Position Statements

Brain Health is Womenʼs Health

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports collaborative action to establish brain health as a crucial aspect of women’s healthcare. A comprehensive approach includes promoting brain health, detecting cognitive impairment (CI) to facilitate accurate diagnosis and early intervention, and identifying and addressing the needs of individuals who are caregivers for loved ones with CI.

NPWH believes a need exists for extensive research to better understand modifiable factors that influence brain health, improve one’s ability to make an early diagnosis of CI, establish effective therapies to prevent and treat CI, and support families and caregivers of individuals with CI. NPWH endorses federal and state policies that devote resources to finance the needed research and that ensur e access to needed diagnostic, care, and treatment resources for individuals with CI, caregivers, families, and healthcare providers.

Background

Cognitive function refers to memory, speech, language, judgment, reasoning, and planning and thinking abilities.1 Brain health is a term commonly used to describe healthy cognitive function.2,3 Changes in these functions may indicate CI. These changes may range in their level of severity, may be progressive, and may have treatable causes.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition’s (DSM-5’s) diagnostic categories of minor and major neurocognitive disorders (NCDs) reflect the range in CI severity. Minor NCD is a condition in which the individual has mild but measurable changes in cognitive function that are noticeable to the person affected and to family members and friends but do not affect the individual’s ability to carry out activities of daily living (ADLs).1 Minor NCD may be progressive. Approximately 15%-20% of persons aged 65 years or older have minor NCD.4 Major NCD is impairment characterized by decline in at least two cognitive domains (e.g., memory, attention, language, visuospatial function, executive function) severe enough to affect a person’s ability to perform ADLs; the individual also may exhibit behavioral and psychological symptoms.1 Dementia is a commonly used term for major NCD.

Alzheimer’s disease (AD), a progressive degenerative brain disease, is the most common cause of dementia.1 Most statistics on dementia reflect data related to AD. As of 2018, about 5.7 million adults in the United States have AD, with 5.5 million of them being aged 65 years or older. As the size and proportion of this older U.S. population grows, it is projected that 7.1 million persons aged 65 or older will have dementia, primarily AD, by 2025.1 The annual number of new cases of AD and other dementias will likely double by 2050 unless research discovers the key to prevention.1

These statistics do not reflect pre-clinical AD. Current thinking is that Alzheimer’s-related brain changes may begin 20 or more years before symptoms occur.1 No proven strategies are available to prevent AD. However, recognized risk factors for cognitive decline and AD, some modifiable, do exist.5,6 Increasing evidence suggests that lifestyle interventions may have a long-term impact on preserving brain health. The Alzheimer’s Association published a report in 2015 summarizing existing evidence related to risk factors and risk reduction (Box 1).5

All nurse practitioners (NPs) who care for midlife and older adults play a critical role in early recognition of CI. Early signs and symptoms include problems with memory or language, noted deficits in personal or instrumental ADLs, and concerns reported by the individual or a family member or caregiver.7-9 Assessment to detect CI is a required component of the annual wellness visit established in 2011 for Medicare recipients under the Patient Protection and Affordable Care Act.7

The Alzheimer’s Association has published guidance on detection of CI during the annual wellness visit. This guidance includes an algorithm for health risk assessment, patient observation, unstructured questioning, and structured assessment.7 Use of a structured cognitive assessment instrument can improve detection of CI in primary care settings by identifying individuals who may need further evaluation. Validated brief cognitive assessment tools that can be administered in 5 minutes or less in the primary care setting are available. Individuals whose assessment findings indicate possible CI should be evaluated further or referred to a specialist.7 Several initiatives have provided lists of these assessment tools, as well as recommendations and strategies NPs can use to address brain health and CI (Box 2).10-12

Early detection of CI and diagnosis of dementia are integral to individual and family counseling, advance care planning, and consideration of supportive therapies.13-15 The years from diagnosis to end-of-life may be fraught with poor health and disability, resulting in loss of independence and, over time, a substantially lowered quality of life. When interprofessional team members work together with the individual, family members, and caregivers, the changes that occur throughout the course of the disease process can be anticipated and the best care provided.

The impact of this disease on quality of life extends to the more than 16 million adults in the U.S. who provide unpaid care for loved ones with dementia.1 Approximately two-thirds of these informal caregivers—that is, 10.7 million of them—are women, and more than one-third of these women are the daughters of the individuals with dementia.1 The average age of caregivers is 49 years, although about one-third of them are aged 65 years or older.1,16 One-fourth of caregivers belong to a sandwich generation—that is, they are caring not only for an aging parent but also for children younger than age 18.1

Caregiving tasks include helping with instrumental ADLs (e.g., shopping, providing transportation, managing finances) and personal ADLs (e.g., bathing, dressing, feeding). In addition, caregivers may coordinate healthcare and support services. As dementia progresses, caregivers often must manage behavioral symptoms of the disease (e.g., aggressive behavior, wandering).1 Such tasks can take an emotional and physical toll on caregivers, as well as affect their financial status if they must modify or terminate paid employment and pay for healthcare services for themselves and their care recipient.1,16 In many cases, their own needs go unrecognized and unattended.15

A call to action has arisen to transform policies and practices affecting the role of informal caregivers as a major source of care for a growing population of older adults with dementia. A strategic national-level action plan will be required to address the needs of these caregivers. Policies to create evidence-based training for informal caregivers specific to the care of individuals with dementia, provide support such as expanded family leave and job protection for working caregivers, and fund evidence-based caregiver services are critical. Policies must recognize the needs and values of a diverse population of caregivers and the individuals under their care.15,17,18 Box 3 lists resources devoted to caring for caregivers themselves.

Implications for women’s healthcare and NP practice

Nurse practitioners who provide healthcare to women of all ages have the opportunity to address brain health during annual well-woman visits and/or during other visits if concern about patients’ cognitive function arises. In addition, NPs are likely to see, on a regular basis, a large portion of the roughly 10.7 million informal caregivers who are female. NPs are in an excellent position to identify women who are in the caregiver role and address their physical and mental health needs, including their brain health needs.

Recommendations

Nurse practitioners who provide healthcare for mid-life and older women, as well as women of any age who may be caregivers for loved ones with dementia, should:

  • raise the topic of brain health as part of women’s health during routine healthcare visits;
  • address risk factors for cognitive decline that may be reduced with lifestyle changes (e.g., improved nutrition, regular physical activity, cognitive training, smoking cessation);
  • include a question about memory or cognition on health risk questionnaires;
  • observe for signs and symptoms of CI;
  • use an evidence-based protocol for screening and diagnostic evaluation of patients’ brain health and referral for further evaluation if indicated;
  • include a question about any caregiving responsibilities in health assessment;
  • offer additional screening for caregivers to assess preparedness for caregiving and caregiver strain;19,20
  • develop health system partnerships to connect individuals with dementia and their caregivers with community agencies to identify needs and access help;
  • collaborate with affected individuals, caregivers, and an interprofessional team to facilitate decision making and planning (e.g., living arrangements, advance care planning, end-of-life care) that addresses changing needs over time and across care settings; and advocate for policies at local, state, and national levels that address the needs and values of individual with dementia and their caregivers.

NPWH will provide leadership to ensure that:

  • continuing education programs and other evidence-based resources are available for NPs to learn and update knowledge regarding brain health, dementia, and caregiver needs;
  • ongoing collaborative engagement occurs with a variety of stakeholders to address brain health and caregiving issues as important components of an older women’s health agenda;
  • research moves forward in all aspects of brain health to prevent dementia, treat existing CI, help those with CI maintain function and quality of life, and support caregivers; and
  • policies strongly support individuals and families in coping with the physical, emotional, and financial burden of dementia.

 

References

  1. Alzheimer’s Association. 2018 Alzheimer’s Disease Facts and Figures. alz.org/alzheimers-dementia/facts-figures
  2. Alzheimer’s Association. Brain Health. 2018. alz.org/help-support/brain_health
  3. National Institute on Aging. What is Brain Health? 2018. brainhealth.nia.nih.gov/
  4. Roberts R, Knopman DS. Classification and epidemiology of MCI. Clin Geriatr Med. 2013;29(4):753-772.
  5. Baumgart M, Snyder HM, Carrillo MC, et al. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective. Alzheimers Dement. 2015;11(6):718-726.
  6. Moga D, Roberts M, Jicha G. Dementia for the primary care provider. Prim Care Clin Office Pract. 2017;44(3):439-456.
  7. Cordell CB, Borson S, Boustani M, et al. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141-150.
  8. Falk N, Cole A, Meredith TJ. Evaluation of suspected dementia. Am Fam Physician. 2018;97(6):398-405.
  9. Scott J, Mayo A. Instruments for detection and screening of cognitive impairment for older adults in primary care settings: a review. Geriatr Nurs. 2018;39(3):323-329.
  10. Alzheimer’s Association. Cognitive Assessment Toolkit. 2013. alz.org/professionals/healthcare-professionals/cognitive-assessment

 

Position Statement | Eliminating Preventable Maternal Deaths

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports coordinated and collaborative efforts at federal, state, local, and professional organization levels to eliminate preventable maternal deaths. For 2011-2015, the pregnancy-related mortality ratio (PRMR) in the United States was 17.2 deaths per 100,000 live births.1 This statistic translates to an average of 700 women dying of pregnancy-related complications each year, a rate that remains higher than that of any other resource-rich country.1 The CDC estimates that 3 in 5 pregnancy-related deaths in the U.S. are preventable.1

NPWH advocates for legislation, policies, and initiatives that promote access to care, establishment and implementation of evidence-based healthcare practices to improve maternal outcomes, and ongoing research into the contributing factors to maternal mortality and effective preventive strategies.

Reducing racial and ethnic disparities in maternal mortality must be a priority. The most recent data have shown that, compared with non-Hispanic white women, non-Hispanic black women had PRMRs that were 3.3 times higher and American Indian/Alaska Native women had PRMRs that were 2.5 times higher.1 NPWH supports action at all levels that address socioeconomic factors, barriers to access to quality healthcare, and implicit bias on the part of healthcare providers (HCPs), all of which contribute to disparities in healthcare services and health outcomes.

Women’s health nurse practitioners (WHNPs) who provide care for women before, during, and in between pregnancies are uniquely qualified to address the known contributing factors for preventable maternal mortality and to optimize health outcomes. WHNPs who specialize in high-risk antepartum and postpartum care are particularly well suited to enhance health outcomes for women with identified maternal morbidity and mortality risks.

Background

In the U.S., a pregnancy-related death is defined as one that occurs during pregnancy or within 12 months of the end of a pregnancy that is causally related to the pregnancy. This causality refers to deaths related to a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.1 A death is considered preventable if it is determined that a chance existed that the death could have been averted by one or more changes to community, health facility, patient, provider, and/or systems-level factors.2

Data from the 2011-2015 CDC’s national Pregnancy Mortality Surveillance System (PMSS) report indicated that cardiovascular (CV) conditions led to more than 33% of the pregnancy-related deaths during this time period.1 For the purpose of this data collection, CV conditions included cardiomyopathy, other cardiovascular conditions, and cerebrovascular accidents. Other leading causes of pregnancy-related death were non-CV health conditions, infection, obstetric hemorrhage, amniotic fluid embolism, and hypertensive disorders of pregnancy. Deaths attributable to suicide, drug overdose, homicide, or unintentional injury were not included in this analysis. Causes of death varied with timing during the pregnancy-through-postpartum continuum. Box 1 lists leading causes of death by time relative to this continuum.

Role of maternal mortality review committees
Beyond gathering data on causes of maternal mortality, a concerted effort to understand contributing factors and the potential for prevention of maternal deaths is critical. State-level multidisciplinary maternal mortality review committees (MMRCs) are expanding across the nation, with the goal to identify and analyze maternal deaths using a standardized, systematic process. For each death, the committees make six key decisions: Was the death pregnancy related? What was the cause of death? Was the death preventable? What were the critical contributing factors to the death? What are the recommendations and actions that address the contributing factors? What is the anticipated impact of these actions, if implemented?3

In a recent collaborative report, 13 state MMRCs identified 251 pregnancy-related deaths that occurred between 2013 and 2017.1 The committees were able to make a determination on preventability for 232 (92.4%) of the 251 deaths. Among these 232 deaths, 139 (60.0%) were determined to be preventable.1 The MMRCs categorized contributing factors for these preventable pregnancy-related deaths into five levels: community factors, health facility factors, patient factors, provider factors, and systems-level factors. Preventive strategies were identified for each level, with recognition that most deaths had more than one contributing factor and required more than one preventive strategy (Table).1,3

The comprehensive, multidisciplinary approach of MMRCs facilitates recognition of mental health conditions, including substance use disorders (SUDs), as a leading contributor to maternal deaths (these mental health-related deaths occur primarily in the first year postpartum). In identified cases, a mental health condition was associated with the majority of deaths from unintentional injury, accidental drug overdose, or suicide.3-5 Standardized MMRC data collection and decision forms have been expanded to include specific components regarding mental health and SUDs in order to help MMRC members better understand the role of mental health conditions in terms of pregnancy-related deaths.3

The U.S. Department of Health and Human Services is authorized through the 2018 Preventing Maternal Deaths Act to provide funding to states to establish and sustain MMRCs, disseminate findings, implement recommendations, and develop plans for ongoing HCP education in order to improve the quality of maternal care.6 Shared information from MMRCs can inform policymakers and other stakeholders in their efforts to prioritize recommendations and provide resources to translate them into action. More than 40 states now have an active MMRC in place or in development. Information about which states have or are planning to have MMRCs is available hereA.

Translation of evidence into action
Translation of recommendations from MMRCs and other evidence-based sources into action, along with the study of outcomes, is crucial to eliminate preventable maternal deaths. The Alliance for Innovation on Maternal Health (AIM)—a national partnership of HCPs, public health professionals, and advocacy organizations under the auspices of the Council on Patient Safety in Women’s Health Care— provides resources for this purpose with the creation of safety bundles focused on high-risk maternal conditions.7,8 Safety bundles are evidence-based practices that, when consistently acted upon by the healthcare team, have been shown to improve patient outcomes.9 Each AIM safety bundle has four domains: readiness, recognition, response, and reporting/systems learning. AIM provides support and technical assistance at state and healthcare system levels to implement the bundles. Other resources for translating evidence into action include the American College of Obstetricians and Gynecologists, the California Maternal Quality Care Collaborative, the Center for Reproductive Rights and Black Mamas Matter Alliance, and the Society for Maternal-Fetal Medicine. A list of resources is provided in Box 2.10-26

Legislation and policies are needed to facilitate action that promotes maternal health and reduces maternal morbidity and mortality. Federal and state legislation has expanded support for MMRCs, the work of the Council on Patient Safety in Women’s Health Care, and other maternal health initiatives. Federal-level bills have been introduced to extend Medicaid coverage eligibility to include 1 year of postpartum care. This coverage is particularly important because the 2011-2015 PMSS data indicated that 51.7% of pregnancy-related deaths occurred in the postpartum period, with 18.6% occurring 1-6 days postpartum, 21.4% occurring 7-42 days postpartum, and 11.7% occurring 43-365 days postpartum.1 Extended Medicaid coverage could change postpartum care to an ongoing process tailored to each woman’s own needs rather than a single encounter. The American College of Obstetricians and Gynecologists’ recommendations for a first postpartum visit at 3 weeks and a second visit no later than 12 weeks postpartum would be facilitated.18 A first visit earlier than the traditional 6 weeks, with follow-up at 12 weeks, would allow for better monitoring of risk factors and signs/symptoms of maternal complications, including mental health concerns. HCPs would have more opportunity to provide education, counseling, and any needed referrals, as well as a coordinated transition to well-woman care in the first year postpartum.

Importance of reducing racial/ethnic outcome disparities and implicit racial/ethnic bias
Preventive strategies that address community, health facility, patient, provider, and systems-level factors must give utmost priority to reducing the racial and ethnic disparities in pregnancy-related mortality that have persisted over time. Although the overall PRMR in the U.S. in 2011-2015 was 17.2 deaths per 100,000 live births, racial/ ethnic comparisons revealed significant differences. Non-Hispanic black women and American Indian/Alaska Native women had PRMRs of 42.8 and 32.5 deaths per 100,000 live births, respectively, as compared with 13.0 deaths per 100,000 live births for non-Hispanic white women.1 Causes of these disparities in maternal mortality are not fully understood and are likely multifactorial. Data have indicated that racial and ethnic minority women, compared with non-Hispanic white women, are less likely to (1) receive early and regular prenatal care, (2) have access to maternal-fetal medicine specialists, (3) give birth in higher-quality hospitals, and (4) attend a postpartum visit.27,28 Compared with non-Hispanic white women, non-Hispanic black women are more likely to have health conditions that place them at risk for maternal morbidity and mortality and they have twice the rate of unplanned pregnancies.28

Substantial evidence indicates that implicit racial/ethnic bias exists among HCPs—as it does in the general population—and that this bias can affect patient–HCP interactions, treatment decisions, treatment adherence, and patient outcomes.29,30 (Implicit biases are unconscious attitudes that can influence affect, behavior, and cognitive processes.) More research is needed to fully understand how implicit bias affects patient care and outcomes and whether certain intervention strategies can help address this bias within healthcare.

Implications for women’s healthcare and WHNP practice

WHNPs provide healthcare for women before, during, and in between pregnancies in a variety of settings. The care they provide before and in between pregnancies places them at the forefront to assess for and address known risk factors for maternal complications prior to pregnancy. Box 3 highlights risk factors that can be identified prior to a pregnancy and mitigated by care tailored to each woman’s needs. WHNPs provide essential routine and high-risk pregnancy and postpartum care that includes identification of factors that may place a woman at an increased risk for maternal complications, implementation of care to mitigate risks, and collaboration within the healthcare team when complications occur to foster the best patient outcomes.

With the recognition that up to one-half of pregnancy-related deaths occur in the first year postpartum, the role of WHNPs in the transition from postpartum to well-woman care is crucial to continue to monitor risks and provide appropriate care, including attention to mental health. A concerted effort at community, health facility, patient, provider, and systems levels is critical to make progress in the goal to eliminate preventable pregnancy-related deaths.

Recommendations

NPWH recommends that WHNPs who provide healthcare for women before, during, and in between pregnancies should:
• be aware of their state’s status regarding existence of or plans for an MMRC and monitor data reports.
• seek active involvement in planning and implementing evidence-based maternal mortality preventive strategies at community, provider, patient, health facility, and systems levels to address MMRC-identified causes and contributing factors.
• engage in self-reflection regarding potential for implicit bias and seek educational activities that increase awareness and enhance patient–provider interactions.
• participate in research to more fully understand contributing factors to preventable maternal mortality.
• participate in maternal health quality improvement projects that facilitate translation of evidence to practice with outcomes evaluation
• advocate for local, state, and federal policies and legislation that address known contributing factors, including racial/ethnic disparities related to maternal mortality.

NPWH will provide leadership to ensure that:
• continuing education(CE)programs and other evidence-based resources are available for NPs to learn and update knowledge regarding causes, contributing factors, and strategies to eliminate preventable maternal mortality.
• CE programs and other evidence-based resources on strategies for NPs to recognize and address racial/ethnic biases in themselves and at their healthcare facilities are available.
• collaborative engagement with other professional organizations continues to advance the development, implementation, and evaluation of multidisciplinary best practices that will eliminate the preventable maternal mortality.
• polices at all levels support access to quality care for women throughout the reproductive-age continuum.
• research moves forward in all aspects of prevention of maternal mortality.

References

1. Petersen EE, Davis NL, Goodman D, et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 States, 2013-2017. MMWR. 2019;68(18):423-429. cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm

2. Metz TD. Eliminating preventable maternal deaths in the United States: progress made and next steps. Obstet Gynecol. 2018;132(4):1040-1045.

3. Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees. 2018. reviewtoaction.org/Report_from_Nine_MMRCs

4. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol. 2016;128(6):1233-1240.

5. Smid MC, Stone NM, Baksh LP, et al. Pregnancy-associated death in Utah: contribution of drug-induced deaths. Obstet Gynecol. 2019;133(6):1131-1140.

6. 115th Congress. H.R. 1318 – Preventing Maternal Deaths Act of 2018. congress.gov/bill/115th-congress/house-bill/1318.

7. Mahoney J. The Alliance of Innovation in Maternal Health Care: a way forward. Clin Obstet Gynecol. 2018;61(2):400-410.

8. Council on Patient Safety in Women’s Health Care website. 2019. safehealthcareforeverywoman.org/

9. Resar R, Griffin FA, Haraden C, et al. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2012.

10. Council on Patient Safety in Women’s Health Care. Patient Safety Bundles. 2019. safehealthcareforeverywoman.org/patient-safety-bundles/

11. California Maternal Quality Care Collaborative. Maternal Quality Improvement Toolkits. cmqcc.org/resources-tool-kits/toolkits

12. ACOG. Postpartum Toolkit. Racial Disparities in Maternal Mortality in the United States: The Postpartum Period Is a Missed Opportunity for Action. 2018. http://acog.org/-/media/Departments/Toolkits-for-Health-Care-Providers/Postpartum-Toolkit/ppt-racial.pdf?dmc=1&ts=20190613T1434044080

13. Black Mamas Matter Alliance. Advancing the Human Right to Safe and Respectful Maternal Health Care. Center for Reproductive Rights. 2018. blackmamasmatter.org/wp-content/uploads/2018/05/USPA_BMMA_Toolkit_Booklet-Final-Update_Web-Pages-1.pdf

14. ACOG. Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol. 2019;133(5):e320-e356.

15. ACOG. Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133(1):e26-e50.

16. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25.

17. ACOG. Committee Opinion No. 762: Prepregnancy Counseling. Obstet Gynecol. 2019;133(1):e78-e89.

18. ACOG. Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018;131(5):e140-e150.

Position Statement: Expanding Access to Hormonal Contraception

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the right of each individual or couple who desire to use contraception to be able to do so. Barriers to obtaining and successfully using contraception must be eliminated, particularly for the most vulnerable individuals and populations. NPWH advocates for federal- and state-level policies that remove barriers and increase access to affordable, safe, and effective contraceptive methods for all reproductive-aged individuals. Multiple strategies involving legislation, regulations, consumer education, and innovation are necessary. Over-the-counter (OTC) access to hormonal contraceptives (HCs) and pharmacist-provided HCs are two specific strategies that can lower barriers to obtaining safe, effective contraception.

NPWH will provide leadership through policy advocacy, consumer and healthcare provider (HCP) education, and support of research on outcomes related to innovative strategies to expand access to HCs. NPWH supports the right of all individuals to access comprehensive sexual and reproductive health services and to make choices that meet their own needs. Continue reading »

Male Sexual and Reproductive Health: The Role of Womenʼs Health Nurse Practitioners

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the right of all individuals to quality, evidence-based sexual and reproductive health (SRH) care that is non-judgmental, respectful, and culturally appropriate. SRH is an important component in individuals’ overall physical, emotional, and social well-being. SRH encompasses sexuality, sexual relationships, and all matters related to the function and processes of the reproductive system.1 The SRH of one individual often intertwines with that of another individual or individuals. Continue reading »

Men with breast conditions: The role of the WHNP specializing in breast care

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the role of the women’s health nurse practitioner (WHNP), as a member of a multidisciplinary breast care specialty team, in providing specialized breast care for women and men. Furthermore, NPWH supports the removal of any restrictions to the provision of male breast care that are based on the WHNP credential. Continue reading »

Position Statement: Cervical Cancer Screening

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports a concerted effort to continue to improve cervical cancer screening rates and timely, appropriate follow-up and treatment when screening results are abnormal. The goal is to reduce cervical cancer incidence, morbidity, and mortality. NPWH supports ongoing research to ensure that screening guidelines are based on the best evidence available. Furthermore, NPWH supports policies at the local, state, and federal levels that ensure access to cervical cancer screening services and follow-up as needed. Continue reading »

Healthcare for Transgender and Gender Non-Conforming Individuals

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms each individual’s right to quality, evidence-based sexual and reproductive healthcare and encourages each individual to strive for a healthy self-concept of sexuality and gender identity. Although NPWH has historically focused on the care of cisgender women, we recognize the importance of providing quality sexual and reproductive healthcare to all individuals, regardless of gender identity. Table 1 provides gender identity-related terminology and definitions.1  Continue reading »

Position Statement: Human Papillomavirus Vaccination

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports an intentional and concerted effort to improve human papillomavirus (HPV) vaccination rates—with the goal of ending cancers caused by HPV. All nurse practitioners (NPs) who provide healthcare for adolescents and young adults are crucial to the success of this effort, and are encouraged to take these steps in their clinical practices: Continue reading »

Human Sex Trafficking

The National Association of Nurse Practitioners in Women’s Health (NPWH) recognizes the critical role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for adolescent and adult females in terms of identifying, assessing, and responding to the needs of trafficked female individuals. Adolescent and young adult females comprise the majority of trafficked persons in the United States and globally, most specifically as victims of sex trafficking. NPs must be well prepared to identify, assess, and provide care for these individuals and have access to the resources to do so.

Many trafficked persons are seen in healthcare settings, yet they remain unidentified.2 Healthcare providers (HCPs) either are not aware of or do not respond to signs, when present, that a patient may be a victim of sex trafficking. A validated screening tool is not yet available. However, NPs can draw from existing evidence in related areas—especially intimate partner violence, sexual assault, homeless and runaway youth, child abuse and neglect, and individuals experiencing trauma in general—for clinical guidance. In addition, NPs can consider practice recommendations from colleagues in social service, advocacy, healthcare, and law enforcement who have expertise in human trafficking identification and intervention.

NPWH supports a comprehensive, coordinated, multidisciplinary approach to meet sex-trafficked individuals’ complex needs and help them address the challenges they face. To that end, NPWH supports research initiatives to develop a validated screening tool to better identify patients who are victims of sex trafficking, as well as to better understand the most effective manner in which to meet their emergency, short-term, and long-term healthcare needs.

Legislation and regulatory policies should focus on eliminating the demand for trafficked individuals in the first place, and on targeting persons and agencies that condone human trafficking. NPWH supports the development of legislation, regulatory policies, and advocacy efforts that protect the safety, rights, dignity, and cultural values of trafficked individuals.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct or support research in a concerted effort to increase knowledge and provide resources for NPs to identify, assess, and respond to the needs of trafficked female individuals.

Background

In 2000, the U.S. Trafficking Victims Protection Act (TVPA) updated post-Civil War slavery statutes to further guarantee freedom from slavery and involuntary servitude.3 For this purpose, sex trafficking was defined as the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex act.3 Severe forms of trafficking in persons was defined as sex trafficking in which the person induced to perform such act has not attained 18 years of age or sex trafficking for the purpose of subjection to involuntary services, servitude, peonage, debt bondage, or slavery.3 The TVPA was re-authorized most recently in 2013.4 Today, the terms modern slavery, trafficking in persons, and human trafficking are used as umbrella terms meeting the TVPA definition.

Accurate statistics for the incidence and prevalence of human trafficking are elusive because of the clandestine nature of the crime and trafficked individuals’ reluctance to identify themselves. Worldwide, it is estimated that 20.9 million persons are victims of trafficking and that among this group, 4.5 million (22%) are victims of forced sexual exploitation.5 Within the U.S., trafficked individuals may be transported across borders from other countries or they may already reside here. Data from a Bureau of Justice Statistics report for January 2008 through June 2010 identified 527 confirmed victims of trafficking, with 80% of these cases being classified as sex trafficking, 10% as labor trafficking, and 10% as undetermined.1 Eighty-three percent of the sex-trafficked individuals in this report were U.S. citizens, with 94% of them being female. The commercial sexual exploitation of minors comprised 64% of the cases. Of note, these data reflect only reported and investigated cases; the numbers may greatly under-represent the true extent of the problem. In 2015, the National Human Trafficking Resource Center (NHTRC) hotline received 21,957 calls across all states, with 4,314 calls reporting sex trafficking.6 

Females at high risk for being victims of sex trafficking include those who are young, live in extreme poverty, have limited education and work opportunities, engage in drug use, and/or have a history of instability or abuse in their families of origin. They may be more vulnerable if they have mental or physical disabilities. Adolescent females who are runaways and/or homeless are particularly vulnerable.2,7

Trafficked individuals face numerous barriers to disclosing their situation to HCPs. They may fear harm to themselves, family members, or friends; fear deportation if not legally in the U.S.; have language barriers; distrust authority figures; feel they do not have any options; be ashamed of their situation and the stigma they believe it carries; or have a criminal record. Traffickers may use monitoring devices to track these individuals’ every move to deter them from seeking help. In addition, some trafficked individuals may not under-stand the concept of coercion or that they are victims of an illegal activity.2

Patients who have been trafficked are at high risk for long-term physical and mental health con-sequences related to inflicted trauma and depriva-tion of their basic needs for survival. Health conse-quences may include unintended pregnancies; sexually transmitted infections (STIs), including HIV; poor dentition compounding malnutrition; depression; post-traumatic stress disorder (PTSD); and suicidal ideation. Commonly reported physi-cal symptoms include fatigue, headaches, back pain, and weight loss.8

Implications for women’s healthcare and WHNP practice

WHNPs and other NPs who provide women’s healthcare should be aware of indicators that raise suspicion that an individual presenting to a healthcare setting may be in an exploitative circumstance. Warning signs identified by anti-trafficking experts include:

Hypervigilant, fearful, or submissive demeanor; evidence of being controlled;

Provision of vague answers to questions or a script-like recitation of her history;

Delay between the onset of an injury or illness and the seeking of healthcare, in context with other indicators;

Discrepancies between an individual’s explained cause and the clinical presentation of her injuries;

Accompaniment by another person who answers questions for the individual and refuses to leave her alone during the visit;

Inability to produce identification documents;

Signs of physical abuse (e.g., cigarette burns, bruising), sexual abuse, medical neglect, torture, depression, PTSD, and/or alcohol or substance use disorder;

Tattoos or other markings indicating a claim of ownership by another;

Recurrent STIs;

Trauma to her genitals or rectum; and/or

History of repetitive abortions or miscarriages.2,7,9,10

WHNPs are particularly qualified through their educational preparation to recognize and provide needed healthcare services and referrals for adolescent and adult females who are victims of sexual, physical, and/or emotional abuse. Trauma-informed care for these patients places an emphasis on helping the individual feel safe and reclaim control of her life and decisions. Goals of a trauma-informed approach in care are to avoid re-traumatization, to emphasize the patient’s strengths and resilience, to support development of healthy short- and long-term coping mechanisms, and to promote healing and recovery.2

No official guidelines are available regarding the most effective manner in which to provide for the emergency, short-term, and long-term healthcare needs of trafficked patients. However, expert opinion supports these approaches:

Foster trust and relationship building, which includes an assurance of confidentiality.

Ensure privacy prior to discussing potential trafficking with the patient.

Recognize potential danger to the patient and/or her family members if she reports the crime.

Incorporate safety planning for both the patient and staff.

Use a trauma-informed approach in assessment and treatment.

Provide care for any immediate needs (e.g., treat STIs, diagnose a pregnancy).

Provide culturally appropriate services.

Mitigate language barriers; provide a professional interpreter when needed.

Establish a list of local resources for collaboration that provides wraparound services for the individual.

Contact the NHTRC hotline at 1-888-373-7888 for guidance on the next steps and referrals if needed.2,7,11

The NHTRC provides detailed information for HCPs concerning identification, assessment, and response to the needs of patients who have been trafficked.

Recommendations

WHNPs and other NPs who provide healthcare for adolescent and adult females should:

Be familiar with and educate staff about warning signs indicating that a patient may be a victim of sex trafficking;

Establish a plan in the healthcare setting for safety of both the patient and staff;

Establish partnerships with local social service providers, mental health providers, religious leaders, legal advocates, and law enforcement representatives for comprehensive services;

Serve as change agents in their communities through mentoring programs for at-risk youth, advocacy for policy changes to aid recovery of trafficked individuals, and engagement in activities that will promote greater cultural awareness of gender inequalities; and

Assess their own learning needs with regard to the unique and complex needs of trafficked individuals and seek continuing education as appropriate.

NPWH will provide leadership and resources to ensure that:

Educational programs for NP students with a population focus that includes adolescent and adult females impart evidence-based knowledge and skill building for the development of competencies to identify trafficked individuals and provide healthcare and appropriate referrals for them; and

Continuing education programs are available for NPs to obtain evidence-based knowledge and competencies to identify and provide healthcare and appropriate referrals for trafficked individuals.

References

1. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008-2010. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2011. 

2. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Waltham, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, and Committee on Violence Intervention and Preven-tion, Massachusetts Medical Society; 2014.

3. 106th U.S. Congress. Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386. 2000. 

4. U.S. Department of State. U.S. Laws on Trafficking in Persons. 2016. 

5. International Labor Organization. ILO 2012 Global Estimate of Forced Labor: Executive Summary. 2012. 

6. National Human Trafficking Resource Center. 2015 NHTRC Annual Report. 2016. 

7. Clawson H, Dutch N, Solomon A, Grace L. Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Planning and Evaluation; 2009. 

8. World Health Organization. Understanding and Addressing Violence Against Women: Human Trafficking. 2012. 

9. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human sex trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49. 

10. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. 2016. 

11. Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health. 2010;55(5):462-467. 

Prevention and Management of Opioid Misuse and Opioid Use Disorder Among Women Across the Lifespan

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports the role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for women across the lifespan in the provision of safe and effective treatment of pain. In certain cases, this treatment may include the prescription of opioid pain relievers (OPR). NPWH acknowledges that NPs must use evidencebased strategies to reduce harm from the misuse of OPR and to prevent the development of opioid use disorder (OUD). These strategies include screening for opioid use/misuse/abuse, educating patients about the risks associated with OPR misuse, and following evidence-based guidelines when prescribing OPR.1,2 In addition, when OUD is identified, NPs qualified to provide medication-assisted treatment (MAT) should follow evidence-based guidelines and prescribe within federal and state regulations.

Use of OPR in general should be reserved for acute pain resulting from severe injuries, medical conditions, or surgical procedures, and only when non-opioid alternatives are ineffective or contraindicated. When OPR are prescribed, they should be given at the lowest necessary dose for the shortest duration (usually <14 days).2 Although many NPs in primary care treat acute pain, the treatment of chronic pain is best achieved through a multimodal and multidisciplinary approach that includes a team member with expertise in pain management. This approach is particularly advantageous when chronic pain management includes OPR use.1,2 NPs should consider evidence-based nonpharmacologic therapies and non-opioid medications as first-line treatment for chronic pain. Primary care NPs with adequate training who prescribe OPR for chronic pain should follow evidence-based guidelines such as those provided by the CDC.1

Whether prescribing OPR for acute or chronic pain, NPs should use risk-mitigation strategies to reduce the potential for harm from misuse or abuse. These strategies include checking state prescription drug monitoring programs when available to assess a patient’s history of controlled substance use, avoiding concurrent prescription of benzodiazepines, and establishing realistic treatment goals with patients. In addition, overdose mitigation includes consideration of co-prescribing the opioid antagonist naloxone when appropriate, along with education about its use to reverse respiratory depression from OPR overdose.1-3

For individuals with OUD, MAT has proven to be clinically effective.4-7 MAT entails the use of medications along with counseling and behavioral therapies to treat OUD and to prevent opioid overdose.4 This recovery-oriented treatment approach has been shown to improve patient survival, increase retention in treatment, decrease drug-related criminal activity, increase patients’ ability to gain and maintain employment, and improve birth outcomes among pregnant women with OUD.The Comprehensive Addiction and Recovery Act (CARA) was signed into law in July 2016.The law includes a section authorizing NPs who meet certain criteria, including participation in a mandatory 24-hour education program, to receive a waiver to prescribe the opioid agonist buprenorphine as a crucial component of treatment for OUD. NPs who receive this education and waiver are able to work within their individual state prescribing laws to provide increased access to OUD treatment.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct and/or support research, all in a concerted effort to increase knowledge and provide resources for NPs to prevent and reduce harm from OPR misuse. NPWH will actively monitor and engage in the process needed to implement CARA so that access to treatment for OUD can reach all women in need.

Background

Pain can be acute or chronic in nature. Acute pain may be related to disease, injury, or recent surgery and typically diminishes with tissue healing. Chronic pain is consistent pain that lasts more than 3 months; usually has neurologic, emotional, and behavioral components; and often affects function, social roles, and quality of life.1,2 At least 116 million adults in the United States have chronic pain conditions.9

Some efforts to improve pain management, despite clinicians’ best of intentions, have had adverse effects. The number of prescriptions for OPR quadrupled between 1999 and 2013.10,11 During this same time period, deaths from opioid use/misuse have also quadrupled.10 In 2014, more than 28,000 persons in the U.S. died of opioid overdoses, with at least half of these overdoses involving prescription OPR.10 These overdose death rates are highest among persons aged 25-54 years.10 

Lethal overdose is not the only risk associated with prescription OPR. Every day, more than 1,000 persons are seen in emergency departments (EDs) for reasons related to misusing prescription OPR.12 Hospital admissions for nonfatal overdoses are on the rise. Other serious consequences include falls and fractures in older adults, sleep-disordered breathing, cardiac arrhythmias related to methadone use, and immunosuppression.2

More than 4 million persons in this country abuse or are dependent on opioids.13 In fact, as many as 1 in 4 persons receiving prescription OPR in primary care settings for chronic noncancer pain struggles with addiction.14 More than 60% of persons taking OPR for at least 3 months are still taking them 5 years later.2 Abuse of OPR results in more than $72 billion in medical costs each year, which is similar to the cost of chronic diseases such as asthma and HIV infection.3

About 25% of persons who abuse OPR obtain them through their own prescriptions, and about 50% of persons who abuse prescription OPR obtain them for free or buy them from friends or relatives.15 Others get OPR by stealing from friends or relatives or from drug dealers.15 If unable to obtain prescription OPR, persons with OUD may turn to heroin. In fact, dependence on or abuse of prescription OPR has been associated with a 40-fold increased risk of dependence on or abuse of heroin.16

The increase in OPR prescriptions has not been accompanied by an overall change in the amount of pain reported. Recent systematic reviews have shown at most only modest benefits of OPR for chronic pain when balanced with potential risk of harm.17,18

The use of safer and more effective treatments for chronic pain could reduce the number of persons who develop OUD or experience an overdose or other adverse event related to opioid use. Studies have supported a range of effectiveness for nonpharmacologic approaches to chronic pain management that include behavioral, psychological, and physical-based therapies and non-opioid pharmacologic treatments such as acetaminophen, non-steroidal anti-inflammatory drugs, and selected anticonvulsants and antidepressants. Use of multiple modalities is likely to be more effective than a single modality.1,2 Because of the complexities involved, the initiation of treatment and the ongoing care for patients with chronic pain are most safely and effectively directed by a multidisciplinary team that includes pain management specialists.1,2

The CDC’s OPR prescribing guidelines include a recommendation for clinicians to offer or facilitate MAT for patients with OUD.1 MAT is underutilized, with only 20% of adults with OUD receiving needed treatment each year. Cost and access are primary barriers.19 With implementation of CARA, NPs, as part of the treatment team, will be able to prescribe some of the medications used in MAT, thereby expanding access to patients.

Implications for women’s healthcare and WHNP practice

Although both men and women experience opioid misuse/abuse and related fatalities, certain gender-related differences exist. Women, when compared with men, are more likely to be prescribed OPR, to use these agents long term, and to receive prescriptions for higher doses.20 Every 3 minutes, a woman goes to the ED for a reason related to prescription OPR misuse/abuse.21 Evidence suggests that women, relative to men, may progress to dependence on OPR at a more accelerated rate.22 

Men are more likely than women to die of an opioid overdose, but the gap is closing. Prescription OPR overdoses in women cause more deaths than do overdoses of benzodiazepines, antidepressants, and heroin combined.21 In fact, for women, OPR are involved in 7 out of 10 prescription drug-related deaths. Intentional OPR overdoses are involved in 1 in 10 suicides among women.2020

The potential for adverse events related to OUD extends to women across the lifespan and beyond the direct health effects. OUD places women at risk for behaviors that further jeopardize their well-being, including prostitution, stealing, and other criminal activities that are often associated with violence. Women with OUD may engage in these risky behaviors in order to support themselves and their addiction. These behaviors place these women at risk for experiencing legal ramifications of their criminal activities, being victims of violence, and acquiring sexually transmitted infections. Women who inject opioids through intravenous or intradermal routes are at added risk for contracting HIV and hepatitis C infections.3,23

Nurse practitioners should ask female patients of all ages about the use of prescription OPR and other medications for nonmedical reasons as part of routine alcohol and substance use screening. Validated screening tools are available to use with adolescents, pregnant women, and adults.23,24 Early identification of opioid misuse/abuse allows NPs to provide evidence-based brief interventions,25 actively participate in MAT if they meet criteria for prescribing treatment medication, and/or make referrals for additional services when needed.

AdolescenceAttention to prevention, as well as early identification of opioid misuse and OUD in adolescents, is critical. In 2014, 467,000 adolescents were nonmedical users of OPR, with 168,000 having OUD.13 Most adolescents who misuse OPR get the drugs from a friend or relative rather than through their own prescription.26 Girls aged 12-17 years may be particularly vulnerable. These girls are more likely than males in this age group to use psychoactive drugs, including OPR, for nonmedical reasons, and they are more likely to become dependent.27 NPs should screen adolescents for opioid misuse and OUD. It is particularly important to follow state and federal regulations regarding confidentiality when an adolescent needs OUD treatment.28

The reproductive yearsSubstance abuse, including abuse of opioids, is most prevalent during the reproductive years. OPR are widely prescribed for women in this age group. NPs should assess pregnancy status, sexual activity, and contraceptive use before prescribing OPR to reproductive-aged women.10 For women who are pregnant or could become pregnant while using OPR, NPs should discuss potential risks versus benefits, as well as alternative treatments. Data are limited, with a few studies suggesting a small increased risk for birth defects (e.g, neural tube defects, gastroschisis, congenital heart defects) associated with maternal OPR use, particularly when drug exposure occurs in early pregnancy.29-31 As would be done with all patients, when OPR are indicated for treatment of acute pain in women who are pregnant, NPs should prescribe the lowest dose for the shortest duration of use. Care of pregnant women taking OPR for chronic pain should be multidisciplinary.

Medication-assisted treatment is important for pregnant women with OUD. Withdrawal from opioid use during pregnancy has been associated with adverse outcomes such as preterm labor and fetal demise.23 Continuous exposure to opioids in utero —whether opioid use is illicit, prescribed for maternal pain, or through MAT—may lead to neonatal opioid withdrawal syndrome (OWS). Neonates with known in utero opioid exposure should be monitored for and treated as needed for withdrawal symptoms. The range and severity of symptoms experienced by neonates are related to the type of opioid, the duration of exposure, and concomitant exposure to other substances while in utero.32,33

Many pregnant women with OUD are late in seeking prenatal care and are erratic in attending appointments.23 But early, regular prenatal care is essential for women with OUD so that they can receive support and early treatment referrals to reduce their risks of harm and adverse pregnancy outcomes. Laws that require reporting of substance abuse during pregnancy may deter women with OUD from seeking prenatal care.34,35 NPWH opposes policies that require reporting or criminalization of substance abuse during pregnancy and supports repeal of existing laws with such mandates. WHNPs and other NPs who provide healthcare for pregnant women are on the forefront to identify, support, and provide appropriate referrals and collaborative care for pregnant women with OUD.

Mothers receiving MATwith the exception of those who are HIV positive or continuing to use illicit substances—should be encouraged to breastfeed.23,28,36 Breastfeeding supports mother–infant bonding and may reduce the severity and duration of neonatal OWS.37,38 Minimal levels of methadone or buprenorphine are found in breast milk, regardless of the maternal dosage.22,39 Both medications are considered safe during breastfeeding.23,36,39 It is important to maintain open lines of communication for early identification of relapse. If relapse does occur, mothers should be provided with assistance to transition to bottle feeding with formula or donor milk.36

Older ageAlthough women older than 65 years are generally at low risk for opioid abuse, specific concerns regarding their use of OPR still exist. WHNPs and other NPs who provide healthcare for older women should be cognizant of potential increased risks with OPR use related to reduced renal function and drug clearance, co-morbidities, polypharmacy, and impaired cognition, as well as an increased risk for falls and fractures.1 Even women older than 65 can experience OUD.

Recommendations

Women’s health NPs and other NPs who provide healthcare for women should:

Use evidence-based guidelines for management of acute and chronic pain.

Use risk-mitigation strategies when prescribing OPR for acute or chronic pain.

Assess pregnancy status, sexual activity, and contraceptive use, as well as discuss potential risks and benefits, before prescribing OPR to women who are pregnant or could become pregnant.

Use a nonjudgmental, respectful approach when broaching the topic of substance use/abuse.

Screen all women at least annually—at well-woman visits, initial prenatal visits, and other visits when indicated—for substance use/abuse with a validated screening tool. Include questions concerning use of prescription drugs for nonmedical purposes.

Provide an evidence-based brief intervention when substance abuse is identified and make referrals for additional services as needed. Know which services are available in the community.

Use evidence-based guidelines if prescribing OUD treatment medication in collaboration with an MAT team.

Collaborate in specialty care for pregnant women with OUD.

Be aware of state reporting laws for substance abuse during pregnancy and advocate for retraction of legislation that exposes pregnant women with substance use disorders to criminal or civil penalities.

References

1. Dowell D, Haegerich TM, Chou R. CDC. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.

2. Washington State Agency Medical Directors’ Group. Interagency Guideline on Prescribing Opioids for Pain. 2015.

3. U.S. Department of Health and Human Services, Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. 2013.

4. SAMHSA. Medication and Counseling Treatment. 2015.

5. Addiction Treatment Forum. MAT with Methadone or Buprenorphine: Assessing the Evidence for Effectiveness. 2014.

6. Fullerton CA, Kim M, Thomas CP, et al. Medication- assisted treatment with methadone: assessing the evidence. Psychiatr Serv. 2014;65(2):146-157.

7. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv. 2014;65(2):158-170.

8. U.S. Congress. S.524 – Comprehensive Addiction and Recovery Act of 2016.

9. Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9(10): 883-891.

10. CDC. Wide-Ranging Online Data for Epidemiologic Research (Wonder). Atlanta, GA: CDC, National Center for Health Statistics; 2016.

11. Frenk SM, Porter KS, Paulozzi LJ. Prescription Opioid Analgesic Use Among Adults: United States, 1999–2012. NCHS Data Brief, No. 189. Hyattsville, MD: National Center for Health Statistics; February 2015.

12. SAMHSA. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. The DAWN Report. Rockville, MD: SAMHSA; 2013.

13. SAMHSA. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 2015.

14. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105(10):1776-1782.

15. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of pastyear nonmedical use: United States 2008-2011. JAMA Intern Med. 2014;174(5):802-803.

16. CDC. Vital Signs: Demographics and Substance Use Trends Among Heroin Users – United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719-725

17. Agency for Healthcare Research and Quality. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. 2014.

18. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.

19. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. JAMA. 2015; 314(14):1515-1517.

20. CDC. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013; 62(26):537-542.

21. CDC. Vital Signs: Prescription Painkiller Overdoses: A Growing Epidemic Among Women. July 2013.

22. SAMHSA. Substance Abuse Treatment. Addressing the Specific Needs of Women: A Treatment Improvement Protocol. Tip 51. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2009. store.

23. American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women and the American Society of Addiction Medicine. Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. May 2012. Reaffirmed 2014.

24. National Institute on Drug Abuse. Chart of Evidence-Based Screening Tools for Adults and Adolescents. Revised September 2015.

25. SAMHSA. Quick Guide for Clinicians Based on TIP 34: Brief Interventions and Brief Therapy For Substance Abuse. Rockville, MD: SAMHSA; 2015.

26. National Institute on Drug Abuse. Drug Facts: Prescription and Over-the-Counter Medications. Bethesda, MD: NIDA; 2015.

27. National Institute on Drug Abuse. Research Reports: Misuse of Prescription Drugs. Last updated August 2016.

28. American Society of Addiction Medicine. National Practice Guidelines for the Use of Medication in the Treatment of Addiction Involving Opioid Use. 2015.

29. Broussard CS, Rasmussen SA, Reefhuis J, et al; National Birth Defects Prevention Study. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204(4):314.e1-11.

30. Whiteman VE, Salemi JL, Mogos MF, et al. Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. J Pregnancy. 2014:1-8.

31. Yazdy MM, Mitchell AA, Tinker SC, et al. Periconceptional use of opioids and the risk of neural tube defects. Obstet Gynecol. 2013;122(4):838-844.

32. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012; 129(2):540-560.

33. SAMHSA. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. Rockville, MD: SAMHSA; 2016.

34. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. Committee Opinion No. 473: substance abuse reporting and pregnancy: the role of the obstetrician-gynecologistObstet Gynecol. 2011;117(1):200-201. Reaffirmed 2014.

35. Guttmacher Institute. Substance Abuse During Pregnancy. Washington, DC: Author; 2014.

36. Reece-Stremtan S, Marinelli KA. ABM clinical protocol # 21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015;10(3):135-141.

37. McQueen KA, Murphy-Oikonen J, Gerlach K, Montelpare W. The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Adv Neonat Care. 2011;11(4):282-290.

38. Pritham UA. Breastfeeding promotion for management of neonatal abstinence syndrome. J Obstet Gynecol Neonat Nurs. 2013;42(5):517-526.

39. Wong S, Ordean A, Kahan M; Society of Obstetricians and Gynecologists of Canada. SOGC clinical practice guideline: substance use in pregnancy: no. 256, April 2011. Int J Gynaecol Obstet. 2011;114(2):190-202.

Approved by the NPWH Board of Directors: December 2016

Prevention of Alcohol-Exposed Pregnancies

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for reproductive-aged women in the use of evidence-based strategies to prevent alcohol-exposed pregnancies (AEP). Use of these strategies should extend to alcohol screening at least yearly for all adolescent and adult patients. In addition, all sexually active, reproductive-aged women who could become pregnant and who drink alcohol should be counseled about the potentially deleterious effects of alcohol on a developing fetus. They should be advised to use effective contraception to prevent pregnancy or to stop drinking alcohol. Women who are trying to get pregnant should be advised to abstain from drinking alcohol. Pregnant women should be screened for alcohol use at their initial prenatal visit and during each trimester thereafter.1 For those who screen positive for risky alcohol use, NPs should provide a brief behavioral intervention, refer them to specialty services as needed, and plan appropriate follow-up.

Furthermore, NPWH recognizes that early and regular prenatal care for women with alcohol dependence is essential in order to encourage healthy behaviors and provide support and early treatment referrals to reduce risks of harm. Laws that require reporting of alcohol/substance abuse during pregnancy as potential child abuse or ne glect may deter women with alcohol dependence from seeking prenatal care.2,3 Therefore, NPWH opposes policies that require reporting or criminalization of alcohol/substance abuse during pregnancy and supports repeal of existing laws with such mandates. NPWH will provide leadership and collaborate with other organizations and agencies to deliver education and skills training for NPs, develop policies, and conduct and/or support research in a concerted effort to prevent AEP.

Background

Prenatal alcohol exposure is the No. 1 preventable cause of birth defects and intellectual and developmental disabilities in children. Alcohol, a known teratogen, readily crosses the placenta and persists in amniotic fluid after a woman’s serum alcohol level metabolizes to zero. Toxicity is dose related, with the greatest risk to the fetus in the first trimester.With regard to preventing fetal alcohol spectrum disorders (FASD) and other adverse pregnancy and birth outcomes associated with prenatal alcohol exposure, there is no known safe amount of alcohol use at any time during pregnancy

FASD is an umbrella term describing a range of possible effects that include physical, intellectual, behavioral, and learning disabilities and language delays, with lifelong implications for individuals prenatally exposed to alcohol.5 FASD are completely preventable if alcohol is not consumed during pregnancy. But many pregnant women do drink alcohol; the estimated prevalence of FASD in first-grade students in the United States is 2%-5%.The lifetime cost of caring for an infant with fetal alcohol syndrome, a single disorder within the FASD continuum, is approximately $2 million.In addition to FASD, alcohol use during pregnancy is associated with increased risks for spontaneous abortion, intrauterine growth restriction, stillbirth, preterm birth, and sudden infant death syndrome.8

In 2005, the U.S. Surgeon General advised that pregnant women not drink any alcohol, pregnant women who have already consumed alcohol stop doing so, and women considering becoming pregnant abstain from drinking alcohol.9 Despite this recommendation, the number of women who drink alcohol while pregnant has not decreased significantly.10 Ten percent of pregnant women report drinking some amount of alcohol in the past month and 3.1% report binge drinking.10

The fact that about one-half of all pregnancies are unplanned poses a particular challenge to the prevention of AEP. Approximately 3.3 million reproductive-aged women report drinking alcohol in the past month and having sex without using contraception.11 An additional challenge is that only 1 in 6 U.S. adults reports ever having talked with a healthcare professional about their drinking.11 Therefore, many adults may be unaware of the potential risks of alcohol use to their own health or to the health of a developing fetus.

Implications for women’s healthcare and WHNP practice

Strong evidence suggests that alcohol screening and brief intervention (SBI) is effective in reducing risky alcohol use among women of childbearing age.12,13 Leading U.S. healthcare organizations and agencies, including the U.S. Preventive Services Task Force,14 the CDC,11 and the American College of Obstetricians and Gynecologists,15 recommend that alcohol SBI be implemented at least yearly for all adults in primary care settings. Likewise, all pregnant women should be screened at the first prenatal visit and once during each trimester thereafter.

Alcohol SBI involves using a validated screening tool to identify a woman’s drinking patterns, whether her alcohol consumption is creating a health risk for herself or others, and whether she has symptoms of dependency. If at-risk drinking is identified, the NP engages the woman in a brief motivation-enhancing intervention to reduce drinking. The main goal of alcohol SBI is to motivate patients to be aware of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating the risk, and make their own decisions. Referral to specialty care for further assessment and treatment is made if a woman is unable to moderate risky alcohol use on her own. The CDC’s Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices provides guidance for incorporating universal alcohol SBI within clinical practice.This guide includes information on the use of a variety of screening tools validated for use with adults, including pregnant women.

WHNPs and other NPs who provide healthcare for reproductive-aged women have a responsibility to provide clear, fact-based information regarding risks associated with drinking any amount of alcohol during pregnancy. Furthermore, they have the responsibility to identify women with at-risk drinking habits and provide counseling and referrals for treatment as appropriate.

Recommendations

WHNPs and other NPs who provide healthcare for reproductive-aged women should:

Adopt a non-judgmental respectful approach when broaching the topic of alcohol use.

Counsel each reproductive-aged woman in their care that there is no safe amount of alcohol consumption during pregnancy and provide fact-based information regarding risks.

Provide alcohol screening with a validated screening tool annually and during each trimester of pregnancy.

Provide an evidence-based brief intervention when at-risk alcohol use is identified.

Advise all pregnant women who drink alcohol  to stop doing so.

Advise all women planning a pregnancy who drink alcohol to stop doing so.

Advise all sexually active women who drink alcohol and could become pregnant to use effective contraception to prevent pregnancy or to stop drinking.

Recognize that not all women are able to stop using alcohol without support.

Refer women for additional services if they cannot stop drinking on their own. Know which services are available in the community.

Provide follow-up as needed to monitor women’s drinking, provide encouragement and support, and, if necessary, refer for specialized help.

Be aware of state reporting laws for alcohol/substance abuse in pregnancy and advocate for retraction of legislation that exposes pregnant women with alcohol dependence to criminal or civil penalties.

NPWH will provide leadership and resources to ensure that:

Educational programs for NP students with a population focus that includes reproductive-aged women impart evidence-based knowledge and skill building for the development of competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.

CE programs are available for NPs to obtain evidence-based knowledge and competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.

References

1. Nocon J. Chapter 15: Substance use disorders. In Mattison DR, ed. Clinical Pharmacology During PregnancyAmsterdam: Academic Press, an Imprint of Elsevier; 2013.

2. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 473: Substance abuse reporting and pregnancy: the role of the obstetriciangynecologist. Obstet Gynecol. 2011;117(1):200-201. Reaffirmed 2014.

3. Guttmacher Institute. Substance Abuse During Pregnancy. Washington, DC: Author; 2014.

4. Mattison DR, ed. Clinical Pharmacology During Pregnancy. Amsterdam: Academic Press, an Imprint of Elsevier; 2013.

5. Sokel RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA. 2003;290(22):2996-2999.

6. May PA, Baete A, Russo J, et al. Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics. 2014;134(5):855-866.

7. CDC. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. Atlanta, GA: CDC National Center on Birth Defects and Developmental Disabilities; 2014.

8. Bailey BA, Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Res Health. 2011;34(1):86-91.

9. U.S. Department of Health and Human Services. U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy. Washington, DC: US Department of Health and Human Services; 2005.

10. Tan CH, Denny CH, Cheal NE, et al. Alcohol use and binge drinking among women of childbearing age – United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015;64(37):1042-1046.

11. Green PP, McKnight-Eily LR, Tan CH, et al. Vital signs: alcohol-exposed pregnancies—United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2016; 65(4):91-97.

12. Bertholet N, Daeppen JB, Wietlisbach V, et al. Reduction in alcohol consumption by brief alcohol intervention in primary care: systematic review and metaanalysis. Arch Intern Med. 2005;165(9):986-995.

13. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645-654.

14. Moyer VA; Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210-218.

15. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 496: At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol. 2011;118(2 pt 1):383-388. Reaffirmed 2013.

Approved by the NPWH Board of Directors: August 2016

The Doctor of Nursing Practice for Women’s Health Nurse Practitioners

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports a pragmatic approach for the continuing evolution to the Doctor of Nursing Practice (DNP) degree as entry level for women’s health nurse practitioners (WHNPs). During the transition, study of the impact of DNP education on quality, access, and cost of healthcare should be ongoing. Policies must be in place to ensure that currently practicing WHNPs are not disenfranchised from practice in any way. Furthermore, NPWH advocates for concerted strategies to maintain an adequate number of highly qualified WHNPs to meet the healthcare needs for individuals and communities.

Background

In October 2004, the American Association of Colleges of Nursing (AACN) published a position paper with the recommendation to transition the entry-level degree for advanced practice registered nurses (APRNs) from the master’s degree to the DNP by the year 2015.The AACN position paper outlined several trends to support the need for a practice doctorate for advanced nursing practice. These trends included continuing expansion of scientific knowledge, technology and informatics advances, increasing complexity of healthcare systems, the need for improved patient outcomes, and the need for parity with other healthcare professionals.

The Institute of Medicine (IOM) 2011 report, The Future of Nursing: Leading Change, Advancing Care, recognized that more would be expected of the APRN as the healthcare system grows in complexity, scientific knowledge continues to expand, and technology advances.2 APRNs would need competence in aspects of healthcare that require additional coursework and aligned clinical experiences. Further, the IOM report recognized the importance of DNP-prepared APRNs as clinical scholars who translate research and positively affect individual and population health outcomes at organizational and systems levels.

Based on the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice, DNP curricula go beyond that of master’s programs.3 DNP programs prepare APRNs as leaders in evidence- based practice, quality improvement, systems thinking, and clinical scholarship. DNP curricula provide critical learning in the areas of informatics and technology, healthcare policy and advocacy, population health, and inter-professional collaboration to improve healthcare.

In 2015, the National Organization of Nurse Practitioner Faculties (NONPF) reaffirmed a commitment to advancing the DNP degree as entry level for the NP role.4 Further, NONPF recommended that all NP programs provide a postbaccalaureate to DNP with a seamless, integrated curriculum that prepares graduates with NP core competencies,population-focused  competencies,and competencies of the DNP Essentials.3

Significance to women’s healthcare and WHNP practice

NPWH affirms that master’s and certificate programs have fully prepared WHNPs with the competencies required to provide safe, quality healthcare for women. NPWH also recognizes the growing complexity of healthcare environments and the continuously expanding body of scientific knowledge regarding women’s health and healthcare needs. DNP education provides WHNPs with advanced competencies significant to providing women’s healthcare and enhancing NP practice.

Women benefit when WHNPs are prepared with the highest level of scientific knowledge and the ability to translate that knowledge quickly and effectively into practice. Proficiency in leading quality improvement strategies that create and sustain positive change at organizational and policy levels leads to improved health outcomes. Advanced preparation in the inter-professional dimension of healthcare enables WHNPs to facilitate collaborative team functioning. DNP-prepared WHNPs provide a critical interface between practice, research, and policy, with a focus on women’s health.

NPWH also recognizes challenges that must be addressed regarding the move to the DNP as entry level for WHNP practice. The DNP degree will require longer educational programs that add to educational costs. Longer educational programs may also slow the number of WHNPs prepared to meet national healthcare shortages. Financial gain for the WHNP prepared at the DNP level is not guaranteed.

NPWH recommendations

DNP education must include availability for preparation in the WHNP population focus.

• The DNP curriculum for the WHNP population focus must incorporate the WHNP Guidelines for Practice and Education.7

NPWH and other APRN organizations must collaborate to address the challenges presented in making the transition to the DNP as entry into practice for APRNs in an informed and equitable manner.

NPWH and other APRN organizations must participate in and support research to study the impact of DNP education on quality, access, and cost of healthcare.

NPWH will continue to advocate at organizational and legislative levels to ensure that policies and regulations support the practice of all WHNPs. NPWH will support only those policies and regulations for NP practice, education, and reimbursement that do not disenfranchise WHNPs without DNP degrees.

References

1. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. October 2004.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

3. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. 2006.

4. National Organization of Nurse Practitioner Faculties. The Doctorate of Nursing Practice NP Preparation: NONPF Perspective. 2015.

5. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. 2012.

6. Population Focused Competencies Task Force. Population-Focused Nurse Practitioner Competencies2013.

7. National Association of Nurse Practitioners in Women’s Health. Women’s Health Nurse Practitioner: Guidelines for Practice and Education. 7th ed. 2014.