Most of us have heard some variation of "How nice it must be to work in such a happy place with all those mothers and babies." This year's flood of information about maternal mortality and severe maternal morbidity in the United States has reminded us that even healthy pregnancy and birth carry risk. The maternal mortality rate is higher in the United States than in other developed nations and is rising while others fall. Literally hundreds of women will die this year due to childbirth in a rich country well provided with healthcare resources. Many of the women who die will be healthy women who expect, and are expected, to have a normal birth and go home with a healthy child. Every maternal death is a sentinel event.

We also know that some women are at a higher risk, whether through age, health issues, or lifestyle. In most cases, those risks are the warning indicators that tell physicians, midwives, and nurses to watch carefully for complications. Note that I did not say "should intervene without evidence of actual danger." We can do as much harm in pregnancy by adding unneeded interventions as by waiting too long.

We still must ask ourselves why there is so much variability in quality of care. And what can nurses do to change the future of maternal health? Many resources exist-from state Maternal Mortality Review Committees to the state Perinatal Collaborative to the Alliance for Maternal Health (AIM)-that can inform and support best practices that will prevent or resolve issues related to hypertension, hemorrhage, and other factors related to the high maternal death rate.

Nursing professionals are well positioned to promote evidence-based care. Nurses are the most numerous group of healthcare professionals. They are also the most likely people to be at the bedside in order to be the first to see changes in bleeding or blood pressure or breathing. The skills of expert obstetric nurses mean that they are often both the first to recognize and the first to act in an emergency.

Here is a checklist of possible actions at the personal, institutional, and system levels where nurses can have an impact. It is based, in part, on the work of the many dedicated obstetric nurses with whom I have been privileged to work.

[check mark] Know what the rates of cesarean birth and birth complications in your hospital are and how they compare with others in your area and nationally. Is there a pattern that suggests opportunities for improvement? Who monitors quality assurance and risk management on your unit?

[check mark] Ensure that the protocols and clinical policies for your units are reviewed regularly and kept up to date. This includes tools such as massive transfusion protocols and measured rather than estimated blood loss at delivery. How do they compare with national recommendations such as the AIM patient safety bundles?

[check mark] What relevant competencies, such as fetal heart rate monitoring interpretation, are required on your unit? Are providers as well as nurses required to complete them? Can nursing leadership and the Obstetrics Department Chair work together to ensure everyone has the same competence?

[check mark] Participate in your hospital or health systems quality review committees for obstetrics and be confident that everyone's voice can be heard. If there is not one, can you promote the idea to other physicians, midwives, and nurses?

[check mark] Are you maintaining your personal knowledge of evidence-based best practices? Membership in professional organizations, specialty certification, and continuing education are all ways to stay at the forefront of your profession.

[check mark] What larger-scale opportunities to understand pregnancy complications and fetal, infant, and maternal mortality exist in your state? Is there a Perinatal Collaborative? Are you in an AIM state? Is there a Maternal Mortality Review Committee, and can nurses be members? In which of these does your hospital participate?

[check mark] Check your own personal engagement with your work and your personal biases. Are you the nurse who spends most of the time with your patients or the one "watching the strip" from a desk? Do your expectations lead you to judge women and perhaps listen less attentively because someone does not fit into your image of the "good" mother? Nursing shifts are long and hard, but we agreed to do this, and every family deserves equally excellent care.

[check mark] Pay attention to each woman in such a way that when a problem occurs-whether it be hemorrhage, worsening preeclampsia, or a maternal loss-your professional practice and dedication to your patient contributed to the solution and not the problem.

If these are all things you and your colleagues do, then congratulate yourselves for the progress you have made. If not, please be part of the change that decreases the risks of maternal death. Nurses spend more time with women during childbirth and recovery, seeing what is happening in real time, than anyone else. You have the knowledge and ability to mediate complications and often to prevent disaster. Thank you for your caring.

-Jan M. Kriebs, MSN, CNM, FACNM

Adjunct Professor

Midwifery Institute at Jefferson

Philadelphia, Pennsylvania