feminists in the 1960s and 1970s were very well educated (i.e., Betty Friedan, author, majored in psychology) but nurses were diploma educated. Usually in a “proper place” or rather of some social standing in communities, feminists were often the wives of prominent citizens, whereas nurses were cultivated from the working class. In Vance’s and Talbot’s views professional nursing began to develop an awareness of feminist issues in the 1970s: science advancements demanded that nursing become more educated; nurse feminist activism in leadership literature impacted nursing; and nursing education began to incorporate curricula changes to include political content, although it was not required by the National League of Nursing for accreditation of nursing schools.180 At that time, Talbott noted, the ANA created a “point person,” that is, one or two nurses who attended congressional meetings in the interest of nursing and health care policy which helped nursing’s visibility on national health care issues.181 In 1974, at the federal level, ten nurses formed the Nurses for Political Action, later called the Nurses’ Coalition for Action in Politics (N-CAP) becoming the ANA’s political arm.182 Their purpose was to eventually “make nursing a national, viable force in changing the health care delivery system” and through the ANA “a viable and visible political arm.”183 As had been the case during earlier periods of feminist activity, nursing focused on promoting its own intra-professional interests, such as the development of nursing practice policy and procedures; moving nursing education out of hospitals and into the collegiate system (Nurse Training Act, 1965); development of nurse-midwifery as a specialty of nursing (American College of Nurse Midwives, 1955); and the expansion of professional organizations for other specialties within nursing such 136 as AWHONN, the American Association of Critical-Care Nursing, 1969, the American Nurses Foundation (supporting nursing research), and others.184 Advance practice nursing began in 1964 at the University of Colorado Medical Center. Nurse educator and pediatric nurse, Loretta Ford, and pediatrician Henry Silver, collaborated to develop a nurse practitioner program for public health nurses that would fill a gap of pediatric medical care needed in rural Colorado.185 The idea was funded by grants from the federal government through Title VIII of the Public Health Service Act in 1965. The purpose was to produce nurses that would promote health care prevention, therapeutics, and education. Nurse practitioner programs proliferated across the United States. By 1996, there were 63,532 active nurse practitioners diagnosing, treating, and teaching prevention of health care conditions in their patients.186 Autonomy in practicing nurse practitioners soon became an issue for physicians who also opposed nurse practitioners’ extended patient care responsibilities and objected to the lost revenue from insurers. But state and federal laws supported the important role that nurse practitioners served as primary providers of health care whose duties included, depending on state-to-state regulations, diagnosing, prescribing medicine, and writing orders either independently of a physician or with some physician collaboration. In 2005, there were 115,091 practicing nurse practitioners.187 Nursing edged even closer to autonomy when advanced nursing practice and community-based nursing became more independent as much of patient care moved out of acute care hospitals and into outpatient community settings. The move was the result of reduced Medicare/Medicaid and private insurer reimbursements to hospitals as fee- for-service changed to the PPS system.188 Neighborhood health clinics for outpatient medical and obstetrical care were less expensive to operate, especially with costs paid by 137 federal programs’ aimed at outpatient visits rather than higher-priced inpatient charges and costs. Reimbursement for advanced practice nurses in outpatient settings became less costly than physician charges for healthcare reimbursement. Nursing education nationally began to offer advanced practice nursing programs and expanded outpatient clinical experience for undergraduate nursing students in addition to acute care hospital experience.189 These opportunities required more independent and sophisticated clinical patient assessment skills from novice nurses without the support of senior nurses’ hospital nursing expertise. The feminists and the women’s movement prompted the nursing leaders in the 1970s to continue the professional autonomy sought by nursing leaders of the early 20th century. But the relationship between feminists and nursing was initially uneasy. An “Uneasy Alliance” Between Nursing and Feminists An overview of nursing literature on feminism and nursing, while not a focus of this paper, reveals a history of “an uneasy alliance” between nursing and feminists since Florence Nightingale’s time.190 According to the nursing literature, feminists favored equality economically and politically and devalued nursing for its lack of assertiveness towards the male establishment (physicians). Instead of embracing feminine qualities of tender womanhood, feminists discredited it.191 The tenuous relationship between feminists and nursing can be traced back to Sophia Palmer’s American Journal of Nursing editorial of 1908 when she reminded the readership that the views expressed by writers, such as nurse activist and feminist Dock in her letter in the same issue, are not those of American Journal of Nursing. If the official voice of nursing, at the time the American Journal of Nursing, did not support nursing’s political engagement in feminist issues with inequality and suffrage, then the 138 majority of nurses followed the lead. But not all influential nurse leaders were of the same persuasion. Some such as Wald, Dock, Nutting, and Sanger and others envisioned that suffrage would help achieve nursing’s pursuit for registration, public health improvements, and nursing education curriculum changes. Feminists and nurse activists have both aimed for gender equality socio- economically and politically. Nurses have long been underscored as the “physician’s hand”192 However, because nursing’s subservient role precluded overt opposition to domination, there was a disconnect between feminists and nursing, especially since the 1920s when nurse employment moved into the hospital setting under the supervision of physicians.193 In the 1960s and 1970s, nurses were not able to practice unsupervised by physicians, therefore, they could not subscribe to the feminist ideology of equality and power.194 Some feminists have undervalued nursing’s singular pursuit of professional autonomy because of perceived anti-feminist, traditionally ‘feminine’ values among nurses. Vance et al, point out that individual nurses such as Nightingale and Sanger were credited by feminists for their work as social and medical reformers, but not identified as nurses.195 A full investigation on nursing and feminism is found in a 2004 dissertation by Susan Gelfand Malka titled “Daring to Care: American Nursing and the Second Wave of Feminism, 1945 to the Present.”196 Relying on the works of mostly Ruth Rosen and Alice Echols, among others, she reviewed nursing’s reaction to feminism the types of grass roots feminism that sprung up in American society in the 1960s .197 For the purposes of this discussion, I include all feminists whether female or male, white or non- white. 139 Malka’s dissertation reveals that many feminists “denigrated” nursing. There are many examples. Caroline Bird wrote in 1968 that Freudian Old Masculinists are women who are mentally and physically unable men’s work, stating “Most women are Old Masculinists, especially nurses, executive secretaries, company housekeepers and married women who don’t go out to work.”198 Furthermore, New Masculinists are businesswomen who are “Women’s Women” who do not subscribe to specific feminine duties or define a woman’s place. Robin Norwood, a marriage, family and child therapist, wrote in 1986 that, among other careers, nurses came from ‘dysfunctional’ families in the context of families who lack emotional caring, and, therefore, nurses were merely care-givers who seek feeling needed by their patients.199 Simmons and Rosenthal wrote that when feminists in the early 1970s described women’s plight as powerless, dependent, and servile, the feminists were actually describing nurses.200 Lurie wrote that graduated nurse practitioners found themselves still subordinate to physicians in their jobs as advanced practiced nurses.201 In 1991, Ellen Baer, a renowned nurse scholar who is now professor emeritus from the University of Pennsylvania School of Nursing, wrote in an op-ed in the New York Times that liberated feminists “disdain” nursing because nurses do not exhibit the power and authority of masculine behavior; that Working Women magazine (1988) listed nursing, teaching and social work as some of the “ten worst jobs”; and that television media portrayed nurses as “dumb and over- sexed.”202 Document after document highlighted the subordination of nurses. The result was a continued tension between nursing and feminists. According to Malka, many feminists in the 1960s were labeled “radical” feminists who pushed for women to change the male status quo by boldly confronting men and male sexism. A women’s rights rally at the White House in Washington, DC 140 included feminists throwing housewives’ aprons into a huge trash pile to symbolically protest subordinate domesticity, a direct affront to student nurses’ uniforms at that time that included wearing an apron, proudly, in anticipation of their graduate profession. Meanwhile, NOW’s mission was to correct discrimination against women and campaign for equal rights by joining the male system to change it in support of women’s issues. Both groups raised public consciousness, but some radical feminists distanced nurses who were socialized into a caring profession. Radical feminism evolved by the early 1970s becoming cultural feminism that promoted womanhood as a culture coupled with noted differences from men in the biopsychosocial spheres. Some in nursing began to warm to the idea of a culture of womanhood. Cultural feminism evolved to include differences even among women, such that values and caring were included in feminism.203 Public opinion of feminism had also changed with the exposure by feminists of the sexism that invaded both public and private lives. By 1985, the pervasiveness of sexism had begun to re-structure the fabric of American society, not only for whites but for members of minorities as well. Other feminists, such as Carol Gilligan (1982) and Sara Ruddick (1984) , published in support of nursing’s compassionate attributes. Gilligan believed that the feminine voice struggles between compassion and autonomy, virtue and power.204 Ruddick’s pedagogy teaches women to “be your own woman” through self-reliance, resilience, and tolerance, using illustrations through the life of her heroine, Virginia Woolf.205 The polemic discourse between the two groups of feminists and left nurses to struggle with not only the subordination encountered in hospitals and with physicians, but, seemingly, also with seemingly the group of feminists who undervalued nurses as 141 well. If one group of feminists supported the nurses’ plight, the other group galvanized some nurses to join the second women’s movement and garner support to fight for professional autonomy. Feminists did not join nursing; it was nursing that joined the feminists and the women’s health movement that was already well underway in the 1980s. Feminists and the Caring Professions Though some feminists may not have supported the caring professions that held such values as empathy, compassion, and nurturance, many other feminists supported those values and supported nurses who possessed those values. Code’s discourse on What Can She Know? Feminist Theory and the Construction of Knowledge published in 1991 argues for the epistemology of the creation of woman-centered knowledge as opposed to the episteme of white, male philosophers whose “truth” was assumed by academics to be the truth for all humanity, male and female, white and non-white.206 Code specifically highlights nurses’ expert knowledge in the realm of nurturance, compassion, sympathy, and empathy, qualities noted to be “non-authoritarian” and “subordinate.” She admonishes other feminists’ demands for objectivity in the creation of feminist theory while ignoring the inclusion of feminine subjective qualities. Woloch speaks of expanding the “woman’s sphere” to include women’s professions, such as teaching, nursing, library work, and social work in the service sector.207 Every edition of Our Bodies, Our Selves, written by self-proclaimed feminists, supported health collective clinics staffed with nurse practitioners holding advanced degrees. Feminist Judith W. Leavitt lauded women in the health professions and devoted half a book to midwives and nurses and their struggle for public professional acclaim.208 142 Francis Ricks wrote in 1992 that feminists focused on reforms bearing social, economic and political importance rather than women’s values and caring from a feminist point of view. Feminist research on caring and the caring professions emerged slowly well into the 1980s in the feminist literature and that there was an “absence of caring rhetoric in the feminist literature.”209 Anne Summers supports Ricks’ thesis that there was a distancing between feminists and nurses beginning in the Crimean War.210 She explains that in England “ladies” of upper and middle class status who employed domestic servants believed themselves superior by reason of their refinement in social graces, position in society and opportunities afforded them by their husbands’ money. Ladies of ‘refined culture’ set themselves apart from working class women, i.e., domestics--and apprenticed nurses. In modern times, feminists were often wives of prominent men in communities. Vance and Talbott concurred in their interviews with me. Feminists were frequently campaigning not only for their own benefits but for women’s rights and equality socially, economically, and politically for their less fortunate sisters who did not have the social standing or economic status to speak for themselves. Most nurses held diploma education until the 1970s when hospital-based schools of nursing began a phased-out in lieu of collegiate education, either two- or four-year schools. The popular publication Our Bodies Ourselves was first published in 1970 in newsprint followed by six book editions published in 1973, 1975, 1984, 1992, 1998 and 2005. The original authors, several of them nurses, admitted their middle class status (preface of first book edition) and stated a dedication to the women’s health movement and the book as an empowering resource for all women who seek knowledge about their bodies, and, through a feminine lens, how to steer themselves through life and the 143 medical system.211 One chapter is devoted to just the medical system maze itself. The 1984 edition’s chapter on “The Politics of Women and Medical Care” was formerly called “The American Health Care System,” which in the 2005 edition is titled “The Politics of Women’s Health” all designed to help women access good medical care. Since 1970, many changes have taken place in American society that gave women from multicultural backgrounds and ethnicities social, economic, and political rights as well as the right to good medical care. Some of those changes include the right to abortion; more birth control options; removal of many barriers for the union of gay and lesbian couples; and medicine to abate AIDS. The advent of “drive-thru” deliveries and breast cancer surgery met with public criticism and activism; the numbers of women have increased in professions such as medicine, law and business; and medical research is now conducted for woman-specific outcomes and many times by women researchers. Information is widely available on women’s health now, in print and on the Internet that was not readily available prior to the 1992 edition of Our Bodies Ourselves. The Internet was just beginning in 1986 and the World Wide Web program was invented in 1990 by Tim Berners-Lee of the Massachusetts Institute of Technology, Boston, MA. While feminists began research into caring as a theoretical concept, many nurse scholars, including Dr. Madeleine Leininger who, in 1978, conceived and initiated the National Caring Research Conference, “developed an ethic of care…and infused nursing education that virtually all new nurses would be shaped by it.”212 The philosophy of the national organization whose first meeting took place in 1987, was that caring is the essence of nursing. The mission of the, now, International Association for Human Caring (IAHC), is to advance the body of knowledge of caring and caring research within the discipline of nursing.213 The web site notes that “caring is the unique and 144 unifying focus of the profession.” The National League for Nursing and the many in nursing scholar community currently support nursing research into the theory of caring.214 Nursing and Politics After nurse feminists illuminated the application of feminism to professional nursing’s quest for autonomy, what had motivated professional nursing to enter the public arena of health care policy when the majority of nurses were absent during the suffrage movement and again in the 1960s and 1970s? Malka’s evidence points to the impact of scholarly research into the history of nursing undertaken in the 1970s and 1980s by nurse scholars. Interviews with nurses Vance and Talbott, who wrote of their lived experiences with the nursing movement of the 1970s and 1980s, concurred with the evidence in Malka’s dissertation that nurse feminist activism in leadership literature from the 1970s/80s impacted the future of nursing education. Nurses are now more educated, in universities and colleges. Individual nurses at the grass roots level in communities are now the men and women who are involved in school boards and local, state and national political activities. In Vance and Talbott’s views, nurses have finally attained education and status. Malka’s findings support their viewpoint, discovering that newly educated nurses in the 1990s were “shaped” by the nurse feminist scholarship in the 1970s-1980s. In the 1990s, nurses began to have a voice in the public sphere of national economics in health care administration and in national health care policy.215 National nursing organizations gained momentum since the 1970s in shifting from lobbying for intra-professional issues to more public issues in Washington, DC to ensure that nursing had a say in shaping national health care policies.216 For example, the ANA strongly 145 supported the 1971 Equal Rights Amendment with its telegram campaign sent to the House of Representatives urging prompt passage of the Amendment.217 Prior to the 1990s, nursing made gains on “intra-professional issues” such as moving nursing education out of hospitals and into university-based education, advanced nurse practice certification and licensure, and establishment of the National Institute of Nursing Research.218 Although no individual nurse activist, such as Barton, Dock, Wald, Nutting, or Sanger, has taken up the battle for health care policymaking, national nursing organizations, such as the ANA, AWHONN, NAPNP or ACNM, backed by the Code of Ethics for Nurses, and Nursing’s Social Policy Statement, are at the forefront. The ANA’s recent updated publication Nursing’s Social Policy Statement, Second Edition, is a professional declaration of nursing’s contract with society such that society will know what services to expect from the profession of nursing.219 It was first published in 1980. The very idea of publishing this statement professed nurses support for accountability and responsibility in their actions. Each individual nurse may rely upon the declaration, along with the Code of Ethics for Nurses along with Nursing’s Social Policy Statement, Second Edition, discussed in Chapter One, to guide the practice of nursing in education, research and clinical practice active in developing policies to promote patient safety and reduce health care risks. By 1995, the 1980 definition of nursing was embellished. Nursing was defined as the diagnosis and treatment of human responses to potential health problems. In 1995, the dimensions of caring and understanding in nursing practice were included to facilitate the patient’s health and healing. It simply stated acknowledgement of professional nursing rights in helping to direct health care policy along with responsibility and professional accountability to the public. The 1995 statement declared 146 “nurses help people identify long and short term health goals and act as advocates for people dealing with barriers encountered in obtaining health care.”220 It declared professional nursing’s autonomy and freedom for its future direction within the scope of clinical practice as a “self-regulated” profession. The 2003 edition of Nursing’s Social Policy Statement, Second Edition, also states that nursing will be involved in creating public policy, reaching beyond professional nursing care of individual, family, community or population at large within the health care system. Nursing made bold attempts in the 1990s to have a voice at the national level when New Jersey nurses in professional practice advocated publicly for their patients. The Code of Ethics for Nurses and Nursing’s Social Policy Statement underpinned the political action of the five nurses from New Jersey who publicly called for insurers to pay for longer postpartum hospital stays by enlisting Senator Bradley’s aid. That advocacy changed national health care for all mothers in the United States. Nursing and the Political Socioeconomics of Maternity LOS The ANA has been nursing’s collective voice in Washington, DC since 1896 lobbying for nursing’s interest in public health, nursing registration, and nursing education.221 The nursing voice was absent in the public health arena the 1980s when federal maternity benefits were reduced to shortened LOS, yet present in the 1990s when maternity LOS was lengthened. What prompted professional nursing to find its voice in the 1990s? Professional nursing found that the DRG health care policy in the 1980s impacted nurses’ jobs when nursing was left out of the DRG decision-making. Nursing was not included in the socioeconomic decision to shorten maternity LOS in the early 1980s because the nursing care components within childbirth related DRGs was non-existent. If nursing components for patient education and maternal and 147 newborn care after childbirth had been included initially in childbirth-related 1983 DRGs, nursing might have been able to influence the length of maternity hospitalizations that mothers and their newborns needed in the 1980s. Instead, maternity LOS was reimbursed at 24/72 without nursing’s input until the 1990s when nursing found its political voice. In a 1985 paper from ANA’s Center for Research, the ANA reported that there was no measurement in place to measure nursing care in any DRG category (special care units had some “nursing resources” measured).222 Therefore, the ANA conducted a study which was a collaborative effort between the Health Care Finance Administration researchers and a group of nurse scientists from the ANA Center for Research. Twenty- one DRGs were examined using 1,600 chart audits from two hospitals in Milwaukee, Wisconsin. Charts were examined for nursing resource utilization and nursing costs in an effort to assess the relationship between DRGs and nursing care. Based on the research, nursing components for DRGs were developed using a patient classification system that determined nursing care was present in 20 to 28 percent of hospital costs for two-thirds of the DRGs studied. The results provided evidence that insurers were not reimbursing appropriately and that more studies were needed. The study outcomes eventually ensured increased payments for DRGs from insurers. Kippenbrock asked several nurse leaders in 1992 what they would have liked to have witnessed in nursing’s history.223 Among the interviewees was Faye G. Abdellah, the U.S. Deputy Surgeon General from 1982–1989, on nursing’s lack of involvement when DRGs were legislated in 1983. Dr. Abdellah explained, “Of the 467 DRGs developed, not one of these included a nursing service component with related predetermined costs…” for nursing care or nursing costs. She further explained, “To 148 have included a nursing cost component for each DRG initially would have changed the entire future of nursing practice and education... we are just now catching up” She believed that reduced hospital budgets and nursing staff related to the DRGs structure might have been influenced by nursing’s lobbying efforts had it occurred. Rothberg, in 1985, agreed stating, “major legislative initiatives were emerging and in no instance was nursing being consulted.”224 In other words, if professional nursing had numerically calculated a nursing component in each DRG, more money would have been allocated per DRG, thereby securing nursing jobs as a revenue-producing component in each DRG. As a result of the lack of nursing care components, hospitals received reimbursements that lacked costs associated with nursing care. Therefore, hospitals had to reduce their nursing staff to keep within their budgets.225 The ANA did not have any statistics on what portion of patient care was related to nursing care prior to 1983 to support lobbying efforts. This is an example of the lack of economic and political consciousness that professional nursing should have had on issues external to nursing’s own internal issues. The late 1980s and early 1990s produced a flurry of nursing research, even in Australia, that teased out the cost of nursing care in patient care and in DRGs.226 Professional nursing found that health care policy impacted nursing and nurses in the 1980s when nursing was left out of the decision making when DRGs were initiated. Professional nursing organizations have increased their visibility and are now included in helping to contribute to national health care policymaking. The ANA published a lengthy position statement in November 1995 (http://www.nursingworld.org/readroom/position/social/scnnat.htm) outlining patient readiness and conditions to be met before mothers and newborns were to be discharged. 149 It also advocated for home visits after discharge. Current national and international topics are accessible on ANA’s web site for Nursing's Legislative and Regulatory Initiatives: The Code of Ethics for Nurses, discussed in Chapter 1, supplied the foundation for six New Jersey nurses to advocate for all mothers nationally by presenting a case that mothers and newborns should be allowed longer postpartum convalescence in the hospital. Socialization into political activism in nursing education underpinned the drive that the five nurses undertook to approach Senator Bill Bradley. They were prepared to express their concerns for mothers’ and newborns’ improvident reduction of maternity LOS. But, they have not come forward to take the credit for their patient advocacy. Do they fear of repercussions in the job market if they identify themselves, much like the nurses in the Cruelty in the Maternity Wards article? The history of nursing is replete with examples of nurses’ subjugation to male domination in employment, economics, politics, and society in general.227 Ashley reminds us that the ethos of male domination and female subservience between nurses and physicians persisted even into the 1970s when opposition to the newly created advance nurse practitioner programs surfaced that allowed graduates to practice independently. Only a few states had legally sanctioned nurse practitioner programs. Graduates of basic nurse preparation schools to this day practice under the direct supervision of physicians and hospital administrations. The next chapter will reveal what happened when nurses found their political voice in the 1990s. Summary This chapter has presented an overview of childbirth from colonial midwifery home birth practice to the control of childbirth by physicians and hospitals in the U.S. 150 The history forms the fabric of America’s present-day practices and policies on birthing babies in the United States. Figure 6.1 captures the salient influences on America's history of childbirth. In the 18th century childbirth in homes gradually changed from all-female attendant midwives to include male midwives and eventually doctors. Physicians brought to the 19th century techniques learned from their European mentors through training and apprenticeship. Since obstetrical education prior to the 20th century was predominantly male-dominated, male physicians birthed babies in hospitals instead of female midwives. The promised superiority of medical interventions and obstetric anesthesia became the rationale for medical care and childbirth in hospitals instead of homes. The women’s and nursing movements of the 19th and 20th centuries challenged the control that physicians and their “workshops,” the hospitals, had over women’s health care. Hospitals stratified patient care according to class and ability to pay creating a divided culture within hospitals. Physicians and hospitals aided each other in maintaining control over childbirth that continues to the present day. Nursing professionally organized in the late 19th century creating the ANA, the Nursing Organization of Public Health Nurses, and the National League for Nursing. These organizations and their early leaders aimed to make nursing professionally autonomous but lost momentum in the first half of the 20th century when, under economic pressure, clinical nursing moved into hospitals. Physicians and hospitals subordinated and dominated nurses in hospitals preventing nurses from gaining professional autonomy and having a formal voice in patient care. 151 Professional nursing in the late 20th century developed its own professional body of science and a voice of its own by organizing nursing education, publishing scholarly research, contributing to health care administration in hospitals, and lobbying for national health care policy. Although professional nursing’s national prominence was absent when Medicaid adopted the Prospective Payment System for DRGs in the 1983, professional nursing was in the forefront in the 1990s. 152 +⇑ Public Sentiment On Obstetrical Interventions Progressive Era I 1890-1913 I Women’s & Nursing Movements 1830s 1st Women’s Health Movement National Association Of Colored Women; National Social Physicians Boston National Childbirth Congress of Security Hill 153 Practicing Lying-In AMA Widows Congress of Children’s Moves Into Mothers Act of Burton Midwifery Opens Starts Pensions Mothers Bureau Hospitals BecomesPTA 1935 Act IIIIIIIIIIIIIIIIII 1700s 1750 1810 1832 1848 1862 1890 1897 1910 1912 1914 1920 1921 1924 1930 1935 1940 1946 Mostly Midwifery Seneca GFWC; Flexner Twilight Sheppard Leap in Women Colonial Diminishes Falls 5%Childbirth Report Sleep Towner Hospital Advocate Midwifery Convention in Hospitals Act Admissions for Natural Childbirth; Health Childbirth Insurance Proliferates High 2nd Women’s DRGs Limit Clinton | **World Wars Divert Homeland Attention** | Tech Health Maternity Signs Medicine Movement Reimbursements NMHPA IIIIIII 1950 1960 1981 1987 1995 1996 1998 Congress NMHPA NMHPA Limits Medicaid Bill Introduced Begins Figure 4.2. Timeline of Significant Influences on Childbirth in America and on Public Sentiment Regarding Obstetrical Interventions: 18th, 19th, and 20th Centuries. Endnotes 1. Dr. Margaret Heldring, staff assistant to former Senator Bill Bradley, United States Senate. In personal communication, May 17, 2002. 2. Wertz, R., & Wertz, D. (1989). Lying-in: A History of Childbirth in America. New York: The Free Press. 3. Wertz & Wertz, 1989. 4. Wertz & Wertz, 1989. DoHistory. (January 1, 22, 1785). Martha Ballard's Diary Online. Retrieved February 20, 2005, from 5. Wertz & Wertz, 1989. 6. Wertz & Wertz, 1989. 7. DoHistory. (January 1, 22, 1785). Martha Ballard's Diary Online. Retrieved February 20, 2005, op cit. 8. Ibid. 9. Ibid. Wertz & Wertz, 1989. 10. Wertz, D. (n.d.). Reader’s Companion to Women’s History: Childbirth. Retrieved March 3, 2005, from Houghton Mifflin College Division Web Site: http://college.hmco.com/history/readerscomp/women/html/wh_005400_childbirth. htm>. 11. International Center for Traditional Childbirth. (2003). History of Black Midwives. Retrieved February 20, 2005, from 154 12. Ladd-Taylor, M. (n.d.). Reader's Companion to U.S. Women's History: Midwifery. Retrieved November 29, 2005, from Houghton-Mifflin College Division Web Site: ry.htm>. 13. Birmingham-Pittsburgh Traveler. (n.d.). A Ritual Tradition: Midwifery Among Southern African-Americans . Retrieved February 20, 2005, from http://northbysouth.kenyon.edu/2000/women/midwifery%20page.htm 14. American College of Nurse Midwives. (2005). The History of the American College of Nurse-Midwives: Adapted from Varney's Midwifery, 3rd ed. Reprinted with permission from Jones and Bartlett Publishers. Retrieved November 29, 2005, from American College of Nurse Midwives Web Site: http://acnm.org/about.cfm?id=67 15. Caton, D. (1999). What a Blessing She had Chloroform: the Medical and Social Response to the Pain of Childbirth from 1800 to the Present. New Haven: Yale University Press. 16. Wertz & Wertz, 1989. 17. Rateliff, K. (September 30, 1998). Titus 2 Birthing: A Return to a Biblical Birthing Model. Retrieved February 20, 2005, from Geocities.com Web Site: http://www.geocities.com/titus2birthing/birthhistory.html Wertz & Wertz, 1989. 18. Caton, 1999. 19. Wertz & Wertz, 1989. 20. Caton, 1999. 155 21. Caton, 1999. 22. Rateliff, September 30, 1998. 23. Wertz & Wertz, 1989. 24. Caton, 1999. Wertz & Wertz, 1989. Control of infection epidemics really began with the advent of antibiotics after World War I. 25. Wertz & Wertz, 1989. 26. Wertz, op cit March 3, 2005, h.htm> 27. Wertz & Wertz, 1989. 28. Wertz & Wertz, 1989. Wertz, op cit March 3, 2005, h.htm>. Feldhusen, A. F. (2005). The History of Midwifery and Childbirth in American: A Timeline. Retrieved March 3, 2005, from Midwifery Today: the Heart & Science of Birth Web Site: http://www.midwiferytoday.com/articles/timeline.asp 29. Stevens, 1999. 30. Wertz & Wertz, 1989. 156 31. Litman, T. J. (March 1997). 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The Sheppard-Towner Act of 1921 provided grants to states to develop health services for mothers and children. The act was the forerunner for federal grants-in-aid to states. 143. Caton, 1999. Stevens, 1999. 144. Lewenson, 1993. 145. Lewenson, 1993. Reverby, 1987. 146. Lewenson, 1993, p. 41. 147. Lewenson, 1993, p. xiii-xxiv, 277. Reverby, 1987. 148. Muff, J. (1982). Socialization, Sexism, and Stereotyping: Women's Issues in Nursing. St Louis: C.V. Mosby Co. p. 182 149. Melosh, 1982. 150. Melosh, 1982. Reverby, 1987. Stevens, 1999. 151. Roberts & Group, 1995. 152. Lewenson, 1993; Reverby, 1987; Roberts & Group, 1995. 153. Roberts & Group, 1995. 168 154. Reverby, 1987. 155. Melosh, 1993. 156. Nightingale, F. (1861). Notes on Nursing: What it Is, What it Is Not. New York: D. Appleton & Co. Reverby, 1987, p. 182 157. Reverby, 1987. 158. Reverby, 1987. Roberts & Group, 1995. The surplus of graduate nurses was also the result of the goal to expand of numbers of nursing schools by early nursing leaders such as Wald, Dock, Robb and especially Nutting of Johns Hopkins School of Nursing, later of Columbia University. 159. Roberts & Group, 1995. Hospital nursing today does not seem any different now than the plight then of private duty nurses’ long hours, shift duty and minimal wages from an individual employer, the patient. However, pensions and staff education are often available now to nurses, especially to those working in large group practices and hospitals. 160. Lewenson, 1993, p. 277. Roberts & Group, 1995. 161. Palmer, S. (1919). Are Nurses Alive to Their Opportunities? American Journal of Nursing, 20, 90. 162. Palmer, S. (1921). Editorial Comment. American Journal of Nursing, 22, 639. 163. Denton, D. R. (1976). The Union Movement in American Hospitals, 1846-1976. Ph.D. Dissertation, Boston University, p. 99-139. 169 164. Carper, B. A. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing Science, 1(1), 13-23. Chinn, P., & Wheeler, C. (1985). Feminism and Nursing: Can Nursing Afford to Remain Aloof from the Women's Movement? Nursing Outlook, 33(2), 74-77. Donaldson, S. K., & Crowley, D. M. (1978). The Discipline of Nursing. Nursing Outlook, 26(2), 113-120. Donaldson, S. K., & Crowley, D. M. (1978). The Discipline of Nursing. Nursing Outlook, 26(2), 113- 120. Ellis, R. (1984). Nursing Knowledge Development. In J. Fitzpatrick & I. Martinson (Eds.), Selected Writings of Rosemary Ellis: In Search of the Meaning of Nursing Science (p83-95). New York: Springer. Johnson, D.(1974). Development of Theory: A Requisite for Nursing as a Primary Health Profession. Nursing Research, 23,372-377. Meleis, A. I. (1992). Directions for Nursing Theory Development in the 21st Century. Nursing Science Quarterly, 5, 112-117. Meleis, A. I. (1997). Theoretical Nursing: Development and Progress (3rd ed., Rev.). New York: Lippincott. 165. Lewenson, 1993; Rogge, 1987. 166. Mundinger, M. O. (1980). Autonomy in Nursing. Germantown, MD: Aspen Systems Corporation. 167. Bunting & Campbell, 1990. 168. Radcliffe Institute For Advanced Study, Harvard University . (2003, February). Heide, Wilma Scott, 1921-1985. Papers, 1968-1985: A Finding Aid. Retrieved June 22, 2006, from President and Fellows of Harvard College Web Site: eId=sch00269>. 170 169. Ibid; Chinn, 1985; Dunbar, 1981; Lewenson, 1993, p. 265-282 for a fuller discussion on scholarly recognition of more modern nurse activists needed within the profession. Also, MacPherson, 1983; Roberts, 1983. 170. MacPherson, 1983. 171. Chinn, P. (Ed.). (1981). Advances in Nursing Science: Women's Health. : Aspen Systems Corporation. 172. Chinn, 1985. 173. Roberts, 1983. 174. Mason, D., & Leavitt, J. (1998). Policy and Politics in Nursing and Health Care (3rd ed.). Philadelphia: W.B. Saunders Company; Milstead, J. (Ed.). (1999). Health Policy and Politics: A Nurse's Guide. Gaithersburg, MD: Aspen Publishers, Inc. 175. Kalisch in Simmons, R. S., & Rosenthal, J. (1981). The Women's Movement and the Nurse Practitioner's Sense of Role. Nursing Outlook, June, 371-375. p.372. 176. Rothberg, J. S. (1985). The Growth of Political Action in Nursing. Nursing Outlook, 33, 133-135.; Rowell, P., & Knauss, P. (1981). The Legislative Task Force: A Method to Increase Nurses' Political Involvement. Nursing Outlook, December, 715-716.; Underly, N., Doxsey, K., & Reeves, D. M. (1981). Establishing a Nursing Legislation Subcommittee. Nursing Outlook, December, 717-719. 171 177. Talbott, S. W., & Vance, C. N. (1981). Involving Nursing in a Feminist Group- NOW. Nursing Outlook, October, 592-595. Vance, C., Talbott, S., McBride, A., & Mason, D. (1985). An Uneasy Alliance: Nursing and the Women's Movement. Nursing Outlook, 33, 281-285. Talbott, S., & Mason , D. (1986). Political Action in Nursing: The Role of Nursing Education. Dean's Notes, 7(4), 1-3. 178. Baer, E. (1991, February 23). The Feminist Disdain for Nursing. New York Times, op-ed. 179. Edelstein, R. G. (1971). Equal Rights for Women: Perspectives. American Journal of Nursing, 71, 294-298. 180. The argument that nurse educators began incorporating how nurses should become more politically active is presented in a dissertation published in the DAI 2004, Malka , S. G. (2003). Daring to Care: American Nursing and the Second Wave of Feminism, 1945 to the Present (Doctoral dissertation, University of Pennsylvania, 2003). Dissertation Abstracts International, A64/11, 4179. 181. Underly, N., Doxsey, K., & Reeves, D. M. (1981). Establishing a Nursing Legislation Subcommittee. Nursing Outlook, December, 717-719. 182. Rothberg, 1985. Also, Roush, A. (May 31, 2005). New York State Nurses for Political Action Records, 1976-1978. Retrieved July 17, 2005, from 183. Rothberg, 1985 p.134-5 184. American Nurses' Association. (2005). Voices from the Past: Visions of the Future. Retrieved July 11, 2005, from 172 185. Health Resources and Service Administration Division of Nursing. (1997). Federal Support for the Preparation of the Nurse Practitioner Workforce Through Title VIII. Retrieved June 22, 2006, from U.S. Department of Health and Human Services Web Site: Elizabeth Blackwell Health Center For Women. (2003, September 9). Loretta C. Ford: Pediatric Nurse Practitioner. Retrieved June 22, 2006, from Hobart and William Smith Colleges Web Site: 186. Barnett, J. S. (2005, November). An Emerging Role for Nurse Practitioners— Preoperative Assessment. Retrieved June 22, 2006, from Journal of Association of Operating Room Nurses, Gale Group Web Site: 187. Barnett, 2005. 188. This author’s lived experience as a staff nurse in the Obstetrical Clinic, Brigham and Women’s Hospital, Boston, MA, 1987-1995. 189. Milstead, J. (Ed.). (1999). Health Policy and Politics: A Nurse's Guide. Gaithersburg, MD: Aspen Publishers, Inc. 190. Vance, C., Talbott, S., McBride, A., & Mason, D. (1985). An Uneasy Alliance: Nursing and the Women's Movement. Nursing Outlook, 33, 281-285. 191. Pinch, W. J. (1981). Feminine Attributes in a Masculine World. Nursing Outlook, October, 596-599. 192. Melosh, B. (1982). "The Physician's Hand": Work Culture and Conflict in American Nursing. Philadelphia: Temple University Press. 173 193. Vance et al,1985. 194. Vance et al, 1985, p282. 195. Vance, et al 1985, p 281. 196. Malka , S. G. (2004). Daring to Care: American Nursing and the Second Wave of Feminism, 1945 to the Present (Doctoral dissertation, University of Pennsylvania, 2004). Dissertation Abstracts International, A64/11, 4179. Also, Symmonds, J. M. (1990). Searching for a Paradigm: Historical Development of Nursing and the Women's Movement During 1870-1920 and 1970-1990. Unpublished doctoral dissertation, Peabody College for Teachers of Vanderbilt University. 197. Rosen, 2000. And Echols, A. (1989). Daring to Be Bad: Radical Feminism in America, 1967-1975. Minneapolis: University of Minnesota Press in Malka, 2004, op cit. 198. Bird, C., & Briller, S. W. (1968). Born Female: the High Cost of Keeping Women Down. 199. Norwood, R. (1985). Women Who Love Too Much: When You Keep Wishing and Hoping He'll Change (1st ed., Rev.). New York: Pocket Books. 200. Simmons, R. S., & Rosenthal, J. (1981). The Women's Movement and the Nurse Practitioner's Sense of Role. Nursing Outlook, June, 371-375. 201. Lurie, E. E. (1981). Nurse Practitioners: Issues in Professional Socialization. Journal of Health and Social Behavior, 22(March), 31-48. 202. Baer, 1991. 203. Malka, 2004. 174 204. Gilligan, C. (1982). In a Different Voice: Psychological Theory and Women's Development. Cambridge, MA: Harvard University Press. 205. Ruddick, S (1984). New Combinations: Learning from Virginia Woolf. In Ascher, C., DeSalvo, L., Ruddick, S. (Ed.), Between Women: (pp. 137-159). Boston: Beacon Press. 206. Code, L. (1991). What Can She Know? Feminist Theory and the Construction of Knowledge. Ithaca: Cornell University Press. 207. Woloch, N. (1984) Women and the American Experience. New York: Alfred A Knopf. 208. Leavitt, J. W. (Ed.). (1984). Women and Health in America. Madison: University of Wisconsin Press, Ltd. 209. Ricks, F. (1992). A Feminist's View of Caring. Journal of Child and Youth Care, 7(2), 49-57. Also, on the Internet at fem.html>. Baines, C., Evans, P., & Neysmith, S. (1991). Women's Caring: Feminist Perspectives on Social Welfare. Toronto: McClelland & Stewart and Fisher, B., & Tronto, J. (1990). Toward a Feminist Theory of Caring. In F Abel & M Nelson (Eds.), Circles of Care: Work and Identity in Women’s Lives (pp. 35-62). Albany: State University of New York in Ricks, F. (1992). A Feminist's View of Caring. Journal of Child and Youth Care, 7(2), 49-57. Also, on the Internet at 175 210. Summers, A. (1983). Ladies and Nurses in the Crimean War. History Workshop Journal, 16, 33-56, in Rendall, J. (1984). The Origins of Modern Feminism: Women in Britain, France and the United States, 1780-1860. New York: Schocken Books, p. 349, Footnote #74. 211. Boston Women's Health Book Collective (1984). Our New Bodies Ourselves (4th ed.). New York: A Touchstone Book by Simon & Schuster, Inc. Also, Boston Women's Health Book Collective (2005). Our Bodies, Ourselves (7th ed.). New York: A Touchstone Book by Simon & Schuster, Inc. 212. Malka, 2004, abstract. 213. International Association For Human Caring. (n.d.). Caring as Social Action. Retrieved May 4, 2006, from International Association for Human Caring Web Site: 214. Boykin, A. (Ed.). (1995). Power, Politics, and Public Policy: A Matter of Caring. New York: National League for Nursing Press, Pub. No. 14-2684. And Boykin, A., & Schoenhofer, S. (2001). Nursing as Caring: A Model Transforming Practice. Boston: Jones and Bartlett, Sudbury, MA for National League for Nursing. 215. Chinn, 1985. Milstead, J. (Ed.). (1999). Health Policy and Politics: A Nurse's Guide. Gaithersburg, MD: Aspen Publishers, Inc. 216. American Nurses’ Association web site 176 217. American Nurses Association. (2005). Voices from the Past: Visions of the Future. Retrieved July 11, 2005, from Journal of Nursing, July 1971, Vol. 7, p. 1293. 218. Roberts & Group, 1995, p. 99. 219. American Nurses Association (2003). Nursing’s Social Policy Statement, Second Edition. Washington, DC: American Nurses Association. Additionally, this edition compares the 1980 and the 1995 statements. 220. Ibid, p. 66. 221. Dunbar, S. B., Patterson, E., Burton, C., & Stuckert, G. (1981). Women's Health and Nursing Research. In P. Chinn (Ed.), Advances in Nursing Science (pp. 1-15). Rockville, MD: Aspen Systems Corporation. 222. McKibbin, PhD, R. C., Brimmer, PhD, RN, P. F., Clinton, PhD, RN, J. F., Galliher, PhD, J. M., & Hartley, PhD, S. (1985). DRGs and Nursing Care. Washington, DC: American Nurses' Association Center for Research. 223. Kippenbrock, T. A. (1992). Wish I'd Been There: A Sense of Nursing History. Nursing and Health Care, 12, 208-212. 224. Rothberg, 1985. Also, in Buerhaus, P. I., & Staiger, D. O. (1996). Managed Care and the Nurse Workforce. Journal of the American Medical Association, 276, 1487-1493; and Himali, U. (1995). Managed Care: Does the Promise Meet the Potential? The American Nurse, 27(4):1,14,16. 177 225. Kovner, C., & Gergen, P. J. (1998). Nurse Staffing Levels and Adverse Events Following Surgery in U.S. Hospitals. Image: Journal of Nursing Scholarship, 30, 315-321. 226. Ballard, K. A., Gray, R. F., Knauf, R. A., & Uppal, P. (1993). Measuring Variations in Nursing Care per DRG. Nurse Management, 24(4), 33-41. Bostrom, J., & Mitchell, M. (1991). Relationship of Direct Nursing Care Hours to DRG and severity of Illness. Nursing Economics, 9, 105-110. Caldera, K. (1985). Standards, DRG's and Their Potential Impact on the Future of Nursing. Mass Nurse, 54(9), 4. Long, L E., & Mann, R. (1998). [Australia] Casemix: Challenges for Nursing Care. MJA, 169, S44-S45. Also on the web: 227. Ashley, J. (1976). Hospitals, Paternalism, and the Role of the Nurse. New York: Teachers College, Columbia University. 178 CHAPTER 5 THE HISTORICAL PATH: FROM HUMAN RIGHTS TO MOTHERS’ RIGHTS Introduction This chapter describes professional nursing’s contribution to the creation of the Newborns’ and Mothers’ Health Protection Act of 1996. Primary sources include my interviews with a key sponsor of the law, former Senator Bill Bradley, and two of his assistants, Colleen Meiman and Dr. Margaret Heldring. Meiman was a Health Care Policy Fellow in 1995 for Senator Bradley. Heldring, a psychologist, succeeded Meiman as a Robert Woods Health Care Policy Fellow in 1996, also under Senator Bradley.1 Bradley, Meiman, and Heldring provided valuable information on how politics actually worked and insight to the drama that transpired in the closing hours just before the bill was to be signed into law by President Clinton. The events that led up to the drafting of NMHPA began in the 1970s as socioeconomic and political events impacted maternity LOS. The story unfolds in this chapter and the next. This chapter lays the groundwork as to why professional nursing was not involved in the 1980s, but was present in the 1990s. How the Newborns’ and Mothers’ Health Protection Act of 1996 Became a Law The Urge to Curb Expenses, 1970s-1980s The rationale for discharging mothers early after childbirth in the hospital began to appear in the 1970s. Not only did mothers want shorter maternity LOS, but, also hospital administrators and Medicaid reformers wanted to save money. While Congress sought to reform welfare, the current presidency, the Carter Administration, sought to improve human rights at home and abroad. In 1977, for instance, in the United States, President Carter requested that the Health, Education and Welfare Secretary Joseph A. 179 Califano develop a national health insurance proposal.2 Subsequently, in 1979, Congress increased the budget for maternal-child health-care services under Title XIX, known as Medicaid (federal health insurance for poor mothers and children, and the disabled).3 Medicaid funds are approved by Congress for grants-in-aid to states that subsequently control how the funds are dispersed based on the needs and size of their populations. At the same time that Carter and Califano were liberalizing health benefits, hospital costs soared due to the enormous advances in health-care technology.4 Meanwhile, the federal minimum wage and FICA taxes increased nationally, and state minimum wages increased in 26 states. Because of the upward spiral in costs, the Congressional Budget Office (CBO) denied the Carter Administration’s budget request5 and filed a report titled "Controlling Rising Hospital Costs."6 Based on that report, Congress passed the “Hospital Cost Containment Act of 1979.” This Act controlled federal grants-to-states for hospital reimbursements for Medicaid inpatient admissions.7 In 1981, the CBO suggested that Congress reduce the federal deficit by restricting the outlay of federal dollars. Several large budget categories targeted for restructuring included national defense, the environment, and health care. As a result of the report, Congress passed the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35) requiring a balanced federal budget. The Act resulted in major reductions in appropriations for many large budget categories.8 Reduced health care appropriations caused a corresponding reduction in grants to states for hospital reimbursements for Medicaid recipients.9 As early as 1979, prospective reimbursement plans for Medicare/Medicaid recipients included a fixed per-admission dollar amount based on the patient’s diagnosis, such as gall bladder surgery, or childbirth. 180 This scheme created 467 “diagnosis-related-groups” or DRGs.10 Instead of a retrospective, charge-based system, a pre-determined fixed cost was developed for each DRG inpatient hospital discharge diagnosis based on a calculation incorporating region and type of hospital (i.e., teaching or community) among other criteria.11 Teaching hospitals received more money than community hospitals because of the cost of the research and development of technology. By 1983 a new law, the Social Security Amendments of 1983 (Public Law 98-21) included the Prospective Payment System (PPS), in Titles V and XIX that called for PPS to begin in 1986 with a three year phase-in period. The phase-in actually began in 1987.12 Without question, fixed-cost PPS reduced hospital revenues. There was a natural concern that hospitals would simply increase charges to private insurers to recover lost federal revenues, thereby increasing health care costs instead of reducing them. In 1983, the federal government encouraged all insurers to (1) use the Prospective Payment System, (2) to require larger deductibles and more co-insurance responsibility by the insured, and (3) use the less expensive health maintenance organization (HMO) insurance plans.13 The federal government’s suggestion amounted to a price-fix among insurance plans in order to prevent hospitals from forwarding the cost recovery to private payers The suggestion may be considered antitrust by definition. The conduct of antitrust is collusion among businesses in the same industry to set a price or other secret or illegal collaborations that prevent free trade.14 When the federal government suggested price- fixing using PPS, it reduced the opportunity for free trade in the insurance industry. Hospitals were unable to recover lost revenues from private insurers and simply had to limit expenditures by reducing the labor force,15 reduce plant and facility costs, and 181 shorten hospital lengths of stay for all inpatient diagnoses.16 This last category was especially cost-saving for hospitals with maternity services since childbirth is the most frequent hospitalization discharge diagnosis.17 Hospitals across the nation soon began discharging mothers earlier and earlier. Historical Definitions of Early Discharge Length of hospital stay for childbirth varied from region to region in the U.S. with the longest stay in the Northeast and the shortest in the West, yielding a lack of uniformity in maternity LOS.18 Early discharge in the literature was defined from six to forty-eight hours post delivery.19 Some hospitals and insurance companies agreed to define early discharge by the number of hours from delivery, while others defined early discharge by the number of midnights the patient stayed.20 There were often no community services to replace lost nursing surveillance during postpartum convalescence.21 When NMHPA became law in January 1998, it contributed to uniformity in defining early discharge for the maternity patient in the United States. Shortening Hospital Length of Stay Childbirth is the most common reason for hospitalization with four million babies born annually since the 1970s, making mothers and their newborns on the largest group targeted when Medicaid and private insurers reduced maternity benefits. Maternity LOS was suddenly reduced by 75% from four days to one day (Chapter 1), with research into the safety of doing so, for vaginal childbirth in the late 1980s. Similarly, after cesarean delivery, LOS was reduced by 50% from eight days to three days.22 By the 1990s, private insurers followed suit.23 There is little doubt that insurance savings were driving these medical decisions. 182 The rationale for the 24/72-hour time frame for early discharge is not stated in the Congressional Record or the medical literature and appears to be arbitrarily chosen by Medicaid reformers.24 The Bradford Experiment conducted in England in 1951 may be a possible “template” for the 24/72-hour time frame. Low-risk mothers were discharged early from the hospital to alleviate a bed shortage, followed by home by visits from public health nurses for lost hospital services.25 In the U.S., voluntary early discharge programs often provided home health visits by nurses. In contrast, 24/72 discharge of maternity patients in the U.S. in the 1980s and 1990s were required to leave the hospital with no provision for follow-up care.26 The rationale for extending maternity LOS by one day in NMHPA 1996 to the 48/96-hour time frame is also unclear in the literature. In a senate hearing conducted on September 12, 1995, research outcomes on maternity LOS were presented that indicated inconclusive evidence on the medical safety of early discharge for newborns.27 Dr. Judith Frank, chair of the Committee on Fetus and Newborn of the New Hampshire Pediatric Society asked “Is 47 hours too early or too short, and 49 hours all right?” She testified that the idea is that the decision should be between the physician and the mother as stated in the ACOG and AAP guidelines.28 Dr. Richard Marshall from the National Association of Health Maintenance Organizations testified that 48/96 originated in the 1970s/1980s during the home birth movement as the definition for early discharge when the norm was four days for vaginal birth and 6 days for a cesarean. The 48/96 was considered a safety net offered as an alternative enticement for hospital birth rather than home birth. Follow-up care was provided in early drafts of NMHPA, but not in the final NMHPA law.29 The original crafters of NMHPA mandated either a home visit by a public 183 health nurse or a follow-up clinic or physician visit, but House Speaker Newt Gingrich (R-GA) confidentially stated in 1996, “at the 11th hour” that “he would make sure the bill wouldn’t pass if the provision wasn’t struck from the bill…”30 The rationale for his statement is based on the Republican platform that advocates less governmental intrusion overall, and, certainly, decreased public assistance for health care. The majority party in congress in 1996, both the House and Senate, was Republican.31 Current Early Discharge Defined The return to normal physiological homeostasis for mothers after childbirth occurs within 48 hours following vaginal birth.32 This fact may contribute to the rationale for the current early maternal discharge timeframe used by federal and private insurers for discharge of vaginally delivered patients. No rationale is cited for choosing the 96-hour time frame for cesarean patients. However, the American College of Obstetricians and Gynecologists, along with the American Academy of Pediatricians recommended in 1992 that postpartum hospitalization be set at 48/96.33 An early discharge is considered anything less than 48/96. The American Academy of Pediatrics published the first research-based evidence that accurate newborn screening should be done no earlier than 24 hours after birth.34 Maryland used this evidence for the 48/96 hours discharge time frame in passing its state law to extend maternity LOS.35 Regulations of LOS by States Whereas PPS for Medicaid maternity recipients began in the late 1980's, HMO's and private health insurers adopted the guidelines for the 24/72-hour limits beginning in the early 1990's.36 Maryland, in May 1995, was the first state to pass an early discharge law requiring private insurers to pay for up to 48/96 hours after delivery, followed by 184 New Jersey in June 1995, and North Carolina and Massachusetts in the same year.37 By 1996, 24 more states enacted early discharge laws extending LOS to 48/96. Why Maternity LOS Became a Federal Law Though 24 states had already passed laws requiring insurers to reimburse hospitals for postpartum stays beyond the 24/72-hour length of stay, a federal law was required to govern and make uniform early maternal discharge in all states. Insurance commissions in each state regulate health insurance companies. But many corporations self-insure and are not regulated by state health insurance commissions, leaving mothers under those plans with unregulated maternity LOS. To correct the disparity in maternity LOS, Senators Bill Bradley (D-NJ) and Nancy Kassebaum (R-KA) introduced the NMHPA to the Senate in June 1995, while in the same month Representatives Jerry Lewis (R-CA) and Frank Pallone (D-NJ) sponsored an introduction in the House of Representatives.38 Getting NMHPA Through Congress The federal NMHPA bill had a turbulent path through the Congressional House and Senate before becoming a law. Several key players in Washington, DC, who initiated the NMHPA bill consented to personal and telephone interviews with me that described the strategies used to push the bill through congress to become law. My telephone interview with Senator Bill Bradley gave a first-hand account of the process, and his reasons for becoming so involved with NMHPA. Colleen Meiman, at the time a 1995 health policy fellow on loan from the Department of Health and Human Services, became Senator Bradley’s legislative assistant and wrote the first draft of the NMHPA bill in 1995 after meeting with the six New Jersey nurses in Senator Bradley’s office. 185 I interviewed two of the New Jersey participants, Ann Twomey, RN, and President of Hospital Professionals and Allied Employees (HPAE), and in a separate interview, Jeanne Otersen, not a nurse, but a public policy expert with HPAE, who accompanied the nurses. HPAE is a union of registered nurses and health care professionals in New Jersey.39 When asked why New Jersey nurses approached the state’s union for professionals for help, Otersen described that unionized nurses do not fear job reprisals when they express advocacy for patient care, or economic issues. She told the story of one non-union nurse who was suspended from her hospital job for speaking with a reporter advocating for patients during the campaign for the New Jersey state NMHPA bill. Twomey and Otersen both described how four other New Jersey nurses (Otersen provided their names) joined them to meet with Meiman and Senator Bradley while in Washington, DC, for the national Nurses March on Washington. The march was organized nationally to advocate for safer patient care, better register nurse staffing, and less unlicensed personnel at the bedside, in U.S. hospitals. The march was scheduled for March 31, 1995. The New Jersey group of nurses met in Bradley’s office on March 30, 1995, after traveling from New Jersey to Washington, DC, by train. According to Otersen, the march was organized by the nurses from the Revolution: The Journal for RNs and Patient Advocacy, an organization that is now a “research and education organization funded by the California Nurses Association, and endorsed by the American Association of Registered Nurses.”40 At the time of the march, however, the organization was not affiliated with the California Nurses Association. It was co-sponsored by the ANA. During the meeting with Senator Bradley, the nurses expressed their concerns with the 186 safety of early discharge of mothers and their newborns and presented the cases of babies who died, one of which was from Senator Bradley’s district in New Jersey. According to Otersen, he was “engaged and interested” in their advocacy for mothers and newborns during the meeting. Meiman drafted the first NMHPA bill within a short time, and he introduced it to the Senate on June 19, 1995. Meiman agreed to be interviewed by me on her role and commitment to the health of mothers and newborns. Heldring, the health care policy fellow who followed after Meiman’s fellowship expired, revised NMHPA in 1996, also consented to two independent interviews with me.41 Dr Heldring related how the Bauman family story in Senator Bradley’s district deeply moved the Senator. The Bauman’s, profiled in a Good Housekeeping article “Home Too Soon,” lost their daughter to sepsis infection within 24 hours after discharge from a maternity LOS of only 24 hours. 42 Senator Bradley became involved in NMHPA when nurses and mothers in his constituency requested federal help. He credits his history in the Senate budget battles and financing issues in Title 20 that gave him the credibility for “getting the job done” and the reason why nurses sought his assistance.43 Senator Bradley’s constituents, including the nurses, were concerned that mothers were going home 24 hours after delivery with little time for recovery from delivery and with their babies at risk for jaundice, infection and feeding problems. Ms. Meiman did not remember the nurses’ names, nor did she record them. When she relayed the nurses’ information to Senator Bradley he was at first was unimpressed. Senator Bradley’s focus was finance, taxes, and the budget. Health care was not important enough for him at the time to hire a full time staff person for health care, according to Meiman. Furthermore, the Republican– 187 dominated congress led by the Speaker of the House of Representatives, Newt Gingrich, developed a party platform titled “Contract with America” that called for less government intrusion in American life. 44 According to Ms. Meiman, Bradley believed the intrusion of government into the health insurance industry, ie., getting NMHPA through congress, was probably ill-timed for there were major issues that occupied congressmen’s agendas, such as getting HIPPA into law, cutting Medicare and Medicaid budgets, and making Medicaid a capped block grant.45 Though policy analysts in Washington, DC thought the NMHPA bill was insignificant, it “hit a nerve across the country.” Americans believed they were paying high insurance premiums and not getting the care in return. Americans had developed intolerance for aggressive insurers. Meiman reported that three weeks after introducing the bill Bradley noted that everywhere he went issues on the budget or commerce were taking a back seat to “this little baby bill.” The bill had tapped into the public’s “huge well of discontent” with the cost saving strategies employed by some of the more aggressive insurers. Congressmen, preoccupied with HIPPA, Medicare/Medicaid and the “Contract with America” became absorbed into the frenzy created by the media. Ted Koppel’s Nightline (ABC) led the way with a segment on the impending bill that featured nurses, doctors, and insurers.46 Nursing’s Involvement in NMHPA Legislation The five nurses from New Jersey explained to Colleen Meiman in Senator Bradley’s office their concerns with maternal and newborn outcomes of discharge at 24/72 hours after childbirth. The Senator was distraught when he learned that in his district Baby Bauman had died from an infection, something that would have been discovered if the baby had the baby stayed longer in the hospital. Dr. Heldring offered the 188 name of one nurse with whom she worked on the legislation. I spoke with that nurse, Ruthann Johnson, a clinical liaison in infomatics for nurses in Camden, New Jersey, who consented to be interviewed. She advocated for longer maternity LOS guidelines at both the state and federal level along with helping to craft NMHPA. Another nurse responded to a spring of 2005 advertisement placed in the New Jersey State Nurses’ Association newspaper in my effort to locate the other nurses who approached Senator Bradley’s office. The lone nurse who responded requested anonymity to preserve her current position in a private foundation. She revealed that she faxed a case to Senator Bradley’s office detailing an example of an insurance company’s refusal to approve a longer maternity LOS for a young mother acutely ill with post cesarean complications. The anonymous nurse shared that it was the third such refusal by an insurance company. The young mother’s incision dehisced, which led to a fistula accompanied by infection, resulting in extended wound care and intravenous antibiotics. The mother lived in a third floor walk-up apartment building with only the young father of the baby to help with baby and wound care. The nurse, noting unsafe home conditions, advocated for a longer LOS for the mother and her baby. Hospital administration consented but was never reimbursed by the insurance carrier. Why the other New Jersey nurses who approached Senator Bradley did not respond to my request in the New Jersey State Nurses’ Association newspaper to participate in the study can only be speculated. They may have: 1) not seen the article; 2) feared reprisal for their job security if they came forward with information; 3) moved away; 4) lost interest; 5) retired from nursing; 6) died. Neither Twomey nor Otersen saw the article in the newspaper. Otersen provided the names of several nurses that 189 accompanied them to Senator Bradley’s office. Meiman described the nurses as in their thirties and older. The anonymous nurse who did respond to the newspaper article was in her forties during the 1995 campaign to expand maternity LOS. I asked her to look back to her basic nursing preparation in the late 1960s/early 1970s, and she agreed it was not within the hospital nursing culture to advocate for patients’ health care dilemmas. Dr. Heldring wrote an article crediting the un-named nurses who journeyed to Washington, DC in the spring of 1995 to enlist Senator Bradley’s legal and political help for establishing longer maternity hospitalization.47 When queried seven years later, for the names of the nurses, she lamented that she did not remember their names and that Senator Bradley’s scheduler would have written their names in the appointment book. Senator Bradley, when asked, demurred that the appointment book was unavailable, buried in his Princeton University archives. New Jersey nurses became proactive at a time when there was national reaction to insurers’ practice of denying payments for services. The New Jersey law to extend maternity LOS was passed in June 1995 at the same time that NMHPA was introduced to the federal congress; its text was closely patterned after the New Jersey law. NMHPA became a federal law in only 15 months.48 Twenty-six states had already passed state laws extending LOS with many more states with pending laws. By the time NMHPA became law thirty-eight states had passed their own LOS laws. Why the need for a federal a law federal law when so many states had begun to pass laws of their own? State health-insurance commissions do not regulate all insurers. Senator Bradley decided to introduce a federal bill to capture a larger group of mothers. The success of the legislation hinged on grassroots efforts by mothers, fathers, 190 pediatricians, obstetricians and nurses who were, according to Bradley, “outraged” by anecdotes reported by the media of morbidity and mortality related to EMD. Many of the anecdotes were presented at a congressional hearing on September 12, 1995. The congressional hearing accepted testimony from some parents whose newborns were very sick, or died, from EMD; physicians who cared for mothers or newborns who experienced morbidity from EMD; two of the largest HMO insurers, Kaiser Permanente of California, and Harvard Community Health Plan of Massachusetts that believed that EMD was not only less costly but also safe; three medical organizations (solicited by the Bradley office) who all testified in favor of NMHPA, ACOG, AAP, and AMA; and two nursing organizations. Meiman recalled that once the AMA gave its support for NMHPA, it brought “clout” and more congressional co-sponsors. ACOG and AAP did most of the work, according to Meiman, with the AMA in a supportive role. The nursing organizations, though absent during Medicaid reform in the 1980s, offered testimony and prepared statements in the 1995 Congressional Record.49 Of four nursing organizations that could have testified, only two did so: the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and the American College of Nurse Midwives (ACNM). Although the ANA published support for NMHPA and “joined several other provider organizations in urging Senate leaders to act on the bill as soon as possible”50 and advocated a reimbursable home visit by an nurse,51 the ANA, and the National Association of Pediatric Nurse Practitioners (NAPNP) were absent from the congressional hearing.52 The Chicago Department of Public Health presented testimony in support of follow-up health services for mothers and newborns after early discharge, but not the American Public Health Association (APHA) or public health 191 nurses (PHN). It is interesting to note that public health nurses do not have their own professional nursing organization, even though PHNs were the backbone of professional nursing in the early 1900s. The National Organization for Public Health Nurses (NOPHN) was one of the first professional nursing organizations in the United Sates, founded in 1912.53 In 1952, it merged with the National League of Nurse Educators that became the National League for Nursing (NLN) also in 1952. PHNs are now represented by only a section of the APHA, a non-nursing national organization comprised of twenty- four sections, one of which is the Public Health Nursing (PHN) section ( “Sections,” not even as a separate Public Health Nursing Section. 54 The APHA executive board web site, lists twenty-four members, one from each of its twenty-four sections, mostly physicians, as well as several public health officials, a dietitian, a social worker, and one nurse who represents the PHN section. The PHN section is splintered into four councils ( APHA; 2) Association of Community Health Nurse Educators (ACHNE); 3) Association of State and Territorial Directors of Nursing (ASTDN); 4) American Nurses Association (ANA). The President/Chair of each of these organizations is a member of the Quad Council that meets several times a year and annually with the APHA executive board. The executive board’s director is a male physician. The twenty-four-section membership in the public health organization infrastructure yields strong teamwork behind the nation’s public health, but its web site does not explain how it interfaces with the U.S. Department of Health and Human Services (DHHS) the publisher of Healthy People 192 2000 and Healthy People 2010 (Chapter One). Though professional nursing is part of the APHA infrastructure, it is not represented as an autonomous public health nursing organization where at one time, it was one of the premier professional nursing organizations, NOPHN, with a mission and autonomy in the early 1900s. Public health nursing currently has even splintered into the four representative nursing organizations listed above. None were present at the congressional hearing on the NMHPA bill. Beth Benedict was Chair of the PHN Section of the APHA in 1995, (now at CMS), and wrote, “Many times APHA supports what comes out of congressional legislation by advocating for implementation…And the support is usually found in the policy statements. Also, APHA often works with other advocacy groups to support a bill's passage, and that work is not necessarily in the form of testimony, but rather having APHA staff meet with congressional staffers, etc. APHA does a fair amount of this type of advocacy, and has over the years.” Benedict shared that any PHN statement on NMHPA would have been co-authored by the APHA Governing Council and the Maternal and Child Health Section of the APHA in meetings with congressional staffers. Other advocacy groups would have been included to support the bill’s passage. Of note, Benedict’s statement is on APHA’s involvement, not the PHN Section’s activity, or PHNs lack thereof. Benedict does not recall being asked for any input into the NMHPA bill. I asked Betty Bekemeier, a subsequent chair of the PHN section, presently at the School of Public Health and Community Medicine, University of Washington, Seattle, WA, if PHNs have lost their voice under the aegis of APHA and she agreed that often there have been missed opportunities to testify or provide professional nursing leadership. 193 She wrote in an email “Often it has been because we have found out too late; sometimes due to our own lack of capacity to ‘jump’ when needed; sometimes due to our lack of visibility and influence.” The PHN section currently recognizes these insufficiencies and has taken steps to “be more proactive.” Benedict’s and Bekemeier’s viewpoints highlight that PHNs are not necessarily represented in full in public health policymaking as they once were in the late 1800s and early 1900s. Marjorie Buchanan, the current Chair of the PHN section of APHA and successor to Bekemeier, concurs noting the concern for PHNs lack of voice in past and present matters. She credits Bekemeier with the vision that recognized deficiencies in awareness and visibility of public health nurses and the PHN section and began initiatives to include PHN in public health policymaking by working collaboratively with their Quad Council, the APHA Action Board, and the Resolutions/Policy Committee. To facilitate the PHNs campaign to become more visible, I contacted Catherine Garner and she agreed to share her information with Buchanan on Garner’s initiative that separated NAACOG from ACOG. The future of the organization for public health nursing, once the backbone of professional nursing, remains to be seen. I also contacted NAPNP for their input on the 1995 NMHPA initiative. According to Mavis McGuire, former Executive Director of NAPNP, and Joseph Casey, Director of Membership, Chapters and Communication Director, NAPNP was very involved in supporting the national NMHPA bill prior to the September 1995 congressional hearing, but behind the scene. Casey wrote that the absence of NAPNP and PHNs in the forefront, and from the congressional hearing, was based on a rotation system in representing the numerous professional nursing organizations in congressional hearings. 194 Deborah Hardy Havens, President of Capital Associates, Inc, and a former lobbyist for NAPNP, concurred, stating that invited witnesses are kept to a minimum due to time constraints. Benedict also concurred on the time constraints, noting that the APHA may not have testified because it was not selected in an invitation-only process to testify on the bill.55 Hence, of the key players, only AWHONN and ACNM were at the congressional hearing. At the time of the congressional hearing in September 1995, NMHPA was written to include a home visit after discharge. By September 1996, the home visit was eliminated from NMHPA as too costly. The ANA, however, continued to advocate for a home visit, but NMHPA became law without the home visit provision.56 Had public health nurses or ANA presented testimony about why it was necessary for mothers and newborns be re-evaluated in the home environment, then the home visit portion may not have been eliminated. On November 6, 1997, the ANA again tried to lobby for a home or provider visit provision shortly after early discharge under 48/96 and worked with Representative Steve LaTourette (D-OH) who introduced an amendment to NMPHA for insurance coverage for a post-delivery follow-up home or provider visit if the maternity LOS was less than 48/96.57 The amendment was referred to committee for further consideration, but the amendment never returned to the House floor for a vote. On November 25, 1997 the amendment was referred to the subcommittee of the House Education and the Workforce on Employer-Employee Relations. It “died” in committee; it simply was allowed to expire.58 AWHONN fully supported NMHPA (referred to as senate bill S 969). But AWHONN also critiqued S 969, advocating the inclusion of other non-physician 195 providers, such as Certified Nurse Midwives (CNM). NAPNP also supported a change in language from “physician” as the health care provider to just the word “provider” which included nurse practitioners as well. AWHONN also cited its March 1994 position statement on “Shortened Maternity and Newborn Hospital Stays” that supported research-based, cost efficient quality nursing care. When AWHONN testified that S 969 allowed for freedom of choice by providing a “safety net” for mothers to choose to remain hospitalized in consultation with her doctor, the endorsement may also have ensured the need for hospital-based maternity nursing positions which were being cut by hospital administrators as a reflex to insurers’ managed care cost reduction strategies. ACNM provided testimony that digressed from the point of the focus of the hearing in a self-serving way. Recorded in the congressional hearing record is the ACNM organization’s historical mission and credentialing of certified nurse midwives (CNM), the ACNM pointedly stated: The ACNM is opposed to S 969…NMHPA of 1995 as it is currently written…we oppose any time limits on inpatient care and we cannot support legislation that does not recognize the legal scope of practice of providers other than physicians (example certified nurse midwives and pediatric nurse-practitioners) who are capable of determining when inpatient care is medically necessary for a mother or newborn.59 The ACNM further commented that while agreeing that payers should reimburse hospitals for inpatient care, CNMs should be reimbursed for health care services in homes, birth centers, and office settings that substituted for hospitalization as providers, a diversion from the topic on the table. Their point was that the CNMs wanted to be included as providers of care so as insurers would pay them and wanted the wording to be changed to reflect it. Meiman concurred, stating that after the congressional hearing she received several members from ACNM bringing with them a lengthy letter that they 196 ACNM was very “upset” about the choice of words, and Meiman simply had overlooked it. Had the ACNM just asked for the change in words, Meiman said she would have gladly changed it to providers. ACNM feared that insurers would not pay for midwives if the law was written for physicians, omitting any other providers of maternity care, e.g., midwives or advance practice nurse practitioners. The congressional hearing for NMHPA was not the forum for ACNM’s own special interests and should have been heard elsewhere. AWHONN supported that CNMs should be included as inhospital providers but strangely omitted PHNs and PNPs, the providers making home visits, but did support the inclusion of home visits. ACNM did not support AWHONN’s statements. The ACNM did support pediatric nurse practitioners as inhospital providers in NMHPA, but omitted public health nurse providers even though there was a provision for home visits. A home visit was already written into NMHPA, and no one foresaw the necessity to lobby for the provision, or the possibility that it might be excluded one year later. Mentioned earlier, at the turn of the 20th century nurses practiced either private duty nursing, or public health nursing. Public health nurses promoted health prevention through health education as well as treatments for ailments. The National Organization for Public Health Nursing was organized in 1912, which joined the ANA in 1952. Eventually, the American Public Health Association (APHA) absorbed the public health nurses who now are a section of the APHA. A nurse chairperson heads the PHN section of the APHA. Divisiveness between the two nursing organizations was apparent in the ACNM opposition to NMHPA. ACNM was once the American Association of Nurse-Midwives 197 (AANM), started in 1929 as the Kentucky State Association of Midwives by nurse- midwives working for the Frontier Nursing Services. As the nurse-midwife movement grew nationally, the choice before AANM was to be either absorbed within an already established nursing organization or to be a separate and independent national organization. In 1955, AACNM chose to stand apart and became known as the independent ACNM organization. Even though one the objectives of the organization was to ‘establish channels for communication and cooperation with other professional and nonprofessional groups,” the ACNM did not appear to have negotiated a compromise with AWHONN in its statements to the congressional hearing on NMHPA. Or did it? Consider the statement of ACNM: “we oppose any time limits on inpatient care” with AWHONN’s statement: “AWHONN supports…freedom of choice …for mothers to choose to remain hospitalized.” The statements are similar. NMHPA’s 1995 draft included the “attending physician, defined as the obstetrician, pediatrician or other physician attending the mother or newly born child;”60 The final draft of NMHPA changed the wording from “physician” to “provider” and defined “provider” to include nurse midwives and nurse practitioners. NMHPA’s final wording also states that insurers are required to pay for a minimum of 48/96 if the mother in consultation with her provider chooses to stay for 48/96; mothers were not required to stay for 48/96, as some interpreted it.61 NMHPA placed the direct responsibility in the hands of the mother in consultation with her provider, and no provider could offer incentives for her to leave the hospital earlier than 48/96. The language of ACNM’s request was, unfortunately, placed 198 in the negative context, but the two organizations were essentially making the same statement, and the final NMHPA reflects the nursing organizations’ desired input. Strategies to Test and Gather More Support from the Public for NMHPA: The Media Senator Bradley declared in our interview that people were “outraged” that mothers were discharged so early after delivery. Newspapers and magazines around the country published articles depicting the pulse of Americans on this issue. The Ladies’ Home Journal and Good Housekeeping both wrote on the questionable safety issues for new mothers and babies discharged from hospitals as early as eight hours after delivery.62 In 1995, Senator Bradley stated he asked a friend at Good Housekeeping to write an article on EMD to gauge the national level of interest on EMD. The article appeared in the October 1995 issue and included a coupon for readers to send to Senator Bradley’s office if they supported increased maternity LOS. Readers responded by mailing 85,000 coupons from all corners of the nation.63 In a campaign to garner votes for NMHPA’s passage from other senators, Bradley’s office grouped the coupons by state to impress upon these senators that their constituents wanted maternity LOS extended. A subsequent issue of Good Housekeeping editorial included a picture of Senator Bradley “digging into a mound of letters sent by GH readers” who supported his efforts to extend LOS for mothers and babies.64 Senator Bradley also contacted the Ladies’ Home Journal before introducing the NMHPA bill to congress, requesting they publish an article on EMD to gather a pulse on the issue from a national readership. The November 1995 article generated 50,000 reader responses to the editor requesting that policymakers extend maternity LOS. The Boston Globe reported that Massachusetts was joining a nationwide movement to lengthen maternity stay to 48 199 hours.65 Indeed, families nationwide were “outraged” with what the media tagged as “drive-thru deliveries.” Marketing of sensational stories of newborns and mothers compromised by EMD was also aided by television. The helplessness of mothers and newborns was depicted in an ER episode aired May 16, 1996.66 One author of NMHPA contacted the producers of ER and asked to have a storyline included on EMD. It was positioned to air shortly after Mother’s Day, May 12, 1996. The storyline is about a near-death experience of a baby and the medical expense of an emergency-room visit instead of one more postpartum day in the hospital. The terrified new parents bring in a sick two-day-old baby to the emergency room who is treated and eventually returned home with its parents. The episode highlighted the national trend towards EMD and the associated morbidity. Congressional Support and Opposition to the NMHPA Bill Despite popular support for the LOS issue, the NMHPA bill generated fierce opposition. Bradley noted that insurance companies and HMOs lobbied against the increased cost to the insurance industry. Dr. Heldring noted the industry feared that doctors and nurse practitioners from other specialties might also pressure for legislative control in determining LOS for other diagnoses. Dr. Sharon Levine associate medical director, the Kaiser Permanente, Oakland, CA, and Dr. Richard Marshall, chief of pediatrics, Harvard Community Health Plan, Boston, MA testified that 24/72 was safe and cost effective; and that 48/96 was mandating clinical guidelines.67 Yet, it was the insurance companies that originally mandated clinical guidelines by limiting the LOS to 24/72 by reducing payments to hospitals. 200 Another source of opposition came from the Republicans, who dominated both the House of Representatives and the Senate during the Clinton Administration.68 The Republican platform supports big business, maximum profits and lower costs. The insurance industry opposed increases in LOS because of increases in their costs. But increased LOS spending was voted down when the Democrats argued for protecting mothers and newborns through appropriate use of government power, an anathema to most conservatives. Managed-care companies provided testimony to protest the financial impact that NMHPA would place on the industry.69 It was assumed that the law would pass quickly in Congress because it was an election year. But in Senate Report 104-326 in July 1996 the CBO estimated the average federal expense of increasing maternity LOS cost from 1997-2002 for Medicaid to be about $35 million, split between states and the federal government, with a federal cost of about $20 million and the states’ share of about $15 million.70 Estimated private insurance cost increases by the CBO were about 0.02 percent after employer-based reaction adjustments in wages and/or additional employee premium contributions. The dollar-amount was estimated to be about $130 million extra a year for 1997 increasing to $220 million by 2001. The General Accounting Office in 1998 concurred with the cost analysis. 71 Senators such as James Jeffords (R-VT) expressed concern that NMHPA was a “treatment guideline for length of stay” that places the U.S. government squarely in the role of practicing medical care.72 He believed that NMHPA would also interfere with free market competition among plans and sponsored an amendment with two provisions: 1) for timely research for optimal discharge; 2) that NMHPA should be “sun-setted,” that is, 201 eliminated in 5 years (2001). But the female senators made it clear that NMHPA was a permanent, not a temporary, solution.73 When the vote on the amendment was taken in committee, it was a tie. Senator Nancy Kassebaum cast the tie-breaking vote against the amendment, sending the message that NMHPA was a significant change in policy. The amendment was rewritten with the research arm of the amendment retained, but sun- setting NMHPA was struck from the amendment.74 A mandated postpartum home visit by a nurse based on available research studies was originally written into NMHPA by Colleen Meiman, but this was eventually eliminated by demand of the Speaker of the House Newt Gingrich (R-GA) who almost derailed NMPHA at the eleventh hour. Several senators, Kassebaum (R-KA), Mike Dewine R-OH), and Bill Frist (R-TN), a cardiac surgeon, all supported the home visit provision. But Gingrich in the final days opposed the home visit as too costly for insurers. As the Republican House leader, Gingrich threatened to influence other senators’ votes if the home visit provision was not struck from the bill. Republican senators would be counseled by the Speaker to vote against NMHPA if they wanted to gain favored votes for their own special projects. Such political power plays in Congress are common. On September 5, 1996 amendment number 5193 was offered by Senator Frist (R-TN) to delete the provision that required insurance companies to pay for a follow-up visit post discharge either as a home visit by a nurse or a provider visit to a clinic or office.75 The rationale for striking the terminology was offered by Senator Bradley, in compliance with House Speaker Newt Gingrich’s off-the-record request, to delete language to give the mother the “option of demanding home care.” Legislators, Bradley said in compromise, did not want to interfere with insurance rate plans and 202 consumers where premiums would increase to cover home visits, nor did legislators want to interfere with the premium rates set between insurance plans and providers. All ten women senators (five Republicans, five Democrats) signed a letter to Senate Majority Leader Bob Dole (R-KS) urging him to request a vote in favor of NMHPA. Ten days before Mother’s Day, Senator Bradley asked senators to vote for the NMHPA.76 Senators Patty Murray from Washington, Barbara Mikulski of Maryland, and Diane Feinstein from California also spoke in support of NMHPA suggesting that some of the male senators might dissent.77 The ten women senators urged their male colleagues to vote for NMHPA and when the final votes were cast, there was no “gender vote” or partisan vote. The bill passed unanimously. A Senate roll-call vote on September 5, 1996, shows a 98-0 victory for the NMHPA bill, with Hatfield (R-Oregon) and Murkowski (R-Alaska), both Republicans, abstaining. 78 The NMHPA bill was then included within the Departments of Veterans’ Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act (VA-HUD Appropriations), a collage of bills that the Senate was to vote on later that day. The VA-HUD Appropriations bill passed 95-2 in the Senate with 3 not voting. The 2 nay votes were from Senators Brown (R-Colorado) and Feingold (D-Wisconsin) who notably voted ‘yes’ during the senate NMPHA vote. Their opposition may have been against other bills, line-items, within the VA-HUD Appropriations bill. Two of the three senators who did not vote were the same who did not vote during the NMHPA vote, Hatfield and Murkowski; they may have been absent from the senate, or were against other line items. The third, Senator Inouye (D-HI), voted for NMHPA but may have chosen the no-vote option in the VA-HUD bill in reaction to some other item in the 203 Appropriations bill or he may simply have been absent. It is clear that NMHPA scored a resounding political victory. The 433-member House of Representatives voted on September 24, 1996 and decisively approved the VA-HUD Appropriations bill containing NMHPA.79 Three hundred eighty-eight representatives voted yes, 25 voted no, 20 did not vote (total 433). Of the 433 representatives, 44 were women, of whom 15 were Republicans, and 29 were Democrats: 43 of 44 women voted in favor of the appropriations bill. One female Democrat, Senator Patricia Schroeder (Colorado), did not vote because she retired in 1996. The 25 who voted “no” were men. Senator Bradley on interview made several relevant comments on the legislative opposition to NMHPA: Newt Gingrich didn’t really have a role in it. Leadership in the Clinton Administration tried to stonewall it because it didn’t come from them. So I decided to add an amendment in an appropriations bill; chose that route because a friend, (Senator) Barbara Mikulski, a Democrat of Maryland, attached it in her subcommittee. You see, you get one from each side to help you. There was nothing/no one in the House… Now Gerald Solomon, a Republican on the Rules Committee, cared about this issue in the House, and helped to get it to pass in the House…Up to the last minute the Clintons opposed it….Don’t know why, they didn’t want it in an appropriations bill; I said ‘…this is what its gonna be’; Hillary and Bill took all the credit--all they did was sign the bill… It took someone who knew what he was doing and I thought of putting it in an appropriations bill. Colleen Meiman had a different opinion. The Clinton White House was thinking ahead to the presidential election in the year 2000. They wanted Vice President Albert Gore to win the Democratic nomination, and Senator Bradley was a contender for the nomination. Therefore, they did not want Bradley’s name attached to a successful NMHPA law, a popular health care platform on which to 204 run for President of the United States. The Clintons “erased” Senator Bradley’s name on all documents that moved to the executive branch for approval thereby taking credit for the bill upon its return to congress. The VA-HUD bill included several line items, not just NMHPA. In voting for the bill all items needed to pass Congress to be sent to the President for his signature. The drafting of the bill along with its many revisions was complicated, and the work of many congressmen and women and their staffs. In the public papers of President Clinton, he stated at the signing of the VA-HUD Act of (fiscal) 1997 that “the Congress has responded to my call to include three bipartisan provisions aimed at eliminating a range of health care crises…a mental health parity…the Newborns’ and Mothers’ Health Protection Act of 1996…and my proposal to assist the children of Vietnam veterans…with spina bifida.”80 In the manner of all presidents since Washington, President Clinton claimed credit--for all three. The political maneuvering was actually like negotiating a minefield, such as Senator Bradley’s strategy to “get one [congressman] from each side of the aisle,” that is, one Democrat and one Republican, to agree to support the NMHPA bill, or Gingrich’s threatened dissent. Senator Bradley also faced opposition from the executive branch when President Clinton declared it was he that asked Congress for NMHPA. Another example of political maneuvering is House Representative Gerald Solomon (R-NY) who “jumped all House rules”81 to support NMHPA. The influencing of vote-getting to promulgate a bill is another example of political maneuvering. For instance, the vote for the VA-HUD amendments 205 finally came up for a vote on September 24, 1996 in the House of Representatives, barely two days before Clinton signed the bill into law.82 Why at the very last minute, when congressional vote could have derailed the whole VA- HUD bill and the NMHPA amendment, just before executive signing, did House Speaker Newt Gingrich threaten dissent? He needed congressional support for one of his own projects? The suggestion of “arm twisting” for political favors bodes strong in this instance.83 Despite the political arm twisting, mothers and newborns from all socioeconomic levels across the nation now enjoy extended LOS due to of the efforts of nurses, mothers, doctors, the leadership of Senators Bradley and Kassebaum and their staffs, and many other senators and representatives. Summary The Newborns’ and Women’s Health Care Protection Act of 1996 offered standardization for early maternal discharge. That many states had already begun policymaking in support of longer postpartum hospitalization indicated that the socioeconomic and public health aspects of very early maternal discharge were of great concern nationally. Yet a federal law was necessary to include a larger number of mothers insured under various types of health insurance plans. Five nurses advocated for mothers and newborns when they approached Senator Bradley to ask for his legal help. Nursing organizations testified at a congressional hearing in support of NMHPA with statements that included revisions for the final bill, and they were included. Senators Bradley and Kassebaum and their staffs worked to promulgate a bill into law that would affect every mother and newborn in the United States. Women legislators from both branches of congress banded together to gather support from other male 206 legislators. However, some male legislators still strongly opposed NMHPA. Eventually, the bill passed unanimously in the Senate and won a majority vote in the House of Representatives. Even though there was inadequate evidence-based research to determine criteria for optimal length of maternal-newborn hospitalization, NMHPA was legislated to expand maternity LOS in 1996 by one day, effectively doubling the hospitalization for mothers and newborns. 207 Endnotes 1. William Warren (Bill) Bradley, was a Democratic Senator from New Jersey 1978- 1996; born in Crystal City, Jefferson County, Mo., July 28, 1943; graduated from Princeton University 1965; attended Oxford University, Oxford, England, as a Rhodes Scholar and received a graduate degree in 1968; represented the United States in 1964 Olympic Games (basketball) at Tokyo, Japan; served in the United States Air Force Reserve 1967-1978; author; professional basketball player 1967-1977; a businessman; elected as a Democrat to the United States Senate in 1978; reelected in 1984 and 1990 and served from January 3, 1979, to January 3, 1997; was not a candidate for reelection as senator in 1996; was an unsuccessful candidate for the Democratic presidential nomination in 2000; senior advisor and vice chairman of the International Council of J.P. Morgan & Co., Inc. 1997-1999; essayist for CBS evening news; visiting professor, Stanford University, Notre Dame University and the University of Maryland 1997-1999; chief outside advisor, McKinsey & Company 2001-2004; presently, a managing director for Allen & Company LLC, New York City. Colleen Meiman Colleen is currently a senior program analyst in the Office of State and National Partnerships, Bureau of Primary Health Care under the Health Resources and Services Administration (HRSA) within the U.S. Department of Health and Human Services (DHHS). Her department provides support for community-based preventative and primary care to underserved populations and people with special needs. HRSA works closely with CHIP, Children’s Health Insurance Programs, to help states insure children. In 208 January 1995, she was in DHHS and was loaned to Senator Bradley’s office needing a health care policy staff assistant. Meiman relates that it was a good fit since she was looking for a fellowship in health are policy. She moved back to DHHS by December 31, 1995 when her fellowship ended, but continued to follow NMHPA’s progress. Dr. Heldring, Colleen Meiman’s successor, began her Congressional Science Fellowship on Health and Policy in the October of 1995 in the office of Senator Bill Bradley who had recently introduced the Newborns and Mothers Health Protection Act dated June 27, 1995. It was introduced in the House of Representatives on June 28, 1995 by Representative Pallone (Democrat, New Jersey) and sponsored by Jerry Lewis (Republican, California). According to the University of Illinois web site 1984 until 2001, she was a clinical assistant professor in the Department of Family Medicine at the University of Washington. She practiced psychology independently and published and lectured widely in both mental health and primary care. She is a past president of the Washington State Psychological Association and past chair of the American Psychological Association's Committee of State Leaders. She has been honored on the state and national levels for her leadership. Dr. Heldring served as the Director of Health Policy for Bill Bradley's 2000 presidential campaign and, previously, as chief health advisor to Senators Bradley and Paul Wellstone. She provided congressional 209 staff leadership for the 1996 maternity stay legislations and the 1997 provision for mental health services for children in the Child Health Insurance Program (CHIP). She is currently the President and Executive Director of a nonprofit, bipartisan organization, America's Health Together. The mission of this organization is to advance a broad view of health and health care, provide effective public education about universal health care, and to promote health and social justice. Dr. Heldring is the editor of the Department of Family Health Policy for Families, Systems and Health and is on the Editorial Advisory Board for The American Family Physician. Dr. Heldring was the first psychologist to run for public office in Washington State. 2. Titles V and XIX were created in 1966 within the Social Security Act of 1935 (CBO, 1979; Dept of Health & Human Services, 1981. 3. Titles V and XIX, 1981. 4. Goldfarb, D. L., Mintz, R., & Yeager, M. S. (1982). Financial Management: Why did Hospital Costs Increase in 1981? Hospitals, July 16, 109-114. 5. Dr. Theresa Karl, professor in Political Science, UCLA, personal communication, 1999. Her father, a pediatrician, was a member of the commission charged with determining needs for improving maternal and child health in the nation. She stated that Congress denied the committee’s recommendations based on costs. The Congressional Budget Office report of 1979 supports her statement. Congressional Budget Office (1979). Controlling Rising Hospital Cost: Report to Congress. Washington, DC: Congress of the United States. 210 6. Congressional Budget Office (1981 to 1987). Reducing the Deficit: Spending and Revenue Options. Annual Report to the Senate and House Committees on the Budget: Parts I, II, III. Washington, DC: Congress of the United States. 7. CBO, 1981. 8. CBO, 1983. 9. CBO, 1983. 10. U.S. Public Law 98-21; Office of Technology Assessment, Government Printing Office, 1985. 11. Public Law 98-21. Rosko, M. D. (1989). A Comparison of Hospital Performance Under the Partial-Payer Medicare PPS and State All-Payer Rate-Setting Systems. Inquiry, 26 Spring, 48-61. 12. CBO, 1983 p. 113; U.S. Public Law 98-21. 13. CBO, 1983, p. 112-113. 14. Legal-Explanations.Com. (2004). Antitrust Laws. Retrieved August 2, 2005, from 15. Himali, U. (1995). Managed Care: Does the Promise Meet the Potential? The American Nurse, 27(4):1,14,16. This article interviews Cheryl May, at the time a senior policy analyst specializing in managed care in the department of nursing practice at the American Nurses’ Association. She noted that a reduced labor force in managed care included nursing staff positions. 16. Office of Technology Assessment (1984). Medical Technology and Costs of the Medicare Program: Summary. Washington,DC: U.S. Congress, OTA H-227, October. 211 17. Centers for Disease Control & Prevention. Trends in length of stay for hospitalized delivery in the United States 1970-1992. MMWR Morbidity & Mortality Weekly Report (1995); 44: 335-337. 18. National Center for Health Statistics, Series 13. Data on Health Resources Utilization, on the internet: 19. Bragg, E.J., Rosen, B., Khoury, J.C., Miodovnik, M., and Siddiqi, T. A. (1997). The effect of early discharge after vaginal delivery on neonatal readmission rates. Obstetrics and Gynecology, 89(6), 930-933; Brooten, D., Roncoli, M., Finkler, S., Arnold, L., Cohen, A., Mennuti, M. (1994). A randomized trial of early discharge and home follow-up of women having cesarean birth. Obstetrics and Gynecology, 84(5), 832-838; Campbell, I.E. (1992). Early postpartum discharge - an alternative to traditional hospital care. Midwifery, 8(3), 132-142; Carty, E., & Bradley, C., (1990). A randomized, controlled evaluation of early postpartum hospital discharge. Birth 17(4): 199-204; Lemmer, C.M., 1987, Early discharge: outcomes of primiparas and their infants. Journal of Obstetrical, Gynecological and Neonatal Nursing, 16(4), 230-236; Norr, K.F., & Nacion, K. 1987). Outcomes of postpartum early discharge 1960-1986. A comparative study. Birth, 14(3), 135-141; Welt, S.I., Cole, J.S., Myers, M.S., Sholes, K.M., Jelovsek, F.R. (1993). Feasibility of postpartum rapid hospital discharge: a study from a community hospital population. American Journal of Perinatology, 10(5), 384- 387. 212 20. Margolis, L. H., Kotelchuck. M., & Chang, H. (1997). Factors associated with early maternal postpartum discharge from the hospital. Archives of Pediatric Adolescent Medicine, 151(5), 466-472.. 21. Kotagal, U. R., Atherton, H. D., Eshett, R., Schoettker, P. J., & Perlstein, P. H. (1999). Safety of Early Discharge for Medicaid Newborns. JAMA, 282, 1150- 1156.. 22. Center for Disease Control & Prevention, MMWR, 1995; Declercq, E., & Simmes. D. (1997). The Politics of “drive thru deliveries”: Putting Early Discharge on the Legislative Agenda. Milbank Quarterly, 75(2), 175-202. Margolis, L. H., Kotelchuck. M., & Chang, H. (1997). Factors Associated with Early Maternal Postpartum Discharge from the Hospital. Archives of Pediatric Adolescent Medicine, 151(5), 466-472. 23. National Center for Health Statistics, Series 13. Data on Health Resources Utilization, on the internet: for Healthcare Research and Quality. (n.d.). HCUP Databases. Healthcare Cost and Utilization Project (HCUP). Retrieved June 18, 2005, from 24. Parisi, V. M., & Meyer, B. A. (1995). To Stay or Not to Stay? That is the Question. New England Journal of Medicine, 333, 1635-1637. 25. Theobald, G. W. (1959). Home on the Second Day: the Bradford Experiment: the Combined Maternity Scheme. British Medical Journal, 2, 1364-1367. Annas, G. 213 (1995). Women and Children First. New England Journal of Medicine, 333, 1647-1651.; Declercq & Simmes, 1997. 26. Kotagal et. al., 1999, PL 98-21; Theobald, G. W. (1959). Home on the Second Day: the Bradford Experiment: the Combined Maternity Scheme. British Medical Journal, 2, 1364-1367. Public Law 98-21; NMHPA Public Law 104-204. 27. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, To Require that Health Plans Provide Coverage for a Minimum Hospital Stay for a Mother and Child Following the Birth of the Child. In Hearing of the Committee on Labor and Human Resources United States Senate, 104th Congress, First Session. (pp. 1-84). Washington, D.C.: U.S. Government Printing Office. 28. American Academy of Pediatrics and American College of Obstetricians and Gynecologists (1992, 1997). Guidelines for Perinatal Care (3rd & 4th ed., Rev.). Washington, DC: ACOG and AAP. 29. Lack of follow-up care after discharge was cited in Braveman, P., Kessel, W., Egerter, S., & Richmond, J. (1997). Early Discharge and Evidence-based Practice: Good Science and Good Judgment. JAMA, 278, 334-336; NMHPA, 1995. NMHPA, 1995. 30. Dr. Heldring, personal communication, 2003. Congressional Record, 104th Congress, Amendment 5193 corroborates Dr. Heldring’s statement. U.S. Senate Bill Clerk. (n.d.). Amendment No. 5192, 5193 to Require that Health Plans Provide Coverage for a minimum Hospital Stay for a Mother and Child Following the Birth of the Child, and for Other Purposes. Retrieved March 21, 2005, from U.S. 214 Government Web Site: http://thomas.loc.gov/cgi- bin/query/F?r104:30:./temp/~r104PLbyfK:e35014: 31. There were 53 Republicans and 45 Democrats in the Senate. The House of Representatives had 234 Republicans and 192 Democrats. U.S. Congress. (n.d.). Biographical Directory of the United States Congress: 1774-Present. Retrieved March 18, 2005, from U.S. Government Web Site: 32. Cunningham, F. G., et al. (1997). Williams Obstetrics (20th ed.). Stamford, Ct: Appleton & Lange. 33. American College of Obstetricians and Gynecologists (1992). Guidelines for Perinatal Care (3rd, Rev.). Washington, DC, p.105-108. 34. American Academy of Pediatrics (1996). Newborn Screening Fact Sheets. Part I. Pediatrics 98(3)part 1 of 2, 473-501. 35. 1995 Maryland Laws Ch. 503. 36. Congressional Budget Office (1983). Reducing the Deficit: Spending and Revenue Options. Annual Report to the Senate and House Committees on the Budget: Parts I, II, III. Washington, DC: Congress of the United States.; Massachusetts Emergency Regulations, Chapter 218, 105 CMR 130.660-130.669, an Act Further Defining Childbirth and Postpartum Care Benefits, Nov. 21, 1995. 37. Carpenter, J. A. (1998). Shortening the short stay: One program explores the benefits of early discharge & home care. AWHONN Lifelines, 2(1), 28-34; Declercq & Simmes, 1997. 215 38. U.S. Senate. (1995, June 27; legislative day June 19). S.969 Newborns' and Mothers' Health Protection Act of 1995 (Introduced in the Senate). Retrieved October 11, 2001, from United States Congress Congressional Record Web Site: House of Representatives. (1995, June 28). HR1950 IH. Newborns' and Mothers' Health Protection Act of 1995 (Introduced in the House). Retrieved August 11, 2005, from U.S. Congress Web Site: 39. Health Professionals And Allied Employees. (2005). HPAE: New Jersey’s Professional Health Care Union. Retrieved August 19, 2006, from Health Professionals and Allied Employees Web Site: 40. California Nurses Association. (2005). About Us: Revolution: the Journal for RNs and Patient Advocacy. Retrieved August 16, 2006, from California Nurses Association Web Site: 41. Permission to quote informants was obtained in writing and on audiotape. Dr. Heldring was interviewed in person and audio taped. A second interview with Dr. Heldring was by telephone for further clarification on the issues. The consents and interview guide with open questions are found in the Appendix A. Some questions led to other clarifying questions not included in the guide. The participants’ primary accounts are recalled from seven years ago, with issues ranging from concerned constituents to full passage of the bill as a law. 216 42. Kasindorf, J. R. (1995, October). Home Too Soon. Good Housekeeping, 221, 116- 119. 43. Senator Bradley ‘s involvement with social issues prompted nurses to approach him. Social Security Administration. (2001 Compilation date of Social Security Laws). Title XX: Block Grants to States for Social Services. Retrieved March 29, 2005, from United States Government Web Site: defined as block grants to states for social services, including education for children, first enacted in 1975. The Office of Community Services, Administration administers title XX of the Social Security Act for Children and Families, Department of Health and Human Services. It appears in the United States Code as §§1397-1397f, subchapter XX, chapter 7, Title 42. Senator Bradley believed passionately in educating children, voting for budget surpluses to be placed towards Head Start, special education, more teachers, and more after school programs. 44. U.S. House Of Representatives. (1994, September 27). Republican Contract with America. Retrieved January 23, 2006, from U.S. Congress Web Site: 45. Kaiser Family Foundation. (2004). Medicaid and Block Grant Financing Compared. Retrieved January 23, 2006, from Compared.pdf>. 217 46. ABC News. (November 17, 1995). Nightline with Ted Koppel: Drive-Thru Deliveries. Retrieved January 23, 2006, from Guests included: Allison Bissar, Dr. Holly Roberts, Dr. Harris Berman (Tufts Associated Health Plan), Obstetric Nurse (un-named), Dr. Timothy Johnson (ABC News Medical Director), Kelly Anne Guli, Dr. Valerie Parisi (University Hospital, Stony Brook). Anchor: Ted Koppel The segment was thirty minutes long. 47. Heldring, M., & James McGregor Burns Academy of Leadership, University of Maryland (1998). Fighting for Health Care on the Hill: A Tale of a Senator, a Psychologist, and the American People. Professional Psychology: Research and Practice, 29(1), 3-4. 48. Declercq, E., & Simmes. D. (1997). The Politics of “Drive thru Deliveries”: Putting Early Discharge on the Legislative Agenda. Milbank Quarterly, 75(2), 175-202. In 1966 the average length of time for policies to overcome hurdles was 25.6 years. By 1994 laws pertaining to maternal and child health took just over a year to pass through the congressional and executive branches. 49. U.S. Government Printing Office (1995). Hearing of the Committee on Labor and Human Resources United States Senate, 104- First Session, S. 969 (Senate Hearing 104-237, ISBN 0-16-052035-5). Washington, DC: U.S. Government Printing Office. 50. American Nurses Association (1996). ANA Urges Senate to Act on Maternity-Stay Bill. The American Nurse, 30 (6): 10. 218 51. Brider, P., (1996). Headlines: AJN Newsline. American Journal of Nursing, 96(7), 69-70. and ANA, stating limited funds for many political support projects, simultaneously had a major involvement with the introduction of the Patient Safety Act bill which was concerned with staffing levels, the replacement of skilled registered nurses with unlicensed assistive personnel, and patient outcomes. American Nurses Association. (1999). Washington Watch. Retrieved December 29, 2005, from American Nurses Association Web Site: 52. The National Association of Public Health Nurses, founded in 1912 dissolved in 1952 to join the ANA and NLN. Lewenson, S. B. (1993). Taking Charge: Nursing, Suffrage, and Feminism in America, 1873-1920. New York: Garland Publishing, Inc. Dr. Lewenson is currently Associate Dean of the Leinhard School of Nursing, Pace University, NY, NY. She is also the President of American Association for the History of Nursing (2005).; 53. National Institute of Health. (2005, June 24). Finding Aid to the National League for Nursing Records, 1894-1952. Retrieved December 27, 2005, from Web Site: National Library Of Medicine 54. Public Health Nursing . (2003). Welcome to the APHA Public Health Nursing Section Web Site. Retrieved December 27, 2005, from American Public Health 219 Web Site: http://www.apha.org/index.cfm>. 55. Benedict, Beth E. (CMS/ORDI) December 19, 2005, 11:38 AM. Re: Newborn’s and Mothers’ Health Protection Act of 1996. 56. American Nurses Association. (1999). Washington Watch. Retrieved December 29, 2005, from American Nurses Association Web Site: 57. U.S. House of Representatives. (1997, November 6). An Amendment: Requirement for Post-Delivery Follow-Up Care for Early Hospital Discharges After Childbirth. Retrieved December 29, 2005, from U.S. Library of Congress Thomas Web Site: 58. U.S. House Of Representatives. (1997). All Actions: Rep Steve C. LaTourette's Amendment Referred to House Subcommittees. Retrieved December 29, 2005, from U.S. Library of Congress Thomas Web Site: http://thomas.loc.gov/cgi- bin/bdquery/z?d105:HR02854:@@@X 59. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, op cit, p. 74. 60. U.S. House of Representatives. (1995, June 28). HR1950 IH. Newborns' and Mothers' Health Protection Act of 1995 (Introduced in the House). Retrieved October 11, 2001, from U.S. Congress Congressional Record Web Site: 61. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204, September 26, 1996. 220 62. Laurence, L. (1995, November). Babies at Risk. Ladies' Home Journal, 112, 103- 108. Kasindorf, October, 1995. 63. Kasindorf, October, 1995. 64. Laurence, November 1995. Levine, E. (1996, January). Editor's Notebook. Good Housekeeping, 222, 24. 65. Kong, D. (1995, August 1). Panel Ok's Bill on Hospital Maternity Stays. Boston Globe, p. 57. 66. Wells, John, (Season 2, Episode 22; 16, May 1996), “John Carter, M.D.” National Broadcasting Company Television. 67. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, op cit. 68. U.S. Congress. (n.d.). Biographical Directory of the United States Congress: 1774- Present. Retrieved March 18, 2005, from U.S. Government Web Site: 69. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, op cit. 70. U.S. Senate. (1996, July 19). Senate Report 104-326-Newborns' and Mothers' Health Protection of 1996. Section on Cost Estimate. Retrieved April 2, 2005, from bin/cpquery/T?&report=sr326&dbname=cp104&>. 71. Murphy, R. P. (December, 1998). Letter from the General Accounting Office to Committees on Finance, Commerce, Education and the Workforce and Ways and Means (B-281397). Washington, DC: U.S. Government Printing Office. U.S. General Accounting Office (1998). Letter to the Committees on Finance, Commerce, Education and the Workforce, and Ways and Means from Robert P. 221 Murphy, General Counsel with Enclosure: Analysis of a Major Rule (NMHPA) (B-28197, GAO/OGC-99-12). Washington, DC: U.S. Government Printing Office. The cost-benefit was analyzed along with the law’s regulations. 72. U.S. Senate. (1996, July 19). Senate Report 104-326-Newborns' and Mothers' Health Protection of 1996, op cit. Senator Jeffords’ additional comment was attached at the end of the report. 73. Dr. Heldring described Senator Jeffords’ amendment to sun-set NMHPA after 5 years. The female senators led by Senator Kassebaum made it clear that NMHPA was not to be taken lightly, that NMHPA was permanent. 74. U.S. Senate. (1996, July 19). Senate Report 104-326-Newborns' and Mothers' Health Protection of 1996, op cit. 75. U.S. Senate Bill Clerk. (n.d.). Amendment No. 5192, 5193 to Require that Health Plans Provide Coverage for a minimum Hospital Stay for a Mother and Child Following the Birth of the Child, and for Other Purposes. Retrieved March 21, 2005, from U.S. Government Web Site: http://thomas.loc.gov/cgi- bin/query/F?r104:30:./temp/~r104PLbyfK:e35014: 76. U.S. Senate (May 2, 1996). Congressional Record Article 1 (page s4636). Washington, DC: U.S. Government Printing Office. 77. Murray, P. (September 6, 1996). U.S. Senate Roll Call Votes 104th Congress - 2nd Session Vote #272. Extensions of Remarks by Senators on NMHPA. Additional speeches by several senators were given the day after the September 5, 1996 senate vote. In Senator Murray’s speech she refers to the May 1, 1996 letter from the female senators to Senator Dole, then President of the Senate. 222 78. Senate Bill Clerk. (September 5, 1996). U.S. Senate Roll Call Votes 104th Congress - 2nd Session, Vote #272. Retrieved March 18, 2005, from U.S. Senate Web Site: ngress=104&session=2&vote=00272>. 79. House of Representatives Bill Clerk. (September 24, 1996). Final Vote Results for Roll Call 426. Retrieved March 18, 2005, from U.S. House of Representatives Web Site: 80. Clinton, W. (1996, September 26). Statement on Signing the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1997. Retrieved April 12, 2005, from Government Printing Office Web Site on Executive Public Papers: http://www.gpoaccess.gov/pubpapers/search.html. Type in Appropriations Act 1997. 81. Dr. Heldring in interview, May 24, 2002. Dr. Heldring noted that this political maneuvering may be off the record. Scrutiny of the Congressional Record provided no deviation from House rules, therefore, it must have been behind the scenes. 82. House of Representatives Bill Clerk. (September 24, 1996). Final Vote Results for Roll Call 426, op cit. 83. Redman, E. (1973). The Dance of Legislation. New York: Simon and Schuster. 223 CHAPTER 6 MEDICAID-INSURED MOTHERS AS A VULNERABLE MATERNITY POPULATION IN THE HEALTH-CARE SYSTEM Introduction Public sentiment in the 1950s began questioning physicians’ and hospitals’ childbirth practices in the United States. Women wanted less interference in childbirth and less time in the hospital. By the 1960s and 1970s, the women’s movement, the nursing movement, and the women’s health movement were underway. Federal health legislators seeking welfare reform bought into the rising sentiment to reduce time spent in the hospital for childbirth. The Medicare Payment Reform Act of 1983, Public Law 98- 21, instituted the PPS and DRGs leaving Medicaid-insured mothers to be the first group of mothers to experience shortened maternity LOS in the United States in the 1980s. Yet, when NMHPA was made law in 1996, its language was never intended to include Medicaid-insured mothers. This chapter chronicles the rise of consumerism from the 1950s. It examines why NMHPA omitted Medicaid mothers initially, the effects of shortened LOS for Medicaid mothers, and how they eventually came to be included in NMHPA. The role of professional nursing in childbirth eventually came to the forefront as the nursing profession matured and gained ground in self-determination through practice guidelines as well as political clout. As the United States shortened LOS, so did other select industrial countries. The stark contrast made between countries’ maternity LOS’s highlights the sharp measures taken in the United States. Five questions that surround the impact of NMHPA on Medicaid-insured mothers and all mothers in the United States frame this chapter: 1) What was the influence of consumers on maternity LOS? 224 2) How did the activism of professional nursing eventually influence the average length of stay (ALOS) for all mothers in the United States? 3) What were the experiences of the Medicaid-insured mothers as the first group of mothers with shortened maternity LOS under DRGs and how did NMHPA eventually cover Medicaid mothers? 4) What is the comparison between public and privately insured mothers’ maternity LOS in hospitalization utilization? 5) What is the comparison of maternity LOS’s downward trends in several industrialized countries with those in the United States? Targeting Consumer Reforms on Birthing Practices to Decrease Maternity LOS From the 1950s to the 1970s, the post-World War II women’s movement stirred women’s passions on many issues including birthing practices in the U.S. The legacies of childbirth reformists earlier in the century (Chapter 4) paved the way for the women’s movement to demand less medicalization of childbirth in America. Reformists in the 1960s recognized that change was needed not only concerning levels of obstetrical intervention such as forceps use or episiotomies, but also for more participation from all women, including minorities, in their health care choices. The natural childbirth movement grew out of this philosophy. Earlier discharge after birth dovetailed well with the women’s movement’s popular notion that mothers should have less medical intervention in childbirth.1 According to some feminist historians, one of the factors giving rise to the modern women’s movement may have been the post World War II hospital volunteer movement.2 225 During World War II, while men fought the war abroad, women in America supported their families by finding employment in factories, as secretaries, or in hospitals as nurses, aides or volunteers. When American soldiers returned after the war, many women returned to their homes to raise their families. However, many women challenged by the autonomy and independence they experienced as paid workers during the war searched for meaning outside the purely domestic realm. Volunteerism, though by definition unremunerated, provided some of the same liberating effects enjoyed by women during wartime. Plenty of opportunities appeared where women’s newly developed workplace skills and social confidence could be put to use. In the medical field, for example, women homemakers signed up to care for returning veterans and other patients in hospitals including maternity patients (of whom there were many, the post-war baby boom being in full swing by the 1950’s). Rosemary Stevens, a Stanley I. Sheerr Professor in the Department of History and Sociology of Science at the University of Pennsylvania, makes a point that volunteerism may have been the start of the modern women’s movement when female volunteers complained about the unjust practices observed in the male-dominated obstetrics and gynecological professions controlling labor and delivery suites across the nation. Women volunteers became concerned with the medical interventions they witnessed used on laboring mothers. 3 They echoed their concerns in letters written to women’s magazines describing what they saw.4 Nurses’ Demands for Change in Childbirth Practices Maternity LOS began to decline in the 1970s and 1980s in part due to consumerism, technological advances, and socioeconomic and political reasons.5 226 Technological advances were made in fetal surveillance for structural and genetic errors. Medicines to reduce morbidity and mortality from pregnancy-induced hypertension and premature labor were also utilized. Access to prenatal care improved with the expanded enrollment of mothers with Medicaid benefits, which helped to identify many mothers with high risk pregnancies. The lack of obstetrical nurses’ influence on patient care and their subordination to the male-dominated ACOG in the 1950s left the nurses no recourse but to expose the unnecessarily humiliating or perverse medical maternity practices through media outlets. Articles appeared in popular women’s magazines such as Redbook, Ladies Home Journal, and Good Housekeeping as well as national newspapers describing hospitalized childbirth as a terrifying experience.6 One such article appeared in the Ladies Home Journal in 1958 titled “Cruelty in Maternity Wards.”7 It detailed the experiences of women in childbirth as described by nurses and lay readers. An anonymous registered nurse from Chicago wrote a letter to the editor of Ladies Home Journal requesting that the magazine, being “a champion of women’s rights,” expose the intrusive medical obstetrical practices in the 1950s. In the letter she leveled seven charges against obstetrical interventions that were either psychologically harmful (“you had your fun, now you can suffer”) or physically cruel (“Often she is strapped in the lithotomy position…for as long as 8 hours”) to laboring mothers.8 The result encouraged letters from around the country from mothers and nurses with similar charges of cruelty. Physicians contacted in large urban hospitals denied that maltreatment of maternity patients happened in “their” hospitals and maintained that if the cruelties existed they 227 were probably rare and “indefensible.” No physician concurred with the nurses that the cruelties actually existed. The Ladies Home Journal author wrote: A number of nurses and doctors deny indignantly that any tortures ever take place in modern delivery rooms, and attacked Registered Nurse for having written to us. An equal number of nurses confirm that they do take place, and applaud us for bringing the facts to public attention.9 Practice variations from hospital to hospital may have been grounded in the culture of the hospital. Some nurses appeared to be physicians’ “handmaidens”10 supporting physicians’ rhetoric that the standard obstetrical interventions were appropriate for medical reasons. Other nurses advocated for laboring women - often anonymously for fear of recriminations or, worse, job loss - through the national media as their only recourse. Nurses in the 1950s and 1960s were powerless to effect change in hospitals, since they fell under the direct supervision of physicians and hospital administration. Nursing education was still controlled by hospitals and physicians. Nurses did not yet have professional autonomy because clinical practice standards were not yet developed to change the practice of clinical nursing. Change in the status of the nursing profession occurred when nursing education began to move out of hospitals into two and four-year colleges and universities in the 1950s and 1960s.11 The initial standards for nursing practice that began to effect change in clinical nursing were developed in 1965.12 The standards and guidelines for obstetrical nursing practice were published in 1980. Although a nascent movement for change was emerging within the nursing profession in the 1950s, nurses, concerned about the standards of maternal care, were unaided by vocal, politically astute, grassroots feminist organizations such as “mothers 228 for change.” It was in the 1960s that mothers as consumers and activists began demanding less obstetrical intervention as part of the wider women’s health movement.13 While some writers in the Ladies Home Journal article mentioned hospitals that extended kind treatment, several hospitals across the nation were accused of cruelty but none were specifically named. The names of nurses who leveled the charges were not printed, but the editor claimed to have interviewed everyone who was quoted except two anonymous writers. The demographics of the maternity population were not described, although some hospitals were mentioned as “humane city hospitals” implying that the population consisted of urban dwellers. Community hospitals were implicated as breaching the “humane” treatment of laboring women when the suburban hometowns of some of the writers, such as West Covina, CA, or Jeffersonville, NY, were revealed.14 One writer stated, “My first child was born in a Chicago suburban hospital. I wonder if the people who ran that place were actually human…the nurses refused to moisten (my lips)…I was left alone…”15 Large urban hospitals were also accused of cruelty. One Los Angeles CA nurse wrote, “So often a delivery seems to be ‘job-centered’-that is, get the job done the easiest, quickest way possible with no thought to the patient’s feelings.”16 And from New York City, “I was a newcomer to this country, and was not prepared for the way we mothers were herded like sheep, strapped down and cut and sewed--without being given anything to ease the pain.”17 The Ladies Home Journal encouraged its readership to become proactive and demand change to correct intolerable obstetrical practices. The women’s health movement activists of the 1960s and 1970s became politically involved, publishing 229 exposés on egregious medical issues and insults to women, and generally encouraging activism to produce change.18 Women on Medicaid benefited from the activism of their middleclass “sisters”19 who demanded respect for all women medically, politically, and socio-economically. Although professional nursing, most likely because of fear of professional reprisals, was absent from the forefront of the women’s health movement, 20 it was a professional nurse, in 1958, by writing to the Ladies Home Journal, who initiated the public advocacy for change in the conventional obstetrical practices at a time when childbirth practices were driven by patriarchal physicians and hospitals. Prior to the 1950s, hospital policy and procedure committees were not required for hospital accreditation. These committees, therefore, were not channels used by the nursing profession to effect change. Hospital accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began in 1951 (as Joint Commission on Accreditation of Hospitals –JCAH) with very modest nursing standards initiated in 1953.21 JCAH surveys were conducted by physicians who focused on hospital and physician care. Though it was 1965 that the first Standards of Organized Nursing Services were formulated by the ANA, they were not incorporated into JCAH’s revised nursing standards until 1970. Thus, in the 1950s professional nursing organizations such as the American College of Nurse-Midwives (ACNM), or the ANA were unable to change or affect hospital practice.22 The Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG, now AWOHNN) was not in existence until 1969. Physicians opposed midwives because physicians feared losing “teaching material” and revenue to 230 midwives.23 Therefore, midwives practiced in hospitals under the supervision of physicians and were unable to change a static medical model. The Role of Professional Nursing Organizations in Changes in Childbirth Practices Control of the (almost exclusively male) physicians’ professional organizations until the 1980s. The Association of Women’s Health, Obstetrics and Neonatal Nursing (AWHONN), originally named the Nurses’ Association of the American College of Obstetricians and Gynecologists (NAACOG), organized in 1969 within the American College of Obstetricians and Gynecologists (ACOG).24 AWHONN was unable to effect change for practicing nurses until the 1980s at which time, while still under the aegis of the ACOG, standards of maternity nursing care were crafted. In a national effort, it became independent of ACOG only in 1993. Catherine Garner, a member of the Board of Directors of NAACOG from 1989 to 1991, was president of the organization in 1992 when the separation from ACOG began.25 In personal communication, she wrote that the position of Executive Director of NAACOG was up for renewal. She recalled that the NAACOG board in February 1992, after years of discussion, voted to separate from ACOG legally and financially, to reflect the independent practice of nurses. As the executive director was committed to remaining with ACOG, it necessitated a search for a new director. ACOG objected to the separation. NAACOG board did not relent, ACOG, therefore, in June 1992, demanded a full separation of the two organizations within the next six months. NAACOG and ACOG proceeded to disentangle their distribution of operational assets that totaled over $30 million. With so little time for NAACOG to prepare for independence, ACOG assumed NAACOG would dissolve, but instead it prevailed with its strong leadership. NAACOG 231 became AWHONN on January 1, 1993. Regional southeastern NAACOG chapters objected but the die was cast. AWHONN filed for its own non-profit (501-C3) status. Gail Kincaide, the current Executive Director of AWHONN since May of 1993, concurred, adding that AWHONN has continued a political presence in Washington, DC, (see website), and its educational mission and membership continue to grow nationally.26 The wide success of AWHONN is evident to this day with its new publication, Every Woman: the Essential Guide for Healthy Living (www.ewmag.com) published for professional offices and now available on news stands for the general public since late 2005. Nurses and Shortened Maternity LOS in the 1990s A nationwide survey of over 7,000 nurses on the state of nursing care in U.S. hospitals reported nurses’ responses on patient LOS and patient acuity. 27 Patients were being discharged earlier and sent home not fully recovered from acute health conditions. An exemplar is a case described earlier by one New Jersey nurse who, in 1995, faxed to Senator Bradley’s office a description of her cesarean patient with a wound infection who was to be sent home on intravenous antibiotics because her public assistance health insurance would not approve her continued hospitalization. The patient stayed in the hospital, but the hospital was not paid. The nurses’ responses were consistent with the American Hospital Association’s annual nationwide survey of hospitals: “…in 1994… length of stay in community hospitals had fallen a dramatic 4.3%.”28 By the late 1980s, the ALOS for all admissions declined due to DRG-PPS. It continued to decline more sharply in the early and mid- 232 1990s when private insurers, in addition to Medicaid, began using PPS-type reimbursements to hospitals, including deliveries (Figure 6.1). Meanwhile, nurses cared for mothers who held private insurance and for those on Medicaid assistance. Were mothers on public assistance discharged earlier than women with private insurance? Yes and no. Many mothers were privately insured through health maintenance organizations (HMOs) which also accepted patients with Medicaid benefits.29 HMOs, which began in 1929,30 operate under the concept of managed care, which provides, offers or arranges coverage of designated health services for plan members for a fixed, prepaid premium.31 Managed care, initially designed to help the patient gain access to the lowest cost health care on behalf of the patient, evolved to directly manage the costs of health care for the patient on behalf of the HMO. By the early 1990s, barely three years after the federal government initiated DRGs and PPS for public assistance programs, HMOs adopted the same system. As previously outlined, in 1983 the federal government phased in PPS for Medicare and Medicaid, to begin in the latter half of the 1980s, and encouraged private insurers to do likewise. Payments for diagnoses and maternity benefits were limited in scope. The Harvard Community Health Plan (HCHP) in Massachusetts was one such HMO that attempted to limit maternity benefits. In a memorandum written by the Director of Obstetrics dated September 10, 1993, and revealed by a confidential source, reduced LOS for obstetrical patients with uncomplicated vaginal deliveries were planned in order to bring the “ALOS to national standard.”32 The memo stated: “The team has crafted a proposal that aims for…clinician acceptance and satisfaction with the program.” 233 One of the physicians on the committee stated confidentially that in reality, the plan “met with stiff nurse and physician opposition.”33 The plan was initially developed over several months beginning in December 1992 into 1993, piloted in December 1993 and implemented in 1994. By May 1995, the Chief of Obstetrics, Dr. David Acker at the Brigham and Women’s Hospital, had contacted Senator Lois Pines (introduced earlier) to request state action in extending maternity LOS. By February 1996, Massachusetts’s law had extended maternity LOS to 48/96. The HCHP plan was restructured to meet state requirements. In another memorandum from the Massachusetts’ Department of Public Health dated April 23, 1996, the department requested urgent promulgation of regulations to implement extended maternity LOS. The memo stated, “In some cases, payment has been refused for lengths of stay exceeding 24 hours for an uncomplicated vaginal delivery.”34 HMOs in Massachusetts and across the country reduced LOS for obstetrical patients in order to save money without research into the patient safety but were soon required to extend maternity LOS. Many states passed legislation in 1995 to increase maternity LOS, the first being Maryland, followed by New Jersey and Massachusetts.35 Physicians in Maryland (Dr. Susan Panny) and Massachusetts (Dr. David Acker) along with legislators initiated both states’ laws. In New Jersey, it was maternity nurses, alarmed by EMD, who prompted New Jersey legislators to advocate for patients.36 it was also New Jersey nurses who took the advocacy to the national level and entered the public arena of health care policymaking. 234 The result of the six New Jersey nurses’ advocacy is supported by a 2003 article in the journal Pediatrics where Malkin et al performed a retrospective 113,147-chart audit covering births in Washington State during 1989-1990.37 They predicted a 36% decreased mean probability of neonatal mortality if more hours were allowed for maternity nurses to observe newborns for potential evolving morbidity. The authors calculated that neonatal deaths would decrease 2.6% for every extra hour spent in the hospital for up to 15 extra hours beyond the shortened LOS.38 The overall maternity ALOS rose from 2.5 days in 1998 to 3.1 days reported in 2000, which is equivalent to 1987 hospital stays before maternity-related DRGs were initiated. The prediction outcome remains to be published. In another study, Madden explained that in her HMO, days three and four are the critical days for neonatal surveillance for evolving complications. Since one in 200 births succumbs to evolving conditions (i.e., cardiac, infections) within the first 28 days, follow-up visits either at home or in the clinic on those days are critical to the reduction of neonate morbidity in the absence of hospitalization. The average LOS has lengthened steadily since 1995 when, one by one, states began passing laws to expand maternity LOS.39 The rate of passage of extended LOS laws increased even more when states learned that longer maternity hospitalization would soon become a federal law. What the federal government reduced by way of allocations to states that then reduced reimbursements for maternity LOS, the federal government eventually lengthened. Unfortunately, one postpartum home visit for continued surveillance was not included in the final version of NMHPA of 1996. 235 Impact of Early Discharge on Newborns Mothers and newborns sent home 24/72 did so before recovery from childbirth was complete (Chapter 2). Newborns were not under the surveillance of maternity nurses for potential failure to feed correctly, jaundice, or the onset of infection. It became the mother’s responsibility to evaluate the newborn for these potential complications. The effects of early newborn discharge caught media attention in New Jersey when baby Bauman died from sepsis and other babies experienced morbidity.40 In the September 1995 federal congressional hearing discussed in Chapter Five, the Bauman, Davies, and Fallon parents testified on the impact that EMD had on their newborns.41 Maternity LOS for Medicaid Insured Mothers and NMHPA Discussed in this chapter were instances of nationwide insensitivity towards laboring women that helped propel the campaign for less medical intervention in childbirth championed by women’s movement of the 1960s and 1970s. The following discussion on the legislative and economic background of the LOS debate forms the backdrop to the political history of maternity LOS from 1981-1996. The central questions are: What were the experiences of the Medicaid-insured mothers with shortened maternity LOS under DRGs? What is the comparison between public and privately insured mothers’ maternity LOS in the United States? How did NMHPA eventually cover Medicaid mothers? What is the comparison between maternity LOS’s downward trends in several industrialized countries with those in the United States? A brief understanding of Medicaid and its interface with childbirth follows. The introduction will provide a backdrop for the ensuing implications of how NMHPA affected Medicaid-insured mothers 236 What is Medicaid? The Medicaid program is a federal program financed jointly with matched payments between the federal government and each state government.42 The federal government contributes between 50% and 83% of the payments for services provided under each state’s Medicaid program, with each state determining the level of funding required to administer its Medicaid program. The amount of money allocated by the federal government and matched by any given state is calculated on each state’s need: a process that allows states to tailor their needs independent of other states. The amount of funding allocated by the federal government and matched by any particular state will be determined using a formula based on a given state’s per capita income, the number of people enrolled in Medicaid and the medical services provided by that state. For example, New York State’s funding will differ from that allocated and matched by North Dakota or Virginia. Additionally, only the individual states (and not the federal government) track the dollar amounts spent on services. States’ Medicaid Reimbursements for Childbirth Recently, the private Kaiser Family Foundation analyzed the childbirth services covered by each state.43 Each state provides coverage for nurse midwife services, some with/without physician backup. Some states limit the number of prenatal visits (10-12). Four states stipulate which kind of reimbursement method (PPS or fee-for-service) is required and the amount of co-payment ranging from $0.50 to $5.00 per visit. Though the federal government does not track how each state spends its allocation of Medicaid monies, the states are required to account for the states’ expenditure of federal money to the federal government, which in turn collates the tracking information into large 237 databases. Such databases include the National Hospital Discharge Survey (NHDS) - established in 1965 at the time Medicare and Medicaid were created - and the ongoing Health Care Utilization Project (HCUP) developed in the late 1988. The NHDS collects inpatient data from about 500 short-stay (less than 30 days) non-federal hospitals nationally. HCUP is a collection of data volunteered from participating hospitals across the nation on health care cost, quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, state, and local levels. I use these two databases to examine the quality of care experienced by Medicaid maternal patients, and to compare the LOS of Medicaid recipients with that of non- Medicaid insured mothers, to answer the first two of the questions posed earlier in the chapter. But before analyzing the data, it is necessary to describe the typical profile of Medicaid enrollees. Medicaid-Insured Mothers Under NMHPA Who are Medicaid recipients and how did NMHPA affect Medicaid-insured mothers? Medicaid recipients are mostly poor urban dwellers, from diverse ethnic and cultural minorities.44 They comprise one third of U.S. urban hospitals’ patient population.45 The top 6 out of 10 medical conditions billed to Medicaid are related to infancy and childbirth, and these contribute to one-third of all Medicaid hospitalizations.46 For diagnoses related to just childbirth, 54% of hospitalizations are billed to private/other (commercial, ERISA) insurers, 40% to Medicaid, and 6% are uninsured at discharge. The numbers of Medicaid recipients was large and NMHPA would have been costly to the federal government. 238 Consequently, NMPHA’s wording did not cover the Medicaid sector for extended maternity LOS. 47 The original wording stated that NMHPA pertained to group health plans and health insurance issuers that applied to merely 35% of mothers nationally.48 The provisions …shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as it applies to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market. (NMHPA sec. 2751) Federal definitions of health concepts and types of plans and insurers are outlined in the Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act).49 NMHPA references the ERISA definitions in NMHPA’s rules and regulations: “A health insurance issuer is an insurance company or organization (including HMO) in the business of insurance and subject to each state’s insurance commission laws.”50 A group health plan, also according to ERISA, is an individual or group employee welfare benefit plan maintained by an employer that pays for medical care. The terminology intended that NMHPA be applied to employer-based insurance plans in the private sector, for ERISA refers only to self-insured non-governmental plans. ERISA covers approximately one-half of all privately insured women. “In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws.”51 These definitions were explained in the Interim Rules and Regulations published in the October 1998 Federal Register available to insurers to utilize in their compliance with the new law.52 The Federal Register is a government publication that publishes the rules and regulations associated with new laws. It also calls for a comment period from any 239 interested parties that might help to clarify issues. The Final Interim Rules and Regulations are then published after the comment period in a subsequent issue of the Federal Register. By assuming NMHPA did not apply to Medicaid, costs associated with extended maternity LOS in states already burdened with Medicaid programs could be avoided. Some states interpreted NMHPA to mean that Medicaid was exempt from NMHPA. The final interim rules and regulations that clarified NMHPA’s role for Medicaid-insured mothers were published in August 1999.53 How NMHPA Eventually Applied to Medicaid-Insured Mothers The wording of NMHPA did not address whether Medicaid would pay for extended LOS for its recipients, nor did the first set of Interim Rules, dated October 1998.54 According to a letter dated September 11, 1996, from Sarah Jaggar, Director, Health Services Quality and Public Health Issues General Accounting Office to Senator Ron Wyden of the Budget Committee, not all States applied NMHPA to their Medicaid programs. 55 The letter was written before the bill was signed into law. Lawmakers knew that Medicaid would not cover maternity LOS for Medicaid mothers even before the law was passed. According to insider documents archived by Senator Bradley’s health care policy fellow Colleen Meiman (Chapter 5), there was concern about the Medicaid- recipient pool. Preparatory documents written for Senator Bradley’s testimony at the September 12, 1995 congressional hearing before the Labor and Human Services Committee, chaired by co-sponsor Senator Kassebaum, acknowledged that the NMHPA bill did not specify whether or not Medicaid mothers would be covered. It covered privately insured mothers, approximately 35% of births nationally. It omitted ERISA insured mothers and some commercial plans. Medicaid language was purposely omitted 240 because Medicaid paid for over 35% of all births nationwide and would have increased the federal deficit by about $265 million between 1997 and 2002.56 To have included Medicaid mothers in NMHPA would have presented two problems. First, the bill would have covered a total of 65% of mothers publicly and privately/other insured in the United States boosting costs to Medicaid and insurers. Next, the increased costs from Medicaid would have rendered the bill a Finance Committee issue instead of a Labor Committee issue at a time when Congress was mostly Republican and the Contract with America was strong (Chapter 5). The fear was that NMHPA would not pass. By eliminating Medicaid mothers, NMHPA would apply to only group health plan insurers. It was a law written for privately insured women.57 However, NMHPA would not supercede states’ laws that offer more provisions than the federal law. For instance, Massachusetts and New York passed state laws that superceded NMHPA that required hospitals to provide minimum LOS for all mothers.58 In Massachusetts, May 1995, Dr. David Acker, Chief of Obstetrics at the Brigham and Women’s Hospital, in Boston, called former state Senator Lois Pines asking her to introduce a bill into the Massachusetts legislature that would extend maternity LOS.59 In Maryland, Dr. Susan Panny of the Department of Health and Mental Hygiene,60 and in New Jersey, nurses 61 were concurrently initiating their state’s LOS laws. By November 21, 1995 Massachusetts Governor William Weld signed the bill into law under Chapter 218, An Act Further Defining Childbirth and Post Partum Care Benefits. The law established both insurance and hospital regulations.62 Chapter 218 mandates health insurance policies and plans to provide coverage for minimum lengths of stay for mothers and newborn….” 241 Under hospital licensure regulations an amendment was added: The amendment to the regulations at 105 CMR 130.660-130.771 establishes the minimum lengths of stay for mothers and infants following delivery at 48 hours for vaginal deliveries and 96 hours in the case of a cesarean…The regulation further requires hospitals to develop protocols for early discharges that are consistent with standards established by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. Furthermore, the law provides that if the mother, in consultation with her physician and pediatrician, chooses to be discharged before 48/96, Massachusetts-based insurance companies were required to provide a home visit within 48 hours of discharge. Note that position statements on EMD from professional nursing organizations were not referenced in the Massachusetts law, only ACOG and AAP. NMHPA applied to group health insurance plans, and in the early 1990s states’ Medicaid programs began enrolling its recipients in managed care organizations (MCOs) to reduce expenditures. As a response to financial pressures, a new health insurance plan strategy, managed care, emerged in the 1970s designed to restrain the high cost of medical care. Managed care refers to a variety of techniques for controlling medical costs by capping fees to physicians and other clinical services. The overall aim of a managed care organization (MCO) such as an HMO, was to place administrative control over the cost of, quality of, and/or access to, health care services for enrollees through the application of managed care techinques.63 In 1991, 5% of all Medicaid recipients were enrolled in MCOs, and by 1998, over 50% of enrollees were covered by managed care.64 Therefore, some Medicaid mothers were covered by NMHPA in the early 1990s. A fax memo dated September 20, 1996 from Nancy-Ann Min, Associate Director for Health and Personnel, to legislative director, Jack Ebeler, stated that the 48 hour discharge 242 should apply to any health plan that contracts with Medicaid to enroll Medicaid recipient, although the memo acknowledged the language in NMHPA was vague. Of the 50% of enrollee covered by MCOs, the percentage of childbearing women in MCOs was unknown, but over half of that 50% of enrollees were adult women. In the case of those Medicaid mothers not enrolled in MCOs, the American Hospital Association in January 1999 wrote to the administrator of the Health Care Financing Administration, Nancy-Ann Deparle, asking for clarification on the issue of NMHPA’s application to Medicaid insured mothers.65 The Final Interim Rules on group and individual health insurance enforcement, released August 20, 1999,66 clarified the issue by placing the responsibility of state insurance compliance under the auspices of Health Insurance Portability and Accountability Act (HIPPA).67 HIPAA, briefly, was passed in 1996 just before NMHPA. Title I of HIPAA protects health insurance coverage for workers and their families if they change or lose their jobs. Title II of HIPAA requires the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. HIPAA required “group health plans and health insurance issuers to provide certain guarantees for availability and renewability of health coverage in the group and individual health insurance markets.”68 HIPAA relied on the definitions of terms found in the gold standard, the Employee Retirement Income Security Act (ERISA), which based its definitions on terms found in the Public Health Service Act (PHS Act). So, how did NMHPA eventually cover Medicaid mothers? It was through the “dance of legislation.”69 Political maneuvering captured Medicaid mothers under the 243 NMHPA umbrella. When NMHPA became law, it contained provisions that affected three departments of the federal government: Labor, Health and Human Services, and Treasury. To coordinate enforcement, the three departments agreed that if an issue under HIPAA concerned at least two of the three departments, then the regulations, rulings and interpretations would apply to all three departments.70 Since all three departments were affected by NMHPA, they all had to comply with NMHPA provisions. NMHPA regulations in the Federal Register relied on group health plan and insurer definitions from HIPAA that were crosschecked with ERISA and the PHS Act. But, crucially, HIPAA provided additional definitions, one of which defined a “nonfederal government” plan as a government plan that was not federal, that is, a state government plan, such as Medicaid. When HIPAA clarified that the Center for Medicare and Medicaid (CMS) was responsible for implementing and enforcing various provisions of HIPAA, CMS was then able to compel States to apply NMHPA to Medicaid recipients: “Health benefits coverage under a group health plan provided under a State plan must comply with the requirements of NMHPA of 1996 regarding requirements for minimum hospital stays for mothers and newborns in accordance with 45 CFR 146.130 and 148.170 [HIPAA regulations].”71 Beginning in 1999, NMHPA covered Medicaid mothers. Additionally, the 6% of mothers who were uninsured also benefited from this ruling. Most hospitals instituted one discharge time for all mothers, 48/96, rather than discriminate LOS by payment source. Hospital Utilization by Medicaid-Insured Mothers The purpose of this section is to examine the extent to which prejudice may have occurred in the EMD of mothers and newborns on Medicaid compared to mothers 244 privately insured. Federal government statistical databases will aid in the discussion. Since the majority of Medicaid recipients are concentrated in urban public hospitals, the focus will be on the public hospital population. Hospitals’ Discriminatory Utilization Practices In the early 1900s, hospitals and physicians marginalized people on public assistance. Patients were stratified by their ability to pay for accommodations and by the quality of medical care they received.72 (See Chapter 4 for a discussion of the evolution of hospitals from charitable institutions in the late 1800s serving the poor to places of businesses in the early 20th century.) Not only class but also race determined the locus of medical care. Black physicians cared for black patients in black hospitals. Occasionally, black patients were admitted to white hospitals where black physicians were allowed into the hospital to care for them. And, at times, black patients were cared for by white physicians, but in basement wards. But typically, racial segregation prevailed in the heath care system, as in society as a whole. A case in point is that black obstetrical patients in the deep southern states in the 1930s rarely delivered in hospitals even though close to 50% of all other women were delivering in hospitals.73 By the 1970s, health care was more widely available to previously excluded groups with hospital utilization for childbirth reaching 97% and, in the late 1980s , maternal-child benefits under Medicaid expanded to enroll more recipients.74 However, the expansion of Medicaid while socially beneficial, burdened hospitals with increased financial expenditures due to the disparity in reimbursement rates between Medicaid and private insurers. Thirty-three percent of the patient population in public hospitals was subsidized by federal health care policy in which reimbursements were well below that of 245 private insurers.75 Therefore, a third of a hospital’s revenues came from reduced prospective payments for services and almost half of that third, 46%, of childbirth reimbursements were from Medicaid managed care. Following the implementation of managed care by Medicaid and private insurers, hospitals received less revenue from insurers even though newly developed technological advances such as electronic fetal monitoring and cardiac bypass surgery contributed to increased hospital expenditures.76 Hospitals as businesses searched for ways to reduce expenditures. Costs for hospitalized childbirth, the most frequent admission diagnosis to hospitals, were scrutinized. Shortening inpatient LOS was one way to curtail expenses. The CDC reported a trend for decreased ALOS for all deliveries from 1970 (4.1 days) to 1992 (2.6 days).77 Statistical evidence in government tables suggests that Medicaid recipients were initially discharged earlier than privately insured patients (Tables 6.1 and 6.2).78 In parts of the U.S. during the early 1990s, Medicaid expanded enrollment of Medicaid recipients into MCOs.79 In fact, one study admitted that Medicaid mothers were discharged before other mothers, but with follow-up home visits, in an effort to determine the safety and cost-effectiveness of limiting maternity LOS to 24-hour discharge after childbirth.80 This nonrandomized study conducted in Alabama included a select cohort of 972 women who met eligibility criteria of an uncomplicated vaginal birth for discharge at 24 hours after delivery. Seventy-five percent of the participants were African-American, and all subscribed to Medicaid. Several home visits were conducted during the first week after discharge. Ninety-eight percent (956) of the mothers had normal physical assessments. Two mothers (0.7%) were readmitted for infections. Ninety-three percent (795 of 856 in the study) of newborns had normal exams 246 at the home visit, with 61 (7%) requiring a telephone consultation with a pediatrician, and 12 (1.4%) needing a pediatric clinic visit. While no newborn was readmitted to the hospital in the Alabama study, the low- risk, low-income population had a complication rate of 7%, more than double the 2-3% rate recorded in several newborn studies reviewed in Chapter 2. Cost savings of $506,139 were calculated for the 2-year study period (1993-1995). The study population comprised 17% of their delivering patients. The study, in addition to being nonrandomized, made no comparison with a group of mothers from the other 83% of delivering mothers. In 1981, the federal government suggested that all payers, not just Medicaid, use the PPS to prevent costs from being shifted to private insurers by hospitals (for a fuller discussion see Chapter 5). By the mid-1980s, private insurance companies also began offering products using MCO strategies to decrease costs and boost profits.81 One effect of these changes can be seen in hospital utilization statistics. In 1990 the ALOS for vaginal deliveries was 2.3 days, but by 1993 it was 1.8 days. Similarly, cesarean delivery ALOS was 4.5 days in 1990; by 1993, it was 3.6 days.82 Hospital utilization statistics for maternity became the focus of the Health Care Finance Administration HFCA (now CMS) and insurers as costs were scrutinized. Background of Hospital Utilization Statistics For Medicaid Recipients The Hill-Burton Act of 1946 (for full discussion see Chapter 4), was created to expand the number of hospitals in the United States. Hospitals built under this Act were required to provide “ ‘a reasonable volume of services to those unable to pay’—a free care obligation.”83 Since Medicaid/Medicare recipients comprised 33% of the patient population in public hospitals at that time, the construction of additional hospitals 247 coupled with monies available through Medicaid programs for disadvantaged groups offered an attractive partnership.84 The monies helped to offset the burden of free care obligation. Still, with health care expenditures galloping out of control, hospitals increased costs to insurers through the 1970s (see Chapter 1). By 1981, Congress, concerned with burgeoning federal expenditures on Medicaid/Medicare, drafted an Omnibus Reconciliation Act to create the prospective reimbursement system (see Chapter 4). The 1983 Federal Act was based on the National Hospital Discharge Survey (NHDS) data that tabulates hospital utilization statistics and federal dollars spent on health care. NHDS also details hospital usage by demographic and diagnostic categories, one of which is childbirth. 85 The Center for Medicare and Medicaid still conducts the NHDS annually. A brief overview of the survey is presented in the next section. Selected tables from government websites show that maternity LOS was targeted for reduction in order to control spending in federal grants to states’ Medicaid programs. Medicaid mothers were discharged earlier than privately insured mothers because reimbursements were lower from Medicaid than from private insurers. Description of the NHDS and HCUP Databases The NHDS is a voluntary survey of hospitals conducted by states to track hospital utilization through retrospective discharge audits. It tracks who uses the hospital, what and how often procedures are performed, and the ALOS. The outcome results are sent to the CMS for tabulation to determine how and where health care dollars are spent by each state and region throughout the United States. The NHDS is public information, 248 published both in print form and on the Internet, making it easily available to corporate businesses and other interested parties, nationally and globally. The tabulated results ultimately drive public and private health policy and government spending. For example, individual state spending for maternal and child health, collected since its inception in 1935 (Title V of the Social Security Act of 1935), increased every decade until 1990.86 When Medicaid recipients began enrollment in MCOs, almost every state showed that block grant allocations were maintained at the same level for the decade 1991 to 2001. That Medicaid spending was held constant suggests that the reduced Medicaid expenditures were greatly reduced to hospitals in the late 1980s evidence by the shortened maternity LOS to 24/72. Each NHDS annual summary provides national estimates based on surveys of short stay and specialty hospitals that volunteer to share their inpatient and discharge statistics. Approximately 200,000 or more medical records from over 500 hospitals across the U.S. provide the information.87 Measurements used are frequencies, rates and percent distributions of discharges, days of care and average lengths of stay. Additionally, data on discharges by patients’ age, sex, race, region, bed size and on the ownership of the hospital are presented in numerous distribution tables. Patients’ diagnoses are coded into the distribution tables using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).88 HCUP is a federal-state partnership that began in 1988 to build a multi-state health care database system.89 This partnership is federally sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP gathered voluntary state discharge data from 1988-2000 from short-term, non-Federal, community hospitals (e.g., general and 249 specialty hospitals such as pediatric, obstetrics-gynecology, and oncology hospitals). Long-term care, rehabilitation, and psychiatric hospitals are not included. The purpose of the HCUP databases is to allow comparative studies of health care services and the use and cost of hospital care. It offers five different databases: National Inpatient Sample (NIS), Kids’ Inpatient Database (KID), State Inpatient Databases (SID), State Ambulatory Surgery Databases (SASD), and State Emergency Department Databases (SEDD). The NIS holds inpatient data from over 1,000 hospitals sampled. KID (starting in 1977) samples pediatric inpatient discharges. The SID (1995) database houses abstracts from states that participate in the surveys. SEDD (1999) gathers data from emergency room visits that do not include admissions to the hospital. Since state participation is voluntary, not all states are represented in the databases. From 1988-1992 about 11 states participated; 17 States from 1993 –1994; 19 States for 1995 and 1996; and 22 States for 1997-1998. Therefore, the data for HCUP is not entirely representative of all of the United States. This study uses the NIS database for comparative information on health care services available during 1988-1998.90 Data used include: admission and discharge status, length of stay, and expected payment source. Other information available in the database but not needed in the focus of this paper includes: primary and secondary diagnoses and procedures, patient demographics (e.g., gender, age, race, median income for Zip Code), total charge, and hospital characteristics (e.g., ownership, size, teaching status). Tables 6.1 and 6.2 are a composite of many tables developed by the NHDS from the National Center for Health Statistics under the Center for Disease Control and Prevention, and from the Healthcare Cost and Utilization Project (HCUP), covering the 250 years 1981-1998.91 The tables were developed for this study to examine the LOS’s between Medicaid mothers in comparison to privately insured mothers. Complete information on the design and operation of the NHDS protocols is available at data, presented in this chapter, is permitted as noted in the copyright information published on the website.92 Tables 6.1 and 6.2 compare ALOS for childbirth, coded as deliveries in government statistics, from 1981 to 1998. Table 6.1 reviews 1981 to 1989, the years before DRGs and the PPS, and shows a constant LOS; Table 6.2 reviews 1990 to 1995, after DRGs were in place and the ensuing rapid decrease in LOS. The discussion to follow shows that Medicaid mothers were initially discharged before privately insured. The statistics for vaginal versus cesarean section deliveries were subcategorized and by 1990 begin to reveal the rapid decrease in LOS for both types of deliveries. Table 6.3 demonstrates ALOS by vaginal delivery versus cesarean section for the years 1996 through 1998 to examine the effect of NMHPA on ALOS, which, of course, increased. The trend for decreasing LOS began to reverse and increase nationally in 1996 as more states passed laws to halt what the populace perceived to be an unsafe decline in maternity LOS even before NMHPA became law. Half the United States by the time NMHPA was passed in September 1996 rode the wave of emergency healthcare policymaking to extend maternity LOS. The year 1996 was also an election year for sponsoring politicians. Race was categorized as White, Black, and Not Stated in the NHDS, but for simplicity in Tables 6.1 and 6.2, Black and Not Stated were collapsed into Nonwhite for 251 this study. Generally, Nonwhites had slightly shorter stays in the hospital than Whites for all years suggesting LOS was based either on payment source, race, or both. Oddly, LOS by source of payment was listed only for all hospitalized females, not by deliveries. However, HCUP studied source of payments. (The implication of the payment sources will be examined in the following section that looks at the HCUP database.) The size of hospital was originally included in the NHDS but was dropped by 1988 shortly after DRGs and standard reimbursements took effect. The size of the hospital was recorded prior to DRGs and, in general, the larger the hospital, the longer the ALOS for deliveries. Larger hospitals are usually urban centers with large Medicaid populations. Prior to DRGs, mothers stayed longer, garnering more revenue for hospitals. DRGs standardized ALOS because reimbursements were consistent by diagnosis. Hospitals soon released mothers in accordance with the reimbursements received from insurers. Table 6.3 shows an up-swing in maternity LOS, especially between the years 1996 and 1997. As previously mentioned, thirty-eight states had passed laws extending maternity LOS, but by 1997 the federal NMHPA had captured the rest of the states. The other result of NMHPA was that the earlier regional differences in maternity LOS between the Northeast, Midwest, South and West became more standardized by 1997. Sources of Payment for Childbirth The NHDS and HCUP databases provide comparative information on reimbursement for childbirth by payment source for ALOS, such as private or commercial insurance, or by Medicaid. Comparing the maternity ALOS between insurers begs the question: was there a difference in maternity LOS by type of payment? It is documented that Medicaid’s reimbursement rate is lower than private insurers, tying 252 the level of medical care to source of payment.93 Tables 6.1 and 6.2 lists ALOS by Medicaid payment for the years 1982-1994. No reason was given for NHDS’s discontinuance of the tabulation in 1995, but HCUP collated information from 1988 forward. Similarily, no indications were given that differences in payment by race, region, or by procedure were considered, but, again, HCUP provides numbers and graphs. The NHDS listed Medicaid payment by age groups for females. The steady decline in ALOS is evident across all parameters reviewed but especially so by region. Compared to the Northeast or Midwest, the South and West show consistently lower ALOS by Medicaid payment from 1982-1994. In 1985 for example, the ALOS in the Northwest reimbursed by Medicaid payment was 7.1 days; in the West it was 3.5. By 1994 the figures were 4.3 and 2.9 respectively. The Kaiser Family Foundation national survey in 2001 on Medicaid coverage of perinatal services indicated that due to managed care objectives there are significant differences across states in Medicaid reimbursments for obstetrical services.94 Beginning in the early 1990s, Medicaid enrollees were gradually shifted into health plans such as HMOs that used managed care strategies.95 HMOs were initially more prevalent on the west coast than the east coast, with shorter lengths of stays in the western region of the nation than in the eastern region. Shorter LOS then migrated from western states to eastern with increasing popularity of managed care plans during the 1990s. The standardizing effect of DRGs for childbirth also contributed to the equalizing of regional LOSs. 253 The HCUP database provided more information on Medicaid and LOS.96 Some facts obtained from HCUP’s year 2000 Fact Book No. 3, imported from the internet, is presented as follows: Who Is Billed for Hospital Stays for Obstetric Care?97 (Figure 6.1) Figure 6.1 provides sources billed for obstetric care for Medicaid enrollees at their discharge for perinatal services in the early 1990s. The Omnibus Reconciliation Act of 1981 reduced allocations to Medicaid on average 5% per year during the years 1982- 1984 to maintain Medicaid enrollees to just under 20 million recipients. Doing so curbed the annual growth rate to less than 8%.98 It also made accessibility to perinatal care for mothers less available as depicted in the pregnancy loss column in Figure 6.1. Unidentified health problems from lack of prenatal care or scant prenatal care increased the chance of perinatal morbidity or pregnancy loss. In Figure 6.1 there were more antepartum and postpartum admissions for mordibidity than there were deliveries. African American infants of mothers with poor prenatal care suffered 10.7 neonatal deaths per 1000 births compared to 7.9 neonatal deaths per 1000 births among white infants.99 The passage of the law required states to find other means of paying for public health assistance, notably by encouraging the prospective payment reimbursement system employed by the new HMOs that were quickly gaining ground, especially in the west, with Arizona leading the way.100 By 1984, states’ inability to pay for public health assistance from reduced allocations compelled Congress to reassess the impact of the Omnibus Reconciliation Act of 1981. Bridging eligibility in Medicaid with federal standards for poverty levels, Congress expanded enrollment to include previously ineligible populations, thereby increasing Medicaid coverage for maternal-child health.101 Also included in the expanded 254 scrolls were phase-in and reimbursement strategies resulting in a proposed annual growth rate of 12% until 1990. From 1990-1992, Medicaid spending growth had increased to an average of 27% per year. Concurrently, an economic recession was gripping the nation, and the majority in Congress were conservative Republicans with the Executive Branch also Republican. The Republican platform advocated smaller government with less public assistance.102 Hospitals were either downsizing, merging, or going out of business.103 To financially assist those hospitals with a disproportionate amount of public assistance caseloads, Public Law 102-234, the Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991 was enacted in November 1991.104 From 1993-1996 Medicaid growth reverted to under 8% as the economy improved and managed care strategies became more prevalent nationwide.105 The guarded growth rate of Medicaid was augmented by capped reimbursements, an MCO strategy discussed above. Medicaid reimbursements at a rate lower than private or commercial insurers yielded the results in Figure 6.2: How Does Cesarean Section Rate Differ by Payment Source?106 (Figure 6.2) The graph above demonstrates that women of low-income status are as marginalized now by the healthcare system as they were at the turn of the 20th century (Chapter 4). Medicaid mothers and the uninsured total 40.1% cesarean rate, yet have the shortest LOS and account for over a third of the discharges for childbirth. Medicaid Mothers Under Managed Care Without the benefit of other internal memos from hospital corporate boardrooms across the nation on fiscal decisions, I can offer some assumptions about maternity LOS 255 for Medicaid recipients from statistical charts available from governmental agencies. The Chartbook on Medicaid states that there was an increase in enrollment of Medicaid recipients into managed care organizations (MCOs) in the early 1990s. Over a similar time period, 1993 to 1995, HCUPnet’s (HCUP on the internet) hospital discharge statistics (Figure 6.3) show a trend for very early discharges for vaginal deliveries.107 The HCUPnet figures show that the enrollment of Medicaid recipients into MCOs lowered the ALOS from 2.3 days (Table 6.2) in 1990 to 1.8 days by 1993 for a vaginal delivery. By 1994, when private insurers began limiting reimbursements for childbirth based on the 1983 federal government recommendation, maternity LOS had dropped again and by 1995 stood at 1.5 days, a loss of almost a whole day in the hospital. Figure 6.3 shows the second and third declines in vaginal deliveries, from 1.8 to 1.6, then to 1.5. The ALOS began to increase under the influence of the impending 1996 NMHPA law. Figure 6.3 supports evidence also found in Oleske’s 1998 research in California and Florida that Medicaid mothers had fewer cesarean deliveries than mothers with private insurance.108 In other words, more Medicaid mothers delivered vaginally than privately insured mothers. Since cesarean mothers stayed longer than vaginally delivered mothers, it might appear that more Medicaid mothers were discharged earlier than privately insured mothers, which may have helped produce the three distinct declines in vaginal LOS in 1990, 1993 and 1995. The results may be a product of artifact, but the data presented did not discuss if variables were controlled or if regression analysis was performed. 256 Childbirth LOS Abroad Compared to the U.S. Maternity LOS declined worldwide as each country could easily share and compare statistics readily available on the internet with other countries.109 The diversity of discharge times postpartum in other industrialized countries emphasizes that there is no clear consensus about optimal hospital LOS for maternity. Tables 6.4 and 6.5 compare selected statistics for maternity LOS among other countries and the United States. Canada’s Institute for Health Information (CIHI) surveyed all its provinces for maternity ALOS (Table 6.4) and noted a trend for decreased LOS from 1984 to 1995.110 The Canadian statistics were reported every two years from 1984 to 1995. The U.S. provided yearly statistics (Table 6.2); therefore, Table 6.4 presents the U.S statistics averaged every two years in order to make comparisons with the biannual Canadian figures.111 Statistics for U.S. vaginal and cesarean LOS for the years 1986-1989 were unavailable. Table 6.4 shows that although Canadian ALOS showed a downward trend, it was not as aggressive as in the U.S. Table 6.5 presents available ALOS for selected industrialized countries. The downward trend for ALOS was also demonstrated in other countries but still not as aggressive as in the U.S. Tables 6.3, 6.4, and 6.5 show clearly that the U.S. differs from other similarly industrialized countries in the medical care offered to Medicaid postpartum mothers. In every country maternity LOS exceeded the U.S. maternity LOS. In addition, follow-up home visits were and are provided for mothers in other countries, but not in the United States.120 NMHPA’s original language provided for a home visit but was eliminated in favor of reduced costs to insurers.121 However, 26 states that passed 48/96 maternity LOS 257 laws prior to the onset of NMHPA included a home visit if the mother, in consultation with her physician and pediatrician, chose to be discharged prior to 48/96.122 Some of those states include more than one home visit, often without restrictions on time of discharge. Summary Consumer-driven demand in the 1960s and 1970s to decrease maternity LOS helped hospitals reduce expenditures. But, insurers went overboard in slicing the length of stay too severely and too quickly without adequate research or replacement services as a safety net. Professional nursing organizations began to develop practice guidelines and standards of care for nurses as professional nursing began to move towards more independent practice in hospitals even under the scrutiny of physicians. As maternity LOS fell, practice nurses were concerned over the increased acuity of inpatients yet the hospital stay continued to decline. This prompted political action on the part of both nurses and physicians. Hospital utilization statistics, reflecting the early days of DRGs, provide evidence that Medicaid mothers were initially discharged earlier than privately insured women. However, this discrepancy in LOS did not prevail once private insurers “jumped on the bandwagon” of MCO policy to discharge mothers and newborns at 24/72. Eventually privately insured mothers joined Medicaid-insured mothers in shortened maternity LOS. The NMHPA law implemented in January 1998 was lobbied and crafted for middleclass women who had access to group health plans. But the central questions remained: how were Medicaid-insured mothers and their newborns affected in their 258 postpartum recovery? And how did professional nursing advocate for them? NMHPA applied to private insurers and not ostensibly to Medicaid. Chapter 5 described how nurses advocated for the poor and disadvantaged by giving case examples to Senator Bradley in an effort to force all insurers to pay for extended LOS’s, especially those who were sick. Even the American Hospital Association wrote a letter in January 1999 asking for clarification on NMHPA’s applicability to Medicaid insured mothers. Marginalized in the healthcare system, Medicaid mothers made up 40%, of admissions, yet by misinterpretation of the definition of non-federal governmental insurance plan they were not covered by NMHPA initially. States and hospitals were unclear as to NMHPA’s applicability beyond group health plans and health industry insurers. In answer to the calls from states’ Medicaid programs and medical associations, the Interim Final Rules for NMHPA applied the definition of a non-federal governmental plan to state Medicaid plan from the newly passed HIPPA law. This allowed the previously disallowed Medicaid-insured mothers to be included under NMHPA. Hospitals subsumed uninsured mothers under NMHPA in order to streamline standardized discharge time. As countries watched the United States struggle with definitions and laws, their own maternity LOS also drifted downward, trending towards shortened LOS. But greater levels of maternal care remained the norm abroad, and LOS was not reduced as sharply as that in the U.S. Crucially, countries abroad offered home visits to assist women in their adjustment to motherhood. The Internet brought globalization to maternity LOS by making readily available discharge statistics collected by the U.S. and other countries. The U.S. Medicaid program 259 and other health insurers in the U.S. may not have consulted with or ignored other countries about their rationale for longer LOS. The U.S. insurers slashed maternity LOS reimbursements sharply and without follow-up services. Cost containment was considered before maternity practice and safety. Neither did the U.S. health care system provide home follow-up visits under NMHPA in lieu of shortened nursing and medical surveillance as practiced in other countries and as suggested by research studies findings conducted in the United States. 260 Table 6.1. Average Length of Stay by First Diagnosis (Delivery), and Other Variables: Before DRGs, 1981 through 1989 ALOS 1981 1982 1983 1984 1985 1986 1987 1988 1989 By Delivery: Vaginal/Cesarean 3.3/6.4 3.2/6.0 3.2/5.8 3.0/5.5 2.7/5.2 2.6/5.2 2.6/5.0 2.5/4.9 2.6/4.8 Race White/Non- 3.7/3.9 3.5/3.6 3.6/3.4 3.4/3.4 3.3/3.2 3.3/3.1 3.1/3.0 2.9/2.8 2.9/2.8 White Medical Payment All Females N/A 5.7 5.5 5.1 5.0 5.3 5.2 5.1 5.0 Hospital Sizes 4.2 3.5 3.4 3.3 3.3 3.2 N/A N/A N/A All U.S. 3.7 3.9 3.6 3.4 3.3 3.2 3.1 2.9 2.9 Northeast 4.5 4.3 4.3 3.9 3.8 3.7 3.2 3.4 3.4 Midwest 4.0 4.2 3.8 3.7 3.5 3.4 3.5 3.0 3.0 Southern 3.5 3.7 3.4 3.4 3.3 3.2 3.3 2.9 2.9 West 2.9 2.9 2.9 2.7 2.6 2.6 2.5 2.4 2.4 Adapted from NHDS (http://www.cdc.gov/nchs/data/series/sr_13/sr13_133.pdf) and HCUP ( Table 6.2. Average Length of Stay by First Diagnosis (Delivery) and Other Variables: After DRGs, 1990 through 1995 ALOS 1990 1991 1992 1993 1994 1995 By Delivery: Vaginal/Cesarean 2.3/4.5 n/a 2.1/4.0 1.8/3.6 1.6/3.4 1.7/3.6 Race White/Non-White 2.8/2.8 2.7/2.8 2.6/2.5 2.8/2.3 2.7/2.1 2.1/2.3 Medical Payment All Females 4.9 4.8 4.5 4.5 4.3 n/a Hospital Sizes 4.2 3.5 3.4 3.3 3.3 3.2 All U.S. 2.8 2.8 2.6 2.5 2.4 2.1 Northeast 3.2 3.1 3.0 3.0 2.6 2.4 Midwest 2.7 2.8 2.6 2.5 2.4 2.1 Southern 2.9 2.9 2.6 2.4 2.5 2.2 West 2.3 2.3 2.2 2.0 2.0 1.9 Adapted from NHDS (http://www.cdc.gov/nchs/data/series/sr_13/sr13_133.pdf) and HCUP ( 261 Table 6.3. Average Length of Stay by First Diagnosis (Delivery) and Other Variables: After NMHPA, 1996 through 1998 ALOS 1996 1997 1998 By Delivery: Vaginal/Cesarean 1.8/3.5 2.1/3.8 2.1/3.7 Race White/Non-White n/a n/a n/a Medicaid Payment n/a n/a n/a All U.S. 2.2 2.4 2.5 Aver/vag/cs Aver/vag/cs Aver/vag/cs Northeast 3.1/2.2/4.0 2.8/2.3/4.5 2.9/2.5/4.4 Midwest 2.6/1.8/3.5 2.4/2.1/3.8 2.5/2.2/3.7 Southern 2.6/1.9/3.4 2.4/2.0/3/7 2.4/2.0/3.5 West 2.4/1.6/3.3 2.2/1.9/3.3 2.3/1.9/3.6 Adapted from NHDS (http://www.cdc.gov/nchs/data/series/sr_13/sr13_133.pdf) and HCUP(http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp#overview) Table 6.4. U.S. and Canadian ALOS 1984-1995 __ Country 1984-85 1986-87 1988-89 1990-91 1992-93 1994-95 U.S./Canada ALOS 3.3/5.3 3.1/5.1 2.9/4.8 2.8/4.3 2.5/3.7 2.3/3.0 Vaginal 2.7/4.7 -/4.5 -/4.2 2.3/3.7 1.8/3.2 1.6/2.6 Cesarean 5.2/7.6 -/7.4 -/7.0 4.5/6.4 3.6/5.8 3.5/5.0 262 Table 6.5. Comparison of Maternity ALOS in Select Industrialized Countries. Country 1994-1995 U.S. 112 2.3 Australia 113 4.0 Azerbaijan 114 (in Russia) 5.0 Japan 115 (same in 1998) 116 6.5 Norway 117 4.5 Sweden 118 4-5 days United Kingdom 119 3.0 ______ 263 • Women with Medicaid coverage or who are uninsured account for about two in five obstetric hospital stays. • Women hospitalized for antepartum or postpartum care are more likely to be uninsured or covered by Medicaid than women admitted for delivery. • Women admitted to hospitals due to pregnancy loss are more than twice as likely to be uninsured than any other type of obstetric patients. Figure 6.1. Source Billed for Obstetric Care From: 264 • Women with private insurance have the highest cesarean section rate (24.4 percent) which necesitates a longer maternity LOS. In contrast, women without insurance are least likely to have cesarean sections (18.6 percent). • Among women covered by Medicaid, about 1 in 5 undergoes cesarean section, and have the shortest maternity LOS. Figure 6.2. Cesarean Section Rate by Payment Source from: 265 Figure 6.3. Average Length of Hospital Stay for Vaginal Deliveries Source: 266 Endnotes 1. Haire, D. B., & Elsberry, C. C. (1991). Maternity Care and Outcomes in a High-Risk Service: the North Central Bronx Hospital Experience. Birth, 18(1), 33-39. Other natural childbirth activists are chronicled in Edwards, M., & Waldorf, M. (1984). Reclaiming Birth: History and Heroines of American Childbirth Reform. Trumansburg, NY: The Crossing Press. 2. Edwards & Waldorf, 1984. Stevens, 1999. 3. Stevens, R. (1999). In Sickness and in Wealth: American Hospitals in the Twentieth Century. Baltimore: Johns Hopkins University Press. 4. Mitford, J. (1992). The American Way of Birth. New York: Penguin Books. Stevens, 1999. 5. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. Retrieved March 14, 2004, from U.S. Department of Health and Human Services Web Site: medicaid/default4.asp> for an over of Medicaid history: For additional information on Medicaid history from 1978-1998 6. Mitford, 1992, p.60. 7. Shultz, G. D. (May, 1958). Cruelty in Maternity Wards. Ladies Home Journal, 44- 45, 152-155. 8. Shultz, 1958, p. 154. 9. Shultz, 1958, p. 45. 10. Shultz, 1958, p. 45. 267 11. Melosh, B. (1982). "The Physician's Hand": Work Culture and Conflict in American Nursing. Philadelphia: Temple University Press. Reverby, S. (1987). Ordered to Care: The Dilemma of American Nursing, 1850-1945. Cambridge: Cambridge University Press. 12. Tone, B. (1999, December 20). History of Nursing Education with Remarks by Dr. Joan Lynaugh, Professor Emeritus at the School of Nursing, and Associate Director of the Center for the Study of the History of Nursing, University of Pennsylvania. Retrieved December 16, 2004, from Nurse Week Web Site: 13. Caton, D. (1999). What a Blessing She had Chloroform: the Medical and Social Response to the Pain of Childbirth from 1800 to the Present. New Haven: Yale University Press. Wertz & Wertz, 1989, op cit. 14. Shultz, 1958, op cit 15. Shultz, 1958, p. 153. 16. Shultz, 1958, p. 154. 17. Shultz, 1958, p. 154. 18. Ehrenreich, B. (2002). Body Politic. Ms Magazine, 2(12), 49-50. Doris Haire, 1991. 19. Ehrenreich, 2002. 20. Chinn, P., & Wheeler, C. (1985). Feminism and Nursing: Can Nursing Afford to Remain Aloof from the Women's Movement? Nursing Outlook, 33(2), 74-77. Roberts, J. I., & Group, T. M. (1995). Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession. Westport, Ct: Praeger. 268 21. Wakefield, B. (1994). The Evolution of the Joint Commission's Nursing Standards. Journal of Healthcare Quarterly, 16(3), 15-21. 22. American College of Nurse-Midwives. (2003). History of the American College of Nurse-Midwives. Retrieved December 4, 2004, from Obstetric and Neonatal Nurses (AWHONN). (2002). History of AWHONN. Retrieved December 2, 2004, from 23. Melosh, 1982. Reverby, S. (1987). Ordered to Care: The Dilemma of American Nursing, 1850-1945. Cambridge: Cambridge University Press. 24. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2002). History of AWHONN, op cit. AWHONN (2003). AWHONN Then & Now: Past Presidents Discuss the Organization's Impact & Future. AWHONN Lifelines, 7, 301-307. AWHONN press release May 8, 2003, AWHONN Celebrates 10-Year Milestone. Retrieved September 18, 2005 from 25. Dr. Catherine Garner, personal communication, February 6, 2006. 26. Gail Kincaide, personal communication, September 29, 2005. 27. Sindul-Rothschild, J., Berry, D., & Long-Middleton, E. (1996). Where Have All the Nurses Gone? Final Results of Our Patient Care Survey. AJN, 96(11), 25-39. Consistent with this trend, 66% of the participants in the AJN survey reported declines in length of stay and 77% reported increases in patient acuity. …The 269 latest plunge was also most likely due to changes in health care financing-- specifically, the nationwide move toward managed care. A 1995 report from Congressional Budget Office found that while HMOs increased the use of outpatient services by 3% over traditional fee-for-service plans, on average HMOs used 34% less inpatient care. The CBO report emphasized that at least half of the reduction in medical costs achieved by HMOs came from cutting the length of hospital stay for childbirth.” 28. Ibid. 29. Chartbook on the History of Medicaid on the web: overview on Medicaid history from 1978-1998: cit. 30. Ross-Loos, Los Angeles, CA, founded an HMO in 1929. Described on the web accessed 5-16-04 31. Definition of managed care obtained from The Managed Care Resource accessed 5- 15-04 32. Buechler, L., & Smith, K. (April 10, 1993). Harvard Community Health Plan Memorandum to Glenn Hackbarth & Jennifer Leaning, MD on Reduced Obstetrical Length of Stay recommendations. 33. HMO physician on staff at the Brigham and Women’s Hospital, personal communication, July, 1999. 34. Walker, Ed.D, Deborah, Assistant Commissioner, (May 22, 1996) to Advisory Committee and Interested Parties in Early Discharge Emergency Regulations. 270 Massachusetts Executive Office of Health and Human Services, Department of Public Health Memorandum on Approval of Early Discharge Regulations-Final. 35. Carpenter, J. A. (1998). Shortening the short stay: One program explores the benefits of early discharge & home care. AWHONN Lifelines, 2(1), 28-34; Declercq, E., and Simmes. D. (1997). The politics of “drive thru deliveries”: putting early discharge on the legislative agenda. Milbank Quarterly, 75(2), 175- 202. 36. New Jersey State Nurses Association Position Statement, SNA Spotlight Section (April/May 1995). New Jersey RNs Speak Out About Early Postpartum Discharge. The American Nurse, 27(3). Ibid, Senator Bradley’s Senate speech: he noted 83,000 constituents wrote letters to his office in support of his bill. 37. Malkin, J. D., Keeler, E., Broder, M. S., & Garber, S. (2003). Postpartum Length of Stay and Newborn Health: A Cost-Effectiveness Analysis. Pediatrics, 111, 316- 322. 38. Ibid. 39. Carpenter, 1998. 40. Laurence, L. (1995, November). Babies at Risk. Ladies' Home Journal, 112, 103- 108. U.S. Senate (September 12, 1995). Senate Hearing 104-237: S. 969, To Require that Health Plans Provide Coverage for a Minimum Hospital Stay for a Mother and Child Following the Birth of the Child. In Hearing of the Committee on Labor and Human Resources United States Senate, 104th Congress, First Session. (pp. 1-84). Washington, D.C.: U.S. Government Printing Office. Senator Bradley mentioned the other babies, Drumm (Philadelphia), Jones (New York) 271 and Avandolglio (Tennessee) in his May 2, 1996 speech to the Senate to gather support for his pending NMHPA bill: pg s4636 of CR, also found on the internet at: 41. Ibid. 42. Medicaid Chart Book: A Profile of Medicaid Website, 43. Kaiser Family Foundation. (2000). Medicaid Coverage of Perinatal Services: Results of a National Survey. Retrieved March 22, 2004, from identifying how federal monies are allocated for maternal child services per state. 44. Institute of Medicine (2000). America's Health Care Safety Net: Intact But Endangered. Washington, DC: National Academy Press. Herein referred to as IOM. 45. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. 46. Agency for Healthcare Research and Quality (July 2003). Healthcare Cost and Utilization Project (HCUP) 1988-2000: A Federal-State-Industry Partnership in Health Data. Retrieved May 11, 2004, from Department of Health and Human Services Web Site: < http://www.ahrq.gov/data/hcup/hcup-pkt.htm > 47. Liu, Z., Dow, W. H., & Norton, E. C. (2004). Effect of Drive-Through Delivery laws on Postpartum Length of Stay and Hospital Charges. Journal of Health Economics, 23, 129-155. News page from UNC Chapel Hill describing a study examining the impact of changes in health laws. Accessed 3-22-04 272 available online at www.sciencedirect.com Dr. Dow, in email communication with me on March 10, 2004, wrote, “Medicaid regulations are often covered in different sections of legislation than are laws covering private payers…some states may have simply overlooked… or explicitly chosen not to cover Medicaid births because of [increased] costs in already expensive Medicaid programs.” 48. Newborns’ and Mothers’ Health Protection Act of 1996. Public Law 104-204, September 26, 1996. Also available online at: U.S. Congress. (1996.). Title VI: Newborns and Mothers Health Protection Act of 1996, of the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1997 (H.R. 3666). Retrieved 2002, from < http://frwebgate.access.gpo.gov/cgi- bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ204.104.pdf> page 110 STAT 2935. 49. ERISA section 733(a) & (b)(2) from U.S. Department of Labor. (2005, June 18). Health Plans & Benefits: ERISA. Retrieved June 18, 2005, from Office. (n.d.). Table of Contents Public Health Service Act. Retrieved June 22, 2550, from http://www.fda.gov/opacom/laws/phsvcact/phsvcact.htm 273 50. ERISA section 733(a) & (b)(2) op cit, http://www.dol.gov/dol/allcfr/ebsa/Title_29/Part_2520/29CFR2520.102-3.htm and PHS Act section2791(a) & (b)(2) 51. U.S. Department of Labor. (2005, June 18). Health Plans & Benefits: ERISA. Retrieved June 18, 2005, from plans/erisa.htm> 52. U.S. Government Printing Office. (1998, October 27). Interim Rules and Regulations, Vol. 63, No. 207. Retrieved February 25, 2004, from 53. U.S. Government Printing Office. (1999, August 20). Interim Final Rule With Comment Period. Retrieved February 25, 2004, from 54. U.S. Government Printing Office. (1998, October 27). Interim Rules and Regulations, Vol. 63, No. 207, op cit. 55. Jaggar, S. F. (September 11, 1996). Maternity Care: Appropriate Follow-Up Services Critical with Short Hospital Stays. Report to the Honorable Ron Wyden, U.S. Senate. Retrieved June 6, 2004, from U.S. General Accounting Office Web Site: bin/useftp.cgi?IPaddress=162.140.64.21&filename=he96207.pdf&directory=/disk b/wais/data/gao> From Sarah F. Jaggar, Director, Health Services Quality and Public Health Issues, to Senator Ron Wyden, Chair, US Senate Budget Committee. 274 56. Baumgardner, J. (1996). Federal Cost Estimate: Newborns' and Mothers' Health Protection Act of 1996, Bill Number S . 969 [Report to Senate Committee on Labor and Human Resources]. Washington, DC: Congressional Budget Office. 57. Annas, G. (1995). Women and Children First. New England Journal of Medicine, 333, 1647-1651. 58. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. 59. David Acker, MD, Chief of Obstetrics, Brigham and Women’s Hospital, Boston, MA. Personal Communication, October 2002 60. Davis, K. (Winter 1996, Southeastern Regional Genetics Group). Newborn Screening and Early Discharge of Mothers and Newborns; Some Recent Legislative Activities. Retrieved April 3, 2005, from University of Alabama Civitan International Research Center Web Site: 61. New Jersey State Nurses Association Position Statement, SNA Spotlight Section (April/May 1995). New Jersey RNs Speak Out About Early Postpartum Discharge. The American Nurse, 27(3). 62. Massachusetts Emergency Regulations, Chapter 218, 105 CMR 130.660-130.669, an Act Further Defining Childbirth and Postpartum Care Benefits, Nov. 21, 1995. 63. University of Washington School of Medicine (n.d.). Ethics in Medicine. Retrieved May 16, 2004, from 64. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. 275 65. A letter from Rick Pollack, Executive Vice President, Government and Public Affairs, American Hospital Association, January 1999, to Nancy-Ann Deparle, Administrator, Health Care Financing Administration, U.S. Government, Website accessed 6-6-04 grassroots/advocacy/comment/1999/cl990125mothers.html> 66. Federal Register. (1999, August 20). Federal Enforcement in Group and Individual Health Insurance Markets; Interim Final Rule With Comment Period, Vol. 64, No. 161. Retrieved February 25, 2004, from U.S. Government Printing Office bin/waisgate.cgi?WAISdocID=55171436651+18+0+0&WAISaction=retrieve> 67. Center for Medicare and Medicaid. (September 16, 2004) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Retrieved 2004, from U.S. Department of Health and Human Services Web Site: 68. Federal Register. (1999, August 20). bin/waisgate.cgi?WAISdocID=55171436651+18+0+0&WAISaction=retrieve>,o p cit. 69. Redman, E. (1973). The Dance of Legislation. New York: Simon and Schuster. Eric Redman spent two years on staff for Senator Warren Magnuson. Redman was instrumental in gaining passage for the National Health Service Bill, a task that encountered maneuvers, counter-maneuvers, frustrations, and finally triumph. He masterfully gives the legislative process a life of its own. 70. Ibid. 276 71. Ibid. 72. Stevens, 1999. Wertz, R., & Wertz, D. (1989). Lying-in: A History of Childbirth in America. New Haven: Yale University Press. Murrell, N., et al. (1996) Racism and Health Care Access: A Dialogue with Childbearing Women Health Care for Women International 73. Ibid. 74. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. 75. Ibid. 76. Office of Technology Assessment (1984). Medical Technology and Costs of the Medicare Program, Summary. Washington: Congress of the United States, OTA- H-228, July. Office of Technology Assessment (1984). Medical Technology and Costs of the Medicare Program: Summary. Washington, DC: U.S. Congress, OTA H-227, October. Office of Technology Assessment (1985). Medical Testing and Health Insurance, Summary. Washington: Congress of the United States, OTA-H-384 August. 77. Centers for Disease Control & Prevention. (1995) Trends in Length of Stay for Hospitalized Delivery in the United States 1970-1992. MMWR Morbidity & Mortality Weekly Report 44: 335-337. 277 78. National Center for Health Statistics, Series 13. Data on Health Resources Utilization, on the internet. Website accessed March-April 2004. Tabulated annual statistics reviewed from years 1981 to 1998. http://www.cdc.gov/nchs/products/pubs/pubd/series/sr13/ser13.htm> 79. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. 80. Brumfield MD, C. G., Nelson MD, K. G., Stotser RN, D., Yarbaugh RN, D., Patterson MSN, P., & Sprayberry MSN, N. (1996). 24-Hour Mother-Infant Discharge with a Follow-up Home Health Visit: Results in a Selected Medicaid Population. Obstetrics & Gynecology, 88, 544-548. 81. University of Washington School of Medicine (n.d.). Ethics in Medicine. Retrieved May 16, 2004, from Bradford, M. (1985). Insurers Jumping on the HMO Bandwagon. Business Insurance, 19(51). 82. National Center for Health Statistics, Series 13. Data on Health Resources Utilization, Agency for Healthcare Research and Quality. (n.d.). Overview of HCUP. Healthcare Cost and Utilization Project (HCUP). < http://www.hcup- us.ahrq.gov/overview.jsp > , op cit. Agency for Healthcare Research and Quality for an overview of HCUP software tools us.ahrq.gov/toolssoftware/ccs/ccs.jsp#overview> 278 83. Litman, T. J. (1997). Appendix: A Chronology and Capsule Highlights of the Major Historical and Political Milestones in the Evolution of the Relationship of Government Involvement in Health and Health Care in the United States. In T.J.Litman & L.S. Robins (Eds.), Health Politics and Policy (3rd ed., pp. 445- 471). Albany: Delmar Publishers, p.449. 84. National Association of Public Hospital and Health Systems, 1999 in IOM, 2000. 85. National Center for Health Statistics 86. U.S. Department of Health and Human Services, (2001). Celebrating 65 Years of Title V: The Maternal and Child Health Program, 1935-2000. A Review of Federal Appropriations and Allocations to States for Maternal and Child Health Programs Under Title V of the Social Security Act. Each state’s table showed block grant allocations by year over 65 years and how grant monies were allocated to services as determined by each state. 87. National Center for Health Statistics. (1983). Utilization of Short-Stay Hospitals: Annual Summary, 1981. Introduction. Retrieved March 2004,from 88. International Classification of Diseases, 9th Revision, Clinical Modification (5 ed.). Salt Lake City, UT: Ingenix. 89. Agency for Healthcare Research and Quality. (October 2004). HCUP Overview. Healthcare Cost and Utilization Project (HCUP). Retrieved from < http://www.hcup-us.ahrq.gov/overview.jsp> 90. Agency for Healthcare Research and Quality. (2005). HCUP Databases. Healthcare 279 Cost and Utilization Project (HCUP). Retrieved June 18, 2005, from 91. National Center for Health Statistics, Series 13. Data on Health Resources Utilization, cit. Agency for Healthcare Research and Quality. (n.d.). Overview of HCUP. Healthcare Cost and Utilization Project (HCUP). us.ahrq.gov/overview.jsp> , op cit. 92. National Center for Health Statistics. (2004). How to Cite Publications. Retrieved February 6, 2004, from U.S. Center for Disease Control and Protection Web Site: 93. Mitford, 1992. HCUP Website: Agency for Healthcare Research and Quality, Rockville, MD. 94. Kaiser Family Foundation. (n.d.). Medicaid Coverage of Perinatal Services: Results of a National Survey. Retrieved June 20, 2005, from 95. Center for Medicare and Medicaid. (2000). A Profile of Medicaid: Chartbook 2000. J., & Koplan, J. (1996). Length-of-Stay After Delivery: Managed Care Versus Fee-for-Service. Health Affairs, 15(4), 74-80. 280 96. Agency for Healthcare Research and Quality. (2000). Care of Women in US. Hospitals, 2000: HCUP Fact Book No. 3. Retrieved May 11, 2004, from Department of Health and Human Services Web Site: 97. Agency for Healthcare Research and Quality. (2000). Care of Women in US. Hospitals, 2000: HCUP Fact Book No. 3. Retrieved May 11, 2004, from Department of Health and Human Services Web Site: 98. Omnibus Reconciliation Act of 1981, Public Law 97-35; Klemm, J. D. (Fall 2000). Medicaid Spending: A Brief History. Health Care Financing Review, 22, 105- 112. 99. Vintzileos, A., Ananth, C., Smulian, J., Scorza, W., & Knuppel, R. (2002). The Impact of Prenatal Care on Neonatal Deaths in the Presence and Absence of Antenatal High-Risk Conditions. American Journal of Obstetrics & Gynecology, 186, 1011-1016. Retrieved January 16, 2006, from 100. American Medical Association (1995). Medicaid: The Role of the States. Policy Perspectives. JAMA, 274, 267-270. Moore, P., & Hepworth, J. (1994). Use of Perinatal and Infant Health Services by Mexican-American Medicaid Enrollees. JAMA, 272, 297-304. 101. Klemm, 2000. 281 102. Republican National Committee. (2006). GOP History: Republican Principles. Retrieved January 16, 2006, from http://www.gop.com/About/AboutRead.aspx?AboutType=3&Section=19 103. Stevens, 1999. 104. U.S. Congress. (1991, November 20). Medicaid Voluntary Contributions and Provider-Specific Tax Amendments of 1991. Retrieved June 21, 2005, from http://thomas.loc.gov/cgi-bin/query/D?c102:1:./temp/~c102LJgVah:: 105. Klemm, 2000. 106. Agency for Healthcare Research and Quality. (2000). Care of Women in US. Hospitals, 2000: HCUP Fact Book No. 3. Retrieved May 11, 2004, from Department of Health and Human Services Web Site: 107. Agency For Health Care Research And Quality. (n.d.). HCUP: Clinical Classifications Software for ICD-9-CM. Retrieved June 18, 2005, from Classifications Software (CCS) is a diagnosis and procedure categorization scheme that can be employed in many types of projects analyzing data on diagnoses and procedures. CCS is based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), a uniform and standardized coding system. The ICD-9-CM's over 12,000 diagnosis codes and 3,500 procedure codes, are collapsed into a smaller number of clinically 282 meaningful categories that are sometimes more useful for presenting descriptive statistics than are individual ICD-9-CM codes. 108. Oleske, D. M., Linn, E. S., Nachman, K. L., Marder, R. J., & Thompson, L. D. (1998). Cesarean and VBAC Delivery Rates in Medicaid Managed Care, Medicaid Fee-for-Service, and Private Managed Care. Birth, 25, 125-127. 109. Galmacci, G. (2001). The Impact of the Internet on Researchers' Training. In Batanero, C. (Ed.), Training Researchers in the Use of Statistics (pp. 159-169). Granada, Spain: International Association for Statistical Education and International Statistical Institute. Also, on the internet, retrieved September 19, 2005, from: 110. Ibid. Wen, S. W., Liu, S., Marcoux, S., & Fowler, D. (1998). Trends and Variations in Length of Hospital Stay for Childbirth in Canada. Canadian Medical Association, 158, 875-880. 111. Canadian Institute of Health Information. (n.d.). Discharge Abstract Database. Retrieved April 21, 2004, from 112. See Table 6.2. 113. Brown, S., & Lumley, J. (1997). Reasons to Stay, Reasons to Go: Results of an Australian Population-Based Survey. Birth, 24, 148-158. 114. Dilbazi, Tamilla, Dr., (Winter 1995). Empty Maternity Hospitals and Traditional Azerbaijani Birth Practices. Azerbaijan International, 3.4 . Retrieved May 18, 2004, from 283 rnity.html> 115. Declercq, E., and Simmes. D. (1997). The politics of “drive thru deliveries”: putting early discharge on the legislative agenda. Milbank Quarterly, 75(2), 175-202. 116. Hattori, R., & Hattori, H. (1999). Breastfeeding Twins: Guidelines for Success. Birth, 26(1), 37-42. 117. Declercq & Simmes, 1997. 118. Janson, S., & Rydberg, B. (1998). Early Postpartum Discharge and Subsequent Breastfeeding. Birth, 25(4), 222-225. Righard, L., & Alade, M. O. (1997). Breastfeeding and the Use of Pacifiers. Birth, 24, 116-120. 119. United Kingdom Department of Health. (June 2001). National Health Service Maternity Statistics, England: 1995-96 to 1997-98. Retrieved May 27, 2004, from 120. Perinatal Data Collection Unit. (1998). Births in Victoria 1992-1996. Retrieved May 27, 2004, from Australian Government, Department of Human Services Web Site: 121. The original version of NMHPA contained a provision for a nurse home visit. Per Dr. Margaret Heldring in personal communication 5-24-02, Newt Gingrich refused to allow it, citing the Republican platform for less government in private affairs and supporting big business, in this case, private insurance companies. The September 11, 1996 letter from Ms. Jaggar to Senator Wyden, op cit, highlights that a visiting nurse provision was in the original text. The complete text of the 284 final NMHPA on the web: < http://frwebgate.access.gpo.gov/cgi- bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ204.104.pdf> page 110 STAT 2935 op cit, or 122. Carpenter, 1998. 285 CHAPTER 7 CONCLUSION: PROFESSIONAL NURSING’S ROLE IN THE POLITICAL AND SOCIOECONOMIC EXTENSION OF MATERNITY LENGTH OF STAY IN THE UNITED STATES Introduction Chapter 7 concludes the social history of underlying political and socioeconomic conditions that prompted professional nursing to take public political action on behalf of mothers in the United States. A summary of findings is presented in this chapter. There is a thread of nurse militancy throughout the history of nursing, and indeed, it was unionized nurses from New Jersey who approached Senator Bradley. Since the late 1800s, a minority of nurses has campaigned for the welfare and advancement of the nursing profession. Some of those demands reviewed in this research project were events such as educational standardization for nursing schools, the development of professional nursing organizations, state registration and licensure, in the early 1900s. The 1940s began the unionization of the nursing workforce for economic security and improved working conditions in hospitals. The 1950s started the movement of hospital schools of nursing into the collegiate system, along with the founding of nursing science and our body of knowledge through nursing research. Afterwards, the development of nursing ethics and the social policy contract that stated publicly professional nursing’s future direction for self-determination in professional autonomy. By the 1960s, the development of standards of nursing practice began and the proliferation of specialty nursing organizations. In the 1970s and 1980s, the feminist theory was incorporated into nursing curricula by feminist nurse activists. Finally, in the 1990s, the movement of professional nursing began into the public arena of health care policymaking.1 The events reviewed 286 substantiated that the nursing profession has evolved to become a self-determined profession. The self-determination underpinned the patient advocacy that six nurses from New Jersey displayed in 1995 when they demanded a federal law to prevent insurers from limiting reimbursement for maternity LOS so severely that hospitals discharged mothers and their newborns less than 24/72 hours after childbirth to reduce costs, often without follow-up services. Several other issues were discovered and substantiated in the investigation of the origin of NMHPA: 1) when the federal government reduced allocations to states, they then reduced reimbursements to hospitals for Medicaid recipients, and hence, shortened LOS; 2) the federal government also suggested in a congressional budget report (Chapter One) that other payers do the same, a price-setting gesture that is an illegal business practice in the United States; 3) the federal government in 1996 extended maternity LOS to 48/96 under the NMHPA law excluding Medicaid insured mothers, but eventually included all mothers and newborns. The extension occurred without adequate research into optimal discharge time. Patriarchal hospitals, physicians, and politicians had leading roles throughout the history of mothers’ childbirth practices in the United States, mostly without input from professional nursing. The outcome of this historical investigation presents emerging issues and concerns in the following sections and why future nurses should be at the forefront in the public arena health care policymaking such that nurses are never again omitted as key players in public health policy. 287 Renewal of Political Activism in Professional Nursing Quest for Autonomy in Professional Nursing Abated in the Early 1900s The American Nurses Association has had a political arm since its inception whose mission was to be the political voice for the nation’s nurses. Feminist nursing scholars in the early 1900s, and again in the latter 1900s, held professional nursing accountable for continued political involvement that could determine the direction of nursing’s autonomous future. Unfortunately, the political engagement of professional nursing in the early 1900s abated when the nurse activists aged. Other nurses did not continue the activism when nursing resources were drained due to the flu epidemic of 1918, the Great Depression and the two world wars. These four events diverted political interest in nursing’s quest for professional autonomy. The influx of nurses into hospital nursing to care for war veterans and the sick who were unable to pay for private nurses after the Great Depression, coupled with the proliferation of hospital nursing education programs to re-supply the nation with educated nurses, abated the fight for professional autonomy. Hospitals and physicians came to control nursing’s educational programs in hospitals and employment. In its Visions of the Future: 100 Years of Nursing, published in 1996, the ANA chronicled its visions from 1896 to the present.2 For example, Wald, Dock, Nutting and Robb published articles in the American Journal of Nursing in the early 1900s on the current issues facing nursing at that time (Chapter Four): progress in acquiring state-by- state nurses’ registration through licensure; nursing education curriculum standardization; military nursing headed by nurses, not the military; and public health care promotion nestled in settlement houses founded by nurses and welfare activists. 288 The National Organization of Public Health Nurses was once strong in leadership and autonomy in the early 1900s. Unfortunately, it was absorbed by the NLN, then re- absorbed by a non-nursing organization, the APHA. The PHN section of APHA has, by its own admission, missed opportunities to be at the forefront in policymaking. Their omission from NMHPA legislation is one major example. Strong leadership in the Quad Council is currently addressing this serious issue. Like the public health nurse activists, Lillian Wald and Lavinia Dock who sought professional autonomy, will the current leadership in PHN forge a new frontier in public health nursing as autonomous nurses in practice? Will autonomous Nurse Practitioners be the new public health nurses? Will they merge, or survive independently as specialties of nursing? Intra-professional Nursing Issues Activism by many nurses for economic security in hospital employment led many nurses to join non-nurse labor unions that began sporadically in the 1920s and 1930s, then increased in the 1940s. The ANA, whose focus since the early 1900s was on professionalism and education, objected to nurses’ unionization citing labor unions as unprofessional for nurses. Nevertheless, many nurses continued labor union activities by forming their own nurses’ collective bargaining units across the United States. The ANA agreed in principal for better wages and benefits for nurses, but supported collective bargaining instead of labor unions for the nation’s nurses. In 1946, the ANA presented the newly minted ANA Platform: the Plan for the Future. It was in response to the dwindling membership in ANA by nurses who viewed the ANA as not protecting nurses’ economic security (Chapter four). Many, many nurses across the nation were instead joining labor unions to improve their wages and hours. The 289 ANA stated that labor unions were “unprofessional” and soon developed its own plan to win back its constituency. Briefly summarized, the ANA’s plan was to sanction collective bargaining (not labor unions), that nurses have a greater participation in planning and administration of nursing service in hospitals and other institutions, development of continuing education for all nurses, and the inclusion of minority racial groups in all nursing endeavors. By mid-twentieth century professional nursing faced almost insurmountable powerlessness. Nurses who tried to change medical practice did so by indirect appeals to the public-at-large, exemplified by the letter to the Ladies Home Journal editor written by an anonymous nurse in 1958 (Chapter Six). Professional nursing issues focused on moving nursing education into the collegiate system to pursue autonomy through professional development, developing nursing science and a body of knowledge through nursing research, development of nursing ethics and social policy, constructing nursing policy and procedures, and expanding organizations for nursing specialties. A resurgence in women’s rights and equality beginning in the 1960s prompted professional nursing to renew its quest for autonomy by participating in policymaking in much the same way that early 20th century nurse activists such as Clara Barton, Lillian Wald, Lavinia Dock, Adelaide Nutting, Isabel Hampton Robb, Margaret Sanger and others, did for nursing’s autonomy in the early 1900s. In mid 20th century, professional nursing continued its endeavors to increase its autonomy as a profession by developing a code of ethics, a social policy statement, and nursing practice and advance practice guidelines. In 1950, the ethical code for nursing surfaced as the American Nurses’ Association published the Code of Ethics for Nurses. 290 The research arm for ANA was begun in 1952 followed by the American Nurses Foundation in 1955. Its mission was to conduct and publish scientific research, and by 1970 to award research grants. Nursing research included developing public health objectives and policies, and the effects of health care policies on public health. Too often, nursing research is published in just nursing journals. The results of nursing research should be disseminated to the public in lay literature as research done by nurses for the health of the nation. Advance practice nurses’ programs, begun in 1964, were sanctioned by the ANA by the 1970s, and in collaboration with nursing and medical organizations, coordinated program standards, certification, and scope of practice. The 1964 Nurse Training Act provided $287 million in federal funds for minorities and students who could not afford a nursing education. Nurse practitioners and clinical nurse specialists, such as nurse anesthetists, certified nurse midwives, etc, have greatly contributed to autonomy in professional nursing since the 1960s. In the 1970s, the ANA renewed its involvement in public health care policy. First, the ANA strongly supported the 1971 Equal Rights Amendment. The 1970s political action group from ANA, N-CAP, or Nurses Coalition for Action in Politics, stated: “if we are to have a voice in health care policies, that affect us and our patients” then nursing must become politically active.3 This affirmation was the beginning of nursing’s move from the private circle of professional nursing issues into the public arena of health care. Central to that arena was professional nursing’s contract with American society called Nursing’s Social Policy Statement, about the nature and scope of nursing practice that declared professional self-determination.4 Next, in the early 1980s, professional nursing 291 wrestled with the introduction of the new hospital reimbursement system, the Prospective Payment System. Not having been consulted in the development of DRGs (Chapter Four), ANA’s reaction was to “…have a voice in health care policies that affect us and the patients we care for.”5 The initial backlash for nursing from the introduction of PPS and limited allocations for DRGs without nursing care components was nurse layoffs by hospital administrations, increased patient acuity, and a nursing shortage as laid-off nurses sought employment in other fields. Nursing’s omission reaffirmed that a revival in nursing’s participation in public policy was essential. Feldman and Lewenson noted that the first nurse to serve in Congress was in the House of Representatives in Washington, DC, Eddie Bernice Johnson whose first elected term began in 1992.6 Since then, many more nurses have been elected to Congress. The ANA has tracked the nurses and their terms on the Internet.7 Nurse scholars in the 1970s and 1980s noted the similarities between the activism of feminist reformers and professional nursing’s goals, both advocating for equality with the male status quo for economic security and independence. Scholarly works led many nurse educators to incorporate the ideology of women’s rights and equality into nursing curriculum for nursing students. By the 1990s, those nursing students were graduate nurses, many holding advance practitioner degrees, in positions as hospital nurse administrators, public health, officials in town governments, state legislators, even ANA, helping to create public policy, and health care policy. By the 1990s, societal changes leading towards more equality in social and economic spheres were the girders for the freedom that the six nurses needed to demand that national health care policy change. The ANA developed health care policy objectives 292 for professional nursing then progressed to become the third largest political action committee. The ANA then forged support for improved access to health care services with quality care for patients.8 The ANA renewed professional nursing’s political activism by moving into the public spotlight and offering an agenda for health care reform. Specialty nursing organizations such as AWHONN, ACNM, and NAPNP, among others, have worked collaboratively with ANA on public health care policy. In March 1995, six nurses approached Senator Bill Bradley to legislate for the extension of maternity LOS citing strong clinical evidence related to EMD of the deleterious effects of shortened maternity LOS. In May 1995, a nurses’ March on Washington served notice to the government, the nation, and HMO health insurers that patients deserved optimal care: patents came before profits. Revival of Autonomy in Nursing Many nurses of the late 1800s and early 1900s were public health nurses practicing autonomously, serving the public in the settlement houses and in homes. These nurses were very much involved in public health objectives in collaboration with local, state and federal governments. Today, public health nurses are represented by a section of the American Public Health Association (APHA), a non-nursing national organization. PHN specialty is represented by four member organizations: the ANA, ACHNE, ASTDN, and the PHN section of APHA, splintering the once autonomous NOPHN specialty organization. The future of nursing must include participation in public health care research and policymaking. To omit public health care policymaking would allow others to determine nursing’s future direction, such as paternalistic physicians and hospitals did in the 1920s, 293 or insurers in 1983 with the onset of DRGs. Such could be the case if PHNs are marginalized from public health care policymaking. The PHN section of the APHA was unaware of the 1995 congressional hearing on NMHPA bill according to the section chair, Beth Benedict (Chapter Five). The specialty of PHNs is currently represented by four agencies: PHN section of APHA, Community Health Nursing, ANA, and the State and Territorial Directors of Nursing. The splintering of the PHN specialty dilutes the effectiveness of self-determination as declared in Nursing’s Social Policy Statement. PHNs may need to explore ways to become self-determined as they once were known under NOPHN. There are many examples of professional nursing becoming independent. Military nursing came under the direction of nurses instead of military officers; nursing education moved out of hospitals into the collegiate system; and the National Institute of Nursing Research (NINR) was created as a branch of the National Institutes of Health, the United States Department of Health and Human Services, in June 1993. Its roots originated in 1946 as a Division of Nursing within the Office of the Surgeon General, Public Health Service. By 1986, the National Center for Nursing Research was founded at the National Institute of Health (NIH), later becoming the NINR of the NIH. Another instance of nursing becoming self-determined occurred in 1993 as AWHONN, formerly NAACOG under the aegis of ACOG, separated to become an independent professional nursing organization operated by nurses, for nurses. We now look forward to the maturing independence of the public health nursing specialty in much the same way. 294 Education in Nursing The answer to the question on why nurses were silent until the 1990s is a long and arduous journey. The nursing vocation was created during a time when most women usually were not as educated as their male counterparts. Apprenticeship was the original mode of learning to care for the sick. As standardization of nursing education became the norm, hospitals became the workshops for their education. Paternalistic physicians and hospital administrators took control of hospital-based nursing education. Early nurse activists believed that the single most important factor in gaining professional recognition was underpinned by education, but failed in their attempt to gain autonomy. Ashley critiqued that wholly reforming women’s subservient role to men in society was a better choice than trying to win independence for nurses through education and licensure. She neglected to identify that other influences derailed early activists’ quest for autonomy, such as aging nurse activists with no one to carry on the plight, the flu epidemic, World War I, the Great Depression, and another world war, that sapped the energies of professional nursing to pursue professional autonomy. Yet, Ashley agreed that nurse practitioners’ advanced education in the 1960s and 1970s as the key to autonomy in professional nursing practice today. Nurse educators in the 1950s and 1960s also believed that moving nursing education into the collegiate system, along with research that developed a body of knowledge, was the path to autonomy and self-determination. Truly, from the 1960s through the 1980s, both the issues of women’s inequality and nursing’s autonomy were addressed simultaneously as nursing feminists joined mainstream feminists. 295 The journey from dependence to autonomy and self-determination was aided by nursing education. The explanation as to why nurses for the first time publicly participated in the origination of a law, the Newborn’s and Mothers’ Health Protection Plan of 1996, is thus: the addition of feminist theory on equality and self-determination in nursing education, noted by Vance and Talbott (Chapter Four), and self-determination for professional nursing publicly asserted in declarations in the Code of Nursing Ethics for Nursing and the Nursing’s Social Policy Statement (Chapter One), underpinned the patient advocacy milieu that has been the cornerstone in professional nursing since its inception in 1873. Armed with their education and bolstered by the code of ethics and nursing’s social policy, six nurses approached Senator Bradley’s office to demand a federal law to extend maternity LOS. The Issue of Maternity Length of Stay: The Expansion and Contraction of Maternity LOS from 1890- 1996 Until childbirth moved into the hospital in the 1920s, recovery time varied by type of attendant, midwife or physician, interventions used by physician, and/or by the onset of infection and ensuing convalescence. After the move of childbirth into hospitals, technology interventions, economics of revenue, women’s groups, and finally, politicians influenced maternity LOS from the1930s through 1996. By the 1930s/1940s infection rates improved, but the lack of nursing and medical personnel due to war shortages necessitated a reduction in maternity LOS from two weeks to four days for a vaginal delivery and six days for a cesarean. The technology expansion in the 1950s resulted in insurers paying higher charges without restraint making more revenue available to hospitals and physician. Maternity LOS increased again to ten days in an effort by hospital administrators to help cover the high costs of technology. But by the 1970s, 296 mothers and women activists demanded less medical interference in childbirth. Hospitals and insurers agreed, finding that maternity LOS costs were highest in the first couple of days after childbirth. Therefore, starting with Medicaid’s reduced reimbursements, insurers and hospitals reduced maternity LOS. The public outcry and nursing activism in the 1990s against the severely reduced LOS led to another slight increase in maternity LOS by 1996, this time driven by attempted research into optimal discharge timing for mothers and newborns (Chapter Two). Unfortunately, NMHPA omitted the first group to experience very early discharge, Medicaid insured mothers. Eventually, NMHPA applied to all mothers in the United States based on definitions of health plans found in the gold- standard, the Public Health Service Act. The description of the varying lengths of time mothers experienced in childbirth recovery in the hospital is illustrated in Table 7.1. It depicts the cycles of extension and reduction of maternity LOS in the hospital from the late 1800s to the present, much of it under the influence of obstetrical anesthesia interventions. Physicians, hospitals, insurers, and politicians have controlled maternity LOS over the last 100 years. Nurses in the 1990s, supported by public health objectives, their code of ethnics and social polity statement, along with professional nursing organizations in Washington, DC, finally had input in the health care decision-making for maternity LOS. The origin of the Newborns’ and Mothers’ Health Care Protection Act of 1996 was passed despite male-dominated legislators. In 1995, the congress had 433 members in the House of Representatives, but only 44 were women (19%); of the 100 senators, there were ten women (1%). Together, 54 congressional women represented the nation’s 297 approximately 144 million women according to the year 2000 census, compared to 138 million men represented by 479 congressmen.9 Legislators implemented DRG public health care policy in 1983; yet nursing’s input for its development was omitted because there was no nursing research yet available to determine the nursing components. Shortly, nursing’s political activism resurfaced after nursing scholars in the 1970s and 1980s criticized professional nursing for its lack of involvement in feminism and health care policymaking. One theory argued that the resurgence of nursing activism was due to the lack of measured nursing care components within each DRG. Others argued a weak feminist consciousness on equality and autonomy that nursing scholars illuminated through a revived study of nursing’s history by nurse historians. 10 The outcome of their research galvanized nurses to make curriculum changes that included feminism and political activism. By the 1990s, nursing became involved in public health care policymaking on the national level.11 298 Table 7.1. Maternity Length of Stay in the 19th and 20th Centuries Maternity Length of Stay in the 19th and 20th Centuries 1890-1920 1930s/1940s 1950s 1960s 1970s/1980s 1988-1995 1996 2-3 weeks 2 weeks 4 days/8 days 10 days 4 days/8 days 24/72 hrs 48/96hrs 299 Endnotes 1. Feldman, H.R., & Lewenson, S. B. (2000). Nurses in the Political Arena: The Public Face of Nursing. New York: Springer Publishing Co., Inc. 2. American Nurses Association. (2005). Voices from the Past: Visions of the Future. Retrieved July 11, 2005, from American Journal of Nursing, November 1946, p. 729. 3. Barbara Curtis, RN, Chairperson, N-CAP, The American Nurse (January, 1981) Vol. 13(1), p.12. 4. American Nurses Association. (2005). Voices from the Past: Visions of the Future. Op cit. 5. American Nurses Association. (2005). Voices from the Past: Visions of the Future. Op cit., From an article in the American Journal of Nursing, January 1981, p. 12. 6. Feldman & Lewenson, 2000. 7. American Nurses Association. (2005). 2005 Nurse State Legislators. Retrieved November 30, 2005, from American Nurses Association Web Site: 8. American Nurses Association. (2005). Voices from the Past: Visions of the Future. Op cit. 9. Spraggins, R. E. (March 2003). Men and Women in the United States: March 2002. Retrieved June 20, 2006, from U.S. Department of Commerce, U.S. 300 Census Bureau Web Site: 544.pdf>. 10. Keeling, A., & Ramos, M. C. (2001, September 21). Position Paper. Nursing History in the Curriculum:. Retrieved June 22, 2006, from American Association of the History of Nursing Web Site: Role of Nursing History in Preparing Nursing for the Future. Nursing and Health Care 16(l): 30-34. And Malka, S. G. (2004). Daring to Care: American Nursing and the Second Wave of Feminism, 1945 to the Present (Doctoral dissertation, University of Pennsylvania, 2004). Dissertation Abstracts International, A64/11, 4179. 11. Feldman & Lewenson, 2000. 301 APPENDIX A APPROVAL FORM FOR NURSING RESEARCH 302 APPENDIX B CONSENT TO PARTICIPATE IN A RESEARCH PROJECT 304 University of Massachusetts Amherst School of Nursing CONSENT TO PARTICIPATE IN A RESEARCH PROJECT Dear Participant, I am Jan Leonard, a doctoral student in nursing, conducting a historical research inquiry into the role of professional nursing in maternity length of stay in the hospital from 1981-1996 in the United States. My faculty advisor is Dr. Eileen Breslin. I am asking to interview you to gain any information that you may have on the law in 1981 that reduced federal Medicaid grants to states that ultimately reduced maternity length of stay, and/or the law in 1996 that extended maternity length of stay for all mothers in the United States. The researcher would like to understand what socioeconomic and political influences that may have been occurring at the time these laws were created. The interview will take about 30 minutes or as long as you need to explain the circumstances. Arrangements can be made to include several interview sessions if needed, at your convenience. Please let me know if you would like a summary of my findings. To receive a summary you may email me at or send a written request to me at c/o Dr. Eileen Breslin, University of Massachusetts, Arnold House, PO Box 30420 Amherst, MA 01003-0420. The outcome of this historical investigation will illuminate for nurses previous issues and concerns in maternal health policymaking. As nurses become more politically involved in future health care policymaking in women’s health this research will provide a societal benefit as an exemplar to first develop criteria from outcome research, then create policy for health care. The researcher would like to either conduct phone interviews with note taking, or, if in person, audiotape the interview so that valuable information that you share is not lost. You will be asked on audiotape to state your name and that you give permission to 305 be interviewed. If you object to being audiotaped, the researcher would like to take notes during the discussion. If it is a phone interview, the Consent to Participate will be emailed or faxed to you for return to the researcher. Since this is a historical research project you should understand that your name might appear as a credit to a historical finding in the written copy of the research. Any notes or audiotapes will be stored in a lock file cabinet in the researcher’s possession for a period of five years for the purpose of data retrieval and then destroyed. No other persons will have access to the data during the five years. Participation in this research is voluntary and you may refuse to participate or withdraw at any time. If you have any future questions regarding this research project you may contact the researcher at any time. No funding is associated with this research project nor are there any costs to you. Sincerely, Jan Leonard RN,C, MS Doctoral Student in Nursing, University of Massachusetts Amherst Approved by the Scholarship and Human Subjects Review Committee _July 3, 2003 Approval expires ______(Date) ******************************************************************* 306 Title: Professional Nursing’s Role in the Social History of the Newborns’ and Mothers’ Health Protection Act of 1996, from 1981-1996 Principal Investigator: Jan Leonard RNC, MS Date: ______Sponsor: Dr. Eileen Breslin, Dean Schools of Nursing & Public Health, University of Massachusetts Amherst Research Participant's Name:______Date: ______Signature:______Date:______ 307 APPENDIX C INTERVIEW GUIDE 308 Interview Guide 1. How did you become involved in writing the Newborn’s and Mother’s Health Protection Act of 1996? 2. Who crafted the original bill? 3. Why was this legislation successful as opposed to reports of consumer’s being denied coverage for treatments for other terminal conditions, for instance, there was media coverage on a man seeking treatment for his sick wife, which were eventually denied? 4. How did Bill Bradley become involved? 5. Who opposed the bill? 6. Was there a gender vote? 7. Maryland was the first state to extend maternity LOS, but New Jersey was the state to propose a federal law. Why not Maryland? 8. Tell me about Newt Gingrich’s politics a. How did his own politics affect the legislation in terms of vote-getting on bills? b. How can one person, Newt, get a bill Dropped?! 9. David Hyman, law professor at U. of Maryland, wrote an article commenting (read Hyman’s comment to the interviewee) on Bill Bradley’s “its common sense” statement. What do you think about the Hyman article? 10. Why did Sen. Solomon pre-empt House Rules in opposition to Newt Gingrich? 309 BIBLIOGRAPHY ARTICLES Allen, D. (1985). 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