Education, Morbidity, Mortality, Postpartum period, Teaching



  1. Suplee, Patricia D. PhD, RNC-OB
  2. Bingham, Debra DrPH, RN, FAAN
  3. Kleppel, Lisa MPH, PMP


Purpose: The purpose of this study was to assess postpartum nurses' knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications.


Study Design & Methods: Registered nurses (RNs) who care for women during postpartum (N = 372) completed an electronic survey. Descriptive statistics and bivariate analyses were used for data analysis.


Results: Fifty-four percent of nurse participants were aware of the rising rates of maternal mortality in the United States and 12% accurately reported the correct percentage of deaths that occurred during the postpartum period. Ninety-three percent of nurses were more likely to identify hemorrhage as a leading cause of maternal mortality. On the day of discharge, 67% of RNs spent less than 10 minutes focusing on potential warning signs. Ninety-five percent of RNs reported a correlation between postpartum education and mortality; however, only 72% strongly agreed it was their responsibility to provide this education. Nurse respondents who were over the age of 40 were significantly more likely to report feeling very competent when providing education on all of the postpartum complication variables measured (p values <0.001-0.003).


Clinical Implications: The majority of nurses in this study were not up-to-date on the rates and timing of maternal mortality during the postpartum period in the United States. They did not always provide comprehensive education to all women prior to discharge from the hospital after childbirth. There is a need for nurses to provide consistent messages about potential warning signs that may ultimately reduce maternal death and severity of maternal complications.


Article Content

The postpartum period is identified as a time of complex changes that take place in a woman's physiology and immunology; these changes are affected by the interplay among a myriad of biological, psychosocial, and behavioral factors (Suplee et al., 2014). In the Listening to Mothers Survey (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013), when asked about their postbirth experiences, women described having inadequate support and being unsure of how to navigate fluctuating hormones, disrupted sleep, recovery from birth, and newborn care and feeding. Women reported they needed more guidance on common postpartum health concerns (Declercq et al.). These findings may suggest that there is an information gap; women may not be able to determine if the symptoms they notice after birth are normal and expected, or abnormal requiring urgent or emergency medical attention.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Approximately 61% of maternal deaths occur during the postpartum period (Creanga et al., 2015). Maternal mortality rates have increased in the United States from 7.2/100,000 in 1987 to a rate of 17.3/100,000 live births in 2013 (Centers for Disease Control and Prevention, 2017). Other researchers have estimated the 2014 maternal mortality rate is considerably higher and calculated the rate to be 23.8/100,000 live births (MacDorman, Declercq, Cabral, & Morton, 2016).


The majority of pregnancy-related deaths occur less than 42 days after women gave birth; thus, strategies to reduce maternal morbidity and mortality during this time period are needed. There is consensus from national organizations such as the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the American College of Obstetricians and Gynecologists, and United States Department of Health and Human Services (USDHHS) that efforts are needed to improve how women are cared for during postpartum (Kleppel, Suplee, Stuebe, & Bingham, 2016). One of the AWHONN recommendations is to improve education about postbirth warning signs that registered nurses (RNs) provide to women prior to discharge from the hospital after childbirth. The rationale of providing all women who gave birth with this information is that clinicians cannot predict with certainty which women will experience postbirth complications or death. Nurses who provide postpartum predischarge education are well positioned to provide women with evidence-based education on postbirth warning signs.


A review of research in PubMed and CINHAL using search terms that included postpartum education, discharge teaching of postpartum complications, and consistency of postpartum teaching led to identification of a limited amount of research on these topics. In a qualitative study using focus groups with a sample of 52 nurses who worked in six different hospitals, we found most nurses reported they taught women about the postbirth warning signs (Suplee, Kleppel, & Bingham, 2016). However, content of what nurses taught was inconsistent in its delivery, and at times inaccurate. This study also showed that some of these nurses were unaware of the most common causes of maternal morbidity and mortality. When the literature search was expanded to include nurse discharge education and patient outcomes as search terms, a handful of relevant studies were found. In a recent study focusing on nursing discharge education, when nurses had a better understanding of safe practices of prescription opioids, patients had a better understanding of safe use (Costello, Thompson, Aurelien, & Luc, 2016). Koelling, Johnson, Cody, and Aaronson (2005) assessed discharge education received by patients with chronic heart failure and found that focused patient education by nurse educators improved clinical outcomes, including significant cost reductions from rehospitalization. Results of studies discharging patients with asymptomatic chronic diseases suggest face-to-face patient education by well-informed healthcare providers, including nurses, provide the most benefit in improving health behaviors such as compliance (Gold & McClung, 2006).


More research is needed to determine best methods and timing for providing education on postbirth warning signs because women have described the first few days after giving birth as exhausting, emotionally charged, and physiologically draining (Declercq et al., 2013). Given these learning conditions, the postpartum discharge education RNs provide to women must be clear, concise, and accurate. Obstetric nurses are well positioned to improve maternal outcomes when armed with accurate knowledge, enhanced teaching skills, and adequate time to communicate the message. The purpose of this study was to measure postpartum nurses' knowledge of maternal morbidity and mortality, and to explore the content of nurses' teaching about postbirth warning signs. Institutional review board approval was obtained from Rutgers University.


Study Design and Methods

This is a cross sectional study of 372 postpartum or mother/baby nurses across the United States who were AWHONN members and completed a 25-item electronic survey via Survey Monkey(C). The survey was designed by the research team based on results of a previous study on this topic using nurse focus groups (Suplee et al., 2016). It was designed to assess knowledge (i.e., rates, trends, and leading causes of maternal mortality) and teaching skills (i.e., when teaching occurs, length of time, and how competent nurses feel about teaching this content). The survey was revised several times by the research team members for flow and accuracy after it was reviewed by content experts for face validity. Reliability of the survey was not measured.


An electronic membership list (email) was obtained from AWHONN. Members who had identified themselves through AWHONN as postpartum or mother/baby nurses were invited via email to participate in this study in May of 2016. The email included a link to the electronic survey. The original email was sent to 3,759 nurses. Approximately 1,128 (30%) of the nurses who were sent the email opened the email and 416 (37%) started the survey. Of the 416 nurses who started the survey, 372 (89%) completed the entire survey. Each potential participant received three emails (the original and then two reminders 1 week apart). Internet protocol addresses were not tracked or used in analysis of these data. Data were analyzed with JMP 12 (SAS Institute, Cary, N.C.). Only completed surveys were included in the analysis. Descriptive statistics were generated to describe sample demographics. Bivariate analyses using chi square and t tests were used to examine possible associations between demographic variables, knowledge of maternal morbidity and mortality, and teaching.




Sixty-eight percent (n = 253) of the nurses were over age 40. Fifty percent (n = 187) were baccalaureate-prepared nurses and 34% (n = 126) held a graduate degree. Sixty-four percent (n = 239) held various certifications and 62% (n = 232) had greater than 10 years of experience as a postpartum nurse (Table 1). Participants were employed in 49 of the 50 states (except Utah) and the District of Columbia. Sixty-six percent (n = 244) were employed at hospitals with less than 3,000 births per year. Thirty-six percent (n = 135) reported they worked in a facility with a cesarean birth rate greater than 30%; an additional 21% (n = 79) were not sure of the cesarean rate at their facility.

Table 1 - Click to enlarge in new windowTable 1. Sample Demographics


When nurses were asked about the trends in maternal mortality, 46% (n = 169) were not aware that maternal mortality rates have increased; 27% (n = 100) reported maternal mortality has stayed the same; 19% (n = 69) reported that it has decreased; and 54% (n = 203) reported maternal mortality has increased. There were significant differences in the distribution of responses due to age (p = 0.017) with older nurses (ages 41 and above) more likely to report that rates have increased compared with nurses who were 40 years of age or younger and those with more than 10 years of postpartum experience more likely to report an increase in rates compared with nurses with less experience (p = 0.014). There were no significant differences in the distribution of responses due to education type or specialty certification. Fifteen percent (n = 56) of the nurses were aware of the most current specific rates of maternal deaths in the United States (16 per 100,000 births reported by the CDC at the time of this study); 56% (n = 209) reported a lower number of deaths and 28% (n = 105) reported a higher number. Only 12% (n = 45) correctly identified that 61% of deaths occur during postpartum. When identifying the three leading causes of maternal death in the United States, nurses reported hemorrhage (93.3%, n = 347), hypertension (68.5%, n = 255), and infection (39%, n = 145) as the top three answers. There were no significant associations between age, education, experience, or certification and choosing the correct response about the most common causes of maternal deaths and timing of maternal deaths. When nurses were asked about how they stay current with evidence-based practice in maternal and infant health topics, 80% reported that they read articles, books or published guidelines, or accessed information online.



Timing of when nurses provide the majority of postpartum discharge education to women was explored. Sixty-five percent (n = 243) of the nurses reported they provided the majority of all predischarge education throughout the patient's stay, whereas 29% (n = 107) provided the majority of education on the day of discharge. On the day of discharge, 24% (n = 89) of nurses reported spending >30 minutes; 30% (n = 112) 21-30 minutes; 36% (n = 134) 11-20 minutes; and 10% (n = 37) <10 minutes. As a subset of "all" postpartum teaching, nurses were asked about time spent specifically teaching women about warning signs of potential complications. Responses ranged from <5 minutes to >30 minutes, with the majority (67%) of nurses reporting spending <=10 minutes (Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. Time Spent Teaching Women about Postbirth Warning Signs Prior to Discharge from the Hospital after Childbirth

When asked about nurses' responsibility to teach warning signs prior to discharge including to those women with no risk factors or identified complications, 72% (n = 266) strongly agreed and 23% (n = 85) agreed that it was their responsibility to provide this education. Most (95%) stated there is a relationship between postpartum education nurses provide women prior to discharge from the hospital and postpartum maternal morbidity and mortality.


Nurses were given a selection of pregnancy complications and asked to choose how likely they were to discuss these topics with all postpartum women (Table 2). The three topics very likely to be discussed with women included postpartum depression (81%), hemorrhage (77%), and infection (74%). The topics that were least "very" likely to be discussed with women were the potential for a cardiac event (8%) and pulmonary embolism (16%).

Table 2 - Click to enlarge in new windowTable 2. Likelihood of Registered Nurses Discussing Potential Complication Topics with All Women Prior to Discharge from the Hospital after Childbirth

Nurses reported feeling very competent/competent when providing education about postpartum complications ranging from 97% (n = 362) for hemorrhage to 66% (n = 245) for a cardiac event (Table 3). Nurse respondents over the age of 40 were significantly more likely to report feeling very competent when providing education on all of the postpartum complication variables measured (p values <0.001-0.003). Education was not significant for any of the teaching variables.

Table 3 - Click to enlarge in new windowTable 3. Registered Nurses' Perception of Competence with Discussing Topics with Women

Clinical Implications

All respondents were members of AWHONN. Over a third of the nurses who responded to the survey held a graduate degree. In the United States, only 13.2% of RNs hold a graduate degree (USDHHS, 2010). Over 60% of the nurse respondents were certified in various women's health/neonatal certifications, were over the age of 40, and had over 10 years of postpartum experience. These data indicate that the respondents to the survey were an educated, professionally connected (AWHONN members), and experienced group of RNs.



Our results suggest RNs may not be keeping current on trends in maternal mortality as 88% of the respondents did not know that 61% of maternal deaths occurred in the postpartum period and 46% did not know about the rise in maternal mortality in the past decade. Although yearly rates may vary, having a better understanding of these rising rates may lead nurses to realize the important role they play in teaching all women about postpartum warning signs, not just those with identified risk factors prior to discharge. Nurse educators can play a key role in providing continuing education to all postpartum nurses on this topic.


Attribution of causes of maternal deaths has shifted over time. In our study, nurses were more likely to choose hemorrhage (93.3%), hypertension (68.5%), and infection (39%) as the leading causes of maternal mortality. Although nurses did not correctly identify the leading two causes of maternal deaths for women in the United States at the time of the study (noncardiovascular disease and cardiovascular disease), hemorrhage and hypertension are the leading causes of maternal mortality worldwide (World Health Organization, 2015). These data indicate that nurses may be aware of maternal mortality but not the most recent statistics or trends in the United States.



Ninety-five percent of RNs reported a strong relationship between postpartum education and postpartum maternal morbidity and mortality. Although 72% of RNs reported that they strongly agreed and 22% agreed that it was their responsibility to teach women about the warning signs of potential complications prior to discharge, 6% did not agree. That more RNs didn't "strongly agree" about their teaching responsibility after reporting that there was a strong relationship between postpartum education and postpartum morbidity and mortality is concerning. One possibility for this finding is that nurses have reported that there is too much education that needs to be shared during the postpartum hospitalization and women are too overwhelmed to comprehend most of this information (Buchko & Gutshall, 2012). Further research is needed to identify how nurses might contribute to quality improvement efforts to decrease rates of maternal mortality by providing evidence-based comprehensive education to women prior to discharge after hospitalization for childbirth.


More than half of RNs reported spreading their teaching of the required education over the hospital stay compared with 29% who stated that the majority of the education was done on the day of discharge. In addition to the large volume of critical, time-sensitive information to be taught prior to discharge, a woman's ability to understand discharge teaching is influenced by other factors, such as inadequate sleep, physical and emotional changes, possible side effects of medications, and low health literacy (Chugh, Williams, Grigsby, & Coleman, 2009). More importantly, there may be the need to repeat education throughout the woman's stay or to use techniques such as "teach back" to improve actual comprehension of the material (Agency for Healthcare Research and Quality, 2010). More research is needed to determine the "best" time to teach about potential complications that may arise after discharge.


Almost half (46%) of RNs spent less than 20 minutes educating women on all necessary topics prior to discharge. And when asked how much time they spent specifically teaching about warning signs of potential complications of pregnancy prior to discharge, two-thirds of nurses reported <=10 minutes. More research is needed to determine if this is an adequate amount of time to spend on this topic.


Most nurses reported feeling very competent or competent on teaching about all of the potential postpartum complications except for cardiac disease. Nurses with more years of clinical experience reported feeling more competent when providing most of this information. Although we did not identify any studies to indicate whether nurses avoid teaching topics based on their feelings of competence with a given topic, it is logical to assume that RNs may avoid teaching topics where they feel less confident of their mastery of the topic. The reported lack of competence is problematic for the women they are educating. Because cardiovascular disease has become one of the leading causes of maternal mortality in the United States, strategies designed to increase nurses' confidence in teaching this topic are needed.


The leading topics that nurses reported that they would "very likely" teach all women included: postpartum depression, hemorrhage, and infection. The three leading topics that nurses were "not likely" to discuss were pulmonary embolism, cardiac event, and venous thrombosis. Data were also captured on topics that nurses felt were "only relevant" to specific women that more often included: cardiac event, preeclampsia/eclampsia, hypertension, and pulmonary embolism. Although many women will not experience a postpartum complication, all the topics presented in the survey are relevant to all childbearing women, albeit some more than others. How nurses decide if the information was relevant to teach a specific woman is not clear and was not captured in this study. Suplee, Kleppel, Santa-Donato, and Bingham (2017) present specific nurse and patient discharge educational resources that have been pilot tested and are beginning to be used by nurses throughout the United States. These authors suggest providing all women with consistent messages on potential postpartum complications.


We found nurses in our study needed additional education to advance their knowledge about maternal mortality and potential postpartum complications women may experience after discharge. Yet, 80% of these nurses reported that they read articles, books or published guidelines, or accessed information online. More research is needed to identify more effective methods of educating nurses on maternal mortality and postpartum complications.



The nursing sample of AWHONN members is not representative of all nurses who care for postpartum women and therefore these findings are not generalizable. It is not known how many email invitations were actually received by potential participants and the overall response rate of using an electronic survey was similar to other studies (Hardigan, Succar, & Fleisher, 2012). "Cardiac disease" was used as a general topic in the beginning of the survey; however, in some questions later in the survey it was referred to as a "cardiac event." The wording may have led nurses to believe women are more at risk for having a myocardial infarction instead of cardiac disease, therefore limiting their ability to choose this as an important topic.



All women are at risk of potential complications of pregnancy during the postpartum period. Because it is impossible to accurately predict which women will suffer from a postbirth complication, we recommend all women be provided education on postbirth warning signs. Nurses caring for women during the postpartum period are responsible for providing comprehensive information at the appropriate literacy level and evidence-based patient teaching so all women can recognize and respond quickly to obtain needed care.


This study identified gaps in knowledge of nurses on maternal mortality and in delivery of consistent education to all postpartum women about potential postpartum complications. More research is needed that focuses on best practices for providing postpartum education on postbirth warning signs and how to more effectively integrate this education into postpartum discharge teaching. Currently, it is not known whether providing education on postpartum complications will lead to changing rates of maternal morbidity or mortality in the postpartum period, another area worth exploring.



This project was supported by the Association of Women's Health, Obstetric, and Neonatal Nurses and some of the activities in this publication were supported by funding from Merck, through its Merck for Mothers program and are the sole responsibility of the authors. Merck for Mothers, the company's 10-year, $500 million initiative to help create a world where no woman dies giving life. Merck for Mothers is known as MSD for Mothers outside the United States and Canada.


Dr. Suplee is a consultant to AWHONN; Dr. Bingham is a consultant to AWHONN; and Ms. Kleppel is a former employee of AWHONN.




Agency for Healthcare Research and Quality. (2010). The teach back method: Tool 5. Retrieved from [Context Link]


Buchko B. L., Gutshall C. H. (2012). A renewed commitment to improving quality and efficiency of postpartum education during hospitalization. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41, S123. doi:10.1111/j.1552-6909.2012.01362_7.x [Context Link]


Centers for Disease Control and Prevention. (2017). Pregnancy mortality surveillance system. Retrieved from [Context Link]


Chugh A., Williams M. V., Grigsby J., Coleman E. A. (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management, 25(3), 11-32. Retrieved from [Context Link]


Costello M., Thompson S., Aurelien J., Luc T. (2016). Patient opioid education: Research shows nurses' knowledge of opioids makes a difference. MEDSURG Nursing, 25(5), 307-311, 333. [Context Link]


Creanga A. A., Berg C. J., Syverson C., Seed K., Bruce F. C., Callaghan W. M. (2015). Pregnancy-related mortality in the United States, 2006-2010. Obstetrics & Gynecology, 125(1), 5-12. doi:10.1097/AOG.0000000000000564 [Context Link]


Declercq E. R., Sakala C., Corry M. P., Applebaum S., Herrlich A. (2013). Listening to mothers III: New mothers speak out. New York, NY: Childbirth Connection. [Context Link]


Gold D. T., McClung B. (2006). Approaches to patient education: Emphasizing the long-term value of compliance and persistence. American Journal of Medicine, 119(4 Suppl. 1), S32-S37. doi:10.1016/j.amjmed.2005.12.021 [Context Link]


Hardigan P. C., Succar C. T., Fleisher J. M. (2012). An analysis of response rate and economic costs between mail and web-based surveys among practicing dentists: A randomized trial. Journal of Community Health, 37(2), 383-394. doi:10.1007/s10900-011-9455-6 [Context Link]


Kleppel L., Suplee P. D., Stuebe A. M., Bingham D. (2016). National initiatives to improve systems for postpartum care. Maternal and Child Health Journal, 20(Suppl. 1), 66-70. doi:10.1007/s10995-016-2171-1 [Context Link]


Koelling T. M., Johnson M. L., Cody R. J., Aaronson K. D. (2005). Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation, 111(2), 179-185. doi:10.1161/01.CIR.0000151811.53450.B8 [Context Link]


MacDorman M. F., Declercq E., Cabral H., Morton C. (2016). Recent increases in the U.S. maternal mortality rate: Disentangling trends from measurement issues. Obstetrics & Gynecology, 128(3), 447-455. doi:10.1097/AOG.0000000000001556 [Context Link]


Suplee P. D., Bloch J. R., McKeever A., Borucki L. C., Dawley K., Kaufman M. (2014). Focusing on maternal health beyond breastfeeding and depression during the first year postpartum. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43(6), 782-791. doi:10.1111/1552-6909.12513


Suplee P. D., Kleppel L., Bingham D. (2016). Discharge education on maternal morbidity and mortality provided by nurses to women in the postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 45(6), 894-904. doi:10.1016/j.jogn.2016.07.006 [Context Link]


Suplee P. D., Kleppel L., Santa-Donato A., Bingham D. (2017). Improving postpartum education about warning signs of maternal morbidity and mortality. Nursing for Women's Health, 20(6), 552-567. doi:10.1016/j.nwh.2016.10.009 [Context Link]


United States Department of Health and Human Services, & Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Retrieved from [Context Link]


World Health Organization. (2015). Trends in maternal mortality 1990-2015. Retrieved from [Context Link]