Background: The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. Objective: To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. Methods: We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. Results: There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. Conclusion: The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

The purpose of our study was to test whether registered nurses assign the correct Apgar score when provided all pertinent data, whether they assign an Apgar score even if all pertinent data are not provided, and to evaluate the Apgar score’s interrater agreement. We conducted a REDCap survey and provided nurses with color photograph/vignette combinations of neonates, some of which lacked pertinent data points needed to correctly assign Apgar scores. Over 90% of study participants assigned Apgar scores even if data points for heart rate or respiratory effort were omitted. Participants’ correct assignment of the component score for respiratory effort was affected by the description of the respiratory effort and whether neonatal heart rate was known. Interrater agreement was generally low to moderate. Our findings are consistent with earlier findings and support the conclusion that the Apgar score requires significant revision or needs to be retired and replaced.

Background:The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. Objective:To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. Methods:We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. Results:There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. Conclusion:The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

Microaggression can influence perinatal health outcomes; however, the science is limited by inconsistencies in the definition and measurement of the term.

A summary of JOGNN's commitment to promoting justice, equity, diversity, and inclusion in health and health care through editorial policies and processes and published articles.

Purpose: Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence. Design and methods: Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user." Results: Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 +/- 2.17 years vs. 16.79 +/- 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance. Conclusion: CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM. Practical implications: Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit. (C) 2021 Elsevier Inc. All rights reserved.

Final thoughts on the opportunities and challenges ahead for nurses and nursing in the context of the The Future of Nursing 2020-2030.

Black women die from pregnancy-related causes in the United States three times more frequently than White women.

The pandemic has challenged nurses and their care of women, newborns, and childbearing families in unique and unforeseen ways.

BACKGROUND AND PURPOSE:Rural healthcare provider's willingness to implement pediatric resuscitation may be impeded by comfort level. The purpose of this study was to evaluate the psychometric properties of the Pediatric Advanced Life Support Skill Self-Efficacy Inventory (PALS-SSEI).METHODS:A 19-item inventory was created based on PALS skills. The PALS-SSEI was completed by 94 participants in a study to test the effects of simulation training on PALS knowledge and skill.RESULTS:Six clinical content experts rated the content validity of the PALS-SSEI as high. Item and factor analysis supported the tool's construct validity. A Cronbach's alpha coefficient of 0.88 supported the internal consistency of the tool.CONCLUSIONS:The PALS-SSEI demonstrated good initial psychometric properties. The tool can be used to assess self-efficacy for PALS skills among healthcare providers.

Introduction Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has significant potential for advancing our understanding of labor dystocia. While evaluating contraction frequency and amplitude is a common component of labor dystocia management, the literature describing the relationship between measures of uterine activity and labor dystocia is heterogeneous and has not been synthesized to identify the best methods for use in clinical investigation. Methods We conducted a literature search for original research exploring the relationship between uterine activity and labor dystocia published between 2000 and 2019. Included articles were critically reviewed and synthesized. Results Across 11 identified studies, investigators employed 3 different techniques for monitoring uterine activity and 9 different measures were employed. Uterine activity measures, including Montevideo units, uterine electromyography power density spectrum and sample entropy, and the fall‐to‐rise ratio of contraction shape, detected patterns associated with labor dystocia or cesarean birth. Discussion The use of multiple regression with clinical covariates and a uterine activity measure increased the accuracy of predicting cesarean delivery. Uterine electromyography may be especially useful to evaluate labor dystocia phenotypes to differentiate uterine muscle fatigue from understimulation and lead to algorithms for increased precision in the diagnosis of labor dystocia and innovative approaches to treatment.

Introduction Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has significant potential for advancing our understanding of labor dystocia. While evaluating contraction frequency and amplitude is a common component of labor dystocia management, the literature describing the relationship between measures of uterine activity and labor dystocia is heterogeneous and has not been synthesized to identify the best methods for use in clinical investigation. Methods We conducted a literature search for original research exploring the relationship between uterine activity and labor dystocia published between 2000 and 2019. Included articles were critically reviewed and synthesized. Results Across 11 identified studies, investigators employed 3 different techniques for monitoring uterine activity and 9 different measures were employed. Uterine activity measures, including Montevideo units, uterine electromyography power density spectrum and sample entropy, and the fall-to-rise ratio of contraction shape, detected patterns associated with labor dystocia or cesarean birth. Discussion The use of multiple regression with clinical covariates and a uterine activity measure increased the accuracy of predicting cesarean delivery. Uterine electromyography may be especially useful to evaluate labor dystocia phenotypes to differentiate uterine muscle fatigue from understimulation and lead to algorithms for increased precision in the diagnosis of labor dystocia and innovative approaches to treatment.

We have all met someone or heard someone speak who inspired us in a unique way and perhaps gave us hope in an aspect of life that may, at the time, have seemed rather tumultuous and disheartening. I had such an experience in October 2019 when I heard the Honorable Lauren Underwood speak about her experience as an elected representative at the American Academy of Nursing annual policy conference in Washington, DC. Lauren Underwood, RN, BS, MS, MPH, is in her first term as a member of the United States House of Representatives from the 14th District of the State of Illinois ( Underwood, 2020 Lauren Underwood 14th District of IllinoisAbout. https://underwood.house.gov/aboutDate: 2020 Google Scholar ). I was a resident of that Illinois District for more than 20 years several decades ago. Illinois’s 14th Congressional District comprises the western and northwestern suburbs and rural areas that lie in a collar around the metropolitan area of Chicago and its proximal communities.

I am writing this editorial on March 30, 2020. It is a quiet, cool (some would say cold) morning in the mountains of Colorado where I am privileged to live. The sun is coming over the eastern ridge and reflecting off the snow that is awaiting May and perhaps even June to finally melt away for the short Rocky Mountain summer at our altitude of more than 9,000 feet. As I gaze on this pristine view of creation with Pike's Peak in the distance, I am mindful of my many known and unknown professional nursing and midwifery colleagues who continue to labor under the reality of COVID-19 and the many individuals who lie in America's hospitals fighting for their lives as human and material resources for their effective care dwindle by the hour.

Fifty years is a milestone often celebrated—be it a birthday, an anniversary, or a significant event in history. For the Journal of Obstetric, Gynecologic, & Neonatal Nursing (JOGNN), 2021 marks the publication of its 50th volume. Volume 1, Issue 1 was published in June 1972. Technically, JOGNN will not have published for 50 years until Volume 51 is published in 2021 and 50 years have elapsed since the publication of its first issue. When JOGNN was launched, Editor Ruth Young, RN, noted the following in her inaugural editorial: The new Journal of Obstetric, Gynecologic and Neonatal Nursing offers a fresh, new opportunity for nurses in OGN nursing to report thought, trend, policy and research. It represents an expansion of limited existing opportunity to publish in these specialty areas. It is an opportunity to take the lead in OGN nursing, and who should be better qualified to take this lead than those directly involved in these areas? It serves as a source of encouragement for research in obstetric, gynecologic and neonatal nursing. The Association [Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG)] has grown rapidly and now is even more firmly established as the spokesman for obstetric, gynecologic and neonatal nursing through this journal. (Young, 1971Young R. Silhouette of a new journal.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1971; 1: 14Google Scholar, p. 14) Also, in the first issue, Jane Edwards, RN, MSN, a charter member and former officer of NAACOG reported that “. . .the Journal will provide obstetric, gynecologic and neonatal nurses with information—current thought, policies, trends and research in this specialty! The Journal is the voice of the Association” (Edwards, 1971Edwards J. Letters: Goals.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1971; 1: 56Google Scholar, p. 56). In his editorial in the first issue, Michael Newton, MD, Director of the American College of Obstetricians and Gynecologists at the time, noted that the emergence of NAACOG and its journal represented a clear delineation of the specialty of obstetric, gynecologic, and neonatal nursing (Newton, 1971Newton M. The growth of a nursing specialty.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1971; 1: 10-11Google Scholar). However, Newton challenged his nurse colleagues and NAACOG to develop standards of competence and accredited methods for knowledge acquisition, maintenance, and updating in obstetric, gynecologic, and neonatal nursing similar to those in place at the time by the American College of Nurse-Midwives. He stressed the need for urgency in these initiatives and the requirement for interdisciplinary collaboration and interorganizational efforts to clarify and develop the specialty. Although the terminology has changed over the years from obstetric to maternity nursing and from gynecologic to women’s health nursing, and the singular nursing specialty of OGN has evolved to more separate specialties of maternity (including the healthy neonate), women’s health, and neonatal nursing, the challenge presented by Newton remains. It is critical, ongoing work that is necessary for the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) to meet the goal of enhancing the abilities of nurses to provide evidence-based care for women, childbearing families, and their infants. In 1992 NAACOG became AWHONN and JOGNN was retained as its official publication (Haller, 1993Haller K.B. Harbingers of change: 1993.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1993; 22: 14Abstract Full Text Full Text PDF Scopus (1) Google Scholar). JOGNN’s Editor Karen Haller, RN, PhD, wrote that the move of NAACOG to AWHONN: Brings the organization out from under its parent organization, ACOG. A parent-child relationship may be based on respect, but it is not collaborative. The parent is the dominant part, and the relationship is hierarchical. This type of relationship became unacceptable to NAACOG members in 1992. (Haller, 1993Haller K.B. Harbingers of change: 1993.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1993; 22: 14Abstract Full Text Full Text PDF Scopus (1) Google Scholar, p. 14) You may or may not be aware that as an AWHONN member, you have free electronic access to the archives of all issues of JOGNN from Volume 1, Issue 1 to the present time. During my recent pilgrimage through those archives, I learned that JOGNN’s nickname was originally JOGN Nursing. I also learned about the various individuals who served before me on JOGNN’s Editorial Board and as editors. Interestingly, during at least the first 10 years of JOGNN, there were always physicians on the journal’s editorial board, which reflected the close and somewhat dependent relationship between NAACOG and ACOG. JOGNN’s previous editors include Ruth Young, RN; Pam Saroff; Mark Hobbs; Judith Serevino; Annette Flanagin, RN, MA; and Karen Haller, RN, PhD. Finally, I was struck by the topics of the journal’s articles, many of which were very contemporary, and read with delight as many names appeared of people I have known or known of across the years. On the occasion of JOGNN’s 10th anniversary, Helen Wohlert, RN, MS, former president of NAACOG, reiterated the objectives for the journal announced by NAACOG when the new journal was established: To stimulate interest in obstetric, gynecologic and neonatal nursing; to add to the professional knowledge of the obstetric, gynecologic and neonatal nurse; to provide leadership in obstetric, gynecologic and neonatal nursing; to provide incentive for quality nursing care and to give added stature to an already quality branch of medicine and nursing. (Wohlert, 1982Wohlert H. Happy birthday.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1982; 10: 14Google Scholar, p. 138) It is interesting that although different words are used, some of these original ideas remain central to JOGNN’s core publishing mission and the new, expanded statement of its aims and scope (see Table 1). JOGNN’s new mission statement focuses on the recipients of nursing care, women, their families, and their infants, while positioning nurses within the interdisciplinary context of contemporary health care, regardless of setting. JOGNN’s editorial team and Editorial Advisory Board, in collaboration with the editors and Editorial Advisory Board of Nursing for Women’s Health and AWHONN staff, worked during 2020 to develop this more complete, contemporary description of the journal’s aims and scope. We hope that you find JOGNN’s new aims and scope statement appropriate to undergird the ongoing and future work of JOGNN’s scholarly contributions to the discipline of nursing and the specialties of maternity, women’s health, and neonatal care. We invite your comment.Table 1JOGNN’s Updated Mission, Aims, and Scope StatementsJOGNN is the scientific journal of the Association of Women's Health, Obstetric and Neonatal Nurses. The mission of JOGNN is to advance the health and health care of women, childbearing and childrearing families, and newborns across all settings through the bimonthly publication of peer-reviewed nursing and interdisciplinary scholarship.JOGNN leads the development of nursing knowledge in the specialties of women’s health, maternal, and neonatal care by publishing articles on related aspects of nursing and interdisciplinary research, practice, and policy. Articles published in JOGNN promote diversity, equity, and inclusion and contribute to the emotional, psychological, and physical well-being of women throughout their lifespan, their infants, and their families at the individual, community, and population levels. Articles may focus on innovative or novel approaches to the provision of women’s health, maternity, or neonatal care; global and international perspectives with applicability to practice in North America; health equity and social determinants of health; health promotion and disease prevention; evidence-based quality improvement; and health policy.The target audience of JOGNN is nurses, midwives, advanced practice nurses, other providers, and related professionals of women’s health, maternity, neonatal, and/or related interdisciplinary care. Therefore, articles have clear implications for practice, research, and/or policy and contribute to the evidence base for the provision and development of care beyond the study setting. Article types include original research, reviews, health care improvement and evaluation, principles and practice, critical commentary, methods, and case reports. Open table in a new tab Finally, I am pleased to announce the appointment of Cheryl Tatano Beck, DNSc, CNM, FAAN, as Associate Editor for Qualitative Methods. Dr. Beck brings her well-known reputation and expertise as a qualitative researcher to JOGNN’s editorial team where she will shepherd the review and editorial decision-making for qualitative manuscripts submitted to JOGNN for publication consideration. I am grateful for the financial support of AWHONN to make Dr. Beck’s appointment possible. Throughout the five decades of organizational change and growth, the changes in scopes of practice for nurses at the registered nurse and advanced practice levels, the rapid development of graduate education in nursing, and the overall advancement of nursing specialties, JOGNN has been an ongoing presence in the peer-reviewed literature. The journal was launched by forward-thinking nurses who recognized the need for nurse leadership through scholarly publication by nurses in obstetric, gynecologic, and neonatal nursing. We honor these nurses by looking back to the beginning, reviewing the journal’s path across the decades, being faithful stewards of the journal during this time, and by looking forward to what is to come for JOGNN as it passes its 50th milestone. Editor in Chief

In February 2019, the Executive Board of the World Health Organization (WHO) declared that 2020 would be the Year of the Nurse and the Midwife. This designation marks the 200th anniversary of the birth of Florence Nightingale. Nightingale’s foundational work during the Crimean War (1853–1856) and after is regarded as the primary force that began the transformation of nursing from unskilled work to a highly regarded health care profession based on the principles of science and of art. The WHO declared that “working closely with key partners including, the International Confederation of Midwives (ICM), International Council of Nurses (ICN), Nursing Now and the United Nations Population Fund (UNFPA), we will: •Celebrate the contributions of health workers, with particular focus on nurses and midwives, in improving health globally, •Acknowledge, appreciate and address the challenging conditions nurses and midwives face while providing care where it's needed most and •Advocate for increased investments in the nursing and midwifery workforce” ( World Health Organization, 2019a World Health Organization2020—Year of the nurse and the midwife. https://www.who.int/news-room/events/detail/2020/01/01/default-calendar/2020---year-of-the-nurse-and-the-midwifeDate: 2019 Google Scholar , para. 2).

Earlier this year, the National Academies of Sciences, Engineering, and Medicine (NASEM; 2020) released the consensus study report Birth Settings in America: Outcomes, Quality, Access, and Choice (Birth Settings). For those who are committed to the care of childbearing women, their infants, and their families in the United States, this report must not be ignored, dismissed, or forgotten in the context of our nation's larger and critical focus on the coronavirus pandemic. The Birth Settings report was requested by Congresswoman Lucille Roybal-Allard and Congresswoman Jaime Herrera Beutler in 2018 and was sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health.

It is no surprise to the informed American that the maternal mortality rate in the United States is tragically high, especially in light of the fact that we spend more dollars per birth than any other country (Rosenthal, 2013Rosenthal E. American way of birth, costliest in the world. New York Times.https://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.htmlDate: 2013, June 30Google Scholar). Unfortunately, dollars spent do not translate to the best outcomes; in fact, our maternal mortality rate is substantially higher than the rate of any other developed country in the world (GBD 2015 Maternal Mortality Collaborators, 2016GBD 2015 Maternal Mortality CollaboratorsGlobal, regional, and national levels of maternal mortality, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1775-1812https://doi.org/10.1016/S0140-6736(16)31470-2Abstract Full Text Full Text PDF PubMed Scopus (620) Google Scholar). Regardless of absolute numbers, any woman’s death during pregnancy, childbirth, or afterward is a tragedy for her infant(s) and children, family, community, and the health care providers involved in her care. The problem of maternal mortality in the United States has received increasing scrutiny in recent years by researchers, the press, and legislators because of the apparent rise in rates since the early 2000s and the disparities in rates by race and ethnicity. Non-Hispanic black women have a 3.4 times higher mortality ratio than non-Hispanic white women (Creanga et al., 2017Creanga A.A. Syverson C. Seed K. Callaghan W.M. Pregnancy-related mortality in the United States, 2011–2013.Obstetrics & Gynecology. 2017; 130: 366-373https://doi.org/10.1097/AOG.0000000000002114Crossref PubMed Scopus (533) Google Scholar). In their recent editorial, MacDorman et al., 2018MacDorman M.F. Declercq E. Thoma M.E. Making vital statistics count: Preventing U.S. maternal deaths requires better data.Obstetrics & Gynecology. 2018; 131: 759-761https://doi.org/10.1097/AOG.0000000000002598Crossref PubMed Scopus (9) Google Scholar described the reality in which accurate U.S. national data on women who die during pregnancy, childbirth, or within one year of pregnancy remain elusive because of the limitations of the three different systems used to capture and track these deaths. These three systems include the National Vital Statistics System (Centers for Disease Control and Prevention, 2019Centers for Disease Control and PreventionNational vital statistics system.https://www.cdc.gov/nchs/nvss/index.htmDate: 2019Google Scholar), the Pregnancy Mortality Surveillance System (Centers for Disease Control and Prevention, 2018Centers for Disease Control and PreventionPregnancy mortality surveillance system.https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htmDate: 2018Google Scholar), and state-level Maternal Mortality Review Committees (MMRCs). The National Vital Statistics System is the official source of U.S. maternal mortality data derived from death certificates compiled from the states. To promote more accurate reporting of maternal deaths, in 2003 the U.S. standard death certificate was revised to include an item to ask if a woman who died was pregnant within the past year or at the time of death (Centers for Disease Control and Prevention, 2017Centers for Disease Control and PreventionRevisions of the U.S. standard certificates and reports.https://www.cdc.gov/nchs/nvss/revisions-of-the-us-standard-certificates-and-reports.htmDate: 2017Google Scholar). Implementation of the revision occurred slowly, and by 2007 only half of U.S. states had incorporated the question. However, by 2016, all but two states had done so (MacDorman et al., 2018MacDorman M.F. Declercq E. Thoma M.E. Making vital statistics count: Preventing U.S. maternal deaths requires better data.Obstetrics & Gynecology. 2018; 131: 759-761https://doi.org/10.1097/AOG.0000000000002598Crossref PubMed Scopus (9) Google Scholar). Unfortunately, despite the inclusion of the question to allow more accurate identification of potential pregnancy-related deaths, researchers found significant errors in the data provided by states (Daymude et al., 2019Daymude A.E.C. Catalano A. Goodman D. Checking the pregnancy checkbox: Evaluation of a four-state quality assurance pilot.Birth. 2019; (Advance online publication)https://doi.org/10.1111/birt.12425Crossref PubMed Scopus (7) Google Scholar). More than three decades ago, the CDC established the Pregnancy Mortality Surveillance System to fill informational gaps about causes of maternal death with more clinical information (Centers for Disease Control and Prevention, 2018Centers for Disease Control and PreventionPregnancy mortality surveillance system.https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htmDate: 2018Google Scholar). Using deidentified death certificates linked to birth or fetal death certificates, CDC clinicians and scientists review the deaths of girls and women ages 12 to 55 years who died while pregnant or within one year of pregnancy for causes related to or aggravated by pregnancy or its management. Findings from this system indicate that women’s deaths in the United States from pregnancy-related causes steadily increased from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014. This ratio means that approximately 700 women die each year from pregnancy-related causes, or two women die per day. The data also indicate that from 2011 through 2014, 40.0 deaths per 100,000 live births occurred among Black women compared to 17.8 deaths per 100,000 among women of other races and 12.4 deaths per 100,000 among White women (Creanga et al., 2017Creanga A.A. Syverson C. Seed K. Callaghan W.M. Pregnancy-related mortality in the United States, 2011–2013.Obstetrics & Gynecology. 2017; 130: 366-373https://doi.org/10.1097/AOG.0000000000002114Crossref PubMed Scopus (533) Google Scholar). During this time, the five leading causes of pregnancy-related deaths identified in the Pregnancy Mortality Surveillance System data were cardiovascular conditions, other preexisting medical conditions, infection, hemorrhage, and cardiomyopathy. The third critical system used to monitor maternal mortality and, more importantly, to assess and identify opportunities to prevent women’s deaths are MMRCs. Although a number of states had such committees in operation in the early 2000s, in 2015, the CDC, the CDC Foundation, and the Association of Maternal and Child Health Programs collaboratively launched the Building U.S. Capacity to Review and Prevent Maternal Deaths initiative, which is funded through the Merck for Mothers program (Zaharatos et al., 2018Zaharatos J. St. Pierre A. Cornell A. Pasalic E. Goodman D. Building U.S. capacity to review and prevent maternal deaths.Journal of Women’s Health. 2018; 27: 1-5https://doi.org/10.1089/jwh.2017.6800Crossref PubMed Scopus (33) Google Scholar). The Web site for the initiative (CDC Foundation, 2019CDC FoundationBuilding U.S. capacity to review and prevent maternal deaths.https://www.cdcfoundation.org/building-us-capacity-review-and-prevent-maternal-deathsDate: 2019Google Scholar) and the related Review-to-Action Web site developed by the Association of Maternal and Child Health Programs (Building U.S. Capacity to Review and Prevent Maternal Deaths, 2019Building U.S. Capacity to Review and Prevent Maternal DeathsReview to Action.http://reviewtoaction.orgDate: 2019Google Scholar) contain a multitude of reports and resources to advance the work of MMRCs and publicly distribute information related to that work. Through the work of MMRCs in various states, researchers and clinicians concluded that 50% or more of pregnancy-related deaths in the United States are preventable (Metz, 2018Metz T.D. Eliminating preventable maternal deaths in the United States.Obstetrics & Gynecology. 2018; 132: 1040-1045https://doi.org/10.1097/AOG.0000000000002851Crossref PubMed Scopus (8) Google Scholar, Zaharatos et al., 2018Zaharatos J. St. Pierre A. Cornell A. Pasalic E. Goodman D. Building U.S. capacity to review and prevent maternal deaths.Journal of Women’s Health. 2018; 27: 1-5https://doi.org/10.1089/jwh.2017.6800Crossref PubMed Scopus (33) Google Scholar). In articles in this issue, researchers describe use of data from the California Pregnancy-Associated Mortality Review committee to determine quality improvement opportunities in the areas of readiness, recognition, and response for major causes of maternal mortality identified through the systematic analysis of maternal deaths in California (Morton et al., 2019Morton C.H. Seacrist M.J. VanOtterloo L.R. Main E.K. Quality improvement opportunities identified through case review of pregnancy-related deaths from preeclampsia/eclampsia.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 275-287https://doi.org/10.1016/j.jogn.2019.02.008Abstract Full Text Full Text PDF Scopus (12) Google Scholar, Morton et al., 2019Morton C.H. VanOtterloo L.R. Seacrist M.J. Main E.K. Translating maternal mortality review into quality improvement opportunities in response to pregnancy-related deaths in California.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 252-262https://doi.org/10.1016/j.jogn.2019.03.003Abstract Full Text Full Text PDF Scopus (14) Google Scholar, Seacrist et al., 2019Seacrist M.J. Morton C.H. VanOtterloo L.R. Main E.K. Quality improvement opportunities identified through case review of pregnancy-related deaths from sepsis.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 311-320https://doi.org/10.1016/j.jogn.2019.02.007Abstract Full Text Full Text PDF Scopus (7) Google Scholar, Seacrist et al., 2019Seacrist M.J. VanOtterloo L.R. Morton C.H. Main E.K. Quality improvement opportunities identified through case review of pregnancy-related deaths from obstetric hemorrhage.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 288-299https://doi.org/10.1016/j.jogn.2019.03.002Abstract Full Text Full Text PDF Scopus (13) Google Scholar, VanOtterloo et al., 2019VanOtterloo L.R. Morton C.H. Seacrist M.J. Main E.K. Quality improvement opportunities identified through case review of pregnancy-related deaths from cardiovascular disease.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 263-274https://doi.org/10.1016/j.jogn.2019.03.001Abstract Full Text Full Text PDF Scopus (3) Google Scholar, VanOtterloo et al., 2019VanOtterloo L.R. Seacrist M.J. Morton C.H. Main E.K. Quality improvement opportunities identified through case review of pregnancy-related deaths from venous thromboembolism.Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019; 48: 300-310https://doi.org/10.1016/j.jogn.2019.02.006Abstract Full Text Full Text PDF Scopus (3) Google Scholar). As a national leader in work to understand why women died during or after pregnancy and what can be done to prevent such deaths in the future, the California Maternal Quality Care Collaborative, 2019California Maternal Quality Care CollaborativeResources & toolkits.https://www.cmqcc.org/resources-toolkitsDate: 2019Google Scholar has developed many resources and toolkits in several areas for use by organizations and clinicians to help prevent maternal deaths. Nurses can use findings from the articles presented in this issue to identify opportunities to improve care at unit, organization, and community levels to combat preventable deaths of women from pregnancy-related causes. In a recent Institute for Healthcare Improvement blog, Berwick, 2019Berwick D.M. The Triple Aim: Why we still have a long way to go. IHI Improvement Blog, 2019, February 14http://www.ihi.org/communities/blogs/the-triple-aim-why-we-still-have-a-long-way-to-goGoogle Scholar revisited the Triple Aim of better care for individuals, better health for populations, and lower per capita cost. He reminded us that while the first aim rests on the idea of health care as a repair shop, the second aim is based on the assertion that society needs us (health care providers) to help its members stay healthy; this is better health for the population. When we apply these principles to maternity care and the prevention of women’s deaths during or after pregnancy, it is apparent that quality, comprehensive, integrated, and holistic care for each woman and for childbearing women overall that is grounded in an understanding of the social determinants of health and childbearing families’ needs for ongoing social support are central to our battle against maternal mortality in the United States. Quality improvement opportunities are all around us, not just at the bedsides of women during birth-related hospitalizations. It is imperative that each nurse, midwife or nurse practitioner, physician, therapist, or anyone else who comes in contact with women during pregnancy or afterward is informed and vigilant regarding the signs and symptoms of pregnancy-related complications that may indicate the need for evaluation, intervention, or the involvement of other more skilled or specialized health care providers. Each must know how to recognize signs and symptoms, what to do, and how to do it in a responsive, timely, and organized manner that assures every woman receives care that protects her in the bounds of safety and assures the best possible outcomes.

JOGNN's editorial office occasionally receives manuscripts for publication consideration that are labeled in the title or in the abstract as pilot studies. However, on review of the objectives or aims of the study, it is clear that the project was not designed as a pilot study. Sometimes it seems that the project was retrospectively labeled a pilot study when some aspect of the methods was not achieved, particularly the proposed sample size. It is inappropriate to label a study a pilot after the fact because the objectives or aims of a pilot study should be specific to its purpose.